Tag: public health

Interview: “I Used That Anger to Feed My Activist’s Soul,” Says Former TAC General Secretary

Dr Vuyiseka Dubula-Majola, the former General Secretary of the Treatment Action Campaign, reflects on her journey and new role at the Global Fund. PHOTO: Joyrene Kramer

By Biénne Huisman for Spotlight

Dressed in a dark jacket, rain is pelting Vuyiseka Dubula-Majola’s face as she rushes past bare trees in Geneva, Switzerland. Along with her two children, Dubula-Majola has newly moved into a house in nearby Genthod, from where she commutes to work by train.

In October, the Global Fund to Fight AIDS, Tuberculosis [TB] and Malaria, appointed Dubula-Majola as head of their community, rights and gender department. The Global Fund has allocated tens of billions of dollars around the world to fight HIV since its inception in 2002.

Five weeks into the job, Dubula-Majola tells Spotlight that a big challenge for her will be to hone a new tool – that of diplomacy.

Laughing, the former General Secretary of the Treatment Action Campaign (TAC) says that in the past, diplomacy has not been her greatest strength.

“In this new job, I am required to be diplomatic,” she says. “Basically, diplomacy is being nice in the face of atrocities, and I am not that person. So it will be a huge challenge for me, it’s going to take a shift. I will have to keep asking myself, ‘what value I can add in this position?’ While developing new tools and new ways of fighting, without being the noisy person in the room.”

The power of collective action

Known for not mincing her words, the activist-scholar is talking to Spotlight over Zoom while walking to the Global Fund’s offices in central Geneva. She adds: “Activists don’t like bureaucracies by nature, but you have a voice here. You have political currency to shift things. It’s a tough one, but I’m there.”

In a 2014 TedX talk hosted in London, an inflamed Dubula-Majola told the audience that she is angry – angry with her father, angry with her government, angry at everyone. But that she was using her anger to fuel her work.

Vuyiseka Dubula-Majola was recently appointed at head of the Global Fund’s community, rights and gender department. PHOTO: Supplied

While she is in Switzerland, Dubula-Majola’s heart still brims with African proverbs, such as: “When spider webs unite, they can tie up a lion.” She has experienced the power of such collective action first-hand at the TAC, but now she’ll be applying it on a different stage. Indeed, her new job is “to ensure that the Global Fund strongly engages civil society and promotes human rights and gender equality”, with a particular focus on supporting community led organisations.

As a role model for her new diplomatic duties, Dubula-Majola cites American public health official Loyce Pace. “Loyce Pace who runs the health program in the United States government, she is very effective in what she does while hardly saying anything in public. But she is shifting norms – bringing priority to black and poor people. She uses her allies and many other people similar to her to say things louder than she could…I guess this is another step of growth in my activist journey – to still be as effective, as radical, the very same eagerness and passion, but silently.”

‘There was no time to dream’

Dubla-Majola grew up in a village near Dutywa in the Eastern Cape. Aged 22 in Cape Town in 2001, she spiralled with depression after being diagnosed with HIV. But instead of resigning herself to what was then still a death sentence for most people, she joined the TAC – working night shifts at the McDonalds drive-through in Green Point, while by day she joined the fight to bring antiretrovirals and other medicines to South Africa.

“As a 22-year-old, I did not have fun, there was no time to dream,” she recalls. “I was fighting for my life and the lives of others. I never thought I would have children, I never thought I would get married, I never thought I would love again. Because there was also the issue of who infected me, how did this happen? You start resenting relationships.”

At the forefront of social justice activism for most of South Africa’s young democracy – a role model for people living with HIV, and for those fighting inequality – Dubula-Majola lead the TAC from 2007 to 2013, after which she joined Sonke Gender Justice as director of policy and accountability. She holds an MA in HIV/AIDS management from Stellenbosch University; her PhD from the University of KwaZulu-Natal examined “grassroots policy participation after a movement has succeeded to push for policy change,” using MSF’s [Médecins Sans Frontières] pioneering antiretroviral sites in Khayelitsha and Lusikisiki as samples.

‘Build and regain the dignity of poor people’

In 2018, when Stellenbosch University offered her a job as director of its Africa Centre for HIV/AIDS Management, Dubula-Majola was circumspect. Why take up appointment at a white male-dominated institution shackled by slow transformation, in an elitist town? But she took on the challenge to become the transformation she wanted to see.

Dubula-Majola tells Spotlight that while relishing the privilege of academia – a space to reflect – it saw her away from “the heat of the activist fire” for too long. Five years later, a new challenge awaits.

Reflecting on Stellenbosch, she says: “This [job at the Global Fund] is even harder, because it’s not just one country, one university. This is all the continents of the world. All of them facing the same thing, the struggle here is to build and regain the dignity of poor people around the globe.”

Despite her early misgivings about relationships, Dubula-Majola married fellow TAC activist, Mandla Majola. Their children, now aged 10 and 16, are HIV-negative. Presently Majola is helping with their friend Zackie Achmat’s independent campaign for the 2024 general elections, after which he will join his wife in Geneva. The family will unite in Switzerland for Christmas though – “which will be the most miserable and cold Christmas,” says Dubula-Majola, laughing. “It will be our first winter Christmas and our last. As we just arrived a month ago, it doesn’t make sense to travel back to South Africa for the holidays.”

Overall she says she remains hopeful, adding that movements like #MeTo are lessons in global solidarity.

Her thoughts on continuing the fight against HIV: “It is up to HIV positive people, and those who want to remain HIV negative, to steer towards an AIDS-free generation. We must stop complaining, thinking politicians will do everything for us, and do it ourselves.”

Meanwhile, Global Fund representatives have voiced confidence in Dubula-Majola’s ability to lead. Marijke Wijnroks, head of the organisation’s strategic investment and impact division, said in a statement: “Following an extensive search process, I am delighted to say that we found the ideal person for this role. As a person living with HIV, Vuyiseka’s lived experience and leadership style are well aligned to what we need from this critical role.”

