healthcare gazette
NOVEMBER/DECEMBER 2015 • ISSN 2078-9750
Natives grow paler waiting for the NHI White Paper
PG 6
New hope for early Alzheimer’s patients PG 18 20
32
FEATURE
Heartache of unhealthy lifestyles – what it costs us in lives
52
NEWS
Grim toll of kidney donor and dialysis machine shortages
57
FOCUS
Collaboration on Ebola vaccine changes R & D forever
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5 www.hmpg.co.za
RESEARCH
Digoxin – tried and tested?
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Contents | 03
Co nt ent s FEATURES
NEWS
06
Natives grow paler waiting for the NHI White Paper
29
Marketers of unhealthy foods exploit our ‘survival’ DNA
PROFILES
42 force
Glenda Gray: A formidable
RESEARCH
56
More evidence against antibacterial soaps
56
Atmospheric carbon dioxide concentrations and zinc deficiency
14
32
Rendering a dangerous healthcare ocean safer
Grim toll of kidney donor and dialysis machine shortages
45
Surfing the genome wave – Dr Craig Venter
FOCUS
18
34
New hope for early Alzheimer’s patients
Using cutting-edge science to tackle NCDs?
20
The heartache of unhealthy lifestyles – what it costs us in lives
36
High-tech exercise medicine boosts healthcare
38
Don’t measure who died and why – it’s confidential!
24
SA’s debilitating ‘diabesity’ pandemic threatens healthcare delivery
48
Surgeons bicker as penis recipient impregnates girlfriend
52
Collaboration on Ebola vaccine changes R & D forever
39
Is SA’s NHI ready for ‘health tourism’? – a cautionary tale
40
Gauteng’s negligence continues, major overhaul underway
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
57
58
Digoxin – tried and tested?
HPV vaccination and pregnancy outcomes
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HAS THE EXPERIENCE AND RESOURCES TO GIVE YOUR PRACTICE THE EDGE IT NEEDS
Ed’s Letter | 05
Ed’s Letter EDITOR Chris Bateman
C h r i s B at e m a n
CONTRIBUTORS Taryn Springhall, Anne Hahn & Bridget Farham SUB-EDITOR Diane de Kock
Dishing up some ‘lifestyle-gevaar’
T
he tsunami of
in what one American researcher calls
non-communicable
a ‘food swamp’ and are biologically
diseases (NCDs) which
wired to pay more attention to food
threaten to engulf our
than other things in our environment
hard-pressed, under-
and at the mercy of ubiquitous,
staffed and often dysfunctional public
cheap and aggressive marketing of
healthcare facilities has put the
unhealthy food items. Heave some
spotlight firmly on the sea of change
unhelpful cultural attitudes, fuelled by
needed in our lifestyles. We know
our horrific HIV/AIDS legacy, into the
what’s required across all income
world’s highest Gini coefficient, and fat
groups and geographical areas – but
suddenly becomes a fatal attraction,
it’s the harnessing of political will and
wrongly signalling physical and financial
the means of achieving this that will
wellbeing. A few innovative (private)
ultimately prove pivotal.
healthcare funders are on the money
This, the second-ever edition
(literally) when it comes to using
Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EDITOR-IN-CHIEF Janet Seggie EXECUTIVE EDITOR Bridget Farham MANAGING EDITOR Ingrid Nye TECHNICAL EDITORS Emma Buchanan, Paula van der Bijl PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens HEAD OF SALES AND MARKETING Diane Smith | +27 (0) 12 481 2069 | sales@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renee van der Ryst Azad Yusuf Benru de Jager Ladine van Heerden
of the Healthcare Gazette, carries
ubiquitous technology and behavioural
a raft of stories outlining what our
economics to ‘nudge’ people into
grossly unhealthy lifestyles cost us
appropriate exercise and nutrition;
individually and as a society – and
but they reach mostly the privileged
some of the more innovative solutions
few. Law-making takes time (we have a
being proposed. Take a look at the
batch around smoking and salt content,
numbers, which you’d think would spur
with others in the pipeline), so maybe
every activist and advocacy group,
it’s high time government tried making
government and the private sector into
some ‘white propaganda’ as all-
unified action; 70% of all South African
pervasive as killer fast-food marketing.
women and 45% of men (over 35) are
Speaking of legislation, we also
overweight or obese, while 12% of all
highlight clumsy law-making where the
Printed by Paarl Print
of us are either pre-diabetic or living
Health Department is taking on Home
Publisher website: www.hmpg.co.za
with full-blown diabetes. Premature
Affairs at the SA Law Commission,
deaths caused by heart and blood
ironically to enable us to continue
vessel diseases (CVDs) in those of
finding out just what South Africans
us of working age (35 - 64 years) are
are dying of, so we can craft and build
expected to increase by 41% between
interventions more effectively. It’s an
2000 and 2030. It’s all because we live
interesting old world! Enjoy.
CUSTOMER SERVICE & ONLINE SUPPORT Gertrude Fani | +27 (0)72 635 9825 | publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 | tshepisom@hmpg.co.za LAYOUT AND DESIGN Tenfour Media
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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Natives grow paler waiting for the NHI White Paper You know South Africa’s (SA’s) healthcare system is terminally ill when one medical scheme covers, in full, a claim of R16.5 million which represents one patient’s 20-day hospital stay.
T
By Marika Sboros and Chris Bateman he claim (which
date). In the vacuum, the NHI
Discovery Medical Scheme
detractors grow. Sceptics say just
paid) wasn’t for high-tech
untangling the complexities of hospital
(or any) surgery, smart
standards to apply the national Health
cancer drugs, stem cells,
Department’s draft regulations on
cloning, or anything one might expect
minimum standards across both
modern medicine’s practitioners to
private and public sectors will prove
dream up to justify such an exorbitant
nightmarish. Enforcing them equally
(some might call it obscene) bill. It was
would prove the ultimate litmus test.
for haemophilia, a rare, life-threatening condition in which the blood doesn’t clot properly. The claim’s financial blood-letting
landscape permanently and has fuelled
Here are the NHI fault lines …
One cannot wish away existing “fault
could have killed off a smaller scheme,
ongoing, even wild, speculation in
lines”, says Prof. Laetitia Rispel,
or seriously destabilised its risk pool. It
the media and healthcare fraternity.
University of the Witwatersrand’s newly
is more proof, if any were needed, that
It’s probably a little dog-eared in its
appointed head of Public Health.
SA’s healthcare system is a ‘sick-care’
nineteenth version, which Motsoaledi
Delivering her inaugural address on
system in urgent need of life-saving
doesn’t see as untoward. England
campus this September, Rispel says
intervention.
“have been annually fine-tuning theirs
these faults have mired the NHI in
Sceptics say just untangling the complexities of hospital standards to apply the national Health Department’s draft regulations on minimum standards across both private and public sectors will prove nightmarish National Health Insurance (NHI),
for the past 67 years”, he told the
controversy and effectively undermined
first mooted six years ago, could be the
Healthcare Gazette in an exclusive
“progressive and far-reaching
prescription. Whether it will be is crystal
pre-release interview.
health policies in SA, leadership and
ball stuff, despite the eternal optimism
Speaking on 5 October, Motsoaledi
management”. Among the yawning
of the government’s irrepressible
insisted he was “not pulling the
cracks Rispel identified:
National Health Minister Dr Aaron
wool over anyone’s eyes”. He was
• Corruption, and tolerance for
Motsoaledi – and the tantalising
“just waiting for the next available
ineptitude and leadership, management
White Paper on Universal Health
opportunity to brief cabinet – if they
and governance failures
Care Coverage he’s dangled before
call me I’ll go running” (consulting
• Lack of a fully functional district health
expectant stakeholders, only to snatch
a calendar with Healthcare Gazette
system, which is the main vehicle for the
it away again. The anxiously awaited
he picked out 20 October as the
delivery of primary healthcare
document will alter the healthcare
earliest available cabinet briefing
• The health workforce crisis.
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Feature | 07
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
There is also the vexed question of
driver of these “unusually high costs”
an NHI financial scaffold.
was because some haemophilia cases
Rispel pointed out that SA spends
require treatment with “an extremely
8.5% of its gross domestic product
high-cost medication, NovoSeven” (a
on healthcare – around R332 billion in
licence for Novo Nordisk to print money
monetary terms – but with half spent
if ever there were one).
in the private sector, catering for “the
High-cost medications are clearly
socioeconomic elite”. The remaining
a driver of healthcare crises globally.
84% of the population, who carry a far
Broomberg told us that Discovery
greater burden of disease, depend on
Health Medical Scheme data on
the under-resourced public sector,” she stressed.
Dr Jonathan Broomberg, CEO of Discovery Health
Many earlier gains and
cost and use of specialty, high-cost medicines showed a four-fold increase in the number of claimants since 2008,
improvements were compromised by
accuracy”. Instead of asking whether
with each patient costing in excess
an ineffective national response to the
SA could afford an NHI, the question
of R500 000 a year. “This is as much
country’s quadruple disease burden:
was “whether we can afford not to”,
as 80 times higher than the average
communicable disease (especially
Motsoaledi said.
cost of other claims for medicine,” he
HIV, AIDS and tuberculosis), non-
Prof. Ian Sanne, a specialist physician
said, “and Discovery Health Medical
communicable diseases (NCDs, also
and professor of internal medicine and
Scheme’s high-cost medicines spend
called chronic diseases of lifestyle, such
infectious disease at the University of the
reached R1.1 billion in 2014.” This
as obesity, hypertension and diabetes),
Witwatersrand, agreed, adding: “We
value was predicted to double in the
maternal, neonatal and child deaths, and
don’t have a choice. We can’t afford
next five years, especially considering
deaths from injuries and violence.
not to implement an NHI, and we have
current local and global trends, the
“Globally there was a significant shift in healthcare systems towards value-based reimbursement models that better align incentives for efficiency, effectiveness and quality of care” Broomberg At the Hospital Association of
to increase expenditure.” Where will
increasing NCD burden, and other
South Africa (HASA) late-September
that money come from? Speaking in
demand-side factors, Broomberg said.
conference, Motsoaledi reiterated
his personal capacity to the Healthcare
that he would be appointing a five-
Gazette, Sanne, who is also CEO and
say it could resolve disproportionate
person public/private National Health
director of the HIV NGO Right to Care,
cost-benefit ratios. So too could
Commission, headed by an expert
said expenditure on education for
the Competition Commission’s
academic with the President and himself
Services SETA (Sector Education and
comprehensive review of SA’s
second and third in command.
Training Authority) was leading to an ill-
healthcare system that began in 2012,
defined output. He would replace that
looking inter alia into “hospital and
with NHI funding.
specialist costs showing dramatic
It has become a cliché these days to talk of healthcare costs spiralling
increases which cannot be justified on economic grounds”. The Commission
He derided those who “want us to
into the stratosphere. That situation
also began a Market Inquiry into the
cost the NHI down to the last cent”,
will only worsen with time, even though
private healthcare sector in January
saying this futuristic speculation was
Discovery’s highest claim cost for
2014, to probe high prices in private
“an exercise in futility”. Nobody could
another patient in 2014 – R6.97 million
healthcare, the “general state of
have predicted that antiretroviral drugs
(also a haemophiliac who underwent
competition in this sector”, and to
for HIV/AIDS would drop from R314 per
12 months treatment) – appears (to the
see what can be done to achieve
person in 2009 to just R89 per person
healthcare ‘elite’) relatively cheap at
accessible, affordable, high-quality and
two years later. A decade ago, one HIV
the price. That worked out at just over
advanced private healthcare in SA. Final
positive patient costs R10 000 to treat
R583 000 a month, a doddle compared
recommendations and findings are
per annum; today it costs less than
with more than R800 000 a day for
expected towards the end of this year.
R1 000, he said. Every cost calculation
the originally cited 2010 R16-million
was based on “serious assumption – it
claim. According to Discovery Health
had been too much “fact-free” debate
cannot be done with any measure of
CEO Jonathan Broomberg, the main
about the drivers of high healthcare
Broomberg said historically there
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Photo: Chris Bateman
.
Not having an NHI is unaffordable – Motsoaledi
Fans of a workable, sustainable NHI
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Minister of Health, Dr Aaron Motsoaledi
“Doctors seemed unwilling to accept that RWOPS was taking seasoned specialists and physicians away from vital mentoring and training responsibilities in the public sector to earn extra money in the private sector.” Motsoaledi costs. The inquiry would create “an
running private healthcare facilities
with all of this and put up something
objective and comprehensive evidence
once the highly controversial law was
that is sustainable.”
base” that would “allow informed
reproclaimed. “If you want a licence to
debate and discussion on the real
run a private hospital… do we just give
drivers of cost” and what could be done
you a licence, or do we put conditions?
about them.
We’ll give you a list of needs, if you want
Forever altering the healthcare landscape
to run this hospital – you can operate, for
“It will be like abolishing Bantustans and
example, if you immunise so many kids,
coming up with a new country; some
check so many children’s eyesight and
were not happy, but unfortunately that
hearing… screen them. You cannot just
has to happen.”
Motsoaledi’s White Paper lays out
open – we’ll say: ‘If you open here, these
specific conditions under which all new
are the services that are needed’.”
healthcare practices and facilities may
As profound as “abolishing Bantustans’’
Motsoaledi said there was not a
Citing the 2011-launched national schools healthcare programme aimed at 12 million learners, of all income
operate so that patients in desperate
single healthcare organisation that
levels – which he described as “one of
need of preventive and curative services
would not be deeply affected by the
the most important programmes in the
can finally access them. Motsoaledi said
White Paper, ranging from deeply
re-engineering of primary healthcare”
a Register of Needs in a reproclaimed
contested medical scheme rules to
– he said State health screening of
Certificate of Needs (CoN) law would be
the Board of Healthcare Funders (BHF)
28 000 children in the poorer quintiles
a pillar of any Universal Health Coverage
and the Health Professions Council
had shown that one-third had
dispensation. Admitting outright that
(HPCSA). “There will be no more
eyesight, hearing, speech or oral
the timeline for healthcare practitioners
papering of cracks in the wall like the
hygiene problems. “So what do I do?
to apply for a CoN was untenable in
Prescribed Minimum Benefits war
I have to seek out audiologists, speech
the recently withdrawn, poorly scripted
around Regulation 8 (pricing of medical
therapists and optometrists – and the
legislation, Motsoaledi said specific
services). “That was zama-zama (try, try).
only way I can address this is to go to
conditions would be attached to
When we put in the NHI, it will do away
the private sector.”
