**2. Methods**

An organized procedure was followed to ensure a high quality review of the literature regarding the subject of interest. First, a comprehensive search of peer-reviewed journals was completed based on a wide range of key terms including, but not limited to, "global health," "health security," and "health systems." Databases searched included PubMed, Ovid, and Google Scholar. Next, a search of websites such as the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) was conducted for policy and review statements on major threats to health security and leading cause of mortality worldwide. Based on these findings, further literature review was conducted using key terms such as "Trauma," "Cardiovascular Disease," "Stroke," "Maternal Health," "ATLS," "ACLS," "EMS," and "NRP." Literature review continued with articles identified as having potential for further review from the references sections of articles previously collected. The literature search ultimately generated 109 articles referenced in this review, which were published between 1980 and 2019. The collective information gained from this literature review was synthesized to identify the impact of programs and initiatives aimed at improving outcomes from the greatest threats to health security. These were organized into sections and are presented as examples of the extent to which these systems of care impact health security internationally.

#### **3. Trauma systems**

Traumatic injury is a disease without boundaries; it is one of the leading causes of morbidity and mortality worldwide and places a particularly heavy burden upon countries with limited resources. Road injuries alone killed 1.4 million people in 2016, about three-quarters (74%) of whom were men and boys [3]. Despite greater knowledge of injury causes and prevention, the growing global population, traffic, and urbanization cause morbidity and mortality secondary to trauma to remain a major health concern worldwide. Ensuring timely access to advanced trauma care as an international health security measure requires an organized network of prehospital emergency care and a standardized system of trauma care that can be replicated and delivered to patients in rural community hospitals and major academic tertiary care centers alike.

One of the largest initiatives in improving trauma care to-date has been the Advanced Trauma Life Support (ATLS) course. This training program was developed in 1978 by the American College of Surgeons following the tragic event of an orthopedic surgeon piloting his plane, who crashed into a Nebraska cornfield with his family, killing his wife and severely injuring his three children [4]. Insufficiency in the system of emergency medical care was recounted by this surgeon, who called for a system change to improve the care for trauma victims everywhere. ATLS focuses on the initial stabilization and resuscitation of the trauma patient, referencing the "Golden Hour" as the most important, as 30% of all trauma deaths occur

**49**

**Rank**

1

Lower respiratory

infections

1,890,008

2

Diarrheal diseases

1,577,891

3

Low birth weight

Lower respiratory

infections

127,782

HIV/AIDS

108,090

1,149,168

4

Malaria

1,098,446

5

Childhood cluster

Drowning

Interpersonal

Self-inflicted injuries

COPD

309,726

230,490

violence

216,169

86,327

diseases

1,046,177

6

Birth asphyxia and

Tropical cluster

Lower respiratory

Interpersonal violence

Cancers of

respiratory system

261,860

Cirrhosis of the liver

Hypertensive heart disease

Tuberculosis

1,605,063

Childhood cluster

diseases

1,359,548

Cancers of

respiratory system

1,238,417

Malaria

1,221,432

732,262

Stomach cancer

605,395

250,208

Road traffic injuries

221,776

165,796

infections

92,522

Fires

Cerebrovascular diseases

90,845

Drowning

87,499

124,417

Cirrhosis of the liver

100,101

diseases

35,454

Fires

33,046

Tuberculosis

32,762

birth trauma

729,066

7

HIV/AIDS

370,706

8

Congenital heart

disease

223,569

9

Protein energy

Protein energy

War

Lower respiratory

Self-inflicted injuries

Tuberculosis

495,199

189,215

infections

98,232

71,680

malnutrition

30,763

malnutrition

138,197

10

STDs (except HIV)

Meningitis

Hypertensive

Poisoning

Stomach cancer

Colon or rectal cancer

476,902

185,188

81,930

heart disease

61,711

*Most common causes of death worldwide by age group, 2002 (adapted from WHO prehospital trauma care systems) [2].*

