Healthcare Gazette - 2016 Nov/Dec

healthcare gazette

NOVEMBER/DECEMBER 2016 • ISSN 2078-9750

Ignoring behaviour change – HIV peril PG 5

MAKING C-SECTIONS SAFER FOR MOTHERS PG 23 10

14

NEWS

Union-plagued PE hospital CEO “preventatively redeployed”

17

RESEARCH

Current exercise recommendations not enough

32

FEATURE

Risky business: Hiring and firing in SA’s hospitals

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FOCUS

Focus on . . . teenage pregnancy

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Contents | 01

C on t ent s 5 23

NEWS 5 Better treatment for HIV distracts from risky behaviour trends 6 Sugary drinks tax unlikely to cut obesity, says UCT professor 6 Lifetime Achiever award for beleaguered hospital CEO 7 Patients “cured” of TB may still have active infection 8 HPCSA acts to cut interns’ hours

8 Artificial hearts costly, but have a place – top surgeons 10 Union-plagued PE hospital CEO preventatively redeployed

14 DASH diet prevents gout flare-ups 15 Lymphatic filariasis increases risk of HIV 15 Fruit and vegetables too expensive 15 Nasal flu injection effective

FEATURES 17 Risky business: Hiring and firing in SA’s hospitals 23 A 3-minute check to reduce C-section deaths

10 Feed a cold, starve a fever

FOCUS

11 Possible bacterial link to non-communicable disease

28 Focus on . . . HIV treatment

11 Exercise might prevent alcohol harm

RESEARCH 14 Exercise recommendations not enough 14 Contraceptives may increase vitamin D levels

10 17

32 Focus on . . . Teenage pregnancy

PROFILE 36 Professor Linda-Gail Bekker – striding the world stage

CLINICIAN’S VIEW 38 Saving mothers’ lives

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Because the X-ray detector is too limited to cover the entire bone structure, the range has to be enlarged using a stitching method that may have to bring together up to five images. “this not only takes time, during which the patient – who could be in severe pain and discomfort – has to remain motionless, the radiographer has to set the stitching range manually, which could prolong the process further,” she explained. tests of Samsung’s new fast stitching capability for the gc85a showed that it reduced total stitching time by 31 percent. not only is the actual time required for processing stiches images reduced, its advanced S-guide technology allows radiographers to set the stitching range with just a few clicks. Should the patient move, it also allows for immediate adjustments to be made. “this effectively reduces the number

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of retakes that may be required, not only saving time for the radiographer, but also reducing the patient’s waiting time and exposure to radiation,” ms Voget added.

Another significant advance for the gc85a is its Bone Suppression imaging processing technology. generally, when bone structures in the chest need to be suppressed to enable easier detection of tumours. this requires the patient to effectively have two X-rays – and a double dose of radiation. in addition, the accuracy of this diagnostic method could be compromised if the patient moves slightly during the process. “the new Samsung bone suppression capability is a post-processing process

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which requires only a single X-ray. the bone suppression software converts the conventional X-ray into an enhanced, soft tissue image without the ribs and clavicles that might obscure early-stage tumours,” she said. other new advances available for the Samsung gc85a include proven radiation dose optimisation; and Simgrid, a new software solution that reduces high frequency scatter noise in X-ray images.

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Ed’s Letter | 03

Ed’s Letter C h r i s B at e m a n

EDITOR Chris Bateman

Maternal health outcomes and HIV under the spotlight

W

ith the latest Saving Mothers report showing that 98% of deaths from bleeding associated with caesarean delivery occur at public hospitals (mainly district ones), it’s little wonder that Prof. Sue Fawcus, a lead author of the report, is asking uncomfortable questions.

The Mowbray Maternity Hospital veteran outlines these in our Clinician’s View column, wanting to know how her committee’s recommendations will be implemented, who will be responsible and whether the minimum requirements for a safe C-section service are in place at each and every relevant hospital.

We look at where these measures are succeeding or coming up short in our Features section, which includes an exposé of cynical interference in the running of hospitals by politicians in at least two provinces.

Our News section kicks off by asking whether SA is dropping the ball on addressing risky HIV behaviour, which has a loud echo in both our healthcare worker-friendly Focus topics: tackling our povertyinducing teenage pregnancy crisis and the introduction this September of early antiretroviral treatment (ART) for all people with HIV infection.The alarm bells on the unacceptably high rate of teenage pregnancies first sounded last year – figures show that an average of 99 000 girls have been falling pregnant every year since 2011 and those numbers are increasing (StatsSA).

Government-sponsored research also estimates 39% of girls aged 15 - 19 have been pregnant at least once.

This multi-factored failure of public policy stands in stark contrast to the hopeful launch of the new HIV testand-treat programme, which looks set to provide a huge boost to SA’s ART roll-out,

already the largest HIV treatment programme in the world.

Moving back to News, we report on the wider utility of the much-touted new mechanical heart (prolonging life for the few, but too expensive for the many), red-flag-waving research revealing how TB infections can linger, long after a 6-month drug treatment course which is intended to achieve a “cure”, and the HPCSA belatedly reducing interns’ dangerously long working hours.

We ventilate the debate about the sugar-sweetened beverage tax due next year and question whether it is really the right intervention to make a populationlevel difference to obesity, given the multiple factors influencing this driver of rampant non-communicable diseases in SA. Some health economists think not and question the actual science upon which government has based its move.

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News | 05

Better treatment for HIV distracts from risky behaviour trends By Lauren Burley Copley Government’s proposed adoption of a voluntary national test-and-treat antiretroviral treatment (ART) programme has evoked heated debate over whether SA is dropping the ball around HIV. SA has only “managed the consequences of reckless sexual behaviour, but is failing to address the actual behaviour,” says Dr Tony Behrman, CEO of SA’s largest general practitioner doctor group, the Independent Practitioners Associattion Foundation of SA (IPAF).

Addressing medical professionals at a Health Quality Assessment (HQA) conference in Centurion on 22 July, he said “despite the positives of SA having the world’s largest prevention and detection HIV programme, latest trends show that it’s being overshadowed by new problems”.

These include a drop in the average age of onset to age 17, increase in multiple sex partners, lower condom usage at younger ages and the emergence of new resistant strains of HIV that don’t respond to normal HIV medications – problems highlighted in the HSRC’s 2012 SA National HIV Prevalence, Incidence and Behaviour Survey Report.

Even more alarming, added Dr Behrman, was that youth aged 15 - 17 seemed to have no fear of getting HIV or its consequences, partaking in risky, “anything goes” sexual practices.

However, Siraaj Adams, board member of the HIV Clinicians Society, argues that the concerns around social behaviour and sexual practice can “mostly be managed through the current prevention components within

the government’s HIV treatment programme”.

Regular HIV screening, free condom provision, medical male circumcision, family planning, sexually transmitted infection (STI) treatment and in the future, pre-exposure prophylaxis (PEP), medication appear to explain Adams’ optimism. In addition, Adams is upbeat that “Dr Yogan Pillay (deputy director general, programmes, at the National Department of Health) and his team have responded with a task team to address HIV socio-sexual behaviour especially in young women”.

He believes government has done an amazing job with the rollout of the world’s largest HIV treatment programme despite challenges relating to staff shortages, limited infrastructure and treatment funding.

So if Behrman’s argument that government has to find ways to start changing sexual behaviour and not just treating the resulting infections is correct, how does one tackle this complexity? Adams concedes we need more initiatives to address the sexual behaviour issues: “Technically, we’ve created the perception that unprotected sex is less risky since there’s the morning-after pill, the human papillomavirus (HPV) vaccine can

prevent genital warts, circumcision lowers your risk of acquiring HIV, and we can avoid HIV infection by taking PEP medication.”

However, despite the accessibility of biomedical prevention choices, Adams says “it’s ultimately the individual patient’s choice to protect him or herself by voluntarily and actively seeking treatment options currently available”.

Dr Behrman maintains we need to involve doctors and healthcare workers in a more concerted sexual education drive at schools and clinics to change perceptions and empower young people to become sexually more responsible.

“We must enable youth to make more informed decisions by committing to a regular sexual partner and recognising that using good mechanical protection is still the safest way to avoid getting infected.”

end HIV exceptionalism

SAMA, the largest doctors’ body in the country, called on the National Department of Health this September to help reduce HIV stigma by making HIV testing as routine as testing for diabetes, cancers, and other diseases as part of the new test-and-treat policy.

SAMA chairman, Dr Mzukisi Grootboom, welcomed the national public sector rollout of test and treat for HIV, which brings SA into line with the most recent WHO guidelines, calling it “immense”. He said having to wait for treatment was “not clinically appropriate”.

In the past, patients could only start treatment after it was established that their CD4 count was lower than 500. “For many thousands, even millions of patients, this means they can start their treatment sooner, and will become stronger quicker . . . [it] will certainly make a huge difference in our efforts to deal more effectively with HIV and AIDS,” he said.

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Sugary drinks tax unlikely to cut obesity, says UCT professor

The 20% tax on sugarsweetened beverages announced for next year by the Treasury this August is highly unlikely to address “something as complex as obesity”, says University of Cape Town nutrition scientist Prof. Marjanne Senekal.

