Healthcare Gazette - 2015 Oct

healthcare gazette

OCTOBER 2015 • ISSN 2078-9750

Noakes’s adversaries get him in the ‘dock’

PG 30

Weighing up bariatric surgery PG 18 06

26

FEATURE

Pain management – global sound of silence

46

NEWS

Man impaled on crowbar saved by trauma team

56

FOCUS

Snipping away at the HIV pandemic, one foreskin at a time

HE ALT HCARwww.hmpg.co.za E GAZ ETTE | OCTOBER 2015

RESEARCH

Don’t eat margarine and other interesting snippets

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Contents | 03

C on t ent s FEATURES

06

Pain management – the global sound of silence

NEWS

26

Man impaled on crowbar saved by hospital trauma team

PROFILE

43

‘Changing sides’ SAMA unionist now Limpopo’s Health MEC

RESEARCH

56

Don’t eat margarine and other interesting snippets

FOCUS

12

Contested PMB amendments – “funders the chief

beneficiaries”

18

Weighing up bariatric surgery

30

Noakes’ adversaries get him in the ‘dock’

34

Load shedding – the new health crisis?

46

Snipping away at the HIV pandemic, one foreskin at a time

52

Exciting discovery offers more effective pain relief in RA

36

‘Populist politicians’ take aim at ‘soft target’ doctors

38

Inept drug supply management causing stock outs

54 – are men at greater risk?

Underdiagnosis of osteoporosis

40

A prince in high-tech shining armour to the rescue

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

57

Paracetamol – how much should we be using?

58

Herbal medicine – not a good idea before an anaesthetic

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

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

Healthcare in one shocking, amazing and resilient country

W

elcome to

on the populist bandwagon, going on

your new

television, radio and into print to pillory

Healthcare

hapless doctors doing the best they

Gazette (the

can under trying circumstances, with

new name for

vital equipment, either inappropriate,

Hospital Buyers Guide), the most widely

unmaintained or (often) entirely absent.

circulated magazine of its kind in the

When patient-deaths occur, politicians

country, containing news, features,

who suspend the doctors involved –

health-leader profiles, a focus on recent

and slam them in public – before a

research and treatment advances

preliminary probe has even begun, leave

and reviews of articles in top scientific

themselves wide-open to charges of

journals. This inaugural edition contains

populist opportunism and do lasting

a fascinating mix, ranging from the

damage to the very cause they were

fast-evolving political and economic

elected to further, namely improved,

fracas over who gets what share of the

more equitable healthcare for all.

private healthcare cake to exposing

How? Well, as national health minister,

a profound gap in medical training,

Dr Aaron Motsoaledi (one of the two

to an uplifting story of unthinkably

villains of this piece) so often says, fixing

successful trauma surgery. We also

the public healthcare sector is vital to

look at how dysfunctional supply-

the success of the impending National

chain management continues to risk

Health Insurance set-up. Alienating the

(and even cost) the lives of those least

already struggling people you have to

able to afford healthcare, with some

rely on to deliver on your constitutional

frightening impromptu case studies of

mandate is the equivalent of shooting

KwaZulu-Natal hospitals. With the best

yourself in both feet. The public may

monitoring and electronic systems in

end up thinking overworked public

the world, sans appropriately tailored

sector doctors are inept, uncaring and

human skills and training, this ongoing

abrasive – hugely damaging in itself

headache, (which brings out amazing

– but if doctors end up thinking the

innovation and adjustments among

politicians are these things, they will vote

our healthcare professionals), seems

with their feet. That is not something our

intractable. This makes it especially

shocking, amazing and resilient nation

hard to swallow when politicians jump

can afford. Enjoy the read!

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

SUB EDITOR Diane de Kock 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 and Paula van der Bijl PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens HEAD OF SALES AND MARKETING Diane Smith | +27 (0) 12 481 2069 | sales@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renee van der Ryst Azad Yusuf Benru de Jager Ladine van Heerden CUSTOMER SERVICE & 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 Printed by Paarl Print Publisher website: www.hmpg.co.za The Health and Medical Publishing Group is a wholly owned subsidiary of the South African Medical Association (www.samedical.org).

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Pain management – the global sound of silence

By Chris Bateman

W

orld-wide, and

Journal of Pain in 2012.[1] South

perhaps be better but guess what?

particularly in

America, Africa and the Indian sub-

They were as bad. We actually found

South Africa (SA),

continent proved to have “very, very

that vets in North America get 20

patients are

poor pain education at undergraduate

times more attention paid to pain

unwittingly forced

level”. Then, in 2012, the IASP shifted

management in their training, meaning

to suffer in silence because doctor

the survey spotlight to First-World

that animals get better treated there

training in formal pain management

countries, canvassing 242 medical

than human beings.” On home turf,

is almost non-existent, with the best

schools in Europe (The Appeal Study), [2]

a survey of SA’s nine medical schools

local medical campus undergraduate

only to find that pain management

revealed that only the University

training in pain management consisting

training consisted on average of about

of the Free State’s campus had a

A total of 17 European medical schools had no pain education of any kind, while the rest claimed to have integrated the subject into other training blocks, but were unable to quantify this. of “about four hours”, in a student’s

0.2% of medical students’ curriculum

dedicated full-time pain unit, backed

fourth or fifth year.

over their full six years of training.

by a “few hours-long” stand-alone

A total of 17 European medical

pain management course, something

This is according to Cape Townbased anaesthetist, Dr Milton Raff,

schools had no pain education of any

unique to that campus. “The others

a member of the International

kind, while the rest claimed to have

claimed it was integrated into their

Association for the Study of Pain

integrated the subject into other

other subjects, but the best I could

(IASP) Developing Countries Working

training blocks, but were unable to

find was via a Family Medicine block

Group, and former president of Pain

quantify this.

where undergraduates got three to

SA, who said the best country for pain management training is France. “It’s absolutely shocking,” he said upon describing how the IASP studied pain education in developing countries, publishing their findings in the British

USA – animals in pain better off than humans

four hours in their fourth year,” says Raff. “Overall students are absolutely under-equipped to manage both acute and chronic pain when they

“We thought that North America

leave university in SA. Globally and

(Canada and the United States) would

locally, there are no clinical end

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 07

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Medical training: “We are more than our diseased organs” – PROF RICHARD HIFT

I

n most medical curricula, undergraduate and postgraduate, there is a serious lack of exposure to non-discipline-bound, syndrome-centred experience and instruction, such as pain, depression and disability,

admits Professor Richard Hift, chair of the Medical Committee of Deans.

This is the consequence of a hundred years of narrowly specialty-

based training programmes, which by their very nature tend to focus on organ systems, rather than on the organism as a whole – in all senses:

Dr Milton Raff, a member of the

physical, psychological and social, adds Hift, who is also Dean of the

International Association for the Study

School of Clinical Medicine at the University of KwaZulu-Natal (UKZN).

of Pain (IASP), Developing Countries

“Sadly, Deans are not being petulant in stating that new topics can only

Working Group, and former president

enter into the curriculum if something else drops out – it is no secret

of Pain SA

that curricula are subject to serious, increasing overload.” He says the

solution does not lie in devoting “some extra hours” to orphan subjects

points prescribed that enable a newly graduated medical practitioner to deal with pain issues,” he asserts. A check on also provided little cause for celebration.

“Thinking colleagues have been urging this for decades – but medical

time pain clinic, to part-time pain

schools, worldwide, have proved themselves extraordinarily resistant

clinics at Stellenbosch and Cape Town

to attempts to bring about radical curricular reform in the clinical years,

universities and at the University of the

and to shift the focus away from department-led teaching to something

Witwatersrand. However, Professor

much less rigid and more generalist and holistic in nature.” A number

Richard Hift, chairperson of the

of initiatives were being explored around the world, and at UKZN,

Committee of Medical Deans, said

“we’ve just commenced planning our CCCP (continuous clinical and

there were now also active, enthusiastic interdisciplinary and research-productive

and community settings. Though our specialist departments will have an

Pietermaritzburg and Inkosi Albert

important contribution, it will be as enhancers of learning in this setting,

Luthuli Central Hospital in Durban.

not as the dominant providers. We hope to move away from organs

Raff said that unless you were an

and their disease to people and their problems – and this very much

anaesthesiologist “rotating through

includes enhanced competence in dealing with the physically failing

the pain clinic discipline in your post

body – it is a move away from narrow, technical excellence to another

graduate training it’s unlikely that as a

form of excellence, global proficiency in promoting, maintaining and

specialist in any other discipline you’d

restoring health”. Among many advantages of such a system would be

have ever worked in a pain clinic”. This

the space to ensure that important issues such as pain management were

meant that doctors were not clinically

comprehensively and holistically addressed over periods of months of

equipped to diagnose and treat pain

clinical experience, rather than as in the form of “a bolus of information

states, leading ultimately to poor management and patient dissatisfaction.

Far from just complaining, Raff and

injected into an already crowded curriculum”. One of the most “crippling fallacies” in medical education was that brief exposure to a topic (and

by brief, Hift means even exposure as long as the typical clinical block of

his associates at Pain SA (which acts

4 - 6 weeks) was sufficient to result in lasting changes in understanding,

as the local chapter of the IASP), have

performance and behaviour. “Sadly, there are many parallels among our

grasped the nettle, working through

traditional system for the training of postgraduates, our specialists.”

the examining body, the SA Colleges of Medicine, to create a postgraduate

(HPCSA) for registration. Asked when

community placement programme) curriculum, which will see students

working for long, uninterrupted periods in non-specialist hospital, clinic

pain clinics at Grey’s Hospital in

Professions Council of South Africa

they were centred around the problems experienced by people, and not the diseases which affected their organs. This was not a new sentiment:

It ranged from Bloemfontein’s full-

which will be submitted to the Health

of topics within the curricula. However, the only genuine and lasting

solution lay in fundamentally redesigning undergraduate curricula so that

postgraduate training in South Africa

sub-specialty in pain management

such as pain management. An intermediate step is the reprioritisation

In the meanwhile Dr Raff and his colleagues around the country were

to be congratulated on their important initiative. “There is little in human experience that is as debilitating as chronic severe pain, and it is indeed an area that deserves a much stronger focus than it has traditionally received,” said Hift.

this might become available he said HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 09 the aim was to begin training in 2017 but cautioned that with the current pressure on expanded medical training platforms, very few hospitals would be able to implement it. The Healthcare Gazette has established that probably only Helen Joseph Hospital in Gauteng and the Pelonomi Hospital in Bloemfontein will be likely to offer this training. When this was put to Raff, he reluctantly confirmed it.

With pain undertreated, undermanaged and poorly managed across the globe, the IASP chapters took on medical deans in their own countries, but the overarching response was that it would have to be at the expense of some other discipline. Summed up, Raff said in the ‘petulant response’ of: “OK, you want pain, we take out appendicitis.

So it’s recognised, but very little is done about it,” he added.

“We actually found that vets in North America get 20 times more attention paid to pain management in their training, meaning that animals get better treated there than human beings.” On home turf, a survey of South Africa’s nine medical schools revealed that only the University of the Free State’s campus had a dedicated full-time pain unit, backed by a ‘few hours-long’ stand-alone pain management course, something unique to that campus.

30 doctors enrolling. “It’s very basic but

albeit far short of what was required.

funding to train three African fellows

more than they’ve ever got,” says Raff.

He says the average private GP cannot

per annum in pain management (two

Focusing on pain as a disease and its

afford to see a patient for more than

Nigerians and one Mauritian at present),

diagnosis and management, the course

14 minutes, which is less than half

resulting in IASP certification after an

moves doctors away from the traditional

the time required by a patient in

intensive three- month course. Raff

view of pain as merely symptomatic.

pain. “You have to use a bio-psycho-

began the training in Cape Town with

The second course is more intensive.

social approach because the disease

assistance from Dr Rene Krause at St

Cleverly entitled, ‘Know Pain’, and with

itself has so many implications, not

Luke’s Hospice. The current incumbents

the intention of creating a ripple effect

the least of which is depression.”

are being trained at academic hospitals

via a ‘train the trainer’ programme, the

Equity in access to pain management

attached to UKZN and the University

first 20 doctors enrolled in mid-June for

remained a huge headache because

of the Free State. Two other ongoing

the nine modules on various aspects of

only the luckier patients would get

pain management trainings were also

pain. Sponsored by Pfizer through a non-

referred to a pain clinic which adopted

kicked off by Raff, the first in his current

restrictive educational grant, Pain SA

the correct holistic, multidisciplinary

capacity as chairperson of the pain

members deliver the course pro-bono.

approach. This meant that 80% of the

Pain SA had garnered some overseas

committee of the World Federation of Anesthetists (WFSA). Called Essential Pain Management (EPM) and sponsored by the WFA, the weekend course, split between Cape Town, Johannesburg and Pretoria, usually sees between 20 and

Holistic approach to pain sadly lacking

population would probably remain without any pain management, “unless you’re really lucky and end up in the Bloemfontein clinic – which

Raff said the various private initiatives

probably reduces the overall burden

should begin to have some impact,

by about one percent”. Raff stressed

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

that many State pain patients were

job in providing pain training. “It

little in human experience that is as

Workman’s Compensation Act cases,

is always difficult to add courses to

debilitating as chronic severe pain,

which meant that pain management

busy undergraduate curricula. Pain

and it is indeed an area that deserves

was automatically excluded from any

assessment and management is also

a much stronger focus than it has

funding benefits. “So we’re sitting with

taught in palliative care which needs

traditionally received,” he added.

a government and parastatals that

to be strengthened in undergraduate

don’t recognise that pain is a disease

curricula – we find it more effective to

1. Bond, M. A decade of improvement

entity on its own. So you have people

provide training to academic lecturers

in pain education and clinical practice in

dropping out of work and costing

and encourage them to integrate

developing countries. BJP 2012 (612):

the economy billions every year, not

this into their courses. In this way

81-84.

to mention the cost in the quality of

palliative care and pain management

2. Appeal (Advancing the Provision of

family life,” he said.

becomes part of current courses

Pain Education and Learning) Study: The

Partly because of the lack of

without having to find dedicated time

first-ever Europe-wide review of pain

training, doctors were reluctant to

in the curriculum. We’re encouraged

education for undergraduates in Europe.

use highly effective opioids such as

by the new Comprehensive Pain

Conducted by independent research

morphine, particularly with children,

Management division being set up at

company Adelphi Research in 15

whose pain management differed

UCT by Dr Romy Parker,” she added.

