Harvard Humanitarian Initiative FREDERICK M. BURKLE, JR., MD, MPH, DTM, FAAP, FACEP PROFESSOR & WOODROW WILSON SENIOR INTERNATIONAL PUBLIC POLICY SCHOLAR SENIOR FELLOW & SCIENTIST HARVARD SCHOOL OF PUBLIC HEALTH FUTURE HUMANITARIAN CRISES: 21 ST CENTURY CHALLENGES TO SURGICAL PRACTICE & POLICY
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Future Humanitarian Crises: 21st Cenutry Challenges to Surgical Practice and Policy
Emergency Surgery Workshop Davos 2011: Presentation by Prof Frederick Burkle, MD, Senior Fellow & Scientist, the Harvard Humanitarian Initiative, Harvard School of Public Health, Kailua, HI, USA
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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
• 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
• 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”*