2011

Annual report

Troms Mine Victim Resource Center

Annual report 2011

Contents
Focus of action Major achievements What makes a survivor? Iraq and Lebanon a new type of war Cambodia delivery as a potential trauma The Village University Teaching manuals 3 4 6 7 8 10 12 Main scientific publications Financial outline Partners TMC Board members TMC research team Partner organizations 13 14 14 15 15 15

Troms Mine Victim Resource Center

troms mine viCtim resourCe Centre (tmC)

TMC is a medical action research center at the University Hospital of North-Norway. In collaboration with partners TMC form trauma systems including care for mothers and newborns in rural and remote areas in Iraq, Lebanon, Cambodia, Laos and Vietnam. TMC coordinates networks of thousands of trauma care providers in the South. TMCs main aim is to develop new and evidence-based models for trauma care and maternal and perinatal health in the South. All interventions are designed and implemented according to scientific standards.

annual report 2011

Published by Troms Mine Victim Resource Center, June 2012. P.O. Box 80, University Hospital North Norway, N- 9038 Troms, Norway Norwegian registered org. no. 986 001 832 Tel +47 777 54177 Email: tmc@unn.no Editor: Margit Steinholt Executive editor: Hans Husum Layout: Ole Kristian Losvik Print: Hustrykkeriet, University Hospital North Norway Front page photo: Rune Stoltz Bertinussen

trauma Care Foundation (tCF)

TCF is a Norwegian humanitarian foundation working for people caught in wars and minefields they did not ask for and are unable to call a halt to. TCF develops trauma manuals, teaching aids and documentaries for low-resource settings and operates TMCs book- and AV-projects

Follow us

Web: www.traumacare.no Facebook.com/traumacare.no Twitter.com/traumacare

FoCus oF aCtion
trauma Care as mass mobilization
Studies in the minefields and war zones of Iraq and Cambodia document that trauma care is more than pure medical interventions: Survival depends on a structured social response by the affected communities. Immediate life support by trained local first helpers reduces mortality. Preliminary results from studies in Cambodia indicate that the chain-of-trauma-survival reduces maternal and perinatal mortality rate. It also proves that including lay-people; traditional birth attendants in the network, is as crucial as in the trauma system.

the modern warFare

saFe blood transFusion

Modern warfare causes terrible injuries hitherto unseen. In Iraq and Lebanon TMC develops trauma system models in order to respond to mass casualties caused by the latest weapon systems. Experiences from the wars and revolutions in the Arab countries show that civilians are under more severe and deadly attacks than ever.

Trauma victims and mothers bleeding after delivery need blood transfusion. TMC is testing and developing local models for rural blood banking in areas where blood-born diseases are endemic and transfusion of blood is not fully accepted.

up and going again with loCal teChnology

limb salvage surgery

With partners in European trauma centers we are developing new methods to rescue severely damaged limbs aiming to delegate limb salvage skills to the rural district hospitals in the South. A workshop in Sampov Loun, Cambodia produces high quality equipment for external fixation of complicated fractures of the extremities. The exfix, including a DVD instruction for doctors, is now sold to hospitals in Cambodia and abroad.

At workshops in the mine fields of Cambodia aids for amputees and other disabled are designed and produced from local materials by local technicians and rehab workers.

the village university sharing knowledge

Trauma Care Foundations teaching manuals are published in a variety of languages. However; the Village University is more than teaching trauma care and maternal health issues to locals. TMC also conducts international workshops in the South where the latest scientific results are shared. In 2010 TMC started a 3 year research program in Battambang, Cambodia. The school is especially designed to meet the needs of the poor, and it builds vital research and medical capacity among local health workers.
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delivery liFe support

98 % of maternal and perinatal deaths occur among the poor in low income countries. The majority of these fatalities can be avoided by simple interventions.

Annual report 2011

major aChievements
the ConClusion oF the troms model
The Troms model for trauma care has been developed, refined and systematically evaluated over 15 years in conflict areas in Northern Iraq and Cambodia. With the article Trained lay first responders reduce trauma mortality, Murad and Husum, Prehospital and Disaster Medicine, Nov Dec 2010, TMC can conclude that the model works. TMC future strategy will therefore be distributing our knowledge and the model to new areas and the more urban declined midwives and doctors.

Further networking in the south

Our partner Trauma Care Foundation Cambodia, has expanded and exported the trauma model to Vietnam and Laos. The maternity program Delivery life support will be adapted to Vietnamese conditions, and there is also interest for the model in Laos

Mr Buth from TCF- demonstrating the external fixation system at the 11th States Parties Meeting in Phnom Penh November 2011.

