Surgery in low‐income countries during crisis: experience at Médecins Sans Frontières facilities in 20 countries between 2008 and 2014

Abstract

keywords humanitarian, global surgery, quality improvement, disaster, warThe global burden of trauma and surgical conditions fall disproportionately on low-and middle-income countries (LMICs) [1,2]. Inopportunely, developing countries are least equipped to provide essential surgical care [3]. As a result, LMICs have a significant burden of unmet surgical needs [4]. When these fragile health systems are disrupted by conflict, a natural disaster or an epidemic the capacity for and quality of surgical care decreases even further [5]. In response, M edecins Sans Fronti eres (MSF) provides surgical humanitarian assistance in countries affected by crisis through one of the five operation centres; one of these is Operations Centre Brussels (OCB).Describing the epidemiology of surgical care at MSF-OCB projects improves planning for humanitarian assistance and provides a unique opportunity to examine surgical needs that were otherwise unmet by national healthcare systems [6]. From 2008 through 2014, MSF-OCB performed 119 524 operations at 45 projects in 20 countries. The majority of operations were obstetric (range 28-42% of operations by year), general surgical (e.g. hernias, appendicitis; range 15-49%) and unintentional trauma-related (e.g. road traffic crash, burn; range 10-42%). Violence was also a common cause of surgical need (e.g. land mine or bomb injury, gunshot wound; range 7-15%) (Table 1). MSF-OCB teams provided safe anaesthesia, often by task sharing, in the face of complex care needs evidenced by low perioperative death rates (i.e. death from time of anaesthesia care to discharge from the recovery ward; 0.2-0.3% of operations). From 2008 through 2014, the orthopaedic care capacity was deliberately improved to meet the needs of conflict-related projects (Figure 1). This was done by developing fracture care guidelines for nonorthopaedists, as well as recruiting expatriate orthopaedic surgeons. More detailed operative epidemiology of these sites has been reported previously [6][7][8]. Commitment to quality surgical careMSF-OCB uses data from operational and clinical research at each project to identify opportunities to better the care provided by both national and international staff [9]. Some examples of published quality improvement programmes and lessons learned from the process are listed below:• establishing minimum standards of skill and training required for humanitarian surgery before field missions; [6] • creating management pathways for complex genital fistulas; [10] • strengthening local ambulance services to reduce maternal and neonatal mortality; [11] • monitoring post-operative surgical infection rates in austere contexts; [8] • providing and maintaining minimum resource inputs for humanitarian surgical activities during conflict or disaster; [12] • ensuring safety while relying on surgical and anaesthetic task sharing in Africa. [13] These studies further MSF's mission to improve surgical care despite crisis and build capacity useful long after a conflict or disaster subsidies [14, 15]. Lessons ...

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The Effect of Conflict on Obstetric and Non‐Obstetric Surgical Needs and Operative Mortality in Fragile States

“…Obstetric needs are an important component of surgical burden in all humanitarian settings [19, 22]. In this study, obstetric indications represented one third of operations during non‐conflict and one fifth of operations during conflict periods.…”