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Past, Present and Future of Emergency Medicine in Africa
Dr George Oduro, KATH Emergency Department
With the past, I have nothing to do nor with the future. I live now. -Ralph Waldo Emerson
I never think of the future. It comes soon enough. - Albert Einstein
Where I work
The Past
God has no power over the past, except to cover it with oblivion. - Pliny the Elder
Africa is huge
Africa is diverse
Africa is huge! USA (minus Alaska)
China
India
Europe
Japan
Total area 28Million sq km
Africa is 30Million sq km
Africa is diverse in language and in culture
Gap minder data
Societies in transition
Increasing age and longevity
Rural urban migration high urbanisation growth; also brings with it slum formation
Burden of disease
Conflict and violence
Natural and man made disasters
Increasing road traffic accidents
54
65
66
75
75
76
69
51
59
61
69
72
71
64
African Region
South East Asia Region
Eastern Mediterranean Region
Western Pacific Region
European Region
Region of the Americas
Global
Life Expectancy at birth in WHO Regions, 1990 and 2009
2009 1990
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
30
35
40
45
50
55
60
65
70 2009 1990Life expectancy at birth in years in the African Region, by country, 2008 and 1990 some countries have lost years
30
35
40
45
50
55
60
65
70
75
80
Mau
rita
nia
Bu
rkin
a Fa
so
C
te d
'Ivo
ire
Nig
eria
Seyc
hel
les
Co
mo
ros
An
gola
Gu
inea
-Bis
sau
Equ
at.G
uin
ea
Gh
ana
Mau
riti
us
Cap
e V
erd
e
Togo
Mal
i
Uga
nd
a
Sen
egal
Alg
eria
Gam
bia
Mal
awi
Ben
in
Sier
ra L
eon
e
Rw
and
a
Gu
inea
Mad
agas
car
Mo
zam
biq
ue
Eth
iop
ia
Nig
er
Lib
eria
Erit
rea
2009 1990
Life expectancy at birth in years in the African Region, by country, 2008 and 1990 other have gained years
Healthy life expectancy at birth in years in WHO Regions, by sex, 2007
45
55
56
64
65
65
58
46
57
57
70
69
69
61
40 45 50 55 60 65 70 75
African Region
Eastern Mediterranean Region
South East Asia Region
European Region
Region of the Americas
Western Pacific Region
Global
Male Female
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Trend in life expectancy at birth in years in the African Region, by sex, 2003 to 2009
45
47
49
51
53
55
57
2003 2004 2005 2006 2007 2008 2009
Male
Female
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Adult mortality rate per 1000 population in WHO Regions, 2009 and 1990
383
209 188
146 125 116
176
366
261 236
157 162 166 207
2009 1990
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Adult mortality rate per 1000 population in the African Region, by country, 2009 and 1990
0 100 200 300 400 500 600 700 800
African Region
ZimbabweLesotho
SwazilandSouth Africa
MalawiTanzania
CARChad
BurundiNigeria
DRCBotswana
CameroonCongo
Burkina FasoKenya
Cte d'IvoireGabon
NamibiaMauritania
GhanaSaoTomePrincipe
EthiopiaEritrea
2009
1990
Under-5 mortality rate per 1,000 live births by WHO Region, 1990, 2000, 2009
175
153
107
48
34
16 10
30
50
70
90
110
130
150
170
1990 2000 2009
Africa
SEAR
East Med
Global
West Pac
Americas
Europe
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
MDG-4: Trend in under-5 mortality rate (probability of dying by age 5; per 1,000 live births)
165
147
131 121 119
107
1990 2000 2005 2008 2009 2011 2015
2005 MDG Target: 55
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Child Mortality Goal 4
23
50
Live births Under-five deaths
Africas burden of under-five deaths in the world 2009
While Africa accounts for about a quarter of worlds live birth, it accounts for half of the all under-five deaths
MDG-5: Trend in maternal mortality ratio (per 100,000 live births)
850 830 780
690
620
1990 1995 2005 2008 2009 2015
2015 MDG Target: 213
Health care workers
2.2 5.6 10.9
14.8 20.0
33.2
14.2 9.0 10.9
15.6 18.4
72.5 65.0
28.1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Physicians Nurses