European countries, the APPEAL study

both emotionally and physically from

Professor Errol Holland, a former

involved the review of publicly available

adults. “Apart from the Red Cross

chair of the Committee of Medical

curricula from 242 undergraduate

Children’s Hospital (Cape Town), the

Deans, said current curricula were

medical schools. The study went

way kid’s pain is handled countrywide

so full that pain management had

beyond existing research by providing

is shocking,” he added.

become an ‘orphan’ discipline. “I

a more comprehensive analysis and

totally agree that it’s something so

understanding of pain learning. The

International Hospice and Palliative

fundamental that it needs to be

research was conducted from April

Care Association and CEO of its local

addressed properly,” he added. His

to September 2013 and is part of a

equivalent, said there was no doubt

successor, Professor Hift, said Dr

Europe-wide initiative aimed at raising

that training in pain assessment and

Raff and his colleagues around the

the profile and importance of pain

management must be improved

country were to be congratulated on

education. The research was funded by

and that Pain SA was doing a good

their important initiatives. “There is

Mundipharma International Limited.

Dr Liz Gwyther, chairperson of the

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Contested PMB amendments – “funders the chief beneficiaries”

I

If promulgated as proposed, ‘short-sighted’ changes to the Medical Schemes Act, in particular sections of Regulation 8 will financially hurt both beneficiaries of medical schemes and many private practitioners – via inadequate funder payments for prescribed minimum benefits (PMBs). By Chris Bateman

n spite of reassurances to

member. PMBs cover both chronic

scientific basis upon which he

the contrary by both the Board of

and catastrophic conditions suffered

is proposing the amendments.

Healthcare Funders and Dr Anban

by medical scheme members and are

Pillay, deputy director general for

intended to offer them a measure of

funders and politicians, was that

Health Regulation and Compliance

The oft-heard rhetoric, both from

financial protection. However, since the

“paying in full” (the existing and

Management at the National

‘provider-cost deficient’ 2006 NHRPL

historically much-contested regulatory

Department of Health (NDOH), most

list was drawn up there have been

wording for PMBs) amounted to

doctor groups remain deeply wary

numerous advancements in medical

a “blank cheque” for doctors.

of the arbitrary way in which medical

technology and procedures, which are

However, the truth was that this would

aid rates have been linked to the

not included. This means that unless

“unfortunately affect not only our

Feedback from the funding industry was that medical aids were only prepared to pay an “unsustainable” 30% of the costs of running a medical practice “deeply flawed” 2006 National Health

the list is updated, patients stand to

patients but also a lot of colleagues

Reference Price List (NHRPL) tariffs

no longer be funded for optimal and

in private practice by forcing them to

(adjusted for CPI).

up-to-date treatment.

charge prices at a level below the cost

The proposed legal amendment, induced by decade-long pricing strife and intransigence by most

Where’s the science? – SAMA

of running their practices”.

Grootboom contends that the minority of doctors whom funders

Dr Mzukisi Grootboom, chairman of

claim charge way more than the

sector, errs on the side of funders,

the 17 000-member South African

average medical scheme rates, or

allowing (but not obliging) them to

Medical Association (SAMA), says the

who fraudulently abuse the system,

negotiate tariffs with any healthcare

amendment is “difficult to explain”,

can easily be identified and held to

provider for which no co-payment

given that the Minister of Health failed

account. Using this minority to justify

or deductible is payable by the

to give the profession and patients the

legislation based on an outdated,

stakeholders in the private healthcare

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 13

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

A

Healthcare prices architect in last-gasp appeal

former legal adviser to the Council for Medical Schemes (CMS), who drew up the much-contested 2006 National Health Reference Price

List (NHRPL), has told healthcare providers and funders to ‘man-up’

and bury the hatchet – or face ceding pricing control to government.

Stephen Harrison, a nine-year veteran of the CMS (2000 - 2009), has

watched with growing exasperation for more than a decade as the players now suddenly and potentially most affected by his price referencing (in

terms of the new Regulation 8 amendment) continue to grandstand while failing to move towards any solution or mutual accommodation.

‘Get it together’- ex CMS lawyer,

Now a lecturer in emergency medicine at the Cape Peninsula University

Stephen Harrison

of Technology, Harrison bluntly told the annual Board of Healthcare Funders

(BHF) conference in Cape Town last month that the “degree of hopelessness

flawed and unscientific pricelist

and despair” displayed in the private healthcare industry’s submissions to the

would simply chase doctors out of

Competitions Commission healthcare enquiry invited “a radical interventionist

the profession. Any further erosion of

approach” from government.

the widening historic gap between

With the Regulation 8 amendment – due for enactment probably early

what medical aids pay doctors and

next year – now basing Prescribed Minimum Benefit (PMB) pricing on the 2006

what it costs doctors to deliver

NHRPL and, in his opinion, likely to benefit funders at the cost of patients and

services would damage overall

providers, his message to delegates was clear.

healthcare delivery, threatening the

“For goodness sake let’s actually resolve this impasse and come up with

very existence of private practice.

a practical solution. This is an opportunity for a small group of leaders in the

The private practice doctors, whom

health sector to come together. The publication of the amendment provides an

a reading of the latest Council for Medical Schemes (CMS) annual report

just introduced more subterfuge in the industry. We need a reality check ... and

80-150% of medical aid rates, would

to admit that we’re now at a crossroads.” Earlier he said private healthcare sector

“simply leave the profession, change

leaders needed to “stand up ... remember we’re all in this boat together”.

professions or go overseas”, he

While he accepted the bone-fides of the national health department in

claimed. Grootboom said feedback

introducing the legislative amendment to attain a greater degree of certainty in

from the funding industry was that

the market – and that it did not intend to increase co-payments by patients – the

medical aids were only prepared to

net effect of Reg 8 would be to create greater disparity between what providers

pay an “unsustainable” 30% of the costs of running a medical practice. He described those few GPs and (mainly) consultants who charged three or four times the medical aid rates as “outliers”, stressing that there were mechanisms in the current system to deal with them, “particularly those medical aids that have well-resourced IT platforms and can document practices that grossly abuse. There is also the Health Professions Council of SA (HPCSA) that can deal with unethical conduct,” he added.

Definition of “pay in full” remains unresolved

Health Minister, Dr Aaron Motsoaledi, chief architect of the proposed

opportunity to do that. I’m not optimistic that this (regulation) is a sustainable

way forward – historically we’ve never addressed the heart of the problem, we’ve

showed charged on average between

charged and what medical schemes paid. The gap cover market would burgeon and patients would either be denied care or revert to the public sector.

“You can argue the long-term reductionist effect on premiums (as schemes

save on PMB payout amounts), but the crunch will come when the consumer

gets ill and needs cover for PMBs. The original intention for PMBs has been lost.

If you go back to the memorandum on Medical Schemes Bill of 1998, this was to protect necessary and cost-effective care and not to shift patients arbitrarily to a

public hospital when their benefits are depleted.” The amendment would create a significant barrier to necessary care and flouted Section 2 in the Constitutional protection of Section 27 – that government would take reasonable, progressive legislative and other measures within its resources to achieve the progressive realisation of access to healthcare. “To me this is a retrogressive step in the

protection of rights of consumers. The main role-players are intractable and in significantly dug-in positions,” he stressed. The protagonists needed to move

from unilateral action, confrontation and ‘adversarialism’ to joint problem-solving; from competition for slices of the pie to a focus on enlarging the pie, and from entrenched respective positions to respective interests as departure points.

Harrison advocated ‘Codesa-type’ talks between the adversaries, saying South Africa had a rich history of resolving seemingly impossible disputes.

amendment to Regulation 8 of the

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 15 Medical Schemes Act, and the Board

behind the current Competitions

of Healthcare Funders (BHF) (which

Commission Healthcare Inquiry is to

warmly welcomes the change), claims

find reasons to justify price control.

doctors have “a blank cheque” under

They cite the current amendment as

the current Act. For a variety of

strong circumstantial proof of this and

complex legal reasons, no court has

have launched a patient advocacy

yet ruled on or engaged with all the

campaign outlining the “iniquitous

facts behind whether the legislator

history” behind the NHRPL from the

meant that medical aids must “pay in

time medical aids began in South

full” what the doctor charges or what

Africa (in 1947) to the “discredited”

medical schemes set as payment rates.

In practice it is the patient that most often suffers, paying for the shortfall regardless of whose interpretation pertains on the day. Motsoaledi’s draft tries to introduce greater certainty

Dr Anban Pillay, NDOH head of Regulation and Compliance

Pillay rolls out evidence of ‘abuse’

changes in 2006 to the proposed set-up. SAMA says the 2006 schedule was “anything but” the cost-based tariff it was disingenuously disguised as, and was implemented despite loud protestations by healthcare

Displaying a graph of local healthcare

professionals. Not only did it fail to

2006 NHRPL tariffs (adjusted for

provider billing for PMBs versus

reflect realistic prevailing costs at

CPI). Healthcare economist, Alex

non-PMBs, Pillay said the variance

the time, but the technological and

by linking medical aid rates to the

Archer described the proposed amendment as “retrogressive, undermining the whole ethos of the current system which is to protect families from massive medical expenses and prevent dumping on the state” van den Heever, warns that if passed

dramatically illustrated how providers

scientific advances in healthcare

the amendment will not only reduce

hiked their bills for PMBs: “It’s like

had resulted in more than 1 000 new

financial risks for medical schemes

walking into a restaurant and there

services becoming available since

but shift the cost burden further onto

are no prices on the menu. The waiter

2006. The net result was that “the

consumers, who have virtually no power

says, ‘choose what you like, but when

public needs to understand that

to negotiate with healthcare providers.

you leave I’ll decide what you have

doctors cannot be expected to charge

to pay’.” He said the current system

for their services at below the cost of

Social Security Administration

meant funders had to pay whatever was

running their practices”.

and Management Studies at the

billed, with no opportunity to negotiate.

University of the Witwatersrand

While he agreed that it was a small

School of Governance, said: “No

subset of healthcare providers abusing

country in the world expects

the payment system, he said this had

consumers to fight at the point of

“a massive impact” on the medical

service about a price for healthcare”

scheme involved. “It’s about dealing

and described the regulations as “a

with this behaviour and its impact. More

unintended consequence of this

gift to vested interests”. Pillay says

and more providers will start doing it –

is that those who remain in the

the aim of the draft regulation is to

until it becomes the norm. We want a

profession have to work longer hours

protect medical schemes from open-

reimbursement system that is fair to both

while still being unable to fund their

ended liability for PMB claims. At

patients and providers – and one that

retirement. A few (doctors) have

last month’s BFH annual conference

results in no co-payments,” he asserted.

even resorted to unacceptable and/

Van den Heever, chair of

Pillay claims the Council for

in Cape Town he told delegates

Amendment threatens private practice, as we know it “We have to make a living and the

or fraudulent behaviour, driven by

that a recent overview of private

Medical Schemes will protect

trying to make ends meet. The most

health insurance in South Africa

consumers by not approving medical

shocking thing about this is that

by the Organisation for Economic

schemes benefit packages if they

we’ve yet to see any evidence of

Development and Co-operation

fail to make adequate provision for

alleged widespread abuse or trends.

(34 countries with market economies)

members.

It would be far more helpful if the

showed that South Africa was second only to the USA in high prices.

Grootboom and his colleagues believe one of the chief motivations

NDOH, rather than play politics while dancing to the tune of different

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

funders, showed us the evidence,”

bills. While medical bills could

comments Pillay.

be submitted at present using

Dr Tony Behrman, CEO of the

multiple digital platforms, these

Independent Practitioners Association

summaries were not catered for in

Foundation, predicts that if passed

current medical scheme systems.