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Feature | 11 For the CoN, he would need a
workers’ crisis, and the contention that
training advisory task team (increasing
well-defined Register of Needs by
doctors were leaving SA in droves.
bedside experience to supplement
geographical area. His researchers
Motsoaledi said migration of doctors,
academic study) and was studying a
initially went “very deep to research
even between developing countries,
report by the deans of medical schools
and try and geographically map the
was a global phenomenon. The South
on remunerative work outside the Public
availability of healthcare in KwaZulu-
African Development Countries (SADC)
Service (RWOPS). “When I compare
Natal (a pilot probe)”. They found, via
had agreed not to poach healthcare
myself with some of the newly qualified
‘geo-informatics’ that this province’s
workers from one another, yet an influx
medical interns, I believe I was better
healthcare provision, with the exception
of neighbouring country doctors into SA
trained,” he added.
of Pietermaritzburg (the capital) lay
continued. When his SADC healthcare
almost entirely along the coast. “If you
partners complain that SA is a major
map clinics and other facilities, surgeons,
culprit, Motsoaledi’s response is to
gynaes, paediatricians – they’re all sitting
advise them to “speak to the private
along the coast. There’s nothing in the
sector; that’s where most of them go”.
middle; how do you provide universal health coverage to people away from the coast, especially if you don’t sit down with healthcare providers, whether
Healthcare workers – nowhere to run to on NHI
RWOPS abuse a big deal – Motsoaledi He said doctors seemed unwilling to accept that RWOPS was taking seasoned specialists and physicians away from vital mentoring and training responsibilities in the public sector to earn extra money in the private
Addressing concerns that doctors,
sector. “They are abandoning medical
uncertain and insecure in the six-year
students,” he charged, repeating a
fundamental features of our healthcare
vacuum since an NHI was first mooted,
theme he has raised repeatedly, and
system that need intervention: the fee-for-
Motsoaledi said they would “vote
which his provincial counterparts have
service payment system and fragmented
with their feet”. The United Nations
been probing, even threatening criminal
silo-structure in which doctors, hospitals
General Assembly had long adopted
charges. When asked to respond to
and all other providers work. “Numerous
universal health coverage as the most
the same healthcare survey which found
studies in the USA and elsewhere show
effective tool to deliver more equitable
that 81% of doctors had yet to take
clearly that these features not only
healthcare to more people. “So when
the necessary steps to ensure ease of
add to costs, but may compromise
those youngsters I spoke to in 2009 told
integration into the new NHI model
patient experience and quality of care.
me that the moment I implement an NHI
(once implemented) Motsoaledi shot
Globally there is a significant shift in
they’ll pack their bags and go… I said,
back: “It’s all in their minds – the White
healthcare systems towards value-based
and still say, to them: There’s no place to
Paper is not out yet”.
reimbursement models that better align
run to, everyone is doing it!”
private or public?” Broomberg highlights other
incentives for efficiency, effectiveness
Sanne agreed that migration
Sanne said that there was recognition within the healthcare
and quality of care. This includes a
of medical personnel was a global
sector that the population in SA had
big shift away from fee for service
phenomenon, adding that he believed
doubled in last 20 years, yet the output
reimbursement towards other payment
the issue in SA had been “blown
of training institutions in the healthcare
models, such as capitation, fixed fees
out of proportion”. Of doctors in his
sector had remained stable. “Part of the
and other risk-sharing contracts with
medical school class, more than 50%
revitalisation of healthcare in SA includes
healthcare providers.”
were practising outside the country:
plans for medical, nursing and pharmacy
“It’s ongoing, my own organisation is
schools to increase, if not double their
attracting qualified doctors back, and
output,” he said.
Pay doctors for cost-efficiency – Broomberg
“Claims data from Discovery Health
overall I do not believe this (exodus) is due to NHI.” A 2014 survey of 500 SA doctors,
Turning to the rising tide of NCDs or diseases of lifestyle, Motsoaledi said if the Council for Medical Schemes
Medical Scheme shows significant
which showed a confidence level of
(CMS) told him a nationwide response
opportunity to increase remuneration for
43% in the future of the healthcare
was needed to the ever-escalating costs
healthcare professionals by improving
system over the next five years, singled
of hypertension he would “go to the
quality of care and patient outcomes
out doctor and nurse training and
root of the problem”, not build more
and eliminating some associated spend
moonlighting by State-employed
hospitals. In this vein, he warned the
in control of the treating doctor,”
specialists as major issues. Asked for
tobacco industry that SA’s reputation
Broomberg said.
a response, Motsoaledi said he was
for strong anti-smoking laws was about
working with the vice-chancellors of
to be significantly enhanced via further
several universities to form a nurse
legislation. He said the World Health
Another perennial debate at medical conferences is the health
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
health ministers were invited, that a concept known as leap frogging, which takes full advantage of speedily evolving technology, would enable implementation of NHI schemes in developing countries. “It might have taken 100 years to lay underwater communication cables in Europe and more than that to reach every single household, but cellphones arrived and simply leap-frogged that.” The use of technology, changing business models (something Motsoaledi suspected spoke “very loudly” to his HASA-delegate audience) and behaviour change Prof. Laetitia Rispel, head of Public Health at the University of the Witwatersrand
were essential requirements for “leapfrogging”, but speed, and doing things
Organization (WHO) had warned this
the fee-for-service payment system and
April that the global tidal wave of NCDs
the fragmented silo-structure in which
would render any health minister who
doctors, hospitals and all other providers
did not take drastic steps “incapable of
work,” Broomberg said. Numerous
presenting a credible health budget’’.
studies in the USA and elsewhere
on a mass scale were vital.
NHI critical – so keep faith and be accountable
had clearly shown that these features
In concluding her inaugural address,
not only added to costs, but could
Rispel said she had painted a bleak
compromise the patient experience and
picture of the SA health system,
the quality of care. Globally there was
and fault lines seemed more like
a significant shift in healthcare systems
huge cracks requiring radical
CM
Broomberg remains upbeat about
towards value-based reimbursement
treatment. However, these were “not
MY
both the NHI and the future of open
models that better align incentives for
an inevitability”. A “metaphorical
medical schemes. “SA faces a number
efficiency, effectiveness and quality
repair” of fault lines would ensure
of challenges in rising healthcare
of care, he says. “This includes a
success of the proposed NHI system.
costs, which we share with most global
big shift away from fee-for-service
This would require “political will,
healthcare systems,” he observed.
reimbursement towards other payment
leadership and stewardship at all
“Increasing costs are driven by a
models, such as capitation, fixed fees
levels, meritocratic appointments of
combination of supply- and demand-
and other risk-sharing contracts with
public service managers with the right
side factors.” Demand-side factors
healthcare providers. “Claims data
skills, competencies, ethics and value
included the volume of healthcare
from Discovery Health Medical Scheme
systems, effective governance at all
services consumed each year, including
show there is a significant opportunity
levels of the health system to enforce
an ageing insured population, as well as
to increase remuneration for healthcare
laws, appropriate management
the rapid increase in chronic diseases of
professionals by improving the quality
systems, and citizen involvement
lifestyle. “This growing demand typically
of care and patient outcomes and
and advocacy to hold public officials
adds an additional 4-5% each year to
eliminating some of the associated
accountable”. Existing evidence
healthcare inflation, over and above any
spend that is in the control of the
suggested that a high-performing
increases in tariffs charged by healthcare
treating doctor,” Broomberg said.
public health sector was “one of
Discovery confident about strong open medical schemes
professionals and other providers,” Broomberg said. Supply factors referred to issues such as the number of healthcare professionals, hospitals and other service providers, how these are
Technologically “leap frogging” the staff shortage crisis
the most redistributive mechanisms to reduce health inequalities”, Rispel said. Change in the status quo was “not optional, but a critical necessity”,
Earlier this year, World Bank president
and NHI-envisaged reforms provided
cost and rapid entry of new medicines
Dr Jim Yong Kim told the World
“exciting opportunities for health system
and technologies. “Our healthcare
Economic Forum in Davos, Switzerland,
change in SA, rarely available in most
system has two fundamental features,
where Motsoaledi and five other global
countries”.
organised and paid, as well as the high
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
C
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CMY
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DISPENSING SHORT COURSE IN DISPENSING FOR DOCTORS (DISTANCE) This course is based on the recommended standard for the dispensing course for prescribers in terms of Act 101 of 1965 as amended, which was developed by the South African Pharmacy Council, in consultation with the other statutory health councils. Licensing with the relevant authority as a ‘Dispensing Health Care Professional’ can only take place once the certificate is awarded. The Dispensing Course is available through the Foundation for Professional Development (FPD) in association with the Health Science Academy. ASSESSMENT
COURSE OBJECTIVES To enable health professionals to dispense and ensure the quality use of medicines prescribed to the patient. At the end of the course the participants will be able to: • Identify and apply ethical, legal and therapeutic considerations in all facets of dispensing. • Evaluate prescription and assess patient profile. • Dispense the prescription. • Manage the procurement and storage of medicines. • Advise patients to ensure quality use of medicines and improve health status. CERTIFICATION
Participants will be assessed through: • Portfolio of evidence • Written questionnaire • Dispensing Practical Exam - scheduled on a specific date
Successful participants will receive a Course Certificate of Completion from the Health Science Academy should they successfully complete the assessment process. This certificate must then be submitted in terms of regulation 18 of Act 101 of 1965, as amended. The course is accredited through FPD for 30 CPD points.s
COURSE STRUCTURE
COURSE FEE
The Dispensing course leads to a certificate of completion at a National Qualifications Framework (NQF) level 6. To obtain the certificate a minimum of 30 credits must be obtained. Each credit represents about 10 notional learning hours. The course is taught through distance education, training workshops are provided on request.
R2 300 (Inclusive of all VAT and taxes where applicable) the course fee includes all study material, assessment, practical examination and certification.
ENTRANCE REQUIREMENTS All Medical Practitioners. STUDY MATERIAL Participants will receive a comprehensive ‘resource guide’ covering all the study units and annexure containing ‘additional’ information which may be required. You will also receive an ‘assessment documentation guide’, consisting of learning activities, multiple choice and short questions that need to be completed.
A member of SAIHCM
The practical examination will be scheduled on a specific day, participants will be notified about the date, venue and time. A minimum group of 20 participants will be needed to schedule a practical examination. Study material will be posted as soon as full payment has been received. REGISTRATION TSHEPO GAOFETOGE Tel: 012 816 9100 Fax: 086 567 0340 Email: tshepog@foundation.co.za Address: P.O. Box 75324, Lynnwood Ridge, 0040 Website: www.foundation.co.za
Foundation for Professional Development (Pty) Ltd, Registration number 2000/002641/07 Registered with the Department of Education as a Private Institution of Higher Education under the higher education act, 1997. Registration number 2002/HE07/013 H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
A member of the SAMA Group
Rendering a dangerous healthcare ocean safer Take a tidal wave of patients, a trickle of specialists and a small shoal of medical students eager to palpate, probe and prick (at the very least) and mix them together in the public sector sea for several consecutive years. No CPD points for guessing the range of adverse events that can, and will, inevitably follow.
T
By Chris Bateman he reality is that
don’t regularly call on specialists
to encounter, let alone perfect. The
these ongoing ratios
to teach and supervise certain
UCT/GSH academic complex takes a
cost provincial health
procedures – that’s still a pragmatic,
Pan-African view on skills development,
authorities billions of
but now lower-impact, necessity.
and the versatile laboratory (all bulk
rand in litigation pay-
outs every year, never mind – in a best-case professional scenario – a
An 11-year journey…
equipment on wheels to enable 15-minute, discipline-specific set-up) buzzes with French, Dutch and English
Begun in 2004, the Clinical Skills
accents (the majority of African origin),
of overworked and under-supervised
Centre has grown exponentially via
testimony to the global ubiquity of
doctors and nurses.
progressive budgeting and tailored
medical training.
debilitating knock to the confidence
Yet one single, carefully considered
specialist equipment-company funding.
When it comes to undergraduate
cross-disciplinary intervention that
Today it has a simulation laboratory
correctly trains under- and post-graduate
with traditional simulation equipment,
to build skills longitudinally. Take
medical professionals – without
a ‘patient-less’ simulated ward and a
Emergency Medicine training for
harming anyone or repeatedly invading
health and rehabilitation laboratory – all
medical students; while first-year
the privacy of patients – is making a
organised according to functions, not
students do basic life support as taught
difference at Groote Schuur Hospital
disciplines – in what Weiss describes as
to lay people, third-years progress
(GSH), and far wider afield.
“an important ideological step towards
to intermediate life support using a
programmes, simulation is scaffolded
The University of Cape Town
integrated, multidisciplinary training”.
bag-mask device and automated and
(UCT)’s public and privately funded
A generalist who has swum the seas of
manual defibrillators. Fourth-years are
simulation hub, spread across three
public sector hospitals, private practice
taught how to intubate a patient during
spaces in the hospital, populated
and occupation medicine, Weiss has
resuscitation and to work with different
with high- and low-fidelity manikins
helped source private sector funding
kinds of drugs (e.g. cardiac resuscitation
and equipment, and staffed by
for two young anaesthesiologists
drugs) and advanced treatment
several full- and part-time experts
who have a passion for developing
algorythms, building skill toward difficult
(both generalist and specialist) is an
simulation-based education. Today
intubations and IV access (central and
enviable hybrid teaching model. Dr
this journalist is watching post-grad
other forms of vascular access). By fifth
Rachel Weiss, director of the UCT
students acquire endoscopy skills,
year they’re pacing and ‘cardioverting’
Clinical Skills Centre and an expert
guiding instruments past life-like
patients with deadly slow and fast heart
in curriculum design and education,
swollen airways, down burnt throats and
rates. “We also teach the so-called ‘soft
puts it succinctly: “Here you can give
past tumours, not to mention doing a
skills’: how to work as a team around
standardised teaching to everyone,
needle cricothyroidotomy (aka ‘crike’ or
a bed, function as a team leader and
without harming patients or imposing
emergency airway procedure) – basically
communicate effectively in high stress
a major teaching burden on busy
a range of airway problems that in a
environments, so by sixth year they are
specialists”. That’s not to say they
clinical patient setting might take years
able to run a full resuscitation scenario
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Feature | 15
Anaesthesiologist, Dr Andrie Alberts, leads colleague Dr Ulla Plenge through a procedure
Anaesthesiologists and UCT Simultation Lab instructors, Dr Rowan Duys (left) and Dr Ross Hofmeyr, flank registrar Dr Lara Veronese, as she practices a procedure H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
by themselves, taking responsibility for
blood cultures or learn how to create a
manageable conditions (mild cardiac
keeping somebody alive until more
sterile field while suturing.” It is not only
failure or hypertension) to simulate
competence arrives.” Weiss says she
the patient who is at risk in a hospital;
situations and help teach medical
had to learn all this on the job 30 years
healthcare workers have a high risk of
students how to communicate by
ago; “today these guys learn it all
contracting TB from infected patients
giving them feedback. Weiss says the
right here”.
or blood-borne diseases such as HIV
more junior the doctor, “the more
and hepatitis during needle stick
they tend to palpate the patient’s liver
injuries. The Centre fits and supplies
repeatedly to learn” – not ideal for
every student with TB respirators in
tertiary in-patients lying vulnerably in
the wards and works with activism
a ward. “We did a study in 2011 and
lab is an expensive (but ultimately cost-
group TB PROOF to break the silence
found that patients are completely
effective) exercise; an advanced life
around occupational TB. A partnership
disempowered. They sometimes get
support casualty manikin costs R140 000
with Becton Dickenson, manufacturers
students coming up to them five times
while the price tag for a programmable,
of safety needles, actively promotes
a day to practise on them – and they
wireless theatre manikin is close to
awareness and ensures that students
still say yes! Patients become de-
R1 million – “we wouldn’t let third-years
receive intense, small-group,
personalised. They also told us they
near him,” quips Weiss. The useful
supervised practicals with a range of
didn’t really want to be repeatedly
life-span of a manikin is five years, while
different safety devices. Simulation-
examined, but that they understood
all machines need constant calibration.
based training provides opportunities
students had to learn, which is quite
“People don’t always appreciate the
to standardise care; instead of ‘see
sad,” she adds. Her five-year plan is to
behind-the-scenes support required
one, do one, teach one’ in the ward,
secure about R200 000 per annum to
to run a simulation lab effectively and
students can, for example, insert inter-
appoint a coordinator who recruits and
cost-efficiently,” says Weiss. Opening a
costal drains on pork ribs or manikins
systematically trains a team of patient
door on a bank of built-in cupboards,
repeatedly until they get it right.
partners who can even be ‘shared’
she pulls out a small clear plastic box
Here’s where the real diamonds on the
across institutions and programmes,
Costly but hugely effective
Setting up and maintaining a simulation
Setting up and maintaining a simulation lab is an expensive (but ultimately cost-effective) exercise; an advanced life support ‘casualty’ manikin costs R140 000 while the price tag for a programmable, wireless ‘theatre’ manikin is close to R1 million – “we wouldn’t let third-years near him,” quips Weiss of equipment with its contents list
training sea-bed lie; simulation means
thus gradually creating programme
neatly taped on the lid – stock-taking
less risk to patients, students speedily
sustainability. She intends paying these
and student discipline here are non-
improving hand-to-eye coordination
patients, citing models used in the USA
negotiable, while recycling plays a major
skills, and more people taught in less
where payment is standard practice
part in keeping the consumables budget
time. “You can stop and correct errors
even though an ethic of volunteerism is
manageable.
and re-do things. We see them making
far more entrenched. “We have a lot of
a mistake and we stop that before
patients here who cannot work because
it gets ingrained. It’s optimal and
of their condition, so this would be job
project that is either currently adding
repeated practice. As a student you
creation and they’d replace the patients
major value to the teaching programme
may never get a chance to do this stuff
in the actual wards. Our in-hospital
or soon will be via cyber-reach believe
before your internship. Here you learn,
patients are really ill – so it’s actually a
in getting the basics right. “Patient
so that one day when you end up in a
human rights issue,” she adds.
safety is our first priority; for example,
deep rural hospital, people don’t die
to inculcate a lifelong respect for
from preventable errors.”
