repetitive, or even as being a futile exercise based on poor data. Such criticisms ... limitations of past medical care in order to derive information to guide future ...
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mortality. S At, Med J 1995; 85: 147-149. 5. Chegwidden A, Kotze DC. Pattinson RC. A saleable solution - on site syphilis testing in the Witbank district (Letter). S At, Med J 1998; 88: 796 (this issue). 6. Oelport so. Serological screening of cord blood for syphilis. S Af, Med J 1988; 73: 528-529. 7. Delport SO. On-site screening for maternal syphilis in an antenatal clinic. S Afr Med J 1993; $3: 723-724. 8. Oelport SO, Van den Serg JHY. On-site screening for syphilis at an antenatal clinic. S Af, Med J 1998; 88: 43-44. 9. Fehler HG, Ballard RC. Pilot study to evaluate the feasibility of on-site APR screening at antenatal and dedicated sexually transmitted disease clinics in South Africa. S Afr J Epidemio/lnfect 1998; 13: 1-5. 10. Jenniskens F, Obwaka E. Kirisuah S. er al. Syphilis control in pregnancy: decentralisation of screening facilities to primary care level. a demonstration project in Nairobi, Kenya. Int J Gynaecof Obstet 1995; 48: 5121-5128.
Health
randomised controlled trials or laboratory experiments. AIDS was discovered as a result of a review of the records of patients with Pnemocystis carinii pneumonia who were being treated with pentamidine. The fundamental notion of hospital inpatient audit is a process of summarising the successes, failures and limitations of past medical care in order to derive information to guide future health care, and to generate the necessary information for action.
Salim S Abdool Karim Centre for Epidemiological Research in Southern Africa Medical Research Council Durban
Hospital inpatient audit information for action Over a century ago, William Farr demonstrated the pUblic health value of routine vital statistics as a basis for public health policy and action. In a similar vein, regular hospital information from both inpatients and outpatients can prOVide a powerful impetus for public health action. In this issue of the SAJPH (p. 785), Chopra et al. describe the patterns of disease presenting to paediatric wards in Hlabisa Hospital and conclude that most of the ill-health being treated in hospital could have been prevented by known community-based interventions such as provision of clean water. Regular review of inpatient data can provide information on the demographic profile of patients, the patterns of disease, changing trends in disease burden or severity, quality of care and case-fatality rates. Obstetrics is noteworthy for its general ethic of audit through monitoring of perinatal mortality rates. In addition, maternal deaths are scrutinised to identify causative factors to be avoided in future. It is indeed unfortunate that audit is not practised more often in both public and private health care. Perhaps litigation is a concern. Moving away from audit of individual patients with a focus on adverse outcomes, hospital inpatient audits can encourage clinicians to reflect on group outcomes. This broadening of perspective from individual patient management to outcomes in groups of patients creates a shorter leap for clinicians to understand patients within the context of their communities. Hospital inpatient information can therefore be informative, not only about the medical care prOVided to patients but also about whether the communities are deriving adequate benefit from known effective public health measures. The practice of audit, particularly self-reflection, is sometimes criticised as being boringly descriptive and repetitive, or even as being a futile exercise based on poor data. Such criticisms are inaccurate. Criticisms of the quality of the data merely perpetuate a chicken and egg situation; if clinicians know that their records may be reviewed at some later date, they have an incentive to keep detailed accurate records. If, on the other hand, the records are never going to be seen again, why bother? While it is true that audit is essentially an exercise in descriptive epidemiology, there is no reason why it should not be conducted in a manner that is scientifically rigorous. It is simply not true that major discoveries are made by large
Occupational health and public health The history of public health is fraught with contention over the definition of occupational disease.' Economic, social and technological changes are often accompanied by changes in disease patterns among workers, and by sociopolitical conflict as to who should bear the cost of such change. This story has been well told with regard to tuberculosis in South Africa.' As a consequence of this conflict most industrialised societies have adopted legal and administrative systems for compensation of a narrow range of occupational diseases. In South Africa, the interests of miners were historically accommodated within a racially based system which provided for the compensation of certain chest diseases associated with mining. Outside the mining sector, occupational diseases were an afterthought, so that by 1991, the last year for which statistics are available, only 104 claims for occupational disease had been accepted. Compensation payments are clearly of great importance for South African workers confronting poverty, unemployment and poor social security.' However, there is good reason to question whether compensation systems focused on administrative definitions of occupational disease will promote the health of South Africa's workers in the long run. In this addition of the SAMJ, Campbell and Williams' remind us that disease among mineworkers on South African goldmines is variously caused by inhalation of quartz dust, droplet-spread infection, single-sex living in hostels, and impoverished rural labour reserves. While mining has at least been the subject of pUblic inquiry, the multiple roots of ill-health in sectors other than mining have remained firmly out of sight. The construction industry is an example where hazardous and arduous VlOrk and reliance on migrant labour are likely to have had significant health impacts. Yet we have only the sketchiest notion of worker health in this sector.' In the agricultural sector farmworkers are exposed to worksite hazards in the form of infections, organic dusts, agrichemicals and farm machinery. Here too the health costs of poor housing, violence, and alcoholism associated with
SAMJ
Volum, 8 No.6 fun, 1998
