Extreme Drug Resistant Tuberculosis; Red Cross Society & Legal Protection of Certain Emblems Bill: briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
24 October 2006
EXTREME DRUG RESISTANT TUBERCULOSIS; RED CROSS SOCIETY AND LEGAL PROTECTION OF CERTAIN EMBLEMS BILL: ADOPTION

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
South African Red Cross Society and Legal Protection of Certain Emblems Bill [B25-2006]
South African Red Cross Society Bill PowerPoint presentation
TB, MDR-TB and XDR-TB in South Africa PowerPoint presentation
Report on TB, MDR-TB and Extreme Drug Resistant TB in South Africa (not presented)
National Tuberculosis Crisis (not presented)

SUMMARY
The Committee, after a briefing by the Department’s legal expert and Director Emergency Medical Services and Disaster Management, unanimously adopted the South African Red Cross Society Bill.

It then received a briefing by the Director General of Health on extreme drug resistant tuberculosis. Although the Department was adamant that it was doing everything it could reasonably be expected to do, Members from the Inkatha Freedom Party and the African Christian Democratic Party raised concerns around testing, counselling, the procurement of medicines as well as Government’s will to address the crisis. The Committee said it would expect future interactions to provide details on the success of the Directly Observed Treatment System (DOTS) programme, the Khomanani programme as well as on how many people had been infected. Greater awareness around testing was identified as one of the key prevention measures.

MINUTE
The Chairperson noted that the Committee had already been briefed on the proposed legislation and had called for public submissions but none had been received. If Members still had concerns the Committee would deal with them as they arose.

South African Red Cross Society Bill Presentation
Mr Peter Fuhri (DOH: Director Emergency Medical Services and Disaster Management) and Mr Selo Ramasala (DOH: Acting Chief Director: Legal Services) recapped on the presentation the Department made to the Committee in June. The presentation detailed the historical background of the Red Cross Society and its South African branch. It also touched on the Red Cross Act and why there was a need for the proposed Red Cross Society and Legal Protection of Certain Emblems legislation. Benefits to the Government included improved disaster management and the Red Cross’ greater involvement in community based projects.

Discussion
Dr R Rabinowitz (IFP) was curious about the origin of the Red Cross, the Red Crescent and the Red Crystal.

Mr Fuhri explained that the red cross on the white background had a very simple origin: it was merely a reversal of Switzerland’s national flag. The Red Crescent and the Red Crystal had religious connotations - the Red Cross was now an international movement and it was important to also be representative of other belief systems.

Dr Rabinowitz found it strange that despite the fact that the proposed legislation would affect them, the Red Cross failed to respond to the call for public submissions. She wondered how they felt about the legislation.

Mr Fuhri assured the Committee that although the Red Cross had had no inputs into the final version, they had worked very closely with the Department during the drafting stages of the legislation. The Red Cross was satisfied with the way the Bill had been formulated.

Dr Rabinowitz thought that it would be useful for the Committee to have an idea of what the Roman Statute said.

Mr Ramasala explained that the Roman Statute gave rights to the international criminal court to deal with international crime, some of which were war crimes. The proposed legislation was not in way intended to be in conflict with or substitute the Statute. He added that some of the most powerful countries in the world were vehemently against the Statute apparently because of their perceived involvement in international crime.

Dr Rabinowitz thought it strange that according to Clause 14 people who wanted to use the symbol would have to approach the Minister of Health rather than the Red Cross itself.

Mr Ramasala explained that it was the Minister of Health and not the Red Cross who would be responsible for the implementation of this legislation. The Red Cross had in principle agreed to many of the provisions contained in the Bill. They felt that the provisions in Clause 14 were appropriate. He pointed out that it would be difficult for the Minister to authorise usage without having consulted the Red Cross.

The Chairperson referred Ms Rabinowitz to paragraph 4 of the memorandum on the objects of the Bill which clearly indicated that the South African Red Cross Society and the International Committee of the Red Cross were two if the bodies that had been consulted during the drafting of the Bill.

