LOOKING INWARD
How to see the human in every patient
SPECIAL DIABETES FOCUS
Combating complications
4 Myths debunked
WARD WARRIORS
How to build resilience in SA’s health workers
AI DOCTORS ARE COMING But they won’t be stealing high-skill jobs
SPECIAL SECTION
SAPHEX/GP Expo/Pharmacy Show/Hospital Show
As a subsidiary of Macleods Pharmaceuticals – a leading Indian pharmaceutical company with a footprint in 170 countries across the globe, Macleods South Africa continues the legacy of providing patients with innovative, safe and high-quality medication.
Our operations in South Africa have been driven by the market for essential medicines, such as anti-TB and ARV products. After many successful years in the public sector, and with more than 90 products registered with SAHPRA, we entered the private sector in November 2022.
We provide high quality, cost-effective treatments to patients in a variety of therapeutic categories.
We take pride in our robust manufacturing operations and quality standards. We strive to meet these by focusing on achieving the highest benchmarks of hygiene, cleanliness and eliminating cross-contamination. Our manufacturing facilities are equipped to meet the mandatory prerequisites of various international regulatory bodies and are therefore successfully inspected by USFDA, WHO Geneva, UK MHRA, ANVISA and others.
Integral to our operations, are our R&D and bioequivalence centres. Our comprehensive R&D facility consists of scientists and staff who focus on the development of active pharmaceutical ingredients (APIs) and formulations. With 250 beds, we have carried out more than 2 500 bioequivalence studies in the past 10 years.
For more information about our range of scheduled medicines, kindly contact us on +27 21 879 3003 or email infosa@macleodspharmasa.com
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Select articles were originally published by The Conversation.
Copyright ©2024 MIMS – a division of Arena Holdings (Pty) Ltd. All rights reserved. Apart from any fair dealings for the purposes of private study, research, criticism or review as permitted under the Copyright Act, no part may be reproduced by any process without permission, nor stored in a retrieval system. MIMS – a division of Arena Holdings (Pty) Ltd – is an independent company and not affiliated to any healthcare company or professional association. The advertising pages carried in Health in Focus are independent and have no influence over the editorial content. Although every effort has been made in compiling and checking the information to ensure that it is accurate, the author, the publisher and the editors shall not be responsible for the continued accuracy of the information, or for any errors, omissions and inaccuracies in this publication, whether arising from negligence or otherwise or for any consequence arising therefrom. Healthcare professionals should rely on their own clinical knowledge and judgement when treating patients and Arena Holdings (Pty) Ltd is not liable for any consequences of potential mistreatment.
About us
Founded in 2008 DNAlysis has positioned itself at the forefront of personalised medicine, both in South Africa and abroad. Our extensive portfolio of genetic tests, based on the most current science, enables healthcare practitioners around the world to provide uniquely personalised treatments to their patients, achieving a more precise, predictable and preventative approach to healthcare.
Our mission
Recognised as a leader in the industry, thousands of healthcare practitioners have come to rely on the DNAlysis
team for support and training, while our tests have gained a reputation for being clinically relevant and scientifically robust. Laboratories in Johannesburg and Helsinki process more than 3000 DNA samples per month, reporting on Nutrigenomics, Pharmacogenomics, Ancestry and Risk Screening - fostering growth and innovation in the healthcare industry.
Our vision
Personalised healthcare is the practice of moving away from a one-size fits all approach to a more targeted, preventative approach for better health outcomes.
We are proud to have developed and will continue to develop cutting edge reports across the health spectrum that are unique and truly differentiate us in the market. We firmly believe that one can only find true value in these tests when interpreted by a healthcare professional and are committed to ensuring the ethical and appropriate use of genetic tests in practice. This puts the education of healthcare practitioners as one of our top priorities, and we will continue to work closely with the medical community to drive the growth of personalised medicine around the world.
Personalised healthcare is the practice of moving away from a one-size fits all approach to a more targeted, preventative approach for better health outcomes
info@dnanalysis.co.za
Visit our website at: www.dnanalysis.co.za
Watch our Medcheck explainer video here
Clinical trials on prescription drugs deduce risk, recommended dosage, and other data based on outcomes in the trial population. This approach is based on a flawed notion – the idea that most people process drugs at a similar rate and in a similar manner. The reality is that significant inter-individual variation exists in our ability to break down prescription medications, much of which is due to genetics.
Four out of five patients carry at least one genetic variant that may affect targets for commonly prescribed drugs.1
Without genetic testing, these variants may go unnoticed, undermining the safety of various prescription drugs.
Features of Pharmacogenomics
Minimise trial and error prescribing
Reduce side effects
Improved patient compliance
More effective treatment outcomes
Genotype guided prescribing
Features of the Medcheck test
Reports on over 200 medications
Your genes don’t change, so results may be used for future prescriptions
Provides detailed information on drug-gene interaction, drug-drug interaction, as well as drug-nutrient interactions
Improved patient outcomes
Contact DNAlysis at admin@dnalysis.co.za if you would like to offer the Medcheck test in your practice.
Scott Colman is the driving force behind the SAPHEX/Pharmacy Show/GP Expo/Hospital Show, to be held in Johannesburg in March 2024. Since its inception in 2017, the Show has grown into a premier event on the South African health conference circuit. Fuelled by his vision of an even bigger and better event, Colman shows no signs of slowing down. We caught up with him on one of his rare pit stops.
Q Briefly describe your career background.
A I have been involved in business-to-business media publishing and events for over 20 years. During that time, I have worked for leading publishing and events companies in Europe, the Middle East and Far East.
Q How did the SAPHEX Show come about in South Africa – and in what year did it launch?
A SAPHEX stands for the South African Pharmaceutical Exhibition. Its name was derived from the sister event we own, namely EAPHEX for the East African market. SAPHEX launched in 2017 as purely a pharmaceutical manufacturing event.
We bring buyers and suppliers together for two days, giving everyone involved the chance to drive business, increase their network and learn from their peers
Q The Show has evolved to include many different sectors in the healthcare industry (pharmaceutical manufacturing, pharmacy, GP medical practice, and nursing. How did this come about?
A After the 2017 event, we decided to include the pharmacy sector as we had many pharmacists join the first show, but obviously had very little to offer them other than pharma manufacturing. For this reason, we added The Pharmacy Show (TPS) to the line-up and colocated TPS with SAPHEX. What followed was the addition of the GP Expo - and now this year, the Hospital Show. I believe we are likely to develop only these areas further from this point, and will not add any further additional sectors to the event.
Q As CEO of Future Publishing Solutions, what exactly is your role with regard to the Show?
A My current role in SAPHEX is purely an overseeing role. I still have a number of accounts with which I stay in touch, but my role is more looking at opportunities surrounding the event and understanding how we can expand further into other areas across the business.
Q What is the main purpose of the Show both for the exhibitors and delegates?
A The purpose of the event is simple. We have always set out to give both the exhibitors and visitors value for
their money and their time respectively. We simply look to bring buyers and suppliers together for two days, giving everyone involved the chance to drive business, increase their network and learn from their peers.
Q How do you rate the success of the Show?
A SAPHEX and its collocated shows are not at the level we would have expected, but this is largely down to Covid. Before the pandemic, we were growing our events at a fast pace. During 2024, we will be getting back to where we were in 2019. This year will see a jump in attendees and a return to strong levels of visitors. Overall, the success of SAPHEX has been fantastic for many of the companies involved, especially for those regular exhibitors who support our event year-on-year. Many of our exhibitors have been with us since the first event.
Q What are positive things that exhibitors or delegates have told you about participating?
A I think the best example of how the event has had a positive effect on exhibitors and delegates alike is the fact that it continues to deliver high-quality conference sessions that are free to attend. In turn, this drives a highquality audience to the exhibitors who generally feel our event is good value for money. The positivity normally gets shared on social media - especially by those who are attending for the first time. It certainly kickstarts a large series of positive comments, given the scale of the event.
Q Is there an inspiring example of how the Show has impacted one of the exhibiting companies?
A There are several stories. One in particular stands out. Without naming the company, we have helped a business survive and flourish by allowing it to attend the event after it lost a significant amount of money through no fault of its own. At the end of the day, business is business, but when you hear a story of desperation and sadness, it’s important, in my opinion, to try to help, and this is what we did. The company in question has since exhibited at our show and will again be present in 2024. For me, its progression as a business since our help some four years ago is a great success story to which we contributed.
Q What is the biggest challenge in putting an event of this magnitude together?