Speaking just days after attending an international nutrition conference in Stellenbosch this September, she said healthcare workers should rather encourage healthy dietary patterns based on energy-dense foods and promote physical activity.

Her comments were made in

response to a statement by several local health economists who labelled the government tax an “empty gesture”, based on equivocal scientific evidence and mathematical modelling that indicates 220 000 people or 0.4% of the population may benefit.

They say the very science the government relies on concludes that such a tax would have an “insignificant impact”. Linking economic interventions to changes in diet and physical activity was shown by scientists at the Behaviour and Health Research Unit at the University

of Cambridge to be “far less compelling than some proponents have claimed”. Critics suggest the tax is an “arbitrary tax grab”, exploiting poor people who tend to seek out drinks with a high energy content.

Naturally sugar-rich fruit drinks are excluded while no account is taken of sugar added to food or hot drinks (though a straight sugar tax has been mooted).

Senekal said energy intake to weight ratio was “key” in dealing with obesity.

“People always want the magic bullet, such as extremely low carbs, but with multifactoral conditions like noncommunicable diseases and obesity you’ll never have one change that is going to be the big answer.” She doubted whether the sugar tax would have any effect, adding that “women in some cultures don’t want to lose weight”.

Lifetime Achiever award for beleaguered hospital CEO

Mseleni Hospital’s Dr Kobus Viljoen accepts Dr Fredlund’s Lifetime Achievement Award

The Rural Doctors Association of SA has chosen to give its Lifetime Achievement Award to a hospital CEO who was battling a raft of union-related charges until September this year. Part of his ordeal involved being ordered by his provincial head office to stay at home for 4 months, and the extensive catching up he now has to do made him unable to receive the accolade in person.

Dr Victor Fredlund, 60, CEO of the deep rural Mseleni District Hospital near the Mozambican border in KwaZulu-Natal, sent his

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News | 07

Patients “cured” of TB may still have active infection The vast majority of HIVnegative patients who have been “cured” of TB infection still have actively inflamed lung lesions at the end of their treatment course, a Stellenbosch University (SU) study published in Nature Medicine this October shows. A third of purportedly cured patients have new or exacerbated lesions.

The surprising findings highlight how important it is for healthcare workers to retain a high index of suspicion, even if a smear test at the end of a TB treatment course is negative, Dr Stephanus Malherbe, of SU’s Immunology Research Group, told HG. “We’re working on better tools to monitor treatment response, but this study (of 99 HIV-negative, TB-diagnosed and ‘cured’ patients) shows that TB almost goes back into a latent subclinical phase after treatment,” he said. The findings would be a catalyst for further

tests around immune therapy and immune modulation, but already they emphasised the importance of improved counselling and advanced testing.

Advanced imaging, accurately showing the sites of inflammation during and after treatment, revealed only 14% of the study group had no remaining inflammation in the lung after treatment was completed. SU worked in collaboration with the Catalysis Foundation of Health, Rutgers New Jersey Medical School, Stanford University School of Medicine and the National Institutes of Health in the USA. Malherbe said the findings point to the crucial role for the body’s immune response to suppress or eradicate any residual live bacteria after treatment. Any treatment aimed at boosting the immune response should improve outcomes. Instead of “patting a patient on the back” once their

smear was negative, healthcare workers who saw anything vaguely suspicious should send them for an X-ray and arrange a follow-up appointment, counselling them to eat healthily and to avoid smoking or drinking.

second-in-command, Dr Kobus Viljoen, to receive the award in his stead since work commitments made it impossible for him to attend.

According to the award citation, the sprightly 60-year-old missionary veteran’s leadership and compassion have impacted virtually every sphere of life in the Umkanyakhude district. From building toilets to teaching basic sanitation, pumping water from nearby Lake Sibayi to reticulate through the hospital and surrounding community, Fredlund also helped buy community tractors for ploughing, set up market and subsistence gardens, helped build classrooms, a 1 000-seater community hall, a computer centre,

sports facilities, facilitated a local market and launched several youth employment projects.

His upliftment includes the Lulisanda Kumtwana project which, at one stage, had 3 000 registered orphans under its care, many of them AIDS orphans. He pioneered the concept of academic scholarships for rural children, the local teaching of maths and science and the bursary-linked return of healthcare workers to their own communities. Together with his equally tireless wife Rachel, he continually hosts local destitute and homeless children in the wooden home they built and has sponsored the living expenses and school or university fees of countless others over the years.

Accepting the award on his behalf, Dr Viljoen said the Fredlund household at night was a mix of foreign students, volunteers and children – often with Fredlund entertaining them on his trusty guitar. A fearless surgeon with a penchant for cardiology, he had conducted “every -ectomy and -otomy in the book”, and regularly conducted hernia operations, hysterectomies and total hip replacements, while his clinical brag list included three full-term extra-uterine deliveries (incidence 1 in 30 000). Viljoen summed up Fredlund by quoting former US president, Harry Truman: “It’s amazing what you can accomplish if you don’t mind who gets the credit”.

TB lesions in patient’s lungs – baseline, month 1 and month 6 after treatment

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HPCSA acts to cut interns’ hours The maximum continuous working hours for hospital interns has been reduced from 30 hours to 26 hours (including a 2-hour hand-over period), by the HPCSA, which also advised that interns need ‘’periods of rest” and mandatory provision of sleeping areas.

Prof. Ben Luke, chairman of the HPCSA sub-committee for internship training, said that if rest periods could not be ensured (due to workloads), then individual hospitals should “look into” putting shorter shifts in place.

He confirmed an earlier statement by the National Department of Health’s hospital chief Dr Terence Carter that a

hospital’s training accreditation by the HPCSA could be revoked if mandatory sleeping areas were not provided.

Luke was speaking as complaints by doctor activist groups such as Safe Working Hours reached a media crescendo with an 80-minute television documentary highlighting the physical and emotional exhaustion of five interns at a northern KwaZulu-Natal deep rural hospital going viral. (https:// vimeo.com/180480648).

Western Cape was the first province to announce it would institute shorter shifts from 1 January 2017, saying no intern would work longer than 24 hours.

Luke said his committee recognised that, in certain hospitals, 26-hour shifts were required, which is why mandatory periods of rest were being instituted. “There are two main issues: young doctors need to be trained in a safe working environment, and there should be teaching during their after-work hours.”

He stressed that no intern should work alone in any ward without some senior supervision.

Interns worked a 07h30 to 16h00 day before continuing around the clock to go home at 01h00 the following day. “We recognised that this is too long,” he said.

Doctors groups universally welcomed the move.

Artificial hearts costly, but have a place – top surgeons Mechanical heart IMPLAN­ tation, which can prolong life for 6 - 8 years, is currently too expensive for the developing world, even though it buys time for end-stage patients awaiting scarce human hearts, says Prof.

Johan Brink, director of Clinical Services in the Christiaan Barnard Division of Cardiothoracic Surgery at the University of Cape Town Private Academic Netcare Christiaan Barnard Hospital.

Memorial Hospital mechanical heart recipient, Mrs T Somji Speaking after the annual congress of the World Society of Cardiothoracic Surgeons hosted in Cape Town from 9 - 12 September this year, he was responding to the stir caused by rapid advances in artificial cardiac device implantation. Dr Willie Koen,

another internationally renowned heart transplant surgeon who practises at the nearby Netcare Christiaan Barnard Memorial Hospital, believes mechanical heart transplantation will “totally replace” donor heart transplantation within 15 years.

While conceding that they currently do not have the same longevity as the biological option, Koen says mechanical heart device implantation occurs twice as often as donor heart transplantation in Europe, Australasia and North America.

“With its rapid development, we expect this to improve to match the 20-year or more longevity of the biological option within a decade,” he adds. Earlier this year Koen conducted two highly successful life-prolonging mechanical heart transplants at his hospital. The devices (costing R1.5 m or more) require no antirejection drugs which often cause

Dr Willie Koen and his mechanical heart recipient patient, Philasande side-effects, making up the cost difference in drug savings alone within 5 years. Brink said the new technology prolonged life in a SA pool of possibly thousands of candidates, only 40 of whom they can help annually with donor heart transplants, calling the drug saving costs “exaggerated”. The current transplant “holy grail” was pig hearts using human gene therapy, a clinical reality some believed possible within 10 years.

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Union-plagued PE hospital CEO preventatively redeployed

The union-beleaguered former CEO of Port Elizabeth (PE)’s Dora Nginza Hospital, Dr Nthombi Quangule, sent home for 6 months as her head office probed allegations of “gross mismanagement”, was last month “preventatively redeployed” as director of hospital services for the Eastern Cape.

A spokesman for the Eastern Cape Health Department, Siyanda Manana, confirmed that a second probe had been instituted after the promised release of the first investigation against her failed to transpire. Dora Nginza Hospital

made headlines in February this year when long-standing critical shortages in the maternity unit were aggravated by a union strike in which near burnt-out doctors and nurses were prevented from doing ward rounds by strikers.

