The influential Flexner report of 1910 was the precursor of innovation in modern medical curricula, and by correctly placing knowledge of the human body and of biological science at the centre of medicine, great strides were made in medical education and practice.
Globally, cost-effective and equitable delivery of healthcare is becoming a challenge. In the South African (SA) context, balancing the burden of disease and the patient load within available resources, while still maintaining quality of care, is becoming unsustainable. Our public healthcare services need to support a growing population of uninsured citizens together with immigrants from elsewhere in Africa seeking care, and while the reasons for the problem are both economic and related to health service design and delivery, it is compounded by an ageing population, a rising burden of infectious and chronic diseases and the global shortage of adequately skilled healthcare workers. The leaders of today will need to do something different in order to avoid collapse of the system.
I read the article by Van Hoving et al. with great interest. Two interesting aspects of the study are that it included patients in the prehospital setting, and involved both the Division of Emergency Medicine and the Department of Civil Engineering at their institution (Stellenbosch University, Western Cape, South Africa). The authors acknowledge that it is a pilot study with many limitations. Nevertheless, important lessons can be learned from it that may improve the design and performance of future studies.
Grossly inadequate and uncoordinated government spending on treatment of mental illness - which affects one in six South Africans - is costing South Africa (SA) 2.2% of its annual GDP. It is also failing to reduce the 230 attempted suicides recorded daily, while 48% of people living with HIV/AIDS continue to suffer from a mental health condition (South African Depression and Anxiety Group (SADAG) Mental Health Fact Sheet).
'What happened in the past is totally out of my control now.' With that simple yet life-giving affirmation, Daryl Brown, 27, legless in a wheelchair after jumping into the path of a London underground train on 29 September 2013, sums up the sea-change in his world view.
Despised apartheid-era chemical warfare expert Dr Wouter Basson, dubbed 'Dr Death' by his detractors and currently practising as a highly respected cardiologist in Durbanville, Cape Town, failed to show that he even 'reflected on the possibility that he violated medical ethics'.
Only one of the most vital patient care domains in public healthcare facilities today meets minimum local and international standards - that of positive caring staff attitudes - but while patient waiting times have increased, other critical areas show 'marginal to good' improvements.
The soaring costs of private medical indemnity insurance for specialists in the higher-risk disciplines are preventing these thinly spread state-employed doctors from seeking extra income in the private sector - benefiting state patients and improving professional supervision of junior colleagues.
Prof. Nicoli Natrass is an economist who has contributed substantially to the understanding of health issues in South Africa (SA). In this important book she addresses the background factors that contributed to the dark AIDS denialism period in SA's healthcare history. Although the book deals primarily with the AIDS pandemic, many of the insights contribute to a better understanding of the way in which all conspiracy beliefs function.
The Primary Health Care Approach and Restructuring of the MB ChB is the distillation of Dr Nadia Hartman's research into the extent to which alignment was achieved between the PHC philosophy, espousing a biopsychosocial approach to patients, and the reformed MB ChB curriculum that was implemented in 2002.
The American author Joan Didion once commented that she writes to discover what she thinks and feels. We all possess a creative capacity that can help us to expand our understanding of our inner and outer worlds. Insight into who we are and what drives us helps us to be more effective in all areas of our lives.
Listerial brainstem encephalitis (LBE) is an uncommon form of listerial central nervous system infection that progresses rapidly and is invariably fatal unless detected and treated early. We report on six adult patients with LBE, of whom five were managed or co-managed by our unit during the period January - June 2012. All presented with a short prodromal illness followed by a combination of brainstem signs, including multiple cranial nerve palsies with emphasis on the lower cranial nerves, ataxia, motor and sensory long-tract signs, a depressed level of consciousness and apnoea. In two cases the diagnosis was delayed with adverse outcomes. LBE may be difficult to diagnose: clinicians may not be aware of this condition, the brainstem location may not be recognised readily, general markers of inflammation such as the erythrocyte sedimentation rate, C-reactive protein level or white cell count may be normal, and the cerebrospinal fluid is typically normal or there are only mild and nonspecific findings. Serological tests are unreliable, and diagnosis is achieved through blood cultures, magnetic resonance imaging and clinical recognition.
