Want to Help African EM? Think Local.
One of the greatest threats to African emergency care development is an imported, Western understanding of the standard of care. If outsiders want to have a positive impact on African emergency medicine, we need to talk less, listen more, and focus on local talent and resources.
Originally published on Emergency Physicians International (April 18, 2016)
By Jason Friesen, MPH, EMT-P
Recent events in Africa have highlighted the continent’s ongoing and urgent need for improved emergency medical care. Examples—both positive and negative—include the Ebola crisis, several terrorist attacks, inaugural consensus statements from the African Federation for Emergency Medicine (AFEM), the U.N. Decade for Road Safety Action, and, perhaps most importantly, the sustainable development goals’ (SDGs) inclusion of injuries and maternal mortality as priority health concerns. The attention is welcome, for better or for worse, when the routine disasters that emergency medical providers specialize in make it to the international news cycle, raising awareness and questions. One can’t help but hope that the billions of dollars spent on HIV/AIDS, malaria, and tuberculosis in Africa will one day be matched with funding to address routine emergency medical conditions.
But how would Africa respond if such a thing were to come to pass? A Nigerian physician described in a New York Times opinion piece what may represent the prevailing sentiment: “We need to put in place systems to provide lifesaving care for accident victims [so they can] 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 [in Nigeria]. We need to improve our roads, and we need a high-quality ambulance system to drive on them. And we need paramedic schools…” He concluded the article by calling for an African response, with international support, adding: “It’s time the global public-health community paid attention to Africa’s urgent need for emergency medical care.” But where the global public-health community joins Africa on the path to quality emergency care is exactly where things begin to get complicated.
In 2009, I started a nonprofit organization, Trek Medics International, to donate equipment and ambulances and offer prehospital emergency medical training in low- and middle-income countries. Over the past seven years, along with a growing community of emergency medical professionals in multiple countries, Trek Medics has given its undivided attention to the challenges of providing emergency medical care in resource-limited settings. We have learned a great deal about local response, international support, and how attention from the global public-health community gets translated into community programs. We have also learned that much of conventional wisdom falls flat when tested in the real world—that equipment, training, and ambulances have very little to do with developing effective emergency medical systems, and that much of what Africa is being told of emergency medical care tends to overlook important details and ignores many difficult realities. What is the way forward, then, in helping African communities to dig deeper into what works and what doesn’t, or what’s needed and what isn’t?
There are undoubtedly myriad reasons why much of Africa has very limited access to even basic emergency medical care, but I believe the two biggest obstacles have been 1) uncoordinated communications and 2) poor roads. Acute emergency medical conditions are defined by their dependency on time for favorable outcomes, so if there is no way to reliably call for help when and where it’s needed then it doesn’t matter how well trained the medical personnel are or how well equipped the hospitals are. The same goes for well-stocked ambulances: if any communities are inaccessible by road, the ambulance is worthless. In Port-au-Prince, Haiti, for example, 70% of its approximately 3.5 million residents cannot be reached by road. When the government of Brazil donated 35 new ambulances to Port-au-Prince, the hidden but obvious implication was that over two-thirds of the population would be excluded from access to emergency medical care provided by those ambulances. Ironically, the communities that are best suited for Western-style, door-to-door ambulance response are also the demographic groups with the least need for emergency care—the affluent, who are both healthier and fewer in number.
The good news is that access to one of the most critical pieces of emergency care, telecommunications, is no longer a problem. Nearly every African has affordable access to mobile phones, and the Internet is not far behind. This gets Africa off the hook for becoming dependent on the over-priced and contextually inappropriate emergency communications systems offered by Westerners—technologies developed incrementally over 50 years and, until recently, relying almost exclusively on landlines and radios.
That leaves roads as a major impediment to improving the quality and availability of emergency medical care for all Africans. But that shouldn’t be a showstopper—societies have been transporting the sick and injured for as long as there have been places where care and hospice are offered. The only reason ambulances are now deemed the preferred method of transporting the sick is because Western countries decided it was so—for themselves. In that vein, African countries need to be taking account of the unique social, cultural, and political factors that may inhibit the development of their own emergency medical care systems. An honest appraisal of the significant differences between the problems Western emergency medical systems were developed to solve, and those that African countries must solve today, should leave little question that Western emergency medical professionals with limited knowledge of emergency medical care outside their own contexts may not be the most reliable sources to consult.
Most Westerners have never lived in communities where 24/7 emergency medical care isn’t available, leaving them with very little idea or appreciation of how their system got to where it is. In the U.S. there are more than 3,000 ways to organize an E.M.S. system, while in the U.K., Canada, Australia and most of Western Europe, there’s basically a single uniform national system. Is one better than the other? If Western systems are truly delivering the highest quality of emergency medical care possible, how could such variation be possible, let alone tolerable? The reason is because, as a rule, emergency medical systems have very little to do with medical care when they’re first conceived—the focus at the outset has always been on organizing and coordinating reliable access to ensure rapid transport to the hospital (which is where all that funding is really needed). If you solve that problem, the science, technology, and resources will follow. There is a deeply local and nuanced evolution that emergency medicine undergoes in each new country where it is embraced. As one healthcare analyst, who sought treatment for the same injury in nearly ten countries, wrote, “each nation’s health care system is a reflection of its history, politics, economy, national values.”
