Forgotten: Emergency Care in the Context of Public Health Care Frameworks

In the 1970s and 1980s, discussion around what and how health systems should be implemented sparked a heated debate. In 1978, the Alma-Ata declared that ‘Health for All’ should be the international goal of countries through Primary Health care. Unfortunately, the Alma-Ata failed, likely due to not specifying where how it was to be funded and the inability to hold countries to their commitment. After this, the concept of selective primary health care emerged, a way to package health services in a cost effective manner. Although both of these approaches aim to improve health, neither of them specifically mention emergency care, and where it belongs in the context of these frameworks and life.

Ziad Obermeyer conducted a study in low-and middle-income countries (LMICs) about the emergency care available. In “Rethinking emergency Care is key to ‘Health for All,’” he summarized his findings. He shed light on the fact that people in LMICs still get pneumonia, diarrhea, heart attacks and asthma. Something I think most people don’t realize is that studies consistently put emergency conditions at the top of list of causes of death and disability worldwide. The number 1 cause of death in LMIC is Ischaemic heart disease at 11.5% of deaths in LMIC, while HIV/AIDS was the 4th cause of death at 6.1% (Razzak & Arthur). Despite this, LMICs tend to have a lack of emergent care facilities, leading to an average of 10 times the caseloads of primary care doctors in the region. I believe that because of this, emergency health care should be a part of any country’s health system, even if it wasn’t in the plans of health care in the 1970s and 80s.

In the Alma-Ata Declaration, statement V says that all people should be at a level of health “that will permit them to lead a socially and economically productive life” by 2000. It then explained that the key to this target is primary health care. While I do agree that primary health care is necessary to track and prevent diseases and should be implemented around the globe, Obermeyer states that 10-15% of deaths in Nigeria occur in emergency care facilities. Most of these people are young and generally healthy, so they lose the most productive years of their lives. If primary health care and emergency health care both support preserving a productive, healthy life, then why didn’t Alma-Ata include emergent care?

Included in the principles of selective primary health care is the idea the main disease problems of poor countries can be solved through low-cost technical inventions, as Cueto explains. In this is the philosophy that “international agencies had to do their best with finite resources and short-lived political opportunities” (12). Though emergent health care was not originally discussed when it came to selective primary health care, I believe that these philosophies are very similar to what Obermeyer observed. In higher income countries, a small portion of the national medical expenditures helped emergency care providers focus on improving quality and training. As many providers in emergent care facilities in LMICs don’t have specific training, select LMICs have benefited from this training too.

The end of the Alma-Ata and the Cueto article on selective primary health care both focus on cost-effectiveness and the reallocation of resources. Investing in emergency care could relieve the burden of primary care doctors, allowing them to better serve their community. Emergency care could also alleviate some of the death and disability in LMICs, allowing for a more productive workforce, possibly boosting the country’s economy. Though the Obermeyer article doesn’t suggest a specific intervention, it does mention the opportunity for low cost, quality education of providers. This, along with a possible creation or renovation of an emergency care facility, could be perceived at a cost-effective strategy. As such, emergency health care would be a valuable addition to health care around the world, even if it’s philosophy is the only thing that might line up with other health care strategies.

  1. Should emergency care systems be thought of as separate of primary health care and selective health care, or are they already integrated into this framework? Are emergency care systems necessary if a strong public health care system is in place?
  2. Would implementing an emergency care facility in rural areas be feasible due to the lack of access to them and the number of providers that would be needed? How could communities be involved in the implementation of an emergency care facility or practices?
  3. Would you consider emergency care a magic bullet?
Alma-Ata Declaration. USSR. 6-12 Sepetember 1978.
Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.
Obermeyer, Ziad. “Rethinking Emergency Care Is a Key Part of ‘Health for All'” Brookings. N.p., 25 Aug. 2015. Web. 20 Oct. 2015.
Obermeyer, Ziad, Samer Abujaber, Maggie Makar, Samantha Stoll, Stephanie R. Kayden, Lee A. Wallis, and Teri A. Reynolds. “Emergency Care in 59 Low- and Middle-income Countries: A Systematic Review.” Bulletin of the World Health Organization Bull. World Health Organ. 93.8 (2015): n. pag. Web. 20 Oct. 2015.
Razzack, Junaid, and Arthur Kellermann. Emergency Medical Care in Developing Countries: Is It Worthwhile? (n.d.): n. pag. Web. 21 Oct. 2015.