Conducting a surprise late-night medical ward inspection that week, Quangule also caught eight nurses – the entire ward complement – asleep in unoccupied patient beds.

Coinciding with doctor allegations of leadership autocracy, major staff shortages, non-appointment of consultants to available posts, outstanding overtime payments

and burn-out, this led to the Bisho head office telling her to stay away “for her own safety”. Manana said Dr Quangule had provided answers in the second probe, but they were “being careful, because we don’t want to leave anything to chance”. Quangule was director of hospital services before she was appointed CEO of Dora Nginza Hospital. Her re-appointment was described by Manana as “preventative redeployment”.

The Dora Nginza Hospital upheaval was prompted by extreme staff and equipment shortages. Public Service accountability monitor director, Jay Kruuse, said redeployment should be limited to cases where allegations were without substance. Quangule’s continued placement at Dora Nginza was rendered “intolerable” by other employees and third parties, he added.

Feed a cold, starve a fever The old wive’s tale says “feed a cold, starve a fever” and a recent study suggests that there may well be some truth in this.

The study, published in Cell, worked on the premise that symptoms of acute illness include anorexia and hypothesised that there is a biological basis for this.

Mice with Listeria monocytogenes infection (a common cause of food poisoning) generally stop eating and eventually recover.

When they were force fed, they died. It was the glucose in the diet that did the damage – proteins and fats were fine.

Similar studies in mice with viral infections gave the opposite effect – the mice survived when force fed glucose and

died if given a compound that prevented glucose metabolism.

Different parts of the brain were affected depending on whether the infection was viral or bacterial, showing that the animal’s different metabolic needs depended on which part of the immune system was activated.

The study has many implications for clinical practice, from how to feed – or indeed not feed – those with critical illnesses in intensive care, to the potentially damaging effects of using antiinflammatory drugs to dampen normal immune responses to illness and inflammation.

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News | 11

Possible bacterial link to non-communicable disease Parts of the cell walls of bacteria, which can be shed even when the organisms are dormant, can affect physiological processes linked to noncommunicable diseases (NCDs) such as Alzheimer’s, Parkinson’s and diabetes, according to an international study done jointly with the University of Pretoria.

Prof. Resia Pretorius, director of the Applied Morphology Research Centre at the University of Pretoria’s Physiology Faculty, working with colleagues from the University of Manchester, found that a single molecule from a bacterial cell wall component can lead to the anomalous behaviour of 100 million clotting molecules.

They believe this effect may be a major contributor to many inflammatory NCDs. Published in the August edition of Scientific Reports, the study reported tests showing that tiny amounts of

lipopolysaccharide, which are shed by dormant bacteria, caused a highly anomalous clot to form dense deposits with very different fibres from the surrounding tissue.

The discovery reveals an intriguing infectious link Bacteria in blood taken from a patient with Alzheimer’s disease to diseases that are considered way explained “much about non-communicable and could the biology of many of these generate new avenues for diseases. This opens up novel treatment research that target means – including nutritional – for this process, which has been their prevention and treatment”. unknown until now.

Pretorius explained that Prof. Douglas Kell, research lipopolysaccharide could make chair in Bioanalytical Science at holes in the blood/brain barrier, the University of Manchester, said while a leaky gut, common to discovering that tiny amounts of many inflammatory conditions, bacterial cell wall material had seriously compromises the such a massive effect on causing immune system. blood to clot in an unusual

Exercise might prevent alcohol harm Exercise offsets at least some of the risks of cancer and all-cause mortality associated with drinking alcohol, according to a recent study published in the British Journal of Sports Medicine.

The study, of more than 36 000 men and women over the age of 40 in England, and 353 049 person-years of followup over nearly 10 years, suggests that exercise, even at the current public health recommendations for physical exercise, offsets at least some of the risks of cancer and all-cause mortality associated with drinking alcohol.

It is well-known that high alcohol consumption is linked to

an increased risk of death from any cause and specifically cancer and cardiovascular disease. However, in spite of public health campaigns to reduce alcohol consumption, levels of drinking remain high, with 24% of men and 18% of women reporting drinking more than recommended levels. Although there is limited evidence that physical activity may prevent some of these harmful effects, previous studies were limited by pooling non-drinkers and ex-drinkers, which overestimates the protective effect of moderate drinking.

This study used a detailed categorisation of weekly alcohol intake and found a direct

association between alcohol con­ sumption and death from cancer, looking across the spectrum of drinking habits, from within the guidelines, to hazardous drinking.

In people who met the minimum guidelines for physical activity, the effect of drinking was reduced for deaths from all causes and nearly gone for deaths from cancer.

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Bite-sized summaries of the latest scientific advances Contraceptives may increase vitamin D levels

Exercise recommendations not enough There is plenty of evidence to show that exercise can prevent a range of chronic conditions and cancers, but just how much exercise is still debated, mainly because most studies focused on just one area of physical activity. Now a study in the British Medical Journal looked at the dose-response associations between total physical activity and risk of breast cancer, colon cancer, diabetes, ischaemic heart disease and stroke events

using metabolic equivalent minutes/week of any form of exercise. The bottom line was that anyone who achieved physical activity several times higher than the current recommended minimum has a significant reduction in the risk of the five diseases studied.

Kyu HH, Bachman VF, Alexander LT, et al. 2016. Physical activity

Previous studies have found that taking oestrogen in hormone replacement therapy or oral contraception may be associated with higher serum levels of vitamin D, but whether this was a causative effect or due to other lifestyle factors was unclear. A large US study has now found 20% higher vitamin D levels in combined pill users. The findings suggested that contraceptives containing oestrogen tend to boost vitamin D levels, and those levels are likely to fall when women stop using contraception.

and risk of breast cancer, colon

DASH diet prevents gout flareups Eating a diet high in whole grains, fruit, and vegetables and low in red meat and saturated fats may significantly reduce serum uric acid, according to a randomised study. The new study, reported in Arthritis and Rheumatology, randomly allocated 103 adults with hypertension (mean age 51.5) to the Dietary Approaches to Stop Hypertension (DASH) diet or to a control diet typical of the average US diet, each for 30 days before switching to the other diet for a further month. The DASH diet is high in whole grains, fruit, vegetables, fish, poultry, and low-fat dairy foods and is low in red meat, saturated fats, and sugar.

cancer, diabetes, ischemic heart

Harmon QE, Umbach DM, Baird

disease, and ischemic stroke

DD. Use of estrogen-containing

Jurascheck SP, Gelber AC, Choi

events: Systematic review and

contraception is associated

HK, et al. Effects of the dietary

dose-response meta-analysis for

with increased concentrations

approaches to stop hypertension

the Global Burden of Disease

of 25-hydroxy vitamin D. JCEM

(DASH) diet and sodium intake on

Study 2013. BMJ 2016;354:i3857.

2016;101(9):1658. DOI:10.1210/

serum uric acid. Arthritis Rheumatol

DOI:10.1136/bmj.i3857

jc.2016-1658

2016;39813. DOI:10.1002/art.39813

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Research | 15

Fruit and vegetables too expensive Several international guidelines recommend two fruit and three vegetable servings a day, but this is seldom followed.

Nasal flu injection effective

Lymphatic filariasis increases risk of HIV The link between parasite infestation and increased risk of HIV infection has been controversial. This study from Tanzania suggests that, parasitic infestation by Wuchereria bancrofti, causing lymphatic filariasis, does significantly increase the risk of acquiring HIV. Researchers studied roughly 18 000

participants from households in southwest Tanzania, who were tested for circulating filarial antigen, an indicator of W. bancrofti adult worm burden. HIV incidence in those infested with worms was significantly higher than in those negative for the worm.

The Prospective Urban Rural Epidemiology (PURE) study suggests that availability and affordability are the main reasons for this. Participants from 18 countries were enrolled between 1 January 2003 and 31 December 2013. The cost of fruit and vegetables relative to household income was recorded. The lower the income, the higher the relative cost of fruits and vegetables, particularly in low-income countries.

Intranasal live attenuated influenza vaccine provides similar protection against flu in children – and similar herd immunity – to the inactivated flu vaccine by injection. In June this year, US authorities had recommended against the use of the nasal vaccine for the 2016 - 2017 flu season, saying it had no effect. However, this study, from the Annals of Internal Medicine, suggests otherwise.

Miller V , Yusuf S, Chow CK, et al. Avail-

Loeb M, Russell M, Manning V, et

ability, affordability, and consumption

al. Live attenuated versus inacti-

Kroidl I, Saathoff E, Maganga L, et

of fruits and vegetables in 18 countries

vated influenza vaccine in Hutterite

al. Effect of Wuchereria bancrofti

across income levels: Findings from the

children: A cluster randomized

infection on HIV incidence in southwest

Prospective Urban Rural Epidemiology

blinded trial. Ann Intern Med

Tanzania: A prospective cohort study.

(PURE) study. Lancet Glob Health

2016; Published online ahead of

Lancet 2016;388(10054):1912-1920.

2016;4(10):e664-e665. DOI:10.1016/

print 16 August 2016. DOI:10.7326/

DOI:10.1016/S0140-6736(16)31252-1

S2214-109X(16)30186-3.

