There’s a drastic shortage of public health podiatrists in SA, reports Daily Maverick. Currently, there are about 300 podiatrists in South Africa, with only 45 state-employed podiatrists in Gauteng, three in KwaZulu-Natal, and only one school of podiatry on the African continent.
Worldwide, a diabetic foot ulcer is reported once every 1.2 seconds, with 15 to 20% of patients with diabetes developing diabetic foot ulceration. And every 20 seconds, there is an amputation related to diabetic foot ulceration.
“When you put a diabetic podiatric programme into a population, over three to five years you reduce the number of bed days, the number of ulcers, the number of amputations. You save lives,” said Sean Pincus, a Cape Town podiatrist. “About 67% of amputations would not be necessary if there were a podiatry programme.”
A proper podiatric programme has the potential to reduce the number of diabetic patients facing diabetic ulceration and amputation.
Podiatrists play an important role in reducing diabetes-related amputations. They can provide minor treatments, pick up complications and ensure early hospital referrals for diabetes-related complications, says Simiso Ntuli, head of podiatry at the University of Johannesburgʼs (UJ) faculty of health sciences.
At the moment, there are about 300 podiatrists registered with the Health Professions Council of South Africa. Around a sixth of these work in the public health sector, says Lucas Breedt, national executive secretary of the Podiatry Association of South Africa.
“This is not because podiatrists choose to be in the private sector, but because the public sector has yet to make adequate provisions for the profession,” he says.
Diabetic amputations in South Africa are common, says Professor Joel Dave, who launched the Diabetic Centre at Groote Schuur Hospital and is head of the department of endocrinology. The 2021 International Diabetes Federation Atlas puts the number of South African adults between 20 and 79 with diabetes at 4,234,000 (or 11.3% of the adult population). A further 1,922,200 are estimated to be living with undiagnosed diabetes. South Africa falls within the top five countries for the number of people with diabetes in Africa.
Diabetic neuropathy results in diabetic patients being unable to feel when there is something wrong with their feet. The “pathway” that is often seen in the diabetic foot is that friction causes a callus or corn; this then breaks down and becomes an ulcer; the ulcer becomes infected; the infection causes gangrene; and this complication leads to amputation, said Pincus.
“Podiatrists would get involved in the friction [and] callus part,” he said. “We cut the callus off, advise them on footwear, reinforce everything the doctors have said – even about their blood sugar control, reinforcing medication, [making] sure they understand.”
Groote Schuur Hospital’s Acute Care Surgery Unit sees two to three diabetic-related amputations weekly on average, ranging from minor foot debridement to major limb amputations, said Prof Christo Kloppers, head of acute-care surgery.
The vascular surgery unit at Charlotte Maxeke Johannesburg Academic Hospital, meanwhile, performs two to five major diabetes-related amputations weekly, says Dr Taalib Monareng, head of the unit. This number reflects only amputations among those patients referred to the vascular surgery unit for poor blood supply, and not the total number of diabetes-related amputations in the hospitalʼs cluster, which is far higher.
Well-functioning foot clinics at primary healthcare level, with access to podiatrists and orthotics, would contribute to the prevention of ulcers and amputations, he said.
There is only one school of podiatry on the continent, the podiatry department at UJ, offering a four-year Bachelor of Health Sciences degree, accepting 37 students into the first year of study each year, reports Daily Maverick.
Within legislation in SA, podiatry is not included as a “mandatory package of care” that patients should be receiving at primary healthcare level, said Ntuli.
“This has meant that the significance, the role podiatry and podiatrists will play in the management and care of diabetic patients in particular, has not been magnified where it should have been,” he said.
Ntuli said the podiatry department at UJ has been engaging with the Gauteng Department of Health to change this and position podiatry in the manner of dentistry, speech and hearing services, which are available within the public and primary healthcare spheres.
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