Tag: SAMRC

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How an SAMRC Study Found that HIV Deaths in SA May be Massively Undercounted

On By ModernMedia
Photo by Sergey Mikheev on Unsplash

By Chris Bateman

It is widely acknowledged among health and demographic experts that relying solely on what is written on death certificates does not paint an accurate picture of what people in South Africa are actually dying of. Now, an SAMRC study has provided evidence that the undercounting of deaths due to HIV might be even greater than previously thought.

Many in health circles were surprised by a recent South African Medical Research Council (SAMRC) study that found that 23% of deaths in a nationally representative sample drawn from 2017/2018 were due to HIV. By comparison, Stats SA data for roughly the same period puts the figure at only 5.7%.

That Stats SA’s HIV mortality figures differs from other sources is not new and not in itself surprising. This is because Stats SA reports a relatively straight-forward count of what is written on death certificates – where it is known HIV is often not indicated, even if it is the underlying cause of death. By contrast, the new SAMRC study looked at autopsy reports, death certificates, medical records, and interviews with next of kin to come up with its much higher estimate.

The thing that did come as a surprise, is just how much higher the SAMRC figures were than anticipated. Previously, the real number of HIV deaths were thought to be around double the Stats SA number, rather than four times as much. For example, according to Thembisa, the leading model of HIV in South Africa and the basis for UNAIDS’s estimates for the country, around 12% of deaths in the country in 2018 were due to HIV.

“Accurate mortality data are essential for informed public health policies and targeted interventions; however, this study highlights critical gaps in our cause-of-death data, particularly in the underreporting of HIV/AIDS and suicides,” says Professor Debbie Bradshaw, study co-author and Chief Specialist Scientist at the SAMRC Burden of Disease Research Unit, in a media statement. (The study also found substantial under-reporting of suicide on death certificates.)

Multiple data sources

The study was conducted in three phases, examining deaths that were registered in 27 randomly selected health sub-districts between 1 September 2017 and 13 April 2018.

In addition to the examination of autopsy reports, death certificates, and medical records, trained fieldworkers interviewed next of kin to conduct verbal autopsies using a World Health Organization (WHO) questionnaire that had been translated into the country’s nine official languages.

Based on these various sources of data, the cause of each death was categorised into one or more of 44 categories and then compared to the cause of death indicated on the person’s death certificate. (The process for ensuring accuracy, including a review shared by a team of 49 medical doctors, is described in detail in this report.)

The researchers collected data for over 26 000 deaths, although not all types of data were available for each death. Medical records were available for over 17 600 cases, forensic pathology (autopsy) records for 5 700, and about 5 400 verbal autopsies were conducted. In the end, “to save costs”, not all medical records were reviewed.

Overall, for just over 15 000 deaths, the researchers could link and compare their assessment of why a person died to what was written on death certificates.

‘Poor agreement’

The researchers found that “there was poor agreement between the underlying cause of death obtained from the study and the official cause of death data”. The cause of death was the same in only 37% of cases. In addition to the under-reporting of HIV, the researchers also identified “severe under-reporting” of suicide as a cause of death.

A strong link between TB and HIV was observed, with TB responsible for 46% of deaths among people with HIV and 63% of TB deaths occurring in individuals with HIV. Together, these two diseases accounted for almost 30% of deaths.

Some question marks

As noted earlier, the new numbers are substantially higher than estimates from the highly respected Thembisa model. According to their data only 12% of deaths from mid-2017 to mid-2018 were due to HIV-related causes, with a further 9% of deaths occurring in persons with HIV but due to other causes.

Dr Pam Groenewald, a co-author of the new study and also with the SAMRC, describes Thembisa as “an excellent source”. She tells Spotlight they had a long discussion with the Thembisa researchers, “but we weren’t able to fully explain the differences”.

The study authors cite several factors that might contribute to a higher proportion of HIV deaths in their study. Firstly, the weighted national causes of death validation sample aimed to represent the registered deaths in the country, and it was known that deaths in rural areas and child deaths were under-represented. Secondly, deaths that occurred in private sector hospitals were not represented. Groenewald says the HIV-linked deaths in private hospitals are “definitely lower”, but doubts they would have had a significant impact on their findings.

One thing in favour of the study numbers is the fact that the cases they identified with HIV/AIDS as the underlying cause of death were independently reviewed by clinicians. As Groenewald points out, they looked at medical records of people admitted to and who died in hospital, including CD4 cell counts and HIV viral loads. The suggestion is that if someone had a very low CD4 count and a very high HIV viral load at the time of death, then it is very likely HIV played a role in their death, unless of course they died of a clearly non-associated cause like injuries from a car accident.

On the other hand, it might be argued that since HIV is very widely tested for in South Africa, it is more likely to appear on medical records than other less tested for diseases.

Another interesting wrinkle is that the proportion of deaths from HIV/AIDS from this study was higher than anticipated based on observed declines in adult mortality. It is widely accepted that the decline in adult mortality and the increase in life-expectancy over the last two decades was driven by antiretroviral therapy keeping more people with HIV alive. While the new findings do not challenge this narrative, it does suggest the effect may be less pronounced than previously thought.

What to do?

The researchers suggest their study has immediate implications for the country’s response to HIV and TB.

