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History and Development of Trauma Care in the United States

Trunkey, Donald, D.

Section Editor(s): Peltier, Leonard F. MD, PhD

Clinical Orthopaedics and Related Research: May 2000 - Volume 374 - Issue - p 36-46
Section I: Symposium: History of Orthopaedics in North America
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SDC

Until recently the development of systems for trauma care in the United States has been inextricably linked to wars. During the Revolutionary War trauma care was based on European trauma principles particularly those espoused by the Hunter brothers. Surgical procedures were limited mostly to soft tissue injuries and amputations. The American Civil War was remarkable because of the contributions that were made to the development of systems for trauma care. The shear magnitude of casualties required extensive infrastructure to support the surgeons at the battlefield and to care for the wounded. For the first time in an armed conflict, anaesthetics were used on a routine basis. Despite these major contributions, hospital gangrene was a terrible problem and was the cause of many mortalities. World War I and World War II were noteworthy because of the contributions made by surgeons in the use of blood. One of the major lessons of World War II was the reemphasis of how frequently lessons have to be relearned regarding the treatment and care of wounds.

Between the Korean Conflict and the Vietnam War the discovery was made of the tremendous fluid shifts into the cell after severe hemorrhagic shock. As a consequence, the treatment of patients with shock was altered during the Vietnam Conflict, which resulted in better outcomes and less renal failure.

The first trauma centers for civilians were started in the United States in 1966. Since 1988 the number of states with mature trauma systems has expanded from two to 35. During the same period, many studies have documented the efficacy of trauma systems in reducing unnecessary mortality and disability.

Reprint requests to Donald D. Trunkey, MD, Department of Surgery, L223, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.

From Oregon Health Sciences University, Portland, OR.

The current review shows the evolution of trauma care in the United States beginning with the War of Independence. Where possible, the efforts to introduce systems in the delivery of trauma care will be highlighted. Development of trauma care in the United States has mirrored the development of surgery in general. It has benefitted from the introduction of anesthesia, aseptic techniques, antibiotics, and modern technologic advances. However, development of trauma care systems for civilian patients lagged behind the development of surgical care in heart disease and transplantation. In contrast, the delivery of trauma care led all other medical development during twentieth century wars and conflicts. More recently, the development of a trauma system to treat civilians has shown dramatic improvement. Results are not only encouraging but may serve as a model for other surgical tertiary care delivery systems.

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Trauma Care During the Revolutionary War

Leonardo18 has divided American surgery into four parts; the first of which was dominated by Hunterian principles. Most of the surgeons during the Revolutionary War were graduates of Scottish and London schools of medicine. According to Rutkow,33 John Morgan was the first colonial physician to initiate the separation of internal medicine from surgery. Early in his career Morgan served as a surgeon to provincial troops in the Pennsylvania Campaign in the war between the French and the English. He then went abroad to study with William Hunter and later studied in Edinburgh. He also lectured and studied in Paris and presented the methods used by the Hunter brothers. Eventually he became medical director of the Continental Army. Other physicians and surgeons who played a role in the Revolutionary War include John Bard, John Jones, William Shippin, Samuel Bard, William Baynham, and John Warren. Arguably, Bard may have been the first individual to publish a scientific paper on a surgical topic from the American colonies. This was done through an English physician (Fothergill) who published Bard's successful laparotomy to remove a nonviable fetus from a 28-year-old woman.33 Jones, however, authored the first surgical work written by an American and printed in North America. More importantly, he published "Plain, Concise, Practical Remarks on the Treatment of Wounds and Fracture"33 in 1775, which became the guide for surgeons during the Revolutionary War.

Shippin was another physician who studied anatomy in London with Hunter and eventually replaced Morgan as chief physician and medical director of the Continental Army in 1777. Samuel Bard also studied in London and eventually performed an operation on General George Washington for a large abscess involving the thigh. The Warren brothers studied medicine in the United States: Joseph was killed at the Battle of Bunker Hill and John served in the Continental Army as a hospital surgeon from 1775 to 1782. Finally, Benjamin Rush should be mentioned because he signed the Declaration of Independence and later became Surgeon General for the middle department of the Continental Army for 2 years. Trauma care was limited to treatment of patients with minor and moderate soft tissue injuries and amputation was the most extensive operation performed.

