Fifty Years of Dialysis in Africa: Challenges and Progress
2015; Elsevier BV; Volume: 65; Issue: 3 Linguagem: Inglês
10.1053/j.ajkd.2014.11.014
ISSN1523-6838
AutoresRashad S. Barsoum, Soha S. Khalil, Fatiu A. Arogundade,
Tópico(s)Healthcare Systems and Reforms
ResumoThis review addresses the development of dialysis services in Africa in the face of past and contemporary challenges. Maintenance dialysis treatment programs developed in 29 countries over the past 50 years, usually many years after their independence and the end of subsequent territorial and civil wars. Eight countries had the resources to launch national dialysis programs, conventionally defined as those accommodating at least 100 patients per million population. Additionally, based on information obtained from international and local publications, conference proceedings, and personal communications, it appears that limited short-term dialysis therapy currently is available in most African countries. Currently, the prevalence of and outcomes associated with dialysis in Africa are influenced significantly by the following: (1) local health indexes, including the prevalence of undernutrition and chronic infections; (2) per capita gross domestic product; (3) national expenditures on health and growth of these expenditures with incremental demand; (4) availability and adequate training of health care providers; and (5) literacy. In an attempt to reduce the socioeconomic burden of maintenance dialysis treatment, 12 countries have adopted active transplantation programs and 5 are striving to develop screening and prevention programs. Our recommendations based on these observations include optimizing dialysis treatment initiatives and integrating them with other health strategies, as well as training and motivating local health care providers. These steps should be taken in collaboration with regulatory authorities and the public. This review addresses the development of dialysis services in Africa in the face of past and contemporary challenges. Maintenance dialysis treatment programs developed in 29 countries over the past 50 years, usually many years after their independence and the end of subsequent territorial and civil wars. Eight countries had the resources to launch national dialysis programs, conventionally defined as those accommodating at least 100 patients per million population. Additionally, based on information obtained from international and local publications, conference proceedings, and personal communications, it appears that limited short-term dialysis therapy currently is available in most African countries. Currently, the prevalence of and outcomes associated with dialysis in Africa are influenced significantly by the following: (1) local health indexes, including the prevalence of undernutrition and chronic infections; (2) per capita gross domestic product; (3) national expenditures on health and growth of these expenditures with incremental demand; (4) availability and adequate training of health care providers; and (5) literacy. In an attempt to reduce the socioeconomic burden of maintenance dialysis treatment, 12 countries have adopted active transplantation programs and 5 are striving to develop screening and prevention programs. Our recommendations based on these observations include optimizing dialysis treatment initiatives and integrating them with other health strategies, as well as training and motivating local health care providers. These steps should be taken in collaboration with regulatory authorities and the public. Africa is a massive continent that accounts for 22.6% of the global land mass. It is divided geographically into the Sahara, desert zone, and the tropical heavily cultivated Sub-Sahara and is divided politically into 5 zones: North, West, East, Central, and South (Fig 1). The continent accommodates 1.1 billion inhabitants (15.5% of the world population), with a population growth of 2.46% per year compared to the world average of 1.15% per year. This trend is projected to increase the proportion of Africans to 25% of the world population by 