International

WMA slams proposal to criminalise health work protests

A proposal to outlaw all industrial action by health professionals in Slovakia has prompted the World Medical Association (WMA) to make a direct plea to the Slovak Prime Minister and the Speaker of the Slovak Parliament to reject the idea.

The proposal from a member of the ruling party in Slovakia is to change the country's legislation so that all industrial action by physicians and other health professionals is made a criminal offence. But, in a strongly worded letter to the Slovakian Prime Minister Robert Fico and Speaker Pavol Paška, the WMA's President Dr Cecil Wilson and Chair of Council Dr Mukesh Haikerwal say such a move would deprive health professionals of their basic right to fight for their working conditions. It would also send out to the world the wrong signal about the democratic status of the Slovak Republic. Dr Wilson said: ‘The Slovakian Chamber of Medicine has urged us to intervene because of the seriousness of this proposal. The World Medical Association deplores any attempt to criminalise physicians who are pursuing their basic civil rights. We also seriously question whether such a move would be legal under international law.'

In their letter the WMA leaders declare: ‘We acknowledge that there are situations where an unlawful act of a member of the profession is incompatible with exercising the profession of a physician. However, this must be a serious offence or it must directly demonstrate that person's inability to serve medical responsibilities.'

The letter adds: ‘As physicians we abide by strict ethical codes and the health and wellbeing of our patients is paramount. Nevertheless physicians and other health professionals must not be deprived of their basic human rights. They must not be criminalised for pursuing their basic civil rights in a free, just and democratic society. If these proposed changes come into effect, we seriously question whether the amended law(s) will comply with Article 1 of the International Labour Organization Convention Against Forced Labour. They will certainly adversely affect the rights and welfare of the medical and health professional communities in the Slovak Republic with unmeasured consequences for others in Slovak society. On behalf of the World Medical Association we urge you to reject this proposal completely. This proposal would send a wrong signal about the democratic status of the Slovak Republic and be subjected to intense international scrutiny.'

 

Africa 

South Sudan: MSF hospital destroyed after deliberate attack

Doctors Without Borders (Médecins Sans Frontières) (MSF) has strongly condemned destruction at its hospital in Pibor town, South Sudan, which it said was ‘purposefully conducted’ to render the hospital inoperative. This deprived around 100 000 people of healthcare, as they fled into the bush seeking safety from the conflict between the South Sudan Army (SPLA) and the David Yau Yau armed militia group. Therapeutic medical food and hospital beds were looted from MSF’s hospital over the weekend of 11 - 12 May. More extraordinary was the ‘systematic and purposeful’ damage to the infrastructure that rendered the hospital unusable without major repair work. ‘A special effort was made to destroy drug supplies, strewing them on the ground, to cut and slash the warehouse tents, to ransack the hospital wards, and even to cut electricity cables and rip them from the walls,’ said Richard Veerman, MSF Coordinator of Operations for South Sudan. The MSF hospital is the only hospital facility for Pibor county, the nearest alternative being more than 150 km away. Three thousand patients were treated over the first three months of the year in this hospital. More than 100 patients, including SPLA soldiers, received surgery for war wounds. ‘The rainy season has just started and we know from previous years that malaria and respiratory diseases such as pneumonia will start to claim lives if there is no healthcare available,’ said Veerman. In a report issued in November last year, ‘South Sudan’s hidden crisis’, MSF documented the devastating health consequences when people have to flee to the bush and when medical assistance is unavailable. Humanitarian access and medical assistance would need to be resumed in Pibor county in the coming days or weeks. ‘It is unthinkable that there will be no healthcare whatsoever for the next six months for some 100 000 frightened and vulnerable people hiding in the swamps,’ continued Veerman. This is the sixth time an MSF medical facility has been looted or damaged in Jonglei State in the past two years. More recently, MSF had suspended activities in Pibor on 19 April this year because of threats to and intimidation of staff and patients. Having sought assurances that medical humanitarian activities and staff would be respected and could be pursued without hindrance or obstacles, an MSF team was preparing to return and restart medical activities when the looting and destruction happened.

 

South Africa

Health insurance plan ‘soon’, price regulation certain – minister

The white paper on National Health Insurance (NHI) would be out for public comment ‘very soon,’ Health Minister Aaron Motsoaledi promised in his 15 May budget speech, warning it would go hand in hand with price regulation of the private healthcare industry.

‘It doesn’t matter what you call it … every citizen has the right to access … quality, affordable healthcare,’ he said during his budget vote speech to Parliament. Successful implementation of the scheme would need a dramatic improvement in public healthcare services, and a ‘drastic’ reduction in private healthcare fees. ‘We need to firmly regulate prices in private healthcare,’ he said. His comments come as the Competition Commission published the terms of reference for its market inquiry into the private healthcare sector, due to begin later this year. The probe is expected to explore the reasons for the steady rise in private healthcare prices in recent years.

It follows years of state concern over the affordability of private healthcare and the market dominance of groups such as Life Healthcare, Netcare and MediClinic. The Department of Health hopes this will provide the evidence it needs to devise a strategy for controlling private healthcare prices, which, with the exception of medicines, are unregulated.

Dr Motsoaledi said his officials were ‘eagerly awaiting’ being called to give evidence before the Competition Commission. Explaining why the white paper had taken more than 18 months after the green paper was released in 2011, he said: ‘We did indeed take a long time … There were lots of inputs and developments that needed our very careful attention and consideration. It will be released with a clear plan on how NHI is to be implemented.’

