NEWSLETTER - DAY 04 THURSDAY 21st FEBRUARY
Mechanical heart close to being viable T
he development of a mechanical alternative to a heart transplant for a child that could be construed as durable for a lifetime was a “formidable” challenge which would prove to be extremely expensive for hospitals. However, there was cause for optimism, due to prospective trials which could advance the support of children - and those involved in treating children with heart disease must take on the challenges “respectfully and courageously”. These were the words of Charles Fraser, Surgeon in Chief at Texas Children’s Hospital during the Christiaan Barnard Hospital Lecture. In an address entitled A Mechanical Alternative to Transplantation, Fraser said hundreds of thousands of patients needed transplants every year. With only 2000 heart transplants being conducted in the US a year, there was an extremely low likelihood of a child receiving a donor heart. For this reason, the world needed a “transformational advance” to build on the transformational
Mechanical heart
By SUE SEGAR event of the first heart transplant conducted in Cape Town by Dr Chris Barnard. “In terms of actual community benefit we are not meeting the need.” “We have been making incremental progress which has been really good but to broadly apply a new therapy … to those that need, we need something that is transformative … to more people,” Fraser said. The challenge was formidable because “in childhood particularly, we have a number of problems. Children grow, they are very active and their response to medicine is different. The potential application is measured, not in terms of months or years, but in decades so we have to have a mechanical device which is either easily interchangeable or one that is durable for a lifetime - and neither of these propositions exist right now.” “A transformative event in mechanical support for a child would be a device that would be capable of sustaining that person either in its original implanted form for
Charles Fraser
a lifetime or one that can be easily changed out. “So that seems to me to be a very significant challenge in mechanical support in children.” Fraser said there was widespread hope that the upcoming trials for the small Jarvik device would result in an incremental advance in support of children. “But the clinical experience is very limited … and I hope we don’t repeat mistakes.” There were some clever devices being worked on at institutions including the Indiana University and at the Texas Heart Institute as well as in Australia. But, asked whether he was optimistic that he would see a mechanical device for children in his lifetime, Fraser said: “It is intuitively difficult for me to imagine that a mechanical solution is going to be the end point for children. I think it is more plausible that it will be a biologic solution of some sort. “The line of thinking that Professor Doris Taylor of the Texas Heart Institute and her colleagues are pursuing is exciting. It might be the wrong one to bet on. I don’t know. -That line of thinking is very exciting … my money is on that. A biologic substitute is more logical to me.”
‘Obscene’ failure to treat african patients T
he failure to treat patients with cardiac and noncommunicable diseases in Rwanda was “obscene” because the global resources to address the problem existed. These were the passionate words of Gene Bukhman, Assistant Professor of Medicine at Harvard Medical School during the plenary entitled Starting a Heart Programme in Africa: Lessons from Rwanda. In an address which contrasted the health spend on American patients with that of patients in Rwanda, Bukhman said Africa did not have the resources to deal with the problem of cardiac illnesses and the world could do more.
By SUE SEGAR “Just like with HIV and TB, there are not those resources… “These diseases are affecting children and young adults. They are not lifestyle diseases,” said Bukhman, who has been closely associated with Rwanda for the past seven years and who is involved in a programme with that country called Partners in Health. Bukhman said the amount of resources available to rural Africa was still “ridiculously low” compared to the way life was valued in the United States. “In the US, we spend 800 dollars per person per year and
African patients are marginalised compared to those of the USA
we are arguing about whether its too much to be spending 50 to 100 dollars a year in Rwanda for Rwandan life and that doesn’t make any sense. “How can we be valuing those lives so differently?” The Rwandan government placed extraordinary value on health as a human right and, as a nation, Rwanda had become a strong voice on the nature of cardiac and non-communicable disease in rural Africa “and how it is imperative to address it now,” Bukhman said. “What we know from history is that, even in 1960, people thought there were the resources to address these problems and, given the extraordinary growth in resources we have seen between now and then - it has been almost 20-fold - there are certainly the resources globally to address this now.” A key lesson which the world could learn from the Rwandan experience is that the nature of cardio-vascular and non communicable diseases in rural Africa was different, Bukhman said. Far from being related to smoking, diabetes and bad eating, these were not lifestyle diseases. “Secondly, is that having a simultaneous commitment to both the treatment of sick patients and prevention is very reasonable, and, thirdly, with good leadership and good partners it is possible to have extraordinary gains in the health of the poor.” Bukhman said his association with Rwanda had changed his life. “It is inspiring to see the extraordinary changes the government has led over that period. What has made those changes possible has been that leadership and its ability to co-ordinate partnerships. It has been a privilege to be part of that team.”