A The main challenge is getting exhibitors to make sure they have completed every form and questionnaire we supply to onboard them to the event. It always takes a lot of effort to ensure exhibitors are fully and correctly set up. Beyond this, it’s the challenges that are out of our control for visitors coming to the event, such as weather and traffic issues. You simply want a sunny day where everyone can arrive without encountering any issues. This rarely happens, but we are aware that it’s not something we can control!
6 Q What will the future bring for the Show –what, in your opinion, are potential growth areas?
A Honestly, SAPHEX, The Pharmacy Show, GP Expo and the newly launched Hospital Show complete our series of events that we will run together. Every area of the show is currently at 20% of its opportunity and all areas will most likely grow significantly over the next five years.
Q In terms of the African continent, you have not only hosted healthcare conferences in South Africa, but also in Ghana and Kenya. Are there any challenges specific to those countries that you had to overcome?
A Every event and region has its challenges. From Europe through the Middle East to Africa, there’s not a smooth route to delivering a good event. Our event in Kenya is one of the events that continuously tests our ability to deliver a good quality show. Mainly this is down to suppliers and venues which are unfortunately hard to find. We still today have issues with venues in Kenya; they simply are not big enough for what we need as a venue.
Q How can digital technology benefit your healthcare conferencing business?
A In the wake of the COVID era, digital technology has significantly evolved and become an integral part of the
strategies employed by events companies, offering numerous benefits. This transformative period has led to a shift in focus for many events companies, aiming to accommodate a broader online audience and enhance networking opportunities. Looking ahead, in 2025, we are set to unveil a groundbreaking platform for our exhibitors and visitors. This platform is designed to facilitate extensive interaction, not only during the event, but also before and after, opening up a realm of possibilities for enhanced digital learning experiences. The horizon for events companies, exhibitors, and attendees is now characterised by limitless opportunities, reshaping the landscape of how we perceive and engage in events.
Q How would you describe yourself as a person? Is there a saying or success mantra that holds true for you?
A I’m lucky you are asking me this question and it’s not being answered by someone else! Simply put, I’m a family man who has always loved to travel and have fun outside of work. I love sports and still train up five to six times a week, although this is always balanced out with a beer post-workout!
My mantra? “Success is not the key to happiness. Happiness is the key to success. If you love what you are doing, you will be successful” – from the well-known humanitarian and physician Albert Schweitzer.
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Tasneem Abrahams wears many hats. In her practice, she helps young adults with neurological conditions to cope and feel validated. As a health advocate, she manages an organisation to support those with autism. She is also a knowledge partner of the 2024 GP Expo, compiling the Private Practice Business Conference speaker programme.
Q You graduated as an occupational therapist from the University of Cape Town in 2002, and then proceeded to work in a variety of settings, including mental health, spinal cord injury, neuro-rehabilitation and special education. During this journey, you have honed in on mental health. What motivated you to focus more on this area?
A It was during my time in London, working in community-based adult learning disability and for a specialist borderline personality disorder pilot project within the NHS, that my passion for mental health was truly ignited. This experience opened my eyes to the long road we still needed to travel in South Africa in terms of destigmatising mental health and promoting community reintegration following a mental-health diagnosis, but also gave me hope for what was possible. When I returned to South Africa, I knew that I wanted to remain in the mental health space.
While working at a high school for learners with mild intellectual disabilities, I realised there was a gaping hole in the availability of services outside of a school setting for teenagers and high school leavers, who do not have a severe enough intellectual disability to benefit from sheltered or protective employment, but are also not “mainstream” enough to find gainful employment in the open labour market. Many of these learners presented as neurodivergent and I was convinced that many learners at my school had been misdiagnosed by the system as having an
intellectual disability, when they really just lacked the holistic support to help them thrive in a neurotypical world. Serving this population became my mission and I consequently left the school to start my own practice.
Q Describe the term neurodivergence. In broad terms, how do you see the role of an OT in this regard?
A Neurodivergence refers to individual brains that diverge from what is considered “typical” and therefore become marginalised and pathologised for the way they function in society. Conditions that fall under the umbrella of neurodivergence include ADHD, autism, dyspraxia, Tourette’s, dyslexia and many more. I may be biased, but I do believe occupational therapy is one of the most holistic health professions. We are trained to assess and treat physical, psychological, cognitive, emotional and social aspects, not only of the individual, but also of the systems and contexts within which they operate.
I like to refer to our profession as the “doing therapists”. Often, it is not the big, hairy, audacious goals individuals struggle to achieve that cause the greatest friction in their lives, but rather the sum of all the smaller, seemingly insignificant tasks they struggle with, such as keeping on top of the laundry, being punctual for appointments, handing in work on time, or remembering to pay the bills. In the context of neurodivergence, the role of the OT is to identify the tasks and activities with which an individual struggles, analyse what skills they have the capacity to develop to improve performance in these tasks, and then
help them develop these; or assess how the environment can accommodate their brain differences to facilitate their optimal engagement in their context.
Q You work a lot with young adults –particularly those with ADHD. What are some of the challenges they face and how can occupational therapy help?
A No two ADHD individuals are the same. Broadly speaking, there are three types – Inattentive, Hyperactive/Impulsive or a combination of both. These are based on which combination of executive functions are impaired.
For example, when inhibitory control is impaired, this might look like constantly interrupting and speaking over others, reckless and impulsive behaviour, or starting tasks without planning or fully understanding the instructions.
An OT might engage the person in activities that require inhibition to practice the skill while the OT scaffolds the level of support. The OT might also assess the environments where this creates a problem and recommend environmental supports to facilitate inhibition.
On the other hand, when initiation is impaired, the person will struggle to get started, even with tasks they have a keen interest or engagement in, and as a result will often be labelled unmotivated or lazy. This is often a result of overwhelm and not knowing what the first step is. An OT might help the person learn how to break down tasks into smaller chunks, create a plan and take the first step in the plan.
When working memory is impaired, this might look like forgetfulness, losing track of what they are doing or saying while doing it, difficulty with following instructions and constantly making “silly” mistakes in their work. An OT will use various intervention strategies to work on improving working memory or to identify strategies like tech tools, or recommending reasonable accommodation at school or work.
Q What is the most valuable advice you can give other healthcare providers starting out in private practice?
A I think every new business owner struggles with cash flow. In the beginning, there are no clients yet, but you have expenses that are essential to providing a quality service. The most important thing you can do when starting a practice is to create a roadmap of how you plan to grow your business in the first 12 months. Break these actions down into weekly goals that incrementally build on each other to achieve your 12-month goal. Review this plan every 90 days. This plan must include how you plan to manage your cash flow by identifying what actions you need to take to build your client base, ensure you get paid timeously, and how you plan to keep a handle on your expenditure. Save for up to at least three months of runway to cover expenses in the beginning and start marketing your services at least three months before you are ready to open.
Abrahams is a director of Jozi4Autism, a nonprofit company promoting awareness of autism in Johannesburg. With a particular focus on under-represented groups, it encourages social integration of children and families on the spectrum within the context of their community; and promotes accessible delivery of services and support networks.
Jozi4Autism works closely with Autism South Africa and local charity organisations Caring Women’s Forum and F.E.E.D. Its flagship event is the annual Jozi4Autism fun walk at the Johannesburg Zoo. In 2023, over 1 000 people attended the walk as individuals, families, businesses and organisations, for a day of fun for everybody, inclusive of autistic children and their families.
Q You founded the Private Practice Growth Club in 2019 in order to assist healthcare providers in private practice. Tell us more.
A The Private Practice Growth Club started as an online community of support for health professionals who were thinking of starting, working in, or trying to grow a private healthcare practice. This eventually evolved into a knowledge-based platform that offers courses, webinars and digital products. It also hosts networking events, as well as connecting practitioners with products and services. Additionally, I offer one-on-one consulting. I also have a YouTube channel where I share tips, tools and tutorials, and interview guest experts and featured practice owners on all things private practice.
Q What would you still like to achieve in your work and what changes do you hope to see in the mental health and neurodiversity space?
A As a passionate advocate for my profession, I would like to play a role in ensuring other medical professionals recognise the key role and value the occupational therapy profession holds in mental health overall. I would like to inspire more OTs to serve the neurodivergent adult population, and I hope to one day contribute to the scientific body of knowledge around ADHD through research. I will continue to educate and create awareness about ADHD, whilst also supporting the empowerment of neurodivergent individuals to self-advocate as experts by their own lived experience. I would like to see ADHD included in the list of Prescribed Minimum Benefit conditions, and I want to see the inclusion of Occupational Therapy in the medical schemes’ mental health baskets of care, because currently only Psychology, Psychiatry and Clinical Social Work are recognised as mental health professionals.
