24 April 2008
Kwazulu-Natal is the epicentre of the HIV epidemic in South Africa. 16.5% of people over the age of two are infected with HIV (South African National HIV Survey, 2005).
Mortality among young adults and infants has massively increased in the last decade. It is a province desperately short of health-care resources, particularly doctors willing to work in rural areas.
Despite this, the Kwazulu-Natal (KZN) Department of Health has yet again taken disciplinary action against a doctor without good reason, this time Dr Mark Blaylock of Manguzi hospital. He has been suspended without pay for a month because on 5 February 2008, in an act of anger linked to the charge of misconduct against Dr Colin Pfaff (which was later withdrawn) as well as comments made by the MEC for Health, Ms. Peggy Nkonyeni, questioning the integrity of rural doctors, he took the MEC’s official portrait photo off the wall and put it in the bin.
The letter of suspension can be downloaded here. It accuses Dr Blaylock of disrespect toward the "political head of the KZN Health Department".
Dr Blaylock subsequently formally apologized for this conduct.
We have been informed that a letter from the KZN Department of Health on 22 April states that the punishment is not punitive but a “deterrent” and that “the sanction imposed should be one that will teach him a lesson to conduct himself appropriately and not recommit the offence in future.”
This action is reminiscent of the decision of the state to take disciplinary action against Dr Cosa Gazi when he stated that the Minister of Health should be charged with manslaughter for failing to provide AZT to pregnant women. In a landmark court judgment on 24 March 2006 (Costa Gazidis versus Minister of Public Administration and Others A 2050/04), Judge Bertelsmann (Transvaal Provincial Division) found in favour of the Applicant, Gazi. The judge wrote:
If these comments, or the widespread criticism of the policy not to supply AZT, did cause any prejudice to the department of which the appellant was an officer, such prejudice existed already when the comments were made. There can therefore be no casual link between the appellant’s actions and any prejudice the department may have suffered.
Likewise in this case we would argue that the political head of the provincial health department suffered no further loss of respect or prejudice because of Dr Blaylock's expression of anger.
Ms. Nkonyeni has a track record of incompetence. This includes falsely accusing microbicide researchers of unethically experimenting on people, supporting the charlatan and vitamin salesman Matthias Rath and threatening disciplinary action against Dr Colin Pfaff for raising funds to roll out a model dual therapy programme for the prevention of mother to child HIV transmission.
According to an article in the Mercury (17 April) Nkonyeni is also currently being investigated for corruption. The article states that:
An affidavit submitted to court by the Scorpions contains allegations that the MEC and other senior members of the health department unlawfully influenced decisions related to the procurement of goods and/or services.
Scorpions investigator Clarence Jones also cited allegations that Nkonyeni had a personal relationship with the owner of a private company that had won a R1,5-million order from the department.
The affidavit, submitted to the Pietermaritzburg magistrate's court earlier this month, was used in support of an application for warrants to search the department's Pietermaritzburg offices and those of Rowmoor, the company which apparently charged the department R1,5-million for a cancer scanner, which it has been claimed could have been supplied for R425,000.
The ANC and government have much work to do to repair the damaged relations with HIV clinicians and health professionals due to the past decade of state-supported AIDS denialism, particularly those who give up privileges and opportunities to work in under-serviced rural areas with disadvantaged communities. The equation seems to be this: you insult an MEC and we suspend you without pay to “teach you a lesson” – one less doctor for one month, which almost certainly means lives lost in Manguzi.
The TAC appeals to the new leadership of the ANC to keep its promises and rid South Africa of the real guilty, self-serving and corrupt officials in the health department.
The TAC appeals to its supporters to protest about the suspension of Dr Blaylock. Fax a letter of disapproval to Ms Peggy Nkonyeni, MEC for Health, Kwazulu-Natal at +27 (0) 33 395 2258. Copy letters to ANC President Jacob Zuma (Fax: 086 633 1402). Demand that Nkonyeni withdraws the suspension of Dr Blaylock.
