Human Interest

Officials Try Salvaging the Reputation of Asbestos

The fortunes of asbestos have declined in recent years, after the realisation that inhaling asbestos fibres could lead to cancer. However, debate about the safety of this mineral hasn't ended yet - at least not in Zimbabwe. This country is the world's fifth largest producer of chrysotile fibre, or white asbestos - after Russia, Canada, China and Brazil. Earnings from the industry in Zimbabwe are expected to top 40 million US dollars this year through exports to over 50 countries, the major export destinations being the Far East, Middle East and Africa. Zimbabwe's two asbestos mines employ 7,000 people - no small number in a country facing 70 percent unemployment. Another 120,000 persons benefit from the extraction in downstream industries. With this mind, Zimbabwe's government has renewed efforts to draw a distinction between white asbestos and crucidolite, or blue asbestos, and amosite (brown asbestos). A government-funded body - the National Chrysotile Asbestos Taskforce - claims that white asbestos is not harmful if produced and used carefully. Blue and brown asbestos were mined mainly in South Africa and Australia - but production has ceased because of fears about the health hazards of these asbestos varieties. Zimbabwe's argument is proving a tough sell in the European Union (EU) and the United States. Due to pressure from environmentalists and trade unions, the EU has given its members until 2005 to remove all asbestos from the market. Argentina, Australia, Chile, Croatia and Saudi Arabia have also banned the substance. The speed with which Zimbabwe's government has thrown its weight behind white asbestos has been unmatched by its commitment to improving safety standards. Although government signed an International Labour Organisation convention on the safe and controlled use of white asbestos in 1986, authorities only ratified it in May this year. Rabelan Baloyi - an occupational health specialist who sits on the taskforce - says that as a result of this delay, government lags behind in adopting legislation that will compel the industry to adequately protect workers from exposure. In addition, it has yet to guarantee compensation for those already affected - whose number is a closely-guarded industry secret. As it continues with efforts to promote white asbestos, Zimbabwe might also find matters complicated by a 2001 ruling of the World Trade Organisation (WTO). (Source: Wilson Johwa,IPS, Dec 18 2003)

Directly observed treatment for tuberculosis:Less faith, more science would be helpful

Drugs cure tuberculosis. So why does the disease remain in the top 10 causes of global mortality, with 1.8 million deaths a year? Most deaths are in low and middle income countries, where a major challenge is to ensure that drugs are available and people complete the long treatment. The World Health Organization has been tackling the global problem of inadequate tuberculosis control for some years and launched a new programme of integrated care in 1994, called directly observed treatment, short course (DOTS). By using a six month course of drugs, including rifampicin, WHO has mobilised money, people, and systems in countries to tackle the global problem with good progress. Its strategy is divided into five key aspects: political commitment, access to sputum microscopy, short course chemotherapy using direct observation of treatment, an uninterrupted supply of drugs, and a recording and reporting system. There is little argument that resources, drugs, political support, and active management of programmes help improve control of tuberculosis. However, debate continues over whether direct observation of patients taking their treatment by health workers (or their delegates) is essential for successful control. It seems to have arisen out of special programmes in the United States, where direct observation of treatment was part of multifaceted strategies and special studies in Africa. It was at the core of WHO's strategy at launch in 1995, with the director general saying that direct observation by a health worker was the biggest health breakthrough this decade. Direct observation remains core to the current WHO strategy: recently published guidelines say that the key treatment principle of direct observation of treatment remains the same, whichever method of implementation is chosen. The problem with this global policy is that there are currently four carefully conducted trials in Thailand, South Africa, and Pakistan, and these studies show little or no advantage of direct observation over self treatment at home in relation to cure (figure). What is more, these studies were carried out in settings with relatively low cure rates—exactly where better control of tuberculosis is needed. What are the implications for global policy with these research results? We think that WHO and others should reflect on the mismatch between this research evidence and its own beliefs, expressed individually or as consensus statements. Other data are of course important, and this reflection needs also to consider that direct observation costs more than other methods, is paternalistic towards patients, and it can take health workers away from other essential tasks. Some health services may be of such poor quality that patients would prefer not to attend, so potentially direct observation could reduce adherence. Enthusiasts make the world go round, but there is a belief among specialists in tuberculosis that it is unethical not to provide direct observation. This attitude stifles debate and good research into alternatives to direct observation is replaced by semantics. For example, specialists state that direct observation of treatment is more than a mechanical procedure of dropping medicine into a patient's mouth; it is a human bond between a patient and the health worker, to transmit a recognition of the value of treatment success. What would be more helpful is to look at all the strategies to promote adherence. For example, we know that defaulter retrieval action seems to work in some settings; so why not try defaulter actions for self treating patients who do not visit the clinic once a month? What about some good research on staff support and supervision, health education, or various forms of prepackaging? What about peer assisted treatment support? We need a variety of methods to help patients complete their treatment, as well as exploring the circumstances where direct observation will be useful. The energy going into insisting that direct observation is essential and non-negotiable has its own opportunity costs. We believe that there are good arguments for dropping the insistence on direct observation and turning the passion into credible methods for developing, evaluating, and promoting sustainable measures to improve adherence.(Source: BMJ 14 October 2003).

