Expert Commentary: The injured child in Africa
InformAfrica – In an expert commentary published by JETS, Dr. Ademuyiwa and colleagues provide a comprehensive literature overview of the challenges and stumbling blocks in providing trauma care to the most vulnerable “poorest of the poor” in Africa – the child in a low-income country.
As an example of the injury burden, when this author reviewed pediatric trauma at his previous institution over a 6-year period, the age group 0-13 years comprised 36% of the total trauma load of a large teaching hospital (treating both adults and children) in the northern suburbs of Cape Town, South Africa, with nearly 8000 children treated for injuries annually (data on file-previously presented at International Trauma Congress 2006, Durban).
Africa is indeed a continent of contrasts with relatively well-equipped and supported semi-First-World facilities in parts of the continent (South Africa, Egypt, Botswana, parts of Nigeria, Zambia, Uganda and Namibia), yet with non-existent facilities in many other parts of sub-Saharan Africa. The burden of disease is very different from many other world regions, especially the developed world, with tuberculosis, other infectious disease, malnutrition and the ravages of HIV-AIDS high on the list of mortality determinants.
With this focus on communicable disease and a lack of recognition by governments in lower and middle income countries (LMIC) that trauma is a distinct preventable disease, the services treating trauma are indeed struggling. These “islands of excellence” are trying to cope with the general “sea of indifference” as shown by many governments and health services in Africa.
The greatest challenge is one of access, particularly access to care for the indigent patient, more so for children, since there is only one dedicated state-funded children’s hospital with a major trauma center in sub-Saharan Africa (Red Cross Children’s Hospital, Cape Town, South Africa). Simple solutions to access and prehospital care have paid off in places like Ghana, where the work of Drs Mock, Quansah and the World Health Organization (WHO) team led to basic system development in that country. This has been reviewed in some detail by the authors and is well worth noting. There is much written on trauma in general in the published literature; yet, there is a dearth of child-specific publications, hence the importance of this review.
There remains some light at the end of the tunnel. A number of international aid agencies have established teaching centers in Africa, such as the Aga Khan Hospital, the Emory Global Surgery Program (together with the Pan African Association of Christian Surgeons) among many other similar ventures. The hope is that they address the issues from an Afrocentric perspective within a cost-effective framework and not try to replicate First-World ideas in a rural setting.
The WHO has established tools to enable governments to work on system development, and the Trauma Society of South Africa has set criteria for Trauma Centers relevant to South and southern Africa, with the intent to enable system development. South Africa is also the first country with Trauma Surgery as a surgical sub-specialty after training in General Surgery, which includes the care of the injured child and must therefore look to support the rest of Africa in training staff to meet this need. Cost-effective trauma registries, such as the TraumaBank® of the Trauma Society of South Africa, may additionally assist in this endeavor. The Trauma Society of South Africa has a website (www.traumasa.co.za) where resources are available to assist in the provision of trauma care to Africa.
Active programs of injury prevention are essential, especially when one reviews the incidence of motor vehicle collisions in the pediatric population, where up to 84% of these cases were injured as pedestrians. This is an indictment on the lack of prevention, especially as we enter the WHO Decade of Action on Road Safety 2011-2020! Additionally, interpersonal violence is prevalent in parts of Africa, where a culture of violence remains as a consequence of foreign imperialist oppression.
The establishment of the African Federation of Emergency Medicine (www.africanemergcare.ning.com) has also directed the attention of the emergency medicine fraternity squarely on Africa and the organization is intending to publish a journal, relevant to Africa, in the near future. The establishment of emergency medicine standards for Africa, together with the passion of African surgeons for improving the plight of the injured child, will ensure a mortality and morbidity reduction over time, in a similar fashion to that seen in the First World; however, African governments need to realize that the initial cost will only be realized over an 8-10 year period.
In conclusion, it remains for me to congratulate the authors of the review for their fortitude and courage to address the needs of the injured child and to recommend this thoughtful overview to our readers.
For references and all other information, visit the Journal of Emergencies, Trauma, and Shock webpage: The injured child in Africa
Hardcastle TC. The injured child in Africa. J Emerg Trauma Shock [serial online] 2012 [cited 2012 Jul 3];5:62-3. Available from: http://www.onlinejets.org/text.asp?2012/5/1/62/93115
Courtesy JETS, for educational purpose