PERIPHERALIA

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I was in one of the first groups of private general practitioners 
to volunteer to work for the new National Health Insurance 
clinics. As I trained in the British NHS and first went into an 
NHS clinic practice over 45 years ago I was interested to 
revisit primary care practice. The work, I found, was very 
rewarding but unfortunately after a year I had to give up my 
sessions due to my own ill health.

I am going to select just one clinical condition, hypertension, 
to illustrate gaps that appeared in my knowledge of current 
primary care practice. It was surprising to see so many 
morbidly obese patients, mainly female, with hypertension. 
Their weights were between 90 to 130 kg or above and 
their BMIs were usually above 35, a reasonable number over  
40 and a few above a BMI of 50. 

The patients were on a lot of medications from the four 
different groups of anti-hypertensives on the code (diuretics, 
betablockers, ACE inhibitors and CCBs) and usually had 
come in for repeat medications. Despite all their medications 
their blood pressures were often uncontrolled. A reasonable 
number were taking 8, 10 or 12 different pills (many, as 
expected, had diabetes and other complications of obesity). 
One small female patient, aged 53, who weighed 108 kg (BMI 
35 +) was on 21 different medications. She had no complaints 
although her blood pressure and blood glucose were still 
uncontrolled despite her 21 medications.   

My problem was how I was going to manage these sorts of 
patients from the perspective of a primary healthcare clinic 
when they were often attending several OPD clinics at two 
district hospitals and a tertiary hospital. It needed a lot of 
time to collect some basic information and measurements 
while the benches outside in the corridor were groaning 
with the weight of more patients waiting to see me. I would 
need to follow up the patients several times and try and 
get reports from hospital OPDs such as medical, diabetic, 
orthopaedic and the pain clinic. 

I found trying to rationalise medication use in these 
patients was not an easy business. A recent study from Israel 
discontinued the pills that a group of elderly patients were 

taking (they were each taking an average of seven or more 
pills). They stopped five drugs per patient for more than 
90% of the patients and only 2% needed to have the pills 
restarted. Almost all the patients reported an improvement 
in their health.

I seemed to experience a sequence of these conundrums 
during my clinic sessions.  Many of the patients’ blood 
pressures and blood sugars were uncontrolled despite what 
appeared to be adequate medication. Working under the 
principles of proportionality and heresy I have assumed that 
some protection was better that none. I was also intrigued 
to find out where all the pills actually ended up and whether 
they were actually taken. About a third of the population in 
and around Pietermaritzburg live in informal settlements 
and shack dwellings so probably about fifty percent or more 
of the patients attending a government clinic would be living 
in these types of crowded shelters, sharing a room with 
relatives and others. Where, I wondered, did they put their  
8 or 12 or 21 pills? 

I am lucky enough to live in a two bedroom house with 
running water and I am on four pills a day following a 
myocardial infarction. It takes me all my concentration to 
line these pills up on a shelf in my bedroom and remember 
to take them before I go off to my consulting rooms in the 
morning. How, I wondered, did these patients manage all 
their pills while living in one room with several others? 

Some of the difficulties in delivering primary health care 
appear to be the rational and practical application of modern 
medical concepts within the contexts and life worlds of 
the patients. These are some of the great and exciting 
challenges that face us as we build up the National Health 
Service. Because of the advances in medicine, the problems 
of providing health care to the growing volumes and the 
changing morbidities of our patients may require us to 
rethink our ultimate objectives.

Chris Ellis 

Family Physician, Pietermaritzburg, KwaZulu-Natal 
e-mail: cristobalellis@gmail.com

Clinical conundrums in  
primary health care