Doctors go to court

Medical association says new certificate of need will fuel brain drain. The SA Medical Association (SAMA) is mounting a legal challenge against the National Health Bill, which will require every new and existing medical establishment to obtain a certificate of need from government to be allowed to practise. The health department's intention is to correct the skewed distribution of healthcare resources, which sees hospitals and health technology concentrated in well-heeled urban areas rather than in poorer or rural areas. This means that a GP who wants to open a new practice in an area with a proliferation of doctors could be denied authorisation because Pretoria deems that his or her services are not needed there, or that practising GPs could be denied permission to continue operating where they are. The medical establishment is in an uproar. It says the provision will, by fuelling the brain drain, achieve the opposite of what it intends. At a SAMA meeting in Cape Town , a decision was made to take government to court to get the provision set aside. In the private sector, GPs' share of the pie has been eroded by specialists and private hospitals and the fact that medical aid schemes typically take 90 days or more to pay claims. In the public sector, bad working conditions and poor remuneration have resulted in many top academics and young doctors emigrating. For many doctors, the certificate of need is the last straw, coming as it does hard on the heels of the Medicines & Related Substances Amendment Control Act, which prevents dispensing by doctors except in areas where there are few pharmacies. The National Convention on Dispensing has mounted a separate court challenge against this provision. Under section 36 of the bill, nobody will be able to operate, buy or modify a health establishment (increase the number of beds or purchase certain equipment) without obtaining a certificate of need from the health director-general (DG). They have two years from the commencement of the act to obtain one - or be guilty of a criminal offence. In deciding whether to grant a certificate, the DG must take into account the need to promote an equitable distribution and rationalisation of health services and healthcare resources, and the need to correct inequities based on racial, gender, economic and geographical factors. Other criteria include: the demographics and epidemiological characteristics of the population to be served; the need to protect or advance persons designated in terms of the Employment Equity Act establishment will be financially sustainable. It's no secret that Pretoria does not have the information systems to verify the accuracy of many of these poorly defined criteria, not least whether a practice will be financially sustainable. SAMA chairman Kgosi Letlape compares the certificate of need to the former Group Areas Act and influx control. The provision plunges doctors into extreme uncertainty, says Prof Bob Williams of Natal University's school of law. And since the bill contains no right of appeal to the courts, practitioners who are denied a certificate can only take the minister's decision on review. In a review, a court cannot set aside the decision. A court can intervene only if the doctor proves that the minister did not act in good faith or did not properly apply her mind to the issue, which is difficult to prove, says Williams. Sonderup says the right way to get doctors to practise in rural areas is to improve the healthcare infrastructure and support in these areas. Simply increasing the number of doctors won't improve health outcomes, he says. The bill was passed with minor amendments in the national assembly on September 5. Most opposition parties voted against it. It will go before the national council of provinces on November 18. (Source: The Financial Mail, 10 October 2003).

Towards a better map: Science, the public and the media

The increased attention paid to science by all forms of media is welcome, but raises the question of whether more coverage means more public awareness and understanding of science.Thinking about how the public understands science has moved on from the 'deficit model' which focussed on a putative failure of 'the public' to know enough science. Instead we now recognise more types of public and more ways in which they engage with scientific knowledge. This means that new and better tools are needed to understand the way in which the media affect public knowledge of science. This is an analysis of science reporting and the impact it has on its audiences of readers, listeners and viewers. This report provides an in-depth contemporary assessment of the media's role in the public understanding of science. It is based on: * an extensive analysis of the way science and science related issues were reported on television news, radio news and in the press during a seven and half month period in 2002(involving a total of 2,214 stories) * two nationwide surveys (both with representative samples of over 1,000), conducted in April and October 2002, tracking the public's knowledge, opinion and understanding of science-related issues reported in the media. While there is now a body of research both on the public understanding of science, and, to a lesser extent, on the media coverage of science, there have been few empirical attempts to relate the two. This study addresses this gap, and looks at what and how people learn about science from the media. While the study looks at some general aspects of science, we focus our attention on three contemporary issues: climate change, the MMR (Measles, Mumps and Rubella Vaccine)controversy and cloning/genetic medical research. All three issues have received regular attention in the media, and all have serious implications for public policy. They are, in short, the kind of issues that people in a deliberative democracy should know something about. Looking at the relationship between media content and public knowledge, the authors, provide a better map of the way people learn about science from the media. Central to this approach is the understanding that what matters is not just media content, but how people engage with that content. So, for example, there is little point in the news media covering science in great detail and depth if it does not also generate much public interest. Some science stories may stick in the public mind, others may be either misunderstood or ignored. By tracking both media content and public understanding, we can explore not only what people know, but why they know it.

