healthcare gazette
MAY/JUNE 2016 • ISSN 2078-9750
Gauteng bubonic plague scare highlights hygiene needs
PG 10
Dealing with depression PG 34 11
18
NEWS
Screen for diabetes at TB clinics, urge experts
26
RESEARCH
Global obesity trends – heading for disaster
30
FEATURE
Addressing SA’s stark health inequalities
H EALT H CARE G A ZE TTE | J A NU A RY 2 0 1 6 www.hmpg.co.za
FOCUS
All about eczema
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Once monthly Oral
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and this
Contents | 03
C o nt ent s 09
NEWS 09 Untreated ADHD raises psychiatric risk 10 Gauteng bubonic plague scare highlights hygiene needs 11 Screen for diabetes at TB clinics, urge experts
19 Pioglitazone and the risk of bladder cancer 19 More evidence for link between Zika virus and fetal brain abnormalities 19 Fast for longer at night and reduce risk of breast cancer recurrence
12 TB drug price cut push for May
19 Say no to the smoothie
13 Robotic prostate surgery could reduce recovery time
FEATURES
14 SA suicide numbers among world’s worst
20 Smoke and mirrors – seeing through the clouded tobacco debate
14 X-ray backlog solution hampered by data costs
26 Addressing SA’s stark health inequalities
15 New drugs could restore old antibiotics
FOCUS
17 12 childhood gastro deaths in the Western Cape
RESEARCH 18 Don’t over-treat hypertension in diabetics 18 Second malignancies after radiotherapy for prostate cancer 18 Global obesity trends – heading for disaster
30 All about eczema 34 Dealing with depression
PROFILE 38 Derek Yach: Global health innovator
CLINICIAN’S VIEW 42 Detecting depression: Where, how and then what?
20 30
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Medchem Pharmaceuticals CC Tel no: 012 348 0752 • Fax: 012 348 0873 • Email: medchem3@gmail.com
Ed’s Letter | 05
Ed’s Letter EDITOR Chris Bateman CONTRIBUTORS Toni Younghusband, Clare van der Westhuizen, Bridget Farham, Leverne Gething
C h r i s B at e m a n
SUB-EDITOR Diane de Kock
Melting the disease icebergs, one diagnosis at a time
U
nderdiagnosis; the phrase crops up time and again in this edition, whether it be for ubiquitous depression, rarer pulmonary arterial hypertension (PAH) or little-known adult attention deficit hyperactivity disorder (ADHD). The reasons are varied and complex but it speaks to the constant need for broadening knowledge levels among healthcare workers and patients. What immediately grabbed my attention in taking a bird’s eye view of this edition is that it’s nearly always just a few passionate torchbearers who move us towards a tipping point of practical know-how and lifesaving awareness. Whether it’s the starfish syndrome (making a difference by throwing a comparatively few beached individuals back into the sea to swim another day) or a
population-level advance in medicine that improves treatment outcomes, these are the heroes who stoop to help, always open to others and the wider context. In South Africa too many expert healthcare workers, who could easily make a huge difference, are blinded in their professional silos and will probably complain the loudest when “unreasonable” NHI requirements kick in. Speaking of passion; it isn’t lacking in the e-cigarette debate when it comes to the favoured tools of harm reduction. We’ve elicited the views of some of the world’s experts – both local and abroad – to help lift the dense cloud of smoke on this issue. Elsewhere we look at what seems to be a frightening red flag on potential disease spread through woeful service
delivery. Bubonic plague was detected (albeit in a rat) in a Gauteng squatter camp recently, during a prolonged rubbish collectors’ strike. It speaks to the pre-emptive alertness of the local environmental health authorities, backed by the National Institute for Communicable Diseases (NICD), but is not the first instance of potential and fatal disease outbreaks via woeful sanitation, waste and water management by dysfunctional local authorities. Another story worth singling out, on the general underdiagnosis theme, is the call to co-screen for TB and diabetes at the individual, disease-specific facilities – it’s a pragmatic suggestion that could save countless lives through early diagnosis and treatment of highly prevalent comorbidities.
Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham MANAGING EDITORS Ingrid Nye Claudia Naidu TECHNICAL EDITORS Emma Buchanan, Paula van der Bijl PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens HEAD OF SALES AND MARKETING Diane Smith | +27 (0)12 481 2069 sales@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renee van der Ryst Azad Yusuf Benru de Jager Ladine van Heerden CUSTOMER SERVICE AND ONLINE SUPPORT Gertrude Fani | +27 (0)21 532 1281 publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 tshepisom@hmpg.co.za LAYOUT AND DESIGN Tenfour Media Printed by Paarl Print HG online issues: https://issuu.com/ hmpg/stacks The Health and Medical Publishing Group is a wholly owned subsidiary of the South African Medical Association (www.samedical.org). For information on subscribing to Healthcare Gazette, please contact sales@hmpg.co.za.
06 | Corporate Profile
Bidvest Medical driving 21st century radiology transformation The global radiology environment is undergoing significant change, driven by the digital revolution on the one hand and the emergence of new, innovative suppliers who are challenging the dominance of the traditional radiology giants, on the other. South Africa is not immune to these trends and Bidvest Medical, a relative newcomer to the sector, is starting to punch well above its weight as it drives these changes forward and helps radiology departments and practices meet the challenges facing healthcare providers in the 21st century. Wholly owned by the Bidvest Group, Bidvest Medical supplies diagnostic radiology imaging solutions that are relevant to a broad range of health facilities from hospitals to smaller clinics, private radiology practices and mobile providers. According to Bidvest Medical general manager Juneid Docrat, the company’s offering spans the entire spectrum of radiography: from superb imaging and agnostic picture archiving, to historic film digitisation and image management; as well as high resolution, energy efficient medical monitors and displays, and powerful workflow solutions. “While there is no doubt that the rise of digital technology has resulted in improvements in patient diagnosis and treatment in recent years, it has also wrought unexpected challenges for practices. Not least of these is the need for greater productivity and the risk this poses to patient care.” Docrat says. “At Bidvest Medical, our goal is to ensure that our clients receive the best possible return on their investment while also making their day-to-day operations more productive and profitable. All our products from our entry-level through mid- to high-end X-ray equipment is priced extremely competitively. We also offer tailored finance and flexible rental solutions, all backed by a buy-back guarantee.” “However, we firmly believe that practice productivity and profitability can and should be achieved without compromising on patient care.” Bidvest Medical therefore focuses on delivering the most appropriate solutions that enable medical professionals to diagnose accurately and quickly. These solutions incorporate products sourced from several of the world’s most innovative developers and manufacturers of radiology equipment including Samsung, Konica Minolta, Ramsoft, Vidar and Jusha. This is backed by superior service and support of the highest quality. Trained radiology technicians, located at each of Konica Minolta’s 20 branches throughout the country – significantly reducing service turnaround times – are supported by the entire Bidvest Medical service team based at the company’s head office in Ormonde, Johannesburg.
Show, test and touch innovation Bidvest Medical is taking the process involved in the acquisition of advanced medical technology and equipment to a new level in South Africa, with the development of an interactive showroom at its Johannesburg premises. Scheduled to open later this year, the new showroom will provide clients with an unprecedented, hands-on testing and purchasing decision-making experience. “The power, versatility and capability of the latest radiology technology cannot be conveyed adequately in photographs, pamphlets and diagrams. The development of this multi-million-rand showroom will enable clients not only to look at and touch the equipment but also test it and see it in action, all in the context of a functioning radiology practice,” said Nicolene Voget, diagnostic imaging product manager at Bidvest Medical. “We look forward to welcoming clients to the showroom.”
Corporate Profile | 07
The Bidvest mobile healthcare truck – tough enough to take on difficult terrain. Juneid Docrat, General Manager, Bidvest Medical
Bidvest Medical innovation goes mobile With many people across Africa deprived of essential diagnostic and primary healthcare services because of their location or socio-economic circumstances, Bidvest Medical has developed an innovative, mobile solution. The company recently built its first robust, go almost anywhere, use virtually anywhere (with single phase electricity) healthcare truck. Equipped with a state-of-the-art Konica Minolta X-ray system and digital panel, the truck has been used for tuberculosis screening of thousands of offenders at prisons across the country. Bidvest Medical can also customise healthcare trucks for other applications such as mass screenings for lifestyle and communicable diseases, mammography screening, as well as basic healthcare: vaccinations, simple examinations, eye tests, dental care and preand postnatal care. Contact details: Telephone: 011 661 9500 Website: www.bidmed.co.za Email: info@bidmed.co.za
Precious Mdlankomo of Mmidi Occupational Health Services (right) and Nicolene Voget, diagnostic imaging product manager at Bidvest Medical in the Bidvest Medical healthcare truck.
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News | 09
Untreated ADHD raises psychiatric risk
Lack of clinical knowledge and financial support for adults with attention deficit hyperactive disorder (ADHD) is a major barrier to treatment and diagnosis of a disorder affecting an estimated one million South Africans, aged 20 - 50 years old. This is the finding of a study thesis completed by Dr Renata Schoeman, a psychiatrist and University of Stellenbosch Business School (USB) topof-the-class MBA student. It involved a three-part study study: a retrospective database analysis of all claims submitted over a 2-year period to one of the country’s largest medical scheme administrators, a survey of all registered psychiatrists (588, with 455 in private practice) treating adult ADHD patients, and a qualitative analysis of key local psychiatry and neurology opinion leaders. Schoeman found that, if left untreated or misdiagnosed, adult ADHD increases the risk of other psychiatric phenomena such as anxiety, mood disorder and substance abuse. At work, people with ADHD displayed
poor time management, goal setting, stress management and organisational skills, which had a major impact on colleagues. While medical schemes routinely covered childhood ADHD, they seldom provided benefits for adults who struggled to afford private treatment over and above their monthly medical aid costs. This led to huge undertreatment. “It’s a costly, chronic disorder, with significant impact on the quality of life of patients and their families,” she emphasises. She cites the condition’s disability-adjusted life years (DALYs) at 424/100 000. General practitioners routinely misdiagnosed or inappropriately diagnosed complex presenting symptoms. They and many psychiatrists (especially those who qualified before adult ADHD was recognised as a disorder) had limited knowledge about adult ADHD. “Also, you cannot assess properly in 15 minutes. It often presents with comorbidities. Those who primarily complain of ADHD symptoms are often students and professionals wanting the
drugs for study purposes, so vigilance is needed.” Schoeman has developed a new funding model. She’s confident it will help medical aids come to grips with long-term patient needs and improve access to diagnosis and/or treatment. She believes medical aid funding reluctance may be due to a lack of knowledge and the risk of overdiagnosis, which further strengthens the case for raising the diagnostic bar.