“as is”, the amendment will result in

There was “every possibility and

healthcare providers quickly agreeing

likelihood”, therefore, that schemes

to charge what medical schemes

would simply not reimburse medical

are willing to pay – because patients

practitioners “for months or years”

will simply refuse to pay out of their

pending finalisation of such reports.

own pockets. “The market will rule

BHF chairman, Dr Clarence Mini

and specialists and hospitals will find

These reports may also contain patient information requiring specific

their bills remain unpaid because the

the NDOH’s submission to the

consent for sharing such confidential

average South African can’t afford the

Competition Commission inquiry

information. Dr Grootboom said

excess,” he said.

spoke about an independently

this lent statutory authority to an

produced, cost-based tariff. This was

already worrying trend among

doctors nor hospitals were consulted,

at wide variance with the proposed

medical schemes to get doctors to

explaining that “this is our attempt to

legal amendment. “The department’s

perform administrative functions on

solve the problem – we’re wide open

health inquiry submission recommends

their behalf. SAMA was examining

to alternatives over the next three

that the state establish a negotiation

the legal validity of all the intended

months while the draft is open for

framework to support collective

amendments, as well as the practical

comment and input”.

bargaining using a cost-based

implications for both its members and

Pillay conceded that neither

The proposed legal amendment, induced by a decade-long pricing strife and intransigence by most stakeholders in the private healthcare sector, errs on the side of funders, allowing (but not obliging) them to negotiate tariffs with any healthcare provider for which no co-payment or deductible is payable by the member Grootboom said one of the key

structure as a point of departure,”he

their patients, and would soon be

failures of the legislative funding

said. Archer described the proposed

submitting this to the minister.

framework was the lack of a risk

amendment as “retrogressive,

equalisation fund and enforced

undermining the whole ethos of the

Mini, speaking at the end of the BHF

enrolment (where all employees have to

current system, which is to protect

conference in July, said BHF-initiated

contribute towards a fund to widen the

families from massive medical

task teams would focus on “inclusive

risk pool). “Somebody needs to monitor

expenses and prevent dumping on

solutions and consensus” during the

how much burden of disease a scheme

the state”.

draft amendment input period. He

is dealing with and then set aside a relevant risk fund. These are all key deficiencies – the minister, for political reasons, is actually missing the point.”

Patient advocacy group, Section 27,

Anaesthetists wake colleagues to another problem

BHF chairperson, Dr Clarence

appealed to all service providers to take part in creating a “road map” that would provide fair remuneration to all parties and avoid patients sitting with co-payments. The BHF has

Meanwhile the South African Society

been in tariff negotiations with the

a “step backwards” and diminished

of Anaesthesiologists (SASA) said

SA Dental Association (SADA) for the

patient access to healthcare services,

another amendment to Regulation

past 18 months and last month met

pushing more South Africans towards

5 of the Medical Schemes Act, while

with them to evaluate coding changes

dysfunctional public healthcare.

less publicly reported, required

and set up a risk advisory panel.

Several patient advocacy groups,

attending doctors to provide a

Pushed on when the “road map”

SAMA and the South African Private

“discharge summary” to medical

would be finalised, Mini said a draft

Practitioners Forum (SAPPF), believe

schemes for all ailments, including

would “probably be ready between

the amendment is unconstitutional.

PMB conditions, for hospital and

mid-September and mid-October”,

SAPPF CEO, Dr Clive Archer, said

doctor (potentially all medical)

describing it as “open-ended”.

said the proposed amendment was

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 19

Weighing up bariatric surgery The heavyweight division – a disease of lifestyle

By Taryn Springhall

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

B

One size doesn’t fit all

ehind the US and the UK, SA ranks third in the

only certain aspects of their lifestyle but their stress-coping mechanisms

A starting point to determine whether

too. Coping with stress is very deeply

prevalence of obesity

a patient is a candidate for bariatric

ingrained in an ‘old’ part of the brain

– a statistic that converts

surgery is to check their body mass

that people find very difficult to

to a sizeable portion of the 2.8

index (BMI), which will then guide

reprogramme and therefore resort

million deaths a year globally due to

strategies. “There’s still something

back to the same coping mechanisms

complications and non-communicable

of a generalised approach to obesity

time and time again.

diseases (NCDs) directly linked to being

where we try to squeeze all patients

overweight or obese.

into a one-size-fits-all treatment. A BMI

world with the highest

According to a report by the Health

of 25 - 30 classifies a patient as obese

Before and after – what the data say about bariatric surgery

Systems Trust (HST), more people die

and indicates that they will succeed

in SA from obesity than of poverty in

with a lifestyle programme and the

spite of malnutrition, impoverishment,

guidance of a dietician,” Prof. Tess

and high incidences of infectious

van der Merwe, CEO of the Centre of

success rates of bariatric surgery in

diseases such as HIV/AIDS and

Excellence for Metabolic Medicine and

treating obesity are still prevalent within

tuberculosis. Possible reasons for

Surgery in South Africa (CEMMS (SA))

the medical fraternity and the general

Misconceptions around the safety and

In spite of malnutrition, impoverishment, and high incidences of infectious diseases such as HIV/AIDS and tuberculosis, more people die in SA from obesity than of poverty the epidemic have been put down

and head of SASSO, endocrinologist

public. Prof. Tess van der Merwe, stressed

to increasing westernisation and

explained. “A BMI over 30 means

that these are a result of confusing

urbanisation of the population over the

that a patient is morbidly obese

accredited bariatric surgery with surgeries

last few decades, meaning that South

and will most likely need to be seen

performed in unaccredited facilities.

Africans are leading more sedentary

by a physician on a regular basis to

“Obesity treatment has been a

lifestyles, increasing their intake of

be screened for comorbid diseases

much exploited field of medicine for

readily available fast foods high in fat,

such as diabetes and hypertension in

decades around the world,” said Prof.

salt and sugar and consuming more

combination with other therapies to

van der Merwe, adding that the first

alcohol than most countries. A trend

assist with weight loss.”

gastric bypass was performed almost

mirrored by SA’s disease profile (World

Patients with a BMI over 40 are

30 years ago with much subsequent

Health Organization 2012) shows a

classified as super-obese and their

research improving outcomes. “It’s true

dramatic increase in modifiable NCDs

success rate for losing weight using

that accredited bariatric surgeries have

like diabetes, hypertension, strokes,

only behaviour modification is less

been around as long as unaccredited

certain types of cancer and heart

than 5%. For the morbidly and super-

surgeries but unfortunately the high

disease – all a result of obesity.

obese, the simple equation of calories

level of disapproval from the academic

in v. calories out is not the sum total

community, international federations

designed to combat the epidemic and

of their inability to lose weight. Vice

and medical practitioners is a result of

encourage balanced diets, exercise and

chairman of the South African Society

procedures like the jejunoileal bypass

regular health screenings that often

for the Study of Obesity (SASSO), Dr

(JIB) which were popular because

offer some form of incentive outside of

Andre Potgieter explained that in a

they were inexpensive. However, the

the improvements to their health and

patient with a BMI over 40, certain

mortality rate of 30% was so high that

well-being, aren’t proving effective for

physiological changes and biological

they are now banned in this country

everyone. As a result, bariatric surgery

drivers make weight loss extremely

and should not be associated with

has come under the spotlight as a

difficult, and have become automated.

accredited bariatric surgery.”

The upsurge of lifestyle programmes

viable medical answer to SA’s morbid obesity pandemic.

On a psychological level the patient is also required to change not

She explained that SASSO currently oversees 12 accredited Centres of

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Bariatric surgery success Chantel du Preez, 32, a medical technologist from Emalahleni, Mpumalanga

The reality is that treatment and costs related to treating obesity and its associated conditions threaten to torpedo any progress in improving health service delivery across both public and private sectors Excellence for bariatric surgery around

gland that controls appetite, (which are

and cognitive behavioural therapy for

the country that conduct four surgical

more powerful than the hormones that

his weight loss success, despite being

procedures (gastric bypass, gastric

signal that you have eaten enough) or

an ideal candidate for bariatric surgery.

sleeve, laparoscopic gastric band and

where the procedure itself has failed,

Having been overweight all his life, at

the Roux-en-Y gastric bypass) that

not the patient and they require a

152 kgs with a BMI of 43 and on chronic

qualify as having successful long-term

biliary pancreatic diversion (BPD).”

medication for diabetes and associated

outcome data that meet the criteria

The remaining 96% of patients

health issues, Berkman’s endocrinologist

of international associations and the

can be categorised into profiles: 30%

recommended the surgery after having

academic community. These 12 centres

of patients exceed their physicians’

tried numerous diets.

are required to submit patient data as

expectations, 30% don’t put in the

part of their accreditation. According to

maximum effort and don’t see the

people who can’t lose weight any other

“Surgery is a viable option for

Prof. van der Merwe, these facilities are

full benefits of surgery but they

way,” said Berkman. “I had to meet

on par with international standards and

also don’t return to their previous

the criteria set out by my medical aid

the data show that only 4% of patients

weight. The remaining 30% will have

to qualify for surgery which included

will fail in their endeavour to lose

to be monitored by their surgeon or

seeing a number of health professionals,

weight after gastric bypass surgery.

physician on a six-monthly basis for

attending support group meetings and

their lifetime to help them stay on

following a low-calorie diet.”

“If a patient does fail to lose weight after surgery, in 9 out of 10 cases it’s

track and committed.

because they have not changed certain contributing factors to their lifestyle and stress-coping mechanisms. Sometimes

Banting v. bariatric

Berkman was waiting for a surgery date when he heard about Prof.

Noakes’s low carbohydrate high fat (LCHF) diet and implemented the

While short-term dietary-induced

recommend changes to his diet. “My

severe form of depression that reverses

weight loss in the morbidly obese

weight loss accelerated dramatically and

their ability to lose weight,” said

is possible, it is unusual for it to be

I found it much easier to maintain losing

Prof. van der Merwe. “In exceptional

sustained. An exception to this rule is

weight than it had been in the past.”

cases failures in gastric bypass can be

PR professional Brian Berkman, who

attributed to patients who develop

credits a combination of Prof. Tim

and went onto to lose 70 kgs, that he

extremely rare tumours in the pituitary

Noakes’ much publicised ‘Banting’ diet

has kept off for two years and is no

they turn to alcohol or develop a

Berkman cancelled his surgery

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 23

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

to addiction has never been proven.

What we do know is that because of triggers in the limbic system, some people under certain circumstances will repeatedly reach for sugary foods because it has become an automated response of coping with stress signals.”

Prof. van der Merwe concluded that: “For many, the answer to losing weight is in how they can implement cognitive behaviour skills to undo the automated pathway in the limbic system. And for that they need the help of a therapist.”

Cape Town PR Executive and former food critic, Brian Berkman, pre-Banting diet and post-Banting diet

Economies of the scale – weighing up the cost of bariatric surgery

longer on medication for diabetes.

that it was an extremely valuable tool

While he no longer needs surgery, he

in his weight loss. At 82 kgs, Berkman

says that he would reconsider surgery

now enjoys an active lifestyle and as a

the perceived cost and insurance cover

should he put the weight back on.

previous restaurant critic for the Cape

for weight loss surgery are prohibitive

Berkman endorses the premise that

Times newspaper, has built a new career

factors in pursuing the option.

hidden sugars in carbohydrates should

and life that doesn’t revolve around food.

Historically, weight-loss interventions

be replaced by a higher fat intake.

“I was never advised by any of the dieticians I had seen to completely

A balanced approach

For those struggling with morbid obesity,

were regarded as cosmetic because obesity was not considered a medical condition in its own right. However, in

Prof. Tim Noakes’s claims around

recent years the relationship between

carbohydrates very strictly because

the consequences of a traditional

obesity and non-communicable diseases

of the long-standing belief that a

balanced diet has sparked widespread

has received increasing attention

balanced diet includes carbohydrates.

debate from the medical fraternity.

and according to clinical specialist

But the solution for me is to have no

Prof. Tess van der Merwe summarises

at Discovery Health, Dr Noluthando

bread, no added sugar and be very

by saying that people should be wary

Nematswerani, the cost of weight-loss

aware of where sugars are present in

of extreme diets and that moderation

surgery may also be a contributing factor

my diet.”

is still the basis of any good diet.

to the perceived reluctance of medical

remove sugar from my diet and to limit

“The professionals who really know

Berkman believes he made the

schemes to fund it.

right choice by opting for the diet over

and understand this field would have

As one of the first medical schemes

the surgery. “People who think that

given you exactly the same message

to cover weight-loss surgery, Discovery

surgery is the magic bullet to never

around a balanced diet for the last 20 - 30

Health considers patients against their

picking up weight again are mistaken.

years because there is research to

qualifying criteria for surgery, such as

Eating post-surgery is very restricted;

support this information,” said van der

the member’s BMI and obesity-related

similarly, LCHF is effective for people

Merwe. “My advice to people is to not

comorbidities. “It is both important

who stick to the diet. Sticking to the

label good carbohydrates as the enemy.

and clinically appropriate for all

diet meant I didn’t have to cover the

Potatoes, brown rice, beans, lentils and

patients to undergo a rigorous work-up

cost of surgery and I’m able to keep

brown bread and other unprocessed

process in multidisciplinary Centres of

my weight down by the choices I’m

carbohydrates that don’t contain a lot of

Excellence. This team should include an

making rather than by being limited

refined sugars and saturated fats are not

endocrinologist, dietician, psychologist/

by a smaller stomach pouch or a less

contrary to a good diet.”

psychiatrist and the patient, amongst

absorptive digestive tract.”

