A Journal of Internal Medicine study compared people who drank tea against those who did not, and found had a lower risk of vascular disease.
Among 485 934 adults in China followed for a median of 9.05 years, there were 14 863 cases of cardiovascular disease, cerebrovascular disease, pulmonary heart disease, and peripheral artery disease. Regular tea consumption was linked with an 11% lower risk of experiencing these outcomes. The lowest risk was estimated at approximately 6–8 cups per day among weekly drinkers.
Black tea showed more consistent inverse associations with vascular disease than green tea. Regarding strength, moderate-strength tea was associated with the lowest risk. Interestingly, “burning hot” tea was associated with an elevated risk of vascular disease.
“Joint analyses showed that tea consumption, smoking status and physical were collectively associated with vascular risk, with the favourable combination of habitual tea consumption, non-current smoking and high physical activity associated with the lowest risk,” the authors wrote.
People with multiple sclerosis (MS) who are treated with rituximab have an increased risk of developing inflammatory bowel disease (IBD), particularly Crohn’s disease, although the absolute risk remains low. This is according to the first large population-based study in the field, led by researchers at Karolinska Institutet and published in JAMA Neurology.
Rituximab belongs to a group of drugs known as anti-CD20 therapies and is currently the most used disease-modifying treatment for MS in Sweden. As the use of anti-CD20 therapies has increased, cases of inflammatory bowel disease have been reported among patients receiving these treatments, raising concerns among neurologists. Until now, however, evidence from large studies has been lacking. The new study is the first population-based study to systematically investigate the association.
The researchers analysed nearly 14 000 treatment episodes among people with relapsing-remitting MS, using data from Swedish registers. They compared rituximab with three other highly effective MS treatments: natalizumab, dimethyl fumarate and fingolimod.
Inflammatory bowel disease was more common among people treated with rituximab than among those receiving any of the other three treatments, even after differences in follow-up time were taken into account. After adjusting for other differences between the groups, the researchers found that the risk was around ten times higher with rituximab than with the other MS treatments.
Few patients developed the disease
Despite the increased relative risk, the absolute risk remained low. Fewer than two per cent of patients in any of the treatment groups developed inflammatory bowel disease within ten years of starting treatment. The increase in risk corresponded to approximately one additional case for every 131 patients treated with rituximab for five years rather than with one of the other treatments. Most of the cases were Crohn’s disease.
“This is the first large study to quantify the risk of inflammatory bowel disease associated with anti-CD20 treatment for MS. The results show that this is a potential adverse effect that should be considered when choosing an MS treatment. At the same time, the increased risk needs to be weighed against the benefits for the individual patient. Anti-CD20 drugs are among the most effective treatments for preventing MS relapses,” says Peter Alping, researcher at the Department of Medicine, Solna, and last author of the study.
See the scientific article for information about funding and potential conflicts of interest.
In adults with septic shock undergoing surgical source control, a new study found that adding intraoperative dobutamine to norepinephrine reduces the risk of acute kidney injury (AKI) over norepinephrine alone.
International guidelines recommend dobutamine for management of septic shock and cardiac dysfunction with persistent hypoperfusion in adults, but this is based on very low–certainty evidence, and there is even less for dobutamine plus norepinephrine.
Norepinephrine is a potent vasoconstrictor and can decrease regional renal blood flow, potentially increasing AKI risk. Conversely, the role of dobutamine in septic AKI prevention “has remained controversial,” the researchers noted in their study published in JAMA. While dobutamine can increase renal blood flow and glomerular filtration rate, some prior observational studies suggested an association with greater AKI progression or need for kidney replacement therapy (KRT).
Open-label randomised clinical trial
The researchers therefore conducted a multicentre, open-label, randomised clinical trial conducted across 39 tertiary hospitals in China, from June 2024 to August 2025). Adults with septic shock requiring surgical source control of anticipated duration > 1 hour were eligible. Key exclusions included recent use of dobutamine, levosimendan, epinephrine, or recombinant human B-type natriuretic peptide.
Of 714 patients screened, 584 were randomised 1:1 (stratified by site): 290 to dobutamine plus norepinephrine and 294 to norepinephrine alone. Median age was 67.5 years (IQR 55–76); 32.9% were female. Most patients had preoperative septic shock; common procedures involved gastrointestinal perforation (41.8%) or obstruction (29.6%).