ADHD causes and diagnostic clues n Predominantly genetic, though often combined with environmental factors n Proven links to maternal health, pregnancy and premature birth n People don’t “outgrow” ADHD – they just get better at managing the symptoms n Functional impairment essential for proper diagnosis n Impoverished environment: lack of skills, development, training and coaching. Tip: A motivation to medical aids of lifelong ADHD may swing adult patient funding.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
Gauteng bubonic plague scare highlights hygiene needs
Personal and community hygiene took centre stage in South Africa (SA) this March when bubonic plague was found in one of several rats killed in Tembisa’s Mayibuye Township on the East Rand, during a lengthy strike by a local refuse removal company. While the National Institute for Communicable Diseases (NICD) moved quickly to bolster local environment health department control measures (flea spraying, rodent trapping and poisoning), John Frean, the NICD’s associate professor at the Centre for Opportunistic, Tropical and Hospital Infections, calmed public fears. He said 13 rats were collected from the informal settlement by the two agencies as part of a monitoring programme testing for various
rodent-borne diseases. On 16 March this year one tested positive for plague. “There’s no need to panic. Correct measures are in place to control any spread to humans,” Frean said. Insecticides were being sprayed, both where the infected rodent was found and further afield, while ongoing lab testing on captured rats continued. A human would only be infected if an infected flea, which had been feeding on the infected rat, had no other rodent to feed on, he said. Large-scale rodent deaths were needed to leave fleas “without their meal”, encouraging them to turn to humans. “We haven’t found any evidence of a large-scale rodent die-off, which means the risk to humans at this point doesn’t exist,” he stressed.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
Gauteng health department spokesperson, Steve Mabona, urged personal and community hygiene. Frean said township residents could reduce risk by keeping their immediate surroundings clean. “We can trap, poison and gas as many [rats] as we want, they just breed to fill the vacuum – so unless we clean up, we’ll never reduce them to acceptable numbers. They’ll always be with us but it’s possible to get them to numbers which aren’t a health threat.” The strike by workers from refuse removal company Pikitup, which was in its sixth week, exacerbated the rat problem, especially in informal settlements which had inadequate disposal facilities, Frean said. The last outbreak of bubonic plague in SA was 34 years ago in the Eastern Cape, according to the NICD.
News | 11
Screen for diabetes at TB clinics, urge experts A molecular biology researcher and the executive director of Diabetes South Africa (SA) last month called for dual screening for TB and Type 2 diabetes, plus improved state diabetes funding, saying this will save thousands more lives. Twice as many diabetics die annually in SA than people with TB and/or HIV combined. Diabetes/TB co-morbidity also sharply steepens the overall upward fatality curve. Speaking on 7 April 2016 at a World Health Day function in Stellenbosch, Dr Katharina Ronacher, associate professor in Molecular Biology and Human Genetics at Stellenbosch University, said a very effective way to reduce the huge population of undiagnosed diabetics (SA has 3.5 million known diabetics plus 5 million estimated to be pre-diabetic) would be bi-directional screening. With 12% of TB sufferers estimated to also have Type 2 diabetes, screening all patients at TB clinics (with the HBA1C blood test to establish glucose levels over the last 3 months) would enable more effective treatment for comorbidity. Conversely, diabetes clinics should screen patients for TB via questionnaires (i.e. any persistent coughing in the past 3 weeks), followed by a sputum sample/chest X-ray, if indicated. “None of this is happening,” she asserted. Ronacher is researching treatment outcomes among patients with active TB who do and don’t have diabetes. Completed research shows that diabetics are more
likely to get TB and more likely to fail TB treatment (i.e immuno-compromised). A ground-breaking study found the diabetes-undiagnosed population in Bellville, Cape Town to be 25%, confirming suspicions that coloured populations are genetically more susceptible than most other racial groups.
In India up to 50% of TB patients have diabetes, with the local undiagnosed Indian population prevalence similar to that among coloured populations. Prevalence among blacks is 5 - 8% and 4% among whites. Margot McCumisky, executive director of Diabetes SA, said non-governmental organisations received no funding from government, resulting in under-treatment and huge ignorance about diabetes. “There’s also no framework for the monitoring and surveillance of diabetes,” she added. Diabetes among black people was “burgeoning”, she warned. The TB infection rate in SA across different populations is around 75%, and 10% higher in diabetics.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
TB drug price cut push for May % of total (421) patients included in trial
100%
Long-term (24-month) treatment outcomes after treatment with delamanid in combination with an optimised background treatment regimen: MDR- and XDR-TB patients 74.5%
55%
57.3% 48.5%
50%
45%
25.5%
25.3%
17.2%
16.7% 8.3%
6.6%
11.4%
7.8%
1% 0%
Favourable
Cured
Completed
Unfavourable
Died
Failed
Defaulted
Treatment outcomes Long-term treatment
With bedaqualine and linezolid finally cheaper, accessible and profoundly impacting thousands of South Africans with multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB, the government, backed by Médecins Sans Frontières (MSF) is price-wrestling for delamanid, the latest TB “wonder drug”. In an interview with Healthcare Gazette early in April this year, Dr Grania Brigden, MSF’s global TB advisor for drug access in Geneva, said an MSF probe showed that a month’s course of the Japanese-made delamanid (as yet unregistered in any high-burden TB country), could be manufactured for between R53 and R130. Otsuka Pharmaceuticals have since February been offering delamanid, with robust safety data on children aged 6 and older and adults (Phase 3 trials results due next year), at the dollar equivalent of R4 250 for a month’s course. Results from its Phase 2b study show 74.5% (versus 55%) cure or treatment complete and a
Short-term treatment
mortality drop from 8.3% to 1%, after 6 months of use. South Africa’s DR-TB and HIV chief, Dr Norbert Ndjeka, confirmed that a delamanid clinical access programme similar to that for bedaqualine (compassionate use) 4 years ago, was being set up with a Medicines Control Council Committee (MCC) to vet whether patients qualified. His department, backed by the MCC, was in early April negotiating with Otsuka and hoped for a signed deal by May this year.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
An estimated 2 000 patients are receiving bedaqualine and the subsequently introduced linezolid, the latter manufactured by Pfizer, who’ve just won the South African tender for a month’s linezolid treatment at R3 000 – a full third of the price government paid over the previous 3 years. Some 30 000 free courses of bedaqualine (the first new TB drug in 50 years) were controversially donated free to India and several other countries over 4 years by its manufacturer, Janssen Pharmaceuticals (Johnson and Johnson), in conjunction with the United States Agency for International Development (USAID). This came just after South Africa agreed to pay Janssen R10 000 per course, the world’s lowest price yet. Bridgen observed wryly that donations were “unsustainable”. “Donations are usually time limited. What we need is affordability and sustained accessibility,” she added.
News | 13
Robotic prostate surgery could reduce recovery time
One of the country’s most accomplished users of the robot-assisted da Vinci surgical system, Durbanville urologist Gawie Bruwer (over 80 successful prostatectomies) last month urged his colleagues to “grab the chance” to upskill themselves and enhance patient outcomes. Among 17 urologists countrywide accredited to use the sophisticated multi-armed, roboticassisted laparoscopic device of which five are in use countrywide (Netcare’s Chris Barnard, Waterfall City and Umhlanga hospitals, Mediclinics Durbanville Hospital and the Urology Hospital in Pretoria), Bruwer has data to back his exhortation. With 85% of all radical prostatectomies now conducted on the da Vinci system, Bruwer says half his patients are being discharged from a general ward the next day, compared with all patients who undergo open surgery being discharged from 4 days later, after a stint in the intensive care unit. Only two of his patients needed intensive care, because of non-surgical complications. Having reduced his console time to about 2 hours from the 5 hours it took when he was training
on the device in October 2014, Bruwer is enthusiastic. “It’s the best thing I’ve seen … amazing technology. There’s no way you can compete with this technology without learning how to do it.” Half his patients were able to have intercourse and “virtually nobody” experienced any urinary leakage by 6 months postoperatively, while 3.3% had blood transfusions (10% for open surgery) – all major improvements on open surgery. The clincher for Bruwer is comparing the technology with brachytherapy (the precise implantation of a radioactive pellet at the cancer site). “From the da Vinci we get a clear, clean anatomically removed specimen; 40% of my patients had their Gleason Score (aggressiveness of the cancer) upgraded on the final post-op histology.” This meant the disease was more aggressive than initially predicted. Similar evidence was not available with brachytherapy, but indications were that additional early intervention was required. Brachytherapy use in South Africa is 73% above the global norm – cause for clinical and ethical alarm. Other da Vinci applications in rarer current local use are partial nephrectomy and
cystectomy, while future areas will include colorectal surgery, gynaecology, pelvic floor repair, thoracic procedures and select ear, nose and throat (ENT) work. More than1 100 prostatectomies have been robotically conducted nationwide since October 2013.
Medical aids now funding robotic surgery
As evidence grows for da Vinci robotic prostatectomy outcomes, medical aids are ‘’coming to the party”, while her hospital group is temporarily carrying co-payments to medical aids that fund the relatively new procedure, says Christine Taylor, hospital manager at the Durbanville Mediclinic. “Slowly but surely they’re coming to the party. We are still writing off a significant amount of money in the difference between what the procedure costs and what we get (from the medical aids), because it’s still a learning curve for us,” she said. Discovery Health, for example, had “significantly” upped their payment from between R120 000 and R130 000 per procedure (a robotic operation including doctor and allied health professional fees costs R190 000), while others continued to only pay open surgery prostatectomy rates. Taylor said the average out-ofpocket patient costs (which MediClinic is carrying) stood at between R30 000 and R40 000. “We’re establishing the service and hope more medical aids soon realise what the advantages for the patient (and them) are,” she added.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
SA suicide numbers among world’s worst About 23 South Africans with mental health problems commit suicide daily while 16.5% of their compatriots suffer from common mental health problems, the South African Depression and Anxiety Group (SADAG) said at a mental health summit held in Sandton in March this year. Focusing on South Africa (SA)’s dismal mental health record and treatment on World Health Day (7 April 2016), SADAG said 460 South Africans attempt suicide every 24 hours. It singled out the lack of treatment in public health institutions and the stigma attached to mental health as among the biggest problems.
SA was among the weakest four countries providing mental health treatment, with 75% of clinic staff not having a caring attitude. President of the South African Society of Psychiatrists, Dr Mvuyiswa Talatala, told delegates that the country simply did not have enough specialists to address mental health and that on average, since the year 2000, fewer than 20 student psychiatrists were passed annually. He said it was unacceptable that a person should wait 4 months to see a psychiatrist. “The biggest problem is access to medical health. Government is blocking access to treatment. In some government hospitals there are only two psychiatrists.” In the private sector, the latest available figures from the
country’s largest medical aid, Discovery Health, show a 41% increase in mental disorder payouts (between 2008 and 2012), rising from R96.7 million to R494.6 million, but figures for the public sector (where over 80% of the population are treated) remain unavailable. Talatala, who runs a private practice in Diepkloof‚ Soweto‚ said black people were more aware of mental health. There are people who are comfortable seeking help from sangomas and that is fine because sangomas listen and that is very important‚“ she said. Grossly inadequate government spending on mental health is costing SA 2.2% of its annual gross domestic product, while 48% of people living with HIV/AIDS suffered from a mental health condition.
