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COPYRIGHT Ó 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED

The Burden of Musculoskeletal Injury in Low and Middle-Income Countries: Challenges and Opportunities

By David A. Spiegel, MD, Richard A. Gosselin, MD, R. Richard Coughlin, MD, Manjul Joshipura, MD, Bruce D. Browner, MD, and John P. Dormans, MD

Investigation performed at Children’s Hospital of Philadelphia, the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; the University of California at Berkeley School of Public Health, Berkeley, California; San Francisco General Hospital, the University of California at San Francisco School of Medicine, San Francisco, California; Academy of Traumatology, Ahmedabad, Gujarat, India; and the University of Connecticut Health Center, University of Connecticut School of Medicine, Farmington, Connecticut

The global burden of injury is substan- effective addition to the health system in The most comprehensive assessment of tial, and injuries are predicted to be a low and middle-income countries11,12. global mortality and morbidity has been leading cause of death and disability The goals for this review were (1) to provided by the Global Burden of over the next few decades1-6. The ma- provide a public health perspective on Disease project (www.who.int/healthinfo/ jority of this burden will be borne by the burden of injury in low and middle- bodproject/en/index.html). The initial low and middle-income countries, income countries, (2) to discuss the Global Burden of Disease Study was where preventive strategies are often delivery of musculoskeletal trauma care published in 1996, and was based on nonexistent and barriers to the timely in resource-challenged environments, data collected in 19901. That study and appropriate care of the injured (3) to highlight deficiencies in physical introduced the disability-adjusted life include absent or inefficient systems for resources and human resources for year (DALY), drawing attention to the the delivery of trauma care, inadequa- health care, (4) to outline approaches to importance of nonfatal outcomes, and cies in the number and the distribution teaching and training, and (5) to de- suggested that disability plays a major of health-care facilities and workers, a scribe the information flow between role in determining the overall health lack of infrastructure and/or physical economically developed and underde- status of a population. Specific diseases resources, and a lack of education and veloped regions. and injuries have been disaggregated training. Addressing the burden of in- into three major groups: Group I jury in low and middle-income coun- The Global Burden of Injury (communicable diseases, maternal and tries has become a public health Background perinatal conditions, and nutritional priority. So-called essential services, The World Bank classifies countries in deficiencies), Group II (noncommuni- which are low-cost, high-yield, and July of each year on the basis of per cable diseases), and Group III (injuries) target major health problems, should be capita gross national income. As of (Table II). Injuries are further divided made available to every person in the 2005, countries have been classified (in into intentional (self-inflicted violence, world7-10. While surgery has been tradi- U.S. dollars) as low income (<$875 per interpersonal violence, war, and other) tionally viewed as a high-cost treatment year), lower-middle income ($876 and unintentional (those resulting lying outside the realm of the traditional to $3465), upper-middle income from road traffic crashes, poisoning, public health model, evidence is ($3466 to $10,725), and high income falls, fires, drowning, and other). The emerging that the burden of surgical (‡$10,726)13. Developing is the term overall rank for each category of unin- diseases such as trauma is substantial, commonly used to describe low and tentional injury, in terms of both and that essential surgery may be a cost- middle-income economies (Table I). deaths and DALYs (1990 and 2001), is

