Strengthening emergency care: experience in central Haiti
Authors: Regan H Marsh, Shada A Rouhani, Paul Pierre, Paul E Farmer
Journal: The Lancet Global Health (2015)

Although substantial advances have been made in global health delivery, particularly within prevention and treatment of infectious diseases, including HIV/AIDS and malaria, under-5 mortality, and vaccine-preventable illness, gaps continue to exist in universal health coverage, especially with regard to management of non-communicable and surgical disease, including trauma.1Vasan A Ellner A Lawn SD et al.Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI).BMC Med. 2014; 12: 6Crossref PubMed Scopus (23) Google Scholar In much of the world, injuries (intentional and, especially, unintentional) are now a leading cause of death in children and young adults.2Institute for Health Metrics and Evaluation (IHME)GBD cause patterns. IHME, University of Washington, Seattle2013Google Scholar The Declaration of Alma-Ata,3WHODeclaration of Alma-Ata: international conference on primary health care.http://www.who.int/publications/almaata_declaration_en.pdfDate: 1978Google Scholar which affirmed "health for all by 2000", might have been endorsed in 1978 by almost all nations' ranking health officials, but this goal has yet to be met in most low-income and middle-income countries. To meet this goal, however tardily, global health implementers have increasingly focused on building comprehensive health systems, providing a broad base of care with the flexibility and adaptability to meet these needs,4Calvello EJ Broccoli M Risko N et al.Emergency care and health systems: consensus-based recommendations and future research priorities.Acad Emerg Med. 2013; 20: 1278-1288Crossref PubMed Scopus (37) Google Scholar, 5Frenk J The global health system: strengthening national health systems as the next step for global progress.PLoS Med. 2010; 7: e1000089Crossref PubMed Scopus (204) Google Scholar sustained by robust and integrated referral systems. As our experience in central Haiti at the University Hospital at Mirebalais shows, and as others have argued,6Hirshon JM Risko N Calvello EJ et al.Health systems and services: the role of acute care.Bull World Health Organ. 2013; 91: 386-388Crossref PubMed Scopus (27) Google Scholar integrated systems of emergency care are a fundamental component of the health system. Emergency care systems are uniquely positioned to respond to the array of life-threatening emergencies, including acute trauma, surgical disease, acute infectious illnesses, exacerbations of chronic disease, and more routine medical needs that nonetheless require timely attention. Historically, emergency care has been underrepresented in the advances of global health, perceived as the domain of highly functioning and costly health systems.7Hsia R Razzak J Tsai AC Hirshon JM Placing emergency care on the global agenda.Ann Emerg Med. 2010; 56: 142-149Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 8Razzak JA Kellermann AL Emergency medical care in developing countries: is it worthwhile?.Bull World Health Organ. 2002; 80: 900-905PubMed Google Scholar, 9Kobusingye OC Hyder AA Bishai D Hicks ER Mock C Joshipura M Emergency medical systems in low- and middle-income countries: recommendations for action.Bull World Health Organ. 2005; 83: 626-631PubMed Google Scholar In most developing countries, including those in which Partners In Health works, under-resourced Ministries of Health have been reluctant to include comprehensive emergency care in their essential packages of services, leaving a substantial gap that has been inconsistently and variably filled by private-for-profit and humanitarian organisations. The scope of emergency practice has been variably defined globally. Generally, emergency care is deemed the component of health care focused on delivery of curative interventions, mainly for critical surgical and medical conditions with threat to life or limb. Elements of severity and immediacy are essential to the designation of an emergency condition. Emergency services themselves are broader than emergency care, including population-level interventions in addition to individual care.4Calvello EJ Broccoli M Risko N et al.Emergency care and health systems: consensus-based recommendations and future research priorities.Acad Emerg Med. 2013; 20: 1278-1288Crossref PubMed Scopus (37) Google Scholar The essential components of high-quality emergency services include pre-hospital (ambulance systems) and hospital-based services; trained personnel; supplies, such as biomedical equipment, medications, and other materials; information systems; and monitoring and assessment.10Jamison DT Breman JG Measham AR et al.Disease control priorities in developing countries. 