Healthcare Gazette - 2017 May/Jun by HMPG

HEALTHCARE GAZETTE

MAY/JUNE 2017• ISSN 2078-9750

DEM BONES, DEM BONES – EFFECTIVE ANTIDOTES TO THE RISK OF OSTEOPOROSIS FRACTURES PG 17 6

NEWS

Diagnosed autism linked to maternal grandmother’s smoking in pregnancy

RESEARCH

Trans-fat restrictions linked to fall in cardiovascular events

FEATURE

The statin story – separating fact from fiction

H EALT HC AWWW.HMPG.CO.ZA R E G A ZETTE | J A NU A RY 2 0 1 6

FOCUS

Interesting developments in epilepsy treatment

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Contents | 01

Co nt ent s 5

NEWS 4

“Artiﬁcial pancreas” promotes better control for young diabetes patients

Considering blood group when evaluating patient risk of heart attack

arge study conﬁrms some antibiotics linked to increased miscarriage risk

ew Pharmacy Advisory Board established

11 SA vaccine-monitoring technology saving lives around the world 12 SA-developed smart pill box helps ﬁght against TB 12 Clinical trials to start on SAdeveloped cancer diagnosis and treatment theranostic

Diagnosed autism linked to maternal grandmother’s smoking in pregnancy

Drug combination may prevent eye problems in juvenile arthritis sufferers

14 Trans-fat restrictions linked to fall in cardiovascular events

Kidney-failure risk in living kidney donors

14 Sugary drinks tax in California cuts sales by 10

Bioprinting for osteoarthritis

nemployment bad for the heart

15 Waist measurement a stronger prediction of death risk than BMI

10 Brain abnormalities found in people with bipolar disorder

RESEARCH

15 “Extreme” comorbidity common in patients with chronic heart failure

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FEATURES 17 Dem bones, dem bones – effective antidotes to the risk of osteoporosis fractures 22 The statin story – separating fact from ﬁction

FOCUS 28 Interesting developments in epilepsy treatment 30 Focus on ... antibiotics

END NOTE 32 Surplus people

02 | Ed’s Letter

Ed’s Letter EDITOR Marilyn de Villiers CONTRIBUTORS Marilyn de Villiers Bridget Farham

M A R I LY N D E V I L L I E R S

Published by the Health and Medical Publishing Group (HMPG)

FROM THE EDITOR’S DESK

CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham MANAGING EDITOR Naadia van der Bergh

As I put together the content for this edition of Healthcare Gazette – the ﬁrst since my appointment as editor – I was consistently amazed at the quagmire of challenges and dilemmas facing healthcare professionals from any number of sources. Among these is the peculiar dichotomy in the healthcare arena: on the one hand, there is increasing specialisation and the emergence of “super-specialists” in many disciplines. Then there is the ongoing drive towards a multidisciplinary approach to treatment. Healthcare Gazette’s mission is to try and bridge that divide by providing those involved in the healthcare industry – from medical professionals to administrators and suppliers – with insight into the latest developments and trends (see our news section and epilepsy article) across disciplines

and functions. Our article on postmenopausal osteoporosis, for example, examines the subject from the perspectives of different specialities, which together offer an integrated approach to the treatment of this debilitating disease. But perhaps one of the most frustrating, and potentially dangerous, challenges facing every healthcare professional is the rise of the super-duper specialist, the oracle of all medical wisdom – Dr Google. Thanks to Dr Google, patients who spend five minutes reading a blog shared on Facebook often believe they know more than professionals who have spent years studying. One example of this is the vilification of so-called “big pharma” that underpins campaigns such as the war on statins. Our article on high cholesterol looks not only at some of the latest developments and

treatment options, but also some current statin mythology. It’s strange that many patients who shun statins – based on Dr Google’s advice – are often among the most persistent in demanding inappropriate antibiotic treatment. Our focus on antibiotics looks at the consequences of this and suggests approaches to deal with the rising tide of antibiotic resistance. As a publication for the entire healthcare sector, our goal is also to highlight issues that affect everyone within the industry and, hopefully, encourage wider discussion. Letters to the editor can be emailed to me at healthcaregazetteeditor@ gmail.com. We’d also welcome your feedback, constructive comments and suggestions for future articles. I look forward to hearing from you. Till next time.

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Help for underage gamblers Traditionally considered an 'adults only' issue, a growing number of children are affected by problem gambling. With this in mind, the South African Responsible Gambling Foundation (SARGF) is striving to address the issue with a number of initiatives. Chief among these is the National Schools Programme. As part of this, SARGF has developed a learning pillar called Taking Risks Wisely (TRW), which is incorporated into school curricula. The course material has been developed around the reality that children are exposed to gaming and that it may seem attractive; and with this insight in mind, it aims to help them make wiser choices about risky behaviour. SARGF also provides assistance through its toll free support line at 0800 006 008. This hotline offers free, professional counselling for problem gamblers – important, because as Dr Heidi Sinclair, treatment and counselling manager at SARGF explains, a professional counsellor will be able to help both parents and children understand they dynamics that have pushed the child to seek distraction or solace in gaming. “Often, the issue is created by poor self-esteem, and the counsellor will be able to provide suggestions to help families address this in a more constructive manner,” Sinclair says. While parents may not like to think that their children are gambling, the reality is that they are. In fact, according to research cited by Knowtheodds.org, 2.1% of US residents aged between 14 and 21 are problem gamblers. “No similar statistics are available in South Africa, but it's clear that extensive exposure to gambling puts children and teens at risk: while the media glamorises casinos and gambling, family exposure – occurring every time parents purchase a lottery ticket or host a social game of poker, for example – make gambling an everyday part of life for youth. The Internet makes online gambling readily accessible, and the games children play on their tablets often groom them for real-world gaming.” She urges parents to look out for signs that their children may have become involved in gaming. These include the classic symptoms associated with risky behaviour, including sudden mood swings, a lack of interest in activities that have previously brought pleasure, a drop in school marks and absenteeism from school. Other, more specific signs that a child may have started gaming include buying items that they wouldn't be able to afford on their usual allowance, or running out of money and asking for financial assistance. A sudden and intense interest in sport may also be a warning sign, especially if the child displays a disproportionate response to a team's win or loss. This may indicate that they are placing bets on the teams. Visits to online betting sites are a red flag. If you or anyone you know has a gambling problem, contact the SARGF helpline tel: 0800 006 008 for free advice and counselling.

South African Responsible Gambling Foundation @SARGFoundation www.responsiblegambling.org.za +27 11 026 7323 info@responsiblegambling.org.za

“ARTIFICIAL PANCREAS” PROMISES BETTER CONTROL FOR YOUNG DIABETES PATIENTS

O E OF THE MOST difficult and potentially dangerous situations for young children with type 1 diabetes is the development of hypoglycaemia. But having children continually monitor their blood-sugar levels and

manually inject insulin is stressful both for the child and their caregiver. ow the niversity of Virginia Center for Diabetes Technology has developed what it calls an “artificial pancreas” device that pilot tests indicate holds great benefits for young type 1 diabetes sufferers, by helping them to better control their condition. According to a report published in the Diabetes Technology & Therapeutics journal, the device aims to automate blood sugar control in young people with type 1 diabetes. The artificial pancreas features a reconfigured smartphone running advanced algorithms. This is wirelessly linked to a bloodsugar monitor and an insulin pump worn by the patient, as well as to a remote monitoring site. The study compared how well 12 children, aged between

5 and 8 years old, were able to control their diabetes, using their usual insulin pump and continuous glucose monitor v. the artificial pancreas, which had been adapted for use by young children with parental-lockout controls. The children were taken to a resort where they used the artificial pancreas for 68 hours. Thereafter, they were followed for another 68 hours while using their regular home-treatment regimen. While using the artificial pancreas, the children had lower average blood-sugar levels and spent more time within the target blood-sugar range, without an increase in hypoglycaemia. The device is now being tested in the children’s home environment. Clinical trials are also planned for testing the artificial pancreas on people with type 1 diabetes aged 14 years and older.

CONSIDERING BLOOD GROUP WHEN EVALUATING PATIENT RISK OF HEART ATTACK A PATIE T’S B OOD GRO P should be considered when assessing their risk for heart attacks, together with cholesterol, age, sex and systolic blood pressure. That’s what delegates at the recent 4th World Congress on Acute Heart Failure, in Paris, France, were told by Tessa Kole of the niversity Medical Centre

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News | 05

Groningen, the etherlands, and the lead author of a metaanalysis of studies reporting on cardiovascular events involving O- and non-O-blood individuals. The study included 1 362 569 subjects described in nine articles. There were a total of 23 154 cardiovascular events, which the researchers analysed within three categories: all coronary events, combined cardiovascular events and fatal coronary events. They found that the odds ratio for all coronary events, as well as for combined cardiovascular events, was

signiﬁcantly higher in carriers of a non-O-blood group. However, there was little difference between the O- and non-O-blood groups for fatal coronary events. “We demonstrated that having a non-O blood group is associated with a 9 increased risk of coronary events and a 9 increased risk of cardiovascular events, especially myocardial infarction,” said Ms Kole. The mechanisms that might explain this risk are under study. It has been suggested that the higher risk for cardiovascular events in non-O-blood-group

carriers may be due to their having greater concentrations of von Willebrand factor, a bloodclotting protein. Further, non-Oblood-group carriers, speciﬁcally those with an A blood group, are known to have higher cholesterol. And galectin-3, which is linked to poor outcomes in heart-failure patients, is also higher in those with a non-O blood group. “We need further studies to validate if the excess cardiovascular risk in non-Oblood-group carriers may be amenable to treatment,” she concluded.

