Understanding and Addressing the Global Need for Orthopaedic Trauma Care

Agarwal-Harding, Kiran J. MD; von Keudell, Arvind MD; Zirkle, Lewis G. MD; Meara, John G. MD, DMD, MBA; Dyer, George S.M. MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.00323
Current Concepts Review
Abstract

The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.

Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.

The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.

Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.

Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.

Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics.

Author Information

1Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, Massachusetts

2SIGN Fracture Care International, Richland, Washington

3Program in Global Surgery and Social Change, Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts

4Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

E-mail address for K.J. Agarwal-Harding: kagarwal-harding@partners.org

E-mail address for G.S.M. Dyer: gdyer@partners.org

Article Outline
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Global Health and Orthopaedic Trauma

Definition of Global Health and Its Relation to Orthopaedic Trauma

Global health is a field that has grown dramatically in scope and popularity. Once focused on infectious diseases, global health today is the study, research, and practice of improving and achieving worldwide equity in health1. Health equity addresses not only disparities in disease burden and access to care but also the underlying socioeconomic, demographic, and geographic power dynamics that give rise to these disparities2. Inequity in health and the ongoing plight of the world’s poor is perhaps most visible during humanitarian crises, such as the recent earthquakes in Haiti and Nepal, and the ongoing violent conflicts in Iraq and Syria, which overwhelm an already strained capacity in many countries to manage high volumes of predominantly traumatic injuries3-9. But in reality, this just scratches the surface of the true worldwide trauma epidemic, with many injuries and deaths occurring daily from common causes like road traffic collisions.

Trauma kills more people worldwide than HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome), malaria, and tuberculosis combined (Fig. 1-A)10-13 and disproportionately affects low and middle income countries (LMICs) (Table I) as well as the young who constitute the backbone of any country’s workforce14,15. For every death, many more individuals live with trauma-related disability, contributing to a vicious cycle of poverty because of associated health-care costs and decreased productivity, with global repercussions16-18. An estimated $7.9 trillion of cumulative gross domestic product will be lost worldwide over the next 15 years from decreased economic productivity due to injury, with losses often 50% greater in LMICs than in high income countries (HICs)19. If all-cause injury mortality in LMICs was reduced to the level seen in HICs, >2 million lives, 50 million disability-adjusted life-years (DALYs), and $786 billion could be saved annually15. Addressing worldwide disparities in injury burden and access to care is essential for achieving health equity. In this article, we explore the role that orthopaedic trauma care can play in achieving health equity, as well as innovative means of building manpower and reducing costs to someday make quality orthopaedic care accessible for all.

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Road Traffic Collisions

A quarter of all injuries are caused by road traffic collisions—the eighth leading cause of mortality and the sixteenth leading cause of disability worldwide20-22. Halving the number of global deaths and injuries from road traffic collisions by 2020 has been identified by the United Nations as a Sustainable Development Goal23. However, road traffic injuries are still on the rise, particularly in LMICs, where traffic regulations and infrastructure development have not kept up with the increasing number of vehicles on the road24-26. Many road safety regulations, infrastructure developments, and education programs could cost-effectively avert a substantial number of fatalities in LMICs27-29. However, financial and political barriers to the implementation and monitoring of these interventions remain for many governments29,30.

Injury-related disability is largely preventable through injury prevention and quality surgical care25. Most road injuries are musculoskeletal in nature31, and several studies have shown the heavy burden of musculoskeletal injuries in LMICs32-34. Femoral shaft fractures from road traffic collisions occur at an estimated annual incidence of 2.9 million worldwide (Fig. 1-B), with rates in LMICs double those in HICs35. Although more research is needed on the epidemiology, economics, and disparities of trauma, there is a clear need worldwide for orthopaedic surgeons to advocate for and address the global burden of musculoskeletal injuries, particularly those sustained on the road.

