CHILDREN'S SURGICAL NEEDS ARE UNJUSTIFIABLY NEGLECTED IN POOR COUNTRIES
21 October 2002
There are only 39 qualified paediatric surgeons working in sub-Saharan Africa, although 6–12% of the child admissions there are for surgery, according to a study published in the Bulletin of the World Health Organization today. Ten of these surgeons work in West Africa, and the other 29 in East and southern Africa — most of them in Kenya and South Africa. "To continue to exclude basic surgical care from child health programmes destines children to death and disability. This situation is ethically unacceptable", the authors, Stephen Bickler from the USA and Heinz Rode from South Africa, conclude.
At the centre of their study is the main government referral hospital in Gambia, where paediatric admissions needing surgery were 11% of the total. Most of these were for injuries — mainly road traffic accidents, falls, burns and accidental poisoning. The remainder were mainly for congenital anomalies and surgical infections.
In rural East Africa, there are 40 000 episodes of injury per year per 100 000 of the general population, causing 100 deaths. Mortality associated with injury is higher in cities; in an urban area of Uganda it was estimated at 217 per 100 000. Poor roads and vehicles, crowded transport systems and lack of law enforcement cause a high rate of traffic accidents. Armed conflict — 11 major wars were being fought in Africa in the year 2000 alone — also takes a heavy toll. Up to 200 000 child soldiers (i.e. 5–16 years of age) are thought to be participating in such conflicts at present. Landmines kill or mutilate 12 000 people a year, many of them children.
The long-term outcome for children who do not receive adequate surgery has not been sufficiently studied, but one indicator is the high disability rates in developing countries. In one study 12% of households reported a disability related to injury. The most common of them are from mismanaged burns, fractures and dislocations.
Why do such needs get so little attention despite their high visibility? The authors point to the generally low priority children's needs are given in many under-resourced health systems and the frequent under-investment in hospital services in the poorest countries. Related to this is the common belief that the knowledge, skill and equipment required for adequate surgery are unaffordable. Unsuccessful attempts to copy the services provided in western hospitals have reinforced this misconception. The authors recommend defining a cost-effective package for paediatric surgical care. It should be based on the epidemiology of childhood surgical diseases, and define which operations are appropriate, at which level of the health system they should be made available, and the training needed to carry them out.
In some cases, children are sent to richer and better equipped countries for treatment. The intention is laudable, the authors note, but the money spent on caring for a single patient in this way would cover the cost of several weeks of surgical teaching in a developing country. The one encouraging feature of this study is the large number of opportunities the authors see for improvement.
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For the full text of article by Bickler and Rode, click here