Page 3 - 58peadiatric-surgery-speciality1-7_opt

Paediatric Surgery Specialty and its Relevance to Africa 5

because they often set the agenda for health care priorities of many 32 specialists work in Malawi, with a population of 10 million. 31,32 In
developing countries. Nigeria, fewer than 40 practicing paediatric surgeons cater to a pae-
Socioeconomic and Cultural Factors diatric population (less than 18 years of age) that exceeds 80 million.
Africa remains a predominantly illiterate and poor continent, with the This gives a ratio of one paediatric surgeon to about 2 million children
28
majority of the population surviving on less than US$2 daily. Due (compared to 1:100,000 in North America). The few paediatric sur-
to the lack of health insurance, out-of-pocket private expenditure on geons available are often overworked and are largely inaccessible to
health care is the norm. Therefore, health care is in direct competition the overwhelming majority of the populace. The void is filled at best by
with the basic subsistence needs for food, shelter, and clothing. In the nonspecialist surgeons or general practitioners and at worst by quacks
few countries where health care is free or subsidised for children, sur- and traditional healers.
gical conditions are often excluded. Unfortunately, even families that The reasons for the shortage of trained paediatric surgeons are not
can afford to pay may be unaware that surgical treatment is feasible farfetched. Lack of facilities and supporting personnel has limited
or available for a variety of disabling, disfiguring, or life-threatening the capacity to train paediatric surgeons locally, and opportunities
congenital or acquired conditions. for training overseas have been severely curtailed. To compound this
A persistent cultural attitude toward congenital anomalies continues problem, paediatric surgery is not a popular choice of career for aspiring
to hinder access to corrective surgery. Congenital anomalies may be surgeons. This situation has been attributed to the heavy workload,
ascribed to supernatural causes or the curse of the gods. Fortunately, a frustrating lack of facilities, and poor compensation. Under these
egregious behaviour such as the sacrifice of malformed babies has been conditions, it is difficult to attract young surgeons with the promise of a
largely eliminated, although reluctance to seek treatment persists. rewarding and satisfying career. The endemic brain drain has also played
a role in depleting the number of practicing surgeons, many going
Poor Health Care Facilities
overseas for further training but never returning to their home countries.
Jan H. Louw established the first paediatric surgery unit in southern
The workforce shortage cuts across the entire spectrum of paediatric
Africa at the Groote Schuur Hospital in Cape Town in 1948; this care, including nursing, radiology, anaesthesiology, and pathology.
10
became a full department in 1952. Since then, several other centres
have emerged in South Africa where medical care in general and paedi- Recommendations
atric surgery services in particular have advanced to a level comparable The relevance of paediatric surgery in Africa and other developing
33
with many Western countries. The practice of paediatric surgery as a regions is no longer in doubt. However, if the impact of the paediatric
specialty has now been established in several other African countries, surgical practice as part of essential health care to children is to be felt,
but unfortunately the majority of these are plagued with poor facili- then a major paradigm shift is needed. Some of the ideas presented here
ties and dysfunctional health care systems. The only dedicated chil- have been drawn from the seven-point strategy advocated by Bickler
dren’s hospital in sub-Saharan Africa is the Red Cross War Memorial et al., which should be required reading for all paediatric surgeons and
Hospital, Rondebosch, South Africa. Here, paediatric surgeons enjoy health policy makers in Africa (see Table 1.2). 6,13
facilities in a major clinical and research paediatric centre recognised Table 1.2: Strategies for improving paediatric surgery care in Africa.
10
both regionally and internationally.
In Nigeria, with a population of 150 million, the government has
1 Define communities’ health needs with input from the communities.
only recently approved the construction of its first comprehensive
2 Demonstrate the need for paediatric surgical services.
children’s hospital, expected to open in Zaria in a few years. Currently,
most paediatric surgeons in Africa practice in large urban hospitals that 3 Foster community participation.
principally serve adult patients. Many of these centres are overcrowded, 4 Start with what is available and build on existing services.
poorly funded, and lack facilities such as a dedicated paediatric ward, 5 Integrate preventive and curative services.
paediatric emergency room, neonatal intensive care unit (NICU),
6 Facilitate ongoing training.
paediatric radiology, and paediatric pathology, which are considered
basic requirements for a sustainable paediatric surgery practice. Where 7 Remain goal-directed within available resources.
these facilities exist, they are often poorly equipped and are frequently Source: Adapted from Bickler SW, Kyambi J, Rode H. Pediatric surgery in sub-Saharan Africa.
Pediatr Surg Intl 2001; 17:442–447.
operated by doctors who have not undergone dedicated paediatric
training. The lack of paediatric anaesthesia has caused some surgeons
to rely on local anaesthesia or staged procedures for complex cases. 27,29 Research
Referral and Transport African paediatric surgeons should become more involved in clinical
Poor obstetric services limit the ability to perform prenatal diagnosis and basic science research in order to improve the care of their patients
and planned delivery for infants with severe congenital anomalies, and generate awareness for their work. The most fundamental task here
as is routinely obtained in most developed countries. Many pregnant is to collect, analyze, and publish data reflecting local experience with
women do not receive antenatal care, and sometimes the only obstetric childhood surgical disease.
service available is delivery by untrained traditional birth attendants Training
(TBAs). 27,30 Untrained TBAs are unable to recognise congenital anoma- Wider exposure of medical students and surgeons-in-training to pae-
lies for which early surgical treatment is essential to prevent early diatric surgery would likely generate more interest in the specialty.
death. Such conditions include oesophageal atresia, intestinal atresia, Trainees could, however, develop an aversion to the specialty if a
and congenital diaphragmatic hernia. Even when referrals to appropri- positive mentoring environment is not provided. The tendency toward
ate health care facilities are made, the poor condition of rural roads and exploitative and even brutal treatment of surgical residents is an unfor-
inadequate transport facilities often lead to neonatal loss in transit or tunate legacy of Halstedian training. Recognition of the deleterious
presentation in a debilitated and decompensated physiological state. effect of such an abusive environment to surgical education has been
Shortage of Trained Workforce the impetus behind the resident work-hour limitations now in force in
Despite the increasing number of medical schools in Africa, the number most Western countries. Unfortunately, the old habits remain the norm
of doctors practicing on the continent remains grossly inadequate. In in much of Africa, and may be a major obstacle to recruiting bright
Ghana, about 1,500 doctors serve the 20 million population, and only young talent into the specialty. The quality of paediatric surgery train-