Cape Town, South Africa - Two weeks before South Africa's first democratic, all-race elections in 1994, cardiologist Dr Anthony Mbewu stepped off the plane and, after an absence of 27 years, inhaled his first breath of the heady, unmistakable, Western Cape air in the country of his birth. Mbewu, now executive director of research for South Africa's Medical Research Council, left his country in the 1960s when his grandfather, a professor at the former "black" university of Fort Hare, resigned in protest of the ruling National Party's Bantu Education Act. The act, instituting a separate and inferior education system for black South Africans, was originally instituted in primary and high schools before being extended to the black universities where, at that time, very few black South Africans were permitted to study medicine and none were allowed to specialize.
"Many of the black intelligentsia in South Africa left in the late 50s and early 60s and initially went to Zambia and then ended up in the UK, as we did in 1967," Mbewu said. Overseas, many joined the liberation movement and, like Mbewu, trained as health professionals. He voted twice as a British citizen before he was allowed to vote in the country of his birth.
"I returned to South Africa, mainly because I wanted to make a contribution towards building a new South Africa," Mbewu states. "When I left the UK I said to my colleagues that apartheid was dead, but it would take about 20 years to undo the effects of apartheid on South Africa, particularly the education, economic, and health sectors. And I think my words have proven correct, because after the initial euphoria of 1994/95 it has become very apparent that South Africa has a long and very hard road to follow in order to build a better quality of life for all its people."
Over decades of economic sanctions, an academic boycott, and a government dedicated to racial segregation, South Africa produced a diaspora of medical professionals who left their native land for a host of reasons: many never returned. Some stayed, while others were wooed back by the dream of rebuilding a nation breaking free of its calamitous history when Nelson Mandela and the African National Congress (ANC) were voted into power in 1994.
Today in South Africa there are approximately 30000 doctors dealing with sweeping changes to healthcare infrastructure, medical education, and of course, an explosive AIDS epidemic. Less known is the fact that, in a population of 42 million people with mounting rates of hypertension and coronary disease, there are only 156 cardiologists in the entire country. "Projections estimate that something like 25% of deaths in South Africa will be caused by AIDS-related illnesses," says Mbewu. "And because that grabs the headlines, people forget that 22% of South Africans die of heart attacks and strokes."
Mbewu explains to heartwire , "The cardiology profession in South Africa is woefully small, despite illustrious highlights like Christiaan Barnard [who performed the first heart transplant in 1967]." He notes that only about 10 of the cardiologists in South Africa are black in a country where blacks make up 70% of the population. "The other glaring disparity is that of those cardiologists, two thirds of them practice in the private sector, administering to 25% of the population."
The burden of infectious disease such as AIDS, TB, and childhood illness in South Africa cries out for a comprehensive framework of community care physicians, and since 1994 the government has followed a policy of decentralizing medical services. At the same time, the country also faces a dearth of specialists, and cardiologists in South Africa today fear that too few of their fellow physicians are opting to specialize; those that do are not getting the training they need, and some are opting to quit the country altogether.
Dr Lionel Opie (Cape Heart Center, Cape Town) admits he has "mixed feelings" about the changes taking place in medicine in his country. "The thrust of government health policy has been to support primary care in community centers, but as budgets are limited this has unfortunately come at the cost of the teaching hospitals. There had to be some change in the balance, but primary care centers are not working very well. There's not enough follow-through, and there is a certain amount of disorganization, so that these centers are not regarded as attractive working environments by a number of doctors. The whole concept of community care was not a part of the 'old' South Africa, and it doesn't come easily."
Opie gives the example of rheumatic heart disease in rural areas where the number of children with valve disease is soaring. "Our hospital has been limited to only a few valve replacement operations per week. Although promises have been made to increase the numbers soon, our cardiac surgeons fear that they're not getting enough operations to train our residents in cardiac surgery."
But as the 'new' South Africa builds momentum, heart disease, too, is taking a more all-embracing and democratic hold on the country. White South Africans have always suffered from high rates of coronary artery disease that is now spreading to nonwhites. Opie observes, "Those who work in coronary care units say that it used to be really rare to have black patients 10 to 15 years ago, but now it's regarded as much more common."
Mbewu explains, "What we're finding is a rapid socioeconomic transition going on with a rapidly growing black middle class who can afford to smoke, can afford fatty foods, and have a relatively sedentary lifestyle, so we are seeing an increase in coronary heart disease."
Dr Anton Doubell (University of Stellenbosch Medical School, Tygerberg), president of the South African Heart Association, states that the problem is imminent. " We're not just sounding false alarm bells when we're telling policy makers that we are heading for an escalating problem of cardiovascular disease if we don't address it now."
