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These observation makes imperative that preemies with post conceptual age of less than 45 weeks be carefully monitored in-hospital for at least 24 hours after surgical repair of their hernias. Effect of hip muscles stretching in low back pain patients with lumbar Elderly male and female patients should be encouraged to participate in cardiac rehabilitation. A study on comparision of trimacinolone acetonide 0. This unfavorable prognosis is the result of early and wide dissemination, bones marrow involvement and poor response to chemotherapy.

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Cardiac Rehabilitation

The traditional method of diagnosing and managing ileo-colic intussusception is barium enema contrast reduction. In China where this is the most common surgical emergency in childhood, pneumatic reduction has been used for more than 25 years. A recent tendency toward this approach is seen in recent years in Occident. Small bowel aeration is a sign of complete reduction. Gas enema reduction is very successful in patients with: The condition can occur in an isolated form either localized to colon or disseminated throughout the bowel , or associated to other diseases such as Hirschsprung's HD , neurofibromatosis, MEN type IIB, and anorectal malformations.

Clinically two different types of isolated IND have been described: Type A shows symptoms of abdominal distension, enterocolitis, bloody stools, intestinal spasticity in imaging studies Ba Enema since birth, is less common and associated with hypoplasia of sympathetic nerves.

Type B is more frequent, symptoms are indistinguishable from that of HD, with chronic constipation, megacolon, and repeated episodes of bowel obstruction. Management depends on clinical situation; conservative for minor symptoms until neuronal maturation occurs around the 4th year of life, colostomy and resectional therapy for life threatening situations.

The most common congenital diaphragmatic hernia CDH is that which occurs through the postero-lateral defect of Bochdalek. It is caused by failure of the pleuroperitoneal membrane to develop adequately and close before the intestines returning to the abdomen at the tenth week of gestation. The intestines then enter the pleural cavity and cause poor lung development leading to pulmonary hypoplasia a reduced number of alveoli per area of lung tissue.

This defect is postero-lateral in the diaphragm and may vary in size. Stomach, liver or spleen may be partly in chest as well. The clinical presentation is that the newborn becomes rapidly cyanotic, acidotic, and has poor ventilation. Major findings relate to the degree of pulmonary maldevelopment. Chest films will show intestines in the chest. Placement of a radiopaque nasogastric tube may show the tube coiled in the lower left chest. Higher risk factors are: Treatment consist of rapid intubation and ventilation with use of muscle relaxants, placement of a nasogastric tube to prevent gaseous distension of the intestines and preoperative stabilization of arterial blood gases and acid-base status.

Surgery can be undertaken when one of the following objectives are met: Operative management consist of abdominal approach, closure of hernia by primary repair or use of mesh, and correction of malrotation. Postoperative management is very difficult. Due to hypoplastic lungs, there is frequently pulmonary hypertension leading to right-to-left shunting and progressive hypoxemia, hypercarbia, and acidosis that worsens the pulmonary hypertension.

The use of chest tubes may cause overstretching of the already hypoplastic alveoli causing: Postoperatively, the infant should be kept paralyzed and ventilated and only very slowly weaned from the ventilator. The severity of pulmonary hypoplasia, both ipsilaterally and contralaterally, is the main determinant of outcome. ECMO extracorporeal membrane oxygenator has come to reduce somewhat the mortality of this condition. The mortality of CDH is directly related to the degree of lung hypoplasia associated.

Death is caused by persistent pulmonary hypertension and right ventricular failure. Prospective studies of prenatally diagnosed fetus prior to 25 wk.

This unsolved problem has prompted investigators to develop new treatment options such as preoperative stabilization, jet-frequency ventilation, and ECMO. Another area of development is intrauterine fetal surgical repair. To achieve success fetal surgery should: Intrauterine repair has meet with limited success due to herniation of the fetal liver into the chest through the defect.

Disturbance of the umbilical circulation during or after liver reduction causes fetal death. Positive-pressure ventilation after birth reduces the liver before the baby comes for surgical repair. Harrison USFC Fetal Treatment Center has devised separate fetal thoraco-abdominal incisions to deal with this problem "two-step dance" , reducing or amputating the left lateral segment of the liver. Another less invasive approach is enlarging the hypoplastic lungs by reducing the normal egress of fetal lung fluid with controlled tracheal obstruction called PLUGS Plug Lung Until it Grows.

Infants and children will present with either respiratory or gastrointestinal symptoms such as: Occasionally the child is asymptomatic. A rise intrabdominal pressure by coughing or vomiting transmitted to any defect of the diaphragm makes visceral herniation more likely. Diagnosis is confirmed by chest or gastrointestinal contrast imaging. Management consists of immediate surgery after preop stabilization. Most defects can be closed primarily through an abdominal approach.

Chest-tube placement in the non-hypoplastic lung is of help. Surgical results are generally excellent. A few deaths have resulted from cardiovascular and respiratory compromise due to visceral herniation causing mediastinal and pulmonary compression. First described in , Morgagni Hernias MH are rare congenital diaphragmatic defects close to the anterior midline between the costal and sternal origin of the diaphragm.

Almost always asymptomatic, typically present in older children or adults with minimal gastrointestinal symptoms or as incidental finding during routine chest radiography mass or air-fluid levels. Infants may develop respiratory symptoms tachypnea, dyspnea and cyanosis with distress. Cardiac tamponade due to protrusion into the pericardial cavity has been reported.

US and CT-Scan can demonstrate the defect. Trans-abdominal subcostal approach is preferred with reduction of the defect and suturing of the diaphragm to undersurface of sternum and posterior rectus sheath.

Large defects with phrenic nerve displacement may need a thoracic approach. Results after surgery rely on associated conditions. Two types of esophageal hernia recognized are the hiatal and paraesophageal hernia. Diagnosis is made radiologically always and in a number of patients endoscopically. The hiatal hernia HH refers to herniation of the stomach to the chest through the esophageal hiatus.

The lower esophageal sphincter also moves. It can consist of a small transitory epiphrenic loculation minor up to an upside-down intrathoracic stomach major.

HH generally develops due to a congenital, traumatic or iatrogenic factor. Most disappear by the age of two years, but all forms of HH can lead to peptic esophagitis from Gastroesophageal reflux. Repair of HH is determined by the pathology of its associated reflux causing failure to thrive, esophagitis, stricture, respiratory symptoms or the presence of the stomach in the thoracic cavity. In the paraesophageal hernia PH variety the stomach migrates to the chest and the lower esophageal sphincter stays in its normal anatomic position.

PH is a frequent problem after antireflux operations in patients without posterior crural repair. Small PH can be observed. With an increase in size or appearance of symptoms reflux, gastric obstruction, bleeding, infarction or perforation the PH should be repaired. The incidence of PH has increased with the advent of the laparoscopic fundoplication.

A hernia is defined as a protrusion of a portion of an organ or tissue through an abnormal opening. For groin inguinal or femoral hernias, this protrusion is into a hernial sac. Whether or not the mere presence of a hernial sac or processus vaginalis constitutes a hernia is debated.

Inguinal hernias in children are almost exclusively indirect type. Those rare instances of direct inguinal hernia are caused by previous surgery and floor disruption. An indirect inguinal hernia protrudes through the internal inguinal ring, within the cremaster fascia, extending down the spermatic cord for varying distances.

The direct hernia protrudes through the posterior wall of the inguinal canal, i. The embryology of indirect inguinal hernia is as follows: During the third month of gestation, the processus vaginalis extends down toward the scrotum and follows the chorda gubernaculum that extends from the testicle or the retroperitoneum to the scrotum.

During the seventh month, the testicle descend into the scrotum, where the processus vaginalis forms a covering for the testicle and the serous sac in which it resides. At about the time of birth, the portion of the processus vaginalis between the testicle and the abdominal cavity obliterates, leaving a peritoneal cavity separate from the tunica vaginalis that surrounds the testicle.

The typical patient with an inguinal hernia has an intermittent lump or bulge in the groin, scrotum, or labia noted at times of increased intra-abdominal pressure. A communicating hydrocele is always associated with a hernia. This hydrocele fluctuates in size and is usually larger in ambulatory patients at the end of the day. If a loop of bowel becomes entrapped incarcerated in a hernia, the patient develops pain followed by signs of intestinal obstruction.

If not reduced, compromised blood supply strangulation leads to perforation and peritonitis. Most incarcerated hernias in children can be reduced. Associated to these episodes of incarceration are chances of: Symptomatic hernia can complicate the clinical course of babies at NICU ill with hyaline membrane, sepsis, NEC and other conditions needing ventilatory support. Repair should be undertaken before hospital discharge to avoid complications.