Weiss and her anaesthesiology colleagues, each of whom has a pet
infection control, second-year students start with hand-washing (a talk from an infection control nurse whose favourite trick is to put students’ hands under
Giving patients their humanity back
Dr Rowan Duys, an anaesthetist and recent Fellow in Simulation and Education (partially funded by Draeger, who also donated R10 million in medical equipment to the Centre), takes time off from leading a simulation to tell me
One of her dreams is to start a
that as far back as second year, he can
many bugs they’re carrying), while our
patient-partner programme, recruiting
remember wondering what the point
third-years prepare sterile trolleys for
a small group of jobless people with
was of learning to “look after the patient
a ‘glitter-bug’ light to show just how
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
in front of you when the system around you is broken”.
Anaesthesiologist applies his life lessons
Mitigation in a dysfunctional system
R30 000 grant they’re using in-house programming skills and a bank of cardiology electrocardiograms (ECGs)
His colleague Dr Ross Hofmeyr, the
to create an online learning platform
Storz Fellow in Airway and Thoracic
to plug a major learning gap – the
Anaesthesia (predominantly funded
interpretation of ECGs. “We got
What stuck from his internship at
by Stortz, manufacturers of endoscopy
complaints from people teaching sixth-
George Mukhari Hospital, north of
equipment), has tellingly similar
years, saying that students don’t retain
Pretoria, was “the amazing individual
motives: “If I’m a highly skilled
their third-year ECG interpretation
clinicians but a real lack of leadership
anaesthetist working in a dysfunctional
theory.” Online exercises now enable
and training”, while his community
system, my patients will get poor care,
students from third to sixth year to not
service at Hlabisa Hospital in northern
no matter how good I am! You can try
only interpret ECGs, but to assess their
KwaZulu-Natal helped hone his
and tackle that from a management
own knowledge levels. The programme
survival skills. Subsequent work in the
point of view or a political point of view,
allows Viljoen and Weiss to identify
NHS in the UK first exposed him to
but I want to tackle it from a training
where any individual or a cohort of
simulation training and taught him
and education angle,” he asserts. As far
students is struggling and respond
that minimum standards there were
as he knows, he and Duys are the only
appropriately. “It’s the perfect tool for
far better protected and that the UK
Cape Metropole consultants (across
cardiology registrars just before their
“holes in the net” for patient care
disciplines) taking up either part- or
exam – and the template is the same
were far smaller than locally. His more
full-time educational roles. Hofmeyr
whether you’re an undergraduate or a
recent registrar time here left him
says that while anaesthesia is generally
postgraduate student.” They’re busy
painfully aware of the stark differences
very safe, it has a zero tolerance for
with a quality assurance test, having
in skills levels between UK nurses and
adverse outcomes. “Nobody ever
recruited 15 interns from GSH and
their local counterparts – and the
got better because of anaesthesia –
surrounding hospitals for a pilot study
differences in training methodology.
everything we do places the patient at
which involves a pre-test exposure to
“Here you can give standardised teaching to everyone, without harming patients or imposing a major teaching burden on busy specialists” “I developed a real passion for
risk, yet there are low-frequency, high-
the online test, and a post-test. After
developing nursing education and
risk events which we don’t see often,
some software tweaks, it will be rolled
skills levels and finding innovative
but they have dire consequences.”
out to 600, fourth- to sixth-year UCT
ways to train people better,” he
It is here that simulation can avoid
medical students next year as part of
says, explaining a journey that led
things like anaphylaxis, malignant
Viljoen’s PhD research, and thereafter
him to approach Draeger to fund
hyperthermia, major haemorrhage
to a wider audience. She says that
his current post from August this
or difficult intubation. “You hardly
research studies both internationally
year. Nearly five years ago he began
ever get to practise these, but you’re
and locally suggest that “most doctors,
training a short course in anaesthesia
supposed to be good at managing
unless they are cardiologists, suck
to GSH (and other) nurses using the
them,” he adds. His ‘extra value-add’ to
at ECGs” and this bolstered her
simulation lab for scenario-based
the Clinical Skills Centre is developing
proposal and subsequent funding.
training. He believes simulation
a utilitarian e-learning platform for
“We concluded it was essential to have
and communications technology
nurses by creating and tailoring
some kind of method or platform for
are the greatest tools available in
modules on the internet, working with
ongoing ECG practice and feedback,
medical education. In simulation he
a Dutch university. Duys is developing
with modules tailored to the level of the
sees three major areas: technical
a similar algorithm-based e-learning
student – in diagnosing a third degree
skills, crew resource management
platform that can be adapted by any
block, for example, you could have easy
(team interaction, leadership and
medical student to his or her skills
or very difficult variations.”
communication skills), and systems
and knowledge levels. Weiss is no
testing and development, which can
slouch in this department either:
UCT’s world-class Clinical Skills Centre
lead to identifying a latent risk or
drawing on expertise and resources
will increasingly reverberate across the
adverse event during simulation that
from the Division of Cardiology, she’s
country and the continent, as medical
one can report as a real-time human
collaborating with a senior registrar,
professionals emerge more proficient
event – one of the more hidden
Charl Viljoen, who wants to super-
than ever before – with commensurate
life-saving benefits.
specialise in cardiology. With a small
huge savings in lives and money.
What is certain is that the effect of
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
New hope for early Alzheimer’s patients By Chris Bateman
S
cientists appear to
have broken a decadeslong deadlock in the battle against Alzheimer’s disease
Tests show 30% slower decline in memory
given at an earlier stage – something that might be expected given that it apparently had no effect for patients
However, when scientists analysed the
with more serious dementia. “It’s
data more closely, they found that in
entirely possible you’ll show an even
for the first-ever drug that appears to
the 1 300 patients with mild dementia,
bigger benefit if people are given
slow the pace of mental decline.
after announcing trial results
those who had been placed on the drug
solanezumab earlier on,” said Karran.
Says Dr Eric Karran, director of
showed a roughly 30% slower decline in
Scientists said the results also
research at Alzheimer’s Research UK:
memory and cognitive tests than those
support the idea that sticky plaques in
“This is the first evidence of something
who had taken a placebo during the
the brain – the most visible hallmark of
genuinely modifying the disease
18-month trial. This was a fairly small
the disease – are what causes mental
process by delaying cognitive decline
difference from the perspective of the
decline. The drug is an antibody that
in patients in the first stages of the
patients who had not yet suffered the
works by disassembling the building
disease. I think we’re on the verge of
devastating memory loss or profound
blocks that make up the plaques, slowly
a radical breakthrough”. He added
changes to personality that follow later.
causing them to disintegrate. Explained
that in the past 30 years there had
However, the result hinted that the drug
Karran: “What these results validate is
been more than 100 failed Alzheimer’s
could work as long as it was given early
that one of the common hypotheses we
drug trials, with only a few medicines
enough. Questions remained about
have for what causes Alzheimer’s, called
emerging to ease the symptoms of
whether the drug was simply treating
the amyloid cascade hypothesis… that
the disease, but nothing that slowed
the symptoms – improving a patient’s
this is probably correct. And what is
or halted it. “It’s a breakthrough in
mood or concentration – rather than
important about that is that we have a
my mind. The history of medicine
actually delaying the loss of neurons in
number of different mechanisms that
suggests that once you get through
the brain, which drives memory loss. So
are targeting this hypothesis that are
that door you can explore further
to test this, Eli Lilly switched the half of
in clinical development right now, and
therapeutic opportunities much more
the 1 300 patients who had been on the
it could well be that they will succeed
aggressively. It makes us less helpless.”
placebo on to the drug as well – and the
and we may be able to combine
entire group was given solanezumab
therapies later on and get even more
was shown to stave off memory loss
for a further two years. If the drug was
benefit for patients”. Until now, drugs
in patients with mild Alzheimer’s over
just treating the symptoms, the placebo
that targeted the plaques have not
the course of several years. The effects
group would be expected to catch up
appeared to have any effect, leading
would have been barely discernible
over time. The results, unveiled in July
some to question whether some other
to patients or their families, scientists
this year at the Alzheimer’s Association
biological process in Alzheimer’s was
said, and it is no cure. But the wider
International Conference in Washington
the real root of the disease.
implications of the results are hugely
DC, showed that the differences
significant because it is the first time
between the two groups were still
positive, it is likely to be several
any medicine has slowed the rate at
there – a sign that the drug had made
years before the drug would become
which the disease damages the brain.
a genuine impact on the progression of
available on Britain’s NHS – and
The drug, developed by the American
the disease.
further afield. Another phase-three
The drug, called solanezumab,
company Eli Lilly, had previously
“It deflected the course of the
Even if further trial results are
trial is due to report next year and
been tested in a larger group of
disease in an irrevocable manner,” said
patients with both mild and moderate
Karran, who previously worked for Eli
through regulatory approval and
dementia and this trial had appeared
Lilly. The company is now looking to see
be shown to be of sufficient benefit
to end in yet another failure in 2012.
whether the drug is more effective when
to patients.
then the drug would need to go
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Feature | 19
The wider implications of the results have been hailed as hugely significant because it is the first time any medicine has slowed the rate at which the disease damages the brain H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
The heartache of unhealthy lifestyles – what it costs us in lives Premature deaths caused by heart and blood vessel diseases in South Africans of working age (35 – 64 years) are expected to increase by 41% between 2000 and 2030, according to a review of research by Prof. Krisela Steyn of the University of Cape Town (UCT). By Chris Bateman
P
rof. Steyn, of UCT’s
of a heart attack, while about 60 per
Although most heart attacks, heart
Department of Medicine
day died because of a stroke. For every
failures and other chronic diseases
and a former director of the
woman that died of a heart attack,
usually only occurred in middle-aged
Chronic Diseases of Lifestyle
two men died, while about 37 people
and older people, the influences
(CDL) Unit at the Medical
died per day because of heart failure.
of risk factors could start before
Research Council (MRC), believes the
Despite the high death rates caused by
birth and have an effect throughout
negative economic effect of this will
AIDS in SA, the rate of chronic diseases,
life. Therefore, the processes for
be “enormous”. Her review shows that
including heart disease, was increasing
prevention and management of heart
the highest death rates for heart and
rapidly. No data existed on the number
disease “must start early and be
blood vessel diseases, or cardiovascular
of heart attacks or strokes that South
present throughout life”.
diseases (CVDs) in South Africa (SA) are
Africans suffered from daily. However,
She emphasised that in people
found in Indian people, followed by
there was a rule of thumb suggesting
who have several risk factors, the
coloured people, while white and black
that for one death caused by a heart
chance of suffering a heart attack grew
African people have the lowest rates.
attack or stroke, three persons would
exponentially with each additional
Although white and black Africans have
survive such an attack.
factor. This principle could be
similar rates for these diseases, their
Steyn said that research models
illustrated by considering a person
patterns differ considerably. White
suggested that chronic-disease
with three risk factors. The chance
people mainly reflect a pattern of death
deaths increased from 565 per
of suffering a heart attack did not
caused by heart attacks, while black
day in 2000 to 666 per day in 2010
increase by 3 + 3 + 3 = 9, but by 3
people reflect that of death caused by
– and were continuing to climb.
x 3 x 3 = 27, thus the risk increased
stroke, diseases of the heart muscle
More than half the deaths caused
exponentially with multiple risk factors.
and high blood pressure. Her research
by chronic diseases, including heart
To assess the true heart attack risk
review also reveals that between 1997
disease, occurred before the age of
level, the effect of all the risk factors
and 2004, 195 people died per day
65. These were premature deaths
present needed to be assessed. Such
in SA because of some form of CVD.
which affected the workforce and
absolute risk assessment considered
About 33 people died daily because
had a major effect on the economy.
the multiplication effect of risk factors
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Feature | 21
About 33 people died daily because of a heart attack, while about 60 per day died because of a stroke. For every woman that died of a heart attack, two men died, while about 37 people died per day because of heart failure. H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
to identify those who were at highest
Heart failure is caused by the
when the artery lumens appear normal
risk. This implied that the risk for a heart
inability of the heart to pump blood
attack in a person with modest levels
efficiently around the body. This occurs
of many risk factors could be higher
because of damage to the heart
diseases of the heart muscle. In
than that in a person who had only
muscle as a result of various diseases.
cardiomyopathy, the heart muscle
one risk factor at a very high level. The
Circulation becomes slow, causing
becomes enlarged or abnormally thick
known risk factors for a heart attack
excess fluid to be retained in the body.
or rigid, resulting in the inability of the
were present in all South Africans,
A stroke, also known as
on angiography. Cardiomyopathy refers to
heart to function as an effective pump
and effective prevention of heart
acerebrovascular accident (CVA),
disease should start early and continue
occurs when the blood flow to the
throughout life, targeting the entire
brain is interrupted. This could either
when the arteries that supply blood to
population. Every media opportunity
happen when a blood vessel to the
the heart muscle (the coronary arteries)
and regulation needed to be embraced
brain ruptures, causing bleeding, or
become hardened and narrowed,
to maintain healthy, lifelong lifestyles,
becomes blocked by a blood clot.
caused by a build-up of fatty deposits
while early detection of signs and
The affected brain cells then start
(atheroma) in the cells lining the wall
symptoms was vital to avoid serious
to die because of a lack of oxygen
of the coronary arteries. As these fatty
for blood to the body. Coronary artery disease occurs
The risk for a heart attack in a person with modest levels of many risk factors can be higher than that in a person who has only one risk factor at a very high level long-term complications. A full 75%
and other nutrients. The severity of a
deposits build-up gradually, the insides
of heart attacks or strokes occurred in
stroke varies from a passing weakness
of the coronary arteries get narrower
5 - 10% of people who had suffered a
or tingling in a limb to a profound
and less blood can flow through them.
previous event or had many risk factors.
paralysis, coma or death.
Eventually, blood flow to the heart
People should be motivated to seek an
Angina is chest pain or discomfort
muscle is significantly reduced, and,
absolute heart attack risk assessment,
that occurs when the heart muscle
because blood carries much-needed
which includes looking at a person’s
does not get enough blood. This may
oxygen, the heart muscle is not able to
age, gender, smoking status, blood
feel like pressure or a crushing pain
receive the amount of oxygen it needs.
pressure level, diabetes status and total
in the chest, which may also occur
This process leads to ischaemic heart
blood cholesterol level.
in the shoulders, arms, neck, jaw, or
disease, which causes damage to the
back. Angina is a symptom usually
heart muscle.
