The Health Professions Council of SA (HPCSA) has a new lawyer but will it be up to its old tricks when it resumes the hearing against University of Cape Town emeritus professor Tim Noakes in Cape Town today? Noakes is charged with unprofessional conduct for tweeting his views on butter, eggs, bacon and broccoli. Given the myriad ethically and legally questionable delaying tactics and actions breaching its own regulations that have characterised the hearing so far, I wouldn’t be surprised if it is a Groundhog Day rerun of time wasting. There is also yet another surprise expert witness cloaked in more secrecy than Donald Trump’s net worth. Legal costs are soaring all round, but of no concern for the HPCSA – that has deep pockets and staff who don’t have to fork out a cent. Noakes, on the other hand, says he could not have defended himself were it not for a legal dream team working pro bono.
What exactly will the HPCSA and the Association for Dietetics in SA (ADSA) whose former president started this odd nutrition ball rolling straight into Alice in Wonderland territory where it has remained resolutely ever since, get up to this time round? Who knows. It’s possible (as anything is) that the HPCSA could have a eureka moment and realise there are far more important issues it should be confronting – like stratospheric health care costs, a chronically sick health care system, epidemics of obesity, diabetes and heart disease, its own house in terminal disarray according to a ministerial task team report. ADSA’s new executive might even want to leap out of the bath naked and run screaming from the strangulating ties to vested interests that are turning it and its member dietitians into dinosaurs. Below, I consider the good (most likely the miracle) that could come out of this madness. I hope some of it is prescient. – Marika Sboros
By Marika Sboros
The “Banting for Babies trial”, as the HPCSA hearing against Prof Tim Noakes has become known, has been punctuated throughout by twists and surprise turns.
Expect the same when the hearing resumes on February 8, although effects of twists and turns may only be felt in the months and years after the hearing concludes.
The hearing is also being called the “Nutrition Trial of Century”. That may not be hyperbole. The biggest twist so far has come from the evidence: it is increasingly clear this is a not just a trial of one man, an eminent scientist and a medical doctor, fighting for his reputation on a charge of professional conduct against his own professional body – and against dietitians who don’t want him giving nutrition advice that challenges medical and dietetic dogma and threatens their livelihoods.
It is a trial of nutrition science, the nature and purpose of science and evidence-based medicine, the changing role of doctors and dietitians in the information age, patients’ right to information even if it differs from “conventional wisdom”, academic freedom, freedom of speech, and the very real perils of challenging orthodoxy.
Also on trial are the science (more likely lack thereof) on which SA’s government-sanctioned dietary guidelines are based, and epidemics of non-communicable diseases (NCDs) sweeping SA – obesity and diabetes (the two are so closely linked that specialists now refer to them as “diabesity”), heart disease, cancer, even dementia. The incidence of dementia is rising so rapidly in many parts of the globe that experts call it “type 3 diabetes” because of the link with diet.
In a best-case scenario, this trial could provide a prescription that saves people’s lives, extends quantity and quality of lives, brings skyrocketing healthcare costs back down to earth, and transforms healthcare in SA.
That prescription could also cure the HPCSA of terminal illnesses identified in a damning report by the ministerial task team that has been investigating it since March 2015. Among the team’s findings: the HPCSA is in a state of “multi-system organisational dysfunction”.
The hearing follows a complaint Johannesburg dietitian Claire Strydom, then president of the Association for Dietetics in SA (ADSA), lodged against Noakes with the HPCSA in February 2014.
It concerned two tweets in which Noakes, a medical doctor, an internationally renowned scientist and one of the world’s few scientists rated A1 (for expertise in sports science and nutrition), tells a breastfeeding mother that good first foods for infant weaning are low-carbohydrate, high-fat (LCHF).
Noakes was suggesting meat and vegetables – advice that Strydom, ADSA, SA’s paediatric nutrition guidelines and paediatric societies internationally now routinely give.