Note: Dubula-Majola is a former General Secretary of the TAC. Spotlight is published by SECTION27 and the TAC, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

Glaring Voids Threaten SA’s Path to Equitable Healthcare

A coherent, achievable path to universal health coverage now imperative

Glaring voids highlighted in submissions on the National Health Insurance (NHI) Bill threaten South Africa’s path to equitable healthcare access for all, cautions the Health Funders Association (HFA). The organisation has voiced its profound concern, emphasising the disconcerting sway of politics over the bedrock mission of prioritising the well-being of our nation within this critical healthcare deliberation.

“The practical barriers to successfully executing NHI as it is laid out in the Bill are hard to ignore, and yet the numerous concerns and suggestions raised in the consultation process have not been considered or implemented,” says Craig Comrie, chairperson of the National Health Funders Association (HFA).

“The clear shortcomings of the NHI Bill in terms of practical funding mechanisms and lack of collaboration with experienced health funders, among other aspects, have been overlooked for the most part, with only the Western Cape so far rejecting the Bill in its current form.”

The National Council of Provinces (NCOP) Committee on Health’s approval of the NHI Bill with insignificant edits does not address the numerous concerns raised in submissions made by the public and informed stakeholders, including the HFA, on behalf of its members.

The HFA is a professional body representing medical schemes and half of South Africa’s medical aid membership.

“There are constructive solutions to address the problems identified in the NHI Bill effectively, and it is not too late to fix the legislation. While the Bill is rushing towards the President’s pen to be enacted, the HFA respectfully appeals to the President to reconsider the wisdom of signing into law a Bill that has no workable funding mechanism while disregarding solutions proposed by private health funders, leading organisations, businesses and other key constituents,” Comrie says.

“We anticipate considerable resistance to the NHI Bill on Constitutional grounds, and as the HFA, we will continue to advocate for a more achievable approach to fulfilling universal health coverage aims.

“The timing of the recent flurry of activity in moving the Bill through the necessary hoops ahead of next year’s election invites the notion of a blunt instrument, an unrealistic election promise rather than a pragmatic solution for the highly complex health challenges South Africa faces,” he says.

Health Funders Association members, including leading lights in the industry such as Bankmed, CAMAF Medical Scheme, Discovery Health Medical Scheme, Fedhealth, Glencore Medical Scheme, Momentum Medical Scheme, Profmed and PPS Healthcare Administrators, to mention but a few, are ready to work with government to develop evidence-based solutions that will help secure access to quality healthcare for all South Africans.

“There is so much opportunity to make the NHI work. Private public partnerships and collaboration have achieved so much good for the benefit of South Africans in other sectors, and there is much our industry can contribute to help make quality healthcare more accessible and sustainable for all,” Comrie concludes.

In-depth: What is Behind the Shocking Number of Deaths Linked to Lead Poisoning?

Photo by Hush Naidoo Jade Photography on Unsplash

By Jesse Copelyn

An estimated 5.5 million people died of heart conditions linked to lead poisoning in 2019 – more than the number killed by outdoor air pollution over the same period. That’s according to a recent study in the journal Lancet Planetary Health. The number is substantially higher than previous estimates. According to a 2021 World Health Organization (WHO) report there were roughly 900 000 deaths linked to lead exposure in 2019.

The researchers also found that exposure to lead (a powerful neurotoxin) causes more harm to children’s intellectual development than previously thought. The paper estimates that in developing countries, where the condition is most prevalent, a child with average levels of lead exposure loses nearly six IQ points from the metal in their first five years of life (average IQ is 100).

While only about 2% of those living in wealthy countries have lead poisoning, the situation is very different for those in poorer parts of the world. A 2021 study found that nearly half of all children living across 34 low-and-middle income countries have lead poisoning – which is typically defined as a person having at least five micrograms of lead per 100mL of blood.

It’s estimated that the average child in South Africa is well above this threshold – at about 5.59 micrograms. And worryingly, the metal can still cause harm below the clinical threshold. Indeed, any increase in a person’s blood-lead levels is associated with greater health risks, even at the lowest detectable levels.

Part of the reason that lead poisoning is so widespread is that the metal is used in a wide range of everyday commercial products, and poorer countries typically have fewer well-enforced laws to regulate its use. Products include certain paints, ceramic glazescosmeticstraditional medicinesspiceslead-acid batteriesbullets and fishing sinkers.

The metal can make its way from these products into people’s bodies through a number of routes. In some cases – like with alternative medicines or spices – people directly ingest contaminated goods. In others, people breathe in lead dust, which can be generated by unregulated industrial practices. For instance if lead-acid battery recyclers lack proper safety and environmental standards – as is often the case in developing countries – recyclers may simply pour lead-based battery solution onto the ground, contaminating the soil.

Children are most at risk. For one, they’re more likely to put items that contain lead in their mouths, like toys covered in lead paint, or even a thumb coated in lead dust. Secondly, they’re closer to the ground and therefore breathe in more lead-contaminated dust. The theme of this year’s WHO-backed International Lead Poisoning Prevention Week  was “End childhood lead poisoning”.

After it’s ingested or inhaled, some lead is excreted, while the rest is absorbed into the bones, teeth and blood. Children absorb more of the metal than adults and once it’s in the blood, lead can be distributed to various organs in the body. This includes the heart as well as the brain, where it can interfere with neurotransmitter systems involved in learning and memory.

No threshold

The new study in Lancet Planetary Health adds to a growing body of evidence that global lead exposure is far more detrimental to human health than previously thought. While people began understanding that lead was poisonous several thousand years ago, it was only recently that evidence accumulated showing that even tiny amounts of lead can cause damage.

Part of the reason is simply because we didn’t have data on low-level exposure until recently, explains Bjorn Larsen, the study’s lead author. Most people in industrialised countries had very high blood-lead levels during most of the 20th century. For instance, in the late 1970s the average American child had about 15 micrograms of lead per 100mL of blood, which is about 25 times the average today, and three times the present-day threshold for lead poisoning. A major reason was leaded gasoline, which was introduced in the 1920s and phased out from the 1970s onward.

