Section 6, Chapter 1: World Spine Care: A Charity Providing Spine Care in Botswana, Dominican Republic, India and Ghana

Scott Haldeman, Geoff Outerbridge, Stefan Eberspaecher, O’Dane Brady, Deborah Kopansky-Giles, Margareta Nordin, Eric L. Hurwitz, Afua Adjei-Kwayisi, and Rajani Mullerpatan

Introduction

World Spine Care (WSC) is a non-profit charity registered in the United States of America, Canada and United Kingdom. It was founded in 2009 out of a growing realization that spinal disorders were a significant, and often ignored, contributor to the burden of disease, not only in high-income countries, but also in low- and middle-income countries. The latter realization was confirmed when the World Health Organization (WHO) sponsored Global Burden of Disease 2010 report was published, and it was noted that back and neck pain were the number one and number four causes, respectively, of disability in the world.¹ This report also noted that the impact of spinal disorders had increased significantly since the prior Global Burden of Disease Report in 1990. The authors noted that the global disease burden had shifted away from communicable to non-communicable diseases and from premature death to years lived with disability. Low back pain alone was estimated to contribute 10.7% of the total burden of disability worldwide. Back and neck pain combined were noted to have a greater impact on global health than HIV/AIDs, Alzheimer’s disease, malaria, diabetes, lower respiratory infections, depression, stroke, and breast and lung cancer combined. Although there are some conflicting statistics on the relative prevalence of spinal pain in high and low income countries, a recent systematic review of the literature by Jackson et al. suggested that back and neck pain has a higher prevalence in sub-Saharan Africa and low- and middle-income countries when compared to high-income countries.² The World Report on Disability 2011 by the WHO and World Bank noted that global disability (back pain being the greatest contributor) disproportionately impact women, the elderly, rural communities and the poorest quintile of the population.³ Disability is also greater in low income countries.

After visiting a number of low-income countries WSC volunteers noted that there are often little or no resources or expertise to address the disability associated with spinal disorders in these countries. There are often no medical specialists with training in spinal disorders, such as rheumatologists, neurologists, psychologists or surgeons who have completed spine fellowships. What was most striking, however, is the lack of primary care for people with spinal disorders. General practitioners and nurse practitioners had not received training on how to manage spinal disorders, and there were no chiropractors, osteopathic physicians, physical therapists with training in primary spine care or other practitioners who would likely offer interventions consistent with evidence-based guidelines. The observed lack of resources in many of these communities is aggravated by a lack of interest by international charitable assistance organizations in reducing the impact of spinal disorders. The Financing Global Health 2015 report measures developmental assistance for health, which covers financial and in-kind contributions provided by global health channels to improve health in developing countries.⁴ This report notes that of the $36.4 billion that was dispersed on health in 2015, only $475 million was spent on non-communicable diseases. Spending on musculoskeletal disorders, let alone back and neck pain, is not even mentioned in the report. It, therefore, became evident that it will be up to organizations such as World Spine Care to develop programs aimed at reducing the burden of spinal disorders in low- and middle-income countries.

The Goals of World Spine Care

The mission of World Spine Care is “to improve lives in underserved communities through sustainable, integrated, evidence-based, spine care.” Its vision is “A world in which everyone has access to the highest quality spine care possible.”⁵

One of the first decisions that World Spine Care had to consider was the values that would guide WSC programs and to develop a model of care that could be implemented in low resource communities (Table 1-1). Early on it was recognized that any care program had to be fully integrated into local health care systems and be sustainable. It could not be considered an isolated silo that provided a single spine care intervention. Spinal disorders, for the most part are chronic conditions for which programs that only offered short-term interventions are unlikely to have much impact. It became obvious that, without integration into the local health care system, any attempt to provide care to people with spine related problems would not be sustainable. In order to be effective, it is also essential that care offered must be consistent with internationally accepted evidence-based guidelines. Furthermore, it is likely that programs initiated by NGOs from outside the country would have limited impact without an emphasis on education, cooperation and integration of local health care providers.

