The WHO classified snakebite envenomations as an NTD in 2017 for causing enormous suffering, disability, and premature death worldwide. Bites by venomous snakes can cause paralysis, fatal hemorrhages, irreversible kidney failure, tissue damage and more, leading to permanent disability and limb amputation. Over half the world’s envenomation events and deaths occur in India; this epidemic has been termed “the neglected famer’s tragedy” due to a disproportionate increase in agricultural areas, and a “therapeutic black hole” due to ineffective or unavailable interventions within the region. With 5.8 billion people at risk of encounters, and 2.7 million reported cases of envenomings, it is estimated that there are between 81,000 to 138,000 deaths and countless more debilitating injuries each year in the country. 

The WHO developed the Snakebite Envenoming Strategic Plan which calls for a 50% reduction in mortality and disability caused by snakebite envenoming by 2030 through 4 goals: 

1. Empower and engage communities.
2. Ensure safe, effective treatment.
3. Strengthen systems.
4. Increase partnerships, coordination, and resources through strong collaboration.

Project Proposal

Our project focuses on the first WHO goal; Empower and engage communities.  However, it includes aspects of all the 2030 goals by creating an education system that will help prevent envenomations and arm the community with a safe plan to approach such events to reduce morbidity and mortality. The project will focus on educating and engaging community leaders, to promote sustainability and community engagement.  These community leaders will be trained to teach and discuss topics including characteristics of venomous and non-venomous snakes, dispelling, and discussing common misconceptions surrounding proper envenomation management, first-aid, initial management, and stabilization.  Community leaders and community members will also be connected with national partners like the National Snake Bite initiative (NSI) as well as international partners like WHO through The Platform, an interactive Application that allows the public to participate in reporting events and venomous snake sightings, slowly creating a regionalized database. 

Qualitative surveys before and after educational campaigns on community knowledge, perceptions, sociocultural and spiritual understanding and depiction of snakes and snakebite envenoming can help to measure how receptive communities have been to the program. Since envenomation events are underreported, it is difficult to assess any qualitative differences (hospital admission events), however, since we plan to implement this program on a community-by-community basis it may be possible to investigate numbers through local health ministries, clinics, and hospitals to assess different trends before and after program implementation.

Based on the WHO Snakebite Working group budget we estimate this project would not cost more than $15,000 USD, with much of the funds allocated to program creation, program coordinators and educators, community leaders, and program creation.  The WHO allocated over $140 million USD over 10 years worldwide to this problem and $650,000 USD to community education in 10 countries.  Using this logic, we estimated that more than $65,000 would be allocated to a country like India.  If this project were to pilot its educational campaign in a specific region, we estimate no needing more than $15,000 USD. 

By partnering with national partners on the ground like the NSI and community leaders who will continue to train and educate, this program will become sustainable through working with those that are inherently invested in more positive outcomes through education in their own communities. Additionally, the WHO’s Platform application will be promoted during educational programming to further engage and empower the community to take an active role in their own education and safety by sharing photos of potentially venomous snake sightings along with their location data. By promoting effective interventions involving education surrounding proper venomous snake identification, snake education, medical interventions, and effective reporting this program will reduce snake bite deaths and long-term disability and empower at risk communities in India to take their safety into their own hands.  

Discussion

After presenting the proposal to the group, we engaged in discussion on this proposal. One of the questions that sparked deep and insightful conversation was “Why is the focus of this project education, and not ensuring that are adequate and strategically placed life saving anti-venom available?”

Below is a summary of the most pertinent ideas posed:

1. Many companies producing have stopped/gone out of business and even if there was plentiful supply it would still not help with preventing or addressing the problem when most cases of snakebite envenomation that occur are not reported.

2. With an educational campaign the people are able to take power into their own hands.

3. The cost benefit ratio of this method is extremely low. Many people reside far away from any form of health care and in India, the cost of initial treatment has been reported to be as high as USD$ 5,150, which makes investments in anti-venom unsustainable. 