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Access to Orthopaedic Trauma Care

In 2015, the 68th World Health Assembly passed Resolution A 68/15 calling for strengthening of emergency and essential surgical care and anesthesia worldwide as a key component of universal health coverage36. Fewer than 7% of surgeries worldwide are performed in poor health expenditure countries37. Taking into consideration surgical capacity, safety, timeliness, and affordability of care, quality surgery remains inaccessible for 5 billion people worldwide, including 90% of people living in LMICs (Fig. 2)38. Health systems in many LMICs struggle to provide adequate prehospital care, treatment, and rehabilitation of the injured39. In many LMICs, orthopaedic surgical care is deficient at all tiers of the health system, but especially at the rural and district hospital level40,41. Compared with HICs, LMICs have substantially fewer operating rooms, a fraction of the surgeons per capita (Fig. 3), and far fewer essential resources to perform safe surgery32,42-45. These represent “supply-side” limitations that have been well documented in LMICs40,41,46-48.

“Demand-side” limitations, including long travel distances, poor road and safe-transportation infrastructure, fear of surgery and anesthesia, lack of information, cultural barriers, corruption in the health sector, and inaccessibly high costs of care, also pose considerable challenges with little evidence on ways to reduce them39,46,49-52. Approximately 3.7 billion people live at risk of catastrophic health-care expenditures from surgery, with 81.3 million people driven to financial catastrophe annually as a result of the costs of surgery and associated nonmedical costs53. The high burden of injury, crippling economic consequences of disability, and substantial barriers to care fall most heavily on the world’s rural and poor communities38,54.

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The Role Orthopaedic Surgeons Can Play

There is a worldwide need for orthopaedic surgeons to lend their expertise and skills to address disparities in orthopaedic trauma care. Orthopaedic surgeons can and should play a pivotal role in preventing musculoskeletal injury, including training first responders, participating in public awareness outreach, and even engaging in public interest litigation to catalyze government action55. In resource-limited environments where surgery is currently out of reach, training in nonsurgical skills, such as closed reductions, skeletal traction, and wound toilet for open fracture, is essential39. In the case of femoral shaft fracture, skeletal traction has shown modest success, although with complication rates and prolonged treatment that would be otherwise unacceptable if safe surgery were available56-58. Intramedullary nailing of a femoral fracture is a clinically and cost-effective treatment option, with high rates of union and low infection rates comparable with those in the U.S17,59-61.

The Lancet Commission on Global Surgery has identified treatment of open fracture as 1 of its 3 Bellwether Procedures—key interventions that serve as a proxy in evaluating the capacity of a health-care delivery platform to treat a broad range of essential surgical conditions45. In Malawi, open fractures have been successfully treated using standardized protocols from HICs, including sequential debridements, primary external fixation, and early use of local muscle or fasciocutaneous flaps. Despite delayed presentation and higher rates of wound complications, 80% of patients regained limb function62. Further investigation is needed into how orthopaedic surgeries can be safely and effectively delivered in resource-poor settings. However, with the right resources and manpower, outcomes in LMICs should be equivalent to expected outcomes in HICs.

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Essential Orthopaedic Trauma Care

The World Health Organization (WHO) has advocated for universal access to “essential” surgeries, which address large disease burdens, are highly successful treatments, and are cost-effective63. Cost-effectiveness of trauma surgery has been demonstrated by studies in several LMICs64-66. Orthopaedic mission trips, both elective and for disaster relief, also seem cost-effective compared with other important global health interventions66-68 (Fig. 4). While we must further explore cost-effectiveness and affordable methods of delivering care, existing evidence suggests that much of the arsenal of orthopaedic trauma care is essential and must be considered a priority in global health systems development.

The field of global orthopaedic surgery aims to understand and address the burden of musculoskeletal disease and to develop solutions to achieve musculoskeletal health equity. In the following sections, we explore developments that show promise in improving access to quality orthopaedic trauma care, and we believe that such innovations can make orthopaedic care safer and more cost-effective in resource-rich and poor settings alike.