The Private Practice Business Programme, hosted by Take Note Event Management & Private Practice Growth Club, is one of the speaker programmes at the SAPEX/GP Expo/Pharmacy Show/ Hospital Show 2024.
Wednesday, 13 March 2024
09:00
GP EXPO 2024 OPENS – Day 1
09:30 – 10:10
ETHICS TOPIC
SESSION 1
Chair: Joey Swart
Medical Scheme Clawbacks and the Truth about Section 59 Adv Vanessa van Niekerk
10:10 – 10:15 Q&A
10:15 – 10:55
Precision Prescribing with Pharmacogenetics Dr Danny Meyersfeld (Director, DNAlysis Biotechnology)
10:55 – 11:00 Q&A
11:15 – 11:55
15-Minute Break
SESSION 2
Chair: Dr Peter Cruse
Financial Wellness & Tax Strategies for South African Health Practitioners
11:55 – 12:00 Q&A
12:00 – 12:40
The Risk & Retirement Blindspot
12:40 – 12:45 Q&A
30-Minute Break
SESSION 3
Chair: Tasneem Abrahams
Joubert le Roux (Chartered Accountant/ Managing Director: CFO Group)
Raymond Schkolne (Director: Stonebridge Group Services)
13:15 – 13:55
CLINICAL TOPIC
Pharmacogenetics Testing in General Practice (sponsored by Mediclinic)
13:55 – 14:00 Q&A
14:00 – 14:40
Prescribing Success: A Prescription for Ethical & Effective Medical Marketing
14:40 – 14:45 Q&A
15-Minute Break
Dr Lizahn Haasbroek (Product Manager: Specialising in Pharmacogenetics)
Basil Adriaanse (Director: Social Medical Pro)
15:00 – 15:30
15:30 – 16:00
16:00
SESSION 4
Chair: Joey Swart
Why Go Paperless? How Billing & eMR Software Solutions Enable Practice Growth (sponsored by Healthbridge)
The Air We Breathe and Its Impact on Our Health (sponsored by Leosteph)
CLOSING
09:00
09:30 – 10:10
Luis da Silva (CEO: Healthbridge)
Dr Thulja Trikamjee (Specialist Paediatrician & Allergist)
GP EXPO 2024 OPENS – Day 2
SESSION 1
Chair: Tasneem Abrahams
Prescribed Minimum Benefits - from Basics to the Latest Irene Zambelis (Institute of Health Risk Managers – IHRM)
10:10 – 10:15 Q&A
10:15 – 10:55
Setting Up Your Practice for The Long Run: Legal Structures and Compliance Made Simple
10:55 – 11:00 Q&A
Raymond Meneses (Managing Director: Meneses Simpson Inc.)
15-Minute Break
SESSION 2
Chair: Joey Swart
11:15 – 11:55 Using AI to Promote Your Private Practice Footfall & Revenues
11:55 – 12:00 Q&A
Dr Peter Cruse (Director: Take Note Event Management (Pty) Ltd)
12:00 – 12:40 Data Security in the Future-Proofed Practice Suren Govender (COO: iGuardSA)
12:40 – 12:45 Q&A
30-Minute Break
SESSION 3
Chair: Dr Peter Cruse
13:15 – 13:55
CLINICAL TOPIC
A Clinician’s Guide to Genomic Testing: Pointers & Pitfalls in Clinical Practice (sponsored by Mediclinic) Dr Liani Smit (Clinical Geneticist)
13:55 – 14:00 Q&A
14:00 – 14:40
Dealing with Difficult Patients: Practical Tips
14:40 – 14:45 Q&A
Dr Melané van Zyl (Psychiatrist)
15-Minute Break
SESSION 4
Chair: Joey Swart
15:00 – 15:30 Patient Blood Management: The South African Story (sponsored by SANBS)
15:30 – 16:00
16:00
CLOSING
Dr Petro Lize Wessels (Lead Consultant – Patient Blood Management & Transfusion Medicine)
In his role as President of the Pharmaceutical Society of South Africa (PSSA), Tshifhiwa Rabali combines proven industryrepresentation expertise with hand-on experience as a successful and pioneering pharmacist. Clearly passionate about ‘giving back’, he thrives on serving the profession, with a special interest in mentoring young pharmacists – both through the PSSA and in the community he serves.
Q Please give us a brief description of your career path to date
A Immediately after my pharmacist internship, I worked at Adcock Ingram for six months. After that, I opened my own pharmacy. It has been a decision that I still cherish today as I managed to practise my profession fully, serving a most vulnerable and previously disadvantaged community. My pharmacy has produced a lot of other pharmacists who are currently running their own pharmacies, so I have been a role model to them.
I was also one of the pharmacists who was not in favour of renting, so I was given land where I built my own Sebokeng Pharmacy house, and up to today, I am still very happy about that decision. I have trained many of the youth in the community as I always give them learnership positions for a year before they go to Tertiary. Since 2022, when I was approved as a tutor at the South African Pharmacy Council, and my pharmacy as a training facility, I started taking in interns and learner pharmacist’s assistants, which has been very fulfilling for me.
Q What do you enjoy most about your job as President of the PSSA?
A As the President of the Society, I enjoy my interactions with members and all other stakeholders. It is so fulfilling to see that I can make a difference to the Soci-
There are so many opportunities for the pharmacy graduate in South Africa, seeing that we are partly a third world country with many health-related challenges. There will always be a need for more pharmacists who can give service to the citizens
ety and members as a whole. Being a leader of my colleagues brings me joy all the time and gives me passion to do more for them.
Q In very broad terms, how do you see the pharmacist’s future role in South Africa’s changing healthcare landscape.
A The pharmacy profession is changing constantly, and primary healthcare will be the main scope of practice for pharmacists in the future, as it is now. Also, the changing dynamics in manufacturing will always be driven by pharmacists.
Q Name a few important benefits that the PSSA offers the pharmacist/pharmacist profession?
A The Pharmaceutical Society of South Africa represents more than 12 000 pharmacists, pharmacy support personnel, and students. One of our main functions is representing the best interest of our members and the profession with stakeholders like the South African Pharmacy Council (SAPC) and the National Department of Health.
We provide support to all our members, like Continuing Professional Development and professional indemnity insurance, in partnership with PPS Insurance. With the PSSA being a member of the International Federation of Pharmacists (FIP), we also present different discussions and educational materials to our members. Members can always contact the national and branch offices for any support they may need, such as legal queries, SAPC-related matters, and labour issues, and we provide support with resources to the smaller branches.
Q What current initiatives by the PSSA are you particularly proud of? (The uptake of young pharmacists looks impressive.)
A The PSSA is in the third year of a mentorship programme running through the National office. Young pharmacists sign up for the programme and then pair with a mentor (a pharmacist with a few years of experience) who guides them at the start of their career. It is such a brilliant idea, attracting many of our young pharmacists to the Society, and we are very proud of that. The Society is growing yearly in membership thanks to that initiative and other services we provide to members out there.
Q How might the pharmacy profession change in the digital era?
A The changes in the Profession will be positive with ongoing digitisation, as the many manual functions that pharmacists currently do will be taken away from them, and they can concentrate on doing what they are trained to perform – getting involved with the patient and their treatment plan.
Q How would you encourage a newly qualified pharmacist to stay in South Africa, as opposed to practising abroad?
A There are so many opportunities for the pharmacy graduate in South Africa, seeing that we are partly a third world country with many health-related challenges. There will always be a need for more pharmacists who can give service to the citizens. The pharmacy field is also very broad in South Africa, and you can choose various career paths.
Q What skills and character traits are important in order to achieve success as a pharmacist, and why?
A Passion and humility as a pharmacist are very important as they give hope and trust to the people you serve. Entrepreneurship skills are also important if someone wants to be in private practice.
Ms Mogale served as the Deputy President of the PSSA and as previous President of the SAAHIP Sector. Before joining the PSSA as Executive Director, Ms Mogale served as the Pharmaceutical Services Manager under the Mpumalanga Department of Health. Her role includes overseeing the operations of the PSSA, its branches and sectors; executing the or ganisation’s strategies and capital allocation, promoting the organisation’s member benefits, stakeholder management and assisting in the development and formulation of policy. Ms Mogale’s overarching vision for the PSSA stresses the importance of ongoing innovation: “I believe in projects that translate to impact; thus, my vision is to ensure that the PSSA becomes a key innovation destination for the pharmacy profession and reinforces its brand as a progressive, responsive and member-tailored organisation.”
