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ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 376-380  

Learning experiences from orthopedic disability camp in a tribal area of Central India: A long-term retrospective study


Department of Physical Medicine and Rehabilitation, King Georg's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission09-Nov-2020
Date of Decision22-May-2021
Date of Acceptance28-May-2021
Date of Web Publication22-Jan-2022

Correspondence Address:
Sudhir Ramkishore Mishra
Department Physical Medicine and Rehabilitation, King George's Medical University, Lucknow - 226 003, Uttarpradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_617_20

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  Abstract 


Introduction: Developing countries account for 70% of the world's population. In developing countries, medical and surgical health camps not only improve access to health care but also reduce pressure on hospitals and shift the balance of care from institutional-based to community-based services, thus reduce health service costs, but this health camp system yet not become popular because of its own disadvantage. Objective: The aim of this study was to find out the logistics of organizing such a mammoth camp along with long-term functional outcome of operative procedures done on orthopedically handicapped persons during camp. Materials and Methods: This retrograde observational study was conducted from June 2018 to December 2018 on a surgical disability camp (Rahat Camp) at Mandla district of Madhya Pradesh. This camp was organized in March 2010 over 8 days by the state government. During this follow-up study, all the patents were identified by arranging follow-up camp and personal home visits. All the patients and their family member were asked about their camp experience and it was assessed on subjective scale of satisfaction (0–10) and further classify as good (10, 9, and 8), fair (7, 6, and 5), poor (4, 3, and 2), and worse (1, 0) on the basis of score. Results: In this camp, 114 patients out of 5558 orthopedically handicapped patients (2%) were operated. After assessing all the records, conducting twice follow-up camp (September 25, and October 25, 2018), and home visits to camp patients, only 41 patients were traceable. On assessing camp experience among patients, 20% responded good, 45% responded fair, 25% responded poor, and 5% responded worse experience on the satisfaction scale. Conclusion: Surgical camps for orthopedic disabled require long-term follow-up and protocol-based rehabilitation by rehabilitation team for better outcomes.

Keywords: Orthopedic disability, satisfaction scale, surgical camp


How to cite this article:
Mishra SR, Singh YV, Gupta A K. Learning experiences from orthopedic disability camp in a tribal area of Central India: A long-term retrospective study. Med J DY Patil Vidyapeeth 2022;15:376-80

How to cite this URL:
Mishra SR, Singh YV, Gupta A K. Learning experiences from orthopedic disability camp in a tribal area of Central India: A long-term retrospective study. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Jul 4];15:376-80. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/376/336317




  Introduction Top


Access to surgical care remains a significant contributor to a disease burden. Surgery plays an important role in reducing the burden of disabilities in low- and middle-income countries.[1] Developing countries account for 70% of the world's population of which 80% cases are such that which can be cured by surgical intervention. But unfortunately, only in 26% of cases surgical intervention are being carried out worldwide.[2],[3] Only 3.5% of all surgical procedures are performed in the poorest third of the world despite a burden of disease greater than in the rest of the world.[4]

It is found that in developing countries, medical and surgical health camps play a vital role in health-care delivery. As per Gruen et al., health camps are the outreach clinic. There are four different models of such outreach clinic, shifted outpatients model, replacement model, consultation model, and liaison-attachment model.[5] As per Benn et al., free surgical camps for disabled are very useful in remote areas when properly coordinated and organized with frequent follow–up, they facilitate good results in minimum expenditures and prove maximum achievements.[6] In developing countries like India which has the second-largest population in the world and where most of the population lives in rural areas, catering healthcare services equally to all is a big challenge, most of the physically disabled and crippled people are unable to reach the tertiary care health center for corrective surgeries and rehabilitation, and the health camps play a very vital role in providing health-related services to such population.

