In past issues of this magazine we have explored how the epidemiology and management of migraine may differ in other nations when compared with the United States. Not surprisingly, we often find that a nation’s modern political history can exert powerful influences on its healthcare delivery system generally and its management of migraine specifically. Croatia, a geographic area first recognized as an independent nation as recently as 1991 and still healing from the physical and cultural ravages of a violent ethnic and religious conflict that escalated into an equally violent full-scale regional war.

Croatia’s old city of Dubrovnik was largely spared by the war’s opposing forces, and while there remain on its ancient walls and buildings the pockmarks inflicted by Serbian shellfire, it appears undisturbed, as structurally magnificent now as it has been for centuries. In this issue we turn to South Africa, where the influence of that nation’s political history has produced a society that is evolving in the wake of profound political change. 

Via Ethiopian Air the Migraineur field team embarked on the long journey from Dulles to Cape Town International Airport. Driving into the city from the north in a rental car, one soon can appreciate the familiar outline of the enduringly iconic Table Mountain. Eventually we arrived at the Table Bay Hotel, with its namesake waters shimmering just beyond, Table Mountain looming behind and a pleasant waterside complex of shops and restaurants just steps away. The hotel was established by Nelson Mandela to provide a source of employment for the disenfranchised. It is a beautiful place, and the service provided us was friendly, polite and competent.

After a few days of enjoying Cape Town we traveled up the northeastern coast towards Port Elizabeth, stopping here and there along the way and overnight in Plattenberg Bay. 

Our northern destination was Shamwari, a game preserve of extraordinary beauty and the culmination of a project begun in a 1992 by Adrian Gardiner, a Zambian-born businessman with a vision. Gardiner sought to restore over 60,000 acres of degraded, drought-ravaged and over-farmed land so as to return the native flora and fauna of South Africa to a natural environment that pre-dated our human presence. Cheetahs, hippos, lions, giraffe and warthogs. All roam freely, safe from human predation. A magical place. 

But what of migraine and its management in this beautiful country? The legacy of colonialism, apartheid and what followed the political ending of apartheid are reflected in the country’s uneven delivery of healthcare to its citizens. While South Africa’s constitution guarantees its citizens access to healthcare through a two-tiered public/private system, the resources of the public component are scant, and both quality and geographic accessibility are low. Although only 18% of the population regularly use private providers, medical expenditures within that sector account for about half of the nation’s spending on healthcare. Almost 80% of physicians work within the private sector, leaving only a 5th for the public sector. Only 16% of the total population has private medical insurance coverage because the associated cost is still a barrier for the majority of South Africans. 

Compounding the inequities, since the 1970s there has been an exodus of physicians and other health care professionals to other nations, often those with membership in the British Commonwealth. In one survey of physicians trained in South Africa who relocated to Canada, the respondents reported an overwhelming preference for their new homes and practices. Specifically, they preferred working within a socialized health insurance environment that granted wider accessibility over South Africa’s imbalanced two-tiered system. 

It is hardly surprising that migraine care in South Africa would be sparse. The primary care services upon which most migraineurs should be able to rely for diagnosis and initial treatment are limited, and specialist treatment costs too much to be widely accessible. Many of the medications used to treat migraine are either not yet available in South Africa or are not funded by either the public or the private healthcare system. One doctor working in South Africa noted that “for the majority of [migraine] patients you can make a very good clinical diagnosis. But the dilemma comes with the level of treatment that you can provide.” Another South African physician noted that migraine is not perceived by payors to be a serious condition, and that “the burden and the disability of migraine in South Africa are grossly underestimated and under-recognized …leading us to trail the developed world in terms of treatment and management.” For most citizens and physicians in South Africa, then, migraine is a medical afterthought. This is perhaps understandable given the healthcare system’s limitations but is nonetheless most unfortunate as regards a disorder which the World Health Organization (WHO) ranks 2nd – above AIDS, malaria, sickle cell anemia - amongst the chronic medical disorders that erode quality of life. And #1 for females.

To neurologists generally falls the responsibility for managing the more complex cases of migraine. Some recent reports estimate that in South Africa, a nation of approximately 60 million, there are as few as 150 adequately trained and clinically skilled neurologists. By way of comparison, one survey reported there are over 3,000 neurologists in greater Los Angeles. The average US neurologist makes about $264,000 annually; while this is lower than many other US specialties, the average South African neurologist makes about $53,000. 

We thoroughly enjoyed South Africa and were invariably treated with kindness and civility. South Africa is struggling to produce a just and peaceful society whose system of healthcare delivery is effective and equitable, and on behalf of migraineurs in particular we applaud and endorse that effort. 

John F. Rothrock

Benjamin A. Lankford

Photography: Samuel A.Lankford

Editor’s note

Our team took the ferry across Table Bay to Robben Island. Alcatrazesque in its proximity to Cape Town, Robben Island served as Nelson Mandela’s home for 18 of his 27 years of imprisonment. As I stood before his cell, it seemed to me literally transcendent that this man emerged from his imprisonment sufficiently unembittered that as his nation’s first black president he could lead with grace, compassion, dignity and restraint. Revisionist historians will have their way with Mr. Mandela, but having seen some small portion of the path he walked and the country he served, I can only be sorry that those years spent on the island could not have been applied instead to a longer tenure as his nation’s chief spokesman. His passing was a great loss for his country. For all of us.

In some ways, choosing to become a physician is the easy way out. With that choice skin color becomes as much of an irrelevance as are age, gender, religion, socioeconomic status, or any other biologic or demographic factor. You – our “they” – are simply…patients. And it is our sworn obligation to treat you all equally and to the best of our abilities. If our prejudices, be they conscious or unconscious, interfere, then we clearly have failed to meet our sworn obligation. And there will be no reward for that lapse.

Out there, beyond the hospitals, emergency, rooms, and clinics…life is not so simple. Together we must find the way to make it so.

JFR

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