Hi class I hope you are doing well.

 
Today I'm in my office with my colleague and friend,
Dr. Catherine Lynch. 
Thank you so much for being here. 
>> Thank you for having me. 
>> Dr. Lynch is a specialist in Emergency
Medicine, 
she has practiced, taught and researched all over
the world. 
Anywhere from Argentina to Sri Lanka to Tanzania
and 
the list could go on and on and on, on this topi. 
And it's really worked to provide extra levels of
training and 
understanding to healthcare providers in countries
where there's insufficient 
level I guess we could say of expertise of how you
should deal with injuries. 
And I am just so pleased that you could be here
with me today. 
I know that you were up all night- >> [LAUGH] 
>> In the So 
you seem very chipper as always. 
>> Coffee is wonderful. 
[LAUGH] >> Coffee is an amazing drug. 
>> Yeah, it really is. 
>> It's the best, isn't it? 
>> Yes, it is. >> All right, and 
I know that your recent research is really focused
on trauma and injury. 
And that's one reason I wanted to have you here to
talk with my students. 
because I know that in my own experience teaching
global health, 
when I mention global health, students immediately
think of something, 
they think of communicable diseases, they think of
noncommunicable disease. 
But they don't necessarily think about injury and 
the role that it plays in global health even though it
is category 
three of the WHO's classification, the global burden
of disease. 
So I wanted to start by just having you talk in
general about why injury and 
trauma are such important topics in global health. 
>> All right, well thanks for having me. 
And obviously this is a topic that I can talk about for
forever. 
So I think the way to describe it, because many
people don't think about injury, 
the best way to describe it is really tell you my
experience and how I found injury. 
So I started doing global health specifically in South
Africa. 
And South Africa is an incredible country with
incredible disparities juxtaposed to 
each other. 
And my first clinical experience in global health and 
my first global health experience ever I really went
to this small little 
hospital in Cape Flats which is right outside of Cape
Town. 
And I went as a part of the ambulance service into
this hospital, and 
in this tiny little hospital that was a one room clinic,
there were 400 patients, 
there was blood on the walls, there was one
physician and one nurse. 
We came in for one patient, who'd been beaten to
death by his neighborhood 
because he'd done something wrong. 
It's called Kangaroo Justice. 
And so we took that patient and we gave the care
that was appropriate. 
And we took that patient to the referral hospital,
where he needed to go. 
When we walked into that hospital, there was 1
patient, ours and 
15 health care providers, and we had traveled a
total of 10 minutes. 
And in that ten minutes we had changed from the
floor area to the central areas 
of Cape Town. 
>> That's right. >> And that disparity in pair was 
enormous. 
During all of my clinical experience globally, almost
all of 
them every single day there's patients that I see
that are injured. 
That have preventable injuries, whether it's road
traffic accidents or 
its falls or its burns especially amongst kids. 
Everything sort of focuses around these injuries. 
90% of the time we hear all of these things that
happen all over the world, 
like infectious diseases and Ebola, that's
everywhere now. 
But we don't hear about the things that happen
everyday, 
that all of us are at risk for everyday. 
So during most of my clinical time abroad and then
most of time here as well, 
almost half of my patients are injury patients. 
But no one brings to light the fact that not only are
these patients suffering from 
these injuries but we're also at risk >> Sure 
>> Every time one of us travels 
abroad the leading cause of death of Americans
abroad is road traffic injuries 
>> Really. 
>> So we no matter what we do, no matter where
we are, 
the infrastructure of the health infrastructure
wherever it has to be, 
it has to be very strong- >> Right. 
>> To be able to support care for injuries. 
You need to have pre-hospital system, you need to
have care in an acute setting. 
So enough physicians to be able to give care. 
And you need to be able to have a prevention
system, which includes police 
and regulation and helmets and helmet laws, and
alcohol policies etc. 
All of that to prevent injuries. 
And in most international settings, that's not there. 
>> Right. >> So what 
we experience in the United States is by far the
tiniest little portion 
of injuries that happen all around the world. 
And because we're so used to them happening
because everybody is at risk for 
having an injury or an accident every day, we never
talk about it. 
>> Right. 
>> We never think about it, 
we never put our money towards it when it comes to
grants and to fundraising. 
