HEALTHCARE GAZETTE
MARCH/APRIL 2017• ISSN 2078-9750
CLOSING THE TREATMENT GAP ON NEUROPSYCHIATRIC DISORDERS IN SA PG 14 4
8
NEWS
PoPI – a major challenge for healthcare service providers
12
NEWS
Huge strides in medical 3D printing
23
RESEARCH
Mouthwash reduces oral gonorrhoea
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FEATURE
What’s new in cancer pain treatment
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Contents | 01
Co nt ent s 8
23 NEWS
FEATURES
12
4
PoPI – a major challenge for healthcare service providers
8
Huge strides in medical 3D printing
8
Breast cancer-detecting device may be used to detect other cancers
10 Restorative treatment for stroke victims a step closer 11 Carpal tunnel syndrome – to operate or not to operate?
14 Closing the treatment gap on neuropsychiatric disorders in SA 23 What’s new in cancer pain treatment?
RESEARCH 12 Mouthwash reduces oral gonorrhoea 12 “Weekend warriors” as fit as those who exercise through the week 13 Elderly patients do better with female doctors
PRESS RELEASE 30 Global waste group Averda acquires Solid Waste Technologies
END NOTE 32 Cry, the beloved country
13 Diet, lifestyle, BMI and mortality 13 Ask two simple questions to predict depression in the elderly
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02 | Ed’s Letter
Ed’s Letter EDITOR Hannah Kikaya
H A N N A H K I K AYA
HEALTHCARE INFORMATION THAT AFFECTS YOU This edition of Healthcare Gazette is the first under our new set of contributors focused on bringing you the content that keeps you up to date with developments in healthcare that affect you and your work. We will do the hard work of trawling through journals and professional publications to find the information you need, and deliver it to you in easily readable, digestible chunks. We be highlighting updates in management of conditions and disorders that are most relevant to the South African context and making sure that you never miss a crucial change in guidance or best practices in management. As with all HMPG publications, Healthcare
Gazette actively promotes the core values of: research integrity; academic rigor; community engagement and responsiveness; and evidencebased decision-making. Living these values mean we actively ensure that our content is scientifically valid, that news we cover is selected with appropriate consideration of its academic credentials, that we want to hear from you about the topics that are most relevant and useful, and that we will campaign for decisions at all levels of the health sector to be taken on the basis of evidence. Delivering better healthcare to all South Africans is an enormous challenge. But arming our dedicated cadres of health workers and decision-makers with the right
information to help them make choices that extend life and reduce suffering is a good place to start. We pledge not only to deliver you the content we believe is most pertinent, but also to respond to your direction on areas where you need to know more. Please feel free to engage in discussions, debate or comment about any of the articles published here, or suggest topics for future issues. We want Healthcare Gazette to capture the interests of the diverse community of health workers in this country and to be the forum for debating hot topics that affect patient outcomes. We look forward to hearing from you and hope you enjoy the magazine.
CONTRIBUTORS Marilyn de Villiers Bridget Farham Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham MANAGING EDITOR Ingrid Nye COPYEDITOR Kirsten Morreira PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens CHIEF OPERATING OFFICER Diane Smith | +27 (0)12 481 2069 dianes@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renée Hinze Azad Yusuf Ladine van Heerden Charmalin Simpson Ismail Davids 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 Clinton Griffin Travis Arendse Printed by Tandym 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.
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PoPI – A MAJOR CHALLENGE FOR HEALTHCARE SERVICE PROVIDERS By Marilyn de Villiers THE PROTECTION OF PERSONAL Information (PoPI) Act presents a huge and potentially punitive risk for all SA healthcare service providers – from sole practitioner practices to large multisite and multidisciplinary enterprises – even if the breach of a patient’s personal information occurs outside the practitioner’s own practice. That’s according to Dr Wim Booyse, lead in healthcare industry data policy at business consultants Pétanque International, whose recently released white paper on PoPI and healthcare data privacy characterises the current state of healthcare data privacy management in SA as “a free for all”. Dr Booyse said that while most healthcare practitioners recognise and respect the ethical need for patient confidentiality, their current processes and procedures relating to the submission of invoices to medical aid schemes are “not only a violation of the spirit of the PoPI Act, but specific practices clearly constitute a breach of the individual’s right to confidentiality and privacy”. Confidential patient health data is a very valuable commodity in SA and worldwide.
cover has fully disclosed his/her medical condition.
Dr Wim Booyse According to Forrester Research, an international research organisation, the underground value of medical records worldwide is now worth 10 times more than credit card numbers. The latest Breach Level Index reported that the healthcare sector suffered more data breaches than any other industry in the first half of 2016. These directly affected over 100 million people in the USA alone. Many different entities and operations want to get their hands on patients’ private information. Some examples include: ¾ Third-party health data brokers, who use the data to determine the prescribing habits of doctors, or the prevalence of generic substitution and the prevalence of generic “switching”. This is valuable information for the pharmaceutical industry. ¾ Medical data device manufacturers use data to target medical aid schemes to provide certain products and services aimed at a predetermined “health-risk” groups in its membership. ¾ Long-term insurance companies use this data to check, for example, whether a potential client applying for life
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Dr Booyse pointed out that the responsibility of protecting patient confidentiality always remains that of the healthcare provider, who initially obtained the consent from the patient to share confidential health information, when submitting a valid invoice to medical aid schemes. Obtaining written consent from patients to allow sensitive information, such as diagnosis and treatment, to be included on the invoice can no longer be regarded as sufficient within the framework of the PoPI Act. There are now too many other players in the “value chain” between the healthcare practice and the medical aid where data breaches can occur – and the transfer of patient data from the healthcare provider to any one of those links in the value chain does not absolve the healthcare provider from his or her responsibility for protecting that data. The various links in the value chain, however, are not under the same obligation. These links include: ¾ Practice management software vendors. Practice management software is now used by more than 95% of registered healthcare providers in the private sector. However, very few healthcare practitioners (as non-IT experts) are aware of internationally accepted standards that govern aspects such as encryption, anonymisation and basic security standards to which practice management software should comply. ¾ Account bureaus that deal with the complexities involved in
financial and administrative data from medical aid schemes and sell it on to whoever wants it. This includes data relating to: ¾ the financial relationship between a patient and his/her medical scheme ¾ whether the patient has benefits to pay for a particular medicine, for example ¾ the medical treatment exclusions that apply to the patient ¾ other areas of sensitive data.
Diagnosis and treatment
Invoice
3rd
3rd
Self-administered medical aid scheme
Diagnosis and treatment
Third-party administrators
Invoice
3rd Third-party aggregators
3rd Switch
3rd 3rd Accounting bureaus
The healthcare provider claim (invoice) submission value chain (top) and expanded healthcare provider claim (invoice) submission value chain (bottom) (Source: Pétanque International) keeping up with all the rules, provisions and regulations issued by the medical aid schemes for the submission of claims. ¾ Health data switches. Medical aid schemes are reluctant to allow healthcare providers to submit invoices directly into their administrative systems. Switches therefore convert the healthcare provider’s standard claim or invoice into the format required by the medical aid schemes.