M16-0513

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Plasmoquine Capsules contain chloroquine sulphate enclosed in a capsule, making them easy to swallow, with no bitter taste. This makes Plasmoquine Capsules the anti-malarial of choice for doctors prescribing in the treatment of rheumatoid arthritis as well as discoid lupus erythematosis (lupus syndrome)

Reg. No. Z/20.2.6/127 Each capsule contains 200mg Chloroquine Sulphate Monohydrate equivalent to 146.7mg Chloroquine base

Medchem Pharmaceuticals CC Tel no: 012 348 0752 • Fax: 012 348 0873 • Email: medchem3@gmail.com

Feature | 17

Risky business: hiring and firing in SA’s hospitals Strange things happen at election time. Patient care and doctor support can come a very poor second to tub-thumping and vote collecting. That’s if the stories of two highly respected hospital CEOs with impeccable and impressive track records can be believed.

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Fort England hospital staff and patients’ choirs perform at the Mental Health and Quality Assurance Awareness Day

“

One of two local political ward aspirants allegedly called for the hospital to be torched at a rowdy public meeting

W

eird as it may seem, this year’s Rural Doctors Association of South Africa (Rudasa) Lifetime Achiever Award recipient, Dr Victor Fredlund (60), CEO of Mseleni Hospital, spent nearly 4 months at home on officially enforced leave – until this July. Aspirant local political candidates and unions led a charge against his withdrawal of job offers from two cleaners and his firing of a third. Head office bureaucrats insisted that the removal of the veteran stalwart from the far northern KwaZulu-Natal (KZN) hospital was “for his own safety”. They bickered, fudged and stalled, way after any perceived threat to him had evaporated. Then, seemingly at a loss over how to justify his lengthy absence, they charged him in August – for doing exactly what they’d advised him to do.

It got every bit as bizarre for Dr Roger Walsh, CEO at the Fort England Psychiatric Hospital in Grahamstown and his senior clinical staff, culminating in Walsh being ordered by Eastern Cape Department

of Health (DoH) superintendent general Dr Thobile Mbengashe to repair to the provincial headquarters during a wildcat strike in mid-July – also for his own “safety’’.

Walsh refused, citing a Bisho-ordered independent legal probe which had wholly cleared him and his management of 36 fatuous union charges involving alleged wrongdoing, mismanagement, negligence and corruption. The probe, which found local shop stewards ignorant of the terms and conditions of employment and “in need of training”, was ignored by Bisho head office. Head office also reneged on an earlier promise to secure a court interdict against the illegal mid-July wildcat strike.

Members of the three unions had barged into wards, blowing whistles and beating sticks on tables and countertops, ordering workers out, allegedly threatening to burn their homes and at one stage allegedly assaulting Walsh. On 18 July the strikers reportedly stole keys to the kitchen and for the food delivery van. Thinly spread senior clinicians comforted and tended to upset patients, administered medicines,

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Feature | 19

“

Twenty general orderly positions were up for grabs early this year.

There were 2 720 applicants.

cooked food and ordered sandwiches.

Fort England houses 300 patients with mental health disorders, some of them “extremely disturbed and needing constant supervision”, plus 26 prisoners and some of the “most difficult and dangerous” State patients in the country. Walsh’s team warned Bisho that “without proper supervision there is a danger of violence, escapes and relapsing of psychosis going unnoticed”.

“Bizarre” charges

Back in KwaZulu-Natal, Mseleni Hospital’s bemused CEO Victor Fredlund, said of his union saga: “It’s just bizarre. The province’s charge is that I wilfully and deliberately abused my power in dismissing a guy who failed to declare a previous assault conviction in his job application and that I withdrew the job applications of two others who allegedly falsified their addresses.

That’s precisely what head office advised me to do”.

He was speaking just hours after his disciplinary hearing ended on 10 August.

Nearly a month later, he received an email clearing him of all charges. By then he had unilaterally instructed 20 head officesuspended general orderlies and his five pivotal managers to return to work but received instructions that he must charge his chief matron, human resources manager

and the systems manager – for allegedly illegally hiring some orderlies.

Just like at Fort England, where his clinical colleague Roger Walsh was handpicked by the “union-proof” (and thus short-lived) former SG, Dr Siva Pillay, to sort out and improve services at the strife-torn hospital complex, local political conditions were ripe for the plucking. Twenty Mseleni Hospital general orderly positions came up for grabs earlier this year. There were 2 720 applicants. Poverty and joblessness are endemic in the coastal bushland district, 60 km from Mozambique and close to the sprawling Lake Sibayi. Locals catch fish and grow crops to survive and, unsurprisingly, believe any local jobs should be for local folk, a belief reinforced by politicians at local rallies. When it emerged that two of the Mseleni Hospital job applicants were not locals and had allegedly falsified their addresses, the spark of protest was easily lit. One of two local political ward aspirants allegedly called for the hospital to be torched at a rowdy public meeting where Fredlund and his management were publicly accused of taking back-handers and being corrupt in making appointments.

A long list of historical grievances was produced. Two political candidates (initially both ANC), vied to outdo each other and demanded the heads of Fredlund, the

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Rachel and Victor Fredlund hospital matron, the human resources (HR) officer, and the systems manager. All were put on enforced leave by head office.

Standing firm

Fredlund and his earlier colleagues made medical history by describing what is now known as Mseleni Hip Disease (as long ago as 1973), a uniquely localised condition for which they regularly conduct surgery. No such operation happened for 4 months this year as Fredlund – a devout Christian – champed at the bit at home.

His medical manager, Dr Kobus Viljoen, who stood in as CEO, has the required expertise, but was running the hospital and unavailable to do surgery. Viljoen wore his sentiments about the treatment of his senior colleague on his face – a fullsome beard (he stopped shaving in protest on 3 March, the day he took over as acting CEO, removing it when Fredlund was cleared). Among the many anomalies in the saga: the provincial labour relations handbook stipulates a maximum 60-day period of suspension without

charge. Fredlund was kept at home for nearly twice this long without charge.

Anaesthetic machines used to gauge the hospital’s oxygen supply system stood unserviced for months, putting patients in potential danger and at one stage almost forcing the transfer of 40 maternity ward patients to another hospital. A provincial special investigations unit’s lengthy probe into Fredlund (encouraged by him) was kept under wraps, in spite of repeated demands for it to be made public. The provincial DoH was represented by a lawyer at Fredlund’s hearing in alleged contravention of its own disciplinary code.

Even Fredlund’s long-suffering, seemingly phlegmatic response had its limits. He was ready to appeal to the labour court if necessary. “My real frustration is that this is distracting from the battle of fighting disease and poverty. If you’re looking for a battle, there are plenty of things out there to fight, not each other,” he observed wryly.

He declines to quantify any real patient harm caused by his and his senior clinical and administrative colleagues’ lengthy enforced absences. However, HG learnt that at least 19 staff members resigned, including most of his HR department, with none of their functions restored. Adds Fredlund: “I run quite a (proficient) clinical team, and I’m not indispensable. There just wasn’t that much senior cover in my absence. I cannot say how many patients died or not because I wasn’t there, but one friend of mine, a local pastor (and patient), died. My medical staff did a fantastic job in my absence under extreme pressure and abuse. Obviously our system was working very well, so it had degrees of buffering.

But instead of rising to the occasion, they were trying to save a sinking ship. We were on the rise.” Mseleni Hospital won the national Batho Pele service delivery award (across all government departments) last November. The year before that it won the (KZN) Premier’s service excellence award and the year before that the MEC (for KZN Health’s) service excellence award. “Then the (provincial) DoH takes our management apart and plants an atom bomb,” Fredland observes.

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Feature | 21

Political deconstructions

The veteran hospital chief refuses to see the dark side. A friend and confidant to local chiefs and community leaders, he says some good has come of the madness.

“I’ve been seen to be vulnerable by the community, so many have come to express love and concern.’’ The local chief intervened very effectively at one stage to berate rowdy agitators, threatening to banish them from the district if they continued to “act like children”.

The similar political deconstruction of a much-improved provincial healthcare facility was still playing out at Fort England at the time of writing. Walsh and his physician wife Michelle, were known and loved in the Barkley East District where they selflessly ran the local district hospital for many years before his October 2012 appointment. Under orders to reduce costs, he raised the ire of the unions at Fort England when he swapped seven cleaners from better-paid Sunday shifts to Mondays, when only two were on shift. He also made cleaners work a 5-day instead of a 4-day week. The measures immediately improved his hospital’s national core standards cleanliness scorecard, but his shop stewards refused to re-engage until he was removed as CEO. Walsh stayed put, resisting repeated senior officials’ “suggestions” that he be redeployed to Bisho. His courage saw his entire senior clinical staff close ranks behind him, and led to the three unions (Nehawu, Denosa and Nupsaw) upping the ante. Finally, an advocate was hired to do a probe, taking 90 days to produce a report which was sent to head office on 15 July this year. No fault was found with Walsh or his management.