History of medical camps in India[7]

Historically world's oldest medical/surgical camp system is the Indian camp system.[8] The rural Indian communities lack medical and surgical care due to inadequate medical and surgical infrastructure. To bridge the gap between rural and urban areas, India has adopted an outreach model of health-care delivery which is nothing but providing health-care facilities by conducting medical/surgical camp. These camps are organized by government/nongovernment organizations with the help of local leaders and health-care workers who work as a team for success of the camp. Over the decades, these camps improved, evolved, and expanded their scope; transitioning and transforming from targeted approach to targeted free approach by including programs like patient education, primary and secondary prevention, patient employment; also from the random surgery camp system to standard operating procedures based surgical camps.[8]

In India, the Rahat camp is an example of such health camps which work on the basis of Public Private Partnership model and set the examples of what can be achieved by such camps. This study was conducted at Mandla which is a tribal district situated in the east-central part of Madhya Pradesh (India). This Mandla Rahat camp was organized in March 2010 over 8 days by the Madhya Pradesh state government in collaboration with Rotary International. The primary aim of this study was to find out the outcome of a mammoth surgical camp for orthopedically handicapped persons.


  Materials and Methods Top


The duration of the study was June 2018–December 2018.

This study was conducted after obtaining clearance from departmental ethical committee letter R. No. 9862(A)-2018 dated April 22, 2018, at Netaji Subhash Chandra Medical College Jabalpur, India. To gather information about the camp, meeting with the camp organizer was planned which includes chairman of the camp, the camp convener, the general secretary of the camp, and other members of the camp. Information about patients was gathered from doctors, Mandla District hospital, involved in the camp.

During the camp, the outpatient department (OPD) timings were 9.00 am to 5.00 pm, 3 teams were screening the patients. The total effective screening timing was only 7 h (420 min) in a day. On an average, 798 patients were screened every day for 7 days and on the 8th day, OPD was not run in this 8-day mega camp which means per patients only 1 min was available for examination and prescription of treatment in this mega camp.

Inclusion criteria

  1. Physically disabled patients operated during this camp
  2. Complete communication address given in case file
  3. Patients or guardians willing to be part of the study.


Exclusion criteria

  1. Patients or guardians not willing to be part of the study.
  2. Incomplete or no address recorded in case sheet.


During follow-up, all the patients were assessed for postoperative complication, functional improvement postoperatively, and their camp experience were assessed on subjective scale of satisfaction (0–10) and further classified as good (10, 9, and 8), fair (7, 6, and 5), poor (4, 3, and 2), and worse (1 and 0) on the basis of score.




  Results Top


Over 50,000 patients were participated in this Mandla Rahat camp. About 9000 patients were operated on from various faculties such as general surgery, urosurgery, plastic surgery, pediatrics surgery, obstetrics and gynecology, orthopedics, ophthalmology, otorhinolaryngology, and dentistry. This study included only those cases who were operated on for orthopedically handicapped cause.

In this camp, 114 patients out of 5558 orthopedically handicapped patients (2%) were operated. Distribution of various types of deformity and operative procedure performed is shown in [Table 1] and [Table 2], respectively. Among all these, 102 patients were from Mandla district and 12 were from other districts. Block-wise distribution of patients from Mandla is shown in [Figure 1]. During follow-up camp and home visits, documentation and photography of all visited patients were done and interview of all the patients, their relative, and villagers was done to know about their experience associated with this surgical camp.
Figure 1: Block-wise distribution of Mandla camp patients

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Table 1: Deformity distribution

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Table 2: Operative procedure performed

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There were 14 families who were having good experience, 9 families having fair experience, 13 families having poor experience, and 5 families having worse experience associated with this camp [Figure 2].
Figure 2: Patient family satisfaction during follow-up camp

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Neglected congenital talipes equinovarus patients account for 35% who attended the camp and 36% of follow-up cases, among these two patients had a recurrence of deformity because of no follow-up due to poor financial status of family and lack of transportation facility from their village, they also have worst experience with the camp.