Tim Noakes
Debunking the food pyramid
O
besity is soaring in many parts of the world, including South Africa, and fat is not to blame, a controversial sports scientist asserted on the final d a y o f t h e S i x t h Wo r l d C o n g r e s s of Paediatric Cardiology and C a r d i a c S u r g e r y i n C a p e To w n . “ We have been made to believe that a high-fat diet leads to increased LDL (so-called bad cholestrol), increased triglycerides (fatty acids) and reduced HDL (socalled good cholestrol), which all result in arterial clogging. This model is wrong,” Professor Tim Noakes said. Noakes, director of the University of Cape To w n ’ s Sports Science Institute, acknowledged that many do not share his views. But he encouraged medical minds at the conference to interrogate the science behind nutrition before jumping to conclusions. “The US Department of Agriculture’s food pyramid, which places carbohydrates like bread and pasta at the bottom and fats at the top, is a flawed model,” he said. “Diabetes and obesity rates in the US have steadily risen since the adoption
By KATHERINE GRAHAM o f U S DA g u i d e l i n e s i n t h e 1 9 7 0 s and I believe it is because of a higher intake of carbohydrates, as well as consuming more calories overall.” Noakes argues that a significant proportion of the population are carbohydrate or insulin resistant. “When you are insulin resistant and you eat lots of carbs, you raise your triglyceride levels.” ( Tr i g l y c e r i d e s found in the bloodstream and fat tissue can contribute to the hardening and narrowing of your arteries, raising the risk of heart disease.) He believes that the metabolism of every human being is not the same and that those with carbohydrate resistance are unable to metabolise carbohydrates safely. “If 50% of the population is insulin resistant, then it means that our dietary guidelines are 50% wrong,” he said. According to Noakes, by following a high-fat diet, you are able to reverse all coronary risk factors more effectively
than a low-fat diet. Ironically, your saturated fat levels go down when eating a high-fat diet, he said. He also took aim at the “energy in, energy out” model which says that the more you exercise and the less you eat, the more likely you are to lose weight. “People who gain weight are thought to be slothful and gluttonous. If you have not achieved your ideal body weight, people assume it’s because you’re not motivated, ill-disciplined and unfocused.” Referring to the book by G a r y Ta u b e , W h y We G e t F a t , Noakes dismissed the notion that obesity was simply due to doing too little exercise. “This model doesn’t work because it’s brainless,” he said. Rather, he argued, our addiction to food causes us to overeat. “Insulin is the key driver as to how much energy comes into our body,” he said. “If you are insulin resistant, excess energy is stored as fat, which leads to constant hunger and decreased activity. The first goal is to lose weight and then become more active.”
School health is key S
chool health programmes were seen as key in combating the growing problem of cardiovascular disease among young people, which is placing a burden on South Africa’s health system, says health minister Aaron Motsoaledi. Sub Saharan Africa has very limited resources and people felt they were not being supported by the health system,” the minister said during a session on health systems and heart disease, on the final day of the 6th World Congress on Paediatric Cardiology and Cardiac Surgery in Cape Town. “In South Africa we felt we needed to turn a page and focus on diseases that were killing people, the minister said. “The big debate in South Africa was about HIV and Aids when I became health minister. But a senior member of the ANC called me and asked about other deaths, the result of high blood pressure and heart disease and wanted to know what I was going to do about other deaths.” Introducing the minister, Dr George Mensa, a visiting professor at the University of Cape, spoke of how “heart attacks were developing in the developing world” as the incidence of high blood pressure and heart disease, including heart failure, increased among younger people, particularly in sub Saharan
School nurse tend to a child
By RAY JOSEPH Africa and other low and middle income countries. “It is affecting the young, boys and girls, and that is a real reason to pay attention to young individuals. We have to put scientific policy into practice at schools, places where people work and in public places. Motsoaledi told delegates that as part of the “contract” he signed with President Jacob Zuma when he was appointed as health minister, he was tasked with increasing South Africans’ life expectancy, decrease pre natal and childhood mortality, combat HIV, AIDS and TB and strengthen the health care system. An important part of the new National Health Insurance which is being introduced into South Africa was to integrate it into the school health services system, which would allow for the early identification of illness and health problems. “People complain that by the time kids, especially those from rural area, reach hospital it is often too late as the illness was not recognised earlier,” says the minister, adding that there is not a single specialist paediatric cardiologist in the entire Limpopo province.