2nd edn. Oxford University Press and the World Bank, Washington2006http://www.ncbi.nlm.nih.gov/books/NBK11728/pdfGoogle Scholar Emergency care inherently addresses the wide array of illness and injury, including traumatic injuries, surgical disease, acute complications of chronic illness (eg, strokes, myocardial infarction, diabetic ketoacidosis, complications of HIV, tuberculosis, hepatitis C, and other chronic infections), and communicable diseases.9Kobusingye OC Hyder AA Bishai D Hicks ER Mock C Joshipura M Emergency medical systems in low- and middle-income countries: recommendations for action.Bull World Health Organ. 2005; 83: 626-631PubMed Google Scholar Evidence from the Global Burden of Disease Study11Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar shows that mortality from non-communicable diseases and injuries continue to rise (the increase from 1990 to 2010 was 30% for non-communicable diseases and 24% for injuries).11Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar For the 34·5 million annual deaths due to non-communicable diseases,11Lozano R Naghavi M Foreman K et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Summary Full Text Full Text PDF PubMed Scopus (9517) Google Scholar timely emergency care could address many of the time-sensitive causes.6Hirshon JM Risko N Calvello EJ et al.Health systems and services: the role of acute care.Bull World Health Organ. 2013; 91: 386-388Crossref PubMed Scopus (27) Google Scholar Despite a long tradition of medical training, which began in 1861 with the establishment of the National Medical School,12Faculté de Médecine et de PharmacieFaculté de Médecine et de Pharmacie École de Technologie Médeicale (FMP/TM).http://www.ueh.edu.ht/facultes/fmp.php pdfDate: 2006Google Scholar Haiti is not an exception to this general pattern of inattention to emergency care. Little recognition and few public resources are dedicated to these services in the Haitian health system. For example, residency-training programmes for emergency medicine to prepare physicians for the practice of emergency care do not exist. We have seen in Haiti, as elsewhere in low-income countries, that the focus on a basic minimum package has created a spurious dichotomous choice, in which primary care is deemed mutually exclusive of emergency and acute care.13Risko N Calvello EJ de Ramirez SS Narayan M Hirshon JM Including emergency and acute care as a global health priority.Int J Emerg Med. 2011; 4: 75Crossref PubMed Scopus (6) Google Scholar By 2030, road-traffic accidents will be the 5th leading cause of death worldwide with a disproportionate number of deaths occurring in poor countries like Haiti.14Norton R Kobusingye O Injuries.N Engl J Med. 2013; 368: 1723-1730Crossref PubMed Scopus (223) Google Scholar Estimates suggest that implementation of basic trauma care at the facility level could potentially avert 21% of the total injury burden in low-income and middle-income countries (LMICs). Additionally, basic interventions—many of which are done in emergency departments, such as trauma resuscitation, wound management, laceration repair, and tube thoracostomy—for a limited set of surgical diagnoses can reduce 18% of the total global burden of disease in LMICs.15Bickler SW Weiser TG Kassebaum NJ et al.Global burden of surgical conditions.in: Debas HT Donkor P Gawande A Jamison DT Kruk M Mock C 3rd edn. Essential surgery. Disease Control Priorities. vol 1. World Bank, Washington, DC2015Google Scholar Further research is needed, in Haiti and elsewhere, to better estimate the number of deaths averted and DALYs reduced by emergency care. However, high-quality emergency services are likely to have a substantial effect by addressing acute presentations of communicable, non-communicable, and traumatic disease.6Hirshon JM Risko N Calvello EJ et al.Health systems and services: the role of acute care.Bull World Health Organ. 2013; 91: 386-388Crossref PubMed Scopus (27) Google Scholar, 8Razzak JA Kellermann AL Emergency medical care in developing countries: is it worthwhile?.Bull World Health Organ. 2002; 80: 900-905PubMed Google Scholar, 9Kobusingye OC Hyder AA Bishai D Hicks ER Mock C Joshipura M Emergency medical systems in low- and middle-income countries: recommendations for action.Bull World Health Organ. 