Dr Rabinowitz felt that the Bill appeared to suggest that the Red Cross would help to raise funds for the Government. She worked with a Red Cross related non-governmental organisation (NGO) in Johannesburg. They did not get any support from the Government despite the fact that that they did a lot of work assisting people in emergency situations. She asked whether there was any avenue for the funding of the Red Cross.

Mr Fuhri explained that the Department wanted the Red Cross to fund the Government in terms of humanitarian action because they had better mechanisms for getting funding and making appeals. South Africa also used their networks for the distribution of relief goods internationally. The Department hoped that the MOU would also support them in terms of their interaction with the Red Cross. He added that in Gauteng the Red Cross had a government contract for HIV and AIDS related relief work. The Department would like to formalise such agreements through the MOUs.

Mr G Morgan (DA) felt that the intention of the Bill was very good. He asked whether there had been cases in South Africa where the Red Cross emblems had been abused and what the nature of the abuse was. He also enquired as to whether in parts of the world where similar legislation did not exist, abuse of the emblems was common.

Mr Fuhri said that apart from one case that the Red Cross was trying to deal with he was not aware of any widespread abuse of the symbols. There was a humanitarian organisation that was using the red cross on the white background as part of their corporate identity. The Red Cross was trying to deal with the matter informally before going the legal route. He was sure that the Red Cross would have a record of the various abuses or misuses of the symbols. He did not know how widespread international abuse of the symbols was.

Ms Nxake (ANC) commented that as someone who had worked in the municipalities and headed a provincial department on disaster management, she was pleased that very soon the Department would sign a MOU between the Red Cross. In times of disaster (veld fires or floods) the Red Cross often offered assistance to local municipalities. Formalising the arrangement would also benefit local municipalities.

Dr Rabinowitz added that there were already contracts between provincial governments and the Red Cross. The absence of the MOUs had thus not prevented Government from funding the Red Cross. She wondered whether the Committee would have sight of the MOU and how it would affect the will of Government to give ongoing funding. The Member also wondered whether there was no possibility of a consistent funding process that would assist the Red Cross in the provision of disaster management.

Mr Fuhri said that one of the reasons the Red Cross also sought to formalise matters was because at the moment interactions occurred on a very informal basis. It was only at times of disaster or when there was a major issue that the Government looked to the Red Cross for assistance. Government as well as the Red Cross felt hat the latter could even play a role at the preparatory stages of risk reduction as well as in community based approaches to disaster management.

He informed the Committee that the Red Cross had approached the Government with a request to provide for its annual membership to the federation; in return the Red Cross would provide various programmes that the Department was still considering. This finalisation of this agreement was in its final stages; if the Director General approved it the Department would on an annual basis meet the funding requirements of the Red Cross’ membership to the international federation and they would in return provide certain services to the Government.

Ms M Malumise (ANC) wondered why the red lion and the sun emblem had fallen into disuse.

Mr Ramasala would supply the Committee with an answer at a later stage. The Department had not been given the reasons why the Red Cross had decided to discard the emblem.

Ms C Dudley (ACDP) wondered whether the fact the Red Cross would now fall under Government would impact negatively on the society’s ability to fundraise.

Mr Fuhri assured members that there would be no limitations on the Red Cross’ fundraising activities, which was part of their ethos. The Red Cross would still be an entity on their own and if anything the benefits would be complimentary.

Mr B Mashile (ANC) asked whether the Department intended drafting regulations that would clarify the proposed legislation. He was particularly concerned about the implications contained in Clause 5. This clause stated that medical personnel and resources of the Red Cross utilised by the Government would be subject to the laws that governed similar resources and personnel of the Government. He wondered whether the clause had been clarified with the Red Cross and whether the Department appreciated the impact this provision would have. He wondered whether regulations facilitating that particular provision should not be made.

