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Home-based care vital for maternal and child health to counter ‘toxic poverty’

August 12, 2013 in Uncategorized

Community health workers can help improve the well-being of poor and vulnerable mothers and children, writes Mark Tomlinson in this guest post:

In 2011, 6.91 million children under five years of age died globally. While this is a significant reduction from the 11.97 million children under five dying in 1990, most of these deaths continue to occur from preventable causes and almost all in low- and middle-income countries.

In 2005 South Africa was one of only four countries in the world where the under-five mortality rate was higher than the baseline rate established by the Millennium Development Goals initiative in 1990.   This was primarily related to the HIV epidemic, with more than half of child deaths attributed to HIV/AIDS, but about 30% of under-five deaths in South Africa are newborns dying in the first 28 days of life (20,000 deaths each year).  Since 2005, as a result the scaling up of effective programmes to prevent mother-to-child transmission (PMTCT) of HIV and to some extent the roll out of antiretroviral therapy, South Africa has been making considerable progress towards reducing under-five mortality.

While the death of children is the most commonly used metric to illustrate the dire state health systems in many poor countries, more than 200 million children under the age of five (who survive) fail to reach their developmental potential. This has been linked to multiple risks such as poverty, poor nutrition, a lack of educational opportunities, maternal depression and under-stimulating home environments.  Jack Shonkoff and colleagues from Harvard University have used the term ‘toxic stress’ to describe a form of stress that occurs when a child’s stress response system is activated for a prolonged period of time, together with an absence of a supportive caregiving relationship that can buffer the stress.

If this early toxic stress is not reduced it can lead to irreversible changes in brain function and structure.  We are talking here of environments where children are exposed to chronic levels of violence, alcohol abuse, drug use, and unresponsive care.  But we are also talking about environments where children are beaten by caregivers and where their attempts at exploration and play are thwarted.  In the same vein, chronic poverty in the absence of nurturing environments and relationships might be termed ‘toxic poverty’.

To ensure that South Africa improves the health of its entire population and achieves a more equitable distribution of resources, we need effective community-based programmes that focus on pregnancy and the first two years of life – what is now called the first 1000 days of development.  The South African government is currently in the process of re-engineering the primary health care system. One component of this is teams of community health workers (CHWs), professional nurses and other medical professionals who will deliver interventions at the community level.

Over the last five years, my colleagues and I have implemented a randomised controlled trial sto examine the impact of community health workers conducting home visiting in order to improve maternal, infant and child health in Cape Town.  Our project is a partnership between the Department of Psychology at Stellenbosch University, University of California, Los Angeles and a local NGO Philani.

Philani has been operating in Cape Town since the late 1980’s and was initially designed to focus on improving child nutrition.  Philani identifies potential neighbourhood community health workers on the basis of them being women who live in the same neighbourhoods as the mothers and children that they will be serving, as well being mothers whose children are thriving, that is, mothers who are positive role models in the neighbourhoods.

They are called Mentor Mothers and they provide social support to their peers, making home visits to monitor the baby’s progress, providing alcohol, HIV/TB information and skills, as well as making referrals for clinic care on an ongoing basis. Mothers whose children thrive typically have good social skills, an ability to develop caring social relationships, and a sense of pragmatism.

The Philani + mentor-mother intervention is currently underway in Khayelitsha and Mfuleni in Cape Town.  The initial study was funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the USA, and the follow up of children at 3 years old is being funded by a local South African funder Ilifa Labantwana.

Early results indicate that mothers receiving the intervention report a significantly higher number of tasks reflecting well-being than mothers who did not, were more likely to be free of maternal birth complications, and HIV+ mothers were more likely to take anti-retrovirals during delivery.

Infants whose mothers received visits from Philani Mentor Mothers and that were experiencing depressed mood during pregnancy have improved growth and cognitive development when they are 18 months old than infants who did not receive Mentor Mother visits.  These findings are important as we know from previous interventions to improve nutrition outcomes of infants and children, that early improvements in child growth suggest later cognitive, educational, social, and economic benefits.

Preventive and curative services offered by community health workers can contribute to ensuring that we avoid this loss of developmental potential in our children and adults. These community based programmes can supplement overwhelmed health-care systems that do not meet South Africa’s health needs, and certainly cannot meet the needs of the range of diseases confronting many other poor countries throughout Africa and globally.

Professor Mark Tomlinson is based in the Department of Psychology at Stellenbosch University.

Medical scheme blues

August 5, 2013 in Uncategorized

When it comes to medical schemes, I wear three different hats.

Firstly, I belong to our Media24 inhouse scheme, which is administered by Discovery, secondly, I am a trustee and board member of said Nasmed scheme, and thirdly I work as a medical journalist.

This puts me in a unique position, in that I get to see medical scheme issues from all three viewpoints. When I am thinking as a medical scheme member, my thinking is as follows:

I pay lots of money every month for this cover, and when I need medical attention, I want the scheme to cough up. I have been paying for 12 years now, I have never been hospitalised in my life, so if something horrible were to happen to me tomorrow, I want to know that I am covered. Up until now I have always found the scheme efficient and helpful and prompt to pay, but I have belonged to other schemes before, which were a nightmare. Every excuse was found not to settle medical bills, claims were “lost” (oddly enough only the big ones, but the little ones sent in the same envelope were paid swiftly) and getting through to them was more difficult than moving the Union Buildings a metre to the left. I feel for scheme members who are still experiencing this sort of service.