2050.1Worldometers. http://www.worldometers.info/world-population/#growthrate. Accessed June 29, 2014.Google Scholar Population genetic studies confirm that Africa is indeed the land of our ancestors.2Gyllensten U. Genetic study roots humans in Africa. http://news.bbc.co.uk/2/hi/science/nature/1058484.stm. Accessed June 29, 2014.Google Scholar It has been the cradle of many civilizations, most famously that of the ancient Egyptians. The impact of pharaonic civilization on developments in science, engineering, art, religion, and literature is well known. Nephrology is no exception! The pharaohs equated the importance of kidneys to that of the heart, hence keeping them untouched in royal mummies to sustain their long journey to eternity. Many kidney diseases and their management were well described in ancient Egyptian medical papyri.3Medicine in Ancient Egypt. Indiana University. http://www.indiana.edu/∼ancmed/egypt.HTM. Accessed July 21, 2014.Google Scholar Although African leadership regarding kidney disease knowledge was not sustained in subsequent eras, the continent could still catch up with modern developments in nephrology, an important benchmark of which is dialysis. However, this has turned out to be a slow and tedious process, hampered by many ecological, socioeconomic, and political factors, which constitute the subject of this review. In our opinion, understanding these obstacles is essential to guide future development in the continent while facing the anticipated increasing challenge of chronic kidney disease (CKD). It is very difficult to obtain accurate and reliable data about medical services in Africa, let alone dialysis. For example, in a recent review about renal replacement therapy in Sub-Saharan Africa, data from trusted resources were available for only 15 of 47 countries.4Pozo M.E. Leow J.J. Groen R.S. Kamara T.B. Hardy M.A. Kushner A.L. An overview of renal replacement therapy and health care personnel deficienciesin Sub-Saharan Africa.Transpl Int. 2012; 25: 652-657Crossref PubMed Scopus (13) Google Scholar A broader scope was achieved in other reports, but based on less credible resources, such as non–peer-reviewed publications, local registries, and personal communications.5El-Matri A. Elhassan E. Abu-Aisha H. Renal replacement therapy resources in Africa.Arab J Nephrol Transplant. 2008; 1: 9-14Google Scholar, 6Abu-Aisha H. Elamin S. Peritoneal dialysis in Africa.Perit Dial Int. 2010; 30: 23-28Crossref PubMed Scopus (47) Google Scholar, 7Naicker S. End-stage renal disease in Sub-Saharan Africa.Kidney Int Suppl. 2013; 3: 161-163Crossref Scopus (51) Google Scholar Presumably, the most reliable information is what is documented in indexed peer-reviewed periodicals. Interestingly, MEDLINE is void of publications on dialysis from Africa before 1972 and lists only one published paper that year. However, there was a progressive increase over the following years, of which about 100 papers were relevant to this review. African contributions to the world literature on dialysis have increased from 0.06% in 1973 to 1.01% in 2012, a 17-fold increase, albeit a tiny impact. It is noteworthy that this pace of increasing publications is faster in Africa than in the rest of the world (Fig 2). The quality of publications also improved, from simple statistics to now describe clinical outcomes, long-term complications, and even molecular biology and genetics. The African Journal of Nephrology, the official journal of the African Association of Nephrology (AFRAN), is not indexed, yet it is a useful resource on dialysis activity across Africa. It also publishes abstracts of papers presented at the biennial AFRAN meetings, which provide individual-country or single-center data, as well as some collective information with reasonable credibility. The official journal of the Arab Society of Nephrology and Renal Transplantation, initially called Kidney Forum and later the Arab Journal of Nephrology and Transplantation, publishes similar data, mostly on the 7 Arab countries located in the Sahara. There are many local African journals, most of which are neither peer reviewed nor