Words and Music, Medical and Other

We must become smoke-free without the ‘help’ of Tobacco companies. The more we know of their tactics, the more we can be independent influencers for the sake of the health and wellbeing of children in South Africa and beyond.

I am dictating this article on Freedom Day 2019. It is 25 years since my mother-to-be was born, a freedom baby. My due date is May 8th 2019, Election Day. I am likely to come into the world as you are voting. How are you going to vote? Will you vote? Will you think of me?

I won’t have a vote. Nor will about 20 million children in South Africa. I wonder how much you have thought about us as you think about your vote? Because your choice plays a part in determining our future, you should, I think.

I know that it is not so easy to choose how to vote in 2019. I feel my mother’s stress hormones every time she thinks about it. This is on top of the other stresses she feels from money and food worries, violence etc.. We depend quite a bit on government grants and free services to get by. In that way we are not exceptional: more than 60% of South Africa’s children live in very poor households. I feel stressed too.

Vote for me! Vote for us! Not-so-easy, you say. I agree. Let’s think about it.

Not to vote is a cop out: a negative statement of the heart, not a thoughtful action. It won’t help me to grow up in a better environment than my mother did. Don’t abandon hope.

Spoil your vote? Perhaps in a local election as a protest where all the candidates are disasters, but to do it in the national election would be the equivalent of not voting.

Tactical or specific vote? I see these as equivalent (just because I am small, don’t assume that I cannot think). So the next question is ‘heart or head?’. I think you know how I think – it’s heads every time. An emotional vote will increase the chances that either the extremists or the old guard will increase their power – to be avoided! An emotion-led vote is also more likely to be a selfish use of your vote: ‘me and mine’ before ‘country and community’. Even if you are emotional about the difficult lives that so many of South Africa’s children live, you need to turn that into a thoughtful voting response. No cross crosses on Election Day, please!

So let’s think together. How much is your vote for you, and how much is it for others? As a future citizen of South Africa, I urge you to consider the future of all children in South Africa above yourself – and not only your own children, if you are in the minority of well-off South Africans. The median income of South African households is about R1 200 per person per month. Are you in the 50% of people who are below or above this line? Most children are below this line. Look across the line and think.

What would a vote with children (the voteless) in mind look like? It would be one that would increase the likelihood that our best interests would be served. That from conception through infancy, childhood, adolescence and adulthood our physical and emotional development, our resilience, our education, our health and our opportunities (including the disabled among us) would be given the best chances. So very many of us are losing out on these things in 2019. Vote for change. Even, change your vote!

So what would need to change? We need a much less unequal society. There are millions of have-nots who have almost nothing, like my mother. For almost all of us, this is not our fault. Not to vote with this in mind is to recklessly wreck millions of children’s futures – and wreck the country as this situation is a breeding ground for dangerous demagogues and communal violence.

Apart from being an effect of our history, 25 years of crazy levels of inequality (a lot of it led by unemployment) relate to greed and its first cousin, selfishness. Too many ‘haves’ have and hold. Economic growth, even if we had it would not be enough to overcome gross inequality on its own. More must be shared. I don’t think that most ‘haves’ see their having as greed. If you don’t believe that it is, ask the planet (but more of that later). Let’s call it ‘unintended selfishness’, being generous but firm.

Greed also results in persistent inequality via corruption: those who steal and cheat and those who encourage them to do so and benefit thereby. The huge economic toll of grand graft leaves insufficient resources for our many pro-poor policies, including those that could increase youth employment.

That brings me to poor governance. What is the use of progressive laws and policies if, through corruption, weakness and incompetence, their fruits are never tasted? Economic growth, employment prospects and greater equity are strangled at birth. My birth! You might as well strangle me.

(I continue to dictate from the safety of the womb.)

What else needs to change? Almost every aspect of the environment I am to be born into! Pervasive violence and abuse. Only policing it better (I hear a lot about this in election discussions from inside here) will not get at the root causes. Inequality and broken communities need fixing. Who is talking about community mental health interventions? They are not in any party manifesto. It is the same for drugs (including alcohol and nicotine) in my future environment. My mother doesn’t drink or smoke. She doesn’t let anyone who smokes get near me. Thank you, mama! And here we find greed again – tobacco companies and drug barons, for example.

Passing over air pollution, plastic waste and chemical toxins (I wish I could – they are everywhere), I move to a change that will blight my life if it itself is not changed – climate change. My future and that of South Africa’s children is bleak indeed if you don’t vote for change, and change yourself. I’m talking to you ‘haves’ mainly: what you have is unaffordable.

