Ekso Skeleton comes to South Africa

After years of being confined to a wheelchair, a paraplegic patient at the recently established Just Walk Bionics rehabilitation centre in Johannesburg, tremulously takes a few unsteady steps forward. Strapped to her legs is a device that could have easily been at home on the set of a sci-fi movie. With the help of two trained biokineticists, she takes a few more steps forward, balancing her upper body and shifting her weight as she plants a walking stick on either side of the 23kg frame. She makes one circuit around the studio before the strain of being mobile again makes her feel nauseous and she is forced to sit down. After a brief break to recover, she doggedly stands up and commences yet another circuit of the room. Following a severe spinal cord injury caused by a car accident and being told that she will never walk again, here she is….walking. 
 
The device is called an Ekso Skeleton, a bionic battery operated walking suit or wearable robot that is enabling South Africans with spinal cord injuries and neurological disorders to stand up and walk again. The Just Walk Bionics advanced rehabilitation centre is the only centre of its kind in the Southern Hemisphere that has this kind of advanced technology. The centre was opened in June 2013 by Justin Smith, an incomplete quadriplegic who was shot in the neck during a near-fatal car hi-jacking in 2004. 

The Ekso Skeleton is essentially a portable, adjustable, battery-operated bionic walking suit that can be worn over the clothes. It augments mobility, strength and endurance and it enables users to stand and walk with the assistance of a walker or crutches. It is the only FDA and CE approved bionic exoskeleton available. “We took the idea of the external skele­ton, and we added nerves in the form of sensors and motors that represent your muscles and computers that represent your brain,” says Eythor Bender, CEO of Ekso Bionics. The device harnesses the power of battery-operated motors to drive the legs and replace neuromuscular function. Motors power the hip and knee joints, and all motion is initiated through the use of an external controller. The device weighs approximately 23kg but it is designed in such a manner that the user doesn’t have to support the weight of the device. According to Bender, the Ekso Skeleton will be “the jeans of the future"-practical, fashionable, and streamlined enough to wear in economy class.”

Just like this patient at the Just Walk centre, so adamantly proving her prognosis wrong, Smith was also told that he would never walk again. He too embarked on a journey to learn how to walk that culminated in the opening of the Just Walk Bionics rehabilitation centre. He believes that the benefits associated with being able to walk again after years of confinement are wide-ranging. “Being mobile, changing your perspective and being able to look people in the eye again evokes feelings that are hard to describe unless you’ve been there. Experiences that able-bodied individuals would not think twice about”, says Smith. “The psychological benefits of walking again using the Ekso cannot be downplayed.” 

Beyond the psychological benefits, anecdotal evidence suggests that the use of the Ekso has other significant rehabilitative benefits. These include decreases in spasticity, chronic systemic pain, and Urinary Tract Infections. Some patients also experience better overall bladder and bowel function. According to the Kessler Institute, “repetitive motion retrains the nervous system so that individuals, in some cases redevelop walking patterns, but regular movement also prevents secondary complications of paralysis, including cardiac and lung weakness, poor bone density and pressure ulcers”. The Institute maintains that patients who use the Ekso Skeleton can experience a drastically improved quality of life.

This technological marvel is already changing the lives of wheelchair bound people all over the world who have suffered spinal cord injuries. It is also designed for those with neurological disorders such as Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Guillain–Barré syndrome, Parkinson’s disease and generalised weakness caused by other conditions. 

After close to an hour of practising with the Ekso Skeleton and 300+ steps later, the patient at the Just Walk Centre retires to the familiar confines of her wheelchair. And while the current device is only used as a rehabilitation tool, in time personal units will be available through Just Walk Bionics and this patient may not need to rely on her wheelchair at all.

Grahamstown's growing illicit alcohol problem

Her enormous frame takes up the largest part of the double bed, and the acrid smell of stale liquor hangs in the air. Her huge head, triple chin and unruly matted hair bring to mind the figure of the Great Goblin King from the movie The Hobbit. Her sluggish demeanour further re-enforces the image of a large, goblinesque figure grunting orders from a soiled throne. She broods over her hovel in Fingo Village, Grahamstown just as the Goblin King broods over his lair in the Misty Mountains. Kittens frolic amid a sea of empty liquor bottles strewn across a filthy floor and flies buzz angrily around her head. Bedridden from gout and surrounded by poverty and squalor, local illegal beer brewer ‘Mam Siwe’ is the kingpin of the Mtshovalale beer brewers in Grahamstown. Constant police raids, confiscations and hefty fines have turned Mam Siwe into a wily character. She vehemently denies that she is still involved in the brewing and sale of this illegal beer. Although a large 250 litre drum full of potent orange beer greets you at the entrance of her house.  Ask any local where you can buy a vat of Mtshovalale and they will point you in the direction of Mam Siwe’s.

