At present, there is no specific active substance against hepatitis E. As the disease kills 70 000 people every year, researchers are actively searching for one. Researchers in Germany may have found what they’re looking for. The team showed that the compound K11777 prevents host cells from helping the virus out of its shell by cleaving the viral capsid, rendering it incapable of infecting cells.
“The compound is already being tested in clinical trials against other viruses such as Sars-Cov-2,” says lead author Mara Klöhn. “There’s still a lot of work to be done to find out whether it can be used as an active substance against hepatitis E, but it’s a first step.”
The team from the Department of Molecular and Medical Virology at Ruhr University Bochum, published their findings in the journal Hepatology.
In order to infect an organ, viruses need the help of the host cells.
“An effective approach is therefore to identify targets in the host that can be manipulated by drugs so that they no longer perform this helper function,” explains Mara Klöhn.
The researchers became aware of the compound K11777 in a roundabout way: during a control study conducted as part of cell culture studies on the hepatitis C virus with a known active ingredient, they discovered that this active ingredient was also effective against hepatitis E. “However, the drug wasn’t using the same pathway as with the hepatitis C virus, because the hepatitis E virus doesn’t have the target structure that this active substance attacks,” explains Mara Klöhn. This suggested that the drug may have an effect on host cells instead.
The research team narrowed down the possible target structures and turned their attention to cathepsins, which can process proteins, i.e. cleave them.
K11777 inhibits many cathepsin types, ie blocks their function. In vitro tests with human liver cells showed that the compound actually prevents infection with hepatitis E viruses.
“In follow-up experiments, we proved our hypothesis that the compound prevents cathepsin L from cleaving and opening up the viral capsid,” says Mara Klöhn. “This means that the virus can no longer infect host cells.”
Hepatitis E
The hepatitis E virus (HEV) is the main cause of acute viral hepatitis. Approximately 70 000 people die from the disease every year. After the first documented epidemic outbreak between 1955 and 1956, more than 50 years passed before researchers began to address the issue in depth. Acute infections usually clear up spontaneously in patients with an intact immune system. In patients with a reduced or suppressed immune system, such as organ transplant recipients or people infected with HIV, HEV can become chronic. HEV also poses a serious threat to pregnant women. There aren’t any vaccines nor specific active substances against the virus.
President Cyril Ramaphosa at signing ceremony of the NHI Bill at the Union Buildings in Pretoria.
Speech by Cyril Ramaphosa, article from Spotlight
President Cyril Ramaphosa yesterday signed into law the National Health Insurance (NHI) Bill, which is the ANC-led government’s plan for universal health coverage, just 14 days before the country heads to the polls.
The NHI aims to unify the country’s fragmented health system, Ramaphosa said at the signing ceremony at the Union Buildings in Pretoria on Wednesday.
However, he also noted that processes are yet to be established and that the Act’s implementation will be incremental rather than a massive overnight overhaul.
Here are 8 noteworthy quotes from the President’s speech:
“[T]he NHI is a commitment to eradicating the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect”.
“[T]he NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention”.
“The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.”
“The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.”
“The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.”
“The NHI is an important instrument to tackle poverty. The rising cost of health care makes families poorer. By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.”
“Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.”
“The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.”
Here is Ramaphosa’s full prepared speech:
REMARKS BY PRESIDENT CYRIL RAMAPOSA ON THE SIGNING OF THE NATIONAL HEALTH INSURANCE (NHI) BILL, UNION BUILDINGS, TSHWANE, 15 MAY 2024
Minister of Health, Dr Joe Phaahla, MECs of Health, Senior Officials, Representatives of the health fraternity, Representatives of civil society, Representatives of labour, Members of Parliament’s Portfolio and Select Committees, Public representatives, Members of the media, Distinguished Guests, Ladies and Gentlemen,
We are gathered here today to witness the signing into law of the National Health Insurance Bill, a pivotal moment in the transformation of our country.
It is a milestone in South Africa’s ongoing quest for a more just society.
This transformational health care initiative gives further effect to our constitutional commitment to progressively realise access to health care services for all its citizens.
At its essence, the NHI is a commitment to eradicate the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect.
By putting in place a system that ensures equal access to health care regardless of a person’s social and economic circumstances, the NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention.
This vision is not just about social justice. It is also about efficiency and quality.
The provision of health care in this country is currently fragmented, unsustainable and unacceptable.
The public sector serves a large majority of the population, but faces budget constraints. The private sector serves a fraction of society at a far higher cost without a proportional improvement in health outcomes.
Addressing this imbalance requires a radical reimagining of resource allocation and a steadfast commitment to universal healthcare, a commitment we made to the United Nations.