Thus, says Larsen, testing the effects of blood-lead levels that we would now perceive as low wasn’t always possible. For instance, to show that even one or two micrograms of lead per 100ml of blood is harmful, researchers would need to compare people at this (very low) level to those with no lead to observe if they come off worse. But if almost everyone is above two micrograms, this becomes close to impossible as there isn’t anyone to test. And in the absence of data, some simply assumed that the metal was only problematic above a particular threshold.

Bruce Lanphear, a professor of public health at Simon Fraser University, was the lead author of a seminal 2005 paper that showed that lead was associated with declines in IQ even below the clinical threshold set at the time (10 micrograms of lead per 100mL of blood). He explains that by the mid-1990s, when 95% of people were below that threshold, many felt that lead was no longer much of an issue: “my advisors at that point said get out of this line of research, the problem seems to be going away and there won’t be any funding for it. And they were right about one of those two things – I haven’t gotten much funding,” Lanphear says.

As blood-lead levels continued to drop and scientists like Lanphear could study the effects of lead on children’s intellectual development at lower levels, a new consensus emerged. Larsen explains: “Now people are willing to say that in all likelihood the correct way to estimate things is that there is some effect on IQ as soon as we can detect lead in the blood – even at the lowest level these effects start”. Indeed, according to a WHO factsheet, “there is no known safe blood-lead concentration”.

Not only that, adds Lanphear, but research shows that “proportionately, we see greater harms – greater reductions in IQ – at the lowest measurable lead levels”. In other words, the more lead you have in your body, the worse it is, but going from one microgram of lead per 100ml of blood to two micrograms causes more additional harm than going from 15 micrograms to 16. Thus, it’s strangely only through the decline in lead poisoning that its most pernicious effects have been revealed.

Lead ‘poisons’ our cells

As more data is gathered, estimates of the harm caused by lead are constantly being revised upward. The finding that lead is linked to 5.5 million cardiovascular deaths a year is over six times the number previously determined by a 2019 study. It should be noted however that the new estimate is relatively uncertain – the researchers estimate the real value is most likely in the range 2.3 to 8.3 million.

Part of the reason for the updated estimates is that the 2019 research had only looked at the effects of lead on blood pressure, while the new paper considers a wide variety of cardiovascular problems associated with lead.

According to a statement by the American Heart Association from earlier this year these effects include injury to the cells that line the blood vessels, oxidative stress (which can result in cell and tissue damage) and coronary heart disease, which is when the blood flow is restricted, increasing the risk of a stroke or heart attack.

Gervasio Lamas, Chief of cardiology at Mount Sinai Medical Centre and the lead author of the statement, explains that heavy metals like lead can erode cardiovascular health through two broad channels: “one is that toxic metals typically will end up replacing essential metals or ions in vital cellular reactions,” he says.

For instance, lead replaces the calcium in our cells, a mineral which is involved in keeping our hearts pumping, our blood clotting and our heart muscles properly functioning. By removing calcium, lead “poisons these cells,” says Lamas.

He tells Spotlight that the other main route is that toxic metals often interfere with our antioxidant mechanisms. Antioxidants are molecules which deactivate harmful free radicals (chemicals that can attack our cells and DNA). Lead disrupts these antioxidant defences, he says. As a result, free radicals build up, which may cause the blood vessels to harden (called atherosclerosis), blocking blood flow.

Different strands of evidence point in the same direction

To arrive at the conclusion that 5.5 million people died from lead-induced heart conditions, Larsen and his colleague relied on two large observational studies from the United States (where there is lots of data). These studies measured the blood-lead levels of thousands of people and looked at what happened to them over time. They showed that those who had more lead in their blood were more likely to die of heart complications at a younger age, even when controlling for lots of other factors.

Larsen and his colleagues used estimates from these studies to develop a model which calculates the increase in a person’s risk of dying of heart disease at different levels of lead exposure. They then plugged in the blood-lead levels that we observe among people around the world to estimate how much cardiovascular death the metal is linked to.

One contention that emerges from research like this is whether it really shows cause and effect. As Lamas notes, “the populations that are most affected by high lead levels are [more likely] to be underprivileged in some way. They are often either poor or have access to less healthcare or live in areas that are more generally contaminated – things that you would expect would in any case cause [health] problems for them”.

When we find that people who have more lead in their blood die of heart disease more often, this may be due to one of these other factors.

But according to Lamas, there are a number of reasons to be confident that lead is actually the driver of heart disease. The first is that when observational studies (like the ones discussed above) measure the relationship between people’s lead levels and cardiovascular disease, they control for a range of other risk factors, including their socioeconomic status. “Even when you do that, lead still sticks out like a big sore thumb,” Lamas notes.

The other reason is that there are lots of different sources of evidence that all find lead damages cardiovascular health: “there are direct experiments where patients or animals are infused with lead and those show that arterial function [i.e. the ability of our arteries to transport blood] is diminished,” Lamas explains.

Finally, Lamas points to the results of a randomised clinical trial which he and his colleagues published in 2013. In it, they took over 1700 patients who had recently suffered from a heart attack and randomly split them into different groups. One group received a treatment for lead poisoning called EDTA chelation. This is an intravenous medicine that binds with toxic metals in the body before being urinated out. Those who didn’t receive the chelation therapy got a placebo drug.

Five years later, those who got chelation therapy appeared to be better off. They performed better than the placebo group when measured by a composite index that combines factors like patients’ risk of dying and their need to return to hospital for further procedures.

With so many different kinds of research pointing in the same direction, Lamas believes the evidence that lead plays a causal role in heart disease is about as conclusive as in the case of high cholesterol.

And if lead truly is killing 5.5 million people through heart conditions each year, this places it among the top risk factors for cardiovascular disease globally. Despite this, lead poisoning along with exposure to other toxic metals, remains a remarkably overlooked issue. Lamas explains, “at the individual physician level – sitting across from a patient – I’m the only cardiologist I know who routinely checks lead, mercury, arsenic and cadmium”.