Norepinephrine was titrated in both arms to a target mean arterial pressure of 65 mm Hg. In the intervention arm, dobutamine was initiated at 5 µg/kg/min intraoperatively (with dose reduction or discontinuation for tachycardia or arrhythmia). Treatment began after induction for preoperative shock or after recognition of intraoperative shock.
The primary outcome was New-onset AKI or worsening of preoperative AKI (by ≥1 Kidney Disease: Improving Global Outcomes [KDIGO] stage) within 7 postoperative days. This occurred in 66/290 (22.8%) patients receiving dobutamine plus norepinephrine versus 102/294 (34.7%) receiving norepinephrine alone (adjusted risk ratio 0.64; 95% CI 0.49–0.83; P = .001). Absolute risk reduction was approximately 11.9 percentage points.
The benefit was driven mainly by reductions in stage 2 (4.8% vs 9.9%; ARR 0.48) and stage 3 (7.9% vs 13.6%; ARR 0.56) AKI. Stage 1 rates were similar. Secondary outcomes: SOFA score on postoperative day 1 was lower (adjusted difference −0.53; 95% CI −0.98 to −0.07) and urine output 1 hour after intervention start was higher (adjusted difference +0.55 mL/kg/h; 95% CI 0.03–1.07) with combination therapy. No significant differences were seen in most other secondary outcomes, including mortality, kidney replacement therapy, or length of stay.
Adverse events included tachycardia being more common (≈41% with dobutamine plus norepinephrine vs 30%). Other reported cardiovascular events were similar between groups.
The researchers concluded that “While hypothesis generating, these data suggest an opportunity to explore dobutamine treatment response heterogeneity across different clinical subtypes.”
Limitations of the study include being an open-label trial and largely restricted to Chinese patients and settings.
3D structure of a melanoma cell derived by ion abrasion scanning electron microscopy. Credit: Sriram Subramaniam/ National Cancer Institute
Melanoma is one of the most difficult cancers to treat due to its resistance to targeted drug therapies. But a new study from the University of Markey Cancer Center shows that the cancer is playing offence as well as defence: In addition to forming resistance against the MAPK inhibitors that are commonly used to treat it, the cancer also actively suppresses the immune cells that would otherwise help eliminate it.
The study, published in Nature Communications, identified two cell proteins known as ABL1 and ABL2 as key drivers of both processes. These proteins help control cell functions such as growth, survival and communication with other cells, leading to tumour growth when they become overactive. In melanomas, they help the cells keep growing despite treatment by reactivating the growth signals. Meanwhile, they can also trigger a signal that recruits immune-suppressing cells while keeping cancer-fighting T-cells at bay.
“These findings reveal that treatment resistance isn’t happening only inside the melanoma cell,” said UK College of Medicine researcher Rakshamani Tripathi, Ph.D. “ABL1 and ABL2 also help reshape the tumour’s immune environment, essentially creating another layer of protection that allows the cancer to survive therapy.”
But scientists are working on a new play: Nilotinib is a drug that is Food and Drug Administration-approved for chronic myeloid leukaemia, and it works by blocking ABL proteins. Markey researchers have used nilotinib against multiple melanoma cell lines in preclinical testing models, with encouraging results: It shut down the proteins’ growth and survival signals and reduced the cancer’s ability to attract immune-suppressing cells, which allowed T-cells to return.
These findings confirm melanoma’s ABL proteins as a therapeutic target, opening up new possibilities for effective treatment.
“What makes this approach promising is the possibility of attacking resistance from two directions by blocking the cancer’s survival signals while allowing the immune system to reengage,” said Rina Plattner, PhD, professor in the UK College of Medicine Department of Pharmacology and Nutritional Sciences. “Our results provide a strong rationale for continuing to study this strategy and translating it into clinical care.”
Putting Caregiver Wellbeing at the Heart of In-home Support
Photo by Kampus Production on Pexels
By Roxanne Cordes – National Homecare Administrator at Allmed Healthcare Professionals
When a loved one needs care, the focus is naturally centred on them. Are they safe? Are their needs being met? Do they have the right support? These questions are important, but there is another person at the heart of the care arrangement whose needs can sometimes be overlooked: the caregiver. Whether supporting an older person at home, caring for someone recovering from illness or working with people living with conditions such as dementia, caregivers carry significant physical and emotional demands of their own. The level of support they receive can have a direct impact on the quality of care provided.