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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shown in Table III. Subsequent to this in a population, and to inform resource cataracts (0.600), acute myocardial in- landmark publication, burden-of-disease allocation1,23. farction (0.491), unipolar major de- calculations have been revised and The DALY represents the gap pression (0.600), developmental updated2,3. between the health of a population and disability (0.024), birth asphyxia or Injuries accounted for 16% of the an ideal reference state, and it combines trauma (0.381), leprosy (0.153), tuber- world’s disease burden in 1998 and for the years of life lost because of prema- culosis (0.294), poliomyelitis (0.369), 11% in 20012,5. Unintentional injuries ture mortality (YLL) with the healthy spina bifida (0.593), and osteoarthritis were estimated to be responsible for years of life lost because of disability of the hip or knee (0.156). Disability 66% of injury-related deaths and 70% (YLD) (DALY = YLL 1 YLD). One weights are frequently listed for both the of injury-related DALYs (8% of all DALY is equal to the loss of one healthy treated and the untreated condition, DALYs) in 2001, and most occurred in year of life. The years of life lost because and, in a subset of cases, these weights males who were fifteen to twenty-nine of YLL are calculated by multiplying the are the same. It should be recognized years of age6. Road traffic crashes are the number of deaths by the standard life that disability weights do not take into most common cause of death from expectancy in years at the age of death account the context in which the con- injury worldwide, and >90% of the (eighty years for men and 82.5 years for dition occurs. As stated by Allotey et al., deaths from injury worldwide occur women). The years lived with disability the ‘‘experience of a health condition is in low and middle-income countries4. (YLD) are calculated by multiplying the an interaction between a person and the Injuries are twice as common in number of incident cases by the average social, cultural, and environmental males, and 50% of deaths occur in duration of the disease and by a weight context.’’24 Weights for the same condi- individuals between fifteen and forty- factor (disability weight = severity of tion might vary substantially on the four years of age1,4,14. Patterns of injury disease from 0 [perfect health] to basis of the local infrastructure and the differ between urban and rural 1 [death]). availability of support from family environments15,16. While a critique of the methods members and the society. For example, Although there is a paucity of and assumptions used in calculating paraplegics in Cameroon rated their published material quantifying the DALYs23,24-28 is beyond the scope of this health as considerably worse than those burden of musculoskeletal injuries in review, and the methodology continues in Australia24. low and middle-income countries, ex- to evolve on the basis of critical reviews, While acknowledging that it has tremity injuries are thought to be an several issues surrounding the calcula- flaws and limitations, it is also impor- important cause of permanent disabil- tion of the disability component (YLD) tant to emphasize the advantages of the ity17-22. As such, the impact of traumatic are worthy of discussion. As with other DALY: a composite summary measure conditions treated by orthopaedic sur- summary measures of population that allows comparisons across different geons has yet to be quantified on a health, social value choices are incor- conditions or interventions (for exam- global basis. porated. Age-weighting assumes that ple, the costs per DALY averted by there is a social or societal preference to poliomyelitis immunization compared Quantifying the Burden of Disease: value a year of life for a young adult with the costs per DALY averted by liver The Disability-Adjusted Life Year more than for a child or an elderly transplantation). Evidence that certain Traditional measures of population person25. Age-weighting has been elim- surgical treatments can avert DALYs is health have focused on mortality, which inated in the most recent updates from beginning to emerge11,30. In advocating by definition neglects the majority of the Global Burden of Disease Study. for the orthopaedic treatments in low conditions treated by orthopaedic sur- Disability weights for each condition and middle-income countries, research geons. With a growing awareness of the reflect societal preferences for time lived studies focusing on the ability of specific contribution of nonfatal outcomes to in nonfatal health states. The values for treatments to avert DALYs should be the world’s disease burden, there was a a selected group of conditions were supported. need for a summary measure of popu- determined by a panel of experts using a lation health that would reflect this person trade-off method, and they lie Road Traffic Crashes component of disease burden. In re- along a continuum from 0 (complete Much of the literature concerning the sponse, the DALY was developed as a health) to 1 (death). Examples of dis- global burden of injury has appropri- component of the Global Burden of ability weights for traumatic musculo- ately focused on road traffic crashes, Disease Study, initiated in 1988 by the skeletal conditions include dislocations which are predicted to be the third World Health Organization, the World (0.074), fractures (femur [0.372]), pel- leading cause of DALYs worldwide by Bank, and the Harvard School of Public vis [0.247], ankle [0.196], tibia [0.271], 2020, and the second leading cause in Health1. The DALY was designed to and amputations (leg [0.300] and finger low-income countries1,6. The term crash measure the combined impact of mor- or arm [0.102])29. For comparison, has replaced the term accident,as bidity and mortality, in order to quan- weights associated with other condi- crashes are nonrandom and are there- tify the burden of disease and disability tions include spinal cord injury (0.725), fore amenable to prevention6,15.An 917

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TABLE I Selected National Statistics

Income Level According to World Bank Life Expectancy Gross National Index Per Capita Health Physician Country Classification* Population† (in 2004)‡ (yr) Per Capita§ (US$) Expenditure# (US$) Density**

United States High 295,734,134 78 41,440 5711 2.56 United Kingdom High 60,441,457 79 33,630 2428 2.30 China Lower-middle 1,306,313,812 72 1500 61 1.06 Indonesia Lower-middle 241,973,879 67 1140 30 0.13 Egypt Lower-middle 78,887,007 68 1250 55 0.54 Philippines Lower-middle 87,857,473 68 1170 31 0.58 Peru Lower-middle 28,302,603 71 2360 98 1.17 Brazil Lower-middle 188,078,227 70 3300 212 1.15 Kenya Low 33,829,590 51 480 20 0.14 Sierra Leone Low 5,867,426 39 210 7 0.03 Mozambique Low 19,406,703 45 270 12 0.03 Uganda Low 27,269,482 49 250 18 0.08 Nigeria Low 128,765,768 46 430 22 0.28 Ethiopia Low 70,053,286 50 110 5 0.03 Malawi Low 12,707,464 41 160 13 0.02 Ghana Low 21,946,247 57 380 16 0.15 India Low 1,080,264,388 62 620 27 0.60 Nepal Low 27,676,547 61 250 12 0.21 Bangladesh Low 144,319,628 62 440 14 0.26 Pakistan Low 162,419,946 42 600 13 0.74 Afghanistan Low 29,928,987 62 ? 11 0.19 Cambodia Low 13,636,398 54 350 33 0.16 Vietnam Low 83,535,576 71 540 26 0.53

*According to the World Bank classification of countries, low income is <$875/year, lower-middle income is $876 to $3465/year, and high income is ‡$10,726/year13. †Population data are from the United States Census Bureau, International Data Base (www.census.gov/cgi-bin/ ipc/idbsprd). ‡Estimates of life expectancy at birth for 2004 from the World Health Report 200666. §Gross national index per capita for 2004 from World Development Indicators (World Bank April 18, 2006 [www.worldbank.org]). #Based on data from the World Health Report 2006. **Physician density is the number of physicians per 1000 individuals (World Health Report 2006). increase in the number of motorized road traffic crashes from the General the fourth leading cause of DALYs in vehicles has accompanied economic Assembly of the United Nations33. 20303. development within low-income coun- Road traffic crashes are responsi- An increase in injuries from road tries, yet the infrastructure to support ble for approximately 1.2 million traffic crashes has been associated with this volume has been lacking. The deaths worldwide per year, and an economic growth in low-income coun- number of motorized vehicles in China additional twenty to fifty million people tries37. While only 32% of the world’s increased from 60,000 to more than fifty survive with or without a permanent vehicles are found in low-income million over the past fifty years31, disability 34-36. Road traffic crashes countries, they account for 85% of the while in Thailand the number has in- ranked eleventh in both deaths and deaths and 90% of the DALYs attributed creased from 4.9 million in 1987 to 17.7 DALYs in 20012 (Table III), and pro- to road traffic crashes38. Alarming in- million in 199732. The resultant ‘‘epi- jections from data collected in 2002 creases in mortality have been docu- demic’’ of road crashes has led to several suggest that road traffic crashes will be mented (from 1975 to 1998) in Malaysia resolutions on road safety and control of the eighth leading cause of death and (44%), India (79%), Colombia (237%), 918