>> Right. >> But think about your family members, 
and think about your extended family. 
Think about how many people have suffered
injuries, whether minor or major. 
And then end up going and seeing a doctor and
then put that in a different setting 
where there are no doctors >> Sure. 
>> And the disparity is just incredible. 
>> And I would I would think something that you've
mentioned, 
I think is really crucial is that the risk that we all
take. 
>> Yeah. >> Even I'm riding my bike over there. 
>> [LAUGH] Yeah, exactly. 
>> Endure, I think about these a lot. 
>> Yeah. >> But road traffic injuries, 
I mean you and I both end up travelling a lot and
working in different places. 
And you'd like me and I would want a road in
Tanzania. 
I know we've both been on- >> [LAUGH] Yeah. 
>> At nights. 
>> Yeah. 
>> And they're major issues, sometimes you see
there are no lights and 
people are walking. 
>> Exactly. >> Seatbelts are no existent and 
you'll see a family of five in different parts of the
world in one motorcycle. 
>> Yeah. 
>> So I know you've been focusing a lot recently on
road traffic injury. 
And why is that? 
Why is that your focus now? 
>> It's a very interesting question. 
So when it comes to injury, the burden the largest
burden of injury is road traffic. 
>> Is road traffic. 
>> I mean by far without a doubt. 
And a lot of the disparities that we have in sort of
our socioeconomic settings in 
different parts of the world are reflected within the
patients and 
what they suffer when they come to the hospital. 
So it is more likely for a poor patient to get injured in
a motorcycle 
crash compared to a motor vehicle crash, because
it's more expensive- 
>> Of course, yeah. 
>> To be able to buy a car. 
>> Yes, right. 
>> So therefore the people who are already at risk
from a socioeconomic standpoint 
end up becoming more at risk- >> Right. 
>> Because motorcycle crashes are a lot worse. 
So for me to address health, for me the most
important thing is to really address 
this disparity and be able to get to the patients who
needs us most. 
Most of the time that's going to be the road traffic
entry patients, 
the motorcycle patients, motorcycle, taxi drivers or 
pedestrians who are even more in despair in terms
of their access to care. 
And focusing on something that is incredibly
preventable. 
>> Sure. >> There is outstanding data out right
now 
that high income countries have made the market
movement- 
>> Sure. 
>> In terms of reducing fatalities for road traffic
injuries. 
Whereas low income countries haven't because of
the fact that we don't have 
regulations, we don't have helmets that are
enforced, 
we don't have other safety policies. 
We have very little enforcement of any rules from
police. 
>> Sure. 
>> Lack of pre-hospital care in more than 75% of
the world as well as limited 
acute care medicine and emergency medicine. 
All of this comes together to create a perfect storm. 
>> Sure. >> And 
the next sort of big killer in the world of which all of
us are interested for. 
>> Sure, what you just said makes me think a lot
about one of the topics that we 
talked about in class, which is we don't just talk
about determinants of health but 
how they all fit into a web of causation and create
various cycles. 
And what I'm hearing you say is that we perhaps
haven't thought enough 
about how injury actually can perpetuate cycles of
poverty, right? 
>> Yeah. 
Even if I have a bike accident and I break my leg, I
will come right, actually I will 
call, make sure you're actually working at the
hospital, I'll call you first. 
>> Yeah, yeah, yeah. 
>> But then if I don't come into work for a few days,
I don't come into work for 
a few days. 
>> Exactly. 
>> Not the same as if I have a family of nine to feed
and I can't even, 
if I even go to the hospital, if I can get there and pay
the cost for that, it might 
be the difference between my being able to feed my
children for the next week. 
>> Yep, and it goes one step further because a lot
of times you have to even 
refer to different hospitals because they don't have
the specialty level of care. 
So in Rwanda one of the things that we do is we
have a traumatic 
brain injury registry. 
Most of our patients are being referred from outside
of Kigali, the main center. 
>> I see. 
>> So the family has to go with that patient. 
The whole family, because most people who suffer
from motor crashes or 
motorcycle crashes are men between 18 and 44. 
So their wives go with them, 
their children have to go with them because their
wives go with them. 
And the reason why their family goes is because
they don't feed the patients, 
your family has to feed you. 
