Critical care medicine in Africa is largely an
unknown entity in the medical world, though it has recently begun to emerge as
a prominent concern, mostly due to increasing research that has highlighted the
plight of this sub-specialty in Africa (Adhikari et al., 2010, Riviello et al.,
2011). However, the fact that critical care medicine is considered an expensive
sub-specialty of medicine in so many aspects does not help the cause for
recognition and funding. This article aims to explore the plethora of
challenges that the critical care sector in Africa is faced with, and to
provide potential solutions.
healthcare delivery in the developing world already faces many challenges.
Infectious disease interventions with respect to HIV, tuberculosis (TB) and malaria
have been prioritised, and the sectors of maternal and children’s health have joined
the fray in attracting funding support (Kwizera et al. 2012). This is against the
backdrop of poor funding priorities by African governments.
that have looked at the challenges faced in Africa with regard to critical care
medicine have tried to analyse and categorise the problems related to critical
illness management in low-income countries (Okafor, 2009; Dünser et al. 2006).
First and foremost, the African intensive care unit (ICU) patient population
tends to be younger than the ICU population in the developing world (35.5 and
61.8 years respectively ) (Kwizera et al. 2012). This impacts on African
countries’ productivity and presents a significant hindrance to economic development.
The impact is widespread since a lot of critically ill patients are
breadwinners in their families. On another note, a shortage in nursing staff
has led to family members taking time off income generating activities to care
for the sick. The overall mortality rate is comparable across the board in
Africa albeit much higher than in high income countries (30–50% and 8–20.9%
respectively) (Kwizera et al. 2012; Halpern et al. 2004).
Admission diagnoses tend to be similar to those found in higher income countries but they tend to be acute; because of the younger population they should be more survivable if basic resources and practices are put in place. Head injuries are a common reason for admission, and they are associated with higher mortality rates than other conditions (Kwizera et al. 2012; Okafor 2009). This is not surprising, considering that most African ICUs are generally mixed units and do not usually have specialised neuro-critical care resources. This is coupled with the fact that many African countries do not have a functional emergency medical response system. Inadequate transportation of trauma victims to healthcare facilities and delays in definitive care are a result. Adequate emergency care at a crash scene (for example, airway management, positioning, oxygen and fluid resuscitation) is known to improve trauma outcome, but the high number of non-helmet wearing motorcycle riders in African countries, especially Uganda, contributes to the high injury severity and mortality rate of neuro-trauma (Kwizera et al. 2012).
Unsurprisingly, there is also a limited number of ICU beds in the
continent. For example, Uganda as a whole has only one ICU bed for every one
million Ugandans or 0.1 ICU beds/100,000 (Kwizera et al. 2012). This compares
poorly with South Africa (8.9/100,000), Sri Lanka (1.6/100,000), and the United
States of America (20/100,000) (Adhikari et al. 2010). This means that there is
pressure on the few beds that are present, with a resultant high number of
missed ICU opportunities. This limitation is further compounded by a
well-documented dearth of anaesthesiologists, a critical human resource for
ICUs (Hodges et al. 2006; Dubowitz et al. 2010).
Common Illnesses and High Risk Patient Groups
Sepsis is a common cause of mortality in Africa, with rates higher
than those reported from industrialised countries (Jacob et al. 2009). This is
due to insufficient early sepsis care characterised by delayed presentation of
sepsis patients to the hospital, and subsequently to the ICU if they make it or
if such facilities are available (Jacob et al. 2009). The paucity of resources
for managing patients with sepsis (for exam example,
insufficient amounts of fluids, unavailability of intravenous broad-spectrum
antibiotics and unavailability/unreliability of microbiological diagnostics) is
a contributing factor, and even though a recent paper published guidelines to
help resource-poor settings manage critically ill patients with sepsis (Dünser
et al. 2012), it remains to be seen whether its application will carry through
if the basics are not put in place. Early and to a large extent preventable
deaths in the ICU are a common occurrence; the most likely explanation for this
is the lack of trained staff and resources for providing adequate care for
critically ill patients who have a high disease severity (for example, those
with brain trauma, shock or sepsis) (Riviello et al. 2011).