Note: This is part one of a two-part Spotlight special series on lead poisoning.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

Op:Ed – How Collaboration can Help South Africa to Build a Better Healthcare System

Photo by Sora Shimazaki: https://www.pexels.com/photo/diverse-anonymous-colleagues-shaking-hands-at-table-with-coffee-and-folders-5673475/

As various players in South Africa’s health arena give input into the National Health Insurance, and the form it should take, they are agreed on one thing: its goal to achieve quality universal healthcare for all South Africans.

The recent COVID-19 vaccine rollout is a good foretaste of what is possible for South Africa’s healthcare system through the power of cross-sectoral collaboration – and a great case study for health systems strengthening in other countries too.

The rollout saw the public and private sectors, trade unions and community organisations pooling their resources and expertise to get the vaccines to South Africans as fast as possible, and the campaign showed that the country has the resources and expertise to provide a better, more equitable healthcare service.

The question is how we take these lessons and embed them in a healthcare system that serves all of a country’s citizens, and does so in a sustainable way, while adhering to best practice standards.

The clear answer is through the power of partnership – which has been demonstrated to work both here and in the rest of the developing world. Promoting public-private partnerships (PPPs), can accelerate access and distribution of innovative medications. By working together, government, originator companies, and funders can ensure that patients benefit from the latest advancements in healthcare.

Rwanda, for instance, has made significant progress in managing non-communicable diseases (NCDs) through community-based health insurance schemes. Brazil has successfully implemented a comprehensive primary healthcare approach. These countries have prioritised prevention, early detection, and treatment of NCDs, which can be adapted to the South African context.

Locally implemented initiatives under the global Making More Health (MMH) programme include training community health workers to provide primary care services, supporting local entrepreneurs in developing innovative healthcare solutions, and partnering with NGOs to improve access to healthcare in rural areas. These initiatives have helped address complex healthcare issues by empowering local communities and leveraging local resources.

MMH is a social initiative from Boehringer Ingelheim in collaboration with Ashoka, which combines business and social values to unleash innovation and achieve economic and social progress in healthcare. The objective of this long-term initiative is to source social innovation around the world, to explore unconventional partnerships and business models, and to encourage Boehringer Ingelheim employees.

We must also turn our attention to NCDs, which are a major health threat. The WHO estimates that globally, they are responsible for 74% of all deaths. Research into South Africa’s NCD states can play a crucial role in health systems strengthening by identifying the most prevalent diseases, understanding their risk factors, and informing evidence-based policies and interventions. This would help target resources more effectively and improve health outcomes.

This requires robust health data, hosted on a digital infrastructure, which would promote data-sharing among healthcare providers, and encourage the use of standardised data collection methods. This would help create a more accurate picture of the population’s health needs and enable better decision-making across the entire health ecosystem.

We also need to make sure we retain our world-class doctors, and address our critical nursing shortage – it’s estimated we need about 26 000 additional nurses to fill the gap. Without sufficient personnel to deliver healthcare, all the best intentions in the world will not deliver universal health coverage.

We must invest in improving the working conditions and incentives for healthcare professionals in the public sector, strengthen primary healthcare services, and promote collaboration between public and private providers. This would help to ensure that the expertise and experience of these professionals is effectively employed to benefit the broader population.

Moreover, increased collaboration with innovator companies in the private sector, many of whom are already involved in initiatives to strengthen the health system, would ensure patients receive the right treatment while expanding reach across the entire population. This would help tackle inefficiencies, streamline processes, and enable better resource allocation.

The fundamentals of health system strengthening in South Africa include adequate financing, a well-trained and motivated healthcare workforce, efficient supply chain management, and strong governance and leadership. Addressing these gaps – through partnership and collaboration – would help build a more resilient and responsive healthcare system and ensure that South African citizens have access to better healthcare.

Men’s Health Awareness Month: Supporting Men’s Health in the Workplace

To mark Men’s Health Awareness Month, International SOS, the world’s leading health and security risk services company, emphasises the importance of creating supportive workplace environment that foster men’s health and mental wellbeing.

Men’s health remains a significant concern and poorer health profiles for men than for women have been reported, with discrepancies found in metrics including life expectancy, mortality rates, disability-adjusted life years, and non-sex-specific disease death rates.The World Health Organization (WHO) reports that non-communicable diseases (NCDs), are claiming around 74% of all lives lost each year2, and in 2018, NCDs and injuries accounted for 86% of all male fatalities.3

The WHO data shows that men across all socioeconomic groups demonstrate unhealthier smoking practices, unhealthier dietary patterns, higher alcohol consumption levels and higher rates of injuries than women.3 In fact, among the global population that used tobacco in 2020, a significantly higher percentage were men (36.7%), compared to women (7.8%).4 These statistics highlight the need to focus on improving men’s health and organisations can play a vital role in enhancing men’s health within their workplaces.

Men are significantly less likely than women to seek preventive care services, which can often lead to undiagnosed conditions.1 Men are also found to be less likely to have received mental health treatment than women. The stigma attached to illness and men perceiving illness as a weakness are often found to be the reasons why men are not as vocal about their health and mental wellbeing concerns.5

Dr Anthony Renshaw, Regional Medical Director at International SOS, said “Men’s Health Awareness Month provides a crucial opportunity for organisations to re-evaluate their approach to supporting the health and wellbeing of male employees. In addition to physical health, we must also prioritise mental health, as it has a direct impact on overall productivity and workplace satisfaction. Employers can play a pivotal role in fostering open discussions, reducing stigma, and promoting a supportive environment for men to seek the help they may need.”

