Dear Margie

Thanks for your e-mail communication. I am pleased to correspond with you on this topic

You wrote: "Your message was forwarded to me by Dr Bradshaw for comment. Unfortunately the report did not come with the email. I am interested to know where you get your figures from. I am the project leader of national injury surveillance system. We only see about 60 000 non-natural deaths a year and no ways are one-sixth or one-third of these related to traditional medicines. Is this in essence what you are saying? Where do you get these data from? since I have the database on non-natural deaths in SA. Please could you let me know your source?" (End of letter)

I assume that this is the beginning of the government spin control, based on your immediate rejection of my hypothesis without having even read the report. I am however pleased that dialogue is at last opening up, even if it is only a challenge rather than attempt to establish the facts, which clearly no-one yet fully knows. The latest addition of the Report is attached hereto.

The data that I have used is in fact that which Dr Bradshaw provided me with in April last year as “the only information available”, primarily: (Bradshaw D, Estimated Cause of Death Profiles, Based on 1990 Data, CERSA, MRC, 1991), based in turn on data supplied by Stats SA; (Bradshaw, Health and Related Indicators, SA Health Review 1997); (Recorded deaths, 1994. CSS Report No. 03-09-01 (1994) Pretoria: Central Statistical Services). The figures used for comparisons are those of the Dept of Health, which as you can see, confirm the figures which I used in the extrapolations.

Whilst you may be tempted to reject my estimates, I am equally at liberty to reject your scanty data. Your figure of 60,000 non-natural deaths furthermore is clearly out-dated, ultra-conservative and has not been adjusted to take into account the extra few million souls discovered in the last census, both factors of which, even if conservatively adjusted, would together leave the figure more in the region of 80,000 -100,000, excluding homicide, violence, accidents and self-afflicted.

It is no secret that the national database is incomplete and inadequate for your purpose, eg. “Data on mortality and morbidity in South Africa are inadequate. The absence of a comprehensive national health information system poses problems for an analysis of mortality.” (White Paper on Population Policy, RSA, March 1998) Based on this fact, it is impossible to refute my estimations without first collecting the critical data needed to perform the analysis necessary to decide either way. Currently however, the considerable circumstantial evidence clearly positively favours my disturbing position.

Dr Bradshaw conceded the dilemma, stating: “Estimating specific causes of death in South Africa is difficult, the last detailed information being almost a decade old, since the law was changed at that time to exclude the necessity of recording the details of the actual cause of death. The data collection system makes no provision for gathering the type of data needed to determine how many deaths might be attributable to traditional medicines. The overall figures must all be considered to be vast underestimates. There are major problems with the data. Not all deaths in rural areas are registered and many are in the ill-defined category where it was not specified on the certificate.” (Pers comm, Dr D Bradshaw, Centre for Epidemiological Research in Southern Africa, MRC, 6 April 1999)

My simple extrapolation is based on the official figures: 13.71% ill defined, 4.24% undetermined & 1.61% other external, totalling 19.56%. For ease of estimation I used 20% of 40 million to arrive at a rough estimate of 80,000 deaths from unnatural causes, excluding homicide, violence, accidents and self-afflicted. I would not split hairs over the figure in either direction, since I am not trying to calculate, which is impossible without precise data, which simply does not exist, since it still has to be collected. I am merely estimating the possible magnitude of the problem of traditional African medicine (TAM) mortality and trying to bring a solution to bear on these tragic preventable deaths.

Based on the extensive and convincing other diverse data collated in my report, I wrote as follows:

“The crude death rate in South Africa is 8.9 per 1 000 (1995 United Nations estimates, & RSA Stats in Brief, Aug 1996; 9.4/1000 according to DoH), meaning that approximately 400,000 of 40 million South African’s die each year. In the RSA 20% of all deaths are of unknown causes, (according to Stats South Africa: 13.71 ill-defined (15.2, DoH), 4.24 undetermined, and 1.61 other external = 19.56%). (Bradshaw D, Estimated Cause of Death Profiles SA, Based on 1990 Data, CERSA, MRC, 1991)

”“Deaths from traditional African medicines “could” constitute a large portion of this 80,000 estimate and it is not unrealistic to assume that traditional medicine poisoning deaths are responsible for at least 10% of the 80,000 annual deaths from unnatural causes, (excluding homicide, violence, accidents and self-inflicted), ie 8,000 traditional medicine mortalities.

