Surgery and Refugee Populations: A Review
Adam L. Kushner MD, MPH
Abstract:
Although infectious diseases, malnutrition and diarrhea account for the vast majority of deaths in many refugee
situations, many individuals also suffer from traumatic injuries and other surgically treatable conditions.
Understanding the determinants involved in surgical interventions is facilitated by defining baseline, emergent and
chronic phases of refugee situations. International aid organizations often expend vast resources on surgical
interventions with untested benefit. More detailed assessments and further study may help provide insight into
such interventions. This article is a review of the surgical and disaster literature and defines issues for further
study
Introduction:
The health status of refugee populations varies greatly depending upon geographic location, underlying medical
and nutritional status, and the events causing the initial relocation. Although infectious diseases, malnutrition,
and diarrhea are the major causes of death and illness in refugee populations, injuries and surgically treatable
conditions significantly impact these communities. Many international organizations including the International
Committee of the Red Cross (ICRC), Medecins Sans Frontieres (MSF), and the United Nations High
Commissioner for Refugees (UNHCR) spend considerable resources in caring for the health of the estimated
twenty two million refugees and internally displaced persons worldwide.1 This paper will attempt to review the
surgical needs of refugee populations and provide an assessment of areas needed for further research.
Refugee situations caused by natural disasters or conflict occur in over 100 countries around the world.2 No two
situations are equivalent; however, the underlying conditions are of inadequate food, shelter, and medical care.
Refugee situations can be viewed in terms of a baseline, an emergent, and a chronic phase. These three phases
each have distinctive characteristics and requirements with respect to surgical therapy. Based upon the
underlying medical conditions, resources, and input from the international community and local populations,
surgical therapy is either appropriate or an inefficient use of resources.
Baseline Phase:
The majority of refugee situations occur in developing countries located in tropical or subtropical climates. Poor
economic conditions and minimal health care resources characterize these nations. Numerous studies have
documented the limited surgical resources, training, and access to care of these countries as compared to
western standards.3-14 Nordberg characterized the rates of major surgical procedures in Western Kenya and
found them to be at least 20 times lower, on average, than in the West.3 Blanchard et al estimated an overall
rate of surgical operations of 124 per 100,000 in Pakistan14 compared to 8,253 per 100,000 in the United States.
15 These studies help to illuminate the baseline conditions in many of the nations facing refugee crises.
Relative stability and sufficient resources characterize the baseline phase before a refugee situation. Though
these levels may be inadequate when compared to standards set in the west; some mechanism for medical and
surgical care is in place through traditional healers, local governments, or frequently missionary and non-
governmental organization (NGO) hospitals. Factors such as baseline nutritional status, economic and
agricultural resources, belief systems, and education are important components of the refugee response to crisis
events. Healthier populations with better access to services can more easily withstand a crisis. However, all
populations are at risk if sufficient planning and preparation for disasters is neglected.27,41
Accurate studies recording the local resources including trained surgeons, operating room facilities, and rates of
elective and emergent surgery need to be based upon sound epidemiological data. Once the baseline resources
and needs of a community are understood, then proper planning can be initiated to improve facilities and training,
and prepare for potential problems in the future.
The work by Burkett and others has been important in establishing the specialty of geographic medicine. Burkett’
s descriptions of the medical diseases along the Nile valley are informative and useful in establishing a proper
baseline evaluation for the local population.17 Many of the diseases treated in tropical countries are specific to
those regions and foreign physicians without proper training may be at a loss to provide adequate care.16-22
Canadian military surgeons working as part of the international forces in Bosnia reported on the successful
treatment of hydatid disease as part of a humanitarian surgical mission,23 while Fanney reported a misdiagnosis
rate of 82% for cases of pyomyositis treated by volunteer physicians in a Cambodian refugee camp in Thailand.
24 Through better cooperation with local health care providers and a more in depth understanding of baseline
conditions, medical relief efforts can use advanced planning and prepare for varying situations.
