Addressing the burden of post-conflict surgical disease – Strategies from the North Caucasus

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  • This article was downloaded by: [Selcuk Universitesi]On: 21 December 2014, At: 06:49Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

    Global Public Health: An InternationalJournal for Research, Policy andPracticePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rgph20

    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

    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, 669677

    ISSN 1744-1692 print/ISSN 1744-1706 online

    # 2011 Taylor & FrancisDOI: 10.1080/17441692.2011.557667

    http://www.informaworld.com

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    http://www.informaworld.com

  • (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.

    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

    670 K. Lunze and F.I. Lunze

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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 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.

    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 Childrens 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 Ringers 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

    Global Public Health 671

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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 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

    microsurgery techniques.

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

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