17 thoughts on “Forgotten: Emergency Care in the Context of Public Health Care Frameworks”

  1. Hi Katherine,

    Thanks for this insightful post on an issue that I’d never considered in the framework of global health and primary healthcare. I think it is really interesting how you framed your ideas of a more horizontal intervention as a cost-effective strategy, which I think are two concepts that are not usually aligned in this way.

    In terms of your third question, I would not consider emergency care a magic bullet simply because emergency medicine has a wide range of diseases and conditions it treats. I think expanded emergency care could have a magic bullet-like effect. For example, if it turned out that most ER visits were due to heart attacks or other cardiac trouble, better trained emergency care providers might end up working only on cardiac issues, which could make it look like a magic bullet.

    However, I think that if emergency care was improved before general primary care, it could lead to many unintended consequences. Ideally, we would want to improve general care alongside emergency care, but if we assume improving emergency care was the project being funded, then we might find that more patients simply begin using emergency services as their general care. For example, in the chapter written by Moran-Thomas, she talked about how the locals would accept the filters reluctantly but then ask when they would get the wells to filter their water and fix the root of the problem. Similarly, I think if emergency care itself was improved, there is the chance that the patients would ask when general care would be improved instead.

    1. I think your comparison about the filters is a really great point. General health care is very important and not having equal improvements will likely put an unequal burden on one system. I wonder if there would be a way to integrate them together into a more seamless system where you might go for general care on one side and emergency care on the other side. This could lead to the effect though of someone deciding what an ’emergency’ is an what is ‘normal’ or routine. On the other hand, I wonder if emergency care could also be considered teaching community members lifesaving practices, such as home birth techniques, CPR or asthma attack care.

  2. Katherine,
    I really enjoyed your blog. Similar as what Methma said, I haven’t considered emergency care in the context of primary healthcare before.

    In response to your third question, I don’t think emergency medicine is a magic bullet. Although for some emergency situations there may be an easy technological fix, for many cases the treatment is much more complex. In addition, the implementation of emergency medicine requires the allocation of many resources including trained professionals, medicine, and certain technologies. However, I think the implementation emergency care without the fundamentals of primary health care could have magic bullet-like effects. Emergency medicine on its own is not sustainable in the way that it only treats the most pressing concerns and ignores other problems that can contribute to morbidity and mortality. I think your thought of implementing emergency care in addition to primary healthcare is a good idea.

  3. Hi Katherine,
    I really enjoyed your post about emergency care and the questions you posed about it possibly being a magic bullet. I don’t think emergency care would be considered a magic bullet because of all the structural readjustment that would be necessary to implement it as part of the health system. I don’t think there is any quick fix when it comes to emergency medicine (especially in poor-rural places where even bringing in medical technology is a challenge). In response to your second question, I think that in order for emergency care to be integrated into health systems, I think that not only the community has to come together, but the government as well. I think that in order to provide the emergency care units with adequate technology funds must be allocated (from the government) in order to keep everything running smoothly.
    I also think that the issue of too many primary doctors and not enough emergency care doctors is an interesting dichotomy between the situation in the U.S. where there is not enough primary care physicians but many specialists. I wonder if middle and low income countries have less incentives for physician going into emergency care than for primary care?

  4. Hello Katherine,

    I really like the way you shed light on an aspect of healthcare that we haven’t really touched upon so far. Like Methma, Sierra and Silvia I don’t think of emergency healthcare as a ‘magic bullet’ as it doesn’t have a singular focus and involves lasting structural changes. I feel that emergency care systems should be thought of as a part and parcel of primary health care rather than being considered a separate entity as I consider it to be an extension of PHC that simply adds to the capabilities of this system. This is also the reason I think emergency care systems need to exist even if a strong public health care system is this place because common conditions like ischemic heart disease cannot be addressed by a non-emergency response system.