“The study recommends strengthening case finding, follow-up, prevention, and treatment for HIV, AIDS and TB to reduce mortality rates, and underlines the importance of government’s rapid response to counter the recent abrupt withdrawal of Pepfar funding,” Bradshaw comments in the media release.

But more broadly, the findings put the spotlight on major problems in the country’s death certification systems.

“Our findings highlight the need for improved record quality and adherence to testing guidelines within the medical community. Poor record keeping included incomplete documentation of clinical findings and results,” the study authors write.

“A lot of doctors’ report HIV as ‘retroviral disease’, for example, and it’s not coded as HIV,” Groenewald explains to Spotlight.

Urging doctors to record the actual underlying cause of death when writing up death certificates, she also called for improved training in death certification at medical schools.

Doctors’ reluctance to report HIV on death certificates likely has various reasons, including stigma related to HIV and the fact that some medical insurance policies used to exclude HIV, though policies now treat HIV like any other chronic condition.

Overall, Groenewald says, we need to step back and probe the rationale of compiling underlying cause of death statistics.

“The public health aim of the medical certificate of cause of death, (MCCD), is to prevent premature deaths. We therefore need to record the cascade of events or causal sequence of medical conditions leading to death and target our interventions at the underlying cause of death. The coding rules focus on the underlying cause of death, (UCOD), to compile the mortality statistics,” she says.

Groenewald stresses that the law requires doctors to provide accurate information on death causation. The Health Professions Council of SA’s ethical rules also recognised that a statute requiring disclosure about a deceased person’s health must be complied with and is not considered unethical. Contrary to common physician misconception, Groenewald says all this combined to show “it is completely ethical to disclose on a death certificate that a person has died from an AIDS related illness”.

In the meantime, routine mortality data from Stats SA should clearly be taken with a pinch of salt. As Groenewald points out, vital registration data should not be accepted at face value but should be interrogated and cross-checked with other data sources to get coherent and consistent estimates that fit within an envelope of all causes of mortality.

– Additional reporting by Marcus Low.

Republished from Spotlight under a Creative Commons licence.

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Inside the SAMRC’s Race to Rescue Health Research in SA

On By ModernMedia
Mycobacterium tuberculosis drug susceptibility test. Photo by CDC on Unsplash

By Catherine Tomlinson

Health research in South Africa has been plunged into crisis with the abrupt termination of several large research grants from the US, with more grant terminations expected in the coming days and weeks. Professor Ntobeko Ntusi, head of the South African Medical Research Council, tells Spotlight about efforts to find alternative funding and to preserve the country’s health research capacity.

Health research in South Africa is facing an unprecedented crisis due to the termination of funding from the United States government. Though exact figures are hard to pin down, indications are that more than half of the country’s research funding has in recent years been coming from the US.

Many health research units and researchers that receive funding from the US National Institutes of Health (NIH) have in recent weeks been notified that their grants have been terminated. This funding is being slashed as part of the efforts by US President Donald Trump’s administration to reduce overall federal spending and end spending that does not align with its political priorities.

Specifically, the administration has sought to end spending supporting LGBTQ+ populations and diversity, as well as equity and inclusion. As many grants for HIV research have indicators of race, gender, and sexual orientation in their target populations and descriptions, this area of research has been particularly hard hit by the cuts. There have also been indications that certain countries, including South Africa and China, would specifically be targeted with NIH cuts.

On 7 February, President Donald Trump issued an executive order stating that the US would stop providing assistance to South Africa in part because it passed a law that allowed for the expropriation of land without compensation, and separately because the South African government took Israel to the International Court of Justice on charges of genocide in Gaza.

Prior to the NIH cuts, some local research funded through other US entities such as the US Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC) were also terminated.

How much money is at risk?

“In many ways the South African health research landscape has been a victim of its own success, because for decades we have been the largest recipients of both [official development assistance] funding from the US for research [and] also the largest recipients of NIH funding outside of the US,” says president and CEO of the SAMRC Professor Ntobeko Ntusi.

Determining the exact amount of research funds we get from the US is challenging. This is because funding has come from several different US government entities and distributed across various health research organisations. But the bulk of US research funding in South Africa clearly came from the NIH, which is also the largest funder of global health research.

According to Ntusi, in previous years, the NIH invested, on average, US$150 million – or almost R3 billion – into health research in South Africa every year.

By comparison, the SAMRC’s current annual allocation from government is just under R2 billion, according to Ntusi. “Our baseline funding, which is what the national treasury reflects [approximately R850 million], is what flows to us from the [Department of Health],” he says, adding that they also have “huge allocations” from the Department of Science, Technology and Innovation. (Previous Spotlight reporting quoted the R850 million figure from Treasury’s budget documents, and did not take the additional funds into account.)

How is the SAMRC tracking US funding terminations

Ntusi and his colleagues have been trying to get a clearer picture of the exact extent and potential impacts of the cuts.

While some US funding given to research units in South Africa flows through the SAMRC, the bulk goes directly to research units from international research networks, larger studies, and direct grants. Keeping track of all this is not straight-forward, but Ntusi says the SAMRC has quite up to date information on all the terminations of US research awards and grants.

“I’ve been communicating almost daily with the deputy vice-chancellors for research in all the universities, and they send me almost daily updates,” says Ntusi. He says heads of research units are also keeping him informed.