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Building Manpower

Many have answered the call to provide surgical services in resource-poor settings. In addition to public hospitals funded by local governments and private clinics or hospitals run by local surgeons, a tremendous variety of international organizations participate in providing orthopaedic care, including private for-profit organizations, nongovernmental nonprofit organizations, and private volunteer organizations69. Each participant in this health-care ecosystem brings a different agenda and approach, focusing on service, education, and capacity-building to variable extents. There is also high variability in the efficacy with which orthopaedic care is delivered to the poor.

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The Limitations of a Service-Focused Agenda

Volunteer surgical missions are a common means for orthopaedic surgeons from HICs to participate in the care of patients in LMICs, and can be valuable when surgical expertise is otherwise inaccessible70,71. Typically, surgeons and support staff from resource-rich settings visit a resource-poor hospital for 1 to 2 weeks, bringing the majority of their supplies and providing care free of charge72. While laudable in theory, the donation of expertise, time, and resources can be extremely problematic in practice. Surgical missions run the risk of further burdening local providers with expired supplies, failing and irreparable medical equipment, and incompletely treated patients72. Postoperative follow-up is often left to local partners; outcomes are difficult to track and are typically worse than for patients treated in the visiting surgeons’ home institutions, worsening with increasing complexity of the operations performed. In response, visiting surgeons are pushed to perform a few reliably effective surgeries, not necessarily addressing the greatest needs of the patients being served71.

When substandard care is delivered, with inadequate follow-up and little educational benefit to the local staff, surgical missions squander funds better used for sustainable health-care system strengthening73. Without local integration, surgical missions can disrupt local health-care economies, providing free services that unintentionally undermine local surgeons who depend on payments to maintain their practices. Dependence on external assistance reduces access in the long term, as patients seek free care while local surgeons leave for areas without visiting volunteer competitors74.

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The Importance of a Capacity-Building Agenda

Integrating with local care-delivery systems, surgical missions can nurture capacity-building to affect sustainable change75. This relies on identifying and supporting local champions who can continue to operate, train, and care for patients long after visiting surgeons have returned home76. For example, Orthopaedics Overseas has for more than 50 years partnered with Mulago Hospital and Makerere University in Uganda, coordinating efforts to train local staff, build functioning operating rooms, provide outreach to rural communities, and supply a steady stream of short and long-term volunteers77. Visiting surgeons must balance a desire to operate as much as possible with the need to train local providers to end dependence on foreign assistance. Education offers the most valuable and durable gift a mission can provide, helping host surgeons learn new techniques and teach others, further disseminating knowledge and best practices78,79.

With sustainable development in mind, mission trips can foster mutually beneficial institutional partnerships. Partnerships between residency programs in LMICs and HICs have involved resident exchanges, frequent visits by attending surgeons for direct training and support of local staff, and monetary support of LMICs’ programs80. The partnership between the University of California, San Francisco, and Muhimbili Orthopaedic Institute in Dar-es-Salaam, Tanzania, has led to clinical observerships, conferences, and research projects focused on outcomes and quality improvement81. Partnerships like this, fueled by well-planned surgical missions, increase communication and collaboration between orthopaedic surgeons in LMICs and HICs, and may also aid in retention of local staff, avoiding the “brain drain” of skilled health-care workers toward resource-rich settings. Practicing in a high-volume, low-resource setting can be isolating and demoralizing, and professional considerations, rather than socioeconomic factors, are often more influential on the decision to migrate82. Institutional partnerships can give voice and support to surgeons, allowing for meaningful and fruitful participation in orthopaedic research, advanced training, and innovation.

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The Role of Nonphysician Clinicians

Countries and regions must develop systems of managing orthopaedic trauma that are unique to the needs and circumstances of the patients they serve. In many LMICs, there is an important role not only for orthopaedic surgeons, but also nonorthopaedic physicians and nonphysician clinicians83,84. Nonphysician clinicians play a key role in delivering surgical care in most countries in sub-Saharan Africa, particularly to rural populations85,86. Those providing emergency obstetric care have demonstrated patient outcomes equivalent to those of medical doctors87, suggesting the same could be true in orthopaedics. In Uganda, some 200 nonphysician orthopaedic officers in district, regional, and national referral hospitals manage the majority of musculoskeletal injuries88. Orthopaedic clinical officers in rural settings in Malawi manage >80% of the orthopaedic workload, specializing primarily in conservative management of common traumatic injuries89,90. Nonphysician clinicians will play an important part in scaling up orthopaedic trauma care worldwide91,92. Regulation, supervision, continued education, and integration into a broader referral network are critical to ensure a high quality of care.