So the whole family has to move to Kigali to be able
to support your continued care, 
at which point the kids are pulled out of school,
there's no one making any 
money whatsoever, you don't even have your family
around you, 
your extended family, where are your crops if that's
how you make money. 
>> Right. >> So you're really stripped of any 
potential of earning and sustainability of the family
in and of itself. 
>> Sure. 
>> And then once you're better, if you're better, 
if you're lucky enough to get better, you're just left
there in Kigali.
Play video starting at :9:37 and follow transcript9:37
So you have to find your own way back home, and 
hopefully family will be able to support you. 
So it pulls essentially the whole family out into the
hospital setting and 
reduces any ability for them to sort of sustain a
continued growth financially. 
>> Goodness, so the leg injury might heal, but 
the other damage that's been done will continue. 
>> There's been data that's looked at a single bus
accident with an injury to 
a male who's the bread winner of the family, 
has two generations worth of effects in a low middle
income country. 
>> Two generations, that's sombering. 
>> Terrifying. 
>> It's terrifying, it's sombering, and it also makes
me 
think in particular that in terms of development in
general, 
then injury becomes an extremely important topic. 
>> Correct. 
>> And so preventing injury can actually, 
I would assume if there's a two generations impact, 
preventing injury can have a major economic impact
on the future. 
>> On the family, on the community, never mind
even the health costs. 
>> Sure. >> because we haven't even discussed
that. 
But most health care costs come from injury burden
because of the amount of 
cost that's required for a lot of these cases in these
hospitals. 
>> I would assume even with trauma, you have
brain trauma or serious injury, 
the cost would be extremely, if it in fact was it was
even appropriate, 
the equipment needed for rehabilitation. 
>> Correct, yeah, a lot of places there's no
rehabilitation, so 
we have a similar study in Tanzania where we're
taking a look at our traumatic brain 
injury patients. 
Their length of stay in the hospital is weeks, weeks
to months. 
The amount of time they get rehabilitation is
incredibly small because they just 
don't have the capacity given the sheer number of
patients who have it. 
Once they're discharged, they're essentially bed
bound. 
They don't have the ability to have wheelchairs or
reintegration, 
no physical therapy or sort of occupational therapy. 
No reintegration or job searching for them or
assistance in any way. 
So a disability is actually incredibly far more
detrimental to 
the family then you can possibly imagine,
sometimes even than a death would be.
Play video starting at :11:52 and follow
transcript11:52
>> Again, another sombering, really sombering
thought. 
And you're also involved right now, you're doing
some work in Sri Lanka I understand. 
Could you tell me a bit about that? 
Is there research involved? 
>> So we're doing road traffic injury project,
specifically in Sri Lanka, and 
we're actually doing it in three different countries. 
Rwanda and Sri Lanka have funding that's from the
same source, and 
Tanzania has a third set of funding but it's the same
project. 
The goal is to really understand where the
locations 
are that people get in a road traffic crash. 
And to do that a lot of times we use police data. 
We go to the police data sets and we look up where
the crashes occur, 
we use a map and we essentially put them on a
map and do a spatial analysis, and 
try to look to those locations to see what we can
improve in the environment. 
>> Right. 
>> But unfortunately in low and middle income
countries no one tells the police 
where the crashes are because if you tell the police
you get ticket. 
>> Right. 
>> And the less you tell the police the better in a lot
of cases. 
Never mind, they also don't write it down. 
>> Right, exactly, yes. 
>> Right, so a lot of times it just takes more time to
write it down and 
do what you're supposed to do. 
>> Sure. 
>> So there's a lot of under reporting in police data
sets, 
making sort of that method of data collection really
useless. 
So we're trying a new way. 
We want to ask people, because most people know
where the dangerous 
locations are in their own neighborhood. 
>> Of course, right. 
>> So we're going to the people who use the roads
and we're asking them, hey, 
where are the most dangerous areas? 
And from that we're creating a map, from the police
data we're creating a map, and 
we're comparing them. 
We actually have some great results and hopefully
will be published soon. 
But it's showing that it's as effective as the police
data, if not more, 
in terms of finding dangerous locations. 
>> Very interesting. 