Postconceptual age sum of intra- and extrauterine life has been cited as the factor having greatest impact on post-op complications. These observation makes imperative that preemies with post conceptual age of less than 45 weeks be carefully monitored in-hospital for at least 24 hours after surgical repair of their hernias.

Outpatient repair is safer for those prematures above the 60 wk. The very low birth weight infant with symptomatic hernia can benefit from epidural anesthesia.

At times, the indirect inguinal hernia will extend into the scrotum and can be reduced by external, gentle pressure. Occasionally, the hernia will present as a bulge in the soft tissue overlying the internal ring.

It is sometimes difficult to demonstrate and the physician must rely on the patient's history of an intermittent bulge in the groin seen with crying, coughing or straining. Elective herniorrhaphy at a near convenient time is treatment of choice. Since risk of incarceration is high in children, repair should be undertaken shortly after diagnosis. Simple high ligation of the sac is all that is required. Pediatric patients are allowed to return to full activity immediately after hernia repair.

Bilateral exploration is done routinely by most experienced pediatric surgeons. Recently the use of groin laparoscopy through the hernial sac permits visualization of the contralateral side. Testicular feminization syndrome TFS is a genetic form of male pseudohermaphroditism patient who is genetically 46 XY but has deficient masculinization of external genitalia caused by complete or partial resistance of end organs to the peripheral effects of androgens.

This androgenic insensitivity is caused by a mutation of the gene for androgenic receptor inherited as an X-linked recessive trait. In the complete form the external genitalia appear to be female with a rudimentary vagina, absent uterus and ovaries. The incomplete form may represent undervirilized infertile men.

This patients will never menstruate or bear children. Early gonadectomy is advised to: Vaginal reconstruction is planned when the patient wishes to be sexually active. These children develop into very normal appearing females that are sterile since no female organs are present.

A hydrocele is a collection of fluid in the space surrounding the testicle between the layers of the tunica vaginalis. Hydroceles can be scrotal, of the cord, abdominal, or a combination of the above.

A hydrocele of the cord is the fluid-filled remnant of the processus vaginalis separated from the tunica vaginalis. A communicating hydrocele is one that communicates with the peritoneal cavity by way of a narrow opening into a hernial sac. Hydroceles are common in infants. Some are associated with an inguinal hernia. They are often bilateral, and like hernias, are more common on the right than the left.

Most hydroceles will resolved spontaneously by years of age. After this time, elective repair can be performed at any time. Operation is done through the groin and search made for an associated hernia. Aspiration of a hydrocele should never be attempted.

As a therapeutic measure it is ineffective, and as a diagnostic tool it is a catastrophe if a loop of bowel is entrapped.

A possible exception to this is the postoperative recurrent hydrocele. The undescended testis is a term we use to describe all instances in which the testis cannot be manually manipulated into the scrotum. The testes form from the medial portion of the urogenital ridge extending from the diaphragm into the pelvis. In arrested descent, they may be found from the kidneys to the internal inguinal ring.

Rapid descent through the internal inguinal ring commences at approximately week 28, the left testis preceding the right. Adequate amounts of male hormones are necessary for descent. The highest levels of male hormones in the maternal circulation have been demonstrated at week Thus, it appears that failure of descent may be related to inadequate male hormone levels or to failure of the end-organ to respond.

The undescended testes may be found from the hilum of the kidney to the external inguinal ring. The undescended testis found in 0. Testes that can be manually brought to the scrotum are retractile and need no further treatment. Parents should know the objectives, indications and limitations of an orchiopexy: To improve spermatogenesis producing an adequate number of spermatozoids surgery should be done before the age of two. Electron microscopy has confirmed an arrest in spermatogenesis reduced number of spermatogonias and tubular diameter in undescended testis after the first two years of life.

Other reasons to pex are: The management is surgical; hormonal Human Chorionic Gonadotropin treatment has brought conflicting results except bilateral cases. Surgery is limited by the length of the testicular artery. Palpable testes have a better prognosis than non-palpable.

Laparoscopy can be of help in non-palpable testis avoiding exploration of the absent testis. Viens, MS University of Toronto. An umbilical hernia is a small defect in the abdominal fascial wall in which fluid or abdominal contents protrude through the umbilical ring.

The presence of a bulge within the umbilicus is readily palpable and becomes more apparent when the infant cries or during defecation. The actual size of the umbilical hernia is measured by physical examination of the defect in the rectus abdominis muscle, and not by the size of the umbilical bulge.

The size of the fascial defect can vary from the width of a fingertip to several centimetres. Embryologically, the cause of an umbilical hernia is related to the incomplete contraction of the umbilical ring.

The herniation of the umbilicus is a result of the growing alimentary tract that is unable to fit within the abdominal cavity. Umbilical hernias are more prevalent in females than in males and are more often seen in patients with African heritage.

The increased frequency of umbilical hernias has also been attributed to premature babies, twins and infants with long umbilical cords. There is also a frequent association with disorders of mucopolysaccharide metabolism, especially Hurler's Syndrome gargoylism. Most umbilical hernias are asymptomatic; the decision to repair the umbilical hernia in the first years of life is largely cosmetic and is often performed because of parental request, not because of pain or dysfunction.

In the past, some parents use to tape a coin over the umbilical bulge, however, manual compression does not have an effect on the fascial defect. Treatment of umbilical hernia is observation. However, surgical repair is recommended if the hernia has not closed by the age of five. The incidence of incarceration trapped intestinal loop is rare, even in larger defects. Females should especially have their umbilical hernia corrected before pregnancy because of the associated increased intra-abdominal pressure that could lead to complications.

The procedure is simple and incidence of complication such as infection is extremely rare. The repair is usually done as outpatient surgery under general anesthetic. Inguinal and umbilical hernia repair in infants and children. Surg Clinics of North Am 73 3: Swenson's Pediatric Surgery - 5th edition.

The developing human - 4th edition. Philadelphia, WB Saunders, pp. Some observations on umbilical hernias in infants. The comparative incidence of umbilical hernias in colored and white infants. J Natl Med Assoc The three most common abdominal wall defect in newborns are umbilical hernia, gastroschisis and omphalocele. Omphalocele is a milder form of primary abdominoschisis since during the embryonic folding process the outgrowth at the umbilical ring is insufficient shortage in apoptotic cell death.

Defect may have liver, spleen, stomach, and bowel in the sac while the abdominal cavity remains underdeveloped in size. The sac is composed of chorium, Wharton's jelly and peritoneum. The defect is centrally localized and measures cm in diameter. A small defect of less than 2 cm with bowel inside is referred as a hernia of the umbilical cord. Epigastric localized omphalocele are associated with sternal and intracardiac defects i. Cardiac, neurogenic, genitourinary, skeletal and chromosomal changes and syndromes are the cornerstones of mortality.

Cesarean section is warranted in large omphaloceles to avoid liver damage and dystocia. After initial stabilization management requires consideration of the size of defect, prematurity and associated anomalies.

Primary closure with correction of the malrotation should be attempted whenever possible. Antibiotics and nutritional support are mandatory. Manage control centers around sepsis, respiratory status, liver and bowel dysfunction from increased intraabdominal pressure. The protruding gut is foreshortened, matted, thickened and covered with a peel. The IA might be the result of pressure on the bowel from the edge of the defect pinching effect or an intrauterine vascular accident.

Rarely, the orifice may be extremely narrow leading to gangrene or complete midgut atresia. In either case the morbidity and mortality of the child is duplicated with the presence of an IA. Alternatives depend on the type of closure of the abdominal defect and the severity of the affected bowel. With primary fascial closure and good-looking bowel primary anastomosis is justified.

Angry looking dilated bowel prompts for proximal diversion, but the higher the enterostomy the greater the problems of fluid losses, electrolyte imbalances, skin excoriation, sepsis and malnutrition. Closure of the defect and resection with anastomosis two to four weeks later brings good results.

Success or failure is related to the length of remaining bowel more than the specific method used. Initially do an Apt test to determine if blood comes from fetal origin or maternal origin blood swallowed by the fetus. If this coagulation profile is normal the possibilities are either stress gastritis or ulcer disease. If the coagulation profile is abnormal then consider hematologic disease of the newborn and manage with vitamin K. The apt test is performed by mixing 1 part of vomitus with 5 part H2O, centrifuge the mixture and remove 5 ml pink.

If the coagulation profile is abnormal give Vit K for hematologic disorder of newborn. If it's normal do a rectal exam. A fissure could be the cause, if negative then consider either malrotation or Necrotizing enterocolitis. The stress includes prematurity, sepsis, hypoxia, hypothermia, and jaundice.