Mtshovalale (potionsleep) and Imbamba are the street names for illegal beer sold in Grahamstown and Port Elizabeth. Unregulated and uncontrolled, these brews are sometimes laced with anything from common household products to battery fluid and methylated spirits. They can pose severe health risks to the people who consume them.  Despite numerous measures enacted by the government to curb the consumption of alcohol in South Africa, the prolific trade in these brews shows a large oversight by the government to address the illicit trade of alcohol in some of South Africa’s poorest areas.

 

The brewing and sale of illicit alcohol in Grahamstown’s informal settlement stands as testament to this problem. Mam Siwe is just one of many women in and around Grahamstown who brew Mtshovalale to make a living. “I have to support my family, I have 15 people living here, in this house” she says. Although she claims to have retired from the Mtshovalale business, police confirm that vats of beer are confiscated from her premises in Victoria Road on a weekly basis. When in business, Mam Siwe says she sold about 30 to 50 litres of this beer a day at a cost of R2,50 to R3 a litre. The brew is generally made from a concoction of malt, loaves of yeast, pineapples, sugar and bread, many other substances such as methylated spirits and battery fluid are rumoured to give the brews a stronger kick.

Police confiscate bottles of Mtshovalale from brewers on a weekly basis

The brew is the colour of dark orange urine.  The darker the colour, the more potent the brew is said to be. It smells like fermented yeast and pungent sourdough.  Acidic and overripe pineapples leave a rancid taste on your tongue and the pongy fumes linger on your breath long after the beer has been consumed. The beer is stored in cheap plastic ‘Cape Storm’ bottles and the yeast content is so high that it causes the bottles to swell and distort. Locals describe it as ‘potionsleep’ because it causes lethargy and reduces one’s appetite. The high consumption of this beer coupled a with a lack of appetite can cause one to become very ill. Other health side effects include extreme bloating, listlessness and fatigue.

On Bathurst Street, less than a kilometre away from Mam Siwe’s abode, undertaker, Leon Klaas, of Siyakubonga Funeral Homes tells of his experiences in dealing with the bodies of people who have succumbed to drinking-related deaths. Klaas deals with two to three dead bodies a month which have died from drinking related illnesses. “The people who die of drinking too much of the Mtshovalale are very very thin” says Klaas. “Their skin becomes soft and rubs off very quickly, sometimes we have to put sawdust on the bodies to stop them from leaking, they also smell very bad, like old beer and  dirty alcohol” he says. It is thought that the high content of yeast and other strong chemicals causes the bodies to decompose quicker than normal which could explain why the bodies seem to ‘leak’ and the ‘skin rubs off’.

The Mtshovalale problem is not a new one for the Grahamstown Police Department. “The consumption of this concoction is becoming a concern for the SAPS, we are on a regular basis visiting these places where the concoction is being brewed and destroying it,” says Mali Govender, spokesperson for South African Police Service (SAPS) in Grahamstown.  According to Govender, no surveys have been conducted to establish who the brewers are and what ingredients they are using in their brews. Police are also unaware of how widespread the problem is. Illicit alcohol is not taxed or regulated and there is hardly any information available on the patterns of its consumption and the related outcomes, not only in Grahamstown but also in other parts of South Africa. Other African countries experience their fair share of illicit homebrewed concoctions. For example, Zimbabwe has its version of ‘Scud’, Kenya has ‘Jet 5’, Botswana has ‘tho-tho-tho’ (dizzy spell) and Nigeria has Palm Wine (crazy man in the bottle).

The lack of adequate information as well as the lack of measures in place to reduce the sale and consumption of these homebrews is problematic because the illicit alcohol industry poses a large danger to public health and the government fiscus. In addition to evading excise duties and taxes on their products, illicit alcohol blenders such as Mam Siwe have very little regard for sanitation and the safety of their customers. Illegal alcohol products are generally made in unhygienic backyard premises or garages and in some cases there is evidence that illicit alcohol manufacturing is used to fund other forms of organised crime. It is also estimated that illegal alcohol operators generate millions of Rands in tax free revenue. Mam Siwe has been such an obstinate nuisance in Grahamstown that police eventually called in the South African Revenue Service (SARS) to conduct a tax audit on her and found that she owed SARS R27 000 in unpaid taxes due to the lucrative nature of her business activities. She allegedly paid the money and thereafter continued to conduct her illegal alcohol operations.