¾ Third-party medical aid scheme administrators, who sometimes outsource aspects, such as managed care interventions, to “independent” third parties who may or may not be resident in SA. The illegal transborder movement of personal information significantly increases the risk of personal data being sold for commercial gain. ¾ Health data aggregators who collect and process health,
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So what can healthcare practitioners do to protect their patients and themselves from inadvertent transgressions of the PoPI Act? Dr Booyse suggests the following four critical steps: 1. Make informed decisions that translate into defined action plans to entrench compliance with the PoPI Act in your businesses. 2. Change patient consent forms to clearly stipulate the purpose for which consent is sought. 3. Identify, document and deal with data breach risks within the practice from spyware, key-logging, phishing attacks, lost and stolen devices, human error and criminal insider attacks with appropriate, relevant policies and procedures. 4. Ensure that your IT service providers comply with international standards such as, at a minimum, the ISO 27000 series standard for information security management systems. At present, only 17 companies in SA have ISO 27000 certification – and none are in the healthcare sector.
10 WARNING SIGNS OF PROBLEM GAMBLING The South African Responsible Gambling Foundation (SARGF) who's primary objective is to grow awareness of responsible gambling and to manage and minimise the potential harmful effects of problem gambling, through its initiative National Responsible Gambling Programme (NRGP) has identified several warning signs that may indicate a person is developing a gambling problem. These are: 1. 2. 3. 4. 5.
Having constant thoughts about and a preoccupation with gambling Lying or concealing gambling activities from family and friends Attempting to recoup one's losses Taking extreme measures access money to gamble Preferring to gamble rather than attend other important events like a family get together 6. Feeling anxious or moody when not gambling 7. Racking up large debts due to gambling activities 8. Experiencing a deterioration in close relationships as a result of gambling 9. Neglecting personal needs like sleeping, hygiene and eating in favour of gambling 10. Manipulating people into lending or giving money to be used in gambling Like any addiction the first step to receiving help and support is by admitting to the problem. A gambling addiction is difficult to fight alone and support is readily available via the NRGP 24 hour, free and confidential helpline 0800 006 008 or via SMS HELP To 076 675 0710 or email helpline@sargf.org.za
AM OGR ME PR
NATIONAL RE
IBLE GAMBL NS IN O P
G
S
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HUGE STRIDES IN MEDICAL 3D PRINTING By Marilyn de Villiers
A traditional stent (left); customised, 3D-printed stents (middle and right) (Source: Jon Christian)
REGENERATIVE MEDICINE IS undergoing a rapid revolution as 3D printing moves out of the realm of science fiction and into accessible medical reality. In February this year, the American Journal of Respiratory and Critical Care Medicine reported on a collaboration between Toulouse University Hospital’s pulmonology department and a French company, AnatomikModeling, which resulted in the development and implanting of what is said to be the “world’s first” custom 3D-printed airway stent for the treatment of post-transplant complex airway stenosis.
interest in the materials used for these customised 3D devices. Researchers at Northwestern University in the USA recently managed to 3D-print biodegradable stents using a citrus-based polymer for the treatment of weakened-tonarrow arteries. Investigations are underway to evaluate whether these stents could be loaded with anticoagulant, thereby limiting the risk of complications when used in the body. And in the UK, researchers are looking at creating 3D-printed scaffolds made of biomimetic materials, which can be used to address problems of damaged and diseased tissue.
These customised stents are anatomically identical to the patient’s trachea and/or bronchi, overcoming problems faced with patients for whom conventional stents are simply not suitable. Because they do not fit properly, conventional stents can result in further complications such as infection, inflammation and perforation. This is just one of a plethora of reported developments in recent years in the use of 3D printing to replicate the many tubular structures in the human body. The way in which these can be customised for each patient is gaining considerable attention. There is also increasing
BREAST CANCER-DETECTING DEVICE MAY BE USED TO DETECT OTHER CANCERS By Marilyn de Villiers A CANCER-DETECTING DEVICE that has significantly reduced the re-excision rate of patients who have undergone lumpectomies for breast cancer is now being tested for use in prostate, lung and liver cancer. In addition, the Israeli developer of the MarginProbe device is also working on The MarginProbe device (Source: Dune Medical)
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developing a smart biopsy device that will enable surgeons or radiologists to quickly identify and remove the right tissue sample. The breast cancer-detecting device, which received FDA approval in 2012, has been used commercially on more than 10 000 patients in American and Israeli medical centres. The handheld MarginProbe device uses radio-frequency spectroscopy technology to measure the electrical properties of cells. This enables it to
immediately distinguish cancer cells from healthy ones. This means that the surgeon can use the probe to check the margins of the just-removed tissue while the patient is still in surgery. The probe’s sensors send signals to the tissue, and a visual and acoustic signal is reflected back, indicating whether there are still cancerous cells on the margins – in which case more tissue can be removed immediately – or giving the allclear to close up the patient. It’s estimated that one in
four women who undergo a lumpectomy need to have additional surgery after laboratory examination of the excised tumour reveals that the margins surrounding the tumour are not clear of cancerous cells. Clinical trials found that use of the device resulted in a 38.6% decline in re-excisions of patients with intraductal (ductal carcinoma in situ) and invasive carcinoma, while the re-excision rate of those with lobular carcinomas decreased by 18%.
RESTORATIVE TREATMENT FOR STROKE VICTIMS A STEP CLOSER By Marilyn de Villiers A COMPOUND THAT PREVENTS brain-cell death in animals with neurological injuries such as Parkinson’s disease, amyotrophic lateral sclerosis, stress-associated depression and traumatic brain injury could prove to be a game-changer for stroke sufferers too. Researchers from the University of Iowa Carver College of Medicine and the University of Miami Miller School of Medicine found that the compound, P7C3-A20, not only protects brain cells in strokeafflicted rats, but also improves their physical and cognitive outcomes. Thousands of stroke victims suffer long-term physical and cognitive disability that significantly changes their lives. Currently, there are limited treatments for acute stroke that make a real difference to their recovery. A stroke interrupts the brain’s blood supply, causing mature brain cells to die. Reestablishment of the blood flow (reperfusion) also causes cell
Ischaemic stroke death. However, stroke injury also results in an increase in the production of new brain cells (neurogenesis) in two regions of the brain, but most of these new cells die within a week or two. Researchers into new stroke therapies believe that if a way could be found to prevent mature brain cells from dying, while harnessing the surge in neurogenesis, the recovery of stroke victims could be considerably enhanced. The researchers tested the effects of P7C3-A20 on rats
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following ischaemic stroke. The compound was found to reduce loss of brain tissue and increase the survival of new-born neurons 6 weeks after stroke. In addition, rats treated with the compound had better physical and cognitive outcomes than untreated rats. In addition, the treated rats had boosted levels of a substance called nicotinamide adenine dinucleotide (NAD) in their brains. NAD is believed to be important for neuronal health and survival.