Minimal and Acceptable Standards of Care
Perhaps the greatest threat to African emergency medical care is the Western perception of what constitutes a minimum standard of care. Outsiders are prone to make a lot of assumptions about what’s needed to improve the quality of emergency medical care in a foreign country, while also ignoring major problems that they’ve never had to deal with. For example, what good is an ACLS training program if the hospital doesn’t have oxygen? If the nurses can’t take blood pressures? If the vast majority of cardiac arrests are primarily out of hospital and rarely among the patient subset that benefits most from ACLS – bystander-witnessed, shockable rhythm? Nevertheless, ACLS is at the top of almost every emergency medical development laundry list. Would anyone suggest that countries across the globe spend very limited money and resources in an attempt to reach the gold standard of 8% positive outcomes for cardiopulmonary resuscitation?
Vertically-funded programs that include an emergency component are another example of how Western perceptions can stifle African emergency care development. In programs addressing maternal child health, cholera, and even Ebola, for example, well-intentioned foreign epidemiologists and specialists from countries with reliable prehospital emergency response systems are brought in as subject matter experts and given the mandate to develop independent emergency response systems from scratch, focused solely on the targeted disease. In the rare case where the effort succeeds, the funding structures—which might demand that each initiative operate independently of one another—can often create further fragmentation, and, ultimately, political turf wars that ensure the system either stays independent or dissolves. The true irony is that no Western experts would ever accept such a solution in their own community—they would never agree to call 911 for childbirth and 809-562-0567 for a car accident.
“Western emergency medical systems certainly do have some principles worth teaching and emulating, but they are probably nowhere nearly as important and effective for Africans as what Africans can teach themselves.”“Western emergency medical systems certainly do have some principles worth teaching and emulating, but they are prably nowhere nearly as important and effective for Africans as what Africans can teach themselves.”
There are, of course, very strong arguments for why a particular disease needs its own emergency infrastructure. But, in my experience, preventable fatalities caused by Ebola, cholera, or childbirth happen when communities don’t have an organized, reliable way to alert the community to send help and transport when it’s needed. It shouldn’t be surprising that such solutions evade many of the otherwise well-intentioned experts who devise these infrastructures. Emergency medical systems are not links in disease chains, they are public goods. Many Western emergency practitioners are offering emergency specialization when they really need to be looking at it from a public health standpoint, especially in places where access is severely limited.
Western emergency medical systems certainly do have some principles worth teaching and emulating, but they are probably nowhere nearly as important and effective for Africans as what Africans can teach themselves. I can say this because Trek Medics has played a small role in the birth of a first-of-its-kind emergency medical system in Mwanza, Tanzania. The system is run by a diverse group of nearly 100 community members, all of whom have skin in the game: doctors, medical students, firefighters, traffic police, and bodaboda drivers—the demographic group most impacted by road traffic injuries and most well-positioned to help. In September 2015, we sent an Australian paramedic to Mwanza for three months to assist a local community-based organization, the Tanzania Rural Health Movement, in training relevant community members in first aid, scene management, and in the use of a text message-based dispatching software we created, called Beacon, which we’ve designed specifically for communities where advanced dispatching technologies are unaffordable or inappropriate. Our staff member undoubtedly brought a lot of value and experience to the program, but he never made a single decision. Every decision was made by the local participants and was based on a common principle that was both simple and transformative: all communities in Tanzania have the same urgent needs for supplies, vehicles, and training. Instead of waiting for ambulances that likely aren’t coming soon, they pledged to use whatever they had to get the sick and injured people to the hospital.
The system launched in December 2015, and within three days the first call came in for a rather severe motor vehicle collision, including an entrapped patient suffering bi-lateral lower extremity fractures. The bodaboda drivers arrived on the scene in less than ten minutes, followed closely by members of the fire department, who used rudimentary tools to extricate the patient successfully, and then accompanied him in the back of the police pickup truck to the hospital. They did all of this with nothing from outside the community, with the exception of a simple text-based alert system. Since then, the response system has been growing steadily through word of mouth, reaching patients farther and farther away from where it began, and using little more than a laptop and whatever phones the responders had in their pockets.
This program is clear evidence to us that Africa doesn’t need to wait for the international community, and that Africans can now build their own systems to meet the performance standards of their Western counterparts, and for a fraction of the cost. The attitude of the Mwanzans is similar to an ancient African from Tunisia who knew a lot about moving injured and resources in austere conditions, and wrote, “We will either find a way or make one.” There is a belief that by being proactive with what they have, Tanzanians will stand out from the crowd and garner more support. So far, it’s working. Other African countries can do the same and start building systems now, with whatever they have, so that when the international community offers support, Africans will already know where and how it will be used best.
Originally published on Emergency Physicians International (April 18, 2016)