So inequality, unemployment, greed and selfishness, poor governance, our environments and climate change. All needing change if children are to thrive in South Africa. Where will you put your cross?

In choosing a party or a person (even if you vote for another to get what you want i.e. tactical voting), what do I suggest that you look for?

Honest and people-centred leadership (no demagogues in there – that narrows the field!), track record and the spirit of the party or personal manifesto. The manifesto-writing can be clichéd, derivative and trite (unlike my dictation, I hope), but there may be vital positives and negative pointers in them, so have a look – sometimes between the lines. All three of these are unlikely to be found in any one party or candidate, so weigh up the pros and cons of these three essential considerations for your vote.

Mr Smiley’s party manifesto says many things that are good for children and has done many good things for us while in government. They have signally failed on the good governance front in recent times allowing grand theft from the young and our futures, as well as huge slippage through incompetence and greed at municipal level. And Basic Education? Do you think Mr Smiley’s team can change tack and call its troops to order?

One party took the EFFrontery of poverty and inequality and turned it into a form of politics whose radical EFFrontery would have us join Zimbabwe with an economy unable to get off its knees, if their manifesto and shouting is their true intention as a party in government. They say they will give me and all children a tablet to use when I go to school, and many things like that. Mama is thinking of voting for them. Think, mama. Vote for me!

What about the da DA? I like their children-specific claims and aims – first thousand days, early childhood development, education (also found in Mr Smiley’s manifesto) – but I really hesitate at their reactionary health policies. Not child-friendly. Nice energy and climate friendly policies, Mr M. But I worry about your big business links. Is tackling inequality really in your sights. Will your partners (predominantly ‘haves who want to hold’) give you the leeway to improve living wage employment? Better marks for governance (but blotted your copybook with your silly wranglings in the Cape). I might suggest that people give you a thought for local government and be tactical for national.

I can’t give space to all regional, sectional, personality-driven and weirdo parties. (It is nearly time for my sleep). Avoid the religious ones. Mainly use these smaller parties for tactical votes, unless the candidate is a great soul. If you want a flutter and really care about climate change and children and you live in the Western Cape (where they are on the list), you might give the Green Party a nod. Their policies are even more radical than the EFF’s – radicalism is required in this arena. Your votes are meaningless if, by 2030, we all are headed for environmental catastrophe anyway. You can ‘vote for me’ by being decisively green whoever you vote for. Out with coal before I turn 11! Nice to see this sentiment in other manifestos – carbon-free is becoming mainstream in thought. Now for action, those who win on Election Day!

So, please vote on my birthday. A thinking vote. A vote for my future and the future of all South Africa’s 20 million children.

Thanks for reading my manifesto from the womb.

Vote for me! Thank you!

See you soon.

Thembile

These two pictures are of an article I wrote published by the Mail and Guardian newspaper in 2001 during the terrible crescendo of the AIDS epidemic in South Africa. It played a small part in the eventual arrival of a Prevention of Mother to Child HIV Transmission programme in South Africa.

To read the text, I suggest that you download the pictures and enlarge them in your picture program.

If you want to hear more of the history-making fight for this programme, see Prof Haroon Saloojee’s short lecture, given at the South African Child health priorities conference in 2016. A paediatrician, he played a key role in the civil society challenge to the government of the day.

I was privileged to attend part of this conference. As I wrote on World Tobacco Day in 2017, I have taken on a task of reducing children’s exposure to environmental tobacco smoke. ‘Look after little lungs’ is the mantra. I have subsequently partnered with South Africa’s National Council Against Smoking to take this further. We have produced a book that children can use to learn about lung health and the effects of passive smoking in order to become advocates for their own health. I presented this idea at the conference. I wrote an article for publication during the conference. It was published in the Cape Times a few days after the event, but it keeps the conversation going. It is certainly a conversation I intend to keep going in South Africa until all children and pregnant women are protected from the scourge of tobacco.

Here is a link to the article.

Earlier this year I fulfilled a dream – design and produce a T-shirt with messages around reducing the effects of passive smoking on children in Cape Town. We see so much pneumonia, wheezing and uncontrolled asthma produced or aggravated through children being exposed to cigarette smoke in the home. 42% of adult men in the Western Cape smoke and 25% of women – those are the highest figures on the country.

So in March I got the T-shirts made and started to wear one. I have started to give child-sized ones to some of my patients with respiratory problems. I believe that we can empower children to stand up for their right to clean air.

‘Look after little lungs’ is my slogan. This is on the front of the shirt, and on the back it declares  ‘Don’t EVER smoke near pregnant women and children’.

I have had very positive feedback from people in the hospital. Many would like to own and wear such a T-shirt. (Any sponsors out there?)

