Potential of a Hand Transplantation Program in Colombia

Potential of a Hand Transplantation Program in Colombia C. Moreno, J. Bermúdez, L.F. Latorre, and R. DeBedout ABSTRACT The protocols and published results on hand transplantation show acceptable results of this technology. None of the registered groups, however has a sufficient number of patients to allow continuity of the process. In Colombia the main problems are violence, drug traffic, and guerrillas. Thanks to the profitability of drug traffic, guerrillas, who initially were created based on ideologic differences, have become terrorist groups whose main source of income is drug traffic. From that interest comes the use of landmines to protect illicit crops. Colombia is the most mined country in the world, followed by Cambodia and Afghanistan, and the only country in Latin America where there are still landmines. The mines, violence, and trauma produce a large number of people with disabilities and amputations. From 1990 to 2006, the number of victims rose from 21 to 1,041 per year. In Colombia, amputations are more frequently due to trauma than to disease. The fact that 88% of the victims are children and people of working age, affects the political and economic development. These alarming numbers generate a challenge for government, which has led to the creation of policies and laws aimed at comprehensive action against mines. This program under the Presidency has among its objectives assistance to victims, including integrated treatment, prostheses, and other procedures, financed entirely by the government. The number, type of victims, and their motivation to be transplanted, along with government programs directed to their attention, are key factors that we think will enable the continuity of our hand transplantation program at the Fundación Santa Fe de Bogotá, giving Colombia the unfortunate privilege of having the largest number of potential patients for transplantation. ased on the concern to establish a hand transplantation program in Colombia, we began a feasibility study to evaluate the technical capacity and other conditions to implement it. The objectives were as follows. To Assess the feasibility of hand transplant program in Colombia, we sought to identify our technical and scientific capacity. To identify demographic, social, economic, and political factors that will give continuity to the program in Colombia, we documented the number of potential candidate. To evaluate demographic, social, economic, and political factors that permit continuity of the program in Colombia, we enumerated potential patients by evaluating statistics from the National Statistics Administrative Department (DANE) are victims of disabilities and violence, reports from the Presidential Program for the Integral Attention Against Landmines regarding the number of and care for the victims, the social problem of violence by armed groups operating outside the law, drug trafficking, violence, and

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accidents as a factor increasing the possibility of upper limb amputations, the Colombian health system, special regimes (Ministry of Defense, occupational insurance) as possible payers for transplantation, and government programs and laws to treat victims of violence with protection and rehabilitation of the disabled. We established the hand transplant program as a line of research in our institution. MATERIALS Our evaluations of the feasibility and documentation of our technical and scientific capacity were based on the publications of Amirlak et al.1 and Gordon et al,8 which presented guidelines to facilitate access to relevant information about the transplantation process. Hand transplantations should be performed only at institutions with a multidisciplinary team and appropriate technology. Address reprint requests to Constanza Moreno, MD, Division of Hand and Microsurgery, Orthopedic and Trauma Surgery Department, Fundación Santa Fe de Bogotá University Hospital, Bogotá, Colombia. E-mail: [email protected]

© 2011 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710

0041-1345/–see front matter doi:10.1016/j.transproceed.2011.10.014

Transplantation Proceedings, 43, 3529 –3532 (2011)

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3530 To identify the demographic, social, economic, and political factors that allow the continuity of the program, we extracted a search for National Statistics Administrative Department publications about disabilities and victims of violence.5,6 We made several visits to the Presidential Program for Comprehensive Action Against Antipersonnel Mines, which has worked on integral rehabilitation programs for victims, analyzed existing data regarding the number of victims, their care sites, and their rehabilitation status.10,11 We made a detailed analysis about the social problems and violence in our country, including the war process in Colombia12 and its beginnings, philosophy, and funding sources. Based on this we analyzed the problems of public order and insecurity that make violence a major factor in the number of people likely to be candidates. An assessment was performed of the health coverage systems for patients in Colombia,2,3 taking into account the special regimes with emphasis on the pursuit of current laws for attention to victims of violence and landmines.

RESULTS

The evaluation of the technical and scientific capacity showed that this institution meets all of the requirements for implementation. Its hand surgeons have knowledge and experience in reconstructive microsurgery and replantation surgery, knowledge of the process of solid organ transplant, including the immune processes and follow-up. Its entire team of solid organ transplant specialists are trained in the evaluation of recipients and donors, planning, and development of follow-up protocols. The program started in 1988 with kidney and liver transplantation programs. This service has a rigoros process of management and quality of care as a result of experience, strict adherence to protocols, and excellence in medical and paramedical practice. The liver transplantation program has performed ⬎ 150 procedures in adults and children, now grafting 35 to 40 subjects per year. Over 250 kidney transplantations have been done with a 5-year survival rate of ⬎ 85%. Laparoscopic nephrectomics from living donors are done according to international standards. The program is accreditet by Icontec, the entity responsible for accreditation of health institutions in the country and internationally by the International Joint Commission. In Colombia, the main problems are violence, drug trafficking, and guerrillas. After our independence, the country had weak institutions, was poorly settled, and was governed without adequate means to perform its functions. The population felt it was legitimately freed, but the military institution was the only one that maintained authority. It was a highly militarized society in the sense that the militia dominated all social orders. Wars, were generally political. Between 1948 and 1960, a process of violence developed based on ideologic differences between political parties, mainly left vs right. During that period, communist guerrillas began to appear in Colombia and Latin America. They were associated with the Cuban revolution in 1959, which in 1962 began to take was revealed on a MarxistLeninist character. Internal armed movements were created as the preferred routes to destabilize nations. Colom-