Young girl operated with the ex -fix system.

the village university and the researCh sChool in battambang, Cambodia

post-injury malaria

Since September 2010 TMC and partner TCF-Cambodia, has been running a research school for 16 health workers from rural and remote areas. All students are recruited from the network developed over many years by TCF-C and TMC. 6 of the students are female. The school is located in Battambang, Cambodia, and the students attend 2-week courses 7 times per year for 3 years. The long-term aim of the project is to establish genuinely Khmer research capacity in poverty and rural health care.

On March 11th 2011 Dr Tove Heger presented her thesis Malaria and Trauma. Studies of post-traumatic malaria falciparum in Cambodia. Every year, malaria claims the lives of approximately one million people in the poorest regions of the world. There is no effective vaccine. The malaria parasite rapidly develops resistance to most drugs, leaving very few options for treatment. In highly endemic areas the majority of the adult population acquires immunity to malaria, developed through prolonged and repeated exposure to the various variants of the most malignant parasite, Plasmodium falciparum. In spite of clinical immunity, the parasite may be present in such populations, and clinical malaria may relapse when immunity weakens or the parasite changes. During acquired immunodeficiency (HIV), pregnancy, or after trauma, immunity is changed. Dr Hegers study indicates that post-injury malaria increases the risk of postoperative complications and thus adds to the burden of trauma. Besides reduced immunity, trauma may also change the parasite. These research findings are crucial and may contribute to the development of a vaccine.

delivery as a potential trauma

The Delivery Life Support- program has proved to be important in empowering women in the target areas: Antenatal classes in the villages bring knowledge to the women at risk making them more capable of changing hazardous traditions. The training of TBAs and midwives raise both the quality of their work and their status. This will in the long term build more resilient communities where the population can voice their needs and human rights. The DLS program has also proven to tear down some of the cultural barriers between the female patients from rural and poor areas
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Troms Mine Victim Resource Center

Nenad Tajsic, Anne Husebekk, Tor Ingebrigtsen, Dag Fosse Hans Husum at the release of the 2nd revised edition of War Surgery at the bookstore Akademisk Kvarter in Troms.

Yngvild Berggrav and Kjersti Nordskogen Nes, the Norwegian Ministry of Foreign Affairs. Yang Van Heng and Sa Vuthy from TCF-C demonstrate mushroom farming in rural Cambodia.

symposium at the global health ConFerenCe oslo september 2011

The 6th Conference on Global Health and Vaccination Research and the Norwegian Medical Associations 125th Anniversary Conference, took place 12 13 September 2011 in Oslo, Norway. TMC did a presentation of the Troms model for trauma care and maternal and perinatal health, and we received much positive feedback on our strategies. TMC also presented two posters during the conference: The Village University and Traditional Birth Attendants in maternal care, Cambodia

partiCipation oF tmC and tCF-C at the 11th states parties meeting in phnom penh november 2011

TMCs centre leader Margit Steinholt was an observer at this meeting. It proved very useful as our partner TCF-Cambodia had a display of their activities and available equipment, and the venue was a place to network with other organizations working in the same field.

Field visit by the norwegian ministry oF Foreign aFFairs, Cambodia november 2011

Prior to the 11th States Parties Meeting for the Ban Landmine Treaty in Phnom Penh, November 2011, TMC together with partner Trauma Care Foundation Cambodia, hosted two representatives from the Norwegian Ministry of Foreign Affairs. The representatives participated in an extensive field visit where they saw a variety of victim assistance activities as well as the maternity program.

Annual report 2011

what makes a survivor?

the problem: an epidemiC oF trauma.
120 million persons are injured in low- and middle-income countries each year, the rate being 10 times higher than in high-income countries. By 2030 WHO estimates a further 40% increase in global deaths from traumatic injury. The situation is strikingly unjust as the epidemic hits hardest in the South: Conflicts, land mines, cluster munitions, traffic accidents and natural disasters target communities that in addition are burdened from starvation, embargo, endemic diseases and war. The experiences from Gaza and now the conflicts in the Arab countries document that 4th Generation Warfare is an extremely brutal affair. Adequate response from a resilient community is crucial when catastrophe hits. treatment must be done on-site. Weapon engineers make steady progress, developing ever more sophisticated and mutilating weapons. Care providers should therefore feel obliged to find ways of treatment that are feasible to local hospitals. Open fractures and crushed limbs are common casualties from high-energy blasts. The surgical treatment is complicated and has traditionally been centralized to specialized centers. When a land mine blasts one leg off, an open fracture is regularly inflicted to the opposite leg. Proper management of open fractures requires external fixation, but one set of appropriate instruments costs USD 6,000, which is far beyond reach for hospitals in the rural South. TMCs partner in Cambodia; TCF-C, runs a rural rehabilitation-workshop and research centre in the jungle where they produce surgical instruments of export quality based on local technology. The cost is 30 % of equivalent Western products. The instruments are sold including a locally produced instruction DVD for doctors and rehabilitation technicians.