So when I was asked to be the spokesman for World No Tobacco Day (May 31st 2017) on SABC’s Expresso programme for South Africa’s Heart & Stroke Foundation and partner organisations (including the Western Cape Department of Health which employs me) I could not say no.

Click here to see what I did say – with the help of a couple of friends. [Forgive the lame pun a few minutes in.]

The Child Health Priorities Association of South Africa brings together workers in child health together annually. I was a co-convenor of the 7th conference, held in Cape Town December last year. It was a wonderful time together hearing about and debating many issues in South Africa child health.

You can participate in the conference by watching the recordings of most of the sessions at the Association’s YouTube channel.

The next conference will be held in Pretoria in late 2017.

Here we go again. This article was spurred by a challenge to paediatricians to write newspaper articles making the case for breast feeding as a preventer of gastroenteritis by Dr Virginia de Azevedo, the Cape Town City Health Department Manager of the Khayelitsha sub-district which has the highest number of diarrhoea cases reported in Cape Town.

http://www.iol.co.za/news/the-case-for-breast-feeding-1.1664465

Lesley has written an excellent article setting out what the current situation is in South African maternal, newborn and child health. I strongly recommend it to anyone wanting to get a grasp of the issues.

Part 3 covers what might be done and is being done to improve child health outcomes in South Africa.

So now, where would we like to go? Well, if I’ve done my job correctly, you should be able to tell me this. You should be driving us there, itching to move the country on to better outcomes for children.

The vision is big. Turn things on their head; don’t talk of sickness, talk of health. Build, build, promote, promote, prevent, prevent. We have to make children strong; when they are sick, we must get in there early and turn things around. No more HIV; every baby on the breast for at least six months. Join up a primary health care services, clinic with community health centre, community health centre in clinic with district hospital – to provide a more comprehensive service to children, whether parents are cared for. Silos are silly. It just moved to a place where silo-thinking is the subject of ridicule and mirth.
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The second thing we want to build a strong in equitable child health system. The blueprint is on the slide. What the data I have shared with you show is that, if we want healthier children who can look forward to a healthy long life, we must take health services to them – this is true for children to a greater extent than it is for adults in our needy communities because their access to all the aspects of health care is utterly dependent on others. We need to improve the way in which primary health care services in districts are supported by people with more specialised child health knowledge and skills. Note that I do not say paediatricians. The paediatrician is just one of the cadres who need to do this job, or be allowed to do this job.
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So we can move on to how we get to this wonderful situation of resilient children using resilient health services. I will inform you of a few initiatives that you hope you will support while doing your bit to build resilient children in the health services where you work – in your office and beyond its walls.
National Health Insurance (NHI) is fundamentally about increasing equity and the country’s children more than anyone require greater equity. How we do this cost-wise through NHI I’m not qualified to say, but we must try and all work to make something better happen, I have no doubt in NHI is the chosen vehicle. Access to a qualified medical opinion in primary health care is woefully inadequate for children in South Africa, let alone a specialised opinion. We must increase access: NHI promises this. They just get on board and moulded for the children.
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Primary health care re-engineering. These are ministerial initiatives to improve outcomes for pregnant women, newborns and children. While not comprehensive, they do take up some of the themes I have been rehearsing: taking services to children – that’s the Ward-based teams of community workers led by nurses; district clinical specialist teams – a small group of specialised doctors and nurses working in support of the district health system by district or in the catchment area regional hospitals to improve pregnancy care and its associated surgery, to improve neonatal and child outcomes; enhanced school health services aiming to bring services to a captive audience of children and adolescents.
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Number three is two sets of recommendations made to the Minister and thus the health systems by two ministerial committee set up to advise on how the country can save children’s lives and improve their health.

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Here are those reommendations, made independently but with common elements as highlighted. ‘Regional clinicians’ in this slide links conceptually to the district clinical specialist teams. Note the emphasis on training professionals – that’s a result of the audits that tell us how much morbidity and mortality occurs AFTER professionals have become involved in pregnancy, neonatal and paediatric care. The proposal includes undergraduate and basic nurse training as well as formalising what we teach in terms another young professionals about the care of children. Please read more at the link given here.

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This slide precises these approaches in a few words. Focus on the basics. Focus on the potentially severe and damaging conditions. Emergency care and critical care.

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This slide can guide individual clinicians on what they can do in everyday practice to protect children and promote their health. The Road to Health Booklet is a marvellous vehicle by which clinicians can travel with their patient through their words written about what they have done and what they have explained to the caregivers or family.
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Thank you.

