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Death, Denial And Fear: What Listeriosis Cost South Africa

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December 25, 2017, was the worst Christmas for the Warmback family.

The festivities began two days before with the arrival of Keith and Glenda Warmback’s children from the US. There was food and celebration as the couple saw their one-year-old granddaughter for the first time.

“That evening, we went out and my wife had a chicken salad [from one of the fast food restaurants]. The following day my wife Glenda started having a tummy ache. She went to lie down for a while. She fell asleep and I woke her up around 5PM and she said she couldn’t get out of bed because she wasn’t feeling well and had a running tummy,” says Keith.

Keith says he was woken up by barking dogs, in their room where Glenda was asleep, at about midnight.

“I went to see what was going on and I found Glenda on the floor. She said she thought she had a stroke,” he recalls.

He bundled her up and rushed her to the nearest private hospital.

“The staff was disastrous… They were disinterested in my wife’s condition and three others who were there with similar symptoms,” says Keith.

According to Keith, it was just the beginning of a series of mistakes. Eventually, Glenda’s lungs collapsed and she died at 2AM on Christmas day. She was 61 years old; they had been married for 41 of those.

“The painful thing is the incompetence at the hospital,” says Keith.

Keith Warmback lost his wife Glenda to Listeriosis on the Christmas day of 2017. Photo by Motlabana Monnakgotla.

Doctors sited natural causes as a cause of death. The problem is, just 20 days before, the health minister had announced a foodborne outbreak called listeriosis. According to Keith, Glenda had all the symptoms and blood tests indicated she had it but she was never treated for it.

READ MORE: The Rat Race Against The silent Killer

At the time of going to press, Glenda was one of 183 South Africans who had died from this disease since January 2017; 978 had been infected. It is the world’s worst outbreak of listeriosis, according to the World Health Organization (WHO).

“Listeriosis is the name of a disease that people develop when they eat food that is contaminated with the bacterium called listeria,” says Dr Juno Thomas, head of the Centre for Enteric Diseases at the National Institute for Communicable Diseases (NICD).

According to Thomas, this bacterium is found worldwide. It can be in soil, water and even faeces in many animals.

“Once in the environment, it is very difficult to get rid of because it attaches to things very easily. Once it attaches itself in an environment, it produces a layer of a sticky sugary slime that sticks onto the surfaces and makes it difficult to remove and resistant to disinfectants,” says Thomas.

According to Health Minister Aaron Motsoaledi, South African hospitals saw and treated an average of 60 to 80 patients affected by listeria between 2013 and 2016 with no problems.

Then, in July last year, doctors started seeing more cases of newborn babies born with listeria.

Keith looks at an image of his wife (right), Glenda Warmback. Photo by Motlabana Monnakgotla.

It was a cause for concern. They informed the NICD. A search, led by Thomas, began. On November 29, they found that at the time, 557 people had been infected.

“A team from the NIDC interviewed 109 patients to obtain details about foods they had eaten in the month before falling ill. Eighty five percent of the people reported eating ready-to-eat (RTE) processed meat products, of which polony was the most common, followed by viennas/sausages and then other ‘cold meats’,” says Motsoaledi.

Sixty percent of cases were reported in Gauteng, 13% in the Western Cape and 7% in KwaZulu-Natal.

“We think it affected Gauteng the most because of consumer behavior. Things like sausages, polony and viennas are staple street and household foods in Gauteng because they are affordable and quick to prepare. The economy of Gauteng also plays a factor. There are many more people who can afford to buy these items than other provinces,” says Thomas.

Even armed with this information, the source of the outbreak remained unknown.

Symptoms of Listeriosis:

  • Fever
  • Diarrhoea
  • Vomiting

“When you have an outbreak like this you have no idea where it comes from. We also had not seen many cases of listeriosis in the country, meaning it wasn’t a big health priority compared to all the other issues we have to deal with. For example, we saw 30,000 cases of malaria last year, rabies is a big concern, TB and many others were more severe,” says Thomas.

With hard work and vigilance, the outbreak was traced from Soweto.

Nine crèche kids under the age of five got ill and were admitted to the Chris Hani Baragwanath Hospital. Tests revealed that they had been infected. A team went to the crèche the very day and found kids had eaten polony manufactured by Enterprise Foods, owned by Tiger Brands.

“We then visited the Enterprise Foods factory in Polokwane that makes this brand. We took over 28 samples and they tested positive for the outbreak strain. The conclusion from this is that the source of the present outbreak can be confirmed to be the Enterprise Food production facility in Polokwane,” she says.

On Sunday March 4, Motsoaledi ordered a safety recall of all products from Tiger Brands.

