versión On-line ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 no.9 Cape Town sep. 2008
JP van Niekerk
Injuries overall (from road traffic and interpersonal violence) constitute the second biggest contributor to the burden of disease of the Western Cape after the infectious diseases of HIV and TB, according to Matzopoulos et al .1 The road traffic injury (RTI) burden is 6.9%, which is 40% higher than the national figure of 5%. The authors identify four categories of risks for RTI: biological (hearing, vision, psychological factors, age, gender); behavioural (substance abuse, aggressive driving, fatigue, distractive conduct such as cellphone use, non-use of seat belts); structural (poverty, rapid urbanisation combined with poor mass transit amenities, unsafe vehicles, poor road design and maintenance with inadequate provision for pedestrians), and societal (a culture of impunity with respect to the law combined with ineffective law enforcement).
They identify two levels of intervention: upstream and downstream. Upstream interventions refer to systemic measures addressing urban transport infrastructure (roads, pedestrian walkways and bridges, vehicular mass transport), urban planning, appropriate legislation, and effective policing. Road safety is a multifaceted challenge, and the authors stress the imperative of an inter-sectoral approach within government (that is, collaboration between and within various portfolios such as transport, education, urban planning and safety and security) as well as between government and the private sector. Some of the upstream areas they propose, such as motor vehicle design and advertising, are clearly beyond the competencies and powers of the provincial authorities. Downstream interventions are those aimed at road users, such as legislation mandating the use of seatbelts and helmets, licensing of drivers and vehicles, and observation of speed limits.
Quite clearly, there is sufficient legislation on the books to significantly reduce RTI on South African roads. Unfortunately, enforcement is very weak. In the US, where state, county and city police regularly and conspicuously cruise the roads and highways, the near-certain odds of being caught and punished for motor vehicle offences serve as a powerful deterrent.
From the Eastern Cape, Meel2 reports on the atrocious record of fatal RTIs in rural Transkei, where deaths due to traffic accidents are three times higher than the global average. The majority of the victims are mostly young males, who are prone to 'indulge in alcohol and drugs and also tend to practise risk-taking behaviour [of] driving recklessly at high speed'. Meel cites figures showing that road traffic accidents cost South Africa R13.8 billion annually.
Community health workers (CHWs) - who are they and are they of any use?
'South Africa has now identified generalist CHWs as having an important role to play in meeting the health and social needs of the majority', and yet 'the effectiveness of CHW interventions is complex, as the objectives of these programmes are often not associated with clearly delineated processes and outcomes', according to Clarke et al.3 CHWs are community members delivering health care, trained in the context of the intervention, but without a formal qualification. CHW intervention has been shown to be effective, compared with no intervention, where CHWs are assigned specific tasks such as promoting immunisation uptake. However, their effectiveness as generalist practitioners with a broader mandate of responsibility (that might include facilitating water and sanitation provision and improving access to social grants) requires more research.
Simple closed drains are sufficient for mastectomy wounds
In a prospective randomised trial, Nigerian researchers Ezeome and Adebamowo4 assessed the effectiveness of closed simple drainage versus closed suction drainage in the management of post-radical mastectomy wounds, and found no significant difference. Simple drains were just as effective, and moreover cost 15 times less.
Drains are a necessity in radical mastectomy as alternative interventions to prevent fluid accumulation in the wound have been unsuccessful. The significantly more expensive closed suction drains were designed as a more effective method of drainage, but in fact complications such as flap necrosis, early blockage of the drains, pocketing of fluid below the flaps and pain on removal have been associated with their use.
Unusually high prevalence of cryptococcus meningitis in Botswana
Bisson et al.5 from the University of Pennsylvania, Philadelphia, explored the microbial causes of meningitis among patients at Princess Marina Hospital in Gaborone, Botswana, where more than 100 cerebrospinal fluid (CSF) specimens are submitted for culture per month. A sample of 1 307 specimens yielded a 'staggering' 15% occurrence of C. neoformans which, the researchers suggest, is probably related to HIV prevalence in Botswana, arguably the highest in the world. The specimens were cultured for a maximum of only 48 hours, whereas it usually requires up to 7 days of incubation for the cryptococcus to show up in all specimens. The finding of 15% therefore probably represented an undercount. Seventy per cent of the culture-negative specimens showed significant lymphocytosis, consistent with the possible presence of unidentified cryptococcus, TB, or a viral pathogen.
1. Matsopoulos R, Myers JE, Jobanputra R. Road traffic injury: Prioritising interventions. S Afr Med J 2008; 98: 692-696. [ Links ]
2. Meel BJ. Fatal road accidents in the Umtata area of South Africa, 1993-2004. S Afr Med J 2008; 98: 716-719. [ Links ]
3. Clarke M, Dick J, Lewin S. Community workers in South Africa: Where in this maze do we find ourselves? S Afr Med J 2008; 98: 680-681. [ Links ]
4. Ezeome ER, Adebamowo CA. Closed suction drainage versus closed simple drainage in the management of modified radical mastectomy wounds. S Afr Med J 2008; 98: 712-715. [ Links ]
5. Bisson GP, Lukes J, Thakur R, Mtoni I, MacGregor RR. Cryptococcus and lymphatic meningitis in Botswana. S Afr Med J 2008; 98: 724-725. [ Links ]