But, the priorities of government are elsewhere. "They still come to us, quite rightly, with our fairly appalling rates of infant death. And they say, before that problem is solved, why do you want to deal with people who are 70 years old with diseases like atherosclerosis? How can we justify that being the emphasis?"South Africa, old and new
Already, social and infrastructural changes instituted in what Mbewu refers to as "a frenetic pace of legislation" by the ruling ANC are starting to have an impact on health. The most radical of these was the introduction of primary health care for all South Africans, free to those who cannot pay. Other moves included anti-tobacco laws, laws allowing abortion, laws against domestic violence, as well as the more essential mandates to build homes, and supply clean water and electricity to millions of South Africa's poorest citizens.
"We are still in the process of evaluating what's been achieved over the past 6 years," Mbewu stated, although some progress is already evident. For example, national smoking rates have dropped from 36% to 25%, attributed largely to major increases in excise duties on tobacco and the banning of all smoking in public places.State-of-the-art medicine at the tip of the continent
Although most outsiders are aware of South Africa's fractured past, few realize the true clash of affluent first-world wealth and devastating third-world poverty that still exists there today, a contrast epitomized by the country's healthcare system.
Perched at the furthest tip of the continent, South Africa has a selection of first-class hospitals, services, and research facilities found nowhere else in Africa. According to cardiothoracic surgeon Dr Susan Vosloo (Christiaan Barnard Memorial Hospital, Cape Town) the rest of the world tends to underestimate what South Africa has to offer.
"We often have patients from other countries on holiday here who are having some sort of problem, and sometimes they are a bit surprised by the high quality of care. We are getting more and more referrals from foreign patients for the more conventional treatments, from Europe, England, and Israel, though on a very small scale. More people are realizing that state-of-the-art medicine exists in South Africa, and the foreign exchange rate is quite favorable for foreign patients. But overall, the overwhelming perception is that Africa is less sophisticated."
To emphasize her point, Vosloo rattles off a raft of specialty cardiac procedures performed at her hospital, ranging from transplantation to angioplasty to extracorporeal membrane oxygenation for neonates. "There is really nothing in conventional cardiac medicine that we cannot offer our population," says Vosloo.
Viewed alongside the public hospitals, however, the contrasts are galvanizing. Patients checking into some of the state-funded hospitals must bring their own towels and sheets and are not even guaranteed a proper bed. "When I look at the activities in my hospital, says Dr Tony Dalby (University of Witwatersrand, Johannesburg), "I would say they are comparable to good hospitals in the US or Canada, whereas you can drive 6 minutes to Johannesburg Hospital and find that you're in the developing world, with all the deficiencies which one expects to find there."
In terms of cardiovascular medicine specifically, the monumental rift between public and private medicine in South Africa is even more obvious. Dalby explains that the Medicines Control Council oversees the public release of drugs, and that "all of the most recently available agents" used in the treatment of cardiac disease can be obtained in South Africa. Their supply, however, is "severely limited" in the public sector by restrictive Essential Drug Lists that specify which agents are considered necessary. The lists include ACE inhibitors and statins, but exclude GP IIb/IIIa inhibitors and stents, except in very rare circumstances, yet all of these are readily available in the private sector.
Accordingly, a patient with acute MI (AMI) being treated in the public sector would receive a fibrinolytic, most often streptokinase, Dalby says. By contrast, an AMI patient with private medical coverage would get either direct intervention, or a fibrinolytic, (usually tPA, or TNK-tPA). Stents are used in approximately 80% of PCIs, although radioactive stents are not available.
Cost rules supreme in South Africa, where a plummeting currency in 2001 is creating intense anxiety among doctors, insurers, and patients alike. Since January 2000, the rand has fallen nearly 50% from a rate or R6.13 (per US dollar) to R11.53 in February 2002.
"We quake at the prospect of drug-eluting stents as the price is likely to be prohibitive," Dalby comments. "Compare the current cost of CABG at about R120000 ($10408 US) with the projected cost of purchasing one drug-eluting stent (R 22000 to R30000 or $1908-2620 US)." An ACE inhibitor, says Dalby, costs about R300 per month ($26 US), clopidogrel approximately R500 per month ($44 US), abciximab (ReoPro® - Centocor) R10000 ($867 US), and a stent R8000 ($693 US). To put this in perspective, he says, a secretary in a doctor's office would likely earn between 6-8000 per month ($520-693 US).
Radical changes are also transforming the hospitals and medical colleges. Dr Tony Dalby is a cardiologist in private practice and part-time professor at the University of Witwatersrand in Johannesburg. He explains that schools and health units that were strictly segregated during the apartheid era are now open to everyone, a transition that, he says, has gone remarkably smoothly.