X-ray backlog solution hampered by data costs An innovative bid by the Radiological Society of South Africa (RSSA) to sell to government a powerful vendor neutral archiving and storage IT portal that delivers cost-effective, high-quality image reporting across all healthcare platforms is falling on deaf ears. This while some tertiary hospitals sit with an annual tally of an estimated 100 000 black and white unreported (i.e. uninterpreted) X-rays, illustrating the enormous difference such a referral system could make to healthcare outcomes. Speaking to Healthcare Gazette Dr Richard Tuft, executive director of RSSA, said the offer – a private sector-managed fee-for-service instrument that would enable fast, peer-reviewed
interpretation of images across technologies – had been made to provinces, the national health department, national hospital chiefs and top National Health Insurance (NHI) technology officials – all without success. This effectively put on ice a solution to a vital aspect of public sector healthcare delivery for 80% of the population. He said that with fibreoptic networks now commonplace, technology and IT had to be paramount if the NHI was to have any chance of succeeding. The private sector offered enormous expertise, proficiency and willingness, yet the government seemed “almost trying to reinvent the wheel in every possible area. We’re all working
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
in the same direction in the same country,” he added. Pushed on why the initiative was failing, Tuft said in his many meetings with government officials over the past 18 months, there was initial keen interest, followed by silence or the citing of budgetary constraints and/ or cumbersome tender procedures. Prof. Zarina Lockhat, head of radiology at the University of Pretoria and Steve Biko Academic Hospital, said while technological advances in radiology had changed the face of medicine, cost challenges remained. Equipment prices were soaring, while no matter what system one had, the maintenance, staffing and daily care of equipment were major issues.
News | 15
New drugs could restore old antibiotics Newly discovered chemical compounds that make methicillin-resistant Staphylococcus aureus (MRSA) a burgeoning hospital-acquired infection in South African (SA) hospitals vulnerable to the antibiotics they normally resist, may be available by 2024. This emerged last month from an interview with Dr Safwaan Desai, former executive manager: clinical and policy at Metropolitan’s Health Division, now in private practice in the North West Province. He was responding to the latest research from Merck laboratories in New Jersey which shows that the new compounds restore the old antibiotics’ former powers. MRSA is the second biggest cause of death by drug-resistant bacteria in the US and ranks among the top fatality-causing hospital-acquired infections in SA. The bacteria that have evolved are resistant to the most widely used class of antibiotics, called beta-lactams, which include penicillin, methicillin and carbapenems. The drugs work by targeting essential components of a bacterium’s cell wall called peptidoglycans. However, MRSA protects itself by using a type of molecule that can soak up the drug and stop it from working. Desai said if the new resistance-busting compounds reached Phase 3 trials and proved as successful in humans (Phase 4), followed by 2 – 3 years of post-treatment surveillance, they could make a big impact in SA within 8 years. A lot would depend on whether the Medicines Control Council (MCC) promoted the quicker use of the
Artist’s rendering of MRSA drug based on compassionate need, the recent extensively drug-resistant-TB (XDR-TB) drugs bedaquiline and lenazolid being excellent examples. He said the best way to stem the alarming tide of antibiotic resistance was a massive government education campaign targeted at doctors and patients, using workshops, posters and inhouse medical aid newsletters and/or magazines. Medical aids could also use their doctor profiling capacity to measure how often doctors were prescribing antibiotics for certain conditions. Many doctors still prescribe broad-spectrum antibiotics for flu, which is a viral infection. He appealed to doctors to use laboratory tests to identify the infecting organism followed by the use of “rational
and reasonable antibiotics directed towards the most likely organism”. They could then switch antibiotics if necessary, targeted towards the sensibility analysis.
Increasing antibiotic resistance is associated with: n Inappropriate prescribing – using antibiotics where they are not indicated (e.g. for flu) n Marketing effects from pharmaceutical companies n Patient insistence on an antibiotic n Practice volumes and doctor malaise (“no time” to explain why an antibiotic is not necessary) n Doctor knowledge on the rational use of antibiotics n Over-prescribing due to over-cautiousness and fear of medico-legal issues.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
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Bacteria in the gut are known to:
QuatroFlora
As many as 60% of diseases begin in the gastro-intestinal tract – Imbalances lead to a number of unpleasant conditions like diarrhea, constipation, bloating, IBS, allergies, poor digestion and poor nutrient absorption. The bacteria in our digestive system manufacture substances that can either raise or lower our risk of disease, impact the effectiveness of medication, influence our immune response, or nutritional status and our rate of ageing. Clearly, intestinal bacteria are worth paying attention to.
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Probiotics may act through:
KEEPS THE COLON HEALTHY
A total of 100 trillion bacteria live in our digestive system, in either a symbiotic or antagonistic relationship. That is ten times more intestinal bacteria than there are cells in the body. Some groups of bacteria can cause acute or chronic illness, but another group of bacteria offers protective and nutritive properties. These friendly bacteria are called intestinal flora or probiotics. Probiotics are live micro-organisms that, when consumed in adequate amounts, confer a health benefit to the host. The two most important groups of intestinal flora are Lactobacilli – found mainly in the small intestine, and Bifidobacteria – found mainly in the colon. These bacteria are critical for normal development of the intestine and for defense against infections, and are vital for our health.
• Competitive exclusion of pathogens (bad bacteria) causing diarrhea • Formation of antimicrobial substances • Inhibition of adherence of translocation of pathogens by colonization • Enhancment of mucosal barrier function • Immune modulation
Choose a probiotic with strains which have well documented effect on restoring bacterial balance in the intestine and thereby enhancing gastrointestinal wellbeing. A high level of documentation gives a product the opportunity to stand out by showing that the product is well researched in terms of having a positive effect on intestinal health. There is therefore no reason to suffer from chronic diarrhea or other stomach upsets caused by E Coli or rotavirus as regular supplementation with a good probiotic could colonize the gastrointestinal tract thus making it much less likely for pathogens to cause ill effect.
QuatroFlora ALL PROBIOTICS ARE NOT THE SAME ALL PROBIOTICS ARE NOT THE SAME
Gastro-intestinal affect all all of of us us at some time or or ❖Benefi cial bacteria thethe gutgut areare known to:to: Beneficial bacteriain in known Gastro-intestinalproblems problems affect at some time another. Diarrhoea, constipation, bloating and the like are often • Prevent diarrhea or constipation another. 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In laboratory investigations, Bacteria in the gut are known to: down (Lactobacillus bulgaricus) have demonstrated anti-mutagenic • Inhibit adherence of pathogens • Stimulate theofimmune some strains of bulgaricus) effects thought to beLAB due (Lactobacillus to system their ability to bind with have heterocylic • Enhance the musosal barriereffects thought to be due demonstrated anti-mutagenic amines, which are carcinogenic substances formed in burnt • Aid digestion and break down toxins to their ability to bind with heterocyclic amines, which are red • meat. Inhibit adherence of pathogens Tel: 041 3781189 carcinogenic substances formed in burnt red meat. 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Probiotics live micro-organisms whenin consumed bacteria for improving gastro-intestinal health and well-being: Lactobacillus bulgaricus, LBY-27 and Streptococcus thermophilus, ® Probiotics are livehave micro-organisms which,ts.when conin www.betapharm.co.za adequate amounts, strong health benefi STY-31 strains of probiotic bacteria is recommended for improving Bifidobacterium, BB-12®, Lactobacillus acidophilus, LA-5 , gastro-intestinal health and well-being. Lactobacillus bulgaricus, LBY-27, Streptococcus thermophilus, STY-31 sumed in adequate amounts, have strong health benefits. Gastro-intestinal affect all all of of us us at some time or or ❖Benefi cial bacteria thethe gutgut areare known to:to: Beneficial bacteriain in known Gastro-intestinalproblems problems affect at some time another. Diarrhoea, constipation, bloating and the like are often • Prevent diarrhea or constipation another. Diarrhea, constipation, bloating and the like are often • prevent and and stopstop diarrhoea or constipation One of the greatest challenges for human A probiotic can be beneficial in the caused or or eating something thatthat doesn’t • digestion Aidgood digestion causedbybyover-indulgence over-indulgence eating something doesn’t • aid and and breakbreak downdown toxinstoxins wellbeing in the 21st century will be to focus following ailments: agree clear upup of of their own accord. • Produce vitamins B12Kand K agreewith withus,us,and andquickly quickly clear their own accord. • produce vitamins B12 and on the advantage of having a healthy colon and Thisproduct product isnot notintended intendedtotodiagnose, diagnose,cure cureororprevent preventany anydisease. disease. • Diarrhoea orisconstipation This Distressing and unpleasant conditions such as these can, • stimulate the immune system. • Stimulate the immune system Distressing and unpleasant conditions such as these Clinicaldocumentation documentationavailable availableononrequest. request. Clinical Beta Pharmaceutical 041 378 1189 Beta Pharmaceutical 041 378 1189 therefore a good immune system – this is where • Bad breath, gas &same, bloating however, become chronicchronic – and –that caused by a by This product hasprobiotics not been evaluated bythe the MCC. Just all all probiotics areare notnot Justasasallallhumans humansarearenotnotthethe same, can however become andcan thatbecan be caused probiotics can play a significant role. • Allergies, rhinitis, lactose intolerance bacterial imbalance in the intestines. ® clinical documentation same. Insist on QuatroFlora®, with the same. Insist on QuatroFlora with clinical documentation a bacterial www.betapharm.co.za imbalance in the intestines. • Gastroenteritis and playschool diseases in Some groups of bacteria can cause acute or chronic
KEEPS THE COLON HEALTHY ALL PROBIOTICS ARE NOT THE SAME
ALL PROBIOTICS ARE NOT THE SAME
ALL PROBIOTICS ARE NOT THE SAME
News | 17
12 childhood gastro deaths in the Western Cape
In spite of a drop in gastroenteritis deaths since the national roll-out of the rotavirus vaccine, 12 children died and thousands were treated this summer in the Western Cape, according to statistics released in March this year by the Cape Town Metro and the Province. The City of Cape Town reported nine deaths since December while the provincial Department of Health recorded three deaths in the same time frame. A further 25 569 children were treated for diarrhoea since the start of the summer season, with over 3 000 hospitalised, the report shows. In January, three cases of typhoid fever were also reported in the Western Cape. Two were children, both girls aged 9 and 10 in the Cape Town area, while the third patient was a 52-year-old man from the Cape Winelands. The Western Cape
has the country’s best disease surveillance system. Other comparative provincial statistics were unavailable, but are almost certain to vary widely – with many far worse. Diarrhoea is one of the leading causes of morbidity and mortality in South African children, accounting for 20% of underfive deaths. The introduction of a rotavirus vaccine into the national Expanded Programme on Immunisation (EPI) in 2001dramatically decreased the burden of acute gastroenteritis, both in HIV-infected and HIVuninfected children. With the high burden of disease in infants under 6 months, early vaccination at 6 weeks and the booster dose at 14 weeks, allows better early protection. Early studies in the Johannesburg area identified dramatic epidemiological
differences in rotavirus infection among different racial groups. Dehydrating diarrhoea in black children was strongly associated with warm weather, while diarrhoea in white children occurred regularly throughout the year, with a peak incidence in late autumn. Laboratory studies show that bacteria, in particular “classic” enteropathogenic Escherichia coli (E.coli), are the leading cause of diarrhoea in black South African children, and that diarrhoea in white children is largely attributable to rotaviruses. The association of enteropathogenic E. coli with diarrhoea in black children suggests these bacteria are responsible for earlier outbreaks of summer diarrhoea. This aetiological variation (according to socioeconomic class) has major implications for diarrhoea control.