Mr Ramasala explained that the Department had concerns such as these in mind when it provided for Clause 12, which would enable the Minister to make regulations. The Minister may make regulations relating to the use of the emblems by civilians provided these regulations were not in conflict with the legislation. He added that despite the fact that the Red Cross was an independent organisation it was not an "island within the Republic" – it would not be exempt from the laws of the country.

Mr Morgan wondered who had instigated the desire for the Bill.

Mr Fuhri responded that the International Federation of the Red Cross had prompted the drafting of the legislation. Mr Ramasala added that in terms of the conventions referred to in the schedule it was required that member states to the conventions should formulate laws that to a certain extent would ensure some kind of recognition of the work of the Red Cross as an entity within their respective countries.

Adoption of Bill
Dr Rabinowitz said that the medical personnel and resources of the Red Cross were already subject to the laws of the country. She proposed that Clause 5(2), which stated that they had virtually become appointees of the Government should be deleted so as to ensure the body’s independence.

The Chairperson wondered whether Dr Rabinowitz was implying that SANDF personnel who were being used to address issues under Clause 3 and who were subject to the command and control laws of any defence force should not comply with these laws either.

Dr Rabinowitz responded that they had to comply with the laws in any case - no one could act within the country and give services that were against the law. It was assumed that anyone who acted within the country had to act within the law.

The Chairperson pointed out that the clause required them to comply with the laws applicable to similar personnel and resources and not merely general laws. As required by the Defence Act, those employees and resources had to act within the laws of the Department and not outside of its regulations.

Dr Rabinowitz wondered why Cause 14 was called ‘savings’. She asked whether it was not possible to put a time limit of about two years on its requirements. A person could then continue using the insignia until the Minister considered the application. Ms Dudley too was not sure what the heading of the clause referred to.

The Chairperson clarified that Clause 14 aimed to protect the current usages in an almost transitional arrangement and served as a protective measure more than anything else.

Mr Mashile wondered whether the heading of a clause had any legal interpretation.

Mr Ramasala explained that the Department aimed to, through the clause, prevent a situation whereby persons who were using the emblems before the enactment of the proposed legislation would be found guilty of an offence. They would through the provision be allowed to continue using the emblem provided they applied to the Minister within six months of the date of commencement of the section. He agreed that it was a transitional measure.

Ms Dudley wondered why one could then not merely use "transitional measure" instead of "saving". She wondered whether "saving" which she had never seen used before was the normal way of referring to such a provision.

The Chairperson clarified that these were not merely transitional measures. Those who were using the emblems now were not violating the law. They could use all the resources and would be allowed to still carry out their humanitarian work etc. Any practices that existed before the passing of the proposed legislation were by the provisions of Clause 14 recognised as continuing.

Ms Dudley said that if the Committee was satisfied that that was indeed the correct word to use she was satisfied.

The Chairperson said that he always tried to avoid arguing about semantics.

Ms Rabinowitz said that the funding of emergency services was an important issue. Everyone could agree that the funding for emergency services was inadequate and she did not think that the Bill addressed issues around funding. She felt that each party should be allocated some time to debate the matter in the National Assembly.

The Chairperson said that funding of the emergency services could refer to anything and cautioned against introducing a debate that was not necessarily contained in the Bill.

The Committee unanimously adopted the Bill.

TB, MDR-TB and XDR-TB in South Africa presentation
Mr Thami Mseleku (DOH: Director General) made the presentation and was accompanied by Dr Lindiwe Mvusi (TB Programme Manager) and Dr Lindiwe Ndelu (Director: Occupational Health and MBOD). The presentation was aimed at informing the Committee of the nature of the medium and extremely resistant TB strains. It also detailed the prevalence of TB, treatment outcomes and South Africa’s estimated MDR-TB burden. The Department concluded by detailing its immediate responses to the crisis. These included conducting a survey to determine geographical prevalence and the training of clinicians in meeting the demands of the crisis.

