The South African Medical Journal (SAMJ) - first published in 1884 - is a monthly, peer reviewed, general medical journal publishing leading research impacting clinical care in southern Africa.
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The changing fortunes of the District Health System in SA (1994 - 2020): A retrospective review
Background. The District Health System (DHS) forms the foundation of South Africa (SA)’s public health system. Following years of fragmentation and inequity during the apartheid era, building the DHS was seen as a vital element of the strategy to reform the health system in line with the principles of primary healthcare (PHC). SA has made great strides in establishing and strengthening the DHS, and to date there are 52 districts and 240 subdistricts. This process unfolded in a complex, and often challenging, social and political context. Objectives. To present an historical account of the DHS as a focus of national-level policy and strategy from 1994 to present. In doing so, we aim to illuminate the factors influencing DHS development over time, and contribute to an historically aware understanding of SA’s DHS and its contemporary challenges. Methods. We conducted a retrospective scoping review of literature on the DHS in SA from 1994 to 2020. We used database searches to identify primary and secondary documentary evidence, supplemented by purposive searches of databases and institutional repositories, and published and unpublished documentary evidence from the personal archives of key stakeholders. We extracted data on the timing of policy developments and contextual factors influencing DHS prioritisation and strategy using a structured data extraction sheet. Once extracted, this information was organised into a timeline. Results. After full-text review, 134 items were included for analysis. Based on the data analysis, we divided the events of the policy timeline into three periods: 1994 - 2000 (developing the legislative framework for the DHS, establishing local government boundaries and building district-level capacity), 2001 - 2009 (finalisation of the National Health Act, and the effects of the HIV epidemic and vertical health programmes on the DHS), and 2010 - 2020 (development of National Health Insurance legislation and associated efforts to strengthen PHC). This periodisation reflects differences in the pace of policy change, the extent of political prioritisation of the DHS and contextual factors influencing its development. Conclusion. Sustained political commitment to DHS development in SA is evident. However, the development and implementation of the DHS have been both enabled and constrained by various contextual realities, and is best understood in relation to wider health system and sociopolitical dynamics. Further in-depth analyses of the nature, focus and limits of DHS strengthening efforts are warranted. In particular, history-sensitive analyses of the sociopolitical factors that shaped the development of the DHS will inform strengthening efforts going forward.
Copyright (c) 2026 E Whyle, T Assegaai, M Smuts, P Barron, T Masilela, K Vallabhjee, B Engelbrecht, L Gilson, H Schneider https://creativecommons.org/licenses/by-nc/4.0
Thomas Micheal Guntram Ignaz Rehle (1951 - 2025)
Public Health, Societies and Belonging (PHSB) Research Division
Copyright (c) 2026 Public Health, Societies and Belonging (PHSB) Research Division, School of Public Health, O Shisana, L Simbayi, R Ehrlich, L London, A Boulle https://creativecommons.org/licenses/by-nc/4.0
LDL-cholesterol targets and lipid-lowering therapies – a plea to medical schemes and the Council for Medical Schemes
Copyright (c) 2026 A D Marais, D J Blom, D M Blackhurst, F J Raal https://creativecommons.org/licenses/by-nc/4.0
High-dose pyridoxine and peripheral neuropathy: Considerations for clinicians, pharmacists and policy-makers
peripheral neuropathy; pyridoxine; isoniazid; tuberculosis
medicine scheduling; regulatory; SAHPRA, South Africa
peripheral neuropathy, pyridoxine, isoniazid, tuberculosis
pharmaceutical science; epidemiology; public health; regulatory affairs
Copyright (c) 2026 B Job, M Govender, T N Gengiah https://creativecommons.org/licenses/by-nc/4.0
A rare case of paraneoplastic dermatomyositis secondary to smouldering multiple myeloma referred for proteinuria
Dermatomyositis (DM) is often associated with malignancies but less commonly with plasma cell dyscrasias. Myoglobin nephropathy is an uncommon complication of inflammatory myopathies. This case describes a patient who presented with proteinuria because of myoglobin nephropathy caused by dermatomyositis. The dermatomyositis was paraneoplastic with an underlying smouldering multiple myeloma (SMM) diagnosed on investigation. Case report. A 58-year-old mixed-race gentleman was referred for sub-nephrotic proteinuria. Further history taking revealed a 1-month history of proximal muscle weakness and a 5-month history of skin changes suggestive of dermatomyositis. Additional testing showed no associated albuminuria. There was haematuria on the urine microscopy which, with the accompanying raised creatine kinase levels, suggested myoglobinuria. Kidney biopsy confirmed myoglobin nephropathy. Further testing was done to exclude paraneoplastic DM. Investigations for solid organ malignancies were negative. Plasma cell dyscrasia screening revealed an IgA kappa monoclonal band, which was confirmed with serum free light chain testing. A bone marrow biopsy confirmed the diagnosis of SMM based on the revised working group diagnostic criteria for multiple myeloma. This case serves as a reminder of the importance of clinical history and examination. Investigation in this case revealed an extrarenal cause of the proteinuria, and recognition of the presentation of DM led to further investigation for secondary causes. Routine screening for plasma cell dyscrasias is recommended as part of DM work-up to allow the diagnosis to be made early, prior to organ damage.