The many ways in which the heart (and brain) can suffer
CVD refers to any disease of the heart and blood vessels. The most common
aggravated by exercise and is caused
Rheumatic heart disease is
when insufficient blood reaches the
a condition in which permanent
heart muscle. This occurs when plaque
damage to heart valves between the
builds up in the arteries of the heart,
chambers of the heart occurs. The
and is called atherosclerosis.
heart valve is damaged by a disease
Atherosclerosis is a slow,
process called rheumatic fever that
involve the heart muscle, stroke, heart
progressive disease that may start in
begins with a throat infection caused
attack, heart failure and heart disease
childhood, and can eventually impede
by Streptococcus bacteria. These
caused by high blood pressure. A heart
the blood flow through the arteries of
malfunctioning heart valves eventually
attack is also known as a myocardial
the brain, heart, kidneys, and the arms
place stress on the heart muscle and
infarction (MI). When the diseased-
and legs. In the worst-case scenario
a person may require an operation to
roughened arteries of the heart become
the blood flow to these organs can be
replace the diseased heart valve.
too narrow or a clot forms, blood flow to
blocked off entirely.
the heart muscle is restricted. The heart
In ischaemic heart disease the
The Heart and Stroke Foundation,
muscle is left without oxygen, causing
coronary arteries supply blood to the
South Africa. Heart Disease in
death of a segment of the muscle
heart muscle and no alternative blood
SouthAfrica. Media data document
and leaving the heart unable to pump
supply exists, so a blockage in the
compiled by Professor Krisela Steyn,
sufficient blood to the rest of the body.
coronary arteries reduces the supply
Department of Medicine, University
Symptoms include sudden severe chest
of blood to the heart muscle. Most
ofCape Town & Chronic Diseases
pain which could spread down one or
ischaemic heart disease is caused by
of LifestyleUnit, Medical Research
both arms and to the neck.
atherosclerosis, usually present even
Council.Ed. Jean M Fourie, 2007.
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
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SA’s debilitating ‘diabesity’ pandemic threatens healthcare delivery With 12% of all South Africans either pre-diabetic or living with full-blown diabetes, and 70% of all women and 45% of men (over 35) overweight or obese,1 radical lifestyle changes, better prevention and earlier diagnoses are vital if our overburdened health system is to cope. By Chris Bateman
S
cientific estimates
Indian population in SA (11 - 13%),
much-reduced fertility and a growing
vary, but it’s safe to say that
as this group has a strong genetic
proportion of the population above
between two and three
predisposition for diabetes. This is
60 years. In parallel with unfolding
million South Africans
followed by 8 - 10% in the coloured
urbanisation, the population burden
are living with diabetes
community, 5 - 8% among blacks and
of vascular risk factors namely
4% among whites.
hypertension, hypercholesterolaemia,
and at least another five million are pre-diabetic, many without even
A closer look at the historical
diabetes and obesity has increased.
being aware of it, the latter ignorance
prevalence curve of claimants per
The top researchers agree: the scale
leading to inadequate treatment and
1 000 members registered on
of CVD burden poses a threat to the
a host of complications. It takes on
Discovery Health’s chronic illness
health system and calls for timely
average seven years for a person to
benefits shows hypertension claimants
intervention.
get diagnosed with type 2 diabetes,
up from 76 in 2008 to 96 last year. This
meaning that an estimated 30% of
is followed by hypercholesterolaemia,
data is based on the Council for
people present for treatment with
which rose from 40 to 50 claimants
Medical Schemes (CMS) chronic
already developed complications,
per 1 000 members over the same
disease list (CDL) of 27 conditions (now
directly contributing to an increased
period while diabetes mellitus claims
including HIV/AIDS), meaning that it
prevalence of heart disease, stroke,
rose from 19 per 1 000 members to
only shows members who registered in
blindness – about 55% of people
27 members over the same time.
terms of the CDL. While admittedly a
with diabetes are likely to suffer from
Cardiovascular disease (CVD) almost
small snapshot of a much wider trend
diabetic retinopathy, with diabetes
‘flat-lined’ at nearly 11 claimants per
nationally and globally, these three
being the third leading cause of
1 000 members to 12 between these
top-claiming diseases illustrate the
blindness in South Africa (SA), with
years, in spite of CVD increasing
outcomes of poor lifestyle choices by
retinopathy and cataracts accounting
among all age groups and being
South Africans generally. According
for 8 000 new cases of vision
predicted to become the prime
to Dr Noluthando Nematswerani,
impairment every year – amputations
contributor to overall morbidity and
head of Discovery’s Clinical Policy
and kidney failure. Diabetes mellitus is
mortality in people over 50 years
Unit, the tidal wave of chronic NCDs
the fourth largest underlying cause of
old. According to a review of the
(of lifestyle) currently engulfing SA
natural death (by age and sex) in SA.3
top CVD literature, several factors
is because, “we’re forever in a rush,
Tuberculosis and influenza/pneumonia
are contributing to the CVD fatality
eating convenient fast foods and
are numbers one and two, with
shift – an epidemiological transition,
with those less privileged going for
cerebrovascular and other forms of
which has seen a rise in chronic
sugary beverages because they assign
heart disease lying third.3 The highest
non-communicable disease (NCD)
a certain status to them. In most
prevalence of diabetes is among the
and a demographic transition with
canteens, cafeterias and restaurants
2
The Discovery claims prevalence
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Feature | 25
It takes on average seven years for a person to get diagnosed with type 2 diabetes, meaning that an estimated 30% of people present for treatment with already-developed complications, directly contributing to an increased prevalence of heart disease, stroke, blindness, amputations and kidney failure H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
the less healthy stuff is cheaper. It’s more expensive to get a salad than say, ‘slap’ chips or a bunny chow. Access to healthy stuff is limited”. She says that when a lack of physical activity is added to this poor nutrition, “you get more and more people becoming obese with attendant noncommunicable diseases”.
Meaning well, but doing it wrong “Then you also have the stress levels in just making ends meet and long hours at work. We all have good intentions, but if you don’t pack your own lunch, the likelihood of you eating unhealthily is pretty high,” she added. This was highlighted recently by Dr Deborah Cohen, a senior scientist at RAND Corp, a top US-based research organisation, and author of A Big Fat Crisis: The Hidden Influences behind the Obesity Epidemic and How We Can End It. Addressing a Discovery doctor seminar on NCDs in Johannesburg on 6 August this year, she described society generally as a “food swamp” in which we wallow, biologically wired to pay more attention to food than other things in our environment and at the mercy of ubiquitous, cheap and
and nutrition technology and how
them. Teachers and other staff are also
aggressive marketing. This drove a
to themselves “walk the talk” (which
included in the rewards-based lifestyle
global obesity epidemic which in SA
research had shown resulted in better
improvement programme. Then we
sees more than 70% of women above
patient compliance).
have ‘park runs’ – free weekly 5 km
35 years old and 45% of men above 35 years overweight or obese. The World 1
Health Organization (WHO) attributes 82% of deaths in developing and emerging economies to NCDs.
timed runs across the country, where
Investing in children to secure SA’s future
Active Kids report is drawn up annually
Asked how her company made
by a specific country’s research working
anybody can enter every weekend,” she said. The globally-used Healthy
interventions with a social impact
group, in SA comprising of 23 experts
Health was “pushing hard” on ways
wider than just on their higher-
in physical education, nutrition, sport
to make early diagnoses by using
income subscribers, she said they
science, public health and journalism.
their impressive wellness database,
ran multiple social responsibility
It is based on a systematic review of
and sending staff and equipment to
projects. These included, for example,
peer-reviewed literature (previous five
companies where employees were
using Discovery’s Vitality programme
years), dissertations, and non-peer-
properly assessed and screened for
at schools in and around Gauteng
reviewed reports (‘grey’ literature)
glucose and body mass indexes,
in partnership with the City of
dealing with the physical activity and
asked searching questions about their
Johannesburg. “We do things like
nutritional status of South African
physical and nutritional lifestyles and
improving what’s in their tuckshops
children and youths aged between
interventions proposed. Other projects
and using the issues identified in
6 and 18 years. In the context of what
involved assertively educating doctors
the latest Healthy Active Kids report
is now widely-termed ‘diabesity’ (so
on user-friendly high-tech fitness
to design a holistic programme for
strong is the link between obesity and
Nematswerani said Discovery
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H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
diabetes), its findings are fundamental
2030. There are currently 14.7 million
and the diabetes drugs, so it is difficult
to SA’s healthcare planning. The group
diabetics in Africa; however, according
to control both diseases.”
looked at how much children play,
to the IDF around 78% of Africans
how much fast food they eat, how
with diabetes are undiagnosed. The
have to focus their attention on
much TV they watch and how much
main causes for the dramatic rise
primary prevention, raising public
support they get for healthy choices
in diabetes on this continent are
awareness, building capacity for
Kapur says governments will
at home and school. Here are some of
urbanisation and obesity. Millions of
healthcare programmes and offering
the alarming findings around physical
people are migrating from rural to
diabetes services at primary care,
activity and nutrition:
urban areas in pursuit of work and
ensuring patients can receive self-
•A t least half of South African
better opportunities. In a short time
care education and support. They
children are active for less than an
their lifestyles change dramatically:
need to promote breastfeeding (as
hour a day. This is not nearly enough
they adopt a westernised diet high
it is a good prevention of obesity in
and gives SA children a D for
in fat, sugar and salt, and get far
both mother and child) and identify
physical activity.
less exercise than they were used to.
women with gestational diabetes.
• L ess than half the children in SA
Cultural beliefs also play a big role.
Diabetes during pregnancy could
cities take part in an organised sport
According to dietician Suna Kassier,
cause serious complications and
or recreational activity. This is a C.
many Africans still see weight gain as
increase the risk of both mother and
•M ost children spend almost three
a sense of achievement. “It signifies
child developing diabetes later in
hours a day watching TV during
dignity and respect, and shows that
life. “People often say that treating
“People often say that treating diabetes is expensive. I disagree. It is not providing this care that is very expensive – most of the high costs of diabetes come from treating its complications” the week and even more over
you’re enjoying wealth and a good
diabetes is expensive. I disagree. It
weekends. We got an F on
life. Being thin is also associated with
is not providing this care that is very
sedentary behaviours.
hardship, trouble at home and serious
expensive – most of the high costs
illnesses such as TB or HIV/AIDS.”
of diabetes come from treating its
children continues to increase; the
This weight gain leads to overweight
complications. Prevention, early
intake of sugary drinks plays a major
and obesity, which is a great precursor
identification and offering proper
role. Our previous grade of C– has
for type 2 diabetes.
basic care are both essential and
•O verweight and obesity among
dropped to a D. •M ore than two-thirds of youngsters eat fast food at least three times a week. That’s an F.
No disease is an island …
affordable. But not enough is being done to address this.”
Ironically, there are links between
1. Bradshaw B, Steyn K, Levitt N,
diabetes and HIV/AIDS and TB.
Nojilana B. Non-Communicable
According to Dr Anil Kapur, managing
Diseases – A Race Against Time.
director of the World Diabetes
Burden of Disease Research Unit,
recommendations on salt intake,
Foundation (WDF), few people know
South African Medical Research
giving us a D.
that in Africa, more than on any other
Council. Chronic Disease Initiative
continent, there are interactions
for Africa, Department of Medicine,
between these three conditions and
University of Cape Town, 2015.
their various treatments.
2. Hofman KJ, Cook C, Levitt N.
•O nly 50% of children eat enough fruit and vegetables – we get a C–. • L ess than half of children meet the
•F or regulations on food advertising to children SA scored an F–. We definitely have some work to do in this area. Taking a macro-view, globally, 366
“Patients who receive antiretroviral
Preventing diabetic blindness: A
drugs are at a higher risk of developing
priority for South Africa. S Afr Med J
diabetes, as some of the drugs cause
2014;104(10):661-662. [http://dx.doi.
million people have diabetes. The
glucose intolerance as one of the
org/10.7196/samj.8580]
International Diabetes Federation
side-effects. People with diabetes
3. Republic of South Africa. Mortality
(IDF) predicts that this number will
have a greater risk of developing TB as
and Causes of Death in South
rise to 552 million by 2030, with the
diabetes reduces the body’s immunity.
Africa, 2012: Findings from Death
greatest increase expected to be
In addition, the interaction between
Notification. Pretoria: Statistics South
in Africa – where the incidence of
drugs to treat diabetes and TB reduces
Africa, 2012. www.statssa.gov.za/
diabetes will have almost doubled by
the effectiveness of both the TB drugs
publications/P03093/P030932012.pd
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
News | 29
Marketers of unhealthy foods exploit our ‘survival’ DNA By Chris Bateman
W
e have allowed
tion (WHO) attributes 82% of deaths in
Can End It. She was one of several
our society to
developing and emerging economies to
ground-breaking researchers who
become a
non-communicable diseases (NCDs).
spoke at the 6 August Discovery
‘food swamp’ in which we
wallow, biologically wired to pay more attention to food than other things in our environment and at the mercy of ubiquitous, cheap and aggressive marketing. This drives a global obesity epidemic
This ‘survival/obesity’ link thesis
Healthcare doctor seminar aimed at
was recently posited by Dr Deborah
increasing awareness and involvement
Cohen, a senior scientist at RAND
in containing the global NCDs, held
“I’m not advocating telling people what not to eat but rather preventing businesses from putting people at risk”
which in South Africa sees more than
Corp, a top US-based research
at the Wanderers Cricket Ground in
70% of women above 35 years old and
organisation and author of A Big Fat
Johannesburg.
45% of men above 35 years overweight
Crisis: The Hidden Influences behind
or obese. The World Health Organiza-
the Obesity Epidemic and How We
1
Cohen said we use non-cognitive processing for most of our usual activ-
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
ities (outside of planning and thinking about the future) and we are automatically wired to the survival imperative. “We’re biologically wired to pay more attention to food than other things in our environment. It can make us feel hungry even if we’re full. When food is everywhere, that capacity is killing us,” she said. The food industry knows how important it is to capture people’s attention: “The more we look at it, the more likely we are to buy it”. Placement and product design are built around this imperative. End-aisle displays sell 50% better, and if junk food is placed there, that is what people buy. Increased product variety encourages “decision fatigue”, making it more difficult for low-income earners who end up making “trade-offs” resulting in poor and unhealthy decision-making. Cohen said that restaurants and supermarkets are also acutely aware that when people are served or offered more than they need, they eat more than they should.
Tasty and unhealthy temptation everywhere
“We’re biologically wired to pay more attention to food than other things in our environment. It can make us feel hungry even if we’re full. When food is everywhere, that capacity is killing us.” our innate inability to multi-task. The
research conducted in the USA. Giving
assertion that obesity is the result of
the example of her own hypertensive,
Simply “taking personal responsibil-
a person’s own conscious choice and
dentist father who suffered from heart
ity” for one’s weight is no solution
that willpower controls weight flies
disease, she said he was a hard-work-
and highly impractical in the face of
in the face of the existing obesity
ing war veteran, punctual to a fault,
such overwhelming temptation and
epidemic – and more than a decade of
worked six days a week and raised In South Africa the National Department of Health has promulgated mandatory salt regulations, beginning in 2016. This will save an estimated total of 6 400 lives from stroke, 4 300 from non-fatal stroke, and cut hospitalisation costs by R300 million annually. Similarly, a potential SA tax on sugary drinks would cut the number of obese people by 220 000 in three years. Occasionally, industry and not government sets the precedent … Tesco, a leading food retailer in the UK, has banned junk food from its checkout aisles.
