Surgical care for the direct and indirect victims of violence in the eastern Democratic Republic of Congo

The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities [1]. Armed conflict often occurs in low-income countries where fragile health care systems are rapidly overwhelmed during periods of violence and associated population displacement. In such situations, the population becomes even more vulnerable to threats such as poor hygiene, malnutrition, infectious diseases, rape, and poor antenatal care [2]. Infections and obstetric emergencies in particular contribute to substantial mortality in these settings and surgical interventions can make an important contribution to reducing death and disability [3].

An accurate understanding of the surgical needs of populations in conflict is therefore important for program planning and resource allocation. Program audits for Médecins sans Frontières (MSF) operations during 2008 found that only 30% of surgical interventions were due to violence-related injuries; the majority of interventions were for obstetric emergencies and accidental trauma [1]. In this paper we report on surgical interventions carried out by MSF in a zone of active conflict in Masisi, North Kivu, Democratic Republic of Congo, and describe risk factors for violence-related injury.

From September 2007 to December 2009, 2869 operations were performed on 2441 patients (15% re-interventions). The majority (1855, 76%) were female. Median age was 24 (interquartile range 18-31); 152 (6%) were under 5 years of age. Sixty-one patients (3%) were in the military.

1263 (44%) procedures were performed under spinal anesthesia; 1263 (44%) under general anesthesia without intubation, and only 115 (4%) under general anesthesia with intubation. Immediate peri-operative mortality was 0.2% (20); however, in-hospital mortality was unknown.

Surgical Pathology

We found that obstetric emergencies accounted for over half (1463, 51%) of all surgical pathologies, and infections for another quarter (498, 17%). Trauma-related injuries accounted for only one quarter (681, 24%) of all interventions; among these, 363 (13%) were violence-related (Table 1). The proportion of violence-related cases varied from 0-56%, with peaks occurring during major clashes (Figure 1). Gunshot wounds accounted for 94% (341) of violent injuries (Table 2). The most common non violence-related injuries were burns and falls. The most common procedure for trauma was wound debridement while the most common non-trauma-related procedure was Cesarean section (Table 3).

	N	(%)
Obstetrical Emergencies	1463	(51)
Infections	498	(17)
Violence-related Injuries	363	(13)
Accidental Injuries	318	(11)
Other*	142	(5)
Neoplasms	82	(3)
	2869	(100)

*Congenital, Iatrogenic, Vascular, Other Pathology

	N	(%)
Gunshot Wound	341	(94)
Knife	13	(4)
Torture	5	(1)
Rape	3	(1)
Missile	1	(0)
Total	363	(100)

Trauma	N	(%)	Non-Trauma	N	(%)
Wound Debridement	206	(30)	Cesarean section	1304	(60)
Dressing Changes under Sedation	184	(27)	Suturing, I and D, Circumcision	237	(11)
Suturing, Incision and Drainage	126	(19)	Tubal ligation/Dilation and curretage	113	(5)
Fracture Reductions	64	(9)	Dressing Changes under Sedation	112	(5)
Abdominal Surgery/Bowel Resection	21	(3)	Abdominal Surgery*	97	(4)
Amputations	20	(3)	Wound Debridments	94	(4)
Skin Grafts	17	(2)	Minor Surgery**	81	(4)
Other	43	(6)	Other	76	(3)
Total	681	(100)	Total	2188	(100)

*Bowel resections, appendectomies, removal of tumors

**Herniorraphy, Hydrocele repair, hemmorrhoid surgery

This is among the few studies to describe the typology of emergency surgical care in a conflict zone. We found that in this war-ravaged area of Eastern DRC most surgical interventions were unrelated to violent trauma but rather reflected the general surgical needs of a low-income tropical country. Most of the emergency procedures performed were similar to those performed in hospitals in low-income countries not in conflict [9, 10]. The prevention of maternal and fetal mortality was the most common reason for emergency surgery in the Masisi program. Like many populations who suffer a general lack of access to primary health care, this population suffered from accidents, infections, and late-stage neoplastic infections.