In addition to the LCHF diet,

In response to Noakes’s claims that hidden sugars in carbohydrates

others,” said Dr Nematswerani.

While Discovery Health classifies

Berkman worked with a cognitive

are the source of the sugar addiction

bariatric surgery as an elective process, Dr

behavioural therapist to help him make

that keeps people overweight, Prof.

Nematswerani emphasised that bariatric

different choices and said he found

van der Merwe said, “A sugar pathway

surgery is not considered an easy fix

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Feature | 25 for obesity. “Patient education is very

2017. However, all of these surgeries

successful through innovative and

important when it comes to weight-loss

are performed in the private sector.

meaningful partnerships between

surgery. Patients need to understand

At this year’s Bariatric Meeting,

government (national and provincial),

the risks associated with surgery and be

Dr Victor Ramathesele, the first team

service providers and suppliers,

informed about alternatives. Surgery is

doctor for Bafana Bafana and host

funders (medical schemes, insurers and

not for everyone.”

of numerous healthcare talk shows,

donors) and the private sector.

Prof. van der Merwe echoes the

gave a presentation to explore the

His first option was based on a

notion that medical aids are responsive

possibility of extending bariatric

Corporate Social Investment concept

in treating obesity with surgery in

surgery to the public health system.

that could be adapted to manage

appropriate cases. “Our data show that 25% of patients will fund their

According to Dr Ramathesele, SA has a double helping of the problem

obesity with various partners including SASSO and the South African Society

Bariatric surgery costs about R150 000 and, according to Dr Potgieter, this cost can be recovered by medical aids and the patient within four years through savings on medicine and other interventions to manage co-morbidities surgeries, either because they don’t

of obesity – first the affluent who have

of Endoscopic Surgeons, among

have medical aid or are not on the

access to processed, highly refined

others. The overall idea would be to

appropriate plan. But by and large the

food and lead a sedentary lifestyle and

provide training and equipment to

vast majority, about 75% of patients,

then the poor working class who, due

public sector providers to treat state

will get 80% reimbursement from the

to a lack of education, resources and

patients using subsidised equipment

medical aid against 20% co-payment,”

food choices consume poor-quality,

and consumables and jointly developed

said Prof. van der Merwe.

processed foods. A 2009 study of

treatment protocols. A solution that Dr

When asked about the possible

supermarkets in rural SA showed that

Ramathesele believes will improve access

cost savings in bariatric surgery against

healthy food costs up to 110% more,

to those in need, to a necessary but

treating chronic illness over the long

limiting healthy food choices among

expensive service that can be expanded

term Dr Nematswerani said: “The

this group. This leaves behind the stark

nationally to reach more patients.

literature suggests that bariatric surgery

reality that the cost of treating obesity

may be associated with improved clinical

and its associated conditions threatens

a centre of excellence within the public

outcomes in obese type 2 diabetics in

to torpedo any progress in improving

sector and a trust to subsidise patients

the long term. Although preliminary

health service delivery across both the

who have insufficient resources, such

Discovery Health data support this to

private and public sectors.

as low medical aid options, and the

a certain extent, the impact on costs

Some of the prohibiting factors

The second option was to establish

employed but uninsured. Again, this

over the long term continues to be

to providing bariatric surgery in the

option would harness partnerships with

monitored and balanced against the

public system include the lack of

academic institutions and suppliers

upfront surgery costs.”

accredited facilities and providers

of equipment and consumables and

in the public sector, the high initial

requires a very robust procurement

costs for establishing the service

process with suppliers and service

and training staff and competing

providers and transparent tariff

Affordability within the public sector

health priorities. Dr Ramathesele

negotiations with medical schemes.

Bariatric surgery costs about R150

reiterated that despite the obstacles,

The challenge is the initial set-up costs for

000 and according to Dr Potgieter,

the poor are possibly the majority of

such a centre, estimated at R10 million.

this cost can be recovered by

the morbidly obese and due to the

Dr Ramathesele concluded by

medical aids and the patient within

existing burden on the public health

saying that: “Obesity is a problem with

four years through savings on

system, offering bariatric surgery has

socio-economic implications both in its

medicine and other interventions to

economic benefits for all concerned.

cause and effects. The NDP, Strategic

manage comorbidities. Currently,

In his presentation, Dr Ramathesele

Plan and National Plan indicate some

there are around 650 bariatric

outlined two possible options to

priority from government to tackle the

surgeries performed in South African

provide bariatric surgery services to

treatment of obesity which must now

CEMMS(SA)-accredited facilities each

uninsured and indigent populations.

be leveraged but it is for the private

year – a number that is expected to

Both options were based on the

sector to initiate and government

increase to around 1 000 per year by

premise that they could only be

will follow.”

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Miracle survivor Daniel de Wet and his wife Lizl on day 15 of his 19-day recovery at Netcare Milpark Hospital

Man impaled on crowbar saved by hospital trauma team A cool-as-a-cucumber Carltonville mine engineer walked out of hospital 19 days after being impaled from groin to upper-back by a two-metre, 2 cm-thick industrial crowbar – his survival and recovery due to his presence of mind and world-class trauma surgery. The crowbar pierced three of his body cavities: his pelvis, abdomen and chest, missing his heart by 5 cm and destroying a kidney. By Chris Bateman

D

aniel de Wet slipped

to stir up mud in an underground dam

while helping with a

he and a fellow miner were washing out.

trying to keep the other guys calm and

production breakdown

He said he tried to stand up on a metre-

because of the adrenaline rush I had

3.5km underground at

high suction pipe but slipped. To his

absolutely no pain at first. There was

the gold mine this July.

“I was talking the whole time,

utter disbelief, he saw that the gwala had

(initially) only one guy with me, he

He was using the sharpened metal

penetrated between his legs, coming out

became very scared and didn’t know

crowbar, commonly known as a ‘gwala’

just below his shoulder blade.

what to do. I told him to calm down and

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

News | 27 call for help on the two-way radio.” In minutes, a rigger crew with a first-aid pack and stretcher arrived. “They didn’t know how to put me on the stretcher because of the way the gwala was sticking out of my back. I told the guys: ‘Calm down, let’s think what to do’.”

Accustomed to keeping a cool head in dangerous situations by dint of being a member of the mine’s rescue team and trained to deal with emergencies, De Wet instructed the riggers to perch him on the stretcher in a sitting position – the only way he could be carried ‘safely’.

Calm, slow and steady does it

They carried him through knee-high muddy water for some 40 metres in order to reach a station area, where a cage lift was waiting to hoist them to the surface – no mean feat as the bottom of the gwala stuck out below Mr De Wet’s feet.

“On 34-level sub-shaft, mine paramedics met me and gave me morphine for the pain. I remember nothing further, until I woke up two weeks later in Netcare Milpark Hospital,” said De Wet. Fortunately he was in highly professional hands – both at the mine and the hospital. Having been brought up

Where the crowbar entered Daniel de Wet’s body

”I was talking the whole time, trying to keep the other guys calm – because of the adrenaline rush I had absolutely no pain at first. There was (initially) only one guy with me, he became very scared and didn’t know what to do. I told him to calm down and call for help on the two-way radio.” to surface level in three different lifts at a pace that would ensure that he did not suffer adverse decompression effects (more commonly known in deep-water diving as ‘the bends’) he was manoeuvred into a waiting Netcare emergency helicopter, the crowbar tearing the upholstery to accommodate the human ‘kebab’. Nearly four hours after the underground accident, the helicopter touched down at Netcare’s Milpark Hospital emergency department – one of only two Level 1-accredited trauma units in South Africa.

Mining engineer Daniel de Wet prior to his first operation

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

The hospital’s Trauma Director of Netcare Milpark, Prof. Kenneth Boffard, says he had “no idea of what was coming to him, except that it was an impalement”.

He began assembling an appropriate operating team and readying the Lodox low-dose, full body scan X-ray machine to obtain a precise picture which would enable them to plan their surgery. Asked about his initial reaction when confronted by the sight of a person with a metal pole stuck vertically through his body, an unflappable Prof. Boffard responded; “At first it was ‘good grief’ but then I had to apply my mind to the technical problem in order to decide on the best course of treatment”. De Wet was anaesthetised lying on his side. Prof. Boffard explains: “We needed to get him in a position that would enable us to operate, but with the gwala sticking through his back, it was rather awkward. Once he was under, we got some strong paramedics to pull out the gwala by about half a metre so that it was flush with his body. This allowed us to lay him on his back. Fortunately, the gwala had been pressing on the blood vessels and this pressure prevented too much blood loss.” Two surgical teams scrubbed in: one concentrating on the abdomen and one on the chest area.

Staggered operations ensured survival

“We operated twice on Mr De Wet. In order to safeguard the patient, given the traumatic nature of his injury, our first operation could not last any longer than 60 minutes. During this procedure we did massive damage control in order to stem the bleeding and to contain any form of contamination caused by his injury.

Netcare is the only private hospital group in South Africa to have obtained independent classification of its trauma unit by the Trauma Society of South Africa, using the internationally recognised criteria.

“This is a technical exercise in that one has to know when to stop so that the patient can live to fight another day,” explains Prof. Boffard. “During the next, more major procedure (36 hours later when the patient had fully stabilised) extensive repair work was undertaken. This methodology was

Mining engineer Dan de Wet’s Lodox scan

crucial to full recovery.” De Wet says his wife was distraught when she heard of

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

News | 29

Another Lodox view.

Note the crowbar’s proximity to the heart

Prof. Boffard explains: “We got some strong paramedics to pull out the gwala by about half a metre so that it was flush with his body. This allowed us to lay him on his back. Fortunately, the gwala had been pressing on the blood vessels and this pressure prevented too much blood loss.” the accident and one of his colleagues

him outside the intensive care unit (ICU).

“Everyone thought I would resign from

immediately drove her to the hospital.

The sisters, however, allowed them into

mine rescue, but I won’t. I have already

“At the hospital, Prof. Boffard met my

the ICU for 5 minutes and they prayed

attended to three fires underground

wife, and she described his manner as

around their colleague. Says De Wet:

since the accident,” De Wet says.

very calm and reassuring. He reassured

“Even though I was unconscious, they

her that if I arrived at the hospital alive, I

told me later that the tears were rolling

chromed and mounted on a stone

would go home alive.”

down my cheeks when they prayed”.

with a bible verse on it – and De Wet

Mrs De Wet waited anxiously as the

Once he regained consciousness,

His employers have had the gwala

plans to donate it to Netcare Milpark

two surgical teams, led by Prof. Boffard

he had trouble sleeping and felt

Hospital. What I have learnt from this

and Prof. Elias Degiannis, another re-

anxious. “One of the nurses was so

whole experience is: “You must believe

nowned trauma surgeon at the hospital,

kind to me, she would talk to me until

in miracles every day.”

worked to save her husband’s life. Once

I fell asleep. The hospital’s doctors and

the gwala was pulled completely free of

nurses went above and beyond the call

pened according to the textbook. “We

Mr De Wet’s body, the doctors saw that

of duty, not just treating my physical

were well prepared to deal with the

the impalement had caused significant

injuries but also showing great compas-

incoming patient, the mine recovery

damage, destroying one kidney and

sion for my state of mind and my wife’s

team were excellent and Mr De Wet

damaging the small bowel and nu-

emotional wellbeing.” Although he lost

had the benefit of being treated at a

merous blood vessels. After the initial

a kidney, he made rapid progress and

world-class, level-one trauma unit.” No

surgery, Prof. Boffard came out of the

was able to walk after being transferred

doubt the patient’s level-headedness

theatre to speak to Mrs De Wet. “When

to the high care unit, being discharged

was another strong contributing factor.

Prof. Boffard came out with the gwala in

only 19 days after his dramatic accident.

his hand, my wife says she didn’t know

Boffard said the 19-second Lodox scan

gery at Witwatersrand University and

how to thank him,” said De Wet.

revealed what a ‘miraculous’ escape De

president elect of the elite 60-member

Wet had. “It was the longest impale-

international surgery group, said the

ment I’ve ever dealt with, never mind

most common impalements he and his

the survival.” He revealed an added

local colleagues dealt with were “front-

The couple are immensely grateful at

factor that contributed to his patient’s

to-back” usually caused by someone

what Mr De Wet described as “absolute

recovery: De Wet is a seven-time

intending grievous bodily harm,

caring – Prof. Boffard and his wife also

Comrades marathon athlete and was in

burglars jumping out of buildings onto

gave my wife a lot of support”.

superb physical shape.

fences or poles (mostly vertical) and

Going beyond call of duty

The rescue team from the mine

He has since returned to active

Prof. Boffard said everything hap-

Boffard, emeritus professor of sur-

motorcyclists flung off their seats in

came to the hospital to offer support,

duty at the mine and continues to

accidents (normally confined to the

telling the nurses they wanted to pray for

serve on the mine rescue team.

chest cavity).