response i: mass eduCation oF layperson First helpers

The scientific studies of the trauma registry in Iraq (Murad and Husum, 2010) document that early life support given by trained villagers significantly reduce trauma mortality when health facilities are not accessible. This is the reason why TMC trains thousands of laypersons adults and children in basic life support. Delegating skills and knowledge is vital in order to empower the poor and oppressed and to build resilient communities.

External fixators produced at the workshop in rural Cambodia

By 2011 the work shop extended its capacity to serve all surgical hospitals in Cambodia. The equipment is also sold abroad.

response ii: new strategies in trauma surgery

In most low-income countries there is a fundamental shortage of skilled health workers, and the problem increases in rural and remote areas. In a recent publication we report that a surgical training program for non-doctors at rural hospitals in the Cambodian mine fields reduced the rate of postoperative wound infection from 22% to 10%. The result is excellent. Traditionally advanced life-saving surgery is conducted in larger hospitals. However, where ambulances come under attack and transfer of war victims is impossible, the
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warm blood needed

Blood loss is the main killer both in trauma and for poor mothers giving birth. Safe blood service at local hospitals is an urgent task, but it requires accurate screening of blood donors. In most low-income countries the prevalence of hepatitis infections is very high. Carriers of the disease must be excluded as blood donors. With partners in Cambodia and Vietnam TMC has published reports revealing that test methods recommended by WHO are too inaccurate to be used for donor screening. Having identified the problem, work is now in progress to find feasible ways to set up walking rural blood banks.

Troms Mine Victim Resource Center

iraq and lebanon a new type oF war

Since 1997 the mine fields in Northern Iraq has been one of the main rural laboratories where the TCF trauma systemmodel has been developed and tested. During the first period, 1996 1999, the system was designed and monitored by Western trauma experts at TMC. Since 2000 the trauma system has been molded and further developed by local doctors and health workers. Since the invasion in 2003 the trauma system also operates in the war zones of Kirkuk, Diyala and Baquba. During the whole period medical treatment and outcome have been carefully documented in a professional trauma registry. A study in 2011 of a ten-year material (3,200 trauma patients) documents a significant reduction of trauma mortality by year; non-graduate paramedics are able to manage major injuries successfully despite hash working conditions and long transport times (Scand J Trauma Resusc Emerg Med. 2012 Feb 3;20:13.).

the Closure oF the humanitarian spaCe

Israels war on Lebanon in 2006 was the prelude to the massacre conducted in Gaza in January 2009. With colleagues in the Middle East we have conducted extensive research on the new types of injuries seen in Lebanon and Gaza and can conclude that Dense Inert Metal Explosives (DIME) were used by Israel in these wars. A shocking feature of the new type of war is deliberate attacks on rescue personnel and hospitals. In collaboration with the civilian rescue organizations in Lebanon and NORWAC TMC runs a comprehensive training program in South Lebanon to strengthen the local response to such atrocities.

Changing patterns oF injury

Our colleagues in the provinces of Kirkuk and Baquba weekly face mass casualties from high-energy bomb blats, be it Improvised Explosive Devices or modern fuel-air explosives launched in air attacks. In 2011 we saw continuous deliberate attacks on hospitals and ambulances. To help our colleagues cope under desperate working conditions, TMC runs a comprehensive training program in Central Iraq for ambulance crews and doctors at local hospitals in forward life-saving surgery.

Annual report 2011

Cambodia delivery as a potential trauma

To reduce avoidable trauma deaths TMC with partners delegated life-saving skills to non-doctors. In a three-year prospective pilot study in Cambodia 2005 2007 TMC and TCF-Cambodia applied the same strategy for complicated deliveries. Where pregnant women are weak due to malnutrition and endemic diseases, delivery complications should be viewed as a potential trauma to mother and child and managed accordingly. The study was carried out in rural Northwestern Cambodia where access to health services is poor and poverty, infectious diseases and land mines are endemic. The number of deliveries at the new health center has been doubled due to a small waiting area for expecting mothers at the clinic.

waiting house beFore delivery

delivery liFe support (dls) bringing liFe-saving

skills to the village

During the training period midwives, medics and TBAs have contributed with valuable information about what problems the women from remote villages face. As a respond to this info, TCF Cambodia has built waiting houses on the premises of 7 health centres. These houses enable expecting mothers to travel to the health centre some time prior to delivery, thus making the services at the HC more accessible. The health centres report a 30 100 % increase in deliveries after the waiting houses were built. In addition the midwives use the waiting houses to accommodate mothers and their babies after delivery in cases where extra surveillance is needed. Cambodian health authorities consider implementing the concept of waiting houses in national policies.