According to him, of the approximately US$150 million in annual NIH funding, “about 40%…goes to investigator-led studies with South Africans either as [principal investigators] or as sub-awardees and then the other 60% [comes from] network studies that have mostly sub-awards in South Africa”.

Figures that Ntusi shared with Spotlight show that large tertiary institutions like the University of the Witwatersrand, the University of Cape Town, and the University of Stellenbosch, could in a worst case scenario lose over R200 million each, while leading research units, like the Desmond Tutu Health Foundation and the Centre for the AIDS Programme of Research in South Africa, could each lose tens of millions. The SAMRC figures indicate that while many grants have already been terminated, there are also a substantial number that have not been terminated.

Where will new money come from?

Ntusi says the SAMRC is coordinating efforts to secure new funding to address the crisis.

“We have been leading a significant fundraising effort, which…is not for the SAMRC, but for the universities who are most affected [and] also other independent research groups,” he says. “As the custodian of health research in the country, we are looking for solutions not just for the SAMRC but for the entire health research ecosystem.”

Ntusi explains that strategically it made more sense to have a coordinated fundraising approach rather than repeating what happened during COVID-19 when various groups competed against each other and approached the same funders.

“Even though the SAMRC is leading much of this effort, there’s collective input from many stakeholders around the country,” he says, noting that his team is in regular communication with the scientific community, the Department of Health, and Department of Science, Technology and Innovation.

The SAMRC is also asking the Independent Philanthropic Association of South Africa, and large international philanthropies for new funding. He says that some individuals and philanthropies have already reached out to the SAMRC to find out how they can anonymously support research endeavours affected by the cuts.

Can government provide additional funds?

Ntusi says that the SAMRC is in discussions with National Treasury about providing additional funds to support health researchers through the funding crisis.

The editors of Spotlight and GroundUp recently called on National Treasury to commit an extra R1 billion a year to the SAMRC to prevent the devastation of health research capacity in the country. They argued that much larger allocations have previously been made to bail out struggling state-owned entities.

Government has over the last decade spent R520 billion bailing out state-owned entities and other state organs.

How will funds raised by the SAMRC be allocated?

One dilemma is that it is unlikely that all the lost funding could be replaced. This means tough decisions might have to be made about which projects are supported.

Ntusi says that the SAMRC has identified four key areas in need of support.

The first is support for post-graduate students. “There’s a large number of postgraduate students…who are on these grants” and “it’s going to be catastrophic if they all lose the opportunity to complete their PhDs,” he says.

Second is supporting young researchers who may have received their first NIH grant and rely entirely on that funding for their work and income, says Ntusi. This group is “really vulnerable [to funding terminations] and we are prioritising [their] support…to ensure that we continue to support the next generation of scientific leadership coming out of this country,” he says.

A third priority is supporting large research groups that are losing multiple sources of funding. These groups need short-term help to finish ongoing projects and to stay afloat while they apply for new grants – usually needing about 9 to 12 months of support, Ntusi explains.

The fourth priority, he says, is to raise funding to ethically end clinical and interventional studies that have lost their funding, and to make sure participants are connected to appropriate healthcare. Protecting participants is an important focus of the fundraising efforts, says Ntusi, especially since many people involved in large HIV and TB studies come from underprivileged communities.

Ultimately, he says they hope to protect health research capacity in the country to enable South African health researchers to continue to play a meaningful and leading role in their respective research fields.

“If you reflect on what I consider to be one of the greatest successes of this country, it’s been this generation of high calibre scientists who lead absolutely seminal work, and we do it across the entire value chain of research,” says Ntusi. “I would like to see…South Africa [continue to] make those meaningful and leading pioneering contributions.”

Republished from Spotlight under a Creative Commons licence.

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Glenda Gray’s Fierce Fight for Science, the COVID-19 Ruckus, and the Bathroom Row about HIV Drugs

On By ModernMedia
Professor Glenda Gray, internationally known for her research in HIV vaccines and interventions to prevent transmission of HIV from mother to child, received the country’s highest honour, the Order of Mapungubwe, in 2013. (Photo: Biénne Huisman/Spotlight)

By Biénne Huisman

After a decade at the helm of the country’s primary health research funder, Professor Glenda Gray will focus again on doing the science. She tells Spotlight’s Biénne Huisman about her childhood, her passion for research, administering multi-million dollar grants, and a heated argument in the bathroom with an ANC bigwig.

Professor Glenda Gray, the first woman president and chief executive of South Africa’s Medical Research Council (SAMRC), has among others been described as outspoken, credible and tenacious. After a decade at the helm of the SAMRC, Gray retains her reputation for fearlessly speaking truth to power.

“Heading the SAMRC was definitely the best job of my life,” says Gray. “But I am excited about my future, it’s time for another best job. After ten years of doing science administration, it’s time to get back and do the science.”

Perhaps Gray’s fierce spirit was honed in her childhood, growing up in Boksburg on the East Rand, “on the wrong side of the tracks”. She laughs, remembering how American cable news channel ABC sub-titled her first TV interview, due to her strong “East Rand accent”.

Investing in research

From a childhood of counting cents, these days Gray administers multi-million dollar grants and passionately makes the case for greater investment in scientific research.