Copyright (c) 2026 S Meel https://creativecommons.org/licenses/by-nc/4.0
Background. Oesophageal cancer (OC) is common in South Africa (SA), where late presentation limits curative treatment. In resource- constrained settings, staging may not benefit patients with a poor prognosis. The prognostic score for oesophageal cancer (PSOC), based on Eastern Cooperative Oncology Group performance status scale, body mass index and serum albumin, was previously developed to predict short-term survival. Objective. To externally validate PSOC in an independent cohort. Methods. We performed a retrospective validation study using prospectively collected data from two public sector hospitals in KwaZulu- Natal Province, SA. Eligible patients had histologically confirmed OC and complete PSOC data, and were treated with palliative intent. The primary endpoint was survival ≥3 months. Logistic regression assessed associations between PSOC and survival. Discrimination was quantified using the area under the receiver operating characteristic curve (AUROC), calibration with the Hosmer-Lemeshow test and accuracy with the Brier score. Secondary analyses evaluated overall survival (OS) with Kaplan-Meier and Cox models. Results. We included 465 patients (mean age 61 years; male:female ratio 1:1), 97% with squamous cell carcinoma. Higher PSOC scores predicted improved survival (score 4 v. 0: odds ratio 11.87, 95% confidence interval (CI) 4.87 - 28.91; p<0.001). AUROC was 0.681 (95% CI 0.630 - 0.732) with good calibration (Hosmer-Lemeshow p=0.920). Median OS was 4.8 months, with significant survival differences across score groups (log-rank p<0.001). The Brier score was 0.190, indicating good predictive accuracy. Conclusion. PSOC is a simple, validated tool for predicting short-term survival in OC, and may guide decisions on staging v. palliation in high-incidence, resource-limited settings.
Oesophageal cancer; palliative care; prognostic score; risk stratification; external validation; survival analysis; AUROC; calibration; Brier score; South Africa.
Copyright (c) 2026 L Ferndale, S Bhadree, W Chen https://creativecommons.org/licenses/by-nc/4.0
Artificial intelligence (AI) is rapidly reshaping clinical practice, and has prompted the Health Professions Council of South Africa to publish Booklet 20 – its first ethical framework for AI use in healthcare. This review critically evaluates Booklet 20 through the lens of the South African Medical Association AI Task Team, examining its alignment with national legislation, emerging regulatory mechanisms, broader policy commitments and the ethico-social context. Drawing on the Protection of Personal Information Act, the South African Health Products Regulatory Authority’s 2025 guidance for AI‑enabled medical devices, the National AI Policy Framework and the 2024 National Health Research Ethics Council ethics guidelines, the analysis identifies key operational gaps relating to human oversight, disclosure, data sovereignty, equity, accountability and risk categorisation. The article argues that while Booklet 20 establishes an important foundation, its principles require concrete implementation tools, including risk‑tiered safeguards, structured consent templates, meaningful governance co-ordination and context‑appropriate standards for transparency, explainability and bias mitigation. Grounding these enhancements in South Africa’s communitarian ethic of ubuntu highlights the need for relational accountability, fairness and community participation to ensure safe and equitable AI integration. The article concludes with a set of practical recommendations aimed at strengthening ethical governance and supporting patient trust and professional integrity as AI becomes embedded in clinical workflows.
Health Professions Council of South Africa Guidelines
Copyright (c) 2026 S Mahomed, M V Ncube, A Dhai, W Janneker, M Nodikida https://creativecommons.org/licenses/by-nc/4.0
The National Health Insurance Act – was there meaningful public participation?