Physician-to-population and Nurse-to-population ratios (per 10,000 population) in WHO Regions, 20052010
Physician-to-population ratio and Nursing staff ratio (per 10,000 population) in the African Region, by country, 20052010
0.0 5.0 10.0 15.0 20.0 25.0 30.0
African Region
Liberia
Tanzania
Ethiopia
Malawi
Mozambique
Gambia
Mali
Ghana
Uganda
Cte d'Ivoire
Botswana
Namibia
Nigeria
Cape Verde
Algeria
Physician-to-population ratio (per 10,000 population) in the African Region, by country, 20052010
2.2
0.1
0.1
0.2
0.2
0.3
0.4
0.5
0.9
1.2
1.4
3.4
3.7
4.0
5.7
12.1
0 2 4 6 8 10 12 14
African Region
Liberia
Tanzania
Ethiopia
Malawi
Mozambique
Gambia
Mali
Ghana
Uganda
Cte d'Ivoire
Botswana
Namibia
Nigeria
Cape Verde
Algeria
Nursing and midwifery personnel-to population ratio (per 10.000 population) in the African Region, by country, 20002009
9.0
2.7
2.4
2.4
2.8
3.4
5.7
3.0
10.5
13.1
4.8
28.4
27.8
16.1
13.2
19.5
0.0 5.0 10.0 15.0 20.0 25.0 30.0
African Region
Liberia
Tanzania
Ethiopia
Malawi
Mozambique
Gambia
Mali
Ghana
Uganda
Cte d'Ivoire
Botswana
Namibia
Nigeria
Cape Verde
Algeria
Burden of disease
Total burden of disease in DALYs per 1000 population in WHO Regions, 2004
511
273
265
171
164
152
40 140 240 340 440 540
African Region
East Mediterranean
South East Asia
Europe
Americas
Western Pacific
Series 1
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Leading causes of burden of disease shown as percentage of total DALYs in the African Region, 2004
12.4
11.2
8.6
8.2
3.6
3.6
3
2.9
1.9
1.9
0 2 4 6 8 10 12 14
HIV/AIDS
Lower respiratory infections
Diarrhoeal diseases
Malaria
Neonatal Infections and other
Birth asphyxia and birth trauma
Prematurity and low birth weight
Tuberculosis
Road traffic accidents
Protein-energy malnutrition
Infectious and parasitic
diseases, 42.4
Non communicable diseases, 15.9
Respiratory infections, 11.4
Perinatal conditions, 10.1
Unintentional injuries, 5.4
Neuropsychiatric disorders, 5.2
Maternal conditions, 4.0
Nutritional deficiencies, 3.1
Intentional injuries, 2.5
Distribution of burden of diseases as percentage of total DALYs by group in the African Region, 2004
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Distribution of burden of diseases as percentage of total DALYs by broader causes in WHO Regions, 2004
71%
44%
42%
18%
17%
10%
21%
41%
44%
69%
69%
77%
8%
15%
14%
13%
14%
13%
African Region
East Mediterranean
South East Asia
Western Pacific
Americas
Europe
Communicable diseases, maternal and perinatal conditions, and nutritional deficienciesNon-communicble diseasesInjuries
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Distribution of years of life lost by broader causes in WHO Regions, 2004
80%
56%
52%
25%
24%
12%
51%
13%
30%
31%
55%
57%
70%
34%
7%
15%
17%
20%
19%
18%
14%
African Region
East Mediterranean
South East Asia
Americas
Western Pacific
Europe
Global
Communicable diseases
Non-communicble diseases
Injuries
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Health financing
Per capita total expenditure on health (PPP international $) in WHO Regions, 2009 and 2000
157
120
324
614
2218
3346
990
88
62
173
296
1215
1987
568
African Region
South East Asia Region
Eastern Mediterranean Region
Western Pacific Region
European Region
Region of the Americas
Global
2009 2000
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Trend in average per capita total expenditure on health (PPP international $) in the African Regions, 2009 and 2000
80
90
100
110
120
130
140
150
160
2004 2005 2006 2007 2008 2009
Total expenditure on health as percentage of GDP in WHO Regions, 2007 and 2000
6.2
3.6
4.1
6.5
8.8
13.6
9.7
5.9
3.7
4.2
6.8
8.4
12.0
9.2
African Region
South East Asia Region
Eastern MediterraneanRegion
Western Pacific Region
European Region
Region of the Americas
Global
2007 2000
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012. 24/10/2012. World Health Organization, Regional Office for Africa.