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TABLE II Burden of Disease Statistics for 1990 and Projected to 2020: Epidemiologic Transition*

Percentage of Percentage of Total Disability- Total Deaths Adjusted Life Years Major Category 1990 2020 1990 2020

Group I (communicable and perinatal diseases) 44 20 34 15 Group II (noncommunicable diseases) 41 60 56 73 Group III (injuries) 15 20 10 12

*Based on data from: The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 20201.

China (243%), and Botswana (384%)39. cause of death, musculoskeletal injuries Delivery of Care More than 50% of those killed are males are a common source of morbidity 21,48. Up to 50% of those injured in low and between fifteen and forty-four years of The effect of nonfatal injuries is likely middle-income countries receive no age14,36,38,40,41, and these injuries are more much greater than that of fatal in- medical care, and a substantial number common in individuals of lower socio- juries49, although the data remain receive services at a primary health economic status35,42. The global eco- sparse50,51. In an extensive review of the facility staffed by a nonphysician care nomic costs are estimated to be $518 literature, Ameratunga et al. found that provider53,54. In high-income countries, billion per year36,43. The estimated costs the prevalence of disability after a road better organization of trauma systems for low or middle-income countries are traffic crash ranged from 2% to 87%; has reduced mortality by 15% to 20% equivalent to 1% to 2% of their gross however, none of those studies were and has decreased medically prevent- domestic product, which for many conducted in a low-income country 51. able deaths by >50%55. Components countries exceeds yearly developmental For patients who required hospital ad- of a trauma care system include aid given to them. The traffic mix is mission for the management of their both prehospital and hospital-based considerably different in low-income injuries, the rate of self-reported dis- services. countries, and between 41% and 75% of ability was 21% to 57%, whereas phy- With respect to prehospital care, those injured are pedestrians40,41,44. sicians reported disability in only 2% to while formal emergency medical Others who are commonly injured 7% of such patients50. Self-reported services may be unaffordable for the include bicyclists and motorcyclists45,46 disability was identified in 5% to 39% of majority of low-income countries at and passengers on public those seen as outpatients50. A study from present, improvements in informal transportation47. Sweden found that 23% of victims had a mechanisms have resulted in better While closed head injuries and reduced health status at nearly four outcomes54,56-61. In such resource- visceral injuries are the predominant years following injury 52. challenged environments, the majority

TABLE III World Ranking of Unintentional Injuries

Rank in Terms of Disability- Rank in Terms of Deaths† Adjusted Life Years‡ Category* 1990 2001 1990 2001

Road traffic crashes 9 11 9 11 Self-inflicted injuries 12 15 17 16 Interpersonal violence 16 22 19 18 War 20 46 11 49

*Four categories of unintentional injury that ranked among the top twenty causes of global morbidity and mortality in 1990 and in 2001. †Based on data from The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 20201. ‡Based on data from Global Burden of Disease and Risk Factors2. 919