Stroke warning signs
News | 11
CARPAL TUNNEL SYNDROME – TO OPERATE OR NOT TO OPERATE? By Marilyn de Villiers
CARPAL TUNNEL SYNDROME is one of the most common repetitive work-strain injuries, causing pain, numbness and weakness in the wrist and hand. Surgery is often a recommended course of treatment, particularly when the symptoms are severe. Now a new study published in the Journal of Orthopaedic & Sports Physical Therapy has found that physical therapy is as effective as surgery in treating the condition. The study involved 100 women with carpal tunnel syndrome who were randomly allocated to treatment either with physical therapy or with surgery. The 50 patients assigned to the physical therapy group were treated with manual therapy techniques that focused on the neck and median nerve for 30 minutes once a week, with stretching exercises at home. The researchers in Spain and the USA found that the physical-therapy patients experienced faster improvements at the 1-month
mark than the patients who had been treated surgically. At this point, the patients in the physical-therapy group had better hand function during daily activities and better grip strength (also known as pinch strength between the thumb and index finger) than the patients who had surgery. At 3, 6 and 12 months following treatment, patients in the surgery group were no better than those in the physical-
therapy group. Both groups showed similar improvements in function and grip strength. Pain also decreased similarly for patients in both groups. The researchers therefore concluded that physical therapy and surgery for carpal tunnel syndrome yield similar benefits 1 year after treatment. No improvements in cervical range of motion were observed in either patient group. “Conservative treatment may be an intervention option for patients with carpal tunnel syndrome as a first line of management prior to or instead of surgery,” said lead author César Fernández de las Peñas, of the Department of Physical Therapy, Occupational Therapy, Rehabilitation, and Physical Medicine at Universidad Rey Juan Carlos, Alcorcón, Spain. “The study demonstrates that physical therapy – and particularly a combination of manual therapy of the neck and median nerve and stretching exercises – may be preferable to surgery, certainly as a starting point for treatment.”
Carpal tunnel syndrome exercises
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BITE-SIZED SUMMARIES OF THE LATEST SCIENTIFIC ADVANCES “Weekend warriors” as fit as those who exercise through the week
Mouthwash reduces oral gonorrhoea Gargling daily with the antiseptic mouthwash Listerine may control oral gonorrhoea, according to a study in Australia. Researchers in Melbourne looked at 196 gay or bisexual men who were positive for Neisseria gonorrhoea who presented at the Melbourne Sexual Health Centre for treatment. Of the 58 men who tested positive for oral gonorrhoea, 33 were randomly assigned to gargle with Listerine Cool Mint and 25 with a saline solution.
After rinsing and gargling for 1 minute, the proportion of viable gonorrhoea in the throat was 52% in the men using Listerine, compared with 84% in those using saline. Five minutes after gargling, men in the Listerine group were 80% less likely to test positive for gonorrhoea in their throat than the men using saline solution. Chow E, Howden B, Walker S, et al. Antiseptic mouthwash against pharyngeal Neisseria gonorrhoeae: A randomised controlled trial and an in vitro study. Sex Transm Infect 2016;93(2)88-93. https://doi. org/10.1136/sextrans-2016-052753
The WHO and US Department of Health and Human Services recommend at least 150 minutes a week of moderate intensity aerobic activity or 75 minutes a week of vigorous activity through
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the week. However, many people concentrate their exercise over the weekend. Now, recent research suggests that this may be enough to reduce all causes of cardiovascular and cancer mortality. The research, from Loughborough University, UK, was carried out on a pooled analysis of 63 591 adults in England and Scotland. Participants reported the amount of exercise carried out in the previous 4 weeks and were divided into: inactive; insufficiently active; “weekend warrior”; or regularly active. The risk of death from all causes was about 30% lower in “weekend warriors” than in inactive adults. When compared with inactive adults, the risk of cardiovascular death in “weekend warriors” was 40% lower, and the risk of death from cancer was 18% lower. O’Donovan G, Lee I, Hamer M, et al. Association of “weekend warrior” and other leisure time physical activity patterns with risks for all-cause, cardiovascular disease and cancer mortality. JAMA Intern Med 2017;177(3):335342. https://doi.org/10.1001/ jamainternmed.2016.8014 (online first)
Research | 13
Ask two simple questions to predict depression in the elderly
Diet, lifestyle, BMI and mortality
Elderly patients do better with female doctors Elderly hospital patients have a lower 30-day mortality and readmission rate if treated by female doctors, according to a study published in JAMA Internal Medicine. Previous studies have found that men and women practise medicine differently; for example, women are more likely to adhere to clinical practice guidelines and offer more preventative care. However, it is not known whether these differences affect clinical outcomes. In this new study by Tsugawa et al. from
Harvard TH Chan School of Public Health, Cambridge, Massachusetts, 1.6 million admissions of patients aged over 65 for medical conditions, treated by GPs, were analysed. After adjusting for many factors, such as type and severity of the patients’ medical conditions, patient and physician characteristics, and hospital size and type, researchers found that those treated by a female physician had a lower 30-day mortality and readmission rate.
A longitudinal study with up to 32 years of follow-up of 74 582 women and 39 284 men concluded that the lowest risk of premature mortality is in those with an 18.5 - 22.4 BMI and high scores on healthy eating and physical activity, moderate alcohol intake and those who do not smoke. During the 32 follow-up years there were more deaths from cancer (10 808) than from cardiovascular disease (7 189). A combination of at least three low-risk lifestyle factors, along with the BMI range mentioned, was associated with the lowest risk of all-cause cardiovascular mortality. The greatest risk was found in those with a 22.5 - 24.9 BMI with none of the four lowrisk lifestyle factors.
Complex screening tools are no more effective than two simple questions to diagnose depression in older people, according to a review of clinical studies. Early detection and treatment improve prognosis, but traditional screening is difficult because many symptoms, such as weight loss and disturbed sleep, are common problems associated with ageing. Researchers identified 133 studies evaluating 16 diagnostic tools in a total of 46 651 patients aged 60 - 87 years. Most studies used the Geriatric Depression Scale, but six used the Two-Question Screen asking about symptoms in the past month: have you been troubled by feeling down, depressed or hopeless; have you experienced little interest or pleasure in doing things? The results, reported in the British Journal of Psychiatry, showed that the Two-Question Screen diagnosed depression as well as other screening instruments. Tsoi KKF, Chan JYC, Hirae HW, et al. Comparison of diagnostic
Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK.