The HPCSA initially charged Noakes with “unprofessional conduct for giving unconventional advice to a breastfeeding mother” on the basis of a report to its preliminary inquiry committee in September 2014, procured from retired Northwest University nutrition professor Este Vorster. The committee never thought to let Noakes see that report before being charged, despite its legal obligation to do so. That charge has been amended irregularly to specify a time period, January to February 2014, and the means for giving the information, “on a social network (tweets)”.
The HPCSA has so far called five witnesses – Strydom, Vorster, Northwest University nutrition professor Salome Kruger, paediatric professor Muhammed Ali Dhansay, a Medical Research Council unit head, and HPCSA legal officer Nkagiseng Madube. It intends calling more (Stellenbosch psychiatry professor Willie Pienaar to give testimony on ethics, and another whose name the HPCSA has so far refused to reveal).
None of the witnesses’ evidence stood up well under rigorous cross-examination by Noakes’ defence team, headed by Cape Town attorney Adam Pike of Pike Law, with Johannesburg advocate Michael van der Nest SC, and Pietermaritzburg advocate Ravin “Rocky” Ramdass, a medical doctor with 23 years experience as a family physician.
Among other concessions to Van der Nest, Strydom agreed she “probably overreacted” in her response to Noakes’ tweets; he was not in a doctor-patient relationship with the breastfeeding mother; he was actively communicating and debating with her on ADSA’s blog when she lodged the complaint.
Madube held onto this contention that Noakes was not entitled to see Vorster’s report before being charged, but Van der Nest easily undermined it simply with reference to the HPCSA’s own regulatory requirements.
Ramdass similarly undermined all substance in Vorster, Kruger and Dhansay’s evidence, eliciting concessions demonstrating that they had little knowledge of LCHF. All conflated it with ketosis, a natural, benign condition in which the body uses fat for fuel instead of glucose from carbohydrate, and conflated ketosis with ketoacidosis, a pathological, lethal condition seen mostly in type 1 diabetics.
When the defence does present its case, Noakes, according to his statement of evidence, will say NCDs are just the tip of the iceberg. Underneath it lies insulin resistance.
He will present the evidence – comprising 4000 pages, 400 slides, and including 24 well-designed randomised controlled trials (RCTs, the “gold standard” of scientific research) – to show that LCHF outperforms other diets for obesity and type 2 diabetes.
He has told me that if all diabetics around the globe were put onto LCHF, “at least six pharmaceutical companies would go out of business”.
Five years ago, Noakes caused shock, awe and outrage in equal measure after changing his mind on carbohydrate and saturated fat in the diet, and challenging the diet-heart hypothesis. He has documented it in The Real Meal Revolution and Raising Superheroes, the latter on optimum nutrition for pregnancy and children.
Clearly, this hearing has never been a “whodunit”, but is rapidly turning into a “what if” investigation of different hypotheses that could signal a turning point for nutrition science in SA – with a little good faith, good will and lateral thinking on the HPCSA’s part:
- What if Noakes is right about LCHF and Banting?
- What if low-carb, high-fat (LCHF) is a safe, effective, cheap way to combat NCD epidemics?
- What if Noakes is given space to present LCHF science without being demonised?
- What if he is found guilty?
- What if the debate he has ignited is stifled, and doctors and dietitians won’t challenge orthodoxy in case they are similarly prosecuted?
- What if the HPCSA does not re-examine its stated purpose, “to guide the profession and protect the public”, in the light of the ministerial task team’s report?
- What if the HPCSA doesn’t see that to protect the public, it must guide the profession by first exploring the science even when it goes against “conventional wisdom”?
- What if the status quo remains?
In My Story, a recent MNet TV documentary on Noakes, UCT deputy vice-chancellor and law professor Danie Visser says science is “all about disproving current knowledge”, and “to be a good scientist you have to be able to ask hard, difficult questions, and stick it out”.
Former Springbok captain Morné du Plessis says of Noakes: “He asks the right questions and quite often these are uncomfortable.”
Which brings me to a last “what if” that could flow from the hearing:
What if Noakes really is a “force in the world”, as Visser describes him, or as former Comrades Marathon king Bruce Fordyce says: “a national treasure, one of the most important South Africans of all time”?