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of deaths occur in the prehospital [a hospital staffed by an orthopaedic tween the completion of training and setting 21,48, and transport to a medical surgeon]) (Table IV). formal certification, compulsory com- facility is often provided by relatives, With respect to the health work- munity service, and banning the re- police, taxi drivers, and others. A force, current estimates suggest that cruitment of health professionals from community-based strategy empowers there is a global shortage of four million other Organization of African Unity selected individuals to work with the health-care workers, and this global countries67-69. In Thailand, graduates health system to improve the quality of human resource crisis is defined not are required to spend three years in care. Although the specific arrange- only by deficiencies in the absolute rural community service, and the ments will differ between communities, number of workers but also by inade- medical curriculum was modified to lay people may be trained in basic first quacies in the distribution of workers increase the emphasis on training for aid, and the use of both private and both between and within countries64-66. service in rural environments71. Strate- public transport vehicles may be en- Access to an orthopaedic surgeon is a gies to decrease the impact of brain couraged (with drivers trained in luxury in most parts of the developing drain are being developed in other basic first aid) to transfer the injured world. In contrast to the United States, countries as well. to a medical facility in order to im- where there are 2.6 physicians per 1000 prove outcomes59,62. Guidelines for inhabitants, the ratio in low-income Education the development of effective pre- countries has been reported to range While training programs in North hospital trauma care systems have from 0.02 to 0.7466. America and Europe have evolved to- been published by the World Health While 24% of the world’s disease ward greater subspecialization, this ap- Organization60. burden is found in Africa, this continent proach is impractical for most low and has only 3% of the world’s health-care middle-income countries, especially Deficiencies in Physical workers and only 1% of the world’s with regard to the provision of care for Resources and Human Resources resources for health care66. In contrast, the majority of the population who for Health Care while only 10% of the world’s disease reside in rural communities72. Most A logical foundation with which to burden is found in the Americas (in- injured patients worldwide have no develop a hospital-based trauma care cluding the United States and Canada), access to an orthopaedic surgeon, and it system has been developed through the this region accounts for 37% of the is unlikely that this will change in the Essential Trauma Care Project, a part- world’s health workforce and >50% of foreseeable future. As such, the majority nership between the International As- the world’s spending on health care. In of treatment is provided by traditional sociation for the Surgery of Trauma and low-income countries, while the ma- practitioners (such as bonesetters), Surgical Intensive Care (IATSIC) and jority of disease burden is found in rural general medical doctors, general sur- the Department of Injuries and Vio- areas, most health-care workers are geons, or other health-care workers. lence Prevention of the World Health found in urban areas. Many patients receive no medical care Organization. This collaboration led to The migration of health-care at all72,73. Orthopaedic surgeons may the publication of ‘‘Guidelines for Es- workers both between and within (rural have the greatest impact through the sential Trauma Care,’’ a document that to urban) countries, referred to as the teaching and/or training of a range of provides a generic, flexible template for ‘‘brain drain,’’ has been an enormous health-care workers, provided that the human resources (training and staffing) problem66-71. The reasons cited include information is appropriate to the and physical resources (equipment and insufficient remuneration, poor work- local environment (infrastructure, supplies) required to provide essential ing conditions and/or inadequate re- resources, and educational level of trauma care services10,63. Eleven core sources, the political climate, caregivers)19. services are deemed essential (‘‘rights of discrimination, and even persecution69. Training programs in orthopaedic the injured’’). The information is most More than 23,000 health-care workers surgery should be encouraged and useful for health planners, including migrate from Africa each year, and it is supported, but a global strategy to government officials, representatives estimated that each departure costs the improve care for musculoskeletal in- from the ministry of health, and hos- society approximately $184,00066,69,70.In juries must focus on training other pital administrators. These services are Ghana, between 1985 and 1997, 50% of health-care professionals to provide outlined in the estimated trauma-care each graduating class ultimately emi- basic orthopaedic services. The poten- resource matrix, based on four levels of grated to the United States or Great tial orthopaedic caregivers, including health-care facility (basic [village health Britain68. Individual countries have de- general surgeons, general medical doc- post], GP [a hospital staffed by a general vised strategies to decrease the impact of tors, nurses, and other health profes- practitioner who has surgical capabil- brain drain. For example, measures to sionals, should be considered for such ity], specialty [a hospital staffed by a counter the exodus of 33% to 50% of training. Cultivating a positive rela- general surgeon with or without an the medical graduates from South tionship with traditional practitioners orthopaedic surgeon], and tertiary Africa include increasing the time be- may also help to improve the quality of 920

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TABLE IV The Essential Trauma Care Matrix*

Facility Level Service Basic GP Specialty Tertiary

Basic immobilization E E E E Closed reduction PR PR E E Skeletal traction I PR E E Operative wound management I PR E E External fixation (or pins and plaster) I PR E E Internal fixation I I E E Fasciotomy for compartment syndrome I PR D E Radiography D D E E Image intensifier I I D D Hand injury: assessment and basic splinting E E E E Recognition of spinal cord injury E E E E Immobilization (cervical collar or backboard) D E E E Monitoring of neurologic function E E E E Nonsurgical management of spinal injury I PR E E Surgical treatment of spinal injury I I PR E Computerized tomography scanning I D D D Magnetic resonance imaging I I D D

*According to the Guidelines for Essential Trauma Care10,63, the matrix outlines recommendations for physical resources at each level of health- care facility, recognizing that there is some overlap. Basic = a village health post or equivalent, GP = a hospital staffed by a general practitioner, specialty = a hospital staffed by a general surgeon with or without an orthopaedic surgeon, tertiary = a hospital with an orthopaedic surgeon. E = essential, D = desirable, PR = possibly required, and I = irrelevant. care. Although the rate of complications resources available locally. The needs the community.’’79-81 In sub-Saharan following treatment by traditional should ideally be documented by epi- Africa, nonmedical health-care profes- bonesetters remains unknown, cata- demiologic study or local audit. Surgical sionals (for example, assistant medical strophic consequences, such as training programs in high-income officers in Mozambique and orthopae- gangrene and Volkmann ischemic countries are unlikely to meet the needs dic clinical officers in Malawi) have been contracture, have been the focus of of students in low-income countries, trained to treat surgical conditions82-86. numerous articles74-76. Traditional prac- especially those who will work in a rural Short-term educational courses have also titioners are well established in many setting. In a review from Pakistan, been used with success by the Canadian communities throughout the world, only 37% of the general surgical Network for International Surgery (in and working with them, rather than procedures performed were taught in Ethiopia, Uganda, Mozambique, and against them, must be viewed as a ‘‘win- training programs from high-income Malawi) and by others87,88. The IATSIC, win’’ situation. Onuminya demon- countries78. in partnership with the Academy of strated that when traditional boneset- The training of orthopaedic sur- Traumatology, has pioneered a National ters attended a one-day instructional geons is to be encouraged, but alternate Trauma Management Course in India course on the treatment of fractures, approaches must be explored in order to that has trained 4000 doctors in the last there was a substantial decrease in the deliver orthopaedic services to resource- six years. In Ghana, a trauma course rate of gangrene, infection, malunion, challenged environments. One ap- based on the advanced trauma life- and nonunion77. proach has been to introduce the field of support protocols of the American Although training in the basic ‘‘rural’’ surgery, which has been defined College of Surgeons has been developed sciences is appropriate in any setting, as ‘‘need-based multidisciplinary sur- with modifications to suit the needs of clinical training must be specific to local gery under resource constraints to make general practitioners in rural hospitals87. or regional needs and must focus on the surgical care affordable and accessible to The World Health Organization has 921