LARGE STUDY CONFIRMS SOME ANTIBIOTICS LINKED TO INCREASED MISCARRIAGE RISK THERE ARE MA Y CO F ICTI G studies into whether antibiotics can be prescribed safely for pregnant women. Many of these have been criticised for their small sample sizes. ow, a recent study of the thousands of women aged between 15 and 45 covered by the uebec Public Prescription Drug Insurance Plan from January 1998 to December 2009, and published in the Canadian Medical Association Journal, has concluded that many classes of common antibiotics are associated with an increased risk of spontaneous abortion in early pregnancy (up to 20 weeks). Those identiﬁed as increasing the risk of miscarriage include macrolides, quinolones, tetracyclines, sulfonamides and metronidazole. However, although falling within the macrolide class, erythromycin was not associated with increased risk, and nor was nitrofurantoin, which is recommended for the treatment

of urinary tract infections in pregnant women rather than trimethoprim-sulfamethoxazole. “Infections are prevalent during pregnancy,” says Dr Anick Bérard, Faculty of Pharmacy, niversité de Montréal, Montréal, uebec. “Although antibiotic use to treat infections has been linked to a decreased risk of prematurity and low birth weight in other studies, our investigation shows that certain types of antibiotics are increasing the risk of spontaneous abortion, with a 60 to two-fold increased risk.” In the study, 8 702 cases,

deﬁned as clinically detected spontaneous abortions, were matched with 87 020 controls. The mean gestational age at the time of miscarriage was 14 weeks. A total of 1 428 (16.4 ) cases were exposed to antibiotics during early pregnancy compared with 11 018 (12.6 ) in controls. “Given that the baseline risk of spontaneous abortion can go as high as 30 , this is signiﬁcant. evertheless, the increased risk was not seen for all antibiotics, which is reassuring for users, prescribers and policy-makers,” Dr Bérard concluded.

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DIAGNOSED AUTISM LINKED TO MATERNAL GRANDMOTHER'S SMOKING IN PREGNANCY

WHI E THE EGATIVE EFFECTS of smoking during pregnancy on child development have long been noted, a new study has found a clear link between the maternal grandmother’s smoking while pregnant and a girl’s likelihood of displaying certain autistic traits.

Scientists from the niversity of Bristol looked at all 14 500 participants in the Children of the 90s group, also known as the Avon ongitudinal Study of Parents and Children (A SPAC), and found that if a girl’s maternal grandmother had smoked during pregnancy, the girl was 67 more

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likely to display the autistic traits of poor social communication skills and repetitive behaviours. The team also found that if the maternal grandmother had smoked, this increased the risk of her grandchildren having a diagnosed autism spectrum disorder (ASD) by 53 . nlike in the analysis of autistic traits, which was based on over 7 000 participants, the number of 177 diagnosed with ASD was too small to analyse grandsons and granddaughters separately. Paternal grandmothers’ smoking in pregnancy showed no associations with autistic traits or ASD in her grandchildren, male or female. The results of this new study suggest that if a female is exposed to cigarette smoke while she is still in the womb, it could affect her developing eggs – causing changes that may eventually affect the development of her own children. “We already know that protecting a baby from tobacco smoke is one of the best things a woman can do to give her child a healthy start in life. ow we’ve found that not smoking during pregnancy could also give their future grandchildren a better start too,” said one of the authors, Prof. Jean Golding.

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DRUG COMBINATION MAY PREVENT EYE PROBLEMS IN JUVENILE ARTHRITIS SUFFERERS I A C I ICA TRIA ED BY professors from the universities of iverpool and Bristol, a drug combination has been discovered that could help thousands of children with arthritis. The trial was funded by Arthritis Research K and the ational Institute for Health Research. Thousands of children and adolescents with juvenile idiopathic arthritis (JIA) develop uveitis, a condition that causes in ammation in the middle layer of the eye. The drug combination discovery could help prevent them from developing serious complications, including blindness. The full study, entitled

“Adalimumab plus methotrexate for uveitis in juvenile idiopathic arthritis”, was published in The New England Journal of Medicine. The trial found that a drug called adalimumab, in combination with methotrexate, was an effective therapy in children and adolescents with JIAassociated uveitis. The majority (75 ) of the children treated with adalimumab experienced a signiﬁcant reduction in eye in ammation. An early analysis of the data was so convincing that the trial was stopped early. In this randomised, placebocontrolled trial involving 90 of the

target 149 patients with JIAassociated uveitis, it was found that the adalimumab group had evidence of a significantly lower risk of treatment failure than the placebo group. Prof. A V Ramanan, from niversity Hospitals Bristol HS Foundation Trust and the niversity of Bristol said, “ veitis in children is an important cause of loss of vision. This study demonstrates the benefit of adalimumab in children with uveitis. This is the first randomised trial of its kind worldwide, and the results will have a major impact on children with uveitis all around the world.”

KIDNEY FAILURE RISK IN LIVING KIDNEY DONORS

WHI E DO ATI G A KID EY is a sel ess act by living donors, there are certain groups of people who are at greater risk of themselves suffering kidney failure after donation. These include black people, males, older non-black individuals, and people who are overweight and have a close biological relationship to the transplant recipient. These were among the ﬁndings of study of 133 824 living

kidney donors from 1987 to 2015, published recently in the Journal of the American Society of Nephrology. The research team was led by Dr Dorry Segev of the Johns Hopkins niversity School of Medicine and the Johns Hopkins School of Public Health. The study also found that the overall risk to living donors was quite low. The median risk of kidney failure was only one case per 10 000 donors at 5 years after donation, and 34 per 10 000 donors at 20 years after donation. evertheless, those of black race and males had a 3.0- and 3.9-times increased risk of developing kidney failure, respectively. Among non-black donors, older age was linked with greater

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risk, but this was not seen in black donors. Higher body mass index was also associated with an increased risk of kidney failure. Dr Segev’s team used the ﬁndings of their research to develop a risk calculator that can provide personalised risk estimates of developing kidney failure after donation. This may be useful for individuals considering donation, and for clinicians who monitor the long-term health of living donors. “Because living kidney donors voluntarily undergo surgery for no direct medical beneﬁt to themselves, it is incumbent upon the transplant community to provide them with accurate estimates of long-term risk,” Dr Segev said.

News | 09

BIOPRINTING FOR OSTEOARTHRITIS? THE POSSIBI ITY OF bioprinting cartilage tissue that can be used to repair cartilage damage or to treat osteoarthritis has moved a step closer. This follows a team of Swedish researchers successfully generating cartilage tissue by printing stem cells using a 3D bioprinter. The researchers at Sahlgrenska Academy at the niversity of Gothenburg ﬁrst succeeded in ensuring that the stem cells survived being printed. They were then able to in uence the cells to multiply and differentiate to form chondrocytes (cartilage cells) in the printed structure. The results were published

in Nature’s Scientific Reports magazine. “In nature, the differentiation of stem cells into cartilage is a simple process, but it’s much more complicated to accomplish in a test tube. We’re the ﬁrst to succeed with it, and we did so without any animal testing whatsoever,” said Stina Simonsson, associate professor of cell biology, who led the research team’s efforts. The cartilage formed by the stem cells in the 3D bioprinted structure was remarkably similar to human cartilage. Experienced surgeons who examined the artiﬁcial cartilage saw no difference when they compared

the bioprinted tissue with real cartilage. nder the microscope, the cells appear to be perfectly formed, with structures similar to those observed in samples of human-harvested cartilage. However, one major issue must be resolved before the findings can be used in practice to benefit patients. “The structure of the cellulose we used might not be optimal for use in the human body. Before we begin to explore the possibility of incorporating the use of 3D bioprinted cartilage into the surgical treatment of patients, we need to find another material that can be broken down and absorbed by the body,” Prof. Simonsson explained.

UNEMPLOYMENT BAD FOR THE HEART

EMP OYME T IS associated with a 50 higher risk of death in patients with heart failure, according to research presented at Heart Failure 2017 and the 4th World Congress

on Acute Heart Failure held in France recently. The observational study of more than 20 000 heart failure patients found that not being employed was linked with a greater likelihood of death than a history of diabetes or stroke. “The ability to hold a job brings valuable information on wellbeing,” said lead author Dr Rasmus Roerth, a physician at Copenhagen niversity Hospital, Denmark. “Workforce exclusion has been associated with increased risk of depression, mental health problems and even suicide. “In younger patients with heart failure, employment status could be a potential predictor of morbidity and mortality,” he continued. “If so, employment status could help to risk-stratify young heart failure patients and

identify those needing more intensive rehabilitation.” The study included all patients of working age (18 - 60 years old) with a first hospitalisation for heart failure in Denmark between 1997 and 2012. During an average follow-up of 1 005 days, 16 of employed and 31 of unemployed patients died, while 40 of employed and 42 of unemployed patients were rehospitalised for heart failure. After adjusting for age, sex, education level and comorbidities, unemployed heart failure patients had a 50 increased risk of death and 12 increased risk of rehospitalisation compared with those who were employed. The findings therefore indicated that efforts to get patients back into work might be beneficial.

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BRAIN ABNORMALITIES FOUND IN PEOPLE WITH BIPOLAR DISORDER BIPO AR DISORDER AFFECTS about 60 million people worldwide, according to the World Health Organization. It is a debilitating psychiatric disorder with serious implications for those affected, and their families. However, scientists have struggled to pinpoint neurobiological mechanisms of the disorder, partly due to the lack of sufﬁcient brain scans. ow, in the largest MRI study to date, involving 2 447 patients with bipolar disorder and 4 056 healthy controls, a global consortium has published new research in Molecular Psychiatry showing that people with the condition have a thinning of grey matter, particularly in brain regions that control inhibition and motivation – the frontal and temporal regions.

