On-line version ISSN 2078-5135
Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.102 n.5 Cape Town May. 2012
A small but luminous light is appearing on the horizon of South Africa's perilous and corruption-tossed public healthcare ocean. If tended properly it could prove a beacon towards which the entire provincial health flotilla can navigate. The Eastern Cape is saving hundreds of millions of rands annually1 for two main reasons. First is that its health chief, Dr Siva Pillay, refuses to be intimidated by the money-grabbing pirates who thought they had the ship. He's got them walking the plank one by one (1 200 so far), slowly rendering a rickety vessel sturdier and more capable of delivering the health services that its owners (the taxpayer) originally commissioned it for. The other is that those in charge of the flotilla (read Health Minister Dr Aaron Motsoaledi and Finance Minister Pravin Gordhan) noticed and sent in the navy to help, piloting a new procurement and monitoring system that will enable Pillay to identify weaknesses and corruption icebergs - not to mention empower his counterparts in other provinces when the scheme gets rolled out. Suddenly there's more bang for buck.
Whether the other provinces have leaders of similar commitment and calibre, an ingredient absolutely vital to making the scheme work, only time will tell.
Rational use of systemic isotretinoin in acne
Acne affects a significant proportion of people, especially young people. Systemic isotretinoin, an oral retinoid, can be considered to be a 'wonder drug' that has revolutionised the treatment of acne vulgaris, massively improving outcomes in nodulocystic acne. Werner Sinclair discusses the reasons for global guidelines on the use of systemic isotretinoin and provides a timely call for moderation in its use.2
Isotretinoin can 'cure' acne in a significant proportion of cases and is highly effective in all forms and grades of acne vulgaris, even in lower doses. However, in South Africa there is a massive trend towards the universal use of lower dosages of systemic isotretinoin for lesser degrees of acne vulgaris, and it is prescribed by dermatologists and general practitioners alike.
Global and South African guidelines for the use of systemic isotretinoin are: grade IV (nodulocystic or conglobate acne); scarring acne; lesser grades of acne not responsive to at least 3 months of oral antibiotics combined with a topical retinoid, or at least 4 cycles of hormonal therapy in females; dysmorphophobic patients; and Gram-negative folliculitis. In Europe there are severe restrictions on its use. Similar restrictions apply in the USA concerning pregnancy prevention.
The global guidelines on maintenance treatment for acne, after initial clearance, recommend topical retinoids, and hormonal treatment in females.
The use of systemic isotretinoin may result in serious side-effects. Teratogenicity is the best-known serious adverse effect, and the risk of 'retinoid embryopathy' is as high as for thalidomide; mucocutaneous side-effects include initial worsening of acne, xerosis and cheilitis, retinoid dermatitis, and staphylococcal infections of the skin; ocular complications include dry eyes that can persist indefinitely; and severe depression can occur as a rare and idiosyncratic event requiring prompt attention.
The main reason for adhering to global guidelines is to protect patients against the drug's adverse effects. Healthcare professionals must be protected against litigation for possible negligence when they do not prescribe the drug according to the guidelines and adverse events occur. We also cannot risk losing access to the drug, one of dermatology's most valuable assets, as a result of inappropriate use.
Students on state study scholarships (including provinces) often renege on the signed agreements that require them to provide services in return after qualifying.
A shining contrast is the scholarship success achieved by the Umthombo Youth Development Foundation (UYDF).3 Drs Ross and MacGregor played important roles in developing and maintaining this scheme.
The shortage of healthcare workers in South Africa is compounded in rural areas by misdistribution in favour of urban areas. Students of rural origin are more likely to return to work in rural areas, but rural health science students are under-represented at South African universities.
The UYDF was started in one of the most socially deprived and educationally challenged areas in the country. To date the scholarship scheme has produced 115 health science graduates across 14 disciplines. Their pass rate has exceeded 84%. All graduates returned to work in their area of origin, with the majority honouring their work-back contract.
Contributors to the success of the scheme include a strong emphasis on student initiative and responsibility; financial and social support from UYDF; a working partnership with the local community and hospital; and a strong mentoring programme.
Obesity in childhood
Childhood obesity is a major problem throughout the world. The editorial by Van der Merwe4 and an article from Turkey5 highlight aspects of this problem.
Obesity rates among children and adolescents have reached epidemic proportions in industrialised and developing countries, with an estimated 1 out of every 5 youngsters suffering from obesity and a BMI of over 30. Childhood obesity is a strong predictor of adult obesity, and very difficult to treat once established. Childhood obesity also predicts an increased likelihood of cardiorespiratory death.
Since carotid artery intima-media thickness (CIMT) serves as a marker of preclinical atherosclerosis, Ozcetin and colleagues studied the effects of obesity on main carotid artery intima-media thickness and stiffness. They concluded that obese children with risk factors for multiple atherosclerosis could have increased CIMT dimensions, and consequently should be screened for these risks. Ultrasonographic CIMT and arterial stiffness measurements can detect vascular damage at an early stage of development in children with cardiovascular risk factors.
1. Bateman C. Bhisho corruption-busting now the national pilot. S Afr Med J 2012;102(5):274-276. [ Links ]
2. Sinclair W. The rational use of isotretinoin in acne: A call for moderation. S Afr Med J 2012;102(5):282-284. [ Links ]
3. Ross AJ, MacGregor RG. Scholarship success: Umthombo Youth Development Foundation. S Afr Med J 2012;102(5):288. [ Links ]
4. Van der Merwe MT. Obesity in childhood and adolescence. S Afr Med J 2012;102(5):289. [ Links ]
5. Ozcetin M, Celikyay ZRY, Celik A, et al. The importance of carotid artery stiffness and increased intima-media thickness in obese children. S Afr Med J 2012;102(5):295-299. [ Links ]