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recently launched a comprehensive tion to maintain and enhance their useful, and 61% used this resource for training initiative in emergency and knowledge base. However, a large ‘‘in- more than one hour per week. The essential surgical and anesthetic services formation gap’’ exists between the high International Society of Orthopaedic aimed at the ‘‘primary referral’’ level and low-income countries89-93. In 2002, Surgery and Traumatology (SICOT) facility (a basic facility or a facility 56% of low-income countries could not has developed a web portal, active in staffed by a general practitioner), under access journals, and 21% had access to eighteen countries, to facilitate the the direction of the Clinical Procedures an average of two journals93. While the exchange of ideas and educational Unit of the Department of Essential Internet has created an excellent re- materials. One component of this Health Technologies. The Emergency source for the dissemination of health- program is a telediagnostic web site, and Essential Surgical Care Project care information, barriers to effective through which consultation can be (EESC) focuses on the role of the utilization include a lack of computer obtained. World Health Organization in fostering equipment and the inability to access Of the 3000 journals covered by collaboration among international or- educational materials. If services are Medline, 98% originate in developed ganizations, institutions, associations, available, it may be difficult if not countries90. The most useful informa- agencies, nongovernmental organiza- impossible to extract useful data from tion may come from local journals, tions, and individuals to ‘‘promote the voluminous amount of information which are rarely indexed in Medline or appropriate and sustainable standards available. A lack of infrastructure has similar databases95. Page et al. per- through an integrated approach to made access a problem for many low- formed a cross-sectional questionnaire improve the quality and safety of income countries. As of 1998, Africa in various countries (China, Thailand, emergency and essential surgical had a population of 700 million people, India, Egypt, and Kenya) and found that care at resource limited health care but less than one million (80% of whom research published in local journals had facilities’’ (www.who.int/surgery/en/ lived in South Africa) had access to the the highest likelihood of changing index.html). Workshops to ‘‘train the Internet90. practice95. As such, orthopaedic sur- trainers’’ are held in collaboration with When the infrastructure is avail- geons from both high and low-income the Ministry of Health and both local able, health professionals need a mech- countries may potentially serve as ‘‘in- and international partners. Medical anism with which to access reliable formation brokers’’ to improve access to and nonmedical health professionals information relevant to their field. In reliable information. participate, and the three to seven-day response to this need, a number of workshops are often coordinated organizations have developed programs Overview with other local or regional training to improve electronic access to health- The global burden of injury is enor- activities8,12. A needs assessment is per- care information in low and middle- mous and is expected to increase over formed in advance, and a follow-up income countries. The World Health the next few decades, and musculo- assessment is performed afterward. Organization, in January 2002, skeletal injuries will continue to con- A standardized curriculum is pro- launched the Health InterNetwork Ac- tribute substantially to the worldwide vided by the Integrated Management cess to Research Initiative (HINARI), burden of disability. Further epidemio- of Essential and Emergency Surgical providing access to Medline and full- logic study will be required to increase Care tool kit (www.who.int/surgery/ text articles through more than 2400 our knowledge of the impact of mus- publications/imeesc), and the most journals by means of a web portal91,93,94. culoskeletal injuries. Such information recent edition of ‘‘Surgical Care As of 2004, more than 1100 nonprofit will help to develop and promote pre- at the District Hospital—The WHO institutions from 103 of 113 eligible ventive strategies, to inform the decision Manual’’ (www.who.int/surgery/ countries had subscribed to the service, makers for resource allocation, to publications/scdh_manual) serves as which is free in countries with a gross address issues relating to the health the teaching manual. In addition, a national product per capita of <$1000. workforce, and to refine medical cur- Global Initiative for Emergency and The cost is US$1000 per year in coun- ricula. The majority of those injured Essential Surgical Care was launched tries with a per capita gross national worldwide have no access to an or- in December 2005 and represents the product of $1000 to $300093. The thopaedic surgeon, and this is not first coordinated effort to address the Ptolemy project involves a partnership likely to change in the foreseeable lack of adequate capacities for emer- between the University of Toronto and future, so strategies for teaching and gency and essential surgical care ser- the Association of Surgeons of East training must educate and empower vices at the primary referral level in low Africa, and electronic access to the other health professionals to care for and middle-income countries. medical literature is provided for East musculoskeletal injuries, where appro- African surgeons through the University priate. While individuals, institutions, Sharing of Information of Toronto library89. Participating sur- and societies from high-income coun- In addition to formal training, providers geons have found access to full-text tries may play an important role in need access to reliable health informa- articles from journals to be most partnering with colleagues and insti- 922