Some of the bipolar disorder patients with a history of psychosis showed greater deﬁcits in the brain’s grey matter. The ﬁndings also showed different brain signatures in patients who took lithium, antipsychotics and anti-epileptic treatments. ithium treatment was associated with less thinning of grey matter, which suggests a protective effect of this medication on the brain.

By revealing clear and consistent alterations in key brain regions, the ﬁndings offer insight into the underlying mechanisms of bipolar disorder. Mapping the affected brain regions is also important for early detection and prevention. “We created the ﬁrst global map of bipolar disorder and how it affects the brain, resolving years of uncertainty on how people’s brains differ when they have this severe illness,” said Ole A Andreassen, senior author of the study and a professor at the orwegian Centre for Mental Disorders Research at the niversity of Oslo. Future research will test how well different medications and treatments can shift or modify these brain measures, as well as improve symptoms and clinical outcomes for patients.

NEW PHARMACY ADVISORY BOARD ESTABLISHED A EW PHARMACY ADVISORY Board has been constituted to bring together stakeholders across various pharmacy bodies and academia, with the goal of seeking solutions to challenges facing the SA pharmacy sector. The multi-stakeholder Pharmacy Advisory Board, which held its ofﬁcial launch meeting in Johannesburg earlier this year, believes that pharmacists and pharmacies have an increasingly important role to play in the provision of primary healthcare services in SA.

Pharmacists play a vital role in the overall healthcare system, through the provision of affordable and accessible minor-ailments diagnosis and referral, patient education and screening and drug information, particularly in underresourced areas. The new Pharmacy Advisory Board aims to unite pharmacy stakeholders in a common platform to identify key challenges and opportunities in training, quality and regulatory issues, and to help address the skills shortage in the pharmacy sector by supporting

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training for pharmacists, pharmacy assistants and front-shop assistants. The board will benchmark SA pharmacies against international best practice, and help to develop the sector to meet changing local needs. In addition, the Pharmacy Advisory Board aims to add value to the pharmacists and pharmacies of SA by driving insight and education, and facilitating discussion amongst key opinion leaders in the SA pharmacy sector that identiﬁes key challenges and opportunities, creates multi-stakeholder solutions

News | 11

and implements strategies that drive the board’s vision. Among the proposed measures that the board hopes to facilitate are sponsorships of tertiary institutions and teaching posts, professional development portals for pharmacists and frontshop assistants, product training sessions and the distribution of good pharmacy practice

guides and operating procedure manuals. A potential outcome of the new board’s work will also be to support ongoing and effective communication between the SA Pharmacy Council, professional bodies and pharmacists across SA. The new board is supported by RB South Africa, which noted that because pharmacy is a key

channel for health education and the provision of primary healthcare, it recognised the need for a platform for multistakeholder engagement within the pharmacy sector. To ensure that it drives inclusive change, the new seven-member board represents stakeholders from various pharmacy sectors and geographical regions.

SA VACCINE-MONITORING TECHNOLOGY SAVING LIVES AROUND THE WORLD A SIMP E, SER-FRIE D Y technology which started life in a garage in southern Johannesburg is being used by GOs such as the World Health Organization (WHO), ICEF, the International Committee of the Red Cross, the Pan American Healthcare Organization and the Clinton Health Access Initiative to monitor the vaccine cold chain in 54 developing countries across ﬁve continents. According to Ian ester, founder and CEO of Beyond Wireless, which developed the technology, vaccines must be stored between 2 C and 8 C in order to maintain their efﬁcacy. “In many poor regions of the world, even if people have access to vaccines – which is a challenge in itself – there’s often a question mark over whether those vaccines will be effective, because they might have got too hot or too cold before being administered,” he said. Global best practice suggests automatic temperature monitoring of vaccine and other temperature-sensitive drugs as the best option for maintaining the

Ian ester, CEO, Beyond Wireless cold chain, yet many countries in the developing world still lag behind in this regard. This is where Beyond Wireless’s ColdCloud technology, one of only four in the world to have obtained performance, quality and safety (P S) certiﬁcation from the WHO, is assisting. “It’s extremely difﬁcult to ensure that the vaccine cold chain is properly maintained across its entire length,” ester said. “If, for instance, the power goes off in the middle of the night or if a door is accidentally left open, you’re not going to know if the vaccine in the fridge has gone

outside of its temperature range or not. “Our GSM-enabled remote temperature-monitoring device is battery operated, so it’s completely independent of power supplies which, in the developing world, can be both unreliable and dirty. The device sits in the fridge and monitors power supply, door position and temperature, and escalates alarms via email, SMS and a smartphone app when anything goes wrong.” The monitoring solution is also accessible from any standard browser or smart device with an internet connection, enabling health GOs with vaccine fridges in far- ung locations to check on the status of every fridge being monitored. “I truly believe that by improving the monitoring and control of vaccine cold chains in vaccine distribution points around the world, we can save millions of lives, as well as improv e the health and economies of entire societies,” ester concluded.

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SA-DEVELOPED SMART PILL BOX HELPS FIGHT AGAINST TB THE BI A D ME I DA GATES Foundation has chosen an SA company, Wisepill Technologies, to develop a smart pill box for use by TB patients in Africa, India and China. The new pill box, which is designed to record every time medication is taken, can be used by caregivers and doctors to monitor and assist patients to overcome TB by diligently taking their medication. TB medication can take many months to work. It is important that patients take their TB medication every day for the full treatment period. It is also essential that all the recommended TB tablets are taken. “Adherence to medication is one of the major challenges we face on a daily basis, and we are constantly looking for innovative solutions to the problem. The Wisepill Technologies Pill Box is one such solution,” said James Kruger, director of the HIV/AIDS and TB Directorate of the Western Cape Department of Health. Wisepill’s clever pill box has already been given to 3 800 patients in China, as the ﬁrst

The Wisepill smart pill box phase of a rollout which is expected to reach 24 counties in the Chinese provinces of hejiang, Jiangxi and Jilin. The new pill box is very affordable, speciﬁcally designed for blister-packaged TB medications, and has a built-in

audiovisual alarm to remind patients when to take their medication and when to return to the clinic. The device tracks all openings and data can be downloaded and viewed by caregivers. The Arcady Group, on behalf of the Bill Melinda Gates Foundation, selected Wisepill Technologies to develop and manufacture the device. Bruce Thomas, founder and managing director of the Arcady Group stated, “We are grateful to the Gates Foundation for their support, and we are very pleased to have been able to help bring a new, highly affordable technology to the global ﬁght against tuberculosis.” Wisepill Technologies has developed and distributed more than 10 000 medication dispensers to more than 20 countries, and for more than 40 research trials. “We are very proud to be able to provide this affordable reminder and monitoring tool to help in the ﬁght against TB internationally,” said Wisepill Technologies founder and director, loyd Marshall.

CLINICAL TRIALS TO START ON SADEVELOPED CANCER DIAGNOSIS AND TREATMENT THERANOSTIC SA’s public and private sectors are working together to bring a new development in the diagnosis and treatment of cancer to market.

A new theranostic, GluCAB, is set to undergo clinical trials as part of a partnership between the SA uclear Energy Corporation

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( ECSA), the niversity of Cape Town, and a privately owned biotechnology company, BGM Pharma.

News | 13

The term “theranostics” was coined to define an agent that has both diagnostic and therapeutic potential, and also ongoing efforts to develop individualised therapies, and according to BGM Pharma cofounder and president, Martin Magwaza, is the new frontier when it comes to the treatment of an illness that continues to ravage vast numbers of people globally. An initial investment of AR600 million would be required for the clinical trials of GluCAB, to prove its safety and efficacy in a sufficient number of human subjects. Thereafter, more investment will be required to conduct multi-centre and multicountry clinical trials. “Although we are a few years from market readiness – 48 to 60 months – the initiation of clinical studies for a local technology is a significant development. To take a molecule from doctoral thesis to clinical testing for the global market is a huge milestone for the country, and indeed the local healthcare market. It is clear that medical innovation is alive and well in SA,” said Magwaza. ECSA executive manager, new business development, Brian Mphahlele, said that in recent years, cancer research has started to focus on imaging and radiotherapeutic methods that detect relatively small tumours, and selectively target tumours with minimal side-effects or damage to healthy cells. “There are many advantages of the new compound over conventional cancer diagnostics and therapeutic procedures, including improved diagnosis and treatment, reduced patient recovery time, increased survival rates and significantly lower pharmacological toxicity and side-effects. This will not only

Martin Magwaza, BGM Pharma co-founder and president have an impact on individual cancer patients and their families, but it promises to become a socioeconomic driver in healthcare systems around the globe,” Mphahlele said. The GluCAB compound currently being developed has a two-stage cancer-targeting mechanism. The GluCAB compound localises in the regions of the tumour through its passive targeting sub-system via the enhanced permeability and retention effect. Once at the targeted area, the compound uses its active targeting subsystem to attach itself to a speciﬁc receptor on the surface of the cancer cell – delivering a radioisotope into the tumour cell. The delivered radioisotope tracer makes it possible to image and diagnose cancer through computed tomography (CT) scanning. The tracer can also be used as a therapeutic treatment to destroy the cancer cells by seeking malignant cells and killing them through targeted radiation.