Contact the PSSA at:
https://www.pssa.org.za/contactus.html
In 15 years as a primary care physician, I have seen the effects of dehumanising medical care – and the difference it makes when a patient feels they are being respected, not just treated
Renowned US-based primary care physician and medical educator Jonathan Weinkle relates the importance of turning the abstract principle of ‘putting the patient first’ into concrete medical skills.
Jonathan Weinkle Clinical Assistant Professor of Medicine and Part-Time Instructor of Religious Studies, University of PittsburghPatients frequently describe the US health care system as impersonal, corporate and fragmented. One study even called the care delivered to many vulnerable patients “inhumane.” Seismic changes caused by the COVID-19 pandemic – particularly the shift to telehealth – only exacerbated that feeling.
In response, many health systems now emphasise “relational medicine”: care that purports to centre on the patient as a human being. Physician Ronald Epstein and health communication researcher Richard Street describe “patient-centered care” as advocating “deep respect for patients as unique living beings, and the obligation to care for them on their terms.”
In 15 years as a primary care physician, I have seen the effects of dehumanising medical care – and the difference it makes when a patient feels they are being respected, not just “treated.”
Though “relational medicine” may be a relatively new phrase, the basic idea is not. Seeing each person
before you as someone of infinite value is fundamental to many faiths’ beliefs about medical ethics. In my own tradition, Judaism, “personcentred care” has roots in the biblical Book of Genesis, where the creation story teaches that “God created the Human in God’s own image.” As a medical educator, I teach students how to turn these abstract ideas into concrete clinical skills.
Traditional Jewish law sets rules that shape my understanding of these skills. As the influential French sage Rashi wrote in an 11th century commentary on the Bible, it is forbidden to publicly embarrass a person “so that their face turns white,” even while rebuking them. For doctors today, this might mean taking care not to inflict shame on a person with a stigmatised illness like substance use or obesity.
The Bible forbids wronging or abusing strangers not once, not twice, but 36 times – a reminder not to “other”
people or obscure their basic humanity. A similar value appears in the 18th century Physician’s Prayer, written by the German-Jewish physician Marcus Hertz, who states, “In the sufferer, let me see only the human being.”
American Rabbi Harold Schulweis used the concept of “covenant” – a holy, mutual agreement – as a model for the bond between physician and patient, working toward a common goal. This idea inspired my own book, “Healing People, Not Patients.”
Similar connections between medicine, respect and religion are found in other traditions, as well. A 1981 Islamic code of medical ethics, for instance, considers the patient the leader of the medical team. The doctor exists “for the sake of the patient... not the other way round,” it reminds practitioners. “The ‘patient’ is master, and the ‘Doctor’ is at his service.”
In undergraduate classes that I teach for future health professionals at the University of Pittsburgh, we focus on communication skills to foster dignified care, such as setting a shared agenda with a patient to align their goals and the provider’s. Students also read “Compassionomics,” by medical researchers Stephen Trzeciak and Anthony Mazzarelli, which aggregates the data showing caring’s impact on the wellbeing of patients and providers alike.
However, even health professionals steeped in these practices can encounter people whose humanity they struggle to see. Students wrestle with a classic article about “the hateful patient” and practice an exercise called the “second sentence.” This asks providers to look beyond their first impressions of a patient they might have trouble treating with compassion, imagining a “second sentence” that humanises the person in front of them.
The course evaluation is based on a project in which students interview a friend, relative or neighbour about their experience of illness and care. Ultimately, they identify one element
of the person’s care that could have been improved by attending more to the person’s individual needs and listening to their story.
One student recounted her brother’s experience after he suffered a serious sports injury. The trauma team followed protocol precisely, but this meant that they did not register him screaming in pain, telling them that what they were doing was making him feel worse. Only in the hospital did doctors discover that those screams were a clue to a specific injury that should have received radically different care in the field, which could have been caught earlier had the team attended more closely to his words. His sister explored the medical literature on when emergency services need to break their own rules to care for a complex patient, and
with both ears”: listening not only to the patient, but also to what they themselves say to the patient, considering how it will be received. Students are encouraged to go home and practice until the words feel natural in their mouths, not scripted or mechanical – just like they drill anatomy facts and suturing skills.
After their clinical year, the students return to reflect. Many of them report using patient-centred skills in challenging situations, such as validating patients’ concerns that had previously been dismissed.
Yet they also report a work culture where effective communication is often seen as taking too much time or as a low priority. Sixty years ago, Rabbi Abraham Joshua Heschel and psychiatrist William C. Menninger presented on The Patient as
she suggested her own mnemonic – stop-ask-listen-evaluate (SALE) – for how to make “breaking protocol” one of the options in the protocol itself. Another student related his father’s experience living with chronic illness. His condition frequently deteriorated because of delays in refilling medicine through his regular physician’s office. This student pointed to medical literature detailing how pharmacists can be given greater authority to refill medications for chronic diseases, preventing gaps in treatment, which would have saved his father significant hardship.
Down the road at Chatham University, I work with physician assistant students who are about to enter clinic for the first time. These students complete a workshop including many of the same communication exercises, including “listening
a Person to the American Medical Association. Heschel declared that the profession was suffering from a “spiritual malaria,” his term for precisely the “high-tech, low-touch” attitude that my students encounter. The emphasis on technology and a rapid pace of treatment leaves scant room for caring, whether in Heschel’s day or ours.
In both programmes where I teach, I aim to provide new practitioners with tangible skills that their future patients will experience as real “whole-person care” and not just a slogan on a commercial. Those patients will know that the people caring for them value all of them – their livelihoods, their life stories and the worlds they inhabit.
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AI could provide a solution to help human practitioners improve their capabilities. And with diagnosis taken care of, medical staff can spend more of their time actually caring for their patients
Artificial intelligence can now diagnose cancer tumours and eye disease with impressive accuracy. Yet there is little danger of AI soon replacing doctors, radiologists and other highly skilled practitioners. If anything, it should enhance their professional expertise and encourage creativity and critical thinking.
Leandro L. Minku Lecturer in Computer Science, University of LeicesterJeremy Levesley
Professor of Applied Mathematics, University of LeicesterGoogle recently successfully put its DeepMind artificial intelligence system to work recognising eye diseases. With AI also being used to diagnose cancer, and the launch of AI-driven smartphone apps that can discuss symptoms and triage patients, it might sound like we’re not too far from the creation of a fully fledged AI doctor.
Similar progress is being made putting AI to work writing software and evaluating legal contracts. AI has even started to make its mark in the creative world, generating artworks and fashion, evaluating graphic design, and helping people to create music. So does AI pose a threat to highly skilled jobs in the same way it does to ones that involve simple, repetitive tasks?
New technology has been making workers redundant for hundreds of years. But advances in the various in-
dustrial revolutions have also always created other new jobs, and people have been able to adapt. In the end, successful technologies were those where human and machine worked in harmony for the benefit of wider society. But the AI revolution may be different because it could affect as many white-collar professional roles as manual jobs.
That jobs involving lower skilled office work, such as data processing, will be reduced seems inevitable and, indeed, is already starting to happen. But AI is also invading the realm of highly trained professionals, such as software engineers. However, it’s largely happening in a way that shows how AI will be more of a tool than a threat to skilled workers. It may become more common for professionals to be required to learn how to benefit from the power of AI, than for entire jobs to simply disappear.
22 Take computer programming. A longstanding dream of researchers is to develop an AI that can develop complex new software from scratch. The reality is that such a goal is probably a bit too far-fetched. The informal and subjective descriptions usually used to create briefs for programmers are just too imprecise for that.
But researchers have realised that AI can be very powerful at optimising existing software, for instance to make it faster and use less energy. Optimising software requires very specific skills, which most software developers actually don’t have. So this kind of AI could be very helpful in improving software development without threatening existing jobs.
Researchers have started to develop novel ways for AI to detect various types of software bugs in realistic scenarios. And companies such as Facebook already use AI testing tools capable of revealing software crashes, a type of bug that causes apps to abort unexpectedly. These are vital tasks given how increasingly important software is to the smooth functioning
of society, yet they are currently very hard for people to carry out.
We can predict a similar pattern in medicine. Many countries, including developed ones such as the UK, have a shortage of medical staff. For example, there are simply not enough welltrained doctors to be able to accurately diagnose the early signs of eye disease. AI could provide a solution to help human practitioners improve their capabilities. And with diagnosis taken care of, medical staff can spend more of their time actually caring for their patients.