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tutions in low and middle-income 5. Krug EG, Sharma GK, Lozano R. The global Mexico. Inj Control Saf Promot. 2003;10: burden of injuries. Am J Public Health. 2000;90: 45-51. countries to develop and implement 523-6. 23. Murray CJ. Quantifying the burden of strategies to decrease the burden of 6. Norton R, Hyder AA, Bishai D, Peden M. disease: the technical basis for disability-adjusted injury, an exchange of information Unintentional injuries. In: Jamison DT, Breman JG, life years. Bull World Health Organ. 1994;72: Measham AR, Alleyne G, Claeson M, Evans DB, Jha P, 429-45. between and within providers from Mills A, Musgrove P, editors. Disease control 24. Allotey P, Reidpath D, Kouame´ A, Cummins R. resource-challenged environments will priorities in developing countries. 2nd ed. New York, The DALY, context and the determinants of the NY: Oxford University Press; Washington, DC: World also be essential. The time is ripe for severity of disease: an exploratory comparison of Bank; 2006. p 737-54. the orthopaedic fraternity, as well as paraplegia in Australia and Cameroon. Soc Sci Med. 7. Parry E. Essential surgery. Trauma Q. 2003;57:949-58. our colleges, academies, associations, 1999;14:329-33. 25. Anand S, Hanson K. Disability-adjusted life and societies, to take the lead in this 8. Cherian MN, Noel L, Buyanjargal Y, Salik G. years: a critical review. J Health Econ. 1997;16: process. Essential emergency surgical procedures in resource- 685-702. limited facilities: a WHO workshop in Mongolia. World 26. Arnesen T, Kapiriri L. Can the value choices in Hosp Health Serv. 2004;40:24-9. NOTE: The authors thank Stephen Bickler, MD, for his review of DALYs influence global priority-setting? Health Policy. the manuscript. 9. Mock C, Joshipura M, Goosen J, Lormand JD, 2004;70:137-49. Maier R. Strengthening trauma systems globally: the 27. Arnesen T, Nord E. The value of DALY life: Essential Trauma Care Project. J Trauma. problems with ethics and validity of disability 2005;59:1243-6. adjusted life years. BMJ. 1999;319:1423-5. 10. Mock CN, Lormand JD, Goosen J, Joshipura M, 28. Reidpath DD, Allotey PA, Kouame A, Cummins David A. Spiegel, MD Peden M. Guidelines for essential trauma care. RA. Measuring health in a vacuum: examining the John P. Dormans, MD Geneva: World Health Organization; 2004. disability weight of the DALY. Health Policy Plan. www.who.int/violence_injury_prevention/ Division of Orthopaedic Surgery, Children’s 2003;18:351-6. Hospital of Philadelphia, 2nd Floor Wood publications/services/guidelines_traumacare/en/ index.html. 29. WHO annex Table 3: Disability weights. Building, 34th Street and Civic Center http://www.who.int/entity/healthinfo/ 11. Debas HT, Gosselin RA, McCord C, Thind A. Boulevard, Philadelphia, PA 19104. E-mail bodreferencedisabilityweights.xls. Accessed 2008 Surgery. In: Jamison DT, Breman JG, Measham AR, Feb 6. address: [email protected] Alleyne G, Claeson M, Evans DB, Jha P, Mills A, Musgrove P, editors. Disease control priorities in 30. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY Richard A. Gosselin, MD developing countries. 2nd ed. New York, NY: Oxford averted in a small hospital in Sierra Leone: what is the The University of California at Berkeley School University Press; Washington, DC: World Bank; 2006. relative contribution of different services? World J p 1245-60. Surg. 2006;30:505-11. of Public Health, 506 Warren Hall, Berkeley, CA 94720-7360 12. Spiegel DA, Gosselin RA. Surgical services in 31. Wang Z, Jiang J. An overview of research low-income and middle-income countries. Lancet. advances in road traffic trauma in China. Traffic Inj 2007;370:1013-5. Prev. 2003;4:9-16. R. Richard Coughlin, MD 13. World Development Indicators 2006. 32. Suriyawongpaisal P, Kanchanasut S. Road traffic Department of Orthopaedic Surgery, Washington, DC: World Bank; 2006. injuries in Thailand: trends, selected underlying University of California at San Francisco, 1001 determinants and status of intervention. Inj Control 14. Watters DA, Dyke T. Trauma in Papua New Saf Promot. 2003;10:95-104. Potrero Avenue, #3A36, San Francisco, Guinea: what do we know and where do we go? CA 94110 P N G Med J. 1996;39:121-5. 33. United Nations General Assembly. Improving global road safety. Resolution A/RES60/5. Geneva: 15. Kobusingye O, Guwatudde D, Lett R. Injury United Nations; 2005. Manjul Joshipura, MD patterns in rural and urban Uganda. Inj Prev. Academy of Traumatology, A/35, Someshvara 2001;7:46-50. 34. Cole TB. Global road safety crisis remedy sought: 1.2 million killed, 50 million injured annually. JAMA. II, Satellite Road, Ahmedabad 380015 India 16. Moshiro C, Heuch I, Astrøm AN, Setel P, Hemed 2004;291:2531-2. Y, Kvåle G. Injury morbidity in an urban and a rural Bruce D. Browner, MD area in Tanzania: an epidemiological survey. BMC 35. Hyder AA, Peden M. Inequality and road- Public Health. 2005;5:11. traffic injuries: call for action. Lancet. Department of Orthopaedic Surgery, 2003;362:2034-5. University of Connecticut Health Center, 17. Beveridge M, Howard A. The burden of orthopaedic disease in developing countries. J Bone 36. Peden M, Scurfield R, Sleet D, Mohan D, Hyder 10 Talcott Notch Road Farmington, Joint Surg Am. 2004;86:1819-22. AA, Jarawan E, Mathers C, editors. World report on CT 06034-4037 road traffic injury prevention. Geneva: World Health 18. Bickler SW, Sanno-Duanda B. Epidemiology of Organization; 2004. pediatric surgical admissions to a government referral References hospital in the Gambia. Bull World Health Organ. 37. Bishai D, Quresh A, James P, Ghaffar A. National 2000;78:1330-6. road casualties and economic development. Health 1. Murray CJL, Lopez AD, editors. The global Econ. 2006;15:65-81. burden of disease: a comprehensive assessment of 19. Dormans JP, Fisher RC, Pill SG. mortality and disability from diseases, injuries, and Orthopaedics in the developing world: present and 38. Nantulya VM, Reich MR. The neglected epidemic: risk factors in 1990 and projected to 2020. future concerns. J Am Acad Orthop Surg. 2001;9: road traffic injuries in developing countries. BMJ. Cambridge, MA: Harvard School of Public Health; 289-96. 2002;324:1139-41. 1996. 20. Mock CN, Boland E, Acheampong F, Adjei S. 39. Kopits E, Cropper M. Traffic fatalities and 2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Long-term injury related disability in Ghana. Disabil economic growth. Accid Anal Prev. 2005;37: Murray CJL, editors. Global burden of disease and risk Rehabil. 2003;25:732-41. 169-78. factors. New York: Oxford University Press; 21. Mock CN, Adzotor KE, Conklin E, Denno DM, 40. Odero W, Garner P, Zwi A. Road traffic injuries in Washington, DC: World Bank; 2006. Jurkovich GJ. Trauma outcomes in the rural developing countries: a comprehensive review of 3. Mathers CD, Loncar D. Projections of global developing world: comparison with an urban epidemiological studies. Trop Med Int Health. mortality and burden of disease from 2002 to 2030. level I trauma center. J Trauma. 1993;35: 1997;2:445-60. PLoS Med. 2006;3:e442. 518-23. 41. Nantulya VM, Reich MR. Equity dimensions of 4. Peden M, McGee K, Sharma G. The injury chart 22. Mock C, Arreola-Risa C, Quansah R. road traffic injuries in low- and middle-income book: a graphical overview of the global burden of Strengthening care for injured persons in less countries. Inj Control Saf Promot. 2003;10: injuries. Geneva: World Health Organization; 2002. developed countries: a case study of Ghana and 13-20. 923