Part 1 described the context of children growing up in SA. Part 2 outlines some of the indicators of child health and health services in the country:

So what about those health care services? Where are we? Actually, I’m going to postpone

looking at health services as such as I am hoping that when we get there, we can look at them from the point of view of there being a solution rather than a problem. So let’s look at some indicators of child health in South Africa.

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Here’s the first indicator which is in fact not an indicator of child health at all: infant mortality rate or IMR is well established as a measure of a community development, and not directly of health – the poor little canaries (otherwise known as infants) being those who tell us by dying whether we live in a dangerous, poor human environment for not so dangerous human environment. The arrow on this table which comes from the MRC Rapid Mortality Survey published in 2012 shows that South Africa’s infant mortality rate is dropping and has done so rapidly in the last few years. The same is true of the under five mortality rate. This is shown more starkly on the next slide.
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Many of us were desperate during the first few years of the millennium as high rates of death among children stubbornly refused to budge, as the president and his health minister on the subject of AIDS. Things are now shifting nicely. (Except the neonates – the red line at the bottom, – please note)
However there is not much room for complacency here. The absolute level is significantly high still and as the next slide shows –
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This slide shows in the circled area, things things vary considerably by province [the big ? here is the Eastern Cape whose figures based on vital registration seemed to be way out of kilter – led by the former Transkei area – the OR Tambo district – which we saw is one of the areas with high levels of deprivation.] What is more, things vary considerably within provinces. Even in that Nirvana known as the Western Cape province, you will find areas the child mortality levels similar to areas such as Limpopo, and well above the national average. So there is a journey required of us all.
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So what are the children dying of? The top of the list is diarrhoea: one in five deaths under 14 years of age in this country is due to diarrhoea. Perhaps I should say that again. Amongst the youngest children the proportion is even higher. Next on the list are causes of death within the first month of life and the majority of these are within the first week of life and relate to 2 big causes: prematurity with associated complications and, rather sadly, birth asphyxia (euphemistically called “perinatal problems” on this slide). Pneumonia and respiratory infections get in at number three in South Africa. Note that these figures refer to the period before the introduction of rotavirus and pneumococcal vaccines. Evidence from 2009 is diarrhoea and pneumonia deaths are dropping, but neonatal deaths as a whole have not risen to the top of the pile yet. But neonatal deaths are stubbornly sticking at the same level, presenting a challenge to us all.
Had a high status of TB is not only an adult phenomenon. Where did children get there TB bugs from? Why can’t we stop it when we know that their immune systems cannot contain the infection once they have inhaled it? Why do we allow contact tracing to miss children?
I have circled ”immune disorders” because, although there last on the list, this is largely AIDS. But AIDS is a big contributor to all the other causes because, as with adults, HIV is not usually put on the death notification form, or its presence has not been ascertained). Or it is not given as a direct cause of death, but of course it isn’t.
So these 10 causes constitute two out of three deaths. I think you will agree with me that pretty much all of them are preventable to a large degree. Keep this in mind when we come to everyone to go and how to get there. Very obvious where to; but how to get there?
Now looking at hospitals where, beyond neonatal units and wards, just under half of young child deaths happen. (Note that most neonatal deaths occur within the health system, largely in nurseries, in all provinces. We will come back to them soon.) Doctors do most of the therapeutic decision-making in hospitals, so concentrate please.
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This slide is covers admissions to paediatric wards in South Africa and does not include neonatal nurseries. We see that here too has been a gratifying reduction in in-hospital mortality rates – that is, the number of children who died hospital wards per 1000 admissions. If you look at the right hand column on this table, this indicator fell from 50 deaths per thousand admissions in 2009 to 2011. And note (in the centre column) but even though the number of hospitals doing audits and rose as the number admissions monitored, the number of deaths dropped. These figures come from hospitals that audit child deaths (nearly half of all hospitals in the country and predominantly district hospitals). The process involved comes from the Child Healthcare Problem Identification Programme or Child PIP. Things may not be so rosy overall have these figures come from hospitals with clinical enthusiasts. And the next slide…
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… shows causes of death in hospital, and you’ll see that it is very similar to the causes of death overall – with three quarters of all deaths being due to infectious causes. Our old enemy who still laughs at us, diarrhoea, heads the list here too. It is important for us in the health fraternity to recognise that these are deaths of children who have made it to hospital wards and then die. Could more of them have been saved? And we ask again, need the children got sick enough to need hospitalisation? Well, look at the next slide:
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It may explain why children get so sick. Malnutrition is a significant co-factor in hospital deaths – look at the purple and green segment; in many of these the management of malnutrition was sub-optimal, especially if it was severe. Food for thought, if you will pardon the pun.