Trend in total expenditure as percentage of GDP in the African Region, 2004 to 2009
5.2
5.4
5.6
5.8
6
6.2
6.4
6.6
2004 2005 2006 2007 2007 2009
Road traffic deaths: some facts
1 2
3
Road traffic WHO 2004
1.3
Malaria WHO 2008
Leading causes of death
Rank Disease or Injury
1 Ischaemic heart disease
2 Cerebrovascular disease
3 Lower respiratory infections
4 COPD
5 Diarrhoeal diseases
6 HIV/AIDS
7 Tuberculosis
8 Trachea, bronchus, lung cancer
9 Road traffic injuries
10 Prematurity & low-birth weight
Rank Disease or Injury
1 Ischaemic heart disease
2 Cerebrovascular disease
3 COPD
4 Lower respiratory infections
5 Road traffic injuries
6 Trachea, bronchus, lung cancer
7 Diabetes mellitus
8 Hypertensive heart disease
9 Stomach cancer
10 HIV/AIDS
2004 2030
Other key data
Worldwide vehicle ownership is forecast to double by 2020.
Much of this growth will be in emerging markets.
Road traffic injuries cost countries 13% of GDP.
Only 15% of countries have comprehensive laws which address five key behavioural risks.
Prevention works
Evolution of the number of annual road traffic deaths in metropolitan France, 1970-2009
Where are we at now
South Africa
Botswana
Mozambique
Tanzania
Rwanda
Uganda
Ethiopia
Sudan
Nigeria
Ghana
Botswana Currently EC provided by health professionals with little
formal training, many expatriates
Emergency Medicine recently recognised as specialty by Botswana Health Professions Council but there are currently no emergency specialists employed by the Ministry of Health
University of Botswana School of Medicine has a Department of Emergency Medicine that coordinates a 4-year post-graduate Emergency Medicine residency training program
M Med (EM) introduced in January 2011.
First cohort of four EM Residents started January 2011
Forecast annual intake 4-6 Residents Caruso N, Chandra A, Kestler A. Development of Emergency Medicine in Botswana. African Journal of Emergency Medicine 1[3], 108-112. 9-1-2011.
Botswana
University of Botswana also provides staffing for the accident and emergency department of Princess Marina Hospital in Gaborone
Other developments include: Establishment of Botswana Society for Emergency Care
Development of University of Botswana Trauma Research Centre
Creation of University of Botswana Resuscitation Training Centre
Development of a national pre-hospital care system with the Ministry of Health
Botswana Society for Emergency Care
Caruso N, Chandra A, Kestler A. Development of Emergency Medicine in Botswana. African Journal of Emergency Medicine 1[3], 108-112. 9-1-2011.
Tanzania
First EM Residency program started 2010 and first graduates expected 2013
Dedicated Emergency Nursing curriculum introduced in 2011 Currently emergency patients cared for in emergency centres
staffed with rotating personnel with little formal EM training Muhimbili National Hospital inaugurated first full capacity
emergency medicine department in collaboration with Ministry of Health and Abbot Fund Tanzania in 2009
Emergency Medical Association of Tanzania (EMAT) formed and ratified by Ministry of Health 2011
Nicks BA, Sawe HR, Juma AM, Reynolds TA. The state of emergency medicine in the United Republic of Tanzania. African Journal of Emergency Medicine 2[3], 97-102. 9-1-2012.
Rwanda
Post conflict country
Almost all physicians working in EDs are general practitioners
No specialty EM society or post-graduate EM training program in 2007
Lack of prehospital care is major deficiency in EM infrastructure
Wen LS, Char DM. Existing infrastructure for the delivery of emergency care in post-conflict Rwanda: An initial descriptive study. African Journal of Emergency Medicine 1[2], 57-61. 6-1-2011.
Nigeria
Emergency Medicine does not exist as a specialty
No post-graduate EM training program
EDs in Abuja do not have 24/7 physician staffing
Selected emergencies treated only when specialist consultant is available
Wen LS, Oshiomogho JI, Eluwa GI, Steptoe AP, Sullivan AF, Camargo CA, Jr. Characteristics and capabilities of emergency departments in Abuja, Nigeria. Emerg Med J 2012; 29(10):798-801.
Ethiopia
The first official specialty training program began in Ethiopia in November 2010.
No national or regional guidelines exist for triage OPD emergency units In 2008, the University of Wisconsin, United States, and the
University of Toronto, Canada, joined the AAUMF to support Ethiopias first Emergency Medicine post-graduate training programme in EM for physicians and nurses.
Currently 13 physicians are attending the EM residency programme in AAUMF.
Recently, the AAUMF has launched a masters programme in EM and currently there are 20 nurses attending this programme.
In addition, under the AAUMF leadership, the Ethiopian Society of Emergency Medical Professionals (ESEMP) was established in 2012.