  5. Hello Katie,
    I appreciate that you brought up this thought-provoking issue of emergency care in the context of global health. As the commentators above me have mentioned, emergency care and primary care need to be a package deal in order to create a truly effective health system. However, I would like to point out that emergency care can have very interesting meanings when we consider treating infectious disease vs treating chronic disease. In low-middle income countries, the burden of disease tends to lean towards chronic disease. Diseases like ischemic disease occur without warning and therefore need immediate or “emergency” treatment; but they often stem from underlying risk factors. In other words, ischemic disease, unlike physical injuries such as a broken arm, exists with a socioeconomic lifestyle that needs to be addressed with a founded primary care system. In the long term, you cannot simply ace wrap a disease and expect disease not to strike again. This is very similar to the argument against emergency “magic bullet” interventions for infectious disease. Therefore, undoubtedly emergency care has the potential to save lives; especially in rural areas with high levels of critical death from both infectious and chronic disease, emergency care can truly curb death tolls. In fact, even in developed countries, such as the U.S., emergency care saves lives. However, much like a “magic bullet” intervention, it is not sustainable if it does not exist within a horizontal infrastructure, and it can ultimately be very costly. Emergency care should not be treated as a cure-all.

  6. Hello Katherine,

    I enjoyed reading your blog about the need for emergency care and whether it should be categorized as a magic bullet. If one takes the meaning of the word magic bullet literally then from the perspective of the person who is suffering from an emergency it is indeed a magic bullet. However, from a general approach perspective, it may not necessarily be so.

    I would like to give the following example: What has been done to prevent maternal deaths?
    • Most efforts have been concentrated on predicting and preventing obstetric complications, training traditional birth attendants, and community mobilization
    Unfortunately, these techniques have not worked.
    Why have they not worked?
    • Before answering this question, one must take note of the most important fact about maternal deaths from complications: Most complications cannot be predicted and prevented. To put it another way, any pregnant woman can develop complications at any time during pregnancy, at delivery, or in the postpartum period.
    • This means that all pregnant women are at risk. We cannot predict or prevent most of the obstetric complications that lead to death, but these conditions can be treated.
    • Now, let’s look at the five major causes of deaths: hemorrhage, pre-eclampsia and eclampsia, infection, obstructed labor, and complications of unsafe abortion.
    • We cannot predict or prevent hemorrhage, as this can occur anytime during pregnancy. As for eclampsia, research has shown that many eclamptic cases can occur without warning during or after delivery. The role of antenatal care in preventing deaths and disability from infection is limited, according to WHO. Although clean delivery kits and health education might reduce infection rates, the crucial factors that give rise to unclean delivery are probably related more to poverty and lack of facilities, than to ignorance. As for obstructed labor, prediction or prevention has little role to play in alleviating the suffering of women from this complication. What is strongly recommended is treatment that must be made available to all women if outcomes for both mother and infant are to be improved. As for the complications from unsafe abortions, these can be treated in a well equipped and adequately–staffed health facility.
    • Without health facilities to provide life-saving services, women with complications will die. That’s a fact. Thus, the simple truth is that community mobilization efforts will not amount to anything if there are no midwives and doctors in health facilities. If there is no blood, antibiotics, or other drugs to accommodate all the needs of patients.
    Given all these, what can then be done to prevent maternal deaths and disabilities?
    • Agencies and governments have to ensure that health facilities are able to provide emergency obstetric care (EmOC) services. And that these health facilities are supported by a functioning referral system.
    So now the questions are
    1. Is EmOC the magic bullet, and if so does that require more funding?
    2. Is antenatal care the magic bullet that requires more funding and importance?
    3. Are they really mutually exclusive?
    4. Can we dissect the two and draw a line between the two services and keep them divided?

    In my opinion the answer to all these questions is no. They are both two ends of the same spectrum, and any care team should be equipped to provide emergency services, all while focusing on preventive services, hoping that such preventive care would eliminate or limit the need for emergency services.