READ MORE: A Deadly $75-Billion Business

After Motsoaledi’s announcement, Tiger Brands shares fell more than 10% when the market opened on Monday.

“It is devastating for me that our business is linked to this outbreak… we detected low levels of listeria in our products on the 14th of February. We took immediate precautionary measures which included immediately halting production of the affected product, quarantining all affected product within our distribution center and withdrawing all affected products manufactured on that day,” says Tiger Brand CEO Lawrence MacDougall at a press briefing the next day.

MacDougall, however, controversially denied any responsibility for the deaths.

“There is no direct link with the deaths to our products that we are aware of at this point. Nothing… All of our tests and results indicate that we kept a very high standard of quality protocols within those sites. The expectations going forward is that those standards are significantly increased if there is going to be a zero detection of listeria going forward,” he says.

Motsoaledi argues that there is proof the ST6 strain was found at their facilities.

“The fact remains that we have had an outbreak of listeria, we informed them [Tiger Brands], in terms of fair administrative justice, that we got the results and we were going public with them. I don’t think they did enough to make sure their produce is safe for consumption by the public. I believe the best way is for this to be a civil case rather than a government case,” says Motsoaledi.

Renowned corruption buster and private forensic investigator Paul O’Sullivan agrees. He is filing criminal charges against the board of Tiger Brands and has called upon them to step aside pending the outcome of the investigations.

O’Sullivan has teamed up with human rights lawyer Richard Spoor to bring charges.

“What is particularly shocking is that Tiger Brands, in its most recent annual report, placed product quality as number nine on the list of risks facing the company, when it should have been be at number one. We cannot think of a greater risk to the sustainability of any food company, than that of killing off your customers through recklessness or gross negligence. We are 100% certain that it will rank top of the list in next year’s annual report.”

What O’Sullivan finds completely unacceptable is that Tiger Brands is still in denial.

“On the one hand they close and deep-clean all the affected facilities, on the other hand they deny culpability and say they will meet each civil claim on its own merits, thereby indicating they will make it a long-haul for the litigants,” he says.

Gareth Lloyd-Jones, Chief Commercial Officer at hygiene and sanitation service provider Ecowize, however says government is to blame. He argues there should be a surveillance system that protects consumers.

“This type of rigorous investigation has been going on for the past couple of months, which is admirable, relevant and necessary and should have been part of a more robust routine surveillance and monitoring process in terms of food safety and legislation requirements,” he says.

According to retail analyst Syd Vianello, this can tarnish a brand that has spent decades trying to live up to high standards.

“How long is it going to take [Enterprise Foods] to convince consumers that the Enterprise brand is good for purchase again? We are talking about the value of the brand and the protection of the brand equity, insurance won’t even cover you for those kinds of losses. These can carry on for a very long time,” he says.

There is also a rub-off effect.

Ronald Dube, a manager at a supermarket in Johannesburg, says people have been returning all cold meats regardless of brand.

“People are afraid and have been returning all sorts of meat. We have also noted that sales of processed foods have gone down, no matter the brand,” he says.

Many people have also thrown away their cold meats but, according to Dr Johan Schoonraad, waste expert and group tactical specialist at EnviroServ Waste Management, there are only two options for disposing of listeria infected food waste – incineration or treatment and landfill disposal.

“The scale of the problem is too big for the incineration industry to deal with in any sort of reasonable timeframe, which leaves waste management companies with the option to do treatment and disposal to landfill,” he says.

Schoonraad says treatment can take many routes. You could sterilize the food waste, heating it and ensuring the material internally gets to 100 degrees which would kill the bacteria.

“If this was done, we could then landfill it without further treatment being required before disposal,” he says.

The other option is to chemically treat it prior to disposal.

According to Schoonraad, the problem is municipal landfills often have poor access control. The risk here, he says, is that the informal sector could enter and scavenge food material, which is then sold or eaten and could spread the disease.

“However, licensed hazardous waste sites have strict access control with no scavenging allowed at these facilities,” he says.

Nevertheless, South Africa remains in fear of this deadly disease.

Who is mostly at risk:

  • Pregnant women
  • Neonates (first 28 days of life)
  • Very young infants
  • Elderly persons >65 years of age
  • Anyone with a weakened immune system (due to HIV infection, cancer, diabetes, kidney disease, liver disease, people with transplants and those on immunosuppressive therapy such as oral corticosteroids, chemotherapy, or antiTNF therapy for auto-immune disease)

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Young women in Soweto, South Africa, say healthy living is hard. Here’s why

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Data from South Africa has shown that over two thirds of young women are overweight and obese. This predisposes them to non-communicable diseases such as diabetes and hypertension. Most women are not exercising enough, and consumption of processed and calorie-dense foods and high amounts of sugar is common.