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

News | 31

Noakes’s adversaries get him in the ‘dock’ The protagonists in the latest clash of the dieting titans (conventional versus banting diets) agree on one thing; that asking an esteemed panel of Professor Tim Noakes’s medical peers to rule on whether his cyber-advice on breastfeeding babies was ‘unprofessional conduct’ may prove a turning point for nutritional guidance. By Chris Bateman

T

he hearing, postponed

• and finally, what constitutes best-

sion, in that during the period between

in Cape Town early in

practice complementary feeding rec-

January 2014 and February 2014 you act-

June after Noakes’s

ommendations for infants and children?

ed in a manner that is not in accordance

lawyers questioned the proper constitution of

While the last question is not related

with the norms and standards of your

directly to the ‘charge sheet’, medical

profession in that you provided uncon-

the Medical and Dental Professional

professionals in related disciplines will be

ventional advice on breastfeeding babies

Board’s (MDPB) Professional Conduct

scouring upcoming hearings’ evidence

on social networks (tweet/s)”.

Interestingly, there is no reference to Noakes’s Twitter advice being harmful or dangerous in the charge sheet, something the ADSA president, Claire Julsing-Strydom (who brought the original complaint in her personal capacity) has been publicly claiming.

This could open the way for Noakes to bring a counter-claim.

Did he diagnose and treat or merely ‘advise’?

Committee, will focus on three issues raised by Noakes’s cyber-twitter. In it, he advises a mother that when weaning

In terms of the Health Professions

her baby, it should be via a low-

Council of South Africa (HPCSA) rules,

carbohydrate, high-fat (LCHF) diet.

doctors are not allowed to make a di-

The issues are basic, one of them with the potential to set a precedent

agnosis or offer treatment online – even

on how social media should be used

though they may give advice or share

by health professionals. Did Noakes

opinions online. It is here the rub lies; was Noakes ‘diagnosing and treating’

act unethically by: • providing information outside the

Professor Tim Noakes

or simply advising or opining – in line with cyber technology’s all-pervasive

scope of the practice for which he is for answers – and hope that the commit-

‘democratisation’ of fields previously

special interest in nutrition)

tee makes substantive findings on it. The

considered the sole domain of science

• giving one-on-one nutritional

charge sheet claims Noakes is “guilty

and ‘off limits’ to all but the relevant

advice on social media to a

of unprofessional conduct or conduct

specialists? Perhaps most importantly

patient he had not assessed.

which, when regard is had to your profes-

– and this is where his critics bang their

registered (general practice, but with a

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

advising the mother to wean her child onto LCHF foods. “By implication I was saying that the child should not be weaned onto traditional high-sugar, high-carbohydrate processed cereals,” he says. He added that high-carbohydrate, processed food diets became the norm in the USA after 1936, via the Gerber baby foods company, which is now a subsidiary of the Nestlé Group.

“Ironically, these were the first ‘industrial’ (i.e. highly processed foods)

ADSA argues that the advice, via Twitter, is out of kilter with both international and national feeding guidelines for infant and young child nutrition drums the hardest – is he causing harm (in this specific instance, but they claim far more generally)? Interestingly, there

Noakes ‘out of line’ with paediatric guidelines

and they led in time to the highly processed foods that we now eat and think healthy, in part because as infants our taste was conditioned by our early exposure to these non-foods.”

He wants to encourage people to understand that they will be healthier eating ‘real’ foods, not fake industrially processed staples. This change needs

Julsing-Strydom, speaking to journal-

to happen from birth, he emphasises.

being harmful or dangerous in the

ists beforehand, said infants are not

Noakes told Healthcare Gazette that

charge sheet, something the Associa-

supposed to have such a high intake of

he personally wrote the 20 000-word

tion for Dietetics in South Africa (ADSA)

protein (Noakes has consistently said

scientific chapter in Raising Superheroes

president, Claire Julsing-Strydom (who

the LCHF is not a high-protein diet).

but that “every word and every sen-

brought the original complaint in her

She cites several studies showing that

tence” was checked by his co-author

personal capacity) has been publicly

even in infant formulas the amount of

to ensure that it was supported by

claiming. This could open the way for

protein has had to be reduced because

scientific evidence. He claims that his

Noakes to bring a counter-claim.

it impacted on obesity later in life.

chapter argues “in great detail and

is no reference to Noakes’s Twitter advice

“A baby’s little kidneys just wouldn’t

with the support of more than 130

tee’s findings will provide clarity on

manage,” she adds. ADSA argues that

scientific references” giving the

issues that will “advance healthcare

the advice, via Twitter, is out of kilter

8 reasons why infants should be

in the best interests of the public

with both international (WHO Guiding

weaned onto real foods.

and clear any public and profes-

Principles for Complementary Feeding

sional confusion”. A guilty finding

of the Breastfed Child) and national

that the professional conduct committee

could cost the unperturbed Noakes

(South African Paediatric Food-Based

finding could be a “turning point in the

his license to practise as a doctor.

Dietary Guidelines) feeding guidelines

debate about what our infants, and in

That might get him to pull in his

for infant and young child nutrition.

turn adults, should be eating”.

Julsing-Strydom says the commit-

Noakes, who has been researching

horns, reducing the growing public

Noakes agrees with Julsing-Strydom

The hearing was postponed to

health threat that, according to his

infant nutrition for the past four years,

23 November at the Newlands Hotel

critics – many of them internationally

is about to release the follow-up book

in Cape Town after the committee

respected academics in endocrinolo-

to the The Real Meal Revolution (his

chairperson, Advocate Joan Adams,

gy, diabetic medicine and cardiology

guide to the Banting diet) entitled

conceded to Noakes’s lawyers that her

– he allegedly represents.

Raising Superheroes, which deals

committee had no powers to deviate

solely with infant and child nutrition.

from the HPCSA Act and its regula-

the hearing and cannot wait for the

The book is co-written with Bridget

tions. These required a third person

cross-examination of his latest detrac-

Surtees, a registered dietitian and

on her committee to be registered

tors to begin. The mother to whom he

a member of ADSA, who has been

with the MDPB and to be in the same

gave the cyber-advice did not follow it,

practising child and infant nutrition

discipline as Noakes. “We are lacking

raising vexed questions about actual

in London and Sydney for the past

one member,” she admitted, adding

harm caused. She was not present at

10 years before recently returning to

that only the chairperson of the MDPB

the initial Cape Town hearing.

South Africa. He is unapologetic about

could appoint this person.

Noakes, on the other hand, welcomes

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Load shedding – the new health crisis?

As Eskom battles to keep up with South Africa’s power needs, Health Minister Dr Aaron Motsoaledi and private hospitals have begun prioritising alternative power sources to ensure patients do not fall victim to potentially worsening power outages. By Taryn Springhall

D

espite Eskom’s

Eskom has not been clear about how

media reports have highlighted the

promise to keep load

long it will take to restore power

worrying impact that the power cuts

shedding to a minimum,

following a national blackout, experts

are having on the health sector. In June

talk of a national

have cautioned that it could last as

this year, two patients allegedly died

blackout continues to

long as 14 days.

at Letaba Hospital in Limpopo during

erode confidence that the parastatal can actually manage this. While

While the country has yet to experience a national blackout, recent

load shedding due to the hospital’s generators not having sufficient fuel to

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

News | 35

keep life-support machines running. It

Motsoaledi directed his engineers

erators that supply theatres; Netcare

was also recently reported that doctors

to work with the provinces to ensure

plans on spending R150 million over

at Chris Hani Baragwanath Hospital had

an acceptable allocation of resources;

the next two years to counteract load

no choice but to operate on a patient

that generators were maintained; and

shedding; and Life Healthcare has

using light from their mobile phones

that hospitals had enough power-gen-

reportedly invested R40 million since

and iPads during recent load shedding.

erating capacity to supply electricity

2009 on solar heating and backup

to the entire facility. According to

power for critical services, and expects

vincial health departments to ensure

Motsoaledi: money “should not be an

to invest a further R24 million to ensure

that every public health facility has

issue” as there were sufficient funds

off-grid capability for 14 days.

sufficient generators and diesel to

in provincial budgets to provide for

run off-grid for five consecutive days.

backup power supplies.

Motsoaledi has instructed pro-

This happened after “unsatisfactory”

Mediclinic says it costs five times more to generate their own power than to buy it from Eskom, an

Private hospitals prepare for ‘worst -case scenario’

Hendrik Hanekom, this upsurge in

On the other side of the healthcare

operating costs cannot be passed

The initial assessment of 289

spectrum, the country’s largest private

onto patients as medical aids won’t

hospitals, completed on 30 June this

hospital groups are one step ahead of

pay higher rates.

year, found that some hospitals had

the power crisis, having all invested in

more power-generating capacity than

generators and diesel to enable normal

private sector to keep the lights on

they needed, while others did not have

functionality during load shedding.

begs the question of how sustainable

reports from provincial health department heads, and their MECs, on the readiness of public hospitals in the event of outages.

amount that equates to R72 000 per hour. According to Intercare CEO

The additional investment by the

enough. Many generators also did not

According to a recent probe, Inter-

have a completed log book, indicating

care has invested R4 million in backup

this will impact on already soaring

that they were not being maintained.

generators for the emergency gen-

private healthcare costs.

off-grid operations will be, and how

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Dr Aaron Motsoaledi, Minister of Health

‘Populist politicians’ take aim at ‘soft target’ doctors Politicians responsible for healthcare delivery, especially those medically qualified, should stop ‘playing to the crowd’ by making irresponsible and premature statements about doctors who sometimes fail to save lives in an under-equipped and dysfunctional public health system. By Chris Bateman

B

oth the national

entire leadership of the SA Medical

professional conduct is not within their

Health Minister, Dr Aaron

Association (SAMA), bristled at the way

ambit… it’s not their role. Their role is

Motsoaledi and his

in which the politicians, as SAMA deputy

to follow proper process, establish the

KwaZulu-Natal counterpart

chairperson Dr Mark Sonderup, put it;

facts and allow the proper authorities

Dr Sibongiseni Dlomo

“played judge, jury and executioner,

to deal with it – we expect them, both

publicly slammed three doctors whom

with flagrant disregard to due process.

qualified doctors, to know better”. His

they summarily suspended in June

We’re alarmed and concerned that in

chairperson, Dr Mzukisi Grootboom,

and July in Mpumalanga and KwaZulu-

both instances the politicians climbed

promptly e-mailed Motsoaledi asking

Natal when they failed to save the lives

into the fray very quickly with comments

for an explanation and set up urgent

of a critically ill pregnant mother, her

about criminal activity and suspensions.

meetings with the minister, KZN Health

unborn child and a car crash victim. The

You need to be very cautious –

MEC Dhlomo and the chief executives

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

News | 37 of the two hospitals. Said Grootboom:

far side of the hospital and a helicopter

his airway before realising there was no

“We’re appealing for a measured

initially called to transfer her to a bigger

laryngoscope in the hospital. She report-

response. The best thing they could

hospital arrived only three hours later. Dr

edly remonstrated with the paramedics

have said is ‘we’re extremely concerned

Cedric Sihlangu, deputy chairperson of

for bringing the patient to an inappro-

and will deploy all our resources to

the Junior Doctors’ Association of South

priate and under-equipped facility and

get to the bottom of it”. He said the

Africa (JUDASA), said an urgent call was

he was then re-routed to the Mahatma

outcome of such continued political

made to the theatre for the equipment

Ghandi regional hospital. Grootboom

behaviour would be a slow erosion of

to be taken to the labour ward where the

said it was established from the hospital

respect for healthcare professionals and

operation was conducted. The mothers’

manager that Osindisweni had “not had

a loss of faith in the public health system.

heart stopped at one stage while

a laryngoscope for a while”.

“Once that attitude sets in it’s very

oxygen was being administered but she

difficult to reverse,” he warned.

had stabilised after the delivery. “In their

Motsoaledi brings criminal charges

hearts and minds the doctors were doing all they could to save the mother and

How it should be done…

Grootboom said a proper inquiry proce-

child – for people to turn around and call

dure would have involved the doctor’s

Motsoaledi set in motion criminal

them names is pretty disheartening,”

senior consultant or line manager asking

proceedings against the two Evander

Sihlangu said.

for and recording a full report, which they

Hospital doctors in Mpumalanga, saying

Mpumalanga public sector doctor

would then hand over to the hospital

they had, “a tendency to disregard

and secretary general of SAMA’s public

CEO or general manager, before any

instructions with impunity”, after they

sector trade union, Mahlane Phalane

official internal local probe was

performed an emergency caesarean

said the initial SAMA probe showed

launched. Instead the district manager

section on a 37-week pregnant girl, on

that the doctors had acted correctly.

suspended her and the MEC made

15 June, whose heart stopped during an

He labelled Motsoaledi’s comments

public pronouncements – a full day

“Their role is to follow proper process, establish the facts and allow the proper authorities to deal with it – we expect them, both qualified doctors, to know better” eclampsia episode in a labour ward. He

“reckless, premature, misguided and

before the probe. Sonderup concluded:

said that in his 32 years in the medical

irresponsible”.