The recent implementation of the research requirement for specialist registration presents difficulties with regard to the provision of research supervision, particularly in those medical schools that previously followed the path of qualification via the Colleges of Medicine of South Africa examinations. The differences between the requirements for research supervision as stated in the Health Professions Council of South Africa memorandum and those of the Committee for Higher Education are causing disparities between medical schools similar to those that led to the memorandum in the first place. While the research component of specialist training can only improve the quality of both patient care and academic endeavour, it requires an enormous investment of time on the part of both the specialist trainees and their supervisors. In order to deal with this, specific issues outlined in the article need to be addressed.
Background. Deafness is the most common sensory disability in the world. Globally, mutations in GJB2 (connexin 26) have been shown to play a major role in non-syndromic deafness. Two other connexin genes, GJB6 (connexin 30) and GJA1 (connexin 43), have been implicated in hearing loss, but these genes have seldom been investigated in black Africans. We aimed to validate the utility of testing for GJB2, GJB6 and GJA1 in an African context.
Methods. Two hundred and five patients with non-syndromic deafness from Cameroon and South Africa had the full coding regions of GJB2 sequenced. Subsequently, a carefully selected subset of 100 patients was further sequenced for GJB6 and GJA1 using Sanger cycle sequencing. In addition, the large-scale GJB6-D3S1830 deletion was investigated.
Results. No pathogenic mutations that could explain the hearing loss were detected in GJB2, GJB6 or GJA1, and the GJB6-D3S1830 deletion was not detected. There were no statistically significant differences in genomic variations in these genes between patients and controls. A comprehensive literature review supported these findings.
Conclusion. Mutations in GJB2, GJB6 and GJA1 are not a major cause of non-syndromic deafness in black Africans and should not be investigated routinely in clinical practice.
Despite improvements to the Death Notification Form (DNF) used in South Africa (SA), the quality of cause-of-death information remains suboptimal. To address these inadequacies, the government ran a train-the-trainer programme on completion of the DNF, targeting doctors in public sector hospitals. Training materials were developed and workshops were held in all provinces. This article reflects on the lessons learnt from the training and highlights issues that need to be addressed to improve medical certification and cause-of-death data in SA. The DNF should be completed truthfully and accurately, and confidentiality of the information on the form should be maintained. The underlying cause of death should be entered on the lowest completed line in the cause-of-death section, and if appropriate, HIV should be entered here. Exclusion clauses for HIV in life insurance policies with Association of Savings and Investments South Africa companies were scrapped in 2005. Interactive workshops provide a good learning environment, but are logistically challenging. More use should be made of online training resources, particularly with continuing professional development accreditation and helpline support. In addition, training in the completion of the DNF should become part of the curriculum in all medical schools, and part of the orientation of interns and community service doctors in all facilities.
Estimates of the world's population living with disabling hearing loss, defined as >40 dB in the better-hearing ear in adults (>15 years) and >30 dB in children (0 - 14 years), currently run to 360 million people worldwide. Of even more concern is that the majority of those affected live in the low- and middle-income communities of the developing world (South Asia, Asia-Pacific and sub-Saharan Africa (SSA)). As South Africa (SA) falls within SSA, increasing awareness and raising advocacy are key to addressing the problem at a national level. The challenge in addressing this global burden lies not only in early identification in high-risk groups (both children and adults), but also in the provision of early interventions.
Cervical cancer remains an important cause of morbidity and mortality in South Africa (SA). A national cervical cancer prevention programme exists that offers three cervical cytology smears per lifetime, starting after the age of 30 at 10-year intervals. Despite this programme the incidence remains unacceptably high, cases are often diagnosed late, and many patients have poor response to treatment. Primary healthcare systems in many areas are poorly developed, and uptake of cytological screening is generally poor, with some metropolitan areas and regions doing slightly better. Health systems interventions are necessary to improve the quality of screening. In addition, there is often significant loss to follow-up after the initial screening test among women identified with abnormal cytology. Determinants of the high cervical cancer rate and poor outcome of treatment are similar to those in other developing countries and include a low doctor/population ratio, a high prevalence of HIV infections, and competing healthcare needs. A lack of consumer (patient) knowledge and empowerment leads to a low degree of health-seeking behaviour.