Trauma care systems in South Africa

Injury, Int. J. Care Injured 34 (2003) 704–708

Trauma care systems in South Africa J. Goosen∗ , D.M. Bowley, E. Degiannis, F. Plani Trauma Unit, University of the Witwatersrand, Johannesburg, South Africa Accepted 10 April 2003

Abstract Aim: To provide an overview of the provision of trauma care in South Africa, a middle income country emerging into a democratic state. Methods: Literature review. Conclusions: South Africa is gripped by an almost hidden epidemic of intentional and non-intentional injury, largely driven by alcohol and substance abuse, against a background of poverty and rapid urbanisation. Gross inequities exist in the provision of trauma care. Access to pre-hospital care and overloading of tertiary facilities are the major inefficiencies to be addressed. The burden of disease due to trauma presents unique opportunities for reconstruction and clinical research. © 2003 Elsevier Ltd. All rights reserved. Keywords: Trauma care systems; South Africa

1. Geographical and demographic constraints 1.1. Socio-economic South Africa is a middle income country with a GDP per head of US$ 3110.00 p.a. (UK US$ 24,390.00 p.a.), a population of 42 million, and an average life expectancy of 46.5 years for males and 48.3 years for females [22]. Annual incomes vary by a factor of 17 between the highest and lowest socio-economic groups, and a wide discrepancy exists in the services available. In general, 20% of the population have access to private medical funds, usually subsidised by employers, while an estimated 80% are dependent on public healthcare facilities. South Africa spends 7.1% of GDP on health (UK 6.7%) [22]. 1.2. Disease profile Following a transition to democracy in 1994, political violence has virtually disappeared as a cause of injury. All was set for an epidemiological transition from a preponderance of infectious diseases and conditions related to malnutrition and childbirth, to largely chronic and degenerative disease. However, both profiles seem set to co-exist for a long time. In addition, the disease profile was dramatically modified by the HIV/AIDS epidemic, and the persistence of external causes of death (trauma). This quadruple burden of disease profile is unique [3], and is projected to reduce the average ∗

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life expectancy at birth to 41 years by 2010. In 2001, AIDS or AIDS-related diseases were estimated to account for 33% of all deaths [3]. The latest available national figures (1996) showed that 23.29% of all male deaths and 10.22% of all female deaths were due to external violence, and external violence accounted for 35.4% of male and 15.7% of female life years lost [3]. These figures are acknowledged to be prone to under-reporting. The South African non-natural mortality survey [4] represents around 50% of the non-natural mortalities countrywide reported for the calendar year 1999. Homicide was the leading manner of death, followed by traffic accidents (27.8%), undetermined (11.2%), suicide (7.8%), other “accidents” (7.4%). For traffic accidents, the preponderance of pedestrians (41.9%) is notable. Provisional data from 1 month at a sentinel site for non-fatal injures showed that 15.7% of attendances were due to traffic collisions, 29.3% were due to other accidents, and 54.9% were due to violence [15]. Of these, 67.9% were due to social violence, 11.4% due to gangs/syndicate activities, 2.2% were due to rape or sexual assault, and 2.3% were due to legal intervention [15]. 1.3. Urbanisation and substance abuse Migration from the countryside and growth of major metropolitan cities is a key characteristic of the developing world [19], including South Africa. Urbanisation in this manner leads to mass unemployment, lack of adequate