The reality of caregiving
Caregivers play an indispensable role in healthcare, often becoming a constant presence in a client’s daily life. Their responsibilities can range from personal care, dressing and mobility to preparing meals and providing companionship. They may also support people living with dementia or recovering from major surgery, where patience and reassurance are as important as practical assistance. The physical demands of caregiving can be considerable. A typical day may involve lifting and transferring, assisting with mobility, managing equipment and responding to changes in a client’s condition. Needs and moods can also shift throughout the day, requiring constant attention and adaptability. For those providing live-in or in-home care, there may be little opportunity to step away when circumstances become challenging.
The emotional demands can be just as significant. Dementia can bring confusion, fear, frustration and distress, sometimes resulting in angry or hurtful responses. Caregivers need to recognise these reactions as part of the condition rather than taking them personally. Close relationships often develop over time, making illness, decline or loss particularly difficult to process.
Homecare can bring another challenge: isolation. Unlike caregivers in residential facilities, those working in private homes may spend much of the day without colleagues nearby to share concerns or seek advice. Regular contact and accessible support give caregivers a place to raise concerns, discuss changes and seek guidance before challenges become more difficult to manage.
Supporting the person behind the care
Caregiver wellbeing is closely linked to the realities of delivering care, which can be physically demanding and emotionally draining, particularly over time. While this does not mean a difficult day will compromise care, it does highlight the importance of having the right support in place.
That support needs to be practical. Regular check-ins give caregivers a chance to talk through concerns, ask questions and flag changes in a client’s needs before they become more difficult to manage. Clear access to appropriate healthcare professionals and support structures is just as important, particularly when something falls outside the caregiver’s responsibilities. This could include GPs, nurses or other healthcare professionals involved in the client’s care. In a private home, where there may be no colleagues nearby, knowing exactly who to contact can provide valuable reassurance.
Training provides another layer of support. Clear responsibilities, practical skills and ongoing development help caregivers understand what is expected of them and where they need to involve someone else. This is particularly important in homecare, where much of the work happens independently.
Caregiver wellbeing is part of quality care
Care does not happen in isolation. It is a circle involving the person receiving care, the caregiver, family members and the wider healthcare team. Each part of that circle affects the others, which means supporting the caregiver is also part of supporting the person in their care.
A caregiver with the right training, clear responsibilities and access to guidance is better positioned to respond when needs change or a situation becomes difficult. The same applies to emotional support. Having someone to turn to can make it easier to manage the pressures of the role rather than trying to carry every challenge alone.
For healthcare organisations and families arranging in-home support, this means looking deeper than whether immediate care needs are being met. Are caregivers able to raise concerns and ask questions? Do they know who to contact when professional guidance is needed? Are they receiving the training and support required for the role? These considerations are not separate from quality care. They are part of creating a care environment where everyone involved is supported.
Making a year-round commitment
Carers Week offers a vital moment to celebrate those who dedicate their lives to helping others. But caregiver wellbeing cannot be a once-a-year conversation. A truly sustainable care model starts with three simple principles:
When caregivers are supported, care is stronger: The right training, guidance and support help caregivers respond to changing needs with confidence and compassion.
Good support happens every day: Regular communication, professional guidance and ongoing learning give caregivers the practical support they need throughout their careers.
The human side of caregiving matters: Care is built on patience, empathy and relationships as much as practical skills. Recognising the emotional demands of the role is part of recognising the work itself.
Good care ultimately depends on the people providing it. If we want to create safe, respectful experiences for our loved ones, we must also support the professionals who help hold the circle of care together.
A new drug is effective at decreasing recurrence of and death from endometrial cancer, a landmark international study shows. The drug, called sacituzumab tirumotecan (sac-TMT), attaches to a protein on the surface of tumour cells and then delivers a targeted dose of a chemical that leads to cancer cell death.
Cancers of the endometrium are the most common in the female reproductive system. They are becoming more deadly and have few effective treatment options, especially if diagnosed late, researchers say. Moreover, until now, no standard therapies have existed to prevent or stall its recurrence after initial chemotherapy and immunotherapy.
In the phase 3 TroFuse-005/ENGOT-en23/GOG-3095 trial (NCT06132958), sac-TMT reduced the risk of progression by 41% and death by 32% versus chemotherapy in patients with advanced or recurrent endometrial cancer previously treated with chemotherapy plus pembrolizumab.