The lack of centralized information gathering is difficult for relief teams that may approach a new refugee
situation. A better understanding of local resources, health care workers, hospitals, and training will facilitate care
if a disaster or refugee situation occurs. An effort to establish trauma systems in developing countries is one way
to increase disaster preparedness. Mock recently described trauma mortality patterns between nations of
different economic levels.25 The conclusions reached showed that efforts focusing on pre-hospital and
emergency room care may help to decrease mortality. First aid and injury prevention skills are helpful in complex
emergencies and refugee situations where resources are limited. Implementing such efforts will help to limit the
impact of injuries and violence, which according to the Director General of the World Health Organization, “…is
fast overtaking infectious diseases as the principal cause of morbidity and premature mortality.”69
The principles of proper airway management, adequate resuscitation, and wound management are important
tenets in the care of injured trauma patients worldwide.27,28,41,56 Reliance upon sound training and adherence
to accepted surgical principles are a cornerstone for trauma care in developing countries.56 With proper training
and advanced planning local facilities can be useful in some situations. De Wind outlined the successful
experience of an Ugandan Missionary hospital in caring for war wounds with only basic facilities and sound
surgical principles.57 Multiple reports from Croatia describe how civilian hospitals were transformed to care for
war injured patients,33-35 and Behbehani et al reported on the experience of a teaching hospital in Kuwait during
the Gulf War.36
Although missionary and teaching hospitals and local health centers can care for injured patients as the need
arises, much of the effectiveness of these facilities depends upon the initial event and the length and severity of
the emergent phase.
Emergent Phase:
The emergent phase of a refugee situation begins with an initial event. Such events are either natural disasters:
earthquakes, floods, or famines, or armed conflicts such as civil wars and terrorist attacks. Large numbers of
injuries, the breakdown of communication systems and infrastructure, and the need for external assistance
characterize the emergent phase. Much of the surgical literature relating to refugee care has concentrated on
this time period and utilizes many of the principles developed in conflicts such as World War II, Korea, and
Vietnam.28
More recently, Mehran et al described the Canadian military’s surgical experience in Bosina while providing
medical backup for Canadian and UN forces.31,32 Efforts of the Australian Defense Force in Rwanda were
reported by Farrow. Though initiated to provide assistance to UN troops, 84.8% of the patients cared for on this
mission were civilians.46 Unlike the civilian wounded, however, injured UN personnel underwent definitive
treatment in Nairobi, Kenya after initial stabilization. This factor highlights one of the main differences between
military war surgery and civilian conflict situations. The echelon system developed for military forces which
provides for immediate first aid and rapid transport to rear areas for treatment is unavailable for most war injuries.
37 Surgical facilities provided for military personnel along with the logistical support of wealthy Western
governments are unavailable in most refugee and conflict situations.
By far the most experienced organization providing surgical care in areas of conflict and for refugee populations is
the International Committee of the Red Cross (ICRC). Since 1979 ICRC surgical missions have at times been
located in Cambodia, Afghanistan, Sudan, Angola, Somalia, Ethiopia, Rwanda, Lebanon, Gaza, Iraq, and Yemen.
49 These facilities unlike army hospitals are relatively small. Usually two to four surgical teams function with basic
operating equipment and limited laboratory and radiology capabilities. For the years 1985 through 1993, there
were more than 115,000 patients admitted to ICRC hospitals and more than 225,000 operations performed.
ICRC hospitals have provided much insight into the difficulties in undertaking surgery in less than optimal
conditions despite well-trained surgical teams and adequate supplies and equipment. Unlike the reports from
hospitals in Croatia converted to wartime use, ICRC hospitals are created to function efficiently under mass
casualty situations with limited resources.38,49,52 Specific reports from Afghanistan,48,53,54 Thailand,39,61
Gaza,45and Lebanon45,51 have helped to illustrate many of the needs and conditions associated with surgery in
these situations.
The experience of ICRC surgeons has helped to developed a method of triage for war wounded that reflects a
system refined and tested in multiple locations65 and differs from systems developed for the military.63 Coupland
also reported a method for classifying war wounds based upon features of the wound and not the weaponry. This
system facilitates wound assessment and provides for standardized data from the field.62
ICRC experiences have provided insight into the management of war wounds involving bone,66 the technical
aspect of war wound excision,68 musculoskeletal injuries,48 and the management of landmine injuries.64,67
Subsequently, in situations where resources are limited, Coupland has proposed an epidemiological approach
toward managing patients in need of surgery. He points out that most injuries in war remain untreated. The lack
of qualified surgeons or even doctors to perform procedures is likely to do more harm than good. Early first aid
and non-operative management may save more lives or at least conserve limited resources for those who would
benefit the most.43
Conflict and war are not the only events that injure large numbers of individuals. Earthquakes have been
determined to be the most devastating of natural disasters.27 Armenian and Noji’s study of injuries arising from
the earthquake in Armenian in 1989 estimated that 130,000 people suffered injuries and 14,000 were
hospitalized. Natural disasters such as earthquakes and floods have a limited initial event causing a refugee
crisis. Armed conflict and natural disasters such as famines and droughts can progress over long periods of
time. As the emergent phase progresses, malnutrition and disease prevalence increases making a population
more susceptible to illness with compromised immune systems and poorer wound healing mechanisms.
