Poorer countries face tenfold higher burn mortality due to treatment gaps

Missing evidence and limited treatment options mean deaths from burn injuries are ten times higher in poor countries compared with richer ones.

The implications are significant — 11 million people a year suffer burn injuries, and 70 per cent of them are in low- and middle-income countries.

Researchers at the University of Bristol, in the United Kingdom, tried to find out what is needed to close this gap and improve burns outcomes worldwide.

Hollie Richards, a senior research associate at the NIHR Bristol Biomedical Research Centre, hosted at the university, says there are many unknowns regarding the best treatments for burns, because of evidence gaps and inequitable healthcare access.

Burns research is usually conducted in high-income countries, which “means the results are not always applicable or appropriate for lower-income settings”, she tells SciDev.Net.

Richards coordinated the Priorities in Global Burns Research partnership, which surveyed more than 1,600 people in 88 countries about their experiences of burns care and the psychological effects of burns.

The findings are outlined in a paper published in The Lancet, co-authored by Richards in partnership with the James Lind Alliance, a UK-based initiative to involve patients, carers and clinicians in setting research priorities.

‘Lack of consensus’

Richards points to a “lack of consensus” among clinicians around the most effective approaches to burns care, including fluid resuscitation, wound dressings, the timing and type of skin grafts, and psychological interventions to improve rehabilitation.

“All of these treatment choices are influenced by location and socioeconomic factors,” she says.

“In many countries, there are geographical and economic barriers to accessing the best care, and if patients must pay for their treatment, poverty can prevent good care even where it would otherwise be available.”

The top priority identified in the study was the need for better evidence on effective acute burn treatments, while other priorities related to pain relief and the psychological impact of burns. The survey also highlighted a need for more cost-effective burns data.

We need to know what works best in different settings, not just what the best possible treatment is.”

Hollie Richards, senior research associate at the NIHR Bristol Biomedical Research Centre

Globally, 180,000 people die from burns each year. In poorer countries, says Richards, “burns that are survivable in high-income settings are often fatal”.

This is partly due to barriers to accessing good care, such as when the patient can’t afford treatment or is unable to get to a specialist burns service. Infection control can also be more difficult in these settings, especially when a large area of skin has been burned.

“Even if skin grafting to replace the lost skin is available, without adequate follow-up treatment such as physiotherapy, contractures can occur where the grafted skin shrinks and tightens causing major problems with mobility and function,” says Richards, adding that this is particularly problematic for children.

Medical advances, such as artificial skin coverings or innovative wound dressing materials, also remain out-of-reach in low-income countries, while out-of-pocket payments are a huge impediment to accessing burns treatment, which is expensive and often lengthy.

“Clinicians in India told us about patients with severe burns discharging themselves from hospital against their advice because they either cannot afford to pay for the treatment or because they do not want their families to have to go into debt to finance the care,” says Richards.

“In these instances, patients are unlikely to survive or fully recover.”

Psychological toll

As well as physical recovery, rehabilitation involves psychological treatment for the trauma caused by the injury, and by painful treatments, loss of mobility, or scarring.

This is not always available in poorer countries, where survivors may also face social stigma and discrimination due to their scars and disfigurement.

“[A] survivor in Malawi told us that their husband left them with no income because of the burn scarring on their face,” says Richards, adding: “Survivors all over the world told us about the psychosocial impact of being treated differently by others because of their scarring.”

Mark Fisher, an associate professor in the department of plastic and reconstructive surgery at the Johns Hopkins University School of Medicine, in Baltimore, USA, and director of the Johns Hopkins Bayview Adult Burn Center, agrees that improving burn wound care and the psychosocial outcomes of burns are top priorities.

“Patients’ personal psychological well-being and connection with others take a huge toll with severe burn injuries,” he says.

“Progress in these areas will make a huge difference for the world.”

For severely burned children, in particular, quick access to expert care means the difference between life and death, says Fisher.

“In high resource environments, this happens within minutes to hours. In lower-resource environments, delays in care and lack of access to burn teams results in high mortality rates and severe contractures.”

For Fisher, international collaboration across different income settings is “a win-win”.

“Not only does the human suffering of burn patients demand a global human response, but we all benefit through the maintenance and development of expertise through collaboration,” he says.

“Burns can happen on immense scales when natural or man-made disasters arise. We need to be ready and able to respond together.”