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
News | 31
Senior scientist at RAND Corp, Dr Deborah Cohen
three children. “How does an other-
In the 1820s in the USA there were no
traded on consumer “choice fatigue”.
wise responsible person eat too much?
cars and we were losing breadwin-
By restricting impulse marketing and
It’s survival behaviour, reflexive and au-
ners to alcohol with a lot of domestic
junk food promotion, plus introducing
tomatic – there is no conscious control.
abuse thrown in”. The ‘demon drink’
counter-advertising reminding people
Eating is like breathing. Sometimes we
led to the Temperance Movement
just how much they were being manip-
can control our gut, but if we did it all
with Prohibition “going a bit too far”.
ulated, the obesity pandemic could be
the time we wouldn’t be able to do an-
However, this was where the conversa-
pushed back.
ything else! Most of our behaviours are
tion needed to start, she said, dis-
automatic. If we eat a bowl of popcorn
playing a slide of how alcohol control
-State? No. Actually I don’t know why
while watching TV, we only realise it
policies restricted access – pointing
nannies have such a bad name, they
when there’s nothing left. When eating
the way to how to address the obesity
look after our interests. Look at Mary
we’re more likely to pay attention to
epidemic via public health standards
Poppins in The Sound of Music; she
our dinner companion or our kids. We
and regulations – especially when it
recommended a spoonful of sugar and
don’t do it (pay conscious attention to
came to the retail environment. “I’m
that’s better than six!” she joked. Co-
food) because we don’t have to. We
not advocating telling people what not
hen rounded up by questioning wheth-
have better things to do.”
to eat but rather preventing business-
er 30 million South Africans could all
Cohen said that historically, the
es from putting people at risk,” she
be making the same mistake. “Instead
1970’s and 1980’s saw the initiation of
stressed. Recent examples of this in
we have to prepare an environment
hyper-sophisticated food marketing
the USA included standardising the
that takes into account what human
strategies, including the buying of
quality and quantity of school meals,
nature is. We wouldn’t have an obesity
shelf space in stores. What is needed
private hospitals refusing to carry sug-
epidemic if we didn’t live in a food
today is a public health solution, she
ary foods, sweets or drinks and soda
swamp.”
said, citing the evolution of liquor
taxes in the city of Berkley. However,
control in her home country. Two
regulation needed to go beyond
Bradshaw D, Steyn K, Levitt N, Nojilana
centuries ago liquor marketing was
taxes, Cohen said. What are needed
B. Non-Communicable Diseases – A
“ubiquitous”, with Americans having a
are standardised portions and restric-
race against time. Parow: South African
reputation as a “nation of drunkards”.
tions on “bargain combo meals” which
Medical Research Council, 2010.
“Am I recommending a Nanny
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H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
News | 33
The grim toll of kidney donor and dialysis machine shortages An estimated 10 000 South African (SA) men and women of all ages die of kidney disease or failure every year because they do not have access to dialysis or a kidney transplant – while only 300 kidney transplants are performed annually. By Chris Bateman
T
his is according to
at private clinics. In the public health
dialysis treatment. Does the patient’s
both the National Kidney
system, the agonising decision about
house have running water, sanitation
Foundation (NKF) and
who will receive ongoing dialysis until
and electricity in case the patient has
the South African Renal
a donor kidney might be found, and
to perform some kind of home dialysis?
Society (SARN), the latter
who doesn’t, is forced upon hospitals
Does he or she have a good social sup-
of which says people wait on average
by sheer lack of resources. For every
port network? Factors working against
three to five years, with some of the
individual who gets a place in a state-
being included in a state dialysis
more complicated cases waiting up to
run dialysis programme, there are
programme and receiving an eventual
10 years to get a new kidney. President
many more that don’t.
transplant should a donor become
of the SARN, Ms Sarala Naicker, says
Selection criteria include: whether
available include substance abuse by
thousands of people with kidney failure
a patient has dependants and other
the patient, smoking, consumption of
in SA remain untreated and are unable
important responsibilities, the degree
alcohol and, often, obesity.
to access dialysis because of a shortage
to which a patient is able to be educat-
of machines. “All of the facilities are
ed and have insight into the illness and
new kidney patients in SA has soared.
oversubscribed so it’s very difficult to
whether a patient is sufficiently moti-
Kidney failure in SA adults is mainly
put new people on treatment,” she
vated to follow the necessary regimen
due to inherited hypertension
explained, adding that the country has
(for example, the degree to which he
(60 - 65%) or type 2 diabetes (another
actually seen a decline in kidney donors.
or she is compliant in terms of taking
20 - 25%). Kidney failure in the black
If SA were to increase transplanting
medication regularly). Age is also a
population is four times higher than
numbers, more patients would be
consideration. The national guideline
in other groups, due to the high
able to access life-saving dialysis. The
indicates that state hospital patients
incidence of high blood pressure.
Department of Health aims to increase
must be under the age of 60 to qualify
Some of the luckier ones, who meet
the transplant rate five-fold and to
to be admitted to a provincial hospital
the criteria, are able to undergo
double dialysis treatment numbers
dialysis programme.
dialysis at home while awaiting a new
over the next 10 years which will have
In the Western Cape, Groote Schuur
Over the past years, the number of
kidney. Each night, they connect them-
a significant effect on the transplant
and Tygerberg are the only two institu-
selves to a loaned dialysis machine
waiting list and the waiting times. South
tions that offer dialysis, and their cut-off
via a catheter in their stomachs. The
Africa currently provides treatment to
age is 55, unless the person is diabetic,
machine removes waste fluid and tox-
about 8 000 renal failure patients. The
then the patient has to be younger than
ins from their systems, just like normal
Department of Health hopes to increase
50. Other criteria include the extent to
kidneys would, while they sleep. For
this number to about 14 000 by 2025.
which the patient’s domestic circum-
those less lucky there are more sleep-
Most South Africans with kidney
stances support the lifestyle changes
less than restful nights, as they pray
which are necessary to complement the
and ponder their fate.
disease can’t afford to pay for dialysis
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Using cutting-edge science to tackle NCDs By Chris Bateman
S
trategically using
phones with fitness applications and/
behavioural economics
or wear fitness devices with the internet
and the explosion in
being ubiquitous. “We’re faced with an
medical technology to
entirely different world, measuring and
understand what motivates
monitoring our heart rates, steps per
people is pivotal to helping reduce a
day … how we sleep at night. This all
non-communicable diseases (NCDs)
leads to vast amounts of data which we
epidemic responsible for 68% of
can analyse and use in massive quanti-
deaths worldwide.
ties far quicker than ever before. People
This was Discovery Health CEO Dr Jonathan Broomberg’s key message to hundreds of doctors attending an NCD health summit featuring global and local leaders in genomics, biochemistry, obesity and disruptive technology, held at the Wanderers
are also forming teams and friendship/ Dr Jonathan Broomberg
High-impact interventions will save “billions”
family groups – creating the whole idea of social organisations around exercise – this self-measurement and the ensuing big data are leading to major new insights on what motivates people,” he said. Financial nudging or incentives
The cost to the global economy of
– extensively used in Discovery’s glob-
Citing the “deeply disturbing” recent
continuing a business as usual
al Vitality programme – was a highly
World Health Organization (WHO)
approach versus implementing
effective tool in helping people make
report that attributes 82% of deaths in
high-impact healthcare interventions
better choices in an unhealthy culture
Cricket Ground on 6 August this year.
When it came to metabolic risk factors, obesity was responsible for 3.4 million deaths while high blood pressure topped the charts at 9.4 million deaths
and environment that was “built upon the pleasure of the moment”. “We know that the human brain is far from rational. It has immediate reactions, reflexes and slow and fast thinking. Our brains need to be tricked into doing
developing and emerging economies
came to USD7 trillion (R89 trillion)
things if we really want to do them. We
to NCDs, Broomberg said this posed
versus USD11 billion (R139.9 billion),
tend to discount future risk (as in not
the biggest challenge yet to the
creating an overwhelming case for
wearing seat belts or dismissing the
global healthcare community. Poor
mobilising citizens, society and the
chances of a heart attack via a continued
lifestyle choices were the key driver
healthcare professions. “It makes you
poor diet). We understand the risks, but
of the pandemic, compounding any
wonder why we’re not tackling this
when you ask yourself what you do to
pre-existing genetic predispositions.
more aggressively,” Broomberg added.
counter them, the answer is generally
Global estimates for behavioural risk
Reflecting on the historical trajectory of
nothing (or very little),” said Broomberg.
factors put poor nutrition’s contri-
the science of wellness, he said it had
Advertising that pleads with mothers to
bution to NCD deaths at 1.7 million
moved from merely treating diseases in
buy healthy food for their children simply
and insufficient physical activity at 2.3
the 1980s to more aggressive screening
does not work; however, it has been
million deaths. When it came to meta-
in the late 1990s (leading to earlier de-
shown that offering a 15% discount on
bolic risk factors, obesity was respon-
tection of cardiovascular and hyperten-
certain foods resulted in a 6% increase
sible for 3.4 million deaths while high
sive conditions) to a massive explosion
in the healthy foods in their supermarket
blood pressure topped the charts at
in technology in the last five to seven
baskets, the correlation improving as
9.4 million deaths.
years. Today most people carry mobile
discounts increased.
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High-tech exercise medicine boosts healthcare With exercise medicine about to be elevated to specialty status in South Africa, doctors should begin working with their patients to design technology-based, comprehensive lifestyle interventions that both parties can monitor to achieve major health improvements. By Chris Bateman
T
his was the core
NCD risk factor for global morbidity,
Committee had banded together with
prevention message from
with heart disease, stroke, diabetes and
the UN General Assembly and the
Stellenbosch University
cancers contributing to more than three
World Health Organization (WHO) to
sports science and
million preventable deaths annually.
declare NCDs “a catastrophe waiting
medicine researcher,
Sixty percent of premature deaths
to happen”.
Prof. Wayne Derman, to 210 doctors
from NCDs occurred in developing
attending the Discovery Health Non-
countries, with the Lancet’s 2012 special
Low CR fitness causes most NCDrelated deaths
Communicable Diseases (NCDs)
edition describing physical inactivity
Summit in Gauteng on 6 August this
alone as a “pandemic with far-reaching
year. Warning delegates that unless they
health, economic, environmental and
kept up with cutting-edge healthcare
social consequences’’. Delivering his
study of more than 40 000 men and
technology they could end up delivering
talk entitled ‘Disruptive Change; Using
12 000 women published in the British
sub-optimal care, Derman said physical
Innovation in the Prevention of NCD’s’,
Journal of Sports Medicine (BJSM) he
inactivity was now the fourth leading
Derman said the International Olympic
said low cardiorespiratory fitness (LCRF)
Citing the 2009 findings of a three-month
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
News | 37
Prof. Wayne Derman, Stellenbosch University sports science and medicine researcher, at the NCD summit
outstripped obesity, smoking, hyper-
more evidence, there is piles of it. What
Stockholm, Norway, were painted black
tension, high cholesterol and diabetes
we need is commitment (by doctors
and white to look like piano keys with
in ‘all-cause’ deaths data – accounting
and patients to interventions),” said
movement detectors linked to musical
for 16% of men and 17% of women. He
Derman. He again turned to the BJSM
notes so pedestrians could actually ‘play
said there were three choices everyone
to earmark overarching interventions
them’: a ‘before and after’ study found
needed to make on a daily basis that
which researchers outlined graphically
that 66% more people than normal
would predict whether they developed
in what they termed “the population
chose the stairs over the escalator. Col-
cardiovascular disease, diabetes, cancer
prevention pyramid” divided into ter-
leagues of his in London had redesigned
or a chronic respiratory illness. These
tiary, secondary and primary sections.
the London Underground map to show
were: “Whether you smoke, what you
These included public education
how many steps commuters took be-
put into your mouth on any given day
(embracing mass media), the built
tween the various stations. He referred
There were three choices everyone needed to make on a daily basis that would predict whether they developed cardiovascular disease, diabetes, cancer or a chronic respiratory illness. These were: “Whether you smoke, what you put into your mouth on any given day and whether you’re going to exercise”. and whether you’re going to exercise”. It
environment, transit modes and systems,
was also possible to predict who would
settings such as schools and commu-
Exercise as Medicine and www.ideo.org,
die and who would live, simply by mon-
nities and sport-for-all, plus healthcare
a free toolkit in design thinking, guiding
itoring their sedentary behaviour over
professionals and/or hospitals.
behaviour change and designing a prac-
a long period. “If you sit for more than three hours per day it appears to cut your life short by two years – even among
Redesigning the environment
delegates to several websites, including
tice according to a patient’s needs. “You might get swamped and end up doing nothing. In that case just choose two
Elaborating, he said some cycling lanes
physical activity apps, two nutrition apps
shortens life expectancy by the same
were bigger than car lanes in Europe,
and two mindfulness apps and learn to
degree as smoking. We don’t need
while stairs alongside escalators in
use them,” he added.
individuals who exercise regularly. This
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Don’t measure who died and why – it’s confidential! By Chris Bateman
T
he Director General
Germany of census records to kill Jews
(DG) of Health is to
during World War II and an alleged
recommend counter-
raid by Israel on Palestinian census
measures to the South
records in order to “kill, maim and
African Law Commission
arrest” its enemies.
to prevent an amendment to the Birth
The Western Cape Department
and Death Registration Act, making
of Health has developed (from 2000
the cause of death confidential to
onwards) a sophisticated home-grown
all but Statistics South Africa (Stats
mortality data system, working with the
SA) officials. The amendment, as it
City of Cape Town, the University of
stands, effectively torpedoes mortality
Cape Town and the SAMRC to glean
surveillance for public health planning
detailed public health information not
countrywide, even though this is only
available from national vital statistics.
currently happening to any real effect
The province used this vital information
in the Western Cape. The longterm harm of sealing off ‘cause of
DG of Health, Precious Malebona Matsoso
to develop appropriately placed programmes to reduce diarrhoea deaths
The long-term harm of sealing off ‘cause-of-death’ data in death certificates lies in epidemiologists being unable to geographically pin-point where deaths are occurring and why death’ data in death certificates lies
ly and citing the media’s controversial
among children, and evaluate HIV-ART
in epidemiologists being unable to
accessing of the health records of the
and cervical cancer screening pro-
geographically pin-point where deaths
late Minister of Health Dr Manto Tsha-
grammes. By January 2014, the City of
are occurring and why – effectively
balala-Msimang as an example of a
Cape Town had developed an IT system
causing healthcare planners to operate
violation of the doctor-patient relation-
that was capturing deaths by residen-
blind – contributing to even more
ship. He said this “sacrosanct princi-
tial suburb within weeks of the date of
deaths. Life-saving interventions such
ple” held equally true for the dead.
death, automatically coding the under-
as vaccination, prevention messaging
Questioning why it was necessary to
lying cause of death in 70% of cases.
and distribution of resources become
wait for a death before interventions
The rapid availability of specific detail
extremely difficult.
were put in place, Lehohla said stats
of where people died and cause of
drawn from health records (i.e. living
death painted a much richer and clearer
one of the most pragmatic incumbents
patient consultations) could help build
picture of the public health action
in recent years, called in her lawyers
disease profiles. Anonymity was “a fun-
required to address the problems faced
after reading about the effect the new
damental qualifier” to the aggregates
by those communities. That all came to
law will have in the Healthcare Ga-
StatsSA produced on any phenom-
an abrupt end when the Department
zette’s sister journal, the SA Medical
ena of public interest. “Even with an
of Home Affairs (DHA) in an attempt to
Journal (Izindaba) earlier this year.
application of the most sophisticated
streamline its processing and maintain
Informed of the objections (initially by
algorithm, such aggregates cannot be
individual confidentiality suddenly
the SA Medical Research Council –
decomposed (sic) to reveal the specific
last February, introduced a new death
DG Precious Malebona Matsoso,
SAMRC), Statistician General Mr Pali
individual to whom the phenomenon
notification form with the cause of death
Lehohla took a hard line, claiming the
of public interest relates,” he added.
page sealed and only Stats SA legally
Western Cape had been acting illegal-
Lehohla cited the abuse by Nazi
empowered to open it.
