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Vascular Surgery in South Africa in 2021

Open ArchivePublished:April 03, 2021DOI:https://doi.org/10.1016/j.ejvs.2021.03.001
      The Lancet Commission on Global Surgery noted that safe, affordable, and cost effective surgical and anaesthetic care is a prerequisite for full attainment of universal health coverage and in meeting the sustainable development goals.
      • Meara J.G.
      • Leather A.J.M.
      • Hagander L.
      • Alkire B.C.
      • Alsonso N.
      • Ameh E.A.
      • et al.
      Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.
      The commission also asserted that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. In South Africa, this last statement describes both South Africa’s health sectors (private and public), albeit for different reasons.
      In parallel, the global vascular guideline for the management of chronic limb threatening ischaemia (CLTI)
      • Conte M.S.
      • Bradbury A.W.
      • Kolh P.
      • White J.V.
      • Dick F.
      • Fitridge R.
      • et al.
      Global vascular guidelines on the management of chronic limb-threatening ischemia. Joint guidelines of the Society for Vascular Surgery; European Society for Vascular Surgery; World Federation of Vascular Societies.
      has highlighted the increased burden of peripheral arterial disease (PAD) and the need for better research in low and middle income countries (LIMCs) to understand the epidemiology and to improve outcomes for patients with CLTI. The South African vascular surgery community has been slow to react to both the global surgery movement and the need for quality local relevant vascular surgical research, yet it is uniquely poised to do so.
      The South African health system mirrors what transpired in the country in the last decade. A stalled economy, maladministration, and rampant corruption have worsened pre-existing economic and social disparities. This divide is reflected in the country’s two tiered health system, where the vast majority of South Africans still continue to depend on under resourced state run health services while only 15% of the population are able to access the well resourced private health sector, mostly because they can afford very expensive health insurance.
      Roughly 8% of South Africa’s gross domestic product (GDP) is expended on health, equally distributed across the public and private health sectors. This results in maldistribution in the availability of health professionals, access to health facilities, and access to high end health services. This is also evident in the provision of vascular surgery where poor and rural communities are most disadvantaged. Moreover, South Africa’s poor are also particularly severely affected by a “quadruple burden” of disease: high rates of human immunodeficiency virus (HIV) and tuberculosis (TB), maternal and infant mortality, high levels of trauma, and increasing levels of non-communicable conditions such as hypertension, diabetes, and cancers. Covid-19 has undoubtedly added to this.
      Some success in the public health setting has been achieved, particularly in addressing the country’s HIV epidemic. The other public health challenges have however been left behind and this is reflected in the South African life expectancy at birth being 64 years. Addressing this and the unjust distribution of health services is hampered by the constrained economy, recently significantly worsened by Covid-19.
      The profile of vascular disease in sub-Saharan Africa has changed in line with the worldwide rising prevalence of obesity, diabetes (> 6% adults), and hypertension. Not surprisingly, the prevalence of PAD in sub-Saharan Africa is equal to, or higher, than that recorded in high income countries.
      • Johnston L.E.
      • Stewart B.T.
      • Yangni-Angate H.
      • Veller M.
      • Upchurch Jr., G.R.
      • Gyedu A.
      • et al.
      Peripheral arterial disease in sub-Saharan Africa. A review.
      On the other hand, the number of patients presenting with non-atherosclerotic vascular diseases is reducing, but South Africa’s high rates of interpersonal violence and road traffic injuries continues to fuel the vascular trauma pandemic. Vascular access surgery for dialysis also contributes substantially to the vascular surgical workload.
      A high proportion of patients continue to present with end stage PAD largely due to the shortage of vascular surgical expertise. Currently, 65 vascular surgeons serve a population of 60 million. This does reflect an increase over the last decade (50% increase) but as a proportion of the general surgical workforce has dropped from 9% to 6%. Significantly, only 18 of these vascular surgeons are employed in the public sector (approximately one vascular surgeon/three million versus approximately five vascular surgeons/million in the private sector).
      In South Africa, like in other LMICs, an unanswered question remains: Is vascular surgery best delivered by general surgeons equipped to deal with vascular emergencies, in combination with centralised “elective” specialist vascular surgical services? As background, because of the shortage of general surgeons in South Africa, vascular surgery still is a subspecialty of general surgery. Consequently, training of vascular surgeons, which has not changed in 20 years, requires a further two years after having completed five years of general surgical training – undoubtedly a significant disincentive. This and the increasing levels of endovascular surgery training required mandates a review of this policy. However, training more vascular surgeons when the country’s health system is not optimised is counterproductive. For example, despite the shortage of state employed vascular surgeons, newly trained vascular surgeons cannot be employed in the state sector, as the number of posts has not increased in the last 20 years. Furthermore, there has been no appraisal of the number of vascular surgeons required to meet the country’s need. In the meantime, general surgeons in training rotate through vascular surgery to ensure that they are able to perform basic vascular surgical interventions such as embolectomies and uncomplicated vascular trauma. This does satisfy, in part, the aims of the Lancet Commission and, hopefully, as the number of general surgeons increases, will drive an evolution to subspecialist training.
