Category Archives: Health

There’s No Debating Noakes

In a short period of time the Noakes/Banting/Paleo diet has become the power bracelet of our decade. Short on logic, lacking in scientific reasoning, and completely oblivious to established fact, the fad charges on under the misguided leadership of its supreme leader.

Back when I wouldn’t have given much credence to what I now believe will result in the next few million cardiac stents to be sold by the lovely folk over at big Pharma, I jokingly tweeted that I should have considered refrigerating Noakes because after day 5 of the diet he was starting to go off.

Well, never a truer word said in jest and over 2 years later the sponsored book selling professor really has left a bad taste in my mouth. Of course I take full responsibility for goading the man (yes he is just a man) and reminding him on several occasions why much of what he says and promotes is bad science. His vitriolic followers have joined in the mudslinging with only the best defamation one can find in the social media space and the occasional threat of violence.

Naturally those who have the least relevant evidence, anecdotes, and are staunch supporters of the LCHF way of life often remind me how much older, more experienced, and simply more intelligent Noakes is than I. Even the great professor himself has attempted to ridicule my opinions based on my qualifications and research profile. This in spite of the fact that Noakes acknowledged knowing ‘nothing or, at best, very little about nutrition’ prior to December 2010.

It therefore came as a surprise when in late June Noakes challenged me to a debate on the topic of ‘Why Noakes is a quack harming SA Health’. This soon expanded into the title of ‘Why Noakes is a quack and a danger to the health of all South Africans’. It is important to point out that both of these topics were suggested and formulated by Prof. Noakes himself, with no intervention on my part. In fact he was so keen to debate this topic that he suggested the debate take place a mere 4 weeks later. This was not to be due to work commitments on my part and so began the back channel communication to confirm the details and the date of the debate.

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Initially I considered a change in title but as time went on and no suggestion of this was made I began planning my argument based on proving Noakes to be a quack and a danger to the health of our citizens. Something I believe to be true. I should point out that I do not make a living promoting any diet nor have I ever earned a cent from this type of work. Therefore constructing my argument was considerably time consuming given that this was a first for me but a likely fifth or even tenth for UCT’s most controversial staff member.

Following more than 3 weeks of back and forth it was finalised that the debate would take place at the Charlotte Maxeke Johannesburg Academic Hospital Auditorium, adjacent to Wits Medical School, on the 23rd of October between 5 and 8pm. We agreed that tickets would be sold for R50 per person and despite my initial suggestion that all proceeds should go to charity this was the proposed fee structure by Noakes’ people:

 Fee Structure

All seemed well until last Friday when I received a mail notifying me that Prof Noakes feels the title he suggested is unacceptable and is demanding a change to ‘The Tim Noakes (Banting) Diet is a dangerous fad that will kill many South Africans’.

Change of Title

When I took to Twitter to notify my followers and challenge Noakes over this movement of the goalposts he first responded with ignorance and when this failed he attempted arrogance.

Following this I received an e-mail on Saturday night urging me to either change the title or to withdraw from the debate.

Change or Withdraw

There are multiple problems with Noakes’ new proposed title besides for his inconsistency and inability to stick to his guns. Not least of this is the repositioning of his argument into an advantageous position prior to the debate. Some, including the Prof., have argued that the original topic is too focused on Noakes and not the diet, but this is nonsense given that only one man has endeavoured to make himself the face of the Banting diet in this country. If you want to play the LCHF ball you have no choice but to play the LCHF man.

I will debate Noakes but it will be on the original topic or nothing – and therefore nothing it is. The truth is that the leader of the ‘Real Meal Revolution’ doesn’t want a fair or honest debate. He wants another marketing opportunity to sell more cookbooks and peddle a potentially dangerous lifestyle to people who don’t know better and desperately want to trust the formerly respected scientist.

I apologise to those who are disappointed on both sides of the argument and leave you with these two comments which in a few sentences probably prove far more about the dangerous beliefs of Professor Tim Noakes than 3 hours of debate ever could.

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Lies, Damned Lies, and Marie Claire

From an early age most children will be told that drugs are bad. This will be reinforced again and again, usually by a recovering crack addict, who for some reason gets to preach to school assemblies about how to live one’s life. But I digress.

