Violence and healthcare in South Africa

2017-03-10 10:05

Picture: YouTube

The Beloved Country

While South Africans are still arguing about the rightful party to rule and lead its citizens, violence and assault rates are increasing. Just when we think we have seen it all, parliament introduced us to a form of violence most are familiar with in a protest-infested country. It evidently never ends, as concluded by recent xenophobic attacks. It's funny how everyone thinks they are justified when they "over-react". To the state, law enforcement is their reason behind killings and civilian attacks. For protesters, being disgruntled is a good enough answer to strike a fellow human being severely. What makes us a violent country? Should our children react the same way to prove how tough they are? What happens to the affected victims? If dialogues and debates are seemingly rigged, should violence be the answer?

How did we get here?

Our murder, common assault, robbery and hijacking rates have increased according to South Africa's 2015/16 crime statistics. Experts have their theories and explanations, but it is no secret that the increase in violence and injuries have negatively affected our health system. If our children could be sheltered from gruesome images and violent attacks, would we take that route for the sake of our future generations? Everyone has a role to play. With rising crimes and killings, people need to feel prepared. Firearms, weapons, self-defense and street-fighting abilities become our closest allies. If you had no choice but to protect your skin, how far would you go to ensure self-preservation? Could you turn to the dark side to satisfy your basic human needs as well?

I wonder what impact contact sports and cultural practices have on us. We are so used to seeing people pushing and pulling each other on TV that we even call it entertainment. Let's not forget fist fights and well-scripted wrestling matches that we just won't miss.

Head, Neck and Spinal Cord

The brain, the brainstem and the spinal cord are housed within the bony confinements of the head and neck. Our voluntary, involuntary movements and actions are coordinated by these vital structures of the central nervous system. Our very existence is because of our thoughts, memories, reasoning, behaviour, personality, communication, comprehension and interaction with the world. All thanks to the brain. Now imagine a panga, knobkierie, baseball bat or an axe wielded and landing on someone's skull. The hard, heavy blow to the head may cause damage to the underlying brain without cracking the skull. Sharp objects like pangas or knives cause penetrating injuries that also increase the risk of infections to the brain and its surrounding structures. Injuries to the brain range from mild to severe. The injured person can present with various signs and symptoms depending on the extent, affected area of the brain and other associated injuries. The worst that can happen, besides dying, would be losing one's functioning and independence.

At a higher level of the neck, the cervical vertebra injury can affect the brainstem and ultimately lead to breathing cessation. Other cervical vertebrae cover the spinal cord and damage to these can cause paralysis of those upper and lower limbs. Spinal cord injuries may also present with different features; some as bladder and bowel functioning loss. One may either become incontinent, with loss of urine and/or faeces control, or may be unable to empty their bladder or rectum at will.

Picture: HumanBrainFacts

Special Senses

One of our strongest instinct and reflex, blinking, reminds us just how important it is to protect our fragile eyes. Some may be unlucky and lose the gift of sight during political unrest, protests or assault . Eardrum perforation can result from a simple self defense technique and may lead to hearing loss. A punch to the face can be enough to flatten one's nose bridge and disrupt the flow of air through the nostrils. Once in a while at a hospital casualty, we also see people who come in with their tongues cut off.

Rural Hospitals still face a great challenge when dealing with special senses injuries. It starts with emergency care obstacles, lack of necessary equipment for diagnosis and also includes delayed distant referrals to already overcrowded specialized centres.

Physical Disability

There are other injuries besides head, neck and spinal cord that may lead to physical impairment. Fractures to the shoulder or pelvic girdle bones will distort joints and articulation areas for limbs. Limb fractures may sometimes involve too much soft tissue damage to the extent of auto- or surgical amputation. Some fractures may later complicate resulting in shortened bony union resulting in shortened limbs, mal-union causing deformed or swollen limbs and non-union where fractured bony ends don't fuse.

We have a shortage of Orthopaedic Surgeons in public hospitals and a backlog of essential operations to "fix" mostly preventable fractures. Orthopaedic tools and consumables are seen as expensive if the health budget has to stretch to cover dying pregnant mothers and babies, common chronic diseases like obesity, hypertension and diabetes and the ever-rising HIV and TB infections.

Chest and Back

One amusing thing about working in public hospital is seeing how tough gangsters and hard-core criminals with multiple scars and previous stab wounds are scared of needles. Some unfortunately have to be surgically stabbed, again, to save their lives. This will be done if they sustained an injury that has punctured the lung causing air or blood to leak (pneumo or haemothorax) into a potential space called the pleural cavity. I have witnessed and heard regretful statements, vengeance plans and anger outbursts while inserting a chest drain to relieve the pleural cavity.

The unlucky victims of stab wounds to the chest or back may experience major blood vessel injuries or a stab to the heart. Without a Surgeon or Trauma Surgeon in the vicinity or within a reasonable distance, these wounds can be fatal.

Abdomen and Pelvis

After trauma to the abdomen, a trained Surgical Medical Officer (doctor working in a surgical department) or Surgeon, should explore the abdomen if indicated. Bleeding can be concealed and solid organs like liver and spleen may lead to massive internal bleeding and systemic blood loss. Hollow organs; stomach, small and large intestines, may perforate. The contents of these hollow organs will cause further physiological and pathological changes that will worsen the outcome of the injured individual. Sometimes, certain injuries are not fully repaired and may need subsequent operations to attempt functionality restoration. Faeces or urine may be diverted into a bag that one needs to carry under one's clothes. This can be embarrassing to most and has a huge negative psychological impact.

Pelvis injuries do not only affect reproductive organs and the rectum. Vessels situated and passing through the pelvis may be disrupted leading to massive blood loss.

Cost at Hospital Level

The country is losing money through man-made, preventable problems like violent attacks. The cost of dispatching ambulances and helicopters to areas of crisis or protest disasters, the man power needed to attend to emergencies and cost to hospitals cannot be ignored. At hospital level, these critically injured individuals have to compete with pregnant women, newborn babies, children and young adults for health professionals, examination cubicles, resuscitation priorities and specialized care. In a typical rural district hospital with limited casualty beds, one portable ventilator (if they are lucky) and one doctor on call per shift, critically injured patients may take others' chances of survival as they may be prioritized based on their evident and prominent injuries. At regional hospital level, head injury patients may stay in ICU longer occupying one of few ventilators meant for the whole community.

Operating theatres are usually used for caesarean sections as well in many non-specialized hospitals. The Anaesthetic team may not always be capable of handling trauma and emergency caesarean sections at the same time. At times, patients with ectopic pregancies, miscarriages, testicular torsion or fractures from accidental falls may need to await theatre space as some injured patients may take longer in theatre.

The weekend of payday is usually followed by high volumes of patients at hospital casualty centres. Health professionals spend most of their time stitching and fixing other people's work of art. The wards will then overflow with injured patients leaving less room for the sick. Allied and rehabilitation hospital services staff have to treat these patients as well.

The Question

There is an ethical issue around self-defense and we all shy away from it. If one's life is directly threatened, there is a consensus that one can react. What happens when violence is fueled by politics, intolerance, racism, tribalism or power struggles? How about drug or alcohol-induced interpersonal violence? All I know is that violence is the answer to this question:

What is one of the preventable causes of high healthcare expenditure in South Africa?

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