Discussion
Dr Rabinowitz thanked the Department for the briefing which the Committee urgently needed. She noted that the Mr Mseleku had suggested that a person’s willingness to take the prescribed medicine was crucial in addressing the current crisis. She wondered whether he did not think that two of the most important issues related to the capacity of the health services to address the mater as well as Government’s will to treat this as a crisis. The public felt that had it been an Ebola crisis there would have been greater reaction and that Government had been very slow in taking action. In her opinion there were three matters that should be dealt with in a more proactive manner i.e. beefing up the poor testing in a service that was now under strain now; isolation and treatment.

Mr Mseleku responded that the Department accepted that capacity was a challenge in the health sector in general. This could be ascribed to various issues. He reminded members that compared to its neighbouring countries, South Africa was very well resourced. This resulted in neighbouring countries using South Africa as a resource which doubled our capacity problems. It was not an easy matter. He did however not agree that Government was showing little will in addressing the issue.

Dr Rabinowitz felt that while the patient’s history was significant it was not the most important factor anymore since the extremely resistant strain of TB could move from person to person now. There was no need to go through a period of treatment for TB only to discover that one was resistant. Resistance could be identified through culturing and there was a feeling that this process had not been adequately used in the past. According to the specialists from the SAI, microscopy was not sufficient and that culturing would yield results faster. She suggested that culturing had to be done almost routinely in order to identify cases and commence treatment.

Mr Mseleku said that at the meeting of the World Health Organisation (WHO) experts had made it very clear that the rapid tests which were available for XDR-TB could only identify resistance for one of the three drugs. Even that test was not rapid enough because it took about 16 days. He agreed that one could make use of culturing but pointed out that one had to grow it and work through it to see what drug it was resistant to. Testing in this manner for MDR as well as XDR TB would be time consuming. In addition laboratories did not have the capacity to cope with the task.

Most of the people who were tested had also tested positive for HIV. If one was HIV positive, one's sputum often tested negative for TB. The TB infection was then only discovered at a later stage. He added that for many years the Department did not have the diagnostic tools that could be used for dealing with diseases of poverty. The Government was being blamed for not using the "instant solutions" that were available. Closer investigation of these "instant solutions" however revealed that they held little or no merit. He emphasised that there were no instant solutions. The Department would provide the Committee with the information that the WHO had made available (also available on the WHO website). They too denied that there was a rapid testing solution.

It was also important to understand that all strands of TB were infectious. The Department could thus not only deal with XDR-TB in a particular way but had to address TB which had the potential to under certain conditions develop into MDR-TB and XDR-TB. The Department’s goal was to stem the number of people that became multi-drug resistant and to ensure that those who were at the MDR stage adhered to their treatment regime. He said that this meant that the real battle would be to strengthen the adherence model and support systems so that they could ensure that people adhered to their treatment regimes.

Dr Rabinowitz continued, saying that it was also necessary to be less sensitive about who was being treated. South African National Council on Alcoholism and Drug Dependence (SANCA) used to go out and treat TB but now there was a void in trying to identify cases before people became ill. She felt that Government needed to look at a more proactive way so that testing could be done routinely if people came to the hospital and had a cough.

Mr Mseleku said that tracing everyone who had a cough was a massive operation. SANCA had been able to do it because they received a number of international donations. In addition people had to consent to being tested. Earlier that day he had been involved in a debate around whether testing for HIV should be compulsory. The Department was still debating whether culturing should be and testing voluntary and had not even progressed to the point of compulsory testing. He said that people often equated testing for TB with being tested for sugar diabetes but even then one could not test without the patient’s consent. Contrary to popular belief doctors did not perform these tests routinely or without the patient’s consent.

The Department was still discussing the policy implications of voluntary counselling to have an HIV test for anyone who went to a clinic or a hospital. Such counselling would eventually be compulsory. Testing would have to be contextualised within broader challenges.