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The War of 1812

It is unclear whether surgeons during the War of 1812 adopted any of the principles that were established by Larrey during the Napoleonic Wars. Larrey's concepts of establishing a field hospital as close to the battle line as possible to reduce the time between injury and definitive surgical care and the flying ambulance were noteworthy advances in military trauma surgery. One incident does stand out in the War of 1812: the wounding of Lieutenant Morris during the engagement between the Constitution and the British vessel Guerriere.20 According to his surgeon, Amos A. Evans, Lieutenant Morris "received a musket ball in the abdomen about one inch higher than the umbilicus on the Linea Semicircularis and came out above the superior portion or spinous process of the Os Ilium. Applied simple dressings and warm cataplasms. Bled him and gave S.S. which did not operate. Repeated it and gave enemas until a slight fecal discharge was produced. Strict antiphlegistic treatments. Cooling diluent drinks. Not more pain than might be expected under equal circumstances from a wound of the muscles alone. His stomach retains whatever is given him and the abdomen is not much swelled or painful."10 His notes continue for another 9 days and the patient apparently did well and had some pus draining from the wound. It is unlikely that the small bowel or colon were involved.

Between the War of 1812 and the American Civil War, Samuel D. Gross performed experiments on animals to determine the techniques that could be used to successfully treat patients who presented with stab wounds to the abdomen through which injured bowel eviscerated. He published his experiments in 1843, first as an article in the Western Journal of Medicine and Surgery, and later as a separately published text.23 He advocated exploration of abdominal wounds, but while treating casualties during the Civil War, he was not known to have done what he had advocated 20 years earlier.

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American Civil War

Although Larrey was the first surgeon to introduce systematic principles in care of injured people during war, the American effort during the Civil War on the Union and Confederate sides was remarkable. One of the most remarkable aspects was the effort of the Union to publish the Medical and Surgical History of the War of the Rebellion in six volumes.48 The only other national publications comparable with this were done by the French government in 186548 and the British government in 1854, 1855, and 185648 relating to the Crimean War. Although more soldiers died as a result of medical diseases than of penetrating injury, the overall death rate was staggering. The Union enlistments totaled 2,893,304 soldiers and the Confederacy enlistments were approximately between 1,277,890 and 1,406,180 soldiers. The number of deaths is shown in Table 1. Of the 246,712 wounds resulting from weapons of war that were reported in the medical records, 245,790 were gunshot wounds and 922 were saber and bayonet wounds. The average Union mortality rate from gunshot wounds to the chest was 62% and for soldiers with abdominal wounds the mortality rate was 87%. Much of the organization for the Union effort is credited to Surgeon General William A. Hammond.

TABLE 1

TABLE 1

In one of the first reports of the war, Surgeon General Hammond showed that in a 4-month period (September-December 1862) soldiers with flesh wounds of the upper extremity had a very low mortality rate of 1.2% and soldiers with flesh wounds of the lower extremity had a mortality rate of 2%.44 In contrast, the mortality rate of soldiers with gunshot wounds of the humerus and upper arm was 30.7%; of the forearm, 21.9%; of the femur, 31.7%; and of the leg, 14.4%. Wagensteen and Wagensteen44 state that these results were superior to those results reported for soldiers in the Franco-Prussian War, which was fought several years later. In addition to anesthesia, antiseptics first were used by Union medical officers predating Listerian surgery. There were at least three studies by Union surgeons during the Civil War documenting the effectiveness of antiseptics.44,45,48 As reported by Wagensteen and Wagensteen44 in 1863, a study by Goldsmith showed that bromine reduced wound sepsis mortality to 2.6% in 308 patients with hospital gangrene. A comparable group of 30 patients in whom the antiseptic was not used had a 43.3% mortality rate. Wagensteen and Wagensteen also reported that in 1864, Hackenberg reported to the Surgeon General that turpentine was effective in reducing hospital gangrene.44 In the third study by North in 1863 as reported by Wagensteen and Wagensteen49 60 patients with hospital gangrene had a mortality rate of 6.6%. North used "strong nitric acid." Unfortunately, these antiseptics were not used routinely and hospital gangrene was a major cause of death.

