Orthopaedic colleagues who live and practice in low-resource areas around the world have clearly voiced that they want support from better-resourced partners. But such efforts must be sustainable, a key point emphasized by Woolley et al. in their thought-provoking 2019 JBJS “What’s Important” essay regarding orthopaedic care in Haiti. In contrast to “medical missions” offering short-term assistance for a small number of patients, longer-term systemwide gains come from partnerships focused on education and training that acknowledge the central role of local orthopaedic practitioners in addressing the ongoing needs of their patients.
Along those lines, Agarwal-Harding et al. describe a 3-phase pathway for improving ankle-fracture management in sub-Saharan Malawi in their recent JBJS report. In the first 2 phases, the local knowledge base and treatment strategies were assessed. (Greater than 90% of orthopaedic trauma care in the country is provided by nonphysician “clinical officers,” and most ankle-fracture management in Malawi is nonoperative because there is only about 1 orthopaedic surgeon per 1.9 million Malawians). A team of Malawian and US faculty then designed and implemented an education course that reviewed ankle anatomy, fracture classification, and evidence-based treatment guidelines. From that arose standardized protocols to improve fracture-care quality and safety in the face of limited resources.
While these protocols were unique to the Malawian context, I am convinced that similar interventions can be adapted for other low-resource environments—as long as local clinicians are part of the process. With such a flexible and sustainable program in place, efforts can then be directed toward the advancement of surgical skills and development of cost-effective supply chains. We should all support such efforts worldwide, recognizing that the burden of musculoskeletal trauma is a public health issue warranting collaborative solutions with lasting impact.
Marc Swiontkowski, MD
Click here for a related OrthoBuzz post about trauma care in Malawi.
Over the past decade and a half, the problem of musculoskeletal trauma has been identified as impacting more individuals in developing countries than HIV, drug-resistant tuberculosis, and other infectious diseases that are commonly recognized as public health crises. The need for access to surgical treatment for patients who sustain traumatic injuries has recently garnered more attention. Yet funding from nongovernmental organizations and other national/international foundations has not reached the levels necessary to appropriately address this important public health issue.
In the May 15, 2019 issue of The Journal, Agarwal-Harding et al. document the issue of patients experiencing delayed access to musculoskeletal trauma care in the sub-Saharan country of Malawi. Thanks to the development of a trauma-care registry serving both rural and urban health centers in Malawi, the authors were able to clarify the factors associated with delayed presentation for care.
Not surprisingly, those factors included distance from treatment centers and sustaining an injury during a weekend. These issues are likely widespread throughout Africa and in many other developing countries, where EMS services are sparse at best and treatment facilities are generally under-resourced. Although an increasing number of people in developing countries are being injured in road/vehicle-related accidents, many of the patients evaluated in this study did not experience high-energy trauma, but were instead injured from falls and during sporting activities. In short, they experienced the types of injuries that are likely to occur to everyday people doing everyday activities anywhere in the world.
The issue of delayed access to care is addressable if we continue to acknowledge the incredible public health burden that musculoskeletal trauma places on individuals and society within the developing world. These injuries not only affect patient quality of life, but they also have large impacts on families and communities due to a loss of income or disability-imposed restrictions on community engagement. Addressing this issue is of great interest to the readers of JBJS, who are volunteering to serve the orthopaedic needs of the developing world in ever-increasing numbers.
Marc Swiontkowski, MD