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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

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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; bChildren’s 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

Background

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: karsten.lunze@post.harvard.edu

Global Public Health

Vol. 6, No. 6, September 2011, 669�677

ISSN 1744-1692 print/ISSN 1744-1706 online

# 2011 Taylor & Francis

DOI: 10.1080/17441692.2011.557667

http://www.informaworld.com

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(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 Children’s 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 Children’s 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 Children’s 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.

Methods

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

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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 Children’s 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.

Results

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 Children’s Hospital

Vladikavkaz, North Ossetia-Alania.

Available resources Local needs

Anesthesia machines and gas supplies

Sterilising equipment

Surgical gowns, caps, masks, gloves

Operation microscope (with observer tube for

teaching purposes), sterile covers and

replacement lamps

and drapes

Elastic bandages, swabs and dressings

Normal saline and Ringer’s solutions

Electrocouter with ground plates and cables

Complete sets of dedicated instruments for

ENT microsurgery

Needles, syringes

Catecholamines

Antibiotics

Disinfectants

Microsurgical scalpel blades

Absorbable haemostatic sponges

Dedicated suture material

Dedicated drainage catheters

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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 Children’s 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 Children’s 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

microsurgery techniques.

All patients received care at no cost to them and without informal payments.

During our activities in North Ossetia, we operated unhindered, with support from

the North Ossetian health minister and assisted by one of his staff members. Two

German journalists video-documented our activities and reported on the reactions of

the local population without restrictions.

Table 2. Needs assessment of patient recruitment for specialised otological care after the

Beslan disaster.

Number

Hostages held at school in Beslan 1355

Hostages killed 334

Victims hospitalised 661

Victims requiring intensive care 110

Victims initially identified with post-traumatic ear disease 140

Victims identified with post-traumatic chronic middle ear otitis after two years 19

Victims identified with indication for specialised surgery 6

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Management and leadership opportunities were identified as the need for

improvement in coordination of health services and their availability to vulnerable

populations; for mobilisation of current human resource potential by training existing

faculty and junior health professionals; as well as for extension of microsurgery

capacities to other surgical specialties (e.g., ophthalmology) and outreach to

neighbouring post-conflict regions, such as South Ossetia, Chechnya and Ingushetia.

Discussion

This partnership to address the burden of surgical disease in the North Caucasus

region resulted from an act of violence and a humanitarian disaster. In conflict and

post-conflict situations, the most vulnerable populations are most difficult to reach.

Partnering international volunteers with a variety of local stakeholders and involving

citizen groups, such as victims’ representatives and human rights organisations, lent

credibility to reaching out to victims of the Beslan disaster and treating all eligible

consenting individuals with sequelae of blast injuries resulting from insufficient

subspecialty services. Key stakeholders were the health ministry, which oversees all

health-care related activities, and the medical academy, which bundles all medical

training and postgraduate medical education.

Local clinicians instructed during this collaboration continue to provide

subspecialty patient care and train other providers in peripheral facilities. Most

importantly � based on process evaluations and clinical outcomes � they will shape

future training activities, as effective capacity building in the surgical specialties will

require a strong commitment to education (Lancet Editorial 2010). Thus, the conjoint

strategy started to address the local burden of surgical disease by strengthening

subspecialty services for the region. Adequate, sustainable secondary level care, not

only in acute emergency responses but also in longer-term post-conflict contexts and

adapted to local needs, is fundamental for effective health systems, but often

overlooked (Campbell and Doull 2010).

Our concerted approach, built on outdated but existing structures of secondary

care, involved local resources from the beginning. Middle-income countries such

Table 3. Patient characteristics, diagnoses and interventions at the Children’s Hospital

Vladikavkaz, North Ossetia-Alania.

Patient

characteristics

Median age (range) 15 years (1.5 months�44 years)

Gender 5 females

10 males

Diagnoses 10 cases of post-traumatic tympanic perforation

Four cases of chronic otitis media

One case of acute mastoiditis

Interventions Thirteen tympanoplasties (including six with reconstruction of ossicular

chain, two with adenotomy, one with ossicular prosthesis, and one with

ossicular prosthesis and mastoidectomy)

One tympanic tube insertion

One emergency mastoidectomy

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as those in the former Soviet Union or South America offer particular opportunities

to address surgical burden beyond general surgery. Unlike in most low-income

countries, where appropriate anesthesia services are severely limited (Hodges et al.

2007), we could rely on effective anesthesia capacity in North Ossetia.

Our needs assessment found poor infrastructure, inadequate equipment and

supplies, and health professionals � albeit sufficient in number � who were inadequa-tely trained. These factors represent typical barriers to appropriate and effective

delivery of surgical services (Spiegel and Gosselin 2007). Our findings are consistent

with systematic surveys suggesting that strengthening of infrastructure, supplies and

procedures in low- and midle-income countries is urgently needed (Kushner et al.

2010). Substandard facilities threaten patients’ outcomes (Lancet Editorial 2010), and

effective, safe surgery is no luxury for midle-income countries: although this has

not yet been studied for subspeciality services, there is increasing evidence that the

cost-effectiveness ratio of surgical services might compare favourably with selected

primary health interventions (Debas et al. 2006).

An evaluation conducted immediately after the Beslan disaster concluded that

early post-trauma emergency care for victims was appropriately handled by local and

national health resources, whereas international assistance � that unlike in other

emergencies the authorities of the Russian Federation had requested � was deemed

excessive, inappropriate and largely ignoring local needs (Schreeb et al. 2004). Our

own assessment years after the disaster found a disease burden which was the result of

insufficient subspecialty services.We therefore advocate for periodical, reliable data collection beyond the short- and

mid-term phases after a disaster, particularly once international attention and media

coverage have faded, to reveal how both needs and available resources develop over

time and in changing political environments, and to facilitate a meaningful transi-

tion from necessary humanitarian aid to appropriate partnerships for development.