I did go on to speculate that this could be: “”possibly” doubled to 15,000 and taking into account a percentage of deaths attributed to “natural” causes such as eg cardiac failure, 5000 additional of which may be traditional medicine induced, 20,000 is a fairly conservative “maximum” estimate for the number of annual preventable deaths from traditional medicines.” The “eg” could include any of a number of symptoms and other established “natural” causes of death, categorised separately from the “unnatural causes”, and hence I wrote: ”Significantly, the symptoms and causes of death from traditional medicines closely mirror the major causes of death among the black population in South Africa: diarrhoea, fetal distress, renal failure, hepatic failure, respiratory distress and cardiac failure. The additional 5000 estimate from “natural” causes is likewise conservative, because no one is significantly, let alone consistently, capable of determining the true causal agent in all cases.

My point is borne out by other scientists, eg locally: “Amongst black South Africans, the poisoning category is the second in order of importance in the five main causes of death (second only to contagious and parasitic diseases), whereas it is only the third and fourth category amongst the other groups.” (Van Rensburg H & Mans A, Profiles of Disease and Health Care in South Africa, R&H Academica, 1982). Also, internationally, Prof Pieter Joubert, ex Dept. of Pharmacology & Therapeutics, Medunsa, opinioned: "Toxicology services, primarily geared towards the management of cases of drug poisoning, are inappropriate to the needs of developing communities", (Joubert P & Sebata B, S Afr Med J 1982 Nov 27; 62(23)) and: “in developing countries (South Africa), besides infectious conditions, acute poisonings with pesticides, paraffin (kerosene) and traditional medicines are the main causes of morbidity, whilst acute poisonings with traditional medicines is the main cause of mortality.” (Joubert P & Mathibe L, Adverse Drug React Acute Poisoning Rev 1989;8(3))

Joubert reported that in South Africa: “Among whites, medical drug poisonings predominated but among the black developing community, it is traditional medicine poisonings.” (Joubert P, J Toxicol Clin Toxicol 1982 Jul; 19(5)) Whilst researching an earlier report, I assumed that the morbidity and mortality incidence for South Africans using indigenous medicines would be minuscule, but I was stunned to uncover the shocking scientifically recorded and published clinical observation that: "In South Africa, the major cause of death among black South Africans are traditional medicines.” To reassure the reader that this was not a typographical error, the editor, a Clinical Professor of Medical Toxicology, added in brackets "(about 50 % of deaths)". (Ellenhorn's Medical Toxicity: Diagnosis and Treatment of Human Poisoning, Williams & Wilkins, 2nd Edn. 1997)

The main paper referenced in the above-mentioned textbook is Prof. Joubert's “Poisoning admissions of black South Africans”, dealing with acute poisoning admissions to Ga-Rankuwa Hospital, Pretoria, which determined that: “The major cause of fatal poisoning pattern at Ga-Rankuwa appears to be very similar to that reported from Bloemfontein (and is similar to mortality reported from Zimbabwe). Overall, the major causes of mortality were traditional medicines, responsible for 51.7 % of the deaths. Of the patients who died, 62 % were poisoning by traditional medicines. None were deliberate self-poisoning. The main issues were the extremely high mortality and the prevention of poisoning by traditional medicines merits high priority in the health care of the indigenous population of South Africa. The traditional African medicine mortality is extremely high. If poisoning due to these substances can be eliminated, the overall mortality will decrease by about 50%”. (Joubert P, J Toxicol Clin Toxicol 1990; 28(1)) Joubert was an exceptionally dedicated investigator.

Other scientists have however also observed that; “The probability of dying from a ”non-communicable disease” is higher in sub-Saharan Africa than in other market economies. The paradox of higher non-communicable death rates in the adults of the developing world must be attributable to other major determinants of mortality that are more common in these regions. The estimates that are most uncertain are those for sub-Saharan Africa, particularly for the exact composition of non-communicable and injury mortality. As more regions undergo epidemiological transition, particularly premature death among adults will increasingly become a major public-health concern. Surveillance and research to measure and monitor mortality must anticipate this trend.” (Murray C, Lopez A, Mortality by cause for 8 regions of the world: Global Burden of Disease Study, Lancet 1997; 349)