>> So we're going to be able to do this from an
incredibly low cost method, 
just asking people where they know these locations
are. 
>> That's terrific, and also, you can also get data
not just on locations but 
maybe even at different times of the day. 
>> Exactly. 
>> As well. 
>> Exactly, exactly, and a lot cheaper. 
You don't have to go and 
have people do all the paperwork and try to find the
police data and 
do all the data entry, you can do a quick survey
which is something that's going to 
be a lot more useful in a lot of the limited resource
settings. 
>> That's fantastic, and 
so that way you can see where to really focus to
see if there are any 
kind of structural changes that- >> Yeah, putting in
a light, putting in 
a stop sign, having a police officer stand there,
being able to understand what 
the speed is in that area to be able to reduce that if
that's a problem. 
>> Right, just a good old speed bump, right. 
>> Exactly, exactly, makes a huge difference. 
>> [LAUGH] Right, so it seems that in terms of
preventing injury, 
especially road traffic injury. 
And I want to come back to burns in just a moment
as well.
Play video starting at :14:19 and follow
transcript14:19
Road traffic injury, there are multiple approaches,
and we've talked a lot in 
class about their approaches to change, to try to
change individual behavior. 
And then there's structural and legal strategies as
well. 
It seems to me that you really have to think about all
of these levels 
to have an impact. 
>> Yeah, so that is completely true. 
And a lot of the data that we've looked at so far in
road traffic injury specifically 
has looked at individual behavior, and it shows that
nothing changes. 
Nothing changes unless you have this whole
system here. 
Unless you have a law that's put in place, you have
inforcement of that law, 
you have education about that law. 
>> Because the only way to be able to really make
behavior change is to have 
all of those components in place. 
We did a study with one of the master students who
was here who 
looked at specifically handing out one of those
reflective vests that motorcycles 
are suppose to wear. 
There's a law in Tanzania that says you have to
wear it, but nobody wears it. 
So we even handed it out to them, and said, please
wear it. 
>> Right. 
>> And because the law had no enforcement
whatsoever, nobody wore it. 
They had it for free, they were given it, they were
asked to wear it, 
they did everything other than that little piece which
is the enforcement, 
nothing happened. 
>> I've had this experience with bed nets. 
>> Yes, exactly, it's the same thing. 
>> Exactly, exactly the same thing. 
Yeah, something that brings that home for, I have
two things that have happened to me 
that really bring home some of the issues that
you've said. 
One is that, when I was in Sierra Leone in
Freetown, I was really surprised 
to see How many people were actually wearing seat
belts in the front seat? 
And I asked my driver about this, and he said it's
the law. 
And I said, well, I have been in so many places
where it's the law and 
I can't even find a seat belt. 
>> They cut it out most of the time. 
>> Yes, exactly, exactly, because it's got a lot of
other uses. 
>> Exactly, sure. 
>> Yeah and he is said to me they actually had the
police start stopping and 
fining people the equivalent of $100 US, so. 
>> Exorbitant amount of money. 
>> Exorbitant amount of money. 
>> Yeah. 
>> And that's what it took, and it helped the
economy, too. 
>> Exactly. >> Because then they need lots of 
infrastructure there. 
>> Yeah. >> But you're right, 
it really takes that level. 
>> And that's what makes it fun is the fact that you
get to work with people from 
all different angles. 
You have to think about it differently. 
>> Right. >> And you get to meet people who 
are coming at it from a totally different angle. 
>> Right. >> I had never thought of working with 
police officers, but once you do, you see how they
do it that way, and 
working together. 
It just makes it a really cool area to work in. 
>> That's terrific. And that also, I think, 
illustrates the multi-disciplinarity of global health. 
Bringing in all of these different areas. 
Now burns, I know you said burns happen quite a
lot. 
I've mostly seen it mostly with children and 
in areas where women are cooking over open fires
inside their house. 
>> Exactly. >> What can we do to try to prevent
most 
of the burns that take place? 
Are there things that can be done? 
I know it's challenging. 
>> Well, I'll go back one step and 
just bring up the fact that exactly what you said is
probably 100% true. 
When we talk about epidemiology of injuries
particularly, 
men always dominate. 
They're always the ones that are getting injured on
the roads, in falls. 
