Printed in the USA ??CopyrIght 0 1989 Pergamon Press plc
TheJourna/offmergency Mechine. Vol. 7,pp. 485-489, 1989
Emergency
PIETERMARITZBURG:
Medicine
Abroad
A CITY OF VIOLENCE
C. A. V. Perrott, FCS(SA) Previous Head of Department of Surgery, Grey’s Hospital, Private Bag 9001, Pietermaritzburg 3200, South Africa Reprint address: C. A. V. Perrott, FCS(SA), P.O. Box 1049 Scottsville, Pietermaritzburg 3209, South Africa
0 Abstract -State-controlled hospital services in South Africa are racially determined, with separate facilities for the different racial groups. The recent violence seen in and around Pietermaritzburg has resulted in an increasing number of blacks attending hospitals other than their own racially defined institution. The majority of these patients make their own way to hospital, usually from nearby localities, suggesting a demand to utilize “local” facilities. Some 50% of all dogbites, 25% of shootings, and 20% of stabbings were brought in by the police. One third of shootings ended fatally. Possible reasons why some blacks attend hospitals other than their own racially defined, are explored.
?? Keywords - Pietermaritzburg;
GEOGRAPHY
AND
METHODS
Pietermaritzburg, situated in the midlands of Natal, is reported to have a municipal population of approximately 180,000 (whites 62,000, coloureds 15,780, Asians 74,130, Africans 27,806). The city is serviced by two provincial (state) hospitals, namely Grey’s (for whites and Northdale for Asians and coloureds), with Edendale Hospital also a state hospital situated some 12 km away. This latter hospital is controlled by Kwa Zulu Health Services and is the referral hospital for blacks within the area. While the majority of blacks tend to reside in areas that allow access to Edendale Hospital, there does exist the small area of Sobantu, which is situated in close proximity to Northdale Hospital. In addition, there are areas within the city itself that are racially defined but which house people of all races including blacks (so called “grey areas”). For regional purposes, the area was divided into
violence; blacks
INTRODUCTION
Pietermaritzburg has featured prominently in the unrest situation prevailing in South Africa with “civil war” existing in the townships neighbouring the city. During a three-year period, it is estimated that more than a thousand people have been killed, some 3,000 houses burnt, and 30,000 people left homeless (1). This violence, which has recently overflowed into the city itself, together with “criminal” violence has resulted in increasing numbers of black patients being seen at hospitals other than their designated, racially classified “own.” This increase has resulted in concern among staff and management at the Northdale Hospital that services the Asian and coloured communities of the area. Since January 1987, records of black patients presenting to Casualty have been kept separately and these are reviewed in an endeavor to define the extent, the nature, and the origin of patients responsible for the increase.
1) that area north east of the N.3 freeway (comprising Northdale, Woodlands, Eastwood, and certain industries) - referred to as Northdale. 2) Town, comprising the central business district, the white residential area, and lower Church Street, which tends to be a “grey area.” The western and southern limits are those of the municipal boundary. 3) Edendale area from beyond the municipal border. (Figure 1) The records of black patients presenting to Casualty were analysed as to
RECEIVED: 21 November 1988; FINALSUBMISSION RECEIVED:21 March 1989 ACCEPTED:28 March 1989 485
0736-4679/89 $3.00 + .OO
486
C. A. V. Perrott
PIETERMARITZBURG
$ = Hospital ______= Municipal Boundary Figure 1. Map of the Pietermaritzburg area.
1) Mode of transport to hospital 2) Origin 3) Complaints 4) Outcome
RESULTS Over a E-month period (January 1987 to March 1988) a total of 1101 black patients were seen in Casualty, an average of 73.4 per month; the range being 47 to 98 per month with a peak during November, December 1987, and January 1988. Of these 70.5% were male and 29.5 % female. This additional influx represents 2.6% of all patients seen in Casualty and an average of 2.5 patients per day. In all areas studied, there were insignificant monthly variations and the total population over the 15-month period was analysed.
I) Mode of l?ansport Nearly two thirds of patients (63.7 %) made their own way to hospital, either by private vehicle, public transport or walked. The remainder were brought to hospital by “emergency services” namely ambulance (20.4%) or else South African Police (SAP) (14.9%). In respect to ambulance services, one third of patients originated outside of the Pietermaritzburg area; 27.4% and 24.7% respectively were brought in from town of Northdale, whereas only 7.6% originated from Sobantu, the majority from Sobantu making their own way to Northdale. 2) Origin The majority of patients 35.4% came from the Northdale area, while 22% arrived from Sobantu. Town and areas outside of Pietermaritzburg, usually
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from the Greytown area or linked by the N.3 freeway, accounted for 17.7 % and 17.1% , respectively. Some 7.8 % of patients travelled across town from Edendale to Northdale.