      South Africa’s vascular surgical training programme is well established. Training is offered in seven centres that currently can however only accommodate 14 trainees. A small number from other parts of Africa have been trained outside of this restriction.
      The practice of vascular surgery in South Africa reflects that found elsewhere. The majority of peripheral vascular interventions are performed in hybrid operating rooms with high quality imaging facilities. While the cost of high end endovascular interventions such as fenestrated endovascular aneurysm repair/branched endovascular aneurysm repair was previously prohibitive, this is slowly changing and 63 have now been performed since 2016. The highly specialised nature of endovascular interventions has largely restricted general surgeons, cardiologists, and interventional radiologists from working in this field.
      South Africa only spends 0.83% of its GDP on research (Organisation for Economic Co-operation and Development average ∼2.5%). The majority of health research funding available, mostly raised outside the country from global funding agencies, is used to support locally relevant communicable disease research (HIV, TB, and malaria). Unlike countries in the global north, where vascular research is funded through non-governmental organisations, South Africa has no similar funding institutions. Furthermore, academic pathways for trainees such as the academic clinical fellowship in the UK or the MD/PhD programmes in the United States are not available in South Africa. This combination of paucity of funding, lack of a structured pathway for clinician scientists, an overwhelming clinical burden, and the lure of the lucrative private sector translate into low volumes of quality research taking place. However, the South African College of Surgeons has mandated that a Masters in Medicine which includes a research report is required alongside an exit examination in order qualify as a general surgeon. This has increased the research output, albeit at a basic level. It is anticipated that as capacity is developed this will result in some meaningful translational research.
      Despite this paucity, some quality pan-African studies have been published (e.g., ASOS-1 and 2)
      • Biccard B.M.
      • Madiba T.E.
      • Kluyts H.-L.
      • Munlemvo D.M.
      • Madzimbamuto F.D.
      • Basenero A.
      • et al.
      Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.
      with some including large cohorts of vascular surgical patients. Indeed, South Africa has unique vascular pathologies with which to contribute to the body of vascular biology knowledge. HIV for example, lies at the intersection of immunity, vascular biology, and traditional PAD.
      The Vascular Society of Southern Africa (VASSA) is a small society but has a footprint on the African continent in conjunction with the African Association of Thoracic and Cardio-Vascular Surgeons (AATCVS) and the Pan-African Association of Surgeons (PAAS). The current membership is 123 (55 vascular surgeons, 14 trainees). The objectives of the society are
      • the improvement and advancement of the study of vascular disease;
      • to stimulate research in all aspects of vascular diseases;
      • to act as a mouthpiece for medical and allied medical professionals with an interest in vascular disease; and
      • the advancement of knowledge and the science of vascular surgery.
      A significant amount of the groundwork in preparing for the formation of the World Federation of Vascular Societies (WFVS) was performed by VASSA; this resulted in VASSA being one of the founder members. In 2014, VASSA hosted the first dedicated WFVS congress in Stellenbosch. The congress was attended by 250 general and vascular surgeons, of whom 80 attended from 38 other countries. At the time, the country’s first vascular nursing congress was also held, with 100 nurses attending a programme delivered by faculty from Canada, the USA, and VASSA.
      VASSA is intent on improving the delivery of quality vascular surgery in South Africa by, among other initiatives, refining and instituting guidelines appropriate for the South African and African context (most recently on vascular access and PAD). VASSA also contributed to the Global Vascular CLTI guideline,
      • Conte M.S.
      • Bradbury A.W.
      • Kolh P.
      • White J.V.
      • Dick F.
      • Fitridge R.
      • et al.
      Global vascular guidelines on the management of chronic limb-threatening ischemia. Joint guidelines of the Society for Vascular Surgery; European Society for Vascular Surgery; World Federation of Vascular Societies.
      and has endorsed and adapted guidelines from the ESVS.
      • Naylor R.
      • Ricco J.-B.
      • de Borst G.J.
      • Debus S.
      • de Haro J.
      • Halliday A.
      • et al.
      Editor's Choice – Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
      • Björck M.
      • Earnshaw J.J.
      • Acosta S.
      • Bastos-Goncalves F.
      • Cochennec F.
      • Debus E.S.
      • et al.
      European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia.

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