International SOS offers guidelines for organisations to provide workplace support specific for men’s health and wellbeing with the ‘H-O-P-E’ approach:

  1. Hold workplace men’s forum that can act as a safe space. Having a supportive work environment where everyone, particularly men, know that they are allowed the time to address any health concerns is extremely enabling.
  2. Offer male-specific confidential support from mental health professionals.
  3. Provide your team leads with appropriate training to enable them to spot early signs of poor physical and mental health and know where they can signpost their employees to.
  4. Encourage employees to have regular health check-ups, particularly screening for early detection and treatment of NCDs, as well as a mental health assessment if needed.
  1. The World Journal of Men’s Health | Changing Men’s Health: Leading the Future
  2. World Health Organization (WHO) | Noncommunicable Diseases fact sheet
  3. World Health Organization (WHO) | Men’s Health fact sheet
  4. World Health Organization (WHO) | Tobacco fact sheet
  5. National Institute of Mental Health | Men and Mental Health

Collaboration Key to Address SA’s Fatal, Diabetes-linked Cardiovascular Disease Burden

Photo by Hush Naidoo on Unsplash

Only concerted multi-disciplinary collaboration and research will stem the tide of diabetes and diabetes-linked cardiovascular disease (CVD), the latter currently the leading cause of death locally and worldwide, claiming 17.9 million lives annually1.

This was the consensus among some of the world’s leading cardiologists and researchers gathered at the SA Heart Association’s annual congress aptly themed: ‘The Cardiac Collaboration,’ which took place at the Sandton Convention Centre in Johannesburg from 26-29 October this year.

Globally, CVD takes more lives than TB, HIV and malaria combined, while 215 South Africans are killed by CVD every day – with 80% of CVD and strokes being preventable.1,2 The prevalence of diabetes has also increased in South Africa, from 4.5% in 2010 to 12.7% in 2019. Of the 4.58 million people aged 20-79 years who were estimated to have diabetes in 2019, 52.4% were undiagnosed.3

With diabetes being a key driver of CVD – especially in Africa (with limited access to novel drugs and the prevalence of sugar-rich, poverty-driven lifestyles), the mutual consensus at this year’s congress was that collaboration is key.

Dr Zaheer Bayat, Chairperson of the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA), told delegates that endocrinologists and cardiologists would have to work together to improve outcomes for diabetic patients, 30% of whom suffered cardiovascular events. He warned that a 134% increase of people living with diabetes was predicted over the next two decades, translating into a dramatic surge in chronic kidney disease, cardiovascular disease, blindness, and amputations.

Dr Bayat said he intends appealing for mass diabetes screening to find the 52% of people whom researchers estimate are undiagnosed. Ideally, this should be followed by access to cheaply acquired, effective new glucose-lowering drugs.

“The reality is that this country cannot afford all the new treatments for everyone – not private funders, not government. So, drugs are not really a solution – the best solution is to change lifestyle and prevent disease in the first place,” said Dr Bayat.

“We’re here to fight for our patients, not our pockets. Can we afford to have 52% of our patients not knowing they’re diabetic? People who should be contributing to our economy are living with diabetes and eventually dying,” he asserted.

Dr Bayat also said that globally, First World countries such as the USA and Sweden are reducing myocardial infarctions, strokes, and amputations, because they’re doing all the right things together. This included adopting a healthy lifestyle, effective management of sugar, blood pressure and cholesterol and smoking cessation.

“However, here in South Africa with private healthcare representing 15% of healthcare delivery but consuming 50% of the spend and the public sector representing 85% of the population and consuming the other half – we’re not doing nearly as well. With only 200 cardiologists in the country (one per 190 000 population), and even less nephrologists, we need to join together and change the trajectory of diabetes. We must work together to reduce morbidity and mortality,” said Dr Bayat.

According to the SA Heart Association, this graphically illustrates the importance of a multi-disciplinary approach, the very reason why the conference was called ‘The Cardiac Collaboration.’

The SA Heart Association has already begun forging formal ties with other academic societies and next year, it hopes to join and host joint sessions with collaborative meetings to connect a multidisciplinary team in order to achieve a well-rounded balance of care.


  1. https://www.heartfoundation.co.za/wp-content/uploads/2017/10/CVD-Stats-Reference-Document-2016-FOR-MEDIA-1.pdf.
  2. https://world-heart-federation.org/what-we-do/prevention/#:~:text=An%20estimated%2080%25%20of%20cardiovascular,and%20%E2%80%9Cknowing%20your%20numbers%E2%80%9D.
  3. International Diabetes Federation. IDF Diabetes Atlas.10th ed. International Diabetes Federation; Brussels, Belgium: 2021. [Google Scholar] (primary). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10218408/#:~:text=The%20prevalence%20of%20diabetes%20mellitus,%25%20were%20undiagnosed%20%5B5%5D. (secondary).

Surgery Backlog in Northern Cape Getting Worse

Photo by Piron Guillaume on Unsplash

By Refilwe Mochoari for Spotlight

Already long surgical waiting lists in the Northern Cape appear to have ballooned in recent months. In May, the province’s MEC for Health Maruping Lekwene told the province’s legislature that surgical waiting lists in the province stood at just under 4000. According to more recent figures from the Northern Cape Department of Health’s 2023/24 First Quarterly report, the surgical backlog stands at 6373 – an increase of more than 50% on the figure given in May.

Lulu Mxekezo, Northern Cape Department of Health Spokesperson, confirmed to Spotlight last week that the surgical backlogs had indeed increased from around 4000 to around 6000. She said that the numbers fluctuate as the need continues to increase on a daily basis.

“The shortage of specialised theatre staff makes it impossible for us to utilise all theatres daily to perform the procedures,” said Mxekezo, adding that the department will not compromise the safety and lives of patients and operate in theatres with no specialised theatre staff.

The increase in the backlog came despite the outsourcing of some surgical services in the province. Lekwene told the legislature that the Northern Cape Department of Health pays Gauteng-based Medicomed (captured as Medicore-Mets in the legislature minutes) R400 000 per month to assist with orthopaedic surgeries at Robert Mangaliso Sobukwe (RMS) Hospital in Kimberly on a month-to-month basis. He said the company supplies the department with specialised theatre nurses which is a scarce skill in the province. In May, Lekwene told legislators that the company had assisted with 57 surgeries over a two-week period.

