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Apartheid and health: is reformmerely cosmetic?

The wave of violence now gripping South Africahas again focused world attention on the troubles ofthat region. If political conflicts are rife, what ofapartheid? Is it still restricting access of the blackpopulation to health care as was so convincinglyproven in the 1970s and 1980s? To answer this

question, Physicians for Human Rights* and itsDutch sister organisation, the Johannes Wier

Foundation, sent two doctors on a two-week

investigation to identify blocks to reform and areasrequiring support from health workers and aid

agencies overseas. The mission was specifically linkedto the Minister of Health’s announcement of May,1990, that hospitals would be opened to all races.Their report has now been published. 1 The

investigation also covered the question of access toprimary health care by the black population. Is

improvement on the agenda?Information was mainly collected by interview and

observation, since data on admission rates are limitedand there are confounders such as the growth ofprivate practice, which is reducing the number ofwhite patients admitted to state hospitals. The missionmet government officials, members of the medicalestablishment, hospital doctors and nurses, andmembers of the progressive sector in five geographicalareas-Johannesburg, Northern Transvaal/Lebowa,Cape Town, Durban, and East London/Ciskei. Thefindings were that improvements in the health sectorare very patchy and insufficiently supported bygovernment; that many hospitals remain segregated;that access to primary and secondary care is still verypoor for the black population; and that politicallymotivated violence is severely restricting the coverageof health care in many periurban areas. Healthworkers and the Human Rights Commission voicedtheir concern to the mission about complicity of partsof the security forces and the lack of commitment ofthe government to curb violence. The chief

impediments to reform were identified as the

apartheid system and the fragmented health service;entrenched conservatism of hospital superintendents;lack of representative local government; and

government-encouraged mushrooming of privatepractice.

Examples of these blocks were numerous. At GreyHospital in King Williams Town (which is outsideCiskei, a homeland) patients from neighbouringCiskei are referred to hospitals 30 miles away because aseparate administrative system enforces this rule. At

Pietersburg, patients remain segregated in two

separate hospitals which sit side by side; the children’s

*Physicians for Human Rights is based at the University Department ofForensic Medicine, Dundee Royal Infirmary, Dundee DD 1 9ND, UK, andJohannes Wier Foundation is at PO Box 1551, 3800 BN Ammersfoort,Netherlands. A full report of the mission can be obtained from either

organisation.

ward in one housed 75 black children withmalnutrition and infectious disease, while in the otherhospital 2 of 3 white children were about to bedischarged. At Duncan Village near East London, theunpopular and unrepresentative city council cut itsstaff when there was a rent boycott. The first service togo was the care of the communal toilets which, wheninspected by the mission, were completely blockedand offensive as well as being unhygienically sited nextto shops and water points. At Khayelitsha in CapeTown, basic health services are scanty for the halfmillion population and follow-up arrangements forpatients with chronic disorders and disabilities arevirtually non-existent. Preventive and curativeservices are administered separately.

Despite these gloomy features, there are signs ofhope. Attitudes to change are generally positive, andthe non-governmental health sector is rising to thechallenge by organising training and support forprimary health care. Some progressive organisationshave also developed proposals for an insurance-basednational health service. The mission was met with theutmost courtesy throughout the country.What of outside help? First, pressure on the South

African government is still needed, linked to specifictargets such as unification of the fragmented healthsystem and desegregation of hospitals. Second,visiting health workers (academic or otherwise)should be appraised of the inequities present in thesystem and should attempt to make links with rural

settings and primary health care as well as with thetertiary level. Third, assistance to the progressivehealth sector is needed in monitoring changes in thepresent system, in health economics and planning,and in public health/epidemiology.

1. Johannes Wier Foundation (Netherlands) and Physicians for HumanRights (UK). South Africa 1991: apartheid and health care intransition-a report on progress, impediments and means of support.Ammesfoort: Johannes Wier Foundation, 1992.

Glue ear guidelines: time to act on theevidence

Utitis media with ettusion (OME, glue ear) is themost common reason for surgery in young childrenbut a systematic review of management in Britain inthe bulletin Effective Health Care raises some

disturbing questions about variations in clinicalpractice and the effectiveness and appropriateness ofsurgery.1 Thus, the annual rate of surgical treatmentfor OME carried out in the National Health Service in

England and Wales is about 5 per 1000 children under15 years of age and there are substantial differences inrates by region and district.1,2 This variation and

uncertainty in clinical decision making3 is an

international phenomenon--eg, the US Agency forHealth Care Policy and Research (AHCPR) hascommissioned clinical guidelines for the managementof OME.