Dr M Stewart, Department of Chemical Pathology, SA Institute for Medical Research has stated: “There is an urgent requirement for development of diagnostic methods in order to reduce the number of cases in which the death certificate refers only to the final pathology and not the causative agent.” (Stewart M et al, Ther Drug Monit, 1998, Oct, 20(5)) Also: “Since there are as yet no standard methods for the detection of many herbal remedies or their metabolites, careful analysis is (should be) mandatory for the correct identification of the true cause in cases of poisoning.” (Stewart, M et al, Forensic Sci Int 1999 May 17; 101(3)) Further: “It is suspected that many cases are undiagnosed, especially so in South Africa, where patients may die without reaching hospital and do not often admit to ingestion of a traditional remedy.” (Steenkamp V, et al, Hum Exp Toxicol 1999 Oct; 18(10))

Stewart recently conducted an analysis of the Johannesburg forensic database over the years 1991-1995, which interestingly revealed only 206 cases in which a traditional remedy was stated to be the cause of death or was found to be present in a case of poisoning with an unknown substance. (Stewart, M et al, Forensic Sci Int, 1999 May 17; 101(3)) Illustrating just how incomplete the databases are, is his recent prior observation: “70 traditonal African medicine deaths in 8 months at Coronation Hospital, Johannesburg, and this just the few that made it to the hospital alive, only to die there, not to mention those who were/are extremely close to death.” (Dr M Stewart, Personal comm, 31 March, 1999)

It would appear that Dr Stewart is the only sober humanitarian scientist working in this neglected field, having recently written: “In South Africa there exists a window of opportunity for a serious examination and publication of the facts concerning the risks of using traditional herbal remedies. In addition, there needs to be a coming together of those interested in the toxic, as opposed to the beneficial aspects of traditional medicines.” (Stewart M et al, Ther Drug Monit, 1998, Oct, 20(5)) Dr Stewart and colleagues have developed a method for the detection of “Impila” constituents in urine. (Steenkamp V, et al, Hum Exp Toxicol 1999 Oct; 18(10)) Dr Stewart, has focused on “Impila” (Callilepsis laureola) (“health” in Zulu), probably the biggest single killer, yet his annual budget for all his analytical work was a mere R50, 000, with not a cent from the MRC (Pers comm, 31 Mar 99). Perhaps this is why the MRC don’t appear to also have him silently muzzled and on a short lead.

A look at Impila will illustrate how easily its toxic effects might be confused with other pathologies: IMPILA: Byrant A, Zulu Medicine and Medicine Men, Centaur, 1966 – “without doubt a virulent poison”; ·Seedat Y, Hitchcock P, S Afr Med J Jul 31; 45(30) – “acute renal failure”; · Wainwright J, et al, S Afr J Med 1977 Aug 13; 52(8) – “found to cause fatal liver necrosis, widely used as a herbal medicine; nephrotoxic, hypoglycaemic, hepatoxic”; ·Watson A, Coovadia H, Bhoola K, S Afr Med J 1979 Feb 24; 55(8) – “administration of Impila is common, the practice can and does cause poisoning, hepatic and renal tubular necrosis, hypoglycaemia, alteration of consciousness, hepatic and renal dysfunction”; ·Veale D, S Afr Pharm J 1987;(54) – “rootstock is toxic and can be fatal if ingested in small quantities, the main features: confusion, vomiting, diarrhoea, convulsions, hypoglycaemia and liver and kidney failure”; ·Savage A, Hutchings A, “Poisoned by herbs”. Br Med J 1987; 295 – “clinical symptoms of Impila intoxication are abdominal pain, jaundice, hypoglycaemia, disturbed hepatic and renal function”; ·Dehrmann F et al, J Ethnopharmacol 1991 Sep; 34(2-3) – “used extensively as a medicament, nephrotoxic”; ·Bye S, Dutton M, In: Oliver J, ed. Forensic Toxicology. Scottish Academic Press, 1992 – “hepatoxic, nephrotoxic, hypoglycaemic”; ·Steenkamp V, et al, Hum Exp Toxicol 1999 Oct; 18(10)) –“Poisoning with impila is a recurring phenomenon in South Africa and since it leads to rapid death from renal and/or hepatic failure, it is suspected that many cases are undiagnosed; patients may die without reaching hospital and do not often admit to ingestion of a traditional remedy.”