Professional Roles and ARV provision

It is clear that large-scale treatment for HIV will depend on re-thinking the use of human resources if it is to have public health benefits. Health care staff working in multi-disciplinary teams providing long-term HIV care may find their roles changing over time in ways that will need careful management. The role of nurses is of particular importance in many settings, and there is clearly scope for expanding that role with appropriate training and support. Nurse practitioners trained to prescribe a range of medicines and nurse-led clinics are among the options that need to be explored. Specialised pharmacists can also take on a major role in supporting people with HIV on treatment. A system that chooses first-line regimens that can be managed with limited direct involvement from doctors will be able to make more use of other health care staff in managing them. Human resource issues are therefore directly connected with the development of national treatment guidelines. Lay involvement, starting with peer support, may also be needed for a successful large-scale treatment programme. A variety of models for peer support and treatment education are available for use. Social stigma doesn't automatically disappear when services are established (though treatment certainly helps to overcome it). As well as training, resources are needed to prevent occupational exposure to HIV. Continuing professional support and development are needed by all staff involved in delivering HIV treatment, and not only in relation to ARVs.

Moments in Time

Advocacy strategies have long been part of campaigns to build support for a particular cause or struggle,and the history books are peppered with concrete examples of advocacy initiatives.Even in our own times,we have witnessed policy changes that can occur through the powerful persuasion of advocacy.Each successful advocacy strategy takes place in and represents a specific moment in time. Yet,while advocacy arises from and must respond to a unique context,the advocacy strategies presented in this manual can be adapted and applied in other settings.

SA population expected to drop by 26 percent by 2050

The latest world population data sheet of the United States-based Population Reference Bureau estimates South Africa's population will drop from 44-million this year to 35,1 million in 2025, and to 32,5 million in 2050 - a 26 percent decline. It gives an estimated percentage of South Africans between the ages of 15 and 49 with HIV/AIDS at the end of 2001 as 20.1 percent, and life expectancy at present mortality rates at 53 for men and 54 for women. Botswana's population is also expected to go down by 43 percent from the current 1,5 million to 0,9 million by 2050, while slight increases are expected in Namibia and Lesotho's populations, the PRB report says. South Africa's current rate of natural increase - the birth rate minus the death rate - is the second lowest on the continent at 0.9 percent, second only to Botswana's 0.3 percent. Central Africa is expected to be the fastest-growing region in the first half of the 21st century. It will grow to 193 percent compared to its current size by 2050. Western Africa follows, increasing to 142 percent of its 2003 population. The population of HIV/AIDS-ravaged southern Africa is projected to fall by 22 percent, a decline that no one would have predicted in the recent past, the report says. In global terms, the PRB expects India to overtake China as the world's most populous country by 2050, with 1,628-billion people (1,069-billion in 2003) compared to China's 1,394-billion (1,289-billion in 2003). The US is expected to remain in third place with 422 million citizens by 2050 - it currently has 292-million. Nigeria, currently in ninth place with a population of 134 million, is expected to more than double to 307 million by 2050 for sixth place. Other African countries expected to be in the top 20 by 2050 are the Democratic Republic of Congo with 181 million people (now 56,5 million), Ethiopia with 173 million (now 71 million), Egypt with 127 million (now 72 million), Sudan 84 million (now 38,1 million), and Uganda with 82 million (now 25,3 million). Countries expected by the PRB to drop out of the top 20 are Germany, France, and Thailand.(Source: SAPA, 22 July 2003)

Initial estimates from the South African National Burden of Disease Study,2000

Published by: 
Medical Research Council

The National Burden of Disease Study is the first ever national BoD study carried out in SA and is an initial attempt to derive coherent and consistent estimates of the BoD experienced in SA in the year 2000. Estimates are derived from different data sources for the levels and underlying causes of mortality and morbidity.The top 20 diseases are ranked and those contributing the greatest burden are prioritised for seeking cost-effective interventions.

