Laos is one of the most heavily bombed countries in the world. During the period from 1964-1973, over 2 million tons of bombs were dropped by B-52 aircrafts across the 2/3 of the country during the “Secret War”. This nine-year period bombing caused thousands of deaths and a unprecedented human displacement that exceeded a hundred thousand civilians from the poorest areas of the country.
The tragic legacy of that period remains today. Thirty percent (30%) of those bombs remains active (Unexploded Ordnances – UXOs – ), causing over 300 victims every year until 2008, and now down to 50 / year. Nearly 60% of the UXOs accidents result in death, and 40% of the victims are children[1].
If the explosion does not kill the person, it causes severe traumatic injuries resulting in the amputation of limbs in many of the victims. Physical and emotional trauma that takes many years to heal. In addition, many UXO victims suffer from Post-traumatic stress disorder (PTSD), a serious condition that can be devastating for the victim and their families[2].
But there is hope. The wonderful people from Laos are resilient, and they are willing to cope and move forward. I have been in Laos several times in the last few years, in the context of GNU Health implementations both in Mahosot Hospital and the Center for Medical Rehabilitation – CMR – .
The Center for Medical Rehabilitation (CMR), located in Vientiane, is a specialized institution that helps people with disabilities and victims survivors of UXOs. The CMR, formerly known as the National Rehabilitation Center initially provided prosthetic limbs for victims of war. Today they have extended the services to provide services to children with disabilities across the country. Some of the services include medical and community based rehabilitation, special education for the deaf and the blind and vocational school for people with disabilities.
At the moment I had the meeting with the hospital directors, I knew that we had to focus both in short term surgery as well as in the long term psychological, physiotherapy and occupational therapy that would allow the person to be fully functional in the society. Again, I was facing a project in need of Social Medicine.
We trained a local multidisciplinary team of nurses, doctors, physiotherapists, social workers, computer scientists, psychologists, administrative personnel, pharmacists and accountants.
It was during that period that I created the package “functioning and disability“.
Some of the GNU Health functional modules that CMR decided to use included surgery, socio-economics, ICD-10, nursing, physical therapy, stock, accounting, lifestyle, reporting, health services and diagnostic imaging, among others. In addition to those, we included the “functioning and disability” package.
The GNU Health “Functioning and Disability” package integrates the ideas of WHO Health Organization International Classification of Functioning, Disability and Health. This functionality complements the ICD-10 classification of diseases, with the concept of functionality. For example, after a person has been diagnosed with diabetes, we must go beyond the biology and molecular bases of the disease, and evaluate how diabetes impacts of on her daily activities and integration in the society and environment.
GNU Health contextualizes the health condition in the particular individual, key for personalized medicine. In the UXOs example, the related ICD10 codes are visible from the main chart:
- S88 : Traumatic amputation of lower limb
- F43.1: Post-traumatic stress disorder
This diagnostic information is relevant and key for epidemiology and statistics, but if we want to practice medicine, we must take into account the social aspect of these conditions, and how they affect the person in her particular environment.
The GNU Health Functioning and disability assessment has two sections. The first section is a summary of impairments related to the Cognitive, Visual, Hearing, Speech, Hand, Mobility and Activities and Participation .
The second section is a detailed assessment of Body functions, Body structures, Activities and Participation and Environmental factors and barriers. Each of these groups has its own set of qualifiers and components that will provide the health professionals where to put the focus to the time and the context of that person, as well as to evaluate the progression of the conditions.
We can now study, with a multi-disciplinary team, how the body structure and body functioning impairments relate to the person capacities and engagements in social activities; daily household tasks; using the current public transportation system or the level of access to Labor and employment services.
This is my concept of medicine, the assessment of the bio, psycho, social determinants of health and disease. Medicine is, first and foremost, a social science, and GNU Health is first and foremost, a social project.
Celebrating the success of cooperation: During a two-year period of using GNU Health, they have provided over 67,000 medical services, automated their finances, prescriptions, stock management, medical appointments and evaluations, diagnostic imaging, and the demographics tracking for the thousands of patients they assist.
Local capacity building: CMR trained its own local group of professionals who customize and maintain GNU Health, in their own Lao language. This creates a local and ethical business model, very important for the long-term sustainability of the project.
A well-deserved award. The work that CMR has been doing in Laos for the rehabilitation of their people has been magnificent. Their multidisciplinary approach to trauma, from the acute care and surgery, to the physical therapy and the work in the field is an example for many of us. CMR has helped thousands of people every year healing from the UXO physical and emotional scars, moving forward and being able to get re-inserted in society, and we are so proud to have been part of it.
A delegation of the Laos Ministry of Health presented at GNU Health Con 2016 the implementation in the Lao Center for Medical Rehabilitation – CMR – and in Mahosot hospital. We are so proud that they are part of the GNU Health community.
CMR received the GNU Health Social Medicine Award in 2016 for best Institution.
- – Somnuk Vorasarn, Chansaly Phommavong, Khonephet Sely. GNU Health in Mahosot Hospital – GNU Health Con 2016
- A cross-sectional community study of post-traumatic stress disorder and social support in Lao People’s Democratic Republic
We planned to introduce the system in 10 days and expected to start using some basic modules. When the basic modules worked, the plan was to continue implementing more modules . In order to manage to deploy the system at Nkinga in the short time, a medicine manager and an economist from the hospital visited us in Östersund for two weeks to prepare the implementation.