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Research | 19
Bite-sized summaries of the latest scientific advances Global obesity trends – heading for disaster Second malignancies after radiotherapy for prostate cancer
Don’t overtreat hypertension in diabetics Conventional wisdom has it that the lower the blood pressure in diabetics, the better. But this recent study says otherwise. A systematic review and meta-analysis of randomised controlled trials to assess the effect of antihypertensive treatment on mortality and cardiovascular morbidity in diabetics showed that dropping the blood pressure
only reduces the risk of mortality and cardiovascular morbidity in people with diabetes and a systolic blood pressure of more than 140 mmHg. Less than this, and further treatment is associated with an increased risk of cardiovascular death and no observed benefit. Brunström M, Carlberg B. Effect of antihypertensive
This study used systematic review and meta-analysis of observational studies to determine the association between exposure to radiotherapy for the treatment of prostate cancer, and subsequent second malignancies, i.e. second primary cancers. The conclusion was that radiotherapy for prostate cancer was associated with higher risks of developing second malignancies of the bladder, colon, and rectum compared with patients unexposed to radiotherapy, but the reported absolute rates were low. Further studies with longer followup are required to confirm these findings.
treatment at different blood
High body mass is a known risk factor for cardiovascular and kidney disease, diabetes, some cancers and musculoskeletal disorders. Obesity and overweight have been included among the global non-communicable disease (NCD) targets – the object being to halt the rise in obesity at its 2010 level by 2025. The NCD Risk Factor Collaboration says that this is impossible – if post-2000 trends continue, the probability of meeting the global obesity target is virtually zero. In fact, if these trends continue, by 2025, global obesity prevalence will reach 18% in men and go beyond 21% in women and severe obesity will rise beyond 6% in men and 9% in women.
pressure levels in patients with
Wallis CJD, Mahar A, Choo R, et al.
diabetes mellitus: Systematic
Second malignancies after radiotherapy
Smith GD. A fatter, healthier but more
review and meta-analyses.
for prostate cancer: Systematic review
unequal world. Lancet 2016;387:1377-
BMJ 2016;352:i717. DOI:10.
and meta-analysis. BMJ 2016;352:i851.
1396. DOI: 10.1016/S0140-
1136/bmj.i717
DOI:10.1136/bmj.i851
6736(16)30054-X
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
Pioglitazone and the risk of bladder cancer
Pioglitazone, an antidiabetic drug belonging to the thiazolidinedione class, has been shown to improve glycaemic levels in people with type 2 diabetes. As early as 2005, there was a suggestion that people on pioglitazone had more risk of bladder cancer than controls. Now, Tuccori et al. have shown, using a population-based cohort study, that there is indeed an increased risk of bladder cancer among those taking pioglitazone – an overall 63% increased risk, not found with rosiglitazone – so drug-specific and not a class effect.
Fast for longer at night and reduce risk of breast cancer More evidence recurrence for link between Zika virus and fetal brain A recent study published abnormalities in JAMA Oncology sugA new study has provided further evidence for the link between the Zika virus and brain abnormalities in the fetus. Researchers have found genetic traces of the Zika virus in the blood of a woman infected with Zika in the first trimester of pregnancy while visiting Central America. They also isolated the Zika virus in cells cultured from fetal brain tissue. Genetic traces of the virus were detected weeks after the woman’s symptoms of infection had subsided. Driggers R, Cheng-Ying H, Korho-
gests that women who have suffered breast cancer may reduce their risk of recurrence by fasting for more than 13 hours at night. The study focused on recurrence of invasive breast cancer and new primary breast tumours during an average follow-up time of 7.3 years. Researchers found that women who fasted for less than 13 hours a night had a 36% higher risk for breast cancer recurrence, compared with those who fasted for 13 hours or more. The key would seem to be glycaemic control during sleep, reducing overall inflammation.
nen EM, et al. Zika virus infection
Say no to the smoothie Or at least don’t give them to your children. New research, published in the online journal BMJ Open, says that the sugar content of fruit drinks, natural juices and smoothies is “unacceptably high”. Researchers from the universities of Liverpool and London assessed the sugar content per 100 mL of fruit juices, 100% natural juices and smoothies aimed at children, using the pack labels. The average sugar content of the 21 pure fruit juices assessed in the survey was as high as 10.7 g/100 mL or just over 2 tsp, and in the 24 smoothies, it was up to 13 g/100 mL, or just over 2.5 tsp. Over 40% of all the products contained 19 g, or around 4 tsp of free sugars, the maximum daily amount recommended for children. Boulton J, Hashem KM, Jenner KH, et al. How much sugar is hidden
Tuccori M, Fillian K, Yin H, et
with prolonged maternal viremia
Marinac CR, Nelson SH, Breen CI,
in drinks marketed to children? A
al. Pioglitazone use and risk of
and fetal brain abnormalities. New
et al. Prolonged nightly fasting and
survey of fruit juices, juice drinks
bladder cancer: Population based
N Engl J Med. Published online
breast cancer prognosis. JAMA On-
and smoothies.
cohort study. BMJ 2016;352:i1541.
30 March 2016. DOI:10.1056/NEJ-
col. Published online 31 March 2016.
BMJ Open 2016;6:e010330.
DOI:10.1136/bmj.i1541
Moa1601824
DOI:10.1001/jamaoncol.2016.0164
DOI:10.1136/bmjopen-2015-010330
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Packs/adult/year
90
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70 60 D
50
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F
40 30 1960
1970
1980
1990
2000
2010
Year National cigarette consumption 1960 - 2009 in South Africa. Key events are indicated as follows: A: local government banned smoking in cinemas, B: restriction on smoking on domestic flights, C: Tobacco Products Control Act of 1993, D: Tobacco Products Control Amendment Act no. 12 of 1999, E: Tobacco Products Control Amendment Act no. 23 of 2007, F: Tobacco Products Control Amendment Act no. 63 of 2008.
Feature | 23
Smoke and mirrors – seeing through the clouded tobacco debate Existing controls on tobacco use can be very effectively supplemented to save more of the 6 million lives lost every year among the world’s 1.3 billion smokers.
L
egally controlling where you can buy cigarettes, who can buy them, what they cost, slapping dire health warnings on their packaging and disclosing their toxic constituents all have little or no impact on nicotine addicts, especially adults – according to two global experts. Legal enforcement can help slowly change a country’s smoking culture, turn down the tap of debut smokers who become addicted and save the economy billions of rands, but only when you add long-term pharmacological treatments and harm-reducing behavioural changes have you any chance of altering your hardened nicotine addicts’ habit. That’s the over-riding message from a swathe of global scientific studies conducted by epidemiologists, public health experts, psychologists and oncologists consulted by Healthcare Gazette (HG), when speaking to several leading harm reduction experts. A marked divergence in views over the plethora of electric nicotine delivery devices (ENDS) and their efficacy in harm reduction, versus simply tightening, broadening and complying with stiff anti-tobacco legislation as the best way to reduce tobacco-induced morbidity and mortality emerged.
Executive Director of South Africa (SA)’s National Council against Smoking, Dr Yussuf Saloojee, says the lowest smoking rates are found in countries with the best tobacco control policies. He cites the tumbling smoking prevalence in SA since the government adopted comprehensive policies, and points to Canada, Australia and New Zealand as similar shining examples. After decades of neglect, SA emerged in the 1990s as a global leader in the regulation of tobacco use, with the most recent 12-year study showing that for each R1 increase in the cigarette price, the risk of smoking initiation was reduced by between 1% and 2.8% for males. With local smokingrelated deaths estimated at 45 000 annually, smoking among all learners declined from 23% (1999) to 16.9% (2011), a hefty 26.5% reduction. In spite of these gains, a full 17.6% of adults still smoke, with men having a three-times higher prevalence of smoking than women. Female prevalence is 7.3%. Overall smoking prevalence differs greatly by race: 40.1% of coloured people smoke, including 34.4% of coloured women (nearly five times the prevalence among all SA women). Of students in grades 8 - 11, a full 12.7% still smoke cigarettes, including 10.8% of girls. So tobacco controls – and critically, behaviour change – remain priorities for
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
“
Prof. David Abrams
Harm reduction via ENDS and other non-combustible products is no different to methadone replacement for heroin addicts, needle exchanges for injecting drug addicts, condom use for sexually active adolescents, seat belts for cars or crash helmets for motorcycles
Prof. Charles Parry
“
We must not take our eye off the real goal: to reduce premature deaths
this country where legislative change is so far estimated to have saved 1.5 million lives and spared our economy R187.5 billion in costs. Per capita cigarette consumption decreased by 54% from 1999 to 2011. According to locally schooled psychologist, Prof. David Abrams, of the Johns Hopkins Bloomberg School of Public Health and Adjunct Professor of Oncology at the Georgetown University Medical Center, smoking addiction in people with HIV and TB is the biggest cause of their premature deaths and poor quality of life. It hardly bears mention that SA is among those countries with the highest prevalence of HIV and TB, with the former driving the latter. Abrams’ colleague, Dr Derek Yach, a former executive director of NonCommunicable Diseases and Mental Health at the World Health Organization (WHO) and now chief health officer of Discovery Health’s Vitality programme, is one of SA’s anti-tobacco law pioneers and contributed heavily to SA’s tobacco laws. He says while the call for “more of the same” like higher excise taxes will slow uptake in kids, it ignores rising concerns about their regressive impact on the poorer and more addicted smokers. It also ignores advances in the science of nicotine use, which suggests that half of all smokers may not respond to tax increases because of their need for nicotine. “In other words, a onesize fits all approach to tobacco control will not get us close to (the global target of) 5% prevalence,” he asserts. Saloojee, on the other hand, cites economic research showing that lowincome households now spend less of their income on tobacco because they are more price sensitive.
