In South Africa, medical school is a 6 year MBBCh program, after which all doctors must complete a mandatory 3 year internship and community service program in order to become a general practitioner, prior to having the option to specialize further.
Neurology is its own residency program in the country and it is a 4 year program. Most people will have worked for at least one year in a Neurology department as a medical officer, after their community service year, prior to obtaining a residency training post .
During community service or medical officer time doctors complete their College of Medicine and Surgery Part 1 Neurology exams. These exams cover the Basic Sciences, Physiology and Neuroanatomy. During residency each resident will be required to complete a Masters thesis on a neurological topic of their choice and during the end of their 3rd or 4th year of residency, they are required to pass the second part of the college exams.
Currently there are no fellowship training posts within neurology in South Africa. All neurologists work as general neurologists and may develop special interests in certain diseases and elect to specialize their practice.
There is a private and a public health care sector in the country and all training is done in the public sector. The resources are limited, and as a result, access to many neurological diagnostic and treatment modalities is challenging. In the public sector there is extremely limited access to MRI machines and to centers in which have facilities for thrombolysis to be performed. Genetic testing and neuro-immunological testing can be done in major academic centers to a large extent. Unfortunately, treatment disparities between public and private are huge with public having very few new biological treatments available and very limited neuro-rehab. The private sector has access to most biological and immunosuppressants agents as well as great rehabilitation centers. As per an article published by the University of Cape Town, as of 2021 there are only 150 Neurologists in South Africa, of which 35 work in the public sector and the remaining 115 in private. It is also pertinent to note that approximately 85% of the country’s population uses the public healthcare system, which is grossly understaffed in all disciplines, and this perpetuates the compromised patient-to-doctor-ratio.
Commonly seen neurological conditions in South Africa:
South Africa still faces a huge HIV pandemic, with 7.8 million people, or 12.7% of the population, living with HIV . Therefore, we treat many patients with TB meningitis/ TB spine/ TB myelitis, zoster encephalitis and myelitis, cryptococcal meningitis and neurosyphilis. There is also a fair amount of neurocysticercosis seen.
The country faces a very high trauma burden and as such doctors treat high volumes of traumatic brain injuries which can be from concussions, sub/epidural hematomas and even depressed skull fractures, or open head wounds like stab wounds or gunshots to the head. It is estimated that there are 89 000 new TBIs reported annually in South Africa, making it one of the highest incidences of TBIs in the world.
Finally, like the rest of the world there are growing NCDs and the stroke burden is high amongst patients in both public and private sectors. According to the South African Medical Journal stroke is the second leading cause of death in the country with an estimated 75 000 people having a stroke each year. 25.5% of stroke patients die within three months and 38% within 12 months of hospital discharge post stroke. The outcomes are very variable owing to resources and ease of access to hospitals. There is highly limited NeuroIR, with most patients either receiving only secondary prevention; or if they happen to present within the timeframe to an appropriate setting, thrombolysis may be offered.
HIV and the CNS:
HIV is a neurotrophic virus. Nervous system complications of HIV can be seen in up to 40% of patients. Acutely up to 25% of patients can present with an aseptic meningitis or acute demyelinating polyneuropathy. The virus predisposes patients to immunodeficiency and infectious diseases like TB,CMV encephalitis, progressive multifocal leukoencephalopathy ,cryptococcal meningitis and primary CNS lymphoma. However, it also seems to create an inflammatory environment in the brain and may predispose patients to a vasculitis or other vascular events.
Longstanding untreated HIV can result in HIV Associated Neurocognitive Dementia (HAND) which presents with cognitive impairment and motor impairment with characteristic hand movements. HAND is related to longstanding untreated HIV infection, however, research shows that even in patients on ART, between 18% and 52% of these patients had persistent neurocognitive abnormalities.
There are still many questions to be answered and research to be done in understanding the complex interplay of HIV, opportunistic infections, ARVs and the nervous system.
References :
1. A leading cause of death in SA, head trauma is under-researched. Nobhongo Gxolo. University of Cape Town News. October 2021. https://www.news.uct.ac.za/article/-2021-10-04-a-leading-cause-of-death-in-sa-head-trauma-is-under-researched.
2. New HIV Survey Highlights Progress and Ongoing Disparities in South Africa’s HIV Epidemic. Human Sciences Research Council. November 2023. https://hsrc.ac.za/press-releases/hsc/new-hiv-survey-highlights-progress-and-ongoing-disparities-in-south-africas-hiv-epidemic/#:~:text=SABSSM%20VI%20found%20that%20the,to%207.9%20million%20in%202017.
3. Matizirofa, L., Chikobvu, D. Analysing and quantifying the effect of predictors of stroke direct costs in South Africa using quantile regression. BMC Public Health 21, 1560 (2021). https://doi.org/10.1186/s12889-021-11592-0.
4. Krel R, Thomas F, Singh N. Central Nervous System Complications in HIV. Medscape. April 2018. https://emedicine.medscape.com/article/1167008-overview?form=fpf
5. Spudich S, Gonzalez-Scarano F. HIV-1 Related Central Nervous System Disease: Current Issues in Pathogenesis, Diagnosis and Treatment. Cold Spring Harb Perspect Med. 2012 Jun;2(6):a007120. doi: 10.1101/cshperspect.a007120.
About the Author:
 | Dr Yakira Mishan (MBBCH) : Yakira studied medicine at the University of the Witwatersrand in South Africa. She completed her internship and community service in Johannesburg and has been working as a General Practitioner . She is excited to be starting her neurology residency in New York in 2024. She is the Chief blog editor of the WNFO blog and is passionate about creating equitable access to neurological care around the world. |