NEWSLETTER - DAY 04THURSDAY 21st FEBRUARY

Mechanical heart close to being viable

By SUE SEGARThe development of a mechanical alternative to a heart transplant

for a child that could be construed as durable for a lifetime was a “formidable” challenge which would prove to be extremely expensive for hospitals.

However, there was cause for optimism, due to prospective trials which could advance the support of children - and those involved in treating children with heart disease must take on the challenges “respectfully and courageously”.

These were the words of Charles Fraser, Surgeon in Chief at Texas Children’s Hospital during the Christiaan Barnard Hospital Lecture.

In an address entitled A Mechanical Alternative to Transplantation, Fraser said hundreds of thousands of patients needed transplants every year.

With only 2000 heart transplants being conducted in the US a year, there was an extremely low likelihood of a child receiving a donor heart.

For this reason, the world needed a “transformational advance” to build on the transformational

a lifetime or one that can be easily changed out.

“So that seems to me to be a very significant challenge in mechanical support in children.”

Fraser said there was widespread hope that the upcoming trials for the small Jarvik device would result in an incremental advance in support of children.

“But the clinical experience is very limited … and I hope we don’t repeat mistakes.”

There were some clever devices being worked on at institutions including the Indiana University and at the Texas Heart Institute as well as in Australia.

But, asked whether he was optimistic that he would see a mechanical device for children in his lifetime, Fraser said:

“It is intuitively difficult for me to imagine that a mechanical solution is going to be the end point for children. I think it is more plausible that it will be a biologic solution of some sort.

“The line of thinking that Professor Doris Taylor of the Texas Heart Institute and her colleagues are pursuing is exciting. It might be the wrong one to bet on. I don’t know.

-That line of thinking is very exciting … my money is on that. A biologic substitute is more logical to me.”

event of the first heart transplant conducted in Cape Town by Dr Chris Barnard.

“In terms of actual community benefit we are not meeting the need.”

“We have been making incremental progress which has been really good but to broadly apply a new therapy … to those that need, we need something that is transformative … to more people,” Fraser said.

The challenge was formidable because “in childhood particularly, we have a number of problems. Children grow, they are very active and their response to medicine is different. The potential application is measured, not in terms of months or years, but in decades so we have to have a mechanical device which is either easily interchangeable or one that is durable for a lifetime - and neither of these propositions exist right now.”

“A transformative event in mechanical support for a child would be a device that would be capable of sustaining that person either in its original implanted form for

Mechanical heart

Charles Fraser

T h e f a i l u r e t o t r e a t p a t i e n t s w i t h c a r d i a c a n d n o n -

c o m m u n i c a b l e d i s e a s e s i n Rw a n d a w a s “ o b s c e n e ” b e c a u s e t h e g l o b a l r e s o u r c e s t o a d d r e s s t h e p r o b l e m e x i s t e d .

T h e s e w e r e t h e p a s s i o n a t e w o r d s o f G e n e B u k h m a n , A s s i s t a n t P r o f e s s o r o f M e d i c i n e a t H a r v a r d M e d i c a l S c h o o l d u r i n g t h e p l e n a r y e n t i t l e d S t a r t i n g a H e a r t P r o g r a m m e i n A f r i c a : L e s s o n s f r o m Rw a n d a .

I n a n a d d r e s s w h i c h c o n t r a s t e d t h e h e a l t h s p e n d o n A m e r i c a n p a t i e n t s w i t h t h a t o f p a t i e n t s i n Rw a n d a , B u k h m a n s a i d A f r i c a d i d n o t h a v e t h e r e s o u r c e s t o d e a l w i t h t h e p r o b l e m o f c a r d i a c i l l n e s s e s a n d t h e w o r l d c o u l d d o m o r e .

“ J u s t l i k e w i t h H I V a n d T B, t h e r e a r e n o t t h o s e r e s o u r c e s …

“ T h e s e d i s e a s e s a r e a f f e c t i n g c h i l d r e n a n d y o u n g a d u l t s . T h e y a r e n o t l i f e s t y l e d i s e a s e s , ” s a i d B u k h m a n , w h o h a s b e e n c l o s e l y a s s o c i a t e d w i t h Rw a n d a f o r t h e p a s t s e v e n y e a r s a n d w h o i s i n v o l v e d i n a p r o g r a m m e w i t h t h a t c o u n t r y c a l l e d Pa r t n e r s i n H e a l t h .

B u k h m a n s a i d t h e a m o u n t o f r e s o u r c e s a v a i l a b l e t o r u r a l A f r i c a w a s s t i l l “ r i d i c u l o u s l y l o w ” c o m p a r e d t o t h e w a y l i f e w a s v a l u e d i n t h e U n i t e d S t a t e s .