"Medicine, in a way, was one of the real sort of avant-gardes of integration in the country," Dalby recalls. Even before the elections of 1994, hospitals like his, Milpark Hospital in Johannesburg, were seeing the color bars breaking down.
"Today, all of the hospitals in the country are integrated, within the wards, within the nursing staff, and within the doctor staff. And that has gone amazingly well," says Dalby. "I would not tell you that it has gone entirely without problems: every so often you will find the 'Old Objector' who doesn't want this. But it is of amazement to me when I see whites who as little as 15 years ago wouldn't have wanted to talk to black people, now being looked after by black doctors, being operated on by them, and being cooperative and helpful."Education system overhauled
In the medical schools, where an international reputation for first-class training was established during the colonial era, program quality seems to have endured with a resiliency characteristic of Africa itself. "We do have very high basic medical training in South Africa, Opie told heartwire . "Our medical schools have a very good reputation."
Mbewu concurs, adding that he believes the high standards have been "maintained" despite radical changes to admissions, including affirmative-action policies. "I think the standard medical training offered in SA medical schools are equal to any in the world. The quality of the clinical skills that doctors in South Africa have tends to be much higher than in most Western countries, partly because they see so much disease: they get a lot of practice."
Dalby has watched his classrooms change color, from approximately 85-90% white in years gone by to 65-80% nonwhite today. "All the medical schools are seeking to train doctors of color to serve the whole population," Dalby says. This transition has not always been an easy one, especially for students themselves, many of them coming from schools that, because of the Bantu Education Act, have not had the resources or emphasis on academics to adequately prepare them for a university education.
"It is difficult to explain this properly," Dalby says carefully, "but what has been the problem is that you are dealing with young students who haven't had the schooling that might be necessary, or ideal, to learn the practice of medicine. And there are language problems as well...and when you're talking away and teaching, one of the problems for these students is just simply following the medical technical language."
"But I must tell you," Dalby continues, "and this is a very deep-seated feeling of mine, that having got through some difficult years, there is no alteration in the standard [of medical education] as a result of the affirmative action going on. I do not believe there has been a significant fall in standards. That has been my experience, and I'm thrilled by it."
Not to say that there is not room for improvement. Mbewu describes other sorts of changes taking place in medical programs. "In some ways the professional ethos within medical practice was really about 10-15 years behind." He explains that it was only in 1997 that South Africa's private, largely white medical association was united with the public, predominantly black organization to create today's South African Medical Association and certain reforms were introduced, including continuing medical education. "Previously the idea was that you became qualified in medicine, you set up your practice, and you need never open a textbook or journal thereafter. And what we did was to say no, in modern medicine, it's lifelong learning. Now it is mandatory for every medical professional in South Africa to undergo routine professional development which is monitored by earning 50 points per year."
A similar merger took place in September 1999 to form the South African Heart Association (SAHA). Previously, South Africa had had two cardiology organizations, the Southern African Cardiac Society representing cardiologists and allied professionals, largely in academic centers, and the South African Society of Cardiac Practitioners comprised primarily of private cardiologists. "Obviously that was an unhealthy situation," SAHA President Doubell told heartwire . "Now we have one society with standing committees that can look at teaching and training, education, ethical issues, guidelines, private practice and all of these different issues...it's a very positive development."
|Cardiovascular research in South Africa|
In terms of research, South Africa, despite years of academic isolation, has made important, if often overlooked contributions to the body of cardiovascular knowledge. In addition to Barnard and his famous heart transplant, Dr John Barlow, who first described mitral valve prolapse (Barlow syndrome), is also South African. In recent years, more and more South African cardiologists have participated in international, multicenter trials, but, as Opie explains, conducting major single-center trials in South Africa isn't feasible.
"We can't easily do major trials here without external funding; we just have too few patients at our academic centers, and our governmental medical system with the emphasis on the community clinics is not set up for such trials, unless we work through specialized clinics supported by international pharmaceuticals." Opie continues, "We are in a situation where we don't have vast sums of money for research, so it is difficult to develop any one item in very great depth. So it's better to ask yourself where the research is leading so that you can try and evolve new ways of thinking. Then, having thought it out carefully, one has to undertake only the most essential experiments, which are sometimes the cheapest, rather than having the luxury of pursuing a large number of projects all in greater depth."
In fact, Opie was investigating mechanisms of sudden cardiac death at London's Royal Postgraduate Medical School, with little intention of returning to South Africa, when he was lured back in 1970 by the Christiaan Barnard Fund. Barnard himself established the fund (using proceeds from his popular autobiography One Life) with the aim of enticing South African researchers and cardiologists overseas back to their home country and developing cardiac research initiatives in South Africa.
Vosloo, who also participates in European studies and contributes to international databases, points out that megatrials are privileges of countries with a basic level of population health.