Episodes of OME vary in duration and the

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condition remits spontaneously and sometimesrecurs. Severity of accompanying hearing loss varies.Consequently a cross-section of young children,although it will show a high prevalence of bilateralglue ear,4 will greatly overestimate the numbers ofchildren with persistent and severe hearingimpairment. About 50% of ears with the conditionwill have recovered spontaneously after 3 months, andonly about 5% will still have the condition after 12months. 5

Unless children with OME are assessed

systematically and repeatedly, a considerable

proportion will undergo unwarranted surgery, withlittle or no resulting benefit. Preoperative assessmentshould not only encompass the history of hearingdifficulty and disabilities (eg, speech or learningproblems); it should also document persistent andsevere hearing impairment and include evaluation bypneumatic otoscopy and tympanometry. Black et al6evaluated the effectiveness of surgery in children whohad been previously selected for surgery byotorhinolaryngologists and found that over 30% ofchildren did not have evidence of effusion at

myringotomy. This result partly reflects the fact thatpreoperative assessment was inadequate and failed toidentify those who had recovered spontaneously.Another survey3 showed that 36% of consultant

otorhinolaryngologists placed patients on the list forsurgery at the first visit.There is no good evidence for the post hoc

explanation often invoked for dry taps-that nitrousoxide anaesthesia causes the effusion to drain duringinduction. Trials with trained and "validated"

otoscopists show dry-tap rates of less than 10%.7,8When the otoscopist is unable to match such figures,the diagnosis should be confirmed by the presence of atype B (flat) or C, (peak at less than - 200 mm H20)tympanogram.9There is no consistent evidence from randomised

controlled trials that medical therapy, including nasaldecongestants, mucolytic agents, or antibiotics

significantly affects the natural rate of resolution. Apromising non-surgical intervention is autoinflationwith nasal balloons (Otovent) which, provided thechild complies by continuing their use, is associatedwith short-term improvement in otoscopic findingscompared with controls.10,11 Trials are now neededwith longer follow-up in which effects on hearing areexamined.The use of hearing impairment (eg, >_ 25 dB

hearing loss) alone as an indication for surgery istroublesome. The underlying justification for surgicalintervention should be the reduction of disability dueto hearing impairment. It is often assumed that

hearing impairment in children with OME will resultin disability in areas such as social functioning,language competence, speech production, andeducational achievement. Thus the diagnosis of OMEis often used as an explanation for the failure ofchildren to meet parental expectations of their

educational achievement.12 However, work in thisarea has failed to find a causal link between OME andsevere disability; Haggard and Hughes13 go as far as tosay that if such a link does exist it is only likely to be theresult of an extremely persistent history of hearingimpairment starting at an early age.

Health care resources should be concentrated onthose with a persistent and severe hearing impairment.A period of watchful waiting (3-6 months, dependingon the season) to establish which children have abilateral persistent severe hearing impairment is asensible policy and should not be regarded as aharmful delaying tactic. If this strategy is combinedwith the use of a provisional waiting list, children inneed of surgery can be treated more rapidly becausethose who improve spontaneously will avoid

unnecessary intervention and those in greatest needwill not encounter delays in getting surgical treatment.The review of the nineteen randomised controlled

trials’ indicates that mean improvement in hearingwith either grommet insertion or adenoidectomy isabout 12 dB after six months and falls to under 5 dBafter a year. This estimate of mean hearing gain masksa large variation in effect between children, rangingfrom no change to very substantial improvements.However, none of the studies was designed to

determine factors to identify the subset of childrenwho will benefit most from surgery-ie, those whohave an effusion that is unlikely to resolve

spontaneously. The clinical importance and impact onthe child of small gains in hearing remain unclear.The next step should be to initiate a few large

multicentre, multidisciplinary trials to examine theeffectiveness of a range of interventions (includinghearing aids) with broader outcome measures,

subgroup analysis, and assessment of cost-

effectiveness.

1. Effective Health Care. The treatment of persistent glue ear in children.Bulletin no 4. Leeds: University of Leeds, 1992.

2. Black N. Geographical variations in use of surgery for glue ear. J R SocMed 1985; 78: 641-48.

3. Smith IM, Maw AR. Secretory otitis media: a review of management byconsultant otolaryngologists. Clin Otolaryngol 1991; 16: 266-70.

4. Zielhuis GA, Rach GH, Bosch AV, Broek PV. The prevalence of otitismedia with effusion: a critical review of the literature. Clin Otolaryngol1990; 15: 283-88.

5. Zielhuis GA, Rach GH, Broek PV. Screening for otitis media witheffusion in preschool children. Lancet 1989; i: 311-14.

6. Black NA, Sanderson CF, Freeland AP, Vessey MP. A randomisedcontrolled trial of surgery for glue ear. BMJ 1990; 300: 1551 - 56.

7. Dempster JH, Browning GG, Gatehouse SG. A randomised study of thesurgical management of children with persistent otitis media witheffusion associated with a hearing impairment. J Laryngol Otol (inpress).

8. Maw AR, Herod F. Otoscopic, impedance, and audiometric findings inglue ear treated by adenoidectomy and tonsillectomy: a prospectiverandomised study. Lancet 1986; i: 1399-402.

9. Fiellau Nikolajsen J. Tympanometry and secretory otitis media. ActaOtolarynol 1983; 394 (suppl).

10. Blanchard J, Maw AR, Bawden R. The treatment of otitis media witheffusion in children by autoinflation. In: Molta G, ed. New frontiers ofotorhinolaryngology in Europe. Bologna: Monduzzi, 1992.

11. Stangerup SE, Sedeberg-Olsen J, Balle V. Autoinflation as a treatment ofsecretory otitis media. Arch Otolaryngol 1992; 118: 149-52.

12. Black N. Glue ear: the new dyslexia? BMJ 1985; 290: 1963-65.13. Haggard M, Hughes G. Screening children’s hearing: a review of the

literature and the implications of otitis media. London: HM StationeryOffice, 1991: 65.