It was this knowledge that sparked the establishment of the Health Life Trajectories Initiative. It’s being run in South Africa, India, China and Canada and aims to provide interventions that can help young women stay healthy before, during and after pregnancy.

In South Africa, this randomised controlled trial will provide one-on-one support as well as peer group sessions to over 6000 young women. The idea is provide them with information, and to help them set and maintain goals for healthier lifestyles.

Researchers from the Medical Research Council and Wits University’s Developmental Pathways for Health Research Unit are running the South African arm of the study. We wanted to start by better understanding our target population – that is, young women aged between 18 and 24 living in Soweto.

READ MORE | Local Solutions Can Boost Healthier Food Choices In South Africa

Soweto is a large, densely populated urban township which comprises one third of Johannesburg’s population. Soweto is becoming rapidly urbanised, but the majority of people are still very poor and struggle to provide food for their families.

We conducted a series of focus group discussions and in depth interviews to unravel health behaviours, barriers and facilitators to wellbeing and health with young women from Soweto who had not yet had a child. We also asked them about what sorts of interventions they’d prefer to support and guide them.

The women offered important insights that showed it’s not enough to simply promote healthy eating and exercise without considering the very real environmental and structural constraints present in South Africa.

Barriers to healthy choices

The 29 participants spoke about many different facets of health. These included happiness and mental wellbeing, faith, social support, body image, and lifestyle behaviours.

They identified many barriers to healthy eating, among them the cost of and access to healthy food options. Some women also said they had little access to exercise facilities such as gyms and were afraid to exercise on the streets because they feared being assaulted or harassed. One woman said:

No, I don’t feel safe because we have drug addicts, traffic, women trafficking: it’s not safe for us to walk in the streets.

The women we interviewed painted a picture of an environment in which healthy behaviours are difficult to implement or sustain. One said:

Small businesses that are opening up in my community and they all sell fries, literally they just all sell fries…

Women told us that cheap and unhealthy fast foods are on every street corner: “bunny chow” – hollowed out bread stuffed with curry – vetkoek (a fried dough bread stuffed with different fillings) and fried chips are affordable and available within a few steps of most houses. As a result, women did not want to go out of their way to purchase healthier, more expensive foods.

Our interviewees also didn’t feel able to demand that healthier food be bought for their homes, because many were not contributing financially and were therefore not in a position to control food purchases. Women reported being financially dependant on relatives and male partners.

READ MORE | New Ways Of Thinking On Health, Arts And Humanities Are Emerging In Africa

Exercise

They also said that opportunities for physical activity were neither provided nor prioritised for women in Soweto. Some women said that a lack of facilities made it difficult for them to participate in any exercise, as they did not have access to gyms or fields to exercise.

Other women told us that there were gyms, sports grounds, parks, and even free aerobics classes at community halls in their area. However these facilities often get vandalised quickly, and can no longer be used. More importantly, they didn’t feel safe enough to exercise on the streets, perhaps by jogging or running. They also felt unsafe walking around in leggings or tights. Women were fearful of human trafficking, sexual assault, and violence – very real issues in this community.

Crucially, our research found that young women did not see obesity as a sufficient reason to change their behaviour. But they said they would be motivated to exercise and eat better if they were diagnosed with a non-communicable disease like diabetes.

This suggests that obesity has become normalised in South Africa – and this needs to be addressed.

Policy interventions

These findings are now being worked into our interventions, and we are cognisant of the contextual realities that may affect young women’s ability to change their lifestyles. We hope that this research, along with whatever findings emerge from our interventions, will inform policy makers and motivate them to implement necessary changes in this community.

Women in Soweto and in South Africa in general need support to live healthier lifestyles. This support needs to come from policy makers. If South Africa does not step up and support young women by providing them with access to safe spaces and affordable healthier foods, and by controlling the oversupply of unhealthy options, the country may not be able to curb its ever increasing rise in obesity and related non-communicable diseases.

-Alessandra Prioreschi: Associate Director and Researcher at the Developmental Pathways for Health Research Unit (DPHRU), University of the Witwatersrand

The Conversation

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Measles: Should Vaccinations Be Compulsory?

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Following a measles outbreak in Rockland County in New York State, authorities there have declared a state of emergency, with unvaccinated children barred from public spaces, raising important questions about the responsibilities of the state and of individuals when it comes to public health.