Political sledgehammer approach is counter-productive
The harm reduction lobby strongly disagrees with Saloojee and many politicians, including SA’s health minister, Dr Aaron Motsoaledi, who would like to ban all alternative nicotine delivery devices (ANDS), a broader range than just e-cigarettes. There are an estimated 200 000 e-cigarette smokers alone in SA. Yach, Abrams and several other researchers
say that from a harm reduction perspective, banning ANDS is simply wrong-headed. Citing global actuarial projections of one billion tobacco-related deaths by the turn of the next century (unless the Framework Convention on Tobacco Control (FCTC) signed by 180 countries, including SA, is complied with and tightened further), Yach believes e-cigarettes and other nicotine delivery devices such as vaping pipes and new ‘heat-not-burn’ products offer us a chance to reduce that total. “People smoke for nicotine but die from tar,” he emphasises. Abrams cites last year’s Public Health England (PHE) independent evidence review estimating e-cigarettes to be 95% less harmful than ordinary cigarettes. However, Prof. Charles Parry, director of the Alcohol, Tobacco and Other Drug Research Unit at the SA Medical Research Council, says this finding has not been properly unpacked by the media. It can be as much as 95% for some people, but is not an average; it is a maximum possible benefit for some individuals but was by no means the benefit that all e-cigarette users would derive, the average benefit being much lower. Abrams says Parry offers a “misleading misrepresentation” of the data which gave an average of the total population estimated benefits and would save millions of lives if everyone switched to complete e-cigarette use instead of cigarette use. Saloojee says his main objection to ANDS is that even the newer devices don’t deliver enough nicotine in a palatable way to satisfy smokers (delivering nicotine much slower than ordinary cigarettes), therefore ruling them out as cigarette replacements. He predicts addicts will use them in nonsmoking areas, lighting up “properly” again where they legally can, thereby increasing their nicotine load. Abrams and Yach reject this, saying the new modular or tank systems can deliver as much nicotine as cigarettes (in experienced users), with respected studies showing them to induce a 27% quit rate and to be 2.7 times as likely to help a cigarette smoker quit, compared with one who did not use e-cigarettes. Although conceding that higher-end e-cigarette brands are less toxic than ordinary cigarettes, Saloojee says the combination of
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
Feature | 25
Dr Yussuf Saloojee
multiple manufacturers and the absence of a regulatory authority controlling the purity of ENDS, means poisons like chromium, acrolein and formaldehyde will be found to varying extents in various products. As long as people continued to smoke even a few cigarettes a day, the risk of dying early remains excessive compared with never smoking. Smoking 1 - 4 cigarettes a day carried a 60% excess risk of dying early and smoking 5 - 9 cigarettes a day doubled the risk of dying early. Saloojee concedes that if, for every person who uses e-cigarettes and complies with the highest regulatory standards, there is one fewer person smoking conventional cigarettes, “that would be good”. However, dual use was most common, and asking heavy smokers to switch to the exclusive use of e-cigarettes was like asking heavy drinkers to switch to non-alcoholic or low-alcohol beer. He advised ANDS advocates to help SA complete its unfinished traditional tobacco control policies, “instead of going off in search of Nirvana”. Yach, who worked for years with Saloojee, observed that it was Saloojee’s mentor in London, Michael Russell (ex University of Cape Town) who in the mid-1980s first highlighted the need to separate tar from nicotine and developed nicotine gum to do that. Since then, and especially over the last 5 years, billions of dollars of new research and development investments had transformed reduced-risk products to make their nicotine experience closer to cigarettes. While Saloojee
remains sceptical, Yach says trends across the US, Europe and the UK suggest that profound shifts are underway in tobacco companies, and are acknowledged as such by investors who followed tobacco stock. Companies were publically committing to making tobacco obsolete and safety and/ or content norms were being developed and implemented. Abrams says studies of the major biomarkers of cancer or other chemicals in ANDS indicated substantially (9 - 450 times) lower levels compared with the smoke from cigarettes, cigars, hookah and other combustible tobacco products. Headline-grabbing studies on the high levels of formaldehyde in ENDS “completely exaggerated the harms under normal use”. Perhaps fundamentally important, especially for SA, the PHE study found that nearly half the population surveyed (44.8%) did not realise e-cigarettes were much less harmful than smoking, while there was no evidence to suggest that e-cigarettes acted as a route into smoking.
England and Sweden lead the way Some 30 years of surveillance and follow up found that the hugely popular Swedish low-nitrosamine “snus” (a moist powder tobacco product placed under the upper lip) actually led to less smoking among adolescents, not more, as was feared. Sweden had by far the lowest cancer rates in the European Union and death rates from all causes among Swedish men were about five times lower than among
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
“
The economic costs of tobacco outweigh the gains in taxes
END with re-fill bottles
“
The PHE study found that nearly half the population surveyed (44.8%) did not realise e-cigarettes were much less harmful than smoking, while there was no evidence to suggest that e-cigarettes acted as a route into smoking
European men, thanks in part to snus, says Yach. As snus use increased, so smoking decreased. Snus was banned in all EU countries except Sweden (and Norway which isn’t in the EU). In Finland the ban slowed down the drop in smoking. In Norway, by contrast, snus consumption among adults rose from 4% in 1985 to 28% in 2012 – while overall tobacco use fell by 20%. The scientists consulted argue that harm reduction via ENDS and other non-combustible products is no different to methadone replacement for heroin addicts, needle exchanges for injecting drug addicts, condom use for sexually active adolescents, seat belts for cars or crash helmets for motorcycles. Initial fears for all these modalities were that they would aggravate matters, but experience and hard science proved otherwise. According to Abrams, 35% of smokers in the UK are using e-cigarettes to quit and 21% are using nicotine replacement therapy (NRT). Yach argues that governments have become addicted to tobacco excise tax and fear they will lose a valuable source of revenue. Saloojee rubbishes this, saying the economic costs of tobacco outweigh the gains in taxes and argues that government could tax e-cigarettes just as easily if they were concerned about revenue.
A global chess game with vastly different motives Yach says he “distrusted” every single counter chess move by tobacco
companies, adding that he felt hugely vindicated when a watershed enquiry, supported by the WHO, and the World Bank declared in 1999: “Evidence … reveals that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of WHO to control tobacco use. The attempted subversion has been elaborate, well financed and usually invisible”. Yach argues that while we must be informed by history and unacceptable corporate behaviour, “we must not take our eye off the real goal: to reduce premature deaths”. And that is what the range of new reduced-risk products may well achieve, using market forces in ways public health cannot. We cannot rely on “trust” when it comes to the tobacco industry but should require independent verification of their words through measured deeds.
Staying the distance
Abrams says behavioural and pharmacological treatments are effective tobacco-use cessation options, but only if used as recommended for a sufficient length of time. He has another caveat: these interventions are expensive, not accessible, and unappealing to smokers. By contrast, ENDS were scalable, appealing and cost effective and therefore had potentially much greater impact by reaching and helping more smokers quit. ENDS were more widely available and appealing to smokers than conventional nicotine replacement therapies and in the UK were even starting to displace cigarette smoking. Research showed that intensive use of ENDS for a month or more was associated with a six times greater chance of cessation and a 20.4% quit rate. Yach says the prospect of a billion tobacco-related deaths before 2100 is a “dreadful prospect”. “E-cigs and other nicotine-delivery devices such as vaping pipes offer us the chance to reduce that total. We need to keep that prize in mind and redouble our efforts to make up for 50 years of ignoring the simple reality that smoking kills and nicotine does not.”
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Addressing SA’s stark health inequalities There are few places where South Africa’s public-private healthcare divide is more dramatically illustrated than in the treatment of pulmonary arterial hypertension. Survival rates differ by several years depending on whether treatment is in the public or private sector.
I
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pulmonary hypertension
magine working in a top South African tertiary hospital’s pulmonary clinic for half a dozen years, getting close to your young patients and then watching one or two die every year for lack of internationally available drugs that would have probably given them another 5 - 10 years. That’s the situation at Groote Schuur Hospital (GSH) where pulmonologists, in stark contrast to their colleagues at the private Milpark Hospital in Johannesburg (and potentially other private local hospitals), are keeping some 35 pulmonary arterial hypertension (PAH) patients alive on a thin and inadequate diet of drugs, in spite of their best efforts to overcome drug access challenges. Lack of awareness of PAH by both patients and caregivers, and the failure of public and private funders to provide resources for the management of the disease have meant that most patients have little or no access to any of the treatments approved by international guidelines. Pulmonologists working with PAH patients in developed countries have access to newer, more effective drug
combinations. This has meant a decrease of 10% in the overall number of lung transplants performed for PAH (12% down to 2% in just a few short years). Lung transplants are a therapy of last resort for end-stage PAH, but are unavailable anywhere in Africa except at Milpark Hospital. Foreign pulmonologists can also confidently boast that the chances of their patients surviving at least another 5 years, postoperatively, are about 45%. In South Africa (SA) the chances of survival drop by another 10%. Yet, as Paul Williams, the country’s most experienced PAH pulmonologist (at Milpark Hospital) and widely regarded as the father of local lung transplantation observes, those patients wouldn’t have survived for another 2 years without a lung transplant, so it remains a net gain. In recent years, more and more of his PAH patients are living longer, mainly because his team’s dogged attempts to obtain the hugely expensive lifeprolonging drugs have begun paying off. The only registered PAH drug in SA is sildenafil (better known locally as
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Feature | 29
Revatio or Viagra). Yet Milpark Hospital now has 20 patients on Bosentan (Section 21 permission via the Medicines Control Council (MCC), i.e. compassionate use approval) and has obtained entry into a macicentan trial (the newest drug in its class) for 10 more patients and put half a dozen patients onto intravenous drugs such as iloprost. Williams explains that only by using a combination of three drugs does he have a fighting chance of prolonging life, but at a cost of R150 000 per person, per month. Besides the MCC, the second battle front is with funders. There’s only recently been some headway here for his patients, who come from across all racial groups and social strata. Besides their condition, they have one vital thing in common – medical aid cover.
Greater public/ private partnership would save lives
The picture is not half so rosy (if such a term is even vaguely appropriate) in the public sector, powerfully illustrating SA’s globally widest income gap and resultant grossly unequal access to medical treatment. Until National Health Insurance (NHI) manages to work some magic in bringing the public and private sectors together for greater equality in medical care, PAH patients at Groote Schuur Hospital will continue to die with little hope or access to medicines. Shortly before this article was written, the hospital’s pulmonology team celebrated the donation of the newer drug ambrisentan by a private pharmaceutical company, which is suitable for five of their patients, meaning those beneficiaries will now get two out of the three drug classes they need – a major boost to their quality of life, and possibly, longevity. Five of the PAH unit’s patients (just over 14%) are HIV positive. The pulmonologists unpack the significance of this percentage: HIV is a major risk factor for PAH and with SA having the second highest HIV prevalence in the world, this low ratio illustrates the rock-bottom diagnostic knowledge levels for PAH. “We should be seeing hundreds annually but we’re missing most of them,” says Williams, who also has a minority of HIV-positive patients with PAH.