“ I n t h e U S, w e s p e n d 8 0 0 d o l l a r s p e r p e r s o n p e r y e a r a n d

‘obscene’ failure to treat african patients

By SUE SEGAR w e a r e a r g u i n g a b o u t w h e t h e r i t s t o o m u c h t o b e s p e n d i n g 5 0 t o 1 0 0 d o l l a r s a y e a r i n Rw a n d a f o r Rw a n d a n l i f e a n d t h a t d o e s n ’ t m a k e a n y s e n s e .

“ H o w c a n w e b e v a l u i n g t h o s e l i v e s s o d i f f e r e n t l y ? ”

T h e Rw a n d a n g o v e r n m e n t p l a c e d e x t r a o r d i n a r y v a l u e o n h e a l t h a s a h u m a n r i g h t a n d , a s a n a t i o n , Rw a n d a h a d b e c o m e a s t r o n g v o i c e o n t h e n a t u r e o f c a r d i a c a n d n o n - c o m m u n i c a b l e d i s e a s e i n r u r a l A f r i c a “ a n d h o w i t i s i m p e r a t i v e t o a d d r e s s i t n o w , ” B u k h m a n s a i d .

“ W h a t w e k n o w f r o m h i s t o r y i s t h a t , e v e n i n 1 9 6 0 , p e o p l e t h o u g h t t h e r e w e r e t h e r e s o u r c e s t o a d d r e s s t h e s e p r o b l e m s a n d , g i v e n t h e e x t r a o r d i n a r y g r o w t h i n r e s o u r c e s w e h a v e s e e n b e t w e e n n o w a n d t h e n - i t h a s b e e n a l m o s t 2 0 - f o l d - t h e r e a r e c e r t a i n l y t h e r e s o u r c e s g l o b a l l y t o a d d r e s s t h i s n o w . ”

A k e y l e s s o n w h i c h t h e w o r l d c o u l d l e a r n f r o m t h e Rw a n d a n e x p e r i e n c e i s t h a t t h e n a t u r e o f c a r d i o - v a s c u l a r a n d n o n c o m m u n i c a b l e d i s e a s e s i n r u r a l A f r i c a w a s d i f f e r e n t , B u k h m a n s a i d . Fa r f r o m b e i n g r e l a t e d t o s m o k i n g , d i a b e t e s a n d b a d e a t i n g , t h e s e w e r e n o t l i f e s t y l e d i s e a s e s .

“ S e c o n d l y , i s t h a t h a v i n g a s i m u l t a n e o u s c o m m i t m e n t t o b o t h t h e t r e a t m e n t o f s i c k p a t i e n t s a n d p r e v e n t i o n i s v e r y r e a s o n a b l e , a n d , t h i r d l y , w i t h g o o d l e a d e r s h i p a n d g o o d p a r t n e r s i t i s p o s s i b l e t o h a v e e x t r a o r d i n a r y g a i n s i n t h e h e a l t h o f t h e p o o r . ”

B u k h m a n s a i d h i s a s s o c i a t i o n w i t h Rw a n d a h a d c h a n g e d h i s l i f e .

“ I t i s i n s p i r i n g t o s e e t h e e x t r a o r d i n a r y c h a n g e s t h e g o v e r n m e n t h a s l e d o v e r t h a t p e r i o d . W h a t h a s m a d e t h o s e c h a n g e s p o s s i b l e h a s b e e n t h a t l e a d e r s h i p a n d i t s a b i l i t y t o c o - o r d i n a t e p a r t n e r s h i p s . I t h a s b e e n a p r i v i l e g e t o b e p a r t o f t h a t t e a m . ”African patients are marginalised compared to those of the USA

Debunking the fooD pyraMiDBy KATHERINE GRAHAMO besity i s soar ing in many

parts of the wor ld, inc luding South Afr ica, and fat i s not to b lame, a controvers ia l sports sc ient ist asserted on the f ina l day of the S ixth Wor ld Congress of Paediatr ic Cardio logy and Cardiac Surgery in Cape Town.

“ We h a v e b e e n m a d e t o b e l i e v e t h a t a h i g h - f a t d i e t l e a d s t o i n c r e a s e d L D L ( s o - c a l l e d b a d c h o l e s t r o l ) , i n c r e a s e d t r i g l y c e r i d e s ( f a t t y a c i d s ) a n d r e d u c e d H D L ( s o -c a l l e d g o o d c h o l e s t r o l ) , w h i c h a l l r e s u l t i n a r t e r i a l c l o g g i n g . T h i s m o d e l i s w r o n g , ” P r o f e s s o r T i m N o a k e s s a i d .

Noakes, d i rector of the Univers i ty of Cape Town’s Sports Sc ience Inst i tute, acknowledged that many do not share h is v iews. But he encouraged medica l minds at the conference to interrogate the sc ience behind nutr i t ion before jumping to conc lus ions.