Copyright (c) 2026 A Dhai https://creativecommons.org/licenses/by-nc/4.0
Gun violence – South Africa’s neglected public health emergency
Firearm violence, HVIPs, gun control, intervention to prevention continuum, health systems impact.
firearm violence; trauma care, hospital based violence interventions, violence prevention, legal and policy advocacy
Clinical care; commercial determinants of health; social and behavioural sciences
Copyright (c) 2026 D Peacock, P Navsaria, C Taylor https://creativecommons.org/licenses/by-nc/4.0
Agreement between various non-invasive blood pressure measurement sites in the obese population using the VitalStream system as control
Background. The incidence of obesity and hypertension, with all their associated complications, is on the rise globally. Non-invasive blood pressure (NIBP) is often difficult to measure in obese individuals owing to the increased circumference and conical shape of the upper arm. The forearm and ankle may serve as convenient alternatives to measure NIBP. The aim of this study was to identify the most accurate site for NIBP monitoring in obese patients. Objectives. To statistically determine an agreement between different NIBP sites (upper arm, forearm and ankle) and our control blood pressure (BP). A secondary objective was to investigate agreements between different NIBP sites, anthropometric variables (body mass index (BMI)/mid-upper arm circumference/conicity index) and the control, with the goal of deriving a correction formula for BP. Methods. A prospective cross-sectional study was conducted at a provincial tertiary hospital in Gauteng Province, South Africa. Fifty participants aged 20 - 60 years, with BMI 35 - 40 kg/m2, were recruited. Using appropriately sized cuffs, NIBP measurements were obtained from the left upper arm, forearm and ankle. Simultaneous continuous BP measurements were recorded using the VitalStream device on the contralateral hand. Bland-Altman plots and regression analyses were employed to evaluate agreement and derive correction formulas for each measurement site. Results. Bland-Altman analysis revealed significant biases across sites, with ankle systolic BP showing the greatest deviation (mean bias +14.44 mmHg, 95% confidence interval 8.26 - 20.62). Regression analyses identified significant agreements for mean arterial pressure at the upper arm, enabling a correction formula with high reliability (p<0.001). Forearm and ankle measurements demonstrated wider limits of agreement and were prone to overestimation, especially in systolic and diastolic pressures. Conclusion. Upper arm NIBP measurements were the most accurate in the obese population. Alternative sites, such as the forearm and ankle, demonstrated inconsistent reliability, and require careful interpretation. Correction formulas can enhance the accuracy of NIBP readings but may be cumbersome for routine clinical use. Future studies should focus on refining measurement protocols and evaluating the efficacy of conically shaped cuffs for improved accuracy.
Copyright (c) 2026 L M van Dyk, N Mdzinwa https://creativecommons.org/licenses/by-nc/4.0
The impact of the COVID-19 pandemic on maternal mortality in a South African metropole (2020 - 2021): A retrospective cohort study
Background. During the COVID-19 pandemic, there was a notable increase in maternal deaths across South Africa (SA). Pre pandemic, the Western Cape Province, SA, had made significant strides towards reducing maternal mortality, including HIV-related deaths. However, this progress was reversed in the pandemic period despite a relative protection of maternity services. The direct biological impact of SARS- CoV-2 may not be the sole reason for the increase in mortality. Objective. To evaluate the relative change in the maternal death rate (MDR) for non-SARS-CoV-2-related deaths during the pandemic v. pre pandemic in 2019. Methods. We conducted a retrospective cohort study including all pregnant women with a pregnancy outcome enumerated in the Provincial Health Data Centre in the Metro West region of Cape Town from 1 January 2019 to 31 January 2022. Cause of in-facility maternal death and relationship to SARS-CoV-2 infection was determined by folder review. We used interrupted time series (ITS) analysis to assess the impact of the pandemic period on non-SARS-CoV-2 causes of maternal mortality. Results. Over 98 000 women were included, with 68 deaths reviewed. The ITS model demonstrated no statistically significant change in the MDR for non-SARS-CoV-2-related deaths during the pandemic, with confidence intervals (CIs) that crossed the null for both a step change at the start of the pandemic (3.12/10 000 pregnancy outcomes; 95% CI –1.66 - 7.90) and a subsequent attenuation in the pre-pandemic downward gradient in MDR (slope change 0.47/10 000 pregnancy outcomes per month (95% CI –0.02 - 0.96). Folder review of deaths demonstrated an increase in opportunistic infections as a cause of death relative to the pre-pandemic period, mainly in women with HIV. Conclusion. Maternal healthcare services were largely protected from service disruptions during the COVID-19 pandemic. However, the increase in HIV-related opportunistic infections suggests that optimising maternal health requires an all-encompassing, functional healthcare ecosystem that can robustly maintain services for all health conditions.