Publication Webpage http://www.mrc.ac.za/policybriefs/policybriefs.htm

Are our teens still not getting the HIV message?

Pharmacies are doing a brisk trade in the morning-after pill, especially among teens. It seems that even though there is a high risk of contracting HIV/AIDS, young people are still having unprotected sex and are concerned simply with preventing unwanted pregnancies. A spot survey conducted by The Star of a number of pharmacies around Johannesburg, revealed that chemists are doing a roaring trade in the three available types of morning-after pill. E-GEN-C, NorLevo and Ovral 28 must be orally ingested by a woman within 72 hours of her having had unprotected sex. The pills can be obtained over the counter without prescription and it seems young women are taking advantage of this. Graham Naughtin, a pharmacist at the Cliffview Medicare Pharmacy at Cresta, says that about 70 boxes of the morning-after pill are sold every weekend. While they are 90% effective in preventing pregnancy, they do not protect the user against any sexually transmitted infections (STIs) or AIDS.A locum doctor at the Selgo Pharmacy in Braamfontein, Blessing Motgatlha, says she has noticed a 50% increase in the use of the morning-after pill in the past two years. Lipalesa Malebanye, a pharmacist at Bruma Pharmacy, says where condom usage has dropped, there is a notable increase in the use of the morning-after pill, especially by teenagers. A teenager, who does not want to be named, says she has taken the morning-after pill four times this year alone. She adds that contracting an STI was not something she was concerned about at the time. While these drugs might prevent unwanted pregnancies, they do have side effects. Professor Basil van Iddekinge, a gynaecologist at Wits Medical School, says the morning-after pill is not meant for continuous or repetitive use and he stressed that it is not a long-term contraceptive. A women should rather use a non-emergency, long-term type of contraceptive. Van Iddekinge says one of the main problems of the morning-after pill is that it may alter the user's menstrual cycle. He explains the emergency pill is meant to be just that, used in an emergency. An emergency would be when the condom broke during intercourse, or perhaps when a woman has sex even though she did not intend to do so. Another emergency would be in the case of rape. Meanwhile, loveLife CEO, David Harrison, says the awareness organisation has not picked up this trend. If this is the case, it is really worrying that young people are being more irresponsible in their sexual activities, he says. Harrison warns that youngsters should employ dual protection to prevent pregnancy and STIs. The chief director of maternal, child and women's health unit in the department of health, Dr Eddie Mhlangu, holds Harrison's point of view. It's worrying, on the one hand, that people are not using condoms despite the threat of AIDS, while on the other, it is encouraging that it is cutting down on the number of unwanted pregnancies, he says. (Source: The Star, 14 April, 2003).

South Africa recognises violence as a health issue

Health Minister Dr Manto Tshabalala-Msimang said 9 December that South Africa had long recognised violence as a health issue and that the health department was currently running a number of programmes to combat the scourge. Msimang was speaking in Port Shepstone at the World Health Organisation's local launch of the World Report on Violence and Health - a report that came about as a result of a motion tabled by South Africa in 1996 at the world health assembly. The minister told Dr Etienne Krug, the WHO's Geneva-based research coordinator that the health department was considering plans to put health warnings on alcohol.She said that while there were a number of clearly identifiable risk factors for violence, two stood out above all others - poverty and alcohol. The latest Statistics SA report on the causes of death in South Africa, non-natural causes remain the highest single cause of death. and a significant portion of the health budget was being spent on emergency services . In some areas, up to half a hospital's budget went to emergency outpatient service. Violence-related injuries are the main cause of admission for emergency services. The WHO report has made recommendations that governments and others involved in combating violence should try out new ways of preventing violence, evaluate them and roll out the methods that work well. According to Msimang, the health department was currently doing just that. It was, she said, involved in a project along with the Education Department for reducing violence in schools. Also the department of health, as part of the government's Victim Empowerment Programme, had trained over 500 nurses to adopt a more caring attitude towards survivors of violence. Specially trained health workers can also collect forensic evidence to assist the police and the courts in effectively prosecuting offenders. Were designing training and curriculum models and will ensure that such services become much more accessible to all, she said. In assuring WHO representatives that government was taking their report and recommendations to heart, Msimang said a central team, consisting of representatives from all major sectors responsible for violence prevention, was being set up. to organise an intersectoral plan to combat violence.( SAPA, 9 December 2002).