“This is not the way the game is played.

profession he had “never seen such an

The second death, in mid-July,

operation done on a young girl outside

occurred at the Osindisweni Hospital

of it – let the proper people deal with

theatre”. In stark contrast, Professor Guy

near Verulam on the KwaZulu-Natal

issues of professional conduct. We’d

Richards, academic head of critical care

north coast after pedestrian, Revishan

perhaps understand if the MEC was a

at Wits University and director of the

Pandather, 19, was hit by a car in nearby

teacher or something but he’s a doctor

Department of Critical Care at Charlotte

Canelands. A private security guard,

and should know better. They should try

Maxeke Academic Hospital, said that

Prem Balram, alleged that he bled to

not to be populist about these issues”.

the doctors, one with 15 years’ experi-

death on a stretcher without being given

ence and a teacher of a course on ob-

medical attention. Shortly afterwards,

the National Convention on Dispensing

stetric emergencies, should be “praised

KZN Health MEC Dr Sibongiseni

(NCD) and an executive council member

for their heroic actions in trying to save

Dhlomo, went on television (prior to any

of the Society for General/Family Prac-

the baby’s life”. Richards said they had

probe being conducted), saying he was

titioners (SGFP), said such “demoralis-

very little time before the baby suffered

“appalled” by the incident.

ation of doctors” was now happening

brain damage. The interventions failed

The distraught doctor who attended

We ask the politicians to please stay out

Dr Norman Mabasa, chairman of

with “monotonous regularity”.

to save the baby and the teenage mother

to Pandather appealed to SAMA for

died 10 days after being transferred to a

help when she was summarily suspend-

and this must be condemned. The

private hospital. SAMA’s own unofficial

ed prior to being called to a formal

ministry is supposed to regulate, not

preliminary probe concluded that an

inquiry by the region’s district health

disorganise and demoralise. The

emergency C-section was necessary

manager. The Healthcare Gazette has

message must be to follow due pro-

to save the baby’s life, presenting the

established that paramedics delivered

cess without fail.” Mabasa is a former

only chance of stopping the mother’s

the patient (who had been fitted with a

SAMA general manager, chairperson,

seizures. There had been no time to

manual breathing-assistance device) to

president and a former Limpopo

transfer the mother to the theatre on the

the doctor who tried to suction and clear

Health MEC.

“Doctors seem to be under siege

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

38 | News

Inept drug supply management causing stock-outs Poor drug supply chain management by inappropriately-skilled provincial officials – not the ‘red herring’ of manufacturer supply issues cited by National Health Minister, Dr Aaron Motsoaledi – are primarily responsible for massive medicine stock-out problems in the public health system. By Chris Bateman

T

his is the conclusion

blowers, who insisted on anonymity,

policy at the TAC, said that the

reached by Ground

said veiled threats had been made

NDOH, “keeps shifting the focus to

Up, a community news

for talking out, citing a “henchman

international supply shortages, but

organisation focusing

in a big, pricey suit and pointy shoes,

this is a red herring”. He said drugs

on social justice stories

talking the whole time on his cell

such as penicillin and abacavir – an

in vulnerable communities, the

phone” who came to their facility from

antiretroviral used to treat HIV – were

Treatment Action Campaign (TAC),

the National Department of Health

the exception as they were facing

and its Stop Stock Outs advocacy

(NDOH). Reportedly, the man told

actual supply problems. “To deal

campaign. Verifying claims made in

them that the national health minister,

with this crisis we must address

three identically labelled anonymous

“knows the names” of the doctors

the underlying problems of poor

letters detailing stock-outs in

who were reporting stock outs. They

management, cadre deployment

healthcare facilities in KwaZulu-

qualified their complaints by saying

and under-investment in medicines

Natal (KZN) (reflecting widespread

the NDOH was “trying to get it right”

distribution,” he stressed.

pockets of dysfunction nationally),

but were hamstrung by provincial

Ground Up said items included basic

dysfunction while health workers

problems with suppliers and even

over-the-counter medicines such as

were innovatively sourcing alternative

referred to an international report that

paracetamol. As of 10 June this year

drugs using the private sector. Yet

“shows that we are not the only

King Edward Hospital had 389 line

provincial medicine depots continued

country that has shortages”.

items out of stock, Northdale Hospital

to fail hospitals and clinics because

Responding to the latest specific KZN

Motsoaledi has repeatedly cited

200, Grey’s Hospital 132, Ladysmith

of poor stock level maintenance,

revelations, Motsoaledi said: “It is

Provincial Hospital 191, East Street

poor processing of orders and dismal

quite unfortunate that this whole saga

Clinic 96, and Imbalenhle Clinic 159,

distribution. A national audit by Stop

emerged from KZN, because this is

the last facility stock-out count taken

Stock Outs last year found that only

one of two provinces where we are

was taken 5 June. Sterile water for

20% of reported cases were caused by

piloting. KZN in particular is fully

inhalation, alcohol, and eye-drops were

manufacturing issues. The remaining

covered by the new cell phone tech-

absent as were various antibiotics,

80% were attributed to management

nology that traces drug stock-outs

some antiretrovirals and some doses

and logistical challenges between the

right up to facility level”.

of fluconazole, an essential drug

medicine depot and clinics at both

In his closing speech at the South

used to treat two potentially lethal

provincial and district levels. These

African AIDS Conference on 12 June

opportunistic infections associated

included incorrect quantities of drugs

Motsoaledi admitted that when drugs

with HIV. Several products used for

being ordered by clinics, inaccurate

are not out-of-stock internationally

the management and treatment of

forecasting of drugs per population,

and were still being manufactured the

tuberculosis are also out of stock

and poor stock management at

problem lay with logistics. “I never

across most facilities. The whistle

facility level. Marcus Low, head of

denied, I never ran away,” he added.

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

40 | Short news articles

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

News | 41

A prince in high-tech shining armour to the rescue A high-tech, ATM-like dispensing system to serve the huge numbers of healthy South Africans on chronic medication and currently forced to spend hours or even days collecting medicine from overcrowded public healthcare facilities, is on the horizon later this year. ByTaryn Springhall

K

nown as a remote

Patients from rural locations can

questions or offer the patient guidance

pharmacy dispensing unit

spend up to an entire day travelling

(PDU), this fast-tracking

and queuing, only to be turned away

innovation could prove a

by overworked public facility staff at the

replace crucial patient/pharmacist

game changer in public

dispensing window. According to Anele

interaction, Group Chief Operations

health, reducing the risk of hospital - or

Yawa, TAC National national Secretar-

Officerand/Director of Right to Care,

clinic-acquired infections, alleviating the

ysecretary;, “‘Most of the essential drugs

Kurt Firnhaber says;, “Because of the

critical country-wide shortage of nurses

are here in the country, but they are not

shortage of pharmacists in the public

and pharmacists and most importantly,

in the patients bodies. This is a symptom

sector, we believe automation is a way

providing quicker access to appropriate

of a suffering health system”..’

to bring the pharmacist to the patient.”.

about their medicine regime.

As far as the fears that PDUs will

National Health health Minister-

care for people with stable chronic conditions (via shorter queues).

Custodian of the world’s largest HIV programme, South Africa (SA)

Firnhaber went on to explain that

minister, Dr Aaron Motsoaledi, has be-

filtering patients through the system

gun publicly spearheading a campaign

means they can be monitored more

to provide treatment to healthy chronic

closely. By engaging with a pharmacist

PDU technology also provides an interactive video link directly to a qualified pharmacist to answer questions or offer the patient guidance about their medicine regime regularly suffers from stock-outs of

patients outside of public healthcare

one-on-one, missed collections can be

both antiretroviral (ARV) and tuber-

facilities, embracing retail pharma-

followed up with a phone call or sms

culosis drugs, despite their ongoing

cies, community centres and churches

as a reminder or to find out if there’s

availability at public sector depots. A

to distribute chronic medication.

a problem.

survey conducted by the Treatment

Non-profit organisation (NPO), Right

Action Campaign (TAC), at the end of

to Care, says introducing PDUs into

chronic patient care, PDUs can also

last year revealed that five of the nine

the system is the next logical step.

be the start of a robust supply chain

provinces were severely affected by stock-outs with more than one in three health facilities reporting a shortage of

Not so impersonal …

Apart from potentially improving

and help prevent stock-outs. The data generated by the PDUs can be used to forecast what medicines are needed

drugs for both conditions. A full 32%

Designed for SA and currently manu-

and when – essential to ensuring the

of these stock-outs lasted for over a

factured in Germany, patients access

supply chain is well managed. “One

month and 25% for less than a week,

their chronic medication by entering

of the ways of solving the problems in

hugely underscoring the potential

their unique patient number and PIN

the supply chain is through information

value of an automated dispensing

code. PDU technology also provides

and a pharmacy automation system

system in supplementing the existing

an interactive video link directly to

will help us access that information,”

distribution chain.

a qualified pharmacist to answer

said Firnhaber.

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Profiles | 43 Unionist-turned-Health MEC Dr Phophi Ramathuba

Mabasa lights her way…

“Your former allies will become your potential adversaries because they now expect you to deliver what you represented them about. You’ll have to deliver on what you expected others to do. The other problem is that there are camps based on political differences and you receive different levels of loyalty. This is why in the main, new incumbents bring in their own people. People can cause you embarrassment. You’re also going into a province hungry for service, destitute both financially and by its rural nature. There are clinics you can’t

‘Changing sides’ – SAMA unionist now Limpopo’s Health MEC

reach by phone, that have no roofs that you cannot reach comfortably by car, that have no water. Don’t own what was not your creation, but do try to address it,” he advised, adding:

S

he’s known countrywide

she genuinely believes she’s uniquely

“It’ll be hard, if not impossible to turn

as the strident public health

better qualified for the job than

around (he couldn’t do so in his 18

activist voice of the South

Mabasa was. Mabasa, now back

months there). Don’t punish yourself

African Medical Association (SAMA),

in private practice in Krugersdorp,

for lack of successes but try and be

slamming national and provincial health

chairing the National Convention

a messenger of hope. I felt that I’d

departments wherever there’s dismal

on Dispensing and a panelist on

left before I’d even started. I think

patient care, drug stock-outs or non-

one of the Medical and Dental

you need a longer-term MEC there to

payment of doctor salaries – you name

Professions Board (MDPB) disciplinary

have any results.”

the dysfunction. Now suddenly, she’s the

committees, actually agrees. “Unlike

surprise MEC for Health in one of the

me, she’s a political animal, served

sum up what his main ‘take home’

country’s most bankrupt and historically

for a long time as treasurer to the SA

message would be for Ramathuba,

corruption-ridden provinces – Limpopo.

Communist Party’s Limpopo branch,

Mabasa replied: “Focus on the

Dr Phophi Ramathuba was head-

Asked by Healthcare Gazette to

represented SAMA in COSATU and

work ethic of those entrusted with

hunted and put on the short-list of

worked for over a decade in that

the responsibility of managing the

candidates by Limpopo Premier,

province’s public sector hospitals –

institutions, get the right people in

Stanley Mathabatha, her appointment

she knows the political players,” says

the right places – and get the funding

this June prompting the National

Mabasa, whose soft-spoken style of

to enable better healthcare. If you

Health Minister, Dr Aaron Motsoaledi

leadership, has won him wide respect.

have the money and the people to

to quip to her: “You’re going from

However, he does have a few words

use it properly, you may succeed”.

throwing stones to catching them”.

of advice and caution about running

Mabasa said he found himself in the

She follows in the footsteps of

a provincial health department, which

political crossfire once elections came

another SAMA leader, Dr Norman

immediately prior to his appointment

along. “The job didn’t allow me to do

Mabasa (variously, former SAMA

saw more than R25 million in health

what was within me. I’m not used to

chairperson, general manager and

contracts awarded to State officials,

defending. I prefer realistically analysing

president between 2009 and 2012 and

and the entire province virtually

the situation, so it didn’t sit well with

Limpopo MEC from 2012 to 2014).

bankrupt (under central government

me. This was not what characterises my

Without intending one-upmanship,

administration).

involvement in healthcare.

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Gazette’s ribbing in her stride.

Ex-SAMA leader, ex-Health

Describing it as “just practical” she

MEC, Dr Norman Mabasa

said she was travelling to all the districts and hearing and reading presentations by various directorates.

“We have leadership challenges, if you look at some of the hospitals and clinics. It’s not that they cannot perform, but they’re not given guidance. One needs to make sure what the attitudes are. If you’re CEO of a hospital you need to appreciate why you’re there and what you’re doing.

Clinical governance is a priority for me – you cannot change things on the ground when the leadership attitude is still negative.” She believed in “giving people chances” not just firing.

This would allow her to see “who is untrainable and unchangeable” and only then redeploy them elsewhere.

She said that at top leadership level, health was “a very specialised sector – you don’t just go in and fire people.

Look at Professor Househam (recently retired ANC-appointed DG of Health in the Western Cape) – when the DA

Tripartite alliance background “an advantage”

(Democratic Alliance) came in they over the past financial year there’d been a genuine attempt to “turn

kept him”.