Veronese N, et al. Combined
performance of Two-Question
Comparison of hospital mortality
associations of body weight and
Screen and 15 depression screening
and readmission rates for Medicare
lifestyle factors with all cause and cause
instruments for older adults:
patients treated by male vs female
specific mortality in men and women:
Systematic review and meta-analysis.
physicians. JAMA Intern Med
Prospective cohort study. JAMA Intern
Br J Psychiatry 2017;210(4):255-
2016;177(2):206-213. https://doi.
Med 2017;177(2):206-213. https://doi.
260. http://doi.org/10.1192/bjp.
org/10.1001/jamainternmed.2016.7875
org/10.1001/jamainternmed.2016.7875
bp.116.186932
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(Source: Gallo Images | Daily Sun | Jabu Khumalo)
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Feature | 15
CLOSING THE TREATMENT GAP ON NEUROPSYCHIATRIC DISORDERS IN SA Despite the existence of extensive official policies regarding mental healthcare in SA, the Life Esidimeni tragedy has shown how, regardless of the apparent soundness of the legislation, a lack of resources means that the policies are not being implemented. Neuropsychiatric care in SA remains woefully underfunded and inadequate. By Marilyn de Villiers H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 7
National health ombudsman Prof. Malegapuru Makgoba speaks during a media briefing to announce the final report on the Life Esidimeni psychiatric patients’ deaths on 1 February 2017 in Pretoria, South Africa. (Source: Gallo Images | Sowetan | Sandile Ndlovu)
“
... around threequarters of people in SA who suffer from a mental disorder do not currently receive any mental-health intervention
N
EUROPSYCHIATRIC DISORDERS rank third in their contribution to the overall burden of disease in SA, after HIV/AIDS and other infectious diseases, according to the Ekurhuleni Declaration on Mental Health that was published in April 2012. The Ekurhuleni Declaration also noted: over 16% of adults in SA have a 12-month prevalence of mental disorder; around threequarters of people in SA who suffer from a mental disorder do not currently receive any mental-health intervention; there is considerable inequity in mental-health service provision especially between the private and the public sectors and also between urban and rural areas; mental-health services within general healthcare and community-based mental-health services are underdeveloped; and improved primary mental healthcare would reduce the number of mental-health visits to secondary and tertiary healthcare facilities. In 2013, the National Health Council approved SA’s Mental Health Policy (MHP) Framework and Strategic Plan 2013 - 2020, which was developed in line with the Ekurhuleni Declaration on Mental Health. Fast forward 4 years to 1 February 2017 and screaming headlines quoted the report of the health ombudsman, Prof. Malegapuru Makgoba, that 94 mentally ill patients had
died while in the care of the Gauteng Health Department. The department had terminated its long-standing contract with the Life Esidimeni (LE) hospital group and moved more than 1 300 patients to NGOs, many of whom were unregistered, and provided an “unstructured, unpredictable, substandard caring environment”. Two weeks later, Prof. Makgoba announced in parliament that the number of deaths linked to the LE tragedy had topped 100 and was rising, as more people came forward. This is hardly in line with the lofty pronouncements of the Ekurhuleni Declaration, or the acclaimed MHP Framework and Strategic Plan 2013 - 2020 with its detailed timelines and clear directions designed to ensure that the best quality mental healthcare reaches all those who require it. What has gone wrong? Is the LE tragedy just a grotesque manifestation of a treatment gap that the MHP Framework has widened rather than bridged? “As in many areas of public service delivery in SA, we have excellent policies but fall down in terms of implementation,” said Dr Rita Thom, psychiatrist at the Oxford Healthcare Centre, who has authored or coauthored several papers on primary mental healthcare in SA. However, Prof. Sean Kaliski, head of division: Forensic Psychiatry at UCT, said the health gap problem had its roots way beyond current policy. “Our problem essentially is a lack of trained health practitioners and facilities where neuropsychiatric disorders can firstly be diagnosed, and then treated,” he maintained. “Primary care health practitioners have to develop some expertise in eliciting obvious psychiatric symptoms in those they treat, together with an appreciation of the basic tests that are required to make the diagnoses. In other words, an awareness of these illnesses is crucial. The difficulty, however, is knowing when identified cases ought to be referred to secondary or tertiary facilities. This generally depends on resources.” Resources. That’s a recurring theme when looking at the treatment gap of mental disorders in SA.
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THE WHO PYRAMID Some even report treatment gaps of up to 90%. Longstay In response to facilities and specialist psychiatric this crisis, the WHO services developed a pyramidal Psychiatric Community services in mentalframework regarding general health hospitals services the “optimal mix for Primary care services for mental health services” mental health (see Figure 1) intended Informal community care to guide governments in the conceptualisation Self-care Low High of equitable and viable Quantity of services needed mental health policies and plans. The SA MHP Fig 1. WHO service organisation pyramid for an 2013 - 2020 framework optimal mix of services for mental health is aligned with the WHO’s Framework. This treatment gap in neuropsychiatric The WHO’s primary disorders is not unique to SA, as most recommendations include: limiting the other low- and middle-income countries number of mental hospitals or specialist also suffer serious resource shortages. Low
Informal services
Costs
Frequency of need
High
Prof. Kaliski noted that the Western Cape and Gauteng are probably the best resourced provinces – and yet over 100 mentally ill patients died in Gauteng, partly due to a lack – or misuse – of resources. “The other provinces have meagre to virtually no resources,” Prof. Kaliski said. “The Eastern Cape has had an enormous amount of money pumped into their public health service but this does not seem to have resulted in much improvement. The Northern Cape has only two or three psychiatrists for the entire province, while Valkenberg Hospital, one of four psychiatric hospitals in Cape Town, has at least 12 psychiatrists on its staff. The entire public health system should be restructured.” In its Treatment Guidelines for Psychiatric Disorders (2013), the SA Society of Psychiatrists (SASOP) noted that “the situation in SA mirrors the global move away from residential institutions. Fewer beds are available at ever-rising cost. Patients, their families and caregivers increasingly have to rely on their own resources.” Prof. Makgoba’s report into the circumstances surrounding the death of mentally ill patients in Gauteng provides useful insight into the treatment and
services (at the top of the services pyramid), and simultaneously developing mental health services in communities as well as in general hospitals; integrating mental health into primary healthcare; building informal community mental healthcare services; and promoting selfcare (at the base of the framework). The WHO also proposed that, at each tier, certain combinations of professionals and lay people might be utilised in order to provide or facilitate the delivery of services. For example, at primary healthcare level, the provision of mental health services should increasingly become the responsibility of primary-care workers such as nurses or doctors, who must receive ongoing training and supervision from specialist mental health professionals such as psychologists and psychiatrists.