Cerebral palsy patients account for 15% of patients who attended camp and 30% of follow-up cases, among these only one patient showed functional improvement postoperatively, he had good follow-up, received physiotherapy postoperatively for 15–20 days, he also received orthosis but lost follow-up after 4 months. Thus after initial improvement, his condition deteriorated. In nine patients, functional status does not improve and two patients deteriorated postoperatively.

It was found that extreme poverty and illiteracy among villagers were the main cause of negligence toward health and poor attendance in follow-up camps. The main cause of recurrence of deformity was the lack of postoperative rehabilitation services which was expected to be provided by the camp organizer. Other causes of failure of surgery were lack of postoperative cast care education leading to early removal of cast, slippage of cast, poor management of postoperative stiffness, early weight-bearing, poor compliance, and poor patient selection, in cases of cerebral palsy [Table 3].
Table 3: Postoperative complications of surgery

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  Discussion Top


The goal of every medical mission is to fulfill a child's greatest wish: “The chance to be Normaland/or independent.” Providing safe surgeries to people and working toward a long-term consistent and persistent solution laid the foundation of a successful and unique medical mission model in remote areas of the world.[9] Timely upgradation of medical facilities in Mobile Surgical Units (MSUs) is need of this world today. In India, MSUs play a vital role in bridging the gap between rural and urban areas. These camps cater to a large no of population irrespective of their location; thus, it becomes very difficult for mobile surgical unit to fulfill all expectations of poorly complained physical disabled patients in one sitting at camp, without rehabilitation services.[8] Publicity plays a major role in the success of the camp, but the reality is much time there is overpublicity which is as dangerous as lack of publicity, as people think that every condition can be cured in these camps and surgery is the only treatment.

People living in remote and underdeveloped areas are mostly illiterate and poor, these areas mostly deprive of health-care and educational facility. The health camps play a vital role in reaching basic health-care facility to people living in these areas. As follow-up camps are not the component of such health camps, people attending such camps are unaware of role of follow-up, they are not interested in follow-up.[10] These people think that only surgery will cure everything and this attitude leads to failure of surgery and the patient faced another mental trauma after physical trauma (surgery).

As per Dutta et al., camp-based surgical health-care delivery system is full of challenges and deficits which play a vital role in deciding the outcome of such camps.[8] These camp-based surgical health-care delivery systems are unable to accomplish the serial microtargets to ensure the patients' well-being. Thus, such camps always carry a big question mark when it comes to accountability and garnering public faith. There are multiple medical and nonmedical factors which affect the outcome of a surgical camp. They also stated that in such camps, there is poor surgeon-to-patient ratio, which leads to very poor surgeon and patient interaction affecting patient assessment, counseling, planning of treatment, and follow-up. In surgical camps, especially for disabled, it is the teamwork of devoted surgeons and paramedical and rehabilitation staff which facilitates services in remote areas and with frequent follow-up, there are maximum achievements of good results in minimum expenditures.[7],[10] In any surgery, there is a very significant role of nonsurgical components which include preoperative patient preparation, postoperative rehabilitation, and supportive medical care which decide and contribute significantly to the surgical outcome.[5] These entire factors usually get overlooked and compromised in favor of operative components in such camp-based surgical health-care delivery system.

Thus, the community surgical camp system, though sustainable, continues to draw unfavorable criticism, arouses sociopolitical conflict, and stimulates reflex media responses. Among other problems, these surgery camps are riddled with human resource challenges like shortages of paramedical personnel to manage patient attendees, surgeons, and the unwanted media sensationalism around the morbid/extreme outcomes. All these factors lead to complication, recurrence of deformities, and bad experience among patients.

In this study also, we found that there were poor surgeon-to-patient ratio, improper management of health resources, deficiency of paramedical staff, and improper planning of camp, all these lead to poor follow-up, incomplete treatment, recurrence of deformities, and bad experience among the patients and their families, all these lead to lack of faith among the people about such surgical camps.