Head of nuclear medicine at the niversity of Pretoria and the Steve Biko Academic Hospital, Prof. Mike Sathekge, said that while theranostics and nuclear medicine are not the only way to treat cancer – management is multidisciplinary – the theranostics approach is the most exciting development, and certainly the way of the future. “When treating cancer, it was useful to have insights into tumour biology, thus optimising management with a treatment that’s targeted. That’s why the theranostics approach is so effective. It uses the same molecule to diagnose and treat, providing a roadmap for a personalised treatment plan and leading to a patient-speciﬁc successful outcome. With this modality of treatment, there is no hit-and-miss due to targeted molecular imaging probes,” he explained. Initially, the new theranostic will be used to seek, identify and treat solid mass tumours such as those found in breast and ovarian cancer.

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BITE-SIZED SUMMARIES OF THE LATEST SCIENTIFIC ADVANCES Sugary drinks tax in California cuts sales by 10%

Trans-fat restrictions linked to fall in cardiovascular events Counties in the state of ew York, SA, that have introduced restrictions on transfatty acids in restaurants and takeaway outlets have seen signiﬁcantly fewer admissions for cardiovascular events than counties with no restrictions. This study was published in JAMA Cardiology recently. Partially hydrogenated oils used in baked goods, yeast breads, fried foods, chips, biscuits and margarines are the main source of trans fatty acids in the diet. In 2007, ew York City restricted trans-fatty acids in all public eating places.

Researchers compared the number of admissions for myocardial infarction (MI) or stroke in 11 counties that restricted trans-fatty acids with 25 counties with no restrictions from 2002 to 2013. Although these events were already declining throughout the State of ew York before the first restrictions were brought in, after 2006, populations with restrictions experienced a significant additional decline in rates of admission for MI or stroke compared with populations with no restrictions. The significant decline in MI and strokes came at least 3 years after the restrictions were implemented. Brandt E, Myerson R, Perraillon M, Polonsky TS. Hospital admissions for myocardial infarction and stroke before and after the trans-fatty acid restrictions in New York. JAMA Cardiol April 2017. http:/doi.org/10.1001/ jamacardio.2017.0491

Sales of sugar-sweetened drinks in Berkeley, California, fell by almost 10% after an excise tax was introduced, according to research published in PloS Medicine. The tax was introduced in 2014 in Berkeley – a tax of USD0.01 per fluid ounce on drinks with added caloric sweeteners – adding an average of USD0.68 to a USD2.00 bottle of cool drink and USD0.12 to a USD1.00 can. In the first full year of the tax, the city raised USD1 416 973.00 (about USD12.00 per capita), and the money is being used for child nutrition and community health programmes. Researchers carried out a before-and-after study of store scanner records from 15.5 million checkouts in two large grocery chains in Berkeley and comparison cities. They also studied 26 stores of various types in Berkeley and did a randomdigit telephone survey of consumption by residents. One year after the tax was implemented, sales of sugar-sweetened drinks fell by 9.6% in Berkeley, while sales of untaxed beverages rose by 3.5%. Sales of water rose by 15.6%, and sales of untaxed fruit,

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vegetable and tea drinks rose by 4.4%. Sales of sugar-sweetened beverages in surrounding areas with no tax rose by 6.9%. Silver L, Ng S, Ryan-Ibarra S, et al. Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: a before-and-after study. PLoS Med April 2017. http://doi.org/10.1371/ journal.pmed.1002283

Research | 15

Waist measurement a stronger prediction of death risk than BMI For some time researchers have thought that waist measurement was a better predictor of risk of all-cause mortality than body mass index (BMI), and now a large study published in the Annals of Internal Medicine backs this up. The study included 42 702 participants from 10 years of the Health Survey for England and the Scottish Health Survey. The participants’ mean age was 57.7, and 46.8 were men. Of the participants, 43.7 were overweight (BMI 25 30) and 25 were obese (BMI 30). The overall prevalence of central obesity was 53 – deﬁned as a waist-to-hip

ratio of 0.85 or higher in women, and 0.90 in men. The prevalence of central obesity among normalweight, overweight, and obese participants was 28.7 , 60.2 and 72.7 , respectively. A total of 5 355 people died over 383 542 person-years of follow-up. Compared with the normalweight participants without central obesity, only normalweight and obese people with central obesity were at increased risk for all-cause mortality. Compared with normal-weight participants without central obesity, all those with central obesity were at increased risk for death from cardiovascular disease and there was no difference between men and women.

Hamer M, O’Donovan G, Stensel D, Stamatakis E. Normal weight central obesity and risk for mortality. Ann Intern Med April 2017:1-2. http://doi.org/10.7326/L17-0022

“Extreme” comorbidity common in patients with chronic heart failure A primary care study in the UK has found that patients with chronic heart failure often have seven or more conditions – “extreme” comorbidity – and take multiple medicines. This is the first study of heart failure in the community, which is where most patients receive their care. Researchers analysed data from the Primary Care Clinical Informatics Unit at the University of Aberdeen on 1 424 378 patients aged >18, registered with 314 practices in Scotland. The team identified 17 285 patients (1.2%) with a diagnosis of chronic heart failure due to left ventricular systolic dysfunction. The results, reported in the British Journal of General Practice, showed that patients with chronic heart failure had much higher levels of comorbidity than

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patients without, after standardising for age, sex, and social deprivation. The most striking difference was in the proportion of patients with seven or more conditions, as the odds of this “extreme” comorbidity were four times higher in patients with chronic heart failure than in those without (13.9% v. 1.1%; odds ratio 4.10 (95% confidence interval 3.90 4.32)). Patients with chronic heart failure had nearly eight times the odds of coronary heart disease as controls (7.98 (7.72 - 8.25)), in addition to a higher prevalence of atrial fibrillation and chronic kidney disease. They also had considerably higher rates of anxiety- and stress-related conditions. Polypharmacy, defined as taking five or more repeat drugs, was substantially higher in patients with chronic heart failure. But much of the additional prescribing was accounted for by comorbidity. Researchers recommended that clinical guidelines and health services should put much greater emphasis on managing this complexity, as this is clearly “the norm”. Baron-Franco B, McLean G, Mair FS, et al. Comorbidity and polypharmacy in chronic heart failure: A large cross-sectional study in primary care. Br J Gen Pract 2017;67(658). http://doi. org/10.3399/bjgp17X690533

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Feature | 17

DEM BONES, DEM BONES – EFFECTIVE ANTIDOTES TO THE RISK OF OSTEOPOROSIS FRACTURES Osteoporosis may occur in as many as 50% of women between menopause and death, and is often undetected until fractures occur. However, there are pharmacological interventions and lifestyle modifications, including moderate exercise, that can help to prevent it. By Marilyn de Villiers

STEOPOROSIS IS A SI E T, insidious disease. It is often undetected until factures occur – fractures which often result from minimal trauma, or even no trauma at all. According to the American Association of Clinical Endocrinologists (AACE), osteoporosis is believed to be responsible for more than 2 million fractures in the SA annually, leading to 432 000 hospital admissions, almost 2.5 million medical ofﬁce visits, and about 180 000 nursing home (frailcare) admissions. In addition, women with hip fractures have an increased mortality of 12 - 20 during the following 2 years, while more than half of all hip fracture survivors are

unable to return to independent living. However, Prof. Ian Reid of the Faculty of Medical and Health Sciences at the niversity of Auckland believes the risk is even higher. Writing in the autumn 2017 Royal Australian and ew ealand College of Obstetricians and Gynaecologists’ magazine O&G, he stated that more than 50 of postmenopausal women would have a fracture of some sort between the onset of menopause and death. As overall longevity increases, osteoporosis researchers generally predict a “dramatic increase” in the number of fractures among postmenopausal women. The question many researchers and healthcare providers are grappling with is

OSTEOPOROSIS TREATMENT ALGORITHM APP NOW AVAILABLE The American Association of Clinical Endocrinologists (AACE) has developed an algorithm and guideline app which provides evidencebased information about the diagnosis, evaluation, and treatment of postmenopausal osteoporosis for endocrinologists, physicians in general, regulatory bodies, healthrelated organisations and members of the public. Aimed at reducing the risk of osteoporosisrelated fractures, it can be downloaded free of charge from app stores.

QUO VADIS HORMONE REPLACEMENT THERAPY? Even though hormone replacement therapy (HRT) – either oestrogen alone or in combination with progestin – slows bone turnover and increases bone mineral density (BMD), reducing fracture risk of postmenopausal women by 20 - 35 , this treatment regimen is generally avoided. In their 2016 paper Postmenopausal osteoporosis and its therapies’, Drs Chattopadhyay and D K Sharma of the Central Drug Research Institute in ucknow, India, state that studies had positively associated HRT with higher incidences of cardiovascular events, as well as endometrial and breast cancers. “As the overall risk outweighs the beneﬁt of HRT, this treatment regimen is generally avoided,” they said.

when and how best to treat osteoporosis. Prof. Reid noted that while the risk of osteoporosis was defined in terms of bone density in the 1990s, “more recent epidemiology studies have indicated that, while bone density is an important risk factor, clinical risk factors (such as age, weight, personal and family history of fractures, smoking, glucocorticoid use and falls) are also important.” This supports the ational Osteoporosis Foundation of South Africa ( OFSA) Guideline for the Diagnosis and Management of Osteoporosis. Published in 2010, this guideline states that a distinction should be made between the diagnosis of osteoporosis and the assessment of risk. In other words, a diagnosis of osteoporosis – which is based on t scores for bone mineral density (BMD) – does not necessarily indicate the immediate introduction of an intervention. The AACE concurs, noting that while low BMD is a major indicator of fracture risk, individual patients could sustain fractures at different BMD levels. Factors other than bone density, therefore, in uence fracture risk. It’s not surprising, therefore, that there is controversy about the type of intervention required. Most guidelines agree that patients with t scores of –2.5 should be treated, while those with scores above –1.0 should not. The question is what to do about those with t scores that fall between those numbers. In these instances, the OFSA guideline indicates that other factors should be considered – particularly those relating to the patient’s risk of fracture, based on the Fracture Risk Assessment Tool (FRA ) calculator, as well as the costs and efficacy of available treatments, which can range from non-drug, lifestyle measures to drug therapy. aunched by the niversity of Sheffield in 2008, the FRA tool is freely available and is used around the world for millions of fracture calculations every year.

