Tulane University receives $12 million NIH grant to develop drug and vaccine against Lassa fever

Tulane University receives $12 million NIH grant to develop drug and vaccine against Lassa fever

The National Institutes of Health has awarded Tulane University more than $12 million to test a promising drug treatment against Lassa fever and develop a vaccine against the deadly disease endemic in parts of West Africa.

The NIH’s National Institute of Allergy and Infectious Diseases awarded virologist Robert Garry two, five-year grants for the preclinical research — $5.72 million to evaluate a potent Lassa fever antibody drug cocktail and $6.32 million to design a vaccine based on a recently discovered key antibody target on the surface of the virus.

Lassa fever is a severe and often fatal hemorrhagic illness caused by Lassa virus. There is no vaccine against the virus, which infects more than 300,000 annually.

“These two projects complement each other. In West Africa, we need a drug to treat acutely infected patients as well as a preventative measure to stop it,” says Garry, professor of microbiology and immunology at Tulane University School of Medicine. “Vaccine initiatives in rural Africa are difficult so you are never going to be able to vaccinate everyone. You need to be able to treat people when they get sick.”

The vaccine will test antibodies that target a recently identified viral surface structure, called the surface glycoprotein, which can block it from infecting a host cell. The vaccine will also incorporate similar glycoproteins against Ebola that are already being tested in clinical trials.

“Ebola is likely to come back, and Lassa isn’t going away so you have to protect against both,” Garry says. “We think we can do it with one shot.”

The other project will test the three most potent Lassa antibodies to see which formulation will work best in a drug therapy. Together, the three have been highly protective in early animal studies, Garry says. Collaborators include Tulane virologist Dr. James Robinson and scientists at Zalgen Labs, The Scripps Research Institute, the University of Texas Medical Branch at Galveston and the Sanford Burnham Prebys Medical Discovery Institute.

Tulane researchers have been studying Lassa in West Africa with a team of collaborators for more than 14 years. They have developed a rapid test to diagnose the disease in the field and spent years collecting blood samples from survivors to identify critical antibodies against the virus.

Blood tests can now spot early pancreatic cancer

Blood tests can now spot early pancreatic cancer

Typically, pancreatic cancer is only discovered when the tumours are already too large to treat.

By the time pancreatic cancer is detected, it is so severe that four out of five people will die after diagnosis, but a new blood test may accurately detect pancreatic cancer in its early stages. This discovery offers new hope for people at risk of this fast-moving and often fatal disease, researchers said.

Pancreatic cancer affects the pancreas, a gland which is located in the upper abdomen. Pancreatic cancer is often referred to as the “silent disease” because symptoms are few and non-specific, mostly leading to late diagnosis.

Cancer of the pancreas tends to affect people over the age of 50, and most sufferers are aged 65 to 80 at the time of diagnosis. Men are at slightly higher risk than women.

One of the deadliest cancers

More than 53 000 people in the United States are diagnosed with pancreatic cancer annually. It is the fourth leading cause of cancer death. While statistics provided by the Cancer Association of South Africa (Cansa) may not be the leading cause of death through non-communicable disease in South Africa, the survival rate is still at a low of 20%, although survival is on the increase through the advance of medical technology.

“A long-standing concern has been that patients with pancreatic cancer are often not diagnosed until it is too late for the best chance at effective treatment,” said study co-author Robert Vonderheide, director of the Abramson Cancer Center at the University of Pennsylvania. “Having a biomarker test for this disease could dramatically alter the outlook for these patients.”

Biomarkers in blood can detect pancreatic cancer

Using stem cell technology to create a cell line from a patient with advanced pancreatic ductal adenocarcinoma, researchers were able to turn back the clock on the progression of the disease. In doing so, they found a pair of biomarkers (or identifiers) in the blood that picked up pancreatic cancer in human cancer cells at different stages of tumour growth.

“Genetically reprogramming late-stage human cancer cells to a stem cell state enabled them to force the reprogrammed cells to progress to an early cancerous state, revealing secreted blood biomarkers of early-stage disease along the way,” said a summary of the report, published in the journal Science Translational Medicine.