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shelter and basic infrastructure. When combined with weak social services and obvious disparities between the ‘haves’ and ‘have-nots,’ it results in a high degree of social exclusion leading to overall social dysfunction, crime and violence [6]. Fisher and Charlton (2001) recently documented the relationship between urbanisation and alcohol/drug abuse, and being a victim of violence, perpetration of an act of violence and suicide [6]. Urbanisation leads to household-crowding and poverty, both recognised risk factors for pedestrian accidents [19]. In a recent study from Cape Town [16], 60% of trauma patients showed positive alcohol levels on breath analysis, 28% could be classified as problem drinkers, or possible chronic alcoholics, on the basis of a questionnaire and, on urine analysis, 40% of patients were found to have used at least one illicit drug in the recent past. In South Africa, 76% of all deaths after interpersonal violence have been shown to be alcohol related [24]. Alcohol and other forms of substance abuse are also major associated factors in the high trauma rates on South Africa’s roads. Seven percent of drivers with illegal blood alcohol levels account for nearly 30% of non-fatal and 47% of fatal driver deaths [24], but injury to drunken pedestrians shows even greater alcohol relatedness, as pedestrian accidents account for 72% of adult traffic deaths [23]. 1.4. Violence against women Violence against women in South Africa is a particular concern; rape of women, children and even infants is prevalent [9,17]. In South Africa, women are often viewed as inferior to men, as possessions and in need of being led and controlled, with violence frequently being used to resolve a crisis of male identity. Poverty and heavy alcohol consumption increase the risk of violence against women and educational, economical, and social empowerment are protective [11,8]. In a recent study, the lifetime prevalence of experiencing physical violence from a current, or former, husband or boyfriend was 24.6 and 9.5% had been assaulted in the previous year [10]. 1.5. Demilitarisation By the early 1990s, an estimated 670,000 individuals had received military training of some sort. Following the transition to democracy, large numbers of combatants were returned to civilian life, or entered the country from neighbouring lands, while entry into the global economy led to restructuring and wholesale retrenchment in industry. A large number of recently unemployed combatants are believed to have turned to violent crime, using weapons from the struggle, neighbouring countries, and theft from an abundant local stock. At the same time, the South African Police was reformed from a military structure into a civilian service.

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1.6. Time and distance South Africa is a country of vast distances, which is a relatively minor issue compared to the difficulties of extraction of an injured patient from an informal urban settlement, with access proscribed by limited street lights, rudimentary address systems, and earthen tracks for roads. For patients injured in these environments, the 10–20 km to hospital becomes vast indeed. Fortunately, attacks on emergency vehicles, which occurred during times of political instability, are no longer an issue. Overloaded emergency rooms further compound the delay to definitive care and potentially increase adverse events, as demonstrated by an average 455 min time from injury to surgery for head injuries, the ideal being less than 240 min, and a 51% (n = 49/96) incidence of preventable hypoxia or hypotension, potentially causing secondary brain injury [18]. 1.7. Access The constraints of time and distance limit access to basic trauma care, as seen in most of the developing world [14]. The result is a preponderance of pre-hospital deaths with more of a bimodal (80:10:10) distribution of death. An audit performed in a staff model health maintenance organisation in the gold mining industry from 1994 to 1998 showed 75% of pre-hospital deaths due to interpersonal violence, and 32% of pre-hospital deaths due to road traffic accidents, to have an Injury Severity Score of 30 or less, i.e. potential survivors had they had rapid access to hospital [7]. Lack of access to pre-hospital care may also be the reason why 47.6% of injuries arrive at hospital by private vehicle [25]. In South Africa, it is believed that the average pre-hospital time is in the region of 120 min. Pre-hospital time longer than 1 h impacts negatively on survival in hospital [20], possibly due to prolonged hypoxia/hypo-perfusion. 1.8. Funding The discrepancy in incomes and its effects were discussed. Private funding for trauma care includes: medical aid, partially funded (and tax-deducted) by employers, for the upper echelons of the labour force, and mandatory insurance for road accidents and occupational injuries. The National Healthcare Plan [21] aims to improve parity by ensuring co-contributory funding for the employed. This would leave the 32% unemployed outside the private net, and totally dependent on the state for healthcare funding. After 1994, central government changed the accent on funding from secondary and tertiary hospitals to primary care. At the same time, hospitals were formally de-racialised. Many previously “white” teaching hospitals “suffered a decline” in standards, but every patient had access to hospital care, without proven deterioration in outcome. Public funding for tertiary care (intensive care,

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CT, MRI) is still severely proscribed, whereas the number of private CT- and MRI- scanners in one province (Gauteng) at one stage exceeded those in the whole of Britain. 1.9. Prevention Strategies of prevention form the core of the Government Healthcare Plan relating to trauma. Admirable legislation exists for the protection of individual rights, gun control, alcohol and substance abuse, etc. but with one of the lowest police to population ratios in the world, and an overburdened judicial system, law enforcement as a secondary preventive strategy assumes a secondary role.