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News | 39
Is SA’s NHI ready for ‘health tourism’? – a cautionary tale By Chris Bateman
A
Nigerian woman identified as 37-year-old
Bimbo Ayelabola and her quins
Bimbo Ayelabola has been let off a R2.9 million (£145 000) bill by a British
National Health Service (NHS) hospital after delivering quintuplets there. The news report in the UK’s Telegraph newspaper is concentrating the minds of South Africa’s (SA’s) universal healthcare budgetary architects, with at least 1.7 million foreign nationals currently estimated to be living in this country – and dismal patient fee collection already costing tens of millions of rand every year in most provinces. Ayelabola underwent a complex caesarean section in 2011, but failed to pay any of the cost of the operation
Photo: News Group Newspapers Ltd
and neonatal care for her five babies.
Constitutional and medical ethical imperatives on treatment hold serious budgetary implications once the local NHI system gets underway
According to the Telegraph, Homerton
for almost two weeks after the birth of
pletely unacceptable that people living
University Hospital in East London will
two boys, and three identical girls, in
outside the UK think they can abuse
not chase Ayelabola for the outstand-
April 2011. Although her visa had report-
our NHS. We expect and are support-
ing bill. The hospital claims that it sent
edly expired, she continued living in her
ing the NHS to make every effort to
one request for payment, more than six
sister’s apartment with the children and
reclaim money owed to it”.
months after she left the hospital, and
did not return home until February 2013.
did not take any further action when
Ayelabola recently spoke to London’s
that there were 1 692 242 people – or
this was returned unpaid. The mother of
The Mail newspaper, saying: “What is it
3.3% of South Africa’s population – who
five, who is a make-up artist, has since
that’s my fault? I don’t understand. They
were not citizens in 2011. Similar figures
returned to Lagos and claims she never
blamed me that I came to the UK and I
were recorded the year following the
The 2011 South African census found
received her bill. “I have never received
just came to use the system, which I did
census (in the 2012 General Household
my bill. If I had it, I would pay it,” she
not do. If it (health tourism) is a problem
Survey) and experts are on record as
is reported as saying. Ayelabola’s story
in the UK, you should talk to the NHS. I
saying it is unlikely this number has
follows claims by NHS whistle-blowers
have never received my bill. If I had it, I
increased significantly. Tough new SA
that managers are instructing them
would pay it.”
immigration regulations declare a person
to turn a blind eye to health tourists,
The UK Telegraph reports that
undesirable if they overstay their granted
because it is too much trouble to chase
Ayelabola is separated from her
period, banning them from returning
them for money.
wealthy husband, Ohi Nasir Ilavbare,
for increasingly lengthy periods linked
but that he is involved in the lives of
to their illegal stay. However, constitu-
a visitor’s visa after discovering she was
his children. She is also believed to
tional and medical ethical imperatives
pregnant in 2010, and stayed with her
have been banned from returning to
on treatment hold serious budgetary
younger sister in the UK early in her
Britain for five years. A Department of
implications once the local NHI system
pregnancy. She remained in the hospital
Health spokesman said: “It is com-
gets underway.
Ayelabola is said to have obtained
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40 | News
Gauteng’s negligence continues, major overhaul underway By Chris Bateman
M
edical lawsuits
(Democratic Alliance), Mahlangu said
R5.758 billion was irregularly spent pri-
against Gauteng’s
the department had lost 168 cases
marily by the Gauteng education, roads
Health Department
in court. While she did not have “the
and transport and human settlement
increased by over
correct information” about how many
departments. This was more than the
R4 billion between
cases had been won, Mahlangu said
R3.751 billion irregularly spent in the
April last year and March this year – and
eight were settled out of court. “Part of
2013/14 financial year and the R4.688
now stand at R13.1 billion. Claimants
the strategy is to engage more with the
billion irregularly spent in the 2012/13
hoping for financial redress to deal
patients and families. All the hospitals
financial year. Tellingly, the irregular
with whatever pain and suffering
have mechanisms now; they’re called
expenditure related mostly to non-com-
they’re facing are in for a long wait; the
... redress committees. Where we know
pliance with supply-chain management
province paid out just R544 million in
that we’ve wronged the family or pa-
rules and regulations, a long-standing
damages and settlements for medical
tient, we’re able to engage with them
charge made by independent health
claims between January 2010 and the
much more and admit guilt. We’ve also
advocacy and activist groups. In terms
current 2014/15 financial year. Moves
introduced a dispute resolution mech-
of fruitless and wasteful expenditure,
are afoot, however, to stem the tide of
anism,” she said. Until recently the de-
a total of R415.6m was wasted in the
claims and to speed up pay-outs.
partment fought cases in court, but she
2014/15 financial year, primarily by
had instructed her officials to do things
the Health and Roads and Transport
provincial health department’s annual
differently. “We are going to look at all
departments. Mahlangu also revealed,
report, tabled in the Gauteng legisla-
the merits of all cases and on the basis
in answer to a written question from
ture in early September and in answer
of that settle where we need to settle
Bloom, that the Charlotte Maxeke
to questions posed to its Health MEC,
– but also negotiate with the families.”
Johannesburg Academic Hospital had
Qedani Mahlangu. The province’s
Bloom welcomed the department’s
been unable to do a single gall-bladder
health department failed to receive
readiness to negotiate with victims but
operation since March last year be-
clean overall financial audits for the third
slammed Mahlangu for obfuscating on
cause of broken laparoscopy equip-
financial year in a row, mainly due to un-
how many cases her department had
ment. Fifty-one patients were currently
paid patient fees, reported Mahlangu’s
won since January 2010, adding: “Well,
waiting for gall-bladder operations at
colleagues, Premier David Makhura and
I can tell you how many, zero, nothing.
the hospital. Normally, some six gall-
Finance MEC, Barbara Creecy.
They’ve lost every single one,” he said,
bladder operations were done every
adding that the R544 million was “an
month, so the backlog was now more
Mabona, said there were currently 1
astounding figure” that could have
than eight months because of the bro-
780 medico-legal claims at various
gone to improving hospital facilities.
ken equipment, Bloom said. Mahlangu
These figures emerged from the
Departmental spokesperson, Steve
stages in court, dating back to 2010, most of them emanating from Chris Hani Baragwanath, Tembisa, Charlotte Maxeke and Pholosong hospitals.
Irregular spending up 18.6% since 2012/13
promised new laparoscopic equipment within eight weeks and said prospective gall-bladder surgery patients were in the meantime being referred to the
Makhura and Creecy revealed that
Helen Joseph Hospital. Other broken
ing the department by meeting with
more than R5 billion in public money
equipment at the flagship hospital
clinical managers and other healthcare
had been irregularly spent by Gauteng
this year includes the mammography
professionals to advise on record-
government departments and agencies
machine, lifts, air-conditioning units in
keeping and identification of potential
in the 2014/15 financial year. Speaking
operating theatres and a sterilising
claims. Replying to a question in the
on 1 September at a media briefing
machine – leading to an ongoing
Gauteng legislature from Jack Bloom
at the provincial legislature, they said
shortage of clean linen.
Retired judge Neels Claassen was help-
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42 | Profiles
Glenda Gray: A formidable force By Leverne Gething
N
ational Research
HIV. Her research into post-exposure
only saved lives of many children, but
Foundation A-rated
prophylaxis for prevention of mother-
also improved the quality of life for
scientist Glenda Gray
to-child transmission (PMTCT) led
many others with HIV and AIDS.”
was recently appointed
to the development of clinical
president of the South
guidelines that have been adopted
African Medical Research Council
(MRC). With a distinguished academic
background in paediatrics and HIV, Gray intends to maintain her ongoing research
internationally.
Garlanded in awards
Game-changing interventions In her new role Glenda’s single-
minded determination to develop game-changing interventions to end
Her expertise has been garlanded in
SA’s TB and HIV epidemics remains
awards. In 2002 Glenda received the
unfettered. “From discovery to clinic
director and co-founder of the Perinatal
Nelson Mandela Health and Human
– bench to bed – funding for research
HIV Research Unit of the University
Rights Award for her work on mother-
is critical. I am interested in ensuring
of the Witwatersrand, based at
to-child transmission of HIV-1. In
we do both blue-sky research and
Chris Hani Baragwanath Hospital in
2003 she received the International
translational research and that we
Soweto, and a member of the Vaccine
Association of Physicians in Aids Care
fund throughout the value chain of
and Infectious Diseases Unit at the
‘Hero of Medicine’ award.
disease. We are also interested in
commitments throughout her tenure. As professor of Paediatrics and
Fred Hutchinson Cancer Research
In June 2012 she received a DSc
funding the next-generation scientists
Center in Seattle, USA, she has a long
(honoris causa) from Simon Fraser
and funding black African scientists
pedigree in key research. This includes
University, Vancouver, and in the
and to develop research capacity in
the development of HIV vaccine
same year was admitted into the
historically disadvantaged institutions.
trials in South Africa and ongoing
American Academy of Microbiology.
assessment of efficacy of microbicides
In 2013 she received South Africa’s
research – from discovery (bench) to
as preventive HIV therapy. She is co-
highest honour, the Order of the
clinical (bed) – we must be involved in
principal investigator of the US National
Mapungubwe, granted by the
all aspects of research to find solutions.
“We must do cradle-to-the-grave
Institutes of Health-funded HIV Vaccine
President for: “Her excellent life-
I want to grow medical science in
Trials Network (HVTN) and director of
saving research in mother-to-child
South Africa so that we become a
HVTN International Programmes.
transmission of HIV and AIDS that has
formidable force,” she says. “I want to
changed the lives of people in South
foster discoveries that change lives,
Africa and abroad. Her work has not
and I hope that the HIV vaccines we are
Dr Gray’s research has contributed significantly to the understanding of
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developing countries could feed their infants formula to avoid transmitting the virus through breastmilk. Global health leaders were recommending that women in developing countries shouldn’t use formula, arguing that the risk of babies dying from contaminated water outweighed that of contracting HIV. Glenda wanted to educate women so that they could make a choice; she found that women in Soweto were able to use formula safely. The reaction from activists who had led previous boycotts against baby formula makers was harsh. Everything about that presentation testing now show us the way to more
age of six. Unusual for a pupil from
was quintessential Glenda: the drive
effective regimens for the future.”
the local high school she gained a
to save lives, the willingness to buck
place to study medicine at Wits, and
convention, and her insistence on
just not enough funding: “I need at
went on to carve a path in paediatrics.
asking the community – her patients –
least three times the budget I have
Around this time, the late 1980s,
However, she says that there is
to be truly effective, to fund diverse
South Africa was in the grip of the
research. We have the vision but not
emerging HIV/AIDS epidemic. As
the means to be world-class medical
a young physician Gray was drawn
researchers – even though we have
into HIV activism, working in an
the ability and the scientists.”
underground organisation opposed
R30 million has already been
to the apartheid government. Her
what they wanted.
In 2015 her approach hasn’t changed
She speaks of promise for the future. “In my own research, I hope that
“I want to foster discoveries that change lives, and I hope that the HIV vaccines we are testing now show us the way to more effective regimens for the future” awarded by the MRC to previously
portfolio was to work in townships
the HIV vaccines that we are testing
under-resourced universities to
with healthcare workers in the field
over the next few years show us the
fund research into the prevention,
of HIV, and to organise emergency
way to developing more and more
reduction and control of disease in
medical teams to treat people injured
effective HIV vaccines. Promise is
South Africa. With the Department
during anti-government protests.
being shown that we are on the
of Health and the private sector, the
By the time Glenda qualified as
path to eradicating paediatric HIV in
MRC is also facilitating the National
a paediatrician, every third child at
children in South Africa, that at long
Health Scholars programme, worth
Baragwanath Hospital was HIV-positive,
last women and child health are on
R36.2 million, to support 1 000 PhD
and HIV was the most common cause
the political agenda, and that intimate
graduates over the next 10 years.
of death in children admitted.
partner violence and child murder are
If Glenda’s sheer energy and
Glenda had planned to be a doctor,
receiving the attention they deserve. “In the real world, I want to make
determination are anything to go by,
not a researcher, but the crisis propelled
her goals will be attained.
her to be both, and she began looking
a difference by increasing the funding
for affordable ways to prevent mother-
to young scientists, to assist in making
to-child HIV transmission.
universities that previously were not so,
Carving a path in paediatrics
In 1996 Glenda presented her first
to be research active. I want to grow
Gray was the fifth of six children
research paper to an international
medical science in South Africa so we
brought up in the mining town of
AIDS meeting – and walked straight
become a formidable force in Africa
Boksburg, east of Johannesburg, and
into a tempest. The subject was
and beyond. I want discoveries that
wanted to become a doctor from the
whether or not HIV-positive women in
change the lives of South Africans.”
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Profiles | 45
Surfing the genome wave – Dr Craig Venter By Chris Bateman
A
1960s Newport
via advances in genome sequencing
on human genotypes – and is now
Beach surfer, Vietnam
and engineering.
working on synthetic methods to
war veteran and self-
Having achieved the quickest
rewrite genetic codes. The latter work
confessed adrenalin
PhD in Californian history, Dr Craig
stands to transform energy production
junkie who belatedly
Venter, named by Time Magazine (in
(for example, recycling carbon instead
began an illustrious medical career, is
2007 and 2008) as one of the globe’s
of burning it into the atmosphere),
on the verge of revolutionising global
100 most influential people, built the
food production and manufacturing.
health, agriculture and manufacturing
world’s most comprehensive database
His scientific team’s work in
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One of the globe’s 100 most influential people, Venter built the world’s most comprehensive database on human genotypes – and is now working on synthetic methods to rewrite genetic codes epigenetics has led to precision medicine that can tailor highly effective
health and life insurance industries.
corresponding factors in ourselves that
“Our company’s name is Human
regulate all kinds of processes – and all
therapies to individual patients and
Longevity. We’re not trying to directly
of this is contained in a linear genetic
predict diseases up to 20 years in
increase the length of a lifetime. In fact
code. Five years ago we built the first
advance. Addressing the Discovery
it’s very similar to Discovery’s Vitality
genetic chromosome (synthetic). While
Health Non-Communicable Diseases
Programme – promoting a healthy
the human genome is the most complex
(NCDs) summit in Johannesburg via
lifestyle. There’s no one disease we’re
part of all of it, we’re excited about
video-link on 6 August this year, Venter
focused on or interested in. If we get
applications across the entire space,” he
said that his company’s work would
new preventive medicines, that’s great.
told a fascinated audience of hundreds
usher in a “transformative era” for the
Epigenetics is a new field looking at
of doctors. His company is also making
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Profiles | 47
are mutated and which drugs will work.
disease. He revealed that the cost
We have very specific RNA vaccines
of sequencing genomes in Europe
that are individualised and very precise.
was currently no more than $1 000, a
Within a couple of weeks of getting the
quantum drop from a decade ago.
tissue from the patients we have precise
“Also, the more knowledge you
quantitative information versus guessing
have of your own life, the more chance
blindly like most medicine today. We
you have of changing your own life
understand the programming. It’s clear
outcomes. We all have a pre-existing
from the patient’s DNA in his genome
condition to something in our genetic
why he or she got cancer in the first
code. That will be useful in getting the
place – and that they would probably
right policy to the right people and the
have got it sooner or later. In healthy
right risk factors to the right people.”
individuals cancer doesn’t appear if
In the future, exercise patterns, dietary
you have a good immune system, but if
patterns and pharmaceutical patterns
you have a suppressed immune system
could be examined for each type of
because it’s under stress or genetically
change in the genetic code. With
suppressed, you greatly increase your
over half of all our genes contributing
risk of cancer.”
to functions of our brain, it was also
His team found 25 000 mutations
highly feasible that predicting what
in a tumour that were different from
type of memory a person would have
the patient’s genome. “From those
would become possible. He described
protein changes, we come up with
autism (for example) as “not a single
unique drugs that we know will work
disease. Every single child has a
on that person’s biochemical pathways
different set of mutations of genes
with these mutations,” he explained. In
affecting the brain”.
future physicians would become much
Venter said prevention was the
more like “team captains helping their
ultimate goal of his entire scientific
patients navigate through all this new
approach. “If we can prevent disease
information – the goal is for all of us to
(in patients) at the earliest stages
try and prevent diseases by detecting
of their lives, they can live longer,
them early”.
healthier lives.” Every human being
Human Longevity’s goal was
has 1 trillion human cells, but 200
to sequence 1 million genomes by
trillion bacterial cells, called our
2020 and the challenge now is to get
microbiome. This determines most of
sufficient diversity of patient samples
our metabolism and health outcomes.
and diseases. “The more knowledge
Human beings have “500 or so”
you have, the more lives you can
major chemicals circulating in their
individualised RNA vaccines and can
save,” Venter added. Key for all health
bloodstream, 60% from the human
now predict dementia 20 years before
is socioeconomic conditions while
metabolism and 30% from the different
the first symptoms show, preventing the
poor diet or high stress environments
animals they have eaten.
advancement of Alzheimer’s disease
are aggravators. People in poor
versus trying to treat it after it has
socioeconomic regions have much
now only from the human genetic
already begun to manifest.
shorter lifespans and a greater risk for
code. In the future we’ll have a greater
infectious diseases.
understanding of how the chemicals
Cancer from genes and mutations
Venter singles out sanitation
“We can’t predict all of this right
in the food affect us in different ways. I believe we can totally prevent disease at the early stages in people’s lives.