Public Health Medicine; Public Health; Maternal Health; Obstetrics and Gynaecology
Copyright (c) 2026 M Hunter, L Hannan, A Boulle, M Matjila, M Ismail, J Euvrard, M-A Davies, E Kalk https://creativecommons.org/licenses/by-nc/4.0
The clinical profiles and outcomes of patients with herpesviruses in cerebrospinal fluid: 2019 - 2022
Background. Herpesviruses are ubiquitous and commonly cause neurological syndromes. A paucity of data exists describing the clinical profiles and outcomes of these viruses in cerebrospinal fluid (CSF). Objectives. To describe the clinical profile and outcomes of patients with a positive CSF viral panel testing for six herpesviruses (herpes simplex virus 1 and 2 (HSV1; HSV2), varicella zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV) and human herpesvirus 6 (HHV6)). Methods. A retrospective descriptive study included all hospitalised patients aged 13 years and older in whom a herpesvirus was detected by a herpesvirus panel performed on CSF. A folder review was performed to acquire demographic, clinical and laboratory information. Results. We identified 204 CSF herpesviruses in 184 patients. Most were people living with HIV (n=137/184, 74.5%). EBV was the most frequently identified herpesvirus (n=152/204, 74.5%). The herpesvirus was considered the cause of the clinical neurological syndrome in 20 patients (20/184, 10.9%), of whom most had VZV (7/20, 35%). Patients with VZV presented with encephalopathy (4/11, 36.4%), meningoencephalitis (3/11, 27.3%) and stroke (3/11, 27.3%). Encephalopathy, seizures and lower-limb weakness (n=5/19, 26.3%) were more common in patients with CMV. Those with HSV1 presented with seizures (n=2/5, 40%) and those with HSV2 with encephalopathy (n=3/6, 50%) and meningoencephalitis (n=2/6, 33.3%). EBV was the most common herpesvirus in patients with tuberculosis (TB) (45/49, 91.8%). Antiviral therapy was prescribed in 19/184 (10.3%) patients. The in-hospital mortality rate of all patients was 21.7%. Conclusion. EBV was the most common herpesvirus detected on CSF. Most patients with TB and HIV had EBV detected in their CSF, which may represent reactivation in these patients. This study highlighted the undertreatment of CMV and overtreatment of EBV. Greater awareness regarding the clinical indications for antiviral therapy in this setting is needed.
Copyright (c) 2026 W P du Plessis, M Saadiq Moolla, G van Zyl, L Festus, L Nyasha Sigwadhi, A Parker https://creativecommons.org/licenses/by-nc/4.0
Depressive symptoms among community service doctors in South Africa
Background. Medical doctors face occupational stressors threatening their mental health, particularly junior doctors in South Africa. There is a higher prevalence of depressive symptoms among medical doctors compared with the general population. The consequences of this to health systems and the patients doctors treat is a major public health concern. In South Africa, prevalence of depressive symptoms among community service doctors servicing public sector healthcare is largely unknown. Objectives. To determine the prevalence of possible depression, and predictive factors thereof, among doctors in their community service year in South Africa. Methods. A national descriptive cross-sectional survey was distributed electronically between October and December 2022. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for depression. Demographic, occupational and individual characteristics were included as potential predictive factors. Results. A total of 217 participants were included in the analyses. Prevalence of depressive symptoms was 96.3% (standard error 0.13, 95% confidence interval 92.87 - 98.40%). Predictors of higher scores included: women, drug use, feeling neutral or disagreeing that one worked outside of normal working hours, working in KwaZulu-Natal or North West, burnout (emotional exhaustion), working in orthopaedics, obstetrics and gynaecology departments or the National Health Laboratory Service, first choice of placement, financial difficulties, and accessing mental health services. Predictors of a lower score included: perceiving sufficient resources at work, using colleagues to cope, good work-life balance, and certain departments, particularly neurosurgery. Conclusion. There is an extremely high prevalence of depressive symptoms among community service doctors. Supporting these doctors at an individual, organisational and structural level should be a priority for national policy-makers.
