I thank the editors of the Journal of Pediatric Gastroenterology and Nutrition for inviting me to discuss the topic of pediatric gastroenterology in South Africa. The views expressed are entirely my own and are a result of personal experience in the Department of Pediatrics, University of Witwatersrand, Johannesburg. The situation in South Africa is complex and I will try to address various economic, political, and healthcare issues that influence the health services offered in South Africa.
PEDIATRIC GASTROENTEROLOGY IN SOUTH AFRICA TODAY
Historically, many of the pioneers of general pediatrics in South Africa contributed significantly to the understanding of basic gastroenterology. Since the mid 1900s, South African pediatricians performed pioneering basic and clinical research in diseases such as acute diarrhea, kwashiorkor, and marasmus. In recent years, however, progress toward establishing pediatric gastroenterology as a vital clinical and research subspecialty in South Africa has stagnated. In fact, the Health Professions Council of South Africa (the medical control body) does not recognize pediatric gastroenterology as a subspecialty. There are no formally trained pediatric gastroenterologists in South Africa and no pediatricians practice this discipline exclusively. There are no fellowship training programs in pediatric gastroenterology. Care of children with gastrointestinal or liver disorders varies from center to center. There are seven academic medical schools in the country. Some of the pediatric departments in these university hospitals have divisions of pediatric gastroenterology, such as the Red Cross Children's Hospital, Cape Town. Here, general pediatricians with an interest in gastroenterology offer gastroenterology services; although the majority of their clinical duties are in general pediatrics. The Departments of Pediatrics and Pediatric Surgery in Cape Town even perform a limited number of liver transplants in children. Statistics are not available on the epidemiology of many of the gastrointestinal and liver diseases in South African children, so it is difficult to determine the extent of these diseases. There is no doubt that these diseases occur and are treated by general pediatricians, adult gastroenterologists, or pediatric surgeons. The field of adult gastroenterology is well established throughout the country, as are the fellowship training programs in this field. Collaboration with the adult units in some centers allows training for general pediatricians and surgeons in endoscopic procedures.
Why has the field of pediatric gastroenterology not received the attention it deserves and why did it not develop in South Africa at the same time that many of the other pediatric subspecialties were expanding? Pediatric subspecialties such as cardiology, nephrology, neurology, and developmental pediatrics, oncology, and neonatology were established in the 1970s and the 1980s and are recognized by the Health Professions Council of South Africa. Many are established departments in academic hospitals staffed by trained subspecialists working exclusively in their discipline. The reasons pediatric gastroenterology did not follow a similar route of development are unclear and many factors may have been at play. The need for specialists in pediatric gastroenterology and hepatology was possibly hidden by the fact that the predominant nutritional and gastroenterologic disorders facing South African children relate to acute and chronic infectious disease and are therefore closely linked to primary health care and are managed at a general pediatric level. The impetus to promote this area may have been further diminished by the emigration of general pediatricians who completed fellowships abroad and those who received training in adult gastroenterology units.
Given the current economic climate and the problems in health care in South Africa, I wonder not only whether it is possible to develop the infrastructure needed to establish a viable pediatric gastroenterology subspecialty, but also whether it is a critical priority. South Africa is a country of contrasts, combining aspects characteristic of both the developing and the developed world. The level of medical training and the care available in some areas and to some sectors of the population is highly specialized. However, there are some hard, cold facts about the health care available to the majority of South Africans, which must enter in to any consideration of the development of further pediatric subspecialty care.
GENERAL STATISTICS ON SOUTH AFRICA
The population of South Africa is approximately 44 million, with 44% of the population being younger than 18 years of age. In 1996, 55.3% of households had no running water and 12.4% were without basic sanitation facilities (Census in brief: The people of South Africa population census, 1996. Report No. 03–01–11;1996). The expanded unemployment rate is 34.4% (Central Statistical Service, October household survey, 1996), whereas one in three households has an available income of less than 1,000 Rand ($110.00 US) per month (Reality Check, Kaiser Political Survey, Dec 1998). The infant mortality rate is 40 to 50 deaths per 1,000 live births. Two thirds of the deaths of children younger than 5 years are a result of diarrheal disease. By 2010, AIDS is expected to double the child mortality rate (HIV/AIDS and Human Development South Africa, UNDP, 1998). South Africa has one of the highest violent crime rates in the world. More than 16% of deaths in South Africa occur as a result of trauma (not all traumas are the result of crime) compared to the World Health Organization's global figure of 5% (Poverty and Inequality in South Africa. Final Report. May 1998). Child abuse, including sexual and physical abuse increased by 117% between 1993 and 1996 (Children's Rights Centre, Durban, South Africa). In 1998, approximately 34,000 cases of sexual assault in children were reported (Child Protection Unit, South African Police Service, 1999).
