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4 Paediatric Surgery Specialty and its Relevance to Africa
Historical Background low- and middle-income countries. Although comprehensive data on
Modern archaeology has uncovered evidence of surgical operations in the incidence of paediatric surgical conditions in Africa is lacking,
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Africa that predated the Neolithic age, including children as patients. available information suggests that trauma, congenital anomalies, and
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The first medical school was established in Alexandria, Egypt, by surgical infections are common. Yet, the focus on the prevention and
Herophilus in the fourth century b.c.e. and developed further in the treatment of infectious diseases has often led to the neglect of trauma
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third century b.c.e. by Erasistratus. Therefore, the concept of surgery and other surgical disease as important factors in the overall disease
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is not alien to the continent, notwithstanding the lack of progress that burden in children from these regions.
occurred over many centuries. Despite the perceived high costs and limited availability of a trained
The practice of paediatric surgery as a specialty in Africa has its workforce and equipment, surgery is often an essential and integral
roots in South Africa during the 1920s with paediatric surgeons from part of basic health care, as in cases of treatment of injuries, urinary
the Hospital for Sick Children, Great Ormond Street, London, as retention, and inhaled foreign bodies, or preventive, as in the case
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pioneers. In the late 1940s and 1950s, the first paediatric surgical unit of elective hernia repair. In fact, Gosselin et al. performed a cost-
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was established at Groote Schuur Hospital in Cape Town by Jan H. effectiveness analysis to evaluate the costs and disability-adjusted life
Louw, and since then, the practice of paediatric surgery in Africa has years (DALYs) saved by the provision of surgical services to children in
become firmly established. Several national and regional organisations a rural hospital in Sierra Leone, and the positive effect was comparable
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have been formed to promote the practice of paediatric surgery. In 1994, to that of other public health interventions.
the Pan African Paediatric Surgical Association (PAPSA) was formed, Failure to recognise the importance of surgical treatment has led
which held its inaugural meeting in Nairobi, Kenya, in March 1995. In to neglect by both governmental and donor agencies. Of the estimated
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2004, the African Journal of Paediatric Surgery (AJPS) was founded by 234 million major surgical procedures performed worldwide annually,
Francis Uba. This publication has already achieved listing in MEDLINE, which is 7 times the number of persons infected with HIV, only 3.5% of
thus removing a major obstacle to the growth of the specialty. these are performed in the poorest nations, many of which are in Africa. 17
In the past five decades, many Africans have trained in paediatric The view of surgical disease as being relatively unimportant
surgery, both overseas and recently in indigenous residency programmes. has been amplified by a lack of accurate epidemiological studies.
Paediatric surgery divisions now exist in several departments of surgery, However, emerging data highlight the need to re-examine conventional
many of which participate in the education of medical students and thinking. One report from a rural hospital in Malumfashi, Nigeria,
general surgery residents. In a few centres, subspecialty training in and another from a large urban hospital in Banjul, The Gambia,
paediatric surgery has been established with a formalised curriculum. showed that paediatric surgical cases account for 6.6% and 11.3% of
Regulation and oversight of paediatric surgery training has been carefully all paediatric admissions, respectively. 18,19 In both studies, 80–90% of
maintained by professional bodies that administer the examination and all paediatric surgical admissions were due to congenital anomalies,
certification required for credentialing as a subspecialist. surgical infections, and trauma. Determination of the true incidence of
Currently, examination and certification in paediatric surgery have congenital anomalies is difficult due to the associated stigma still seen
been organised on a regional basis. In South Africa, surgeons who in many native populations. In South Africa, with better surveillance
have completed general surgery training and an additional two years of systems and greater awareness among the population, the incidence of
subspecialty training may take the specialty examination in paediatric congenital anomalies is about 12 per 1,000 live births. 20
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surgery offered by the College of Medicine of South Africa. In West Among surgical diseases, trauma is an important cause of morbidity,
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Africa, surgeons become eligible for examination and certification in mortality, and disability in African children. According to estimates
paediatric surgery after a minimum of two years of general surgery by the World Health Organization (WHO), injuries account for
training and a further 20 months of subspecialty training under the aegis 13% of the childhood disease burden and nearly 1 million deaths
of the West African College of Surgeons. 12 per year in developing countries. 22,23 Africa’s children are at more
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African surgeons have made significant contributions to the practice risk of dying from motor vehicle crashes than European children.
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of paediatric surgery and have also championed the development of the Deen et al. have projected that the relative contributions of injuries
specialty locally. Many paediatric surgeons with roots in Africa have and noncommunicable diseases to the childhood disease burden in
achieved local and international recognition for their clinical, research, developing countries will increase from 28% in 1990 to 45% by 2020.
and leadership roles. As a prime example, the dominant hypothesis Reports from urban and suburban West Africa indicate that trauma is
on the aetiology of intestinal atresia was the outcome of a series of responsible for about 9% of attendance in a children’s emergency room
experiments performed by Jan Louw and Chris Barnard at the Red and is the most common cause (47%) of paediatric admissions. 19,24 Even
Cross Children’s Hospital in Cape Town. This seminal work, published in rural Africa, where studies are few, there are indications that trauma
in Lancet in 1955, provided direct evidence for vascular accidents as is an important cause of paediatric admissions to health facilities. 18,25
the likely mechanism in the pathogenesis of intestinal atresia during Recently, there has been a growing recognition of the importance of
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foetal development. Louw was honoured with the prestigious Sir Denis surgical disease in the global effort to reduce the burden of disease.
Browne Gold Medal by the British Association of Paediatric Surgeons WHO has developed the Global Initiative for Emergency and Essential
(BAPS) in 1980. The 2004 honouree for this award was another South Surgical Care (GIEESC), which currently includes pilot projects in 17
African, Sir Lewis Spitz, who rose to the Nuffield Chair of Paediatric countries, of which 8 are in Africa.
Surgery at the Hospital for Sick Children, Great Ormond Street, Barriers to Effective Paediatric Surgical Care
London. Recently, Sid Cywes was accorded the honorary fellowship The most significant obstacle to the development of paediatric surgical
of the American College of Surgeons. Additionally, Donald Nuss, who services in Africa is the lack of interest shown by the various govern-
developed the minimally invasive repair for pectus excavatum, began ments as well as the nongovernmental organisations (NGOs). The
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his training in Africa.
role of the NGOs is quite crucial because their contribution to health
Burden of Surgical Diseases in African Children care expenditures in many African countries is substantial and occa-
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With only 11% of the world’s population, Africa bears 25% of the glob- sionally exceeds the health budget of national governments. These
al burden of disease. Several well-known factors, including endemic NGOs, especially the UN agencies (World Bank, WHO, and the United
poverty, poor literacy rates, civil conflicts, and corrupt political leader- Nations Children’s Fund (UNICEF)) and private foundations (e.g.,
ship, contribute to the overwhelming burden of childhood disease in The Bill and Melinda Gates Foundation) exert even greater influence