africa em past present future 31102012

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



European Region



Global

Male Female


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


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


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


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


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


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


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


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


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




European Region


Global

2009 2000


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


Eastern MediterraneanRegion


European Region


Global

2007 2000


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

africa em past present future 31102012

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