Most programs aimed to reduce maternal deaths focus on hospital performance and obstetric protocols. In communities where majority of mothers deliver at home, such strategies will fail. The DLS is a chain-of-survival model that takes life-saving skills to those closest to the women at risk; to the traditional birth attendant (TBA) in the villages, to midwives and medics at the rural health centers, and to the non-graduate surgeons at the districts hospitals. The DLS study in Cambodia is a national pilot in cooperation with the Cambodian Ministry of Health. There are three main causes for maternal deaths: l Post-partum haemorrhage l Eclampsia l Prolonged labour. The DLS training protocol comprises of hands - on methods to treat these complications, as well as regognizing danger signs in pregnancy. The district hospital capacity is upgraded, new surgical techniques introduced and blood service established. The TBAs and midwives travel to rural and remote villages to conduct antenatal classes for pregnant women and their husbands. These classes are essential when it comes to empowering the women most at risk. In 2011 TCF C prioritized the most remote villages for antenatal classes due to limited capacity among the midwives. In 2011 the DLS program in Cambodia was extended to the floating villages in Sangkher district on the Tonle Sap Lake. The number of women in reproductive age in the area is more than 15 000, and up to 90 % of the population is defined as poor. The health centres and the staff were in great need of up-grading, and TCF-C provided training for the staff in the spring of 2011 while one of the HCs was rebuilt. In addition TMC and TCF-C were able to fund the building of a midwife-boat designated for the transport of pregnant women and other patients in need of quick transfer to a health facility. This is the first boat of its kind in Cambodia!

tbas skilled or non-skilled?

The DLS database in Cambodia consists of comprehensive prehospital information on delivery complications. There is however, a mismatch between this recognition of TBA skills on the one hand and TBAs being categorized as non-skilled birth attendants on the other hand, excluded from most traditional training programs in maternal care in Africa and Asia. WHOs definition of skilled birth attendants also affect Cambodian national guidelines. By 2010 TCF-C and TMC became aware of an increasing pressure from Cambodian health authorities on TBAs to NOT attend deliveries in their villages. The official policy is to fine or even imprison the TBAs, however at the same time these women are under dramatic pressure from villagers who persuade and threaten them to catch babies because there are no others alternatives. The working conditions for the TBAs in 2011 thus become increasingly worse without any improvement of delivery services for poor women in remote areas. In stark contrast to international and national policy, the preliminary analysis from the first 3 years of training in Cambodia show a significant reduction in maternal and perinatal mortality in our catchment area. Interestingly enough the largest reduction was in the group of mothers being delivered by the TBAs. The findings indicate that TBAs are life savers, similar to our experience with first helpers in war trauma systems.

Troms Mine Victim Resource Center

Annual report 2011

the village university also a researCh Center

During the wars in Afghanistan and Burma in the 1990ies Trauma Care Foundation developed a new teaching concept the Village University: transferring the knowledge and skills of life-saving surgery from the academic teaching centers out to the battle fields. During that time the Village University was a forum where Western trauma experts introduced Western trauma care strategies. The teaching concept was further developed in the mine fields of Northern Iraq and Cambodia where local trainees took over as instructors and further developed both treatment protocols and teaching methods. formal education and English proficiency. Although many have little formal education, the students have extensive professional experience in their respective fields. The students keep their full-time jobs while taking classes, so the studies require dedication and hard work. 6 of the students are females. The teachers are carefully selected from TMCs network of dedicated and skilled researchers and teachers, from Norway, Cambodia, Thailand and a few other countries. The teaching is groundbreaking; this being the first time a scientific curriculum is presented in written Khmer.