She says that while South Africa’s health department has competing priorities, ideally it should double or triple its allocation to research.

“We spend a lot of time trying to show the Department of Health how important science is. And so while there is commitment from them, they’re so busy worrying about services; healthcare workers, doctors, hospitals falling down, no equipment, no cancer treatment. And so, sometimes science is seen as esoteric and a luxury.”

Speaking to Spotlight during her lunch break at an SAMRC event in Cape Town, Gray adds: “Science gives you evidence to reduce morbidity and mortality. All the things that change people’s lives; like covid vaccines, ARVs, mother to child transmission interventions, typically these stem from research. And so, you can only improve outcomes if you fund research. Currently, the SAMRC gets around R750 million from government a year; in my view, around R2 to 3 billion a year is needed to really make profound investments in research.”

Supplementing the funding from the government, the SAMRC has scores of international funders and collaborators, such as the United States National Institutes for Health. One concern with such international donor funding is that local research may end up pandering to agendas set abroad.

Gray rejects this suggestion. “We [the SAMRC] always fund the ten most common causes of mortality and morbidity in South Africa. So the funders who work with us have to agree on funding what we deem our priorities.”

One of these priorities is transformation. “So I spent ten years of my life changing who we funded, where we funded, how we funded; changing the demographics of the SAMRC, creating an executive management committee that was diverse, and being able to attract a great black scientist [Professor Ntobeko Ntusi] to take over from me,” says Gray.

While having passed the public mantle onto Ntusi in July, the paediatrician and renowned HIV vaccinologist, named one of Time magazine’s 100 most influential people in 2017, will continue her HIV vaccine research. Gray is heading a major USAID funded study aimed at “galvanising African scientists, mostly women, into discovering and making an HIV vaccine.” She also holds tenure as a distinguished professor at the University of the Witwatersrand’s Infectious Diseases and Oncology Research Institute.

Give and take

Speaking to Spotlight, Gray reflects on managing the political side of the SAMRC – the intersection between politics and science: “As the president of the MRC, you have to be very brave and you have to be able to speak truth to power. Sometimes it’s hard, and sometimes it’s easy.”

This, she says, is a dance of give and take: “The relationship has to be flexible. Because, sometimes scientists are wrong and politicians are right. Sometimes politicians are wrong and scientists are right. And sometimes both are wrong, and sometimes both are right. And our egos can get in the way. You know: ‘Oh, you took me off the MAC [Ministerial Advisory Committee], now I’m not going to help you’. That’s not the right attitude to have…”

COVID-19 lockdown ruckus

Gray served on the Department of Health’s COVID-19 MAC at the height of the pandemic. In May 2020, she caused a ruckus for breaking away from the committee’s more measured counsel, turning to the press to criticise government’s lockdown regulations as “unscientific”.

She said the hard lockdown was causing unemployment and unnecessary hardship and malnourishment in poor families. Later as the hard lockdown started to lift, she spoke out against government’s continuation of restrictions on school going, the sale of certain foods and clothes like open-toe footwear, and the limits on outdoor exercise. “It’s almost as if someone is sucking regulations out of their thumb and implementing rubbish, quite frankly,” she told journalists at the time.

Then health minister Dr Zweli Mkhize rebuked Gray’s claims and sidelined her in the MAC before excluding her from a newly constituted MAC in September. The acting Director-General of Health, Anban Pillay, wrote to the SAMRC board urging them to investigate Gray’s conduct. As the fray deepened, the SAMRC board failed to back Gray. The council’s boardwas was acting in a “sycophantic manner aimed at political appeasement”, lamented a guest editorial published in the South African Medical Journal.

Despite this public falling-out, the following year, in February 2021, Gray worked with Mkhize to bring vaccines to South Africa’s healthcare workers.

“So basically at that stage government didn’t have a vaccine programme, and I bailed them out,” she tells Spotlight.

In February 2021, results from a clinical trial showed that the Oxford AstraZeneca COVID-19 vaccine – then intended for rollout in South Africa – performed poorly in preventing mild to moderate illness caused by the Beta variant of SARS-CoV-2, which was dominant at the time.

Gray says she was approached by Mkhize about an alternative vaccine – to which she responded by facilitating the procurement of 500 000 doses of the Johnson & Johnson vaccine through personal connections. These were officially rolled out to healthcare workers on February 17, when President Cyril Ramaphosa received his jab at the Khayelitsha District Hospital. Spotlight previously reported in more detail on the procurement of those first 500 000 doses.

“The vaccines arrived in Johannesburg at about midnight,” Gray recalls. “Then the plane with the president’s vaccine touched down in Cape Town at 12:20pm; and we had to rush it to Khayelitsha to have him vaccinated at one o’clock”.

A bathroom row with a minister

Gray is no stranger to fighting for policies and treatments based on scientific evidence. She recalls an altercation with former health minister Nkosazana Dlamini-Zuma in a bathroom at the presidential residence in Pretoria (Mahlamba Ndlopfu) in the late 1990s – the era of AIDS-denialism under then President Thabo Mbeki.

