Orthopaedics in the Developing World: Present and Future Concerns
To the Editor: First I must congratulate the authors on a well-researched and insightful article.1 I am a 41-year-old African orthopaedic surgeon born and educated in Nigeria. Three national orthopaedic hospitals are dedicated to training in orthopaedic and trauma care, and our training has been primarily tuned to our environment. So for Nigeria, personnel is not a major problem. Our problems are both economic and political.
I presently work with the government of the kingdom of Lesotho in South Africa. There are two orthopaedic surgeons serving a population of about 2 million people. I work in the main hospital in the capital. The rugged mountain terrain, alcohol abuse (a volatile mix), and general low socioeconomic conditions lead to a high musculoskeletal trauma rate. In Africa generally the government employs over 90% of medical labour as medical care is still mostly seen as a social service. The problems of African governments impact directly on medical care. Governments can never really pay specialists adequately, hence the migration of the few well-trained personnel available. Countries with acute shortages, like Lesotho, have to offer “good packages” to get personnel.
A few of the basic problems include extremely poor record keeping by poorly trained and semiliterate staff (I myself have to collect any data I want to use) as well as very few competent assisting doctors. A very poor understanding of orthopaedic surgery by medical administrators leads to complaints about the cost of implants. Another problem is nonexistent maintenance of existing equipment. (We do have an old C-arm. This is an absolute luxury in Africa and is used sparingly.) Heavy patient loads mean that some fractures do not get fixed for 2 to 4 weeks! We lose patients to follow-up because of distances and poverty. Also, poor knowledge and training of the first-contact doctors means that a lot of fairly simple orthopaedic cases are already complicated by the time they get to us. The main disasters are with open fractures.
But having highlighted all these problems, we do succeed reasonably considering the situation. Ninety percent of my work is internal fixation of fractures. We select patients for internal fixation carefully. Our fracture armamentarium includes the following: a mixed range of A/O plates and screws; Küntscher nails, which we use a lot in imaginative ways; a few old locking nails; tibial nails inserted by open technique; Ender and Rush nails, which we use sometimes with cerclage wires; and Moore and Thompson hemiarthroplasties. We were able to do a few total hip replacements a few years ago. We also have some external fixators.
Our infection rates are remarkably low. Preoperative antibiotics continued for 48 hours, copious irrigation of wounds, and use of drains are, of course, standard. What we have learned to do is to improvise as we go along. A vital requirement for safe improvisation is a sound knowledge of the basic principles. It is all pretty frustrating most of the time, but a lot of our patients go home satisfied by African standards! That all this can be done in a country that is classified in the least-developed category of the WHO classification is quite remarkable.
Administrative ineptitude and sheer nonchalance of the decision makers is probably the greatest stumbling block we face daily. The musculoskeletal trauma load in Africa is rising steadily, fueled by increasing numbers of poorly maintained cars on poorly maintained roads, assisted by alcohol. All of these, combined with ignorance, poverty, and lack of personnel (internal and external brain drain), paint a daunting picture for the future of musculoskeletal care in Africa.
How can the West help?
(1) By first understanding that the greatest problems are governments. Working through them does not work. By all means, get permission and approval to operate, but it is better to work through nongovernmental organisations like the Red Cross, who already have a local presence and know how to get around the bottlenecks.
(2) Good basic training of doctors to carry out primary procedures will reduce complication rates. Sponsoring the few local orthopaedic surgeons and general surgeons with an interest in orthopaedics for training workshops, and then using them to run basic practical training sessions for the doctors at the grassroots level, seems to me to be the most workable plan. A well-trained surgeon will be a safe improviser when the situation calls for it. Remember that largely untrained doctors carry out a lot of the surgery in the developing world. They are usually the first contact for the patient.
(3) Adoption of the very simplest techniques of fracture care will put less strain on what is available and cut complication rates. Any implants or equipment donated should be simple and basic. The International Committee of the Red Cross, for example, has very basic and easy-to-learn protocols for fracture care, to which can be added basic internal fixation procedures for training.
(4) Assist health ministries in developing countries to develop simple protocols for musculoskeletal trauma care, with emphasis on simple, easily learnt and reproducible methods, and to put up an efficient referral system for more complicated cases, with the expertise and equipment for these put in a few regional centers. Remember that in the developing world, communication systems taken for granted in the West are luxuries. Ambulance systems, efficient referral systems, and primary trauma care personnel are mostly nonexistent. These factors have to be taken into consideration when designing these protocols.
(5) Assist these health ministries to recruit surgeons and maybe help with remuneration of competent African surgeons and support them with sponsorship for practical workshops, conferences, and supply of practical journals.
I am very interested in grassroots training in primary musculoskeletal care of general care physicians in third-world settings. I am in the process of designing a simple program for training our district doctors in Lesotho in basic fracture care. I would be interested in hearing comments from surgeons who have had experience in the area of training or who are interested in getting into this.
The Author Replies: Thank you, Dr. Oloruntoba, for your kind comments on and interest in our article.1 I greatly appreciate your insight into the current situation for orthopaedic surgeons and patients with musculoskeletal conditions in both Nigeria and the kingdom of Lesotho in South Africa. You have provided a first-hand, succinct, and insightful summary of the challenges and opportunities faced in developing countries. You have also provided sound and insightful advice regarding how can the West help.
While the challenges of local infrastructure are not often easily addressed or solved, cooperative educational initiatives, interest, and support are areas that organizations such as the AAOS and Orthopaedics Overseas (OO) are willing and interested to support. The American Academy of Orthopaedic Surgeons, through its International Committee, has a long history of involvement in the developing world, primarily through its international educational programs. Dr. Bruce Browner (Chairman, International Committee of the AAOS) and I recently traveled to Bloemfontein, South Africa, to represent the AAOS and OO and meet with representatives from the African nations at the South African Orthopaedic Association in support of the newly formed East Central and South African Orthopaedic Association (ECSAOA). The AAOS and OO will be working with the ECSAOA and the South African Orthopaedic Association to organize and participate in an orthopaedic training course in Kampala, Uganda, in 2004 as part of the next ECSAOA meeting. The AAOS and OO recognize the importance of the formation of the first international orthopaedic organization on the continent of Africa and on the importance of supporting the educational activities of the ECSAOA and other similar groups throughout the developing world. We believe that through these efforts and other grassroots training and activities, and through the encouragement, enthusiasm, and commitment of individuals such as you, there is a bright future for those with musculoskeletal conditions in the developing world.
1. Dormans JP, Fisher RC, Pill SG: Orthopaedics in the developing world: Present and future concerns. J Am Acad Orthop Surg