These babies frequently have umbilical artery, vein catheters, have received exchange transfusions or early feeds with hyperosmolar formulas.

The intestinal mucosal cells are highly sensitive to ischemia and mucosal damage leads to bacterial invasion of the intestinal wall. Gas-forming organisms produce pneumatosis intestinalis air in the bowel wall readily seen on abdominal films. Full-thickness necrosis leads to perforation, free air and abscess formation.

These usually premature infants develop increased gastric residuals, abdominal distension, bloody stools, acidosis and dropping platelet count. The abdominal wall becomes reddened and edematous. There may be persistent masses and signs of peritonitis.

Perforation leads to further hypoxia, acidosis and temperature instability. The acid-base status is monitored for worsening acidosis and hypoxia. The white blood cell count may be high, low or normal and is not generally of help. Serial abdominal films are obtained to look for evidence of free abdominal air, a worsening picture of pneumatosis intestinalis, or free portal air.

Therapy consist initially of stopping feeds, instituting nasogastric suctioning and beginning broad-spectrum antibiotics ampicillin and gentamycin. Persistent or worsening clinical condition and sepsis or free air on abdominal films require urgent surgical intervention.

Attempts to preserve as much viable bowel as possible are mandatory to prevent resultant short gut syndrome. Complicated NEC is the most common neonatal surgical emergency of modern times, has diverse etiologies, significant mortality and affects mostly premature babies. Consist of a right lower quadrant incision and placement of a drainage penrose or catheter under local anesthesia with subsequent irrigation performed bedside at the NICU. Initially used as a temporizing measure before formal laparotomy, some patient went to improvement without the need for further surgery almost one-third.

They either had an immature fetal type healing process or a focal perforation not associated to NEC? Some suggestion made are: PPD should be an adjunct to preop stabilization, before placing drain be sure pt has NEC by X-rays, persistent metabolic acidosis means uncontrolled peritoneal sepsis, do not place drain in pts with inflammatory mass or rapid development of intraperitoneal fluid, the longer the drainage the higher the need for laparotomy.

In the initial evaluation a history should be obtained for bleeding disorders, skin lesions, and aspirin or steroid ingestion. The physical exam for presence of enlarged liver, spleen, masses, ascites, or evidence of trauma or portal hypertension. Labs such as bleeding studies and endoscopy, contrast studies if bleeding stops. Common causes of Upper GI bleeding are: Esophagus a Varices- usually presents as severe upper gastrointestinal bleeding in a year old who has previously been healthy except for problems in the neonatal period.

This is a result of extrahepatic portal obstruction portal vein thrombosis most commonly , with resulting varices. The bleeding may occur after a period of upper respiratory symptoms and coughing. Management is initially conservative with sedation and bedrest; surgery ir rarely needed. Treatment consist of antacids, frequent small feeds, occasionally medications and if not rapidly improved, then surgical intervention with a fundoplication of the stomach.

This was thought to be uncommon in children because it was not looked for by endoscopy. It probably occurs more often than previously thought. Treatment initially is conservative and, if persistent, oversewing of the tear through an incision in the stomach will be successful. They bleed when there is ectopic gastric mucosa present. Total excision is curative. Occasionally requires surgical intervention with local repair or ligation of hepatic vessels.

Anal fissure is the most common cause of rectal bleeding in the first two years of life. Outstretching of the anal mucocutaneous junction caused by passage of large hard stools during defecation produces a superficial tear of the mucosa in the posterior midline. Pain with the next bowel movement leads to constipation, hardened stools that continue to produce cyclic problems.

Large fissures with surrounding bruising should warn against child abuse. Crohn's disease and leukemic infiltration are other conditions to rule-out. The diagnosis is made after inspection of the anal canal. Chronic fissures are associated with hypertrophy of the anal papilla or a distal skin tag. Management is directed toward the associated constipation with stool softeners and anal dilatations, warm perineal baths to relax the internal muscle spasm, and topical analgesics for pain control.

If medical therapy fails excision of the fissure with lateral sphincterotomy is performed. Meckel's diverticulum MD , the pathologic structure resulting from persistence of the embryonic vitelline duct yolk stalk , is the most prevalent congenital anomaly of the GI tract. MD can be the cause of: Diagnosis depends on clinical presentation. Rectal bleeding from MD is painless, minimal, recurrent, and can be identified using 99mTc- pertechnetate scan; contrasts studies are unreliable.

Persistent bleeding requires arteriography or laparotomy if the scan is negative. Obstruction secondary to intussusception, herniation or volvulus presents with findings of fulminant, acute small bowel obstruction, is diagnosed by clinical findings and contrast enema studies.

The MD is seldom diagnosed preop. Diverticulitis or perforation is clinically indistinguishable from appendicitis. Mucosal polyps or fecal umbilical discharge can be caused by MD.

Overall, complications of Meckel's are managed by simple diverticulectomy or resection with anastomosis. Laparoscopy can confirm the diagnosis and allow resection of symptomatic cases. Removal of asymptomatic Meckel's identified incidentally should be considered if upon palpation there is questionable heterotopic gastric or pancreatic mucosa thick and firm consistency present. Histology features a cluster of mucoid lobes surrounded by flattened mucussecreting glandular cells mucous retention polyp , no malignant potential.

Commonly seen in children age with a peak at age As a rule only one polyp is present, but occasionally there are two or three almost always confined to the rectal area within the reach of the finger. Most common complaint is bright painless rectal bleeding. Occasionally the polyp may prolapse through the rectum. Diagnosis is by barium enema, rectal exam, or endoscopy. Removal by endoscopy is the treatment of choice.

Rarely colotomy and excision are required. Wilms tumor WT is the most common intra-abdominal malignant tumor in children affecting more than children annually in the USA. It has a peak incidence at 3. WT present as a large abdominal or flank mass with abdominal pain, asymptomatic hematuria, and occasionally fever. Other presentations include malaise, weight loss, anemia, left varicocele obstructed left renal vein , and hypertension. Initial evaluation consists of: The presence of a solid, intrarenal mass causing intrinsic distortion of the calyceal collecting system is virtually diagnostic of Wilms tumor.

Doppler sonography of the renal vein and inferior vena cava can exclude venous tumor involvement. Metastasis occurs most commonly to lungs and occasionally to liver.

Operation is both for treatment and staging to determine further therapy. Following NWTSG recommendation's primary nephrectomy is done for all but the largest unilateral tumors and further adjuvant therapy is based on the surgical and pathological findings.

Important surgical caveats consist of using a generous transverse incision, performing a radical nephrectomy, exploring the contralateral kidney, avoiding tumor spillage, and sampling suspicious lymph nodes.

Nodes are biopsied to determine extent of disease. Stage I- tumor limited to kidney and completely resected. Stage II- tumor extends beyond the kidney but is completely excised. Stage III- residual non-hematogenous tumor confined to the abdomen.

Stage IV- hematogenous metastasis. Stage V- bilateral tumors. Further treatment with chemotherapy or radiotherapy depends on staging and histology favorable vs. Non-favorable histologic characteristics are: Prognosis is poor for those children with lymph nodes, lung and liver metastasis.

They tend to occur in younger patients. Routine abdominal ultrasound screening every six months up to the age of eight years is recommended for children at high risk for developing WT such as the above-mentioned syndromes. It was originally thought that WT developed after the two-hit mutational model developed for retinoblastoma: When the first mutation occurs before the union the sperm and egg constitutional or germline mutation the tumor is heritable and individuals are at risk for multiple tumors.

Nonhereditary WT develops as the result of two-postzygotic mutations somatic in a single cell. The two-event hypothesis predicts that susceptible individuals such as familial cases, those with multifocal disease and those with a congenital anomaly have a lower median age at diagnosis than sporadic cases. It is now believed that several genes' mutations are involved in the overall WT pathogenesis. Loss of whole portions of a chromosome is called loss of heterozygosity LOH , a mechanism believed to inactivate a tumor-suppressor gene.

Children with the WAGR association shows a deletion in the short arm of chromosome 11 band 13 11p13 but a normal 11p15 region.

Up to a third of sporadic WT have changes in the distal part of chromosome 11, a region that includes band p The region of the deletion has been named the WT1 gene, a tumor suppressor gene that also forms a complex with another known tumor-suppressor, p WT1 gene express a regulated transcription factor of the zinc-finger family proteins restricted to the genitourinary system, spleen, dorsal mesentery of the intestines, muscles, central nervous system CNS and mesothelium.