And I don't know what guys do, but they end up
getting injured all the time. 
Women- >> We have this Y chromosome. 
And I am certain that something about our Y
chromosome- 
>> I don't know. 
[LAUGH] >> Mine excluded of course. 
>> But women, they end up getting injured in very
particular patterns. 
>> Uh-huh. >> So they're always the one burned. 
And they're always the ones who end up in sort of
getting injured within the home. 
>> Sure, right. >> Most of the time with burns or
scalds, 
or those kinds of things. 
And so their prevalence is a lot higher, so women
and 
children end up getting a lot more burns. 
Drowning for kids is a lot higher because of some of
the same reasons. 
But looking at that, that's a really good way to be
able to understand how we need 
to focus in the area of injury on women because it's
something that we're 
probably going to ignore if we just look at injury in
general, 
focus on road traffic injuries. 
We're going to forget women and 
how they end up- >> Right. 
>> Suffering from this in the home. 
>> Sure. 
>> And you're completely right that most of the
time, 
it is cooking related to scalds and burns. 
It is home heating related issues as well. 
So understanding how women cook in the
household, 
how they take care of fires that they use. 
How they have utensils or things to be able to hold
hot, 
scalding water, understand what safety
mechanisms can be there. 
>> Sure. >> A lot of people end up cooking over 
an open flame. 
>> Right, yes. 
>> Or over an open area. 
With pots and pans that fall over. 
>> Sure. >> Because they don't have money to buy 
the real things. 
And the environment itself isn't even set up to stop
the fire. 
>> Sure. 
>> Nevermind to stop a child from running into the
fire. 
>> Of course. 
>> So there needs to be there again, it's going to be
a compilation of things. 
It's going to be a compilation of allowing that
education to take hold amongst 
mothers, young mothers especially who don't have
a lot of resources. 
>> Of course. 
>> Free resources to be able to set up a fire that
has something that 
is surrounding it to prevent it. 
To go along with education for the rest of the family
on how to change their 
environment so that it is completely protected for
the kids. 
But once it happens, 
then we also have to have a health system that
should be able to handle this. 
>> Sure, of course. 
>> Burn care is some of the most expensive care in
the world. 
And sometimes makes some of the most incredible,
lifelong horrible effects. 
>> Of course. 
>> Debilitating effects as well disfiguring effects. 
Which can have a huge lifetime long impacts on
families. 
>> Sure, I've talked women who have been
unintentional burns, 
there's a whole other area. 
>> A whole different area. 
>> Intentional burns, right, 
that go to important issues of intimate partner
violence and injury as well. 
>> Correct. 
>> But many of them have been in situations where
then the husband 
rejects them and sends them away and keeps the
kids. 
These can be communities in which women don't
have many economic opportunities. 
And again, you see these cycles continue and
continue and continue. 
It's really something that we should be more aware
of. 
And I think it's almost as if, people drive, we buy
bike. 
We see road injury we say, that's terrible. 
It's horrible. 
And then we go on driving. 
>> Right, right. 
>> So it's almost, I don't want to say that we're
newer to it, but 
at the same time, because it's something that does
happen, 
we don't think necessarily think about it in the same
way. 
>> Right. 
>> It doesn't necessarily seem exotic. 
>> Exactly. >> And one of the things we're trying to 
do in this class is to de-exoticize global health. 
And we talk about infectious disease, and people
always think malaria, 
tuberculosis, etc. 
That's absolutely right, but diarrhea and lower
respiratory infection. 
>> Pneumonias, yeah, exactly, exactly. 
>> Pneumonias, these are killers, they're killers,
and this even ties together. 
I mean, frail, elderly person, as we're all living
longer. 
Has a fall, breaks a leg, breaks hip, goes in the
hospital. 
Probably going to die, if they're going to die, 
it's a lower respiratory infection, right? 
That'll be one of the things, that that kills them. 
So all of these things are inter-related as well. 
>> Yeah, most definitely. 
We have a new project that's specifically looking at
falls among the elderly 
in Brazil, 
because the amount of morbidity that is linked just
to falls in elderly people. 
It's the most mundane thing in the world. 
Everybody falls, right? 
>> I know. right, yes. 
>> But it actually causes a huge burden of
mortality. 
