FREDERICK M. BURKLE, JR., MD, MPH, DTM,FAAP, FACEP

PROFESSOR &

WOODROW WILSON SENIOR INTERNATIONAL PUBLIC POLICY SCHOLAR

SENIOR FELLOW & SCIENTISTHARVARD SCHOOL OF PUBLIC HEALTH

FUTURE HUMANITARIAN CRISES: 21ST CENTURY CHALLENGES TO SURGICAL PRACTICE & POLICY

DOCUMENTING IMPACT

• WHO estimates that burden of surgical disease to dramatically increase by 2020

• True scope of the burden of surgical disease is unknown

• Neglected as an essential public health & humanitarian intervention

• Catalyzed formation of FMTs/FSTs

Nickerson JW, et al: Growing Pains: Surgery in Humanitarian Crises. Submitted for publication

DOCUMENTING IMPACT: QUANTITATIVE

• 185 peer reviewed publications on humanitarian surgical care: Primarily descriptive or anecdotal

• Only 11 (7 natural disasters/4 complex emergencies) provided some semblance of population based data

• Pooled statistical analysis NOT possible…

• Lack standardized indicators, local burden of disease, surgical caseload, reporting time, inconsistencies in classification of surgical pathologies & procedures, perioperative mortality, long-term surgical outcomes, etc…

Nickerson JW, et al: Growing Pains: Surgery in Humanitarian Crises. Submitted for publication

DOCUMENTING IMPACT: QUALITATIVE

• Surgeries: primarily soft tissue injuries, delayed primary closure, skin grafting, debridement.

• Followed by orthopedic, general surgery & OB/GYN procedures

• As duration lengthened, procedures reflected local burden of disease NOT the crisis event: hernia repairs, C-Sections, appendectomies; MSF: ½ obstetric emergencies

Nickerson JW, et al: Growing Pains: Surgery in Humanitarian Crises. Submitted for publication

UNMET CHALLENGES FOR FMTs

• Need to envision surgical care within context of a larger disrupted health system

• Services & supplies cannot always simply be transplanted/adapted into the local or austere environment

• Poorly equipped to manage patients with untreated tropical diseases

• Must develop standardization of data collection &

reporting; critical for population-level comprehensive understanding of the burden of surgical disease

Nickerson JW, et al: Growing Pains: Surgery in Humanitarian Crises. Submitted for publication

HUMANITARIAN CRISES: TODAY – 2020s*

• Unconventional warfare

• Rapid unsustainable urbanization dominates excess mortality

• Climate change migration: a major fatality event

• Biodiversity crises most critical

• Emergencies of scarcity & land grabbing

*Burkle FM, Future Humanitarian Crises, PDM, 2010

HUMANITARIAN CRISES: TODAY – 2020s*

• Increased frequency of major weather-related disasters & deaths

• Earthquakes major cause of casulaties

• Increased threat of nuclear events

• New vocabulary, new mandates, new challenges

• The common thread: all result in Public Health Emergencies

*Burkle FM, Future Humanitarian Crises. PDM, 2010

POPULATION EXPOSED TO CONFLICT

RM Garfield, J Polansky, FM Burkle, Jr

LESS DECLARED WARS…BUT MORE PEOPLE EXPOSED TO CONFLICT THAN EVER BEFORE

THE MYTH OF POST-CONFLICT

• Difference between populations at war and post-conflict is getting blurred with this low level of ‘conflict intensity’

• Resource base: 10% of what it was before conflict

• Absent essential surgical services

• Weaponry & intimidation remains

• 47% of countries return to conflict in 10 years; 60 +% in Africa

GLOBAL TERRORISM 2010

•

11,604 terrorist attacks with 49,901 victims (13,186 killed) in 72 countries in 2010

BIODIVERSITY CRISES

• Contain majority of world’s plants & vertebrates: The biological oxygen of the world

• Biodiversity hotspots: Have lost at least 70% of its original habitat High biodiversity is major safeguard against infectious

disease

• 80% of major conflicts occurred in 23/34 of the most biologically diverse & threatened places