PAH notoriously difficult to diagnose
Far too few PAH patients are recognised at lower levels of care – it’s a complex diagnosis, totally unlike ordinary and hugely widespread hypertension, where screening merely requires a blood pressure machine. “These patients don’t fall into your lap … it’s a slow process of inward referral,” says Williams. The Groote Schuur PAH patients will almost certainly all die, most of them over 5 years too early, with their doctors keeping them alive on a therapeutic diet that includes Viagra and other suboptimal (but more affordable and available) drugs. PAH is a relatively rare disease, its prevalence in SA, speculatively extrapolated from Australia’s 50 000 known PAH patients in that country’s 20 million population. According to Capetonian Gabi Lowe, mother of Jenna who died last year of PAH after a long, bravely borne illness which saw her set up the Jenna Lowe Trust for fellow sufferers, this could put the local patient cohort as high as 100 000 (among 52 million South Africans). Greg Symons, Head of the GSH Pulmonary Hypertension unit says: “My gut feeling is it’s not quite that high but nobody really knows. While it’s a relatively rare disease, it’s still a significant burden. The difficulty is in making a true diagnosis. The gold standard is with an angiogram and right-heart study, but you need a catheter lab (for the latter) and very few state hospitals have those facilities. It makes equitable access very difficult”.
Tragic mismatch in public and private care
Williams, the only practising lung transplant physician in Africa, describes the mismatch between the two health sectors as “a tragic story”, adding that only 30% of PAH patients respond to just one drug. In Europe the latest PAH guidelines recommend starting patients with advanced PAH on combination drug therapy from the outset (America and Australia being other countries which routinely offer the
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“
Dr Paul Williams
Nobody in their right mind overseas would treat a PAH patient with just one drug – it would be seen as close to criminal neglect. The situation here is extremely depressing and it’s been a very nihilistic approach so far. I mean, how do you tell a patient that someone with TB is more important than them?
“
Lack of awareness of PAH by both patients and caregivers, and failure of public and private funders to provide resources for the management of the disease have meant that patients have little or no access to any of the treatments approved by international guidelines
Clinical exam, ECG, CXR, echocardiography
Normal
PH confirmed
Look for alternative diagnosis
ABG, ANF, LFTs, HIV, PFT, TOE, V/Q, CTPA, spiral CT, sleep studies
Non-category 1 PH Treat for underlying disease
Uncertain
Cardiac catheterisation and proceed accordingly
Category 1 PAH suspected Cardiac catheterisation
Category 1 PAH confirmed
Vasoreactivity
No vasoreactivity
Calcium channel blockers
PAH-specific therapy
Diagnostic algorithm for patients with suspected pulmonary hypertension. ECG = electrocardiography; CXR = chest radiography; PH = pulmonary hypertension; ABG = arterial blood gas; ANF = antinuclear factor; LFTs = liver function tests; PFTs = pulmonary function tests; TOE = transoesophageal echocardiography; V/Q = ventilation-perfusion scan; CTPA = CT pulmonary angiogram; CT = computed tomography.
recommended full drug combinations). “Nobody in their right mind overseas would treat a PAH patient with just one drug – it would be seen as close to criminal neglect. The situation here is extremely depressing and it’s been a very nihilistic approach so far. I mean, how do you tell a patient that someone with TB is more important than them?” He said the classic age-profile base of PAH disease was in patients between 20 and 40 years although it could range from 2 years old to the late 50s. He was enthusiastic about a GSH initiative of sending two pulmonologists, Dr Greg Calligaro and his surgical colleague Dr Tim Pennel, to Australia to
learn not only about the latest PAH drug treatment but, more importantly for SA tertiary medicine, lung transplantation. Williams, who has managed some 90 lung transplants over the past dozen years, says it is “fantastic that they’re getting on board. We fully support them and are collaborating with them – but it has to be seen in the proper context of all of us having access to drugs. We need the MCC to make them available to us without having to rely on compassionateuse provisions,” he added. The aim of GSH’s respiratory team is to get Calligaro (managing lung transplant patients in the run-up to their transplant and afterward) and Pennel (surgical
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Feature | 31
“
Williams explains that only by using a combination of three drugs does he have a fighting chance of prolonging life, but at a cost of R150 000 per person per month
Chest film view showing cavity in right lung and infiltration. aspects of lung transplantation) trained up in Sydney, both returning to Cape Town in February next year, having managed scores of Australian PAH and other lungdiseased patients. The pulmonology pair will form the bedrock of what is hoped will be a new Centre of Excellence for patients with serious or end-stage pulmonary disease (of which PAH forms a relatively small percentage). Symons is confident that with the willing and enthusiastic support of GSH management, a very strong argument for better state funding can be made on academic grounds (especially for lung transplants), given the huge knock-on benefits of enhanced skills among the swathe of disciplines needed. Calligaro stressed: “Thoracic transplantation is the pinnacle of medical services that an academic institution can provide”. With GSH’s organ transplant pedigree and PAH drugs having advanced
substantially, the “travesty” for both Calligaro and Symons remains that the gold-standard therapy is just not available to them (or anyone in the public sector). The first-ever joint SA Heart Association and SA Thoracic Association Working Group meeting was held in Johannesburg on 23 May 2014 and was aimed at addressing the plight of PAH patients. The group unanimously resolved to increase PAH awareness, promote education and research and establish databases and registries, tailor the European Guidelines for PAH to SA conditions, engage with funders to provide essential therapies (at an optimal cost) and to urge the MCC to approve these. Asked about progress since then, Williams said the local guidelines had yet to be published. “Other than that, everyone seems to be focused on their own areas of activity,” he said.
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All about eczema By Leverne Gething
With winter upon us, inclement weather raises the risk of eczema flare-ups among sufferers.
E
ailable
czema describes changes in the upper layer of the skin that include redness, blistering, oozing, crusting, scaling, thickening and sometimes pigmentation. It often begins early in life, and allergy tends to be more of an issue in babies and young children. While there is a paucity of data on the prevalence of atopic eczema in South Africa, the International Study of Asthma and Allergies in Children Phase I reported a prevalence of from 5 - 10% in Cape Town school children. Despite a great deal of medical research, the cause of eczema is still poorly understood. The underlying disorder is a barrier dysfunction of the skin, and the main symptom is itch. Responding to the
armacies
itch sets off the “itch-scratch” cycle, where scratching the itch causes damage to the skin, which causes more itching, and so on. Anything that interrupts this cycle is beneficial.
Making an accurate diagnosis
It is usually easy to diagnose eczema by looking at the skin, but while diagnosis is based primarily on symptoms, the medical history is also important. This includes family history, other atopic diseases such as asthma and hay fever, possible exposure to irritants, whether any foods are related to flare-ups, sleep disturbances, past treatment for skin symptoms and use of steroids or other medications.
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Dr Paul Potter
“
The underlying disorder is a barrier dysfunction of the skin, and the main symptom is itch
Dr Paul Potter of the Allergy Diagnostic and Clinical Research Unit, Department of Medicine, University of Cape Town (UCT) Lung Institute and Groote Schuur Hospital, says that in young children dietary factors are important triggers of exacerbations and specific immunoglobulin E (IgE) sensitivity to common allergens may be confirmed by skin-prick testing or immunoCap® RAST tests. True sensitivity to foods is best confirmed by a controlled food challenge. In older children and adults eczema may fluctuate in severity, and multiple visits may be required or a patient may be referred to a dermatologist. Allergy UK reports one dermatologist’s succinct description of the difference between eczema and other itchy rashes as “the others are rashes that itch, eczema is an itch that rashes”.
Mechanisms of the disease
Healthy skin provides a strong, effective barrier protecting the body from infection or irritation. Eczematous skin may not produce as much fats and oils, and is less able to retain water. Gaps open up between the skin cells and moisture is lost from the deeper layers, allowing bacteria or irritants to gain access, causing the skin to become irritated, cracked and inflamed. Most children and adults with eczema experience secondary infection in the form of flare-ups with oozing and weeping, often with yellowy crusts. The usual cause is infection with Staphylococcus aureus, which may require treatment with oral antibiotics. Five important factors commonly identified in eczema sufferers are: n drying out of the skin n the itch-scratch cycle n local irritants n allergy n infection.
Evolution or revolution in clinical management?
There has, of late, been something of a paradigm shift in the management of eczema, with a move to a proactive
approach rather than the traditional (and well-accepted) reactive approach. In the reactive approach topical steroids are given only when the rash appears, and stopped when the rash resolves. The proactive approach uses a maintenance regimen of long-term, low-dose, intermittent application of anti-inflammatory therapy to areas of skin which are clear but have been chronically affected by eczema in the past. This is applied together with regular emollient (moisturising) treatment of unaffected skin. However, UCT-trained Dr Richard Aron, who has rooms in Cape Town and London and treats patients all over the world through online consultations, has a unique though simple approach that has helped many. He says a common flaw in conventional therapy is the use of potent steroids in short bursts followed by socalled steroid holidays. “This results in eczema rebound on a regular basis”. He uses antibiotics actively in order to knock out the Staphylococcus aureus infection, which he regards as “the single most important factor causing the inflammation in atopic eczema and contributing to flares”. Dr Aron dilutes steroids and antibiotics into a moisturiser for long-term treatment, tailoring the creams to each patient’s needs. His treatment generally includes 30 g of a low-potency steroid cream and 300 g of moisturiser, which may be diluted in children, depending on their age. The cream should be applied up to six times a day, which may be reduced over time as the condition improves. He says results can start to be seen in 5 to 9 days. His website shares many patient testimonials, and there is a Facebook page (Dr Aron’s Eczema Treatment Discussion Group) created by parents of children who have been treated successfully.
Difficult cases
Occasionally eczema may respond poorly or not at all to standard treatments, and in these cases it is recommended that the patient be referred to a specialist. A course of oral corticosteroids may finally bring the inflammation under control. Alternatively, immunosuppressant medicines may be tried to modify the skin’s
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Focus | 35
inflammatory responses. These treatments require a great deal of monitoring to minimise the risk of side-effects. Phototherapy is another option for unresponsive and severe eczema. Ultraviolet B light therapy can be extremely beneficial – as can PUVA, a combination of oral psoralen followed 2 hours later by ultraviolet A light exposure.