One biomarker known as plasma thrombospondin-2 (THBS2), combined with a known later-stage biomarker called CA19-9, “consistently and correctly identified all stages of the cancer,” said lead author Ken Zaret, director of the Penn Institute for Regenerative Medicine.

“Notably, THBS2 concentrations combined with CA19-9 identified early stages better than any other known method. “The test could be done with an inexpensive, commercially available protein-detection assay, researchers said.

Further work needed

In principle, the test could be applied right away, though researchers cautioned they want to do further work “to be absolutely certain of the cutoff values that we have for what is a significant or likely call for disease,” a spokeswoman said in an email. “Some more work will be needed but in general the test and concept could be applied,” she said.

A key population for the test would include people with a family history of pancreatic cancer, those with a genetic predisposition to the disease, or who had a sudden onset of diabetes after the age of 50. Earlier this year, a separate team of researchers in the United States and China unveiled a new blood test for detecting pancreatic cancer. That method involved finding a protein dubbed EphA2 found in pancreatic tumours, according a report in the journal Nature Biomedical Engineering.

e-health key in leveraging the quality of healthcare services

e-health key in leveraging the quality of healthcare services

Information and communication technology (ICT) is no longer just bits and bytes; it has become a tool to scale the world to greater heights. Various sectors have embraced it as a tool driving development, the health sector inclusive.

During the African Health Forum of the World Health Organisation that was held last month, e-health was one of the topics discussed.

e-health is the use of ICT to provide and support healthcare service delivery.

Edith Munyana, the health network and systems administrator specialist at the Ministry of Health, explains that e-health is a broad matter which encompasses different aspects, ranging from patients having online access to medical services to doctors carrying out operations through online platforms.

Rwanda has embraced the use of digital health with the Ministry digitalising systems such as Rwanda health management information system, a tool used in validation and analysis of statistical data tailored to integrate health information management activities. There is also the electronic logistic management information system which provides an effective and sustainable supply chain system for medicines and other health commodities, among others.

Forms of e-health

e-health encompasses a number of sub-domains including, electronic medical records, telemedicine, mobile health (mHealth), health IT systems and virtual healthcare.

Dr Fidel Rubagumya, the Founder of Rwanda Children’s Cancer Relief, defines electronic medical records as a digital version that contains a patient’s medical history.

When a patient is referred, for example from Butaro Cancer Centre to King Faisal Hospital, and everything that was recorded at Butaro is lost and the doctors have to start from zero. This he says affects the subsequent treatment. However, with this system all this can be improved upon, he says.

Munyana says telemedicine is where healthcare professionals diagnose and treat patients in multiple locations by means of telecommunications technology.

“Ability to carry out telemedicine consultations between district and referral hospitals has helped reduce the number of patients that are transferred from district to referral hospitals and outside Rwanda.”

With health IT systems, health portals help to disseminate health information to promote healthy behaviour in patients.

Munyana says the trend of e-health has picked momentum as more service providers and patients come aboard.

In regards to electronic medical records, there are 12 hospitals with registration and billing modules and 340 health facilities with one module of EMR (HIV package). Also there are 15 sites with facilities of telemedicine, says Munyana.

ICT as a tool for quality healthcare

Andrew Rugege, the director, International Telecommunication Union (ITU) for Africa, says ICT is a tool capable of accelerating the provision of excellent health services to citizens.

He says there is a lot of work to be done not only in Rwanda but all over Africa in terms of e-health development.

“The slow progress is allover Africa but we are going to double our effort. Our aim is to simplify access to e-health services and make it as simple and as cheap as possible such that even the person deep down in the village can access it,” Rugege says.

Rubagumya, however adds that, in as much as we are building hospitals and other infrastructure there are still a few specialised doctors.

“e-health can be used with the use of video-conferencing or tele-videos, among others, to optmise the few specialists we have to help guide general practitioners to diagnose and treat complex cases,” he says.

Challenges

Munyana says the cost of advanced e-health infrastructure, for example, telemedicine infrastructure, plus the accessibility challenge in remote areas is still an obstacle.

Rugege says the different e-health initiatives in place pose a challenge without proper coordination.