“The US Department of Agr icu l ture ’s food pyramid, which p laces carbohydrates l ike bread and pasta at the bottom and fats at the top, i s a f lawed model ,” he sa id. “Diabetes and obes i ty rates in the US have steadi ly r i sen s ince the adopt ion

of USDA guide l ines in the 1970s and I be l ieve i t i s because of a h igher intake of carbohydrates, as wel l as consuming more ca lor ies overa l l .”

Noakes argues that a s igni f icant proport ion of the populat ion are carbohydrate or insu l in res istant. “When you are insu l in res istant and you eat lots of carbs, you ra ise your t r ig lycer ide leve ls.” (Tr ig lycer ides found in the b loodstream and fat t i ssue can contr ibute to the hardening and narrowing of your arter ies, ra is ing the r i sk of heart d isease. )

H e b e l i e v e s t h a t t h e m e t a b o l i s m o f e v e r y h u m a n b e i n g i s n o t t h e s a m e a n d t h a t t h o s e w i t h c a r b o h y d r a t e r e s i s t a n c e a r e u n a b l e t o m e t a b o l i s e c a r b o h y d r a t e s s a f e l y .

“I f 50% of the populat ion i s insu l in res istant, then i t means that our d ietary gu ide l ines are 50% wrong,” he sa id.

A c c o r d i n g t o N o a k e s , b y f o l l o w i n g a h i g h - f a t d i e t , y o u a r e a b l e t o r e v e r s e a l l c o r o n a r y r i s k f a c t o r s m o r e e f f e c t i v e l y

t h a n a l o w - f a t d i e t . I r o n i c a l l y , y o u r s a t u r a t e d f a t l e v e l s g o d o w n w h e n e a t i n g a h i g h - f a t d i e t , h e s a i d .

H e a l s o t o o k a i m a t t h e “ e n e r g y i n , e n e r g y o u t ” m o d e l w h i c h s a y s t h a t t h e m o r e y o u e x e r c i s e a n d t h e l e s s y o u e a t , t h e m o r e l i k e l y y o u a r e t o l o s e w e i g h t . “ Pe o p l e w h o g a i n w e i g h t a r e t h o u g h t t o b e s l o t h f u l a n d g l u t t o n o u s . I f y o u h a v e n o t a c h i e v e d y o u r i d e a l b o d y w e i g h t , p e o p l e a s s u m e i t ’ s b e c a u s e y o u ’ r e n o t m o t i v a t e d , i l l - d i s c i p l i n e d a n d u n f o c u s e d . ”

R e f e r r i n g t o t h e b o o k b y G a r y Ta u b e , W h y We G e t Fa t , N o a k e s d i s m i s s e d t h e n o t i o n t h a t o b e s i t y w a s s i m p l y d u e t o d o i n g t o o l i t t l e e x e r c i s e . “ T h i s m o d e l d o e s n ’ t w o r k b e c a u s e i t ’ s b r a i n l e s s , ” h e s a i d . R a t h e r , h e a r g u e d , o u r a d d i c t i o n t o f o o d c a u s e s u s t o o v e r e a t .

“ I n s u l i n i s t h e k e y d r i v e r a s t o h o w m u c h e n e r g y c o m e s i n t o o u r b o d y , ” h e s a i d . “ I f y o u a r e i n s u l i n r e s i s t a n t , e x c e s s e n e r g y i s s t o r e d a s f a t , w h i c h l e a d s t o c o n s t a n t h u n g e r a n d d e c r e a s e d a c t i v i t y . T h e f i r s t g o a l i s t o l o s e w e i g h t a n d t h e n b e c o m e m o r e a c t i v e . ”

Tim Noakes

School health programmes were seen as key in combating the

growing problem of cardiovascular disease among young people, which is placing a burden on South Africa’s health system, says health minister Aaron Motsoaledi.

Sub Saharan Africa has very limited resources and people felt they were not being supported by the health system,” the minister said during a session on health systems and heart disease, on the final day of the 6th World Congress on Paediatric Cardiology and Cardiac Surgery in Cape Town.

“In South Africa we felt we needed to turn a page and focus on diseases that were killing people, the minister said.

“The big debate in South Africa was about HIV and Aids when I became health minister. But a senior member of the ANC called me and asked about other deaths, the result of high blood pressure and heart disease and wanted to know what I was going to do about other deaths.”

Introducing the minister, Dr George Mensa, a visiting professor at the University of Cape, spoke of how “heart attacks were developing in the developing world” as the incidence of high blood pressure and heart disease, including heart failure, increased among younger people, particularly in sub Saharan

Africa and other low and middle income countries.