Background

Worldwide, road traffic accidents (RTAs) account for about 1.3 million fatalities and, on average, 3% of a given country’s GDP. Over half of these deaths occur among vulnerable road users, such as pedestrians, cyclists, and motor cyclists. Approximately 93% of all of the world’s RTA-associated mortalities occur in middle- to low-income countries, even though they have only 60% of the world’s vehicles. Road traffic injuries cause considerable economic losses to individuals, their families, and to countries as a whole that take a considerable toll even years or decades after the incident occurred. These losses arise from the cost of treatment as well as lost productivity for those killed or disabled by their injuries, and for family members who need to take time off work or school to care for the injured.

 The country of Ghana experiences, on average, 2,000 RTA-associated deaths and 14,000 RTA associated injuries annually. At the Korle-Bu teaching hospital in Accra, Ghana, the largest health facility and teaching hospital in Ghana and the main referral site for all of southern Ghana, between 2016 and 2017, 62% of deaths in the hospital’s accident center were related to RTAs. These RTA-associated deaths and injuries cost the country around 1.6% of its GDP, which amounts to over $1.3 million per year.

In the early 2000s, the Ghanaian government began to recognize the serious socio-economic impact of RTAs on its country. To address the issue, the National Road Safety Commission (NRSC) was established to collect data on RTAs and propose solutions and policies in response. Various data was collected, such as the number of annual deaths and injuries and road user classes associated with these fatalities. Data collected demonstrated that, in Ghana, the road user class with the highest share of fatalities was consistently  pedestrians (824; 39.5%) followed by motorcycle users (437; 21%) and bus occupants (364; 17.5%). Considering RTAs in the context of emergency care, studies showed that, again at the Korle-Bu Teaching Hospital, almost 40% of emergency care visits were from RTAs, followed distantly by falls and interpersonal violence. Of the victims that died upon or after arrival to the hospital, 50% were pedestrians, 31% were passengers, and 18.7% were motorists.

From the numbers provided, it’s readily apparent that deaths caused by injuries, and, specifically, RTA-associated injuries, rank among the top ten causes of death in Ghana. It was concluded that underlying drivers of this issue were broadly two-fold: there was a high proportion of RTA-associated injuries due to poor road conditions and unregulated driving practices, and emergency care providers were lacking in proper, formal trauma-based care, both prehospital and when they arrived to an emergency care facility.

To address these shortcomings, various sizable mitigation measures were adopted by Ghana’s government in an attempt to decrease the number of RTAs and their associated costs. In 2004, Ghana established a National Ambulance Service (NAS), providing over 200 ambulances staffed with formally trained, BLS-certified EMTs for pre-hospital care. Ghana’s first EM residency program was established in 2009, followed one year later by its first 2-year Emergency Nursing degree program. More recently, in 2019, the NRSC passed the National Road Safety Authority Acts that were designed to promote and mandate best road safety practices, both in road users and road developers. However, despite these resolutions, RTAs and their associated injuries and deaths continue to remain consistently high in the country.

A literature review of available research on Ghanian RTAs revealed several limitations in the studies. While the NRSC has been instrumental in collecting RTA data and devising protocols to mitigate RTAs, there is still a lack of detailed, objective research on RTAs in Ghana. Additionally, there are significant inconsistencies in the source of the data and whether it is a registry-based report or a population-based study. The causes of accidents are not well-documented, and there is limited data available detailing where the majority of RTAs occur aside from the regions most heavily affected. According to data from 2016, over 75% of RTAs occur in 5 regions (Ashanti, Greater Accra, Eastern, Central and Brong Ahafo), of which four of the five regions correspond to the four most populous regions (with the exception of Ahafo, which is the least populated). Interestingly enough, however, about 60% of RTA fatalities were in non-urban sections of the road networks. Despite this information, we were unable to find details regarding where the specific accidents occur within each region.

Research collected by the University of Ghana’s School of Public Health identified the following risk factors that were highly associated with RTAs: stop-light violations, improper signaling, speeding. However, we believe that the study used to determine these risk factors relied too heavily on subjective analysis, leading to potentially erroneous and biased data. Therefore, we propose utilizing traffic cameras for gathering objective data in areas with a high burden of RTAs. This analysis will allow local authorities to identify risk factors that lead to RTAs, resulting in the utilization of emergency medicine services.

In short, an objective method of identifying common risks, causes, and associations of RTAs is crucial in order to decrease morbidity and mortality as well as the need for emergency care. This is especially important, as Ghana spends over $130 million USD each year on RTA-related injuries alone.

