|Year : 2021 | Volume
| Issue : 4 | Page : 1-2
Trauma rehabilitation services in low- and middle-income countries: The challenge to human recovery
Timothy Craig Hardcastle
Department of Surgery, NRMSM, University of KwaZulu-Natal; Trauma Service, Inkosi Albert Luthuli Central Hospital; Health Sciences Research Division, Durban University of Technology, Durban, South Africa
|Date of Submission||22-Jun-2021|
|Date of Acceptance||28-Jun-2021|
|Date of Web Publication||16-Oct-2021|
Timothy Craig Hardcastle
Depatment of Surgery, NRMSM, University of KwaZulu-Natal, Congella; Trauma Service, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Mayville; Health Sciences Research Division, Durban University of Technology, Durban
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hardcastle TC. Trauma rehabilitation services in low- and middle-income countries: The challenge to human recovery. Adv Hum Biol 2021;11:1-2
Trauma remains an under-appreciated, yet massive, disease burden in many low- and middle-income countries (LMICs). Up to 90% of the world's trauma mortality occurs in LMICs. Over and above this, there is much prolonged morbidity from chronic disability and delayed return to work and community, due to the challenges with access to adequate and appropriate rehabilitation services, particularly for patients who require in-patient rehabilitation.
Trauma systems are intended to ensure access to care in a timely fashion and also aim to get the right patient to the right care, with continuous care from injury to rehabilitation, but also involving prevention and quality assurance. The systems in high-income countries (HICs) have step-down facilities and sub-acute facilities where in-patient rehabilitation is possible, after initial definitive trauma care at a trauma center. These step-down facilities are seen as a part of the bigger system and decant the patient from the acute-care hospitals preventing bed-blocks. In certain LMICs, this same system is in place where there is an active privatised health-care sector, at great expense to the patient or their funder.
The majority of LMICs are often not so fortunate. Acute care beds are easily blocked by patients with head-or spinal cord injury since there is nowhere to decant these patients for rehabilitation. This leads to shortages of beds and difficult triage decisions. The effect of this lack of rehabilitation access leads to loss of quality life years, economic challenges for the affected individuals, their families and the community as a whole. In many LMICs, the injuries that lead to mortality or morbidity would be easily managed if there was a dedicated rehabilitation initiative as part of the overall care of the injured.
A recent publication examined the challenges to trauma care in LMICs with a focus on Africa and found that there were vastly fewer basic trauma care facilities when compared to HICs. This may explain why patients with much less severe trauma die either in the pre-hospital or the in-hospital environment, or from less severe injury. This also suggests the reason behind a lack of rehabilitative services for people with injuries. Similar findings for the care of musculoskeletal injury was found in another study from the COSECSA group in Central and Southern Africa, where the lack of access to equipment and consumables considered the norm in HICs hampers optimal assessment and treatment of fractures and soft-tissue injury. This leads to a rehabilitation burden in the world of over 1 billion persons from the consequences of fractures, amputations, spinal cord injury, traumatic brain injury or other injuries. This only includes in-patient care, not outpatient follow-up and rehabilitation, but leads to disability life years lost mainly between the ages of 20 and 69 years, which encompasses the working age population, emphasising the importance of prioritising rehabilitation to achieve individual and societal benefits.
Africa bears a large brunt of this LMIC burden and a study from Ghana shows that only 17% of trauma patients received any (very limited) rehabilitation even at the major trauma facility. Mostly, this was of short duration (once a day for a week). They concluded 'African trauma systems must measure the long-term outcomes from their treatments and provide the inpatient medical rehabilitation services that are a standard of care for trauma victims elsewhere in the world'.
Even rehabilitation therapists admit that there is poor use of outcome assessments in the management of major trauma cases with chest and abdominal injuries, which carry significant risks of weakness and poor recovery after prolong intensive care unit (ICU) ventilation, making the need for such assessments important in the evaluation of rehabilitation success.
