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
Life Expectancy at birth in WHO Regions, 1990 and 2009

2009
African Region
South East Asia Region
Eastern Mediterranean Region
1990
54
51
65
59
61
66
Western Pacific Region
69
75
European Region
75
72
Region of the Americas
76
Global
71
64
69
WHO Regional Office for Africa. Atlas of Health Statistics of the African Region 2012.
24/10/2012. World Health Organization, Regional Office for Africa.
70
2009
1990
Life expectancy at birth in years in the African Region, by country, 2008 and 1990 some countries have lost years
65
60
55
50
45
40
35
30
75
Mauritania
Burkina Faso
Cte d'Ivoire
Nigeria
Seychelles
Comoros
Angola
Guinea-Bissau
Equat.Guinea
Ghana
Mauritius
Cape Verde
Togo
Mali
Uganda
Senegal
Algeria
Gambia
Malawi
Benin
Sierra Leone
Rwanda
Guinea
Madagascar
Mozambique
Ethiopia
Niger
Liberia
Eritrea
80
Life expectancy at birth in years in the African Region, by country, 2008 and 1990 other have gained years
2009
1990
70
65
60
55
50
45
40
35
30
Healthy life expectancy at birth in years in WHO

Regions, by sex, 2007
45
46
African Region
55
57
56
57
64
European Region
65
65
58
Global
40
45
Male
50
55
60
70
69
69
61
65
70
75
Female
Trend in life expectancy at birth in years in the African Region,

by sex, 2003 to 2009
57
55
53
Male
51
Female
49
47
45
2003
2004
2005
2006
2007
2008
2009
Adult mortality rate per 1000 population in

WHO Regions, 2009 and 1990
383366
261
209
236
188
146157
2009
162
125
166
116
207
176
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
Zimbabwe
Lesotho
Swaziland
South Africa
Malawi
Tanzania
CAR
Chad
Burundi
Nigeria
DRC
Botswana
Cameroon
Congo
Burkina Faso
Kenya
Cte d'Ivoire
Gabon
Namibia
Mauritania
Ghana
SaoTomePrincipe
Ethiopia
Eritrea
2009
1990
Under-5 mortality rate per 1,000 live births by WHO

Region, 1990, 2000, 2009
175
170
153
150
Africa
130
107
110
SEAR
East Med
90
Global
70
West Pac
50
Americas
48
Europe
34
30
16
10
1990
2000
2009
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
2005 MDG Target: 55
1990
2000
2005
2008
2009
2011
2015
Child Mortality Goal 4

Africas burden of under-five deaths in the world 2009
50
23
Live births
Under-five deaths
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
2015 MDG Target: 213
1990
1995
2005
2008
2009
2015
Health care workers
Physician-to-population and Nurse-to-population ratios

(per 10,000 population) in WHO Regions, 20052010
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
72.5
65.0
33.2
2.2
9.0
20.0
15.6 14.818.4
10.9 10.9
5.6
Physicians
Nurses
28.1
14.2
Physician-to-population ratio and Nursing staff ratio

(per 10,000 population) in the African Region, by country, 20052010
0.0
African Region
Liberia
Tanzania
Ethiopia
Malawi
Mozambique
Gambia
Mali
Ghana
Uganda
Cte d'Ivoire
Botswana
Namibia
Nigeria
Cape Verde
Algeria
5.0
10.0
15.0
20.0
25.0
30.0
Physician-to-population ratio (per 10,000 population)

in the African Region, by country, 20052010
0
African Region
Liberia
Tanzania
Ethiopia
Malawi
Mozambique
Gambia
Mali
Ghana
Uganda
Cte d'Ivoire
Botswana
Namibia
Nigeria
Cape Verde
Algeria
10
12
14
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
Nursing and midwifery personnel-to population ratio (per 10.000

population) in the African Region, by country, 20002009
0.0
5.0
10.0
African Region
Liberia
Tanzania
Ethiopia
Malawi
Mozambique
Gambia
Mali
Ghana
Uganda
Cte d'Ivoire
Botswana
Namibia
Nigeria
Cape Verde
Algeria
15.0
20.0
25.0
30.0
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
Burden of disease
Total burden of disease in DALYs per 1000 population in

WHO Regions, 2004
African Region
511
East Mediterranean
273
South East Asia
265
Europe
171
Americas
164
Western Pacific
152
40
140
240
340
440
540
Series 1
Leading causes of burden of disease shown as percentage of

total DALYs in the African Region, 2004
0
10
HIV/AIDS
12
14
12.4
Lower respiratory infections
11.2
Diarrhoeal diseases
8.6
Malaria
8.2
Neonatal Infections and other
3.6
Birth asphyxia and birth trauma
3.6
Prematurity and low birth weight
Tuberculosis
2.9
Road traffic accidents
1.9
Protein-energy malnutrition
1.9
Maternal
conditions, 4.0
Neuropsychiatric
disorders, 5.2
Unintentional
injuries, 5.4
Nutritional
deficiencies, 3.1
Intentional
injuries, 2.5
Infectious and
parasitic
diseases, 42.4
Perinatal
conditions, 10.1
Respiratory
infections, 11.4
Non
communicable
diseases, 15.9
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
Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies
Non-communicble diseases
Injuries
African Region
71%
21%
8%
East Mediterranean
44%
41%
15%
South East Asia
42%
44%
14%
Western Pacific
18%
69%
13%
Americas
17%
69%
14%
Europe
10%
77%
13%
Distribution of years of life lost by broader causes in