MORENO, BERMÚDEZ, LATORRE ET AL

bia became the scene of conflicts due to revolutionary wars. Rural guerrillas, originating partly within peasant bands, grew in the forested and mountainous areas of the Andes. These groups began to organize armies (Popular Liberation Army, Revolutionary Armed Forces of Colombia [FARC], National Liberation Army, etc), which conquered territories and became stronger. Over time, and into the 1990s, Colombia became the leading producer of coca in the world. Its expansion occured in the southern jungle area, where the most significant groups of FARC had settled. This new source of income gave FARC a military-political horizon and social base.12 Antipersonnel mines used as a means to protect their illicit crops. Worldwide landmines and unexploded cluster munitions cause a significant number of injuries to the musculoskeletal system. In every conflict since 1938, landmines have been used extensively, resulting in death or injury to noncombatants, rather than only achieving military objectives. The use of mines has increased; terrorist weapons deployed on civilian populations seek to limit their access to properties, roads, and even basic needs.13 A mine victim may suffer initially from any of the following: multiple injuries due to fragmentation, amputation of one or more limbs, and loss of senses, such as sight, hearing, or touch. If the person survives the initial injury, he is confronted by a functional loss, disfigured body, chronic pain caused by injury or amputation, and posttraumatic stress syndrome. Reintegration into society depends on physical rehabilitation, patient motivation, and the support system.9 Unfortunately, there is little information about outcomes of individuals who suffer amputations as a result of mines. Limited studies have suggested that these lesions have far-reaching effects. Studies about the social costs of landmines in Afghanistan, Bosnia, Cambodia, and Mozambique have shown that 25% to 87% of the victims have difficulties to perform activities of daily living, and more than 6% of the households have at least one affected person. Most mine incidents occur in developing countries or regions where the victims are peasants, farmers, or displaced persons. As a source of livelihood, they depend on their skills. Survivors need to regain their abilities to participate in their family life, work, and society. One study has suggested that households with a landmine victim were 40% more likely to have difficulties to provide food for the family.13 It concluded that the cost of medical care and rehabilitation adds to the economic disability and to the physical burden resulting from a mine injury. If the victim is a child, his future is at stake, because he will depend on others for the rest of his life. In some cases, victims of landmines have become beggars to survive. Landmines have disabled individuals, left families with a disability, and maimed whole societies. Their effects are widespread and continue long after the conflict has ended.7 Colombia is the most mined country in the world, followed by Cambodia and Afghanistan, and the only Latin American country where there are still landmines. In 31 of

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the 32 country’s departments, the population is at risk by the presence or suspected presence of antipersonnel mines (APMs) and unexploded cluster nunitions (UCMs).11 Armed groups on all sides have used, and non–stak-armed groups continue to use, (APMs), and improvised explosive devices (IEDs) as tools to halt the advances of the other side. A total of 714 of the 1,099 municipalities in Colombia have experienced an event, involving landmines. The number of events shows an increasing trend to 2004, the after which there were decreases in 2005, 2007, and 2008 and increases in 2006 and 2009. Despite this, between 2002, year in which the Democratic Security Policy started and 2009, the number of events has increased by 56% (Fig 1), which contrasts with other safety indicators, such as subversive activities, which were reduced by 55% over the same period. The presence of APMs and UCMs affects the mobility of people, the productivity of land, and governance. In Colombia, 97% of events occur in rural areas. There is high overlap between illicit crops and APMs/UCMs11 (Fig 2). Mines, violence, and trauma produce a large number of people with disabilities and amputations. Throughout the country, 857, 132 people are registered with disabilities, of which 12% are victims of mines and violence.5,6 From 1990 to 2006, the number of victims has risen from 21 to 1,041 per year.11 In Colombia, amputations are more frequently due to trauma than to illness.6 Social, political, and economic development is affected, because 88% of victims are children working-age adults.11 In response to this problem, the country has a legal framework and institutions, whose mission is to develop coordinated actions: Comprehensive Action Against Antipersonnel Mines and Unexploded Cluster Munitions (AICMA). They are guided by a State Policy and a National Plan 2004 –2009 designed and executed by all stakeholders for a sustainable, effective, and verifiable approach (Law of the Republic number 812 of 2003, and Colombian National Development Plan 2002 to 2006.) The country also has a general legal framework regarding assistance to victims, survivors, and their families affected by APMs and UCMs, one of the main components of AICMA in the country. Law 418 of 1997 regulates the rights of victims of violence, among which are those from APMs.

Fig 1. Events reported caused by landmines and unexploded cluster munitions 1999 to 2009.4

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Fig 2. Illicit crops and their relationship with landmines and unexploded cluster munitions. Red points correspond to landmines and unexploded cluster munitions Yellow Ponts correspond to illicit crops.