Looking at special groups, children account for 11–12% of all ICU
admissions, of which there is a mortality rate of 40–60%, which is considerably
higher than in industrialised countries (Henry et al. 2011). Paediatric medical
patients have a higher mortality than paediatric surgical patients, probably
because a lot of the post-operative patients are elective surgical patients who
are admitted for observation. Most paediatric medical patients are children
with acute respiratory failure in need of mechanical ventilation. The
relatively young population in low income countries (LICs), and the fact that
respiratory illness is the leading cause of deaths in under five year olds in
these countries (Kwizera et al., 2012), implies that more emphasis should be
placed on strengthening paediatric critical care resources in LICs.
Obstetric admissions are a common occurrence largely due to
perioperative cardiac arrest occurring as a consequence of peripartum
haemorrhage, eclampsia and/or sepsis (Okafor 2007). The introduction of protocolised
care for peripartum emergencies and the establishment of the obstetric high dependency
unit (patient monitors, more intense nursing and protocols without mechanical
ventilation) will improve outcomes in this group. This would need to be
significantly embedded into maternal and child health initiatives that aim at
achieving the millennium development goals.
The fact that HIV is endemic in Africa explains why HIV and AIDS is one of the most common co morbidity related reasons for admission in this population. Due to the advent of easily accessible, highly active anti-retroviral therapy, together with septrin prophylaxis, the incidence of HIVrelated diseases (such as pulmonary infection with Pneumocystis jiroveci, which usually presents as acute respiratory failure) has markedly decreased (Mocroft et al. 2010). Chronic obstructive pulmonary disease is a very rare cause of acute respiratory failure in the African setting. Other rare HIV-related causes of ICU admission are viral encephalitis and liver failure.
Resource-Based Challenges and Proposed Solutions
Having discussed common illnesses found in African ICUs, we turn
our focus to resource- based challenges and their solutions. We will use Uganda
as an example. The per capita income in this equatorial East African nation is
less than four dollars a day, and one third of
the population lives below the poverty line. In light of this, the provision of
critical care may not appear to be a rational or cost-effective priority in a
country where the annual healthcare expenditure is just over 100 dollars per
person (Central Intelligence Agency, 2008). However, looking at it more
critically, poor health seeking behaviour, low doctor-patient ratios and the
low numbers of primary health facilities means late illness presentations
requiring life-saving acute care are rife and are the commonest causes of death
in hospitals countrywide. This would make critical care medicine at regional
referrals a higher priority than normal, while the government tries to solve
the longer-term problems of the primary healthcare.
Assuming the governments in
African countries decide to tackle this problem, development of critical care
capacity must involve the education of nurses and physicians countrywide.
Recognition of the initial clinical syndromes of sepsis or hypovolaemia,
combined with an awareness that critical illness need not lead inevitably to
fatal deterioration, is vital to ensuring early initiation of basic treatments
such as antibiotics administration and fluid resuscitation. The WHO released
the Integrated Management of Adolescent and Adult Illnesses guidelines that
focus on acute care at the basic primary level (WHO, 2009). In Uganda this
toolkit is being rolled out at the district hospital level.
when funding is available, the procurement system is plagued by rampant
corruption that leads to tenders being fraudulently awarded. This is also
characterised by the end users not being involved in the procurement process,
assuming they even have the technical expertise. Simple devices like patient
monitors, syringe pumps, suction machines and glucometers are a rare resource
and yet they play a significant role in guiding and delivering therapy.