Rather than reflecting the mere availability of services, meaningful needs

assessments have to distinguish whether conflicts increase or modify disease burden,

and whether they limit the availability of or access to health services (Lunze 2009,

Kushner et al. 2010). We believe that the Beslan disaster led not only to an increase

in the disease burden as we describe it, but also to impaired victims’ care seeking

for mental health reasons.

During the terror act in Beslan, victims had to endure extreme violence for several

days under inhumane conditions. The resulting psychological trauma is considered a

quaternary pattern of injury (Wolf et al. 2009). Although national and international

organisations responded early to mental trauma with psychosocial counselling andrehabilitation (Parfitt 2004, UNICEF 2004), we suspect post-traumatic stress disorder

to substantially impair victims access to treatment even years after the trauma.

However, our planning focused on the delivery of surgical care rather than addressing

potential barriers to accessing this care. Investigating and addressing mental health

effects of terrorism and violence is immensely difficult in the complex and chaotic

setting during and after disasters (North and Pfefferbaum 2002). Although it would

have been relevant, we did not have the capacity nor did we attempt to measure to what

extent psychosocial impacts and mental trauma affected patients’ access to elective,

subspecialised surgical services.

On the basis of our needs assessment, we had planned operations for 19 identified

patients with ear complications. In fact, only a minority of six Beslan victims

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consented to an operation. The majority of patients were operated on for advanced

pathologies less commonly encountered in effective health systems, which were not

conflict-related. Even assuming that some families raised sufficient funds to access

care elsewhere, we believe that a number of disaster victims did not reach our services

due to psychosocial barriers. We consider the negative impact of terror on survivors’

mental health, mediated even after years by daily stressors of a post-conflict society

with ongoing violence (Miller and Rasmussen 2010), to have impaired our recruitment

of this vulnerable patient population for surgical treatment.Several studies investigating mental health in Beslan victims confirmed our

anecdotal observations that the terror attack persistently impaired the psychological

well-being of victims as well as of their families and caregivers (Scrimin et al. 2006,

Moscardino et al. 2008). Regardless of being directly or indirectly exposed, the

disaster influenced the reorganisation of family life and the disruption of community

ties (Moscardino et al. 2010). Cultural values and gender differences factor into

victims’ coping strategies and are inherently complex in this society, where deeply

rooted traditions shape everyday life (Moscardino et al. 2007).

Therefore, assessment of mental health effects, neglected during our own planning,

should be part of programming efforts when responding to the burden of surgical

disease, particularly in conflict or post-conflict settings. This could be done in

collaboration with groups or organisations with expertise in post-conflict psychoso-

cial health who have an established relation with the population. Involving human

rights groups in the planning process, albeit a delicate step, can assist in identifying

and accessing these populations, to which international organisations have less access,

for security and various other reasons.

Limitations

Adequate funding is a crucial requirement to transition the response to the global

burden of surgical disease from � in many cases � helpful short-term volunteer

surgical missions to sustainable and more meaningful efforts (Farmer and Kim 2008,

Farmer 2010). Given the current working conditions for NGOs in the Russian

Federation, in spite of uniting a whole variety of stakeholders, we deliberately chose

to act as members of civil society and not as an organisation, in order to safeguardour own security and minimise risks for the organisations we worked with. This has

severely limited our ability to seek funding, which is difficult to obtain for a region

with a volatile security situation and travel restrictions for foreign personnel.

More long-term efforts than our interventions are required to ensure ongoing

appropriate surgical care delivery at international standards. To achieve proficiency

in specialised techniques such as otologic operations usually takes several years of

postgraduate training at a dedicated institution. While this is hardly feasible in a

middle-income country, training health personnel abroad carries the risk of brain

drain through those who are not willing or able to return to their home country.

Conclusions

We identified a number of strategies that we believe might be helpful when planning

capacity building for surgical care in post-conflict settings:

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(1) Building on available secondary care in midle-income countries can address

the post-conflict burden of surgical disease beyond general surgery.

(2) Partnering international with local stakeholders, including citizen groups, can

create credible partnerships to access vulnerable populations in politicisedenvironments.

(3) Needs assessments beyond the short- and mid-term phases after a disaster are

essential to facilitate a meaningful transition from humanitarian aid to

partnerships for development.

(4) Psychosocial impacts might affect both needs and care seeking and should be

assessed as part of a comprehensive approach when responding to the burden

of surgical disease in conflict or post-conflict settings.

(5) Health-care delivery planning will have to accommodate a case mix that willnot only include conflict-related burdens, but also advanced and natural

course pathologies resulting from health systems insufficiencies.

Given how rapidly post-conflict situations change, these strategies will have to be

adapted over time and place to given � and changing � needs, political and security

circumstances. Short-term surgical missions focusing on a limited range of pathol-

ogies have a recognised value and have made substantial contributions to many of the

disadvantaged in this world (Farmer and Kim 2008). In a public health framework,

humanitarian operations and skills training have been considered selective preventive

interventions of political violence at the level of society at large (De Jong 2010).

However, sustainable change requires sustained investments of time and resources

beyond an initially vertical mission and critical analysis, in order to create the

conditions that incentivise current health professionals to continue working in and

developing their professional environment. We see a true value of our strategies in

the ongoing commitment to our partnership, which now aims at integrating the

important pillar of high-quality surgical care delivery into broader efforts of

strengthening the local health system through management and leadership.

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