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South African Journal of Surgery

On-line version ISSN 2078-5151
Print version ISSN 0038-2361

S. Afr. j. surg. vol.55 n.4 Cape Town Nov. 2017




"The Malignant Epidemic" remains the neglected stepchild



Three decades ago, David Muckart coined the term "the malignant epidemic" to describe the blight of trauma afflicting South Africa.1 This apt phrase combining Churchillian gravitas with Socratic insight emphasizes that trauma is a disease of epidemic proportions and should be managed in a similar manner to other epidemics, using a coordinated systematic response which mobilises all sectors of society. At the same time as Muckart expounded this concept, the HIV/ AIDS epidemic of equally biblical proportions was emerging in Southern Africa. The fate of these two epidemics over the subsequent three decades was divergent. The HIV/AIDS epidemic caught the imagination of civil society and became a celebrity cause par excellence,2 whilst trauma remained neglected and ignored. Hardly anyone ever considered the fact that trauma is as ruthless a killer as HIV, strikes down the young and productive sectors of society and is perhaps the most preventable of all diseases. HIV/AIDS was a story of how civil society, activists, celebrities, religious leaders and philanthropists could come together to overcome official inertia and force governments and multi-national drug companies to act. The HIV/AIDS community turned a feared and lethal illness into a chronic condition within three short decades. This achievement has not been emulated by the trauma fraternity and the story of trauma remains one of official and public disregard and neglect. Whilst the fight against AIDS seems to have gained the upper hand, trauma remains all pervasive and the levels of interpersonal violence in South Africa remain unprecedented in any other society ostensibly at peace. The high levels of interpersonal violence are mirrored by alarmingly high levels of road traffic related carnage. After two decades of democracy there is no sign that the malignant epidemic of trauma is abating.

This epidemic, however, was not ignored by an iconoclastic group of South African trauma surgeons who assiduously documented the epidemic for over six decades.3 These surgeons who worked predominantly in major trauma hospitals in Durban, Pietermaritzburg, Johannesburg and Cape Town applied an Aristotelian world view to their external environment and developed a surgical epistemology known as pragmatic empiricism and a surgical praxis based on selective conservatism. This group applied this pedagogy and presented and published their data in the international arena. Their endeavors have had a major impact on the local and international practice of trauma care and have defined global algorithms for the management of trauma. The group has also challenged dogma and used clinical audit to replace surgical superstition with solid evidence-based praxis. Whilst the academic output of surgery in general from South Africa has waned over the last twenty years, trauma surgery has remained a bastion of academic excellence in a sea of mediocrity and anecdote. Yet, despite this, trauma remains unfashionable and underfunded.

This edition of the SAJS refocuses our attention on trauma as the major surgical challenge facing both South Africa and, with international geo-political instability, the globe. Contemporary South African trauma surgeons are presenting their research at the International Trauma Conference which was initiated by the Trauma Society of South Africa and hosted by the Groote Schuur Trauma Unit. The conference acknowledges the fact that the management of an epidemic requires complete mobilisation of society. The AIDS/HIV activists showed how to mobilise public opinion, the church, celebrities, politicians, business, schools and radio stations to drive a comprehensive response to an epidemic. We need the same response to trauma. We need research, infrastructure, prevention programs, youth-based initiatives, fund raising and a systems-based response, if we hope to halt the malignant epidemic. I believe this edition of the SAJS will serve as a spark to ignite a systematic response which will contain and eventually overcome the malignant epidemic.

DL Clarke



1. Muckart DJJ. Trauma - the malignant epidemic. S Afr Med J. 1991;79(1):93.         [ Links ]

2. Robins S. Long live Zackie, long live AIDS activism, science and citizenship after apartheid. J South Afr Stud. 2004:30(3);651-72, doi: 10.1080/0305707042000254146.         [ Links ]

3. Selective conservatism in trauma management: a South African contribution. Clarke DL, Thomson SR, Madiba TE, Muckart DJ. World J Surg 2005; 29:962-965. 2.35        [ Links ]

4. Is Clinical Research in Oesophageal Cancer in South Africa in Crisis? A Systematic Review.Loots E, Sartorius B, Madiba TE, Mulder CJ, Clarke DL.World J Surg. 2017 Mar;41(3):810-816. doi: 10.1007/s00268-016-3778-5. Review        [ Links ]

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