Describing cancer as a “100% genetic
However, he laser-beamed in on
President Barack Obama talks about
disease” Venter said it was, however,
improving sanitation, saying this
the era of precision medicine; well it
not literally inherited from parents, but
would increase human longevity more
was individualised before that. We
came from accumulated mutations
than anything else, followed by diet
believe we’re doing individualised,
within ourselves. “We know which genes
and understanding the risk for heart
precision medicine,” Venter said.
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Surgeons bicker as penis recipient impregnates girlfriend The world’s first recipient of a transplanted penis is still thriving 22 months later, reportedly having successfully impregnated his girlfriend, who is now in her final trimester. However, peers of his transplant team have begun questioning the long-term benefits of the operation. By Chris Bateman
D
r Elmi Muller,
patient, whose identity has been
unlike a solid organ transplant,
a former head of
jealously guarded by the clinicians, is
involve multiple tissues, resulting
the South African
one of 250 annual formerly hopeless
in a complex immunogenicity.
Transplantation Society
known penile amputees across
While microsurgical problems were
and head of Groote
the country: victims of failed ritual
overcome several years ago, one of
Schuur Hospital’s Transplantation
circumcision, with several reported to
the main obstacles which prevent
Services, queries whether the operation
have contemplated suicide, so powerful
the expansion of composite tissue
will ultimately prove worthwhile, given
is the cultural stigma. The intervention
transplantation worldwide is the
the long-term effects of the high-dose
is arguably particularly apt in South
immunological effect of these grafts
immunological suppression required.
Africa, where the prevalence of penile
on the recipients. Dr Muller said:“The
Citing abundant literature on difficulties
loss is way above the international
true challenge is weighing up the
faced by hand-transplant recipients,
average, especially in Xhosa-speaking
long-term risk of immunosuppression
she also openly ponders whether the
regions of the Eastern Cape. A
and opportunistic infection
21-year-old patient, from the rural
snapshot of the only available hospital
against the functional ability of
Eastern Cape, fully appreciated these
admission data for life-threatening
the transplanted organ”. The
“The true challenge is weighing up the long-term risk of immunosuppression and opportunistic infection against the functional ability of the transplanted organ” inherent longer-term risks beforehand.
post-ritual circumcision complications
risk of rejection was of particular
While conceding that the impact on
in that province stood at 200 patients
concern when the transplanted
the quality of life of the recipient might
in December 2001 alone, with 11
tissue contained skin and lymphoid
be excellent, she says “a few important
mutilations.
tissue that elicited a strong immune
questions” need answering by the Tygerberg Hospital transplantation team, led by urology chief Dr Andre van der Merwe.
It might work, but will it last?
response. Without appropriately strong immunosuppression, the potential for acute rejection and
Writing in a paper submitted to
irreversible destruction of the
the South African Medical Journal
donated tissue was high. Citing the
a multidisciplinary team at Tygerberg
(SAMJ) this August, Dr Muller
composite tissue transplantation
Hospital on 11 December 2014. The
said composite tissue transplants,
experience gained from 50 patients
The operation was performed by
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Focus | 49
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Plastic surgeon, Prof. Frank Graewe, urologist, Prof. Andre van der Merwe and immunologist Prof. Rafique Moosa
in 36 centres, who underwent hand transplantations worldwide, she said the desirable health outcome and expected quality of life years gained was reported to be “questionable” when weighed up against the risks of immunosuppressive therapy. “Penis transplantation is a life-
To illustrate her point, Dr Muller said that with uterus transplantation the (transplanted) uterus is removed after two pregnancies so that the patient will not be exposed to lifelong immunosuppression acceptance of a physician’s opinion,
risks but it should also consider the
enhancing rather than life-saving
even by sophisticated patients, “what
emotional effect of such a graft.
therapy and therefore the side
amount of risk should an individual
Another reason why composite tissue
-effects of these drugs remain of
be advised to accept for a non-life
transplantation remains limited in
particular concern as they contribute
threatening condition? Is a young male
many countries is because of limited
to significant morbidity with chronic
patient who lost his penis in a ritualistic
donor availability (from brain-dead
use,” she writes.
procedure able to weigh up his sexual
donors). South African organ donation
ability and normality with his long-term
rates are currently among the lowest
health in general?”
in the world and many cultural and
Uterus transplantation: discard after use
She said that protocols in hand
religious barriers exist which prevent
transplantation required very strict
families from consenting to organ
To illustrate her point, Dr Muller said
entry criteria based on physical as well
donation. The country’s public
that with uterus transplantation the
as emotional assessment. It is for this
education programmes were also
(transplanted) uterus is removed
reason that finger transplantation,
seriously lacking.
after two pregnancies so that the
for instance, is not taking place, as
patient will not be exposed to lifelong
the risks are judged to outweigh the
immunosuppression.
benefit of a single finger. Not only
Dr Muller also said that given
should the informed consent of the
the existing cultural and language
recipient include information on the
barriers and the general unquestioning
immunosuppression and physical
Culturally a penis is not easily donated Muller said it was “interesting to
note” that the family of the local
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Focus | 51 penis donor insisted on a penis
full Tygerberg psychiatric department
procedure would be delivered to the
reconstruction after death. “It seems
(in addition to the research ethics
people who needed it most by being
a strange request if the family was
expert used previously) for future
on offer in state facilities to vulnerable
completely comfortable with this
assessments, but the availability
groups that were unable to afford or
donation. Asking donor families for a
of plastic surgeons remains at a
access state-of-the-art healthcare.
part of the deceased person’s body
premium. He said it is difficult to
that has strong associations with body
schedule a transplant as “these things
success was the culmination of 4 years
identity has the potential to put them
come in as emergencies and the
of clinical and ethical preparation,
off transplantation completely and
donor is never planned”. His team
intensive laboratory work on cadavers,
this could negatively impact on organ
had hoped that the international
frustration in finding willing donors,
donation rates for solid organs in
publicity would lead to an additional
and careful groundwork to ensure that
South Africa,” she added.
funding boost from national
the procedure and its concomitant
Van der Merwe said the transplant
Responding to the criticisms,
government to the provincial health
lifelong immune suppressant
Van der Merwe conceded that they
authority, but this had not emerged.
treatment were replicable and
had encountered an immunological
His transplant group had been
affordable to all.
suppression complication in the
invited to submit a full paper to the
form of an atypical infection of the
prestigious Lancet medical journal in
of Tygerberg Hospital, emphasised
patient’s foot some months after the
the UK. This would include not just
that the procedure was not an
transplant. While it “gave us grey
the case support for their operation
answer to the ongoing loss of life
hairs” the infection had responded
but all of the difficulties and problems
and reproductive organs caused by
successfully to ciprofloxacin and
they encountered.
inexpert ritual male circumcision.
some creams and the patient was soon back at work. The only other post-transplantation problems were a urethral leak and a stricture problem, which were relatively easily resolved
Recipient “impeccably” briefed beforehand
Dr Dimitri Erasmus, chief executive
“While hugely significant, this is a life-changing, not a lifesaving procedure. The focus should remain on preventive efforts,” he said. The nine-hour operation was conducted
Dr Muller said composite tissue allo-
by a team led by Prof. Van der Merwe,
his patient had fully appreciated
transplantation for the restoration of
head of SU’s Division of Urology, with
the relative risks and benefits of the
congenital or acquired deformities
his university counterpart in plastic
operation, Van der Merwe replied:
was not new. Not only hand, but
surgery, Prof. Frank Graewe and SU’s
“Well, he made his partner pregnant
face, knee, trachea, uterus and
Department of Medicine chief and
very quickly after the transplant, so
oesophagus allografts had so far
transplant immunologist, Prof. Rafique
that probably shows that he does
been transplanted successfully.
Moosa, in attendance.
via a second operation. On whether
understand the longer-term risks.
The Tygerberg advance gives
A similar transplant procedure
The allegation that he may not have
hope to victims of botched ritual
was performed in Guangzhou General
understood is a bit paternalistic,”
circumcisions, survivors of penile
Hospital in China in 2006, involving
he added.
cancer and potentially even to men
a 44-year-old recipient who lost his
with severe erectile dysfunction. The
penis in an accident, but surgeons
long-standing critic who was “less
pre-and postoperative transplant
had to remove the organ two weeks
than supportive”, revealing that
team included Dr Nicola Barsdorf,
later when skin problems resulted in
provincial health authorities had
Head of Health Research Ethics at
an aesthetic setback. Graewe said
declined them permission to continue
Stellenbosch University (SU), who said
the Chinese used a very different
with transplants (there were nine
that the research team addressed the
approach, warming the donor penis
candidates). However, he stressed
issue of therapeutic misconception
up with an infrared lamp post-
that this had nothing to do with Dr
(i.e. the risk that a research participant
operatively, which had increased
Muller’s reservations but was the
may not fully understand the
the metabolic requirements instead
result of an all-inclusive cost analysis
experimental nature of the treatment)
of increasing the blood supply as
showing the transplantation to have
“impeccably”. The patient had
they had. However, the crucial
cost R300 000. After several months
been counselled repeatedly over an
difference appeared to have been
the province reversed its decision and
extended period about the potential
inadequate psychological work-up,
had since reinstated the programme.
risks and benefits. The transplant
he stressed, adding that the
The interdisciplinary team has more
team’s partnership with local public
recipient’s girlfriend had strongly
recently gained the backing of the
health structures also meant that the
objected to the result.
He described Dr Muller as a
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Collaboration on Ebola vaccine changes R & D forever By Chris Bateman
A
vaccine that is
which by the end of this August had
100% protective
claimed 11 300 lives, infecting 28 073
against the Ebola
people in Guinea, Liberia and Sierra
virus took less than
Leone. The death tally included 513
12 months of field
health workers among the 881 health
trials before scientists were confident
worker infections, a frighteningly high
enough to vaccinate all people at risk
proportion of heroic men and women
after close contact with an infected
professionals and lay workers who put
person – marking a turning point in the
themselves directly and repeatedly
history of research and development.
in harm’s way. In stark contrast to the
According to Børge Brende, Minister
speedy vaccine collaboration, only
of Foreign Affairs in Norway (one of
when isolated Ebola carriers popped
The death tally included 513 health workers among the 881 health worker infections, a frighteningly high proportion of heroic men and women professionals and lay workers who put themselves directly and repeatedly in harm’s way the vaccine’s major funders), if the
future outbreaks. He called the trial
up in Britain, Spain and America –
current results hold up, it may prove
outcome a “sensational result”, and
prompting near hysteria in the media
to be the silver bullet against Ebola,
put it down to an extra-ordinary
(particularly in America) – did the
helping to bring the current outbreak
and rapid collaborative effort driven
under-funded and poorly prepared
to zero and enabling control of all
by the urgency of the Ebola crisis,
World Health Organization (WHO) and
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
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System
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frican South A es Medicin ry Formula
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The ESSENTIAL MEDICAL REFERENCE for every healthcare professional! 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 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 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.
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GAZE TTE |
Email: dianes@hmpg.co.za NO VEMBER/D E C EMBER 2 0 1 5 Tax invoice to be posted on dispatch of order
The WHO declared Liberia free of Ebola virus transmission in the human population this August – having previously declared the country Ebola free in May – only to see the deadly virus resurface six weeks later How it works
explains Dr Feinberg. “So the vaccine
The vaccine used in the Guinea study
will likely be used in at-risk communities
is called VSV-EBOV, which the WHO
where and when it is required. However,
vaccine went from initial testing in
describes as a good microorganism that
it will also hopefully provide an
humans to demonstration of vaccine
has borrowed the guise of the Ebola
important additional approach to help
efficacy and safety in a large Phase III
virus but does not contain the virus. It
protect health workers who care for
study in Guinea in less than 12 months
tricks the body of the vaccinated person
Ebola-infected patients. We are doing
– a record time. “Normally, it takes
and triggers an immune defence against
additional research on the vaccine
about a decade or more for a vaccine
the Ebola virus, protecting the person if
to provide a comprehensive set of
to come to this point,” explained
they come into contact with someone
data to inform licensure decisions by
Prof. Peter Smith, an epidemiologist
who is infected. Mark Feinberg MD,
regulatory agencies and to facilitate
and specialist in vaccine trials from
of Merck Vaccines (which provides the
the development and implementation
the London School of Hygiene and
vaccine), says it works in a similar way to
of policy decisions by key international
Tropical Medicine and a key advisor.
live, attenuated vaccines against other
and national authorities,” he added. A
viral infections. He said the ability of
drawback of the current formulation of
Paule Kieny, who leads the Ebola
this vaccine to elicit prompt immune
the vaccine is that it must be kept very
Research and Development (R & D)
responses against the Ebola virus
cold in a tropical country with sparse
effort at the WHO, said that the work
following administration of a single
electricity. Future work will be needed
marked a turning point in the history
dose represented a vital attribute.
to develop a more thermo-stable
of research and development. “We
After VSV-EBOV is further studied and
formulation.
now know that the urgency of saving
licensed by regulatory authorities,
lives can accelerate R & D – we will
Merck plans to produce enough doses
assembled, embracing scientists,
harness this positive experience to
to control future outbreaks, stockpiling
physicians, epidemiologists and experts
develop a global R & D preparedness
them for other Ebola emergencies. At
from the WHO, Norway, Canada,
framework so that if another major
this point, the vaccine will not be used
Guinea, Doctors without Borders,
disease outbreak ever happens again,
like common vaccines such as those for
universities of Florida, Maryland and
for any disease, the world can act
polio and measles (which are routinely
Bern, and the London School of Hygiene
quickly and efficiently to develop and
administered). “Ebola is not a common
and Tropical Medicine. Says Dr John-
use medical tools and prevent a large-
infectious disease, and outbreaks arise
Arne Røttingen, head of infectious
scale tragedy.
in sporadic and unpredictable ways,”
disease control at the Norwegian
individual nations respond with slow but growing efficacy. The clinical development of the
Assistant Director-General Marie-
A massive vaccine trial team was
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Focus | 55 Institute of Public Health and chair of
minimise the time necessary to gather
that for a prolonged initial period
the trial’s steering group: “We knew it
more conclusive evidence needed for
seemed out of control, with the world
was a race against time and that the
eventual licensure of the product”.
seemingly looking on helplessly. The
trial had to be implemented under
The trial will now include 13- to
virus is spread among humans via the
the most challenging circumstances.”