indexed. Many of their publications are single-center experiences with few national data, the merit of which may be challengeable. Moreover, most of these are difficult to retrieve and remain trapped within local institutional libraries. However, the best of these journals can be discovered through the African Journals Online (AJOL; www.ajol.info), a South African initiative launched in 1999. This provides the ability to search several hundred local journals that are peer reviewed, regularly published, and reasonably scholarly. It encompasses many disciplines, a few of which are medical, for example, the African Journal of Health Sciences. Though the portal is nonspecialized, it can be used to retrieve interesting data and research papers in renal medicine. Two local journals provide forums for good papers beyond their immediate domains, thereby serving as "regional." The South African Journal of Nephrology constitutes a good information resource about Sub-Saharan Africa, whereas the Saudi Journal of Kidney Diseases and Transplantation often provides data on Africa at large, with emphasis on the Arab African countries. For many decades, personal communication was almost the only way of obtaining data on African nephrology.8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar, 9Barsoum R.S. Ethical and moral dilemmas arising from uremia therapy in the Third World—a 'KAP' review.Prog Artif Organs. 1986; 85: 89-96Google Scholar, 10Barsoum R.S. Overview: end-stage renal disease in the developing world.Artif Organs. 2002; 26: 737-746Crossref PubMed Scopus (80) Google Scholar, 11Barsoum R.S. Burden of chronic kidney disease: North Africa.Kidney Int Suppl. 2013; 3: 164-166Crossref Scopus (26) Google Scholar This approach remains inevitable, despite the possibility of errors, if a comprehensive profile of the continent is to be captured. In addition to their valuable personal notes, many colleagues have provided relevant articles published in local journals, and they often had the privilege of accessing official national data that otherwise would not have been obtained. All available information indicates that the development of dialysis in Africa reflects the stormy modern history of the continent, including foreign occupation, civil wars, violence, poverty, illiteracy, and disease. It is impossible to split the provision of this sophisticated treatment from the supervening sociopolitical environment in the continent during the second half of the past century. But it also is clear that committed African dreamers have challenged almost insurmountable obstacles to establish dialysis programs. The beginning of dialysis activity in Africa was in 1957,8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar only 12 years following Willem Kolff's breakthrough in the Netherlands.12Fresenius Medical Care. History of hemodialysis. http://www.fmc-ag.com/262.htm. Accessed July 14, 2014.Google Scholar The sole general physician in Krugersdorp, a small town in South Africa, built the first dialysis machine in the continent, which was a cross between a Kolff coil and a rotating drum. He used it to treat 2 patients with acute renal failure and although both died shortly after, the event was a historic landmark. The next attempt was made a year later in Egypt. Professor Nagy El-Mahallawy of Ein-Shams University in Cairo imported a primitive Alwall dialyzer, which he used to treat a woman with acute renal failure who died after a few sessions.8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar Efforts were resumed in both countries in 1962 to 1963, when both peritoneal dialysis (PD) and hemodialysis were used routinely for the management of acute renal failure and poisoning in Cairo and Johannesburg university hospitals. Two North African universities in Tunisia and Algeria and one in Kenya joined the club during the same period. The first patient in the continent to receive hemodialysis by a Scribner shunt was treated at Kasr-El-Aini medical school of Cairo University in February 1964. In the following years, dialysis services were started in Nigeria (1965), Sudan (1968), Libya (1972), Zimbabwe (1972), and Morocco (1977). Dialysis for the management of acute renal failure subsequently was adopted in other leading teaching institutions in the rest of Africa.8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar, 13Musa A.R. A personal reflection on the history of renal medicine in the Sudan.Arab J Nephrol Transplant. 