Mbengashe ordered Walsh not to report at Fort England until 5 August. Says Walsh: “When I went back to work the unions wanted to know what I was still doing there”. He took the most pragmatic option – a holiday with his wife in Namibia until 26 August. Upon his return Mbengashe re-instituted the probe, with fresh allegations against him. Walsh endured a 4-hour grilling, with Mbengashe again ordering him to stay away from the hospital,

Mbengashe justifying this in writing with: “I cannot afford any industrial action at this time”.

Doctor bodies respond

Dr Desmond Kegakilwe, chairperson of Rudasa, said Walsh and Fredlund were clearly dedicated, vocation-driven doctors who helped develop healthcare delivery systems independently of political dispensations or changes. “These are not the first such cases. No matter how good and dedicated you are, you will always end up the victim if corruption comes in and you are the obstacle to whatever agenda these corrupt individuals have. Political power is used to give out this and do that, and nepotism comes in. As an organisation we will fight tooth and nail against this.

We must optimise service delivery – you can’t sacrifice it on the altar of individual agendas, however powerful the people are.

Our objective is quality rural healthcare.

We’re going to be watching these and similar cases very carefully in future.”

The chairperson of SAMA, Dr Mzukisi Grootboom said: “It boggles the mind that somebody, (referring to Fredlund), would get such accolades from the very department which, when he most needed them, decided to turn a blind eye for political expediency”. SAMA was “extremely perturbed” at the treatment meted out to doctors who’d dedicated most of their lives to servicing needy outlying communities, especially in the context of a country with a dire shortage of rural doctors and basic healthcare services.

A spokesman for the KwaZulu-Natal DoH, Sam Mkhwanazi, who was emailed a detailed list of HG questions, responded: “There are ongoing disciplinary matters involving a number of officials from Mseleni Hospital. However, it is not the practice of the department to ventilate in the public (sic) internal and confidential matters which are employer-employee related”. The Eastern Cape DoH failed to respond to HG SMSs, voice messages or emails.

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Mseleni Hospital

“

This distracts from the real battle of fighting disease . . . If you’re looking for a battle, there are plenty of things out there to fight

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Feature | 23

A 3-minute check to reduce c-section deaths SA’s caesarean section rate remains stubbornly high and a tragic number of women still die from postoperative complications.

Patricia McCracken investigates what is going wrong and how a 3-minute check could save many lives.

T

he statistics make grim reading. Thousands of SA women have bled to death following caesarean sections in recent years. The country’s hopes of reaching the 2015 Millennium Development Goal target of reducing maternal mortality by 75% from 1990 rates have fallen by the wayside. In homes around the country, families are destabilised and children orphaned by these tragically preventable losses, as healthcare leaders struggle to protect pregnant women from the dangers of delivery. But experts are convinced many lives can be saved with simple changes.

SA’s National Committee for Confidential Enquiries into Maternal Deaths (NCCEMD) first sounded the alarm almost 20 years ago.

It has tracked maternal deaths since 1998 in a series of triennial reports. SA’s institutional maternal mortality ratio showed 25% fewer maternal deaths in 2011 - 2013 at 53.47 per 100 000 live births, compared with 71.29 per 100 000 in the previous reporting period of 2008 - 2010. A major contributor to this result was better control of hypertension complications, with deaths from this cause dropping 18% since the 2002 - 2004 NCCEMD report.

But this achievement highlighted the stark reality that deaths due to obstetric haemorrhage had shot up by 24.7% over the same decade, sparking campaigns to make

C-sections safer and better controlled.

Yet the most recent report for 2011 - 2013 showed 5.5 deaths from haemorrhage for every 10 000 C-sections performed, according to a report in the SAMJ in April 2015 by Gebhardt et al. These authors found that most mothers died after C-sections in provinces with an overall low C-section rate, pointing to lack of experienced staff. Many women died in an ambulance before, during or after referral. At least 70% of cases of bleeding during or after C-sections were classified as avoidable – a point stressed by Fawcus et al. and Gebhardt et al. when they declared that maternal deaths from bleeding associated with C-sections constitute a national emergency in an article and an editorial respectively in the May 2016 SAMJ.

Grim toll

The NCCEMD’s Prof. Sue Fawcus has contributed a companion piece in this issue, summarising the obstacles to reducing maternal deaths from bleeding associated with C-sections: defensive surgery; failure to prevent excessive bleeding; failure to recognise an emergency; logistical failure from facility level upwards; and lack of skills. She

Clinical factors in maternal deaths

The 2011 - 2013 NCCEMD report noted that lack of appropriately trained doctors played a varying but significant role in maternal deaths due to the following causes: • Anaesthesia – 47% • Obstetric haemorrhage – 27% • Pregnancy-related sepsis – 24% • Complications of hypertension – 19%

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also outlines the solutions currently being implemented: clinical protocols, practical training, anaesthetic input and the NCCEMD’s minimum standards for C-section consensus document. The grim toll caused a shake-up of how C-sections are provided for, conducted and monitored.

Maternal deaths from bleeding associated with C-sections have recently fallen from a peak of 40 per 100 000 live births in 2012 to 28 per 100 000 live births. “It is relatively rare but we have given such tragedy a lot of priority,” says Dr Carol Marshall, national coordinator of District Clinical Specialist Teams (DCSTs). “We recognised that we must find ways to provide every hospital doing C-sections with enough staff, equipment and training.”

Even so, more than 2 years after the powerful suboptimal care call to save the lives of SA’s contributes to deaths mothers, those at the rockface The 2011 - 2013 NCCEMD report noted of healthcare service delivery that lack of appropriately trained doctors still struggle to implement and nurses appeared to be an increasthe solutions. An action ingly important contributory factor in plan will be presented in the assessable maternal deaths: forthcoming 2015 Saving Medical Mothers report, notes Prof. category 2008 - 2010 2011 - 2013 Fawcus. In the meantime, Doctors 9.3% 15.6% a toxic cocktail of factors Nurses 4.5% 8.8% prevent the country’s mothers from having some security that they will return home to bring up a healthy baby. One lingering problem is bringing women into the healthcare net.

Hotspots still exist, often in very rural areas, where delivery in facility is low, whether because women cannot reach the facility easily or because they do not wish to.

Vhembe in Limpopo, one of the NHI pilot districts, had an overall rate of 90.2% of deliveries in facility in 2013, according to a district disease profile published

by Health Systems Trust in 2015. But in Mutale, one of its local municipalities, the rate was only 38.5% for the same period.

This can obviously make it more difficult to tackle obstetric complications swiftly. The district’s C-section rate was a conservative 18.8% in 2013, lower than the national and Limpopo provincial averages, reflecting the SA challenges to making C-sections promptly available to women who need them. “Nationally, we are working to improve the quality of response and care for mothers in labour and to correct historic healthcare imbalances,” says Dr Marshall. The logistics of consolidating C-sections at hospitals with larger and more skilled staff are being analysed. To assist with this, the Free State has been piloting improved maternity ambulance services, including ensuring that patients in labour are taken to the nearest hub hospital with full maternity services rather than simply the nearest facility where they might be referred on again. Meanwhile maternity waiting homes are also gradually being established around the country.

“Women who have been identified with potential complications such as a big baby, small pelvis or a second C-section would then already be in a safe place by their due date,” says Dr Marshall. “The challenge is that women can feel reluctant about giving birth further away from home so we need to ensure that the benefits of this concept are better understood.”

C-section hotspots

By contrast, there are also anecdotal reports of C-section hotspots. “C-sections now make up about half of all our deliveries,” says Dr Yoshua Bwambale, clinical manager for anaesthesia and ICU at the Lower Umfolozi War Memorial Hospital in Empangeni, KwaZulu-Natal (KZN). Potential complications referred by primary health care (PHC) clinics in the surrounding rural area do not account for all of this, Dr Bwambale believes: “You would have to ask the obstetricians.” Overall the rate of C-section in KZN public-health facilities is at least 30%, says Dr Mergan Naidoo, an NCCEMD member who is head of family medicine at Durban’s Wentworth Hospital and at the University of KwaZulu-Natal.

The WHO used to recommend a C-section cap of 15% of deliveries. It withdrew this in 2010, stating: “There was no empirical

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Feature | 25

actual number of deaths from bleeding during and after a C-Section in each province 50 45 40

DURING AFTER

35 30 25

TOTAL TOTAL N TREND

20 15 10 5 0

Kw Ga aZ ute ul ng uN Li ata M mp l pu o m p Ea al o st ang er a n N Ca or p th e W F e N ree st or th Sta W ern te es c te ap rn e Ca pe

evidence for an optimum percentage. What matters most was that all women who need C-sections receive them.” It is not likely that the WHO envisaged the country’s high rates becoming the norm. In the SA private sector, C-section rates are among the highest in the world, possibly as high as 90%, according to Dr Naidoo. The problem is lack of skilled staff, he says: “Even some regional hospitals do not have all the specialists they need to carry out a full obstetrics service. Defensive medicine and litigation avoidance are two main reasons why underskilled doctors can decide on C-section and why this is by far the most common operation performed in SA.” Similar problems are faced in the Eastern Cape by Dr Sibongile Mandondo, an obstetrics and gynaecology specialist with the Amathole District Clinical Specialist Team (DCST). This was established in 2013 as part of PHC re-engineering to improve healthcare quality and outcomes for mothers, newborns and children.