    1. I want to thank you for your comment because it allowed me to have a more tangible idea of interventions that have tried to help in emergency situations but have not fully succeeded. I also completely agree that neither EmOC nor antenatal care are magic bullets, but rather necessary in a system of achieving better health for mothers. I think your idea of having each care team be able to provide emergency services along with preventive care being their primary focus is necessary in a system in order to not confuse people as to which system is stronger or which system to go to, as Methma mentioned. I still think, however, that there’s likely to be an issue of access to these care teams in general.

  7. Hi Katherine,

    Thank you for your extremely insightful perspective on emergency care. Like others have mentioned above, I had never previously thought of this idea.

    With regards to your first question, I agree with the others that and believe that emergency health care systems should be viewed as horizontal care rather than a vertical intervention. This is because it requires significant large changes to the health care system. I view emergency health care as a section of primary health care, both are structured to address a general spectrum of health care issues. Emergency care systems are very necessary to ensure a strong public health care system. They can prevent many unnecessary deaths by providing quick responses to afflictions.

    In response to your second question, implementing an emergency facilities in rural areas may pose challenges but are definitely achievable. One would need to reimagine emergency care in the context of developing countries. Using human capital- nurses, individuals of the community, transporters- could prove to be quite useful while designing emergency systems.

    Lastly, emergency systems are not magic bullets because they are general responses to a variety of health issues. However, emergency care is specialized and should therefore be distinguished from primary care. Emergency care is an essential complement to primary care and should be viewed as a necessary but not sole tool towards addressing health issues.

  8. Thank you for your post. I think it’s useful to think of emergency health care and general primary health care in terms of emergency care being “reactive” and primary health care being “preventive.” I think focusing on emergency care to start off with, and building upon this and gradually shifting resources and attention towards primary health care might be the best way to go about creating a sustainable health care system. To answer your second part of your third question, therefore, I think that strong primary health care might make emergency care redundant. If one can successfully prevent emergencies through a strong primary health care system then emergency health care might not be necessary.

    I am not sure at all about your second question: it seems like emergency health care in rural areas is very important, and would be more feasible than trying to implement primary health care facilities in rural areas.

  9. Thanks for all of your comments! Several of you (Sierra, Harsh, Shreya, Methma) have brought up the point that emergency care can only be implemented if it is alongside effective Primary Health Care, which is what I read about mainly. Ria, I appreciate your opposing view in that maybe having emergency care with PHC could be redundant, and therefore might be more useful in rural areas. I think that, as Niki brought up, oftentimes chronic diseases and ’emergency’ situations might be caused from underlying risk factors or environmental stressor. So is there ever anything that’s truly an emergency that can’t be prevented? Or is emergency care necessary because it’s a more cost-effective way to treat immediate health problems that might have multiple risk factors? This brings me to Divya’s point of reimagining the context emergency health care in a developing country. In her lecture to the class, Amy Moran-Thomas brought up the question of “What happens when people experiencing an emergency don’t think it’s an emergency?” How does what decide what constitutes an emergency?

    1. Hey Katie!
      I found it so interesting that you brought up this idea of defining emergency care. It reminds of the Marburg scare in Angola back in 2005. Marburg is a hemorrhagic virus similar to Ebola, and in 2005 significant foreign resources were siphoned towards preventing a global outbreak. Like Ebola, it is this fearsome disease that tends to re-emerge spontaneously and cause a brutal, inevitable death. However, that year 250 people died of Marburg in Angola. On the other hand, 40, 000 people died of malaria. Personally, I wonder what gives us the right to treat certain situations as emergencies over others. Perhaps part of it goes back to Nicholas King’s theory, and the worldview of emerging disease.

      1. I think that’s a great point and brings me back to Amy Moran Thomas’ lecture as she also discussed emergency care I believe. I think she also discussed the concept of who has the ability to determine what is and isn’t an emergency for another place. I also wonder what happens when one person decides what is an emergency, and if that disease would then because ‘exceptional’ right away. I think it’s a thin line, but that some sort of structure might still need to be built.