2008; 1: 29-30Google Scholar Military hospitals were pivotal in introducing dialysis for treating casualties of war, which supervened for many decades during the past century. As peace was gradually achieved, certain centers started small maintenance dialysis programs, which required only a limited number of enthusiastic experts, a few machines for hemodialysis or even none for PD, and a small budget. Only a few countries could afford to expand these maintenance dialysis initiatives into national government-sponsored programs. A previous excellent review suggested that maintenance dialysis treatment was available in 32 African countries in 2007.5El-Matri A. Elhassan E. Abu-Aisha H. Renal replacement therapy resources in Africa.Arab J Nephrol Transplant. 2008; 1: 9-14Google Scholar There have been many changes since, with maintenance dialysis programs being introduced in new countries and abandoned in others. Some countries offer limited short-term dialysis, including transient treatment to bridge an episode of reduced kidney function, preparation for a transplant, or tiding the patient until traveling abroad for further management. This review includes data for 29 countries with at least one cohort of patients treated regularly by dialysis for at least 1 year (Table 1). Although these countries constitute just more than half of the 54 African countries, they collectively have 879 million inhabitants (82% of the total African population).Table 1Relevant Data for African Countries With Maintenance Dialysis ProgramsDialysis MilestonesMaintenance Dialysis6Abu-Aisha H. Elamin S. Peritoneal dialysis in Africa.Perit Dial Int. 2010; 30: 23-28Crossref PubMed Scopus (47) Google Scholar, 7Naicker S. End-stage renal disease in Sub-Saharan Africa.Kidney Int Suppl. 2013; 3: 161-163Crossref Scopus (51) Google Scholar, 8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar, 23Naicker S. Integrated management: chronic kidney disease, diabetes mellitus, hypertension.Afr J Nephrol. 2013; 16: 6-13Google Scholar, 36Coulibaly G. Kaboré G.E. Diallo O. et al.Management of end-stage kidney failure: a challenge for the countries of Sub-Saharan Africa example of mineral and bone disorders in Burkina Faso.Med Sante Trop. 2013; 23: 193-196PubMed Google Scholar, 37Kaze F.F. Ashuntantang G. Kengne A.P. Hassan A. Halle M.P. Muna W. Acute hemodialysis complications in end-stage renal disease patients: the burden and implications for the under-resourced Sub-Saharan African health systems.Hemodial Int. 2012; 16: 526-531Crossref PubMed Scopus (12) Google Scholar, 38Shibiru T. Gudina E.K. Habte B. Derbew A. Agonafer T. Survival patterns of patients on maintenance hemodialysis for end stage renal disease in Ethiopia: summary of 91 cases.BMC Nephrol. 2013; 14: 127Crossref PubMed Scopus (23) Google Scholar, 39Goleg F.A. Kong N.C. Sahathevan R. Dialysis-treated end-stage kidney disease in Libya: epidemiology and risk factors.Int Urol Nephrol. 2014; 46: 1581-1587Crossref PubMed Scopus (13) Google Scholar, 40Dreyer G. Khan F. Kawale Z. et al.Starting a new hemodialysis unit at a central hospital in Malawi—activities and outcomes from the first year of service.Afr J Nephrol. 2013; 16 ([AFRAN abstract 17]): 21Google Scholar, 41Soonarane B. Mauritius: insufficient dialysis machines in hospitals and clinics of the island.Indian Ocean Times. August 22, 2013; (Accessed July 15, 2014)http://en.indian-ocean-times.com/Mauritius-Insufficient-dialysis-machines-in-hospitals-and-clinics-of-the-island_a1928.htmlGoogle Scholar, 42Dosseh E.D. Kassegne I. Sakiye K. et al.Management of secondary hyperparathyroidism in patients with chronic kidney disease undergoing dialysis in Togo.Med Sante Trop. 2012; 22: 65-68PubMed Google Scholar, 43Ben Maïz H. Nephrology in Tunisia: from yesterday to now.Nephrol Ther. 2010; 6: 173-178Crossref PubMed Scopus (9) Google ScholarTx7Naicker S. End-stage renal disease in Sub-Saharan Africa.Kidney Int Suppl. 