INTERNATIONAL

Neuroanaesthesiology in South Africa

Lapale Moipolai, MBCHB, DA(SA), M Med (Anaes)

Busi Mrara, MbBch, FCA, Certified Critical Care

Carein Strydom, MBChB (UP), DA(SA), FCA (SA), M Med (Anaes) (UFS)

Makhosazana Dlamini, BSc (Biochemistry) (UFS): MbChB (UFS), DA(SA), FCA(SA)

Lapale Moipolai, MBCHB, DA(SA), M Med (Anaes)
Anaesthesiologist (Private Practice)
Sessional Consultant, Universitas Academic Hospital, University of the Free State
Chairperson, SASNACC

Busi Mrara, MbBch, FCA, Certified Critical Care
Professor and Head of Anaesthesiology and Critical Care
Walter Sisulu University

Carein Strydom, MBChB (UP), DA(SA), FCA (SA), M Med (Anaes) (UFS)
Anaesthesiologist, Universitas Academic Hospital
University of the Free State

Makhosazana Dlamini, BSc (Biochemistry) (UFS): MbChB (UFS), DA(SA), FCA(SA)
Fellowship in Neurocritical and Trauma (RcOA)
Consultant Anaesthesiologist, Chris Hani Baragwanath Academic Hospital
General Secretary, SASNACC

Introduction
South Africa is well known in the world of medical history through the pioneering works in the heart transplantation success of the Christian Barnard Team in Groote Schuur in the 1960s. Likewise, the neurosurgery specialty reported the first successful separation of craniopagus O’Hare Siamese twins at Johannesburg Hospital in 1968. The Chris Hani Baragwanath Hospital undertook the separation of Mpho and Mphonyana Mathibela in 1986. A team led by Prof. Benjamin Carson at Ga-Rankuwa Hospital, Medical University of Southern Africa, successfully separated Luka and Joseph Banda from Zambia (1998). Before that, they unsuccessfully attempted separation of the Makwaeba twins; they lost the twins shortly after the surgery (1994). Neuroanesthesiology has been practiced in South Africa for a long time and at a high level of competence.

The healthcare sector in South Africa comprises of the public sector, which serves about 83% of the population and the private sector, serving 17%. Resource distribution is skewed towards the privately insured at the expense of the majority. For a population of about 56.3 million people, there are 242 neurosurgeons and 1891 anesthesiologists on the Health Professions Council of South Africa (HPCSA) register, including those not doing clinical work, retired, or outside of the country.

Neuroanaesthesiology Education
Neurosurgery is a well-established discipline in South Africa and is practiced in all nine provinces to a varying degree of complexities in surgical case profile and resource availability. Nine medical faculties of neurosurgery are associated with different universities/academic hospitals where undergraduate and postgraduate training in neurosurgery is being undertaken. Similarly, departments of anesthesiology of these universities undertake under- and postgraduate training in anesthesia. The undergraduate level training in medicine degree is five years in duration wherein a clinical rotation in anesthesia is mandatory; anesthesia is an examinable course. Postgraduate (PG) training in anesthesia is four years, during which a varying duration of rotation on neurosurgery is employed. Registrars (PG students) are exposed to neuroanesthesia management principles of different neurosurgical procedures. There is a single exit examination conducted for all medical schools by the Colleges of Medicine of South Africa (CMSA) at the PG level. This exam's requirements include a recognized training portfolio and a Master of Medicine (MMed) dissertation from the associated university.

At present, official training (fellowship) on neuroanaesthesiology is not available. Dr. Anthony Reed, the Vice-Chairperson of SASNACC, is a neuroanesthesiology fellow from Southampton. Recently, he trained three fellows from Kenya and one from South Africa at the University of Cape Town. The SASNACC initiated a program during early 2020 to observe and compile different program syllabi and curricula of various teaching departments of anesthesiology. The aim was to establish a national standard for training and competence in neuroanesthesiology. This was interrupted by the global SARS-CoV-19 pandemic and will resume in due course of time.