Minister
“As part of the NHI we will place seven specialists in each of (South Africa’) nine provinces, including a gynaecologist and a paediatrician, and specialist nurses. We have already filled 46 percent of all the new posts.” Doctors in private practice will also be contracted to see NHI patients, he said. His department had begun to put into practice a promise by President Zuma during his 2010 State of the Nation address to reinstate health programmes in schools. The schools programme, which was already operating in a pilot phase in several areas, with the intention of replicating it country-wide, was targeting “very poor” schools. “The European Union has helped us purchase 30 vehicles. We now have 10 full mobile clinics equipped with operating theatres, 10 mobile eye care clinics and 10 dental clinics. One of the diseases being targeted was rheumatic fever, says Motsoaledi, adding that he was convinced that it could be eradicated. “Our aim is primary protection through early detection and we are targeting the school going kids and their parents. We have good guidelines in place but people just ignore them, especially in the rural areas. We need to ensure that they are followed.” As part of its strategy the Health Department has recruited hundreds of experienced, retired nurses into the programme to work with schools. “We did not have a satisfactory strategy aimed at the heart until now, but believe our new plan will help with combating heart disease.
Oscar Pistorius
The transcendence of injury W
hen Wayne Derman, who was a member of the South Africa medical team at the Sydney and Athens Olympic Games, was asked to look after the Paralympics team in Beijing in 2008 he wasn’t sure if he was up for the job. “I said I couldn’t do it, that I had no experience with limited ability athletes,” said Derman, a professor of sports and exercise medicine at the University of Cape Town, who is one of South Africa’s leading sports scientists. But Derman, who was also part of the South African Paralympics medical team at the London Olympics, accepted the position – and it changed his life and the way he now views people with disabilities, he told the 6th World Congress of Paediatric Cardiology and Cardiac Surgery in Cape Town this week. “I have seen fantastically abled
Wayne Derman
By RAY JOSEPH people being disabled and disabled people being abled,” he said. As is normal at a medical conference it is standard practice for speakers to disclose any possible conflicts – which Derman did before he launched into his presentation, “Behind the lens: the London 2012 Paralympics Games. Disclosing a close doctorpatient relationship with “Blade Runner” Oscar Pistorius, South Africa’s multi-gold Paralympics medallist who has been charged with the Valentine’s Day murder of his girlfriend, he told delegates. “I wish this talk was a week ago. I have looked after Oscar for the last five years. The events of the last week have left me and my family shocked to the core of our souls and our heartfelt sympathies go out to both families involved.” Derman said while the number of competitors and size of the Olympics Games had reached a plateau, the Paralympics was a “growth industry” both in the number of competitors and in public interest. “Among my reasons in going to London was to see if it could help change what young people think about disability and whether it would change attitudes,” he said. “It did, the media helped swing it. It helped make ordinary people experts on disability.
Sport at an Olympics level was about competitors pushing themselves to extremes – “and for athletes with a disability there is another layer of complexity. Disabled athletes had an ability for the “transcendence of injury”, said Derman, citing the example of athlete Arnot Fourie, who suffered a serious hamstring injury during the Paralympics. “He underwent treatment, did not go home - and four days later ran his best time ever, coming fourth in the world. Another athlete, Ilse Hayes, suffered a serious injury but went on to earn a silver medal a few days later. “They transcended injuries that would have sent any rugby player home,” he said. One thing in common with most disabled athletes was their self-deprecating sense of humour that saw them able to make jokes about their disability, he said. “If you can laugh at yourself you can beat ego and remove yourself from the moment.” Advances in technology was becoming a threat to the Paralympics where sometimes better athletes were beaten because their opponents had access to better, lighter equipment. “The tech makes a huge difference and it is something that will have to be carefully looked at in the future,” he said.
memories of the 6th world congress
This newsletter was produced by the team at HIPPO. www.hippocommunications.com