The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.
The NHI Bill presents an innovative approach to funding universal healthcare based on social solidarity.
It proposes a comprehensive strategy that combines various financial resources, including both additional funding and reallocating funds already in the health system.
This approach ensures contributions from a broader spectrum of society, emphasising the shared responsibility and mutual benefits envisioned by the NHI.
The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.
The NHI carries the potential to transform the healthcare landscape, making the dream of quality, accessible care a reality for all its citizens.
The NHI Fund will procure services from public and private service providers to ensure all South Africans have access to quality health care.
The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.
Through more effective collaboration between the public and private sectors, we can ensure that the whole is greater than the sum of its parts.
The effective implementation of the NHI depends on the collective will of the South African people.
We all need to embrace a future where healthcare is a shared national treasure, reflective of the dignity and value we accord to every South African life.
Preparations for the implementation of NHI necessarily require a focused drive to improve the quality of health care.
We have already begun implementing a national quality improvement plan in public and private health care facilities, and are now seeing vast improvement.
In signing this Bill, we are signalling our determination to advance the constitutional right to access health care as articulated in Section 27 of the Constitution.
The passage of the Bill sets the foundation for ending a parallel inequitable health system where those without means are relegated to poor health care.
Under the NHI, access to quality care will be determined by need not by ability to pay. This will produce better health outcomes and prevent avoidable deaths.
The NHI is an important instrument to tackle poverty.
The rising cost of health care makes families poorer.
By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.
The NHI will make health care in the country as a whole more affordable.
The way health care services will be paid for is meant to contain comprehensive health care costs and to ensure the available resources are more efficiently used.
Through the NHI, we plan to improve the effectiveness of health care provision by requiring all health facilities to achieve minimum quality health standards and be accredited.
Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.
The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.
There has been much debate about this Bill. Some people have expressed concern. Many others have expressed support.
What we need to remember is that South Africa is a constitutional democracy.
The Parliament that adopted this legislation was democratically-elected and its Members carried an electoral mandate to establish a National Health Insurance.
South Africa is also a country governed by the rule of law in which no person may be unduly deprived of their rights.
We are a country that has been built on dialogue and partnership, on working together to overcome differences in pursuit of a better life for all its people.
The NHI is an opportunity to make a break with the inequality and inefficiency that has long characterised our approach to the health of the South African people.
Let us work together, in a spirit of cooperation and solidarity, to make the NHI work.
In the stomach, so-called parietal cells are responsible for acid production. They react not only to the body’s own messenger molecules, but also to bitter-tasting food constituents such as caffeine. In a study published in the Journal of Agricultural and Food Chemistry, researchers tested bitter compounds on a human gastric cell line. Their results help to clarify the molecular regulatory mechanisms by which bitter substances influence gastric acid production.
It is known that taste receptors for bitter substances are not only found on the tongue, but also on the surface of other tissues and cells. These include the parietal cells of the stomach, which secrete protons into the stomach – ie, produce gastric acid. Recent studies have already shown that the bitter taste receptors found in parietal cells are involved in the regulation of gastric acid release. However, the underlying molecular signaling pathways are not yet fully understood.
Gastric cells as a test system
To further clarify the molecular interaction between bitter substances, bitter taste receptors, and gastric acid production, a research team led by Veronika Somoza, Director of the Leibniz Institute in Freising, has carried out a study on a cellular test system. This involves human parietal HGT-1 cells, which are able to secrete protons and, like taste cells, have bitter taste receptors.
Veronika Somoza’s team initially developed a working hypothesis based on the results of previous studies and the findings on signal transduction pathways in taste cells. According to this hypothesis, bitter tasting food constituents stimulate bitter taste receptors that are embedded in the cell membrane. This releases calcium ions inside the cells, leading to ion channel opening. This, in turn, allows sodium ions to flow into the gastric cells from the outside, ultimately contributing to the release of protons.
Hypothesis confirmed
First author Phil Richter explains: “We have successfully tested this mechanism with the two bitter substances caffeine and l-arginine. As expected from previous results, both food constituents were shown to stimulate gastric cell proton secretion in our test system.” The PhD student adds: “For the first time, we were able to demonstrate that the transient receptor potential channelsM4 and M5 are involved in the signaling cascade not only in taste cells but also in gastric cells and ensure an influx of sodium ions into the cells.”
Senior Scientist Gaby Andersen says: “By using knock-out experiments, in which we specifically switched off one type of bitter taste receptor in the cells, we were also able to show for the first time that there is a link between bitter taste receptors and the activation of the ion channels.” The scientist emphasizes that the results not only contribute to a better understanding of the role of taste receptors in the stomach but would also show that HGT-1 cells could be suitable as a replacement model for taste cells.