Figure 1. The world’s thirty-four biodiversity hotspots (numbers) and the location of all armed conflicts with >1000 casualties between 1950 and 2000 (points) (conflict data from Arnold 1991, Sarkees 2000, Gleditsch et al. 2002). Biodiversity Hotspots as follows: 1 – California Floristic Province; 2 – Polynesia-Micronesia; 3 – Madrean Pine-Oak Woodlands; 4 – Mesoamerica; 5 – Caribbean Islands; 6 – Tumbes-Chocó-Magdalena; 7 - Tropical Andes; 8 – Chilean Winter Rainfall and Valdivian Forests; 9 – Cerrado; 10 – Atlantic Forest; 11 – Succulent Karoo; 12 – Cape Floristic Region; 13 – Maputaland-Pondoland-Albany; 14 – Madagascar and the Indian Ocean Islands; 15 – Coastal Forests of Eastern Africa; 16 – Eastern Afromontane; 17 – Horn of Africa; 18 – Guinean Forests of West Africa; 19 – Mediterranean Basin; 20 – Irano-Anatolian; 21 – Caucasus; 22 – Mountains of Central Asia; 23 – Himalaya; 24 – Western Ghats and Sri Lanka; 25 – Mountains of Southwest China; 26 – Indo-Burma; 27 – Sundaland; 28 – Philippines; 29 – Wallacea; 30 – Southwest Australia; 31 – Japan; 32 – East Melanesian Islands; 33 – New Caledonia; 34 – New Zealand.

34 BIODIVERSITY HOTSPOTS

RAPID URBANIZATION

CLIMATE CHANGE &

BIODIVERSITY CRISIS

MIGRATION

ESCAPING CONFLICT

POPULATION

FAILING ECONOMICS

& HUMAN

SECURITY

“POST CONFLICT”

POPULATIONS

THE MAJOR 21st CENTURY CRISIS

CONTRADICTIONS of GLOBALIZATION

• 6% of population are urban squatters in Developed countries

• 78% of population are urban squatters in the Developing world

• Asia: Disaster prone

• Africa: Violence prone

RAPID UNSUSTAINABLE URBANIZATION

• Highest Worldwide Under age 5, Infant Mortality, & Maternal Mortality Rates

• Urban slums: > 1 Billion/no political voice > 1 latrine per 150-200 people; Pay a fee; 10 min walk > No privacy = Rape epidemics > No international humanitarian representation > Extreme poverty rate exceeds total population growth > New SPHERE standards possible??

• Sanitation ignored; infectious diseases more prevalent

• Unknown but worsening burden of surgical disease

EMERGENCIES OF SCARCITY

• Worldwide scarcity of energy, food & water

• Resource competition becoming aggressive”… called “distributional conflicts”*

• Worsening healthcare worker crisis; surgical expertise rare

• Global scarcity is now defining the public health status of nations

*Less than 1,000 deaths/year

WEATHER-RELATED DISASTERS

0

100

200

300

400

500

600

700

1980s 1990s 2000-10

INCREASE IN MORBIDITY & MORTALITY

WARMER EL NINO YEARS: DOUBLING THE RISK OF EXPERINCING

CONFLICT SINCE 1981

DISASTER MEDICINE & SURGERY

• Loses credibility when seen only as “emergency

phase junkies”

• Broader array of surgical capabilities than single service teams

• Physical diagnostic exam skills & decoding vital signs are crucial…understanding the culture is critical

• A multidisciplinary professional discipline…must adapt to these new challenges & determine

what roles and responsibilities we collectively have…

CONCLUSIONS

• Humanitarian assistance has moved from rural to urban areas: largest disparity between the “have & have not” populations since Alma Ata

• Humanitarian medicine & surgery community are NOT prepared to protect the urban public

health infrastructure…or health care system

• NOT prepared to handle emergencies of scarcity

• Emergency surgery (collectively) MUST develop operational options for future crises