TABLE 1-1. The values of the WSC program.⁵

Sustainable: To empower local governments and communities to assume control of their spine care programs in collaboration with WSC. Patient-centered: Care engages the patient/family in decision-making and is oriented to address the needs and priorities of the patient. Evidence-based: The emphasis is on evidenced-based, integrative care. Education: To educate the community and local health professionals. Research: Add to the body of knowledge of spine care. Global: To bring access to spine care, without barriers, to underserved communities around the world. Sensitive: To be sensitive to the local customs and culture of the communities in which we operate. Compassion: To have compassion for those whom we serve.

Principles in the Development of WSC Programs

The WSC mission, vision and values statements lay out the key principles that are used in the determination of appropriate projects and the elements that must be satisfied for the project to be viable. These include the principles of evidence-based care, integrated care and sustainability. The model of evidence-based care in the WSC clinics is a two-way model that used evidence to inform the care, and collects data to measure the efficacy of the care and help further improve that care. WSC uses the most current clinical practice guidelines and best available evidence to inform the clinical examination, treatment and education of patients.

WSC’s model of care emulates the priorities set out by the WHO, namely the attainment of the highest available standard of health, improving access to care (with a target of universal health care), provision of evidence-based care, and care provision that is people-centered and integrated with other health services.

In 2016, the WHO achieved global support for their Framework on Integrated, People-Centered Health Services (IPCHS) and launched an interactive web platform⁶ for the purpose of sharing knowledge and promoting collaboration regarding IPCHS.⁷ This framework identifies five key strategies that are proposed to support the global movement of health systems toward integrated health care. These strategies include:

1. Empowering and engaging people and communities;
2. Strengthening governance and accountability;
3. Reorienting the model of care;
4. Coordinating services within and across sectors; and
5. Creating an enabling environment.

As part of the IPCHS initiative, the WHO invited individuals and organizations to submit practice examples for inclusion in the Practices portal on this web platform. World Spine Care was invited to submit its model of care and practice example from Botswana. Following WHO review and assessment of required criteria, the WHO recognized WSC as a promising practice in 2016 and included it on the web platform for others to review, learn from and potentially collaborate with. The WHO identified that WSC’s model of care met the inclusion criteria and noted that one of the strengths of WSC’s model was its transferability/scalability. WHO identified that WSC utilized four of the five strategies and that it emulated the principles of integrated and people-centered health services. The WSC practice example can be found on the WHO IPCHS web platform.⁸

Over the past three years, the WHO has worked to produce its Global Strategy on Human Resources for Health: Workforce 2030 report.⁹ This report identified that a primary objective of the strategy is to “optimize performance, quality and impact of the health workforce through evidence-informed polices on human resources for health, contributing to healthy lives and well-being, effective universal health coverage, resilience and strengthened health systems at all levels.” In its partnership with local governments WSC has committed to enabling access to evidence-based spine care without economic barriers. Financial barriers prohibit access to health care services, particularly in low- and middle-income countries (LMICs). Removal of these barriers is a preliminary step towards universal health coverage. Training and up-skilling of the health workforce is also essential for the delivery of primary spine care and is required for the attainment of integrated and sustainable healthcare services. As a human health resource strategy, WSC’s model includes the facilitation of advanced training for health workers through its scholarship program, which is supported by collaborating academic institutions and WSC clinic host governments. The scholarship program supports the long-term sustainability of WSC clinics with up-trained local health workers eventually forming the primary care health team at all WSC sites.

The ability of WSC to expand to other jurisdictions has also been acknowledged by the WHO practice example. The scaling up of health care programs such as WSC requires commitment on the part of local government and policy makers, health professional training programs, and WSC partners and funders. Transferability of clinical programs such as WSC requires an appreciation of and knowledge about local customs, cultures and traditions. This also requires the application of evidence-based guidelines, mechanisms for collecting, analyzing and sharing data, and standardized clinical policies and practices.