“We found that many countries don’t have strategies and policies on e-health. More awareness is needed on this matter for policy makers and leaders to be able to make fitting strategies and policies and also do capacity building for health workers,” he says.

Way forward

Munyana says to overcome these challenges there is need to mobilise funds to increase the number of health facilities to be connected and also to work with local governments and stakeholders to avail internet facilities in remote health facilities.

Rugege points out that the International Telecommunication Union agreed to do a joint initiative called “be healthy be mobile”, to accelerate Sustainable Development Goals.

“The initiative has three sides; the first one is digital health leaders to help develop policies; the second is digital health platform for the different initiatives; and the third is access and sustainability.

“The initiative will help build a common platform for e-health services by bringing them into one framework. We shall also do resource mobilisation to ease access to devices used in accessing these services,” he says.

Jean-Philbert Nsengimana, the Minister of Youth and ICT, says with the right type of investment, e-health will be on the right track.

“Something has been done both on the level of public health and on the consumer’s side. There are several start-ups providing different services such as Babylon health Rwanda, and I think that’s where most of the focus needs to be to improve our healthcare services,” he says.

“The use of ICT in health is very important, more so in prevention, reducing the cost of healthcare by cutting unnecessary travel expenses in search of quality medical services.”

ANC BACKS USE OF INDIVIDUAL TAX REFUNDS FROM MEDICAL AIDS FOR NHI

ANC BACKS USE OF INDIVIDUAL TAX REFUNDS FROM MEDICAL AIDS FOR NHI

The African National Congress (ANC) says it supports a proposal by the health sector to redirect individual tax refunds from medical aids to fund the National Health Insurance (NHI).

The party’s education and health commissions have given a report back on the resolutions taken during the recent ANC policy conference.

Chairperson of the committee on health and education Naledi Pandor says about R22 billion is paid out annually in tax rebates that could go towards improving South Africa’s health sector.

“We thought this would give a very important catalyst to the health sector as we seek to implement the National Health Insurance.”

She says the implementation of the NHI remains a priority.

“NHI will succeed by the degree to which it addresses prevention rather than treatment, and as primary healthcare, it is extremely important to the successful implementation of the NHI.”

The committee has also proposed that the ANC review its current policy cycle from the current five-year period to 10 years with regular reviews to monitor whether these policies are being implemented.

Eco Media Village and Milost to built largest private hospital in West Africa

Eco Media Village and Milost to built largest private hospital in West Africa

The proceeds are expected to be used for specific working capital, the development and construction of the hospital. The debt facility will bear interest at an annual rate of 5%, payable quarterly in cash. Construction at the site is expected to be launched following the closing of the financing and the filing with the U.S regulators for an initial public offering (IPO).

The Chief Executive Officer of Eco Medical Limited, Peter Ahiekpor said, “It’s a good day for Ghana and Africa as a whole today. Building a medical facility where the three major languages of Ecowas will be practiced will not be an easy journey by itself but is worth it. Lots of strategic planning has gone into this project for the last three years and based on the strength of this project, we are very glad to have an institutional investor like Milost to invest in this project that will bring medical care to the average African.”

In connection with the foregoing, the Investor has been granted the right to nominate 2 directors for Eco Medical Limited’s Board. Closing is expected to occur by July 31, 2017 and is subject to the execution of definitive documents. The financing was arranged and negotiated on behalf of Eco Medical Limited by Palewater Advisory Group Inc. Eco Medical Limited has also retained the services of Palewater Advisory Group as an in-house advisor pertaining to the IPO on Nasdaq.

The CEO of Milost Global Inc, Egerton Forster stated, “This is our first investment in Ghana and we are happy to be part of Eco Medical Village’s growth story, most importantly that we are investing our capital in a company with a great story to tell. We continue to look for great investment in Africa opportunities such as this.”

Mandla J. Gwadiso, the Chief Investment Officer of Milost Global Inc stated, “Peter and his team that is led by MB Africa Investments (Pty) Ltd have done an amazing job and this is nothing but proof that Ghana is not small and that it plays a crucial role in the enhancement of the West African economy as an emerging market. Milost looks for companies that resemble Eco Medical Village, companies with a prevailing and preeminent value creation strategy.”