The important association of WT1 mutation and WAGR syndrome with intralobar nephrogenic rests immediately suggest that WT1 expression be necessary for the normal differentiation of nephroblasts. Inactivation of WT1 only affects organs that express this gene such as the kidney and specific cells of the gonads Sertoli cells of the testis and granulosa cells of the ovary.

WT1 has been shown to cause the Denys-Drash syndrome. Most of the mutations described in DDS patients are dominant missense mutations. A small subset of BWS has a 11p15 duplication or deletion. The region 11p15 has been designated WT2 gene and is telomeric of WT1. This might prove that two independent loci may be involved in tumor formation. A gene for a familial form FWT1 of the tumor has also been identified in chromosome 17q. There also might be a gene predisposing to Wilms tumor at chromosome 7p, where constitutional translocations have been described.

Mutation in p53 is associated with tumor progression, anaplasia and poor prognosis. Most WT are probably caused by somatic mutations in one or more of the increasing number of WT genes identified. A few chromosomal regions have seen identified for its role in tumor progression. LOH at chromosome 16q and chromosome 1p has been implicated in progression to a more malignant or aggressive type Wilms' tumor with adverse outcome.

These children have a relapse rate three times higher and a mortality rate twelve times higher than WT without LOH at chromosome 1p. Patients with WT and a diploid DNA content indicating low proliferation have been found to have an excellent prognosis. Hyperdiploidy high mitotic activity is a poor prognostic feature of Wilms tumor, rhabdomyosarcoma and Osteosarcoma. Nephrogenic rests are precursor lesions of WT. Two types are recognized: Also the association between BWS and some cases of hemihypertrophy with abnormalities of more distant loci on chromosome 11p raises the possibility that the putative WT2 gene might be more closely linked to PLNR.

An advantage of genetic testing is that children with sporadic aniridia, hemihypertrophy or the above discussed syndromes known to be at high risk for developing WT can undergo screening of the germline DNA.

This might identify if they harbor the mutation and need closer surveillance for tumor development. Neuroblastoma NB is the most common extracranial solid tumor in infants. More than new cases are diagnosed annually in the United States.

NB is a solid, highly vascular tumor with a friable pseudocapsule. Most children present with an abdominal mass, and one-fourth have hypertension. Horner's syndrome, Panda's eyes, anemia, dancing eyes or vaso-intestinal syndrome.

Diagnosis is confirmed with the use of simple X-rays stipple calcifications , Ultrasound, and CT-Scan. Management of NB depends on the stage of disease at diagnosis. Localized tumors are best managed with surgical therapy.

The Evans classification for NB staging comprised: Stage I - tumor confined to an organ of origin. Stage II - tumor extending beyond an organ of origin, but not crossing the midline. Ipsilateral lymph nodes may be involved. Stage III - tumor extending beyond midline. Bilateral lymph nodes may be involved. Stage IV - remote disease involving skeleton, bone marrow, soft tissue or distant lymph nodes.

A poor outcome is characteristic of higher stages, older patients and those with bone cortex metastasis. Other prognostic variables are: Neuroblastoma is a malignant tumor of the postganglionic sympathetic system that develops from the neural crest: In vitro three cell types have been identified: These cells are responsible for producing cathecolamines and vasoactive substances which help in diagnosis and follow-up therapy.

NB can behave seemingly benignly and undergo spontaneous regression, mature into a benign ganglioneuroma or most commonly progress to kill its host. This disparate behavior is a manifestation that we are dealing with related tumors with differently genetic and biological features associated with a spectrum of clinical behaviors. Conclusive associations with environmental factors have not been proved in NB.

Hereditary factors are important in NB since a few cases exhibit predisposition following a dominant pattern of inheritance. LOH of the short arm of chromosome 1 is also associated with an unfavorable outcome, suggesting that a tumor suppression gene may be found in this region. The common region of deletion or LOH resides at the distal end of the short arm of chromosome 1 from 1p Loss or inactivation of a gene at this site is critical for progression of neuroblastoma.

A few candidate genes from this site have been mapped. Gain of chromosome 17 is associated with more aggressive tumors. N-myc protooncogene is found on chromosome 2p and its activation results in tumor formation. The amplified N-myc sequence is found on extrachromosomal double minutes DM or on homogeneous staining regions HSR involving different chromosomes in neuroblastoma N-type cell lines.

N-myc amplification is strongly associated with advance stages of disease, rapid tumor progression and poor outcome independent of the stage of the tumor or the age of the patient. NB tumors associated with N-myc amplification needs aggressive therapy. N-myc amplification associated with deletion of 1p is correlated with a poor outcome.

Deletion of the long arm of chromosome 1 1q- is also a poor prognostic sign. Though most NB cells are diploid, a good number of them are hyperdiploid or triploid. Neuroblast cells needs nerve growth factor NGF for proper differentiation.

NB tumor cells do not respond to NGF or do not express the receptor. High TRK-A levels correlate strongly with improved survival and plays a role in the propensity for tumors to regress or differentiate into a more benign nature.

Alteration in the NGF receptor function or expression promotes tumorigenesis. In conclusion, high levels of TRK expression are associated with better prognosis, earlier stage, lower patient age and lack of N-myc expression. Neuroblastomas in newborns, cystic tumors, bilateral tumors in infants, and infants less than one year of age with neuroblastoma stage IV-S can undergo neuronal cell differentiation with spontaneous regression.

It is thought that high level of TRK-A found in this cases might explain differentiation and regression as high level of this glycoprotein is associated with a favorable prognosis. Regression might be associated with non-affected tumor cell apoptosis. Other biological markers associated with NB are the multidrug resistance-related protein MRP gene, telomerase activity and bcl-2 gene activity. MRP shows a strong correlation with an advanced clinical stages and poor prognosis.

High telomerase activity is associated with poor prognosis and high N-myc amplification. The bcl-2 gene produces a protein that prevents neuronal cell death apoptosis and promotes tumor progression. Bcl-2 expression is associated with a poor outcome. Apoptosis in NB may result in tumor progression.

The RET proto-oncogene is a protein tyrosine kinase gene Ret protein expressed in the cells derived from the neural crest. The activation of RET involves a chromosomal inversion of the long arm of chromosome 10 that juxtaposes the tyrosine kinase encoding domain of RET to the amino terminal sequences of at least three unrelated genes.

Germline mutations in the RET gene have been associated with neuroblastoma, pheochromocytoma, multiple endocrine neoplasia MEN 2, familial medullary thyroid carcinoma MTC , radiation-induced thyroid papillary carcinoma, and recently Hirschsprung's disease. RET analysis is a suitable method to detect asymptomatic children with MEN at risk to develop MTC allowing us to consider thyroidectomy at a very early stage of neoplasm development C-cell hyperplasia or prophylactically.

High levels of neuron specific enolase and serum ferritin levels are associated with a poor prognosis in NB. Nm and ganglioside GD2 are still other tumor markers associated with poor outcome, active disease and tumor progression. It has a peak incidence before the age of five years, and a second surge during early adolescence. Head, neck and pelvic malignancies are more prevalent in infancy and early childhood, while trunk, extremity and paratesticular sites are largely a disease of adolescents.

RMS arises from a primitive cell type and occurs in mesenchymal tissue at almost any body site excluding brain and bone. The predominant histologic type in infants and small children is embryonal rhabdomyosarcoma, occurring in the head and neck, genitourinary tract and retroperitoneum.

Embryonal RMS is associated with a favorable prognosis. Botryoid RMS is a subtype of the embryonal variety, which ordinarily extends into body cavities such as bladder, nasopharynx, vagina, or bile duct. The alveolar cell type, named for a superficial similarity to the pulmonary alveoli, is the most common form found on the muscle masses of the trunk and extremities, and is seen more frequently in older children and young adults. Alveolar RMS is associated with a poor prognosis.

This unfavorable prognosis is the result of early and wide dissemination, bones marrow involvement and poor response to chemotherapy. Clinical findings, diagnostic evaluation and therapy depend upon location of the primary tumor and are beyond the scope of this review. Head and neck RMS are most common and occur in the orbit, nasopharynx, paranasal sinuses, cheek, neck, middle ear, and larynx.

Most are treated by simple biopsy followed by combined therapy or preoperative chemotherapy and radiation followed by conservative resection. Operations for extremity lesions include wide local excision to remove as much of gross tumor as possible.

The trend in management is more chemotherapy with conservative surgical therapy. Survival has depended on primary site, stage of disease, and treatment given. Most RMS occurs sporadically. Other risk factors in the development of RMS include maternal use of marijuana and cocaine, exposure to radiation, and maternal history of stillbirth. Alveolar and embryonal RMS are the most genetically studied sarcomas in children. In alveolar RMS novel fusion genes encoding chimeric fusion proteins have been identified.