Project Proposal

We believe one way to do this is to utilize traffic cameras that are already in place in these high traffic areas to analyze accidents. As the infrastructure is already in place for surveillance – all we need to do is collect and analyze the footage, which has limited costs associated with it. We would need to pay salary to 1-2 data analysts in order to analyze the information. If more cameras were needed, this would cost anywhere from $65-80,000 USD per camera installation. After installation and retrieval of the camera data, what information will we collect? First, we would like to identify what specific intersections and roadways are involved in RTAs. We also would collect temporal statistics such as day of the week, month and time of day as well as weather conditions. The type and number of vehicles involved in the accident as well as identifying whether the drivers are local versus nonlocal are also important characteristics. Lastly, we would look at whether drivers violated traffic laws such as running a redlight or were speeding as well as being in the incorrect driving lane.

The data collected from this proposal can be used to promote infrastructure changes to lessen the risk of future RTAs. In particular, the installation of crosswalks have been proven to mitigate incidences of motor accidents. According to a 2017 study, 68% of pedestrian fatalities from RTAs in Ghana are related to “pedestrian crossing behaviors.” However, the study was limited in its ability to deduce further information from these incidents, such as the causality of the accident. The review of the stop light camera footage from the event would allow the local government to determine if more facilities such as crosswalks may be beneficial to install in populated intersections.

Conclusion

The high prevalence of RTAs in Ghana is a public health concern that dramatically burdens the emergency medical community. We believe that the data collected from traffic cameras can be used to more concretely understand the risk factors that lead to motor accidents in Ghana. Ultimately, this information can be used to improve infrastructure features to mitigate risk of future accidents.

Mental health conditions are the leading cause of disability worldwide, accounting for an estimated 175.3 million years lost to disability (Figure 1). Inequalities in access to or quality of mental health care globally are directly related to social, structural, and economic determinants. Increasingly, research suggests that these socioeconomic inequalities lead to health issues not just for disadvantaged populations but for all those involved in unjust or unequal societies. In addition, most of our information on global access to mental health care is limited to formal psychiatric care, which discounts other forms of local or indigenous healing practices.

Disasters have countless impacts on communities and can cause stress due to feelings of powerlessness, loss of community life and culture, and destruction and physical displacement. An estimated 1 in 3 highly exposed trauma survivors may experience post-traumatic stress disorder (PTSD), and 1 in 4 may experience major depression. Psychological distress, which does not meet the criteria for another formal psychiatric diagnosis, is nearly universal after exposure to a disaster and deserves significant attention as well.

It is also crucial to ensure that mental health responses after disasters are conscious of unique local contexts. Previously, priorities in disaster responses have primarily been defined by mental health professionals mostly by nations of the Global North, which gives insufficient attention to locally-defined priorities. These established programs focus mainly on major neuropsychiatric disorders as defined by Western professionals and assume that the features, courses, and outcomes will mirror those seen in the cultures where they were initially developed. Existing programs and literature also tend to focus on PTSD, with other forms and manifestations of psychological distress falling through the cracks. This focus on applying formal diagnosis and treatment assumes that they are generalizable across cultures and may marginalize indigenous forms of healing that could be vital to the community.

Key Priorities

With these concerns in mind, we want to highlight some key priorities in creating a culturally sensitive mental health care program in the post-disaster setting. First, we need to remember that systemic factors such as structural violence and poverty are important determinants of mental health outcomes (Figure 2). Thus it is imperative to first support efforts addressing basic socioeconomic needs and promote physical safety of the population. In addition, mental health programming may be carried out in tandem with medical colleagues addressing other problems to increase coverage and decrease the need for additional infrastructure.  

Figure 2: Proximal and distal factors of the social determinants of mental health with sustainable development goals mapped onto the different domains. 

In assessing the community’s mental health needs, there should be an effort to learn and adapt to the local context, as an individual’s response to suffering is likely influenced by the religious, spiritual, and moral context of the local community. In addition, classification systems used in mental health evaluation (i.e., DSM-5) should be modified to integrate the knowledge of culturally specific idioms of stress, taking into account also differences related to class, gender, age, sexuality, minority/majority position. Lastly, special attention must be given to those with existing psychopathology as these individuals are at risk of having worse outcomes in response to disasters. 

Proposed Solution

Guided by these principles, we proposed examples of programming components that partner with the local community and integrate an understanding of local resources and traditions of healing. 

1. Work with psychologists, community health workers, and local religious leaders to facilitate memorial services in response to possible losses in the community.
2. Promote education on when and where to seek service, especially in social settings that communities frequently gather. 
3. Develop programs that go beyond the toolkit of professionals and mobilize indigenous resources and family-specific social activities to encourage people to also rely on support from immediate social networks. 
4. Partner with specialists to support task-shifting to local non-specialist providers.
5. Establish screening protocols for aid workers and staff working in disaster settings as these individuals are also at risk for mental health issues.

We want to have a continuous evaluation of the program in four outcomes areas, each with different indicators:

• Relevance (indicated by population need and cultural and contextual fit)
• Effectiveness (indicated by mental health outcome)
• Quality (indicated by adherence, competence, and attendance)
• Feasibility (indicated by coverage and cost)

While some of the indicators, such as coverage, helps to define operational characteristics of the program, other factors, such as cultural and contextual need, support the program by engaging with local stakeholders. Information regarding these indicators can be obtained using various methods, including community surveys, national health system records, cohort studies, and observational studies.

Though the world’s mental health burden is experienced heavily in low and middle-income countries (LMICs), often only a tiny portion of the annual operating health budgets in these countries will go toward addressing mental health issues. For example, the Emerald (Emerging mental health systems in LMICs) study, which was a multinational study conducted to assess the infrastructural and policy needs for expanding mental health services in Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda, revealed that in some LMICs, there is less than $0.25 per person per year available for mental health budgeting. In addition to limited resources and finances, mental health programs face other challenges related to sustainability, such as poorly trained staff and a lack of understanding about service delivery processes and quality improvement. High turnover of senior-level policymakers can prevent longitudinal advocacy and agenda-setting, and low community participation can also be a barrier.    

While the exact cost for our program is difficult to predict given system collapse and displacement of populations in the post-disaster setting, here we provide an estimation of a possible budget using the operating budget of the NGO Médecins Sans Frontières (MSF) in 2020 as a starting point. 

• MSF Operating Budget 2020 = €550,000,000 Euros, with 80% spent on programming spending (€440,000,000)
  • €440,000,000 spent across 10 countries = €44,000,000/country in 2020
  • *Presuming 2% for mental health budget allocation = €880,000 for mental health budget/country/year
• ~350,000 Mental Health Consultations across 10 countries
  • ~35,000 Mental Health consultations annually per nation engaged 
• €880,000 / 35,000 consultations = €25/consultation (used for medications, counseling, etc) 

Even assuming just 2% of the operations budget is allocated to mental health programming, it can be estimated that major NGOs may be able to make a more significant fiscal investment in mental health than what public services can currently offer in LMICs. In the emergent setting, the surge of financial resources from these agencies towards affected groups presents new opportunities and motivation for development. Additionally, the destruction or collapse of health systems amidst destabilization may provide opportunities to build more equitable and person-centered care systems. Furthermore, media attention can stir public interest and political willpower to dedicate more resources to mental health treatment systems. 

Historically, international health actors have not prioritized the transition of care from transient emergent systems to nascent local infrastructure. Thus two types of investment are needed to ensure a smooth transition and subsequent strengthening of the local health system. Initially, startup investment from aid organizations is needed to maintain operating budgets amidst transitions. Then continuous funding for long-term service delivery from health departments or public agencies is required to promote infrastructure longevity and tackle some of the previously mentioned system-level challenges impeding sustainability of programming. 

Summary

  In summary, our current understanding of and approach to global mental health focus on priorities does not pay sufficient attention to local priorities and marginalizes indigenous healing techniques. Guided by an understanding of the social determinants of mental health, at-risk populations in disaster settings, and the crucial importance of adapting to local contexts, we proposed several priorities in infrastructure support, assessment, and intervention when establishing culturally sensitive mental health care programs. Outcomes of the program will then be evaluated in its relevance, effectiveness, quality, and feasibility and used to modify the program in response to changing needs in the post-disaster setting. While the increase in support from NGOs during times of disaster will likely result in increased resources available for mental health programming, transition, and down-scale of post-disaster services to local health systems will never be sufficient nor sustainable without addressing systems-level problems. 