Measles virus is spread by people coughing and spluttering on each other. The vaccine, which is highly effective, has been given with mumps and rubella vaccines since the 1970s as part of the MMR injection. The global incidence of measles fell markedly once the vaccine became widely available. But measles control was set back considerably by the work of Andrew Wakefield, which attempted to link the MMR vaccine to autism.

There is no such link, and Wakefield was later struck off by the General Medical Council for his fraudulent work. But damage was done and has proved hard to reverse.

In 2017, the global number of measles cases spiked alarmingly because of gaps in vaccination coverage in some areas, and there were more than 80,000 cases in Europe in 2018.

Anti-vaxxer threat

The World Health Organisation has declared the anti-vaccine movement one of the top ten global health threats for 2019, and the UK government is considering new legislation forcing social media companies to remove content with false information about vaccines. The recent move by the US authorities barring unvaccinated children from public spaces is a different legal approach. They admit it will be hard to police, but say the new law is an important sign that they are taking the outbreak seriously.

Most children suffering from measles simply feel miserable, with fever, swollen glands, running eyes and nose and an itchy rash. The unlucky ones develop breathing difficulty or brain swelling (encephalitis), and one to two per thousand will die from the disease. This was the fate of Roald Dahl’s seven-year-old daughter, Olivia, who died of measles encephalitisin the 1960s before a vaccine existed.

When measles vaccine became available, Dahl was horrified that some parents did not inoculate their children, campaigning in the 1980s and appealing to them directly through an open letter. He recognised parents were worried about the very rare risk of side effects from the jab (about one in a million), but explained that children were more likely to choke to death on a bar of chocolate than from the measles vaccine.

Dahl railed against the British authorities for not doing more to get children vaccinated and delighted in the American approach at the time: vaccination was not obligatory, but by law you had to send your child to school and they would not be allowed in unless they had been vaccinated. Indeed, one of the other new measures introduced by the New York authorities this week is to once again ban unvaccinated children from schools.

Precedents

With measles rising across America and Europe, should governments go further and make vaccination compulsory? Most would argue that this is a terrible infringement of human rights, but there are precedents. For example, proof of vaccination against yellow fever virus is required for many travellers arriving from countries in Africa and Latin America because of fears of the spread of this terrifying disease. No-one seems to object to that.

Also, on the rare occasions, when parents refuse life-saving medicine for a sick child, perhaps for religious reasons, then the courts overrule these objections through child protection laws. But what about a law mandating that vaccines should be given to protect a child?

Vaccines are seen differently because the child is not actually ill and there are occasional serious side effects. Interestingly, in America, states have the authority to require children to be vaccinated, but they tend not to enforce these laws where there are religious or “philosophical” objections.

There are curious parallels with the introduction of compulsory seat belts in cars in much of the world. In rare circumstances, a seat belt might actually cause harm by rupturing the spleen or damaging the spine. But the benefits massively outweigh the risks and there are not many campaigners who refuse to buckle up.

I have some sympathy for those anxious about vaccinations. They are bombarded daily by contradictory arguments. Unfortunately, some evidence suggests that the more the authorities try to convince people of the benefits of vaccination, the more suspicious they may become.

I remember taking one of my daughters for the MMR injection aged 12 months. As I held her tight, and the needle approached, I couldn’t help but run through the numbers in my head again, needing to convince myself that I was doing the right thing. And there is something unnatural about inflicting pain on your child through the means of a sharp jab, even if you know it is for their benefit. But if there were any lingering doubts, I just had to think of the many patients with vaccine-preventable diseases who I have looked after as part of my overseas research programme.

Working in Vietnam in the 1990s, I cared not only for measles patients but also for children with diphtheria, tetanus and polio – diseases largely confined to the history books in Western medicine. I remember showing around the hospital an English couple newly arrived in Saigon with their young family. “We don’t believe in vaccination for our kids,” they told me. “We believe in a holistic approach. It is important to let them develop their own natural immunity.” By the end of the morning, terrified by what they had seen, they had booked their children into the local clinic for their innoculations.

In Asia, where we have been rolling out programmes to vaccinate against the mosquito-borne Japanese encephalitis virus, a lethal cause of brain swelling, families queue patiently for hours in the tropical sun to get their children inoculated. For them the attitudes of the Western anti-vaccinators are perplexing. It is only in the West, where we rarely see these diseases, that parents have the luxury of whimsical pontification on the extremely small risks of vaccination; faced with the horrors of the diseases they prevent, most people would soon change their minds.