3) Complaint The vast majority presented with trauma, but the other disciplines of medicine (10.4%), paediatrics (4.8%), gynaecology (1.6%), and surgery (2.4%) also were represented. While it is often difficult, in retrospect, to differentiate between stabbings and assaults, these represented the most common traumatic insults, followed by motor accidents, shootings, dog bites, and burns (Table 1). The most commonly traumatised area was the upper limb (from shoulder to fingers), followed by the head and neck region, chest and back, lower limb, face, and finally, the abdomen (Table 2). Of these patients, 5.5% presented with injuries sustained at work, either in domestic service or else in industry. The majority of these were hand injuries and lacerations. The nature of patients brought in by emergency services (Table 3) shows that the South African Police (SAP) tended to bring bodies for death certificates as well as a number of assaults, stabbings, gunshot wounds, and bites. Of the 33 patients with dog bites, 18 (54.5%) were brought in by the SAP as were 26.2% of gunshot victims. In addition, 20% of burn patients were referred via the SAP. Ambulance services brought a large number (20.5%) of nontrauma patients.
4) Outcome Of all patients seen, 42.4% were treated and discharged, while a further 27.6% were transferred to Edendale Hospital, following resuscitation and stabilisation. One hundred eighty-two patients (16.6%) were admitted to Northdale Hospital, and 12.3% either were brought to hospital to be certified dead or died shortly after admission while still in Casualty (DOA and DAA). Some 1% of patients either left before completion or refused treatment. Analysis revealed that of those patients brought in by ambulance 41.3% were admitted, 23.6% were transferred to Edendale Hospital, 13 % died, and 8.1% were treated and discharged. Of patient deaths (Table 4), 40.7% appeared to be unrelated to trauma and are assumed to be of “natural causes.” Stab wounds, usually of the chest, were the commonest
Table 1. Type of Complaint Number (%) Traumatic Assault Stabs Motor Vehicle Accidents Shooting Dog Bites Burns Medical W.C.A Paediatrics Surgical Gynaecological
260 (39.2%) 204 (30.6%) 99 (14.9%) 42 (6.3%) 33 (4.9%) 25 (3.6%) 115 (10.4%) 61 (5.5%) 53 (4.6%) 26 (2.4%) 16 (1.6%)
Table 2. Regions Involved In Trauma Number (%) 237 (26.4%) 220 (24.6%) 164 (16.2%) 126 (14.0%) 115 (12.6%) 37 (4.1%) 899
Upper Limb Head and Neck Chest and Back Lower Limb Face Abdomen Total
Table 3. Referrals via “Emergency Services” and Total Number of Types of Trauma (%)
Assault Stabs Shootings MVA Burns Dog Bites DOA Nontraumatic
S.A.P.
Ambulance
Total
29 (11.2) 40 (19.6) 11 (26.2) 12 (12.1) 5 (20) 16 (54.5) 37 9 (3.3)
26 (10) 72 (35.3) 6 (19) 53 (53.5) 2 (6) 0
260 204 42 99 25 33
5: (20.5)
273
form of traumatic death. In the case of shootings, however, one-third of the patients died, as did 20% of motor vehicle victims.