THE J OURNAL OF B ONE &JOINT S URGERY d JBJS. ORG THE BURDEN OF MUSCULOSKELETAL INJURY IN LOW AND M IDDLE- VOLUME 90-A d N UMBER 4 d A PRIL 2008 INCOME COUNTRIES:CHALLENGES AND OPPORTUNITIES

42. Hyder AA, Ghaffar A. Socioeconomic differences low- and middle-income countries: recommendations in Plateau State, Nigeria. Trop Geogr Med. in road traffic injuries. J Epidemiol Community Health. for action. Bull World Health Organ. 2005;83:626-31. 1986;38:167-71. 2002;56:719. 59. Mock CN, Tiska M, Adu-Ampofo M, Boakye G. 76. Onuminya JE. The role of the traditional 43. Jacobs G, Aaron-Thomas A, Astrop A. Estimating Improvements in prehospital trauma care in an bonesetter in primary fracture care in Nigeria. S Afr global road fatalities. TRL Report 445. London: African country with no formal emergency medical Med J. 2004;94:652-8. Transport Research Laboratory; 2000. services. J Trauma. 2002;53:90-7. 77. Onuminya JE. Performance of a trained 44. Afukaar FK. Speed control in developing 60. Sasser SM, Varghese M, Kellermann A, Lormand traditional bonesetter in primary fracture care. S Afr countries: issues, challenges, and opportunities in JD. Prehospital trauma care systems. Geneva: World Med J. 2006;96:320-2. reducing road traffic injuries. Inj Control Saf Promot. Health Organization; 2005. 78. Blanchard RJ, Blanchard ME, Toussignant P, 2003;10:77-81. 61. Sasser SM, Varghese M, Joshipura M, Kellerman Ahmed M, Smythe CM. The epidemiology and 45. Li G, Baker SP. Injuries to bicyclists in Wuhan, A. Preventing death and disability through the timely spectrum of surgical care in the district hospitals of People’s Republic of China. Am J Public Health. provision of prehospital trauma care. Bull World Pakistan. Am J Public Health. 1987;77:1439-45. 1997;87:1049-52. Health Organ. 2006;84:507. 79. Banerjee JK. Concept and practice of rural 46. Oluwadiya KS, Oginni LM, Olasinde AA, Fadiora 62. Arreola-Risa C, Mock CN, Lojero-Wheatly L, surgery. New Delhi: B.I. Churchill Livingstone; 1993. SO. Motorcycle limb injuries in a developing country. de la Cruz O, Garcia C, Canavati-Ayub F, Jurkovich GJ. 80. Jena TK, Agarwal AK. Surgical training-distance West Afr J Med. 2004;23:42-7. Low-cost improvements in prehospital trauma care education. A training tool for rural surgeons. Indian J 47. Afukaar FK, Antwi P, Ofosu-Amaah S. Pattern of in a Latin American city. J Trauma. 2000;48: Surg. 2003;65:50-4. road traffic injuries in Ghana: implications for control. 119-24. 81. Tongaonkar RR. Scope and limitations of rural Inj Control Saf Promot. 2003;10:69-76. 63. Mock CN, Joshipura M, Goosen J, Maier R. surgery. Indian J Surg. 2003;65:24-9. 48. Mock CN, Adzotor E, Denno D, Conklin E, Rivara Overview of the Essential Trauma Care Project. World 82. Vaz F, Bergstr¨om S, da Luz Vaz M, Langa J, F. Admissions for injury at a rural hospital in Ghana: J Surg. 2006;30:919-29. Bugalho A. Training medical assistants for surgery. implications for prevention in the developing world. 64. Chen L, Evans T, Anand S, Boufford JI, Brown H, Bull World Health Organ. 1999;77:688-91. Am J Public Health. 1995;85:927-31. Chowdhury M, Cueto M, Dare L, Dussault G, Elzinga 83. Lavy CB, Mkandawire N, Harrison WJ. 49. Mohan D. Evidence-based interventions for road G, Fee E, Habte D, Hanvoravongchai P, Jacobs M, Orthopaedic training in developing countries. J Bone traffic injuries in South Asia. J Coll Physicians Surg Kurowski C, Michael S, Pablos-Mendez A, Joint Surg Br. 2005;87:10-1. Pak. 2004;14:746-7. Sewankambo N, Solimano G, Stilwell B, de Waal A, Wibulpolprasert S. Human resources for health: 84. Laloe V. Training programme for general 50. Ameratunga S, Hijar M, Norton R. Road-traffic overcoming the crisis. Lancet. 2004;364:1984-90. practitioners in emergency surgery and obstetrics in injuries: confronting disparities to address a global- Woldya, Ethiopia. Trauma Q. 1999;14:339-44. health problem. Lancet. 2006;367:1533-40. 65. Narasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G, Elzinga G, Nordstrom A, Habte 85. Garrido PI. Training of medical assistants in 51. Ameratunga SN, Norton RN, Bennett DA, Jackson D, Jacobs M, Solimano G, Sewankambo N, Mozambique for surgery in a rural setting. S Afr J Surg. RT. Risk of disability due to car crashes: a review of Wibulpolprasert S, Evans T, Chen L. Responding to 1997;35:144-5. the literature and methodological issues. Injury. the global human resources crisis. Lancet. 2004;35:1116-27. 2004;363:1469-72. 86. Rennie JA. The training of GPs in emergency surgery in Ethiopia. Trauma Q. 1999;14:335-8. 52. Maraste P, Persson U, Berntman M. Long-term 66. World Health Report 2006: working together for follow-up and consequences for severe road traffic health. Geneva: World Health Organization; 2006. 87. Mock CN, Quansah R, Addae-Mensah L, Donkor injuries—treatment costs and health impairment in P. The development of continuing education for trauma Sweden in the 1960s and the 1990s. Health Policy. 67. Bundred PE, Levitt C. Medical migration: who are care in an African nation. Injury. 2005;36:725-32. 2003;66:147-58. the real losers? Lancet. 2000;356:245-6. 88. Lett R. Canadian Network for International 53. Mock C, Ofosu A, Gish O. Utilization of district 68. Dovlo D, Nyonator F. Migration by graduates of Surgery: development activities and strategies. Can J health services by injured persons in a rural area the University of Ghana medical school: a preliminary Surg. 2000;43. of Ghana. Int J Health Plann Manage. 2001; rapid appraisal. Human Resources for Health. 89. Beveridge M, Howard A, Burton K, Holder W. The 16:19-32. 1999;1:42-54. Ptolemy project: a scalable model for delivering health 54. Mock CN, nii-Amon-Kotei D, Maier RV. Low 69. Pang T, Lansang MA, Haines A. Brain drain and information in Africa. BMJ. 2003;327:790-3. Erratum utilization of formal medical services by injured health professionals. BMJ. 2002;324:499-500. in: BMJ. 2003;327:1016. persons in a developing nation: health service data 70. Oyowe A. Brain drain: colossal loss of investment 90. Edejer TT. Disseminating health information in underestimate the importance of trauma. J Trauma. for developing countries. The Courier ACP-EU. developing countries: the role of the internet. BMJ. 1997;42:504-13. 1996;159:59-60. 2000;321:797-800. 55. Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich 71. Wibulpolprasert S, Pengpaibon P. Integrated 91. Kale R. Health information for the developing GJ, Mock CN. Systematic review of published strategies to tackle the inequitable distribution of world. BMJ. 1994;309:939-42. evidence regarding trauma system effectiveness. doctors in Thailand: four decades of experience. Hum J Trauma. 1999;47(3 Suppl):S25-33. Resour Health. 2003;1:12. 92. Godlee F, Horton R, Smith R. Global information flow. Lancet. 2000;356:1129-30. 56. Husum H, Gilbert M, Wisborg T. Training pre- 72. Blanchard RJ, Merrell RC, Geelhoed GW, Ajayi OO, hospital trauma care in low-income countries: the Laub DR, Rodas E. Training to serve unmet surgical 93. Katikireddi SV. HINARI: bridging the global ‘Village University’ experience. Med Teach. needs worldwide. J Am Coll Surg. 2001;193:417-27. information divide. BMJ. 2004;328:1190-3. 2003;25:142-8. 94. Aronson B. Improving online access to medical 73. Watters DA, Bayley AC. Training doctors and 57. Husum H, Gilbert M, Wisborg T, Van Heng Y, information for low-income countries. N Engl J Med. surgeons to meet the surgical needs of Africa. Br Med Murad M. Rural pre-hospital trauma systems improve 2004;350:966-8. J (Clin Res Ed). 1987;295:761-3. trauma outcome in low-income countries: a 95. Page J, Heller RF, Kinlay S, Lim LL, Qian W, prospective study from North Iraq and Cambodia. 74. Bickler SW, Sanno-Duanda B. Bone setter’s Suping Z, Kongpatanakul S, Akhtar M, Khedr S, J Trauma. 2003;54:1188-96. gangrene. J Pediatr Surg. 2000;35:1431-3. Macharia W. Attitudes of developing world physicians 58. Kobusingye OC, Hyder AA, Bishai D, Hicks ER, 75. Oguachuba HN. Mismanagement of elbow joint to where medical research is performed and reported. Mock C, Joshipura M. Emergency medical systems in fractures and dislocations by traditional bone setters BMC Public Health. 2003;3:6.