Where to start when speaking of EMS in Africa? We are used thinking about ERs and ambulance services as the base of any emergency. However, they must work properly to guarantee efficient care and it is easier said than done.

EMS around the world: the real problem of some regions of the world, like EMS in Africa, is the system. Without an efficient emergency medical system, ambulance service, emergency departments and facilities cannot work in the right way, and without a proper education and training programme, who will work in the system? Plus, who will work on the ambulances?

All of these questions depend on another unique question: how to do it? We spoke with Prof. Terrence Mulligan, Co-founder and Vice President of the IFEM Foundation, who held a conference during the Africa Health Exhibition 2019 about the Global Emergency Medicine development.

What is the situation of EMS in Africa?

“I was trained in the US in Emergency Medicine. There are 6 or 7 countries were emergency medicine is fully developed, many other countries are in the middle of development, while the majority of countries are at the very beginning of it or they never get started, like African regions. After the training in Emergency Medical Specialist, I also get further training afterwards in how to set up the system.

In the majority of schools, they teach you how to take care of the patients but they do not teach you how to build the system, so it is another type of skill. Of course, taking care of patients is strictly important, but it is also knowing how to set up a training programme system, how to work with National Government bodies, how to get special recognition and things like funding and financial strategies for insurance, for example. Also for legislation policies, health regulations. You might have answers in any fields of emergency medicine. So building an emergency medical system is like building a system into a system.

At the very centre you have people to treat and doctors education, while on the other hand, you have the knowledge on how to run an emergency department, how to set up a training programme. Development in emergency medical care goes beyond the knowledge of the care itself. It embraces the entire system.

How are you involved in medical care development of countries throughout Africa?

I got involved in African emergency medical care, working in South Africa where in 2004 I started and there we can find the most advanced systems of the entire African country. I helped them in setting up training programmes but also administration and management and giving some more advanced training. But when I started with them, they were not at step zero. Having worked with them for a long time, in 2008 was set up the African Federation of Emergency Medicine (AFEM) and it started with a project for becoming a society of emergency societies. Who does all this work? What countries design to start building the emergency medical system? Who is responsible for that work? The answers can be a handful of pioneers, but what they usually do is set up an emergency medical society.

When we built the AFEM, we meant to help to build an emergency medical society in African Countries. Once emergency medical societies are built, then every single country can develop its own programmes. Now, 8 countries in Africa have emergency medical societies, and I think 9 have emergency medicine speciality. Statistics are encouraging and things are developing even faster, and each year, a new country in Africa is heading on. While in other parts of the world there are 60 countries in which emergency medicine is recognized as a speciality, we hope that in the next 15 years Africa will be able to start a new era of emergency medicine thanks to this development.”

Another difficulty is the diversity among African Countries. How language and cultures can become barriers to standardization?

“Diversity is a value that we have to take into consideration, like different languages, dialects and cultures. However, if we watch them, we can discover that they are more similar than strikingly dissimilar. Since in Africa there are increasing demography and a spreading epidemiological situation than other cities of Western Countries, it’s not grossly 100% different, not even 50%, also because guidelines are built to suit generally most countries.

In places where this was developed, there are already solutions. For example, generally, on 700 problems, 200 are everyone’s problems, while the other 500 are just yours and it’s up to you to figure them out. In many African countries, in particular, you have also to respect their traditions. Around 30% of countries have to be reinvented in every aspect, while 70% already has a standard.

We already know more or less what physicians have to do, what an emergency department should look like, an idea of how much Government should be involved, and what benefits to expect. So we put together the curriculum on emergency medicine for the African Federation. The curriculum is what you need to teach and the African curriculum is roughly a model of International Federation of Emergency Medicine and 10 years ago we made curricula for medical students, doctors and for speciality training.

