PLoS ONE 2020; 15: e0241845. doi: 10.1371/journal.pone.0241845
To determine the etiology, presentation, and available management strategies for primary adrenal insufficiency in South Africa A 23-question survey was sent to 23,321 physicians. It covered several domains including patient demographics, etiology, presentation, therapy, and barriers to diagnosis and treatment, 704 responses were received that highlighted significant disparities in the physicians expertise, availability of diagnostic resources and management options between public versus private settings
This article highlights many key differences relevant to the management of primary adrenal insufficiency (PAI) in South Africa, an upper-middle income country characterized by the coexistence of public (accessed by 85% of the population) and private health systems. The study covered all ages, but included 48 children and adolescents < 16 years. The prevalence of PAI derived from this survey was higher than previously reported, but remained about 10-fold lower than that reported in Western countries which is 136 per million. This lower number could be due to the study design (survey) but also more likely to the lack of timely diagnosis. Second, within South Africa, tuberculosis remains the leading cause of PAI among the poorest patients while autoimmune PAI is the leading cause in those accessing the private health system. This serves as a reminder that international speakers who teach in low-income countries should be familiar with the situation faced by the trainees in these settings. Third, even simple diagnostic tests were not always available in South Africa: electrolytes were deemed sometimes or never available in 32% of private practice physicians and in 67% of public practice physicians. For CT scan of the adrenals, the figures were 27% and 52%, respectively. Finally, while differences between the public and private systems were modest, overall access to corticosteroids and in particular to fludrocortisone remained poor. For instance, fludrocortisone (which is included in the WHO List of Essential Medicines since 2009), was sometimes or often unavailable for 52% of the patients in the public system and 57% of those in the private system.
Overall, this article is a reminder that optimal patient care requires well-trained physicians, access to diagnostic tools and access to appropriate medicines. Again, as demonstrated by Armstrong et al. in the following article (13.7), pediatric endocrinologists need to work with other stakeholders to improve global patient care.