Butterworth Hospital, which services three community health centres (CHCs) and a smaller district hospital, conducted about 40% of the Mnquma subdistrict’s deliveries.

It has become “a success story that models the safe and accessible C-section that the country is seeking to achieve with minimal resources,” says Dr Mandondo.

“Butterworth has shown what you can achieve with passion, commitment from management and teamwork between the DCST and the facility. Maternal outcomes have been excellent, with four maternal deaths in 2013 and just two in following years.”

Of the 3 500 deliveries in Butterworth in 2014, about 800 had been referred in. C-sections accounted for 660 of total deliveries, a rate of less than 20% although this excludes the significant number of cases referred from Butterworth to Frere Hospital in East London, a tertiary hospital about 120 km away. What is more, of the 172 C-sections done in Butterworth between June and September 2014, about two-thirds were emergency rather than elective.

In 2015, 908 C-sections were done at Butterworth, with a further 1 095 deliveries referred to Frere. Dr Mandondo sees Butterworth’s 37.5% increase as potentially

lifesaving because it points to patients with labour and delivery complications having better access to care, reducing haemorrhage deaths among mothers. The facility’s maternal mortality ratio of 97 per 100 000 deliveries dropped to 77 per 100 000 in 2015.

“If the mother lives in a rural area where the roads are very bad and there could be a delay in the ambulance reaching her and bringing her to us, we are more likely to suggest planning a repeat C-section,” says Dr Mandondo. “Butterworth has 106% maternity bed occupancy rate and no maternity waiting home. One has been constructed at Tafalofefe in our subdistrict but it is yet to be equipped and furnished.”

Life-saving task shifting

Task shifting at Butterworth made increasing C-section numbers possible. With 25% HIV prevalence, task shifting through introducing nurse-initiated antiretroviral therapy (ART) had already contributed to a steady decrease in HIV-related maternal mortality. HIV-positive mothers are not automatically delivered by C-section – as long as the membranes are intact, vaginal deliveries with forceps, if indicated, are preferred, says Dr Mandondo.

In 2014, Butterworth became a pilot for professional nurses being coopted as assistant surgeons in theatre, supporting a

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“

If the mother lives in a rural area where the roads are very bad and there could be a delay in the ambulance reaching her . . . we are more likely to suggest a C-section

Comparison of C-section (CS) rate and Case Fatality Rate (CFR) from C-Section per province, 2011 - 2013

35 30 25 20

CFR CS RATE

15 10 5

Kw Ga aZ ute ul ng uN Li ata Ea mp l st e op W rn o es C te ap M rn C e pu a m pe a N lan or g th a F W N ree est or th Sta er n te Ca pe

0

“

Staff chose to put the health of the population first because they understood how key C-section is to saving maternal and newborn lives

surgeon and an anaesthetist and assisted by a scrub sister. Since then, advanced midwives have also been brought into theatre to assist, and 620 C-sections have been performed with nurses or midwives standing in as assistant surgeons. Another 100 or so were assisted by doctors if complications were expected. This decreased unnecessary referrals to the tertiary hospital from 353 in 2014 to 236 in 2015, as well as reducing the number of times an ambulance was called, which can have a turnaround time of up to 4 hours.

All three pillars of the health system – skilled workforce, interfacility transport and adequate HR and equipment resources – were challenged at Butterworth Hospital. Resignations and retirement had reduced doctor numbers from 11 to 7. The outpatients department handles nearly 60 000 patients, with 70% unreferred, making it difficult to ensure cover from pooled CHC doctors on calls. Secondments did not help immediately, with Cubantrained family physicians and UK-qualified doctors usually needing 2 months of upskilling to become competent in anaesthetics. The number of midwives increased from 24 to 34, including two operational managers – although the recommended ratio of 16 midwives per 100 000 deliveries suggests that Butterworth Hospital should have a total of 48.

“Nurse assisting is the way to improve access to safe C-section in rural districts, although we need to ensure this is endorsed nationally by the Nursing Council,” says Dr Mandondo. “Both doctors’ and nurses’ skills have been improved through initiatives such as Essential Steps in Managing Obstetrics Emergencies (ESMOE), Helping Babies Breathe (HBB) and Management of Small and Sick Newborns (MSSN).

“Staff chose to put the health of the population first because they understood how key C-section is to saving maternal and newborn lives. A number of theatre nurses and advanced midwives have left because of incorrect payments and notches so there are still shortages of all staff cadres.”

Ability to deliver quality care with C-sections remains a national concern.

One simple but effective contribution to tackling that seems to be using a checklist before, during and after any C-section, says Dr Naidoo. He based this on a pilot study using a modified WHO surgical checklist for C-sections.

“One regional hospital that piloted the checklist saw an 85% improvement in surgically related maternal mortality, with postpartum haemorrhages decreasing by 58%,” says Dr Naidoo. “Checklists work best when there is a checklist champion at each institution.” The safety checklist is being included with NCCEMD recommendations for minimum safety standards when conducting a C-section and is being incorporated into the ESMOE programme. Dr Marshall would like to see treatment guidelines for all on the walls of every operating theatre.

Dr Bwambale, checklist champion at the Lower Umfolozi Hospital, agrees: “Many incidents in surgery are preventable but nobody wants to talk about human error. We must reduce it and the checklist makes us focus. We check that equipment is working, that blood is available and that the theatre team are familiar with the patient’s prevailing problems and what skills they can expect in each other from their rank and experience.

“You expect a pilot to check a plane every time before he takes off and this checklist is the equivalent for C-section. It takes only about 3 minutes and it helps us save lives.”

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Focus on . . .

HIV treatment The expansion of SA’s HIV treatment programme to all of those who test positive for HIV will require a shake-up in the way the disease is diagnosed and treated. Here we review the policy changes and implications for disease management.

By Leverne Gething

How HIV affects the body and causes disease HIV attacks and kills T-helper blood cells – crucial immune system cells that kill other cells that have been infected with germs. Without T-helper cells many other immune system cells cannot work properly, including the B-cells which make antibodies. While a person infected with HIV may not show any symptoms for years, if left untreated the number of T-helper cells drops steadily – and eventually becomes so low that risk of infection by other illnesses increases dramatically and the symptoms of AIDS appear.

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N MAY, SOUTH AFRICA’s (SA’s) MINISTER of Health, Aaron Motsoaledi, announced that SA will offer antiretroviral treatment (ART) to all with a positive HIV diagnosis – called universal test and treat (UTT) –

by September. SA has the world’s largest HIV treatment programme and is among the first countries in Africa to formally adopt UTT. Now those diagnosed as HIV-positive will be offered ART as soon as possible, instead of having to undergo an additional CD4 cell count test to determine eligibility for treatment.

After the announcement Prof. Salim Karim‚ director of the Centre for the Aids Programme of Research in SA (CAPRISA)‚ said: “The impetus for this policy change emanates from compelling new evidence from the START trial presented at the Vancouver AIDS conference last year.” The Strategic Timing Anti Retroviral Treatment (START) study, conducted in 35 countries in 2011, had 4 685 HIV-positive

participants. Half started HIV treatment as soon as they were diagnosed, while the rest waited until their CD4 count dropped below 350. (Previously UTT patients in SA had to have a CD4 count of 500 before being eligible for antiretrovirals (ARVs)).

The group starting treatment later had double the incidence of TB‚ non-Hodgkin’s lymphoma‚ Karposi’s sarcoma and nonHIV-related disease – 86 vs 41 in those who received treatment immediately. The evidence that starting treatment early was beneficial was so compelling that the trial was stopped early as it became unethical to delay treatment. Said Anthony Fauci‚ director of the US National Institute of Allergy and Infectious Disease: “Early therapy conveys a double benefit‚ not only improving the health of individuals but at the same time‚ by lowering their viral load‚ reducing the risk they will transmit HIV to others. These findings have global implications for the treatment of HIV.”

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Feature Focus | 29

Testing important

The more people on treatment‚ the lower the new infection rate will be. Therefore, in SA those who are HIV-negative or do not know their HIV status should be encouraged to test at least once a year. The Department of Health (DoH) has called on leadership across SA society to mobilise communities to talk about the reality of the disease burden in order to encourage more responsible behaviour and regular HIV testing.

Coverage and noncompliance

With around 3.5m South Africans already receiving ART, the country’s existing HIV treatment programme can largely be seen as successful. This is in part due to a 2013 decision that gave about 180 000 HIV-positive people access to fixed-dose combination ARVs containing emtricitabine, efavirenz and tenofovir, with only one tablet having to be taken daily instead of the usual three to five. This reduced pill burden also improved adherence to treatment. All SA HIV patients now receive this single-dose ARV as the norm.

In order to prevent stockouts of ART which occur because demand outstrips supply and there is poor communication between facilities and the DoH, healthcare workers need to monitor their stock effectively and order supplies timeously. The DoH has also launched an application that anyone can download to address medicine stockouts.