New research directions
A 2010 study published in the Journal of Allergy and Clinical Immunology found that a second skin barrier structure, consisting of cellto-cell connections known as tight junctions, is also faulty in eczema patients. Tightening both leaky barriers may be an effective treatment strategy for eczema patients. Says Dr Lisa Beck, lead author and associate professor in the Department of Dermatology at the University of Rochester Medical Center: “Over the past 5 years disruption of the skin barrier has become a central hypothesis to explain
the development of eczema. Our findings challenge the belief that the top layer of the skin or stratum corneum is the sole barrier structure. It suggests that both the stratum corneum and tight junctions need to be defective to jumpstart the disease”. Researchers at Oregon State University found in a mice model that eczema can be triggered by a malfunctioning protein known as Ctip2. It was already known that Ctip2 controls body fats that keep skin healthy and hydrated, but it has now been discovered that if the protein is not performing properly, it can cause atopic dermatitis, a common type of eczema. Getting to the bottom of which genetic factors influence eczema is the best hope for prevention of this disease in the future.
What can healthcare workers do to help patients? Good patient-physician contact and patient education – primarily a nurse challenge –
“
Dr Aron dilutes steroids and antibiotics into a moisturiser for long-term treatment, tailoring the creams to each patient’s needs
IN N SK TIO C N PENETRATION O A N D AL F IR LER RIT G EN AN S
HING ITC
SC
DIS BAR TUR RIE BE R FU D
ING CH T RA
TS
irritation
“
THE ITCH-SCRATCH CYCLE
Allergy UK reports one dermatologist’s succinct description of the difference between eczema and other itchy rashes as ‘the others are rashes that itch, eczema is an itch that rashes’
Eczema can show as redness, blistering, oozing, crusting, scaling, thickening and sometimes pigmentation. can improve compliance with treatment recommendations. Several studies have identified the success of making patients active participants in their care through information and education. For example, Broberg, Kalimo, Lindblad and Swanbeck (1990) found a better therapeutic effect if
routine information given by a physician was supplemented by a nursing consultation of 2 hours. Broberg A, Kalimo K, Lindblad B, Swanbeck G. Parental education in the treatment of childhood eczema. Acta Derm Venereol 1990;70(6):495-499
Recommendations for management The following general recommendations may be beneficial to sufferers: n Avoid overheating and external irritants n Keep the skin covered with clothing to reduce exposure to irritants and trauma from scratching n Avoid skincare products that cause irritation n Avoid wool clothing and rough or occlusive fabrics (cotton is preferable) n Avoid irritants associated with hobbies or occupational exposure
n Avoid potentially harmful habits, for example excessive hand washing n Bath once a day in warm (not hot) water to hydrate the skin and remove contaminated and dead tissue n Pat body dry after bathing – do not rub with a towel n Apply an emollient immediately after bathing n Use a moisturising cleanser n Avoid antibacterial cleansers, which could lead to bacterial resistance.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
SAMA CONFERENCE, EXHIBITION & ANNUAL DOCTOR’S AWARDS 21-23 OCTOBER 2016 Sandton Convention Centre
Universal Access to Healthcare SAMA is the largest medical association in South Africa representing more than 17 000 medical practitioners, both generalists and specialists, in private practice and public sector. The SAMA conference will focus on Universal access to healthcare in order to deliver a better healthcare system to the nation. The 2015 Conference saw an attendance of over 500 delegates The conference attracts not only doctors but representatives from important healthcare stakeholders such as the National Department of Health, regulators, funders, administrators and managed healthcare entities. The South African Medical Association looks forward in welcoming you!
For further information: www.samedical.org/events | Registration now open!
Dealing with depression
“
A ‘wholebody’ illness, involving your body, mood and thoughts
By Leverne Gething
One in ten South Africans will be diagnosed with major depressive disorder (MDD) at some point in their lives.
D
epression is a significant contributor to the global burden of disease. The World Mental Health Survey conducted in 17 countries found that on average 1 in 20 people reported having an episode of depression in the previous year. Major depressive disorder (MDD) is the top-ranking cause of disability in the world. Dr Carla Freeman, specialist psychiatrist in the Division of Neuropsychiatry of the Department of Psychiatry and Mental Health at the University of Cape Town, says that many feel that MDD is on the rise,
but that “we may just be getting better at picking up cases”. The South African Depression and Anxiety Group (SADAG) define depression as: “A ‘whole-body’ illness, involving your body, mood and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things. A depression is not the same as a temporary blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depression cannot merely ‘pull themselves together’ and get better. Without treatment, symptoms can last for weeks, months or years”.
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Feature Focus | 39
This medical condition can have a severe impact on a patient’s life, and is categorised according to this impact: n mild depression has some impact on daily life n moderate depression has a significant impact on daily life n severe depression makes it almost impossible to get through daily life.
How to make an accurate diagnosis of depression
It may be difficult for laypersons and healthcare workers to differentiate between a “normal” depressed mood and MDD. Freeman et al. (2013) highlight the fact that given the enormous distress and impairment associated with depression, and the availability of safe and effective treatments, “clinicians should have a low threshold for diagnosis”. Critical to diagnosis is careful history taking, focusing on the severity of symptoms and associated distress and impairment. At least five of the symptoms listed below need to be present to confirm the diagnosis of depression. Psychological symptoms: n Continuous low mood or sadness (minimum of 2 weeks) n Feeling hopeless and helpless n Absence of pleasure and inability to experience it n Low self-esteem n Feeling tearful n Feelings of guilt or worthlessness n Feeling irritable and intolerant of others n Having no motivation or interest in things n Finding it difficult to make decisions n Feeling anxious or worried n Having thoughts of suicide or self-harm. Physical symptoms: n Moving or speaking more slowly than usual n Change in appetite or weight (usually decreased, but sometimes increased) n Constipation n Unexplained aches and pains n Lack of energy or loss of libido n Changes in menstrual cycle n Disturbed sleep.
A major depressive episode is characterised by a depressed mood on a daily basis for a minimum of 2 weeks, with MDD or clinical depression defined by experiencing one or more major depressive episodes. Dysthymic disorder is characterised by mild or moderate depressive symptoms that are less severe than MDD and occur for at least a 2-year period. Other types of depression include postnatal depression (PND), bipolar disorder and seasonal affective disorder (SAD). PND: Some women develop depression after giving birth. Many women feel a bit down, tearful or anxious in the first week after giving birth; this is often called the “baby blues”, and is so common as to be considered normal. However, the “baby blues” don’t last for more than 2 weeks after giving birth, while PND does. Bipolar disorder: Also known as manic depression, it is characterised by episodes of extreme low moods (depression) and extreme high moods (mania). SAD is characterised by the onset of depression during the winter months or changes in the seasons, beginning and ending at about the same time every year.
The mechanism of depression
Depression results from a combination of factors, such as an imbalance in brain chemicals, family history (genetic component), thoughts or beliefs that increase the risk of depression, and traumatic or stressful life events. The onset of depression may be provoked by many factors, including: n Traumatic or challenging life changes (losing a loved one, ending a relationship, losing a job) n Medical conditions such as Parkinson’s disease, stroke, lupus, hypothyroidism, chronic pain, and some cancers n Certain medications, including corticosteroids, anabolic steroids, narcotics, benzodiazepines, progesterone and amphetamines n Alcohol use, which has short- and possibly long-term depressive effects.
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Dr Carla Freeman
There are many interrelationships between depression and physical health; for example, the World Health Organization indicates that cardiovascular disease can lead to depression, and vice versa.
Clinical management
“
People with a depression cannot merely ‘pull themselves together’ and get better
Treatment options consist of basic psychosocial support combined with antidepressant medication or psychotherapy, for example cognitive behaviour therapy, interpersonal psychotherapy or problemsolving treatment. Effective second-generation medications for depression have evolved, including selective serotonin reuptake inhibitors (SSRIs) and serotoninnorepinephrine reuptake inhibitors (SNRIs), which tend to have fewer sideeffects than older (first-generation) antidepressants such as the tricyclic antidepressants and monoamine oxidase inhibitors. Medications used to treat depression begin to work only after 2 - 4 weeks, although some symptoms may improve in the first few days. Often more than one medication has to be tried until the most appropriate one is found for a particular patient. Most antidepressants should be taken for at least 6 - 24 months after the episode of depression has resolved. In mild depression regular exercise often proves beneficial. Patients should eliminate alcohol intake and drug use, as they worsen depression.
Difficult cases
Most types of depression respond to antidepressant medications, psychotherapy, or a combination of these, but sometimes depression doesn’t get better, even with treatment. Says Dr Freeman: “There are a variety of reasons why someone may not respond to treatment, for example concurrent substance abuse and comorbid medical illness. Difficult-to-treat or treatmentresistant cases warrant referral to specialist services”.
New research directions
Research is largely focused on finding a biomarker, for example in the blood or genes which may assist with making a diagnosis and selecting the most appropriate treatment. Innumerable avenues of research are underway into all aspects of depression. Just two recent examples: An international team of researchers led by the University of Granada demonstrated for the first time that depression is more than a mental disorder: it causes important alterations of oxidative stress, so should be considered a systemic disease since it affects the whole organism. Studies of an inhibitor of soluble epoxide hydrolase (sEH) in rodents sees sEH emerging as a therapeutic target that plays a key role in modulating inflammation, which is involved in depression. Inhibitors of sEH protect natural lipids in the brain that reduce inflammation and neuropathic pain. Therefore these inhibitors could be potential therapeutic drugs for depression.
What can healthcare workers do to best help patients?
Being recognised and taken seriously without judgement is crucial for depressive patients. Creating a safe environment for patients to discuss their symptoms openly and in detail will help the healthcare worker to diagnose depression and its severity accurately. Dr Freeman emphasises that MDD is frequently underdiagnosed and undertreated, as patients may not step forward and report their symptoms (this for various reasons, including stigma). Healthcare workers may not ask about symptoms due to other competing conditions, with MDD falling low down on the priority list. “It would make a big difference to assess MDD as part of routine care, especially as it impacts significantly on treatment engagement and adherence in the context of other medical comorbidities.” Freeman CP, Joska JA. Dealing with major depression S Afr.Pharm J 2013;80(6):16-21.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
Efegen XR - is a once daily venlafaxine extended release formulation for the treatment of depression including depression with associated anxiety.1 An anti-depressant proudly made available by Ranbaxy (S.A.) (Pty) Ltd, a SUN PHARMA company. S5 Efegen XR 75/150. Reg No. 42/1.2/0423/4. Each extended release capsule contains venlafaxine hydrochloride equivalent to venlafaxine 75 mg and 150 mg respectively. Pharmacological classification: A 1.2 Psychoanaleptics (antidepressants). Applicant Ranbaxy (SA) (Pty) Ltd. References: 1. Efegen XR package insert, Ranbaxy (S.A.) (Pty) Ltd. (July 2010) Applicant: Ranbaxy (S.A.) (Pty) Ltd, a SUN PHARMA company. Ground Floor, Tugela House, Riverside Office Park, 1303 Heuwel Avenue, Centurion, 0046. Tel: +27 12 643 2000. Fax: +27 12 643 2001. www.sunpharma.com
Derek Yach: Global health innovator
P
Derek Yach, Chief Health Officer and Head of Discovery’s Vitality Institute, promotes public and private sector partnerships to pilot global health reforms.