Subsequent Laws 548 of 1999 and 782 of 2002 modify, add, and extend its scope.10 Decree 1283 of 1996 regulates the operation of the Solidarity and Guarantee Fund from which pays for health care and compensation for victims of violence. Integrated attention to the victims of APMs and UCMs should be provided without preconditions and with no cost to the victim or his family.10 This is a priority of the Colombian government. In 2005, a Critical Path for the Care of Victims of APMs and UCMs was developed in coordination with the Technical Subcommittee on Victim Assistance. Each institution is responsible to seek solutions in the areas of their competence to make the service directed for the victims easier, more timely, and comprehensive. The “Path” identifies the roles and responsibilities of each of the institutions providing health services in the integrated care, from the time of the accident until rehabilitation. Similarly, it has a booklet of benefits to which victims are entitled by Law 418 of 1997. In response to the AICMA, Colombia has developed a strategy to strengthen regional capacities for decentraliza-

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tion of AICMA in conjunction with local governments. The system is coordinated regionally through departmental intersectoral committees. The departments, handled by regional governments, have included action plans at municipal level to work with the affected and at risk communities. This process integrates all voices within a humanitarian approach and according to regional particularities. Its purpose is to promote, guarantee, and repair the right to life as well as the integrity, liberty, and territory of affected and at-risk populations, creating conditions so that individuals, families, and communities achieve social, political, and economic development despite the conditions of violence in the country.10 Colombia has an up-to-date system of information management that maintains detailed information on the problem of landmines and records of the monitoring of victims. Some strengthening projects are being advanced to supply rehabilitation services, and to consolidate regional rehabilitation networks in coordination with the Ministry of Social Protection.10 In Colombia, through Law 100 of 1993, amended and extended by Law 1438 of 2011, the comprehensive Social Security System seeks to ensure the constitutional rights of the individual and the community to obtain a quality of life consistent with human dignity and to protect the associated contingencies. The system includes the obligations of the State, society, institutions, and resources destined to ensure coverage of health and economic benefits as well as complementary services, subject to the principles of efficiency, universality, solidarity, integrity, unity, and participation. By mechanisms subject to the constitutional principles of solidarity, its objectives are to ensure health and economic benefits for those who have an employment relationship or sufficient economic capacity to join the system; ensure the provision of complementary social services, and facilitate extension of coverage until the entire population has access to the system. The philosophy allows sectors without sufficient economic capacity access to the regime and grants benefits in an integrated manner. The Comprehensive Social Security System has been established to unify the regulations and planning of the social security system, as well as to coordinate the providing entities to achieve these objectives.2,3

MORENO, BERMÚDEZ, LATORRE ET AL

The warranty conditions on the provision of health care to victims, within the scope of an academic institution, are supported by the Faculty of Medicine at the Andes University. They will facilitate the development of a hand transplantation program as a line of research with continuity in the Section of Hand Surgery of the Orthopedic Surgery and Traumatology Department. In conclusion, The number, type, and motivation of victims to receive transplants, along with government programs directed to their attention, are key factors that we think will enable the continuity of our hand transplantation program to address the large number of potential patients for transplantation in Colombia.

REFERENCES 1. Amirlak BGR, Gorantla V, Breidenbach WC, Tobin GR: Creating a Hand Transplant Program. Clin Plastic Surg 34:279, 2007 2. Congreso de la Republica de Colombia: Ley Número 100 de 1993 3. Congreso de la Republica de Colombia: Ley 1438 de 2011 4. Davila Ladron de Guevara A: Informe de Gestion Programa Presidencial de acción integral contra minas antipersonal (PAICMA), Enero-Diciembre de 2009. Bogotá: Vicepresidencia de la Republica de Colombia, 2010 5. Departamento Administrativo Nacional de Estadistica (DANE): Información estadı´stica de la discapacidad. Bogota: 2004 6. Departamento Administrativo Nacional de Estadı´stica (DANE) Identificación de las personas con discapacidad en los territorios desde el rediseño del registro. Bogota: 2008 7. Giannou C: Antipersonnel landmines: facts, fictions, and priorities. BMJ 315(7120):1453, 1997 8. Gordon CRSM: Requirements for the Development of a Hand Transplantation Program. Ann Plast Surg 63:262, 2009 9. Meeting of State Parties: Convention on the prohibition of the use, stockpling, production and transfer of anti-personnel mines and on their destruction. Serbia and Montenegro: 2006 10. Observatorio de Minas Antipersonal: Asistencia victimas de minas antipersonal y municiones sin explotar. Cartilla de beneficios para victimas de MAP y MUSE. Bogotá: Vicepresidencia de la Republica de Colombia, 2004 11. Observatorio de Minas Antipersonal: Situación actual de minas antipersonal en Colombia. Bogota: 2006 12. Pardo Rueda R: La historia de las guerras. Bogota: 2004 13. Walsh NEWWS: Rehabilitation of landmine victims—the ultimate challenge. Bull World Health Org 81, 2003, p 1