Meanwhile, the release of the Commission’s draft terms of reference prompted immediate reaction from the health industry. Concerns included the omission in the probe of the effects of the public healthcare sector on rising healthcare costs. Legal experts have called for a more holistic approach by the Competition Commission, saying leaving out crucial elements of healthcare brings too narrow a focus to the inquiry. The omitted areas include the effects of a shortage of doctors and specialists in South Africa on costs, the effects of chronic disease, an ageing population, emergency services, consumables and pharmaceuticals. However, deputy commissioner Trudi Makhaya said this was the start of a consultation process and the Commission would consider arguments for the inclusion of other elements. The role of the public sector was always bound to come up during the inquiry. The Commission has not included areas already subjected to regulatory scrutiny – such as the pharmaceutical industry.

‘We had to prioritise and look at pressing problems in private healthcare that relate to providers and payers, given the resources available to the commission,’ Ms Makhaya said.

Legal teams representing the role players also expressed concern at the wording of the terms of reference and the strong views that suggest some prejudgement.

However, Discovery Health CEO Jonathan Broomberg said they welcomed the inquiry and did not believe the Commission had reached any substantive conclusions at this stage; hence the need for a detailed and lengthy inquiry to allow for a full and detailed understanding of all issues prior to reaching conclusions and making recommendations. The Commission will make recommendations on appropriate policy and regulatory mechanisms that would support the goal of achieving accessible, affordable, innovative and quality private healthcare. It would also make recommendations on whether price-setting mechanisms could be acceptable within the competition policy. The Commission highlights the fact that South Africa has 27 641 doctors (general practitioners and specialists). It is estimated that 10% of the expenditure in the private sector goes to general practitioners and dentists and 20% to specialists. According to the terms of reference, 36% of the total private healthcare expenditure goes to hospitals. South Africa has about 97 registered medical schemes and the three largest administrators are Discovery Health, Metropolitan Health and Medscheme Holdings. Daryl Dingley, a partner at law firm Webber Wentzel, expressed the hope that the probe would consider the financial health of medical schemes and administrators, claim ratios and reserves held by medical schemes, and the effect on expenditure due to greater utilisation of hospitals.

'SA turns corner in HIV fight'

South Africa's success in tackling the HIV/AIDS pandemic should not lead to complacency, Health Minister Aaron Motsoaledi warned in his budget speech. The minister said training nurses to administer antiretrovirals (ARVs) helped to double the number of people receiving treatment from 923 000 in 2010 to 1.9 million in 2013. The cost of ARV treatment dropped dramatically; ‘We are now able to treat many more people per month with the amount of money that we used to treat one person in 2009. This was not the time to relax efforts. I have one very serious request to make. Having turned the corner should not be regarded as a signal for South Africans to be complacent. We still have a very long road to travel with HIV and TB.’

He was speaking as Statistics South Africa revealed that one in 10 South Africans is HIV-positive, with a predicted 200 000 people expected to die of HIV/AIDS this year. Approximately 17% of those infected with the virus are women and around 8% are between the ages of 15 and 24. Life expectancy in South Africa has improved since the new HIV/AIDS strategy was rolled out three years ago.

 

Jolie’s double mastectomy – she had a rare genetic predisposition

Actress Angelina Jolie’s revelation that she has had a double mastectomy and reconstructive surgery because she carries a cancer-causing mutation, has dramatically refocused attention on breast cancer. Dr Carol-Ann Benn, a specialist surgeon and breast disease specialist, who established the Breast Care Centre of Excellence at Netcare Milpark Hospital, said that the genetic mutation known as BRCA1, for which Jolie tested positive and which left her with an exceedingly high risk of developing breast and ovarian cancer, was very uncommon. ‘Less than 10% of women with breast cancer have BRCA1 and another gene called BRCA2,’ she said. Those who tested positive for BRCA1 or BRCA2 had a 50 - 80% chance of developing breast cancer.

To test for the BRCA gene required an index case, i.e. a living relative with breast cancer who has tested positive for the gene,’ she added. A negative BRCA test in an index case, however, did not exclude genetic (inherited) breast cancer, ‘but merely our inability to detect the causative gene or gene combination,’ she observes. She cautioned women with a genetic risk to breast cancer not to rush to have both their breasts removed as a way to prevent the disease. ‘Risk reduction surgery should only be discussed with women who consider themselves to be of high risk. Again it should be offered in multidisciplinary units, after careful consideration is given to all the disadvantages of the procedure and should never be offered as an emergency,’ she observes.

Women diagnosed with breast cancer might elect to have mastectomies but the procedure was not for all women and once a diagnosis of breast cancer was made a non-hurried multidisciplinary approach was recommended for all those diagnosed, she said.

Dr Benn highlights that BRCA mutations are more prevalent in Jewish women of Ashkenazi (Eastern European) descent, African American women, Afrikaners (Dutch descent), and women of Scottish and Hispanic descent. Nevertheless, she adds that genetic mutations can occur in any racial or ethnic group. For concerned women, she recommended to visit a unit that offers multidisciplinary care including psychological counselling and the best possible advice, as there were ‘multiple options’ which could be used to decrease risk, including close screening, risk-reducing medication and surgery. Surgery could only proceed after intensive counselling and assessment of all risks, particularly the patient's personality, anxiety and cancer fear. Women considering risk reduction surgery should note that at the time of breast tissue removal reconstructive procedures should also take place. ‘Deciding to have risk-reducing mastectomies is a difficult decision which can be rewarding in women that fit the criteria,’ said Dr Benn. ‘The Prose Study Group, Rebbeck et al., measured the incidence of breast cancer in 483 BRCA1/2 mutation carriers. The data indicated that bilateral prophylactic mastectomy reduces the risk of breast cancer by approximately 90%.’

 

Chris Bateman

chrisb@hmpg.co.za