From a systems standpoint, hospitals were organized along Department of Army organization.48 For example, at Gettysburg almost every division had its own hospital grouped according to Army corps. These hospitals were located strategically near creeks to provide much needed water. When there were numerous regimental hospitals in one battle, they banded together to form a brigade hospital. The next level of care was the division hospital, and finally the general hospital. Many general hospitals, such as Carver, Stanton, and Campbell were located in or near Washington, DC. The south had one very large hospital, Chimborazo, located in Richmond.11 James B. McCaw was the medical director. The hospital had 6000 beds and treated 76,000 patients. The hospitals in Richmond included Windsor, which had 5000 beds, and Jackson with 2500 beds. According to the United States Sanitary Commission, Jackson Hospital was considered a model of excellent care.11

There were numerous other accomplishments during the Civil War including treatment of open wounds. According to Wagensteen and Wagensteen45 The Sanitary Commission of the United States Army issued a directive "it is good practice to leave the wounds open to heal by granulation." Another accomplishment was the establishment of an ambulance corps. In September 1862 the Secretary of War, Stanton, directed Surgeon General William A. Hammond to form an ambulance corps. This was done under the guidance of Jonathan Letterman, who was at that time medical director of the Army of Potomac. One of the most important innovations during the Civil War was the introduction of nursing care modeled after that established by Florence Nightingale in the Crimean War.33 The Sanitary Commission was founded in 1861 primarily to assist the government in the care of the troops. The commission provided temporary shelters, clean bedding, wholesome food, and much needed nursing care. A leader in this movement was Clara Barton, who later founded the National Red Cross and the School of Nursing at Bellevue Hospital. In the South, Sally Louise Tompkins maintained the Robertson Hospital in Richmond, VA and was the only woman commissioned a Captain in the Confederate States Army.

The medical problems facing the surgeons of the Confederate States Army and Navy were not unique but were compounded by the lack of supplies and in some instances by poor administration. Similar to the surgeons of the Union Army, the surgeons of the Confederate Army had little or no training or experience in military medicine or surgery. The medical department of the regular Army of the new Confederate States of America was initiated by the provisional congress at Montgomery, AL on February 26, 1861. Unfortunately, the medical officers were indifferent toward the maintenance of surgical records and nothing comparable with the documentation of the Union Army exists. However, there is well-documented data from the organization and administration of the Confederate Medical Department.20 For example, the original measure of the Provisional Congress provided for a medical department of one surgeon general, four surgeons, and six assistant surgeons. The surgeon general would receive an annual salary of $3000; whereas the surgeon's pay ranged from $162 to $200 per month and that of assistant surgeons ranged from $110 to $150 for the same period. Fleet surgeons received an annual stipend of $3500; whereas a surgeon's remuneration for the first 5 years after the date of his commission was set at $2200 or $2000, depending on whether he was on sea duty. As noted above, medical and surgical supplies often were difficult to obtain, particularly after the Union blockade was imposed on British ships bringing in such supplies. In many instances, surgical supplies were obtained when Union troops were captured.

In addition to the hospitals in Richmond, numerous principal hospitals were established in the Confederate states: these included Virginia (39 hospitals), North Carolina (21), South Carolina (12), Georgia (50), Alabama (23), Mississippi (three), Florida (four), and Tennessee (two). There were Naval hospitals in Richmond, Charleston, Wilmington, Savannah, and Mobile. The first surgeon general was David C. DeLeon. He was relieved of duty shortly after appointment and after a 2-week temporary replacement he was replaced by Samuel Preston Moore who served as surgeon general for the duration of the war. Moore had significant problems appointing and maintaining an efficient corps of medical officers. Nevertheless, the surgical results were equal to or better than those results achieved in the Union army, which was far better supplied.

