Abstract
The world’s most fragile states contain 38% of the world’s population and are among the world’s poorest. In these states up to 10% of all deaths and 20% of deaths among young adults may be attributed to untreated surgical disease, and over 500 000 women die each year during childbirth. International aid organizations have a presence in fragile states notably the International Committee of the Red Cross (ICRC). The potential for long-term field missions to address disparities in access to acute trauma, surgical, and obstetric care is not to be underestimated. Every opportunity for training and support of local health care staff is to be valued. The success of long-term deployments rests on sound planning before the implementation of programs and honest appraisal of ongoing programs.
Extending Deployments
Emergency humanitarian assistance and long-term deployment would, at first glance, appear to be contradictory concepts in emergency medical response. However, in armed conflict and/or in low-income countries, extending the provision of emergency care into the long term may become an unavoidable necessity and logical consequence of the context. Poverty, inequality, and a lack of functioning political structures typically result in inadequate health infrastructure, poor health indices, and a lack of public and social services[1,2]. This may lead to political instability, conflict, the further destruction of health and social infrastructure, halted or reversed economic development[3], inadequate disaster preparedness, and poor disaster response – completing the vicious circle of the underprivileged. Quoting Didier Cherpitel, as head of the Federation of the Red Cross and Crescent Societies: “Disaster seeks out the poor and ensure they stay poor[4].” Long-term deployments, therefore, are not simply a protracted response to a single emergency, but must serve to build capacity in environments with longstanding deficiencies in health provision or where existing health structures have been decimated by war or disaster. Thus, depending on the context, deployments may substitute or support existing institutions initially, but as far as possible, and as the deployment progresses, long-term deployments should support local health-care services and assist the development of local expertise. Working relationships with local partners and existing ministries of health take on an enduring importance.
Chronic Emergencies
While disaster is usually characterized by a sudden onset and a slow, but constant recovery phase, armed conflict often has a protracted beginning, followed by a steady increase in medical need, which is paired with a progressive deterioration of infrastructure and health care resources[5,6]. Medical teams embarking on mission in areas where there is armed conflict should be prepared for long-term deployment in a constantly changing environment. Equally, after disaster in low-income countries, medical needs are usually insufficiently met by local stakeholders, even when the acute phase is over. A field hospital deployed to help trauma patients after an earthquake will quickly become a care provider for patients with other emergencies, including patients in need of cesarean section, patients injured in road traffic crashes, and those presenting with acute abdominal conditions[7]. Field hospitals will also need to address the chronic health needs of populations to whom regular follow-up and medication is no longer accessible, with surgical centers taking on patients with complications of chronic medical conditions. Patients who received initial lifesaving surgery will require longer-term treatment plans for reconstructive surgery and rehabilitation. With time, the number of patients with disaster-related injuries will decrease while the nondisaster-related emergencies will increase.
The term “chronic emergency” was coined to reflect this and similar situations. As outlined in Office for the Coordination of Humanitarian Affairs’ (OCHA) brief on slow-onset emergencies[8]:
There is a widespread recognition that the nature of humanitarian emergencies is changing. Although catastrophic, sudden-onset events like tropical storms, earthquakes and tsunamis will continue to happen, and will require rapid and well-coordinated humanitarian interventions, many more humanitarian crises emerge over time based on a combination of complex and interrelated circumstances. A slow-onset emergency is defined as one that does not emerge from a single, distinct event but one that emerges gradually over time, often based on a confluence of different events … Human suffering, when measured by the most agreed indicators such as acute malnutrition (wasting) or excess mortality is often higher in situations of chronic vulnerability than in situations in which there is a clear trigger for humanitarian action.
The Changing Emphasis of an Extended Mission
In chronic emergencies it becomes difficult for an emergency medical team (EMT) to define the time point at which to end the emergency mission. Once the decision has been made to extend the deployment beyond the acute phase, attention should turn to the training of local staff and other measures to increase sustainability, which may include the development of working partnerships with local health-care and rehabilitation providers, expanding the roles of local staff, and increasing the capacity of local health services through long-term investment in the development of health-care infrastructure. Emphasis, therefore, turns to long-term planning and development.
Nevertheless, long-term deployment must have defined goals and an end date. Handing over the delivery of health-care services should be built into the planning of long-term deployments from the outset. Positions initially covered by international staff should be increasingly handed over to trained local staff, in preparation for a smooth transition phase, which will eventually lead to the handover of the project. Knowledge and skills should be passed on, together with equipment and hospital infrastructure, to maintain the continuity of medical care after the international team leaves.
Even with the best planning and intent, successful transition and continuity of care may not be guaranteed. Electricity, water, and rent payments must be continued. The retention of medical, administrative, and maintenance staff will depend not simply on the regular payment of salaries at the same level but on working conditions and security. Although these aspects go well beyond the sphere of influence of intervening teams and their organizations, they should be taken into consideration when planning a long-term deployment.