Objective response rates were 35.1% with sac-TMT versus 17.3% with chemotherapy. Common adverse events included anaemia, neutropenia, stomatitis and ocular toxicity, described as manageable. The antibody–drug conjugate targets Trop-2, which is highly expressed on endometrial cancer cells.
Results were presented at ESMO 2026 and published simultaneously in The Lancet. Dr Bhavana Pothuri (NYU Grossman School of Medicine) stated that the findings establish sac-TMT as a new standard after immunotherapy and will require guideline reassessment. Dr Michelle Lightfoot noted the particular relevance for aggressive subtypes that disproportionately affect Black patients, who have roughly double the mortality risk. The drug may also be relevant to other Trop-2-overexpressing tumours (lung, breast, ovary, gastrointestinal).
People with severe mental illness experienced more rapid increases in both weight and long-term blood sugar levels during the first three months after starting treatment with antipsychotic medication. This is shown by a study from Karolinska Institutet and University College London, published in The Lancet Psychiatry.
The researchers analysed electronic health records from nearly 97 000 people in England aged between 18 and 59 with severe mental illness. The aim was to investigate how weight and HbA1c, changed before and after treatment with second-generation antipsychotic medication was initiated.
During the first 90 days after treatment began, HbA1c increased by an average of 0.12mmol/mol per week and weight by 0.21kg per week. Before treatment, the corresponding increases were 0.01mmol/mol and 0.02kg per week, respectively.
After the first three months, the rate of change slowed. From day 91 and up to two years, HbA1c again increased by 0.01 mmol/mol per week, while weight increased by 0.03 kilograms per week.
The study is based entirely on health record data and shows how the values changed around the start of treatment, rather than reporting results from a randomised treatment study. In addition, only around a quarter of the participants had at least one recorded HbA1c measurement and just over three-quarters had at least one weight measurement.
Early follow-up may be important
“The results show that the greatest changes occur early after treatment is initiated. This suggests that both weight and HbA1c need to be monitored from the start of treatment and during the first three months, alongside what is clinically appropriate for each patient,” says Magnus Boman, professor at the Department of Medicine, Solna, Karolinska Institutet, and one of the authors of the study.
The changes differed between medications. The largest increases were seen with olanzapine treatment. Quetiapine, by contrast, was associated with weight gain but only a small change in HbA1c. The increases were generally greater among women.
People who already had prediabetes when treatment began also had a higher risk of developing type 2 diabetes. The estimated proportion who developed the disease within two years was 19 per cent in this group, compared with 3 per cent among people who had normal HbA1c levels at the outset.
An AI model created by researchers at King’s can detect signs of faulty DNA-repair mechanisms in ovarian cancer cells, potentially enabling a low-cost, widely accessible diagnostic tool.
By analysing tissue images, the model recognised tumours with defective DNA-repair mechanisms, which could help clinicians select treatments that exploit this vulnerability.
We are unlocking information hidden in microscopic images of cancer tissue that could transform how we match patients to treatments. By using AI to reveal defects in DNA repair, we could make precision cancer medicine faster, more affordable and accessible to more women with ovarian cancer, not just in the UK but around the world.
Dr Heba Sailem, Reader in Computational Pathology at King’s College London
The study focused on high-grade serous tubo-ovarian carcinoma (HGSOC). Homologous recombination deficiency (HRD), often arising from BRCA1/BRCA2 or related mutations, impairs DNA-damage repair and increases vulnerability to platinum chemotherapy and PARP inhibitors. HRD is therefore a useful biomarker for treatment selection, but current tests require genomic analysis that is costly and less accessible in resource-limited settings.
In the study, published in Nature Communications and led by Dr Heba Sailem, researchers developed HRDPath. Rather than sequencing DNA, HRDPath analyses high-resolution digital histopathology images. It was trained on images from patients with known genomic HRD status and correctly identified approximately 91% of HRD-positive cases, particularly when multiple images per patient were considered.
HRD-positive tumours showed subtle morphological differences, including rounder nuclei and denser cellular packing in certain regions. Defects in DNA repair therefore appear linked to tissue-architecture changes recognisable by AI but difficult to detect by conventional microscopy.
If validated in larger cohorts, HRDPath could use images already acquired for diagnosis, reducing reliance on expensive genomic testing and widening access to platinum and PARP-inhibitor selection for patients whose tumours are likely to benefit.