PHARMACOLOGICAL INTERVENTIONS

According to Dr Harold Rosen, author of an pToDate paper, “Osteoporosis prevention and treatment”, the medications that are most widely used to treat postmenopausal osteoporosis, because of their efﬁcacy, affordability and long-term

safety, are oral bisphosphonates such as alendronate and risedronate. These have been shown to reduce the risk of both vertebral and hip fractures. Once-daily or once-weekly regimens are available. Patients must be encouraged to follow the precise dosing instructions, to ensure that the drugs are properly absorbed, and also to reduce the risk of side-effects and potential complications. Other bisphosphonate options include oral or injectable ibandronate, which reduces the risk of bone loss and spine fractures – but has not been shown to reduce the risk of hip fractures and a once-yearly intravenous dose of zoledronic acid, which not only improves bone density and reduces the risk of spine and hip fractures, but has also been shown to decrease the risk of recurrent fractures in high-risk patients. It is often prescribed for women with contraindications or intolerance to oral bisphosphonates. Most people who take bisphosphonates, however, do not have any serious side-effects, but caution is required in people who have invasive dental work. Other pharmacological options include: ¾ “Oestrogen-like” medications: These are selective oestrogen-receptor modulators such as raloxifene and tamoxifen that provide protection against postmenopausal bone loss. ¾ Oestrogen-progestin therapy: While the Women’s Health Initiative (WHI), a large clinical trial, found that combined oestrogen-progestin as well as oestrogenonly treatments reduced hip and vertebral fracture risk by 34 , the WHI also found that oestrogen slightly increases the risk of breast cancer, stroke and blood clots. evertheless, some postmenopausal women with persistent menopausal symptoms continue to use oestrogen. ¾ Denosumab: Denosumab is an antibody that improves bone mineral density and reduces fracture risk in postmenopausal women with osteoporosis. A newer drug with no long-term safety data, it should not be given to patients with low blood calcium. ¾ Parathyroid hormone: The only medication that works by stimulating bone formation, clinical trials suggest that it could be effective in both the prevention and

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Feature | 19

treatment of osteoporosis. However, it is expensive and requires administration via daily injection.

BONE-HEALTHY LIFESTYLE

Apart from necessary pharmacological interventions, most researchers agree that lifestyle modiﬁcations may improve musculoskeletal integrity and balance, preserve bone strength and prevent future fractures. According to the 2016 AACE clinical practice guidelines (CPGs) on postmenopausal osteoporosis, a bonehealthy lifestyle includes “an adequate intake of calcium and vitamin D”, along with regular exercise to improve strength and balance, no smoking and limited alcohol consumption. However, this is not as straightforward as it seems, particularly when it comes to calcium and vitamin D. Calcium supplementation may slightly increase BMD, and a recent metadata analysis indicated a 15 reduced risk of total fractures. However, ew ealand’s Prof. Reid claims that “there is scant evidence that calcium intake in uences fracture risk, and it is not included in any of the major fracture risk calculators.” Prof Reid also said that there was some suggestion that calcium may even increase hip-fracture risk. In addition, “calcium supplements commonly cause gastrointestinal side-effects, increase the risk of kidney stones and may increase cardiovascular risk, though this remains subject to controversy. In the absence of evidence of fracture prevention, there seems to be little indication for their general use in the postmenopausal population,” he concluded. The AACE CPGs document also refers to the controversy around the cardiovascular risk among calcium supplement users, and concludes that dietary calcium (from dairy products and other calcium-rich foods) is preferred over supplemental calcium. The recommended level is 1 500 mg per day, as calcium intake beyond that level could be harmful. Which brings us to vitamin D. According to the AACE guidelines, vitamin D plays “a major role in calcium absorption and bone health, and may be important in

muscle performance, balance and falling risk and may enhance the response to bisphosphonate (anti-osteoporosis) treatment, increase BMD and prevent fractures”. The guideline authors recommend vitamin D supplementation to ensure an intake of between 1 000 and 4 000 I of vitamin D per day (for people over 50), because of the limited food products that contain sufficient vitamin D. Prof. Reid, however, warns that high levels of vitamin D could potentially increase the risk of fractures and falls, while severe vitamin D deficiency could result in osteomalacia. evertheless, he says, vitamin D is “critical for normal bone mineralisation”, and recommends supplementation of 400 I per day for those not receiving regular exposure to sunlight, such as frail, elderly and veiled women. What about other supplements such as magnesium, vitamins A and K, and so-called “natural oestrogens” The AACE guidelines note that while many people appear to believe that magnesium is necessary to reduce fracture risk, because magnesium is required for adequate calcium absorption, magnesium supplementation does not increase BMD. In addition, there is no evidence that adding magnesium to calcium tablets increases the absorption of calcium. Vitamin A – if taken in excess – has been shown to have a negative effect on bone. However, the jury is still out on vitamin K. While some studies have indicated that vitamin K may reduce bone turnover and loss in postmenopausal women, other studies have failed to replicate these findings. As for iso avones – natural oestrogens – the AACE guideline authors state that although these are widely promoted for preventing bone loss and decreasing fracture risk, “there is no conclusive data” to support this. Three substances which should be avoided – or at least used in limited quantities – are caffeine, alcohol and tobacco. Some observational studies have indicated a link between the consumption of caffeinated drinks (more than two daily), and fractures.

RISK FACTORS FOR OSTEOPOROSIS AND/ OR OSTEOPOROTIC FRACTURES ¾ Alcohol (three or more drinks per day) ¾ Smoking ¾ ow calcium intake ¾ Inadequate physical activity ¾ Immobilisation ¾ Vitamin D insufficiency ¾ ow body mass (BMI 20) ¾ Malnutrition ¾ Falling ¾ High salt intake ¾ High caffeine intake ¾ Excessive exercise ¾ Excess vitamin A ¾ Vitamin C, K, B and B deficiencies ¾ Trace-element deficiencies 6

Source:

OFSA Guideline for

Diagnosis and Management of Osteoporosis (2010).

“

Exercise ... is especially important as it is an inexpensive approach that is available to most people

Meanwhile, excessive consumption of alcohol (three or more drinks a day, where one drink equals 120 ml wine, 260 ml beer or 30 ml liquor) is also associated with increased fracture risk. This is not only because of alcohol’s negative effect on bone formation, calcium deﬁciency and chronic liver disease (which in turn predisposes individuals to vitamin D deﬁciency), but also because alcohol consumption increases one’s risk of falling. In addition, there have been numerous studies that clearly indicate that cigarette smoking increases osteoporotic fractures.

EXERCISE

BREASTFEEDING LINK TO OSTEOPOROSIS? A study involving 1 231 Korean postmenopausal women published in Osteoporosis International in April 2016 indicates a potential link between prolonged breast-feeding and the development of postmenopausal osteoporosis in susceptible women. Susceptible women are defined as those with low calcium intakes and vitamin-D deficiencies. The study concludes that breastfeeding women should ensure that they have sufficient calcium intakes and adequate vitamin D levels.

Exercise is widely recommended as a nonpharmacological treatment for osteopenia and osteoporosis, although OFSA warns that excessive exercise, particularly coupled with poor energy and calcium intake, could result in bone loss. According to Dr Erna Bruwer, biokineticist and senior lecturer at orth West niversity’s High Performance Institute in Potchefstroom, exercise as a treatment modality is especially important as it is an inexpensive approach that is available to most people. It also has other physiological and psychological beneﬁts. She pointed out that exercise therapy, particularly resistance training and weightbearing activity, may increase BMD. It may also modify several risk factors for osteoporotic fractures, such as muscle strength, exibility and balance – important when one considers that an estimated 95 of hip fractures are due to falls. “Effective exercise interventions to increase the BMD are typically those that stress or mechanically load bones, for instance when bones support the weight of the body or when movement is resisted, for example, when doing weight training,” she said. In a 2011 systematic review to examine the effectiveness of exercise interventions in preventing bone loss and fractures in postmenopausal women, Howe et al. found that exercise slightly improved the BMD and slightly reduced the chances of having a fracture: Bone mineral density at the spine: ¾ Women who exercised had on average 0.85 less bone loss than those who did not exercise.

¾ Women who engaged in combinations of exercise types had on average 3.2 less bone loss than those who did not exercise. Bone mineral density at the hip: ¾ Women who exercised had on average 1.03 less bone loss than those who did not exercise. ¾ Women who engaged in strength training had on average 1.03 less bone loss. Fractures: ¾ 7 women out of 100 who exercised had a fracture. ¾ 11 women out of 100 who did not exercise had a fracture. Asked what type of and how much exercise should be undertaken, Dr Bruwer said the pain status of every individual with osteoporosis should be considered. If the woman was relatively pain free, she could follow the American College of Sports Medicine recommendations. These included: ¾ Aerobic weight-bearing activity such as walking, stair climbing, dancing and tennis (4 times weekly) ¾ Resistance training twice a week (muscle strength exercises – free weights, machines, calisthenics, elastic bands, yoga and Pilates) ¾ Flexibility exercises 5 - 7 times a week ¾ Balance and functional exercises, to improve activities of daily living. Exercises that include explosive movements and high-impact loading activities, such as jumping, running or jogging, should be avoided. However, Dr Bruwer said that there were recent studies that indicated an increase in BMD with high-impact exercise. In addition, osteoporosis patients need to understand the mechanical load of their daily and sporting activities – for instance, activities requiring forward bending of the trunk along with twisting (such as golf or sit-ups) produce high compressive forces in the spinal area, and increase the risk of a fracture. Similarly, simply sitting and bending forward to pick up objects could also cause vertebral fracture.