  10. Katherine,

    Thank you on for your post. I like how you focus on an idea that was essentially forgotten. Even I had not considered the presence of emergency care in primary health while doing the readings.

    I definitely agree with the points you make. Emergency medicine is important. People should not die from acute issues that could be easily treated if the appropriate health facilities were in place. Furthermore, the individuals affected in emergency situations are often younger individuals who are usually active and productive members of their community. Thus, saving the lives of these individuals would definitely be an essential and possibly cost-effective initiative.

    In response to your second question, I think implementing emergency health is definitely feasible in low-income situations. Rural areas aside, there a lot of urban areas in developing countries that still need emergency services! These places definitely have the ability to host the emergency facilities. Yet these emergencies services are rudimentary or non-existent. I think this demonstrates how we need more focus sustainable in-country emergency services.

    However, that being said I think often time emergency situations can be chronic situations that finally come to a climax. Programs that address these more general and structural issues prevent many of these acute problems from happening in the first place. Thus more general health programs are just as important as emergency health programs and both should be integrated and implemented if possible.

    1. Derana, you brought up a great point about emergency situations often being the climax of a chronic situation. Because of this, primary care is definitely needed around the world to help manage these conditions, especially because they often hit the most productive members of society. As for emergency care, I think it would be easier to create in urban areas definitely. However, I do remember watching the video for class that showed how an “emergency vehicle” could be created by attaching a bed on wheels to a that was given to the community to a motercycle. It think that emergency care or access to transportation to it could be possible in rural areas too with solutions from within the community or state.

  11. Hi Katie,

    I really enjoyed reading your post that questions why emergency care was not included in the grand vision of the primary health care movement and the Alma Ata Declaration. It was a question that I had not really considered before, and so I’m glad you brought it up. To start off, I guess the reason that emergency care was not included in the conversation in the late 70s is because through primary health care, people were trying to move away from reliance on emergency care. In many countries, especially the US, emergency rooms carry a huge amount of the burden of treating everything from a common cold to traumatic injuries and also carry a gigantic proportion of the cost of health care. By leaning towards primary health care, physicians and policy makers wanted to incentivize prevention and early treatment, rather than waiting until a disease or injury was at a place that required a trip to the emergency room. As far as we can push care towards primary care physicians, there will of course always be a need for emergency care–so much of what we deal with in terms of health issues are conditions that could possibly never have been prevented, but instead were written into someones genetics from the beginning. This is why I think your post is correct–it would be beneficial to investigate more how developing emergency care could benefit different populations.

    To address your first question, I do not think that emergency health care systems should be thought of as separate from PHC because if that occurs the gap between a patient’s PCP relationship and their emergency room visits will widen. Integration and continuity of care between the office and the emergency room is very important to continuing a relationship between a patient and their doctor, and making sure the doctor really knows enough to treat their patient well.

    In terms of your second question, I do not think it is feasible to implement emergency care facilities in rural areas. First of all, how would an organization decide where best to place the facility? Instead, I think an intervention like that of Barry and Andrea Coleman’s organization Riders for Health in the Gambia would be best (from the film we watched in class entitled ‘Rx for Survival: Delivering the Goods.’ Creating a way for health workers to get to different communities as well as making it possible for emergency cases to be transported to local cities to go to hospitals might be more effective.

    In the U.S., urgent care centers and smaller clinics that are open at night and on the weekends are becoming more and more popular. This model might be something that could be replicated in developing countries–a facility equipped with basic emergency tools, but not on the scale of a hospital in the middle of a city.

    1. Hey Zoe! I think the emphasis you put on emergency care being integrated into primary case is important. I think many conditions that are currently treated as emergencies could be prevented through primary care, but that there are still things that needs emergency care (like injuries or a sudden asthma attack from bad air quality one day). I really like your example of Riders for Health because I think this is a way to really help people in rural communities reach health centers. This along with building quicker paths to other cities or nearby towns could help increase access to all health care. I also wonder what you think of relabeling or redefining ’emergency care’ to something that starts to separate it from what Western emergency care is? This might help make it something that’s more integrated into primary care.

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