Shan Naidoo

The South African national health insurance: a revolution in health-care delivery!

A brief overview of the Green Paper on the National Health Insurance (NHI) policy of South Africa is presented. It describes the intention of the NHI to ensure equity, address the inequalities presented by the current private and public health system and present an ambitious plan to change the face of the South African health care system over the next fourteen years. It provides the context of the currents system that provides the case for the change. It also provides some detail on the structure of the proposed new Re-engineered Primary Health Care system as well as the future financing of this bold new health care system for South Africa. The challenge will be in its implementation.

Lead exposure in young school children in South African subsistence fishing communities.

BACKGROUND Lead is an established toxic substance, with wide-ranging health effects, including neurodevelopmental decrements and behavioural problems, even at low levels in blood. Anecdotal reports of lead melting to make fishing sinkers in South African subsistence fishing communities prompted the conduct of an epidemiological study in two South African fishing villages to investigate the extent of lead melting and the associated risks in children. OBJECTIVES The objectives of the study were to determine the extent of lead melting, and the blood lead distributions and associated risk factors in children. METHODS Cross-sectional, analytical studies were undertaken among 160 young school children in the fishing villages of Struis Bay and Elands Bay located along the south-eastern and western South African coastline, respectively. Blood samples were collected for lead content analysis, and anthropometric and hemoglobin measurements were taken. Questionnaires were administered to obtain information about socio-economic status and risk factors for lead exposure. RESULTS Blood lead levels ranged from 2.2 to 22.4 µg/dl, with the mean blood lead level equalling 7.4. Around 74% of the children had blood lead levels ≥5 µg/dl and 16% had blood lead levels ≥10 µg/dl. Socio-economic factors, and lead melting practices were strongly associated with elevated blood lead levels. CONCLUSIONS Blood lead levels in these remote subsistence fishing communities were unexpectedly elevated, given the absence of local lead industries or other obvious sources of lead exposure. Lead exposure and poisoning is an important, yet neglected, public health concern in South African subsistence fishing communities, and potentially on the entire African continent.

Overcoming fieldwork challenges in urban health research in developing countries: a research note

With rapid growth in the global urban population over the next two decades, health will increasingly have an urban bias. The picture of public health is particularly complex in African cities, where rates of urbanisation, poverty and inequity are high. This paper identifies the main data collection problems encountered within a panel study in low‐income areas of Johannesburg, with special emphasis on sampling, access and partnerships. The paper will be of relevance to anyone considering research in the cities of developing countries, especially in Africa.

Nosocomial Outbreak of New Delhi Metallo-β-Lactamase-1-Producing Gram-Negative Bacteria in South Africa: A Case-Control Study.

Objective New Delhi metallo-β-lactamase (NDM)-producing Gram-negative bacteria have spread globally and pose a significant public health threat. There is a need to better define risk factors and outcomes of NDM-1 clinical infection. We assessed risk factors for nosocomial infection with NDM-1-producers and associated in-hospital mortality. Methods A matched case-control study was conducted during a nosocomial outbreak of NDM-1-producers in an adult intensive care unit (ICU) in South Africa. All patients from whom NDM-1-producers were identified were considered (n=105). Cases included patients admitted during the study period in whom NDM-1 producing Gram-negative bacteria were isolated from clinical specimens collected ≥48 hours after admission, and where surveillance definitions for healthcare-associated infections were met. Controls were matched for age, sex, date of hospital admission and intensive-care admission. Conditional logistic regression was used to identify risk factors for NDM-1 clinical infection and associated in-hospital mortality. Findings 38 cases and 68 controls were included. Klebsiella pneumoniae was the most common NDM-1-producer (28/38, 74%). Cases had longer mean hospital stays (44.0 vs. 13.3 days; P < 0.001) and ICU stays (32.5 vs. 8.3 days; P < 0.001). Adjusting for co-morbid disease, the in-hospital mortality of cases was significantly higher than controls (55.3% vs. 14.7%; AOR, 11.29; P < 0.001). Higher Charlson co-morbidity index score (5.2 vs. 4.1; AOR, 1.59; P = 0.005), mechanical ventilation days (7.47 vs. 0.94 days; AOR, 1.32; P = 0.003) and piperacillin/tazobactam exposure (11.03 vs. 1.05 doses; AOR, 1.08; P = 0.013) were identified as risk factors on multivariate analysis. Cases had a significantly higher likelihood of in-hospital mortality when the NDM-1-producer was Klebsiella pneumoniae (AOR, 16.57; P = 0.007), or when they had a bloodstream infection (AOR, 8.84; P = 0.041). Conclusion NDM-1 infection is associated with significant in-hospital mortality. Risk factors for hospital-associated infection include the presence of co-morbid disease, mechanical ventilation and piperacillin/tazobactam exposure.