About 60% of all clinics have already started to use the stock visibility system, which monitors medicine stocks. Patients who download the app and experience stockouts can simply press a button and notify Pretoria. Of course, key to success of UTT is implementation of the National Adherence Policy and service delivery guidelines interventions for linkage to care, adherence to treatment and retention in care.

Non-adherence to long-term therapies such as ART results in poor health outcomes and increases overall healthcare costs, but the challenges and factors involved in poor compliance vary between individuals and across populations.

Patient-related barriers to adherence include: n lack of knowledge and understanding about disease(s) and treatments

np erception and beliefs in relation to disease management n affective factors (depression, anxiety, shame, etc.) ehavioural factors (e.g. missed nb appointments) n factors related to treatment burden and an adverse drug event (treatment fatigue, side effects) n socioeconomic and demographic factors (disease-related stigma, transport, age, etc.) n the lack of support (e.g. social support).

Health system-related barriers can include: n poor-quality interventions (lack of health education, assessment, communication, tracing systems, etc.) n lack of appropriate healthcare providers’ skills and attitude n organisational barriers (waiting time, distance, lack of integration, etc.).

The longer the delay in trying to trace patients who are lost to follow-up, the higher the risk of adverse patient and health service outcomes.

New research

While ART coverage will now expand rapidly to reach the more than 6m people living with HIV in SA, successful lifelong therapy requires routine HIV viral load (VL) monitoring to ensure treatment adherence and control of drug resistance. Simpler, patient-centred and more cost-effective models of care are urgently required that focus on maintaining viral suppression, improve retention in care, and reduce the burden on HIV care providers and laboratories.

Investigating samples from 42 women participating in the CAPRISA 002 Acute Infection Study, Garrett et al. recently published results on a point-of-care VL assay that can provide a result within 90 minutes.

This first clinic-based validation provides early evidence that point-of-care VL assays may be able to fill an important gap in the rapid scale-up of ART globally. Supported by funding from the US National Institutes of Health, the authors will next implement a chronic HIV care model that includes this VL testing and task shifting from professional to enrolled nurses.

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TREATMENT TARGET UTT in SA is a major policy shift that will help move the world towards the global 90-90-90 treatment target set by UNAIDS which envisions that: n by 2020, 90% of all people living with HIV will know their status n by 2020, 90% of all people who are HIVpositive will receive sustained ART n by 2020, 90% of all people receiving ARVs will have viral suppression.

How to minimise patient stress when testing for HIV n Talk to your patients about sexual health and risky behaviour. n Remain impartial and do not comment on or judge your patients’ behaviour. n Tell your patients how long they may have to wait for their test results. n Remind your patients that HIV test results are always completely confidential. n Go through what will happen, and the emotional help that is available should the diagnosis be positive. n Explain that ART is now available as soon as possible after a positive diagnosis. n Explain that should treatment be necessary some side-effects may occur; if they do patients must keep taking ART and discuss their sideeffects with the healthcare team.

Focus on . . . teenage pregnancy Early pregnancy is an issue that cuts across sectors, profoundly affecting the life course of many girls in SA. Now, the National Department of Health has made clear that reducing early pregnancy is a priority. So what should healthworkers be doing to help? By Leverne Gething

SRHR FRAMEWORK LAUNCHED In 2015 government launched an adolescent sexual and reproductive health and rights (SRHR) framework which acknowledges the gaps in services for young people’s SRHR. Its five priority areas are: n increasing coordination, collaboration, information and knowledge-sharing on adolescent SRHR n developing innovative approaches to comprehensive SRHR information, education and counselling for adolescents n strengthening adolescent SRHR service delivery and support on various health concerns n creating effective community supportive networks for adolescents n formulating evidencebased revisions of legislation, policies, strategies and guidelines on adolescent SRHR.

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n unacceptably high rate of teenage pregnancy is not new in SA. Despite interventions from government, including the Departments of Basic Education and Health, and NGOs like loveLife, the incidence is not abating. Numerous studies show that early pregnancy has a multitude of adverse effects on girls, from having to drop out of school to care for their infants, which compromises their future work opportunities, to dire health complications.

Deputy Minister for Social Development, Hendrietta Bogopane-Zulu, says that a shocking number of underage girls are pregnant or are already mothers – as an example, 3 000 girls in the rural Ratlou Local Municipality outside Mahikeng in North West province alone. In 2015 Statistics SA released a household survey, which found that 99 000 underage girls were falling pregnant per year. The study, conducted between 2011 and 2014, found that the number was steadily increasing. The National Strategic Plan on HIV and Sexually Transmitted Infections estimates that 39% of girls between the ages of 15 and 19 years have been pregnant at least once, while according to the Department of Basic Education 20 000 learners in primary and secondary schools fell pregnant in 2014.

While educating young people on consent, contraception and safer sexual behaviour is key to reducing the incidence of teenage pregnancy, the high incidence of rape is deeply entrenched and this, sadly, compounds the problem. Cindy Sikhakhane, a senior social

worker at Childline SA, an NGO that works to protect children from all forms of violence and to create a culture of children’s rights, says that there are a number of other reasons SA girls are falling pregnant at an early age, including peer pressure and substance abuse.

Sikhakhane also says that many communities are reluctant to discuss sex with children, as the subject is considered taboo: “Children have to go and find out information from their friends and then at the end of the day they end up getting pregnant.”

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of HIV and other sexually transmitted infections (STIs) is of great concern. In terms of HIV infection, young women aged 15 - 25 years have the highest risk of contracting HIV in SA, with almost half of 25-year-olds in some areas of KwaZulu-Natal being HIV-positive. However‚ at least three trials involving a range of preventive gels and pills have failed as the young women did not use the products as required.

The education gap

How can I help a pregnant teenager? n Research shows that many young people feel alienated by SA’s public healthcare facilities and perceive healthcare providers to be unsympathetic and intimidating. It is critical that your interaction with your patients is sensitive, caring and nonjudgemental. n Tell them about organisations like loveLife that have supportive and educational programmes. n Encourage your patients to be open with their peers and parents about their experiences and what they have learned. If young people have access to support and factual sex and sexuality knowledge they are less likely to be swayed by peer pressure or make poor decisions based on incorrect information.

disproportionate impact

In society, girls are more adversely impacted by the effects of early pregnancy than the boys involved. Says Sikhakhane: “When a boy has sex at a young age they are regarded as a hero, but when a girl has sex at a young age she is a whore or a slut, so it is the society that we live in that has painted this picture.” She comments that a boy who has more than one partner is regarded as “the man”. Boys are also less affected educationally because they are not affected by the stigma, are able to continue their schooling, and rarely take responsibility or offer financial or emotional support. Bogopane-Zulu says that when preparing long-term pregnancy prevention and family planning programmes, the first step is understanding. In addition to conducting rigorous research to identify root causes, this involves listening to the girls’ stories without judgement. She says that the Department of Social Development focuses on working with pregnant girls in order to understand what happened and how it happened.

Concurrent with the social issues presented by teenage pregnancy – lack of education leading to young mothers not being able to find proper jobs to take care of themselves and their children, thus locking them into a cycle of poverty – transmission

At the same time that SA’s Minister of Health, Aaron Motsoaledi, announced that antiretroviral treatment will be made available as soon as possible after a positive HIV diagnosis (see Focus on HIV on page 28), in the context of teenage sex he also announced that pilot studies would test the use of Truvada‚ a medication that helps prevent HIV infection in young women. However, a mass roll-out of Truvada in high-risk areas will be difficult, as the drug can only be prescribed to those who are HIV-negative. This implies that a vast degree of education around the importance of safe sexual practices and the importance of being tested regularly is necessary.

Gender activists have welcomed talks between the Gauteng Departments of Education and Health about introducing contraception in schools. The two departments have been exploring ways to deal with the problem of teenage pregnancy, and one option considered is a new drug, Implanon, a contraceptive that is implanted under the skin and can prevent pregnancy for up to 3 years. Research shows that making condoms available in schools does not increase sexual activity among learners, but it does decrease the rate of unprotected sex among those who are sexually active.

Remmy Shawa of the gender advocacy organisation Sonke Gender Justice says “Teenagers will have sex. Government has a big role to play in not only educating teenagers but providing them with access to contraception.” According to Shawa, sex education “forms the foundation for young people to make healthy decisions in their sexual lives” and could contribute to reducing unplanned pregnancies and transmission of HIV and other STIs.

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PROFESSOR LINDA-GAIL BEKKER – STRIDING THE WORLD STAGe

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nfinished business and unanswered questions have driven Linda-Gail Bekker to become one of the world’s top medical researchers. At the International AIDS Conference in 2016 she was formally inducted as the president of the International AIDS Society (IAS) – the first female president on the African continent and the third in the IAS’s history.

As well as being a professor at the University of Cape Town (UCT)’s Institute of Infectious Disease and Molecular Medicine, she’s also deputy director and chief operating officer of the Desmond Tutu HIV Centre and has contributed to nearly 300 articles on medical subjects, particularly the SA HIV and TB epidemics.