resources gap that, while the details are specific to Gauteng and the LE situation, could well be the reality on the ground in every other province as well. He noted that the goal of deinstitutionalisation is the cornerstone of the Mental Health Care Act (MHCA) of 2002, and stated that this was universally accepted and was confirmed throughout the investigation by the testimony of almost every witness. “The difficulty was not the concept itself, but how the concept was translated in reality on the ground. The selective interpretation and usage of the legislative framework and strategy was at the heart of the (deinstitutionalisation) project. The project which was aptly named ‘the Gauteng Marathon Mental Health Project’ instead became the ‘Gauteng sprint’.” In other words, deinstitutionalisation was being rolled out far too quickly – largely, Prof. Makgoba stated, to save money, rather than in the best interests of the patients. The NGOs to which the hapless mentally ill patients were sent were supposed to be paid R112 per day per patient, compared with the R320 per day that had been paid to LE. The average cost per patient per day at the
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“
NGOs saw the Gauteng Health Department Marathon Project as a “business opportunity”, as no training or qualifications of NGO staff were a prerequisite for licensing
three public psychiatry hospitals in Gauteng, Weskoppies, Sterkfontein and Cullinan Care and Rehabilitation Centre is R1 960.41, R1 386.13 and R1 486.04, respectively. According to Prof. Makgoba, patients needed quality care, while the NGOs saw the Gauteng Health Department Marathon Project as a “business opportunity”, as no training or qualifications of NGO staff were a prerequisite for licensing. There were other issues, which may – or may not – also be budget related: ¾ The numbers of acute hospital unit beds and NGO beds were grossly inadequate and unable to manage the existing demand for care. Evidence for this was provided in terms of escalating numbers of psychiatric patients in prison awaiting forensic observation. ¾ The Gauteng Department of Health violated its own regulations by disregarding the fact that some NGOs had no licences, or they sent too many patients for the NGOs’ licensed capacity. ¾ For patients with mental disorders to adapt to living in the community, they need the capacity to adapt and be integrated into the community. In addition, specialist level community mental-health services (CMHSs), providing psychosocial and medical care, must be in place in order to provide the level of support required. Gauteng psychiatrists’ warnings that there were
mental-health patients who would not be able to live in the community and that the CMHSs in Gauteng were severely deficient were ignored. ¾ Although community-based mental healthcare is advocated by the MHCA and the mental-health policy provides a plan for CMHSs, the implementation of the policy is not included in the Health Strategic Plan or the National Health Insurance (NHI) white paper. ¾ In fact, the re-engineering of healthcare in SA does not cater specifically for mental healthcare at a community level, as evident by the fact that the district clinical specialist teams do not include a psychiatrist. According to Prof. Makgoba, the mentalhealth treatment gap in Gauteng has widened, and is worse than it was before the implementation of the Gauteng Mental Health Marathon Project, which – he strongly recommended – must be scrapped. There are now no medium-to-longstay beds in Gauteng with 24-hour nursing designed for mental health patients requiring such care, nor has there been any upscaling of CMHSs, or any increase in the numbers of general hospital acute psychiatric beds. “The immediate effect is that the entire referral system is now even more poorly resourced than before the LE project,” he declared, predicting that “many more
ARE ALL MENTAL DISORDERS NEUROPSYCHIATRIC DISORDERS? According to Dr Rita Thom, mental disorders are diagnosed according to specific criteria, which include the impact on the individual’s functioning. Mental disorders include what we call “common mental disorders” such as depressive and anxiety disorders and substance-use disorders, “serious mental illnesses” (SMIs) such as schizophrenia and bipolar mood disorder; and neuropsychiatric disorders (NPs), which include conditions such as dementia, delirium
and psychiatric/mental disorders secondary to a general medical condition. SMIs affect ~4% of the population. There is no accurate estimate of the prevalence of NP disorders, but HIV-associated disorders are probably most common, followed by vascular dementia and then Alzheimer’s disease. There are also significant neuropsychiatric disorders secondary to the very high prevalence of alcohol abuse in SA.
Prof. Sean Kaliski – head of division: Forensic Psychiatry at UCT – defined NPs as a diverse group of disorders that have a known brain pathology and often present with psychiatric symptoms. “However, biological psychiatrists will insist that all psychiatric disorders are actually neuropsychiatric disorders because dysfunction of the brain has to underlie all of their presentations. This is a consequence of the brain-mind dualism debate that remains to be resolved,” he said.
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Congress Programme at-a-glance THURSDAY 7 SEPTEMBER 2017 Pre-Congress Workshops & Meeting
7-9
September
2017
CSIR Convention Centre www.ogupdate2017.co.za
Fetal & Maternal Medicine Workshop: Placenta Gynaecologic Oncology Workshop Urogynaecology Workshop Obstetric Ultrasound Workshop: Case Discussions Infertility Workshop Contraception Workshop South African Society of Gynaecologic Oncology Meeting
FRIDAY 8 SEPTEMBER 2017 Session 1: Obstetrics Session 2: Gynaecology Session 3: Medicolegal and Ethics Session 4: Gynaecologic Oncology Session 5: Reproductive Medicine
SATURDAY 9 SEPTEMBER 2017 Session 6: Urogynecology Session 7: Maternal Medicine Session 8: Fetal Medicine Session 9: Endoscopy Session 10: A Look into the Future
Invited International Faculty Prof Phillip Bennett | United Kingdom Dr Mark Slack | United Kingdom Prof Frederic Amant | Belgium CONGRESS ORGANISERS | Londocor Event Management | Yvonne Dias Fernandes | +27 11 954 5753 | yvonne@londocor.co.za
Classification of mental disorders
Neuropsychiatric disorders
Possible neuropsychiatric disorders
Cognitive impairment
Addictions
Autism
ADHD
Fetal alcohol syndrome
Eating disorders
Dementia (including HIV dementia, vascular dementia and Alzheimer’s disease)
Mood disorders (including bipolar and depression) Neurotic disorders including obsessive-compulsive disorder and anxiety Psychotic states: hallucination and delusion
Behavioural and personality changes
Classification of mental disorders mental healthcare users than those transferred in the LE project will be affected”. He recommended that if deinstitutionalisation of mentally ill patients were to be implemented in SA, it would have to be done with the provision of structured CMHSs, as recommended by the MHP document, with the adequate planning and allocation of designated resources. In addition, specialist-run community/psychiatric services, as described in the MHP, had to be included in the proposed NHI structure, and funded in order to address the needs of people with severe psychiatric disability who required specialist-level care close to their homes. There is, it seems, a very long way to go. In the 2014/2015 SA Health Review, Maxine Spedding, Dan J Stein and Katherine Sorsdah proposed that task-shifting from specialised to non-specialised health workers of psychosocial interventions
to treat common mental disorders would be a worthwhile consideration for SA. They noted that with a high prevalence rate in SA of mental disorders, inadequate public health resources and a chronically overburdened health system resulted in limited access to psychiatric care. “Task-shifting psychosocial interventions from specialised to non-specialised health workers to treat common mental disorders has been widely proposed as a strategy for expanding access to mental healthcare,” they said. Dr Thom pointed out that since the publication of the MHP Framework and Strategic Plan, each province was supposed to develop its own plan. “My impression is that this has been patchy if it has happened at all – and translating plans into concrete action is even more difficult,” she said, pointing out that prior to the LE tragedy, the Gauteng Health Department had developed “an
impressive plan for people with chronic mental illness from 1994.” “At that stage,” she said, “there were many thousands of patients in LE institutions, some of whom had been there for years, and the care was largely custodial. Over the first 10 years (from 1994 to 2004) a process of identifying patients suitable for discharge, transfer to other provinces and referral to residential facilities in the community took place. “Standards for care were developed, and the quality of care in the LE institutions was improved. Standards for NGO care were also developed, and these had to meet specific quality standards before they were licensed to operate. To some extent, a budget was implemented so that funding could be redirected to ‘follow the patient’. “However, health service managers in general lack understanding of the needs of people with severe mental illness. The acute psychiatric units in general hospitals, as well as in the specialised psychiatric hospitals, always need to transfer some patients to institutions like LE for longer-term care, in order to relieve pressure on these acute beds. “The decision to end the contract with LE institutions was made without a proper understanding of this context. It’s not that policy itself that is disastrous – but there needs to be adequate funding, as well as an understanding of the needs of mental healthcare users. “We should have learned from other countries. Even well-developed countries have experienced difficulties with ‘deinstitutionalisation’, and in the past 10 years, international policy has suggested that there needs to be a balance between community care and hospital care. “In SA, community psychiatric and mental health services are woefully underdeveloped and underresourced,” Dr Thom concluded.