Traditional and indigenous healers provide a largely overlooked and misunderstood resource in many Asian, African, and South American nations, playing a key role in the health care of many83,93,94. In South Asia, the traditional practice of Ayurveda, dating back to 3000 BCE, includes surgical practices still used today95. In sub-Saharan Africa, traditional bonesetters use techniques passed down through generations, while others have adopted Western medical techniques albeit outside formal Western medical training96. Patients may seek an orthopaedic surgeon only after experiencing a complication, resulting in the condemnation of bonesetters’ practices by some orthopaedic surgeons97,98. Traditional bonesetters are often the only option for patients, but are even preferentially sought out as a cheap, acceptable, and accessible alternative to Western orthopaedic care99,100. Recognizing the important role of traditional healers in caring for underserved communities, others have advocated for increased collaboration between orthopaedic surgeons and bonesetters100, with improved performance after basic orthopaedic training96.

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Technology and Education

Technological innovations may provide effective solutions for reliably training and supervising nonphysician clinicians and orthopaedic surgeons alike. Telemedicine has been effectively used to extend the reach of trained orthopaedic surgeons, for confidential peer-to-peer communication, clinical outreach, remote supervision or observation in the operating room, and outpatient consultation101,102. Simulation, video, online surgical demonstrations, and case discussions may someday make quality orthopaedic knowledge universally accessible103,104. Online platforms can allow practitioners from many organizations, countries, and backgrounds to share experiences and ideas. Surgeons from LMICs may learn a great deal from the contextually relevant knowledge and experiences of their counterparts in other resource-poor settings. Surgeons from HICs certainly have much to contribute, but may also benefit greatly from the perspectives, low-cost innovations, and ingenuity of surgeons in many LMICs81.

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Innovations to Reduce the Cost of Care

Education, collaboration, and innovation are closely linked, and we must experiment to find new ways to cut costs, deliver high-quality care, and increase accessibility to limited resources. A culture of innovation could stimulate entrepreneurship, technological and organizational development, sustainability, and eventual profitability.

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Medical Supply Systems

Affordable care requires new low-cost technologies. In many LMICs, particularly in sub-Saharan Africa, most medical supplies are imported, costly, and designed without application to the resource-poor setting in mind93. Stanford India Biodesign, a collaboration between Stanford University and the All India Institute of Medical Sciences (AIIMS)105, applies design thinking and innovation to develop low-cost medical devices in India106. Relligo, a low-cost splint for temporary lower-extremity immobilization, is manufactured in India, widely available through the country, and one-fifth the cost of other commonly used splints107. A culture of innovation should be prioritized in other LMICs, and supported through collaborations and investment, to create low-cost technological innovations in orthopaedics specific to the unique circumstances for which they are designed.

Inspired by difficulties of fracture management in resource-poor hospitals, SIGN (Surgical Implant Generation Network) Fracture Care International designs and manufactures an intramedullary nail with distal interlocking screws that can be placed with a long target arm and hand-powered reamers, obviating the need for intraoperative radiographs or electricity108. The SIGN model is to provide education to local surgeons about fracture care and donate instruments and implants to treat the poor. The SIGN surgical online database is used to report, discuss, and evaluate surgeries, with 43% follow-up last year. The SIGN nail has been used to treat >177,000 long-bone fractures worldwide, with demonstrated cost-effectiveness, low complication rates, and good outcomes17,61,109,110. The SIGN nail may also be valuable in HICs, where it could reduce costs and facilitate task-shifting of fracture care to community health centers81. The SIGN nail is an example of a technology designed specifically for a resource-poor context, but with much broader applicability and potential to improve orthopaedic care globally. We believe innovations in low-cost technologies coupled with local manufacturing could substantially improve access to care worldwide and boost economies in LMICs.

