EDITOR'S CHOICE

Ivan Toms: Political and gay activist

Few people are recognised as having influenced society. Ivan Toms, who died prematurely from a curable illness, meningococcal meningitis, was someone who made a positive impact on society.¹ One's first impression of Ivan was of a small man with a ready and impish smile. He had a self-deprecating air and an infectious sense of humour. But on important issues he had a steely resolve to do what he considered right, regardless of the consequences.

In the 1980s, at the height of apartheid's excesses in clamping down on dissent, Ivan risked life and limb to confront police and soldiers hunting down their victims. His experience of the brutality of the people carrying out state policies led him to defy his statutory SADF camp call-up. This defiance resulted in his being jailed for 21 months in Pollsmoor Prison, where he was sexually molested and raped. In sentencing, the judge described Ivan as the antithesis of a criminal and bemoaned the law that forced his jailing.

Ivan was also a campaigner for gay rights. He was open about his own sexual orientation at a time when being gay evoked hostile responses at all levels.

In his professional career Ivan became Cape Town's Health Director, where he was respected and trusted for his sound values and judgement.

Ivan received just recognition from the country in being awarded the Order of the Baobab in Bronze for his 'outstanding contribution to the struggle against apartheid and sexual discrimination'. He epitomised the ethical rule of placing his patients first.

Can best practice be bad medicine?

South Africa's democracy developed a health care system biased in favour of tertiary rather than primary health care. The debate on attempting to reverse this imbalance and an alternative way of rationing is described by Chris Kenyon, Nathan Ford and Andrew Boulle.²

Public health care expenditure in South Africa accounts for 8.8% of the gross national product compared with a global average of 7.9% and 5.1% for other middle-income countries. But our poor life expectancy and other health care statistics show that we should do much better with the money we are currently spending. They advocate a South African system that would determine the cost-effective packages of care at primary, secondary and tertiary levels, which would help us to agree on a set of criteria to evaluate new medical technologies.

In her accompanying editorial³ Bettina Taylor notes at the outset that although funds have been used to strengthen primary health care services, secondary and tertiary care services remain critical to the national health care system.

Challenges include relating to new drugs and cutting-edge technology that have the potential to extend or save lives. Taylor examines the evidence and finds that cost-utility analyses are not the panacea for allocation of scarce resources they are often proclaimed to be. Nevertheless reservations about quality-adjusted life-years (QALYs) in prioritising of scarce resources should not detract from their value in informing price negotiations between funders and manufacturers.

Risky sexual behaviours of high-school pupils

The high and increasing prevalence of HIV/AIDS among South Africa's youth suggests that prevention efforts need to be re-examined. Frank and colleagues⁴ investigated the risky sexual behaviours and demographic factors that place high-school pupils at risk of HIV and AIDS. Condom promotion, STI programmes, the HIV and AIDS Life Skills intervention, and mass media communications have been deficient in reducing the incidence of HIV.

Nationally, 1.5% of adult females reported having been raped before the age of 15, and the HSRC reported that 15% of rape victims were less than 12 years of age.

Gender differences associated with risky sexual behaviours included more females who reported forced sex, more males who used alcohol at last sex, preference for older partners, and accepting money and gifts for sex.

Beliefs that promote male dominance, female sexual submissiveness, and violence contribute to unsafe sexual practices. Adolescents who begin sexual activity early are more likely to have more sexual partners. Relationships of mixed ages cause problems: they hinder negotiating of safe-sex practices, and recieving money or gifts from an older partner increases susceptibility to coercive sex. Another risky behaviour is the use of alcohol before sex, as it reduces one's cognitive abilities to consider protective sex, and increases susceptibility to coercive sex. Parental supervision significantly affects sexual activity and the presence of a supervisory caregiver or a parent could deter early sexual experimentation.

The authors conclude that religious groups and parents need to take a more aggressive role in addressing gender norms and coercive sex. A collaborative approach to AIDS prevention needs to be implemented among all sectors of our society.

JP de V van Niekerk

1. Bateman C. Ivan Toms - a selfless model of social conscience. S Afr Med J 2008; 98: 338,340.         [ Links ]

2. Kenyon C, Ford N, Boulle A. When Best Practice is Bad Medicine: A new approach to rationing tertiary health services in South Africa. S Afr Med J 2008; 98: 350-354.         [ Links ]

3. Taylor B. NICE rationing of specialised health care services for South Africa. S Afr Med J 2008; 98: 368-369.         [ Links ]

4. Frank S, Esterhuizen T, Jinabhai CC, Sullivan K, Taylor M. Risky sexual behaviour of high-school pupils in an era of HIV and AIDS. S Afr Med J 2008; 98: 394-398.         [ Links ]