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Emergency medicine in Eritrea: Rebuilding after a 30-year war of independence
Emergency Medicine in Eritrea: Rebuilding After a 30-Year War of Independence MICHAEL D. BROWN, MD Eritrea became a member of the United Nations in 1993, after a devestating 3O-year war of independence with Ethiopia. Although Eritrea suffers from many of the problems beset by the developing world, the people are determined to rebuild their country. Emergency medical care and emergency services are in their infancy, yet the signs of progress are already visible in the capital city of Asmara. This report describes the current state of the prehospital system and emergency medical care in Eritrea. (Am J Emerg Med 1999;17:412-413. Copyright © 1999 by W.B. Saunders Company) Eritrea is an independent republic in northeast Africa bordered by the Sudan, Ethiopia, and Djibouti. It has an area of 45,754 square miles, which is about the size of Indiana. The geography varies from the mountainous interior to the flat coastal plains. The 600 miles of Red Sea coastline is one of the hottest, driest regions in Africa. The central highlands are much cooler and provide fertile valleys for agriculture. 1 The population in 1997 was estimated to be approximately 3.5 million, with .5 million living in the Sudan as refugees. The population density is 78 per square mile, with 80% living in rural areas. The capital city of Asmara has a population of approximately 400,000. The perinatal mortality rate is 117 per 1,000 births 1 and the life expectancy is 49 years for men and 52 years for women.2 Arabic and Tigrinya are the most widely used languages, with an adult literacy rate of 20%. There are several ethnic groups, but the primary religions are Islamic and Eritrean Orthodox Christian. 1 The per capita gross domestic product is $570, placing it in the lowest economic group according to the World Bank ranking system. 3 Eritrea gained its independence from Ethiopia in April 1993, when the people voted almost unanimously for an independent republic. This followed a devastating 30-year war with Ethiopia. The victorious Eritrean People's Liberation Front (EPLF) was transformed into the People's Front for Democracy and Justice, which has a transitional government in place committed to democracy. 4 After many years of war, Eritreans are now engaged in rebuilding their nation. As in other developing countries, infectious disease is common, and includes meningitis, tuberculosis, polio, rabies, and tetanus. Malaria and other mosquito-transmitted disease, such as dengue, are present along the lowlands of
From the Spectrum Health/Michigan State University Program in Emergency Medicine, Grand Rapids, MI. Manuscript received May 26, 1998; accepted June 2, 1998. Address reprint requests to Dr Brown, Department of Emergency Medicine, 100 Michigan Ave, NE, Grand Rapids, MI 49503. Key Words: Emergency medicine, Eritrea, international. Copyright © 1999 by W.B. Saunders Company 0735-6757/99/1704-0023510.0(3/0 412
the coast. Eritrea's isolation during the war protected its population from the devastating spread of HIV seen in other parts of Africa. Although HIV is present, educational and prevention efforts are underway to contain its transmission. There are relatively few automobiles in Eritrea; however, this is changing rapidly, and the number of motor vehicle accidents is increasing. Bicycles remain one of the major modes of transportation in Asmara and account for a significant percentage of injuries; helmets are almost nonexistent. Penetrating injuries from handguns are extremely rare. Blast injuries from land mines are still encountered because some of the mines from the countryside have not yet been cleared. HEALTH CARE SYSTEM During the war, the Eritrean people showed their selfsufficiency by developing a wartime emergency system with the limited resources at hand. In 1972, the EPLF started training the "barefoot doctors" who ran the hospitals behind enemy lines. 5 These mobile operation tents and wards were often underground and had a capacity of 150 to 200 beds. These large subterranean complexes also contained schools .6 Currently, the health care system consists of a few main hospitals in the larger cities, with a network of clinics and small mission hospitals in the rural areas. The Ministry of Health manages the system and is primarily responsible for providing most of the medical care for the citizens of Eritrea. Although there is currently no medical school or formal residency training program for physicians, there is a medical education system for nurses and other health care providers. PREHOSPITAL AND EMERGENCY CARE IN ASMARA In the capital city of Asmara, an emergency medical service system is in place that functions at a very basic level. The ambulance system consists of approximately 10 transport vehicles, all having a stretcher, driver, and crew. The crew is not medically trained, assisting mostly with movement of the patient and stretcher. Operated by the Red Cross of Eritrea, the service may be initiated with a phone call; the phone number is printed on the side of each vehicle. The system services approximately a 40-km radius from the city center. Rural Eritrea has no emergency medical service available. Mekane Hiwot Hospital serves as the main health care facility in the capital city. The Italians built the facility in the 1930s with the popular design of the time, having multiple small separate structures serving as individual wards. Portions of the hospital have been recently updated, including a large pediatric hospital and new intensive care unit. There
MICHAEL D. BROWN • EMERGENCY MEDICINE IN ERITREA