2005; 83: 626-631PubMed Google Scholar In more developed settings, emergency care provided by trained providers in an emergency department has been shown to improve quality and cost-effectiveness of the general health system. Further, by addressing the growing burden of non-communicable disease and trauma, emergency care serves as part of the public health system. Both of these effects are magnified in LMICs, where the magnitude of effect is potentially greater and the primary care systems are often weaker.16Holliman CJ Mulligan TM Suter RE et al.The efficacy and value of emergency medicine: a supportive literature review.Int J Emerg Med. 2011; 4: 44Crossref PubMed Scopus (40) Google Scholar As part of a comprehensive approach to supporting the Haitian public health system, in March, 2013, Partners In Health opened the University Hospital at Mirebalais (UHM), the largest reconstruction project in the health sector since the 2010 earthquake. The national referral hospital, operated in conjunction with the Ministry of Health, is providing high-quality primary and tertiary care, as well as training Haitian physicians and nurses. The UHM emergency department—a 21 bed modern emergency department, staffed by local physicians and nurses—opened in June, 2013, with clinical support and continuing education provided by US-trained and Canadian-trained emergency physicians. In the first year of operations, the emergency department of the UHM electronically registered nearly 17 000 patient visits, with the number of visits continuing to increase every month. 9411 (56%) of 16 750 patients registered were women, and 4590 (27%) children younger than 15 years (1212 [7%] younger than 1 year, 2901 [17%] younger than 5 years). The most common diagnoses overall were gastritis, upper respiratory infections, chikungunya, urinary tract infection, and gastroenteritis. The recent epidemic of chikungunya, an acute viral disease previously unknown in Haiti, occasioned a large number of visits to the emergency department (448 recorded visits) during May to July. 2520 (18%) of 13 781 patients seen whose data were recorded electronically had sustained trauma, of whom nearly half (1205, 48%) were due to road-traffic accidents. The top diagnoses of admitted patients portray the growing burden of non-communicable disease, surgical, and traumatic disease (panel).PanelMost common diagnoses of patients admitted from UHM Emergency DepartmentNon-surgical admissions •Congestive heart failure•Pneumonia•Stroke•Tuberculosis•Severe anaemia•GastroenteritisSurgical admissions •Fracture, extremity (non-femur, presumed closed)•Fracture, femur•Appendicitis•Bowel obstruction•Fracture, open•Wounds Non-surgical admissions •Congestive heart failure•Pneumonia•Stroke•Tuberculosis•Severe anaemia•Gastroenteritis Surgical admissions •Fracture, extremity (non-femur, presumed closed)•Fracture, femur•Appendicitis•Bowel obstruction•Fracture, open•Wounds In the context of a Haitian health system previously unable to manage this volume of critically and acutely ill patients, high-quality emergency care at UHM should continue to improve health outcomes, as suggested in previous work.7Hsia R Razzak J Tsai AC Hirshon JM Placing emergency care on the global agenda.Ann Emerg Med. 2010; 56: 142-149Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar By reducing fragmentation through truly comprehensive care addressing the full burden of disease,4Calvello EJ Broccoli M Risko N et al.Emergency care and health systems: consensus-based recommendations and future research priorities.Acad Emerg Med. 2013; 20: 1278-1288Crossref PubMed Scopus (37) Google Scholar implemented in partnership with robust surgical and other services, our implementation of emergency care has further strengthened the public health system in central Haiti. Ultimately, our experience with the Ministry of Health in central Haiti suggests the need for high-quality emergency care training programmes to ensure quality care and to build robust emergency networks. Accordingly, Partners In Health and the National School of Medicine (Universite d'Etat d'Haïti) have recently launched the first residency-training programme for emergency medicine in Haiti. We believe that emergency care should be integrated as an essential health service within a comprehensive approach to the health system. Thoughtful investment in emergency care and training in LMICs will meet the broad population health needs, from acute surgical and traumatic disease to acute infections and complications of chronic disease. We declare no competing interests.