17-year-olds, and possibly children
bodily fluids of recently deceased
Funding came from the Wellcome Trust,
from age six, on the basis of new
victims, and carriers with symptoms
Norway, Canada, the WHO and Doctors
evidence of the vaccine’s safety.
including vomiting, diarrhoea and –
without Borders. Merck scientists, along
Crucially, the vaccine has also been
in the worst cases – massive internal
with those from New Link Genetics
given to 1 200 frontline health workers,
and external bleeding. A country is
Corporation, an early developer of the
laboratory staff, cleaning staff and
considered free of Ebola transmission
vaccine, also gave detailed technical
burial teams.
once two 21-day incubation periods
support to field trial staff on the vaccine and its administration.
Virus ‘fenced in’ by vaccinating all contacts
Dr Bertrand Draguez, who has
have passed since the last known case
been leading Doctors without Borders
tests negative for a second time. WHO
efforts to find new tools to combat
declared Liberia free of Ebola virus
Ebola, said more data were needed –
transmission in the human population
for example, on how long the vaccine
this August, having previously declared
offers protection – but that the results
the country Ebola free in May, only to
From early this August the researchers
suggest a “unique breakthrough”
see the deadly virus resurface in six
began using a ‘ring’ strategy – based
in fighting the disease. “Even if the
weeks. The United Nations agency said
on that used in smallpox eradication
sample size is quite small and more
the country had now entered a 90-day
in the 1970s – to test the vaccine’s
research and analysis is needed,
period of heightened surveillance, and
effectiveness. “The premise is that by
the enormity of the public health
saluted Liberia’s “successful response”
vaccinating all people who have come
emergency should lead us to continue
to the recent re-emergence, when six
into contact with an infected person
using this vaccine right now to protect
people were infected, including two
you create a protective ‘ring’ and stop
those who might get exposed to the
who died. “Liberia’s ability to effectively
the virus from spreading further,” said
disease: contacts of infected patients
respond to the latest outbreak is due
Røttingen. Using the ring approach, when the Ebola epidemic in Guinea dispersed into smaller local outbreaks, the vaccinators and the trial team were able to move with it. It allowed the trial to continue and at the same time
A country is considered free of Ebola transmission once two 21-day incubation periods have passed since the last known case tests negative for a second time
contribute seamlessly to the control of
and frontline workers,” he emphasised.
to intensified vigilance and rapid
the Ebola outbreak. In some cases, the
Because the virus was concentrated in
response by the government and
clusters were whole villages. In others,
hot spots across the region, it made
multiple partners,” the WHO said.
the clusters were smaller sections of
more sense to focus on vaccinating
Liberia was the hardest hit in the West
towns and cities. By the first week in
those close to infected patients and
African Ebola outbreak, which began in
September, more than 4 000 close
frontline workers than to embark on
December 2013. Experts have warned
contacts of almost 100 Ebola patients,
a mass vaccination campaign, he
that even after 42 days have passed
including family members, neighbours
confirmed. “Health workers have
the danger is not over, considering that
and co-workers, had voluntarily
been fighting an unfair battle against
some Ebola cases are still surfacing in
participated in the trial. Until then, half
the Ebola [virus] and for the first time
neighbouring Guinea and Sierra Leone.
were vaccinated three weeks after the
there is a prospect of a tool that could
identification of an infected patient
protect lives and break chains of
after the very first outbreak, the number
and others straightaway, to allow
transmission,” said Draguez.
of cases was doubling every three
for comparison of the results. It was found that within 10 days the vaccine protected against the Ebola virus for
MSF heroEs initially ‘out in the cold’
By November last year, eight months
weeks, overwhelming thinly equipped facilities, with rotting bodies lying in the streets and countryside. However,
both groups. The randomisation was
Doctors without Borders were the first
10 months later (September this year)
stopped in early September for obvious
international organisation to treat and
case incidence had plateaued at
ethical reasons, with the WHO saying
follow-up Ebola patients in Guinea,
between 20 and 30 cases per week, for
it was “to allow for all people at risk to
putting them at the forefront of what
eight consecutive weeks, vastly boosting
receive the vaccine immediately and to
has been a torrid and fearful outbreak
the new vaccination programme.
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Atmospheric carbon dioxide concentrations and zinc deficiency
T
he global
at ambient CO2 concentrations
consequences
(375 - 384 ppm) using food
More evidence against antibacterial soaps
of increasing
balance sheet data for 2003
By Bridget Farham
By Bridget Farham
carbon dioxide
- 2007 from the Food and
concentration
Agriculture Organisation. They
H
and washing is known to be
in terms of climate change are
used previously published
now generally well known and
data from free air CO2
accepted. What is probably
enrichment and open-top
less well known is the effect
chamber experiments to
of increasing carbon dioxide
model zinc intake at raised CO2
concentrations on the zinc
concentrations (550 ppm, which
content of important food
is the expected concentration
crops such as barley, wheat,
by 2050). The difference
rice, soya and field peas. These
between the population at
most common. In the light of concerns over the safety
are an important source of zinc
risk at elevated and ambient
and efficacy of antibacterial products, the US Food and
in the diet for billions of people
CO2 concentrations – the
Drug Administration (FDA) introduced a ruling that
around the world.
population at new risk of zinc
Adequate zinc intake is the cornerstone of maternal and
the single most effective way to prevent the spread of infection. Largely through successful marketing, antibacterial soaps are widely believed to be particularly
effective and have proliferated on supermarket shelves. The label ‘antibacterial’ means that the soap contains ingredients with antimicrobial activity, and triclosan is the
manufacturers need to show that antibacterial soap is
deficiency – was the measure
more effective than plain soap and water. Researchers from
of impact.
Korea chose to focus specifically on triclosan to look at the
What emerged was that
efficacy of antibacterial soaps containing this ingredient.
to a paper recently published
the total number of people
Triclosan is known to be effective against bacteria,
in The Lancet Global Health,
estimated to be placed at risk
fungi and some viruses, but adverse effects such as
roughly 17% of the world’s
of new zinc deficiency by 2050
allergy have been reported. And there is also the
population were estimated to
was 138 million, with most of
problem of promoting antibiotic resistance.
be at risk of zinc deficiency in
those affected living in Africa
2011. Zinc deficiency increases
and South Asia – nearly
in vitro and in vivo. The soaps were exposed to 20
the risk of premature delivery
48 million in India alone.
bacterial strains, recommended by the FDA and
child health and, according
and reduces growth and weight
This model highlights a
Researchers compared two types of soap both
tested under conditions that replicate normal hand
gain in infants and young
previously unquantified effect
washing behaviour. Both products contained identical
children, while the mineral
on human health of increased
ingredients, but the antibacterial version contained
is also important in immune
CO2 emissions and should
0.3% triclosan. Results showed no significant difference
function. The global burden
be used to guide possible
in bactericidal activity between plain and antibacterial
of disease attributed to zinc
interventions.
soap when used for normal hand-washing. In vitro experiments did show significantly greater antibacterial
deficiency is high, with more than 100 000 deaths annually
Myers SS. Effect of increased
effects of the soap containing triclosan, but only after
from diarrhoea and pneumonia
concentrations of atmospheric
9 hours of exposure.
in children younger than 5 years
carbon dioxide on the global
attributable to zinc deficiency.
threat of zinc deficiency:
Use plain soap and water!
A modelling study. Lancet
Kim SA, Moon H, Lee K, Rhee MS. Bactericidal
estimated per capita per
Glob Health 2015. [http://
effects of triclosan in soap both in vitro and in vivo.
day bioavailable zinc for the
dx.doi.org/10.1016/S2214-
J Antimicrob Chemoth 2015;dkv275. [http://dx.doi.
populations of 188 countries,
109X(15)00093-5]
org/10.1093/jac/dkv275]
In this study, the authors
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
Research | 57
Digoxin – tried and tested? By Bridget Farham of observational and controlled data, including all studies published from 1960 to July 2014 that examined treatment with digoxin compared with placebo or no treatment. The objective was to clarify the impact of digoxin on death and clinical outcomes across all randomised controlled trials. There were 52 studies systematically reviewed, made up of 621 845 patients. In general those using digoxin were older and sicker than the controls. They had a lower ejection fraction, more diabetes and greater use of diuretics and anti-arrhythmic drugs. The meta-analysis included 75 study analyses, with a combined total of 4 006 21 patient years of followup. What was noticeable was that the baseline differences between treatment groups had a significant
D
effect on the mortality associated with digoxin, including markers of heart failure severity such as the use of diuretics. igoxin has been
consistent with these findings, showing
Studies with better methods and lower
in use since around
that digoxin improves symptoms and
risk of bias were more likely to report
1785, when it was
prevents clinical deterioration. However,
a neutral association of digoxin with
first introduced to
no such experimental trial data exist
mortality, and across all study types there
cardiology by William
for atrial fibrillation, and confusion
was a small but significant reduction
Withering. It is widely used for its positive
about whether digoxin is truly linked
in the all-cause hospital admission risk
inotropic effect in cardiac failure and
to adverse prognosis has led to the
among those using digoxin.
for its negative chronotropic effect
downgrading of digoxin in clinical
in atrial fibrillation – and, of course,
practice guidelines. Furthermore, the
digoxin? There are many who argue
the two conditions often go together.
finding that beta-blockers have no
against it, particularly because of its
However, its use has declined, partially
prognostic effect on patients with heart
narrow therapeutic index. But, particularly
because of concerns about safety after
failure and concomitant atrial fibrillation
in the sick elderly, its side-effects seem to
observational studies reported increased
has again led to questions as to what
be far more tolerable than more modern
mortality with digoxin. However, the
alternatives clinicians have available.
anti-arrhythmics. This analysis seems to
largest randomised controlled trial of
There is therefore a clear imperative to
suggest that there is still a place for this
digoxin in heart failure (the DIG trial)
define the place of digoxin in the clinical
commonly used drug.
showed neutral effects on mortality
management of both heart failure and
and a reduction in admissions to
atrial fibrillation and to guide physicians
Ziff OJ, Lane DA, Samra M, et al.
hospital compared with placebo,
and patients with an indication for
Safety and efficacy of digoxin:
as well as a decrease in mortality
treatment with digoxin.
Systematic review and meta-analysis of
among those with low serum digoxin
This study, published recently
So, should we or should we not use
observational and controlled trial data.
concentrations. There were also several
in the British Medical Journal, is a
BMJ 2015;351:h4451. [http://dx.doi.
smaller randomised trials that were
systematic review and meta-analysis
org/10.1136/bmj.h4451]
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
HPV vaccination and pregnancy outcomes By Bridget Farham
V
accination against the human papillomavirus (HPV) has very rapidly become part of the recommended vaccinations in the schedules of many countries, with millions of women receiving either the bivalent vaccine
against HPV types 16 and 18 or the quadrivalent vaccine against types 6, 11, 16 and 18. So far there are no major safety concerns for either vaccine, either from pre- or postlicensure studies or in reports from major drug and health bodies worldwide. However, as pointed out in a recent article in the British Medical Journal, in 2010 the data safety monitoring board of the randomised bivalent HPV vaccination Costa Rica HPV Vaccine Trial (CVT) raised concerns about the effect of the vaccination on the risk of miscarriage in the parallel PApilloma TRIal against Cancer In young Adults (PATRICIA). In a pooled analysis of the two trials, Wacholder and colleagues found no evidence supporting an increased risk of miscarriage for pregnancies conceived at least 90 days after vaccination using the bivalent HPV vaccine. Their observation of an imbalance in miscarriage rates for pregnancies conceived within 90 days from vaccination in the bivalent HPV vaccination arm compared with the control arm did not allow investigators to “completely rule out the possibility of an increased risk among pregnancies conceived within three months of vaccination�. This study was an observational long-term follow-up of a randomised double-blind trial combined with an independent unvaccinated population-based cohort in a single centre in Costa Rica. There were 7 466 women in the trial and 2 836 women in the unvaccinated cohort. Women in the trial were assigned to receive three
pregnancies conceived less than 90 days from vaccination. There was, however, an increased risk estimate for
doses of bivalent HPV vaccine (n=3 727) or the control
miscarriages in a subgroup of pregnancies conceived
hepatitis A vaccine (n=3 739). A crossover bivalent HPV
any time after vaccination, which may be an artifact of a
vaccination occurred in the hepatitis A vaccine arm at the
thorough set of sensitivity analyses, but since a genuine
end of the trial. Women in the unvaccinated cohort
association cannot totally be ruled out, this should
(n=2 836) received no vaccine. The main outcome was
nevertheless be explored further in existing and
the risk of miscarriage, defined as fetal loss within
future studies.
20 weeks’ gestation, in pregnancies exposed to bivalent HPV vaccine in less than 90 days and any time from
Panagiotou OA, Befano BL, Gonzalez P, et al. Effect of
vaccination compared with pregnancies exposed to
bivalent human papillomavirus vaccination on pregnancy
hepatitis A and pregnancies in the unvaccinated cohort.
outcomes: Long term observational follow-up in the Costa
The results showed that there is no evidence that the
Rica HPV Vaccine Trial. BMJ 2015;351:h4358 [http://dx.doi.
bivalent HPV vaccination affects the risk of miscarriage for
org/10.1136/bmj.h4358]
H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5
1
WHY USE • Gentle soft action • Not habit forming • Mixes easily with food and liquid
?2 • Once daily dose • Lactulose not absorbed to any significant degree.
WHO CAN USE
?2
• All ages: from 1 year to the elderly • Pregnant and breastfeeding women
NEW
200ml Syrup
33 %
ADDED VALUE References: 1. IMS, August 2015. 2. Duphalac Syrup Package insert S0 Duphalac Syrup®. Composition: Each 5ml of Duphalac Syrup contains 3,3 g lactulose. Reg.No. K/11.5/180. Pharmacological Classification: A. 11.5 Laxatives. Name and business address of license holder: Abbott Laboratories S.A. (Pty) Ltd. Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709. Tel: (011) 858 2000. Reg No. 1940/014043/07. For full prescribing information refer to package insert approved by the Medical Regulatory Authority. Date of publication of this promotional material: October 2015. Promotional Material Reference Number: Duphalac - ZAEDULAC140215. www.duphalac.com
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Struggling to keep your patients’ Allergies Away?
Choose Allerway 5 Levocetirizine benefits More effective in relieving nasal congestion with fewer side effects and better itch relief than cetirizine Superior potency for treating wheal, flare and itching than desloratadine Faster onset of action than desloratadine
1,2
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Adults and children 12 years of age or older, 1 TABLET DAILY
Keep Allergies Away with Allerway 5 Dr Reddy’s Laboratories (Pty) Ltd. Reg no. 2002/014163/07. Tel: +27 11 324 2100. www.drreddys.co.za
S2 ALLERWAY 5. Each film-coated tablet contains levocetirizine dihydrochloride 5 mg. Reg. No. 43/5.7.1/0815 Please refer to detailed package insert for full prescribing information. References: 1. Seema Rani, M.C. Gupta, Prem Verma, Dalbir Singh. A Comparative Study of Clinical Efficacy And Tolerability Of Second Generation (Cetirizine) and Third Generation (Levocetirizine) Antihistaminics in Seasonal Allergic Rhinitis. Available at: http://www.scopemed.org/?mno=30140. (Accessed 23/03/2015 2. Garg G, Thami GP. Comparative efficacy of cetirizine and levocetirizine in chronic idiopathic urticaria. The journal of dermatological treatment 2007; 18(1):23-4. 3. Kapp A, Demarteau N. Cost Effectiveness of Levocetirizine in Chronic Idiopathic Urticaria. Clin Drug Invest. 2006;26 (1):1-11. Accessed via Medscape 01/06/2014. Available at: http://www.medscape.com/viewarticle/521307 4. Passalacqua G ,Canonica GW. A review of the evidence from comparative studies of levocetirizine and desloratadine for the symptoms of allergic rhinitis. Erratum in.Clin Ther.2005 Oct:27(10):1669 ZA/05/2015/Allerway/001
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