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The Emerging Role of the Private Sector

In many LMICs, despite substantial investment in health-care development, governments struggle to provide essential care to their citizens. In sub-Saharan Africa, $30 billion in new investment over the next decade is required to meet the region’s health-care needs, two-thirds likely coming from the private sector, which already captures >50% of the health-care market93. Private health-care and public-private partnerships will be increasingly valuable options93,111.

In India, Aravind Eye Care System and Narayana Health are private health-care providers that utilize innovative business models to drive down costs and provide high-quality surgical care to the poor for ophthalmologic and cardiac surgery, respectively. Both use cross-subsidization, where patients who cannot pay for care are supported by profits generated from patients paying the market rate, and additional profits earned by charging for personal amenities. Government partnership further subsidizes care for the most impoverished patients. Both organizations use high volume and low cost to maintain profitable margins, engaging in constant process improvement to provide highly standardized care that reduces waste and maximizes the productivity of staff and resources. To build volume, outreach is conducted to identify and facilitate care for patients who can benefit from surgery112,113. Cross-subsidization is highly scalable—by increasing the number of wealthy patients treated, revenue margins increase rapidly. This model has also been applied in several sub-Saharan African countries, often with additional support from donors and governments93.

Some LMICs are able to attract wealthier patients from HICs. In 2007, an estimated 750,000 Americans sought offshore medical care in countries like India, where prices can be 10% of those in the U.S. Some insurance companies and corporations in the U.S. encourage this so-called “medical tourism” to rein in health-care costs, and orthopaedic care is one of the most commonly sought services114. Medical tourism can unfortunately lure highly skilled physicians away from public hospitals to private facilities catering to foreign patients paying out-of-pocket115,116. However, revenue generated from medical tourists could be used to support health-system development, training, and retention of physicians in LMICs115. In the near future, orthopaedic specialty hospitals in LMICs may benefit from integration of medical tourism with a cross-subsidization model, where high-quality care attracts an international clientele whose fees for elective surgeries cross-subsidize the care of poorer patients. In the right political and economic environment, regions with a high burden of musculoskeletal disease could especially benefit from profitable high-volume low-cost specialized surgical centers.

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No One Size Fits All

Systems for the delivery of orthopaedic trauma care will have to be as diverse as the populations they aim to serve. From building manpower to cost-cutting innovations, each intervention must be made in the context of a country’s cultural, socioeconomic, political, demographic, and epidemiological environment. Some of the world’s emerging economies may have the resources and size to develop high-volume orthopaedic surgical centers that could draw an international clientele and subsidize care and outreach to the poor. Other countries may benefit instead from investing in training nonphysician clinicians and funding district hospitals that care for the rural poor. Regardless of context, however, horizontal integration of health services is critical. Governments and their ministries of health play the vital role of allocating resources for health-care delivery, setting health standards and guidelines, raising public awareness, and reimbursing health facilities for the care of the poor117. Governments must regulate the private sector, device and pharmaceutical companies, and international organizations so that efforts are coordinated and quality care is delivered39.

Despite the great diversity of needs and solutions, there are basic principles of sustainable development of orthopaedic trauma care that are universal. First, equity of orthopaedic care must be studied to understand existing disparities as well as their root causes in order to better devise solutions. Second, collaboration and coordination should be fostered at every level of orthopaedic care delivery—between health-care practitioners of different backgrounds, organizations with different approaches, and countries with different economies and challenges. Third, innovation is key, and we must nurture creativity, rigorously test new ideas, and invest in new innovations with potential to have global applications. The development of global orthopaedic care will require financial investment, participation, research, education, advocacy, innovation, and entrepreneurship. We encourage orthopaedic surgeons to recognize the critical importance of practicing, teaching, and conducting research with the goal of addressing the burden and access to quality care of traumatic injuries worldwide.

Investigation performed at the Massachusetts General Hospital, Boston, Massachusetts

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work.

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