There is in addition, an increasing influx of Western world discarded
or donated, but mostly useful, biomedical equipment. This equipment will work
for at least six to twelve months and then breakdown due to lack of spare
parts. As a result, Africa has in effect become a dumping ground. A policy
toolkit needs to be put in place to guide governments on the types and
categories of equipment they can purchase or receive as donations, and on
recommended simple designs for the construction of ICUs. Even
without expensive resources, high impact critical care medicine can be
practiced. Evidence based practices like early goal-directed therapy for
sepsis, handwashing practices, early identification of childhood illnesses and
early referrals for high level trauma patients are interventions that are
within reach of many healthcareunits on the continent. Innovative practices
that try to match international guidelines have emerged, for example the lack
of commercially prepared enteric feeds at our ICU led us to create a special
diet for our critically ill patients. A single feed consists of a small cup of
silver fish powder; a small cup of instant soya flour; two tablespoonfuls of
sugar; half a teaspoonful of table salt; two crushed multivitamin tablets; and
two tablespoonfuls of cooking oil, all mixed in 250mls of fresh whole milk.
This feed is given through a nasogastric tube every three hours. Feeds stop at
11pm to rest the gut (and avoid overfeeding) and resume at 7am after measurement
of gastric residual volumes.
oxygenation in the absence of face masks and nasal prongs in children, we use
mini oxygen tents made of semirigid discarded polyethene bags. This helps to
improve the fraction of oxygen from 25% to almost 40%
and has been observed with pulse oximeters.
Task shifting has to an extent been successful in other areas of
medicine; a currently successful running model is using the growth of
anaesthesia to grow intensive care medicine. In Uganda, a successful programme
supported by the Association of Anaesthetists of Great Britain and Ireland and
Global Partners in Anesthesia and Surgery (a US based physicians organisation)
has transformed the training domain of physician anaesthetists from two
trainees in 2007 to eight graduates and 22 trainees in 2012.
Additionally, the three- to four-year long programme adopted the
European Society of Intensive Care Medicine (ESICM) diploma curriculum:
Competency Based Training in Intensive Care Medicine (CoBaTrICE), and embedded
it as part of a one-year intensive care medicine module. This is also topped up
by a four- to six month clinical fellowship in a Western ICU to round-off the
education for those interested in pursuing intensive care medicine as a full-time
career. Furthermore, the undergraduate medical curriculum now requires that
trainees partake in a 17-week clinical rotation, including anaesthesia and
critical care, thus equipping junior doctors with the basics of intensive care
medicine. The same principle should be applied to nursing training schools as
While it is generally accepted
that there will not be enough doctors in Africa, training a core group of
anaesthesia-based intensivists would hopefully provide the leadership that is
necessary to drive the growth of critical care across Africa. Many
well-intended Western sourced, funded and driven initiatives fail because
African physicians are not significantly involved from the outset. This failing
process should stop. African critical care physicians should be networked to
share experiences, carry out research and form advocacy groups to lobby for
more resources to improve critical care in Africa.
should be emphasised that critical care medicine plays a significant role in
helping to lower the burden of surgical disease by providing much needed
postoperative care after major surgery in high risk areas like obstetrics,
trauma and paediatrics. Additionally, the realm of infectious diseases (including
HIV, TB and malaria) stands to benefit from critical care, especially with
respect to patients in the acute phases of the respective illnesses. One could
argue that critical care medicine is the missing link to providing holistic
care for patients in this category of illness. This message can be used to
inform priority setting in existing well funded programmes and to tap resources
that can transform critical care medicine in low-resource countries.
Lastly, any well-intending physicians and nurses who want to help
improve critical care in Africa should come open-minded, with the understanding
that the culture in this continent predominates over everything. Do not be
quick to judge, but politely question first why things are the way they are. You
will get some really interesting answers. Please come with a mission to build
capacity; choose a local champion through whom you can help to transform the
community that you are visiting, and above all things, don’t be in a rush. We
Critical care remains a neglected area of health service delivery in Africa, with large numbers of patients with potentially treatable conditions not having access to such services. Further advocacy is necessary to highlight these challenges and to provide sustainable solutions for ensuring access to good quality, inexpensive, basic critical care.