"We have such a big responsibility to so many patients in our country who actually need very basic medicine: it would not be appropriate to spend a lot of money on research, especially if that research could be done elsewhere in the world where the funds are more freely available. We'd rather use our resources to treat our patients more basically."
South Africa has all the growing pains of a newly democratic society, complete with the poverty, illiteracy, and entrenched racism that propel the soaring crime rates for which the country is notorious. South Africans blame these factors, along with the health hurdles still towering on the horizon, for what they see as an ongoing "brain-drain" of the country's finest physicians.
"Every time we lose a graduate, we're weakened on this side," says Dalby. "We could expand so much more quickly if those graduates did not leave and that expertise would be contained in the country, but we are losing that power, that strength. It's a huge problem, a chronic problem."
Dalby emphasizes that it is not a racial issue, but an issue of perceived opportunities: "It would be wrong to think that the people emigrating are of one color, because they are not. It is South African doctors who are leaving, and we're sort of a muddy brown group. People who look at the world and who are affluent enough and qualified enough leave for greener pastures and it's not an issue of white people fleeing a black country."
Doubell points out that studying overseas is often crucial to a physician's development. "A number of my young trainees who want to stay in academic medicine should acquire experience at an overseas training institution to bring a new perspective, but we lose a number of those. Obviously we can't forcefully keep someone here, but I'm afraid once we set someone up in Boston, or London, it's hard to ensure they come back, but obviously the reason for sending them away is to get that expertise back here. I'm not negative about it, but we probably lose more than we can afford in this country."
Not everyone agrees. Mbewu believes that concerns about South Africa's brain-drain are overblown. "There was a much greater exodus of professionals in the 1980s than there is now and the reason is because in the 1980s there seemed to be no hope."
Mbewu claims a lot of black doctors and specialists who, like his grandfather, left during the peak of the apartheid era have now returned to South Africa. Moreover, he notes, "Since 1990 onwards more and more black South Africans have been trained as doctors and more are trained as specialists, so we are getting a brain-gain from among our own people." As well, doctors from other countries, mostly African, are also coming to work in South Africa. "About one quarter of the doctors now working in South Africa are from elsewhere, from Nigeria, Zimbabwe, and Zambia, but also Eastern Europe," says Mbewu. "So the issue of brain-drain versus brain-gain is not all that clear."
That said, Mbewu admits that South African officials have also met with recruitment agencies in the UK and Canada, for example, to discourage them from trying to lure away South African doctors.Should I stay or should I go?
And the doctors who stayed, or returned? They did not necessarily do so for the same reasons. Opie, for one, claims he "effectively brain-drained" after graduating in Medicine from the University of Cape Town, living in the UK for 6 years and the US for 3. "You know, often major life decisions have simple explanations," Opie declared. "I met a South African teacher in London, we married and had a baby and my wife wanted to be with her family in Cape Town. Just at that time Barnard performed the first transplant and cardiology research in Cape Town expanded."
Doubell also trained first as a physician in South Africa, traveled to Montreal, Canada for 3 years of research, but ultimately returned to his home country. In his case, he had always planned to do so. "We had taken a firm decision prior to leaving South Africa as to what our objective was. The time I spent away was wonderful and I always look back at it fondly, but I never had the intention to grab the opportunity to leave."
Vosloo has remained in South Africa partly because of the lifestyle, partly because of the freedom she has as a surgeon. "The main attraction for me is that I can do more than one thing at a very advanced level. For instance, I do mainly adult cardiac surgery, but I do a lot of pediatrics, I do transplantation, I do the extracorporeal membrane oxygenation; if I was to go overseas, I would be lucky if I could do two of those things at the level I am currently doing them." She continues, "We have a lot that we can offer this country. I'm free to go overseas to learn something, then come back and apply it here. Plus, the weather, the living conditions, the quality of life outside work is also very good."
Mbewu concurs: "I have to say that the quality of life that [doctors have] in South Africa is actually very high. Their salary may be one third of that in the United Kingdom and one fifth of that in the United States, but in terms of how they live, the car they drive, the schools where they send their children, the restaurants they eat in, the quality of life is often better than it would be in the US or the UK. So we find that a lot of doctors look at these issues, sometimes they spend time overseas, and afterwards they decide, no, South Africa is a better option."
Dalby believes there are people worried about the future of South Africa who are emigrating if they can, but others, like himself, feel a sense of belonging that overpowers any thoughts of leaving. "We're qualified here, we can do the job here, and we do it well. There are just some of us here who basically have always enjoyed Africa."
"I was born here," he says simply. "It's my place."
Heartwire from Medscape © 2002
Cite this: Cardiology after apartheid: brain-drain and brain-gain at the tip of Africa - Medscape - Feb 20, 2002.