The t 2;13 activates the oncogenic potential of PAX3 by dysregulating or exaggerating its normal function in the myogenic lineage and affecting the cellular activities of growth, differentiation and apoptosis.

PAX7-FKHR tumors tend to occur in younger patients, are more often in the extremity, are more often localized lesions and are associated with significantly longer event-free survival. Still, a small subset of alveolar RMS does not contain either fusion mutation. The focus will be on information enabling farmers to make better decisions regarding what to produce, when to harvest and sell and where to sell. This will include information on:.

In order to ensure that the Government's role and responsibilities in relation to market access and market information are most effectively organised and properly resourced, new initiatives and procedures and their organisational and resource implications are being investigated.

The extension services will also be expected to play a significant role in disseminating such information.

The envisaged reorientation of extension workers will include training in advising farmers on marketing their commodities, and helping farmers to understand marketing costs and margins. Agriculture in South Africa is emerging from a history of protection and subsidisation described in section 1 which affected the structure, efficiency and competitiveness of the sector. Our strategy for achieving our set objectives of making agriculture more efficient, creating jobs and opportunities and using resources sustainably, is based on an outward-looking approach.

In this approach the global village is seen not only as a market for output, but as a tool for effecting efficiency by exposing our producers to international competition.

The objectives of the agricultural trade policy are to enhance and maintain market access for agricultural products and ensure that the sector contributes to its full potential to the export growth target aspired to in GEAR. Agricultural exports are critical to the achievement of this target since their contribution to total export earnings is substantial. The potential for export growth in this sector exceeds the targets set in GEAR.

The agricultural trade policy vision applies to the whole of South African agriculture, which includes diverse producers and agro-industries. For the purpose of this policy, agriculture includes primary agricultural products and agro-industrial products.

The Government's vision is to increase market access for the country's agricultural products, and to see an increase in the supply of highly competitive South African agricultural goods in international and domestic markets.

This will ensure that agriculture makes an optimal contribution to economic growth, food security and job creation, and contributes substantially to the reduction of income disparities.

To achieve this vision, policy must create an environment in which the sector can exploit comparative and competitive advantages and be highly competitive at regional and international level.

This will require effective use of the World Trade Organization WTO framework to eliminate market access barriers set up against South African agricultural exports, and to protect local agricultural industries against unfair trade practices. In the context of this policy paper, static comparative advantage is defined by broad national resource endowment, including soil, climate and water.

Dynamic comparative advantage is based on infrastructure, skills and technological innovations built through a policy regime. On the other hand, competitive advantage is based on individual entrepreneurial ability to capitalise on the existing static and dynamic comparative advantage.

Within the agricultural sector, the main objective of trade policy reform is to sustain the integration of the sector in the global economy in order to encourage internal and external competition and allow greater access to markets, technology and capital for South African agriculture. Effective participation in the WTO to press for global reforms of agricultural trade is critical to the achievement of agricultural trade policy objectives.

To achieve this, the Government will pursue the following strategic objectives: The Government will continue to work to ensure that market access barriers are minimised and, where possible, removed effectively and timeously. South African producers must be protected against unfair trade practices on the part of their competitors. Hence tariffs will be the main instrument for protecting the agricultural sector against unfair competition.

The Government will address these issues by means of three policy instruments, namely trade diplomacy, tariff policy and export promotion. The global trend now is to engage in trade diplomacy to secure improved and equitable market access. Trade negotiations have increasingly become an important tool for opening up markets for South African agricultural products.

Thus trade diplomacy is an integral part of agricultural policy designed to promote competition and efficiency. In the period since April , South Africa has been granted a number of nonreciprocal trade concessions by developed countries and regions. These concessions, though welcome, are of minor significance.

Market access impediments can only be resolved through continuing substantive negotiations. Future negotiations will take place within the following framework: This will influence the SACU agreement currently being renegotiated and any bilateral agreements with countries in the region.

The Government will seek other agreements on agriculture, where benefits are expected to be high. This includes agreements with regional organisations such as Mercosur or the Indian Ocean Rim.

Trade diplomacy involves reciprocal obligations. While seeking improved access to foreign markets for its producers, South Africa will also be required to offer concessions in terms of improved access to its market. Firstly, agriculture will have to play a significant role in prioritising sought-after partners where negotiated agreements will be necessary.

Secondly, complex trade negotiations demand a clear understanding of the interests of the agricultural sector so that appropriate tradeoffs are agreed to. There is a need for a detailed analysis of the threats facing South African producers from international competition and of the impediments to their participation in the global market place.

South Africa's membership of the WTO offers both opportunities and constraints. The Agreement on Agriculture defines commitments for the sector, to be implemented in equal annual instalments over a six-year period starting in These commitments relate to export subsidies, domestic support, and market access. Each member's specific commitments are contained in country schedules appended to the Marrakech Agreement. South Africa's commitments are summarised in Box 2. South Africa's total export subsidy outlay commitment in was R million which must be reduced to R million by the year With the termination of the General Export Incentive Scheme in July , export subsidies are now zero.

In value terms, domestic support commitment was R2. The commitments for and were met. Those products with the highest base rates will decrease by a higher rate than those with more modest base levels, thereby achieving the average reduction required over the implementation period. The tariffication of import permits was implemented relatively smoothly during , with applied levels of tariff generally lower than the ceilings represented by the commitments. Fifty-three product categories have minimum market access commitments.

In most other cases, the applied rate was below the IQTR thereby obviating the need to administer a quota. Total agricultural imports have grown at a faster rate than agricultural exports in the to period. It is also bound by disciplines placed upon technical barriers to trade and the protection of intellectual property, which aim for greater predictability, fairness and transparency. South Africa's priority is to ensure compliance with agricultural commitments in the WTO.

However, many concessions were made during the Uruguay Round to agricultural lobbies in developed countries, and a relatively high level of support remains. South African producers and exporters are left at a distinct disadvantage as are a number of other less developed agricultural exporting countries.

The Government will therefore be seeking the following in the next round of negotiations: The effective use of trade diplomacy requires strategic direction and management, as well as coordination of activities around negotiations to ensure that all are seeking to achieve the same objectives.

To this end, the Government will set up an interdepartmental committee that will forge agreement among the relevant Departments regarding South Africa's priorities in the next round. The NDA will play a leading role in this regard considering the complexity of issues and the likely importance of the sector in the next round.

At sector level, the NDA will effectively deliberate with industry representatives in order to prepare sharply defined objectives and appropriate negotiating strategies. In addition, the NDA will develop mechanisms for monitoring implementation of the agreement by our competitors. Capacity will be developed to debate and articulate implementation problems faced by South Africa, and recommend the necessary policy changes when required.

A strategy for balanced development in the region and a collective approach for seeking market access outside the region, will benefit both South Africa and its neighbours. Since the April elections, South Africa has therefore been involved in negotiations regarding possible trade agreements within the Southern African region.

A precise definition of the FTA and the process of establishing it will be determined in various rounds of negotiations. The protocol allows for a significant element of asymmetry in trade liberalisation, which means that South Africa will open up its markets at a faster rate than other SADC members. Thus the formal outcome as well as the timing of the implementation of the obligations will favour the other SADC members.

It is expected that the protocol will lead to the removal of customs duties on substantially all current trade within ten years. The most prominent demands to date from SADC partners for greater access to the South African market have focused on industrial products such as clothing and textiles. However, many SADC countries enjoy comparative advantages in agricultural products.

An expected outcome is an increase in imports of primary agricultural products from the region into South Africa, and shifts in production patterns due to comparative advantage. Its provisions in relation to trade in agricultural products are: All products will be included in the phasing out of tariffs and tariff reduction will be on a linear basis.

Specific protocols will be designed for sensitive commodities for specific periods of time. South Africa is also committed to other arrangements in the region. This concession will only be granted for a period of eight years with the consent of all contracting parties. However, this prohibition cannot be used to protect a contracting party's own industry against similar products produced in the common customs area.

Secondly, a number of bilateral agreements have already been concluded in the region. The Government will aim to finalise and implement an agreement with Zimbabwe. Currently a number of agricultural products can be exported from Zimbabwe to South Africa free of duty subject to an import permit issued by the NDA.

Agreements exist with Malawi in terms of which all goods produced or manufactured in Malawi may enter South Africa free of customs duty, and with Mozambique according to which specific products and quantities may be imported into South Africa subject to tariff rebates. In all these agreements the NDA will establish effective mechanisms for monitoring agricultural trade resulting from the agreements and their impact on our sector. In future, South Africa's trading relationships with the EU will be of great importance to the agricultural sector.