SAMA chairman, Dr Mzukisi

things around”, with the potential

Grootboom, thanked Ramathuba

” Ramathuba said Mabasa was one

for her department to finally receive

for her “enormous contribution to

of the first colleagues to congratulate

a qualified audit during her tenure.

the Public Sector and our doctors”

her and offer advice. “He indicated

“This current financial year was the first

during her tenure on the SAMA board

to me that I come from a stronger

time we’ve had enough money until

and for her service as the President

It’s almost certain she’ll emerge from her new job less willing to ‘throw stones’ – the glass house she’s in could prove quite unforgiving, with no place to hide position politically – he entered into

31 March – previously funds ran out in

of SAMA’s trade union. “More than

a terrain where he had no clue of

November of the previous year and

most, she understands the challenges

the politics. I’ve worked in the public

we ended up borrowing. I think the

of healthcare in the public sector. We

sector here all my life; I was part of

corruption has changed completely

believe that she’s well poised to tackle

crafting government policy, even

since the province was put under

these challenges and to improve the

though I was representing labour.

administration in 2013. I must say I’m

service and lives or our people in her

One journalist told me he’d collated

quite humbled by this honour. One

province.”

all my SAMA union statements and

has to take seriously the responsibility

was going to take me through each

of looking after six million people’s

from her new job less willing to ‘throw

one, asking what I’ll be doing about

health.” Speaking from the unfamiliar

stones’ – the glass house she’s in could

it,” she laughed. Quizzed on what her

back seat of a chauffeur-driven luxury

prove quite unforgiving, with no place

priorities are, Ramathuba said that

vehicle, Ramathuba took Healthcare

to hide.

It’s almost certain she’ll emerge

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Focus | 47

Snipping away at the HIV pandemic, one foreskin at a time

N

By Chris Bateman

early two million

Management who have partnered with

at government facilities after their

South African (SA)

the Centre for HIV/AIDS Prevention

practices were identified according

men will have been

Studies (CHAPS) and the National

to HIV prevalence demographics

voluntarily circumcised

Department of Health in a bid to

(Johannesburg, Pretoria, Nelspruit,

by the end of this

halve new HIV infections by next year

Uitenhage and Cape Town so far). By

year, about half of the government’s

– via VMMC scale-up. The R55 million

early June this year, a total of 150 GPs

original target – yet even this will have

United States Agency for International

had undergone the rigorous training

conservatively prevented 133 333 new

Development (USAID)-funded

and set-up at their practices, where

HIV infections as a timely new public/

initiative is two-pronged; training or

they were provided with free surgical

private sector initiative kicks in to boost

upskilling 850 general practitioners,

circumcision packs and HIV test kits,

overall efforts. In spite of this, alarm

and increasing VMMC coverage in

and paid either the going medical

bells continue to ring as interventions

the private sector to 100 000 men per

aid rates for insured patients or a

Proven in field trials to reduce the risk of HIV infection by 60% and calculated to prevent one HIV infection for every 5-15 men circumcised, voluntary medical male circumcision (VMMC) is uniquely suited to the SA environment, where 1 400 new HIV infections occur daily, the vast majority via heterosexual transmission for women, twice as vulnerable

year by 2017. Since 2007, what was

median medical aid rate by USAID

biologically and culturally, remain in

originally a Metropolitan Health and

for those patients without cover.

various stages of trial.

CHAPS initiative (government endorsed

Doctors had to be covered through

Proven in field trials to reduce

the programme in April this year) has

medical practice insurance for adverse

the risk of HIV infection by 60% and

resulted in 170 000 Metropolitan Health

events and earned 10 continuing

calculated to prevent one HIV infection

members being voluntarily circumcised.

professional development (CPD) points

for every 5 - 15 men circumcised,

The private sector initiative uptake

after being ‘signed off’ as competent

voluntary medical male circumcision

has slowly accelerated, from 12 000 in

VMMC/CHAPS practitioners. Adams

(VMMC) is uniquely suited to the South

2008 to 20 000 in 2010, through 30 000

said that the theoretical and practical

African environment, where 1 400 new

in 2012 to 45 000 last year. Mr Siraaj

course (plus the in-practice ‘sign off’

HIV infections occur daily, the vast

Adams, General Manager for HIV and

review) was oversubscribed, with 20

majority via heterosexual transmission.

TB at Metropolitan Health, said the

doctors on the waiting list for the next

The latest private sector intervention

R55 million was going towards the

two training weekends (at the time

comes from Metropolitan Health Risk

voluntary training of GPs by CHAPS

of writing). Up to eight doctors were

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

trained in one government facility at a time. The training and support service incorporates a comprehensive package of services including HIV testing, sexually transmitted infection (STI) management, VMMC and condom provision. No sexual contact for six weeks after the procedure and condom use is strongly encouraged (circumcision often being perceived as an ‘invisible condom’).

Funder exclusion barriers removed A significant development in the

lead-up to the current public/private partnership was that all medical aid schemes (both open and closed) within the Metropolitan stable removed all exclusions around VMMC (in 2012).

Before that, members who applied on non-medical grounds were automatically excluded – a significant barrier to HIV prevention efforts. The offer of no out-of-pocket costs for VMMC services by GPs will vastly improve

“If we pursue a downward trend in financing AIDS, we see a devastating slide backward by 2020 – an increase in new HIV infections and AIDS-related deaths and escalating costs of controlling the epidemic”

accessibility, with Metropolitan Health

million lives covered (followed by

HIV, STIs and TB. VMMC is regarded as

data suggesting that 35% of VMMC was

Discovery and MedScheme). Adams

a ‘game-changer’ in SA’s HIV prevention

already being done by GPs with up to

revealed that HIV prevalence among

effort, and all provinces are prioritising

65% of circumcisions being conducted

Metropolitan Health members stood

efforts to accelerate access.

as day procedures in hospital. To give

at 6.5%. He appealed to other medical

Asked about the possible inclusion

some idea of the patient savings of the

schemes to also scrap VMMC exclusions

of Prepex, a non-surgical three-ringed

new initiative, a private GP visit for the

on non-medical grounds, saying the

device that results in the foreskin

procedure costs around R1 000 while a

benefits of the new project accrued to

atrophying and falling off after about

private in-hospital procedure could cost

members of any medical scheme and

seven days and is currently being

a lot more. Over a 10-year time horizon,

that they were a good example of how

piloted by government in four provinces,

it is estimated that VMMC in high-

the private and public sector could work

Adams said it was being excluded until

prevalence areas will save between

together for the benefit of all in the

officially ‘signed off’. While the safety

R1 650 and R9 900 per infection

impending National Health Insurance.

and efficacy of the device were very

prevented. Adams said that in

Government response

Gauteng alone, if 1 000 adult males were circumcised, R26.4 million could

high, “we are promoting the surgical technique (forceps guided and dorsal slit) – the intention is that non-surgical

Current government VMMC efforts

techniques will become an option”.

years. This comprehensively negated

began three years ago after HIV

Prepex’s greatest contribution to the HIV

argument that the money for VMMC

prevention efficacy became clear

prevention battle is that it is relatively

budgets could be better used in other

from the original Orange Farm pilot

pain-free, and can be prescribed and

HIV prevention strategies. “The very

study in Gauteng and two other sub-

fitted by a nurse, enabling task-shifting

opposite is true: VMMC frees up money

Saharan sites. It was initiated after

down from over-burdened GPs.

for other strategies to be enhanced,”

comprehensive consultation with all

However, a downside is that a Prepex

he said. Metropolitan Health schemes

19 stakeholders in the South African

wound takes eight weeks to heal, two

include several closed government

National Aids Council and discussion

weeks longer than healing after surgical

schemes such as Polmed, Transmed

on scientific, social and cultural issues.

circumcision.

and GEMS, making it the largest

It is now official policy and part of the

administrator in the country with three

2012 - 2016 National Strategic Plan for

be saved in HIV treatment over 20

Modelling studies suggest striking implications of scaling up VMMC in

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Prevention options for women, such as microbicides and vaginal rings, while promising, are not yet available. A survey conducted among high-school students in one KwaZulu-Natal health district showed that the HIV prevalence in girls was six times higher than in boys.

averting millions of infections and deaths and saving billions of rands in

A “jolly good show” by (and for) CHAPS

models and professional training. It was behind the original sub-Saharan studies

CHAPS, a USAID-funded NGO, is

that proved the efficacy of VMMC.

delays would constitute a “major

a global leader in implementing

The main pillars of the new three-year

failure to capitalise on scientific

and disseminating evidence-based

public private partnership will include

evidence to save lives and improve

approaches to prevent the spread of

Metropolitan Health initially covering

the quality of our population”.

HIV in southern Africa such as efficiency

the costs of high-quality VMMC to

the long run. Adams said any further

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Focus | 51 over 32 000 men, USAID supplying

Commission was tasked with exploring

disposable circumcision packs to GPs

strategies to ensure that the vision of

where needed, and CHAPS assisting

the global AIDS movement, ‘Zero new

GPs to set up their facilities and address

HIV infections, Zero discrimination

emergencies and adverse events, and

and Zero AIDS-related deaths’, could

supporting their accurate recording and

be realised in coming decades. The

reporting of VMMC services. USAID and

report stresses that a human rights and

CHAPS have also undertaken to help

community mobilisation approach has

create demand and raise awareness of

been central to the successes of the

GP-provided VMMC services.

AIDS response to date, emphasising

Meanwhile Dr Cheryl Baxter, an

Dr Cheryl Baxter, an associate researcher

associate researcher at the Centre for the AIDS Programme of Research (CAPRISA) in Durban, said there was a

at the Centre for AIDS Programme of Research (CAPRISA) in Durban

that failure to fund the AIDS response sufficiently, particularly the contribution of civil society, will have major consequences for continued success

paucity of any comparable data for HIV

among adolescent girls and young

and sustainability under the sustainable

prevention in women. The only currently

women in SA has been described

development goals.

available HIV prevention options for

as “explosive”. A survey conducted

Suzette Moses-Burton, GNP+

women were the ABCs of Abstinence,

among high school students in one

executive director, said the report

Be faithful and Condomise.

KwaZulu-Natal health district showed

presented two “stark and contrasting

that the HIV prevalence in girls was six

pictures. If we pursue a downward trend

times higher than in boys. National,

in financing AIDS, we see a devastating

annual, anonymous sero-prevalence

slide backward by 2020 – an increase

WomEn remain twice as vulnerable

surveys in pregnant women using

in new HIV infections and AIDS-related

Prevention options for women, such

public sector healthcare facilities

deaths and escalating costs of controlling

as microbicides, long-acting vaginal

demonstrate that HIV prevalence in

the epidemic. In the alternative picture,

rings and long-acting injectables, while

sub-Saharan Africa has increased from

with continued investment in AIDS

holding promise, were not yet available.

0.8% in 1990 to 30.2% in 2010. Several

over the next five years, we see HIV

HIV treatment of an HIV-infected

factors contribute to the increased

transmission at low endemic levels, AIDS-

partner would have an impact on HIV

vulnerability of young women to

related mortality significantly reduced

prevention for women but it was not

acquiring HIV in sub-Saharan Africa,

and children born HIV free”.

something that a woman could control

among them the fact that biologically

– the male partner would have to

women appear to be more susceptible

Commission report makes a strong

know his HIV status and if HIV positive

to acquiring HIV than men. According

economic argument for ambitious

would need to be on antiretrovirals

to the US Centers for Disease Control

investment, showing that robust

(and take them as prescribed) for the

and Prevention, the risk of HIV

financial investment in the HIV response

woman to benefit. Oral pre-exposure

infection is 1 per 2 000 contacts for the

now will create significant returns

prophylactics had been shown to work

male partner compared with 1 per

later. Each life-year gained in low- and

in a number of populations (men who

1 000 contacts for the female partner

middle-income countries produces

have sex with men, discordant couples

in penile-vaginal sex. Women are twice

significant gains in GDP. Suzette Moses-

and heterosexuals), but again this was

as likely to become infected as men

Burton added: “With over 10 million

not a currently available HIV prevention

after a single sexual encounter.

people needing antiretroviral drugs

option in SA. “There might be some data on condom scale up, but most of the condoms distributed are male condoms,” Baxter added.

Women bear a disproportionate

Downscaling funding ‘asking for trouble’

Impressively, the UNAIDS-Lancet

today, now is not the time to backtrack on funding and political commitment.

We cannot end the AIDS epidemic without that one last push.”