The research team agrees that the results will provide new insights into the regulation of gastric acid production and thus lead to innovative approaches in treating gastric diseases in the long term. However, further studies are needed to deepen knowledge of the molecular regulatory mechanisms and intracellular signaling pathways.
Contact with nature can lift our well-being by affecting emotions, influencing thoughts, reducing stress and improving physical health, as shown by studies. Even brief exposure to nature can help. One well-known study found that hospital patients recovered faster if their room included a window view of a natural setting.
Knowing more about nature’s effects on our bodies could not only help our well-being, but could also improve how we care for land, preserve ecosystems and design cities, homes and parks. Yet studies on the benefits of contact with nature have typically focused primarily on how seeing nature affects us. There has been less focus on what the nose knows. That is something a group of researchers set out to change, publishing their approach in Science Advances.
“We are immersed in a world of odorants, and we have a sophisticated olfactory system that processes them, with resulting impacts on our emotions and behaviour,” said Gregory Bratman, a University of Washington assistant professor of environmental and forest sciences. “But compared to research on the benefits of seeing nature, we don’t know nearly as much about how the impacts of nature’s scents and olfactory cues affect us.”
Bratman and colleagues from around the world outline ways to expand research into how odours and scents from natural settings impact our health and well-being. The interdisciplinary group of experts in olfaction, psychology, ecology, public health, atmospheric science and other fields are based at institutions in the US., the UK, Taiwan, Germany, Poland and Cyprus.
At its core, the human sense of smell, or olfaction, is a complex chemical detection system in constant operation. The nose is packed with hundreds of olfactory receptors, which are sophisticated chemical sensors. Together, they can detect more than one trillion scents, and that information gets delivered directly to the nervous system for our minds to interpret – consciously or otherwise.
The natural world releases a steady stream of chemical compounds to keep our olfactory system busy. Plants in particular exude volatile organic compounds, or VOCs, that can persist in the air for hours or days. VOCs perform many functions for plants, such as repelling herbivores or attracting pollinators. Some researchers have studied the impact of exposures to plant VOCs on people.
“We know bits and pieces of the overall picture,” said Bratman. “But there is so much more to learn. We are proposing a framework, informed by important research from many others, on how to investigate the intimate links between olfaction, nature and human well-being.”
Nature’s smell-mediated impacts likely come through different routes, according to the authors. Some chemical compounds, including a subset of those from the invisible realm of plant VOCs, may be acting on us without our conscious knowledge. In these cases, olfactory receptors in the nose could be initiating a “subthreshold” response to molecules that people are largely unaware of. Bratman and his co-authors are calling for vastly expanded research on when, where and how these undetected biochemical processes related to natural VOCs may affect us.
Other olfactory cues are picked up consciously, but scientists still don’t fully understand all their impacts on our health and well-being. Some scents, for example, may have “universal” interpretations to humans — something that nearly always smells pleasant, like a sweet-smelling flower. Other scents are closely tied to specific memories, or have associations and interpretations that vary by culture and personal experience, as research by co-author Asifa Majid of the University of Oxford has shown.
“Understanding how olfaction mediates our relationships with the natural world and the benefits we receive from it are multi-disciplinary undertakings,” said Bratman. “It involves insights from olfactory function research, Indigenous knowledge, Western psychology, anthropology, atmospheric chemistry, forest ecology, Shinrin-yoku – or ‘forest bathing’ – neuroscience, and more.”
Investigation into the potential links between our sense of smell and positive experiences with nature includes research by co-author Cecilia Bembibre at University College London, which shows that the cultural significance of smells, including those from nature, can be passed down in communities to each new generation. Co-author Jieling Xiao at Birmingham City University has delved into the associations people have with scents in built environments and urban gardens.
Other co-authors have shown that nature leaves its signature in the very air we breathe. Forests, for example, release a complex chemical milieux into the air. Research by co-author Jonathan Williams at the Max Planck Institute for Chemistry and the Cyprus Institute shows how natural VOCs can react and mix in the atmosphere, with repercussions for olfactory environments.
The authors are also calling for more studies to investigate how human activity alters nature’s olfactory footprint — both by pollution, which can modify or destroy odorants in the air, and by reducing habitats that release beneficial scents.
“Human activity is modifying the environment so quickly in some cases that we’re learning about these benefits while we’re simultaneously making them more difficult for people to access,” said Bratman. “As research illuminates more of these links, our hope is that we can make more informed decisions about our impacts on the natural world and the volatile organic compounds that come from it. As we say in the paper, we live within the chemical contexts that nature creates. Understanding this more can contribute to human well-being and advance efforts to protect the natural world.”