This kind of technology could become even more helpful in countries where the number of well-trained doctors per head of population is much smaller, or for remote communities where accessing any medical advice is difficult. So the kind of research being carried out by Google DeepMind should be welcomed not feared by the medical profession.
We should use AI for the tasks that
AI is good for, so that we can fill in gaps where there is a shortage of staff and where tasks cannot be easily automated. The challenge we do have is to equip students and professionals for the changes to their jobs that will occur and for the new, unknown jobs that AI will create in the future. With appropriate and timely training, fears of high-skilled job losses won’t come true, enabling society to concentrate more on the benefits that AI will bring.
The modern jobs market is very competitive and continuous professional development is already vital in many professions. In some ways, this could place us in a better position than people at the time of the industrial revolution. But current educational trends towards examinations and mechanistic thinking are movements in the wrong direction. Regurgitating facts and processing data is what machines are good for. Creativity and critical thinking, meanwhile, have never been so important for humanity.
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Health workers cope with a huge amount of stress – how to build a resilient health system in
South African health workers are under constant pressure to deliver quality and often life-saving patient care – and many need to perform in resource-strained settings. Fostering individual coping skills and building a strong health system that focuses on everyday resilience may be the best way to deal with the immense challenges they face.
Yogan Pillay
Extraordinary Professor in the Division of Health Systems and Public Health, Stellenbosch University
Flavia Senkubuge
Deputy Dean: Health Stakeholder Relations in the Faculty of Health Sciences, University of Pretoria
Lucy Gilson
Professor and Head, Health Policy and Systems Division, School of Public Health, University of Cape Town
Popular and academic literature is replete with examples of how to cope with daily stresses. Mental health professions have also long researched and implemented strategies to deal with burnout from workplace stressors.
Coping with stress is not a new phenomenon. But COVID-19 and the responses to the pandemic have increased our attention on how people and systems cope with stress-inducing shocks.
This should not surprise us, given the impact of COVID-19 on almost every aspect of our lives. There are indications that many people and countries are still struggling to emerge from its shadow.
Resilience is a relatively new area of study in the health sector and is explained as the ability of an individual to withstand and recover from adversity using their inner strength, optimism, and being flexible and competent.
Everyday resilience is important to ensure health workers can cope with daily stressors, and take action to change their circumstances when they are confronted with challenges. At a health-system level, everyday resilience means that health workers can deal with the systemic challenges in their work environment.
We argue that everyday resilience is needed at two levels: healthcare workers – who mostly bore the brunt of the pandemic in their working and personal lives – as well as the health system.
Saiendhra Moodley
Public Health Medicine Specialist and Senior Lecturer, University of Pretoria
Suzi Malan Manager: Partnerships and Projects at Department of Family Medicine, University of Pretoria
We draw on research around resilience in the health sector to highlight why it’s important to focus on this important quality and the skills to hone it for health workers and for the health system as a whole.
Health workers face trauma daily. Their line of work often requires them to make life-saving decisions in the face of significant resource limitations, as well as high expectations of patients, families, communities and their managers.
The rate of burnout in health workers is high throughout the world. This was exacerbated by the COVID-19 pandemic which contributed to alarming levels of anxiety, depression and traumatic stress among South African health workers.
There have been suggestions about how to build resilience in health workers, including medical students, against daily workplace stresses.
There’s an example of how COVID-19 had an impact on the health workforce from clinical associates at the University of Pretoria’s Health Sciences Faculty who supported mining companies. About 100 clinical associates conducted COVID-19 screening, testing, follow-up and vaccinations. They performed quarantine or isolation-ward duties and provided general healthcare services to miners.
During the peak COVID infections periods, the clinical associates worked an average of 18 hours per day. They
took huge physical and emotional strain. Many of them also had to deal with severely ill relatives and deaths. They met every evening via a virtual call to discuss their experiences and complex cases. This provided an outlet for their emotional strain and an opportunity to improve their clinical understanding.
Because of the direct access to the emotional support provided by the university staff, these health professionals could readily find support when they felt overwhelmed. Halfway through the pandemic, a team of private occupational therapists conducted an eight-week online group-therapy programme with the clinical associates, called the Unsung Heroes programme. Conducting this form of therapy online was unheard of before the pandemic, and included both group therapy sessions, as well as individual consultations. Clinical associates afterwards reported how much these sessions helped them to cope with the burden of COVID.
But the focus on building resilience at the individual level has been criticised as focusing on the symptoms rather than the root causes. For example, studies have argued that building resilience in
frontline health workers may hide the systemic challenges.
These might include a shortage of personnel, inadequate equipment and medicines, and organisational cultures that limit innovation and adaptation. A more comprehensive approach to building resilience would, instead, focus on what some have called everyday resilience, based on everyday capabilities.
Borrowing from the ideas of colleagues working with the London School of Tropical Medicine and Hygiene, everyday resilience is founded on: “...the combination of absorptive, adaptive and transformative strategies that actors in systems adopt in responding to strain”.
Transformative resilience ultimately implies changing the system so that it can continue to change in the face of multiple, future, unpredictable challenges.
The literature suggests the need for further research into the notion of transformative resilience. But we already know a lot about what can be implemented even as the world focuses on the structures, practices and routines needed for pandemic preparedness and control.
There are many proactive (adaptive) examples from South Africa and Kenya of how primary healthcare workers coped before the COVID-19 pandemic. These examples illustrated personal agency, as well as system changes initiated at local level. For example, the temporary reintroduction of user-fees in Kenya, agreed with local communities, until government funding was again transferred to ensure that primary healthcare services were not disrupted.
In South Africa, there are examples of new forms of collaborating across organisations to work towards shared goals. There are also new ways of managing and organising meetings to support learning and enable mutual accountability among colleagues in primary care settings.
Across countries, respectful leadership practices that empowered front-
line workers and strengthened relationships were also found to be very important to everyday resilience.
Similarly, during the COVID-19 pandemic, the Western Cape Department of Health in South Africa introduced the concept of daily huddles. These daily hour-long meetings allowed for key issues to be presented and discussed. They included managers from all levels of the health system – including the private health sector – as well as managers from other sectors of government. As the pandemic receded, they happened less frequently.
The meetings enabled managers to work across silos in the health system across administration and health programmes, for example. Everyone that participated in the huddle could do so freely without sanction. This reduced the hierarchy within the health system.
The presentations in these huddles were evidence-based. They illustrated the importance of realtime information, as well as the use of evidence for decision-making.
Our colleagues who were part of these huddles reported that they used these to build on long-standing initiatives in the province to strengthen the health system.
The COVID-19 pandemic highlighted various challenges to health workers and health systems. These are foremost in our minds. But the sector has faced similar challenges over many decades.
There are many examples of how to strengthen resilience that we can learn from, and scale. What is clear is that unless health systems are organic learning systems and continuously focus on building systems for resilience, we may run the risk of learning anew each time health workers and health systems face a catastrophic event.
Building a strong health system that focuses on everyday resilience may be the best way to deal with everyday challenges, as well as pandemics.
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Running out of medicines is a continual challenge in primary care clinics. A main reason is that nurses often need to manage essential medicine supplies over and above their core duties. Employing a pharmacy assistant would go a long way to avoiding stockouts, freeing up nurses to deliver quality patient care.
Primary healthcare clinics are the main healthcare access point for millions of South Africans.
There are at least 3 467 statefunded primary healthcare clinics across South Africa’s nine provinces. Most South Africans get their essential medicines from public health facilities, which serve 71% of the population.
Nurses often run the clinics as the only available health professionals. But dispensing and medicine
supply management is not their core function. When nurses have to manage essential medicine supply, it takes their attention away from quality patient-care delivery.
This multitasking by nurses is among the main reasons for essential medicine stockouts in the primary healthcare clinics in South Africa.
To improve compliance with medicine standards, the South African government started to train pharmacist assistants to increase
the number of people available to help with medicine management. It recognised that producing enough fully trained pharmacists for deployment in primary healthcare clinics would take five years or longer.
The training programme for postbasic pharmacist assistant qualification is two years – much shorter than that of pharmacists. There are currently 16 250 registered post-basic pharmacist assistants.
The appointment of one pharmacist assistant can free up professional nurses from managing medicine supply. It guarantees that at least 40 patients receive uninterrupted clinical care per day
But many clinics still don’t have one. In my recent research I set out to assess the role of post-basic pharmacist assistants at primary healthcare clinics. The aim was to make recommendations to improve essential medicine supply management.