mental health of medical doctors, depression, burnout, junior doctors
Copyright (c) 2026 T Morar, G M Purbrick https://creativecommons.org/licenses/by-nc/4.0
Doxorubicin-induced early-onset chronic progressive cardiotoxicity, pharmacogenetics and survival among breast cancer patients in Zimbabwe
Background. Early-onset chronic progressive cardiotoxicity (ECPC) is a significant cause of morbidity and mortality among patients who receive doxorubicin-based chemotherapy for breast cancer. Objective. To establish incidence of ECPC in black Zimbabwean women with breast cancer treated with doxorubicin and the resultant survival, and to describe the pharmacogenomic biomarkers’ association with prognosis. Method. A prospective observational study was conducted in Zimbabwe with 50 participants who received doxorubicin-based treatment and were actively followed up to 12 months, with 3-monthly echocardiography and vital status determined at 60 months for all-cause mortality analysis. Results. ECPC was observed in 10% of participants. Median survival for participants who developed ECPC and those without was 11.9 v. 40.8 months. Participants with ECPC had 5-year overall survival (OS) of 0% v. 42% (hazard ratio (HR) 4.19, 95% confidence interval (CI) 1.27 - 13.79; p=0.018) for participants with no ECPC recorded. Median survival was significantly shorter for patients on calcium channel blockers (p=0.01). Cardiotoxicity, pre-existing hypertension and histological grade showed no significant association. Using multivariate analysis, poor OS was observed with ECPC (HR 4.19, 95% CI 1.27 – 13.79; p=0.018) and calcium channel blocker use (HR 2.38, 95% CI 1.07 - 5.32; p=0.034); no association was observed with pharmacogenomic biomarker risk categorisation based on SLC28A3, UGT1A6 and RARG (HR 1.39, 95% CI 0.46 - 4.25; p=0.561). Conclusion. Breast cancer patients with doxorubicin-induced ECPC had poorer OS. The risk of doxorubicin cardiotoxicity and poor survival could not be explained using SLC28A3-scoring pharmacogenomic profile. Breast cancer therapies with lower cardiotoxicity are needed in Zimbabwe and other low-resource settings.
Copyright (c) 2026 T Mazhindu, V A Nyangwara, M Z Borok, C Masimirembwa, T Flaig, T B Campbell, N Ndlovu https://creativecommons.org/licenses/by-nc/4.0
Analysis of adverse events following COVID-19 vaccination and infection: A retrospective, comparative cohort study using a claims database from Discovery Health, a managed care organisation in South Africa
Background. Adverse events following COVID-19 vaccination have been studied extensively in recent years. However, there remains a paucity of data directly comparing adverse events among COVID-19 vaccinees and individuals with SARS-CoV-2 infection within the insured population in South Africa (SA). Moreover, the breadth of conditions assessed in this study exceeds that of most existing research, providing a unique perspective on potential immune-mediated outcomes. This study therefore contributes to a more comprehensive understanding of the risk-benefit profile of COVID-19 vaccination across different age groups. Objective. To evaluate the rate of adverse events occurring in COVID-19 vaccinees compared with individuals who have had SARS-CoV-2 infection. Methods. We conducted a retrospective cohort study, matching vaccinated individuals and those who have had a SARS-CoV-2 infection with comparable unexposed counterparts. Incident risk rates for 99 possible immune-mediated adverse events were compared between populations over a 42-day observation period to estimate relative risk ratios and confidence intervals. We used data from Discovery Health, a large managed care organisation in SA. Results. A total of 3 112 918 individuals aged ≥12 years who received a COVID-19 vaccination were included in the study, with an average of 76% successfully matched to a suitable comparator based on their risk profile. Additionally, 443 220 individuals with documented SARS-CoV-2 infection were analysed, with an average of 99.7% matched to an appropriate comparator. For recipients of the BNT162b2 vaccine, aged 12 - 17 years, we found an increased risk of lymphadenopathy and vertigo, compared with an increased risk of appendicitis, arrhythmia, encephalomyelitis, lymphadenopathy, myocarditis, seizure, syncope, type 1 diabetes and vertigo post SARS-CoV-2 infection. For those aged ≥18 years, we found no increased risk for any conditions post BNT162b2 vaccination. Additionally, no conditions post AD26.COV2.S vaccination had an increased risk for any age group. Post documented SARS-CoV-2 infection for persons in age groups 18 - 39, 40 - 59 and ≥60 years, we found an increased risk of acute kidney injury, anaemia, appendicitis, arrhythmia, axonal and neuronal neuropathy, cerebrovascular accident, deep-vein thrombosis, encephalomyelitis, endometriosis, eosinophilic oesophagitis, fibrosing alveolitis, glomerulonephritis, inflammatory bowel disease, intracranial haemorrhage, lymphadenopathy, myocardial infarction, myocarditis, myositis, pericarditis, pulmonary embolism, rheumatic fever, seizure, syncope, thrombocytopenia, type 1 diabetes, urticaria, vertigo, multiple sclerosis, cholangitis and/or pancreatitis. Notably, not all conditions presented with an increased risk in each age group. Conclusions. Across all age subgroups analysed, the risks associated with SARS-CoV-2 infection exceeded the increased risks following COVID-19 vaccination.
Copyright (c) 2026 K Bernhardt, S Collie, D W C Jacobs, P Mekgwe, G Gray, J Peter, L-G Bekker https://creativecommons.org/licenses/by-nc/4.0