A study by Rutgers Health experts of more than 31 million hospital records shows that infertility treatment patients were twice as likely as those who conceived naturally to be hospitalised with heart disease in the year after delivery. The results were published in the Journal of Internal Medicine.
Compared to those who conceived naturally, patients who underwent infertility treatment 2.16 times as likely be hospitalised for hypertension.
“Postpartum checkups are necessary for all patients, but this study indicates they are particularly important for patients who undergo infertility treatment to achieve a conception,” said Rei Yamada, an obstetrics and gynaecology resident at Rutgers Robert Wood Johnson Medical School and lead author of the study.
The study authors say their results support standards of care that now call for an initial postpartum checkup three weeks after delivery, standards that some health systems have yet to adopt. Much of the elevated risk came in the first month after delivery, particularly for patients who developed dangerously high blood pressure.
“And these results aren’t the only ones to indicate that follow-up should occur early,” said Cande Ananth, chief of the Division of Epidemiology and Biostatistics in the Department of Obstetrics, Gynecology, and Reproductive Sciences at Rutgers Robert Wood Johnson Medical School and senior author of the study. “We have been involved in a series of studies over the past few years that have found serious risks of heart disease and stroke to various high-risk patient populations within those initial 30 days after delivery – risks that could be mitigated with earlier follow-up care.”
The study analysed the Nationwide Readmissions Database, which contains nationally representative data on about 31 million hospital discharges and readmissions per year. The database contains diagnosis codes, which let researchers find specific populations and identify reasons for readmission.
The researchers used data from more than 31 million patients who were discharged following delivery from 2010 to 2018, including 287 813 patients who had undergone any infertility treatment.
Although infertility treatment predicted a sharply elevated risk of heart disease, the study authors said the relative youth of infertility treatment patients kept their overall risk fairly low. Just 550 of every 100 000 women who received infertility treatment and 355 of every 100 000 who conceived naturally were hospitalized with cardiovascular disease in the year after delivery.
The cause of the elevated risk of heart disease associated with infertility treatment remains unclear. The increase in heart disease could stem from the infertility treatments themselves, the underlying medical issues that made patients infertile or some other cause.
“Looking forward, I’d like to see if different types of infertility treatment and, importantly, medications are associated with different risk levels,” said Yamada. “Our data gave no information about which patients had undergone which treatment. More detailed information might also provide insight into how infertility treatment impacts cardiovascular outcomes.”
Disappointment as President prepares to sign flawed bill
The announcement that President Cyril Ramaphosa will sign the National Health Insurance (NHI) Bill into law this week without seeking much-needed revisions is disappointing, although not unexpected, according to the Health Funders Association (HFA).
“The HFA has been preparing for this day, despite our strong belief that a more collaborative approach between the public and private sectors is essential for achieving Universal Health Coverage [UHC] in a timely and effective manner,” says Craig Comrie, HFA Chairperson.
“We are deeply disappointed that the opportunity to review certain flawed sections of the NHI Bill has been missed, as the HFA sees enormous potential for leveraging the strengths of both public and private healthcare to expand access to quality care for all South Africans.
“Throughout the NHI Bill’s development process, the association submitted recommendations centred on collaboration and maximising the sustainability of healthcare provision through the use of a multi-funding model to build the South African healthcare system,” he says.
“Even with the President signing the NHI Bill into law on Wednesday, there will be no immediate impact on medical scheme benefits and contributions, nor any tax changes. The HFA is well prepared to defend the rights of medical scheme members and all South Africans to choose privately funded healthcare, where necessary.
“Our focus, as always, is on protecting and expanding access to quality healthcare for all South Africans. As we await the finer details of the President’s signing, we wish to assure all South Africans that we are ready for this next step,” Comrie says.
“The HFA will continue monitoring developments closely and share updates as necessary. Our goal remains the same: a healthcare system that works for all South Africans, and we will take all necessary actions to support that goal.”
President Cyril Ramaphosa has finished “looking for a pen” to sign the National Health Insurance (NHI) bill into law, and is set to approve the legislation on Wednesday, May 15.
While this “electioneering” move comes as a surprise to many, some experts anticipated this timing. With its signing, the legal battles over it will now begin. An array of medical and professional associations are readying their court papers, armed with numerous expert objections and petitions finding fault with the bill, widely criticised as unaffordable, demoralising and disastrous. But what will it look like in the end? Is it in fact an opportunity to fix public and private healthcare for the better?