“Thabo Mbeki had a national AIDS plan and they were about to publish it. So there was a meeting; we were presenting, and we had data that mother to child transmission interventions were affordable, or that it was actually cheaper to give ARVs to a pregnant woman, than to treat a child who is HIV positive. But they kept on saying it was unaffordable, and that they wouldn’t be doing it. And then, when I saw Dlamini-Zuma in the bathroom, I got into a fight with her and said: ‘but it is affordable!’”

Early years in Boksburg

One of six children born to a “maverick father”, whip-smart but taken to getting involved in crazy schemes, and a mother who later in life became a Baptist minister, Gray says they grew up poor.

“My parents would often run out of money in the middle of the month, having to scrounge for food, borrow milk or buy on the book (credit arrangements). So I know what it’s like to be on the other side of privilege.”

Gray relays how neighbours would drop by at her childhood home to borrow cups of sugar, to spy on their family – as, during apartheid, her father would entertain friends of colour.

Gray matriculated from Boksburg High School in 1980. The next year she enrolled for medical school at Wits, working part-time to pay her way: “I worked at an ABC shoe store, Joshua Door, selling furniture, making Irish coffees at Ster Kinekor, waitressing…”

In 1993, as HIV exploded across the country; pregnant with her first child, Gray watched her own stomach expand while treating HIV-positive expectant mothers at Chris Hani Baragwanath Hospital. “In those days, there were no ARVs for children,” she recalls. “And so women had to navigate this joy of a new life, with the fact that death was looming over them.”

Today, Gray has three children and lives in Kenilworth in Cape Town.

Commenting on her reputation for standing up to pressure, she smiles. “My tongue has gotten me into trouble. How do I feel about that? I just want to make sure that as scientists we let politicians and society know the data and the evidence. I feel passionate about translating science, I feel passionate about evidence. I feel passionate about science changing the world.”

Republished from Spotlight under a Creative Commons licence.

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A Humanist with an Unblinking gaze – Professor Ntobeko Ntusi Takes the Hot-seat at the South African Medical Research Council

On By ModernMedia
Professor Ntobeko Ntusi in front of a painting depicting student protests inside his office at Groote Schuur Hospital – the same office that once housed his mentor, the late Professor Bongani Mayosi. (Photo: Biénne Huisman/Spotlight)

Professor Ntobeko Ntusi may be softspoken, but he is not afraid to stand by his strongly held views. As he is set to take up the hot-seat at the country’s primary health research funder, he tells Spotlight’s Biénne Huisman about his background and his priorities for the new job.

Professor Ntobeko Ntusi’s bearing brings to mind the aphorism “speak softly and carry a big stick” cited by the 26th president of the United States Theodore Roosevelt.

Inside his office at Groote Schuur’s Old Main Building, department head of medicine at the hospital; Ntusi is soft spoken, his words a few decibels above a whisper. However his observations are thoughtful and sharp, crafted with precision. Known to call out issues around race and racism at South African universities – “inbuilt biases” even amongst young students – his level, unblinking gaze commands attention.

Born in Umthatha to academic parents, Ntusi at age 13 was named South African Junior Ballroom Dance Champion at an event in Sasolburg. Some three decades later, the cardiologist with qualifications from around the world, does not sidestep public healthcare debate in favour of keeping the peace.

Catastrophic budget cuts

Earlier this year, Ntusi publicly criticised healthcare budget cuts. R200 million was shaved off Groote Schuur’s coffers just last year, as the Western Cape Department of Health and Wellness announced an R807.8 million shortfall for the coming year. Speaking to Spotlight, Ntusi described communication on the matter by provincial government officials (with healthcare professionals) as “appalling”.

In February, Ntusi was one of a group of executives at the hospital – affiliated to the University of Cape Town (UCT) – who spearheaded a petition to national and provincial treasury, decrying “crippling austerity” and “catastrophic budget cuts”; saying how clinicians with multiplying work hours are watching patients deteriorate, as waiting lists for lifesaving elective surgery grow longer.

At a boardroom table inside his office, he says: “How we ration limited resources, this is causing real moral injury to our front-facing clinicians. I mean, we’re having to deal with complaints from patients who no longer have access to services they have grown accustomed to. This is causing a lot of distress, especially among young doctors, and medical registrars – the engine of our operation – who are increasingly anxious and taking time out for mental health reasons.”

In his present position, Ntusi’s voice has clout. He oversees thirteen divisions – from cardiology to pulmonology, and infectious diseases and HIV medicine – and corresponding research units such as the Desmond Tutu HIV Centre, directed by Professor Linda-Gail Bekker.

‘Hope cannot be a strategy’

Reflecting on how Groote Schuur’s management are responding to these challenges, Ntusi says the hospital’s CEO (since February) Shaheem de Vries, while new, in time ought to bring concrete priorities to the table. “It’s important to have hope, but hope cannot be a strategy,” he says.

This insight may well inform how he approaches his own new job as CEO and President of the South African Medical Research Council (SAMRC), taking over from Professor Glenda Gray. From July, Ntusi will give up his Groote Schuur office, putting away his clinician’s stethoscope, to take up the hot-seat at the country’s primary health research funder at its headquarters behind a facebrick facade in Parow. The SAMRC employs 718 employees and will see Ntusi answer to the National Department of Health, the SAMRC board, and the Parliamentary Portfolio Committee on Health (you can see the latest report to the committee here).