These findings are consistent with program audits from other conflict zones in resource-limited settings. A retrospective review of surgical services of Médecins Sans Frontières in six conflict-settings in both Africa (Chad, Somalia, South Sudan, Democratic Republic of Congo, and Central African Republic) and South Asia (Pakistan) found that only 22% of surgical interventions were due to violent injury, while obstetric emergencies accounted for almost a third (30%) of interventions and accidental injury and infections another third [1].

Male soldiers younger than 20 years of age were more likely to present with violent trauma. While those patients suffering from violent trauma only accounted for 13% of the surgical cases, they needed special support such as long-term rehabilitation and psychological counseling. Hospitals in war zones should plan for these needs.

Our study demonstrated that while this project had fully trained surgeons and anesthesiologists, most of the procedures performed were basic. This was in part due to the limitations of the equipment and the lack of post-operative intensive care. Also, there was likely to be a selection bias against complex trauma, as patients with severe head or chest trauma likely never made it to the hospital as pre-hospital transport took hours to days. Nevertheless, this finding is important as it indicates that most procedures can be performed by general doctors or non-physician clinicians with surgical skills. For example, it has been shown that the most common surgical intervention, emergency obstetrical care, can with adequate training and supervision be performed safely performed by non-doctors [11–13]. In low-income settings such as Niger, Malawi, and Mozambique, surgical task-shifting has resulted in an increased provision in essential surgical services [14, 15]. Similarly, most of these procedures were safely performed with spinal anesthesia and ketamine (general anesthesia without intubation) which are safer types of anesthesia to administer for nurse-anesthetists or anesthesia providers that are informally trained.

The potential for non-surgeons to manage a substantial proportion of surgical needs in resource-limited conflict areas is an important consideration given the lack of local surgeons in resource-limited settings [16] and the danger posed to expatriate surgeons (in particular, the higher risk of kidnapping in certain contexts). In Somalia, where MSF expatriate surgeons are not allowed due to insecurity, all surgical procedures are performed by non-surgeons; operative mortality is <1%. Studies from other settings demonstrate that the training of general doctors with surgical skills and nurse anesthetists is possible, even in a conflict zone [16, 17].

This study has certain limitations. The reported numbers of war-wounded were often higher than the number of victims treated at Masisi district hospital, which was the only health care facility providing surgical care in this community. While some likely died prior to arriving at the hospital from severe injuries, others may not have sought care. This study did not measure reasons for service uptake. While all care was free, there may have been other barriers to accessing care including transportation, insecurity, and other family responsibilities. Civilians and soldiers from both sides of the conflict were treated confidentially and respectfully by hospital staff; however, regional and tribal differences between staff and patients may have prevented some patients from seeking care. Special attention to improve access to care for the war-wounded and IDPs is needed.

Collecting data in conflict settings is challenging, but not impossible [18]. Our study was limited by our data collection methods. While our coding system captured broad categories of surgical pathology, it was limited in documenting types of operations. The coding system did not distinguish between some minor surgeries such as herniorraphy, hydrocele repair, and hemorrhoid surgery or wound suturing, incision and drainage of abscesses, and circumcision. Knowing the exact cause of many diseases without radiology or pathology services was also difficult. We did not have long-term follow-up of patients nor did we track surgical site infection. While this study described the burden of essential surgical disease in a conflict zone, it could not determine the burden of elective surgical disease. Even though many patients with elective surgical disease were evaluated at the hospital, this was unlikely representative of all the type of surgical disease in the community. Population based studies are needed to estimate the unmet burden of elective surgical disease.

In conclusion, programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. While military patients have a greater relative risk of violence-related injuries, civilians still make up the majority of violence-affected cases in terms of absolute numbers. Training of local staff and task-shifting is essential to ensure that surgical services will be provided when conditions become too dangerous for expatriate surgeons to work in the area. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and ultimately the effectiveness of the humanitarian response.