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Nearly one in five, folks, for severe acute malnutrition. 20% overall mortality. True, sometimes it is the underlying disease that contributes malnutrition, that calls for early identification of illness, and earlier intervention to prevent and treat concomitant nutritional diseases. Anyone not want to promote breastfeeding after seeing this slide?
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HIV wields its sickle in our wards as well (red and green segments this time). I have recently reviewed the audit data from hospitals and unhappy report – as in the next slide…

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… that this particular Grim Reaper is having a harder time of it. HIV-associated diarrhoea deaths have dropped by 30% over three years – the third column of figures; HIV-associated TB deaths have dropped by the same margin. Bacterial meningitis deaths dropped by even more. PMTCT, ARV, PCV. More letters child health scrabble game

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But we need to be sober. When our intrepid auditors reviewed their own practice and that of the primary health care system that referred sick children, they found that much more could have been done a lot better. Nearly half the deaths might have been avoided if things had been handled better – please remember that we are talking about things like diarrhoea and pneumonia here. The top of this table indicates the sites where things might have been done better. Hospitals and homes of the main places where care must be improved if fewer South African children are not to die. Delaying getting to care is the main problem in homes raising questions both the recognition of danger signs but also ease of access to primary and urgent health care for our communities. In the lower half of the table, note that every death between one and two modifiable factors were ascribed to clinical personnel who should have done things better. For diarrhoea, this mainly relates to recognition of shock and dehydration and use of fluids – fundamental skills, surely!?
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And for neonates there is a lot that could have been done better too as this slide shows. Why are women presenting late in labour? Why are many pregnancies and booked? Why don’t we know how to look after sick newborns in our nurseries but we don’t equipment properly?

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Most of the deaths I have covered so far are in children under the age of five years. What about the older children? This graph shows that as you get older, your chances of dying of a non-natural cause rise to nearly half of all causes in the ages 15 to 19. Other main causes include AIDS and cerebral palsy. Remember that much cerebral palsy in this country is due to secondary causes such as birth asphyxia and meningitis, so deaths in older children must be considered potentially preventable in this day and age. Taming gangs, alcohol and fast cars is a bigger challenge.
So that is a lot about child health at the extremes – death. But we talk to morbidity in children,
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… We’re talking about the same things that matter less severe scale. So what keeps the primary health care system in hospitals busy the same things that cause children to die. The same things that need to a lot of child disability.
It is important to recognise that children have long-term problems in significant numbers. Herein are the children with neuromuscular diseases and disabilities, congenital conditions such as cardiac disease and haematological disorders, acquired diseases such as type I diabetes, rheumatic disorders and the large number of learning disabled and attention deficit hyperactivity disorder children and young people. I have separated out mental health disorders because these go a long way beyond the severe things like autism to include a huge level of (often undiagnosed) problems of anxiety/depression and substance abuse. There is a lot here that represents the antecedents of adult somatiform disorders that keep the health system very busy. Almost untouched in this country.
One major concern is that the success of programmatic IMCI-based case management in providing primary health care to children, to the lack of access to more sophisticated care within the primary health care system. My corralling children into narrow IMCI-trained nurse-led to services, we have lost decade of clinical nurse practitioner who was able to recognise and treat a lot of common childhood disorders and make a much better referral to a doctor. In improving access to and quality of care for a narrow spectrum disorders, we have inadvertently reduced access to care for children with other disorders and children in the age of five years. I will talk to how this might be remedied later.
You’ll recognise that subliminally I have been sharing new issues around health services even though I said I was leaving for a while. So much of what kills aims children is because of sub-is optimal handling by our health systems, private and public. So let us talk about them overtly:
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The good first: mostly programmatic and acronymic as shown in the slide. The learning purposes it is worth looking up in the acronyms you do not recognise.
When it comes to the not so good, there is much that we know about that affects children as well as adults – in equitable distribution of services and resources, poor service management, staff attitudes, too few staff, waste. The big concern is how some flagship policies such as IMCI, EPI-SA, and PMTCT are inadequately implemented. But on a positive note, much is now being done to remedy this, such as a focused drive to improve efficacy of a complex sequence of activities known as PMTCT with the aim of eliminating new vertical infections by 2015. I have to mention breastfeeding. Do in the health services really believe and its benefits, you wouldn’t think so from the way we don’t provide spaces and energy for it, even some of our maternity services. And have you recognise that with a RVs, breastfeeding is the safer, even life-saving option of HIV-exposed babies in that very large deprived community I spoke earlier? With your support, it can be done with massive benefits for the country and the children.
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It is certainly our intention in the Western Cape – and not only because we looked like a breast with lacteals converging on Cape Town!