The usual culprits we’re all urged to avoid are substances like heroin, cocaine and methamphetamines. Now imagine if I told you there was a drug which millions of people take legally every day which can cause nausea, vomiting, stomach ulceration, severe bleeding and even death without warning. In fairness I’m lying about the warning part because the drug in question is Aspirin and the above information is available in the package insert and from any suitably qualified healthcare provider. The fact that the overwhelming majority of people who take Aspirin, often on a daily basis, will never suffer from any of these side effects is obviously of little comfort to those who take to making mountains out of mole hills using nothing but their stupidity and Facebook accounts.

This brings me to an article published by Australian Marie Claire in April of 2013 which has recently gone viral on social media networks across South Africa. The offending piece from the overrated penal colony claims that your oral contraception is a ticking time bomb which could go off at any moment rendering you anything from depressed to paralysed or even dead. As I’ve already illustrated with Aspirin, every single drug ever created has potential side effects. The important word here is ‘potential’ and the even more relevant concept is ‘risk versus benefit’. The use of any medicine should always be carefully considered for the risk it may pose to a particular patient and the benefit which they may gain from taking it. Some drugs which reduce blood pressure can cause kidney failure, but their benefit in preventing cardiovascular disease due to to high blood pressure most often outweighs the very small risk of causing kidney problems in a subset of patients which we can usually identify.

There are several issues with the Marie Claire article which raises most of its concerns with Yasmin and Yaz, third generation oral contraceptives taken daily by millions of women worldwide. The article selectively chooses to publish evidence about the number of adverse events and even law suits related to these drosperinone containing contraceptives. At no time does it provide any meaningful figures choosing instead to manipulate data so as to make the drug sound far more dangerous than it actually is.

For example if the occurrence of an adverse event in the normal population is 1 in 1 000 000 and in a population taking a drug this increases to 2 in 1 000 000, the best way to report this for effect would be to say that the drug causes a 100% increase in the adverse event. The fact that this is still very unlikely to happen is completely lost and is a common method used by those who wish to distort data to make their point (see Wikipedia for the definition of news media).

We, the medical fraternity, are acutely aware of the risks oral contraceptives. They’re banged into us, excuse the pun, from early on in our training. These include an increase in risk of venous thromboembolism (VTE) or ‘clots’, emotional lability and weight gain, amongst others. It is however important to remember that risk is the chance that something may happen but not a guarantee that it will.

In the case of oral contraceptives the increased incidence of VTE is 3 to 10 events per 10 000 life years on such an agent versus 1 to 5 events per 10 000 life years not taking the drug. Indeed that is as many as 10 times more events but in the overall scheme of things not actually significant enough to flush your pill down the toilet tomorrow morning (this is a euphemism, please don’t poison all of us and the fish with your birth control). Further studies analyzing the increase in relative risk show similar findings with an obviously increased risk of VTE of as much as 4 times in those on oral birth control, however this should be placed in context because pregnancy in itself increases the risk of VTE by up to 20 times and it is still a relatively rare occurrence.

That said it is for this reason that such drugs are only available on prescription from your doctor, who should inform you of the potential risks and complicating factors. I am baffled as to how Professor Kerryn Phelps, who claims to have taken Yasmin at the age of 46 and suffered a complication, could not have known that women over the age of 35 are at considerably higher risk of VTE. The risk in such patients usually outweighs any potential benefits and those of us with a non Australian medical education know this.

Lastly, and perhaps most importantly, is that all patients should be aware of changes to their mental and physical well-being which may be caused by the initiation or cessation of a drug. Such changes should not be ignored as several of the anecdotal case examples in the Marie Claire article seem to indicate. With that said if you’re choosing to get your health advice from any periodical they sell in the queue at your grocery store then you may have more mental health issues than any kind of contraceptive will cause. If you still disagree based on such anecdotal evidence then please find another suitable contraceptive because it’d probably be best for all of us if you didn’t breed.

(For more on interpreting erroneously reported scientific data please read this.)

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The Science of Cancer

The only politician you should trust is a dead one. Thus when politicians take to giving health advice you’d be well advised to ignore them and their pearls of wisdom. Last week member of Parliament Mario Oriani-Ambrosini wrote an article which was meant to discuss his journey with Cancer but instead took a cheap shot at the entire medical fraternity.