2013; 3: 161-163Crossref Scopus (51) Google Scholar, 11Barsoum R.S. Burden of chronic kidney disease: North Africa.Kidney Int Suppl. 2013; 3: 164-166Crossref Scopus (26) Google Scholar, 28Abboud O. Nephrology in Africa: an overview. http://www.slideshare.net/aminawd/nephrology-in-africa. Accessed July 15, 2014.Google ScholarCKD Screening Program44Arogundade F.A. Barsoum R.S. CKD prevention in Sub-Saharan Africa: a call for governmental, nongovernmental, and community support.Am J Kidney Dis. 2008; 51: 515-523Abstract Full Text Full Text PDF PubMed Scopus (103) Google ScholarNephrologist-Related Metrics5El-Matri A. Elhassan E. Abu-Aisha H. Renal replacement therapy resources in Africa.Arab J Nephrol Transplant. 2008; 1: 9-14Google Scholar, 7Naicker S. End-stage renal disease in Sub-Saharan Africa.Kidney Int Suppl. 2013; 3: 161-163Crossref Scopus (51) Google Scholar, 23Naicker S. Integrated management: chronic kidney disease, diabetes mellitus, hypertension.Afr J Nephrol. 2013; 16: 6-13Google ScholarFirst Treatment8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar, 10Barsoum R.S. Overview: end-stage renal disease in the developing world.Artif Organs. 2002; 26: 737-746Crossref PubMed Scopus (80) Google Scholar, 13Musa A.R. A personal reflection on the history of renal medicine in the Sudan.Arab J Nephrol Transplant. 2008; 1: 29-30Google Scholar, 42Dosseh E.D. Kassegne I. Sakiye K. et al.Management of secondary hyperparathyroidism in patients with chronic kidney disease undergoing dialysis in Togo.Med Sante Trop. 2012; 22: 65-68PubMed Google ScholarMaintenance Program Est8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar, 5El-Matri A. Elhassan E. Abu-Aisha H. Renal replacement therapy resources in Africa.Arab J Nephrol Transplant. 2008; 1: 9-14Google Scholar, 6Abu-Aisha H. Elamin S. Peritoneal dialysis in Africa.Perit Dial Int. 2010; 30: 23-28Crossref PubMed Scopus (47) Google Scholar, 7Naicker S. End-stage renal disease in Sub-Saharan Africa.Kidney Int Suppl. 2013; 3: 161-163Crossref Scopus (51) Google Scholar, 11Barsoum R.S. Burden of chronic kidney disease: North Africa.Kidney Int Suppl. 2013; 3: 164-166Crossref Scopus (26) Google Scholar, 23Naicker S. Integrated management: chronic kidney disease, diabetes mellitus, hypertension.Afr J Nephrol. 2013; 16: 6-13Google Scholar, 24Cisse M.M. Ka E. Gueye S. et al.Peritoneal dialysis in a tropical area, a reality.Med Trop (Mars). 2011; 71: 468-471PubMed Google Scholar, 36Coulibaly G. Kaboré G.E. Diallo O. et al.Management of end-stage kidney failure: a challenge for the countries of Sub-Saharan Africa example of mineral and bone disorders in Burkina Faso.Med Sante Trop. 2013; 23: 193-196PubMed Google Scholar, 37Kaze F.F. Ashuntantang G. Kengne A.P. Hassan A. Halle M.P. Muna W. Acute hemodialysis complications in end-stage renal disease patients: the burden and implications for the under-resourced Sub-Saharan African health systems.Hemodial Int. 2012; 16: 526-531Crossref PubMed Scopus (12) Google Scholar, 38Shibiru T. Gudina E.K. Habte B. Derbew A. Agonafer T. Survival patterns of patients on maintenance hemodialysis for end stage renal disease in Ethiopia: summary of 91 cases.BMC Nephrol. 2013; 14: 127Crossref PubMed Scopus (23) Google Scholar, 39Goleg F.A. Kong N.C. Sahathevan R. Dialysis-treated end-stage kidney disease in Libya: epidemiology and risk factors.Int Urol Nephrol. 2014; 46: 1581-1587Crossref PubMed Scopus (13) Google Scholar, 40Dreyer G. Khan F. Kawale Z. et al.Starting a new hemodialysis unit at a central hospital in Malawi—activities and outcomes from the first year of service.Afr J Nephrol. 2013; 16 ([AFRAN abstract 17]): 21Google Scholar, 41Soonarane B. Mauritius: insufficient dialysis machines in hospitals and clinics of the island.Indian Ocean Times. August 22, 2013; (Accessed July 15, 2014)http://en.indian-ocean-times.com/Mauritius-Insufficient-dialysis-machines-in-hospitals-and-clinics-of-the-island_a1928.htmlGoogle Scholar, 45Salah H. An overview of renal replacement therapy in Algeria.Saudi J Kidney Dis Transpl. 