Germa F, Bayleyegn T, Kebede T, Ducharme J, Bartolomios K. Emergency medicine development in Ethiopia:Challenges, progress and possibilities. African Journal of Emergency Medicine (2012) . In press. Accessed at http://dx.doi.org/10.1016/j.afjem.2012.08.005. Elsevier
Ghana
The first EM specialty training program began in Ghana in October 2009.
In 2009, the University of Michigan, United States, KATH, and the Kwame Nkrumah University of Science and Technology, joined forces to establish Ghanas first Emergency Medicine post-graduate training programme in EM for physicians and nurses.
The first six specialists graduated from this program last month. Currently 21 residents are enrolled on the EM residency
programme in Kumasi. Recently, KNUST has launched a degree programme in
Emergency Nursing. In addition, the Ghana Society of Emergency Medicine has been
established in 2012.
Uganda
Starting in 2013
Sudan
Started in 2011
64 residents on EM training programme
Nigeria
We just heard Nigeria has recntly formed EM Society
South Africa Division of Emergency Medicine was formed in 2001 Emergency Medicine recognised as a specialty by the
Health Professions Council of South Africa in March 2003.
College of Emergency Medicine founded in May 2003 by the Colleges of Medicine of South Africa.
The University of Cape Town and Stellenbosch University became the first South African universities to offer a joint Master of Medicine (MMed) degree in Emergency Medicine
The first EM registrars started in their posts in January 2004. To date, over 20 have graduated the 4-year training programme.
South Africa
Currently 42 MMed students registered (including 10 supernumerary registrars)
Students from as far afield as Kenya, Cameroon, Nigeria and Saudi Arabia.
The Division has graduated 7 MMed degrees, 8 Fellows of the College of Emergency Medicine, and 12 MPhil degrees have been awarded so far.
The first students for PhDs in Emergency Medicine enrolled in 2009.
South Africa
Specialist registrars supported by a formal academic programme, a mentoring programme, an ongoing evaluation system and final examination preparation support.
Undergraduate students at both universities are exposed to emergency medicine teaching.
Emergency ultrasound proficiency is a requirement for the final exit examination and an emergency ultrasound rotation has been developed this year supported by a virtual learning component.
South Africa
Emergency Care Institute South Africa has been created.
Covers all essential aspects of emergency medicine, including education and training and outreach into other African countries (including Botswana, Madagascar and Uganda).
EMSSA
African countries training EM specialists
Country Year established
South Africa 2003 PG Fellowship; Nursing Diploma
Ghana 2009 PG Fellowship
Tanzania 2010 PG Fellowship
Botswana 2011 4 year MSc
Rwanda
Ethiopia
Uganda Starting EM program 2013
African countries with national EM societies
Country Year established EM Society
South Africa 2007 EMSSA
Tanzania 2009 EMAT
Botswana 2011 BSEC
Ethiopia 2012 ESEP
Ghana 2012 GEMS
Nigeria
Uganda
Rwanda
Challenges
Economic barriers
Too expensive
Not recognised as key element of health care system
Lack of funding
Lack of infrastructure
Lack of government support
Challenges
Government not supportive
Medicine in general and EM in particular not viewed as directly related to economic development
But - Health Care Systems are often primary employers and primary educators
Challenges
Limited intellectual exchange
Access to text books and journals
Internet access
Ability to attend international meetings
Challenges
Misconceptions about emergency care
All physicians by definition assumed to be qualified to practice emergency care
In general, specialties focus on diagnoses, not on emergency presentations and treatments
Challenges
Trauma care is the only specialised emergency care needed
Patients with multiple problems excluded
Major trauma is serious but a low proportion of emergency cases
Does not recognise the need for triage to prioritise care (fracture tibia versus diabetic ketoacidosis or myocardial infarction)
Challenges
Medical school training
Focuses on correct diagnosis
No focus on triage, emergency care, or assessment of chief complaint
Challenges
Institutional reluctance
Start-up and fixed costs expensive
ED overcrowding and insufficient workforce are considered that is how it always was, that is how it always will be.
Resistant to concept that EM care is important for everyone, and especially for time-sensitive conditions, not just the poor
Controversies
Fix health system before developing EM
Do not train EM specialists
Give established specialists expanded role to care for emergencies
Not ready for EMTs and pre-hospital care
Use community first aiders
Rely solely on non-physician EM health care workers
Reliance on foreign experts may be cheaper than developing own expertise
If you wait for tomorrow, tomorrow comes. If you don't wait for tomorrow, tomorrow comes. - Senegalese Proverb
Why Emergency Medicine?