To facilitate continuing of care for the patient and communication between health providers and collaborating clinical facilities, WSC has developed documentation and outcome instruments for use in all clinic settings, adapted to cultural nuances and integrated with local spine care needs. Each clinician who participates in the program is trained in the documentation, which facilitates ease of transfer of information between clinicians. WSC has developed a documentation toolkit that includes intake, examination, treatment forms, informed consent, summary pages and re-assessment forms. Although translations of these forms are employed in the various clinic locations, conceptually, these are the same for all clinics with only minor modifications to fit local cultures or norms. This toolkit makes it possible to extract information and create a patient database. The information in the database includes such information as patient demographics, presenting complaints, comorbid factors, and patient outcomes and allows for comparison of patient populations seeking care and outcomes between clinics.

A primary concern on setting up a WSC program is whether it can be sustainable over the long term and will continue functioning independent of external aid. From the moment that WSC considers establishing a program in a community, there must be a clear pathway to a locally supported sustainable status. This is achieved through several requirements each of which has to be considered before a program is initiated.

The first is local cooperation. All WSC projects are endorsed, supported and integrated into the local government health care system or a well-established academic institution with the intent of eventually handing the entire project over to local management. Engaging with the local health care system allows more seamless integration of care for the patients and engages the local health care communities, which encourages capacity-building initiatives.

Each clinic is initially established by trying to identify a Clinic Supervisor (CS) with the training and skills to act as the primary spine care provider. When there is no local clinician who can provide spine care, a volunteer CS, to date a chiropractor or physical therapist with advanced training in primary spine care is recruited who is expected to spend at least one year managing the clinic. To ensure continuity of the clinic programs and the quality of care, the CS is generally replaced yearly by a new CS whom he or she fully trains in the clinical procedures. The CS is involved in patient care, communication with other health care professionals, maintenance of the clinic patient data registry, data quality control and management of the WSC housing and facilities. In the case of a volunteer CS, the position is maintained until the local supporting health care system is able to provide a locally trained or supported CS and take over financial support of the WSC clinic. Short-term volunteers are invited to spend 4 weeks to 3 months to provide care and assist with the educational programs. Once local authorities assume oversight of the WSC spine program, WSC maintains a quality control, consultative and educational role and continues to monitor the patient database.

Since the number of volunteers that WSC can provide is limited, a major part of the WSC program is to provide education at all levels. This is done through education at the patient level, the community level, the education of local health care providers, scholarships for primary spine care and fellowships for advanced spine care. Patients are educated on prevention and self-management, which includes information on prevention of spinal disability and physical and psychosocial risk factors for spine related disability. Community education programs include the WHO Straighten Up program endorsed by numerous international agencies, adolescent scoliosis screening and a yoga teacher training program developed around training local residents to teach yoga to patients with pain and reduced mobility. Local health provider education programs include one-day workshops on spine related topics and techniques for the conservative management of spine pain. WSC also coordinates one or two-day conferences which bring in experts from the fields of surgery, conservative care, radiology, epidemiology, and evidence-based care. The latter are supported by many of the major spine societies including the North American Spine Society (NASS), EUROSPINE and the International Society for the Study of the Lumbar Spine (ISSLS). In addition, WSC arranges full scholarships through participating institutions for local students to train in primary spine care such as chiropractic and eventually take over the management of the spine care projects. To date four such scholarships have been arranged at chiropractic institutions in North America and Europe and candidates to date have included trained nursing staff and locally trained medical physicians. Local government is expected to cover living and travel expenses for the candidate and ensure that the candidate is committed to return and assume the responsibility to maintain and continue with the WSC program. WSC has also established relationships with a number of spine surgical centers of excellence that are capable of hosting surgeons to complete fellowship training in spine surgery. The first surgeon trained through the WSC programs completed his fellowship in 2016 and returned to Botswana to set up a spine surgical specialty at the major referral hospital in Gaborone.

