Addressing the burden of post-conflict surgical disease – Strategies from the North Caucasus
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Addressing the burden of post-conflictsurgical disease Strategies from theNorth CaucasusKarsten Lunze a & Fatima I. Lunze b ca Preventive Medicine , Boston University , Boston, MA, USAb Children's Hospital Boston , Boston, MA, USAc North-Ossetian State Medical Academy , Vladikavkaz, Republicof North Ossetia-Alania, Russian FederationPublished online: 23 Mar 2011.
To cite this article: Karsten Lunze & Fatima I. Lunze (2011) Addressing the burden of post-conflictsurgical disease Strategies from the North Caucasus, Global Public Health: An InternationalJournal for Research, Policy and Practice, 6:6, 669-677, DOI: 10.1080/17441692.2011.557667
To link to this article: http://dx.doi.org/10.1080/17441692.2011.557667
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Addressing the burden of post-conflict surgical disease Strategies fromthe North Caucasus
Karsten Lunzea* and Fatima I. Lunzeb,c
aPreventive Medicine, Boston University, Boston, MA, USA; bChildrens Hospital Boston,Boston, MA, USA; cNorth-Ossetian State Medical Academy, Vladikavkaz, Republic of NorthOssetia-Alania, Russian Federation
(Received 24 June 2010; final version received 29 November 2010)
The 2004 terror attack on a school in Beslan, North Caucasus, with more than1300 children and their families taken hostage and 334 people killed, ended afterextreme violence. Following the disaster, many survivors with blast ear injuriesdeveloped complications because no microsurgery services were available in theregion. Here, we present our strategies in North Ossetia to strengthen subspecialtysurgical care in a region of instable security conditions.
Disaster modifies disease burden in an environment of conflict-related health-carelimitations. We built on available secondary care and partnered international withlocal stakeholders to reach and treat victims of a humanitarian disaster. A strategy ofmutual commitment resulted in treatment of all consenting Beslan victims with blasttrauma sequelae and of non disaster-related patients.
Credible, sustained partnerships and needs assessments beyond the immediatephases after a disaster are essential to facilitate a meaningful transition from human-itarian aid to capacity building exceeding existing insufficient standards. Psychosocialimpacts of disaster might constitute a barrier to care and need to be assessed whenresponding to the burden of surgical disease in conflict or post-conflict settings.Involving local citizen groups in the planning process can be useful to identify andaccess vulnerable populations. Integration of our strategy into broader efforts mightstrengthen the local health system through management and leadership.
Keywords: burden of surgical disease; post-conflict; capacity building; NorthCaucasus; Beslan
The North Caucasus remains a region of frequent human rights violations and
resurging violence from armed opposition groups (Lunze 2009). The recent conflict
over South Ossetia and ongoing attacks from militant groups in Chechnya,
Ingushetia and Dagestan illustrate its political instability. Most non-governmental
organisations (NGOs) have withdrawn due to security concerns. Health systems in
the region, economically most disadvantaged within the Russian Federation, are
weakened from past conflicts; while they provide primary care, they lack the capacity
for specialised services.
On 1 September 2004, a group of terrorists attacked a school in Beslan, a small
town with a population of 30,000, situated in the Republic of North Ossetia-Alania
*Corresponding author. Email: firstname.lastname@example.org
Global Public Health
Vol. 6, No. 6, September 2011, 669677
ISSN 1744-1692 print/ISSN 1744-1706 online
# 2011 Taylor & FrancisDOI: 10.1080/17441692.2011.557667
(an autonomous republic that is a part of the Russian Federation and neighbours
Chechnya). In Russia, 1 September is traditionally the first day of school after summer
vacation, when pupils together with their families gather in schools to celebrate. At the
Beslan school, the terrorist group took more than 1300 children and their familieshostage. After 3 days of what is now considered one of the worst massacres on a
civilian population in Europe in recent history (Moscardino et al. 2010), Russian
security forces stormed the building and ended the siege with the use of heavy artillery.
The incident left 334 victims dead and many more injured. During the final storm,
indoor bomb explosions in the gymnasium caused blast injuries in numerous
survivors. Among survivors, traumatic ear defects are the most common blast injury
(DePalma et al. 2005), which are amenable to relatively straightforward treatment but
require subspecialty management (Wolf et al. 2009).In peripheral regions of the Russian Federation, patients requiring services
beyond local capacity are referred to central institutions following a quota system
which provides a limited number of grants for specialized services (WHO 2005).
While initially complex traumatic injuries resulting from the Beslan terror act had
been addressed in North Ossetian hospitals or at major centres elsewhere within the
Russian Federation (Schreeb et al. 2004), several years later many victims had still
not received comprehensive medical care beyond the acute immediate response.
Traumatic blast ear defects resulting from bomb explosions need to be assessedpromptly after the incident. Delays in treatment are associated with further damages
(Wolf et al. 2009), which may require extensive microsurgical reconstruction and
expertise typically found only at major developed medical centres.
Two years after the disaster, clinicians at the Vladikavkaz Childrens Hospital in
the capital of North Ossetia-Alania observed an increased burden of post-traumatic
middle ear injury. Tympanic lesions left untreated caused different pathological
reactions in the mucosal and bony structures of the middle ear, requiring extensive
microsurgical reconstruction procedures to limit destructive processes. In some casesmiddle ear prostheses were needed in order to guarantee an effective conduction of
acoustic waves in the tympanon, to attempt an improvement in hearing or to prevent
further hearing loss. No surgical capacity was available in or near North Ossetia to
perform the necessary microsurgery for these patients.