The Global Network of People Living

burden of the HIV epidemic in

with HIV (GNP+) last month applauded

Abdool Karim S, Baxter C, Frohlich J,

sub-Saharan Africa, and account for

the conclusions of the recent UNAIDS-

Abdool Karim Q, ‘The need for

approximately 60% of all infections

Lancet Commission report, Defeating

multipurpose prevention technologies

in this region. HIV-infected women

AIDS – advancing global health, i.e. that

in sub-Saharan Africa’. 2014 Royal

between the ages of 15 and 24 years

failing to continue funding the AIDS

College of Obstetricians and

represent 76% of the total cases in that

response sufficiently would have “grave

Gynaecologists. DOI: 10.1111/1471-

age group. The rapid spread of HIV

and immediate consequences”. The

0528.12842, www.bjog.org

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Exciting discovery offers more effective pain relief in RA

I

By Anne Hahn

t has been discovered

Early symptoms of RA

that cells of the immune system have their own clocks and can tell the time. “This internal timing drives how they behave, and in

turn how they affect the inflammation that is causing pain and stiffness in rheumatoid disease. Amazingly, these immune cells continue to ‘tick’ when recovered from a patient’s blood, and the clock runs for days in a test

• Fatigue, fever, weight loss • Joint pain and stiffness that is often worse in the morning and lasts for longer than an hour • Joint tenderness and swelling (often finger knuckle joints) • Firm bumps under the skin on arms (rheumatoid nodules) • Joints on both sides of the body are usually affected

tube in the lab,” says Prof. David

RA is a chronic inflammatory autoimmune disorder which occurs when the immune system mistakenly attacks the body's tissues, usually the lining of the joints. This causes painful swelling and can eventually lead to bone erosion and deformity. Treatment is with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying antirheumatic drugs (DMARDs) and more recently biologics.

It is hoped that if timing of

Ray, who together with colleagues

Although Ray cannot comment

medication targets the inflammatory

at the University of Manchester,

on the preliminary study results,

process more effectively, drug dosages

UK, investigated in a recent study

he revealed that the background

may be reduced, resulting in a

(complete but not yet published) the

preclinical studies of inflammatory

reduction in side-effects together with

innovative concept of chronotherapy –

disease in animal models suggested

better pain relief.

timing of medication administration to

“a strong time of day variation in

ensure optimal efficacy.

severity, and that surprisingly this

Gibbs JE, Ray DW. The role of the

Undertaken among patients

effect was driven by clocks operating

circadian clock in rheumatoid arthritis.

living with rheumatoid arthritis (RA),

within the cells of the immune system.

Arthritis Res Ther 2013;15(1):205.

the study rationale is based on the

Therefore, targeting timing in these

[http://dx.doi.org/10.1186/ar4146]

premise that the immune cells that

cells is a new approach to treatment,

Walsh F. Chronotherapy: The science

drive the inflammatory processes (and

and may affect many of the pathways

of timing drugs to our body clock.

therefore the pain) of RA have their

that are important for rheumatoid

www.bbc.com/news/health-27398730

own diurnal (day/night) rhythm.

disease.”

(accessed 16 September 2015).

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Focus | 55

Underdiagnosis of osteoporosis – are men at greater risk?

By Anne Hahn

A

Risk factors for osteoporosis[2] lthough the ‘old

whether patients had broken a bone

woman’s disease’

previously or describe a bone mineral

concept has long

density test. And 35% of women

been disproved,

reported similar omissions. Although

results released by

bone density scanning is not always accessible because of financial

the International Osteoporosis Foundation[1] last year on

and medical aid company

World Osteoporosis

restrictions, the

Day (20 October)

opportunity was lost

show that 90%

to discuss lifestyle

of people in a

factors to prevent

multi-country

osteoporosis and

survey (including

create awareness.

Australia, Belgium,

Osteoporosis is

Brazil, China, India,

defined as a systemic

Jordan, Mexico, South

skeletal disease,

Africa, Spain, United

characterised by low bone

Arab Emirates, the UK and

mass and micro-architectural

USA) were unaware of the fact that

deterioration of bone tissue with a

osteoporotic fractures are common

consequent increase in bone fragility

in men (men have a one in five risk

and susceptibility to fracture.[2] Clearly osteoporosis awareness

of developing osteoporosis while

campaigns need to target doctors as

women’s risk is one in three).

What was even more disturbing

well as the general public.

was that an average of 53% of men in the 50+ age group who had seen

1. http://www.iofbonehealth.org/news/

a doctor for a check-up had never

today-world-osteoporosis-day-new-

had the idea of bone screening or

survey-reveals-90-adults-are-unaware-

risk of fractures mentioned during the

mens-risk-osteoporosis (accessed 17

consultation. Doctors failed to use the

September 2015)

opportunity to discuss bone health or

2. http://www.osteoporosis.org.za

risk factors for osteoporosis, ask about

(accessed 17 September 2015)

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

• Older than 65 years • Having broken a bone after the age of 50 • A close relative with osteoporosis • Poor health • Smoking • Being underweight • Menopause before the age of 45 • Insufficient calcium intake • More than two alcoholic drinks several times a week • Poor vision • Physical inactivity or overactivity (excessive training) • Having one of the following medical conditions: o Hyperthyroidism o Chronic lung disease o Cancer o Inflammatory bowel disease o Chronic hepatic or renal disease o Vitamin D deficiency o Cushing’s disease o Multiple sclerosis o Rheumatoid arthritis • Taking one of the following medications: o Oral glucocorticoids o Cancer treatment (radiation, chemotherapy) o Thyroid medicine o Antiepileptic medications o Gonadal hormone suppression o Immunosuppressive agents

Don’t eat margarine and other interesting snippets

T

By Bridget Farham he journals, and so the lay press,

fatty acids was associated with a 34% increase in all-cause

are currently full of papers that appear to

mortality, a 28% increase in the risk of CHD mortality and

refute conventional wisdom on saturated fat,

a 21% increase in the risk of CHD. It appears that it is the

heart disease and indeed, all cause mortality.

industrial trans fats – margarine and those found in baked

One such paper was published in July in

the British Medical Journal (BMJ) by a group of Canadian researchers. Contrary to prevailing dietary advice, the authors

goods – that increase these risks. There was no association observed for ruminant trans fats.

Further discussion on the effects of what replaces

of this systematic review and meta-analyses claim that there

saturated and trans fats in the diet, so that current dietary

is no excess cardiovascular risk associated with the intake

guidelines are followed, suggests that refined carbohydrates

of saturated fat. Indeed, as the authors point out, there are

are risky, while fruit, vegetables, pulses and grains are

quite a few recent high-profile opinion pieces, informed

not – further support for the ‘no sugar’ and ‘eat real food’

by systematic reviews of randomised trials and prospective

movements that are gaining in popularity. What is clear – and

cohort studies that call for a re-evaluation of dietary

what is hardly happening yet – is that current government

guidelines and a re-evaluation of the effects of saturated fat

dietary guidelines need to be seriously re-examined across

on health. At the same time, many countries have intensified

the board, and not simply contain limp statements about

their public health efforts to remove trans fats from foods.

it being OK to eat cholesterol-containing foods as per the

Granted, the synthesis is of observational evidence, so

recent updated USA guidelines or the recent UK guidelines

causality cannot be inferred, but the findings are striking

that still recommend a high carbohydrate intake while

none the less. There was no clear association between

paradoxically asking people to cut sugar consumption.

a higher intake of saturated fats and all-cause mortality, coronary heart disease (CHD) and mortality, ischaemic

De Souza R et al. Intake of saturated and trans unsaturated

stroke or type 2 diabetes among otherwise healthy adults.

fatty acids and risk of all cause mortality, cardiovascular

Saturated fat intake was also not associated with other

disease, and type 2 diabetes: systematic review and

major causes of death, such as colon and breast cancer.

meta-analysis of observational studies.

However, in stark contrast to this, eating trans unsaturated

BMJ 2015;351:h3978. [http://dx.doi.org/10.1136/bmj.h3978]

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Research | 57

Paracetamol – how much should we be using?

P

By Bridget Farham

aracetamol has been in use since 1956

develop a small and often transient increase in alanine

and is the most widely used over-the-counter and

transaminase activity – a biomarker for liver damage – after

prescription pain killer worldwide. But how safe

using paracetamol in recommended doses for one to two

is it? And indeed, how effective? A systematic

weeks. This effect is more marked in people with osteoarthritis

literature review, published in the Annals of

who use the drug regularly and there is no suggestion that

Rheumatic Diseases, of observational studies from the UK may

therapeutic doses will cause serious liver injury. However, a

shed some light on these questions. The review concentrated

recent editorial in the Australian Medical Journal, while looking

on adverse events (AE) in eight cohort studies.

mainly at deliberate self-harm with the drug, suggests that

The mechanism of paracetamol’s analgesic action is largely unknown, but it appears to inhibit prostaglandin production within the central nervous system and peripheral tissues and

there is a sub-group of people who take paracetamol daily, who may land up with long-term liver damage.

Because the mechanism of action of paracetamol is similar

is generally considered safer than other commonly used

to that of NSAIDS there is a concern about the cardiovascular

analgesics such as non-steroidal anti-inflammatory drugs

safety of the drug and indeed there are studies suggesting

(NSAIDS) and opiates.

that paracetamol may have an adverse cardiovascular safety

Recent studies have questioned the efficacy of paracetamol and one in particular looked at its role in the management of osteoarthritis, suggesting that it is little better than placebo. What

profile – particularly because it can potentially raise blood pressure and promote thrombosis, so this association needs to be examined more closely. However, a recent study of more than

this review has emphasised is that there is

24 000 patients from the UK did not show

a consistent dose-response relationship

any association between paracetamol and

between paracetamol at standard doses

myocardial infarction or stroke.

and the types of AEs that are often seen with NSAIDS. This includes a dose-response relationship between paracetamol and an increasing incidence of mortality, cardiovascular, gastrointestinal and renal AEs in the adult population.

A follow-up editorial in the British Medical Journal asks

How much to take? Indeed an interesting question, since paracetamol has a narrow therapeutic index and patients and doctors alike need to understand this. We understand the toxicology of the drug in overdose, but the pharmacology at therapeutic doses is less clear. The bottom line is that

“Where are we now with paracetamol?” and seeks to answer

paracetamol is less effective than patients and doctors think

three common questions about the drug, such as “will it

it is and the side-effects are far from trivial. With the number

work for specific problems?”, “are there side effects?” and

of people taking paracetamol regularly, we need to find out

“how much to prescribe?” Although paracetamol is routinely

if they are actually getting any benefit from the drug to avoid

recommended for all types of pain, we now know that it won’t

long-term exposure without benefit.

work in all instances. For example, it is better than a placebo for headache, but not as effective as other types of analgesics,

Roberts E, Delgardo Nunes V, Buckner S. Paracetamol: Not

and for back pain it is no more effective than a placebo. There

as safe as we thought? A systematic literature review of

is little evidence that the drug is useful in hip and knee pain.

observational studies. Ann Rheum Dis. [http://www.ard.bmj.

However, the drug is likely to remain the first line of treatment

com/content/early/2015/02/09/annrheumdis-2014-206914.

because of the belief in efficacy and safety in therapeutic doses.

full (accessed 7 September 2015).

On the question of side-effects, most people, doctors and

Dear JW, Antoine, DJ, Park BK. Where are we now with

lay people alike, think that, in therapeutic doses, paracetamol

paracetamol? BMJ 2015(6);351:h3705 [http://dx.doi.org

does not have side-effects. We know that in overdose it

/10.1136/bmj.h3705]

causes potentially fatal liver damage but there is increasing

Mitchell C. Calls for paracetamol action. MJA Insight.

evidence that therapeutic doses cause harm. Studies in

https://www.mja.com.au/insight/2015/34/calls-paracetamol-

healthy volunteers have shown that between 25 - 40% will

action (accessed 7 September 2015).

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

Herbal medicine

– not a good idea before an anaesthetic

By Bridget Farham

M

any people in South Africa and

sedation. Many herbal substances have multiple actions on

elsewhere now use so-called herbal and

one physiological system, for example, decreased activation

alternative remedies in the belief that

of clotting by inhibition of von Williebrand factor and

they are safe, without side-effects and will

decreased platelet aggregation by glycoprotein receptor

not interact with conventional medicine.

interference. Some preparations may cause prolonged

However, a recent publication in the South African Journal

sedation because of effects on the central nervous system,

of Anasthesia and Analgesia suggests otherwise. For

while others may affect multiple systems and cause

example, in South Africa, it is estimated that as many as 27%

problems with both cardiac contractility and haemostasis.

of the population use herbal preparations in addition to

Other preparations are directly affected by anaesthetic

their prescribed antihypertensives and as many as one-fifth

agents. Halothane, for example, causes severe dysrhythmias

of all patients on prescription medication also use herbal

in patients using ephedra.

remedies, high-dose dietary supplements or both. The

Because patients regard these preparations as ‘safe’

figures may rise to 80% if those taking traditional medication

most do not tell their doctors they are taking them and in

are included.

any case most doctors won’t know the potential adverse

This becomes particularly important in the setting of

effects or interactions. Local advice is that patients stop

surgery, since it has been reported that as many as 51% of

all herbal and alternative medication at least two weeks

patients used herbal medication in the two weeks before

before surgery.

an operation. Of the drugs reported, 27% altered clotting, 30% had a direct influence on cardiac rhythm, rate blood

Dippenaar JM. Anaesth and Analg 2015;21(1):15-20.

pressure or serum electrolytes and 20% would increase

[http://dx.doi.org/10.1080/22201181.2015.1013321]

HE ALT HCAR E GAZ ETTE | OCTOBER 2015

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HE ALT HCAR E GAZ ETTE | OCTOBER 2015

HE ALT HCAR E GAZ ETTE | OCTOBER 2015