South Africa is therefore currently engaged in negotiations with the EU with a view to establishing a free trade agreement. The Government's aim is to negotiate greater access to the EU market and remove the discrimination which South African producers currently face. It appears that the terms of the agreement, as far as agriculture is concerned, may fall well short of what is satisfactory to the sector.

The Government will, however, persist over time in arguing the case for improved access for all agricultural products to EU markets. To strengthen the diplomatic approach to opening up trade, South Africa joined the Cairns Group in April This is a lobby group consisting of agricultural exporting countries with relatively low levels of domestic protection.

It operates on an informal basis without disciplinary procedures or strict rules and takes a consensual approach to decision making. This disparate group's strength lies in the fact that through collective action it has more influence and impact on agricultural trade issues than its members have individually.

Its principal lobbying is directed towards major trading countries with continuing domestic agricultural protection.

The Government's intention is to use this platform to negotiate for further liberalisation of international agricultural markets. Since June , the Geneva-based coordination of activities of the Group have been a useful supplement to South Africa's capacity in this field. This section has emphasised the importance of trade diplomacy in agricultural policy. The effective use of trade diplomacy requires careful planning not only of the negotiations themselves, but also of the development of specific agricultural subsectors.

Box 4 outlines some basic guidelines that will be followed by the NDA in all negotiations. The particular objectives of each negotiation must be clearly specified but ultimately all negotiations will seek to achieve: In the final analysis, market access is a means to an end, not an end in itself. The impact of an agreement on the RDP objectives of reducing income disparities, creating employment, enhancing growth and improving quality of life must be clearly demonstrated.

Negotiations will be based on: To this end, a study of South African agricultural structure and competitiveness is being carried out in the Minister's Office which will provide a baseline. This study will be broadened to include characteristics of agricultural subsectors and how these change and affect the objectives above.

Such information must be kept in a database and must be updated continuously. Negotiation mandates must make reference to this database and a full report showing how agriculture will change in the course of the implementation of the agreement will be prepared.

The Parliamentary Portfolio Committee will also be kept informed of all developments. Tariffs will be applied as an important component of specific strategies for enhancing competitiveness and creating jobs through trade-based mechanisms such as liberalisation.

Two strategic objectives of the agricultural tariff policy are therefore to protect domestic agriculture and to facilitate structural adjustments within the sector. It is not Government policy to use customs tariffs as a means for generating revenue.

Various policy instruments will be applied to achieve these objectives. Ordinary duties are limited by negotiated agreements and obligations enshrined in the WTO. The tariff equivalents set through the process of complying with the WTO commitments represent the maximum level of tariff that can be levied, and these are bound against increase.

Agricultural products were tariffed by , thus setting ordinary duties. WTO rules also require that the bound tariff levels be reduced by specified percentages over the periods indicated in the agreements.

South Africa's tariff commitments are presented in Box 2. As a matter of policy, ordinary duties will be constantly reviewed to ensure that tariff levels applied are consistent with the stated policy objectives of making agriculture efficient and competitive. The margins existing between bound and applied are critical if ordinary duties are to be used to influence the restructuring process. Tariffs will be kept under review to ensure that they are both in line with policy and simpler to administer.

In addition, variable import charges can be applied to certain agricultural imports. The variability of such duties has to remain within the bound ceilings. Such a price band scheme can be operated to reduce price variability of certain commodities rather than to increase protection. This is a useful tool for minimising the variability of food prices. Tariff quotas are used mostly in trade agreements and are therefore country and product specific.

Protection against unfair external competition is a major concern of both the Government and the farming sector. The GATT Agreement, , Article VI makes provision for countries to eliminate injury to local industries demonstrably arising from dumping or subsidies, by imposing antidumping and countervailing duties respectively.

Three factors need to be established before such duties are levied: This means the dumping margin must be established 2 that as a result, an industry suffers material injury 3 that injury in 2 is a direct result of the dumping. The Agreement on Agriculture also makes provision for Governments to impose additional tariffs on products over and above the bound levels, to deal with a surge in imports as a result of a drop in prices if: The critical issue for policy is the use of trade remedies where local industries suffer injury due to unfair practice.

The use of these remedies, however, must be within the strict WTO disciplines, which makes them complex mechanisms. Nevertheless, it is policy to strengthen the use of these remedies and reduce reliance on ordinary duties to deal with unfair trade practices. Agriculture will work with the DTI to design agriculturally defined guidelines on the use of anti-dumping, safeguards and countervailing duties. Such systems will not be burdensome, but predictable and able to respond swiftly to problems that arise.

Tariff policies are only as meaningful as the systems put in place to regulate and control the flow of imports. Agricultural trade requires well-qualified and vigilant personnel at the ports of entry. The two principal problems are underinvoicing and misidentification. Since almost all tariffs are raised on the transaction value of a shipment, underinvoicing is a means of illegally underpaying the required tariff.

In both cases, the onus lies with the administration to be vigilant about these problems, and to take severe action. Better training, more agents, improved incentives, and more efficient recording and checking systems are needed. The Department of Agriculture will work closely with the South African Revenue Services regarding the effective implementation of tariff policy.

The importance of export growth to South Africa's development strategy cannot be overemphasised. While an enabling trade-policy environment is a critical element of an export-led growth strategy, the increased level of competition in the global economy demands that Governments design measures to improve the competitive edge of their own producers.

Vital elements of a competitive sector include the transmission of information on subjects ranging from market locations to packaging, labelling and meeting certain technical requirements; the provision of quality control services; and the development of infrastructure.

Although marketing is generally a private-sector function, the Government can also play a key role in facilitation. The main problems faced by exporters are a lack of information and of skills, inadequate access to financing, and poor infrastructure. The Government will therefore use non-trade-distorting mechanisms to assist in providing an environment conducive to export growth. Such measures will be made more effective by: These measures will include: It will, for example, facilitate the sector's participation in trade missions, exhibitions, fairs and other activities that increase international awareness of South African agricultural products.

The Departments of Agriculture will seek partnerships with local authorities to ensure the provision of infrastructure that will lower transaction costs for farmers.

This section of the policy paper has outlined important elements of an agricultural trade policy conducive to:. Deregulation has created an incentive structure that will stimulate and reward investment not only in domestic and export markets but also in the ancillary industries. It is envisaged that the role of the Government will in future pertain particularly to trade diplomacy and to providing an efficient regulatory framework.

The deregulation of domestic agricultural markets and the liberalisation of international agricultural trade have increased, rather than diminished, the need for a framework of standards for the quality and safety of both inputs into crop and animal production and outputs from such production.

Effective measures are needed to maintain such standards through, for example, the prevention and control of epidemic diseases and effective inspection and diagnostic services. In striving to achieve these objectives, the Government wishes to ensure that regulations are not used to erect unfair barriers to those who wish to enter into agricultural production and commerce, and do not, therefore, put limits on competitiveness.

Wherever appropriate, the costs of regulation should be borne by those producers who benefit directly from such measures, and the Government will investigate the most cost-effective ways of implementing regulations.

All countries maintain health and sanitary regulations for exports, imports and domestic products. An SPS measure is applied by a country to protect the life or health of people, animals and plants from risk arising from the entry, establishment or spread of pests, diseases, and disease-carrying or disease-causing organisms. This requires regulation, which includes laws, processing and packing regulations and labelling requirements. Box 5 shows the quality attributes for all food products.

Package attributes Package Materials Labelling. The responsibility for setting food safety standards and enforcing them lies with the Department of Agriculture and other Government institutions, particularly the Department of Health. As a general principle, SPSs will be enforced in accordance with the provisions of the SPS Agreement and other international conventions.

South Africa is a signatory to the following agreements: The relevant international standards, guidelines and recommendations of the Codex Alimentarius will be used as quantitative benchmarks. The NDA will ensure strong participation from the agricultural sector including legal and scientific contributions in the body's international standard-setting activities.

The enforcement of SPS measures will be based on the assessment of risk. Inspection is required in order to establish the processes and production methods used as well as the scientific evidence and prevalence of specific diseases or pests. The inspection function is provided not only to enforce standards for domestically produced commodities destined for exports and local consumption, but also to protect exporters against unfair standards set by importing countries.

Where measures go beyond required SPS standards and are used for protecting industries by the elimination of import competition, they become TBTs. South Africa is a signatory to the Agreement on Technical Barriers to Trade and will use this agreement and its trade remedies as instruments to fight an attempt to restrict its exports through technical barriers. The Department will ensure that standards applied to this country are non-discriminatory and transparent and do not restrict trade more than is necessary.