As a trustee I represent other members on the Board of Trustees, and my role is to speak up and raise issues which affect fellow members on the scheme. As a board member I also have some insight into the finances of the scheme. The only income of the scheme is membership fees and the expenditure is administration and medical costs. Medical schemes as such are non-profit organisations. The only money to be made is on the administration. As a board member, high-cost claims make my throat constrict, because I know a few of those could cripple many schemes.

As a journalist, I am frequently writing about medical schemes – from the perspective of the members (mostly the disgruntled ones – the happy ones don’t contact us) and the medical schemes themselves.

So, in short, I want my medical scheme to pay for everything I claim, yet I want it to remain solvent, and if it doesn’t, I will write an article about it. Whoever said life was simple?

Tell us about your experiences with your medical scheme.

Susan Erasmus
Health24 Deputy Editor

Substance abuse and depression jeopardise health of HIV/Aids patients

August 2, 2013 in Uncategorized

Substance abuse among HIV/Aids patients who also suffer from psychiatric disorders leads to poor adherence to anti-retrovirals (ARVs), HIV disease progression, lower CD4 counts and opportunistic infections. Dr Rehana Kader writes more about this in this guest post.

This is one of the main findings of my recent doctoral study, in which I conducted the first large systematic investigation of alcohol and or drug abuse, ARV adherence and psychiatric disorders among patients receiving treatment from HIV clinics in Cape Town.

The study found that 37% of the patients attending HIV clinics, abuse alcohol as assessed by the Alcohol Use Disorders Identification Test, while 13%, used drugs. More males abused alcohol and or drugs than females. They also reported poor adherence to ARVs and also had lower CD4 counts than females. Unemployed HIV/AIDS patients were significantly more likely to abuse alcohol and drugs.

More patients who abuse alcohol and or drugs were diagnosed with Tuberculosis (TB) than those who did not. Furthermore, alcohol abuse was found to be a direct predictor of TB. This is of great concern as South Africa has a high prevalence of HIV and TB. Research has shown that alcohol use also worsens TB infection, leading to higher rates of patients defaulting on treatment and possible drug-resistant forms of TB.

Please see attached the full opinion editorial, kindly let me know if you would like more information and I will gladly assist.

Dr Rehana Kader is a clinical psychologist. This article is based on her recent doctorate in Psychiatry at Stellenbosch University

Flush mobs

June 27, 2013 in Uncategorized

Earlier this week we watched a so-called poo protest from the safety of our fifth-floor offices in Adderley Street. Later in the day nine people were arrested for flinging human faeces in the Cape Town International Airport Departure Hall.

Clearly, toilets and sanitation are political and emotional issues. While I won’t get embroiled in the ins and outs of pre-election party politicking, I have to just add that this no new issue. I remember in the early nineties when I was working in the townships driving through a  sewage-flooded Old Crossroads after a winter storm.

Back to the issue of toilets. Try and imagine your life without yours. For many thousands of years there were no toilets – there was just the Great Outdoors and a few leaves for loo paper. Centuries ago in many cities people simply flung sewerage into the streets. But with our overcrowded modern cities, an efficient sewerage system is paramount. We just couldn’t live here without it.

Cholera, diarrhoeal diseases and parasitic infections can all be caused by poor or non-existent sanitation. Apparently, in rural areas of India, a man’s eligibility increases hugely if his home has a flush toilet. It isn’t difficult to understand why.

So next time you flush the loo, be grateful. In fact, the average person uses the toilet eight times a day. So you have eight opportunities for gratitude every day. If you think I am joking, just see how helpless you feel when it is blocked up and cannot be used.

Write to us and let us know if you have any ideas on how sanitation problems can be solved in SA, and whose responsibility this is.

Susan Erasmus
Health24 Deputy Editor

Hope for cluster headaches

June 20, 2013 in Uncategorized

A breakthrough procedure for the treatment of Cluster Headaches has been described for the first time in the peer reviewed medical journal of the American Association of Oral and Maxillofacial Surgeons.

The paper was authored by Dr Elliot Shevel, Chairman of the South African branch of the I.H.S. and ethical approval was obtained from the S.A.M.A research ethics committee. Shevel has published widely and is a peer reviewer for Headache and other journals.

The procedure entails the ligation of the internal maxillary artery (MA), and for the purposes of the study was performed on one chronic and four episodic cluster headache sufferers. According to the study  “The pain in Cluster Headache is … most often is localized to the region supplied by the maxillary artery (MA), namely the peri- orbital, retro-orbital, and orofacial areas”.

Shevel’s paper concludes “In the treatment of CH, the possibility must always be borne in mind that the cluster stopped spontaneously, not because of the intervention, but because of the natural progression of the disease. This could not have been the case with patient 1 who had chronic CH. Also, the fact that the attacks stopped immediately after the surgery in 4 of 5 cases makes it statistically highly unlikely that all 4 happened to obtain spontaneous relief directly after surgery. What is also significant is that patient 4 had an attack that started during the surgery. Without prompting and without being aware of what stage the surgery had reached, he reported that the pain ceased at the moment the MA was clamped and cauterized.”

The full scientific text of the published article can be found here.

This video’s link was supplied by the chronic cluster headache sufferer referred to in the study.  For more information or to set up an interview with Dr Shevel please contact Kayleen Naidoo on +2711 484 0933 or

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