Hospital gangrene was as much a problem in the South as it was in the North. Wards and even entire hospitals were fumigated, but this did little to reduce the gangrene and erysipelas. Patients were given sesquichloride of iron and quinine by mouth. In some instances, wounds were treated with nitric acid, turpentine, alum, nitrate of silver, sulphate and chloride of zinc, tincture of iron, tincture of iodine, yellow wash, and Darby's solution. There was no unified treatment of wounds and the results varied from hospital to hospital. A particular blight on the Confederate Medical System was Andersonville prison, where hospital gangrene was rampant. The prison was established in 1864 to relieve some of the congestion associated with the prisons around the capitol of Richmond. There were only 13 doctors to care for 26,000 prisoners. Unfortunately, as Sherman and Grant began their stranglehold of Richmond and the march through Atlanta, the transportation and supply system deteriorated, which lead to deprivation of food, medical supplies, and adequate housing for the prisoners. Of the 15,987 prisoners who were treated in Andersonville, 11,086 died.

The Union recognized the shortcomings of their organization of hospitals. The regimental hospital was not adequate to care for patients who were sick and injured. Furthermore, as the regiment moved on, they could not take the patients with them and it became necessary to establish independent hospitals that could receive the sick and wounded soldiers after the troops moved. These hospitals became known as general hospitals and were permanent. Furthermore, they provided an echelon of care where patients were evacuated from hospitals near the battle line back to safer areas and to hospitals that could provide additional definitive surgery and rehabilitation.

Between the Civil War and World War I there were very few advances in the development of trauma systems. According to Trunkey,41 the first report of civilian surgeons treating soldiers with gunshot wounds of the abdomen appeared as early as 1889 but represented cases (five patients of whom four survived) from 1881 to 1888. According to Rutcow,33 Nancrede reported three patients at the American Surgical Association meeting in 1887. Two of his patients died. Subsequent studies during the Spanish American War and the Boer War showed fairly abysmal results when surgical treatment of soldiers with abdominal gunshot wounds was done.20,41(Table 2).

TABLE 2

TABLE 2

A major advance in the diagnosis of traumatic wounds was the invention of xray by Roentgen in 1895.44 Before this period, it was common to probe wounds. One reason to probe was to remove the missile if possible. The second reason was to determine the trajectory of the missile and predict what organs were injured. In many instances probing caused more harm. One specific example was the probing of Joshua Chamberlain's wound at the Battle of Petersburg.26 A ramrod from a rifle was used to probe the right hip wound (anterior to the greater trochanter) to locate the bullet that eventually was found posterior to the left acetabulum. How much this contributed to his subsequent would problems is not known. Another example is the assassination of James Garfield. Unquestionably, the probing of his wound contributed to wound sepsis and eventual rupture of his splenic artery aneurysm.

Between the Spanish American War and World War II surgeons in the United States began the foundations of modern trauma systems. In 1912, at a meeting of the American Surgical Association in Montreal, a committee of five was appointed to prepare a statement on the treatment of fractures.34 This led to a standing committee. One year later the American College of Surgeons was founded, and in May 1922, the Board of Regents of the American College of Surgeons started the first Committee on Fractures with Charles Scudder as chairman. This eventually became the Committee on Trauma. Another function begun by the College in 1918 was the Hospital Standardization Program, which evolved into the Joint Commission on Accreditation of Hospitals.39 One function of this Hospital Standardization Program was an embryonic start of a trauma registry with the acquisition of records of patients who were treated for fractures. In 1926 the Board of Industrial Medicine and Traumatic Surgery was formed. Thus, it was the Hospital Standardization Program by the American College of Surgeons, the Fracture Committee appointed by the American College of Surgeons, the availability of patient records from the Hospital Standardization Program, and the new Board of Industrial Medicine and Traumatic Surgery that provided the seeds of a trauma system.

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World War I

Relatively new technologic advances were designed and applied during World War I. Blood transfusions were used relatively extensively and to good advantage. According to Wagensteen and Wagensteen45 open treatment of contaminated wounds with delayed closure was accepted at the Inter-Allied Surgical Conference in March 1917. Motorized ambulances were used to great advantage, although care often was delayed as many as 12 to 24 hours after injury. In this preantibiotic era, patients with wound sepsis primarily were treated with topical agents such as Dakin's solution. A commission was appointed to study shock and resuscitation and from these studies, published his classical work.8 Eight million five hundred thirty eight thousand three hundred fifteen soldiers were killed in action or died of wounds or disease. The United States military force numbered 4,734,991 men. The number of American soldiers who died in battle was 53,402; this was exceeded by the number of deaths from disease, which was 63,114 (Table 3).