“It is affecting the young, boys and girls, and that is a real reason to pay attention to young individuals. We have to put scientific policy into practice at schools, places where people work and in public places.

Motsoaledi told delegates that as part of the “contract” he signed with President Jacob Zuma when he was appointed as health minister, he was tasked with increasing South Africans’ life expectancy, decrease pre natal and childhood mortality, combat HIV, AIDS and TB and strengthen the health care system.

An important part of the new National Health Insurance which is being introduced into South Africa was to integrate it into the school health services system, which would allow for the early identification of illness and health problems.

“People complain that by the time kids, especially those from rural area, reach hospital it is often too late as the illness was not recognised earlier,” says the minister, adding that there is not a single specialist paediatric cardiologist in the entire Limpopo province.

school health is keyBy RAY JOSEPH

“As part of the NHI we will place seven specialists in each of (South Africa’) nine provinces, including a gynaecologist and a paediatrician, and specialist nurses. We have already filled 46 percent of all the new posts.” Doctors in private practice will also be contracted to see NHI patients, he said.

His department had begun to put into practice a promise by President Zuma during his 2010 State of the Nation address to reinstate health programmes in schools.

The schools programme, which was already operating in a pilot phase in several areas, with the intention of replicating it country-wide, was targeting “very poor” schools.

“The European Union has helped us purchase 30 vehicles. We now have 10 full mobile clinics equipped with operating theatres, 10 mobile eye care clinics and 10 dental clinics.

One of the diseases being targeted was rheumatic fever, says Motsoaledi, adding that he was convinced that it could be eradicated.

“Our aim is primary protection through early detection and we are targeting the school going kids and their parents. We have good guidelines in place but people just ignore them, especially in the rural areas. We need to ensure that they are followed.”

As part of its strategy the Health Department has recruited hundreds of experienced, retired nurses into the programme to work with schools.

“We did not have a satisfactory strategy aimed at the heart until now, but believe our new plan will help with combating heart disease.

Minister

School nurse tend to a child

When Wayne Derman, who was a member of the South Africa

medical team at the Sydney and Athens Olympic Games, was asked to look after the Paralympics team in Beijing in 2008 he wasn’t sure if he was up for the job.

“I said I couldn’t do it, that I had no experience with limited ability athletes,” said Derman, a professor of sports and exercise medicine at the University of Cape Town, who is one of South Africa’s leading sports scientists.

But Derman, who was also part of the South African Paralympics medical team at the London Olympics, accepted the position – and it changed his life and the way he now views people with disabilities, he told the 6th World Congress of Paediatric Cardiology and Cardiac Surgery in Cape Town this week.

“I have seen fantastically abled

the transcenDence of injuryBy RAY JOSEPH

Wayne Derman

Sport at an Olympics level was about competitors pushing themselves to extremes – “and for athletes with a disability there is another layer of complexity.

Disabled athletes had an ability for the “transcendence of injury”, said Derman, citing the example of athlete Arnot Fourie, who suffered a serious hamstring injury during the Paralympics.

“He underwent treatment, did not go home - and four days later ran his best time ever, coming fourth in the world. Another athlete, Ilse Hayes, suffered a serious injury but went on to earn a silver medal a few days later.

“They transcended injuries that would have sent any rugby player home,” he said.

One thing in common with most disabled athletes was their self-deprecating sense of humour that saw them able to make jokes about their disability, he said.

“If you can laugh at yourself you can beat ego and remove yourself from the moment.”

Advances in technology was becoming a threat to the Paralympics where sometimes better athletes were beaten because their opponents had access to better, lighter equipment.

“The tech makes a huge difference and it is something that will have to be carefully looked at in the future,” he said.

people being disabled and disabled people being abled,” he said.

As is normal at a medical conference it is standard practice for speakers to disclose any possible conflicts – which Derman did before he launched into his presentation, “Behind the lens: the London 2012 Paralympics Games.

Disclosing a close doctor-patient relationship with “Blade Runner” Oscar Pistorius, South Africa’s multi-gold Paralympics medallist who has been charged with the Valentine’s Day murder of his girlfriend, he told delegates.

“I wish this talk was a week ago. I have looked after Oscar for the last five years. The events of the last week have left me and my family shocked to the core of our souls and our heartfelt sympathies go out to both families involved.”

Derman said while the number of competitors and size of the Olympics Games had reached a plateau, the Paralympics was a “growth industry” both in the number of competitors and in public interest.

“Among my reasons in going to London was to see if it could help change what young people think about disability and whether it would change attitudes,” he said. “It did, the media helped swing it. It helped make ordinary people experts on disability.

Oscar Pistorius

This newsletter was produced by the team at HIPPO. www.hippocommunications.com

MeMories of the 6th worlD congress