http://www.nytimes.com/2013/10/18/opinion/africas-trauma-epidemic.html

---------- Forwarded message ----------
From: barry levine 
Date: Fri, Oct 18, 2013 at 9:11 AM
Subject: re: Africa’s Trauma Epidemic
To: "letters@nytimes.com"

To the Editor:

  In all of healthcare, there are only three bargains: potable water, sanitary sewers and vaccines. That's as true today as it was half a century ago when I learned it on my mother's knee.  Everything else (including CAT scans and burn units) is vastly more expensive per life saved.  Where resources are finite (and they're always finite) we must choose to spend dollars where they do the most to save lives, to restore autonomy and to decrease suffering. It's not that Dr. Orekunrin's trauma work isn't critical and valuable. But it's certainly not a rational place to start spending more resources.

Barry Haskell Levine

OP-ED CONTRIBUTOR

Africa’s Trauma Epidemic

By OLA OREKUNRIN

Published: October 17, 2013

LAGOS — It was dusk and I was on my way home from Abeokuta, a vibrant city in southwest Nigeria. My driver had switched off the car’s air-conditioning so I could open the windows and feel the breeze. He was weaving between potholes in the road when suddenly, the scene ahead changed.

A large truck had pulled out carelessly onto the road, knocking a car straight into the median.

That stretch of road is notoriously dangerous, not just because of traffic accidents but also because of armed robbers. It’s for that reason that I suppressed my natural instinct to stop and help.

I was filled with guilt as we passed the wrecked car, because I knew that if the young man at the wheel had been badly injured, there was only a small chance that he would get the emergency treatment he needed.

I knew this because I am a trauma doctor and the founder of West Africa’s first indigenous air ambulance service. Nigeria, a country of more than 170 million people, has no organized trauma response system and no formal training for paramedics. Injured people are often taken to the hospital in a car or minibus or draped across the motorcycle of a good Samaritan, sometimes several hours after the accident has occurred.

Even if the patient does reach a local hospital, it may not have the skilled staff or equipment needed. (There are only a few that do, and there are huge distances between them.) Most of those who are seriously injured probably bleed to death.

So I couldn’t help it when, a few moments later, I said “Stop the car, please.”

I grabbed one of our emergency response bags from my trunk and walked back. I tried to concentrate on the types of injuries the driver might have rather than how unsafe it was walking on that stretch of road, particularly in the evening. Was he bleeding? Was he conscious?

The crash scene had quickly attracted some of the people who typically gather around accidents in Nigeria. Bystanders were pulling the driver out of the car. Before long they were joined by a barefoot “prophet” in a white robe. No Nigerian accident scene is complete without a prophet who commands everyone to stand by while he loudly predicts that the patient will stop bleeding. The patient is often drained of blood by the time the prophecy is complete.

Sadly, these prophets are the best hope that many Nigerians have. Trauma has become a silent epidemic in Africa, an epidemic that will only spread as the economy grows. More and more Africans are buying cars and working in heavy and dangerous industries. At the same time, infrastructure is poor, safety laws lax, and cars badly maintained.

Sub-Saharan Africa has the world’s smallest number of motorized vehicles but the highest rate of road traffic fatalities, with Nigeria and South Africa leading the pack.

The World Bank predicts that in the next two years, road accidents could be the biggest killer of African children between 5 and 15. By 2030, according to the Global Burden of Disease study, road accidents will be the fifth leading cause of death in the developing world, ahead of malaria, tuberculosis and H.I.V.

If you add to these numbers the injuries caused by violent crime and communal conflict, then you have all the ingredients for a public health emergency.

And yet, trauma receives only a tiny fraction of the attention and money given to these three infectious diseases. Every health care conference I attend focuses on vaccines, treatment and training to combat the infamous “triple epidemic.”

Over the last decade, billions of dollars have poured into Africa with the laudable aim of defeating these killer diseases. But that most basic killer, injury, remains neglected.

Part of the problem is that the solutions are so complex. It’s easy to quantify interventions like the number of AIDS-fighting anti-retrovirals or mosquito nets distributed. Pills can be counted, flown in on cargo planes and delivered to large numbers of people in a short time period. But a pill would do very little for someone on a rural road in Nigeria with a head injury and a collapsed lung.

We need to put in place systems to provide lifesaving care for accident victims. They need to be moved to a fully equipped hospital — one with X-ray machines, CT scanners, a burn unit — within the space of 45 minutes. We need at least 10 of these proper hospitals. We need to improve our roads, and we need a high-quality ambulance system to drive on them. And we need paramedic schools — like the one my company is helping to open, the first of its kind in Nigeria.

Some countries in other parts of the world have come up with proactive solutions. In Israel, a group called United Hatzalah helps volunteer emergency workers get quickly to accident sites, by “ambucycle” or on foot, if necessary. But Africa’s challenge will require an African response — and international support.

On the road that night, I quickly assessed that the young man needed urgent medical attention. I gave him oxygen and inserted a makeshift airway. I noted that he probably had internal bleeding and did my best to stem whatever external bleeding I could detect.

A passing taxi then transported him to the nearest hospital. He had a fighting chance. But too many injured Nigerians, forgotten on the side of the road, do not. It’s time the global public-health community paid attention to Africa’s urgent need for emergency medical care.

Ola Orekunrin is a trauma doctor and the managing director of Flying Doctors Nigeria, an air ambulance service.