The Village University has so far maintained a crucial dependency on Western expertise for supervision and research. However, this is a contradiction to the objective of developing sustainable and indigenous trauma systems by enabling local people to make a difference in their own community. It is therefore obvious that building a robust local research capacity is an important, but so far missing, component that must be part of the Village University.

vietnam: Controlled CliniCal study oF

pain relieF outside hospital

researCh sChool
InSeptember 2010 TMC and partner TCF-Cambodia, starteda research school for 16 health workers from rural and remote areas, all from the network developed over many years by TCF-C and TMC. The school is located in Battambang, Cambodia, and the students attend 2-week courses 7 times per year for 3 years. The students are introduced to research methodology and medical subjects relevant to their professional background. Since few people in the Cambodian countryside speak English, language easily becomes a barrier to accessing academic knowledge, which is rarely published in Khmer. We therefore do not have any language requirements for entering the school, and all lectures and prescribed literature are translated to Khmer. The students have been selected on the basis of their personal experience, skills and dedication, rather than
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Persistent pain during long evacuations triggers post-injury stress and poor immune response, thus increasing the risk for complications. Efficient pain relief is therefore crucial in trauma care. For decades TMC and partners have used ketamine, a potent and safe drug for pain relief. However, when starting up the trauma training program in Vietnam TMC found that the national Vietnamese as do most Western trauma protocols recommend morphine for prehospital trauma care. This caused debate between experienced Cambodian care providers recommending ketamine and the Vietnamese doctors. To solve the dispute the Ministry of Health commisioned a comprehensive controlled clinical trial of prehospital ketamine treatment versus morphine for trauma victims in the Quang Tri province. Preliminary findings indicate that ketamine equals morphine in pain relief and with far less dangerous side effects. The results were analyzed in 2010, and the results published in an international conference of trauma in Vietnam March 2012. Our Vietnamese partner RENEW is now expanding the trauma model from the Quang Tri province to other areas close to the Laos border. This is done in collaboration with Ministry of Health, Hanoi, and with financial support from Ministry of Foreign Affairs, Norway.

Troms Mine Victim Resource Center

Cambodia: selF-help groups helping poor

people get going

TMC has documented that chronic pain in mine accident survivors and other trauma victims is a main obstacle for physical and social rehabilitation. Studies indicate that poverty itself acts as a chronic stress or trauma, feeding the pain syndrome. Support for income generation to victimized families should be considered a pain-killer. In 2006 2007, in cooperation with Institute of International Public Health at Oslo University, TMC undertook qualitative studies of self-help groups and microcredit support to Cambodian mine victims. The main findings are that thechain of survival must be extended from the point of hospital discharge to the end-point where victims resettle in their villages. The study shows that peer support by a local and trusted medic helps regain self-esteem and social function. Networking with other mine accident survivors enhances new arenas of friendship and social inclusion. In recent years land grabbing has become a major threat to the poor peasants in several parts of Cambodia. As fertile land is cleared from mines, the poor is chased further out in the jungle where cluster ammunition and land-mines still remains. TMC and TCF-C often hear stories about families who clear unoccupied areas from mines and start growing crops. However, shortly afterwards the alleged owner

appears and claima the land from the ones who risked their own lives by clearing the soil from UXOs. There is an obvious need for structural changes concerning rights to land, rights to health, and rights to a decent standard of living. The people in our study work and live under extremely difficult circumstances. Their lives were shattered by someone elses use of indiscriminate weapons, and they have a justified right for compensation. We foresee that some of the self-help group participants may initiate strategic efforts to gain basic civil rights. Several members of the self - help groups are trained to be instructors themselves. This adds valuable information back to the organization, and it also increases the instructors self esteem and respect. By 2011 the self help groups (SHG) in Cambodia include a total of 240 families in 8 different districts. The beneficiaries are families affected by mine/ cluster accidents, poor widows and very poor families in remote villages. Savings groups in underprivileged villages have been started after model from the Indian Movement Community Aid Alliance.

Annual report 2011 11

teaChing manuals
war surgery
2nd revised edition was released in November 2011. This book takes a unique approach to the subject of trauma and war surgery. This ground-breaking work sets a standard reference for care under difficult conditions, with the lack of medical facilities and proper staff. It promotes a concept of forward life support and surgery, which draws on the resources and knowledge of the local community, which improvises with local equipment and materials, and also includes a complete guide to post-operative, high-energy nutrition based on local foodstuffs and food-processing traditions. The second revised edition contains updates on the injuries caused by modern weaponry, on post-injury physiology, and on damage control surgery.

liFe aFter injury. a rehabilitation manual For the injured and their helpers.

This manual by Liz Hobbs and her Australian team is a goldmine of comprehensive information for assessing needs and carrying out rehabilitation where resources are few. The book is produced by Third World Network in Malaysia and also distributed by TMC. Vietnamese edition is available.