During a crisis situation, resources are limited and the utilization of expensive resources for patients that will not
survive is unwarranted and wasteful. The workload in a war time hospital is enormous. Fosse et al reported how
the use of experienced nurses for minor debridements and other non-operative procedures was able to expand
the capacity of the facility during the siege of Tripoli.51 A study by Gertsch undertaken in Pakistan found that
there was no correlation between operative time and patient outcome or increased postoperative workload.50
Cutting and Agha reported an operative mortality of only 3.2% in the Bourj al-Barajneh Refugee Camp in
Lebanon. The camp was isolated and under siege for six months but was able to care for patients with severe
and complicated wounds because of a rapid transport time, adequate amounts of blood for transfusions and
reliance upon sound surgical principles.45 They also bring up the point that while military victims are young
healthy males, surgery in refugee camps is composed of patients of varying ages with varying underlying medical
conditions and nutritional status.
Experience from the war in Afghanistan has been important in understanding the complexity of treating wounds
presenting long after the time of injury. This factor contributed to high pre-hospital but low in-hospital mortality.
47 Coupland and Howell reported on the management of wounds greater than three days old.53 They
highlighted the necessity of proper resuscitation and adequate debridement. Other observations included the
cultural obstacle of obtaining permission for amputations and the evidence of inadequate first aid in the field.
“The team saw results of suturing war wounds and field laparatomies along with catheter tubing in penetrating
chest wounds, chicken skin dressings, and the parenteral administration of steroid, vitamin and antibiotic
cocktails.” ICRC first aid courses teach only to clean and dress wounds and never to attempt primary suturing in
the field.
Reports from Lebanon also demonstrated a trimodal distribution of war injuries in both civilian and military
populations.45,70 Deaths occurred in three peaks, within the first hour (93.7%), 1 to 4 hours after injury (2%), or
1 to 75 days after injury (4.3%).71
Haddock assisted in reestablishing surgical services in the town of Zakho during the Kurdish refugee relief effort
in Northern Iraq.55 The hospital in Zakho had been abandoned and there was no fresh water, electricity or
sewage disposal. Before the medical team arrived, a temporary electrical supply, waste disposal and a water
supply were established. Utilizing left over equipment and some additional supplies, 19 major and 15 minor
procedures were undertaken during an 8-day stay. Of these procedures, 11 major and 8 minor were for 15
children under 16 years old. The report highlighted the problem of a mobile refugee community. Contrary to
conventional surgical teaching, all wounds were thoroughly debrided and closed primarily. Three cases were also
turned away: an 18 month old child with a fungating retinoblastoma, a 1 year old with a large soft tissue tumor,
and a 16 year old paraplegic boy with an infected, eroding sacral pressure sore. For these cases, the lack of
specialized equipment and postoperative care was an absolute contraindication for surgical treatment and sent to
the main referral hospital for care.
Conditions, material, and expertise of personnel will differ between varying refugee situations. Cobb and
Schecter in a chapter on the surgical aspects of refugee health care outlined two types of surgical problems in
refugee settings.40 The first are situations that can be handled by non-surgeon physicians with some knowledge
and expertise. The second problem requires specialized surgical expertise and resources beyond the scope of
the non-surgeon. When such specialized care is not available, primary health care workers must stabilize the
patient until transfer is possible. The work highlights the importance of proper equipment, a thorough assessment
of the surgical patient, the principles of surgical technique, and the importance of sterility.
Traumatic injuries are prevalent during all phases of a refugee situation; however, mass casualty situations
requires more intensive planning. In a refugee camp, the director of medical care must take into account the
volume of patients, the severity of illness or injury, the skills of the medical staff, the number of doctors available,
and the facilities and supportive services. A triage system must be established. Resources are limited and
therefore, prolonged treatments for unsalvageable patients may not be appropriate.