By Toni Younghusband
owerful limbs cleave the icy waters of Table Bay steadily and confidently, closing the 7.4 km gap between Robben Island and Blouberg Beach. For the lone swimmer, this stretch of surf holds the same compelling challenges as the policies and debates, the reforms and the negotiations he navigates daily from his office on Columbus Circle, New York City, and he slices through the swell with the same mental acuity, quiet determination and vigour he utilises in boardrooms and lecture halls around the world. As a renowned global health authority, South African (SA) scientist Derek Yach is a significant player in shaping the future of world health, using his position as chief health officer and head of Discovery’s Vitality Institute to steer policymakers towards strategies that will ensure healthier populations in a world less burdened by disease. He joined Adrian Gore’s Vitality in 2012 and the Institute was established a year later in May. “Over the past 16 years, Discovery Vitality has gained significant evidence and experience in strategies and programmes to reverse negative health trends,” Gore said at the Institute’s launch. The Institute would use its experience and evidence to show governments and economists what worked and what didn’t to help improve health, and reduce the excess of two trillion dollars currently spent on healthcare. Yach was well placed to lead the charge. Prior to joining Vitality, he served as PepsiCo’s senior vice-president: Global Health and Agriculture Policy, with whom he still works as an advisor. Before that he headed global health at the Rockefeller Foundation; was a professor of Global Health at Yale University; and served as a former
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Profile | 43
executive director of the World Health Organization (WHO) in Geneva, where he lived for 10 years. At the WHO, Yach was cabinet director under director-general Gro Harlem Brundtland, where he led the development of the organisation’s Framework Convention on Tobacco Control, and Global Strategy on Diet and Physical Activity. Asked about his leap into the private sector, Yach says it was prompted by a call from the then-incoming CEO of PepsiCo, Indra Nooyi, who said she wanted critics to work from within her company to support her vision of transforming it into the healthiest food company in the world. The authenticity of her vision, the scale of impact her company had (two billion consumers) and her track record of selling off Kentucky Fried Chicken and Pizza Hut while buying Tropicana and Quaker Oats – plus the challenge of taking years of theory into practice, made it “a relatively easy” choice. Soon after joining PepsiCo, serious investments in research underpinning long-needed product changes (i.e. to cut salt, sugar and fat for starters), the recruitment of ex-pharma research and development leads and the company’s partnership with the world’s largest hummus maker made Nooyi’s vision far more achievable. Yach says he would give the private sector a 65% grade for its impact on global health, the relatively low rating due mainly to the economic recession and “a radical shift” towards the low cost needs of consumers, the failure of governments to apply smart regulations to encourage transition, and the tough reality of shifting consumer preferences towards healthy options. However, he feels “the ship is turning” and rising consumer demand for healthier and more sustainable products will push companies to achieve this.
Tobacco reform pioneer
In SA, Yach’s own reputation as a strategic thinker and resolute health reformist emerged with his establishment, in 1988, of the Centre for Epidemiological Research at the SA Medical Research Council (MRC). It was a heady time in health politics but with diplomatic determination Yach piloted transformative strategies that would change the face of health in SA, particularly around tobacco reform.
And he is still at the forefront of the battle against tobacco though, controversially, has come out in support of electronic cigarettes (e-cigs) while policymakers and health officials worldwide still flip-flop around legislative measures and safety issues. “We need clear, unambiguous messages to smokers about the safety and benefits of e-cigs,” Yach said in an article in Spectator Health. “Traditionalists demand more of the same policies that have significantly reduced tobacco use: excise taxes, full implementation of smoke-free workplaces and more effective anti-smoking advertising. “The call for higher excise taxes ignores rising concerns about their regressive impact on poorer and more-addicted smokers. It also ignores advances in the genetics of nicotine use, suggesting that half of all smokers may not respond to tax increases because of their need for nicotine. In other words, our one-size-fits-all approach to tobacco control is doomed to fail.”
E-cigarettes a vital mitigation tool
Yach, who campaigned against tobacco companies as a student and views them with historical mistrust, nonetheless believes e-cigs could play a major role in helping those smokers most addicted to nicotine to quit smoking. “It’s estimated there will be a billion tobacco-related deaths before 2100. That is a dreadful prospect. E-cigs and other nicotinedelivery devices such as vaping pipes offer us the chance to reduce that total. “As Mitch Zeller, director of the FDA’s Centre for Tobacco Products, says: ‘people smoke for nicotine but die from tar.’ All of us involved in tobacco control need to keep that prize in mind as we redouble efforts to make up for 50 years of ignoring the simple reality that smoking kills and nicotine does not.” Derek Yach was born in Cape Town in 1955 and attended primary and high school in Wynberg, a 15-minute walk from his family home. “My school grades were good enough for medical school so without deep thought I applied, after testing myself in biology to check I would not pass out at the sight of blood.” Student politics under apartheid and community health were major interests. “At
“
Yach says he would give the private sector a 65% grade for its impact on global health, the relatively low rating due mainly to the economic recession and ‘a radical shift’ towards the low cost needs of consumers, the failure of governments to apply smart regulations to encourage transition, and the tough reality of shifting consumer preferences towards healthy options
Derek Yach after completing a two mile swim in Greenwich, Connecticut.
“
Student politics under apartheid and community health were major interests. ‘At the University of Cape Town (UCT) I soon came to see how intertwined the two were and still are, and knew that my future lay in tackling the determinants of health’
the University of Cape Town (UCT) I soon came to see how intertwined the two were and still are, and knew that my future lay in tackling the determinants of health.” It was at UCT that he met his wife Yasmin von Schirnding, environmental scientist and the daughter of a diplomat. The couple has a 12-year-old son, Julian, a keen tennis player and pianist, and today they live in Connecticut in the US, a relatively easy commute to Yach’s Manhattan offices. Yach received his MB ChB from the University of Cape Town in 1979, his Master of Public Health (MPH) from Johns Hopkins School of Public Health in Baltimore in the US in 1985 and an honorary DSc from Georgetown University in Washington DC in 2007. He has authored or co-authored over 200 articles covering the breadth of global health and serves on several advisory boards including those of the Clinton Global Initiative, the World Economic Forum, the National Institutes of Health’s Fogarty International Centre and the World Food Program USA. His Vitality Institute office, shared with CNN, is ideally located just 50 metres from
Central Park for his favoured walk-and-talk meetings with leading corporate players, UN officials, Wall Street executives, Ivy league colleges, Clinton Global Initiative representatives and innovative health start-ups, all of whom Vitality engages with frequently. Here he is well placed to comment on, for example, the similarities between what is neglected in those processes underway in SA related to the National Health Insurance (NHI), and the US Affordable Care Act. “Both countries tend to equate healthcare and access to treatment with better health. Research and policy actions tend to focus on pharmaceutical interventions and relegate prevention, healthy lifestyles, healthier communities and environments and private sector innovations to the margins. “I see healthcare as a needed subset of health that includes prevention, health promotion and cross-sectorial actions for health. The public sector alone is not able to resolve the enormous health challenges faced by global communities today.” In a recent keynote address at an Institute of Medicine meeting in Washington, DC, Yach urged corporations to actively engage in helping to change global health patterns. “Many of the companies on the JSE, as well as in the US, would say that the rising level of healthcare costs and the consequences are big impediments to their long-term productivity and their longterm innovation and retention and that’s why the greater focus on health is coming into being.” As he enters his 61st year, an age when most are looking towards that prize for years of hard work – retirement – Yach, as chair of the World Economic Forum Global Agenda Council on Ageing, is taking on another challenge: exploring the economic opportunities presented by an ageing population. “I believe in retiring the very notion of retirement! And rather drawing upon the only natural resource that is increasing – the wisdom of elders,” says Yach, and with that he steps into the Hudson River to complete yet another challenge: the physical contest between mind and body that he has waged in pools, rivers and seas since childhood in support of his own good health.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
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46 | Clinician’s View
Detecting depression: Where, how and then what?
M
Claire van der Westhuizen
is a medical doctor with an interest in mental health and injury prevention. She obtained her undergraduate degree at Stellenbosch University (SU). Thereafter she worked in a range of clinical settings in SA and the UK. She was awarded her PhD in Psychiatry and Mental Health from the University of Cape Town (UCT) in 2014 for a thesis titled: Mental disorders and violence-related injuries: Prevention opportunities in emergency centres. She is currently a postdoctoral research fellow at the Alan J Flisher Centre for Public Mental Health at UCT.
any individuals with depression do not walk into a consulting room saying, “I am sad. I’m not functioning well. And my sleep is awful.” Nor do these people have any obvious physical signs which would alert a clinician to the presence of significant psychological distress. To put it another way, the 67-year-old type II diabetic who is not adhering to her medication may have more in common with the assaultinjured young man than one might think. This brings us to the “to screen or not to screen” debate. Why should we screen if patients are not complaining of these symptoms? First, we know that high levels of depression are common in certain patient groups in South Africa (SA), such as chronic care patients and injured emergency care patients. Up to a quarter of HIV-positive patients have been found to suffer from depression, and an emergency centre study reported that 25% of the injured study participants had experienced depression and that 60% suffered from a current mental disorder. Second, we know that people suffering from depression may also suffer from comorbid disorders, such as an anxiety disorder. Third, we know that depression may negatively impact factors such as treatment adherence and injury risk. Finally, screening is not difficult or costly. Screening for common mental disorders can take 5 or 10 minutes and is easily accomplished using one of the many validated screening instruments available. In my experience, the most common arguments against screening include the lack of mental health referral resources,
and reluctance from clinicians to open a proverbial can of worms. These are valid concerns, given that mental health has not been prioritised in SA, and that healthcare staff have little time to attend to an overwhelming patient load. These concerns may be addressed by the employment of low-cost brief counselling interventions for mental health which have been shown to be effective in lower-resourced settings. Brief interventions can be offered utilising task-shifting, whereby screening for mental disorders and intervention delivery is shifted away from mental health professionals to primary care staff or trained lay counsellors. A recent emergency centre study in Cape Town demonstrated that lay counsellor-delivered interventions are effective in not only decreasing depression scores, but problem alcohol or drug use as well. An ongoing study (Project MIND) run by investigators from the SA Medical Research Council and the Alan J Flisher Centre for Public Mental Health, based at UCT and SU, is currently investigating effective methods of integrating such interventions into chronic care. So, in summary, we can screen for depression and other mental disorders, there are effective interventions available (psychosocial and pharmacological – see page 44), and evidence is being generated on the most effective way to integrate mental healthcare into other healthcare settings. In the near future, I hope that the elderly diabetic woman struggling with depression and the depressed assault-injured young man with psychological trauma will be able to access comprehensive mental healthcare in SA healthcare contexts, including emergency centres and primary care clinics.
H EALT H CARE G A ZETTE | MAY /J U NE 2 0 1 6
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