Ambrosini believes that he did so in the name of name of ‘hundreds of millions’ of cancer patients worldwide whom he quite obviously feels have been mistreated. The simple fact that none of the evidence supports such a view is clearly lost on the honourable member. Allow me to take you on a journey through the reality that is Cancer in 2013.

There is no doubt that cancer remains and will continue to be a major health problem facing all of humanity for the foreseeable future. The argument that science does not know what causes cancer is completely without foundation. The most basic definition of cancer is that it is the uncontrolled division of cells anywhere in the body. Simply put, this happens because of mutations in proto-oncogenes and tumour suppressor genes which are intended to prevent such cell behavior.

Proto-oncogenes provide the genetic information required for cells to grow and become parts of functioning organs. The mutation of these genes results in oncogenes which can then lead to the proliferation of cancer cells. Tumour suppressor genes, as the name implies, are part of the biological mechanism which defends the body against cancer by destroying cells which are damaged or function improperly. Mutations in these genes potentially result in the inability to prevent the aforementioned uncontrolled cell division. This is an incredibly simplistic and only partially complete explanation of the very complex mechanisms behind cancer, but it is just a glimpse of the volume of knowledge science possesses about one of our greatest enemies.

Patient autonomy, a fundamental of Bioethics, means that Ambrosini is entitled to choose his doctors and his treatment. Tullio Simonici is however not a doctor. He may have once qualified at a medical school but has since been stripped of his medical registration and was in 2006 convicted of fraud and wrongful death. Indeed he has in my opinion lost the right to use the title ‘Dr’. My opinion does not however prevent Simonici from selling the bogus cancer treatment which Ambrosini bought into. The notion that a fungal infection, vaginal thrush for those of you without science training, causes cancer or has any role in the development of the disease is without basis. The additional claim that Sodium Bicarbonate (cooking/baking soda) has any effect on cancer cells or fungus is equally without evidence. The further assertion that a gene (CYP1B1) which encodes for an enzyme acts as a self destruct mechanism for cancer is completely spurious.

According to US figures from the American Cancer Society, where Ambrosini claims 550 000 die each year despite treatment, 67% of people diagnosed with cancer now survive at least 5 years after receiving the bad news. The 5 year survival rates for localised breast cancer are 99% and an even better 100% for regional prostate cancer. It is true that more advanced disease translates to a lower chance of survival regardless of the interventions offered by medical science or the obligatory snake oil peddlers. In the case of Mr Ambrosini lung cancer with spread has relatively poor 5 year survival rates at a meager 4%. The general consensus is that metastatic mesothelioma confers a life expectancy of less than 2 years post diagnosis.

The potential cures for cancer which Ambrosini speaks of will not come from the Dalai Lama nor will they come from discredited medical practitioners trying to make a quick buck on the Internet. Cures will come from science and like them or not “Big Pharma”. The advances we have seen in the treatment and cure of several diseases including certain cancers are directly as a result of the massive investment by doctors, biologists, pharmacists, academic institutions, corporates and governments worldwide.

Cancer is not ‘science’s greatest failure’ but rather an ongoing success story for which the conclusion will sadly come too late for people like Mario Oriani-Ambrosini. It is understandable for terminal patients to clutch at even the smallest chance of survival regardless of any realistic expectation of success. That said muddying the waters with misinformation which only serves to endanger the lives of others is no way to end ones existence, not even for a politician.

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Simple Facts

The Daily Maverick recently published an article written by Mandy de Waal entitled ‘Baragwanath’s shame: a good man dies’. Sadly there are only two shames here and neither is that of a hospital or its staff. Firstly it is terrible that a man lost his life and even more unfortunate that by all accounts he seemed to be a caring and community focused individual. Secondly it is particularly appalling that the death of someone has been used to benefit a journalist and malign healthcare providers who do the very best for their patients in exceptionally difficult circumstances.

Essentially the exposé is about Godfrey Tenehi who passed away due to burns he sustained as a result of a fire in his shack. This is where the truth of the article begins and ends. The poor research and multitude of errors are quite frankly astonishing.

The article claims that an Advanced Life Support (ALS) Nurse was on the scene with the patient yet there is no such qualification. A nurse may have additional Trauma or even ICU qualifications but at no point are they specifically referred to as ALS, as is the case with Paramedics who can achieve this level of qualification. A simple search of the South African Nursing Council’s website would have revealed this simple fact.

