In Africa, surviving serious illness or injury is like participating in Survivor. In order to survive, people need to outwit, outlast and outplay the health system.
The death of the fit, apparently healthy 38-year old Gugu Zulu made news headlines. The events leading to his death are tragic. Zulu, a well-known South African personality died during the Trek4Mandela Kilimanjaro expedition that raises awareness for the #keepingagirlchildinschool movement.
Details on the descent that were supposed to improve Zulu’s condition and allow for further care are sketchy. The timeline in the media reports differ, some saying that it took 4 hours to cover 32 km on a bicycle stretcher, others say 8 hours. Still, how terrifying the experience must’ve been for his wife that remained at his side throughout the journey. Despite discrepancies in timelines and the exact cause of death still pending autopsy results, it appears that the lack of timely access to further emergency care was a contributing factor leading to his death.
Gugu Zulu required urgent emergency care, and he died because he couldn’t get to care. Sadly, the story repeats itself in various African settings on a daily basis where people frequently die because of health system failures. They die because there is no available transport to the health facilities, which are too far apart and ill-equipped. They die because care is unaffordable and healthcare staff are not trained to deal with emergencies. And they die because there are no out-of-hospital care systems (see earlier blogs on access to care and EFAR).
In Zulu’s case (and depending on the route taken) the closest appropriate facility was about 50km away from the National Park. The Kilimanjaro Christian Medical Clinic (KCMC) is a 600 bed facility and it has an emergency care department that doubles as outpatient clinic. It serves the healthcare needs of 15 million people. Time, geographical accessibility and method of transport appears to have been bigger issues contributing to his death than only the availability of an appropriate facility.
The effectiveness of emergency care is dependent on time. The following definition for emergency care was agreed upon at the African Federation for Emergency Medicine (AFEM) consensus conference in April this year: ‘emergency health conditions are those requiring rapid intervention to avert death or disability, and those for which treatment delays of hours or less make interventions less effective.’
Obtaining care for emergency health conditions are a challenge in Tanzania. The country has a doctor to patient ratio of 2 per 100 000 people. Another constraint as highlighted in this case is the lack of formal out-of-hospital services. Formal systems would facilitate the delivery of care at site of injury/illness and continued care during transportation.
That said, Tanzania is one of the very few African countries that has emergency medicine residency and emergency nursing programmes. Local emergency care practitioners have been supported by international faculty to share expertise. In 2011 the Emergency Medicine Association of Tanzania (EMAT) was formed. This organisation works closely with the government to prioritise emergency care and to development emergency care. EMAT and AFEM works closely together to advocate for the unrestricted access to emergency health care.
Ensuring unrestricted access to emergency care by developing sustainable systems requires awareness and funding. Sadly, emergency care does not yet share a similar status to that of high-profile diseases like HIV, TB and Malaria. People are aware of the high-profile diseases and thus they are well-funded and promoted.
The death of Gugu Zulu begs the important question, can global stakeholders in health care continue to ignore the importance of developing strong emergency care and out-of-hospital care systems?
As Olive Kobusingye says,
In future, the stories told in Africa will depend on how well we advocate and continue building emergency healthcare systems.
P.S. I would like to share an idea that we’ve been talking about since the WHO Basic Emergency Course last year. The idea is to travel from clinic to clinic through some countries that has ties with AFEM by cycling and/or using the method of transport that the different communities would use to access care. The purpose is to raise the awareness of how hard it is to obtain emergency care. I would welcome some ideas on how we could make such an undertaking work.