Marrone Bio Innovations, Inc. Products Show Impressive Results in International Trials Against Key Pests and Diseases

Marrone Bio Innovations, Inc. Products Show Impressive Results in International Trials Against Key Pests and Diseases

Marrone Bio Innovations, Inc. (NASDAQ:MBII), (MBI) a leading provider of bio-based pest management and plant health products for agriculture, turf and ornamental and water treatment markets, has reported excellent product efficacy results in fast growing international markets with intense pest and plant disease problems.

The drivers beind the rapid adoption of biologicals are globally recognized and include evidence of increased yields and crop quality when biologicals are integrated into programs. Biologicals are also a key driver behind the reduction or elimination of synthetic pesticide residues on crops for export markets, delay of pest and plant pathogen resistance to chemicals, safety for workers and pollinators, and less environmental pollution.

In South Africa, Grandevo® and Venerate® Bioinsecticides have generated positive trial results in citrus – a key agricultural market. MBI products reduced citrus rust mite populations more than 96% and offered fruit a comparable level of protection as commonly used chemical products. Both Grandevo and Venerate provided effective control of citrus fruit damage caused by false codling moth. This pest bores into the citrus fruit, making them unmarketable. South Africa is Africa’s largest exporter of agricultural products and exports more than 1.6 million metric tons of citrus annually, with most fruit being shipped to the EU and Asia where limits on chemical residues are strictly enforced1. South African growers are increasing their use of biologicals to meet the demands for residue-free food from local and international markets, and in response to the EU’s ban on controversial neonicotinoid insecticides.

In Latin America, field trials with MBI products have demonstrated efficacy in addressing serious, key crop problems. For example, the addition of Regalia® Biofungicide enhanced existing industry programs for controlling coffee rust. Venerate Bioinsecticide, used in integrated pest management (IPM) programs for managing the dreaded coffee berry borer or “Broca,” successfully reduced the number of organophosphate insecticide applications, including that of the controversial chlorpyrifos, by 50 percent. The program with Venerate reduced boring damage by almost 70%, which was 40 percent more effective than the chemical-only program. Broca can cause coffee farmers to lose up to 20 percent of a crop and reduce the crop’s marketable price by 30 to 40 percent2. Coffee rust causes $1 billion in damage to coffee plants across Latin America and the Caribbean.3

Majestene® Bionematicide reduced the most important pest nematodes of bananas (burrowing nematodes) as well as or better than the organophosphate, chlorpyrifos. The burrowing nematode destroys the roots of bananas and plantains so that the plants are starved of water, nutrients, and lack support, causing 30-60% yield loss4. The use of Majestene to control nematodes would be a major step forward in reducing exposure risks to pesticide applicators as well.

In Mexico, both Grandevo and Venerate bioinsecticides have demonstrated effective and reliable control of the Asian citrus psyllid (ACP), a serious pest that transmits HLB disease. The Asian citrus psyllid has devastated Florida groves and has been recently found in California. Field trial data supporting the use of these two MBI-developed bioinsecticides to control Asian citrus psyllid is now being submitted to support label amendments, adding ACP control to existing Grandevo and Venerate registrations and labels in Mexico.

In Asia, Regalia is advancing in banana trials in the Philippines, showing good activity against the most serious disease this crop faces globally, black sigatoka. In previous trials in Costa Rica, Regalia combined with the standard chemical program increased banana girth by 27% compared to the standard chemical program alone. Convential sprays for this disease are 15-20% of the cost of bananas ($1000/hectare, 25-40 sprays per season).5

In Vietnam, MBI’s distribution partner has completed initial trials with Regalia showing a 20% increase in rice yields, and a concurrent reduction in discolored and unfilled grain caused by rice neck blast disease. Also, in citrus trials in Vietnam, Regalia decreased bacterial canker by more than 70%. In insecticide trials, Grandevo performed under intense pest pressure, reducing pest populations for control of red mites, thrips and mealybugs on strawberry, pumpkin, custard apple, orange and dragon fruit.