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*IBS: Irritable Bowel Syndrome. **BGA: Brain-Gut Axis. References. 1. South African registered package insert for Librax® (12 June 1998). 2. Librax® product monograph. http://www.rxlist.com/librax-drug.htm. Accessed 30 June 2011. 3. Sullivan MA, et al. Colonic myoelectrical activity in irritable-bowel syndrome. Effect of eating and anticholinergics. N Engl J Med 1978; 298: 878-883. 4. Wayne HH. A tranquilizer-anticolinergic preparation in functional gastrointestinal disorders: A double-blind evaluation. Calif Med 1969; 111(2): 79-83. 5. Sprung DJ. Do anticholinergic medications really pose a higher risk for adverse effects in irritable bowel syndrome patients over the age of 65? A community based study. Gastroentorology 2011; 140(5):S-359. Librax®, B994 (Act 101/ 1965). Each tablet contains 5mg chlordiazepoxide & 2,5mg of clidinium bromide. For full prescribing information refer the package insert approved by the medicines regulatory authority, 12 June 1998. MEDA Pharma South Africa (PTY) Ltd. Co. Reg.: 2010/000051/07. Suite #166, Private bag X9976, Sandton, 2146, South Africa. Toll free line: 0800 6332 72 (MEDA SA). E-mail: info@medapharma.co.za ZA.LIB.17.03.359.

THE STATIN STORY – SEPARATING FACT FROM FICTION A host of “alternative medicine” websites oppose the use of cholesterol-lowering statins to treat cardiovascular disease, whether by claiming that they are at best useless and at worst dangerous, or by questioning the entire cholesterol-cardiovascular disease link. However, numerous studies have shown that statins do in fact lower “bad” cholesterol and treat cardiovascular disease. By Marilyn de Villiers HEA LTHCARE GAZET T E | MAY/JUN E 2 0 1 7

TATI S – THE GO-TO DR G for the lowering of “bad” low-density lipoprotein ( D ) cholesterol in order to reduce the risk of atherosclerotic cardiovascular disease – have been receiving an increasingly bad rap over the years. This is driven by a host of radical “alternative medicine” proponents such as S-based osteopathic physician and web entrepreneur, Joseph Mercola, a leader of the anti-immunisation lobby, an opponent of uoridation and mammography and a ﬁerce critic of what has become known as “big pharma” and the S Federal Drug Administration. There is also a growing clamour that goes further – not only claiming that treatments such as statins are “useless” at best, or downright dangerous, but also questioning the validity of the very science behind

treatments such as statins by dismissing the whole cholesterol-cardiovascular disease link. Mercola operates one of the internet’s largest and most visited “natural health” information websites, mercola.com, which, he has claimed, is visited by “millions of people each day”. Well over one million individuals are said to subscribe to his electronic newsletter. The fact that he also uses his website – and his pseudoscientiﬁc articles – to market a range of “health” supplements and devices does not seem to concern his vast army of dedicated followers and defenders. Mercola’s website features dozens of anti-statin articles with headlines such as “5 Reasons Why You Should ot Take Statins”, “Statins’ Flawed Studies and False Advertising” and “How Statins Degenerate Your Brain Health”. These articles include throwaway lines such as “statin drugs are

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High D cholesterol caused by diet can lead to cardiovascular disease notorious for causing side-effects like muscle damage and weakness”, and “if you take statin drugs without taking Co 10 or the reduced form, ubiquinol, your health may be at serious risk”. Of course, you can buy a 30day of supply of Mercola-branded Co 10 on the website at a discounted price of 26.97 or a 30-day supply of ubiquinol for 21.97.

There are also dedicated anti-statin websites such as statinnation.net, which features articles authored by its founder, cholesterol sceptic and author Justin Smith, who directed and produced the 2012 British documentary, “Statin ation: The Great Cholesterol Cover- p”. The problem with these websites and articles is that they appear to be scholarly. They are invariably well-written and reference scientiﬁc papers that have been published in prestigious peer-reviewed journals. However, unless one takes the trouble to ﬁnd – and read – the referenced articles, it would not be apparent that their conclusions have invariably been misconstrued, quotes have been judiciously edited, and cautions that further research is required have been conveniently ignored. Statin and cholesterol sceptics received a boost last year when a systematic review of published literature carried out by researchers from the niversity of South Florida, the Japan Institute of Pharmacovigilance and various other international institutions in Japan, Sweden, K, Ireland, SA and Italy – and published in the peer-reviewed British Medical Journal Open – appeared to prove what its authors said were the “contradictions” to the “mainstream view which has been that an elevated level of total cholesterol (TC) is a primary cause of atherosclerosis and cardiovascular disease (CVD)”.

STARTLING SA STATISTICS ¾ Between 1997 and 2004, 195 people died per day because of some form of heart and blood vessel disease in SA ¾ About 33 people die in SA every day because of a heart attack, while about 60 die per day because of stroke ¾ About 5 million SA adults had high blood cholesterol levels in 2000 ¾ The rare inherited condition familial hypercholesterolaemia particularly occurs in the Afrikaans-speaking white community of SA, at a ratio of 1:72 ¾ Blood cholesterol levels vary considerably among the different SA population groups: People aged >30 years with blood cholesterol 5 mmol/L + Male

Female

Black African

24%

32%

White

90%

88%

Coloured

82%

80%

Indian

87%

77%

Source: Heart Disease in South Africa – media data document published by the Heart and Stroke Foundation of South Africa. Compiled by Krisela Steyn, Department of Medicine, niversity of Cape Town, and Chronic Diseases of ifestyle nit at the Medical Research Council, July 2007.

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Feature | 25

CHOLESTEROL-LOWERING MEDICATIONS Type

Generic name

Statins – high intensity Atorvastatin Rosuvastatin

How it works

Side-effects

¾ Decreases the body’s production of cholesterol lowers D levels ¾ owers triglycerides ¾ Slightly raises HD (good) cholesterol levels ¾ Reduces risk of plaque rupture

¾ ¾ ¾ ¾ ¾

Muscle ache and cramps Muscle in ammation Cataracts Fatigue Slightly increased risk of type 2 diabetes

¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾

Well tolerated Mild skin reaction at site of injection Flu-like symptoms Back pain Muscle or back pain Diarrhoea Abdominal pain ausea Bloating Cramping iver injury egative interactions with some medications – digoxin and warfarin Affect absorption of fat-soluble vitamins A, D, K and E Flushing of face and body Itching ausea umbness Tingling Can affect liver Can blunt reaction to insulin and nitroglycerin Can raise uric acid levels Muscle pain and weakness (particularly in combination with statins)

Statins – moderate intensity

Fluvastatin ovastatin Pitavastatin Pravastatin Simvastatin

PCSK9 inhibitors

Alirocumab Evolocumab

¾ owers D levels ¾ Reduces cardiovascular events such as heart attack

Cholesterol absorption inhibitors

Ezetimibe

¾ Impairs body’s ability to absorb cholesterol from food

Bile acid sequestrants

Cholestyramine Colesevelam Colestipol

¾ Attaches to bile from the liver, preventing it from being absorbed back into the blood. Bile is made largely from cholesterol, so these drugs whittle down the body’s supply of cholesterol

iacin (nicotinic acid)

Fibrates

iacin immediate release iacin extended release

¾ owers D cholesterol ¾ Raises HD cholesterol

Fenoﬁbrate Gemﬁbrozil

¾ owers triglyceride levels ¾ Raise HD levels

It may, or may not, be relevant that four of the authors of the study had previously written books that criticised “the cholesterol hypothesis”, and nine are members of The International etwork of Cholesterol Skeptics (THI CS). The review itself has been criticised for a number of shortcomings – several of which were acknowledged by the authors themselves. Cholesterol-sceptics and antistatin proponents will undoubtedly ignore even the authors’ own acknowledgements of the aws in their study.

¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾

evertheless, based on the dubious “science” of the dozens of Mercolas and Smiths proliferating across the internet, patients are increasingly questioning their doctors and healthcare professionals in general about recommended courses of treatment for potentially life-threatening conditions such as cardiovascular disease (CVD). So, what are the facts around CVD and cholesterol One fact is that between 1997 and 2004, 195 people died per day because of some form of CVD in SA, and premature deaths

“

Between 1997 and 2004, 195 people died per day because of some form of CVD in SA

A healthy diet and exercise can reduce your chances of cardiovascular disease

“

One relatively new treatment that is creating a great deal of interest and excitement is the use of PCSK9 inhibitors

caused by CVD in people of working age (35 - 64 years) are expected to increase by 41 between 2000 and 2030. A second fact is that there are dozens, if not hundreds, of scientiﬁc studies and reviews that clearly indicate a direct link between high cholesterol levels and heart disease. For example, a 2007 review involving nearly one million people and published in The Lancet concluded that “total cholesterol was positively associated with IHD (ischaemic heart disease) mortality”. This does not mean that every individual with high D cholesterol should be prescribed a cholesterol-lowering medication. A healthy lifestyle involving a healthy eating plan and regular physical activity is an essential part of managing high blood cholesterol levels. Often, however, lifestyle changes are not enough to bring D levels down to recommended targets. In those circumstances, medication is usually indicated. And statins, which have been used since the 1980s, are usually at the top of the list of options. The latest (2016) recommendations of the S Preventive Service Task Force ( SPSTF) regarding the primary prevention of CVD in adults include the use of low- to moderatedose statins in adults aged between 40 and 75 who do not have a history of CVD but who have one or more CVD risk factors including diabetes, hypertension, dyslipidaemia or smoking, as well as a calculated 10-year CVD event risk of 10 or more, and low- to moderate-dose statins to those with an event risk of 7.5 - 10 . ot surprisingly, these recommendations have raised the ire of the anti-statin lobby, who claim that they are aimed at turning healthy

individuals into patients in order to beneﬁt “big pharma”. In an article “Statins and the prevention of heart disease”, published in the Journal of the American Medical Association (JAMA) Cardiology, the AMA points out that statins are one of the “best-studied medications in randomised clinical trials”, and are “the most effective class of medication for the prevention and treatment of cardiovascular disease”. “Statins are remarkable drugs which are well tolerated by 90 - 95 of patients,” says Prof. Derick Raal, head of the Division of Endocrinology and Metabolism at the Charlotte Maxeke Johannesburg Academic Hospital and the Carbohydrate and ipid Metabolism Research nit in the niversity of the Witwatersrand’s School of Clinical Medicine. However, some individuals do suffer from statin side-effects, the most common of which is muscle pain. There is also some evidence of a link between statin use and the development of type 2 diabetes, but the general consensus seems to be that highcholesterol-induced CVD is a greater risk to a patient’s long-term health than diabetes. SPSTF found no substantive evidence of other commonly cited statin side-effects, such as myalgia and problems with cognitive functions such as memory impairment, Alzheimer’s disease or dementia. Prof. Raal also notes that not all patients with high cholesterol respond to statins. For patients who suffer from the rare genetic disorder familial hypercholesterolaemia (FH), who produce four times more cholesterol than “normal”, and whose cells may have deformed or no cholesterol receptors, statins don’t work. These patients may require a combination of medications. One relatively new treatment that is creating a great deal of interest and excitement is the use of PCSK9 inhibitors, which some studies have found to lower cholesterol levels by as much as 60 - 70 , compared to statins’ 30 - 50 . “ sed in combination with statins, PCSK9 – which has to be injected – offers a valuable addition to our cholesterol-lowering armoury, allowing many patients to get to levels that were previously unachievable,” Dr Raal concludes.

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The convenient pocket-sized design enables you to fit it comfortably into your hospital bag or coat pocket, so it The convenient pocket-sized design enables you to fit it comfortably into your hospital bag or coat pocket, so it can always be at hand for ready reference. South African Medicines Formulary (SAMF), a joint initiative of the can always be at hand for ready reference. South African Medicines Formulary (SAMF), a joint initiative of the University of Cape Town’s Division of Clinical Pharmacology and the Health and Medical Publishing Group, University of Cape Town’s Division of Clinical Pharmacology and the Health and Medical Publishing Group, publishers for the South African Medical Association, provides easy access to the latest, scientifically accurate publishers for the South African Medical Association, provides easy access to the latest, scientifically accurate information, including full drug profiles, clinical notes and special prescriber’s points. The thoroughly updated information, including full drug profiles, clinical notes and special prescriber’s points. The thoroughly updated 12th edition of SAMF is your essential reference to the rational, cost-effective and safe use of medicines. 12th edition of SAMF is your essential reference to the rational, cost-effective and safe use of medicines.

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INTERESTING DEVELOPMENTS IN EPILEPSY TREATMENT Epilepsy can be fatal, but until recently, the treatment options for the disease had barely advanced in 150 years. Lately, however, researchers are learning about the underlying mechanisms of the disease, in order to develop more efficient and effective treatments. By Marilyn de Villiers

“

Research ...could make surgery a more feasible option for patients

PI EPSY IS A COMP E , sometimes fatal neurological disorder. Although it is known to have existed for centuries, the exact mechanism of its main symptom, the epileptic seizure, remains poorly understood. It’s estimated that epilepsy affects about 50 million people worldwide. In Africa, the condition is believed to af ict around 10 million people, according to Dr Ebrahim Malick Samba, the former WHO regional director for Africa. Writing the foreword to the 2004 WHO publication Epilepsy in the WHO African Region: Bridging the Gap, Dr Samba noted that “if properly treated, up to 70 of people with this condition could live productive and fulﬁlling lives, free from seizures. Yet in developing countries up to 90 of the people who have this condition are excluded from care.” As is pointed out in the WHO publication, modern medicine ensures that most of the causes of symptomatic epilepsy can be greatly reduced by prevention and treatment. Most – but not all. According to the American Academy of eurology (AA ), only around 70 of

seizures are able to be controlled with modern medicines, diet, devices and/or surgery. Some people with epilepsy are at special risk for abnormally prolonged seizures or sudden unexplained death. An article published in September 2016 in ScienceDaily – “The worm’ holds the key to treating epilepsy” – about research undertaken at Florida Atlantic niversity was particularly harsh about the current state of epilepsy treatment. “Current methods to control epilepsy are not only inefficient but haven’t improved in more than 150 years, when the first anticonvulsant drug was developed. Treatment options include invasive surgeries and a combination of antiepileptic drugs that surprisingly don’t work in more than 30 of patients. oninvasive treatments are limited for easing symptoms In recent years, fewer and fewer drugs have been introduced most likely due to exhausted screening techniques and less-efficient methods for predicting drug effectiveness.” evertheless, the AA notes that “scientists are studying the underlying causes of the epilepsies in children, adults, and the elderly, as well as seizures that occur following brain trauma, stroke,

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Focus | 29

and brain tumours.” They are constantly looking for new and effective options for treatments, and testing new drugs, including cannabis (see sidebar). For example, ScienceDaily claims that researchers from Florida Atlantic niversity have opened the possibilities for rapid drug screens to treat seizures, by developing the smallest whole-animal electroconvulsive seizure model using a microscopic nematode worm. Other research is directed at gaining a better understanding of the underlying mechanisms involved in epilepsy to enable more effective treatments to be developed. Prof. Klaus ehnertz, head of the neurophysics group in the Department of Epileptology at the niversity of Bonn, Germany, is exploring “evolving epileptic brain networks”, to gain a better understanding of brain activity in epilepsy patients and the roles played by different regions of the brain. The group’s paper, “ ong-term variability of importance of brain regions in evolving epileptic brain networks”, was published in Chaos: An Interdisciplinary Journal of Nonlinear Science this year. The group’s work is particularly signiﬁcant because it shows that the seizure-generating area of the brain isn’t – as commonly believed – the most important node within a large-scale epileptic network. Meanwhile, research undertaken in the SA by Dr Joseph Madsen, director of epilepsy surgery at Boston Children’s Hospital, and Dr Eun-Hyoung Park, a computational biophysicist in the hospital’s department of neurosurgery, could make surgery a more feasible option for patients by pinpointing exactly where in the brain the seizures are coming from. As described in the 2 May 2017 online edition of the journal Neurosurgery, they are developing a computational approach that streamlines the seizure-monitoring process required for surgical planning. It could allow patients to be monitored in one short session, without the need to observe an actual seizure. This approach is not yet ready to be used clinically, but the researchers are optimistic that the advanced computer applications could help more

children with epilepsy to be treated with less risk and at lower cost. The importance of research of the type undertaken by Drs Madsen and Park is underlined by the findings of a study undertaken by the Institute of euroscience and Physiology, Department of Clinical euroscience and Rehabilitation at the Sahlgrenska Academy in Sweden, which showed that there are important, long-term gains to be had when surgical interventions against epilepsy are undertaken sooner rather than later. Anna Edelvik, researcher at Sahlgrenska Academy and senior physician on the Sahlgrenska niversity Hospital epilepsy team, studied and followed up on 500 patients and found that 58 of those who underwent surgery were seizure-free after 5 to 10 years, compared with 17 who had not undergone surgery. The longer the individuals had had epilepsy, the fewer were seizure-free in the long term. As promising as surgery may be for epilepsy sufferers, there appears to be widespread consensus that surgery is really only an alternative for those estimated 30 who do not respond well to more conservative treatment. But why do some individuals respond to medication, while others don’t A research study reported this year in the journal Annals of Neurology – “Pharmacogenetics of antiepileptic drug efficacy in childhood absence epilepsy” – provides some answers. A team led by Dr Tracy A Glauser, director of the Comprehensive Epilepsy Center at Cincinnati Children’s Hospital Medical Center and professor of paediatrics in the niversity of Cincinnati College of Medicine, investigated whether there was a genetic basis for different responses to three drugs (ethosuximide, valproic acid and lamotrigine) used for childhood absence epilepsy (CAE), the most common form of paediatric epilepsy. CAE is characterised by absence seizures, in which children stare into space, unaware of their surroundings. The results of the study suggested that knowledge of specific gene variants in children with CAE may help to predict what drugs would work best for them.

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CANNABIS AND EPILEPSY In 2014, the American Academy of eurology (AA ) called for more research on the use of “medical marijuana” for the treatment of various neurological disorders, as its use as a treatment option was “not supported by high-level medical research”. In April 2017, the AA ’s 69th annual meeting was informed about a dose-ranging, multicentre, randomised, double-blind, placebocontrolled clinical trial of liquid cannabidiol (CBD) – the non-psychotropic cannabis component – that had reduced the number of seizures experienced by 213 people with extremely difﬁcult-to-control epilepsy types (Dravet and ennoxGastaut syndromes) by 54 . The participants had taken CBD as an add-on to their usual treatment regimes. However, 12 participants stopped taking the drug due to side effects such as drowsiness, diarrhoea, tiredness, and decreased appetite.