TABLE 3

TABLE 3

Between the two world wars, some significant advances were made in the development of trauma care for civilian patients. According to Freeark,15 Böhler formed the first trauma care system for civilians in Austria in 1925. Although initially directed at work related injury, it eventually expanded to include all accidents. Blood banking became routine and Fleming discovered penicillin in 1929.45 Unfortunately, excellent consistent trauma care remained elusive.

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World War II

As with many wars, lessons learned in previous conflicts had to be relearned. For example, it was necessary for Churchill to go to the New York Times before he could convince the War Department to provide blood in operating rooms (North Africa).10 In 1943, it was necessary for Major General Kirk to mandate that all military surgical personnel leave all amputation wounds open.45 Nevertheless, antibiotics made wound infections much less of a problem than in previous conflicts; finally Major General Ogilvie directed that all soldiers with colon injuries required colostomy.27 Transportation of the wounded soldiers from battalion aid stations to definitive care facilities was reduced to 4 to 6 hours with a subsequent reduction in mortality. Inadequately treated shock was still a problem and contributed to a high incidence of acute renal failure with attendant high mortality.43

After World War II a serious attempt was made by the American Board of Surgery to form a new Board of Traumatic Surgery.32 This was mentioned in 1952, 2 years after the start of the Korean Conflict, and was considered at two subsequent meetings before it was abandoned.

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Korean Conflict

Several advances in trauma system concepts were developed during the Korean Conflict. The introduction of air ambulances including helicopters reduced the time from injury to definitive surgical care to between 2 and 4 hours. Forward surgical hospitals (Mobile Army Surgical Hospital units) were introduced, which also reduced the time from injury to definitive surgical care. Vascular injuries were repaired, which reduced the number of amputations. Blood was used extensively, but unfortunately shock still remained a problem as did acute renal failure and the resulting high mortality.43

Between the Korean Conflict and the Vietnam Conflict, many developments occurred that impacted heavily on the development of trauma care systems. The importance of ambulance services was addressed in a Scudder Oration by George Curry in 1958.12 Pioneer work by Moyer and Butcher22 and Champion et al8 led to the recognition that patients in shock lost more extravascular fluid into the intracellular space, explaining the high incidence of renal failure when not treated. This also confirmed the observations by Cannon during World War I.8

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Vietnam Conflict

The extensive use of helicopters in the Vietnam Conflict reduced the time from injury to definitive surgical care to less than 1 hour. According to Trunkey,43 by applying the resuscitation principles established by Shires, renal failure became an uncommon problem, but a new syndrome, Da Nang lung, became apparent. This reflected a misunderstanding of some of the principles espoused by Starling before World War I. Specifically, although crystalloid resuscitation was beneficial, overuse contributed to the shock insult to the lung and reperfusion injury (Table 4).

TABLE 4

TABLE 4

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Modern Era

The lessons learned in military conflicts of the twentieth century were applied to trauma care of civilians. However, the evolution of trauma care systems for civilians was accelerated in 1966, with the establishment of two trauma centers. One of these trauma centers was started at San Francisco General Hospital under the leadership of William Blaisdell and the other was started at Cook County Hospital in Chicago under the leadership of Robert Freeark. The rationale for these two trauma centers was multiple. According to Starr,40 Titles 18 and 19 (Medicare and Medicaid) just had been introduced, and the old city and county hospitals were essentially without patients. At the same time, urban violence was on the rise, primarily as a consequence of the increase in urban ghettos and an increase in drug related violence. The leaders of these two trauma centers recognized the need for a systematic approach to trauma care and the concept of a trauma center was pivotal to this overall need.