The World Spine Care Programs

WSC now has programs in four countries on three continents each of which have unique and different cultural, language and political challenges. The challenge in each case was to ensure that the principles and programs felt to be crucial to spine care that WSC adhered to were maintained while at the same time adapting to differences in cultural, local institutional, political and financial norms. This often required negotiation with different local governments or institutions, consideration of the financial and administrative roles of WSC, local ministries of health and education, universities and professional associations.

The following is a description of how the four programs were negotiated and established.

Botswana

In 2011, the Botswana Ministry of Health (BMOH) and WSC signed a Memorandum of Understanding (MOU) that outlined the roles and responsibilities of the two organizations in establishing the first WSC program. (Fig. 1-1.)

WSC was looking for a geographically distinct community with a treatment naive population of about 7,000 to 10,000 that was within a short distance of a district hospital. This would allow primary spine care delivery at the village level while having reasonable access to services such as imaging, laboratory, and emergency medical and surgical care. While discussing these requirements with the BMOH, it was decided that the village of Shoshong and the Mahalapye District Hospital (40 Km apart satisfied these requirements.

In the MOU the BMOH agreed to provide clinic space, furniture, supplies and staff for the clinics including two interpreters and allow for direct referral to all specialists, imaging and laboratory testing. The BMOH also agreed to provide funding for the living expenses of students who were selected to participate in the scholarship programs. The BMOH also agreed to support the WSC research initiatives and to provide housing for the WSC volunteers.

WSC agreed to provide trained and qualified volunteer clinicians on a continuing basis until transfer of responsibility to the government in 2018, as well as furniture for the WSC residence and living expenses for the Clinic Supervisors. WSC also agreed to support transportation for the Clinic Supervisors (to and from Botswana and on the ground), tuition scholarships for Batswana citizens who would spend four years at a chiropractic educational institution and yearly updates on the progress of the clinics and work with the BMOH to further expand the spine care program across the country.

Patients presenting to the clinics are not charged for WSC services, but pay a nominal fee to the BMOH to access the health care system in Botswana. There are no barriers to care at any of the WSC clinics in Botswana or any of the community programs including the biweekly yoga classes.

The WSC clinic at the Mahalapye District Hospital opened in December 2011, seven weeks after the first Clinic Supervisor arrived in Botswana. The Clinic Supervisor worked to establish the second clinic in Shoshong in a government-funded porta cabin on the grounds of the Shoshong village clinic. This second clinic opened in August 2012. Both clinics have run continuously since their opening.

A single Clinic Supervisor ran the clinics until March 2016 when a second Clinic Supervisor was added due to increased patient load and additional project requirements. For the first four years of the project, the single Clinic Supervisors overlapped for at least a month to ensure that the incoming Clinic Supervisor was properly trained in the WSC toolkit and was introduced to all the key stakeholders and other specifics of the project. (Fig. 1-2.)

Because one of the clinics was located in the District Hospital, the Clinic Supervisors had direct access to the other health care providers in the hospital and were allowed direct access to and referral to all health care providers, imaging and laboratory testing. The health care team at the Mahalapye District hospital was very open to collaboration and cross referral, which facilitated an integrative patient care approach. This openness also facilitated a two-way transfer of knowledge that profited all clinicians. The MOU between WSC and the Botswana MOH and the agreement on interdisciplinary care was important in bringing the stakeholders together from the start with little resistance.

The program is now expanding to include a tertiary spine care program at the Gaborone medical teaching hospital with the hiring of the WSC clinical supervisor and the return of a local Batswana orthopedic surgeon who completed his spine surgical fellowship at the Ankara Spine Institute, Ankara, Turkey.