The 'bin of beer' that greets you at the entrance of Mam Siwe's home a thick layer of grime coats the inside rim of the container.

It is mainly the elderly and the unemployed who frequent these taverns and consume this homemade beer. Its attraction lies in its affordability and accessibility. Take for example, Marc Fourie, a 49 year old man often found loitering outside a tavern near Currie Street in Grahamstown, Cape Storm bottle full of Mtshovalale, clutched in his bony hand. He drinks Mtshovalale on a daily basis. In fact he drinks Mtshovalale as if it was water. “I love drinking Mtshovalale, even though it gives me a babalas” he says, after downing 2 litre bottle of the putrid brew as if he were dying of thirst. Fourie has no work and lives off government grants and a measly pension. He occasionally does odd jobs around town to earn a quick buck which he quickly converts into a litre bottle of Mtshovalale. He says he is 49 but he looks as if he is 70. His clothes hang onto his skinny frame and it seems as if cataracts have taken over his eyes.  Whether this aging is due to years of stress, poverty and unemployment or the mere fact that he is drinking this unsavoury liquor is unclear, it’s probably a combination of both.

According to the World Health organisation (WHO), South Africa has one of the highest per capita consumption rates of alcohol in the world and it is continuing to rise. The South African Medical Journal, states that the cost to the fiscus relating to absenteeism, poor productivity, high job turnover, interpersonal conflict, injuries and damage to property is estimated to be around R9 Billion per year. This figure is equivalent to almost 1% of the Gross Domestic Product (GDP). Various measures such as the proposed ban of the sale of alcohol in the Gauteng province on Sundays and a potential ban of alcohol advertising to curb the sale and consumption of alcohol have been met with mixed reactions. “The abuse of alcohol is a multi-faceted problem for which there is no simple solution.” says Adrian Botha, spokesman for the Industry Association for Responsible Alcohol. He adds that “government should address the underlying causes of the abuse in the country instead of choosing ‘simple solutions’ that would not have the desired outcome”.

Everyone has heard about Health Minister Aaron Motsoaledi's contentious plans to increase the drinking age to 21, ban alcohol advertising and, most controversially, stop alcohol sales on Sundays. His plan is aimed at curbing the country's alcohol consumption levels and reducing the 130 deaths that occur every day from alcohol-related diseases, to target the country's record number of road accidents, in most of which alcohol is involved, and to reduce alcohol-related crime and domestic abuse. These measures merely scratch the surface of the problems and may have unintended consequences.

         Mam Siwe's house on the corner of Victoria Road in Grahamstown

 Given the choice, unemployed people like Marc Fourie will always choose cheaper, lower quality, non-commercial alcohol such as Mtshovalale over more expensive commercial alcohol. When a litre of Mtshovalale is sold for R2,50 a pop it’s no wonder that it has gained such popularity amongst South Africa’s lowest income earners. According to the Industry Association for Responsible Alcohol Use, “Public awareness campaigns of the dangers of consuming illicit alcohol are critical as illicit alcohol poses health risks due to bacterial contamination or methanol poisoning.” In addition more rural research is necessary to understand the roots of the problem so that necessary steps can be taken to eradicate it.

Tuberculosis in SA: The disease that won't go away

Of the 22 countries with the highest burdens of tuberculosis infections, South Africa is ranked number 3  after India and China, according to Dr Mary Edginton in a talk entitled ‘Tuberculosis, the disease that won’t go away’  which took place at the Library Hall in Grahamstown on Monday.

Since 1920, when tuberculosis was largely unheard of in South Africa, the infection rate of TB has gone up four fold. South Africa’s rate of tuberculosis infections is 993 per 100 000 of the population.  That’s almost 1000 per 100 000. This figure is extremely high when compared with India and China which have rates of 181 and 75 respectively.

After going through a brief history of the development of TB around the world and subsequent treatments and drugs that have been developed in response to the epidemic, Dr Edginton highlighted the significance of the development of the GeneXpert diagnostic tool.“This is truly a remarkable achievement which has revolutionised the diagnosis of lung TB” said Edginton. 

The GeneXpert is available in South Africa however concern about the capacity of the country to manage the burden of diagnoses was raised by Edginton.