are approximately 500 beds; however, most of these beds are located directly adjacent to one another in the open room wards. The Emergency Department, referred to as the First Aid unit, is staffed by hospital physicians from various specialties on a rotating basis. Although the care of trauma is its primary focus, it also serves as an outpatient clinic and triage area for the major specialty departments with any significant medical, obstetric, or gynecological problem triaged to their respective wards for evaluation. In the First Aid unit, many of the minor procedures are performed by nurses. Minimal equipment is available, and includes oxygen, suction, and suturing supplies. There is no airway equipment, and the only hospital defibrillator is located in the intensive care unit. Laboratory and x-ray are available, but patients must be transported outdoors to a separate building in the hospital complex. All significant trauma cases are transported by stretcher to the operating room for resuscitation, including procedures such as intubation and chest tubes. This also requires a walk through hospital grounds to a separate structure. A general surgeon and anesthesiologist perform the trauma resuscitation. Nursing staff from the nearby intensive care unit will often assist. The only portable x-ray machine is located in the operating area. There is currently no computed tomography in the country of Eritrea. Ultrasound exists, but is mostly used in the Obstetrics unit and is not available for First Aid or trauma patients. A retrospective sample of injury types was obtained for a 3-month period in 1997 (Table 1). All citizens of Eritrea are entitled to free emergency care. The physicians are government employees and are responsible for determining if a patient's medical condition constitutes an emergency. If the visit does not qualify as an emergency, the patient may be obligated to pay for services. The entire hospital is financed by the Government of Eritrea. Donations and support from other nations also contribute to the facility and to the training of health care workers. Recently, a team from Israel assisted with the renovation of the intensive care unit and provided training for both nurses and physicians in the use of the new monitoring equipment and ventilator.
FUTURE OF EMERGENCY CARE After 30 years of civil war, the people of Eritrea are enthusiastic about their future as an independent nation.
413
TABLE1. Types of Injuries Treated in the ED, January through March, 1997
Injury Bicycle accident Blast Bullet Extremity fracture Motor vehicle accident with head injury Laceration Other Total
Pediatric Elderly (<16 yrs) Adult (>65yrs) 13 6 0 4 8 27 17 78
10 4 8 11 30 54 122 243
3 0 0 2 1 2 9 17
NOTE: Data obtained by retrospective review of written patient log; no computer database available.
There is currently a renovation of Mekane Hiwot Hospital underway, to include a new Emergency Department. Although the largely rural population of Eritrea would derive little benefit from an advanced emergency health care system, those living in Asmara will receive improved emergency care. There are also plans for a state-of-the-art private hospital, the Asmara Medical Center. The developers hope to provide specialized medial services to a large portion of northeast Africa and the nearby Arab nations. This facility would not be supported by public funds and would require private insurance or direct payment by the patient. As these projects mature, physicians as well as other health care providers will require training in the technologies that will soon be available.
REFERENCES 1. Borgna Brunner (ed): 1998 Information Please Almanac. Wilmington, MA, Houghton Mifflin Co, 1997 2. Robert Famighetti (ed): The World Almanac and Book of Facts 1998. Mahwah, NJ, K-Ill Reference Corp, 1997 3. Kirsch TD, Holliman CJ, Hirshom JM, et al: The development of international emergency medicine: a role for US emergency physicians and organizations. Acad Emerg Med 1997;4:996-1001 4. Connell D: Eritrea: starting from scratch. Monthly Review 1995;47:29 5. Pateman R: Eritrea, even the stones are burning. Lawrenceville, NJ, The Red Sea Press, Inc, 1990 6. Hammer J: Back from the ruins; can this be an African nation that works? Newsweek 1996; 127:40
From the Spectrum Health/Michigan State University Program in Emergency Medicine, Grand Rapids, MI. Manuscript received May 26, 1998; accepted June 2, 1998. Address reprint requests to Dr Brown, Department of Emergency Medicine, 100 Michigan Ave, NE, Grand Rapids, MI 49503. Key Words: Emergency medicine, Eritrea, international. Copyright © 1999 by W.B. Saunders Company 0735-6757/99/1704-0023510.0(3/0 412
the coast. Eritrea's isolation during the war protected its population from the devastating spread of HIV seen in other parts of Africa. Although HIV is present, educational and prevention efforts are underway to contain its transmission. There are relatively few automobiles in Eritrea; however, this is changing rapidly, and the number of motor vehicle accidents is increasing. Bicycles remain one of the major modes of transportation in Asmara and account for a significant percentage of injuries; helmets are almost nonexistent. Penetrating injuries from handguns are extremely rare. Blast injuries from land mines are still encountered because some of the mines from the countryside have not yet been cleared. HEALTH CARE SYSTEM During the war, the Eritrean people showed their selfsufficiency by developing a wartime emergency system with the limited resources at hand. In 1972, the EPLF started training the "barefoot doctors" who ran the hospitals behind enemy lines. 