Lack of theatre staff

The quarterly report stated that the backlog is fuelled by the lack of theatre staff at RMS hospital, and that the private sector was called in to fill this gap.

When asked by Izak Fritz, Democratic Alliance member of the Provincial Legislature, why the department does not appoint specialist nurses instead of outsourcing these services, Lekwene answered that there are unfortunately not enough theatre specialist nurses in the province.

“For us to take this route, it means that we need to have internal capacity. For instance we will have a neurosurgeon but we will not have an anaesthetist. We have nurses, but we do not have theatre specialist nurses,” he said.

He said they do not enjoy outsourcing, but that because of the urgency and the growing backlog the department has to act swiftly. “However as soon as the backlog has been reduced, we will then try to use our internal staff,” he said.

Lekwene also told the legislature that the backlog was mostly caused by the Covid-19 pandemic. “Remember that for two years during Covid-19, hospitals were closed,” he said.

Left stranded

Some workers at RMS said the long waiting list has left many patients frustrated and stranded. One doctor described the situation to Spotlight as “dire”. “The hospital has four fully equipped theatres but patients do not get help,” he said. He asked not to be named for fear of losing his job.

“Yes, we do have a shortage of nurses, but it is not as bad as they say. We are available as doctors, but without the help from nurses we are unable to perform surgeries at all,” he said.

The doctor said that currently the list of patients that need to receive emergency surgery is longer than 30. He said that for ordinary surgeries such as hip replacements there are patients who have been in hospital for more than 18 months, while some have been waiting for cataract surgery for five years.

A strain on staff and patients

Dennis Segano, provincial chairperson of Health and Other Services Personnel Trade Union in South Africa (HOSPERSA) said the surgery backlog is putting a strain on both nurses and patients.

He said the main problems that they see at RMS is the shortage of specialised theatre nurses and a lack of equipment. “When you enter the theatres there are enough doctors but not enough nurses,” he said. “We have a problem with our theatre nurses who are often outsourced by the service provider to work during their surgery marathons at the RMS hospital but have to wait three months or sometimes even six months before they can get paid.”

Spotlight asked Mxekezo about the late payment allegations but had not received a response by the time of publication.

“We don’t know why the government is not appointing the nurses instead of paying a service provider,” Segano said. “The system is burdened, the nurses in orthopaedic wards are burdened and we feel sad for the patients who have to spend months in hospital. “As a patient when you have a fracture, you must be able to go to theatre immediately, but in this province, you have to wait months before you receive help.”

“Stakeholders are also assisting us in performing theatre marathons to deal with the backlog,” Mxekezo said.

For example, in October last year, disaster relief organisation Gift of the Givers sent a team of theatre nurses and anaesthetists to assist with the backlog at RMS. According to Ali Sablay, the organisations project manager, they performed 72 operations on 72 patients during the catch-up drive.

Long-term solution

When asked what the department’s long-term plans are to reduce the pressure, Mxekezo explained that the operationalisation of theatres in district hospitals with specialised theatre staff will assist in minimising the backlog at RMS as many patients are transferred from districts.

Segano agreed that a long-term solution is to equip district hospitals with decent theatres and specialised theatre nurses.

“Minor fractures must be dealt with at district hospitals. RMS Hospital must only perform serious surgeries,” he said. “If the department can prioritise Harry Surtie Hospital and De Aar Hospital with theatre staff and equipment, RMS Hospital will operate much better and the patients will be helped. It is incorrect to send all patients of the Northern Cape to one hospital in Kimberly. They will not succeed.”

“Permanent employment of theatre staff will also assist in stabilising the surgical backlogs,” Mxekezo said.

Sceptical opposition

Fritz told Spotlight the DA is very concerned about the growing backlog in the Northern Cape and that they have repeatedly highlighted surgery backlogs at the provinces only tertiary facility (RMS).

“When one looks at nursing appointments at the RMS hospital, we see a trend whereby more nurses’ contracts are terminated each year than the amount of nurses who actually get appointed,” he said. “In effect, the hospital only operationalises four of its nine theatres.”

“Despite agreements with private agencies for surgery marathons to help tackle the backlogs, this only has a limited impact because of the inability to operationalise more theatres and to ensure there is an availability of more beds for recovery,” he said.

Fritz said the reality is that the people who require elective surgery often have to wait years to be attended to while their condition progresses. “Only when their case becomes an emergency can they be bumped up the list, and by that time their disease has become worse and their hopes of a full recovery is minimised,” he said.

Wynand Boshoff, the Freedom Front Plus’s (FF+) Northern Cape Provincial Leader, said in an interview with Spotlight last week that the problem with the department is that it is an entity that is riddled with mismanagement and a culture which aims for anything but service delivery.

He said the FF+ is not only approached by patients, but also by doctors on a regular basis who want to leave the health department because of management that he said has completely abandoned services.

“It is clear that more is needed than the appointment of a new minister or a new Head of Department, as the legacy of mismanagement overwhelms individual role players. A comprehensive investigation and steadfast disciplinary action is needed,” he said. “Repeat offenders should not be tolerated in the department, not even in the most humble of positions.”

As Spotlight previously reported, the Northern Cape Department of Health has had several acting heads in the last three years and several senior officials have and are facing charges in court. The current Head of Department is Dr Alastair Kantani, who has been acting in the position since 8 September following the arrests of seven officials, including former head Dr Dion Theys who now occupies the post of Medical Director in the department. In a statement issued by the department on 13 September Lekwene said this action is informed by the constitutional responsibility to ensure relative stability in the delivery of healthcare services in the province.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

AfriForum Report Exposes Dangers of National Health Insurance

The National Health Insurance (NHI) will further widen the inequality gap, put even more pressure on the already overburdened taxpayer and lead to an outflow of medical expertise should it be implemented. AfriForum has detailed these and other consequences of the NHI in a new research report.