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Feature | 23
WHAT’S NEW IN CANCER PAIN TREATMENT? Government’s acceptance of Mario Ambrosini’s Medical Innovation Bill, including the regulation of medical cannabis, opens the door for new treatments for pain in cancer patients. Traditional pain management methods still suffer from doctorpatient miscommunication about the degree of pain experienced, and patients’ fears regarding current medication. By Marilyn de Villiers
T
HREE YEARS AFTER THE LATE Dr Mario Ambrosini – a cancer patient – submitted his Medical Innovation Bill to Parliament, Parliament’s Portfolio Committee of Health made an announcement in late November 2016 about the bill’s most contentious aspect – medical cannabis. The announcement indicated that government would soon regulate medical cannabis for certain health conditions. The new regulatory framework was earmarked for release for stakeholder comment by end January 2017, with implementation possible as soon as April 2017. At the time of writing this had still not occurred. However, in early April, the Western Cape High Court ruled that laws prohibiting the possession, use and cultivation of cannabis in private homes and for personal consumption were inconsistent with the Constitution and declared them invalid. The judgment still has to be confirmed by the Constitutional Court and then referred to Parliament. Dr Ambrosini’s Inkatha Freedom Party colleague in Parliament, Mr Narend Singh, welcomed the announcement, calling it “a victory for every South African unnecessarily suffering because of HIV/AIDS, severe chronic pain, severe muscle spasms, vomiting or wasting arising from cancer, or severe seizures resulting from epileptic
Oxycontin is an opioid pain medication for patients with moderate-to-severe chronic pain. Side-effects include slowed breathing, seizure, confusion, infertility and impotence, and nausea, among others. conditions where other treatment options have failed or have intolerable side-effects”. The euphoria with which the cannabis announcement was greeted is understandable. Former University of the Witwatersrand Professor of Radiation Oncology, Dr Selma Browde, stated in her foreword to the Guide to the Treatment of Cancer Pain in South Africa that “there is far too much unnecessary
THE OPIOID DEBATE
Certain barriers limit the effective use of opioids by healthcare workers, family members and patients. These concerns may be related to the side-effects and risk of dependence when using opioids, as well as the development of tolerance to the chronic use of opioids. Many of these concerns are misguided. Physical dependence, resulting in withdrawal symptoms when a drug is abruptly discontinued, is a normal physiological response to chronic opioid therapy, as well as long-term use of various other medications. Patients can be weaned from the drug slowly. Dependence differs from addiction in that the patient remains compliant with changes in opioid prescription. Psychological dependence may arise from fear of pain recurrence or incomplete pain relief. But as pain is brought under control, requests for additional medication will decrease. Because pain causes sleep deprivation, effective analgesia may initially be associated with sleep. Thereafter, however, with an appropriate drug given at an appropriate dose at the right time, opioid therapy is not associated with either profound sedation or respiratory depression. Addiction is rare in palliative care when opioids are prescribed at appropriate doses to relieve pain. The perception that opioids are only used at the end of life and hasten death is incorrect. Opioids are frequently used for many different conditions associated with severe pain. Some patients use them quite safely for months or years for prolonged pain control and they significantly improve quality of life. Source: Guide to the Treatment of Cancer Pain in SA
suffering experienced by cancer patients at every stage of their condition”. “Despite the means now available to control pain and suffering, these means are not always adequately employed by the oncologists, medical or surgical specialists, or GPs involved in the management of cancer patients. Why is it that in 2015, the suffering of cancer patients is still so prevalent in hospitals, in institutions and in their homes?” she asked. Commenting in the South African Journal of Anaesthesia and Analgesia about the publication of the Guide, Dr G Lamacraft, associate professor and head of the Pain Control Unit in the Faculty of Health Sciences at the University of the Free State, and Dr S Bechan, head of Clinical Unit Pain and Obstetric Anaesthesia at Albert Luthuli Hospital in Durban, put the overall prevalence of pain in cancer patients at about 53%, rising to 64% in patients with advanced and metastatic disease. The Cancer Association of SA (CANSA), however, maintains that the incidence of pain among those undergoing cancer treatment is much lower – about one in three – although this rises to over two-thirds in patients with advanced cancer. Whatever the statistic, there is no question that a sizeable proportion of cancer patients suffer pain. This may be associated with both the disease and its treatment. As we all know, pain is feared, and there is considerable public interest in this health issue around the world. In fact, in the USA, “pain control in advanced cancer” was ranked among the top 20 healthcare priorities by the Institute of Medicine in the 2003 report Priority Areas for National Action. It’s hardly surprising, therefore, that cannabis should be regarded by many as the “silver bullet” for dealing with cancer pain. After all, if – despite the widespread availability of cancer pain relief medications – patients still suffer pain, then perhaps it’s time to
try something different, something “natural” like cannabis. However, in their Guide, the SA Cancer Pain Working Group note that while medicinal cannabinoids (nabilone and delta-9-tetrahydrocannabinol (THC)) are available in some parts of the world, and there is evidence that they may be effective in the treatment of different pain syndromes, there is some concern that at higher doses, THC is “highly sedating and adverse effects are common, dose-related and may be severe”. The authors of the Guide, which was published in 2015 – before parliament’s cannabis breakthrough announcement – state unequivocally that “the use of cannabinoids is not recommended in SA for the treatment of cancer pain”. The Guide is intended for use by nurses, GPs, family physicians and specialists whose work requires them to assess and manage pain in cancer patients. It would also be of interest to allied health workers, social workers, psychologists and other caregivers to people living with cancer. In terms of international law, palliative care, including the effective management of cancer pain, is regarded as a human right. Yet a recent study in SA and Uganda indicated that pain was exceptionally common among all cancer patients referred for palliative care. Why is this so? After all, according to the Guide’s authors, cancer pain management is “inexpensive, safe and effective” and can be administered in a
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According to the WHO’s “analgesic ladder”, analgesic medication must be administered regularly and at the appropriate time interval in order to achieve continuous pain control.