In Dr Rabinowitz’s opinion there were a few people who would not want to be isolated and treated until they were stable in order to protect their families from being infected. Once they had stabilised they could be released under some kind of supervision.

Mr Mseleku agreed that very few people who were sick and contagious would resist being isolated to protect their families. As soon as they felt better however even before they would have stabilised they would discharge themselves. This phenomenon was happening right now and resulted in the incidents of MDR-TB. Hospitals would have to devise a plan for treating people in their homes. Of course one had to deal with those situations where patients might cause public health issues.

Dr Rabinowitz realised that the medicines had terrible side effects and that one could not guarantee that they would work. She understood that the Department was looking for alternative suppliers. The WHO’s Green Light Committee provided medication for free and she knew that Dr Buthelezi had approached the WHO, Treatment Action Campaign (TAC), South African National AIDS Council (SANAC)and the Minister of Health requesting them to send a submission to the Green Light Committee to ask for urgent help in the provision of these drugs. If such request were approved, one would not have to wait for arrangements to be made with preferred providers or for the people to provide the drugs free of charge. There had been a meeting of the Green Light Committee in September. She said that approaching this committee would be one way of getting the medicines into the institutions and would assist in understanding how people reacted to it.

Mr Mseleku responded that the purpose of the Green Light Committee was often misunderstood. The WHO had established it to ensure that countries that found it difficult to procure medicines would be able to approach the committee for procurement in bulk. The Committee then negotiated with the procurers. He added that South Africa had very stringent rules related to how one procured medicines. The Medicines Control Council (MCC) was a very sophisticated body with international standards South Africa did not have problems with negotiating directly with its particular providers and would sometimes in solidarity and support get involved in the Green Light Committee.

The Green Light Committee worked mainly with countries that did not have the capacity to adequately control and register medicines. South Africa did not have such problems. He emphasised that the Green Light Committee could not be seen as a panacea for South Africa because it was not. The WHO workshop had actually agreed that it was necessary to get all the countries in the Southern African Development Community (SADC) region to apply to the Green Light Committee to accelerate matters. One could not wait for this process. He added that South Africa did not need the Green Light Committee because it had a pharmaceutical capacity and the possibility that its own industry could register particular pharmaceuticals for availability. The Department would be undermining this pharmaceutical capacity it were to procure through the green light system.

Dr Rabinowitz asked whether the Department did not think it necessary to call on the urgent support of the private sector to start doing the kind of work that SANCA did before it was closed down due to corruption and mismanagement. Private clinics were giving services to England and she wondered whether they could not be brought back to give services here. She added that people did not have to have sex to get TB nor did they have to default on treatment to get it – they simply needed to be in touch with the wrong people for the wrong amount of time.

Mr Mseleku said that the Department wanted to include clinicians from the private sectors in the training programmes around the TB crisis. They believed that due to a lack of monitoring most of the protocols that were supposed to be followed were sometimes reneged on in private facilities. He added that the Chamber of Mines was working with the Department because TB was prevalent in the mining sector.

Dr Rabinowitz also wondered whether it would not be possible to start training people to be relaxed about using masks. There were countries in the world where people used marks routinely when they had a cold. If masks were popularised so that people could use them when they were ill it would also help. She said that the Department should provide free masks and not just free condoms.

Ms Dudley asked whether a person could pass on XDR TB or do they pass on just TB. She noted that Mr Mseleku had said that one could not catch XDR-TB simply by travelling with someone on a bus. She wondered if this was a 100% guarantee. She said that since no one knew these things an awareness campaign would be appropriate.

Dr Mvusi explained that there were various factors that impacted on transmission. Once an infectious person had been identified it was necessary to try and trace the people he or she had been in contact with. Family members and co-workers were most at risk. The infectiousness of the person impacted on the level of transmission. She explained that the environment in which the person lived also played a role. People in enclosed areas with poor ventilation posed the most risk. Testing would have to start immediately. People who were immuno-compromised were also at high risk. She added that the mining sector due to exposure to dust etc was also a high risk environment and once a XDR case was found there tracing the contacts enjoyed priority. If a person had XDR-TB chances are that they would spread the resistant strain. If that person had also been exposed to other people with sensitive TB risk factors would impact on whether XDR-TB would be spread.