One of the more junior Paramedics treating the patient says that ‘burn wounds are the worst because they are so painful’. While burns can be exceptionally painful this is entirely dependent on the extent and the depth of the burn wound. As it turns out the most severe burns, full thickness or what is also known as third degree burns, are painless because the nerves are destroyed. Since the journalist in this case emphasised the severity of both patients’ injuries, and having dealt with several shack fire victims, it stands to reason that the burns sustained here were mostly full thickness. A quick search of burns on Wikipedia would have revealed this simple fact.

Mandy goes on to describe Baragwanath Hospital as having one of the best burn units on the continent. This is not the case. Chris Hani Baragwanath Academic Hospital (CHBAH) has one of the best burn units in the world. It also has one of the largest most able trauma units as well as a very busy Intensive Care Unit. However CHBAH also serves an estimated population of six million people which means that resources are scarce. These include but are not limited to ICU beds, ventilators, heart monitors, stretchers and staff. On occasion the hospital becomes full and may not be able to cope with any further patients. This is the ‘divert’ as described in the article and had the Paramedic followed the protocol and taken the patients to Charlotte Maxeke Johannesburg Academic Hospital, an eleven minute journey with lights and sirens not 30 minutes as stated, both patients may have been better served on that particular night. A short conversation with any senior emergency service personnel would have revealed this simple fact.

After Godfrey was admitted to the hospital his brother, Ted Tenehi, claims that he was not seen by a doctor and was simply sent to a ward with ‘just a pipe in his mouth’. Ted also claims that despite being told that Godfrey was in the trauma ward this could not be the case because ‘there [were] people there who [were] sitting eating…and walking around’. Mr Tenehi’s ignorance can be forgiven, he is a layperson who is grieving a great loss. This does not excuse the failure of de Waal to explore the truth that no patient can be admitted to a ward without an admitting doctor; that no patient ends up with an endotracheal tube to maintain and protect their airway without a doctor; that no patient with burns is admitted to a hospital without large volumes of pain drugs (usually intravenous Morphine); that a trauma ward is one which has a spectrum of patients some of whom may be very ill and others who are/have recovered. A quick telephone call to any one of the thousands of doctors listed in the phone book would have revealed this simple fact.

The answer to Ted Tenehi’s question of ‘why his brother’s girlfriend was taken to ICU and his brother was taken to an open ward’ is much like many of the other facts in this case, very simple. The greater the percentage of burns the less chance a person has of surviving and the higher the mortality rate. Essentially any patient with more than 60% body surface area burns has a low chance of survival with that chance decreasing exponentially with each increasing point closer to 100%. Given the limited resources in all hospitals patients with a very poor prognosis are not considered candidates for ventilators or ICU beds. These are saved for those we know based on evidence have a fair chance of survival. This is not a South African phenomenon as all healthcare systems need to allocate resources effectively. Much can be said about public healthcare, but none should be without an appropriate amount of understanding of what is involved. When reporting on anything medical or otherwise a little bit of research goes a long way. Perhaps a first year journalism textbook would have revealed this simple fact.

Fabrice Muamba

Given the lack of luck the Irish have with the game of soccer (football if you’re one of those imperialist pigs) St Patrick’s Day was never going to be a good omen. Tragedy first struck when Kaizer Chiefs left a bucket of KFC behind their goal, giving Bennie McCarthy the impetus to score twice. Of course the second tragedy of the day occurred in the league in which Bennie used to be good enough to play.

In the 41st minute of the Tottenham – Bolton game Fabrice Muamba collapsed on the field. According to media reports the first medical responder turned him onto his side after which he was reassessed and then resuscitated. The details are quite sketchy and the TV footage is ‘respectful’ so it’s difficult to say what exactly was done, but it appears as if CPR (Cardio Pulmonary Resuscitation) was performed along with Defibrillation (that ‘cool’ shock thing House does every chance he gets).

The media have largely reported that Mr Muamba suffered a heart attack although some of them later changed this to say that he had suffered cardiac arrest. This is perhaps less informative than telling you that the sky is blue or that Lady Gaga is psychotic. While not impossible it is highly unlikely that a 23 year old fit athlete would suffer a heart attack, kind of like Superman suffering from impotence.

In general an athlete’s heart is stronger and more powerful than that of the average person.  Simple examples of this exist with people like Lance Armstrong and Miguel Indurain, who reportedly had resting heart rates of below 30 at their peak fitness (normal is 60 to 100).

