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Systems: Lessons through managing orthopaedic trauma from catastrophic events

Building the Capacity to Manage Orthopaedic Trauma After a Catastrophe in a Low-Income Country

Furey, Andrew MD, MSc, FRCSC*; Rourke, James MD, M.Sc, CCFP; Larsen, Hans MD

Author Information
Journal of Orthopaedic Trauma: October 2015 - Volume 29 - Issue - p S14-S16
doi: 10.1097/BOT.0000000000000407
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Health care delivery in low- and middle-income countries (LMICs) is challenging and is often compounded when a country is faced with a natural disaster. Natural disasters have affected more than 200 million people per year in the last 10 years, far more than those affected by any armed conflict.1 Although we have witnessed these in developed countries, the reality is that LMICs lack systems and structure to cope with these catastrophes.2 Volunteer surgical teams can assist in the delivery of trauma care, especially in the face of a disaster; however, intermittent surgical and acute care teams represent only a short-term solution and therefore are insufficient. Alternatively, when considering the implementation and practice of orthopaedic trauma care in such an environment, one must consider the initial phase of program development and look further to the future in the development of a resilient program, which is sustainable. This article will discuss developing orthopaedic trauma care capacity in a LMIC after a natural disaster and will describe the specific experiences of a Non-Governmental Organization (NGO) providing orthopaedic trauma care.


Haiti's health indicators published by the World Health Organization (WHO) are alarming3 and Médecins Sans Frontières/Doctors Without Borders has reported that Haiti has a public health crisis.4 The most notable issues contributing to the crisis in Haiti is the insufficiency of numbers of trained medical professionals and the weaknesses in the training programs that exist to bring new medical professionals into the system (ie, 25 doctors per 100,000 people, ranked 155th in the world).5 Despite the larger number of medical students, the graduate level training is often lacking. On January 12, 2010, an earthquake struck Port au Prince. It is estimated that 3.5 million people were initially affected by the earthquake, more than 200,000 people were killed, and approximately 300,000 injured.6,7 The stage was set in a country with limited capacity for response and a major natural disaster which placed high demands on regional and global responses. Haiti represents an appropriate contextual setting to discuss the stages of disaster response and the framework of capacity building. The UN recognize the need to “mobilize and use existing scientific and technical knowledge to mitigate natural disasters, bearing in mind in particular the needs of developing countries.”8


In 1994, Project Medishare for Haiti (PMH) was founded.9 PMH's mission is to create infrastructure and build capacity through programs that are implemented and operated long-term by empowered Haitian citizens. Team Broken Earth (TBE) was founded after the 2010 earthquake with the intention to provide a self-contained multidisciplinary team to provide medical aid and education in a hospital setting.10 In 2011, TBE partnered with Hospital Bernard Mevs (HBM) and PMH with the goal to continue to operate a trauma, critical care, and rehabilitation hospital in Port-au-Prince. The members of TBE are volunteers from various medical disciplines who have deployed to HBM in intermittent teams with each team generally including practicing physicians and residents from a number of relevant disciplines.

Since 2010 multiple teams from across Canada, with 26–30 professionals per team, have travelled and worked in HBM, which is one of the only trauma critical care hospitals in Port au Prince. The current goal of PM and TBE is to train Haitian physicians and allied healthcare professionals in the proper medical procedures for trauma, critical care, and rehabilitation to provide services on par with the WHO critical care standards.3 From the experience of TBE, there have been multiple lessons learnt that highlight both the stages of recovery and problems associated with building capacity.


We have employed a model of capacity building that combines education, communication, relationship development, and infrastructure improvement and is built from tenets proposed by others.11,12 The model is intended to highlight the interdependent nature of the relationship between these critical pillars of healthcare delivery in ultimately building capacity.


Education is a crucial component of any plan to build healthcare capacity and it is one of the key mandates for every TBE team that deploys to Haiti. Team members work closely with local staff to ensure that practical skills are passed on to them through each procedure performed and each element of patient care delivered. Working and learning together is instrumental to the success of the program and results in bidirectional learning; a benefit cherished by the volunteers. To maximize interest for the local physicians and healthcare providers, and ultimately to be effective, education must be aligned with local needs and desires. Teaching skills that are most relevant to the patient population in the facility (in this case Hospital Bernard Mevs) generally helps the teams meet this goal.