>> Sure, sure. 
Sure, sure. And hip replacements like we get here
in 
the US are not always that simple or easy. 
>> No, no, no, correct [LAUGH]. >> And it's really
interesting too, 
when talking to you I know we just talked about de-
exoticizing global health. 
But I also think it's great that your work, 
especially because you work in injury disparities
and a lot of other issues, 
that it really shows how we can't be so rigid in
global health when students 
think about category one, two, and three global
burden of disease. 
All of these issues are interrelated. 
>> Yeah, and I think that's what I love about
injuries, per se, and 
maybe that comes from the fact that I'm a
generalist, 
being an emergency medicine person, as I just love
all kinds of medicine. 
>> Sure. >> I just love to understand all 
the different parts of it. 
But especially in injuries, you're able to get into
biomechanical engineering and 
understand how that affects what's going on. 
You get to work with kids as well as adults as well
as women and men. 
And then different types of topics as far as we
talked about family violence as well 
as road traffic injuries, which are night and day. 
It's just an incredible field and it's so dynamic in so
many different ways- 
>> Right. 
>> That it just makes you think differently every time
you go about it. 
>> Sure. >> And 
coming from a different angle each time. 
>> Sure, sure. >> It makes it really cool. 
>> And I would strongly suspect that while
obviously we want the global burden burden 
injuries to decrease. 
We want to avert as we talk about. 
Nonetheless, as we live longer and 
hopefully increasingly we decrease the burden of
infectious disease. 
What that means is that the global burden of injuries
actually is going to increase. 
>> So looking at- >> As well. 
>> Recent numbers- >> Mm-hm. 
>> Injuries are the only thing that have increased. 
And road traffic injuries, in the last decade, have
increased 33%. 
>> Wow. 
>> So it's happening already. 
We- >> Sure. 
>> Know it's happening already. 
And it's only going to happen exponentially in
certain countries. 
>> Of course, and yeah, I can see Nigeria
population, what, is going to triple me. 
I remember, I've been going to China for 20 years,
working. 
And when I first went to China 20 years ago even in
Beijing, there were cars. 
Now there are cars. 
They are cars. 
>> [LAUGH] Everywhere. 
>> Everywhere, crossing the street. 
I mean, I think about now when I go to Vietnam and 
I'm annoyed just trying to get across the street. 
But you see this is happening there'll be an
increased number of cars, 
an increased number driving all over as we move
into this urban transition and 
just as we get more globalization as well. 
And it really is going to be a key issue. 
>> And a terrifying part is that this urbanization is
happening in the settings 
of low infrastructure. 
>> Of course, exactly, yes. 
>> Because if it happened in the setting of high, like
in New York City, fine, 
we get bigger and bigger- >> Exactly, right, exactly, 
right, yeah, yeah. 
>> It's so rigid, literally, it's a city that's so 
well organized that we can keep getting bigger. 
But when you literally see a bowl of spaghetti as
streets, and 
you see cars everywhere, there's no roads. 
>> There's no actual roads, it's all dirt, there's no
lights. 
And then literally you can't see where the road is
and where the people are- 
>> Exactly, yes. 
>> We're just going to end up having such a big
problem. 
I probably will have work to do for the rest of my
lifetime. 
[LAUGH] >> I was going to say you and 
your mentees have a lot of work cut out for you that
we are fortunate, 
both Duke and Global Health in general, to have
you and 
people like you, who are paying attention to a
problem. 
A problem of huge enormity that I don't think has
always gotten the attention 
that it deserves. 
>> I'll agree with that. >> I don't think it ever got
any 
attention. 
>> Yes. >> Hopefully, soon. 
Hopefully, soon. >> Yes, hopefully, soon. 
So Katherine, again, thank you so much. 
And students, I just want to let you know that, 
think about these things as you are in your own
home. 
As you see your elderly parents or grandparents, or 
when you're getting on your bike or in your car. 
The potential for injury is around us all the time and
if I were really cheesy, 
I'd fall off my chair and say Dr Lynch help me, but I
won't do that. 
>> [LAUGH] >> Anyway, but Katherine, thank you
so 
much as always. 
All right, class, we'll see you soon, bye. 
>> Thanks.