Researchers have identified two common drugs that may, when given together during pregnancy, prevent premature births.
The finding comes from a new, Stanford Medicine-led, artificial intelligence-powered technique for screening drugs to prevent early labour. It uses a comprehensive atlas of the immune system, accurate at cell-by-cell level, to create ‘digital twins’ of the immune systems of individual pregnant women for virtual drug testing.
The study, published online 21 October in Science Advances, builds on two decades of Stanford Medicine research on maternal immune shifts during pregnancy. When the immune clock of pregnancy runs too quickly, preterm labour can result.
After screening several possible treatments with the digital twin system, the researchers identified one drug combination that promises to markedly lower the risk of early labour. It shows sufficient potential that researchers are starting a clinical trial.
“We’re on the brink of having a real impact for the treatment of preterm birth, a global health problem that affects 10% of pregnancies worldwide,” said senior study author Dr Brice Gaudilliere. It has been decades since a new pharmacological intervention for preventing preterm birth.
The winning combination was aspirin and lansoprazole. Low-dose aspirin alone has a modest ability to prevent premature birth; lansoprazole is sometimes used in pregnancy for acid reflux.
“In the digital twin system, these two drugs in combination had a large effect on the delay of labour, 15 times higher than aspirin alone,” Gaudilliere said.
Modelling how the immune clock ticks
Although triggers of labour remain incompletely explained, Stanford Medicine research has shown immune signals play a key role. Early in pregnancy the maternal immune system adjusts to tolerate the fetus. Late in pregnancy, immune changes – including a switch toward pro-inflammatory signals – prepare the body for labour. When pro-inflammatory signals activate too soon, early labour can result.
The new system, SIMCO (simulated immune modelling of clinical outcomes), uses AI and machine-learning to integrate extensive data on immune-cell behaviour during pregnancy.
Researchers collected blood samples from pregnant women and exposed immune cells to multiple drugs. “We measured responses from a quarter of a billion cells, training the algorithm on a massive single-cell dataset,” Gaudilliere said.
“A digital twin has the prerequisite that you understand a biological system very well,” said co-lead author Dr Jakob Einhaus, postdoctoral scholar at Stanford Medicine. “The digital twin represents the complexity and connections in the immune system.”
Einhaus shares lead authorship with graduate students Peter Neidlinger and Olivier Fondeur, and with Dr Masaki Sato (now at the National Center for Child Health and Development, Tokyo).
Longitudinal data from 63 pregnancies were integrated to link cell-behaviour patterns to clinical outcomes and capture inter-patient variability. The algorithm predicts individual immune-cell responses to drugs and, from limited patient data (e.g., a small blood sample), the likely clinical effect on the immune clock of pregnancy.
“You’re making the prediction for one individual based on knowledge of millions of single cells from dozens of patients,” Einhaus said.
Common medications may delay delivery
After validating that SIMCO forecasts time to labour, the team evaluated nine pregnancy-safe drug regimens identified via a drug-repurposing pipeline developed by a group led by Dr Marina Sirota (University of California, San Francisco). Multiple digital-twin copies compared treated versus untreated scenarios for each individual.
The model strongly predicted that the aspirin–lansoprazole combination would delay labour. “Our findings suggest that salicylic acid [aspirin] and lansoprazole act synergistically … this synergy may enhance their immunomodulatory effect,” the investigators write.
Folic acid also delayed immunological progression toward labour. “We’re giving folic acid for spina bifida prevention, but maybe, unknowingly, we’re also helping the maternal immune system adapt to pregnancy,” Einhaus said.
The model indicated specific immune-signal changes: for the aspirin–lansoprazole combination, processes supporting pregnancy continuation are enhanced while those triggering labour are inhibited.
Because the model captures patient variation, it can identify likely responders and non-responders, potentially allowing smaller, more efficient trials restricted to predicted responders.
The combination delayed labour onset in an animal model of inflammatory pregnancy; FDA approval was obtained for a human trial.
South Africa’s public healthcare system finds itself caught between two incomplete revolutions – the democratic dream of a decentralised District Health System, and the march toward National Health Insurance. Health systems experts argue that structural changes won’t save a system that is scared stiff. The most urgent task facing the system, they say, is to help frontline doctors and nurses reimagine what is possible.
Part of what makes an octopus such a nimble, wily creature is that there’s more brain outside its head than in it.