Another concern raised by Edginton was the development of Multi-Drug Resistant TB (MDR-TB) and Extreme-Drug Resistant TB (XDR-TB). “The resistance to anti-TB drugs is the problem of our time” said Edginton, “We are going into the dark ages of TB in terms of Multi-Drug Resistant TB.” However the pandemic is yet to fully hit South Africa.

MDR-TB develops as a result of taking TB drugs irregularly. “What we call ‘stop-start’ drug taking” says Edginton. The core problem lies with health service failure such as ill-equipped clinics, empty drug stores and unmotivated staff members.  Access to clinics in South Africa is also a problem which can hinder TB infected people from taking their drugs regularly. 

South Africa's relatively recent history with the incidence of TB coupled with the problems currently plaguing our public health system show that South Africa is a ticking time bomb for an MDR-TB epidemic to explode.

However international work is making progress in finding better diagnostic tools, newer drugs and new vaccines to attempt to curb the incidence of TB and combat the scourge of MDR-TB.

                                                                                                                   

Human Resources, a persistent problem for the NHI

_{18 months into the initial phase of the National Health Insurance (NHI) scheme and South Africa is still short of 14 351 doctors, according to a recent survey conducted by the South African Institute for Race Relations (SAIRR).}

_{The current shortage of professional medical staff is likely to seriously hamper the government’s proposed National Health Insurance (NHI), medical experts say.}

_{The NHI is a system where universal health care coverage is proposed for every South African citizen however the transformation of the health system has been hindered by inadequate staff numbers and an inequitable distribution of health workers between the public and private sector.} 

_{The SAIRR survey found that staff shortages are not being adequately addressed by government and almost 56% of doctors’ posts are empty. Almost 46% of nursing posts also remain unfilled.} 

_{Lerato Moloi, a researcher at the SAIRR, says “these figures are alarming” and such high vacancies make NHI seem unachievable.}

_{“The two most critical aspects of the NHI are how are we going to fund it and how are we going to staff it” adds Doctor Mark Sonderup, a specialist at UCT Medical School.} 

_{The current health system is overwhelmed by very few resources that is compounded by the increasing population figures where both nurse-to-patient and doctor-to-patient ratios are excessively high,  says South African Medical Association’s (SAMA) public sector doctors' committee chairwoman, Dr Phophi Ramathuba.}

_{Despite these concerns the 2012/2013 South African Health Review states that “training of new doctors has been increased through increasing the intake in training institutions and sending 1000 medical students to Cuba to be trained”. In addition, since the launch of the National Human Resources for Health strategy in October 2011, an extra 40 doctors started training in South Africa in 2011/2012 and 125 in 2012/2013.}

_{In spite of this progress, numbers of doctors graduating from South African universities is decreasing. Between 2004 and 2008 there was a more 6%decline in medical graduates. Specialists who are being trained at the country’s eight medical schools are also not being properly absorbed into the public health sector. “To produce doctors and specialists, you need a functional academic sector. The capacity that we’ve had to train doctors has been under enormous pressure. The capacity to train doctors has been limited. What we need is more medical schools. Despite HIV/Aids, our population is growing. There is an increase in the number of immigrants. We have not kept up with that,” Sonderup says.}

_{In order for the NHI to be a success, the country needs to double the number of doctors it trains each year. The establishment of new medical schools and ensuring vacancies at existing schools are filled is critical to solving the problem and curbing the deficiency. The progress highlighted by the SAHR is insufficient to address the severe staff shortages currently plaguing the country’s health system. Health Minister Dr Aaron Motsoaledi told parliament he had asked deans of medial faculties to think innovative ways to increase student intake but the effects of this ‘request’ remain to be seen in the country’s production of medical graduates.}

_{The human resource problem also goes beyond higher education. A research report published in the South African Medical Journal in 2011 shows that at the time there were estimated 27 641 doctors practicing in South Africa, approximately 23 407 South African-born doctors were believed to be practicing overseas. It is clear that South Africa needs to ‘train and retain’ more doctors in order for the government’s proposed NHI to be a success.}

_{“While government's NHI plan has theoretical merit, in practice it will be exceedingly difficult to implement, particularly within the envisaged time frame of 14 years," Hospital workers union, HOSPERSA, said in a statement to News24 in 2010. The union also went on to say that foreign doctors will have to be recruited if NHI is to be successfully implemented. Sonderup also emphasises the need to recruit more doctors if NHI stands any chance of achieving success. “We have got to turn the tide of people who are still leaving. And we have got to go back and try to actively recruit those who have left. If we got just one-tenth back, we would have the equivalent of a year’s worth of graduates,” he says.}

_{However all is not doomed for the success of NHI. In April of this year the Mail and 
Guardian reported that 350 private doctors will start working part time for the country's NHI system this month at public health facilities. The clinics and hospitals are based at the NHI scheme's 11 pilot sites. Whether this will be enough to address the key challenge of providing and funding human resources within the envisaged timeframe of 14 years remains to be seen.}

Inequality and social stress: the missing element in understanding South Africa’s burden of disease?