Dominican Republic

The program in the Dominican Republic followed a different pattern. Instead of initially negotiating with the national government department of health this program depended on bringing together a number of local stakeholders. In March 2016, a MOU was signed by WSC, the provincial director of the public health care system, a director of the public hospital and two local partner charities. One of the local partner charities agreed to provide physical premises for the clinic and logistical support. The clinic was located on the grounds of the public hospital. The hospital and local private institutions also provided access to basic diagnostic services for the WSC program. (Fig. 1-3.)

The involvement of the Dominican Republic government was a process that took place over two years. Initially, there were some logistical issues that prevented the ministry of higher education from participating in the agreement. It was not until two years later that the ministry of higher education agreed to support a Dominican student through the education process. Given this delay and a general underestimation of the costs associated with keeping the project going, additional local support was required. The senator of the province, which included the city of Moca, agreed to champion the WSC program with the national government and local stakeholders. Finding a local champion has been essential to sustaining the project especially in an environment where bureaucratic channels are difficult to access. (Fig. 1-4.)

Since its opening, the clinic has been staffed by a single clinical supervisor. In addition, seven short-term volunteers have spent time at the clinic. Short-term volunteer visits ranged from 2 to 108 days in duration. The benefit of having the single supervisor increased continuity of care and patient rapport; however, having one clinician significantly limited the operating capacity of the clinic. The responsibilities of the clinical supervisor included direct patient care, management of one permanent clinical assistant and the seven short-term volunteer clinicians as well as supervision of ongoing research activities. Coordination with local health practitioners, hospitals, government officials and other key stakeholders was also part of the supervisor´s responsibilities.

Local healthcare practitioners have been tremendously generous in accepting the WSC program and in providing assistance with the program. Two local medical physicians have assisted with patient evaluations on occasion and make recommendations for referral to medical specialists or facilities not within the district hospital. A general surgeon, director of a nearby hospital, is available and has helped facilitate many logistical solutions such as access to advanced imaging when necessary. A local nutritionist attends the clinic to consult with some of the patients with more severe metabolic issues. The clinic is very well accepted and welcomed by local healthcare practitioners who have been happy to assist at every turn.

The future direction of this program is dependent on expanding the financial commitments locally and internationally, as well as the identification of students to accept one of the scholarships that would allow them to eventually assume control of the program and the establishment of educational conferences and programs for local health care practitioners.

Ghana

The WSC program in Ghana followed another unique path and was established after a direct request from a hospital in Accra and with the full cooperation of the Ghana Health Services (GHS) and a government-supported regional hospital.

A medical doctor from Ghana who had trained as a chiropractor in the USA initiated this program. Upon completion of her chiropractic degree, she returned to Ghana with the vision of establishing an evidence-based, scalable spine care program within Ghana Health Services at the Ridge Hospital in Accra. (Fig. 1-5.)

She approached WSC to assist her in establishing a spine care program at Ridge Hospital. She worked with WSC to solicit the necessary support within GHS to establish a WSC/GHS collaboration agreement. The GHS/WSC spine care program launched in March 2016 and is fully supported and funded by GHS, which supplies all the facilities, staff, supplies, and yearly training by WSC staff. Currently, the clinic is only open two and a half days per week with limited space. In 2017, the first phase of the New Ridge Hospital will be completed and further space will be available for the GHS/WSC clinic allowing for expansion of the program. At that time the project will open to volunteers who wish to spend time working at the clinic for one to three months. (Fig. 1-6.)

As with the other WSC projects, a scholarship has been offered to a local Ghanaian student to travel to the United Kingdom to study chiropractic at the Anglo European Chiropractic College. WSC also provides ongoing clinical supervision and assistance in further expansion of the services within Ghana.

The GHS/WSC clinic is fully integrated into Ridge Hospital and there are no barriers for services such as imaging and specialist care. As with all the WSC clinics, the GHS/WSC clinic uses the WSC toolkit and satisfies all the elements of the WSC model.