Ms Dudley noted that reports indicated that the only way to contain it would be through quarantine yet Mr Mseleku had indicated that one could confine someone only until they were no longer contagious. She wondered whether the Department would come up with a definite policy on this issue.

She also asked whether the Department would disregard routine testing altogether. She said with HIV the test was fairly simple and conceded that the TB be test might be a little bit more complicated. It seemed much simpler to do the routine testing than to do the counselling about the routine testing. She feared that if one started giving people that choice the matter would become more complicated.

Mr Mseleku responded that the Department was not discarding anything but was debating issues. He felt the problem was that Government was not allowed to debate issues but was expected to do what it was told. If the Government asked questions it was seen as lacking the will to address matters. He explained that as policy makers the Department had to reach decisions that were based on a thorough understanding of the policy implications. It had to ensure that when policy was made it was implementable. If this was not the case Government would be accused of failure and policy makers of making policies that were not workable.

He wondered why, if South Africans believed in routine testing so much, they did not get tested routinely. Even people who were much more sophisticated in their understanding of the risks to themselves did not get tested as a matter of routine. If testing for HIV had to become routine the Department would have to cover much ground in terms of the psychology of the disease so that even the implication of the results would become routine themselves. It was also important to remember that HIV and TB were highly stigmatised. In their policy discussions the Department was looking at whether a response was practical in the light of the capacity constraints - it might be easy to do an HIV test but one had to consider whether the laboratories would cope with the implications of such routine testing. He was not sure whether people were psychologically prepared for routine testing. He reminded members that people could only be tested on a voluntary basis. The best option available at the moment was to make counselling around the benefits of testing compulsory at clinics. This would be a starting point.

He added that even in relation to quarantine the Department had a definite policy. For public health purposes the Department would quarantine people who posed a threat to public health. If it were necessary to take legal action it would do so. These instruments were available but it was much more important for the public to understand the need for such policies and such actions so as to avoid unnecessary legal action. He emphasised the necessity of raising awareness.

Mr Morgan said that he was encouraged by the Department’s view on testing and the debates that were being held. He said that he certainly did not agree with compulsory HIV testing in South Africa because it was unconstitutional. He felt that the idea of an opt-out (after being counselled on the necessity of testing) was a good way forward and the concept needed o be tested. He suggested that that route be debated more within the Committee.

He was also encouraged by the fact that the Department had been so willing to engage with the WHO on this topic which was not unique to South Africa. He said that he was particularly interested in the legal aspects. He would like to see quarantine used more where necessary. He wondered whether the provisions of the Health Act were sufficient to achieve the goals set with regard to XDR – TB and whether there was a need for any subsequent legislation on issues around quarantine.

Mr Mseleku said that the Department felt that the legislation was sufficient and was adequate for acting in the interest of public heath.

Mr Morgan fully agreed that tracing was vital in hating transmission. He also wanted to know whether there was any link between the Gauteng-strain and the cases in the other provinces.

Mr Mseleku explained that the KZN strain was called that because it was first identified in that province. It had since been identified in other provinces too. He added that there were also other strains of TB. It was not 100% clear why the new strain had developed.

Mr Morgan sought information on whether in a sector that had significant staff and bed shortages the Department had moved resources to Tugela Ferry where the crisis had hit the hardest. He wondered what effect the crisis would have on the Department’s ability to deliver the other services it was meant to deliver.