She set her sights on medicine as a child while growing up on a farm outside Harare, Zimbabwe. Her maternal grandfather was “a real family patriarch with 15 children”, she recalls.

“I was impressed that he’d studied medicine even though he’d never practised,” she says. “From my school subject choices onwards, all my efforts and energies went into having the medical career that he’d given up.”

Prof. Bekker’s career has been driven by a combination of curiosity and passion: “I’ve never been someone who practises one single thing for hours on end. That’s been my curse

Prof. Linda-Gail Bekker with Anton Pozniak, IAS president elect

and my blessing. It’s wonderful that medicine as a career caters for such an approach.”

Prof. Bekker’s early, formative years of practice were in KwaZulu-Natal. In her internship year at McCord Zulu Hospital in Durban she won the award for the “most enthusiastic houseman”. Postings to district hospitals such as Ngwelezane and Ixopo followed until, she says, “Eshowe stole my heart.” She stayed for 4 years at Eshowe Hospital, which had no interns “so the three or four medical officers worked our tails off at the rock face of healthcare”.

Deep frustration

She originally planned specialising in geriatric medicine and received an award for setting up a community centre for the elderly in Eshowe.

But during those years, from 1988 - 1992, the reality of the AIDS epidemic started to dawn on SA healthcare, with many more people coming into the medical wards. She opted to start looking for solutions to “the deep frustration we all felt about HIV/AIDS”.

She began with a PhD in medical microbiology with Profs Lafras Steyn and Gary Maartens, based at UCT, and also spent time working under Prof. Gilla Kaplan at the Rockefeller University’s Laboratory of Cellular Physiology and Immunology in New York.

This inspiring cohort of supervisors opened up the global medical world to her, medically and geographically, Prof. Bekker believes.

She returned to UCT as research director and clinical consultant at the Infectious Diseases Research Unit. Her dedication to research was rewarded with a personal promotion to associate professor in 2006 and full professor in 2012.

Her first publications were on TB but by 2000, she was beginning to publish on HIV/ TB co-infection. This shift was cemented by “moonlighting” at a prototype HIV clinic at Somerset Hospital. The experience captured her imagination, and her heart.

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Profile | 35

Linda-Gail Bekker and Larry Corey, professor at the University of Washington It had been founded by Prof. Robin Wood, and Prof. Bekker admired his innovative work.

“Our work partnership gelled because we had so many shared interests,” she says.

It became a life partnership as well, when they married in 2000. Their approaches complement each other, she believes: “We’re poles apart. He’s highly focused while I’m totally unfocused. He systematically solves problems one at a time. My default is, let’s start and see what we can do.

“My parents always taught me, ‘If you can think it, you can do it’. So I always take on the world, focus on what we can do, not any downside.”

HIV treatment innovator

Practicalities such as refreshing SA’s “old, tired” condomise campaign, and getting adolescents to act on prevention messages concern her as much today as they did when she and Robin set up the first dedicated HIV clinic dispensing ARVs in Gugulethu in 2000. The couple went on to co-found the Desmond Tutu HIV Centre in 2004 and in 2009 they appropriately shared UCT’s Alan Pifer Research Award, which recognised outstanding welfare-related research. For Prof. Bekker, HIV has been the place where her passionate curiosity about people and medical research intersect.

“Nothing charges my batteries better than a day in the community at an event, hearing about the issues,” she says. “I do that at least once a week although if I had my way, it would be much more often. Injustice makes my hair stand on end – I don’t wait for others to make a better world.”

Member organisations are a great way to contribute to the medical profession, she believes, and she’s chaired the Registrars’ Association of SA and edited the journal of the HIV Clinicians’ Society.

These days, Prof. Bekker “dabbles” in oil painting as a creative outlet. Back in Eshowe, she enjoyed joining in the local amateur dramatic society’s productions, a legacy of which is her easy presence on a platform. Prof. Bekker’s ease in the spotlight has enabled her to contribute her time and expertise to a wide range of international initiatives such as a member of the US President’s Emergency Plan for AIDS Relief (PEPFAR) Scientific Advisory Group, the Scientific Advisory Committee to More Medicines For TB (MM4TB) and co-chaired the National Institutes of Health (NIH) Youth Prevention Research Working Group.

The additional workload doesn’t faze her.

“Fortunately, I walk fast and I talk fast!” she laughs. But she admits her exercise schedule can suffer, “I love to swim lengths”. She also has to be as organised as possible about family life and tries to prioritise a Friday night “family date” with her husband Robin and their adolescent son, Oliver.

Prof. Bekker has sat on the IAS governing body since 2012 and is thrilled that as president she’ll lead a team trying to ensure HIV remains relevant in the global plan: “We are now in the second chapter of the AIDS response. We recognise there are very real competing priorities, from migration to Zika, so we must ensure HIV doesn’t lose ground.

I especially want to be true to my roots and keep the focus on Africa.”

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“

My parents always taught me, ‘if you can think it, you can do it’. So I always take on the world and focus on what we can do.

36 | Clinician’s View

Saving mothers’ lives

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BIOGRAPHY

Sue Fawcus is a professor in the Department of Obstetrics and Gynaecology, University of Cape Town, and head of obstetric services at Mowbray Maternity Hospital. She trained and specialised in the UK and Zimbabwe, worked as an obstetrician in Zimbabwe from 1980 - 1991, and KwaZulu-Natal in 1992 before her current post in Cape Town. Her main work interest is community obstetrics, prevention of birth asphyxia, promoting respectful maternity care, and the reduction of maternal mortality in poorly resourced countries. She was involved in community-based studies of maternal mortality in Zimbabwe and is currently vice-chairperson of the National Committee for Confidential Enquiry into Maternal Deaths, SA, with the responsibility of analysing all deaths due to obstetric haemorrhage, including deaths from bleeding associated with C-section.

ecent articles in the SAMJ presented data from the Saving Mothers (SM) reports in SA, which showed an alarming increase in numbers and case fatality rates (CFRs) from excessive bleeding associated with caesarean delivery (BLDACD): from 78 cases in 2002 - 2004 to 221 during 2011 - 2013. The CFR from BLDACD was at its highest in 2012 at 40 deaths per 100 000 live births but in recent years has shown a slight decline to 28.

The majority of these deaths (98%) were in the public sector, at district hospitals (DHs) where the majority of caesarean deliveries (CDs) are performed, but also significant numbers of deaths occurred at provincial tertiary hospitals, probably due to women being referred after CD from DHs with unresolved bleeding. There are also large inequities between provinces in BLDACD CFRs.

What are the obstacles?

n CD rates are increasing and some may not be indicated, putting women at unnecessary surgical risk. This may reflect lack of skills by doctors and midwives to manage labour properly, misinterpretation of cardiotocography (CTG), fear of litigation and inadequate skills for assisted delivery. meaning that difficult second stage C-sections (CSs) are performed. n Failure to prevent excessive bleeding at CD. This is partly due to inadequate use of oxytocin and other uterotonic agents consequent on lack of consensus between obstetric and anaesthetic doctors. Also, lack of surgical skill, with CDs often being performed rapidly without careful attention to haemostasis, contributes to the problem. n Failure to recognise timeously and act appropriately when bleeding is detected after CD. Internal and revealed bleeding after CD are detected too late in postnatal wards, either due to inadequate monitoring or failure to recognise signs of shock. This is compounded by a reluctance of doctors at DH to re-operate, and rather refer women to the next level of care, where they die on the way or on arrival. n Failure of leadership at facility, district and provincial level to ensure that all the requisites for safe CD are available – sufficient trained staff, adequate supervision, supplies

(medications, fluids, blood products), equip­ ment, and emergency transport. n Failure of training institutions to appropriately skill graduates for working at DHs.

What are the Solutions?

Slight progress has been made in reducing BLDACD deaths due to the following Department of Health and National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD) interventions, which include: n Clinical protocols: NCCEMD algorithms in section manager reports, paediatric public health (PPH) and CS monographs. A PPH training programme, including a lecture, accompanied dissemination of the PPH monograph in the country in 2011. n Practical training: The essential steps in the managing obstetric emergencies (ESMOE) training programme has, since 2008, taught practical modules on managing bleeding at CD; this was recently updated to include training videos on surgical management of PPH and a training DVD lecture on PPH, developed by the Health System Trust in 2014. n Anaesthetic input: SAMJ publications in 2015 on consensus around use of uterotonics at CD. n A consensus document produced by the NCCEMD on “Setting minimum standards for safe CD”, which specifies the requirements for a facility to be able to provide safe CD and is directed at facility and health managers. n District clinical specialist teams to assist skills and functionality at DHs. There are clear examples of the success of certain strategies. For example, in the Free State, rationalisation of facilities to provide safe CD and provision of on-site emergency transport has helped, and ESMOE saturation training in 12 priority districts has shown a 20% decrease in maternal deaths. However, more needs to be done. An action plan in the forthcoming 2015 Saving Mothers report presents a composite plan which focuses on WHAT needs to be done, HOW it should be done and WHOSE responsibility the various components should be assigned to. It summarises minimum requirements to provide a safe CD service and shows the most recent version of the surgical safety checklist for CD.

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