Training of disaster managers at a masters degree level: From emergency care to managerial control

The world has faced huge disasters over the last few decades and concerns have been expressed by nearly all international agencies involved that there is a scarcity of managerial skills to deal with the mitigation and management of disasters. Disaster risks are also on the increase throughout Africa and Southern Africa because of changes in the development process, settlement patterns and conflicts in the region. Emergency physicians are but one important resource in dealing with disasters. The need for a comprehensive multisectoral approach to disasters and more importantly to deal with its mitigation is becoming increasingly evident, especially in developing countries. Hence, the need for specially trained professionals in disaster management. In an effort to improve national, regional and continental capacity, and in support of the South African Disaster Management Act, the University of the Witwatersrand, Johannesburg, South Africa, has developed a Master of Public Health degree in Disaster Management. The MPH is aimed at preparing professionals from health and allied fields to play leadership roles in the management, improvement and evaluation of health and the health‐care system. Emergency physicians have an important role to play in the development of disaster medicine and disaster management programmes and it is important that they engage in this activity, collaborating with colleagues of various other disciplines as appropriate. The following paper outlines the background to the programme and the current programme.

Inequity in poverty: the emerging public health challenge in Johannesburg

In 2005, in recognition of the role of social factors in increasing health inequities, the World Health Organisation established the Commission on the Social Determinants of Health. South Africa is among the most unequal societies in the world. It faces serious public health challenges, including an elevated burden of chronic disease, and high levels of violence. This paper presents data from a cross-sectional study of socio-economic and health status conducted in five Johannesburg housing settlements in 2006. The findings paint a picture of health inequities across and within the study sites, and socio-environmental conditions that undermine the prospects of protecting and promoting health. The authors suggest the need for a new approach to public health in areas of urban impoverishment in Johannesburg and elsewhere.

Poverty, health and policy: a historical look at the South African experience.

The resurgence of interest in links between health and development raises interesting questions about the process of research, policy-making, and implementation in the field of health and poverty. To learn about the process in South Africa, we examined three commissions of inquiry relating poverty and health – in 1929, 1942, and the early 1980s. Power relations of the players were a decisive factor and determined the type and nature of the research conducted.

Rodent control in urban communities in Johannesburg, South Africa: from research to action

Introduction: Rodents are troublesome urban pests, with potentially serious health implications. Preventive efforts require greater understanding of social contexts in which they are prevalent. This study aimed to determine rodent prevalence and identify factors associated with rodent infestations in urban residential settings. Methods: The Health, Environment and Development study is a longitudinal panel study conducted in five settlements across Johannesburg. Data on socio-economic status, domestic behaviour and housing quality are collected annually. Logistic regression revealed risk factors for rodent prevalence at household level. Results: Rodents are a major household problem in all study areas (prevalence 54%). Factors associated with increased prevalence of rats included lower income, living in informal areas, overcrowding, cracks in dwelling walls and internal damp. Conclusion: Socio-economic status, housing quality, domestic behaviour and environmental health services are associated with exposure to rodents in urban Johannesburg communities. This information served as a platform to launch rodent awareness campaigns at study sites.

Exposure to lead in South African shooting ranges

Introduction: Lead exposure in shooting ranges has been under scrutiny for decades, but no information in this regard is available in respect of African settings, and in South Africa specifically. The aim of this study was to determine the blood lead levels in the users of randomly selected private shooting ranges in South Africas Gauteng province. Methods: An analytical cross sectional study was conducted, with participants recruited from four randomly selected shooting ranges and three archery ranges as a comparator group. Results: A total of 118 (87 shooters and 31 archers) were included in the analysis. Shooters had significantly higher blood lead levels (BLL) compared to archers with 36/85 (42.4%) of shooters versus 2/34 (5.9%) of archers found to have a BLL ≥10 &mgr;g/dl (p<0.001). Conclusion: Shooting ranges may constitute an import site of elevated exposure to lead. Improved ventilation, low levels of awareness of lead hazards, poor housekeeping, and inadequate personal hygiene facilities and practices at South African shooting ranges need urgent attention. HighlightsThis is the first study, to our knowledge, of lead exposure in shooting ranges in an African setting.This study indicates highly elevated lead exposure amongst the users of certain private shooting ranges in South Africa.Lead exposure may be a serious, yet under‐studied, source of adult lead exposure in South Africa, and possibly elsewhere on the African continent.

The prevalence and health implications of violence in impoverished communities in Johannesburg.

The experience of violent crime can have a significant impact on the physical and psychological well-being of victims and their families. This paper looks at household experience of violence in five impoverished sites in the city of Johannesburg, South Africa. Five sites were purposefully selected to reflect the prevailing housing profiles in settings of relative impoverishment in Johannesburg. A structured questionnaire was used to obtain information on demographic profiles, socioeconomic data, environmental conditions and health status. Bivariate analyses were conducted to assess the relationship between household experience of violence, and potential risk factors and health/social outcomes. Overall, members of 28% of households had been a victim of violence in the year preceding the study. Across sites, experience of violence within households ranged from 21% to 36%. Perceptions of drug abuse (p=0.01) and drug peddling (p=0.03) as being major problems in the neighbourhood, and living in a house of poor quality (p=0.01), were significantly associated with household experience of crime. In households with experience of violence, fear of crime (p=0.03) and depression (p<0.001) were elevated, and levels of exercise in men were decreased (p=0.05). This paper highlights the high prevalence of violence in impoverished urban areas in South Africa, and contributes to existing evidence regarding the associations between experience of violent crime and psychological ill health in affected communities. The high prevalence of violent crime, and the resultant health and social effects, demand a cross-sectoral intervention to reduce violence, with the health and social sectors playing key roles.