DISCUSSION
The policy of racially segregated hospitals has resulted in the establishment of 3 hospitals within the Pietermaritzburg area, each catering to specific racial groups. Official humanitarian sentiments do allow that in cases of emergency, patients may be treated at the nearest hospital. In accordance with this, the instructions to ambulance personnel are that “critical” patients be transported to the nearest institution. Superimposed upon this situation is the ethical dilemma of medical personnel who abide by the Hippocratic principles of nonracial discrimination and many who
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C. A. V. Perrott
Table 4. Deaths (DOA and DAA) Traumatic Assaults Stabs Shootings MVA Burns Nontraumatic
80 7 40 14 18 1 55 135
(2.7% of all assaults) (19.8% of all stabs) (33.3% of all shootings) (20.5% of all M.V.A) (4% of all burns) (40.7% of deaths)
feel that racially segregated hospitals are not cost effective or manpower effective. All state-run hospitals receive a budget annually, but in recent years due to financial constraints, these budgets have not increased despite an increased population serviced by these hospitals as well as escalating medical costs. As a result of this and staffing restrictions, an overloaded system has resulted with authorities endeavouring to cut costs and hence regulate admissions. The recent escalation of unrest violence, particularly in the Pietermaritzburg area, being mainly internecine between rival black organisations, must result in increased trauma being seen at regional hospitals. Although many patients probably attend their “own” hospital, namely Edendale Hospital, others present at other hospitals within the area. The figures obtainable from Grey’s Hospital represent mainly death certificates whilst those from Northdale Hospital cover a wide spectrum. Although an average of 73.4 black patients per month, or slightly more than 2 per day, has been seen in Casualty over a 15-month period, the added burden has resulted in an additional work load for staff, usually comprising a single Casualty officer. The resident medical staff, who are already overloaded, are being required to assist with assessment, resuscitation, treatment, and even admission and often with prolonged in-hospital care. Nearly two-thirds of patients (63.7%) make their own way to hospital, suggesting that, although they require attention, they might not be construed as “critical” but prefer to utilise the services of a local hospital. This is further supported by the 57.4% of patients originating from Northdale or Sobantu areas (i.e., close proximity). Furthermore, the fact that 42% of patients seen are treated and subsequently discharged confirms the nonseverity of many patients. Thus, it would seem that a significant number of black patients prefer to utilise the services of a “local” hospital rather than their “own” racially designated institution. Possible reasons suggested for this include local logistics of using a hospital on one’s own doorstep or else relating to service offered versus
a reluctance to attend“‘their” hospital for personal or political reasons. Most of the violence within the Pietermaritzburg area revolves around two rival black political groups. One group, often armed with firearms and knives, is striving for political domination. This group has already established firm control within the grounds of Edendale Hospital and, following local skirmishes against the opposing faction, their supporters often lie-in-wait for the wounded to appear at hospital, intent on further clashes. This together with over-crowding and prolonged delays has resulted in many patients seeking alternative avenues of treatment. This is particularly noted in the 7% to 8% of patients electing to travel across town from the Edendale area. Since this review is mainly retrospective, it is only possible to comment on those patients who have freely expressed their reasons for not attending their ‘own” hospital. In many instances, particularly in patients traveling across town from Edendale, this is because of fear as well as an impression of poor treatment likely to be received. While it remains difficult to differentiate criminal from political violence, at least half the patients brought in by the police were thought to be unrest or offence related, as adjudged by the presence of a police guard. This represents 17.3% of all trauma patients seen. Of interest is the high rate of dog bites (54.5%), shootings (26.2%), and stabbings (19.6%) referred by the police. The role of ambulance services has been criticised by some who feel that ambulance attendants have been preferentially referring patients to Northdale rather than to Edendale Hospital where their “turn around” time is considerably longer. The fact that some 92% of patients brought in by ambulance required admission, transfer, or else died attests to the severity of these patients’ trauma. Some 50% (92 of 182) of all black patients admitted to Northdale arrived by ambulance, suggesting that the reasons for referral were in fact justified. Of those patients who died 40.7% appeared to be of “natural” causes whilst one-third of all shootings ended fatally. Since Pietermaritzburg is not known for criminal shootings and since a quarter of all gunshot wounds were referred by the police, this would seem to indicate an increase in unrest violence where gunshot wounds are more commonly seen or else a change in the nature of violence within the area. CONCLUSIONS 1) On average 2 or more black patients utilise the facilities of Northdale Hospital daily. Although
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the majority are treated or transferred to their “own” hospital, 16% to 17 % require immediate admission. 2) The majority of patients make their own way to hospital, usually from the local area. This implies a “demand” by the local residents and a utilisation of “local” facilities. In view of the regional nature it is perhaps time that the authorities controlling hospitals consider regionalisation of services rather than fragmentation.
3) S.A. police utilise the services of Northdale (and to a large extent, Grey’s) for death certifications, but contribute a significant number of traumatic referrals of patients with shootings, stabbings, and dog bites. 4) The ambulance service referrals contributed about half of all admissions, but whether the additional distance to Edendale would have jeopardised patients is difficult to determine.
REFERENCE 1. Leeb W. Death, devastation & destruction-refugees in Natal. Paper presented at Special Committee against Apartheid: Inter-
national Seminar on Women and Children refugees in Southern Africa and Namibia- Harare; 1989.