5 These mobile operation tents and wards were often underground and had a capacity of 150 to 200 beds. These large subterranean complexes also contained schools .6 Currently, the health care system consists of a few main hospitals in the larger cities, with a network of clinics and small mission hospitals in the rural areas. The Ministry of Health manages the system and is primarily responsible for providing most of the medical care for the citizens of Eritrea. Although there is currently no medical school or formal residency training program for physicians, there is a medical education system for nurses and other health care providers. PREHOSPITAL AND EMERGENCY CARE IN ASMARA In the capital city of Asmara, an emergency medical service system is in place that functions at a very basic level. The ambulance system consists of approximately 10 transport vehicles, all having a stretcher, driver, and crew. The crew is not medically trained, assisting mostly with movement of the patient and stretcher. Operated by the Red Cross of Eritrea, the service may be initiated with a phone call; the phone number is printed on the side of each vehicle. The system services approximately a 40-km radius from the city center. Rural Eritrea has no emergency medical service available. Mekane Hiwot Hospital serves as the main health care facility in the capital city. The Italians built the facility in the 1930s with the popular design of the time, having multiple small separate structures serving as individual wards. Portions of the hospital have been recently updated, including a large pediatric hospital and new intensive care unit. There
MICHAEL D. BROWN • EMERGENCY MEDICINE IN ERITREA
are approximately 500 beds; however, most of these beds are located directly adjacent to one another in the open room wards. The Emergency Department, referred to as the First Aid unit, is staffed by hospital physicians from various specialties on a rotating basis. Although the care of trauma is its primary focus, it also serves as an outpatient clinic and triage area for the major specialty departments with any significant medical, obstetric, or gynecological problem triaged to their respective wards for evaluation. In the First Aid unit, many of the minor procedures are performed by nurses. Minimal equipment is available, and includes oxygen, suction, and suturing supplies. There is no airway equipment, and the only hospital defibrillator is located in the intensive care unit. Laboratory and x-ray are available, but patients must be transported outdoors to a separate building in the hospital complex. All significant trauma cases are transported by stretcher to the operating room for resuscitation, including procedures such as intubation and chest tubes. This also requires a walk through hospital grounds to a separate structure. A general surgeon and anesthesiologist perform the trauma resuscitation. Nursing staff from the nearby intensive care unit will often assist. The only portable x-ray machine is located in the operating area. There is currently no computed tomography in the country of Eritrea. Ultrasound exists, but is mostly used in the Obstetrics unit and is not available for First Aid or trauma patients. A retrospective sample of injury types was obtained for a 3-month period in 1997 (Table 1). All citizens of Eritrea are entitled to free emergency care. The physicians are government employees and are responsible for determining if a patient's medical condition constitutes an emergency. If the visit does not qualify as an emergency, the patient may be obligated to pay for services. The entire hospital is financed by the Government of Eritrea. Donations and support from other nations also contribute to the facility and to the training of health care workers. Recently, a team from Israel assisted with the renovation of the intensive care unit and provided training for both nurses and physicians in the use of the new monitoring equipment and ventilator.
FUTURE OF EMERGENCY CARE After 30 years of civil war, the people of Eritrea are enthusiastic about their future as an independent nation.
413
TABLE1. Types of Injuries Treated in the ED, January through March, 1997
Injury Bicycle accident Blast Bullet Extremity fracture Motor vehicle accident with head injury Laceration Other Total
Pediatric Elderly (<16 yrs) Adult (>65yrs) 13 6 0 4 8 27 17 78
10 4 8 11 30 54 122 243
3 0 0 2 1 2 9 17
NOTE: Data obtained by retrospective review of written patient log; no computer database available.
There is currently a renovation of Mekane Hiwot Hospital underway, to include a new Emergency Department. Although the largely rural population of Eritrea would derive little benefit from an advanced emergency health care system, those living in Asmara will receive improved emergency care. There are also plans for a state-of-the-art private hospital, the Asmara Medical Center. The developers hope to provide specialized medial services to a large portion of northeast Africa and the nearby Arab nations. This facility would not be supported by public funds and would require private insurance or direct payment by the patient. As these projects mature, physicians as well as other health care providers will require training in the technologies that will soon be available.
REFERENCES 1. Borgna Brunner (ed): 1998 Information Please Almanac. Wilmington, MA, Houghton Mifflin Co, 1997 2. Robert Famighetti (ed): The World Almanac and Book of Facts 1998. Mahwah, NJ, K-Ill Reference Corp, 1997 3. Kirsch TD, Holliman CJ, Hirshom JM, et al: The development of international emergency medicine: a role for US emergency physicians and organizations. Acad Emerg Med 1997;4:996-1001 4. Connell D: Eritrea: starting from scratch. Monthly Review 1995;47:29 5. Pateman R: Eritrea, even the stones are burning. Lawrenceville, NJ, The Red Sea Press, Inc, 1990 6. Hammer J: Back from the ruins; can this be an African nation that works? Newsweek 1996; 127:40