Neurocritical Care in South Africa is mainly managed by neurosurgeons, with most of the neurosurgery departments is associated with a neurointensive care unit. Interventional Neuro-radiology training is available in three academic hospitals: Chris Hani Baragawanath Academic Hospital, Steve Biko Academic Hospital, and Inkosi Albert Luthuli Academic Hospital. Neuroanesthesia for endovascular surgery is practiced in these centers according to the available skill and resources. There are no dedicated stroke centers in the public service; however, similar services are available in selected private hospitals in Cape Town, Johannesburg, Durban, and Pretoria.

Intra-Operative Neurophysiologic Monitoring (IONM)
The Clinical Neurophysiology Society of South Africa is a non-profit organization for healthcare professionals in the field, primarily clinical technologists with subsequent specialization in neurophysiology. Various monitoring options are available depending on the available resources.

Neurosciences
The broad neuroscience divisions exist within the departments of neurology. The divisions are involved with different academic and research on epilepsy and peripheral nerve disorder.

Public/Private Sector Hospitals
Private healthcare is generally of a high standard and comparable to most first-world countries. The public sector carries the most considerable burden of trauma, pediatric hydrocephalus, and intracranial sepsis procedures, whilst most spine procedures are carried out in private hospitals. All medical doctor/specialist training is offered in the public sector hospitals.

South African Society of Neuroscience in Anaesthesia and Critical Care (SASNACC)
The South African Society of Neuroscience in Anaesthesia and Critical Care (SASNACC) is the special interest group (SIG) under the auspices of the South African Society of Anaesthesiologists (SASA). SASNACC was formed to promote the science and practice of neuroanaesthesia and critical care in South Africa through activities that foster faculty development and exchange of current scientific information, research collaborations, and materials of common interest. SASNACC constitution was approved in 2016 and the first meeting was held on March 23, 2017 during the SASA congress. There were a lot of activities carried out to recruit and popularizing the SIG. These efforts culminated into an Inaugural Congress held on the October 26, 2019 with Prof. Nicolas Bruder as the guest and main speaker. It was a very successful meeting, the first of its kind in South Africa and attracted 107 participants across the neuroscience fraternity.

Delegates at the 2019 SASNACC Inaugural Congress

SASNACC also hosted the first ENLS course on the African soil conducted by Prof. Bhiken Naik (USA) during the 2018 SASA Congress in Johannesburg. We have established relationships with other similar societies/scientific organizations like EURONEURO, SNACC, and NACCS. SASNACC members benefit from reduced registration fees at their annual congresses. Prof. Basil Matta (Cambridge, UK) has been instrumental in training our faculty in neurocritical care. SASNACC also contributes to the neuroanesthesiology program of the SASA Annual Congress by guiding content, topics, and identifying speakers.

Drs. Morakane Mphomane, Makhosazana Dlamini, Hizir Mukkadam, Federico Billota (Italy), and Lapale Moipolai (from L-to-R) during the 2019 EURONEURO in Brussels, Belgium

Conclusion
The major challenge for neuroanaesthesia and neurocritical care in South Africa is the lack of a common standard and benchmark in training and a skewed resource dispersion within the private and public sector. SASNACC aims to forge unity and establish a national standard competence in neuroanesthesia and critical care training and facilitate the professional development of its members and anesthesiology colleagues.

References

1. Wolfowitz J, Kerr EM, Levin SE, Walker DH, Vetten KB. Separation of craniopagus twins. S Afr Med J. 1968;42:412-24.
2. Fieggen G. Neurosurgery in South Africa. S Afr Med J. 2014;104:254.
3. Harrichandparsad R, Nadvi SS, Naidoo A, Mahomed O. "A tale of two cities." A snapshot survey of neurosurgical procedures performed in public and private sectors in eThekwini. S Afr J Surg. 2019;57:61.