Monthly internet meetings of the WSC clinical committee which includes the clinic supervisors from all of the clinics, the WSC clinical program coordinator and other WSC members who are working on the toolkit, quality control and data collection.

India

The WSC program in India was initiated by a process that was again different from the other three countries in that it was established without direct contact with a governmental department. The initial contact was via a WSC executive who was at a university in Mumbai as a visiting professor. (Fig. 1-7.)

The project in India is a collaboration between the MGM Institute’s University, Department of Physiotherapy (MGMIUDOP) in Navi, Mumbai and World Spine Care. Negotiations began in 2014, and the MOU was signed and the project launched in November 2016. This project is a break from the traditional approach of WSC as it is incorporated within an academic institution.

This unique collaboration has the advantage of enabling the mission elements of WSC to be fulfilled immediately. The project is sustainable as it is incorporated into the MGM hospital with all the space, supplies, equipment, furniture and staff being provided by the MGM hospital. The institution provides local staff and clinicians, eliminating the requirement that WSC provide and support volunteer clinicians. Funding is being secured from local funding resources to supplement the support of the institution and provides extra equipment, training and services. A second clinic is under construction in the rural village of Tara, located in Maharashtra, where MGM Institute of Health Sciences operates its rural health center. This rural clinic will satisfy the WSC mission of helping those in greatest need within their environment. (Fig. 1-8.)

This collaboration has created multiple opportunities for research collaboration. The MGMIUDOP has a state of the art movement laboratory with equipment for studying 3D kinematics, kinetics, EMG and metabolic activity. MGMIUDOP and WSC have begun to establish a collaborative research agenda. This collaboration provides the opportunity to create a curriculum for evidence-based primary spine care without having to seek scholarships from Europe or North America and in this way ensure sustainability and scalability.

The clinicians at the MGM/WSC clinic have full access to imaging and referral to medical professionals and specialists. Given its location within the hospital, inter-professional collaboration is easily achieved. This program will also allow volunteers from other parts of the world to spend time gaining experience and assisting in helping people with spinal disorders in rural villages in India.

Clinic Statistics

Table 1-2 lists the patient statistics from the five WSC clinical programs listed above. Given that the data collection instrument was still in the process of being developed, data from the Shoshong and Mahalapye clinics are incomplete and do not include the first two years of operation. The table does give the overall attendance numbers, but the patient statistics listed are from the most recent 220 patients in Mahalapye and 150 patients in Shoshong.

TABLE 1-2. Statistics from the five World Spine Care programs from January 2015 to December 2016. The Ghana and India data are from the opening of the program to December 2016.

	Mahalapye		Shoshong		Moca		Ghana		India
Opening date	2011/12		2012/08		2014/11		2016/03		2016/11
# New patients	779		684		353		74		59
# Patient visits	6486		6103		3332		598		235
# Volunteers	CS – 8 VA – 22		CS - 8 VA – 22		CS - 1 VA – 5		CS - 1 VA - 0		CS - 3 VA - 0
Sex	80% female		72% female		55% female		65% female		56% female
Mean age (years)	48		51		45		41		45
Primary pain location	Low back Upper back Neck Knee	61% 6% 3% 6%	Low back Upper back Neck Knee Thigh Ankle/foot Elbow	44% 14% 3% 14% 4% 4% 3%	Low back Upper back Neck Shoulder Knee Ankle/foot	52% 11% 11% 7% 5% 3%	Low back Upper back Neck Hip Thigh	67% 11% 11% 3% 3%	Low back Neck Upper back Thigh	62% 33% 4% 2%
Interfering pain	80%		85%		79%		72%		45%
Pain duration	91% > 3 months		75%>3 months		67% > 3 months		72% > 3 months		60% > 3 months
Belief in recovery	89% yes		92% yes		97% yes		99% yes		99% yes
Work injury	6%		6%		15%		36%		10%
MVA	9%		5%		4%		5.5%		1%
Primary contact	16%		15%		27%		28%		70%
Non-specific/ mechanical pain	77%		81%		68%		89%		93%
Serious red flag pathology	13%		9%		12%		11%		7%
Data as of 2016/12/31 Clinic Supervisor (CS), Volunteer Associate (VA), Motor Vehicle Accident (MVA)