There is a severe lack of trained medical professionals in Haiti. There are very few orthopaedic surgeons to care for a population of 10.4 million people.13 While providing a service to the population, volunteers can also provide surgical training and support through direct teaching in the operating room,14 and by teaching courses such as those offered by the International Committee of the Red Cross in areas of war and postconflict areas15 or by serving as faculty for combined service and teaching activities in Haiti.13 In addition, long-term education initiatives are being developed such as, the Orthopaedic Trauma Care Specialist (OTCS) Residency Program.16 Both provision of short-term education and the development of a long-term educational curriculum are important contributions of a volunteer surgical team and will contribute importantly to the overall goal of capacity building.


Sustainable and effective communication between NGOs and local stakeholders in the deployment of humanitarian relief teams is a second important pillar in an effort to build capacity.17 In the situation of a disaster, communications are hampered initially by the effects of the disaster itself; however, in achieving an effective sustainable approach to capacity building, communication between NGOs and other agencies are often hampered by perceived threats and academic pursuit.17 Systems within organizations should overcome the challenges of threats to agencies and academic pursuit18 to reduce redundancies, employ cooperation in the interest of patient care, and make best use of the funding agency's financial contributions.

The United Nations (UN) had been involved in Haiti for years before the 2010 earthquake. As a result, as NGOs arrived they presumed that the UN would have substantial information and data.17 Unfortunately, due to the near complete destruction of the UN's own communications infrastructure in the earthquake there was a void of information resulting in relief agencies needing to collect data from the beginning.17 This highlights the challenges in communication during an early response and the need for NGOs to share resources during a response to communicate effectively. The rapid exchange of relevant information and data between agencies and organizations is of critical importance.18 Some relief databases have been created in an attempt to address this issue, but they have not been met with great success. For example, the UN's established Relief Web has suffered from a lack of submissions from NGOs and academics.18


Relationships with all stakeholders must be developed to achieve the goal of sustainable capacity building.1 This involves integrating with various government departments, private sector investors, independent contractors, health care administrators, university administrators, and national/international support agencies to create a shared framework and responsibility.1 The WHO suggests local stakeholders be provided with leadership roles and planning,19 whereas the UN suggests several guidelines for a new approach, many of which emphasize the importance of capacity building within local communities and governments.1

Our team recognized that relationships and networking were, and are an integral part of resilience. For example, before TBE's first trip to Haiti, a relationship between TBE and HBM/Project Medishare (PM) did not exist. As a result, there was decreased opportunity during that trip for integrating education into the process of clinical care delivery. This recognized weakness resulted in formation of a partnership between PM and TBE to develop an educational program at HBM that would leverage the clinical care programs associated with the visiting healthcare teams. Currently, TBE has seat on the board of directors of PM, facilitating the interactions between the 2 organizations in support of the local community. This model of cooperation, as opposed to competition in the NGO domain is one that undoubtedly improves the level of care and education delivered.


The WHO recognizes the importance of establishing appropriate health facilities in developing countries after a disaster19 because investment in basic infrastructure is an essential component of building capacity in health care. Volunteer trauma teams should be encouraged to create new or improved facilities in partnership with local healthcare providers and institutions. After a disaster, such as an earthquake, there is an immediate collapse of the health system, often times leading to more deaths attributable to the damaged delivery system than to the disaster itself.20

Volunteer trauma teams can create opportunities by engaging local stakeholders in assessing needs and developing plans for new facilities. Ideally facilities should allow for continued delivery of care by local providers in the absence of volunteers. In addition to the immediate medical benefits of improved facilities, engaging local contractors, private sector, and government agencies will further advance cooperation, development of a sense of shared responsibility, and ownership of newer facilities.1

In growing its effectiveness in building Haitian healthcare capacity beyond clinical care delivery and education, TBE has secured funds to expand the physical infrastructure at HBM, including construction of a new hospital building, new campus housing for visiting personnel, and water treatment facilities. Consistent with the goal of leveraging educational and clinical activities to expand relationships and maximize local involvement and ownership, local contractors and personnel were used in the construction of the new hospital facilities which will be locally managed long term.


The lessons of the Haitian earthquake have reinforced the need for stronger systems and structures when supporting local stakeholders and foreign NGOs as they move through the stages of disaster relief. One strategy to reduce the errors and learn from lessons is to use the framework outlined in this manuscript to support efforts to build a sustainable system.


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capacity building; surgery; trauma; low middle income country

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