Biomedical subjects
Publications and source records attributed to E Buch.
Historical background to proposals for a Natural Health Service is briefly given. The need for a National Health Service is described and substantiated and obstacles to the transformation of the South African Health Service are described. Suggestions are made for laying the foundation for substantial changes in the future.
In this, the first of a three-part series of articles in which we propose steps towards a comprehensive strategy for the control of HIV infection, we consider briefly the world-wide experience with the HIV epidemic. Our objective is to highlight the problems and controversial issues which are pertinent to strategies for the control of HIV infection. We focus on problems of case-definition, differences between 'African' and 'Western' AIDS and the implications for South Africa, and problems with sensitivity and specificity of tests used at present, particularly in the context of false positivity in a community with a low prevalence of HIV infection. We consider some of the ethical issues, including the need for adequate counselling, the need for informed consent before testing, and the centrality of confidentiality, particularly in the context of possible victimisation and neglect of HIV-positive individuals. Differences between 'notification' and 'reporting' are emphasised. Recommendations are made regarding these problems.
In this, the second of a three-part series of articles in which we propose steps towards a comprehensive strategy for the control of HIV infection, we consider controversies relating to screening for HIV, the indications for and desirability of mandatory testing of certain groups at risk, and the place of voluntary testing in the control of HIV transmission and infection. Key recommendations are that mandatory testing of donors of blood and other vital tissues, patients on haemodialysis and haemodialysis unit staff is justified, and that children put up for adoption may require testing. We make further recommendations regarding HIV testing as a prerequisite for life insurance and recommend that voluntary testing be offered, supported by adequate pre- and post-test counselling. We consider that all health care workers should accept as their moral obligation the care and management of HIV-infected individuals, and that they should be adequately educated and skilled in such work. These recommendations were reached largely by consensus, although there were occasions when individual authors condoned recommendations with which they did not personally agree.
In this, the third of a three-part series of articles in which we emphasise the urgent need for and propose steps towards a comprehensive strategy for the control of HIV infection, we highlight the fundamental importance of an education campaign and the three critical essentials for a successful campaign. The first concerns the responsibility of the State in administering the programme, in providing adequate funds on an on-going basis and in delegating responsibility for the day-to-day activities to the appropriate local authorities and non-governmental organisations. The second relates to the need to establish a multidisciplinary AIDS group representative of groups at risk and of relevant scientific expertise to ensure that appropriate policies are developed and that changes to policy are made in response to changing circumstances, based on sound epidemiological, managerial and educational principles. These must take particular account of circumstances peculiar to South Africa, such as the migrant labour system, which may promote both promiscuity and homosexuality. Thirdly, the need to ensure open, appropriate communication with the groups at risk and the public at large in the development, implementation and evaluation of the education campaign is emphasised. In this context we plead for more psychosocial research. These recommendations were reached largely by consensus, although there were occasions when individual authors condoned recommendations with which they did not personally agree.
Mass immunisation campaigns have been successfully used for vaccine delivery in countries such as Brazil and Turkey as well as in a number of instances locally. Although in some circumstances mass campaigns have been advantageous, they are not recommended as a basic policy for South Africa. Immunisation services should be incorporated into routine primary health care delivery as part of maternal and child services. If these services are adequately delivered there would be no need for mass campaigns.
Sixty people with hyperglycaemia were admitted to Baragwanath Hospital as emergency patients during an 8-week study period in 1981, and one-quarter of them died in hospital. Many of these hyperglycaemic emergencies could have been prevented; 88% of the patients were known diabetics, one-third of whom required only oral hypoglycaemic agents for diabetic control. Sixty-one per cent of the patients had concomitant diseases, primarily infections. Earlier treatment might well have prevented deterioration of diabetic control, yet only 6% of the patients had attended the health services in the previous week in spite of recognizing that they were becoming progressively more ill. These patients were at high risk of subsequent admission, one-third of those discharged being readmitted within 3 months. Attendance compliance during a 3-month follow-up period was poor, and the discharged patients lacked the skills and knowledge necessary to maintain adequate diabetic control. One-quarter of those on insulin could not measure their dose correctly, most could not adequately test their urine and did not know what action to take if they had worsening symptoms of hyperglycaemia or developed intercurrent illness. Hyperglycaemic emergency admissions could be reduced by improving ambulatory diabetic services, thus saving costs of hospital care. Recommendations for improving the hospital service include maintaining a register of patients who have had hyperglycaemic emergencies and special care to ensure that they acquire the necessary knowledge and skills. Other methods of improving compliance regarding attendance and medication should be applied. These recommendations need to be implemented and their efficacy evaluated.
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Secondary FAE is a rare complication, usually located at the duodenum. The typical clinical presentation is like a digestive hemorrhage or a sepsis. We report two cases of FAE with atypical manifestations. The first case presented a lower digestive hemorrhage produced by the fistulization to the sigma. The second case appeared like an intestinal obliteration caused by the full emigration of a prosthesis to the jejunum. We wish to remark the importance of the clinical suspicion of a FAE (Key of diagnosis), and the sparing relevance of the complementary examinations and the urgency of a surgical treatment in order to avoid the high rate of morbi-mortality associated with this complication.