National Osteoporosis Foundation
Challenges of managing osteoporosis in South Africa
The National Osteoporosis Foundation of South Africa (NOF) was established in 1993 with the main aims of (i) propagating public awareness and heightening knowledge of osteoporosis (ii) providing a patient care service (iii) educating doctors and allied health professionals about the prevention and management of the disease, and (iv) promoting and supporting research in the field.
NOF is composed of a Committee of Postgraduate Training and Research, a Committee of Patient Education and Services, a Densitometry Committee and a Committee of Finance and Fundraising. The organisation is managed by a Council of fourteen. NOF has been a member of the IOF family since 1998.
Patient care:Out of a population of 43 million people, 10 million South Africans are of Asian, White and Coloured (mixed-race) descent, and potentially at high risk of developing osteoporosis. Osteoportic fractures are less common in our Black populations, but unlike the situation in Europe and America, the lumbar bone mass of Black and White South Africans is nearly identical! The paucity of accurate local statistics on the incidence of osteoporosis and related fractures is a major stumbling block in the drive to prevent and manage this disease optimally. The transition of especially African subjects from rural areas to the cities in search of work and an improved life will have further implications on their bone health - the nature of which is uncertain and constitutes an important research topic.
In South Africa, where malnutrition and infections (including the HIV/AIDS pandemic and tuberculosis are rife, osteoporosis is not regarded as a health priority. Access to diagnosis and treatment is not available to a large section of the population. In state hospitals, the availability of modern drugs to manage osteoporosis is limited because of high costs.
Yet, only ten years ago, not a single DXA apparatus (to measure bone mass) existed. Today, more than a hundred such machines, and many more ultrasound and other devices to measure peripheral BMD, are scattered all over the country. Most of the modern drugs to manage osteoporosis are available in the private sector. Moreover, as highly active anti-retroviral therapy (HAART) becomes available to treat those suffering from AIDS, the metabolic side-effects of this therapy, including its effects on bone, are becoming clinically relevant.
Despite these constraints, NOF has continued to provide, at minimal cost, osteoporosis sufferers with information brochures, Z-folds, a quarterly newsletter ("Osteonews"), a telephone helpline and support in many other ways.
Education:The education of patients, doctors and allied health professionals including medical aid funders has comprised an important objective of the Foundation since its inception. No less than 10 National Bone & Mineral Congresses (always sporting a number of international guest speakers) and numerous CME symposia / workshops have attempted to keep our health professionals abreast of new developments in the field. In 2000, a Densitometry Course for physicians was held under the auspices of the International Society for Clinical Densitometry. This was followed up by a national DEXA Course for technicians in April 2002. National Guidelines for the Prevention and Management of Osteoporosis was compiled by NOF and published in Sept. 2000.
We are, however, quite isolated here on the southern tip of Africa. In this regard, the IOF has played a fundamental role in helping NOF to perform its educational function - something for which we are immensely grateful.
Research:: The heterogeneity of the South African populations, the transition from rural to urban lifestyles, the existence of areas of endemic fluorosis and extreme calcium deficiency, provide many exciting challenges to a growing number of clinical researchers in the field. Over the years, South African physicians have also distinguished themselves as superb clinical drug trialists - often this activity provides the only way in which some of their indigent patients can gain access to new drugs available to manage osteoporosis. Furthermore, a limited number of basic research laboratories have been at the cutting-edge of more fundamental research in osteology - unraveling the cellular and molecular mechanisms of disease.
Much more, however, needs to be done! Simple, yet fundamental research - often epidemiologic in nature and not that readily fundable by official agencies like the universities - is required. A typical case in point involves studies on the prevalence of different fractures in different ethnic groups, or, an assessment of the "aftercare" ("prevent the next fracture") of patients presenting with a hip fracture.
Challenges and opportunities:Managing osteoporosis in South Africa faces numerous challenges in many areas ranging from increasing awareness and education of both patients and healthcare professionals including funders and the Government, to improving access to diagnosis and therapy, including appropriate reimbursement of said management.
We are, however, blessed with a number of opportunities - not least of all, an established Foundation and committed members, dedicated to improve the lot of those who suffer from this disease. In partnering other organisations both within (e.g. Bone & Joint Decade Action Committee; The Sports Science Institute) and outside our borders (IOF), education, research and above all patient care in osteology will undoubtedly go from strength to strength.
Contributed by Michele Wolman & Professor Stephen Hough, National Osteoporosis Foundation, South Africa
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