A number of points are raised by the statistics in Table 1-2. The primary symptom that is driving people to seek care is low back pain followed by upper back and neck pain. There are, however, a significant number of patients seeking care for musculoskeletal pain in the lower and, to a lesser extent, the upper extremities. This is particularly true at the rural clinic in Shoshong where there are no services for musculoskeletal disorders of any type. It is less evident in the clinics associated with a hospital, but even in these settings it still seems to be the case for a significant percentage of patients. It is also clear that the majority of patients attending the clinic have chronic pain that has been present for greater than three months and that the pain is considered severe enough to be interfering with activities of daily living. Of greater importance, however, is the observation that greater than 10% of patients present with red flags for serious pathology or bony deformity. This is considerably greater than that noted in high income countries. Table 1-3 lists the pathologies that were diagnosed by the Clinic Supervisors in the WSC clinics.

TABLE 1-3. A list of serious pathology and bony deformity presenting to the World Spine Care primary spine care clinics from January 2015 to December 2016. The Ghana and India data are from the opening of the program to December 2016.

Mahalapye District Hospital, Botswana
Situs inversus Cervical fracture Rheumatoid arthritis Polyneuropathy Fractured dens Sprengel’s deformity Klippel Fiel syndrome Pott’s disease Scoliosis Traumatic coccydynia	Cauda equina syndrome Cervical stenosis with radiculopathy Vertebral body compression fracture T7 myelopathy secondary to burst fracture Organic referred – multiple locations Lumbar disc herniation with radiculopathy Lumbar stenosis with radiculopathy Diffuse Idiopathic Skeletal Hyperostosis Blount’s disease Congenital interspinous pseudoarthrosis Peripheral nerve entrapment
Shoshong clinic, Botswana
Peroneal nerve entrapment Hemorrhagic ovarian cyst Hydroseal Metastatic bone tumor Karposi sarcoma Legg–Calvé–Perthes disease Rheumatoid arthritis Malignant GI tumor Paget’s Disease	Vertebral body compression fracture Reflex sympathetic dystrophy Lumbar disc herniation with radiculopathy Lumbar stenosis with radiculopathy Cervical disc herniation with radiculopathy Peptic Ulcer Diffuse Idiopathic Skeletal Hyperostosis Cerebral Palsy
Moca clinic, Moca, Dominican Republic
Traumatic paraplegia Traumatic hemiparesis Cerebral palsy Gout Rib fracture Diabetic polyneuropathy Neurogenic claudication Type II diabetes Facial nerve palsy Polymyalgia rheumatic Myositis HIV Stroke	Arthritis secondary to infection Friedrich’s ataxia Rheumatoid arthritis Motor delay due to in utero hypoxia Vertebral body compression fracture High grade spondylotic spondylolisthesis Jaw fracture Neurofibromatosis with IVF stenosis secondary to dumbbell neurofibroma Benign paroxysmal positional vertigo Cervical spondylotic myelopathy Non-union of shoulder fracture
Ghana clinic, Ridge Hospital, Accra
Discogenic radiculopathy Unstable dens fracture	Uterine Fibroid causing pelvic nerve compression
India clinic, MGM University hospital, Navi Mumbai, India
Discogenic radicular Stenosis radicular	Ankylosing spondylitis Cauda equine

WSC Clinics as Research Environments

Though WSC is a charitable organization focused on providing high-quality evidence-based spine care to underserved communities, research in these communities is also central to the sustainability of the organization. In its infancy, WSC recognized that while the opportunities for spine research in low- and middle-income communities are unlimited and obvious, the body of research in this area is lacking.¹⁰ Recognizing the scarcity of sustainable research efforts in these communities, WSC has implemented a research committee and embraces collaborative research projects with multiple institutions and governments. Scientific research including longitudinal data collection also is an element of each of its signed MOU.