In fact, about two-thirds of an octopus brain is spread across its eight tentacles, each one controlled by a tangle of neurons, its own mini-brain.
These semi-autonomous processing centres allow the octopus to control hundreds of individual suckers, which means tentacles can investigate crevices the eyes can’t see, and even learn from each other without much of the big brain’s help.
The suckers can sample the seafloor and decide whether what it finds is safe to eat, at which point a tentacle turns into a temporary elbow to bring the morsel to its beak.
This is the kind of intelligent and adaptable network that was envisioned for South Africa’s District Health System (DHS).
Where apartheid-era planning demanded top-down compliance, among others to enforce racial oppression and dispossession, the DHS, with its 52 districts and 240 sub-districts, promised to empower staff to respond to patients’ everyday realities, whether they live in a city or a rural village.
In reality, much of the system’s financial and administrative power has pooled at provincial head offices, trapping staff on the ground in the old command-and-control way of doing things.
As a result, frontline healthcare workers clock in every day with the task of executing more than 175 new clinical guidelines (that’s just since 2012) while also racing to meet sometimes out-of-touch performance targets. That is according to 2020 research conducted among district managers in the Eastern Cape, Western Cape, KwaZulu-Natal and Limpopo.
What’s more, layers of red tape added to catch corruption have not deterred politically connected syndicates. Research suggests it has only overwhelmed clinical managers and facility heads who are held accountable for patient experiences but can’t replace even the most basic equipment needed for care, such as a scale, without kicking off a months-long procurement effort.
Under these conditions, health workers have said repeatedly that the work of caring for people gives way to constant administrative self-preservation.
One Eastern Cape manager told researchers: “We will comply now and complain later. If you don’t comply, it means you are failing your district, or your sub-district, or your clinic or your people.”
Much like an octopus might become a danger to itself if it only believes its eyes, the health system’s top-down leadership style is damaging to those it employs and ultimately, to those it serves.
Fear and loathing in the platinum belt
It is possible to bring the original DHS dream to life by shaking the systemic fear out of daily operations.
Leading the charge is SALAD, the South African Learning Alliance for the District Health System.
Established in 2023, SALAD connects academic researchers across several South African universities (including UWC, UCT, NWU, and Stellenbosch) with national, provincial, and district health managers, clinicians, and non-profits to help tackle governance problems.
The team recently completed a pilot project in the North West province’s Rustenburg sub-district with more than 50 managers.
“We started at the sub-district level because if you can strengthen it there, you can learn a lot. There’s much less politics than at the top,” explains Beth Engelbrecht, the former Western Cape health department head and an adjunct professor at NWU and UCT.
Their initial analysis revealed staff were dealing with a mix of helpful and harmful experiences. Mistrust was among the more pervasive issues. “Even in regular meetings, it’s a toxic space,” Engelbrecht says. “If you don’t achieve your target, it’s like a ton of bricks coming down on you.”
To address all this, SALAD teamed up with the North West Systems Leadership Development Programme and the provincial health department to co-design a four-pronged plan.
The executive team got support to transform review meetings into learning spaces, managers attended an accredited short course, and everyone received mentoring, and real-time evaluation.
The most important part of the plan was that all the learning and assessment was happening in sub-district’s wards and daily meetings, using the real problems it faces. Workshops ran in short one or to day blocks spaced over four months, which also minimised disruption to clinic operations.
“When people see the effect of adopting different leadership processes in their relationships with colleagues, that builds its own desire to keep working differently,” explains Lucy Gilson, professor of Health Policy and Systems at UCT.
They gave staff explicit permission to stop expending energy on systemic issues (such as national budget cuts) they cannot alter, says Professor Helen Schneider, a professor of public health at UWC.
“Acknowledge the system-wide issues, but don’t kill yourself worrying about them,” she explains, “focus on what you can do, and then suddenly people discover a certain kind of agency, and they recognise they do have power.”
For instance, managers and clinicians can directly control in their immediate daily operations, how facility meetings are structured, staff schedules, internal communication tone, queue management, and creating psychological safety within their immediate team.
Outside their own facility, they can build strategic alliances, Schneider says, by navigating local trade union relations or engaging clinic committees, negotiating with sub-district support units, or coordinating across public-private boundaries.
The pilot is complete, and the SALAD team is still in touch with health authorities in the North West to figure out how to scale the programme.