Shortly after these two centers were started, the political and administrative genius of R. Adams Cowley were combined when he established the Maryland system of trauma care, which eventually became a statewide system.47 Seven years later in 1976, the American College of Surgeons Committee on Trauma developed a formal outline of injury care called Optimal Criteria for Care of the Injured Patient.2 Subsequently, task forces of American College of Surgeons Committee on Trauma met approximately every 4 years and updated their optimal criteria, which now are used extensively in establishing regional and state trauma systems. More recently, the American College of Surgeons Committee on Trauma working with the American College of Emergency Physicians, has developed some new guidelines for trauma care systems.5 Under the new model, the system of trauma care is inclusive rather than exclusive. In the old system, only patients who were injured severely were treated at a trauma center. Under the new system, all patients, including those with moderate and minor injuries, are part of the model trauma care plan. The model trauma care system cares for patients whether they are in an urban or a rural setting and the providers have been expanded to include teams and system management and prehospital care, trauma care facilities, and rehabilitation services. The components of this system include leadership; system development; legislation; finance; public information, education, and prevention; human resources; prehospital care with the subcomponents of communication; medical direction; triage and transport; definitive care, including the subcomponents of trauma facilities, interfacility transfer, and rehabilitation; and finally a quality improvement program that evaluates all of these components. Other contributions by the American College of Surgeons Committee on Trauma include introduction of the Advanced Trauma Life Support courses, establishment of a national trauma registry (National Trauma Data Bank), and a national verification program. The latter is analogous to the old Hospital Standardization Program and verifies whether a hospital's trauma center meets the guidelines of the American College of Surgeons.

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How Are We Doing?

Since 1984, more than 15 articles have been published showing that trauma systems benefit society by increasing the chances of survival when patients are treated in specialized centers.1,6,7,14,16-18,24,30,31,35-38,46 In addition, two studies have shown that trauma systems also reduce trauma morbidity.21,30 In 1988, a report card was issued on the current status and future challenges of trauma systems.19 At that time an inventory was taken of all directors of state emergency medical services or directors of health departments who have responsibility over emergency and trauma planning. They were contacted by telephone in February 1987 and were asked eight specific questions on their state trauma system. Of the eight criteria, only two states, Maryland and Virginia, had all eight essential components of a regional trauma system. Nineteen states and Washington, DC, either had incomplete statewide coverage or lacked essential components. Not limiting the number of trauma centers in a region was the most common deficient criterion.

In 1995, another report card was issued in the Journal of the American Medical Association.4 This report card was an update on the progress and development of trauma systems since the 1988 report. It was a more sophisticated approach; it expanded the eight original trauma criteria and was more comprehensive. According to the 1995 report, five states (Florida, Maryland, Nevada, New York, and Oregon) had all the components necessary for a statewide system. Virginia no longer limited the number of designated trauma centers. An additional 15 states and Washington, DC had most of the components of a trauma system.

More recently, Bazzoli has upgraded her 1995 report card at the Salishan Conference in 1998.3 There now are 35 states that are actively engaged in meeting trauma system criteria. Many of these states have implemented their systems through Federal support of the Trauma Care Systems Planning and Development Act (Public Law 101-590).29 Although there has been constant growth and development of statewide trauma systems, there still are underserved areas in the United States, particularly in the rural areas. This is unfortunate because one study has shown conclusively that a statewide trauma center makes a major difference in trauma outcome in rural areas once a trauma system has been established.24 Efforts also are underway to integrate military surgical training programs into the civilian trauma systems so that surgeons can maintain their skills in trauma care as the need arises.42 Recent events in Bosnia and Croatia, and more recently in Kosovo, show that these ethnic, sectarian, and religious conflicts will continue. The civilian community owes a great deal to the military for many of the concepts important to a trauma system. It now is time for the civilian sector to repay its debt and provide ongoing training and possibly even support for these predictable military events.

Trauma system development in the United States started at the time of the Revolutionary War. We have learned a great deal from every military event the United States has been involved with. Concepts and ideas also have been borrowed from other countries including Austria and Germany. The optimal trauma system has yet to be developed including those in the United States, and how the optimal trauma surgeon should be trained must be defined. The trauma system must be expanded to cover all geographic areas. Finally, prevention programs that could reduce mortality and morbidity in a far more effective way than care and rehabilitation must also be expanded.

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