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"International Surgery" is synonymous with surgical practice in the face of constraints. The everyday practice of Western surgeons is relatively free of constraints to the extent that they are able to deliver surgical care to very high standards in large volume. Constraints may make achieving such high standards impossible. However, to what extent can the standards of surgical care be dropped but remain compatible with ethical practice in the face of constraints? Is doing what is possible the right thing to do? In practical terms, this question arises in many forms. Should an orthopaedic surgeon working in a developing country undertake his or her first laparotomy without any kind of supervision? To what extent is informed consent compromised in the face of language barriers or urgency? Are there operations which simply should not be done in the developing world? What standard is appropriate when the lives of the hospital staff are at risk? The many constraints on surgical practice relate, in general, to: lack of equipment lack of hospital infrastructure and administration; lack of hospital staff; lack of motivation of staff and lack of access of patients to the hospital. However, the "trump card" of constraints is insecurity. If, for whatever reason, there is insecurity of the hospital, staff or patients, surgical care can easily be rendered impossible. (See what happens when someone produces a gun in the emergency room!) A poor security environment might prevent staff, patients or supplies reaching the hospital; armed people might determine who has priority for treatment; the hospital itself may become a target or an objective worthy of capture. Hospitals in such environments may suddenly be overloaded by the arrival of hundreds of wounded. Wounded people can rarely pay for their treatment. The StEthCon project is an attempt to take the first steps in this domain by quantifying the kind of constraints that apply in the developing world and areas prone to armed conflict. It does not aim to draw up a list of criteria which distinguish between ethical and unethical surgical practice in international surgery. It aims at least to open a dialogue on these complex issues and to bring recognition to the fact that standards of surgical care must change in the face of constraints. But how? And how can a surgeons ensure that the changes in his or her surgical practice are compatible with ethical practice? Furthermore, there may be a point where non-operative management is the only option that is compatible with the premise of "do no harm". Armed Violence Reporting and Research One part of the StEthCon project considers the security environment surgical hospitals in the developing world. This has obvious pertinence to surgeons working in countries affected by armed conflict and widespread political violence. Not only are the surgeons treating the effects of armed violence, but the context in which the armed violence is happening is precisely what may impose severe constraints on surgical care for the wounded. It is clear that armed violence in all its forms is of profound importance to international surgery: it generates the workload and the constraints on delivering surgical care. For this reason, the Office of International Surgery has put a priority on this constraints. In collaboration with the Department of Inner City Health of the University of Toronto, the Office of International Surgery has supported the development of a model of armed violence and its effects. This is the Taback-Coupland model which sits at the heart of "Armed Violence Reporting and Research". The tools available for the reporting and research into armed violence and its effects are given here. Specifically, these tools are the Armed Violence Reporting and Research generic database and codebook. For more detailed explanation of this model, its scientific background and its potential uses go to: www.armedviolencerr.org. As part of the StEthCon project, the Office of International Surgery encourages surgeons working in developing world to research the effects of armed violence. This involves two related activities. The first is simply collating the number of weapon-wounded people who are admitted to hospital in any given geographical area. This may already provide an indication of the security environment. The second activity is to use available reports about individual events of armed violence - whether from the wounded people themselves or from other sources such as media reports - to create a "security profile" of the geographical area. The tools provided here (the empty database and the accompanying codebook) have been designed specifically with the second activity in mind. The Taback-Coupland model focuses on the effects of armed violence on either individuals or populations together with the potential risk factors of these effects: namely, the kind of weapon, the number of weapons used, the psychological aspect of the violence and, in particular, the vulnerability of the victims. The model translates information about the effects and pertinent risk factors found in written or verbal reports into meaningful data which in turn can create a "security profile". This term denotes the ensemble of effects of and risk factors for armed violence in any given context. Furthermore, security profiles change over time and therefore in relation to military or political events. Collecting data about armed violence The Taback-Coupland model can accommodate any act of armed violence using any weapon with any effect. It permits qualitative data from real events to be translated into quantitative data which, in turn, can be entered into a database. To use the Taback-Coupland model, you need to have reports about real events in the context you are investigating. (The definition of an event is given in the codebook). These reports must pertain to individual events and contain a minimum amount of information about the time, place of the event, about the weapon used and about the effects on groups or individuals. Values are put into the database for each event relating to: the context, actors, their weapons, their intent, the vulnerability of the victims and the effects of the armed violence on the victims. The source of these reports can be official reports, media reports, eye-witness accounts or, for example, reports relating to security incidents involving the staff of a particular institution. Using the tools provided on this website The database presented here as an excel spreadsheet is generic. It provides a basis for modifications in the future as it is used. This database is simply a framework; one important feature is that it can be adapted easily to the users' requirements. The precise data collected will depend on the requirements of the reporter or researcher and the context. However, the information collected from any report should still fall into the same six sections which should remain unchanged whatever the nature of the armed violence. These sections are labeled:
The codebook has been written as a guide for this generic data gathering system. It contains the required definitions for entering the values into the database. It also should be adapted in keeping with any changes in the database. For demonstration purposes, two example reports (article 1 / article 2) of events of armed violence are included in the tools and an example database with the two example reports entered. Possible studies using the tools from Armed Violence Reporting and Research Using the tools it is possible for anyone working in a surgical facility to report and research armed violence both as a generator of surgical workload, a phenomenon which requires a preventive approach or describing the immediate security environment which can impose constraints on delivery of surgical care. Possible examples are: Entering into the database individual events of armed violence using as a source hospital records and mortuary records over a period of time. (Note: this requires also finding information about the context of death or injury and not just the immediately available "medical" information. Using media reports from the area concerned to create a "security profile" of the area under concern. This would be particularly powerful if cross referenced to data from a parallel study based on hospital and mortuary data. If the level of armed violence is high or the time available for data entry is short, both of the above examples could generate pictures of "one month of violence". Whilst the exercise of generating security profiles over brief periods may not find themselves published in major medical journals, the exercise would still provide useful tools for surgeons working or planning to work in an international context. Any such "one month of violence" studies, if submitted to the Office of International Surgery will be posted on this website. In the longer term, pulling such studies together may then provide powerful data to support advocacy for bringing about change in the security environment and therefore a major constraint on surgery. Documentation: |
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2005 Office of International Surgery |