HEALTHCARE IN SOUTH AFRICA
Health care is composed of two separate sectors—public (including academic centers that are government financed) and private (privately funded). There are significant disparities in the financial and human resources available in these two sectors. An estimated 23% of South Africans have some degree of access to private sector health care. Costs of health care in the private sector accounted for nearly 61% of total healthcare expenditure in 1992/1993 (Di McIntyre. Input Paper on Health for the Poverty and Inequality Report. 1998). Key challenges in public health care facing the new government in 1994 (at the end of apartheid) were to improve access to health services, to upgrade primary healthcare facilities, and to address the inequities in investment in private versus public health care. Free health care in the public sector for pregnant woman and children younger than 6 years of age was introduced in 1994 and expanded to free primary health care for all patients in the public sector in 1996. An increase in the health budget in real terms is not anticipated; therefore, expansion of primary healthcare services will occur more slowly than planned and will have to be funded out of reductions in hospital services (Government Input Paper: Poverty and Inequality Report–1998). The establishment of an adequate referral network to secondary and tertiary hospitals and the maintenance of these historically underresourced referral hospitals will be severely constrained as a result of this redistribution. The burden of HIV disease and long-term underfunding for HIV/AIDS care has contributed to a deterioration of conditions in academic centers.
IMPACT OF HIV/AIDS
South Africa has one of the highest HIV infection rates in the world, involving predominantly individuals from heterosexual relationships. The prevalence is higher in females than in males. According to the1998 9th HIV National Survey, the estimated number of infected adults was 4.2 million (8.6% of the total population). In 2000, 24% of women attending antenatal clinics were HIV positive (Ante-Natal Survey. Department of Health; 2000) (FIG. 1).
It is estimated that there are 700,000 AIDS orphans in South Africa, and projections suggest that by 2010 there will be between 3.6 and 4.8 million (HIV/AIDS and Human Development South Africa, UNDP, 1998). The ramifications of this epidemic are far reaching. Complex choices face the Department of Health, and the government as a whole, in deciding how best to cope with the epidemic. A current topic of debate is whether to initiate a national strategy to reduce mother-to-child transmission of HIV.
COMMENTS ON MEDICAL TRAINING
Undergraduate medical training is on average 7 years (including internship). It is compulsory for doctors to perform 1 year of community service after graduation. Postgraduate pediatric residency training is a 5-year program. Clinical and practical medical experience in the training programs is intensive because of the large patient load. Training in some of the pediatric subspecialties is possible, but programs vary in the different academic centers, and it is not possible to generalize or describe the different set-ups in each unit.
EMIGRATION AND ECONOMICS
Emigration from South Africa continues to increase, with high crime rate, deteriorating economy, and poor quality of life cited as reasons. Official figures show approximately 65,000 emigrants since 1994, but because of underreporting, the actual number is probably closer to 200,000 people. I have not been able to confirm statistics on the number of doctors who have left the country, although it is estimated that 45% of medical graduates from the University of Witwatersrand leave the country.
The South African currency (Rand) has been in decline since the late 1980s, with dramatic devaluation since 1994. The Rand devalued 38% from January 2000 to October 2001.
FUTURE OF PEDIATRIC GASTROENTEROLOGY IN SOUTH AFRICA
There are no clear-cut or easy solutions to the complex, multifaceted situation in South Africa. The expansion or growth of such subspecialty areas as pediatric gastroenterology seems unlikely because resources are being channeled into primary health care and conditions in the government-supported academic hospitals continue to deteriorate. The emigration of medical personnel and the weakening value of South African currency compound the situation. The repair and purchase of new equipment (e.g., endoscopes) is almost impossible. From a more optimistic viewpoint, there is an established foundation of specialized medical care in some areas. Research possibilities abound because there is a large clinical base and an infrastructure that can support the research. A prerequisite for the development of pediatric gastroenterology as a clinical subspecialty would be the implementation of an infrastructure to offer practical and interventional care.
Despite the grim economic, public health, and crime statistics, I believe that there is a need for pediatric gastroenterology in South Africa and that there is potential for its development. It should be possible to achieve this within the framework of available resources and financial restrictions. The program would have to be tailored to the needs of the community, the diseases prevalent locally, and the resources available. Ideally, the drive to promote this discipline should come from the major academic pediatric departments in the country. We need recognition that pediatric gastroenterology is a discipline in its own right, that the spectrum of gastroenterologic disorders in children is different from that in adults, and that these problems should be ideally addressed by a pediatrician trained in pediatric gastroenterology. Whether this is likely to happen within the public and academic sectors or whether it is possible to develop pediatric gastroenterology within the private sector remains to be seen.
Ongoing support from and contact with the international pediatric gastroenterology community is essential. The potential for international exchange visits and collaborative research exists and could be mutually beneficial. I hope this article highlights not only the problems, but also the potential rewards of practicing medicine in South Africa and highlights, in a balanced fashion, the issues faced by those of us interested in practicing pediatric gastroenterology. I hope that it will stimulate further collaboration with fellow workers in this field worldwide.