This will take time, Gilson says, because leadership development is not written into provincial annual performance plans. Although it’s a frontline change that’s needed, backing from the top is still crucial.
Engelbrecht and Gilson met with a number of national oversight bodies (including the Department of Planning, Monitoring and Evaluation, the Department of Public Service and Administration, and the National Department of Health) to figure out how leadership was being managed on a national level.
“All three of those national bodies said leadership is critical, but all of them confirmed that leadership development is nowhere in any plan an explicit, funded priority.”
Unlike most other national or provincial departments, the Western Cape has embedded leadership development into its structures, budgets and working practices.
Through the Partnership for Health Leadership and Management Capacity Development (PAHLM), for instance, the Western Cape health department and three universities developed a leadership competency framework and a leadership behaviours charter. The framework was tested and developed through two rounds of workshops involving more than 800 public health-system managers and was commissioned and approved by the provincial health department.
The case of the disappearing paramedic examiners
Years of fear and resentment can crystallise in unexpected ways.
In KwaZulu-Natal, a meticulously planned paramedic examination was nearly derailed when a number of paramedic educators and examiners booked off sick at the same time, Caleb Wang tells those gathered for a SALAD online seminar.
Wang, who coordinates in-service training for clinical employees in KZN, is a paramedic by training. Paramedics are an important link connecting household emergencies, clinics, and district hospitals, though training colleges are often regional or provincial facilities.
These assessments are labour intensive, Wang says, and they require large panels of examiners for clinical skills, oral boards, and simulation exercises. It’s a high-stakes situation for students too, since failing means they can’t progress, get promoted or qualify for salary increases.
The exams continued with fewer examiners for the sake of the students, but the sudden changes created a high-pressure environment for everyone involved.
At first, Wang and his colleagues suspected a stomach bug might be behind the chaos, but upon closer inspection, a stranger reality emerged; the examiners were afraid to attend the assessment, and afraid of saying why.
As it turned out, course coordinators leading the different academic tracks were locked in interpersonal feuds. Educators felt helping to assess a rival coordinator’s exam could be seen as a betrayal. Unsure of how to raise such worries without also facing reprisals, people instead took sick leave in self-defence.
Such a fraught emotional landscape can’t be fixed with rules and reprimands. Though managers started to track sick leave application trends for signs of a coming crisis, the underlying issues could only be remedied using a more collaborative, relational style of leadership.
Wang focussed directly on the relationships between co-ordinators. After they had completed a series of communication exercises, management also instituted regular meetings where structured, open dialogue was encouraged.
Topics previously taboo in administrative settings (feelings, assumptions, perceptions, and hidden dynamics) were reframed as important operational intel.
The formerly warring co-ordinators aren’t personal friends today, Wang says, but the approach succeeded in breaking down the seemingly intractable silos and has restored cooperation across the different academic components.
These days, paramedic examinations go off without a hitch.
People who have the confidence to speak up, admit mistakes, or take calculated clinical risks are much better at saving lives and preventing hospital infections than those who keep their head down out of fear.
Nomlindo Makubalo, a paediatrician in an Eastern Cape district clinical specialist team, has seen this first-hand.
Speaking during a webinar on psychological safety in the DHS, she shares an anonymised story of a junior medical officer and ward nurses at a cash-strapped district hospital who were confronted with a critically ill, ventilated 11-month-old infant.
The baby urgently needed intensive care but there were no available ICU beds in the regional or central referral complexes. The rural ward nurses had no formal ICU ventilation training.
In a traditional, fear-based culture, the local team might have panicked and passed responsibility upward or allowed the infant to deteriorate while waiting for official transport sign-off.
But Makubalo and the district clinical specialist team had intentionally built a relationship of psychological safety, so the junior doctor felt safe to call her directly.
She reassured the team and provided real-time, telephonic clinical supervision for two consecutive nights.
The hospital management authorised additional nursing support to relieve ward strain. Supported by this protective leadership umbrella, the frontline team safely ventilated the infant locally for 48 hours until an ICU bed opened.
The baby was transferred and made a complete recovery.
Makubalo says: “Psychological safety and trust translate directly into quality care. When people know you have their back, they will do everything to save a life.”
The physics of success versus failure
In the Western Cape, the provincial government explicitly measures the energy all civil servants expend that never reaches the public.