2. Pre-hospital care South Africa is the only country on the African continent with an organised, statutory system of pre-hospital care, and the National Healthcare Plan aims to ensure at least basic life support available to all within 20 min [21]. In the past, pre-hospital care suffered from racial inequities, where ambulance/fire stations were located in (white) city/town centres, whereas most injuries occurred in the peripheral, black townships. Following the advent of democracy in 1994, this is being addressed. There is a disparity between the need for, and the availability of, primary healthcare facilities, where most injuries could be managed. Sadly, most of these primary healthcare clinics are open during office-hours only and training of primary healthcare nurses does not focus on trauma, prime time for trauma is after-hours and over weekends [23]. Because of a shortage of advanced level emergency technicians in governmental service, several private emergency rescue companies provide highly experienced, advanced levels of pre-hospital care for the funded. Private crews work hand in hand with public crews, since the funded injured fill private trauma centres, and the “Good Samaritan” concept is good for business. Most metropolitan areas are now covered by a private helicopter ambulance service funded largely by an insurance company, because of the cost–benefit for the life insurance industry of lives saved. Once again, a close relationship exists with the public sector. 2.1. Emergency response systems A national emergency number exists, with a burgeoning number of privately funded emergency call systems linked to cellphone systems, anti-hijacking systems, etc. all converging on metropolitan control centres. The result is a rapid response available to the funded, but poor penetration to the unfunded. These metropolitan control centres are also responsible for managing the allocation of tertiary beds in the public sector—but with little effect.

2.2. Choice of destination Bypass of smaller trauma units is a common occurrence in metropolitan areas, whether decided by family, friends, or EMT crews. Unfortunately, this often results in metropolitan units’ having to go on bypass because of overload—for Johannesburg Hospital this occurs for 35% of the time. Private hospitals never close, but a clear system of bypass operates due to the emergence of dedicated trauma centres in fierce competition for outcomes. In rural areas, the available facilities become, de facto, the optimal level of care, because of a lack of alternatives. 2.3. Hospital care The pattern of trauma has changed completely in South Africa, with a preponderance of major trauma due to gunshot-wounds, and a decline in stab-wounds [13]. Overall, admissions for motor vehicle accidents remained stable over the period under review [13]. At present, there are seven specialised trauma units in the country, offering specialist general surgical facilities on the premises, or immediately available, with all ancillary facilities urgently available. The bulk of trauma is managed in regional hospitals, with a surgeon on call and urgently available. Very few district hospitals are capable of receiving and adequately managing major trauma. Pre-hospital care systems are organised around these realities. A career path in emergency medicine is hampered by the lack of specialist registration. A Diploma in Primary Emergency Care exists, while two Universities are contemplating the establishment of chairs in Emergency Medicine. Most see Emergency Medicine as part of Family Medicine, a traditional view, which leaves most metropolitan emergency units staffed by junior, or sessionally appointed, doctors, and most rural areas staffed by part-time general practitioners. Exposure and experience compensates for a lack of a formal career path.South African surgeons of all disciplines are extensively trained and experienced in the management of trauma. An informal audit in our Department of Surgery indicated that 57% of all procedures were undertaken for trauma. Trauma accounts for a significant part of private surgical practice in almost all surgical disciplines. Because of the case-load of trauma, training courses in the management of trauma abound. These include: Diploma in Primary Emergency Care, Advanced Trauma Life Support, AO/ASIF, Advanced Cardiac Life Support, and Definitive Surgical Trauma Care. Based on the USA experience, with a preponderance of penetrating trauma, general surgeons control the care of multiply, or severely, injured patients. The constrained resources of South Africa in the 1980s shaped surgical policy—the principle of selective conservatism for penetrating injury was largely a South African invention of need, where metropolitan teaching units were overloaded with penetrating trauma (knife-wounds) [5]. The strategy of “Damage