Evidence suggests that access to emergency care could reduce 7 of the 15 leading causes of death in middle and low income countries (Razzak & Kollerman, WHO Bulletin 2002, 80 (11))
In-hospital mortality rates are significantly lower at trauma centers than non-trauma centers, especially among patients with more severe injuries (MacKenzie, Rivara et al 2006)
Prospective cohort study shows the care provided by EM physicians during the Emergency Department stay for critically ill patients significantly reduces the progression of organ failure and mortality (Nguyen, Rivers et all. 2000)
EM residency training results in improved patient care in the Emergency Department (Holliman C.J., Mulligan T.M. et al 2011)
Pre-hospital care
Pre-hospital emergency medical care and rescue in Sub-Saharan Africa vary widely
from well-developed sophisticated systems
to basic, rudimentary systems where patients are conveyed with make shift transport
to places where service provision is non-existent
This field of emergency care is in its infancy compared to other health care practices.
Naidoo R. Emergency care in Africa. African Journal of Emergency Medicine 1[2], 51-52. 6-1-
2011.
Pre-hospital care
South Africa has well developed system Namibia and Botswana have well developed systems in
the urban areas. Work needed in terms of:
standardisation of service provision education and training, development of a professional
cadre research into emergency care and rescue.
Emergency medical services may be patients first point of contact with health care system, and immediate, appropriate emergency care has been shown to reduce morbidity and mortality
Naidoo R. Emergency care in Africa. African Journal of Emergency Medicine 1[2], 51-52. 6-1-2011.
Way Forward
Majority of health care workers are not doctors System does not rely on very well trained doctors Train and involve community so they take
responsibility Train community health workers; acute care
workers Train middle level providers Rwanda, GECC
Uganda = Ketamine sedation, surgical procedures Stabilisation then transport rudimentary
ambulance service
Way Forward
Some costing exercises motivating for EM care; may be cost effective to use middle level workers, training commercial vehicle drivers to give first aid, how to handle trauma victims, splint fractures, deliver babies eg Malawian obstetric ambulances
Ghana has just graduated 300 EMTIs; ambulance service. Well attended EMS workshop
Ultrasound is rolling out eg Tanzania, Ghana, SA
Way Forward
Address data gaps that remain a challenge in accurately monitoring progress and ensuring evidence-based decision making on the continent
86
Way Forward
What are the priority areas for training?
Appropriate training in triage and protocols
Emergency medicine specialist training
Protocols WHO guidelines
Modify guidelines to suit local resources and disease burdens
Quality improvement/assurance
87
But there are also opportunities
Needs assessments
Build on existing resources
Concentrate on low hanging fruits
Harness community participation
Right person sees the right patient at the right time
Opportunities
EM specialists as leaders and educators
Expanded skill sets for EM specialists
Design EM locally fit for purpose
Appropriate task substitution**
EM well placed to form alliance with public health
Prevention and public education
Policy advocates
**McPake B, Mensah K. Task shifting in health care in resource-poor countries. Lancet 2008; 372(9642):870-871.
Opportunities
Work with international partners
North-South collaboration
South-South collaboration
Telemedicine; leverage online training resources
Build research capacity currently nonexistent
If capacity is not built quickly we will be overrun
Take advantage of appropriate science and technology
Technology transfer
Medical education research
EM Development pyramid
TERTIARY STAGES
Legislative Structure
National Health Policy
SECONDARY STAGES
Management systems
Economic structure
PRIMARY STAGES
Specialty systems
Academic development
Education / Patient care systems
Local Variations
Mulligan T. The development of emergency medicine systems in Africa. African Journal of Emergency Medicine 1[1], 5-7. 3-1-2011.
EM Care systems
EPs
MOs, Nurses
Advanced emergency care
practitioners
Nurses/Clinical Officers Basic emergency and disaster
care
Transport to hospital Taxi/other commercial vehicles
Police/Fire Service First Aid Level C
Community First Aid Level B 1 per block
Community First Aid Level A 1 per street
Mulligan T. The development of emergency medicine systems in Africa. African Journal of Emergency Medicine 1[1], 5-7. 3-1-2011.
Governance
Nee
ds
Ass
ess
men
t
Surv
eilla
nce
Pre
ven
tio
n
CENTRAL OR REGIONAL HOSPITAL
REGIONAL HOSPITAL
DISTRICT HOSPITAL
CLINIC
Uche and his sister
THANK YOU
With support from the MEPI project