To understand the NHI bill’s consequences and possible remedies better, Quicknews asked medico-legal specialist Martin Versfeld of Webber Wentzel & Associates about the legal aspects of the NHI bill, what it means for doctors in private practice, what can be done to ensure it fixes SA healthcare instead of damaging it further, and what its likely outcomes will be.
“The inequality of South Africa’s healthcare situation is not lost on anyone, least of all those in healthcare,” Martin says. “I think every healthcare professional, every hospital group, every healthcare provider recognises a need to assist South Africans more generally and to ensure there is better access to healthcare.”
Examination of the NHI bill has shown that it will simply exacerbate the problem, with possible wider consequences for the country’s economy (If Eskom’s load shedding is anything to go by – Ed). Viable alternatives towards repairing the beleaguered public healthcare system have been suggested, but political pressures have seen the bill signed into law. At this point, it is a certainty that it will face a barrage of litigation.
NHI, the mirage on the horizon
While the NHI is now set to be signed into law, there were efforts to persuade President Ramaphosa to not sign it. Recently, a South African Health Care Practitioners (SAHCP) petition was presented that contains a number of points and precedent to other laws that were rejected due to serious concerns. This petition had gathered 23 000 signatures from healthcare professionals.
Martin believes that it is a very effective petition, and it may have ‘resonated’ except for its timing. “The challenge that we face here is that it is an election year,” he points out. So while this petition and other appeals to the President to reject the legislation might have merit, and may have otherwise succeeded, it is extremely unlikely that Ramaphosa could go against his party’s goals.
“The NHI is a centrepiece, arguably, of the ANC’s election manifesto and they will be very reluctant to signal a climb-down at this point. So I think Cyril, as much as he might personally take a view that, under different circumstances, would be appropriate – I think he’d be under enormous pressure simply to sign the legislation into law.”
The time to act, with the most impact, will be after the elections.
As soon as NHI is signed into law, there will be a tidal wave of litigation, predicts Martin. This will be the next best time to challenge it. There are two avenues; whether the entire legislation is struck down as unconstitutional, or when it comes to the nitty gritty of implementation, when “the plethora of regulations are introduced.”
Even absent the court battles that will be waged, it will take years to fully implement NHI. Martin points out the length of the process, “The NHI is not going to be implemented to the full extent of what the legislation provides from the get go,” he says – it simply can’t be.
“It will be introduced incrementally by way of the introduction of regulations. So what I would expect as a first step would be to introduce the infrastructure required in order to create this collective pooling of funds.
“They will also be regulations which empower Nicholas Crisp and others to employ the essential staffing required to start to implement NHI.
“So it’s envisaged that there will be a very long process.”
‘Decades of litigation’
“Once the legislation takes effect, of course, the doctors and other stakeholders, including the medical schemes, will have an opportunity to carefully review the legislation and take a view as to whether or not they wish to, at this juncture, challenge certain aspects of that legislation on the basis of the – amongst other things – lack of constitutionality thereof.”
Martin stresses that the objections that have been lodged and engagements made to-date are not wasted effort. “It’s very important that the court sees and appreciates all the efforts that the industry has made in order to engage practically and meaningfully with the government. If nothing else, it puts the government on the back foot and the healthcare providers on the front foot.”
“This is not a matter which anyone is going to take lying down,” he says.
Speaking at a media briefing, SAMA’s chairperson, Dr Mvuyisi Mzukwa, said that the NHI bill will impact not only health professionals, but the country as a whole.
“SAMA has, on various platforms, made its position known that, as doctors, we swore an oath of service to those who seek healthcare from us. We do not believe this Bill will achieve what it purports to do,” he said.
The notion of how physicians resist unjust situations is a relatively new one, since the patient takes priority. Unlike worker resistance, which makes use of strikes and disobedience, the resistance of physicians must work within power structure and never compromise patient care. According to a study by Wyatt et al., “physician resistance includes a refusal to comply with professional expectations of limiting their concerns to the bodily care of patients.” Their review found that physicians have often engaged in resistance when their personal and professional interests were threatened, particularly around issues of autonomy.
Keep calm and carry on?
Despite its name, NHI would not actually provide healthcare insurance – instead Section 33 introduces a financing and single-supplier mechanism reminiscent of Eskom’s doomed model.
For most in the healthcare industry, section 33 is the greatest source of uncertainty and concern. It essentially eliminates medical schemes – but those reallocated funds only account for a fraction of the NHI’s true cost. However, this provision only comes into play once NHI is fully implemented – which could take decades, or just never happen, because of its sheer cost. The real threat, Martin says, is the perception and fear around NHI.