Of course a heart attack is still a possibility if anyone exercises when sick, but given the environment of the Premier League it’s unlikely Fabrice would have been let out of his cotton wool had he been suffering with a cold, or even an ingrown toenail. One, or a top flight club, does not simply take chances with multi-million dollar investments.

So if not a heart attack then what explains cardiac arrest, which literally means ‘heart stop’, in a young healthy athlete?

There are several possibilities and no doubt those who want to take umbrage with this article will find some obscure congenital defect that may have caused the problem. However any good doctor will tell you that common things occur commonly. In this case the likely cause is what’s termed an Arrhythmia. The simple explanation is that your heartbeat, and the electrical impulse that governs it, is as well organized as a North Korean military parade. It is sharp, precise, and repetitive.

If for some reason this rhythm becomes interrupted it will change and become an Arrhythmia. The degree of change depends on a number of factors, and the ability to return to normal depends on several physiological inputs. However the more disorganized the rhythm becomes the less blood your heart pumps out, potentially making it a useless piece of hardware and causing you to fall unconscious and possibly die.

Over the past number of years there has been a lot of research around Sudden Cardiac Arrest (SCA) amongst athletes. In the run up to the 2010 FIFA World Cup (apologies for using the F word) several articles were published in relation to this topic and it was brought to the forefront of discussions in the emergency medicine community.

While the research remains ongoing there are several hypotheses as to why athletes seem to be at risk for SCA. A well established hypothesis is that certain individuals have what is known as channelopathies. Effectively this means that electrolytes (salts like Sodium and Potassium) are not transported as efficiently as they should be into and out of cells. This predisposes a person to abnormal and potentially deadly heart rhythms (Arrhythmia). In these cases genetic testing has been shown to be useful in families where there is a history of SCA, especially among young family members. Often several people in a family are affected, but once this is known a Cardiologist can offer treatment options.

As a rule making a diagnosis becomes more and more difficult the further away one is from a patient. That said based on current evidence it seems possible that Fabrice Muamba may have an undiagnosed channelopathy which then caused an abnormal heart rhythm and ultimately cardiac arrest. It should be noted that Muamba is still alive because he received CPR and Defibrillation very soon after collapsing. These are skills which are proven to save lives and can be performed by people who are not medically qualified but have been on a straightforward 4 hour course.

The message here is to know how to spot these ‘tragedies’, know how to provide the necessary emergency assistance, and to pretty much ignore any diagnosis made by the news media.

Take One For The Team

When I was a medical student I was told on several occasions by different surgeons that ‘if I didn’t stick my finger in it (the rectum), I was bound to stick my foot in it’. I’ve always assumed (and hoped) that they were only speaking literally about the first part, although admittedly there are some odd doctors out there.

I mention this rather strange anecdote because November marks the beginning of Movember, a campaign promoting male health and more specifically awareness around Prostate Cancer. To show your support for the cause one should grow a moustache throughout the month. Naturally this movement has been taken on with much zeal by the same kind of men who think lifting weights and grunting loudly at gym is cool. In fact Movember is the kind of activity often done by groups of males who want to bow to peer pressure but feel that smoking or taking steroids is just too much effort.

Indeed most of the people who actively partake in the campaign, and even the Portuguese women who become involved by mistake, believe that they are doing good. After all Prostate Cancer is the most common cancer in South African men, it kills more than 2500 of us per year, and will affect 80% of men who reach the age of 80. Movember one could argue promotes an important aspect of health, and nails the message home because it is even endorsed by CANSA.

However there is a massive problem with this ingenious marketing concept despised by Gillete executives the world over. Besides the considerable funding raised for the various worthy organizations, the Movember campaign is a failure. This is because the best health advice any doctor could ever give you is that prevention is always better than cure. This is not just a saying but how all healthcare should be run and how every single human being should approach their health and well-being.

Instead of growing a moustache some marketing gurus should apply their minds to convincing billions of terrified men to go for a digital rectal exam. If this is too impossible a task, then even compelling men to make simple lifestyle changes which decrease their risk of developing Prostate and other Cancers would help. The truth is that cultivating facial hair will do absolutely nothing for your health, other than perhaps raising some money so that when you are dying of Cancer at least some caring NGO can sponsor the Morphine for your last few painful days, weeks or months on Earth.