1994; 5: 190-192PubMed Google Scholar, 46Eghan B.A. Amoako-Atta K. Kankam C.A. Nsiah-Asare A. Survival pattern of hemodialysis patients in Kumasi, Ghana: a summary of forty patients initiated on hemodialysis at a new hemodialysis unit.Hemodial Int. 2009; 13: 467-471Crossref PubMed Scopus (22) Google Scholar, 47Odutola T.A. Ositelu S.B. D'Almeida E.A. Mabadeje A.F. Five years experience of haemodialysis at the Lagos niversity Teaching Hospital—November 1981 to November 1986.Afr J Med Med Sci. 1989; 18: 193-201PubMed Google ScholarCapacity(pmp)National ProgramaNational maintenance dialysis program defined as accommodating >100pmp.No.bHighest numbers cited are provided (2008 to July 2014).Density(pmp)% of Total in AfricaRenal SocietyAlgeria19631977300YesYes—2286.0011.4YesAngola——23.8———50.240.3—Burkina Faso—20093.3———60.380.3—Cameroon—20065.9———70.320.4—Congo (Kinshasa)——0.5———70.110.4—Côte d'Ivoire—197615.1———70.350.4—Egypt19581964617cH. Hafez, personal communication, June 2014.YescH. Hafez, personal communication, June 2014.YesYes961cH. Hafez, personal communication, June 2014.11.86cH. Hafez, personal communication, June 2014.48.2cH. Hafez, personal communication, June 2014.YescH. Hafez, personal communication, June 2014.Ethiopia1980dY. Tadesse Mengistu, personal communication, July 2014.20022.1———90.100.5—Gabon——100Yes——42.000.2—Ghana198520062—YesYes30.120.2—Guinea-Bissau—2008————————Kenya1961198413—Yes—170.400.9YesLibya19721972624Yes——305.001.5YesMalawi1988eG. Dreyer, personal communication, June 2014.20113.9—Yes—————Mali—2005————20.130.1—Mauritania——75———30.750.2—Mauritius——970YesYes—88.000.4—Morocco1977fH. Dkhissi, personal communication, July 2014.2000523fH. Dkhissi, personal communication, July 2014.YesfH. Dkhissi, personal communication, July 2014.YesYes300fH. Dkhissi, personal communication, July 2014.9.09fH. Dkhissi, personal communication, July 2014.15.1fH. Dkhissi, personal communication, July 2014.YesfH. Dkhissi, personal communication, July 2014.Nigeria196519818—YesYes1600.958.0YesRwanda——3—Yes—20.180.1—Senegal—20045.2———30.210.2—South Africa19571966157YesYesYes601.153.0YesSudan1968197474.3—Yes—601.623.0YesTanzania1985—————20.040.1—Togo—20086———20.290.1—Tunisia19621976734YesYes—777.003.9YesUganda——1.5———30.080.2—Zambia——3———20.140.1—Zimbabwe197219889.1———30.210.2—Abbreviations: CKD, chronic kidney disease; Est, established; pmp, per million population; Tx, transplantation.a National maintenance dialysis program defined as accommodating >100 pmp.b Highest numbers cited are provided (2008 to July 2014).c H. Hafez, personal communication, June 2014.d Y. Tadesse Mengistu, personal communication, July 2014.e G. Dreyer, personal communication, June 2014.f H. Dkhissi, personal communication, July 2014. Open table in a new tab Abbreviations: CKD, chronic kidney disease; Est, established; pmp, per million population; Tx, transplantation. The timeline of initiating maintenance dialysis services in different African countries is widely variable. Personal initiative was the most important factor in starting any such program. Interestingly, it was not only doctors who were the driving force. For example, a wealthy Sudanese family supported the establishment of the first maintenance PD program in the country, which is still flourishing and contributing significantly to the national end-stage kidney disease program in Sudan.13Musa A.R. A personal reflection on the history of renal medicine in the Sudan.Arab J Nephrol Transplant. 