Across medical bureaucracies, budget remains an issue. The South African government allocated R1.35 billion to the SAMRC for 2023/24. In the council’s latest annual report, diminishing funding from government is listed as a threat; while the ability to attract external funding is listed as a strength.

“A key role of the President of the SAMRC is to engage with organisations like the Wellcome Trust [in the United Kingdom] and the NIH [the National Institutes of Health in the United States] and high worth individuals to attract funding,” says Ntusi.

He points out that the SAMRC has had clean audits for several years running – a remarkable achievement for a South African parastatal. Indeed, the council’s annual performance plan for 2024/2025 states: “Despite interruptions of COVID-19, SAMRC’s exemplary performance and good governance led to the organisation achieving four consecutive clean audits… It is the organisation’s intention to continue on the same path.”

On the SAMRC’s functions, Ntusi explains: “For government, the SAMRC plays a critical role in bridging the gap between strategy and policy, and implementation. In science, it plays a critical role in providing priorities for the funding of research, and capacity building…”

In the SAMRC’s last financial year, R61.6 million was allocated to funding 171 “research capacity development” grants, including 120 to women. The annual report describes this as funding “the next generation of health researchers… with most of these awards aimed at individuals from historically disadvantaged backgrounds.”

For Ntusi, points of focus to be expanded on at the SAMRC include health issues relating to climate or planetary change, epidemic preparedness, “restoring trust in science in an age of misinformation”, digital health and artificial intelligence; and projects linking South African scholars with research entities across Africa. “In many of these countries, they don’t have the research infrastructure and budgets we have in South Africa – it is important to assist them with projects.”

To the US and back home

When he was 14, Ntusi’s family – he is one of three boys – moved to the United States where his mother pursued a PhD in social work. In Philadelphia, Pennsylvania, he continued competitive ballroom dancing while attending Lower Merion High School, where a video on child birth showed in a biology class stirred his passions.

At liberal arts college Haverford, in Pennsylvania, he completed a BSc Honours in cellular and molecular biology, before returning “home” to South Africa in 1999, to enrol in medical school at UCT. Here his initial interest in obstetrics was disappointed – “it was loud and messy, an anti-climax” – seeing him drawn to internal medicine and cardiology instead. In following years, he would study cardiovascular medicine under mentorship of the late Professor Bongani Mayosi.

Like Mayosi, Ntusi was awarded the Oxford Nuffield Medical Scholarship, which funded his D.Phil at the University of Oxford in the United Kingdom. His doctoral research looked at cardiovascular magnetic resonance (CMR – noninvasive tests that produce images of a beating heart) to study inflammatory heart disease.

In 2016, Ntusi took over from Mayosi as head of Groote Schuur’s department of medicine, as Mayosi became dean of the university’s faculty of health sciences. At the time Ntusi continued treating cardiology patients, with ongoing research projects including on HIV-related heart disease.

Seven years later, against pale yellow walls (the same walls decorated by Mayosi back when it was his office) several art works and certificates attest to Ntusi’s time here. He points out one painting of student protestors made by a friend – based on the #FeesMustFall protests at the university in 2016 – “a difficult time”, he says.

In 2018, Mayosi’s suicide was partially attributed by some to pressures relating to the violent protests; while also putting a spotlight on pressure on prominent black academics at UCT, and other tertiary institutions in South Africa. An enquiry found that the “sometimes disrespectful manner” in which protest was conducted, and “instigation of students’ action by some of his colleagues”, caused Mayosi “a lot of distress”.

Displayed on a shelf, beside a stuffed doll of the Archbishop Desmond Tutu and a 2021 SAMRC gold trophy for “scientific achievement”, a burgundy-bound book recounts Mayosi’s legacy. Ntusi penned the introduction, where he writes: “Bongani Mayosi – as a leader, he was awesome. He is one of the most inspiring people I will ever know. He always reminded me: ‘a journey of a thousand miles begins with a few steps’.”

Asked about following in the footsteps of a star such as Mayosi, Ntusi replies: “I am his protégée. There were always room for me to build my own scientific investigations.”

Precarious times

As Ntusi is poised to depart from Groote Schuur, present dean of UCT health sciences Associate Professor Lionel Green-Thompson points out how the cardiologist cared for critically ill patients in COVID-19 high-care wards, particularly during the fear and uncertainty of hard lockdown.

“Sometimes we would work up to 16 hour shifts in the high-care wards; upon finally leaving I’d go outside to find anti-vaccine protestors in front of the hospital. I mean, they were just annoying,” Ntusi recalls.

“Communication around the AstraZeneca vaccine went very badly – increasing confusion and vaccine hesitancy. It is really, really important to advocate for vaccines. And this brings me back to the point of restoring people’s faith in science; redressing the public image of science, a priority I have for the SAMRC going forward.” (After procuring the AstraZeneca SARS-CoV-2 vaccine, the South African government decided early in 2021 not to use it after it showed limited efficacy against mild to moderate COVID-19 in a study.)

Foremost, Ntusi describes himself as a “humanist”. Apart from science, medicine and health equity, his interests include art, wine and dogs. Ntusi lives in Milnerton. A keen runner, he is a member of the Gugulethu Athletics Club.