Films produCed by tCF Cambodia 2010:

What can I do to help the patient bleeding? Public educational film on how to stop bleeding. Length: 4 minutes. What can I do to help the patient not breathing?Public educational film on ABC-CPR. Length: 7 minutes. Guide to Ex-Fix and Orthosis Treatment of Open Fracture. Instruction film for surgeons and medical assistants. Length: 10 minutes. Rural Rehabilitation Workshop. Presentation of the Sampovlun rehabilitation workshop. Length: 6 minutes.

save lives, save limbs. liFe support to viCtims oF mines, wars, and aCCident

This book is indispensible for anyone involved in mine victims assistance, relief work in civil disasters, or even first aid in emergencies and accidents. Yet there is more to Save Lives, Save Limbs than life-saving first aid and surgery - it is also a guide to self-empowerment for rural communities stalked by this deadly epidemic. Step by step it shows how villagers in the South can build support networks to handle victims of mines and other disasters - taking into account the differences in infrastructure, terrain and clime, in healthcare and socioeconomic systems. The book is available in English, Farsi, Pashto, Kurd, Burmese, Shan, Khmer, Vietnamese, Spanish, Nepali and Arabic editions.

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Troms Mine Victim Resource Center

main sCientiFiC publiCations

Fosse E, Husum H: Surgery in Afghanistan: a light model for field surgery during war. Injury 1992; 23: 401 404.

Husum H. Effects of early prehospital life support to war injured: the battle of Jalalabad, Afghanistan. Prehosp Disast Med 1999; 14: 75 80. Husum H, Gilbert M, Wisborg T. Training prehospital trauma care in low-income countries: the Village University experience. Med Teach 2003; 25: 142 48. Husum H, Strada G. Measuring injury severity. The ISS as good as the NISS for penetrating injuries. Prehosp Disast Med 2002; 17: 27 32. Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma 2003; 55: 466 70. Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Landmine injuries: a study of 708 victims in North Iraq and Cambodia. Mil Med 2003; 168: 934 39. Husum H, Olsen T, Murad M, Heng YV, Wisborg T, Gilbert M. Preventing postinjury hypothermia during long prehospital evacuation. Prehosp Disast Med 2002; 17: 23 26. Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Respiratory rate as prehospital triage tool in rural trauma. J Trauma 2003; 55: 466 70. Husum H, Resell K, Vorren G, Heng YV, Murad M, Gilbert M, Wisborg T. Chronic pain in landmine accident survivors in Cambodia and Kurdistan. Soc Sci Med 2002; 55:1813 16. Husum H, Heger T, Sundet M. Postinjury malaria: a study of trauma victims in Cambodia. J Trauma 2002; 52: 259 66. Sundet M, Heger T, Husum H. Postinjury malaria: a risk factor for wound infection and protracted recovery. Trop Med Int Health 2003; 9: 238 42. Heger T, Sundet M, Heng YV, Rattana Y, Husum H. Postinjury malaria: experiences of doctors in Battambang Province, Cambodia. SEAsian J Trop Med 2005; 36: 811 15. Hedelin H, Husum H, Mudhafar M, Edvardsen O. Traumavrd i fattiga lnder - en bys kollektiva angelgenhet. Omhndertagandet av minskadade p landsbygden i norra Irak [summary] . Sv Lktid 2006; 7: 460 63. Edvardsen, O. Et nettverk av frstehjelpere i det minelagte NordIrak: et sprsml om liv eller dd. Thesis, Master Health Science. Tromso University, 2006. Chandy H, Steinholt M, Husum H. Delivery Life Support: chain-of-survival for complicated deliveries in rural Cambodia, a preliminary report. Nurs Hlth Sci 2007; 9; 263 269. Chandy H, Ol HS, Heng YV, Husum H. Comparing two survey methods for maternal and neonatal mortality in rural Cambodia. Women Birth 2008; 21: 9-12 Tajsic N, Husum H. Reconstructive microsurgery can be done in low-resource settings: experiences from a wartime scenario. J Trauma. 2008; 65:1463-7. Heng YV, Davoung C, Husum H. Trauma surgery at the District Hospital: a controlled study of trauma training for rural non-graduate surgeons in Cambodia. Prehosp Disast Med 2008; 23: 483 90 Wisborg T, Murad M, Edvardsen O, Husum H. Trauma systems in Iraq 1997-2004: adaptation and maturation. J Trauma 2008; 64: 1342 48 Tajsic N, Winkel R, Hoffmann R, Husum H. Sural perforator flap for reconstructive surgery in the lower leg and the foot: a clinical study of 86 patients with post-traumatic osteomyelitis. J Plast Reconstr Aesthet Surg 2009: 62: 1701 8