Those in the lowest socioeconomic classes from LMICs are the most vulnerable when exposed to trauma since there is limited access to health care, higher complication rate with impoverished nutrition, little or no education, impacting the ability to work and limiting job opportunities. Civil conflict in sub-Saharan Africa and the lack of economic growth complicate this process further.
With the situation appearing rather depressing it is more depressing that the situation in the upper-middle income region of South Africa is not seeming to improve. As recently as February 2021, the paper by the Louw Group from Stellenbosch highlighted that despite rehabilitation being considered a WHO Human Right, South Africa with the high burden of acquired injuries such as spinal cord damage, limb amputation or head trauma has not prioritized the rehabilitation process as part of the continuum of care. The focus of the health-care system has been on maternal health, chronic lifestyle diseases and HIV-AIDS. This rehabilitation system must be costed, planned effectively and include the primary health model of care. For trauma, it is imperative to ensure provision of equitable, accessible, affordable and evidence-based rehabilitation.
As a trauma surgeon, it is concerning that after resuscitating a dying patient, offering definitive surgical, neurosurgical and orthopaedic care, providing ICU and post-ICU ward care, there is often nowhere to send the patient, for rehabilitation. These are often patients who will generally do very well if rehabilitated, with evidence from the private sector in South Africa showing unexpected return to work rates (personal communication Dr. VS Wilson, Netcare Rehab). Therefore, it behoves the medical community and our rehabilitation colleagues in physiotherapy, occupational therapy, speech therapy, dietetics and psychology in LMICs to motivate and agitate for comprehensive rehabilitation in-patient step-down facilities in the state-funded sector to match the outcomes in the private sector and to offer the majority of patients the same level of care as well-resourced patients of greater financial means.
With all the 'advances in human biology' and the care of trauma, this is an important issue to raise in the medical community. In conclusion, with the scant health resources for equitable rehabilitation services in LMICs, evidence-based methods must demonstrate that for the increased expenditure on rehabilitation, there will be increased return at individual, family, society and country levels across all LMICs.
| References|| |
Chandran A, Hyder AA, Peek-Asa C. The global burden of unintentional injuries and an agenda for progress. Epidemiol Rev 2010;32:110-20.
Hardcastle T. The 11P's of an Afrocentric trauma system for South Africa – Time for action! S Afr Med J 2011;101:160-2.
Alibhai A, Hendrikse C, Bruijns SR. Poor access to acute care resources to treat major trauma in low- and middle-income settings: A self-reported survey of acute care providers. Afr J Emerg Med 2019;9:S38-42.
Chagomerana MB, Tomlinson J, Young S, Hosseinipour MC, Banza L, Lee CN. High morbidity and mortality after lower extremity injuries in Malawi: A prospective cohort study of 905 patients. Int J Surg 2017;39:23-9.
Chokotho L, Jacobsen KH, Burgess D, Labib M, Le G, Peter N, et al
. A review of existing trauma and musculoskeletal impairment (TMSI) care capacity in East, Central, and Southern Africa. Injury 2016;47:1990-5.
Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2021;396:2006-17.
Christian A, González-Fernández M, Mayer RS, Haig AJ. Rehabilitation needs of persons discharged from an African trauma center. Pan Afr Med J 2011;10:32.
Van Aswegen H, Reeve J, Beach L, Parker R, Fagevik Olsén M. Physiotherapy management of patients with major chest trauma: Results from a global survey. Trauma 2019;22:133-41.
Smigelsky MA, Aten JD, Gerberich S, Sanders M, Post R, Hook K, et al.
Trauma in sub-Saharan Africa: Review of cost, estimation methods, and interventions. Int J Emerg Ment Health 2014;16:354-65.
Morris LD, Grimmer KA, Twizeyemariya A, Coetzee M, Leibbrandt DC, Louw QA. Health system challenges affecting rehabilitation services in South Africa. Disabil Rehabil 2021;43:877-83.
Basu D. Diseases of public health importance in South Africa. South Afr J Pub Health 2018;2:48.