Despite 18 years of democracy, inequalities in gender, race, income and geographical location still remain the key markers of poor health in South Africa  according to the 2012/2013 South African Health Review released on 2 April 2013.  

The Review contains commentary from a range of experts on topics such as the social determinants of health, non-communicable diseases, climate change and occupational health. It further states that overcoming these increasing inequities between the rich and the poor is necessary in order to reduce the country’s quadruple burden of disease and transform the public and private healthcare landscapes.

 South Africa is currently in the grips of 4 simultaneous epidemics referred to as the country’s ‘quadruple burden of disease’. This includes HIV and AIDS, diseases relating to poverty and under-development, chronic diseases, injuries and interpersonal violence.

The Review’s findings come amid a burgeoning volume of recent research which shows a direct correlation between social inequalities and poor health. Although there has been overall growth in the economy since 1994, South Africa still has one of the highest income inequalities in the world, with a Gini coefficient (the measure of inequality within a country) that has remained at 63.1.“Despite increased provision of social grants, extreme wealth inequalities and high unemployment likely play an important role in poor health outcomes” says Debbie Bradshaw, director of the Burden of Disease Research Unit at the South African Medical Research Council. Inequality is thus a far more useful determinant for assessing South Africa’s health status than material deprivation in the form of poverty.

An understanding of poverty in the form of material deprivation such as dirty water or poor nutrition is inadequate because relief of such material deprivation such as providing clean water can be reduced to merely a technical matter, asserts Michael Marmot, Professor of Epidemiology and Public Health at University College London. This understanding fails to take into account the socially determined nature and skewed allocation of these resources. “In fact, there are many examples of relatively poor populations with similar incomes but strikingly different health records,” Marmot further adds.

The Spirit Level: Why More Equal Societies Almost Always Do Better, published in 2009 by Richard Wilkinson and Kate Pickett argues that inequality is socially corrosive and leads to more violence, an erosion of trust, increased anxiety and illness, chronic stress and risky behaviour such as increased consumption of alcohol and smoking. These in turn lead to poor health outcomes in terms of physical and mental health, drug abuse, obesity, violence, infant mortality and lower average life expectancy.

According to the Review, violence, alcohol misuse and mental disorders are leading contributors to the burden of disease in South Africa. South African homicide rates are estimated at more than 8 times the global average among males and five times the global average among females. South African drinkers also rank in the top five riskiest drinkers in the world. These are all risk factors compounded by South Africa’s high levels of inequality and income disparities.

Government’s annual death report released on 10 April 2013 confirms that fewer South Africans are dying from HIV/AIDS-related diseases. This is likely a reflection of the success of the antiretroviral programme, says University of Cape Town (UCT) actuary and epidemiologist, Leigh Johnson, in an article for Health-e News Service.  However, more people are dying of non-communicable diseases (NCD’s) such as diabetes. The World Health survey shows that socio-economic inequalities are risk-factors for non-communicable and chronic diseases in low to middle income countries such as South Africa. This could explain the high contribution of NCD’s to the country’s disease burden.

However, the scale of whether a society’s income inequality is a determinant of population health still remains a controversial issue. Critics argue that measuring a nation’s health according to the level of inequality within that country is statistically flawed and does not explain homicide rates, women’s status, life expectancy or obesity.

In spite of this, South Africa has displayed a commitment to reducing the level of inequality within the country by signing the United Nations Millennium Declaration in 2000 which is a global attempt to address unacceptable inequalities within and between countries by the year 2015. These goals include eradicating poverty and hunger, promoting gender equality, reducing child mortality, improving maternal health, combating HIV and AIDS and ensuring environmental sustainability. Unfortunately with only 2 years to go, achieving these goals is proving to be elusive, and in many cases impossible for the country.

The implementation of the proposed National Health Insurance will also attempt to make inroads into reducing the level of inequality in the country’s health but whether this will be a success remains to be seen as many challenges still confront the planning committee.

The Review shows that more needs to be done to address the ‘causes of the causes’ of ill-health, namely those directly influenced by inequality and social stratification. After all, prevention is always better than cure.