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

    appro