The WSC research committee is comprised of full-time members and adjunct members including research scientists, clinicians, and students from different disciplines such as chiropractic, clinical biomechanics, epidemiology, medicine, physical therapy, public health, and qualitative health sciences.

There are several functions under the research committee’s purview including the following:

1. Overseeing and advancing WSC’s research agenda;
2. Attracting graduate students and senior investigators to partner with WSC;
3. Supporting research partners including supervision of students;
4. Identifying funding sources and opportunities;
5. Disseminating its research findings through peer review publications and conference proceedings.

One of the principal projects of the research committee in partnership with the WSC clinical team is the development of culturally relevant patient-reported outcome measures for low-literacy populations.¹¹ Other current and past research projects include construction of a relational database for longitudinal data collection, a case series of patients seeking care at WSC clinics, qualitative studies to better understand the meaning and impact of spine and musculoskeletal disorders,^12,13,14 the relationship between WSC clinicians and traditional healers,¹⁵ a demographic and disease profile of WSC patients, and the perception of selected stakeholders on the integration of WSC into the local health care system. The WSC research committee described the aims, challenges, facilitators, and successes of four of these training and research projects in a separate publication.¹⁰

In building these partnerships and collaborative projects, the research committee hopes to engage researchers interested in spinal disorders from low- and middle-income communities. In this engagement, it is the intention of WSC that resulting research findings can inform future research projects and provide evidence in creating a sustainable model of care for spine care programs.

CONCLUSION

WSC has demonstrated that it is possible to develop evidence-based spine care programs in low- and middle-income countries that can be fully integrated into the local health care systems and that are fully supported by the government ministries of health, local hospitals and universities. The program in Botswana proves that it is possible to expand a program started as a primary spine care program to include secondary and tertiary spine care.

WSC has demonstrated that such programs can be sustainable provided there is full cooperation by the ministries of health, local hospital administration, clinicians already in the community, and university education facilities in the country. WSC has demonstrated that it is possible to introduce and maintain evidence-based care in LMIC spine clinics but not without consistent training of clinicians and the public and monitoring of the program.

It has become obvious that spine care programs can only be considered if there are clinicians trained in primary spine care and that the program follows widely accepted evidence-based guidelines for the management of spinal disorders. WSC has demonstrated that training of local health care professionals is widely accepted and encouraged by everyone involved. This requires cooperation and support of international spine societies to sponsor educational conferences and by spine care training institutions in high-income countries to provide scholarships and fellowships for training at primary and tertiary care levels.

It is evident that the population of patients seeking care from a dedicated primary spine care program in LMICs present with a wide variety of symptoms, predominantly chronic low back pain that is interfering with activities of daily living but also with significant complaints in the upper back and neck as well as in the upper and lower extremities. What has been demonstrated in WSC LMIC clinics is that patients presenting to a spine clinic in these settings have a substantially higher incidence of serious spine pathology and spinal deformity than that noted in similar care programs in high-income countries, which is generally described as less than 5%.^16,17

WSC has demonstrated that spine programs of the type noted in this chapter are a rich source of research data and provide the opportunity to study factors that result in spine related disability in communities with different cultures, psychosocial issues and resources. There is a desire by local authorities to conduct research on spinal disorders and an interest by graduate students to spend time on specific research projects in these communities.

WSC’s model of care is consistent with and supports the WHO’s strategy for Integrated, People-Centered Health Services and the 2016 Global Strategy for Health Workforce. At the core of WSC’s work is the desire to improve the lives of people who suffer from spine disorders by enabling access to quality spine care which is evidence-based, integrated with other health services and centered on the people World Spine Care serves.

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