I found that around a third of the clinics we looked at didn’t have a pharmacist assistant. These clinics were more likely than other clinics to have erratic medicine-supplymanagement practices. Pharmacist assistants contribute positively in reducing essential medicine shortages. There should be urgent plans to employ more of them.
Essential medicines stockouts result in patients having to make multiple visits to health facilities. They spend time waiting and lose working hours. Patients are exposed to unnecessary changes in their treatment regimen as health workers try to compensate for the stockout through dose combination.
My study was done in 11 of South Africa’s 52 health districts. To collect the data, I spoke to 11 district pharmaceutical service managers and reviewed medicine availability reports.
Only 429 (63%) of the 685 primary healthcare clinics had at least one pharmacist assistant. This means that 256 (37%) clinics did not have a pharmacist assistant to manage medicine supply. Nurses had to do the job of managing supplies of essential medicines and dispensing them.
I found that clinics without pharmacist assistants were more likely to have erratic medicine-supplymanagement practices. In one district without post-basic pharmacist assistants, medicine availability was an average of 88%.
Those with pharmacist assistants had markedly better stock levels. In 10 districts where at least a quarter of the primary healthcare clinics had post-basic pharmacist assistants, medicine availability was at an average of 95%. This figure is in line with acceptable norms. These clinics had a lower prevalence of medicine stockouts.
A district pharmaceutical services manager who participated in the research said: “We are doing well on medicine availability thanks to the availability of (pharmacist) assistants in our clinics”.
appropriate temperatures for effectiveness. They also implement stock rotation to use expiring medicines first. This reduces the occurrence of medicines expiring on the shelves.
There have been initiatives within government to encourage the permanent appointment of trained pharmacist assistants in primary healthcare clinics. However, many provincial clinics struggle to permanently appoint at least one pharmacist assistant due to financial constraints. In some instances, donors have stepped in to finance shortterm contracts for pharmacist assistants as a temporary solution.
The lack of effective placements has also meant that the private health sector has absorbed many government-trained pharmacist assistants. The majority of pharmacists (and pharmacist assistants) in South Africa practise in community
The study findings show that pharmacist assistants play a significant role in medicine-supply-chain management in primary healthcare clinics. Additionally, they can free up nurses to focus on providing quality healthcare services.
The appointment of one pharmacist assistant can free up professional nurses from managing medicine supply. It guarantees that at least 40 patients receive uninterrupted clinical care per day.
Pharmacist assistants also have the time and skill to counsel patients on treatment benefits and adherence. This goes a long way to encourage patients to stay on treatment.
Another benefit is the appropriate storage and management of essential medicines. Pharmacist assistants can ensure that medicine is kept at
pharmacies, which are pharmacistowned (independent) or form part of pharmacy chains.
To promote consistent essential medicine availability, National Treasury needs to allocate dedicated funding for the permanent employment of at least one post-basic pharmacist assistant in each of the primary healthcare clinics across South Africa.
Provincial district health services must phase in the permanent employment of post-basic pharmacist assistants. This will go a long way in promoting good medicine supply management at clinics.
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A new study shows that without urgent intervention, many diabetics will soon develop complications that could be prevented through proper screenings. This will affect the individuals, their families, jobs, and even the overburdened health system.Eyitayo Omolara Owolabi Postdoctoral fellow, Arizona State University Anthony Idowu Ajayi Associate research scientist, African Population and Health Research Centre
The world is experiencing a steep rise in the number of people living with diabetes, a chronic condition of significant public health concern. Many developing countries like South Africa now bear the greatest burden.
Diabetes refers to a high level of glucose in the blood. Several factors contribute to diabetes, but obesity and unhealthy lifestyle behaviours are the major drivers. It is a costly disease, and it reduces the quality of life and lifespan, especially if not properly managed.
Eleven percent of South African adults now live with diabetes, the highest prevalence in Africa. Most of them have poorly controlled diabetes. And many others are yet to be diagnosed. A lot of people develop complications as a result of poorly controlled diabetes. These include eye problems, kidney disease and cardiovascular diseases. Some even develop wounds that don’t heal, resulting in limb amputation.
When people develop such complications, they spend more mon-
ey on healthcare. And it places a greater burden on the already overstretched health system. Some even lose their livelihood which, in turn, affects their families.
There have been some studies in South Africa looking at the level of screening for complications for people living with diabetes. But there’s very little focus on the primary healthcare level. And some of these studies were conducted many years ago, so the data may no longer be valid.
It is imperative to determine the current situation, especially at primary healthcare level. Our recent study focused on the Eastern Cape
province. It’s one of the poorest provinces in South Africa, with a high prevalence of poorly controlled diabetes.
We assessed the extent of screening for diabetes-related complications at primary healthcare clinics in this province.
We found that the rate of screening for these complications was very low. Our findings are similar to research done in another rural province in the country. This points to the need to promptly implement measures to improve screening coverage for people with diabetes in South Africa. Doing this will improve health outcomes and quality
of life, and reduce the incidence of devastating diabetes complications.
To keep blood-glucose levels under control and avoid complications, people with diabetes need to pay detailed attention to their health. They must be involved in their care, live a healthy life, and undergo important tests and examinations that help to quickly identify potential problems.
There are guidelines for diabetes management and complications screening in South Africa. Healthcare providers also have a duty to check whether these individuals’ blood glucose is under control, so they don’t develop complications which can cut their life short or disable them.
Primary healthcare clinics are the entry points into the healthcare system. Most people with diabetes are first managed at these facilities. Here they receive medication and are supposed to check their bloodglucose level at every visit.
In addition, primary healthcare providers are supposed to check patients’ eyes and kidney function when they make the diagnosis –and every year after that. Healthcare
workers are also supposed to check the patients’ feet at least once a year. Patients at higher risk of developing foot ulcers need more frequent check-ups to prevent complications like leg amputation.
We wanted to find out how the people living with diabetes in some rural areas of the Eastern Cape, South Africa are being managed. We recruited participants with diabetes from six primary healthcare facilities. By asking them questions and by looking at their medical records, we determined if these measures and examinations were in place at these primary healthcare clinics.
Our analysis showed that out of 372 people, only 71 (19%) of them had been checked for bloodglucose control in the past year. Sixty (16%) of them had been assessed for kidney function and 33 (8.9%) had been checked for bloodcholesterol levels. Just 52 (14%) had undergone eye examinations in the past year.
Foot examination, which helps to prevent leg amputation, was done for only 9 (2.3%). More than half (60%) of these patients had not undergone any form of examination for these potential complications in the past year.
Understanding the potential reasons for the gaps in diabetes management and finding effective solutions for improving screening coverage will cut healthcare costs and prolong the life of patients
None of them had undergone all of these five important screenings.
Our study shows that without urgent intervention, many people with diabetes will soon develop complications that could be prevented through proper screenings. This will affect the individuals, their families, jobs, and even the overburdened health system.
Prevention is cheaper than cure.
Understanding the potential reasons for the gaps in diabetes management and finding effective solutions for improving screening coverage will cut healthcare costs, prolong the life of patients and enable them to lead a quality life.
There are a number of approaches that the country can take. For instance, mobile health technology can be used as a tool to facilitate screening. A similar approach is being used in developed countries. As a result, many of them have been able to cut down the number of diabetes-related complications.
Other countries have also embraced technology-based solutions to train community health workers to conduct some of these examinations under the guidance of experts.
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The World Health Organisation estimates that the number of people with diabetes is 422 million, globally. And between 1980 and 2014 the number of people with the condition almost doubled. Despite the high prevalence of the disease, it is often misunderstood. Here are some common misconceptions about diabetes.
Claire Rostron Senior Lecturer, The Open UniversityDiabetes does affect the pancreas, but it shouldn’t just be thought of as an illness that affects the body from the neck down. If we take this viewpoint we miss the psychological impact of living with this condition. And it’s a big one. As well as the issue of adjusting to the diagnosis of a long-term health condition, people with diabetes are more likely to develop depression. There is even a specific form of depression associated with diabetes known as diabetes distress. It’s when a person is struggling to cope with managing their condition.
Having diabetes affects your mental abilities too. Research suggests that diabetes can affect your ability to think clearly, focus and recall memories.
Diabetes also affects other brain processes, such as how we weigh up food choices. Researchers are also investigating how hormones, such as insulin, seem to regulate food choices. These particular brain effects, within a system called the midbrain dopamine system, offer one potential explanation for why some diabetics find it difficult to follow health advice, no matter how often they are given it.
There is a strong association between type 2 diabetes and obesity,
but that doesn’t mean that everyone who is diabetic is overweight or obese. Nor does it mean that everyone who is overweight or obese will develop diabetes.