Martin has heard of “very negative consequences,” such as on the “decision on the part of students to study medicine; on professionals to stay committed to being in South Africa, leading to significant emigration on the part of healthcare professionals.
“For me, the real concern is less about whether or not NHI will ultimately be implemented in its current form, because I don’t believe it will be simply because we can’t afford it.”
Even if it is implemented, Martin suspects that many doctors will simple opt to operate on a cash basis, and wealthy individuals would be able to pay for specialists, expensive chronic medications and extended hospital stays. Though with the average age of specialists now at around 61, up from 53 in 1996, they may be in short supply in coming years.
There is also the question over what impact the mere threat of NHI will have on those with money and the ability to invest in the economy. Martin is “very anxious about the push factor associated with the perception that we can no longer get the required healthcare services.”
At some point it becomes a question of whether high net worth individuals can afford to pay for private healthcare, like they currently do for solar panels and generators to deal with the loadshedding crisis, and if that becomes a push factor to make them emigrate, taking their wealth, skills and economic contribution with them.
Implementation is still an open question
The devil is in the details, and in this case it is the thousands of specific regulations which will have to be rolled out in order to turn NHI from a law on paper into an actual functioning system.
Martin believes that it is quite likely that the NHI will end up only being partially implemented, if at all. Many of the requirements are quite steep.
All health users will need to have an electronic health record, for example – it will be a colossal undertaking to link South Africa’s 60 million plus, heavily rural, population, not far off of the UK’s 67 million. Just to get such a system running will take years. Still, a nationwide database would be extremely valuable for healthcare.
Even so, the NHI pilot projects failed to deliver on their promise of patient-centric care; the final report on the NHI Phase 1 interventions found that success was driven by factors which included “strong political will, adequate human and financial resources for implementation, good coordination and communication and good monitoring systems in place at the time of implementation.” Factors which worked against the interventions included “inadequate planning, lack of resources, inconsistent communication a lack of coordination where necessary and insufficient mechanisms to monitor progress to ensure course correction.”
(Of the two groups of factors, government initiatives have almost always landed squarely in the latter category – Ed)
In the end, where is the money?
There also is simply no money for the NHI, which is estimated by the Freedom Foundation to cost up to R1 trillion (more, even, than the much decried public wage bill) for full implementation.
Doctors in many provinces are unemployed as their health departments struggle under budget cuts. The Western Cape for example, has a hiring freeze, creating additional workload as positions go unfilled. The strain is being felt by doctors and nurses in hospitals. Already a petition of 1200 HCPs has been sent to the WC government’s offices. Centralised support from the National Department of Health has, in fact, been going backwards, with a number of wage-related issues being dropped squarely on the, already beleaguered, Provincial departments.
The NHI is also without historical precedent, as Martin says “no country that has introduced a form of National Health Insurance has sought to exclude the ability of the private sector to, in parallel, offer an insured medical service.” Ghana trialled a form of national health insurance, only for it to quietly fade away. The system involved capitation, in which a predetermined flat payment is paid to a provider to cover a defined benefit package of services for a patient. In theory, this forces cost containment onto providers.
It is important to note that schemes on the scale of NHI have only been achieved in a mere handful of countries, a list which consists almost entirely of very wealthy countries, with strong tax bases. South Africa’s situation is very different.
“We have a tiny tax base with a massive disease burden,” Martin points out.
Big in Japan
The country that successfully implemented such an initiative the fastest was probably Japan: “it took them 40 years or so,” Martin noted.
Japan, a country noted for the longevity of its people, has a massive tax base and a tiny disease burden, Martin points out. Indeed, for decades it was the world’s second largest economy. Hardly an act that a developing country like South Africa can try and follow in a matter of years, especially when a wealthy country, like the UK, has been struggling to maintain its own NHS.
The economic consequences of attempting it would be a huge tax increase, with high net worth individuals leaving.
Meanwhile, South Africa is a healthcare tourism destination for residents of wealthy countries that have national healthcare, because it has a world-class private health care industry. That source of international income would also fade away, under NHI.
Stick and carrot: building the NHI that South Africa needs
Nevertheless, there is a way forward to Universal Health Care, through successful public-private partnerships.
SAMA’s position also reflects this. “We believe that any form of health reform must be based on a health system that is built on adequate human resources for health, access to essential drugs, medicines and vaccines, suitably utilising evidence-based policies, ethical leadership and governance, as well as being built on digital and technologically integrated systems,” Mzukwa said.
Once the dust from the election settles, then the time will come for healthcare professionals and associations to properly engage with the government on NHI, as it is faced with the reality of implementation.