FOCUS ON … ANTIBIOTICS “Instead of being the default treatment for a host of mild ailments – particularly coughs, colds, and uncomplicated diarrhoea – antibiotics must be considered life-saving medicines to be used when needed.” State of the World’s Antibiotics 2015 – Center for Disease, Dynamics, Economics & Policy. By Marilyn de Villiers

HERE IS GROWI G EVIDE CE from around the world that resistance to all ﬁrst-line and last-resort antibiotics is rising, as a direct result of antibiotic overuse. And it seems that SA GPs could be contributing to this, by prescribing antibiotics in situations where antibiotic treatment is not recommended. That’s according to a recent study, “Antibiotic prescription patterns of SA general medical practitioners for treatment of acute bronchitis”, led by B cube of the niversity of the Western Cape’s School of Public Health, Faculty of Community and Health Services, and published in the SA Medical Journal (SAMJ) in February 2017. This study found that while national and international guidelines for treating acute,

uncomplicated bacterial or viral bronchitis do not recommend the use of antibiotics, 52.9 of the 166 821 private medicalaid patients identified in the study were prescribed one. In addition, despite the fact that many studies have shown that there is little or no benefit in treating predominantly viral acute respiratory-tract infections with antibiotics, the cube study found that the antibiotic prescription rate for viral bronchitis events was significantly higher than for those of bacterial origin – 59.2 v. 53.6 . In contrast, antibiotics were prescribed for 52.7 of bronchitis events of unspecified or unknown origin. The authors suggest that reasons for poor compliance with the guidelines could be related to concerns about “maintaining

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Focus | 31

the doctor-patient relationship, patient expectations, and the fact that GPs are just used to prescribing antibiotics’”. Could this be why – according to the Washington-based Center for Disease, Dynamics, Economics Policy (CDEPP)’s publication, State of the World’s Antibiotics 2015 – antibiotic consumption in SA rose by a startling 219 between 2000 and 2010, compared with 66 in India, 68 in Brazil and the global average of around 30 Meanwhile, antibiotic consumption in most high-income countries levelled off or decreased during the same period. Despite this, the S Center for Disease Control and Prevention (CDC) estimates that antibiotic resistance is responsible for more than 2 million infections and 23 000 deaths each year in that country. A study by iu et al. in 2015 reported that pneumonia killed 935 000 children under the age of 5 years worldwide in 2013, and attributed this to ineffective antibiotic treatment. The SA cube study found that almost 72 of prescriptions for the treatment of bronchitis were for penicillins, cephalosporins and other beta-lactams (broad-spectrum antibiotics). According to CDDEP, common infections such as Escherichia coli (E. coli) and related bacteria have become resistant to newer third-generation cephalosporins. In subSaharan Africa, the prevalence of resistance to third-generation cephalosporins is as high as 47 . In SA, this is estimated to be around 19 , while E. coli resistance to uoroquinolone is around 28 . The incidence of other common antibiotic resistance in SA, highlighted in the CDDEP report, includes: ¾ Methicillin-resistant Staphylococcus aureus (MRSA), a bacterium that can cause a variety of problems ranging from skin infections and sepsis to pneumonia and bloodstream infections, constitutes just under 30 of S. aureus bacteria. ¾ Intermediate resistance in Streptococcus pneumoniae isolates to penicillin, and resistance of Haemophillis influenzae isolates to penicillin is 45 in some settings. ¾ Resistance in Shigella isolates to older antibiotics is 50 (but under 1 for new antibiotics).

¾ Among Klebsiella pneumoniae isolates, third-generation cephalosporin resistance is 32 , while uoroquinolone resistance is 30 . Some good news: laboratory surveillance data in SA show that from 2012 to 2014, vancomycin resistance among Enterococcus faecium isolates decreased from 25 to 7 . More good news from the CDDEP report is that for some antibiotics, resistance levels decrease with declining use, conserving and even recovering some antibiotic effectiveness. “Feasible, practicable interventions could contribute to maintaining antibiotic effectiveness,” the report states. The effectiveness of antibiotic stewardship programmes (ASPs) has been demonstrated at Groote Schuur Hospital in Cape Town. A recent study published in the SAMJ (February 2017) that examined the 4-year outcomes from the hospital’s antibiotic stewardship programme – from 2011 to 2015 – revealed a significant decline in total antibiotic consumption, from 1 046 defined daily doses/1 000 patient days, to 868, within 2 years. The lower rate was sustained for the following 2 years. Despite this lower consumption of antibiotics, particularly of intravenous antibiotics, which fell by some 25 - 30 , while oral antibiotic consumption remained relatively stable, mortality rates barely changed, and neither did 30-day readmission rates. The authors, led by Dr T H Boyles of the Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, concluded that: “This study confirms that the introduction of an ASP into a public sector hospital in SA is feasible, and can produce a sustained reduction in antibiotic consumption without compromising patient care realising a 40 reduction in direct antibiotic costs from the second year onwards, and a much smaller rise in the cost of laboratory tests despite an 8.6 increase in patient bed days from 2011 to 2015.” *The National Institute for Health and Care Excellence (NICE) guidelines and the SA Standard Treatment Guidelines and Essential Medicines List (SA STG/EML).

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THE CE TER FOR DISEASE, DY AMICS, ECO OMICS PO ICY (CDDEP) report proposes the development of national antibiotic policies around the following six key strategies: 1. Reduce the need for antibiotics through improved water, sanitation and immunisation. 2. Improve hospital infection control and antibiotic stewardship. 3. Change incentives that encourage antibiotic overuse and misuse to incentives that encourage antibiotic stewardship. 4. Reduce and eventually phase out antibiotic use in agriculture. 5. Educate and inform health professionals, policymakers and the public on sustainable antibiotic use. 6. Ensure political commitment to meet the threat of antibiotic resistance.

32 | End note

F BIOGRAPHY

Dr Bridget Farham is the editor of the SAMJ, editor of Quest – Science for South Africa and a consultant to the WHO Health Emergencies Programme. She is a medical doctor, who was a seabird biologist in a previous life, and is passionate about disseminating information, and science education. She enjoys writing about and debating “hot topics” in local and global affairs.

SURPLUS PEOPLE

IG RES FOR THE YEAR 2015 from the Refugee Agency ( HCR) showed that there were 65.3 million forcibly displaced people worldwide, 21.3 million refugees, 10 million stateless people and 107 100 refugees resettled in 2015. Of these, 53 come from three countries – Somalia, Afghanistan and Syria. The top hosting countries are Turkey, Pakistan, ebanon, the Islamic Republic of Iran, Ethiopia and Jordan. Europe takes in just 6 , the Americas 12 and Asia and the Pacific (which includes Australia) 14 . There is a stark figure in the HCR 2015 report – 33 972 people a day ee their homes because of con ict and persecution. Experts say that figures such as this haven’t been seen since World War II. The term “refugee” is misleading – most of these people are what are called internally displaced people (IDPs). These people are forced from their homes but have not left their countries – and in most cases cannot do so. Syria is the country that springs to mind when we think about forcibly displaced people generally. But Syrians make up only one-third of the world’s refugees. Closer to home there are three major humanitarian crises unfolding – South Sudan, Somalia and northern igeria. There are at least 1.9 million IDPs in each of South Sudan and northern igeria. In Somalia, there are 6 million people facing starvation. Across the Horn of Africa, there are around 40 million people at risk. The proximal cause of the suffering in Africa is famine. This is largely man-made, even though below-average rainfall has made local food production difficult. The crisis in northern igeria is due to 8 years of violent con ict, leading to widespread displacement and a desperate shortage of essential healthcare. This is part of the Chad Basin crisis, which affects some 17 million people. ikewise, in South Sudan and Somalia, the cause is military con ict disrupting food production and preventing the delivery of any

humanitarian assistance that is available. According to John Campbell, writing in The Conversation, 1 the situation is similar to the events that took place in Ethiopia in the early 1980s. Western governments failed to monitor and intervene in time to prevent or mitigate the famine. It was the global media event, Band Aid in 1984, that focused the attention of Western governments on the situation and the humanitarian assistance, when it arrived, was too little, too late. The causes of famine are complex, but include poor governance, inadequate planning, limited investment in development, ongoing violence and large-scale population displacement – and development assistance to Africa has declined since 1990, and is likely to decline further as the West focuses more on its own concerns. The extent of Western interest in Africa is focused on the ow of oil and other commodities. Along with this are determined efforts to stop illegal migrants and refugees from entering the west. If you think that resettling and aiding people is too expensive for western countries, look at what they are spending on keeping people out – SD21 billion for Trump’s wall between the S and Mexico and the E ’s E R2.5 billion to bottle up migrants in Africa to prevent them from reaching Europe. The current cost for humanitarian assistance for Africa is insigniﬁcant in comparison. What happened in 1980 is nothing in comparison to the scale of the current crisis – affecting an estimated 40 million people. Humanitarian assistance has come far too late and is too little – the E pledged only E R760 million to the Horn of Africa late last year, and smaller pledges were made by European states in February this year. The SA has not yet said what it will pledge in food aid. In the words of Desmond Tutu, “we live in a moral universe”, and what happens to others affects us all. et’s not forget these “surplus people”. 1. Campbell JR. Famine creeps in on Africa while the world’s media look elsewhere. The Conversation. https:// theconversation.com/famine-creeps-in-on-africa-whilethe-worlds-media-looks-elsewhere-76340

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