However, a Public Health England report said that obese adults in England were five times more likely to
develop type 2 diabetes than adults of a normal weight. But there is still a lot of work to be done to fully understand the link between diabetes and obesity. This includes understanding the biological mechanisms that might link the two.
Type 1 diabetes isn’t associated
with obesity. It is considered to be an autoimmune disorder which means that the body’s own immune system attacks the cells that produce insulin in the pancreas. It’s a very successful attack; a type 1 diabetic is no longer able to produce insulin. There is some evidence that type 1 diabetes is genetic, yet not everyone in possession of the diabetes risk genes will develop diabetes. There is also some evidence that type 1 diabetes might be caused by a virus.
Type 1 diabetics do require insulin therapy, but this can be delivered using insulin pumps. These devices reduce the need to inject insulin regularly. The insulin is still delivered via a needle, which is attached to a piece of tubing and then to the
pump, and there are several advantages to this method. One is that it is more discreet and the diabetic avoids the social stigma associated with injecting in public. The second is that it reduces the need to find different injection sites.
There are a range of treatment options for type 2 diabetes, and for gestational diabetes (which develops during pregnancy). These types of diabetes may be treated by lifestyle changes or, in the early stages, might be successfully managed by pills, such as metformin. As diabetics age, or as a pregnancy progresses, there may be a need for insulin or a combination of pills. Those diabetics who are struggling to manage their condition might also be offered a drug such as bromocriptine, which targets areas of the brain that help to regulate the body’s metabolism.
Not everyone who is diabetic is overweight or obese. By the same token, not everyone who is overweight or obese will develop diabetes
There is some evidence that a lowkilojoule diet may return fasting blood-glucose levels to normal in type 2 diabetics, which has led to suggestions that this may be a cure. But there’s no evidence that this is permanent and most doctors agree that diabetes (excluding gestational diabetes) is for life.
The serious long-term complications of diabetes are limb amputation, loss of sight and cardiovascular disease. This is why routine screening is in place to monitor these aspects of diabetic health. In short, some diabetes complications can kill.
Diabetes is a hidden disease and for many people it certainly isn’t easy to manage. Being given healthy living advice and education is not enough to help everyone, and many fail to manage their condition (although some manage successfully until their illness progresses and everything changes). Blood-sugar levels are affected by nutrition, activity, sleep cycles, illness, and stress and other hormone effects. So the signs and symptoms of diabetes are rarely stable.
For most people, diabetes is for life. It is a serious condition that can feel unpredictable and overwhelming, at times. Many people with diabetes report experiencing the stigma surrounding the condition. Some diabetics even have their own misunderstandings and preconceptions. It is therefore vital to raise awareness of the reality of living with diabetes to help improve the experience of it.
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Now more than ever, we are seeing medicine shortages, non-compliance with drug regimens and patients taking more medication to combat side effects. Medicine compounding can help, making it easier for patients to stay on track when it comes to their health.
Medicine compounding has been compared to baking a cake where the recipe is specific to each patient or patient group
Medicine compounding is on the rise. Simply put, it is the process of creating a medicine to meet the specific needs of an individual patient, based on a doctor’s prescription. It involves mixing and adjusting active ingredients, binding agents, fillers, and flavourants to formulate a drug that is tailored to the unique requirements of a patient. Medicine compounding has been compared to baking a cake where the recipe is specific to each patient or patient group.
When commercially available drugs are not suitable for certain patients, compounding can fill the gap. It can, for example, make a medicine easier to take or provide it in a nonstandard strength, as well as substitute ingredients to which patients may be allergic.
Since compounded drugs differ from regular prescription drugs, they cannot be obtained at every pharmacy. In South Africa, as well as globally, compounding is performed by trained and experienced compounding pharmacists, often in special compounding pharmacies. These professionals need to comply with strict regulatory standards to ensure the safety and efficacy of the customised medicines. While the benefits of compounding can be significant, the process must be executed carefully and precisely to maintain the highest standards of production. It is therefore important for patients and healthcare providers to work with licensed and reputable compounding
pharmacies that adhere to regulatory guidelines to ensure the safety and efficacy of compounded medications. Pharmacists involved in compounding should stay updated on industry standards and continually assess and improve their practices.
The earliest known record of a compounded medicine is found in the Sushrata Samhita, a classical Sanskrit text on surgery and one of three foundational texts of Ayurveda – or Indian traditional medicine – that dates as early as the 6th century BC. The modern age of pharmacy compounding began in the 19th century, when various compounds of coal tar were isolated in order to produce synthetic dyes. The process has seen a resurgence with modern-day advances in technology and research methodology – and it is also applied in the veterinary health field.
Here are some key aspects of medicine compounding and the benefits it can offer to patients:
Compounding pharmacists can create medications in specific strengths, dosage forms (for example, liquids, creams, or lozenges), and flavours that are best suited to an individual patient’s requirements.
This is particularly useful for patients who may require an alternative dosage form or have difficulty swallowing conventional pills (such as very young children or the elderly).
With compounding, medicines can be formulated in non-standard dosages to ensure that patients receive the exact amount of medication prescribed by their healthcare practitioner.
This is convenient in cases where commercially mass-produced medications are not available in the exact dosage strength required by the patient.
Compounding pharmacists can formulate medications without specific allergens, dyes, or other ingredients to which patients may be sensitive, reducing the risk of adverse reactions.
This is particularly beneficial for the elderly who generally have reduced medicine tolerance. It is also important for patients with allergies. For example, progesterone is mixed in an oil when prepared as an injection. Since commercially produced injectables often use sesame oil, those who are allergic to sesame can use a compounded version made with olive oil instead.
Compounding enables the creation of single medications that combine multiple active ingredients.
This simplifies the medication regimen for patients who would otherwise need to take many different medicines on a regular basis, making compliance far more convenient. It also helps those who easily get confused when taking many different drugs – such as certain elderly patients.
Compounding is especially valuable for geriatric, as well as for very young, patients who may require different dosage forms to suit their unique needs.
Children and the elderly, for example, may find it difficult to swallow tablets; liquids or transdermal creams can be easier to take. Pleasantly flavoured lollipops or gummies can make “medicine time” far less stressful and even fun for children.
Some patients struggle with certain traditional methods of drug administration. Compounding allows for the preparation of medications in alternative forms, such as transdermal gels, suppositories, or sublingual tablets, providing these patients with more options.
For those suffering from rare diseases or health conditions for which commercially available medications may not exist or be difficult to obtain, compounded medicines can be vital.
To ensure that drug compounding is safe for the patient, precautions need to be taken. These include:
Compounded medications are typically prepared based on a prescription from a licensed healthcare provider, such as a physician or veterinarian.
Compounding pharmacists in South Africa must adhere to strict quality control measures to ensure the accuracy, purity, and sterility of compounded medications.
Compounding pharmacies are expected to comply with Good Pharmacy Practice standards to maintain the highest quality and safety standards.
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Can I break all tablets in half? Can I store my inhaler in the bathroom cabinet? These are questions patients might ask. In fact, healthcare professionals should advise all those starting a new drug regimen, and even chronic patients, on how to take and store their medicines correctly. Pharmacist and MIMS Managing Editor Thealdi Mitchell gives us the lowdown on medicine care.
A friend of my son spent a weekend away with us and his mom packed his ADD (attention deficit disorder) medicine that he needed to take. She mentioned that he struggles to swallow tablets, so she breaks the ADD tablet in half to make it easier for him.
As you may know, this particular tablet is designed using specific technology called an osmotic pump system. A percentage of the drug is contained in the coating, while the remaining percentage is split among layers of differing concentration inside the tablet. The drug is released via a small hole on the side of the tablet. Once the tablet is swallowed, liquid enters it and the drug is pushed through different compartments and membranes in the tablet, resulting in the slow release of the active ingredient. The point of all this is to avoid having to take multiple doses of medication in a day. The patient only needs to take one tablet daily as the active ingredient is released slowly in order to work throughout the day.
This remarkable slow-release technology goes to waste if the tablet is broken! I do not blame the mom, because obviously no one told her not to break the medicine. In all honesty, this was the responsibility of her healthcare provider.
It is important not to break, cut, chew, crush, or open certain medicine. Any tablet or capsule that is long-acting, modified-release, extended-release or controlledrelease should be swallowed whole with water. In most instances, the name of the medicine will be followed by the letters LA, MR, XR or CR.