As per Høiness et al., in children with cerebral palsy pain parameters, quality of life and psychosocial parameters are highly relevant and they should always be considered and incorporated in surgical treatment of such patient,[11] which were lacking in this camp; thus, all families with cerebral palsy patients either had poor or worst experience.

This camp was not linked with any tertiary health-care center, this may also be one of the leading causes of poor outcome of this camp. Surgical camp for orthopedically disabled should be organized in the area which is linked up with tertiary health-care center as most of the disabled patients need at least 6–8 weeks of inpatient rehabilitation training by a team of physical therapy, occupational therapy, and orthotic and rosthetic specialist headed by experienced doctor for better outcomes.


  Conclusion Top


Surgical camps are very beneficial for socially and economically deprived rural Indian communities. Although health-care delivery models by camps have many benefits, it also has its own drawback. Surgical camps for orthopedic disabled require long-term follow-up and protocol-based rehabilitation by rehabilitation team for better outcomes.

Recommendation

  • Camp should be organized at a place which is close to a tertiary health center
  • Postoperative assessment and follow-up should be done by members of rehabilitation team
  • The problem of poor follow-up can be improved by taking the help of block development officers who attend monthly meetings with district collectors
  • There should be free transport facilities of camp patients for follow-up
  • There should be rehabilitation programs for orthopedically disabled patients (especially for children)
  • A person should be authorized to manage follow-up of camp patients.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wu VK, Poenaru D. Burden of surgically correctable disabilities among children in the Dadaab Refugee Camp. World J Surg 2013;37:1536-43.  Back to cited text no. 1
    
2.
Daar A, Singer P, Persad DL. Pramming SK, Matthews DR, Beaglehole R, et al. Grand challenges in chronic non-communicable diseases. Nature 2007;450:494-6.  Back to cited text no. 2
    
3.
Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet 2008;372:139-44.  Back to cited text no. 3
    
4.
Azzie G, Bickler S, Farmer D, Beasley S. Partnerships for developing pediatric surgical care in low-income countries. J Pediatr Surg 2008;43:2273-4.  Back to cited text no. 4
    
5.
Gruen R, Weeramanthri TS, Knight S, Bailie R. Specialist outreach clinics in primary care and rural hospital settings (Cochrane Review). Community Eye Health 2006;19:31.  Back to cited text no. 5
    
6.
Benn AR, Tembhurnikar P, Deshkar AM, Bajpai KS. Supracondylar osteotomy of femur for management of deformities around knee joint: A camp experience in Chhattisgarh. Int J Sci Stud 2015;3:76-81.  Back to cited text no. 6
    
7.
Dutta A, Nagarajan S, Choudhary P. Resetting outcome targets of community surgery camps: The case of the Chhattisgarh tragedy. Indian J Med Ethics 2020;5:45-8.  Back to cited text no. 7
    
8.
Venkatram S. The Guardian. India's Sterilisation Camps Must Give Way to Proper Family Planning. Available from: https://www.theguardian.com/global-development/poverty-matters/2014/nov/22/india-sterilisation-camps-family-planning-tragedy. [Last accessed on 2020 Nov 05; Last accessed on 2014 Nov 22].  Back to cited text no. 8
    
9.
Deshmukh G, Raza H. Experiences of orthopaedic cAMP in a mobile surgical unit (life line express) in central part of India. Malays Orthop J 2013;7:36-41.  Back to cited text no. 9
    
10.
Benn AR, Bajpai KS, Deshkar AM, Singh BP, Singh A, Vibha D, et al. Multilevel soft tissue with bony corrective surgery in lower limb deformities as one sitting procedure in spastic cerebral palsy: An experience from free disabled surgical camps. J Evolu Med Dent Sci 2015;4:8454-60.  Back to cited text no. 10
    
11.
Høiness PR, Capjon H, Lofterød B. Pain and rehabilitation problems after single-event multilevel surgery including bony foot surgery in cerebral palsy. A series of 7 children. Acta Orthop 2014;85:646-51.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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