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Categories : HospitalsTags : 1 Comment

Major SAMRC Study Sheds Light on Causes of Disease and Death in SA

On By ModernMedia
Image by Hush Naidoo from Unsplash
Image by Hush Naidoo from Unsplash

By Nthusang Lefafa at Spotlight

Unsafe sex, interpersonal violence, high body mass index (BMI), high systolic blood pressure, and alcohol consumption are the top risk factors for disease and death in South Africa, according to the Second Comparative Risk Assessment (SACRA2) study conducted by the South African Medical Research Council’s Burden of Disease (BOD) Research Unit in collaboration with a long list of researchers. The study was recently published in a series of 15 related articles in the South African Medical Journal.

The study differs from other assessments of what people in South Africa die of in that it focusses on risk factors rather than on the eventual cause of death. This is, for example, why the study considers factors like unsafe sex or high body mass index rather than HIV or diabetes.

According to a related policy brief, the aim of the study was “to quantify the contribution of 18 selected risk factors to identify areas of public health priority”. The idea is that policymakers can use these findings to address the underlying causes of death and disease in South Africa since the identified risk factors are considered to be modifiable.

“We have to reduce the underlying drivers of disease and death if we are to improve the health of South Africans,” said CEO and President of the SAMRC Professor Glenda Gray in a statement. “Knowing that this is possible, should strengthen our resolve to ensure that this is accomplished.”

Causes of lost DALYs

Rather than only looking at what people died of, the researchers estimated the lost disability-adjusted life years (DALYs) associated with various risk factors. The World Health Organization describes DALYs as “a time-based measure that combines years of life lost due to premature mortality (YLLs) and years of life lost due to time lived in states of less than full health, or years of healthy life lost due to disability (YLDs). One DALY represents the loss of the equivalent of one year of full health.”

The researchers calculated the proportion of the total burden of disease (measured as DALYs) that can be attributed to each of the 18 risk factors in South Africa in 2012. Unsafe sex was top of the list at 26.6%, followed by interpersonal violence at 8.5%, high body mass index at 6.9%, high systolic blood pressure at 5.8%, and alcohol consumption at 5.6%. There were some differences by sex, with alcohol consumption, for example, ranking third in males, while it ranked fifth overall.

“Improvements have been observed, in particular, the reductions in the burden attributable to household air pollution and water and sanitation,” read the policy brief. “On the other hand, shifts in cardiometabolic risk factors, particularly the rapid emergence of high fasting plasma glucose accompanied by increases in high systolic blood pressure and high BMI, can be seen as well as the increased impact of ambient air pollution.”

According to project lead and BOD Unit Director Professor Debbie Bradshaw, while unsafe sex and interpersonal violence remained high on South Africa’s risk profile for the study period, non-communicable diseases combined are at an all-time high and are highly likely to overtake unsafe sex and interpersonal violence as causes of death and disease in South Africa.

Findings only up to 2012

The SACRA2 findings cover the period from 2000 to 2012. One reason for it only being published now is that the study required access to a wide variety of data sources. “Each data set had to be evaluated to identify any weaknesses or possible bias so that we can develop a robust understanding [of] the trends in the risk factors. This is a painstaking task, involving a large number of scientists, and means that we have only been able to describe the trends for the period 2000 – 2012,” says Bradshaw.

While robust and more up-to-date estimates would likely only come from the next SACRA study, it seems likely that some of the trends identified in SACRA2 would have continued in the years since 2012. For example, findings from SACRA2 suggest that the burden attributable to unsafe sex peaked in 2006 and has been declining ever since, largely due to the provision of antiretroviral treatment. Evidence from other sources, such as Thembisa, the leading mathematical model of HIV in South Africa, suggests that the decline in HIV-related deaths and the increase in treatment coverage have continued in the years since 2012.

Bradshaw describes unsafe sex as a lack of condom use which leads to sexually transmitted infections (STIs) and the possible transmission of HIV.

“Condom use is very important. If we get rid of unsafe sex, we will see the number of people being infected with HIV and STIs being reduced,” she said. “It is important that these epidemic drivers are not neglected in the push towards meeting the 90-90-90 management targets for 2022 and the 95-95-95 targets by 2030. HIV communication programmes should continue to promote male circumcision and risk awareness in the context of non-marital relationships to prevent HIV transmission.” (The first 90/95 refers to the percentage of people living with HIV who are diagnosed, the second to the percentage of those diagnosed on treatment, and the third to the percentage of those on treatment who are virally suppressed.)

Interpersonal violence declining

As with unsafe sex, the trend with interpersonal violence in South Africa also appears to be downward, although, as Megan Prinsloo, a researcher at the SAMRC, and colleagues highlight in one of the 15 papers, it continues to be a leading public health problem for the country.

The researchers found that between 2000 and 2012, there was a decrease in the death rate associated with interpersonal violence from 100 per 100 000 to 71 per 100 000. There was also a decrease in lost DALYs attributable to interpersonal violence from an estimated 2 million in 2000 to 1.75 million in 2012.

“Further strengthening of existing laws pertaining to interpersonal violence, and other prevention measures are needed to intensify the prevention of violence, particularly gender-based violence,” the researchers wrote.