Burnout is a form of distress that manifests with features of emotional exhaustion, depersonalization, and reduced personal/professional accomplishment. Emotional exhaustion or unsuccessful coping with stressors, is the fatigued feeling that develops as one’s emotional energies are drained. Depersonalization refers to a student’s indifference, negative or cynical attitude. Reduced personal accomplishment is a negative self-evaluation of one’s abilities which manifests itself with feelings of failure. University education is an intrinsically demanding time which puts university students at risk for burnout, coupled with other burnout risk factors such as individual/personal factors and extracurricular factors. Burnout causes significant physical, emotional, psychological, and spiritual damage to students.  

However, from this article there had been paucity of and discrepancies in data on the overall prevalence of burnout in university students from low- and middle-income countries (LMICs). Students pursuing health-related programs in mostly high-income countries (HICs) had been mostly studied previously.

In this review, 55 articles were included, with a total of 27,940 (female: 16,215, 58.0%) university students from 24 LMICs. The Maslach Burnout Inventory (MBI) was found to be the most widely used tool for measuring burnout in 43 studies (78.2%). The pooled prevalence of burnout was 12.1% (95% CI: 11.9–12.3; p = < 0.001). Pooled significant prevalence of emotional exhaustion, cynicism, and reduced personal/professional efficacy were 27.8% (95% CI 27.4–28.3), 32.6% (95% CI: 32.0– 33.1), & 29.9% (95% CI: 28.8–30.9) respectively. Burnout pooled prevalence was highest among the African region at 35.4%, followed by the Asian region at 30.2%, and the European region at 20.7%. 

Figure 1: Forest plot for the prevalence of burnout in LMICs

In this review, burnout rates found in LMICS were lower than those in HICs, which the author believed to be due to publication bias. Authors further recommended low cost interventions that were needed more in low income countries than in middle income countries for managing burnout. These included mindfulness practices, yoga exercises, and group discussions. The current COVID-19 pandemic was also highlighted as having been found to put university students at a higher risk of burnout. Consequences of burnout in students include absenteeism, drop out, reduced academic performance, depression, alcohol and drug abuse, suicide, professional impairment and dissatisfaction, increased incidence of errors and near-misses.

POCUS, or point-of-care ultrasound, is a focused exam performed and interpreted by an examiner usually at the bedside, that must answer a specific question (is there a pleural effusion, yes or no?). The diagnosis must also be 1) relevant to consecutive treatment decision-making and 2) easily and accurately recognizable by the physician applying the US without extensive training.

There are many advantages to using POCUS in a resource-limited setting, including but not limited to: 

– Portability; relatively inexpensive starting at $2000

– Limited access to other diagnostic imaging equipment (XR, CT, MRI–all of which require additional training to read and use/operate)

– Rapid, noninvasive

– No ionizing radiation exposure

– Improves success and safety of bedside procedures

– Can easily be repeated, quickly, and without increasing radiation exposure, especially if clinical status or physical exam findings change 

– Particularly cost-effective (in the United States) in pediatric appendicitis and trauma (found to have decreased time to OR, decreased CT scans in the pediatric population, shortened length of hospital stay)

Some of the disadvantages include:

– Requirement of formal training

– Issue of how to power/charge and reliable access to this

– Handheld US requires a smartphone

– Supplies (US gel)

– Upkeep and repair

– Image portability (inability to print or save images for patients to share with other healthcare providers)

– Ethical considerations? 

Tying it all Together: Ethical Considerations for POCUS in Resource-Limited Settings

– Cost-effectiveness: some resources are deemed too expensive

– Resource limitations and differences in standard of care between the United States and other countries 

– Practitioners who may be teaching US may have limited knowledge of practicing in resource-limited settings, or there may be discrepancies in both knowledge of using the technology/resources available as well as the common presenting diseases in that region

– Sustainability: in relation to implementing training programs– what happens after instructors leave? Requires adequate planning for system integration and ongoing supervision and skill maintenance

– Limited capacity and inconsistent availability of follow-up care; screening without available treatment