Mr Mseleku responded that all provinces had to identify certain hospitals that would deal with MDR-TB specifically. All provinces have done this and would have to identify more. Depending on the referral systems it would be possible to plan for more space and more staff in the identified MDR-TB hospitals. In KZN specific district hospitals had been identifies specifically for dealing with MDR and XDR-TB. Even those who had been in Tugela Ferry would then be referred to these hospitals. Hospitals thus had to identify the cases and refer them to the designated MDR hospitals. The numbers of MDR was not yet so high that it surpassed the prevalence of TB. Planning should be aimed at avoiding MDR-TB whist at the same time addressing the existing cases of MDR. Emphasis should be on preventing MDR-TB which resulted from non-adherence and inadequate clinical advice. He added that it was agreed that TB could still through the DOTS system be dealt with in a home based system. These strategies should be strengthened.

Dr Rabonowitz in closing appealed to Mr Mseleku to, like she would, follow up on the matter related to testing. Perhaps they would be able to stay in touch on the issue. Her understanding was that the XDR-TB was a clearly identifiable strain. One thus did not have to wait to culture it against the existing drugs since one knew that it was that particular genotype that was resistant to the drugs that were being used. Information she obtained from the SIMR suggested that with regular testing using culturing they would be able to identify the particular strain quite quickly. As far as she knew the Green Light Committee could also donate medication. This to her understanding could be used as an emergency measure. As far as testing was concerned they had created the problem. If HIV had been treated as an ordinary illness the public would have easily agreed to testing. In a sense a hype and hysteria had been created by the way they had been tiptoeing around the issue. She suggested that Treasury could be approached so that more money could be spent on showing videos creating awareness around testing in outpatient stations.

Mr Mseleku said that the debate around testing would continue. The way South Africa dealt with HIV and AIDS testing was informed by international policies. He reiterated that HIV/AIDS and TB carried a certain stigma and fear. Addressing the issue adequately would require a collective approach involving all sectors of society. He repeated that the Green Light Committee was a procurement committee. He said that South Africa could negotiate donation and price on its own. The Green Light Committee would not necessarily make the process faster. Donations were based on the notion that countries who applied did not have the capacity or the money to acquire the medicines. He emphasised that there was no tool for testing resistance. Scientists themselves admitted that testing took time.

The Chairperson said that here was still a lot of follow up discussion necessary. At some pint the Committee would have to be briefed by other related units within the Department. He said that the Department should in future interactions inform the Committee of how it would go about determining the number of people who were infected and had died. Members would also benefit from an evaluation of the effectiveness of the DOTS system and the mechanisms that could be developed to ensure adequate follow up. Such information would be useful too in the context of HIV and AIDS. The National Heath Laboratory Services’ capacity would perhaps also need to be evaluated as they would pay an important role. The Department’s communication strategy (as well as the KHOMANANI programme) would also have to be assessed.

Progress as far as the Tobacco Amendment Bill Public Hearings
The Chairperson reported that Parliament had received 69 written submissions and 25 requests for oral submissions on the Tobacco Amendment Bill. There was still not clarity on whether some of those who had made written submission might want to make oral submissions too. The Committee wanted to ensure that no short cuts were taken when dealing with legislation. He hoped that by the following week Members would have all the necessary information. According to his calculations the Committee would only have about 5 days within which to hold the hearings.

Mr Morgan felt that it would good that the Department would be briefing the Committee on the Bill the following week. He suggested that since the Food and Foodstuffs Bill had been referred back to the Committee and the Members still needed to be briefed on the Department’s audit report, the hearings should be postponed until January or February 2007.

The Chairperson said that the matter would be evaluated at later stage. He agreed that the Food and Foodstuffs legislation would have to be reconsidered but reminded members that they were not obliged to accept the amendments the NCOP had proposed.

Mr Ramasala informed the Committee that the amendment the NCOP had made was very small and related to how the mollusc family was defined.

The Chairperson said that the Committee would discuss the Bill during the following week and would then determine how to proceed.

Mr Morgan wondered whether it was possible for the pubic hearings on the Tobacco Amendment Bill to start the following Wednesday. The Chairperson responded that the Committee would discuss its programme the following week.

The meeting was adjourned.