30,694

76,871

**Table 1.**

**0–4years**

**5–14years** Childhood cluster

HIV/AIDS

707,277

diseases

219,434

Road traffic injuries

Road traffic

Tuberculosis

390,004

injuries

302,208

Self-inflicted

Road traffic injuries

285,457

injuries

251,806

Tuberculosis

Ischemic heart disease

HIV/AIDS

Lower respiratory

infections

1,395,611

Cancers of respiratory

COPD

2,743,509

system

927,889

Diabetes

Diarrheal diseases

1,766,447

749,977

390,267

245,818

231,340

130,835

**15–29 years**

**30–44years**

HIV/AIDS

1,178,856

**45–59 years** Ischemic heart

disease

1,043,978

Cerebrovascular

Cerebrovascular diseases

4,685,722

diseases

623,099

Tuberculosis

COPD

2,396,739

400,708

**≥60years** Ischemic heart disease

5,812,863

**All ages**

Ischemic heart

disease

7,153,056

Cerebrovascular

diseases

5,489,591

*The Impact of Systems of Care on International Health Security*

*DOI: http://dx.doi.org/10.5772/intechopen.93055*

Lower respiratory

infections

3,764,415

HIV/AIDS

2,818,762


#### *The Impact of Systems of Care on International Health Security DOI: http://dx.doi.org/10.5772/intechopen.93055*

*Contemporary Developments and Perspectives in International Health Security - Volume 1*

complications leading to neonatal death continue to have a significant impact on global mortality. Emergency medical services and programs such as ATLS, Advanced Cardiac Life Support (ACLS), and the Neonatal Resuscitation Program (NRP) were created to help deliver essential knowledge and skills to communities with low resources and increased disease burden. In this chapter, we will review the impact of these programs and initiatives aimed at improving health outcomes

An organized procedure was followed to ensure a high quality review of the literature regarding the subject of interest. First, a comprehensive search of peer-reviewed journals was completed based on a wide range of key terms including, but not limited to, "global health," "health security," and "health systems." Databases searched included PubMed, Ovid, and Google Scholar. Next, a search of websites such as the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) was conducted for policy and review statements on major threats to health security and leading cause of mortality worldwide. Based on these findings, further literature review was conducted using key terms such as "Trauma," "Cardiovascular Disease," "Stroke," "Maternal Health," "ATLS," "ACLS," "EMS," and "NRP." Literature review continued with articles identified as having potential for further review from the references sections of articles previously collected. The literature search ultimately generated 109 articles referenced in this review, which were published between 1980 and 2019. The collective information gained from this literature review was synthesized to identify the impact of programs and initiatives aimed at improving outcomes from the greatest threats to health security. These were organized into sections and are presented as examples of the extent to which these systems of care impact health security internationally.

Traumatic injury is a disease without boundaries; it is one of the leading causes of morbidity and mortality worldwide and places a particularly heavy burden upon countries with limited resources. Road injuries alone killed 1.4 million people in 2016, about three-quarters (74%) of whom were men and boys [3]. Despite greater knowledge of injury causes and prevention, the growing global population, traffic, and urbanization cause morbidity and mortality secondary to trauma to remain a major health concern worldwide. Ensuring timely access to advanced trauma care as an international health security measure requires an organized network of prehospital emergency care and a standardized system of trauma care that can be replicated and delivered to patients in rural community hospitals and major academic

One of the largest initiatives in improving trauma care to-date has been the Advanced Trauma Life Support (ATLS) course. This training program was developed in 1978 by the American College of Surgeons following the tragic event of an orthopedic surgeon piloting his plane, who crashed into a Nebraska cornfield with his family, killing his wife and severely injuring his three children [4]. Insufficiency in the system of emergency medical care was recounted by this surgeon, who called for a system change to improve the care for trauma victims everywhere. ATLS focuses on the initial stabilization and resuscitation of the trauma patient, referencing the "Golden Hour" as the most important, as 30% of all trauma deaths occur

**48**

globally.

**2. Methods**

**3. Trauma systems**

tertiary care centers alike.

**Table 1.** within 60 minutes of injury [5]. Despite a paucity of data on the effect ATLS has on trauma mortality, existing evidence supports its practice as a means of decreasing mortality and improving systems of care globally [6, 7].

