Reliable hospital data for developing countries

In many developing countries, there is no system to monitor violence-inflicted wounds that would—consistently and reliably—provide information necessary to create violence-prevention programs. The reason for not implementing a systematic collection of information is usually a lack of funds.

Nonetheless, medical epidemiologist Diego Zavala Zegarra (photo), from the School of Medicine and Health Sciences in Ponce, Puerto Rico, has implemented several projects that have proven that reliable information on violence-inflicted wounds is not just a luxury for developed countries.

Zavala comes from a successful career designing and implementing these tools in several countries in Africa and Latin America with programs characterized by their low cost, easy implementation and positive results.

With more than 25 years working in violence prevention as a member of organizations like Amnesty International, Zavala advocates for approaching violence as a public health issue. "Public health and human rights compliment one another and are natural preventers of violence," says the Bolivian doctor, who is also a member of the International Action Network on Small Arms (IANSA).

Among Dr. Zavala's various projects, two in particular showed potential to be replicated in other regions of the world: the emergency room monitoring system and the mortality monitoring system in forensic labs and morgues.

Hospitals, resources for health and information Zavala's emergency room monitoring system has been adopted by the Pan-American Health Organization in Nigeria, Uganda, Zambia, Kenya, the Democratic Republic of the Congo, and later in Bolivia.

According to Zavala, the project in Africa came from the need to show the feasibility of implementing a violence-inflicted wound monitoring system in low-income countries where data on violence is often inexistent or insufficient.

Since the beginning, Zavala planned on evaluating the project before, during and after its six-month duration. After setting up a training center in 2006, the project was launched in 2007. Each of the African countries chose a major hospital that attended to emergency-room patients who came in with different kinds of wounds. "After six months of collecting data, we had more than 6,000 cases with detailed information," said Zavala.

Each patient who was treated at the hospital is not only registered at the hospital, but their information goes to a central database. Each month, the compiled data are sent across the Atlantic, to the School of Medicine and Health Sciences in Ponce, where Zavala evaluates them.

"I've taken charge of analyzing the data and writing up a report on each institution's analysis quality. After, I send a list of cases for editing and corrections," explains the epidemiologist.
According to Zavala, the most important lesson learned from the process was that establishing a system of epidemiologic monitoring in hospitals does not require substantial investments, since it can be easily adapted to fit routine filing of the patient medical records.

This does not mean that the project hasn’t faced its share of difficulties. More than the lack of resources, the biggest challenge motivating administrative action. “Once we trained people and the necessary material resources were provided, the compilation process worked quite well. If the epidemiological monitoring system failed to prosper, it was because local managers did not enforce it. The project lasted for only six months and, although we gave the hospital management detailed reports with the results, it was not enough to guarantee their support to the initiative,” said Zavala.

The monitoring system is adaptable, it was conceived to fit local resources. Whenever possible locals are trained to analyze the data, in Africa, where it was not possible to do so, the information was sent to Puerto Rico for analysis.

Apart from the system established in hospitals, Zavala is also working on a mortality monitoring system for morgues and forensic science institutes, part of a new World Health Organization project especially conceived for Africa.

“I talked to a number of WHO people and African colleagues who met in London for an international conference on violence prevention this past September. We discussed the possibilities of starting a pilot project in Africa, to be established in forensic science institutes in 10 countries in 2011,” said Zavala.

Out of Africa, into Latin America

The flow of information, project proposals and know-how that began with Zavala in Puerto Rico and went to Africa now returns with even more potential to Latin America. “All these initiatives can be implemented in Latin America. The monitoring systems are already in place regionally, one good example is the one in Cali, Colombia, said Zavala.

According to Zavala, a similar monitoring system was recently implemented in the city of Tarija in Bolívia, one that could easily be replicated in other cities and countries in Latin America. Zavala points out nevertheless, that the project’s success hangs on there being political will on the part of the public health authorities.

The epidemiological monitoring of violence and harm project in Tarija was launched November of 2009 and is still in course. Its goal is to document wounds caused by violence (and related causes) as reported at the emergency room of the Hospital San Juan de Dios, the main hospital in Tarija, and the one which receiving 90% of the urgent medical cases in the area.
“The Tarija monitoring system can help determine the context in which interpersonal violence takes place, paving the way for developing evidence-based strategies for the prevention and control of violence in the city,” said Zavala.

Puerto Rico, hike in violence

Puerto Rico itself would benefit from this type of system. One of the most pressing concerns in the country today is disproportionate increase in gun violence during the last five years. The death rate for males age 20 to 24 is alarming at 134 for every hundred thousand inhabitants, according to a survey made by Zavala and his colleagues at the EMCS in Ponce.

The study entitled “The geographic distribution of the risk of homicides in Puerto Rico, 2000-2007” shows there was a sharp hike in violence over the past few years. The survey, that came out due to an institutional partnership between the Instituto de Ciências Forenses e a Escola de Medicina e Ciências da Saúde of Ponce, states that the general homicide rate for every hundred thousand inhabitants is 19.8 while the total murder rate for men is 38.5 (most of these being attributed to gun deaths).

The survey’s methodology used data from the Institute of Forensic Sciences, but it did not include specifics such as the precise geographic location of the incidents of violence nor ballistic analysis to determine the type of weapon used.

Zavala believes that the monitoring systems that have been successfully established in Africa and Bolivia need to be implemented in Puerto Rico. He also hopes to start the work with one of the main hospitals in Ponce in the first quarter of 2011. To stress the importance of the project, he cites a local mother who said: “I gave my son a gun myself, I decided I would rather visit him in prison than in the cemetery”.

In Zavala’s view, it is crucial that governments take a more active role in combating violence as a public health issue in the region. “United Nation member states must make sure that their respective national small arms and light weapon policies are well integrated with violence prevention policies. Public health and human rights strategies are complementary by nature and are allies in violence prevention and control,” said Zavala.

Cover photo: Diego Zavala
Inside photo: Marcia Farias

Translation by LHM and Danielle Renwick.