“
In terms of international law, palliative care, including the effective management of cancer pain, is regarded as a human right
wide variety of settings from hospitals and hospices to the patient’s own home. “However, cancer pain is frequently inadequately treated. In SA, palliative care has been a low priority among healthcare educators, policy makers and health administrators. Healthcare providers often feel insufficiently prepared to assess and manage cancer pain.” Yet according to Prof. Natalie Schellack of Sefako Makgatho Health Sciences University, “effective treatment, including pain relief and palliative care, helps increase cancer survival rates and reduces suffering”. CANSA offers six key reasons for cancer patients not receiving adequate pain management treatment: 1. Reluctance of doctors to ask about pain or other treatments. They don’t specifically ask about pain (although this should a normal part of every consultation), possibly because they don’t know enough about proper pain treatment. If this is the case, they
should refer the patient to a pain specialist. Some doctors may be wary of prescribing pain medication because these drugs could be abused. However, people who suffer genuine pain are unlikely to abuse pain medication. 2. Reluctance of patients to speak about their pain. Some people might not want to be a nuisance and bother their doctors, they may worry about what their doctors will think of them if they complain, or they may fear that the cancer is getting worse. In fact, many patients expect to have pain and believe they just have to tolerate it. 3. Fear of addiction. Many people fear becoming addicted to strong pain medications and do not understand that if medications are taken for the purpose for which they are intended – to relieve pain and not to get high – then addiction is unlikely. 4. Fear of side-effects. Many people are afraid that pain medication will make
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THE ANALGESIC LADDER
Fig. 1. The three-step analgesic ladder
“
... people who suffer genuine pain are unlikely to abuse pain medication
them sleepy or unable to communicate with family and friends. They also worry that the medication could make them act strangely. Some also have a fear that taking a strong opioid, like morphine, could actually hasten their death. However, there is evidence that suggests that good control of pain systems actually helps people to live longer. 5. Drug tolerance. This is a situation where the more one’s body gets used to a particular drug, the more one would need to continue to manage one’s pain. However, there is no evidence to suggest this develops with cancer patients, but if it does, there is no reason for the doctor or professional nurse not to adjust the dose of the medication slightly. 6. Poor pain assessment. This often happens because doctors and nurses don’t ask about pain, and because patients are reluctant to raise the issue themselves for fear of being seen as whining or complaining.
The WHO’s three-point “analgesic ladder” serves as the mainstay of treatment for the relief of cancer pain, along with psychological and rehabilitative treatments. This methodology, when used appropriately, is not only inexpensive, but has been found to relieve between 70 and 90% of cancer pain. ¾ Point 1. By mouth Wherever possible, analgesics should be administered by mouth. Where oral administration is unsuitable or not possible, alternative routes such as rectal suppositories, continuous subcutaneous infusion, and intravenous administration should be considered. ¾ Point 2. By the clock In order to achieve continuous pain control, analgesic medication must be administered regularly and at the appropriate fixed
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” However, a more practical definition of pain would probably be: “pain is what the experiencing person says it is, existing wherever he/she says it does.” It is also worth remembering that pain has both physiological and psychological consequences that affect both patients and their families. It is isolating and emotionally draining. Effective management of pain therefore requires skills in communication and an adequate understanding of assessment and treatment. CANSA also believes that while medicine is essential to control and manage pain in cancer patients, non-pharmacological therapies can also help to decrease pain. Patients would probably respond to these therapies differently, but they do offer options that those working with cancer patients should consider.
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time interval, such as 4-hourly. The dose should be up-titrated until an adequate level of analgesia is achieved. The next dose should be given before the effect of the previous one has fully worn off. Rescue doses of 50 - 100% of the regular dose may be necessary for incident or breakthrough pain. ¾ Point 3. By the ladder Analgesia should be appropriate for the type and severity of pain, stepping up for persisting or worsening pain, and stepping down as pain improves, if it can be contained with lower doses or less potent analgesics. In patients with mild nociceptive pain, step 1 is a non-opioid analgesic (such as paracetamol, aspirin or ibuprofen) or a nonsteroidal anti-inflammatory drug (NSAID). For step 2, for patients with moderateto-severe nociceptive pain, weak opioids
(codeine phosphate, dihydrocodeine, tramadol and buprenorphine) may be used alone, or in combination with one of the nonopioids from step 1. For step 3, strong opioids (morphine, hydromorphone, oxycodone, buprenorphine and tapentadol) may also be used in combination with a non-opioid from step 1. Steps 2 and 3 include the use of opioids, which may be co-prescribed with non-opioids (paracetamol and/or NSAIDS) as necessary. Because of its lower cost and predictable efficacy and tolerability, low-dose morphine is a preferred option at step 2 for adults and children. Codeine should not be used in paediatric patients. Doctors should also avoid prescribing a weak opioid and a strong opioid at the same time.
These therapies include: ¾ Heat. Heat helps to decrease pain and muscle spasms. It can be applied to the painful areas for 20 - 30 minutes every 2 hours. ¾ Ice. Ice helps to decrease swelling and pain. It may also prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag, cover it with a towel and place it on the area for 15 to 20 minutes every hour. ¾ Massage therapy. This may help to relax tight muscles and decrease pain. ¾ Physiotherapy. This teaches the patient exercises to help improve movement and strength, and decrease pain. ¾ Transcutaneous electrical nerve stimulation. This is a pocket-sized, batterypowered device that is usually placed over the area of pain and uses mild, safe electrical signals to help control pain. ¾ Spinal cord stimulation. An electrode is implanted near the spinal cord. The electrode uses mild, safe electrical signals to relax the nerves that cause pain. ¾ Aromatherapy. This method uses scents from oils or extracts from flowers, herbs and trees to relieve stress and decrease pain.
¾ Guided imagery. This teaches patients to put pictures in their minds that will make the pain feel less intense. ¾ Laughter. Laughter may help to let go of stress, anger, fear, depression and hopelessness. ¾ Music. This may help increase energy levels and improve one’s mood. It may help to reduce pain by triggering the body to release endorphins, the natural body chemicals that decrease pain. ¾ Biofeedback. This teaches the body to respond differently to the stress of being in pain. ¾ Self-hypnosis. This is a way to direct one’s attention to something other than pain. ¾ Acupuncture. This therapy uses very thin needles to balance energy channels in the body. This is thought to reduce pain and other symptoms. Whatever one’s approach to cancer pain management, research has found that a multidimensional approach offers the greatest potential for maximising pain control and minimising adverse effects.