In a healthcare setting, patients might lose out because health workers’ energy is spent navigating internal friction, administrative hierarchies and coping with interpersonal conflict.
The technical term used across the province is “organisational entropy”. Very loosely related to the scientific concept of entropy, it measures the percentage of total energy within an institution consumed by unproductive work.
In the proprietary tool used by the Western Cape government, called The Barrett Model®, wasted energy is measured using a survey. It offers a list of personal and organisational values and asks staff to choose 10 personal values, 10 values that describe the current culture of the organisation, and 10 organisational values they’d like to see in the future.
The cultural entropy score comes from the percentage of current organisational values staff pick that the Barrett Model classifies as “limiting,” such as conflict, friction, and frustration.
At the Retreat Community Health Centre, a facility that provides 24-hour emergency and maternity care in Cape Town, researchers found staff operated in a pervasive climate of fear. Their baseline survey suggested that staff viewed management as administrative police designed to catch staff making mistakes, and as a result, communication broke down into departmental silos.
The three key facility leaders, the facility manager, family physician, and nursing manager underwent leadership assessments and six months of individual coaching. They engaged in weekly reflective learning sets, mapping out communication flows, and examining how their own management behaviours generated fear.
The results were transformative.
When researchers followed up 18 months later, limiting values had dropped out of the top 10 current organisational values, although they still represented 13% of all values selected (down from 33%). In their place emerged positive, unifying values: caring, open communication, teamwork, respect, fairness, and accountability.
This phenomenon is not confined to isolated research sites. The Western Cape Department of Health and Wellness formally tracked cultural entropy across its entire workforce as an official performance metric, achieving a department-wide entropy reduction from 23% to 20.9% between 2013 and 2016.
This systematic drop in friction directly correlated with improved employee retention, stronger teamwork, and smoother service delivery across health districts.
The latest annual report puts cultural entropy cross the provincial public health system at 16%.
The province also tracks leadership skills on an individual, team, and system level.
Tendani Mabuda, who leads the provincial health department’s People’s Development team, argues the proof of the value of strong leadership can be found in the department’s eight year run of consecutive unqualified audits.
“Leadership development cannot alone resolve structural failures or challenges, but it enables managers to be agile and cope with the environment they are facing,” he says.
‘Trust is not a luxury’
For three decades, the unwritten rule within South Africa’s public sector clinics and hospitals has been to hide errors, follow flawed directives to the letter, and brace for new instructions from headquarters.
Stamping out this culture of fear in favour of psychological safety will be crucial to the success of South Africa’s next big healthcare revolution, the National Health Insurance (NHI) scheme.
The scheme, which currently faces about a dozen legal challenges, will change the way resources and healthcare services are pooled and purchased.
At the moment, most provincial health funding comes from nationally raised revenue transferred by National Treasury to provincial governments. The amount each province gets is determined by the provincial equitable share equation. The formula determines each province’s share using factors such as population, poverty and demand for health and education services. Provincial governments then decide how much of their budgets to allocate to their health departments. Separately, the national health department administers conditional grants for specified health services and programmes.
Under the proposed new system, funding would shift from this passive approach, where facilities receive budgets shaped by previous allocations to cover costs such as salaries and supplies, to strategic purchasing.
This means actively deciding which services a population needs, which providers should deliver them and how to pay those providers, with funding decisions guided by health needs and provider performance rather than simply historical spending.
For primary healthcare, contracting units would organise networks of public clinics, district hospitals and participating private providers to serve people within a sub-district, with the NHI Fund purchasing services through these arrangements.
These are hardware updates but, as multiple governance studies have shown, a hardware solution won’t fix a software problem.
And strategic purchasing will require sophisticated cultural software and strong leadership from district and sub-district managers with the ability to build trust, negotiate, manage networks that combine public primary care clinics, district hospitals, private doctors, nonprofits, and municipal health services.
At the heart of all of this, is trust between people, explained health economics professor Susan Cleary during a June webinar.
“You don’t get good quality results if you don’t have good quality relationships, they’re part of performance, and trust is not a luxury.”
Incidentally, an octopus can overcome incredible barriers once it decides to seek safety.
In 2016, staff at the Napier Aquarium in New Zealand arrived at work to find that Inky, one of its star inhabitants, had escaped. Finding the glass lid of his tank left slightly ajar after routine maintenance, he slipped out overnight, navigated a 50-metre drainpipe, and disappeared into the sea.