So we made a skeleton curriculum and for ones who wish to build a curriculum in a country, they can imitate the AFEM curriculum. The AFEM uses that curriculum and modifies it a little bit for the African situation because in some places it is different than in Europe or North America, starting from the resources available in many Western Countries are quite different in Africa. They might know how to deliver high-quality care after been educated by this curriculum, but they might not be able to do it, because they might only be too many problems int he emergency department, so the curriculum must be modified according to the needs. If you are starting a training programme you have to consider to change some aspects, such as the medicines’ name. IFEM together with AFEM has been working side by side with the WHO in order to build the correct division of emergency care. Working with the WHO, IFEM and AFEM have created now assessment tools in order to allow the formal request nearby a hospital; what state of emergency medicine development are you in now? What kind of equipment do you need? Once procedures are confirmed by the WHO they become global priorities.”

In this development that will be focused on pre-hospital care, which place do ambulance activities have?

“The main difference that we must underline is that ambulance service is only a part of the prehospital care system. What we are trying to build knowledge in Africa is the chain of care. Basically, the chain of survival. The matter is: in some regions, there are maybe ambulances (or motorcycles) that bring first care, but crew members maybe are not trained to face the emergency they are dispatching for, or they maybe do not even know how to use the equipment. Plus, few resources and facilities make this process even more complicated.

Ambulance care is part of the emergency and trauma care but it should not be the first thing we will be focused on. We must think about the emergency care system as a pyramid, and each block has its own time to be completed. For example, some tasks can take also years to be finished. And of course if it will take ten years, you won’t wait for ten years to do that, you might start now. It happens frequently that when many think about emergency they think about ambulance service. We have this discussion with many countries where the Government has contacted us and said that they have an ambulance fleet to donate and if we can build an emergency service. However, it is not so easy.

EMS in Africa: the importance of ambulance equipment and trained people

Ambulances must come secondary in this process because the questions are: who is going to work there? What kind of equipment do you have? Are these people trained? Also because we must consider that around 70% of the patients comes to hospitals without an ambulance. They usually come on their own. Reasons can be many and diverse, problems are not so critical, they live in isolated areas, they just underestimate the real situations. However, the reality of the facts is that a few people use the ambulance service. That’s also why the important thing is to improve and, in certain places, create by scratch the entire system of care.

Training the trainers, teaching the teachers. This is how to begin. We can do this in a hospital, or at university, or even in a more scattered way all over the country with specific programmes. So doctors in surgery can learn to be doctors in an emergency because they can be interested in coming an EM medic, but they may not know emergency paediatric. So we can train initial faculty and these trainers start to train their own people and we can help them set those training programmes.

Ambulance service is not the first step you think is correct to take. In some countries, there are ambulance services, like St. John Ambulance, Red Cross, and so on. So right now, what are the developments that must be taken in countries where these realities operate? It doesn’t make any sense having a good ambulance service if you do not have a good emergency system. Realities in Africa are extremely varied. For example, in Cape Town, there are extremely decent emergency services. Some are run by the government, others are private. But the majority of emergency services in Africa are grossly undergrown. Where we want to start – where we think is better to start – is from building emergency departments.

We must remember that only 30% of people come to hospitals with an ambulance. Especially in Africa, where there are no pre-hospital services and people live more than 30 minutes from the nearest hospital, so they must walk or drive motorcycles, bicycles to reach it. When I worked in India, I found similar problems and we did a good job there. You can go into a hospital in Africa and it turns out to be only an ER. It is little to know the equipment, expertise but it’s a place where people recognize they have to go there. So when we recognize those 4 walls as a hospital we start to train people right there, in order to make it become not only a place where care is delivered but a place in which nurse and doctors can learn how to do it.”

EMS Africa: what were the first steps of the project and where has it arrived?

“People who are involved or interested in being in trauma or ambulance system, they should realize there is a huge community of people who not only are experts in EM and emergency trauma but people who are experts in building a system in the country. People coming from all over the world that teaches you how to build an emergency medical system where there is nothing, how to do it where there is something already. In these ten years, the expertise of AFEM managed to create a new better level of EMS in many countries of Africa. For example, now Tanzania has 2 training programmes, Ghana has 4 and Kenya has 2. And it’s extremely difficult. Sometimes it’s easier building an entire system where there is nothing.”