Always advise a patient not to break a film- or sugar-
The bathroom cabinet is the worst place to keep medicine because it tends to be warm and damp. This environment will speed up a medication’s breakdown process
coated tablet. It will not only be difficult to break, but one of the reasons for the coating is to mask the taste; if you break it, it will literally be a bitter pill to swallow! Certain tablets used for arthritis or cancer are toxic and should not be handled by anyone other than the patient - and should definitely not be broken! If these tablets need to be handled, advise the patient to wear gloves or use a pill-counting tray reserved only for cytotoxic meds. Sometimes formulations are not available in a strength that a doctor prescribes, and a tablet needs to be split in half to get the precise dose. For patients with swallowing difficulties, medicine might be available in a liquid or dissolvable form, or a compounding pharmacy might be able to prepare the medicine in an easy-to-swallow formulation.
Sometimes, a higher-strength tablet is split in half because it works out cheaper. This is acceptable if it is done correctly. If a tablet is scored or has a groove down the middle, it is generally safe and easy to split. Refer to the leaflet to check whether you can break a tablet or break open a capsule to empty out the powder. When breaking a tablet, advise the patient to use a pill-cutter, often available for sale at pharmacies. Tablets should be split to obtain only the exact dose required; split tablets might become unstable if kept for a long time with the inside exposed and are difficult to identify later. For this
reason, it is not the best idea to split tablets on behalf of patients at the point of dispensing.
Keep it clean – patients and dispensing staff should wash their and equipment before and after use, and work on a clean, neat surface.
I like to keep my asthma inhaler in the bathroom so that I always remember to have a puff in the evenings before I shower. It’s part of my routine, but I have recently wondered whether it’s the right thing to do…
the instructions say, “keep refrigerated”, this means the medication must be stored at 2-8 °C, ideally at 5 °C. Patients should choose the middle of the refrigerator to store the medicine, pack it so that it doesn’t touch the back or side of the fridge and keep it away from other products. They should not store medication on the top shelf or in the vegetable drawer as these areas are usually warmer. The medication should be kept away from the freezer compartment or airflow vents to avoid the formation of ice crystals. Storing it in the refrigerator door is a bad idea because it will be exposed to uneven temperature each time the door is opened. The fridge should not be opened unnecessarily or the door kept open for long periods. Ensure that the medication is inaccessible to children.
For chronic medication that needs to be refrigerated, it might be a good idea for patients to purchase a thermometer and regularly check the temperature of the fridge, especially during long periods of power interruptions (which we know all too well).
The bottom line is that it is not a good idea. Medicine can be damaged by heat, air, light and moisture. It may become less effective or go bad before it expires.
It is very important to store medicine properly. Medicine-storage instructions are stated on the packaging and in the medication leaflet, but we know that patients often don’t read labels and leaflets. For this reason, it is best to advise your patients on storage requirements.
In general, storage instructions will state: store in a cool dry place at or below 25 °C. Despite its name, the bathroom medicine cabinet is the worst place to keep medicine because it tends to be warm and damp. This environment will speed up a medicine’s breakdown process. Medicines should also never be stored in the car, including the cubby-hole, as it can get too hot - especially in our South African summer!
The kitchen is also not ideal, but if medicine must be kept there, patients should ensure that it is away from the stove, sink or any appliance which heats up when used. They should preferably choose a bedroom drawer or closet with a high shelf, out of the reach of children and pets. Medicine should be stored out of sight; not on the kitchen counter or bedside table.
Medicine should be kept in its original container; the container is specifically designed to keep the medicine stable, protecting it from light and humidity. (Some medicines even have a child-safety cap.) This also makes it easier to check the ingredients, usage instructions and expiry date. It is a good idea to store all medicines in one place so that they are easy to find in an emergency. If the container has a cottonwool ball, it should be removed as it attracts moisture once the container has been opened. However, the sachet with a drying agent, such as silica gel, should be left.
Some medicines, like insulin, antibiotic liquids, eye drops and creams, need to be kept in the refrigerator to maintain sterility, effectiveness, or physical form. If
Do not store all medicine in the fridge. Medicines must be kept in conditions ideal for them; patients should follow the instructions from the medicine supplier, as stated in the medicine leaflet.
The bottom line? Take care of your meds so that they can take the best possible care of you.
Counselling patients on medicine care sometimes falls by the wayside because of long queues in pharmacies and packed waiting rooms – not to mention the increased reliance on home deliveries.
Patients don’t ask questions and often don’t know what they are supposed to ask. They also tend not to read the patient information leaflet. It is the responsibility of the person who hands out the medicine, whether they be a doctor, nurse, pharmacist or pharmacist assistant, to advise the patient on exactly how to take, and take care of, their medicine. We should never assume that the patient knows everything about their medicine, even if they have been using it on a chronic basis.
Remember that advice from the healthcare professional will always outweigh Dr Google!
Jocelyn Moyes Medical Epidemiologist, National Institute for Communicable Diseases
Cheryl Cohen
Co-head of the Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases
Sibongile Walaza Medical Epidemiologist at the National Institute of Communicable Diseases and Lecturer at the School of Public Health, University of the Witwatersrand
The winter months are synonymous with the flu in South Africa. Similar to other countries in the southern hemisphere, South Africa has an annual influenza season stretching from April to August.
Influenza (flu) is an acute respiratory illness caused by an infection of the respiratory tract with the influenza virus. Influenza is spread through respiratory droplets which you breathe in or can pick up from contaminated surfaces. People infected with the influenza virus show a wide range of symptoms such as sudden onset of fever, muscle pains and body aches, cough, sore throat, blocked or runny nose and headache. For most people, recovering from flu involves a few days of mild symptoms which resolve with symptomatic treatment. But for some, the flu can be deadly.
The World Health Organization (WHO) estimates that over 1 billion flu cases occur each year. These include between three and five million cases of severe flu illness with people requiring hospitalisation and between 290 000 and 650 000 deaths each year. In severe cases, influenza can spread to the lungs or weaken your lungs so that you get a bacterial infection. An infection of the lower respiratory tract including the lungs is called pneumonia. In people with underly-
ing heart or lung disease, influenza infection can also cause worsening of these conditions.
Treatment for flu is mainly symptomatic. This includes bed rest and overthe-counter medicines like paracetamol to reduce fever. The best way to avoid getting ill is to get vaccinated. Last year, South Africa saw a spike in flu cases. As epidemiologists who re-
search respiratory diseases, we urge those who do not routinely have a flu vaccine to do so. This will help protect the individual and those around them from severe illness.
The first reason you should strongly consider getting vaccinated against the flu if you haven’t done so yet is
to protect yourself. Results from a modelling study we conducted using 2013-2015 data estimated an average of 10 737 847 influenza-associated illnesses and 11 536 deaths every year in South Africa.
Flu vaccines remain the most effective method available to prevent flu illness, especially severe illness. The main reason to get the flu vaccine is to lower your risk of being sick with flu.
Most individuals infected with the flu virus will have mild illness. But certain groups of people are at risk of having severe flu illness or having flu complications or death. The flu vaccine has been shown to lower the risk of severe illness or complications.
The groups who have a high risk of severe illness or complications include:
Pregnant women at any stage of pregnancy, including postpartum
Individuals with chronic medical conditions (such as cardiac
diseases, chronic renal diseases, diabetes mellitus)
Immunocompromised people (such as people living with HIV, cancer patients)
Elderly individuals (over 65 years). Individuals who fall in the groups above are strongly encouraged to get vaccinated for influenza each year.
Flu vaccination also prevents chronic health conditions from getting worse. For example, flu vaccination has been associated with lower rates of some cardiac events among people with heart disease.
If many people are vaccinated, it will also decrease the spread of influenza in communities. Specifically, health workers are encouraged to vaccinate as they are at risk of getting infected with influenza from their patients. They are also more likely to transmit the virus to their patients, who may be at risk of severe flu illness if not vaccinated.
Ideally, flu vaccines should be administered ahead of the flu season around March or April as it takes approximately 14 days for the body to build immune responses to protect against infection.
However, it is never too late to get the flu vaccine as long as the influenza virus is circulating. It is recommended that people get vaccinated every year because circulating vaccine strains differ each year. The previous vaccination may not protect against the new strain circulating. And the individual immunity wanes over time.
– Namhla Bhenxa, an epidemiologist at the National Institute for Communicable Diseases, is the main contributor to this article.
Courtesy of:
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Empower your practice with the ultimate tool in drug safety. Because patient safety should never be left to chance.
For more information, contact Riette van der Merwe
Tel: 011 280-5856/9 Email: vandermerwer@mims.co.za