Sources: 1USDA Foreign Agricultural Service, Global Agricultural Information Network Report 12/15/16, 2Specialty Coffee Association of America, 3 US AID, 4Pestnet.org, 5American Phytopathological Society

Dr Reddy’s, Lupin, others mull expanding Africa operations

Dr Reddy's, Lupin, others mull expanding Africa operations

Domestic pharmaceutical companies are expanding their Africa operations with a series of product launches, besides planning to foray in new markets.

In FY 2017, drug makers exported medicines worth $ 3 billion to Africa and the continent is the second largest export market for Indian companies after the United States of America.

According to healthcare service provider Quintiles IMS, the overall African drug market is estimated to grow from $20 billion in 2016 to $30 billion by 2021. Much of the projected growth will come with several changes in regulations, increase in health spending and a rise in demand for medicines to treat chronic and lifestyle-related ailments.

One such change in regulation came into force in June with the formation of the South African Health Products Regulatory Authority (SAHPRA) and that is expected to quicken the pace of new product approvals in the country.

“The recent establishment of SAHPRA could usher in a new and much more effective era for the local pharmaceutical sector as the existing Medicines Control Council has struggled to cope with the volume of applications for new medicines and clinical trials. Based on industry figures registering new products with the MCC took three to five years and in some cases even exceeded seven years. We are hopeful that the new body will streamline the process to deal with the backlog and by 2020 registrations will be completed within 18 months of submission,” said Erik Roos, CEO of Pharma Dynamics, Lupin’s subsidiary in South Africa.

South Africa is the biggest market for Indian pharma companies and accounts for nearly a fifth of their exports to Africa. Cipla is the largest generic company in South Africa and Lupin and Sun Pharmaceuticals also figure in the top list of generic drug makers.

In FY 2017, Pharma Dynamics crossed the one-billion revenue mark in local currency for the first time at around Rs 481 crore. The firm it is now looking to grow sales of its tuberculosis products and expand operations in parts of the continent.

“Most of the African countries will increase their generic consumption and more than 70 per cent of the growth is likely to emanate from generic consumption. India has a good potential to contribute big in the situation,” said Udaya Bhaskar, director general of Pharmaceutical Export Promotion Council of India.

Others too are expanding their businesses located in the world’s second most populous continent. Torrent said it plans to launch 7-10 products in Africa each year and its focus markets include South Africa, Kenya, Tanzania and Zimbabwe. Dr Reddy’s Laboratories (DRL) is tapping opportunities in French-speaking countries in Africa, where the presence of Indian drug firms has been limited so far.

Over the last few years, DRL saw a double-digit growth from Africa by strengthening its field force in unrepresented markets and looking at inorganic growth opportunities.

Other than South Africa, DRL is focused on North African countries such as Algeria, Egypt, Morocco and Tunisia. However, the North African market has its own challenges.

“The industry is yet to come to terms with the over 100 per cent depreciation of Egyptian pounds in the last six months. Although there are entry barriers in Algeria and Morocco, yet we are working towards addressing market needs with a focus on complex generics and proprietary products. Some of our filings have already commenced in these markets,” said M V Ramana, the executive vice president & head branded markets of India and emerging countries.

cannabis greenhouse Zimbabwe Considers Legalizing Cannabis Production

cannabis greenhouse Zimbabwe Considers Legalizing Cannabis Production

The continent of Africa is a complicated and intricate tapestry when it comes to cannabis reform.

In some African countries, like Zambia for instance, cannabis is highly illegal and many people go to prison for it. In South Africa, marijuana for medical purposes has leaped forward, and even personal use has made some headway.

Now, it looks like Zimbabwe is considering legalizing the cultivation and use of medical marijuana.

An application has been made to the Government of Zimbabwe, by an as-yet unnamed Canadian company, to cultivate marijuana for medical purposes.

Zimbabwe’s Macro-Economic Planning and Investment Promotion Minister, Dr. Obert Mpofu, stated at an annual general meeting on June 28th of the National Chamber of Commerce, that a Canadian conglomerate is looking to partner with the government to produce medical cannabis.

“We have received numerous inquiries from investors who want to participate and one of them is a big international company that wants to be involved in the production of cannabis,” said Dr. Mpofu. “I laughed and thought they were joking when I receive the inquiry but they are serious. This seems to be big business.”