In that case, Martin says, once government has “considered the cost more carefully and agreed that they need to be more receptive to offers of collaboration with the private healthcare space,” then it can “accept that medical schemes as we know and understand them today can continue to exist and provide a parallel support to those who can afford to pay for medical schemes.”
What can doctors do? Martin advises that they carry on working through their associations. The various healthcare groupings are collaborating to both benefit the government and also to litigate and challenge the legislation and regulations. But these two aims should not be separated into two separate efforts, he says.
“I think there should continue to be an effort to collaborate collectively, to come up with positive solutions for the benefit of all South Africans. I think equally they will obviously have to, in parallel, to the extent necessary, litigate – I believe litigation is entirely inevitable, but they’ll need to collaborate around that.”
Severe traumatic brain injury (TBI) is a major cause of hospitalisations and deaths around the world, affecting more than five million people each year. Predicting outcomes following a brain injury can be challenging, yet families are asked to make decisions about continuing or withdrawing life-sustaining treatment within days of injury.
In a new study published in the Journal of Neurotrauma, Mass General Brigham investigators analysed potential clinical outcomes for TBI patients enrolled in the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study for whom life support was withdrawn. The investigators found that some patients for whom life support was withdrawn may have survived and recovered some level of independence a few months after injury. These findings suggest that delaying decisions on withdrawing life support might be beneficial for some patients.
Families are often asked to make decisions to withdraw life support measures, such as mechanical breathing, within 72 hours of a brain injury. Information relayed by physicians suggesting a poor neurologic prognosis is the most common reason families opt for withdrawing life support measures. However, there are currently no medical guidelines or precise algorithms that determine which patients with severe TBI are likely to recover.
Using data collected over a 7.5-year period on 1392 TBI patients in intensive care units at 18 US trauma centres, the researchers created a mathematical model to calculate the likelihood of withdrawal of life-sustaining treatment, based on properties like demographics, socioeconomic factors and injury characteristics. Then, they paired individuals for whom life-sustaining treatment was not withdrawn (WLST-) to individuals with similar model scores, but for whom life-sustaining treatment was withdrawn (WLST+).
Based on follow-up of their WLST- paired counterparts, the estimated six-month outcomes for a substantial proportion of the WLST+ group was either death or recovery of at least some independence in daily activities. Of survivors, more than 40%of the WLST- group recovered at least some independence. In addition, the research team found that remaining in a vegetative state was an unlikely outcome by six-months after injury. Importantly, none of the patients who died in this study were pronounced brain dead, and thus the results are not applicable to brain death.
According to the authors, the findings suggest there is a cyclical, self-fulfilling prophecy taking place: Clinicians assume patients will do poorly based on outcomes data. This assumption results in withdrawal of life support, which in turn increases poor outcomes rates and leads to even more decisions to withdraw life support.
The authors suggest that further studies involving larger sample sizes that allow for more precise matching of WLST+ and WLST- cohorts are needed to understand variable recovery trajectories for patients who sustain traumatic brain injuries.
“Our findings support a more cautious approach to making early decisions on withdrawal of life support,” said corresponding author Yelena Bodien, PhD, of the Department of Neurology’s Center for Neurotechnology and Neurorecovery at Massachusetts General Hospital and of the Spaulding-Harvard Traumatic Brain Injury Model Systems. “Traumatic brain injury is a chronic condition that requires long term follow-ups to understand patient outcomes. Delaying decisions regarding life support may be warranted to better identify patients whose condition may improve.”
Read more in the study, published May 13, in the Journal of Neurotrauma.
Researchers have identified the primary cause of sensory hypersensitivity related to autism spectrum disorders (ASD), in an area of the brain called the anterior cingulate cortex – a region often examined for cognitive and emotional disorders but overlooked for sensory ones. The results are published in the journal Molecular Psychiatry.
Autism affects approximately 1 in 36 individuals and is marked by significant challenges in social interaction and communication. Around 90% of autism patients also suffer from abnormal sensory hypersensitivity that deeply affects their daily functioning. This hypersensitivity results in exaggerated or dampened responses to common sensory stimuli such as sound, light, and touch, which leads to considerable stress and further social withdrawal. The precise brain region responsible for this sensory dysfunction is unknown, which hinders treatment efforts.
To find out more, a research team led by Director KIM Eunjoon of the Center for Synaptic Brain Dysfunctions and Director KIM Seong-Gi of the Center for Neuroscience Imaging Research within the Institute for Basic Science (IBS) studied a mouse model of ASD.