High BMI and high blood pressure

Image by Marcelo Leal on Unsplash

A high BMI is associated with several cardiovascular diseases, diabetes, and chronic kidney disease, among others. According to one of the SACRA2 papers, high BMI caused around 59 000 deaths in 2012. Over the study period, the burden was higher in males than in females. Type 2 diabetes was the leading cause of death attributable to high BMI in 2012, followed by hypertensive heart disease, haemorrhagic stroke, ischaemic heart disease, and ischaemic stroke.

The researchers found that the average BMI increased between 2000 and 2012 and accounted for a growing proportion of both total deaths and DALYs.

High systolic blood pressure is similarly linked to an increased risk of several conditions, including stroke and heart disease. According to a paper by Beatrice Nojilana, a senior research scientist at the SAMRC, and colleagues, the prevalence of hypertension in people aged 25 and older increased from 2000 to 2012 – 31% to 39% in men and 34% to 40% in women.

But there is some interesting nuance. In both men and women, age-standardised rates for deaths and DALYs associated with raised systolic blood pressure increased between 2000 and 2006 but decreased from 2006 to 2012.

High systolic blood pressure is estimated to have caused around 62 000 deaths in South Africa in 2012. Stroke (haemorrhagic and ischaemic), hypertensive heart disease, and ischaemic heart disease accounted for over 80% of the disease burden attributable to raised systolic blood pressure over the period.

Alcohol abuse

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In another SACRA2 paper, Dr Richard Matzopoulos, chief specialist scientist at the SAMRC, and colleagues, point out that alcohol abuse has widespread effects on health and contributes to over 200 health conditions. They write that, although the pattern of heavy episodic drinking independently increases the risk for injuries and transmission of some infectious diseases, long-term average consumption is the fundamental predictor of risk for most conditions.

The researchers used data from 17 population surveys to estimate age- and sex-specific trends in alcohol consumption in the adult population of South Africa between 1998 and 2016. For each survey, they calculated sex- and age-specific estimates of the prevalence of drinkers and the distribution of individuals across consumption categories.

Among males, the prevalence of drinkers was found to have decreased between 1998 and 2009, from 56.2% to 50.6%, but had increased again by 2016. Among females, the prevalence of current drinkers rose slightly from 19% in 1998 to 20% in 2016.

Speaking to Spotlight, Matzopoulos stresses that alcohol abuse puts a heavy burden on the already strained health system. “When you enter the trauma unit at hospitals on weekends, all you can smell is alcohol,” he said.

He says in some of his research he has noted a shift where young females are engaging in heavy drinking and young males are engaging in binge drinking over weekends. “These patterns are alarming because alcohol abuse can lead to unsafe sex, which may lead to the transmission of HIV and STIs. Excessive alcohol use also has an impact on some NCDs and can compromise the immune system of a person who is on ARV treatment,” he said.

Matzopoulos said government can put in place policies such as the restriction of alcohol sales, banning alcohol advertising, and increasing the price of alcohol.

Republished from Spotlight under a Creative Commons 4.0 Licence.

Read the original article here.

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SAMRC Honours Medical Scientists

On By ModernMedia
Credit: South African Medical Research Council

On Thursday, March the 10th, the South African Medical Research Council (SAMRC) honoured a selection of leading SA medical scientists and researchers at its 8th SAMRC Scientific Merit Awards at a hybrid event.

This year’s Presidential Award, which is awarded to scientists who have made exceptional lifelong contributions to medical research and public health, was bestowed upon Professor Koleka Mlisana, the country’s first black microbiologist. With over 40 years’ experience in health sciences, Prof Mlisana is the current executive manager of academic affairs, research, and quality assurance at the National Health Laboratory Service (NHLS) and Co-Chair of the COVID-19 Ministerial Advisory Committee (MAC). In the 1990s, she was one of the scientists investigating the unknowns of HIV. Her research focused on understanding the body’s response to acute HIV infection.

The Platinum Medal, for South Africans who have made seminal scientific contributions and who have also made an impact on health, especially for those living in developing countries, was awarded to Professor Andre Pascal Kengne. As a physician and an internationally renowned non-communicable diseases epidemiologist, his work focuses on cardiovascular disease, diabetes, and chronic kidney disease. He is the current Director of the SAMRC’s Non-Communicable Diseases Research Unit and holds conjoint appointments as Professor of Medicine at the University of Cape Town, as well as Extraordinary Professor of Global Health at Stellenbosch University.

In the Gold Medal category, which is for researchers who have made substantial and influential contributions that have impacted on health especially in the developing world, the awardees are Professors Tulio de Oliveira, Ntobeko Ntusi, Ambroise Wonkam and Grant Theron.

Silver Medals are conferred to emerging and upcoming scientists and those committed to capacity development. This year, the medal recipients are Professors Diane Gray, Marlo Moller, Rabia Johnson, and Dr Nasheeta Peer.

SAMRC President and CEO, Prof Glenda Gray said that scientific research remains fundamental for reducing the nation’s burden of disease and preventing mortality. “The knowledge produced by these exceptional scientists will carry our country’s legacy of science forward and continue to improve the lives of citizens as it is evident with COVID-19.” Their work shows the country’s ingenuity, she added, noting that “it was scientists in South Africa who first discovered and sounded the alarm on Omicron, which rapidly became the dominant variant of concern.”

Source: South African Medical Research Council (SAMRC)