Currently, in Zimbabwe, individuals convicted of possession of marijuana can receive up to 12 years in prison, so if this effort if successful, it would go a long way to dampen the fires of prohibition.

Dr. Mpofu added that the government is taking this application seriously.

“This company is from Canada and it’s one of the biggest conglomerates in that country, and they are producing cannabis for medical purposes under strict conditions,” said Mpofu. “I don’t see anything wrong and I think if we legalize [cannabis] we will benefit medically because it is used for painkillers such as Morphine. South Africa has done that.”

There has been no word on next steps within the application process, but more information will no doubt be provided in the coming days ahead.

State can cure skewed disease research

State can cure skewed disease research

SA is the top country in Africa for medical research and development (R&D) and one of the top in the world. It invests heavily in R&D, has world-renowned universities and research laboratories and has the highest scientific output per capita on the continent. Yet despite its pre-eminence in R&D, the country’s healthcare system is still weak.

According to the World Health Organisation’s 2017 statistics, SA’s life expectancy at birth is 62.9. This is high for sub-Saharan Africa but low compared with other mid-and high-income countries. In recent initiatives, the Department of Science and Technology directed research funds towards diseases that most affect the country. This effort has been effective, yet there is still gross inequality in research and disease burden.

For example, HIV/AIDS accounts for about 40% of the country’s disease burden, yet it receives far less attention (less than 4% by some calculations) from researchers. This is a grave injustice. SA needs to continue to orient its health innovation system to better target illnesses that affect the largest portions of society. Without guidance and investment from the government, R&D will not help the average South African and inequality will only grow.

Since 2005, SA has invested in nanotechnology research. Nanotechnology is the study and manipulation of matter below 100 nanometres in order to develop new devices and materials. Matter behaves differently at the nano scale versus larger scales and scientists can, therefore, create novel “nano” products.

In medicine, nanotechnology has the potential to enhance HIV/AIDS treatment to cut down on the presence of cancerous tumours and advance new therapeutic strategies such as gene therapy, chemotherapy drugs and immunotherapy.

The department wanted nanotechnology to benefit the poor, so it directed funding towards pro-poor initiatives by prioritising research into diseases such as HIV and tuberculosis (TB). However, many less prominent diseases received proportionately more attention. In an unpublished report by the Mapungubwe Institute, researchers found that Parkinson’s disease accounts for 2% of nanomedicine research, but is only 0.04% of South African disability-adjusted life years. In addition to Parkinson’s, South African scholars study malaria, hepatitis B and Alzheimer’s in greater proportion than their disability-adjusted life years.

On the other hand, HIV/AIDS is severely understudied. HIV/AIDS accounts for 40% of SA’s disability-adjusted life years but represents only 4% of South African nanomedicine research. The gross mismatch between R&D and the needs of South Africans shows that the interests of researchers can be at odds with the needs of the community.

We believe this mismatch is the symptom of global trends in medical R&D and the challenging economics of developing medicines that help the poor. Pharmaceutical companies have little desire to research diseases such as malaria, TB and HIV/AIDS because it will be difficult for them to recoup their R&D costs from medicine sales. In contrast, there is a robust market for cancer and Parkinson’s disease medicines and they are, therefore, willing to invest in R&D in these fields.

As a consequence, well-targeted state intervention is needed to encourage R&D on diseases that do not have a market.

In a provocative book titled The Entrepreneurial State, Mariana Mazzucato provides examples of cases in which the state has inevitably been a lead investor and risk-taker in capitalist economies through “mission-oriented” investments and policies.

They include key technologies such as the internet, nanotechnologies, microbiology and drug discovery technologies, where the state played a leading role in achieving the necessary technological breakthroughs.

The state can risk funding initial R&D in areas that have no clear market but that push the bounds of science. An outstanding example is the iPhone — all the key technologies behind it, such as the touchscreen, the internet and microprocessors, were funded by the state. The Obama administration also provided a direct $465m loan to Tesla Motors to build its model S.