2008; 1: 29-30Google Scholar The first lady in a Southern Sub-Saharan country, herself a patient, pushed the development of the first maintenance dialysis program in her country, in accordance with the plan developed by her treating British physician. Similar stories can be told about many African countries.8Barsoum R.S. History of dialysis in Africa.in: Ing T. Rahman M. Kjellstrand C. Dialysis: History, Development and Promise. World Scientific Publishing Co, Hackensack, NJ2012: 599-610Crossref Scopus (5) Google Scholar It is interesting to note that economic and educational parameters did not seem to have a substantial impact on the development of these maintenance dialysis initiatives (Table 2). However, the political environment seems to have made a considerable difference. Almost all maintenance dialysis programs in Africa happened only after achievement of independence, peace, and political stability.Table 2Economic and Educational Data and Dialysis Availability Across AfricaData from World Health Organization48World Health Organization. Global health expenditure database. http://apps.who.int/nha/database/World_Map/Index/en?id=REPORT_4_WORLD_MAPS&mapType=3&ws=0. Accessed June 15, 2014.Google Scholar and the World Bank.49The World Bank. World development indicators 2012. http://data.worldbank.org/data-catalog/world-development-indicators. Accessed June 15, 2014.Google ScholarNo. of CountriesPopulation(in millions)Per Capita GDPaGDP at purchasing power parity per capita.Average Health BudgetAverage LiteracybAvailable World Bank data on literacy in Africa is incomplete. We could capture relevant information for only 25 countries.Amount Per Capita17-y Growth Per CapitacAmount that average health budget increased over the 17 years leading up to the value in the previous column.Age > 15 yAge > 65 yShort-term dialysis only25195$4,351.30$278.20$190.5066.7%37.5%Any maintenance dialysis program29879$4,164.10$237.20$135.0069.5%39.5%National maintenance dialysis programdNational program defined as accommodating >100 per million population.8224$10,685.80$569.10$310.0082.2%50.7%Abbreviation: GDP, gross domestic product.a GDP at purchasing power parity per capita.b Available World Bank data on literacy in Africa is incomplete. We could capture relevant information for only 25 countries.c Amount that average health budget increased over the 17 years leading up to the value in the previous column.d National program defined as accommodating >100 per million population. Open table in a new tab Abbreviation: GDP, gross domestic product. Africa was an easy target for imperial European military occupation in the late 1800s. Ten percent of Africa was already under European control in 1870. As a result of the "Scramble for Africa," 90% of the continent was occupied by 1914, sparing only Liberia (which was never occupied), Ethiopia (occupied for a short while later), and South Africa (which had become independent in 1910). By 1950, when dialysis was rapidly developing as a new life-saving treatment modality all over the world, the continent was stuck under foreign military control. It took 70 years from the independence of South Africa for all of the remaining African countries to gain freedom. Notably, no African country started a maintenance dialysis program while under foreign occupation. Soon after obtaining their independence, many African countries fell into civil and territorial wars, army insurgencies, massacres, and genocides.14List of conflicts in Africa. http://en.wikipedia.org/wiki/List_of_conflicts_in_Africa. Accessed July 20, 2014.Google Scholar Of the 20 countries for which the date of starting a maintenance dialysis program could be obtained, only one started its program during a civil war; 5, after 1 to 5 years of peace; 4, after 6 to 10 years; and 10, after more than 10 years of stability (Fig 3). Countries that have taken relatively longer than their peers in starting maintenance dialysis programs tended to be embroiled in war (Burkina Faso, Ethiopia, Guinea-Bissau, Mali, and Morocco) or experienced major economic shortages due to climatic or sociopolitical issues (Ghana, Cameroon, Senegal, and Togo). Of the 25 countries that still are not known to provide maintenance dialysis, many have experienced unrest since independence (Fig 3). With the success of initial maintenance dialysis programs in Africa, it was natural to face an overwhelming demand from the huge number of patients with end-stage kidney disease owing to ecological, demographic, and socioeconomic factors.10Barsoum R.S. Overview: end-stage renal disease in the developing world.Artif Organs. 2002; 26: 737
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