Over 90% of deaths related to injury occur in low-income countries where the availability of prevention programs, emergency services, and centers capable of prompt, advanced resuscitation is limited. The majority of these deaths are caused by road traffic injuries [8]. Establishing early advanced trauma care is essential to decreasing global morbidity and mortality due to trauma and is, in part, accomplished with the dissemination of trauma education programs [9]. Studies have shown that as the number of ATSL-trained professional increases, the rates of preventable and potentially preventable deaths decreases (**Figure 1**) [10].

One study of trauma-related deaths before and after the implementation of focused trauma education courses in the capital of Rwanda, including ATLS, found the mortality of severely injured patients decreased significantly in the 6 months following their initiation [7]. Another study reported improved management of trauma patients by practitioners from countries throughout East, Central, and Southern Africa after institution of a primary trauma care course [11]. In the Netherlands, the introduction of ATLS resulted in a significantly improved trauma outcome in the first hour after admission [12]. A study on the impact of mandatory ATLS training on processes of care in rural America found improvement after categorization of trauma centers [6]. Improvement in trauma patient outcomes has also been reported after ATLS training in Trinidad and Tobago [13].

Since its inception, ATLS has gone through several iterations. Its principles have become standard of care in over 50 countries worldwide, with over 1 million physicians trained since the mid-1990s [14–16]. ATLS has developed into a global resuscitation program, with confirmed results in terms of improved patient outcomes, processes of care, and teaching.

#### **Figure 1.**

*Change in mortality over time with increasing number of ATLS-trained providers (adapted from Navarro et al. [10]).*

**51**

**Figure 2.**

*EMS = emergency medical services; a*

*Nakahara et al. [27]).*

*The Impact of Systems of Care on International Health Security*

Cardiovascular disease (CVD) is by far the leading cause of death worldwide. An estimated 17.9 million people died from CVD in 2016, representing 31% of all global deaths, 85% of which are due to heart attack and stroke [3, 17]. Over three-quarters of CVD deaths take place in low-income countries, illustrating a disparity in care and the need for further resource allocation and education. Despite the global burden of CVD, there have been remarkable advances in treatment and prevention. The field of resuscitation has been evolving for more than two centuries with the American Heart Association (AHA) formally endorsing cardiopulmonary resuscita-

Basic life support (BLS) and advanced cardiac life support (ACLS) guidelines have evolved over the past several decades based on a combination of scientific evidence and expert consensus. The AHA and European Resuscitation Council developed the most recent ACLS Guidelines in 2010 using a comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation (ILCOR). These were updated in 2015 and 2018 [19–26]. The efficacy of these guidelines is well borne out in the literature with clear reductions in in-hospital and out-of-hospital mortality when the most critical interventions (e.g., defibrillation, CPR, and rapid transport to an advanced care) are initiated early

Numerous large-scale randomized clinical trials have demonstrated the benefit of timely interventions as well, including antiplatelet therapy, thrombolysis, and cardiac catheterization [17, 32]. Results from these trials have been incorporated into guidelines for inpatient and outpatient cardiac care internationally [33, 34]. Despite these well-established guidelines for the management of ACS, there are still strong differences with regard to the epidemiology, diagnosis, and treatment of patients with ACS, leading to diverging morbidity and mortality rates throughout the globe [17]. Reasons for such differences among different global populations are multifactorial and include differences in population genetics, access to care, diet, socioeconomic status, and treatment modalities employed regionally (i.e., invasive vs. non-invasive strategies) [35, 36]. To address these disparities, much work has been done to universalize treatment protocols by bringing systems of care to areas

Stent for Life (SFL), a European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Congress of the European Association of Percutaneous Cardiovascular Interventions (EuroPCR) coalition, was established in 2008 as a non-profit international network of national cardiac societies and partnering organizations. The mission of SFL was to address inequalities in ST-elevation acute

*Exposure to prehospital bystander interventions among patients who achieved neurologically intact survival.* 

*patients received both bystander and EMS defibrillation (adapted from* 

*DOI: http://dx.doi.org/10.5772/intechopen.93055*

**4. Cardiovascular care**

tion (CPR) in 1963 [18].

(**Figure 2**) [24, 27–31].

most in need.
