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.


We Are The Bigger Person

Unless you’ve been living under a rock or were so mesmerized by living next to one largely resembling a piece of dining room furniture, Thursday the 8th of September was a big day for South African news. Safety and Security Minister Nathi Mthethwa released crime statistics, some of which were improved, some of which were worse, and none of which took into account the FIFA Soccer World Cup and its associated Police presence. In addition President Zuma confirmed Mogoeng Mogoeng as the Chief Justice despite an outcry from many different corners of our society, including shower manufacturers who feel that you just can’t wash off the guilt of raping our constitution.

However, in amongst all of these issues which influence life in South Africa on a daily basis and are likely to continue to do so for the foreseeable future, the biggest story of the day must have been Darren Scott. At least that’s how it seemed amongst the Twitterati, whom despite being called mere “shrill” voices by the Sunday Times are seemingly more and more influential in the level of exposure any particular news story will receive.

It was with much interest that I watched as the story slowly leaked yesterday and then exploded this morning with the strength of a Die Hard film trying to upstage Transformers. If you aren’t aware of the background essentially the now former Jacaranda radio DJ called a colleague the “k word” at a team building event. There are other details to the story but these are irrelevant because any argument based on prejudice is ridiculous before it even begins. There is no justification to Scott’s actions. It is as simple as that.

The response from the public was swift, with a massive wave of criticism and only a few silly individuals attempting to defend the vocabulary of Scott. Scott himself almost immediately apologised and confirmed that he had resigned from his position at Jacaranda. It would appear that both of these actions are sincere acts of contrition even though there have been attempts by commentators to say otherwise. Indeed it is remarkable that in our country with all of its challenges, not least of which are crime and a poor Chief Justice, just one pseudo celebrity can embolden so many to suddenly become such voracious blood thirsty creatures.

My opinion on the racial slur is clear but more important is my opinion on South Africa. We live in a country full of complexities. A country of different races, religions, cultures, sexual orientations, languages and so much more. There is however one common thread amongst us and that is our ability to forgive. In this example we have someone who made a terrible mistake. He has apologised and had also lost his job, a large portion of his income and undoubtedly his status in society. You don’t have to like Darren Scott, admittedly he has lost a fan in me, but a true South African forgives because as a nation built on this notion we more than most know that to err is human but to forgive is divine.

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.