Dilemmas in Long-Term Deployments
Medical teams on long-term deployments face difficult choices from the outset. According to context and needs, admission criteria may be exclusive or inclusive, but they need to be defined from the very beginning because they determine the requirements for staff, equipment, and infrastructure. Although this is essential to the planning, running, and eventual withdrawal from a project, the exclusion of patients with particular conditions will spark ethical discussion within the team. Admission criteria may be difficult to adhere to. Limiting the admission criteria to disaster or war-wounded patients only is ethically and practically difficult to realize. Even the limitation of admissions to emergency cases only will eventually transform a field hospital into a district hospital, as disaster-related emergencies decrease and nondisaster-related emergencies increase over time. Limitations in primary care mean that the majority of patients seen are emergency and not elective cases[9].
Another pitfall to consider is the impact of a long-term humanitarian assistance program on local health-care providers. Health care is not free of charge in many low-income countries. International teams, providing free health care, may present prohibitive competition for local practitioners. While the negative effects of competition may become apparent only after the decision to withdraw from a program has been made, the potential for problems should be mitigated from the very beginning of deployment.
In 2009, the International Committee of the Red Cross (ICRC) set up an independent hospital in Peshawar, Pakistan, close to the border of Afghanistan. Before the program was started, an agreement was signed with the authorities in Pakistan that only wounded from inside Afghanistan be treated so there would be no competition with local health-care providers. As always, treatment provided in the ICRC hospital was free of charge.
Case Study: Médecins Sans Frontières (MSF) Long-Term Deployment in Haiti in Response to the 2010 Earthquake
MSF provided emergency medical assistance after the 2010 earthquake in Haiti. Multiple immediate and long-term population health needs were targeted with a number of different projects serving different medical needs (e.g., trauma, maternity, and primary health care). The main focus was on trauma. During the peak of the emergency intervention, MSF was running 14 operation rooms in 9 surgical centers. Haiti was already in a state of serious health-care crisis prior to the disaster and had no resilience in response to the earthquake. Given the context (a chronic emergency) all MSF emergency interventions were started with the anticipated option to transform them into long-term projects. Having an entire network of MSF surgical centers enabled the establishment of specialized units for the treatment of obstetrics, burns and orthopedics.
One MSF hospital with surgical, obstetric, and orthopedic services was located in Léogâne, close to the epicenter of the earthquake. After a successful emergency intervention that was transformed into a long-term project, MSF made the decision to withdraw in 2015. During these five years, the hospital had admitted 45400 patients, performed 17000 surgical interventions and assisted 25000 deliveries. The hospital provided services in primary health care, surgery, gynecology, pediatrics, neonatology, and mental health. By 2015, the hospital was known and frequented well beyond the city of Léogâne and its surrounding area. National and international staff provided a free and reliable service to patients on a 24-hours-a-day, 7-days-a-week basis without supply ruptures or other noticeable shortcomings. The hospital was filling a significant health-care gap. Closing the project would have left the population of Léogâne without adequate health care. To maintain the service, MSF was looking for possible partners to continue health-care provision. It was difficult to find an organization that was able and willing to take over a hospital of this size. The administrative and financial obligations of such a project are significant and exceeded the capacity of many local organizations, private and public.
Prior to the planned handover, MSF learned that a local orthopedic surgeon had run a private practice in the area before the earthquake. With MSF providing a free orthopedic service, the local surgeon would have clearly faced a tough competitor. Although a single orthopedic surgeon with a private practice could have never cared for the number of patients MSF has taken care of, this example should highlight possible conflicts and underline the clear message of actively searching for possible local health partners from the very beginning of any emergency project.
The ICRC Experience
In addition to short-term programs in response to emergencies, there have been long-term ICRC deployments, lasting up to five years, albeit with a smaller range of specialties. The assortment of deployments illustrates the flexibility in planning necessary to respond effectively to local needs, share responsibility, and build capacity. Some of these hospital projects entailed the deployment of medical and surgical teams; some were purely surgical.
The ICRC has temporarily moved away from the substitution model, as described in Chapter 2, and focused increasingly on clinical support and training, including on-the-job bedside training and theoretical seminars such as the emergency-room training course for acute trauma care, the war surgery seminar, university teaching modules, accredited online training courses, workshops in hospital management, biomedical engineering, and the management of relief operations.
It may be argued that there are only three justifiable situations for the establishment of an independent ICRC hospital today:
1. Protection of the ICRC medical mission and access of patients to adequate health care.
2. A complete lack of local human resources.
3. No other acceptable alternative in service provision due to a total lack of acceptable local partners.
Through these adaptations the ICRC has been able to maintain hospital services particularly important in long-term deployments:
1. Develop and maintain a recognized level of competency in specific fields: surgery, hospital administration, and the overall management of war wounded patients.
2. Deliver care in favor of a target population that is easily identified and accepted as of prime concern to the ICRC: the casualties of war – the wounded and sick.
3. Diversify programs – upstream and downstream – in favor of this target population (prehospital care, amputation stump-revision surgery in conjunction with ICRC prosthetic workshops).
4. Diversify programs – with greater specialization – in favor of this target population: training for maxillofacial reconstructive surgery, vascular surgery, neurotraumatology, vesico-vaginal fistula repair programs.
5. Increase local capacity based on the recognized ICRC competencies: seminars in war surgery and hospital management and systems analysis for hospital finance and administration. Improve prehospital care.
6. Accept the ultimate lesson: there is no single model that fits all situations where the ICRC is called on to intervene.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 24 – Intensive Care Unit Buildup Within a Field Hospital Setting
Full access? Get Clinical Tree