The Government is responsible for setting standards and it must also take responsibility for an effective inspection system that enforces compliance with a large variety of commodity-specific and country-specific regulations. However, the Government may choose to outsource the delivery of some of the inspection functions where it has confidence in the existing private-sector institutions. With the increased use of SPS and health standards to restrict trade, and the increase in trade as a result of globalisation, it is now of critical importance to tighten and improve the provision of inspection services.

Several pieces of legislation exist and are administered through different Government Departments and Directorates. A lack of coordination of inspection activities and duplication have reduced efficiency and negatively affected delivery. The removal of interdepartmental duplication in areas such as enforcement, risk management, laboratory services, information systems and communication will lead to a more efficient utilisation of scarce resources.

The purpose of regulation in respect of breeding is primarily to support the industry through steps which encourage investment in improved stock and provide confidence for those engaged in the purchase and sale of breeding stock. A new Animal Improvement Act will remove such distortions, and ensure that importers and breeders' suppliers of genetically superior animals and genetic material are bound by essential standards that will ensure that the standard of genetic material used in South Africa is sufficient to maintain or improve production efficiency.

The Bill proposes to retain certain valuable regulatory aspects of the existing Act, such as the identification and use of genetic material that could be used to the advantage of the national herd; the provision of animal reproduction services; and the establishment and maintenance of animal breeders' societies. However, the Bill also makes provision for the following important changes:. The benefits to livestock owners of a system of registration, identification and performance monitoring of animals have largely been confined to the white commercial sector.

The costs of this system have increasingly been borne by livestock owners, through registration by breeders' societies, for example, and through charges for the cost of services rendered by the Stud Book and Livestock Improvement Association.

The widening of benefits to emergent farmers and stock owners in commercial areas is now a Government priority. It would be unproductive to expect such an expansion of services to take place on a cost-recovery basis, in the short term at least, but there are considerable benefits to stock owners in having a national system of registration and information on, for example, fertility, milk and wool production and growth.

These benefits include better price realisation, more security against stock theft and better take-off management through performance monitoring. Such a scheme has been initiated in some parts of the country, particularly the Northern Province, and the Government will extend the scheme as rapidly as resources allow.

The responsibility for animal welfare services has been transferred from the Department of Justice to the Chief Directorate Veterinary Services of the Department of Agriculture. This has been done to facilitate the rendering of a humane and effective animal welfare service; provide for the recognition by registration of bona fide welfare organisations; and the setting of minimum standards for services and for the training of inspectors.

In terms of policy, the focus will be upon promoting humane behaviour to avoid unnecessary pain and distress to animals, rather than on individual acts of cruelty. Legislation and codes of conduct to be developed in this area will draw on international experience in the field of animal welfare and animal rights, while taking cognisance of the specific challenges raised in South Africa with regard to cultural diversity and poverty.

The agricultural aspects of new legislation will deal with ceremonial or religious slaughter, experimentation with animals, the transport of animals, their treatment at abattoirs and their export for breeding and slaughtering purposes. Regulations on the latter will be aimed at achieving a balance between the enforcement of transport conditions which minimise stress and discomfort, and the legitimate interests of producers attempting to gain access to the lucrative market of the shipment of live animals.

A proposal is also being considered for the establishment of an Animal Welfare Committee to advise the NDA on animal welfare matters. The Constitution provides a framework for the Government's livestock and animal health services. Animal health control and diseases are listed as a concurrent national and provincial competency. A number of veterinary-related spheres of the Government have also been listed as provincial and local competencies. They include veterinary services excluding regulation of the profession ; facilities for the accommodation, care and burial of animals; the licensing and control of undertakings that sell food to the public; municipal abattoirs and pounds.

The Act now needs revision, however, to bring it in line with the Constitution and to clarify provincial and national responsibilities. It is proposed that under the Animal Health Bill, the NDA be made responsible for the coordination of all aspects of animal disease control and eradication throughout the country. This would involve setting standards for the control of notifiable diseases in animals including game , which are applicable to all the provinces.

The legislation will authorise the Government to: Veterinary medicines The supply of safe, productivity-enhancing and internationally acceptable veterinary medicines is essential for the development of the livestock industry.

Currently, there are several restrictions on effective supply, which the Government is seeking to remove. There are many animal treatments or medicines, including certain food supplements, which can be sold by any registered supplier under the Fertilizers, Farm Feeds, Agricultural Remedies and Stock Remedies Act of Act No.

However, there is also a category of veterinary medicines which cannot be dispensed without professional diagnosis and which is controlled by a separate Medicines Control Act administered by the Department of Health. The limitations of this system are that conflicts can arise over the appropriate regulatory mechanism to be used; that inadequate attention may be given to the specific issues relating to agriculture in considering the registration of new veterinary medicines and the regulations concerning their use; and that insufficient attention is given to the need to establish a properly regulated distribution network which serves livestock owners in poorer areas.

New legislation, and measures being taken by the NDA, are intended to address these limitations. The Committee will be responsible for making recommendations on registration and regulations which will require the approval of both the Minister of Health and the Minister of Agriculture. The latter will also make an appointment to the Board of the Authority. As part of the Act to establish the Authority, stock remedies will be removed from the Act, thereby consolidating responsibility for veterinary medicines and providing a scientific expertise and an effective inspectorate through the Authority.

The Standing Committee recommendations will be expected to facilitate the accessibility of veterinary medicines though regulations on the licensing of dealers and re-packing of smaller quantities, for example , but the task of developing veterinary medicine services will remain the responsibility of the National Department, Provincial Departments and the industry itself.

Particular attention will be paid by the Government to the training of veterinary assistants so that more diagnostic services are made available and more treatments can be undertaken in rural areas, with refrigeration and other facilities made more widely available by commercial suppliers. The Government is responsible for all food and food-related safety, SPS quality control measures. However, VPH also covers milk hygiene which falls under the Department of Health and local authority jurisdiction as well as eggs and fish which lack a proper VPH policy framework at present.

National food safety legislation will: The Government would like to change the perception that this is a policing function into an awareness that it is a facilitating service for the industry. Legislation on plants, seeds, plant protection and plant quality control is necessary for both farmers and consumers, and is becoming increasingly important in the field of international trade where SPS and TBT measures, if inadequately managed, can seriously jeopardise export prospects.

In the area of product standards, the Government has already delegated certain functions to industry-based organisations so that they will carry out some of the tasks of regulation. The underlining principles will be the integrity of assignees in both the domestic and international arenas; the need for an efficient and economic delivery system; and transparency and other criteria that may emanate from South Africa's membership of conventions.

To improve efficiency and sustainability of these services the Government will charge fees to those who benefit from them.

Most of the legislation pertaining to food safety, standards and technical inspection for SPS and TBT, will be consolidated and amended according to objectives and principles that govern the inspection agency. Considerable uncertainty and risk is attached to farming. Agriculture in South Africa is inherently more risky than in many other countries because of low average rainfall, and the wide variability in rainfall both between and within seasons in most parts of the country. In addition to the risks associated with drought, farmers are also confronted by a range of other hazards, including hail, fire, pests and diseases.

In the past farmers have relied upon Government relief programmes as a means of coping with these risks, especially drought. These programmes have, amongst others, reduced farmers' willingness to take other measures to avoid risks, as all such measures entailed costs. Farmers have often also been encouraged to use technologies which are unsuited to areas prone to drought, and harmful to the environment in bad years, in the expectation that they would receive assistance in the event of their crops failing.

The Government will no longer provide drought relief as in the past. Instead, it will promote other options for reducing risk. All risk-reducing measures entail costs, which can be borne either by farmers or by the Government. Whereas in the past there has been a strong reliance on the state, the role of the Government will now be to reinforce farmers' ability to deal with risk in a sustainable manner.

This will reduce dependency and environmentally damaging cropping and other land-use practices. Thus the overall change in the orientation of policy will put the responsibility of coping with drought back into the normal production system. This will cause farmers to exercise greater prudence and make themselves less vulnerable to the effects of drought.

The role of the Government is to assist farmers' own efforts to cope with various risks and, where possible, to take steps to reduce the likelihood of risk. This involves four separate tasks: Research will be aimed at supporting the development of more robust technologies as well as preventative measures to reduce risk. Farmers do not always choose less risky technologies, as has been proved by the widespread replacement of robust food crops such as sorghum and millet by maize.