The state should undertake risky investment to find solutions for its critical medicine research and drug discovery. The focus of private pharma is to focus on less innovative drugs, and private venture capitalists enter only once the real risk has been absorbed by the state.

Bill Gates said the key element to getting a breakthrough is more basic research, and that requires the government to take the lead. Only when that research is pointing towards a product, can we expect the private sector to kick in.

The government should play a leading role as an “entrepreneurial” investor and reap some of the financial rewards over time by retaining ownership of a small proportion of the intellectual property created.

Rather than succumb to its preassigned role as a “market fixer”, the government’s role should include resource mobilisation and setting the conditions for widespread market commercialisation.

It is time for SA to ask: what is it that the public and private sectors can do together to tackle the dire healthcare situation?

There is a great need for science and politics to combine efforts. A diverse set of governance actors, programmes, instruments and influences are needed by each form of new technology.

These recommendations will not immediately solve all of SA’s health problems, but would put the country in a better position to improve its health-innovation system and the wellbeing of its people.

Africa: Could Mediation Cure South Africa’s Medico-Legal Woes?

Africa: Could Mediation Cure South Africa's Medico-Legal Woes?

“We are closer to a solution than we have ever been,” says medical body Sasog

Skyrocketing medico-legal claims threaten to cripple South Africa’s public and private health sectors as specialists face exorbitant litigation. Without drastic intervention, experts warn, health care could soon become unaffordable – or unavailable. Meanwhile, legal experts say mediation could be a solution hiding in plain sight.

“Something’s got to give,” says David Campbell, managing director at medical indemnity insurance company MPLA. He says South Africa’s laws allow for medico-legal claims to haunt health workers up to 19 years after an incident. The possibility that healthcare workers will have to pay for mistakes made years ago is forcing insurance companies to increase medical indemnity rates radically, he says.

“The reason that the premiums are so high is not based on a projection of the future or the present, it’s based on what they might discover you did in the past, which you can’t even remember,” Health Minister Aaron Motsoaledi told Bhekisisa in May.

Bhekisisa previously reported that in 2009 obstetricians and gynaecologists paid R78 000 for insurance. In 2017, the Medical Protection Society’s insurance costs around R800 000 – an increase of 925%.

Motsoaledi has said that professionals specialising in difficult areas of medicine, such as orthopaedic surgery, were among those most targeted by medico-litigation and concurrent rise in insurance prices.

Campbell explains: “High-risk specialists like obstetricians and neurosurgeons will either become unaffordable or unavailable. Obstetricians are already leaving the field – and rightfully so. A 50-year-old obstetrician would be right to worry about a summons of however many zeros arriving at their door at age 69.”

President of medical professional body the South African Society of Obstetricians and Gynaecologists Johannes van Waat says the organisation’s records show about 50 obstetricians left the field in 2016 – almost 7% of their members. He says Sasog expects to lose 100 more this year if the litigious trend persists.

Van Waat explains: “Some members retired, but mostly obstetricians are reverting to gynaecology to avoid delivering babies, since litigation is spiralling out of control.”

Campbell says backlogged claims should be given an expiry date. He adds that legislation should be amended to stipulate that future claims must be prosecuted within three years after the incident occurred, as was the case under the Road Accident Fund. Although he admits this might cause a sudden spate of claims, Campbell argues unclogging the system will give insurers a better chance at predicting future losses. This will in turn bring down medical indemnity rates and the cost of health care, he says.

“The people always pay”

According to health minister Aaron Motsoaledi, claims against his department stood at more than R61-billion as of October last year – a third of the country’s health budget.

Campbell says strain on the budget opens up the department to further litigation. He explains: “If clerical staff aren’t paying the accounts, you don’t have clean sheets and equipment doesn’t get fixed. Administrative problems pose a bigger threat to hospitals than failed operations.”

Bhekisisa reported last month that the North West department of health will cut 2000 of the province’s health posts, or 20%, to compensate for tight budgets. Spokesperson Tebogo Lekgethwane said administrative posts would be among the first to go.

Motsoaledi and Campbell agree the way patients are compensated for claims of medical malpractice and negligence is unsustainable.