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Control” has gained wide acceptance, partially due to its intellectual attraction, and partly due to overload of cases after hours. Relations with other disciplines are generally dictated by the abundant case-loads. No one is seeking more work, and conflict is usually due to competition for resources. The training in all surgical disciplines requires at least 6 months ICU time prior to registration as a specialist. Control of intensive care is not discipline-specific, with anaesthetics, internal medicine and general surgery vying for primacy in the provision of (trauma) intensive care. At present, registration for the discipline of intensive care follows a 2 year post-specialisation course. Registration for the discipline of Trauma Surgery is planned to follow, based on specialist registration in any surgical discipline, plus 2 years spent in a recognised trauma/intensive care unit, followed by an exit exam and a dissertation. While the AIDS population is rarely affected by trauma, due to debilitation and inactivity, the trauma population as a whole constitutes a high risk group for HIV-positivity, and a recent, blinded audit in our trauma unit showed a 37% prevalence of HIV-positivity for trauma resuscitations [2]. HIV-testing following trauma is only performed in case of needle-stick injuries, with or without informed consent. Discrimination against HIV-positive patients is not tolerated in any way. It is accepted [1] that HIV-positive patients suffer more septic complications, have a prolonged stay in all phases of hospital care, but the same rates of survival result for injured patients. Protecting the health and safety of healthcare workers in South Africa is a concern. While the importance of universal barrier precautions is clear, in a survey of university-affiliated hospitals in South Africa, Karstaed and Pantanowitz (2001) recently documented that, during their intern year, 69% of junior doctors sustained one or more percutaneous exposures to blood, with 33% of interns recalling percutaneous exposure to HIV-infected blood. Forty-five per cent recalled a mucocutaneous exposure to HIV-positive blood. Half of the episodes occurred during the first 4 months of internship and only 22% of exposures would have been prevented by universal precautions [12].

3. Inter-hospital transfers All secondary hospitals are designed to provide comprehensive care, but care is compromised by a shortage of specialists, not available posts. Major injuries tend to be referred to tertiary hospitals. Availability of beds is therefore a major problem in teaching hospitals, with decanting of stabilised patients a common occurrence. The benefit of this system is that all care is provided under one roof—there are very few specialist hospitals, where trauma patients with multi-system injuries could fall between specialities.

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3.1. Rehabilitation Rehabilitation following injury is in a dismal state in the public sector, with 25–30% of our acute care beds blocked at any one stage by patients awaiting transfer to rehabilitation facilities. The private sector shows the exact converse, with excellent acute facilities and chronic are facilities abounding. 3.2. Funding No envisaged model of healthcare can sustain the impact of a quadruple hit on the healthcare system, or an increase in trauma care in real terms; prevention may be the obvious answer. As for HIV, this strategy is favoured in the National Health Plan. Resource limitations were discussed. A recent police action in our area of referral, costing Rand 150,000.00 (£ 31,250.00), achieved a decrease in trauma resuscitations of 15% over one admitting weekend, i.e. less than the cost of one major truncal gunshot-wound admitted. Because of lack of affordability, limitations have to be placed on active treatment of certain injuries, e.g. gunshot-wound of the brain crossing the midline [25], and certain admissions to intensive care, e.g. burns more than 70%, age over 75, AIDS, etc. as in the Trauma Unit of the Johannesburg Hospital. 3.3. Research Because of the large patient load, South Africa is perceived as a paradise for researchers. Funding is not a major issue, but the service load of potential researchers is. Most publications are audits. Visiting research fellows and immigrants make a huge contribution. The culture of research as a sine quanon for career advancement is in its infancy, mostly because of opportunities in the private sector, and comparatively poor remuneration in the public sector. 3.4. Vision The transition from a repressive state, where a majority of the population was militarised, whether institutionally, or politically, motivated, to a society of law-abiding citizens is a slow one, projected to take at least 20 years. The legislation enacted to establish the supremacy of the law and individual rights cannot as yet be matched by the necessary capacity. In the meantime, the rainbow nation will be required to turn these threats into opportunities and solutions. It would appear that a staff-model system of healthcare maintenance would be the ideal solution to ensure equity of service provision and case-load, in the development of an inclusive system of trauma care. Examples of how not do it abound internationally.

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