The Government will therefore support research to improve the yield and robustness of all staple-food crops, rather than simply of those requiring relatively high external inputs. The reorientation of research in South Africa is aimed at, amongst others, understanding the constraints and risks faced by the most vulnerable farmers, and at strengthening their ability to deal with risk in a variety of ways.

This will include research and extension regarding a broad range of techniques, including low-input systems to reduce vulnerability, water harvesting, fodder enhancement, and farming systems more generally. Diversification of production systems as well as sources of income for the farm household will reduce risk levels. Risk-minimising measures will include minor steps such as staggering the planting dates of the same crop to reduce the liability of complete crop failure due to the pattern of intra-seasonal rainfall, and major initiatives such as developing a range of crops, livestock and off-farm activities.

Research and extension will support a wide variety of possibilities, depending on farm circumstances. The Government has the responsibility and the opportunity of greatly improving farmers' access to information, for example information on market trends and advances in research, as well as improved climate forecasts, and also of ensuring that the information is accurate and useful.

The NDA and provincial departments will also play a major role in the development of data collection, monitoring and assessment measures as part of a national early-warning system for disaster management under the Department of Constitutional Development. Government measures to control epidemic diseases which threaten farm livelihoods were discussed in the previous section.

As far as migratory pests are concerned, the Government is principally concerned with flying locusts and swarms of redbilled quelea. The Government cooperates with local communities in locust-breeding areas to control this pest. Some 40 million labour days were financed in to assist in a campaign which prevented the depletion of some 9 million tons of pasture. The Government will continue controlling quelea swarms with explosives and chemical treatments but, as in the case of locust control, attention will increasingly be paid to establishing new SADC-wide instruments now that the functions of the SARCCUS subcommittee on migratory pests have been transferred to this larger organisation.

Agricultural taxation compensates farmers to some extent for the measures they take to reduce the impact of disasters on farm income. Currently, special tax measures are available to farmers in the following cases:. Firstly, the Income Tax Act of stipulates that where a farmer has sold livestock on account of drought, stock disease or damage to grazing by fire or plague, and purchases replacement stock within four years, such purchases may be counted as a deduction in the year of purchase.

The effect is to smooth taxable income. Secondly, the Tax Act stipulates that if a farmer disposes of livestock due to drought, and deposits the proceeds with the Land Bank, the deposit will not be deemed as part of the gross revenue for the year. Thirdly, the Act allows deductions for certain drought-related expenditures.

Fourthly, the Act makes provision for certain expenditures which relate to income not capital , such as the allowance for interest on loans or bank drafts to be deductible from income. These four provisions go some way towards assisting farmers in reducing their vulnerability to droughts. However, it is notable that livestock farmers rather than cultivators receive much greater benefits, even though dryland crop farmers are more vulnerable to drought.

One option would therefore be to extend the provisions to all tax-paying farmers, so that they may save in good years as a deduction before the estimation and taxation of total revenue, and will be taxed in the year in which such savings are drawn down when income will be lower, so that average long-term taxation is reduced a little on average, but the main effect is delayed taxation.

The Working Group on Drought and Disaster Management, established by the Minister in , claims that such a measure is likely to have two additional effects that would probably raise overall taxation. Firstly, it is likely that more farmers will register for taxation thereby broadening the potential revenue base. Secondly, there will be a strong incentive for farmers to save and eventually pay some tax rather than reduce tax liability through the purchase of unnecessary or expensive equipment and vehicles.

The Group also says that there would be no need for the Government to establish and manage a stabilisation fund, although most funds are set up in this way such as the Canadian Net Income Stabilisation Account. For insurers, covering drought damages also requires exceptionally high standards of assessment and inspection, resulting in high operating and administration costs.

As for farmers, in the past particularly there was a feeling that drought insurance was overpriced given the fact that the state would generally be expected to respond to their demands in times of extreme stress. However, the removal of ad hoc Government assistance alone will not cause a large number of farmers to take out policies from private-sector insurance companies based purely on commercial principles.

In these circumstances the Working Group feels that it should be considered providing a targeted subsidy on insurance premiums to smaller farmers, especially those unable to benefit from any tax measures due to relatively low incomes. South Africa's earlier attempt to broaden access to drought-inclusive crop insurance was not particularly successful, however. In the first year of its operation, around 12 policies were issued, with uptake being particularly poor in high-rainfall areas.

The number of subscribers dropped every year after that. The scheme carried on for several more years without the Government's involvement, and then ceased altogether. The major problem with the scheme was the low participation rate, which apparently resulted from an inadequately developed pricing structure, an insufficient subsidy and, as mentioned above, the disincentive posed by the existence of other avenues for getting drought assistance from the NDA.

If the Government is to consider attempting anew some form of subsidised, drought-inclusive insurance scheme, it must be mindful of South Africa's own past experience, as well as that of other countries where similar schemes have been attempted with generally disappointing results. Of greatest importance is that the participation rate must be significant, so that the risk-pooling function of the scheme can be fully realised. An effective research system is an essential component of any country's agricultural sector.

This record of success is, however, the result of research aimed almost exclusively at the requirements of large-scale white farmers. Very little effective research has been directed towards small scale, resource-poor producers in the black communities. Furthermore, the research system has operated in an environment in which subsidies encouraged the development of capital-intensive, high-input farming. The Government will ensure that public spending in research is geared towards investigating methods to attain broad policy objectives.

In general, agricultural research must lead to the development and sustained utilisation of agricultural science capacity to increase the biological potential of plants and animals, and to improve the economic management and use of natural and human resources on which the realisation of this biological potential depends.

While agricultural research systems in South Africa have, to some extent, been successful in achieving this, the challenge is to make the production technologies that are the output of such research, applicable to the needs and resources of small scale, disadvantaged farmers. Within the context of overall agricultural policy in this document, a number of challenges have been raised.

An effective research system is critical in that it must find ways for the Government to cope with these challenges. It is Government policy to strengthen the linkages between research and agricultural policy. The following illustrates how research is expected to link up with the main elements of agricultural policy:. Given the Government's export-oriented growth strategy, agricultural research can play a major role in opening up new opportunities through research on non-traditional crops.

It can lead to improved technology which will enable us to exploit comparative and competitive advantages. Thus, in research, attention must be paid to trade-related product development which ranges from product improvement, improving durability either for travel or for shelving, to product presentation and packaging.

Such research is critical to increasing the volume and value of trade in agricultural commodities. To this end the research system must be strongly linked to technology dissemination, which will have to move away from simple message systems to participatory approaches. Against this background, the reform of agricultural research policy will be aimed at: Until , most research was done within the Department of Agriculture's 11 institutes to the benefit of white farmers.

These well-funded and well-maintained research facilities were then handed over to the Agricultural Research Council ARC. The ARC has focused almost entirely on managing its own capacity, organised into some 16 research institutes, most of which do research on commodities. Given the strong support available to researchers at universities, for example their access to social science departments and their ability to link research to training, a strong case can be made out for increasing the relative share of funding going to universities.

Much of the research in the private sector is near-market or development work determined with the help of farmers and their associations. In the past, the research was almost entirely focused on the commercial sector although some results have been useful to small-farmers. The sugar industry, for example, finances all its own research and is developing a strong profile among smallholder producers. Private-sector research employs some scientists or technologists. Numerous reviews of South Africa's agricultural research systems have identified the need to set research priorities to ensure that public expenditure in research helps the Government to meet its objectives.

While priorities set for research in agriculture in the past were supportive of apartheid policy objectives, it has not been easy to reorientate these priorities to fit in with the new dispensation. Such reorientation requires major institutional transformation.

In carrying out this function, DACST seeks to ensure that each organisation within the National Systems of Innovation meets the broad national objectives. In this regard, its policy is that future funding of the ARC will depend on whether its activities and competencies support the RDP principles as well as sectoral policies which are set out in this document. It is therefore of critical importance to the state Departments of Agriculture that the ARC should be a responsive institution for delivering new technology and empowering farmers and scientists from all sectors of society, in order to retain its access to public funding.

It also has profound implications for all professional staff in the research system, many of whom have little knowledge of small scale farmers' needs and other research methodologies such as participatory research. The Government would like to see a strong ARC, which is constantly seeking ways of increasing productivity in agriculture. It is therefore interested in transformation of the organisation in a manner that will ensure excellent services and sustainability.

To this end, a new Board that was appointed in has already begun developing a vision for the institution. Particular attention is given to the needs of resource-poor farmers, improving the linkages to sources of knowledge outside the ARC, and the dissemination of research results. In allocating public funding, the Government will increasingly give priority to the needs of small scale, resource-poor farmers and will consequently focus on the following areas: Land care, and soil and water management.

The Power of Together.