Following an appeal from the Vladikavkaz Childrens Hospital directed at the
last author of this article, who trained there, she procured an ear-nose-throat
(ENT) operation microscope and shipped it to Vladikavkaz Childrens Hospital.
Due to lack of local surgical subspecialty expertise, this was insufficient to meet theBeslan victims needs. Health facilities in North Ossetia are outdated and poorly
equipped. Personnel are skilled in general surgical services, but lack training and
dedicated equipment for microsurgical procedures; and available services are poorly
coordinated due to insufficiencies in management and leadership in the health sector.
The two authors initially arranged for consultation and treatment in Germany forpatients from the Caucasus region with complex middle ear injuries. However, this
approach soon proved unaffordable and unsustainable due to high transport and
medical care costs. Most importantly, treatment abroad did not address the
unavailability of microsurgical services in the North Caucasus. The two authors
670 K. Lunze and F.I. Lunze
therefore partnered with two ENT surgeons skilled in otologic operation techniques
(Professor Thomas Eichhorn, Cottbus, and Dr Christian Offergeld, Freiburg; both
in Germany), the Vladikavkaz Childrens Hospital, the North Ossetian Ministry of
Health, and local citizen groups in order to reassess the situation 2 years after the
terror act and to formulate the following objectives, plans and strategies:
(1) Partner local government authorities, hospital faculty and staff and academic
institutions as well as citizen groups, to identify and address the immediate
need for surgical ENT treatment for Beslan victims and to offer themcomprehensive treatment.
(2) Explore management and leadership challenges that led to the current gap.
(3) Create capacity by appropriately equipping and training surgeons from the
region in microsurgical techniques with the long-term goal to establish
comprehensive subspecialty services in the region.
Building on available structures, from the initial phase on, tasks such as strategic and
administrative procedures, access to patients, patient care and follow-up activities
were equally shared between international and local health professionals. This
common approach allowed for clarifying goals and expectations, and identified
opportunities for management and leadership improvement. It also helped ease
procedural hurdles such as necessary formalities, accreditations and required
permits, and allowed us to operate freely in a highly politicised environment where
security concerns limit the operability of many organisations. In order to assess the
local context from a supply and demand perspective, we conducted an assessment of
local resources, infrastructure and surgical needs. Medical faculty and citizen groups
in North Ossetia delivered the necessary data.
While dedicated operation room capacity including anesthesia and basic surgical
supplies existed and surgical care is established in North Ossetia, there was an almost
complete lack of supplies and equipment for specialised surgery and microsurgery
(see Table 1). Following the determination and coordination of available resources in
Table 1. Available and needed resources for specialised surgery at the Childrens Hospital
Vladikavkaz, North Ossetia-Alania.
Available resources Local needs
Anesthesia machines and gas supplies
Surgical gowns, caps, masks, gloves
Operation microscope (with observer tube for
teaching purposes), sterile covers and
Elastic bandages, swabs and dressings
Normal saline and Ringers solutions
Electrocouter with ground plates and cables
Complete sets of dedicated instruments for
Microsurgical scalpel blades
Absorbable haemostatic sponges
Dedicated suture material
Dedicated drainage catheters
Global Public Health 671
North Ossetia, we procured further specialised supplies and equipment for
microsurgery to complement existing material. To incorporate best surgical practices
into local care, one of the ENT specialists (Professor Thomas Eichhorn) at his
institution in Germany trained a North Ossetian surgeon (Dr Zemfira Tsorieva) in
microsurgical skills, who became competent to identify suitable patients, coordinated
paediatric and adult surgical as well as anaesthesiologic services available in North
Ossetia and ensured follow-up of patients in the post-operative phase.
Victims were identified and characterised using data from medical faculty and
citizen groups in North Ossetia, as well as international academic and WHO sources
(Schreeb et al. 2004). This assessment of specialised surgical needs yielded 19 patients
with complex ear pathologies (see Table 2). Since many victims were mentally
traumatised (Parfitt 2004), we consulted with the victims representatives and human
rights groups to assist medical staff at the Childrens Hospital Vladikavkaz in
accessing eligible patients. As a result, 10 identified victims were evaluated for
surgical interventions by locally trained staff, who also obtained written informed
consent from 14 eligible patients (six of whom were victims of the Beslan disaster),
provided preoperative care and planned for operation room capacities.
We were confronted with four victims for whom surgical treatment was indicated
but who refused treatments for psychosocial reasons, consistent with similar
accounts from citizen groups. We were unable to further characterise the
psychosocial burden and mental disease among the Beslan victims or to quantify
the number of victims who declined treatment for those reasons.
The Childrens Hospital Vladikavkaz provided operation room management,
anesthesia staff and equipment as well as nursing staff for both adult and paediatric
patients. Our team, including international volunteers and local surgeons, performed
and documented, in total, 15 comprehensive microsurgical operations mainly for
complex middle ear pathologies, including one additional non-elective emergency
procedure, without intra- or post-operative complications (see Table 3). During the
operations, local adult and paediatric surgeons from the area were instructed in
All patients received care at no cost to them and without i...