The ASD mouse model has a mutation in the Grin2b gene, which encodes the GluN2B subunit of NMDA receptors. NMDA receptors, a type of glutamate receptor in the brain, have garnered attention in the context of autism due to their crucial role in synaptic transmission and neural plasticity. It was hypothesised that the Grin2b gene mutation in mice would induce ASD-like phenotypes, including sensory abnormalities, and that certain brain mechanisms may play important roles.
The researchers monitored neural activity and functional connectivity in the brains of these mice using activity-dependent markers and functional magnetic resonance imaging (fMRI). In these mice, the researchers discovered increased neuronal activity in the anterior cingulate cortex (ACC). The ACC is one of the higher-order cortical regions that have been extensively studied for cognitive and emotional brain functions, but have been understudied for brain disease-related sensory abnormalities.
Interestingly, when the hyperactivity of ACC neurons was inhibited using chemogenetic methods, sensory hypersensitivity were normalised, indicating the pivotal role of ACC hyperactivity in sensory hypersensitivity associated with autism.
Director KIM Eunjoon states, “This new research demonstrates the involvement of the anterior cingulate cortex (ACC), which has been known for its deep association with cognitive and social functions, in sensory hypersensitivity in autism.”
The hyperactivity of the ACC was also associated with the enhanced functional connectivity between the ACC and other brain areas. It is believed both hyperactivity and the hyperconnectivity of the ACC with various other brain regions are involved with sensory hypersensitivity in Grin2b-mutant mice.
Director KIM Seong-Gi states, “Past studies attributed peripheral neurons or primary cortical areas to be important for ASD-related sensory hypersensitivity. These studies often only focused on the activity of a single brain region. In contrast, our study investigates not only the activity of ACC but also the brain-wide hyperconnectivity between the ACC and various cortical/subcortical brain regions, which gives us a more complete picture of the brain.”
The researchers plan to study the detailed mechanisms underlying the increased excitatory synaptic activity and neuronal hyperconnectivity. They suspect that the lack of Grin2b expression may inhibit the normal process of weakening and pruning synapses that are less active so that relatively more active synapses can participate in refining neural circuits in an activity-dependent manner. Other areas of research interest is studying the role of ACC in other mouse models of ASD.
People with hypertrophic cardiomyopathy were able to use significantly more oxygen while exercising after taking an investigational drug in an international clinical trial, according to a study published today in the New England Journal of Medicine. The finding was also presented at the European Society of Cardiology’s Heart Failure 2024 meeting in Lisbon, Portugal.
The randomised, double-blind Phase 3 trial has 282 participants and is evaluating the experimental drug aficamten, which was developed by Cytokinetics to treat the obstructive form of hypertrophic cardiomyopathy, or HCM.
“By having more oxygen available during exercise, patients with obstructive hypertrophic cardiomyopathy can more easily walk, perform household chores, and do other everyday tasks,” said cardiologist and paper co-author Ahmad Masri, MD, MS. Masri directs the Oregon Health & Science University Knight Cardiovascular Institute’s Hypertrophic Cardiomyopathy Center. “Our latest clinical trial results suggest aficamten is a promising treatment for HCM.”
HCM affects about 1 in 500 people and is one of the most common causes of sudden death for youth and otherwise healthy athletes. Often caused by inherited gene mutations, it thickens heart muscles and makes it difficult for the heart to work as it should. It causes shortness of breath and reduces people’s ability to exercise. The obstructive form of HCM reduces blood flow out of the heart.
About half of the trial’s participants randomised to aficamten. Scientists measured the participants’ oxygen levels while they used treadmills or bicycles. Those who took aficamten had a significant increase in their maximum oxygen use – 1.7mL/kg/min more than those in the control group taking placebo.
Having an increased peak oxygen uptake can improve a patient’s ability to be physically active, whereas reduced oxygen uptake can increase the risk of experiencing heart failure, needing a heart transplant, and dying.
A safer alternative
Non-drug treatment options for obstructive HCM include surgery to remove excess heart muscle. In 2022, the Food and Drug Administration also approved mavacamten as the first drug designed to target the underlying cause of obstructive HCM. However, mavacamten may increase the risk of heart failure and it interacts with several commonly used medications. As a result, patients who use mavacamten must also undergo intense monitoring.
During the past decade, OHSU has been involved in many research studies exploring new HCM treatment options. It has been a centre for several mavacamten studies and is participating in gene therapy research. The university is also currently involved in four other aficamten trials that are evaluating it as a potential treatment for various forms of HCM and in different types of patients, including children.
“This is an exciting time for treating HCM,” Masri said. “While we continue to offer traditional surgical and procedural therapies for HCM, we are now also able to offer patients other treatment options: therapies that were recently approved by the FDA and investigational therapies that are available by participating in clinical trials.”