The health minister says critical funds are lost when the department loses cases of negligence or malpractice and has to pay patients out in lump sums instead of annual payments. He explains that this is because these large upfront payments are, in the absence of local data, often calculated by how much care the affected person will need in their lifetime. In absence of local data on the average life expectancy of patients with conditions such as cerebral palsy, these lifetime costs estimates are often based on calculations from wealthier countries. Cerebral palsy is a disorder that affects children’s ability to move or sit up without assistance. It is often associated with complicated or prolonged labours, says the US nonprofit the Mayo Clinic.

Motsoaledi explains: “There’s no chance South Africa’s life expectancy is the same as America’s – but that’s what the department is paying for.”

The health department may also be paying patients twice: “Charges are based on the child being cared for in a private hospital. But when the case is closed, the child is taken to a public facility – where the state takes care of that same child.”

Campbell says compensation should ideally be based on a nationally standardised level of care, such as one that will eventually be proposed under the National Health Insurance.

In the meantime, Campbell argues that compensation could instead be calculated based on the standard of care – public or private – that patients’ families are able to afford.

He explains: “If the goal is to curtail medical malpractice costs to be in line with our country’s ability to afford, we need a more practical approach to compensation that suits the socio-economic conditions of the patient. The judiciary could decide that that the patient should not be entitled to more at the expense of the greater community.”

Ultimately, he says, everyone is paying for the country’s epidemic of medico-legal litigation, whether it’s through increased doctors’ fees as health workers pass rising insurance costs onto patients or rising taxes as the state recoups costs: “The people always pay. Whether through increased medical aid fees or increased fuel levies – it’s a disproportionate redistribution of wealth.”

A light at the end of the tunnel?

Meanwhile, the health department, legal experts and professional bodies are waking up to the benefits of mediation before litigation.

Mediation starts with accepting that something went wrong, says Motsoaledi: “But instead of fighting in court, let’s sit down and talk about what you as a patient will regard as justice.”

He says the health department has requested the South African Law Reform Commission (SALRC) to legislate that mediation will precede any litigation against the state. Researcher at the SALRC Ronel van Zyl confirmed receipt of a joint request from the departments of health and justice. Van Zyl says the commission will release issue papers on the application in late July.

Society of Obstetricians and Gynaecologists’ Van Waat says the body strongly supports mediation. He says they will this month begin offering free pre-mediation meetings for members and patients wishing to explore litigation.

Van Waat says the prospect of mediation has already enticed some of his members to stay in the field: “We are closer to a solution than we’ve ever been. Since mediation has come onto the scene, a number of obstetricians are hanging around to see what happens.”

As part of meetings, doctors and patients will establish what the dispute is about and try to find suitable trained mediators, says director of mediation at the South African Medico-legal Association (Samla) Alan Nelson. He explains: “Often it seems like a medical problem, but it turns out to be a racial issue where somebody wasn’t treated with the necessary dignity.”

Mediation is not binding until a written agreement is signed and does not stop any party from litigating, he says. “You don’t lose a thing if you try this way first.”

Nelson practised as a litigation lawyer for 40 years before training as a mediator.”I loved every second of it. I thought that if I litigated hard and won cases for patients, I was doing good. At this stage of my life, I have to admit that I wasn’t.”

In 2015 Nelson co-founded nonprofit Mediation in Motion. The organisation has established a fund to provide a qualified mediator to anyone in need.

“Going to to court before mediation is like going into surgery if there is a pill to cure your pain,” he says.

And while litigation can take years before information about the root causes of problems are sent back to hospitals or clinics, these facts are sent back to facilities almost immediately. “The hospital can address the problem. With litigation it’s defend and deny, and more people suffer from the same inefficiency or problem,” Nelson argues.

He tells of two women that both lost their babies at overcrowded hospitals during Easter weekend. The first he represented as a litigation lawyer. He explains: “We won the case and got one of the highest awards ever. But it took seven years out of my clients’ life. I saw a woman go through hell as she lived and relived the death of her baby.

“In the second case, the mediation took one day – and she was thrilled,” says Nelson. The woman did not receive a cash settlement but instead negotiated access to training and mentorship that eventually helped her find a job.

“This woman lost her baby, but through mediation she got a new life.”