Tom Solomon; Director of the National Institute for Health Research (NIHR) Health Protection Research Unit in Emerging and Zoonotic Infections, and Professor of Neurology, Institute of Infection and Global Health, University of Liverpool

-The Conversation

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New Ways Of Thinking On Health, Arts And Humanities Are Emerging In Africa

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Imagine bringing the best of all academic disciplines, artistic creations, activist experience and health care knowledge to bear on understanding and addressing current health care concerns. Rather than silos of people working in their specific areas of interest, imagine collaborations committed to listening and learning from all participants.

This is the vision of Medical and Health Humanities in Africa. It’s a field that grew out of the medical humanities in the US and UK. It brings together academics, researchers, practitioners, creative artists, health care seekers and providers.

Essentially, it straddles disciplines and practices in an effort to address health concerns. Artists compose music to open up understandings of health care and specific conditions, such as delirium. Some academics open up new conversations about existing health concerns like AIDS or use everything from yoga to photography to observation and drawing to help educate health sciences students. Others pair academics and artists to help young people talk about sex and sexuality or tuberculosis.

At its core, Medical and Health Humanities is about conversations and collaborations between people who are interested in health. This encourages new understanding, practice and knowledge. It also seeks to provide “translators” who can make often complex ideas in science and humanities accessible. They can also use creative arts to change perceptions, frame new questions and direct new discussions that result in more nuanced answers to health issues.

While still a relatively new field on the African continent, it is growing and gaining momentum. The latest milestone is the first English-language special issue of the globally respected BMJ Medical Humanities Journal to deal exclusively with work on and about medical and health humanities in Africa.

The special issue came out in December 2018. It showcases work from various countries in Africa, among them Nigeria, Malawi, Kenya, Tanzania and South Africa.

The projects profiled in this special issue, and others elsewhere on the continent, reveal the vital role Medical and Health Humanities can play across Africa in bridging the gaps between disciplines to improve people’s experiences of health care.

Beyond disciplinary boundaries

One of the Medical and Health Humanities projects highlighted in the BMJ’s special edition deals with digital storytelling and antiretroviral adherence in KwaZulu-Natal, South Africa. Another article shows how opium, thalidomide and contraceptives contributed to the making of modern South Africa.

The projects and articles themselves are, of course, important. But another critical element that must not be overlooked is how the field exemplifies inter-, trans- and multidisciplinary research and practice. It removes people from their disciplinary silos.

This is becoming increasingly important across academia. In the worlds of medicine and health, people often work on similar concerns in familiar ways; in doing so, they miss out on new perspectives. Working across disciplines and practices is a way to learn from each other and reflect on how things could be changed for the better.

And, crucially, it creates conversations about how we might improve our collective understanding of health and wellness.

Different forms

On the African continent, the Medical and Health Humanities community is also trying to do things differently when it comes to how research is conducted and presented.

If a field is genuinely committed to collaboration, collective engagement, building networks and relationships, it must do more than work quickly to “produce measurable outcomes” limited to academic articles. It must spend time building connections that extend beyond one event or “outcome”.

We attempted to do this during the writing of the special issue of the BMJ Medical Humanities journal. We were among a group of practitioners in South Africa who pooled resources from two universities to bring as many people who were working on the special issue together as possible. We wanted to ensure that experienced and emerging writers from multiple disciplines and practices had a chance to benefit from each other’s knowledge and experiences.

A workshop was held in 2017 at the Wits Institute for Social and Economic Research (WiSER). Participants came from Zimbabwe, Kenya, Nigeria, Tanzania, Malawi, Swaziland, South Africa, the UK and Canada and presented and discussed their work.

From this, people put together a range of material for the journal and the blog linked to the special edition. Some of this material took the form of academic articles; there are also podcasts, photographs, pieces of music, images and poetry.

This allowed us to present creative and academic work in a format that was more accessible to those with digital access and moved beyond academic journals. After all, part of what the field is concerned with is maintaining critical, intellectual rigour while making information available to people in a number of ways. In doing this the field tries to break down some of the barriers that prevent people from sharing work or ideas.

New networks

There is more to come for the Medical and Health Humanities field in Africa. A group called the Medical and Health Humanities Africa networkhas been established. CODESRIA, the Council for the Development of Social Science Research in Africa, among others, has been drawn into discussions about growing the field’s networks on the continent. The second conference organised by the Malawi Medical Humanities Network will be held in Zomba, Malawi in August and a workshop in Johannesburg in March called State of Dis-ease will continue these exciting new conversations.

-Carla Tsampiras; Senior Lecturer in Medical Humanities, University of Cape Town

-Nolwazi Mkhwanazi; Senior researcher, Wits Institute for Social and Economic Research, University of the Witwatersrand

The Conversation

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