WHO Regions, 2004
Communicable diseases
Non-communicble diseases
Injuries
African Region
80%
East Mediterranean
13%
56%
South East Asia
30%
52%
31%
15%
17%
Americas
25%
55%
20%
Western Pacific
24%
57%
19%
Europe
Global
12%
70%
51%
7%
18%
34%
14%
Health financing
Per capita total expenditure on health

(PPP international $) in WHO Regions, 2009 and 2000
African Region
157
88
120
62

2009
324
173
614
296
2218
European Region
1215
3346
Global
2000
1987
990
568
Trend in average per capita total expenditure on health

(PPP international $) in the African Regions, 2009 and 2000
160
150
140
130
120
110
100
90
80
2004
2005
2006
2007
2008
2009
Total expenditure on health as percentage of GDP in

WHO Regions, 2007 and 2000
6.2
5.9
African Region
Eastern Mediterranean
Region
European Region
2007
3.6
3.7
4.1
4.2
6.5
6.8
8.8
8.4
13.6
Global
2000
12.0
9.7
9.2
Trend in total expenditure as percentage of GDP in the

African Region, 2004 to 2009
6.6
6.4
6.2
6
5.8
5.6
5.4
5.2
2004
2005
2006
2007
2007
2009
Road traffic deaths: some facts
Million people
1.8
1.3 million deaths

20-50 million injured
1.3
1.3
<1
AIDS-related deaths Tuberculosis

UNAIDS 2008
WHO 2007
Road traffic
WHO 2004
Malaria
WHO 2008
Leading causes of death

2004
2030
Rank
Disease or Injury
Rank
Disease or Injury
Ischaemic heart disease
Ischaemic heart disease
Cerebrovascular disease
Cerebrovascular disease
COPD
COPD
Diarrhoeal diseases
Road traffic injuries
HIV/AIDS
Trachea, bronchus, lung cancer
Tuberculosis
Diabetes mellitus
Trachea, bronchus, lung cancer
Hypertensive heart disease
Road traffic injuries
Stomach cancer
10
Prematurity & low-birth weight
10
HIV/AIDS
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. 6-12011.
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. 6-12011.
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
Local Variations
Legislative Structure
National Health Policy
SECONDARY STAGES
Management systems
Economic structure
PRIMARY STAGES
Specialty systems
Academic development
Education / Patient care systems
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
Governance
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
REGIONAL HOSPITAL
DISTRICT HOSPITAL
CLINIC
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.
Prevention
Needs Assessment
MOs, Nurses
Surveillance
EPs
CENTRAL OR REGIONAL
HOSPITAL
Uche and his sister
THANK YOU
With support from the MEPI project

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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

I never think of the future. It comes soon

Gap minder data

Life Expectancy at birth in WHO Regions, 1990 and 2009

Western Pacific Region

Region of the Americas

Healthy life expectancy at birth in years in WHO

Eastern Mediterranean Region

South East Asia Region

Western Pacific Region

Trend in life expectancy at birth in years in the African Region,

Adult mortality rate per 1000 population in

Adult mortality rate per 1000 population in the African Region,

Under-5 mortality rate per 1,000 live births by WHO

MDG-4: Trend in under-5 mortality rate (probability of

2005 MDG Target: 55

Child Mortality Goal 4

MDG-5: Trend in maternal mortality ratio

2015 MDG Target: 213

Health care workers

Physician-to-population and Nurse-to-population ratios

Physician-to-population ratio and Nursing staff ratio

Physician-to-population ratio (per 10,000 population)

Nursing and midwifery personnel-to population ratio (per 10.000

Total burden of disease in DALYs per 1000 population in

South East Asia

Leading causes of burden of disease shown as percentage of

Lower respiratory infections

Neonatal Infections and other

Birth asphyxia and birth trauma

Prematurity and low birth weight

Road traffic accidents

Distribution of burden of diseases as percentage of total DALYs

Distribution of burden of diseases as percentage of total DALYs

South East Asia

Distribution of years of life lost by broader causes in

South East Asia

Per capita total expenditure on health

South East Asia Region

Eastern Mediterranean Region

Region of the Americas

Trend in average per capita total expenditure on health

Total expenditure on health as percentage of GDP in

Region of the Americas

Trend in total expenditure as percentage of GDP in the

Road traffic deaths: some facts

1.3 million deaths

AIDS-related deaths Tuberculosis

Leading causes of death

Ischaemic heart disease

Ischaemic heart disease

Lower respiratory infections

Lower respiratory infections

Road traffic injuries

Trachea, bronchus, lung cancer

Trachea, bronchus, lung cancer

Hypertensive heart disease

Road traffic injuries

Prematurity & low-birth weight

Other key data