[END OF STATEMENT ON DR BLAYLOCK'S SUSPENSION]
Cochrane Reviews are the gold standard in the analysis of the evidence for particular medical interventions. On 16 April 2008 a Cochrane Review by Bjelakovic et al titled Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases was published. It reviewed 67 antioxidant randomised controlled trials of antioxidants that included 232,550 participants. Antioxidants include beta-carotene, lutein, lycopene, selenium, vitamin A, vitamin C and vitamin E.
The review concluded:
We found no evidence to support antioxidant supplements for primary or secondary prevention. Vitamin A, beta-carotene, and vitamin E may increase mortality. Future randomised trials could evaluate the potential effects of vitamin C and selenium for primary and secondary prevention. Such trials should be closely monitored for potential harmful effects. Antioxidant supplements need to be considered medicinal products and should undergo sufficient evaluation before marketing.
TAC has in a number of statements, a pamphlet and on a web page cautiously recommended that people with HIV consider taking a daily multivitamin supplement. For example our HIV help web page states:
There is some evidence that a daily multivitamin supplement slightly slows progression to AIDS. Consider taking a daily nutritional supplement consisting of vitamins B, C and E. Public health facilities are supposed to provide vitamin supplements to people with HIV for free. However, be aware that most of the claims made about vitamin supplements are exaggerated, often grossly so. It is unclear if vitamin supplements are of any benefit to people who eat enough and healthily. If you do not get free vitamin supplements from the public health system and you can afford to eat healthily, you might prefer to spend your money on something else.
The evidence we have relied on for our cautious recommendation is a competent study on HIV-positive Tanzanian pregnant women conducted by Fawzi et al. titled A Randomized Trial of Multivitamin Supplements and HIV Disease Progression and Mortality.
However, another Cochrane review (published in 2005) of multivitamin supplements by Irlam et al. titled Micronutrient supplementation in children and adults with HIV infection which reviewed 15 clinical trials concluded:
There is no conclusive evidence at present to show that micronutrient supplementation effectively reduces morbidity and mortality among HIV-infected adults. It is reasonable to support the current WHO recommendations to promote and support adequate dietary intake of micronutrients at RDA levels wherever possible. There is evidence of benefit of vitamin A supplementation in children. The long-term clinical benefits, adverse effects, and optimal formulation of micronutrient supplements require further investigation.
On the basis of these two Cochrane reviews, we have decided to modify our existing materials and withdraw the recommendation that adults with HIV take multivitamin supplements. This must not be construed as a recommendation against taking these supplements but as an application of the cautionary principle that medical interventions should only receive a positive recommendation if there is compelling evidence or reason to do so.
There of course remain specific health conditions where multivitamin supplements are necessary. Vitamin A supplementation in HIV-positive children should be considered. The World Health Organisation also recommends folic acid supplementation in certain circumstances for pregnant women or women of reproductive age.
Furthermore, adequate nutrition including sufficient micronutrients is critical for people with HIV and indeed all people. Food security remains a serious concern in South Africa. Food prices have been rising at a rapid pace, with wages failing to keep up. Two million households in a 2002 survey in South Africa reported members going hungry and the average worker spends over a third of monthly income on food. State-provided food parcels and social grants are consequently critical to preventing and alleviating malnutrition and hunger; TAC will continue to advocate for the efficient and wide-spread implementation of such programmes.
It might also be justifiable for the state to provide vitamin supplementation to under-nourished people. Given that it is hard for the state to differentiate at public health facilities between under-nourished and well-nourished people, the current policy of providing multivitamin supplements to people with HIV might be justifiable and we make no recommendation for or against this.
But our current understanding is that for otherwise healthy HIV-positive adults, at best the benefits of multivitamin supplements are very small. At worst, mortality is slightly increased. Healthy people (including healthy HIV-positive people) who wish to continue taking multivitamin supplements daily should preferably use low doses.
The findings of the two Cochrane Reviews referenced here also raise questions about the ethics of the marketing methods of companies selling multivitamins to the general public. Vitamin advertisements on South African television and in newspapers frequently make misleading statements based on insufficient evidence. The Advertising Standards Authority needs to address this.
TAC will continue to take note of new research on multivitamin supplements and review our position if new compelling evidence is published.
[END OF STATEMENT ON MULTIVITAMIN SUPPLEMENTS]
[END OF NEWSLETTER]