In its report, the organisation details, among other things, the ideological basis of the NHI, the place it occupies in the ANC’s National Democratic Revolution (NDR), the economic consequences of the centralisation of health financing and the vagueness in the bill itself. Furthermore, the report provides an overview of centralised health systems in a number of other countries and how they compare or contrast with the economic and policy environment in South Africa.

One of the biggest issues with the NHI Bill is its funding. According to the report, four possible sources of income are currently being investigated that will have a negative impact on taxpayers – including payroll tax. This option entails that the government will require employers to recover a portion of their employees’ salaries which will then be remitted to the government – this on top of the deductions that are already recovered from employees’ salaries. South Africa’s marginal income tax is already higher than that of most other countries such as Canada, the USA and Namibia. Although this is the same as Australia, Switzerland and South Korea’s marginal income tax, South Africa has little in terms of service delivery to show for it.

The research finds in almost all the areas of investigation that NHI will be harmful to the economy and negative for the well-being of most South Africans and concludes that the bill should be rejected by parliament and opposed by the health sector.

According to Louis Boshoff, Campaign Officer at AfriForum, this report appears at a critical time where the parliamentary battle over the NHI Bill rages on and many misconceptions about it are circulating. “NHI is easily summarized incorrectly with slogans such as ‘free health care for all’, but the report takes a step back to obtain a more sober and objective picture, namely that the policy is expensive, unmotivated and unworkable,” says Boshoff.

The full report is available at www.jougesondheid.co.za, where the latest information on NHI is posted.

Global Trends for Atherosclerosis Still on the Rise

Source: Wikimedia CC0

Atherosclerosis, caused by arterial wall plaque build-up, is a leading cause of death globally, particularly in the developed countries. Although the mortality rates for this condition fell dramatically during the 20th century, the incidence is now ever increasing. Unfortunately, despite the widespread impact of atherosclerosis – and efforts to curb it – data on the global and national trends of the disease is quite limited.

In a recent effort to address this knowledge gap, a research team from China led by Professor Rongchong Huang decided to conduct a detailed statistical analysis on the impact of atherosclerosis at the global and national levels by using GBD data. The study was published in the Chinese Medical Journal.

“It is unknown how global changes in pertinent controllable variables in recent years have affected the burden of atherosclerosis,” remarks Prof Huang.

The researchers analysed publicly available data from the Global Burden of Disease Study 2019 related to the three main clinical presentations of atherosclerosis, ischaemic heart disease (IHD), ischaemic stroke (IS), and peripheral arterial disease (PAD). The data collected, which spanned the period from 1990 to 2019, included participants of all ages with similar epidemiologic characteristics and in relative proximity, from 21 countries.

Overall, the study had four main goals. The first was to determine the global trends in terms of prevalence, mortality, and disability of the three conditions. The second goal was to identify the years that had the biggest shift in the trends of these indicators. Finally, the third and fourth goals were to analyze global trends based on age, gender, and socioeconomic factors and report global and national patterns, respectively. 

According to the results, there was an overall increasing trend in the global incidence of the three clinical manifestations of atherosclerosis from 1990 to 2019. Notably, the main drivers for this rising incidence were adults aged 20–54. The researchers found this very concerning, given that atherosclerosis with such an early onset is usually caused by preventable factors, such as lack of exercise, dietary habits, and environmental pollution. However, the mortality rates and disability-adjusted life years for IHD and IS declined during this period across all age groups. This could indicate greater awareness regarding these conditions and their early symptoms, as well as advancements in clinical management. 

Nonetheless, the global rise in the incidence of atherosclerosis over the past three decades is a serious problem that warrants special attention towards its root causes. In this regard, Prof Huang explains: “This rise can be attributed to a variety of factors. Firstly, global aging trends have led to a higher prevalence of the disease, given that age is a significant risk factor for atherosclerosis. Secondly, modern lifestyle habits, including high-fat diets, lack of exercise, smoking, and excessive alcohol consumption, have increased atherosclerosis risk. Lastly, there has been a rise in chronic diseases such as diabetes and hypertension, which are significant risk factors for atherosclerosis.”

The researchers also pointed out that the burden posed by atherosclerosis is increasing significantly in low- or middle-income countries, summarising key social and economic development indicators. China, which has the world’s greatest number of deaths due to cardiovascular diseases, is a prime example of this issue.

Taken together, the study paints a grim picture of global cardiovascular health, which is very concerning. “Overall, the burden of atherosclerosis-related disease is still not significantly decreasing and is even trending upward, especially in low- and middle-income countries and in younger populations,” says Prof Huang, “There is an urgent need for more targeted treatment and management in younger populations and in low-middle and middle-income countries.”

Hopefully, the results of these analyses will prompt decision makers, scientists, and medical professionals alike to increase their efforts towards fighting against atherosclerosis and its devastating consequences.

Source: EurekAlert!

Opinion: More Austerity is the Wrong Medicine for Our Public Health Crisis

Photo by Hush Naidoo on Unsplash

By Matshidiso Lencoasa and Dominic Brown for Spotlight

In the context of weak economic growth, lower-than-expected tax revenues, and the implementation of measures to reduce public spending, there is “rising panic” ahead of this year’s Medium Term Budget Policy Statement (MTBPS). The concern for health care provision is palpable as anticipated budget cuts threaten the country’s already fragile and understaffed public healthcare system. There is only one nurse for every 224 patients in the public health system, and over 5 000 nursing posts remain unfilled (something primarily attributed to funding constraints).

In times of poor economic performance, difficult policy choices and trade-offs arise, and it may be tempting for fiscal policymakers to slash public health spending. However, without meaningful consideration of the impact of these decisions on our people and our constitutional right to access healthcare, the MTBPS risks exacerbating the hardships faced in our country.