Husum H, Edvardsen. Trauma as Poverty. Methodological problems when reality gets nasty. In: Ingstad B, Eide H. Disability and Poverty (London 2009, in press). Ol HS, Bjoerkvoll B, Sothy S, Heng YV, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H. Prevalence of Hepatitis B and Hepatitis C virus infection in potential blood donors in rural Cambodia. Se Asian J Trop Med 2009; 40: 963 71 Heger T, Han SC, Sundet M, Larsen S, Husum H. Early diagnosis and treatment of malaria Falciparum in Cambodian trauma patients. SE Asian J Trop Med 2009; 40: 1135 47 Husum H. Severity scoring in rural trauma. Rural Remote Hlth 9 (online) 2009: 1226 Tajsi N, Winkel R, Schlageter M, Hoffmann R, Husum H. Saphenous perforator flap for reconstructive surgery in the lower leg and the foot; a clinical study of 50 patients with post-traumatic osteomyelitis. J Trauma 2010; 68: 1200 7 Husum H. Rural trauma in Iran: are the data reliable? Rural Remote Hlth 10 (online) 2010: 1387 Heng YV, Husum H, Murad MK, Wisborg T. Improving rural prehospital care in the absence of formal emergency medical services. In: Mock C, Julliard C, Joshipura M, Goosen J (Eds). Strengthening care for the injured: Success stories and lessons learned from around the world. World Health Organization, Geneva 2010: 3 7 Murad M, Husum H. Trained lay first-helpers reduce trauma mortality: a controlled study of rural trauma in Iraq. J Prehosp Disast Med 2010; 25:533 39 Bjoerkvoll B, Viet L, Ol S, Lan TN, Sothy S, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H.: Screening test accuracy among potential blood donors. Poor rapid test result accuracy in screening of potential blood donors of HbsAg, anti-HBc and anti-HCV to detect hepatitis B and c virus infection in rural Cambodia and Vietnam: Southeast Asian Journal of Trop Med Public Health, volume 41, September 2010. Murad MK, Husum H. Trained lay first responders reduce trauma mortality: a controlled study of rural trauma in Iraq. Prehosp Disaster Med 2010; 25(6): 533-9 Viet L, Lan TN, Ty PX, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H. Prevalence of hepatitis B and hepatitis C virus infections in potential blood donors in rural Vietnam. Ind J Med Res 2011 (accepted) Murad MK, Issa DB, Mustafa FH, Hassan HO, Husum H. Prehospital trauma system reduces mortality in severe trauma: a controlled study of road-traffic casualties in Iraq. Prehosp Disaster Med 2011 (accepted). Phung TK, Viet L, Husum H. The legacy of war: an epidemiological study of cluster weapon and land mine accidents in Quang Tri Province, Vietnam. SE Asian J Trop Med Publ Hlth 2011 (submitted) Murad MK, Larsen S, Husum H. Prehospital trauma care reduces mortality. Ten-year results from a time-cohort and trauma audit study in Iraq. Scand J Trauma Resusc Emerg Med 2012 Feb 3;20:13. Murad MK, Larsen S, Husum H. Prehospital trauma care reduces mortality. Ten-year results from a time-cohort and trauma audit study in Iraq. Scand J Trauma Resusc Emerg Med 2012; 20(1):13-20. Mudhafar Karim Murad; Dara B. Issa; Farhad M. Mustafa; Hlwa O. Hassan ; Hans Husum. Prehospital trauma system reduces mortality in severe trauma: a controlled study of road-traffic casualties in Iraq. J Prehosp Disast Med (in print). Lejon, H, Edvardsen, O, Husum, H: A qualitative study of first level care providers in rural Cambodia: Are Traditional Birth Attendants skilled or non-skilled care providers? Soc Sci Med 2012 (submitted).

Annual report 2011 13

FinanCial outline 2011

Cambodia: Trauma system, DLS Research School and Cluster program Iraq: Mine & War Victim Assistance Vietnam: Mine & Cluster Victim Assistance, Quang Tri TMC core projects Total (in NOK) 2 655 000 5 070 000 2 000 000 4 852 000 14 577 000

FinanCial support
NORAD

The Norwegian Ministry of Foreign Affairs

The Norwegian Research Council The University Hospital North Norway Private donors

we want to thank our partners

logistiC support
University Hospital North Norway University of Troms Suleimaniah University Hospital, The Ministry of Health, Northern Iraq Directors of Health, Kirkuk and Baquba Cambodian Ministry of Health The National Malaria Centre and WHO, Phnom Penh National Center for Maternal and Child Health, Phnom Penh Provincial Health Department, Battambang, Cambodia Battambang Central Blood Bank, Cambodia Center for Preventive Medicine, Quang Tri, Vietnam The Department of Health and The Peoples Committee in Quang Tri, Vietnam Al Rasoul Hospital, Beirut Directorate General for Civil Defense, Lebanon Vellore Medical School, India. l Prof. Stig Larsen, EPI Center, NVH Oslo (research methodology and statistics) l Prof. Eystein Skjerve, EPI Center, NVH Oslo (research methodology and epidemiology) l Prof. Derek Summerfield, London School of Psychiatry (qualitative methods, action research) l Prof. Knut Wester, Haukeland University Hospital, Norway (head trauma) l Prof. Tore Gutteberg, University Hospital Northern Norway (microbiology) l Prof. Benedicte Ingstad, Oslo University (medical anthropology, qualitative methods) l Prof. Staffan Bergstrm, Karolinska Institute, Stockholm (maternal care, epidemiology) l Dr. Johan Pillgram-Larsen, Ullevaal University Hospital, Oslo (trauma surgery) l Dr. Swee Chai Ang, Royal London Hospital (trauma surgery, teaching) l Dr. Reiner Winkel, Unfallklinik Frankfurt am Main (trauma surgery) l Prof. Fernando Vaz, Eduardo Mondlane University, Mozambique (teaching) l Prof. Alvarez Cambras, Frank Pais International Trauma Center, Cuba (orthopedic trauma). l Project partners l Catholic Relief Service, Laos. l Islamic Health Association Lebanon l All-Nepali Public Health Workers Association l Health Team for Nepal, Norway l NORWAC

advisors in researCh and trauma Care

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Troms Mine Victim Resource Center

tmC board members in 2011

Head of board: Hans Husum, Ass. Prof. Surgery, Institute of Clinical Medicine, Tromso University. Deputy head of board: Odd Edvardsen, Ass. Prof, Faculty of Health Sciences, Tromso. Margit Steinholt, Consultant Obstetrics, Sandnessjoen Hospital. Eystein Skjerve, Prof epidemiology and biostatistics, Norwegian School of Veterinarian Medicin. Anne Husebekk, Prof. Immunology, Consultant Transfusion Medicine, University Hospital North Norway. Ole Kristian Losvik, medical doctor, PhD research fellow, Tromso University. Tor Vadset, film-maker, Tromso. Helle Lejon, Medical doctor, University Hospital North Norway

the tmC researCh team

In addition to the TMC board members the research team comprises of: l Mudhafar Murad, MD, PhD research fellow Tromso University l Yang Van Heng, MPH l Ha Sam Ol, BMA l Houy Chandy, MPH and midwife l Le Viet, MSci l l l l l l l l l Nenad Tajsi, MD, PhD research fellow, Tromso University Tove Heger, MD, PhD research fellow, NVHS Oslo Hedda Hoel, MD Bjorn Bjorkvoll, bioengineer Mads Sundet MD Merete Taksdal, RN Marit Gjertsen, film maker Ahmed Zaradasht, film maker Bjorn Karlsson, orthopedic engineer.

partner organizations
trauma Care Foundation
TCF is a humanitarian foundation developing and producing medical teaching aids and A-V documentaries for oppressed communities in the South. Head of board: Hans Husum Tel +47 9517 1710 E-mail husumhans@gmail.com

projeCt renew vietnam

Dang Quang Toan Web Tel Email www.landmines.org.vn +84 905 129 789 dangtoanqt@gmail.com

islamiC health assoCiation lebanon

Mohammad Heijazi Tel Email +96 1306 5602 mohamad.hijazi@yahoo.com

trauma Care Foundation iraq

Tel Email +44 7077 522037 tcfiraq@yahoo.com

Dr. Mudhafar Murad, Suleimaniah

trauma Care Foundation Cambodia

Mr. Yang Van Heng, Battambang Web www.traumacarecambodia.org Tel +855 1288 9094 mail: yangvanheng@gmail.com

Annual report 2011 15

We know that poor health is just as much a cause of poverty as a consequence of poverty, and we are aware of the links between access to health services, good health and prosperity. We can achieve equity and good health for all, but in order to do so we will have to focus on improving health systems and primary health care services
Norwegian Minister for Development, Erik Solheim on Norways WHO strategy

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Troms Mine Victim Resource Center