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“
... pain is what the experiencing person says it is, existing wherever he/she says it does
PRESS RELEASE
GLOBAL WASTE GROUP AVERDA ACQUIRES SOLID WASTE TECHNOLOGIES
Bolstering its position to one of the largest in SA healthcare medical waste market
Averda SA’s managing director, Johan van den Berg
Averda SA’s healthcare head, Eugene Barnard At the helm of global waste management group Averda’s growth in South Africa is Averda SA managing director, Johan van den Berg. Averda recently increased its footprint in the medical waste market through a strategic acquisition lead by the company’s healthcare head, Eugene Barnard.
Johannesburg, 1 February 2017 – Global waste-management group, Averda, has further invested in the SA market with the acquisition of Solid Waste Technologies (SWT), a healthcare medical waste company with over 20 years’ experience. The acquisition of SWT alongside SharpMed, acquired in 2016, makes Averda one of the largest and most comprehensive end-to-end healthcare waste management businesses in SA. Averda SA’s managing director, Johan van den Berg, said SWT will form an integral part of Averda’s waste-management operations in SA, aimed at offering a complete turnkey solution in healthcare waste management. “As part of a global group, Averda SA is aligned with world-class standards and systems that bring to market a differentiated service based on credibility, compliance, reporting and sustainability,” says Van den Berg. “We’ve recently invested R250 million in the construction of a state-of-the-art hazardous waste landfill site in Vlakfontein, which will support our integrated operations through our strategic acquisitions of SWT and SharpMed.” Eugene Barnard, Averda’s healthcare head, says SA is on a par with global standards for operating and designing hazardous landfills and medical waste treatment facilities, and in meeting regulatory requirements and compliance. “This acquisition boosts our footprint in the medical waste sector and will deliver a consistent and reliable service, world-class
management systems and procedures, the latest waste-tracking technology and traceability, and state-of-the-art medical and hazardous waste technology and disposal facilities. “Our fully integrated waste management solution draws on Averda’s global expertise, experience and strong track record,” says Barnard. “We employ the best people where we operate, and we draw on global expertise to enable skills transfer. We operate state-ofthe-art vehicles and utilise leading software, processes and systems. The successful delivery of a service and operation is paramount to Averda. We’re excited to bring SWT’s expertise and technology … in the healthcare waste area into our business. We look forward to the integration and to collectively furthering our research and investment into new technologies in the healthcare waste industry,” concluded Barnard. Averda is the country’s first multinational waste-management company, with dedicated engineering and design departments headquartered in London to oversee its high standards, delivery, longevity and credibility wherever they operate. Averda is a global integrated wastemanagement company operating in 14 countries and employing over 15 000 people. The company is known for operating in emerging markets where there is a need for an effective waste management solution, and runs successful operations in a number of African countries including Angola, Gabon and Republic of Congo. Issued by Meropa Communications on behalf of Averda. For more information, please contact Lauren Human on +27 78 253 9160 or at laurenh@meropa.co.za.
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WHEN IT COMES TO YOUR MEDICAL WASTE, YOU CAN TRUST US. Averda Healthcare Waste Solutions deliver professional, cost effective waste management solutions, leaving you free to concentrate on everything it takes to be a healthcare provider. Our resources and processes make sure all your medical waste is taken care of in a responsible and ethical manner. Personal, dependable and there for you. That’s our promise. That’s why you can put your trust in us. For an assessment of your medical waste requirements please call us on 0860 783 466.
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32 32 || Clinician’s End Note View
CRY, THE BELOVED COUNTRY By Bridget Farham
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OWARDS THE END OF 2016, around 1 300 psychiatric patients were moved over several months from Life Esidimeni, a group of specialised private facilities, to care homes run by charities. The Life facility delivered healthcare services to indigent patients under contract to national and provincial Departments of Health and Social Development. The end result reverberated around the country and indeed, the world – at least 100 deaths in truly appalling circumstances. The moves were made in the face of appeals by family members, psychologists and advocacy groups that this would be dangerous. They pleaded with Qedani Mahlangu, then Gauteng provincial health minister, to stop the move. They even went to court. But the move went ahead. Ms Mahlangu has subsequently resigned – an unusual move among South African politicians – but too little, too late. As Dan Stein and colleagues point out so well in the April issue of the South African Medical Journal, this was “death by maladministration”. The patients were moved to NGOs who “jostled” over which patients they wanted in what the health ombudsman’s report described as a “cattle auction”. Some sent pick-up trucks to collect them. Several neglected them to the point of death. These people are the “vulnerable and voiceless” in society, who Stein et al. rightly describe as serving as the “canary in the coal mine”. That they died at all is more than shocking. It reflects a growing lack of concern for people who cannot speak for themselves, be they the mentally ill, the elderly and frail or the refugees who are being hounded around Europe because, quite simply, no-one wants them. What is particularly distressing about this tragedy is that people then tried to cover it up. The risks were known before the patients were moved and Mahlangu and her administration simply watched as the
tragedy unfolded. Mahlangu only admitted to the deaths after being quizzed by the shadow minister for health in parliament – at the time the death toll stood at 77. Patients were still dying, even as parliament heard of the debacle. Esidimeni was ignored during the chaotic State of the Nation address, except by one DA MP who unsuccessfully called for a minute’s silence to honour the dead. The deputy president and minister of health then did some fancy footwork in the name of damage limitation. So far, it appears that 27 psychiatric patients have been moved, with the consent of their families, to the Solomon Stix Morewa Private Hospital in Johannesburg. But since there is little or no public knowledge of the fates of the rest of the patients who were moved, it is possible that there are still patients at risk of neglect in unsuitable, but cheap, NGO facilities. The “canary in the coal mine” analogy is apt. We can no longer close our eyes to the corruption and wilful neglect of our public services, and indeed our people, by a government that is increasingly desperate to hold on to power and through it, their access to the public purse. Across the world, humanity is losing its compassion. The events around refugees and asylum seekers in Europe are one example. The hate speech and crimes that are increasing in the UK (and other parts of Europe) and the USA with the rise of the far right are another. Greed and selfishness are becoming acceptable. We must not let this happen. Stein DJ, Chambers C, Daniels I, et al. Death by maladministration: An important category of patient mortality. S Afr Med J 2017;107(4):280. http://dx.doi. org/10.7196/SAMJ.2017.v107i4.12389 Makgoba MW. 2017. The report into the ‘circumstances surrounding the deaths of mentially ill patients: Gauteng Province’. http://www.politicsweb.co.za/documents/thelife-esidimeni-disaster-the-makgoba-report Motsoaledi confirms move of Esidimeni patients to other facilities. Eye Witness News. http://ewn. co.za/2017/03/03/motsoaledi-confirms-move-ofesidimeni-patients-to-other-facilities
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