Rather man up and take one for the gender team, then come home and tell your partner that regular ejaculation is proven to lower the risk of developing Prostate Cancer – you can thank me later.

My Personality Begs to Differ

I’m no Orthopaedic Surgeon but I have a bone to pick with Ndumiso Ngcobo. This past Sunday the teacher turned blogger turned Times columnist focused his attention on some of his best friends, doctors.

In essence Ngcobo asserts that doctors have no personality. That we are as bland as rice cakes or the people who write Sunday columns for the slow dying print media. Some colleagues have assured me that Ndumiso is merely being tongue in cheek, call it professional disagreement but my diagnosis is head up arse.

In his article, which you can find here, Ngcobo descbribes how his mother would have liked him to become a medical practitioner, a feat prevented only by his own laziness. Then again life can pass you by while in a comfy armchair from which you criticize the world.  Failing to discover a medical career Ndumiso is now forced to suffer being surrounded by several doctors clamouring for his attention whilst making bad jokes and worse dinner conversation.

Mr Ngcobo’s assertion is that “one can either choose to have a charming personality or get a medical degree. Not both”. He goes on to say that we can’t be funny and aren’t good looking. Someone please let Riaad Moosa and Michael Mol know of this revelation. I will concede that when doctors get together the conversation is often medical. Just like whenever there’s a doctor at the table everyone without medical training forgets their boundaries and thinks it’s acceptable to ask about their genital discharge.

Then again I really shouldn’t be offended. Not only is Ndumiso Ngcobo’s theory as flawed as the plot in a Twilight film, but his best work from this past week will be in a bin by Tuesday. My best work, and that of my colleagues, gets to celebrate another birthday.

Breast or Bust

Ever heard of a game called Russian Roulette? The premise involves loading one live round into an empty revolver. The barrel is then spun and the weapon pointed at the victim. In a standard revolver the statistical chance of being shot and potentially killed is 1 in 6. Our Health Minister, bless his fast food despising soul, recently decided to play his own version of this game with our nation and its HIV infected children. As of late August 2011 he unilaterally (in consultation with a number of his ‘yes’ men) decided to change South Africa’s breast feeding policy.

 

In essence the government no longer supplies formula milk to any patients accessing the public health system. Thus the only option available to mothers is to breast feed or purchase formula milk privately. This is a financially unsustainable option for the overwhelming majority. The finances are however better for government, who despite announcing the NHI which will purge R225 billion from taxpayers, will be saving in the order of R200 million per year with this move.

 

Of course the economics of Health are such that a short term saving today is often very costly in the long term. The evidence around adopting the approach taken by the Health Department is based on research which shows that infants who breast feed are generally healthier and have better immunity. Add to this the benefit of decreased cost to the state and associated costs to patients, and the decision seems to have merit. Furthermore formula feeding requires good sterilisation techniques to avoid gastrointestinal infections. This is particularly difficult because those in poor communities have been shown to battle with these techniques due to lack of resources.

 

As a direct result a common killer of young children is gastroenteritis. Much like when you have a bad case of food poisoning the time spent with your toilet bowl will drain you of fluid. In children and infants this is particularly dangerous because the progression to a lethal stage of dehydration can be far quicker with parents often failing to see the danger signs. In a country like Cuba where the socioeconomics are similar but the HIV prevalence is not, the choice is simple. If breast feeding offers so many advantages and formula feeding has an increased risk of gastrointestinal infections then the 1 +1 really is equal to 2.

 

However in South Africa we live within the environment of a colossal HIV pandemic. Once again the research here is quite clear. A mother who exclusively formula feeds has no chance of passing HIV onto her baby. A mother who exclusively breast feeds and together with her infant is on ARV’s has such a small chance of transmitting the virus that the risk is considered negligible. The problem is mixed feeding. Infants have a gastrointestinal lining which protects them from contracting HIV and other bugs in their gut. This lining only remains intact if the child is fed strictly one type of milk – breast or formula for not less than six months as recommended by the WHO. Mixing either of these or feeding the child additional cow’s milk, maize milk or any other foodstuff before 6 months will erode the lining destroying the protection. In addition to this there are several social factors to consider. Mothers are educated by health workers but family members with whom the child may be left are often exempt from this process. In addition South African culture means that mothers are likely to feed their children something other than just breast or formula before six months. Moreover working mothers only get 4 months of maternity leave, meaning that if they start breast feeding their children the child will have to be put onto solids or other milks before 6 months which will predispose them to either to gastrointestinal or HIV infection,  or both.