Since there are no approved uses, we have to assess its most popular uses against the above-mentioned risks: a) “Roots as a cough remedy” (Watt J & Breyer-Brandwijk M, The Medicinal and Poisonous Plants of Southern and Eastern Africa, 2nd edn. Livingstone, 1962) b) “Roots as tonics by young girls in the early stages of menstruation.” (Doke C, Vilakazi B, Zulu-English Dictionary, 2nd edn. Witwatersrand Univ Press 1972); c) “Roots for snakebite and administered as enemas and in baths to protect the children of parents who have already lost many children.” (Valley Trust, Personal comm Hutchings) Even more dangerous is Impila’s traditional use during pregnancy and childbirth, likely the biggest killer of all, eg: d) “Roots are sometimes an ingredient in “inembe”, taken regularly during pregnancy to ensure an easy childbirth, and to make an infusion for fertility.” (Gerstner J, Bantu Stud 15 (3) (4), 1941); e) “They are sometimes included in medicines known as “isihlambezo”, which are used by traditional birth attendants to ensure the health of both mother and baby during pregnancy.” (Gumede M, Traditional Healers, Skotaville Publ 1990) Consider the widespread usage of Impila and you ought to grasp the import and urgency of my thesis: “In Umlazi, one of the largest townships in the Durban area, 30% of a random sample of residents had used the highly toxic medicinal plant impila.” (Wainwright J, et al, S Afr J Med 1977 Aug 13; 52(8)) “With approximately 50% of the population using Impila in Natal, it is the second most widely used traditional medicine.” (Ellis M. Medicinal Plant Use - A Survey, Veld and Flora 1986 Sept).

If one looks at the iatrogenic / nosocomial mortalities for the USA, which has the best-computerised data internationally, we see quite clearly that nosocomial adverse drug reaction (ADR) mortalities exceed 100,000 annually. (Lazarou B, et al, Incidence of Adverse drug reactions in hospitalised patients: A meta-analysis of prospective studies. Journal of the American Medical Association, 1998; 279: 1200-5) In South Africa, allopathics are in a 20-40% minority to 60-80% for traditionals.

A simple calculation based on the (1990) US population of 260 million compared to SA’s 40 million, reveals a figure of 15,000+, based on a direct extrapolation, which is perfectly within my ballpark figure of 10-20,000. However, the US figures reflect actual captured data, the real figure being estimated to be double that in real terms. (Holland E & Degruy F, American Home Physician, 1997, Nov 1; 56(7): 1781-1788) Either way, locally, 15-30,000 deaths are distributed between the two types and never-mind how one allocates ratios, one type will inevitably gain by the other type’s loss.

The US figures are for advanced First World scientific medical drug related hospital deaths, where the ADR’s rank from the 4th to 6th leading cause of death. (Editorial, Bandolier, UK NHS, June 1998: 52-3) (White T, et al, Pharmacoeconomics, 1999 May; 15(5): 445-58) Compare our predominantly Third World facilities which most traditional African medicine patients would not even reach before or after death, and my figure of 10-2000 deaths gain ever-increased credibility. It is highly unlikely that South Africa would somehow escape its averaged extrapolated burden.

The percentage of the abovementioned deaths that are considered avoidable / preventable is either near side of a full 50%. (The above references apply, as do the following) (Johnson J & Bootman J, Archives of Internal Medicine, 1995 Oct; 155(18): 19) (Bates D, et al, Journal of the American Medical Association, 1995 Jul; 247(1): 29-34) (Nelson K & Talbert R, Pharmacotherapy, 1996 Jul; 16(4): 701-707) (Bootman J et al, Archives of Internal Medicine, 1997, Oct; 157(18): 2082-2096)

The South African figure would minimally be 15,000 “preventable” deaths annually from all adverse drug reactions. If the allopathic category accounts for 5,000 (even this percentage will be denied by those responsible), then traditional African medicines would have to account for 10,000. The total figure (both preventable and non-preventable) deaths for each category would then accordingly be 10,000 and 20,000 for allopathic and traditional African medicines respectively. I am content to let the authorities argue amongst themselves as to precisely who is responsible for what.

That’s it in a nutshell. I look forward to your information-based response. I do however suspect that you will be under pressure to counter my embarrassing exposé at all costs due to the fact that the MRC are so intimately involved in the ethnopiracy and cover-up of the essence of what I have uncovered. I am however hoping that you will surprise me, by honestly appraising the situation in the light of current data (or rather lack of it) and motivating the generation of the data necessary to scientifically quantify the facts and so facilitate the urgent policy setting and implementation of appropriate solutions.

Yours sincerely

Stuart Thomson

Director, Gaia Research Institute, National Co-ordinator, PHARMAPACT

Peoples Health Alliance Rejecting Medical Authoritarianism, Prejudice And Conspiratorial Tyranny

cc Dr D Bradshaw

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