Apart from trauma, other surgical emergencies common in refugee camps include intussusception, obstruction
from ascariasis or incarcerated hernias, appendicitis, typhoid fever perforation, and amebiasis. All of these
entities are amenable to surgical treatment, yet without the proper resources or personnel a more prudent plan
may be to stabilize the patient with fluids and antibiotics and then transfer them if possible.
As the emergent phase depends upon the international community to provide supplies and resources, decisions
to forgo costly surgical therapy and instead prevent infectious diseases or improve water and sanitation facilities
may be more effective. The discussion on surgery during the Khmer assistance operation in 1979 and 1980
provides insight into the issues. “Surgery in refugee camps is considered to be ’heroic’ and receives a great deal
of attention from journalists and visitors. This can bias their view of an entire program of health–related activities.
It was sometimes difficult to convince visitors of this fact and to demonstrate the importance of other less
spectacular public health programs of equal or greater benefit.”39
Chronic Phase:
One aspect common to refugee situations is their longstanding nature. The third phase is therefore a chronic
situation, marked by long periods of relative malnutrition, and crowded conditions. The refugees may sometimes
have adequate access to medical resources, as seen in the study from Khao I-Dang in Thailand,39 however, the
high prevalence of diseases uncommon to normal conditions may abound and not be recognized by local or
visiting physicians.24
The provisions for the chronic stage of a refugee crisis is trying to rebuild a community, reestablish health care
resources and treat the recurring diseases. The Khao I-Dang study showed that non-war-related surgery out
numbered war-related surgery almost 3 to 1. This facility well equipped with supplies also had an adequate
compliment of trained surgeons on hand to provide assistance. Subsequently, in 1989 through 1991, the hospital
had 300 beds and a staff of 25 expatriate doctors and nurses and 200 locals. The ICRC provided surgical care,
while MSF delivered medical therapy. The study by Fontanet et al showed how quality medical care, and when
necessary surgical intervention, could be delivered to refugee populations for the management of empyema and
other conditions in a refugee population.61
The public health implications of surgery and the treatment of injuries has been examined in recent reports.
29,30,58,60 Aboutanos and Baker examined the impact of wartime civilian injuries and proposed a intervention
strategy to help limit the effects.29 Meddings performed a retrospective analysis between periods of conflict and
post conflict in two ICRC hospitals treating injuries from Afghanistan. His results showed that while the mean
monthly admission rate for injuries decreased by 23% in the post-conflict period, in-hospital mortality significantly
rose from 2.5% to 6.1% (p<.001). He speculated that the availability of weapons after a conflict and increasing
social destabilization contribute to a minimal reduction in injuries and the increase mortality.44
Hermansson et al studied the impact of injury and disability on well being and social integration in a sample of war
wounded refugees in Sweden. The results documented injuries and medical complications representative of
small-scale operations of war with poor access to early medical care. In addition, the degree of disability was not
a factor for well being and social integration after two years in Sweden, though most refugees expressed desires
for repatriation.59 More detailed research is needed of these very complex and emotional issues.
The issue of landmines is another example of the need for proper first aid training, education for refugee
communities, and research into the magnitude of the problem. These weapons are a hazard that continues into
the chronic phase of any refugee situation. The landmines not only affect those injured in an explosion, but also
kills livestock and adds to malnutrition and infectious diseases because of blocked access to arable land, roads,
and health facilities.42 Even upon repatriation refugee are often faced with the threat of landmines, as was
recently seen in Kosovo.
The chronic phase of any refugee situation is quite variable. This is also the phase with the least research.
Studies are needed to evaluate the effectiveness and needs for surgical treatment in many of these situations.
Important interventions include teaching basic first aid, providing relief workers with accurate baseline data, and
conducting relief missions with community involvement whereby skills are transfer to the community for use after
the situation has resolved. The need to prepare for possible future crises must be inherent in any solutions
aimed at solving refugee situations. Of the billions of dollars spent every year on humanitarian assistance, if we
are to make a real difference, then actions into understanding baseline conditions, injury prevention, and
providing a rational epidemiological approach to surgery for refugee populations is imperative.
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