 

For all of these reasons up until recently many HIV positive mothers chose to formula feed. Now given no choice they will be forced to breast feed. At best in any town, city or province of this country 1 in 4 pregnant women is HIV positive. At worst the figure is 1 in 3. The direct result of this new policy, which has been instituted overnight, is a generation of babies born to HIV positive mothers being doomed to a potential death sentence.

 

Indeed much like in Russian Roulette our Health Minister has decided to load a revolver with a single round while pointing it directly at the head’s of our country’s children. We can only hope that his love of breasts helps him sleep better at night, for tomorrow and the day after may be spent digging graves just big enough to fit thousands of suckling infants.

Medical Abbreviations and the NHI

Doctors love abbreviations. In fact modern medicine thrives on them. Your heart attack is an AMI (Acute Myocardial Infarction), your stroke is a CVA (Cerebrovascular Accident), and your cancer is NHL (Non-Hodgkin Lymphoma). These terms form part of a language medical professionals understand, and you the patient do not. So with that said allow me to introduce you to the great equaliser, the NHI (National Health Insurance).

It is quite clear from recent media coverage that journalists are still grappling with the true meaning of the NHI, and based on my discussions with doctors from a junior to a senior level there is even less understanding among medical professionals. Given this background I would have to be either extremely arrogant, frightfully stupid, or perhaps both to assume to be the expert on the proposed system.

Our Minister of Health, Dr Aaron Motsoaledi, would have you believe that there is no other option, that private healthcare is unsustainable and that public healthcare for all is the only way forward. Most people are inclined to side with anything the Minister says because they’re still so excited that a drunken bigot isn’t controlling our health system. Don’t get me wrong. I’m a fan of the Minister, he says the right things at the right times to the right people, but then again so do well versed politicians.

In reality it is too early to say what the NHI will mean on a detailed level somewhat because it will only be fully implemented in 14 years time, but mainly because government’s green paper doesn’t actually detail very much. In essence we currently have a national health system, any patient can walk into any public clinic or hospital and will receive treatment. There is however a catch to the aforementioned. There are not enough clinics or hospitals, there is not enough equipment and there are not enough staff. This is specifically the case in rural areas and townships where health needs have grown far beyond expectations. The simple solution is to increase funding to the public health system that we already have in place, however there isn’t enough money in the fiscus to fund the staggering changes needed to fix all the problems. That’s where you come in, assuming you’re a taxpayer, it’s you who is going to be forking out for all those new hospitals and all that new equipment. Of course this will result in several consequences, those for the system will argue that overall, the pros outweigh the cons; that new infrastructure and a better managed system will mean improved results. On the other side of the argument one of the likely cons of the NHI is the almost certain destruction of private healthcare, at least in its current guise.

The socialist within you may want to argue that private healthcare doesn’t have a place in our society. That National Health is the way to go so that we achieve equality for all in the area of Medicine and allied healthcare. This may all be correct except for one significant factor – doctors.

South Africa produces some of the best medical practitioners in the world. Contrary to popular belief the most talented doctors are not necessarily those working in private. There are brilliant doctors in public settings, and some of the best working in both simultaneously. The private sector does have one clear advantage over public, in that it encourages far more competition. Patients go to doctors who have good reputations and equally good outcomes. They have freedom of choice.

The NHI will however result in the overwhelming majority of doctors, if not all doctors, working for the state. This means no competition. All doctors get paid the same and are incentivised the same regardless of where they work, how good they are, and most importantly how good their patient outcomes are. As a patient you get no choice as to who your doctor will be. Much like the public education system a teacher with exceptional pass rates will be rewarded in the same way as a teacher with shocking failure rates.

In the long term this will create an environment which does not attract the best doctors, and even worse does not incentivise doctors to be as good as they can be. A situation where the doctor with great potential wonders why he should try to excel or why he should even care when the next guy doesn’t and receives the same remuneration (financial and otherwise).

The bottom line of NHI is that just like many medical abbreviations it has terrifying consequences, and its meaning isn’t as simple as National Health Insurance. Its meaning is something far more dangerous to our society – mediocrity.