Austerity context

South Africa’s economic outlook has been riddled with challenges permeating our healthcare system. Over the past decade, the country’s economic growth has underperformed, falling in real terms from 2.3% in 2013 to 0.1% in 2023. National Treasury has responded to this with cuts to social spending, including healthcare. Public health is receiving fewer resources in real terms, and our government spends more on debt-servicing (R340.5 billion in the 2023/24 Budget) than on healthcare (R259.2 billion in the 2023/24 Budget). Moreover, healthcare’s allocation of R259 billion in 2023/24 was the same as last year’s allocation, meaning that the value of resources allocated to healthcare this year is eroded by Consumer Price Index (CPI) inflation, which was projected to be 4.9% at the time of the Budget Speech in February this year.

According to the Public Economy Project, the spending per healthcare user fell from approximately R4 600 in 2012 to R4 300 in 2018. PHOTO: Sourced from the Public Economy Project (PEP) Public services, government employment and the budget

Worse, this allocation needed to account for the rising demand projected for public healthcare services. Currently, about 84% of the population relies on the public health care system. This figure is projected to increase in response to population growth and rising unemployment making medical aid inaccessible for many in the country.

According to the Public Economy Project, after accounting for inflation and population growth, the spending per healthcare user fell from approximately R4600 in 2012 to R4300 in 2018. Based on current budget estimates, it is projected that real per capita public health spending will fall below R3 900 by 2024/25.

Implications for health care staffing

Although the 2023/24 budget proposed a measly 1.5% nominal increase to the public sector wage bill, President Cyril Ramaphosa approved a 3.8% increase for this year. However, Treasury’s cost containment measures have stipulated a hiring freeze for the rest of the 2023/24 financial year and no further allocations towards personnel expenditure. This is despite the Department of Health’s 2030 Human Resources for Health Strategy quantifying that 96 586 additional health workers are required to bolster the healthcare of all provinces to the same standard as the third-ranked province by 2025. This requires an additional cost of nearly R40 billion in total.

The real-life implications for South Africans are dire. Chris Hani Baragwanath Hospital – the largest hospital in Africa and the third largest hospital globally – faces significant staff shortages, cancelling almost 900 surgeries in 2022.  The underpaid and overworked Chris Hani Baragwanath Hospital nurses have reported “pooling funds to buy patients bread.” Doctors at Nelson Mandela Bay’s Livingstone Tertiary Hospital have attributed “suboptimal, undignified patient care” to budget shortages and forecast higher medico-legal claims, which National Treasury described as a “sub-national risk”. However, budget measures that impede public health care’s ability to address staff shortages exacerbate the likelihood of errors by overstretched staff, worsening the medico-legal claims bill for health departments.

Gender and budget cuts

Health budget cuts disproportionately burden women. This burden is evident in the inordinate risk and prevalence of HIV that women face in the country. It is exacerbated by women’s higher and differentiated health needs (including those for reproductive and maternal health). Women-led households are 40% poorer, and unemployment is most prevalent among women. These socioeconomic factors make women more dependent on the public health system.

Budget cuts and underspending clearly have implications for gender equity in the country.

Furthermore, the Department of Health has recognised the healthcare workforce as a critical driver of inclusive economic growth and a means to create decent work for women, especially in rural and underserved communities. Over 90% of nurses in our public health system are women, and in our society of unequal gendered norms, it is also women who carry the care work burden in the home. Many will likely interpret any proposed MTBPS cuts without factoring gender equity implications as an under-appreciation of women’s labour in making a fragile healthcare system and society work.

A case for human rights budgeting

Although improving the country’s economic outlook is imperative, without consideration of the power that fiscal policy has in advancing human rights in the country, there is a likelihood of tabling an MTBPS that impedes the realisation of constitutionally guaranteed human rights in the country.

More than ever, our health system requires inculcation of human rights impact assessments as recommended by the UN Committee on Economic, Social and Cultural Rights, to which South Africa is a party. These assessments could compel policymakers to outline how the resources allocated will protect the right to access healthcare for all in the country, especially when budget cuts are considered. Including these considerations in budget policy may further advance meaningful public participation processes in fiscal policy.

Furthermore, a gender-responsive MTBPS is long overdue and a powerful means to protect the most vulnerable people in the country from reduced social investment. The health budget could be tagged to identify programmes with gender as a principal or significant objective and areas which would need to be protected and consideration of the gendered experience of healthcare to prevent fiscal policy from worsening gender inequities in the country. Budget policymakers should further promote the collection of gender-disaggregated data and establish indicators and benchmarks on gender and other socio-economic factors to advance a more equitable funding allocation.

Lastly, authentic public engagement will allow National Treasury and budget policymakers to solicit and table more equitable fiscal expansion alternatives. Increased public consultation could include extending the pre-budget consultations with the public.

Moreover, civil society organisations like the Institute of Economic Justice and the Alternative Information and Development Centre (AIDC) have proposed alternative approaches to fiscal constraints that could ensure sufficient resources to protect our frail public health system from threats to resource availability. These alternatives should be explored.

One strategy proposed is strengthening the country’s capacity to halt the significant revenue losses owing to to corporate tax abuses, including illicit financial flows (IFF) and  base erosion and profit shifting (BEPS).  IFF refers to the cross-border movement of illegally sourced funds while BEPS refers to when multinational companies shift the profits generated in South Africa to another jurisdiction that has lower or zero tax rates in order to minimise their tax burden.

The Financial Intelligence Centre estimates that between $15 billion and $25 billion is shifted out of our country to tax havens yearly. We call for greater urgency towards implementing publicly disclosed beneficial ownership registries based on country-by-country reporting and the automatic exchange of information, strengthening capital and exchange controls, and increasing South African Revenues Services (SARS) capacity to investigate corporations suspected to be involved in IFF and BEPS. These essential measures can contribute to curbing profit shifting, resulting in more than R100 billion in revenue each year.

The upcoming MTBPS will find National Treasury in a challenging position where various trade-offs will likely be made. In this harsh economic climate, if something has to give, it cannot be the constitutional right to health care for all in this country.

*Lencoasa is a Budget Researcher at SECTION27 and Steering Committee Member of the Budget Justice Coalition. Brown is Director of the Alternative Information and Development Centre and member of the Budget Justice Coalition.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight