By Marika Sboros
At the close of the first week of the fourth session of the Health Professions Council of SA (HPCSA) hearing against scientist Prof Tim Noakes, there were signs of that its case against him is sinking. Whether you see signs as auspicious or ominous depends, of course, on whether you are a friend or implacable foe of Noakes.
Friend or foe – Noakes has both – it wasn’t hard to spot signs in HPCSA advocate Ajay Bhoopchand’s cross-examination of him.
Bhoopchand started midday on Tuesday, October 18. By late Friday afternoon, he had not achieved a single major concession from Noakes.
When he wasn’t accusing Noakes of having brought the case on himself, Bhoopchand failed to undermine the evidence for benefit of low-carb, high-fat (LCHF) foods to treat and prevent serious disease.
Here’s Part 1 of a review of the week:
At one stage, it looked like Bhoopchand would filibuster till the very end of the hearing that runs until October 26. That would have prevented Noakes from calling his three expert witnesses who have flown in from the UK, US and New Zealand.
‘Angels’ under threat
They are British obesity researcher and public health nutritionist Dr Zoë Harcombe, US science and health advocate Nina Teicholz and Dr Caryn Zinn, a New Zealand-based dietitian academic who is also in private practice. The public has dubbed them “Tim’s Angels”.
Bhoopchand objected to Harcombe and Teicholz’s as new additions to the witness list. Zinn was on the list and attended the November 2015 session. However, the HPCSA set the session and took up all the time. As a result, Zinn could not give her evidence.
Noakes’ legal team drew their arguments for new witnesses mainly from the HPCSA’s own submissions. The HPCSA applied successfully to call surprise and secret witnesses at the November 2015 and February 2016 sessions.
Pretoria advocate Joan Adams is chair of the HPCSA’s nominally independent disciplinary committee hearing the charge against him. She ruled that the interests of justice and fairness required that Noakes could call Harcombe and Teicholz.
Noakes is facing a charge of unprofessional conduct for giving unconventional advice to a breastfeeding mother on a social network (Twitter). That was for a single tweet in February 2014 to a stranger called Pippa Leenstra. Noakes tweet that good first foods for infant weaning are low-carb, high-fat (LCHF).
The real ‘beef’ dietitians have with him
Johannesburg dietitian Claire Julsing Strydom, who just happened to be on Twitter at the same time, reported him to the HPCSA. Strydom was president of the Association for Dietetics in SA (ADSA) at the time. For more background on the case, click here to read The real beef dietitians have with him.
Harcombe began giving evidence late on Friday, though only for 45 minutes. However, the fast-talking Harcombe got lots in and resumes on Monday. Her evidence is from her doctoral thesis and research covering the two key issues in the HPCSA case against Noakes.
The first is the science, or lack thereof, behind influential guidelines the US introduced in 1977, and the UK in 1983 (which South Africa follows). The second is the “diet-heart hypothesis” that saturated fat causes heart disease. That hypothesis lies at the heart of the guidelines.
Harcombe said that the diet-heart hypothesis had no evidence to support it then. “It has none now,” she said.
On Monday, she will present evidence undermining a key pillar of the HPCSA case against Noakes: the so-called “Naudé Review”. It is named after lead author and Stellenbosch University academic Dr Celeste Naudé . The evidence suggests that this review is indeed “fundamentally flawed”, as Harcombe will show. And that the researchers involved appear to have done it deliberately to discredit Noakes and LCHF.
The HPCSA hearing against Noakes appears to be growing his fan base. Doctors have attended the hearing to show support. One introduced himself by saying: “I don’t always agree with everything you say, sir. But I’m appalled at what you’re going through. It’s just not right.”
Some of Noakes’ foes have even become more muted of late. I’ve noticed some Twitter “trolls” making the odd positive statement about him.
Bhoopchand gave Noakes endless opportunity to reference the many vested interests keen to see the case against him succeed.
These interests are not just in food and drug companies that have lots to lose financially. They are also the many doctors, dietitians and academics with reputations, careers, funding and businesses at stake if the HPCSA loses this case.
Not just about Twitter
Strydom is just one of many dietitians involved directly or indirectly in this case. Most are ADSA members. ADSA president Maryke Gallagher and her executive regularly voice loyal support for Strydom and against Noakes. Gallagher issued a public statement last year saying that the case against him was “only about Twitter”.
Noakes’ Cape Town lawyer Adam Pike, of Pike Law, has dismissed that. He said that Strydom’s evidence showed that she objected to the content of his tweet. Click here to read: It’s not about Twitter.
Two dietitian academics with vested interests against Noakes and LCHF have been present throughout the hearing. They are retired North-West University Prof Hester “Estee” Vorster and University of Cape Town dietetics professor Marjanne Senekal.
Both have assisted the HPCSA’s expensive outside legal team. The lawyers and the HPCSA have declined to confirm or deny reports that Bhoopchand’s first bill for the February hearing alone was for R1 million.
Vorster wrote a report for the HPCSA Preliminary Inquiry Committee. The committee used the report to charge Noakes but kept it secret from him. That breached the legal principle in South African law that allows accused persons to see all evidence against him in any trial or hearing. In that report, Vorster refers to the Naudé review.
Vorster also wrote the South African guidelines. She’ll be none too pleased with the demolition job Noakes and his experts are doing on the science behind the guidelines.
Click here to read: Legal team fights ‘trial by ambush’
I noticed Vorster frequently passing Bhoopchand little green post-it notes, which he read before asking questions. From the long-winded way he cross-examined Noakes, I could only assume Vorster’s intermittent instructions were directing his strategy.
Senekal has become a consultant to the HPCSA in this case despite being a colleague of Noakes in UCT’s Health Science faculty and co-author of the Naudé review. She is also co-author of a letter that Noakes’ UCT colleagues wrote to the press in 2014. Noakes has repeatedly said that he considers it defamatory.
Who signed the letter?
In it, the authors attack Noakes for making “outrageous, unscientific” claims on diet and disease.
The HPCSA heard evidence that the authors of that letter may have improperly obtained the signature of UCT emeritus professor of cardiology, Prof Lionel Opie, that appears on their letter.
Opie emailed Noakes in 2014, copied to UCT, confirming that he did not sign the letter. He distanced himself from the letter’s contents and said that he thought the authors should retract it and apologise to Noakes.
(Editor’s update: Opie has now said that he did, in fact, sign the letter but had become confused due to illness.)
The letters’ authors have remained resolutely mum. I’ve emailed them frequently, including UCT vice chancellor Dr Max Price, for comment. I have also asked about the ethics of a UCT academic assisting the HPCSA, a statutory body, to prosecute a colleague. Price has stayed mum.
What’s it REALLY all about?
Bhoopchand’s cross-examination appears to have buttressed evidence that Noakes gave on what this case is really all about. And why so many assorted dietitians, doctors and academics are helping the HPCSA to prosecute one man.
Tim Noakes on ethics. https://t.co/DxRaiOWhYF
— Jan Vyjidak (@janvyjidak) October 21, 2016
Noakes made a “dogs that don’t bark” analogy that the case against was never about breastfeeding, babies, weaning or even Twitter. It always was about the safety and efficacy of LCHF to treat and prevent serious disease, he said. In particular, the case was about treatment for obesity, diabetes and heart disease. The diet-heart hypothesis was clearly also very much on trial, Noakes said.
Bhoopchand focused much of his cross-examination on Twitter. He insisted at length that it was an “inappropriate forum” for doctors to give medical or nutrition-related information.
Noakes disagreed. He said that Twitter’s “ self-correction” mechanism did not exist in conventional consultations between doctors, dietitians and their patients.
“The traditional patient to doctor relationship where one person is giving advice to the other is much more fraught with error than is Twitter,” he said.
Information v advice
Bhoopchand tried to get Noakes to concede that he tweeted medical advice not information to Leenstra.
However, Noakes dismissed that, saying that doctors and dietitians regularly dished out information on and off social media. He argued that a lack of information, not advice or access to information, was the real danger. He said that Twitter’s “natural democracy” meant that “what works percolates to the top. What does not work falls to the bottom.”
Bhoopchand said that were no doctor-patient relationship with Leenstra, Noakes should have been “ as a responsible human being”. He should have amplified the information.
The insinuation did not please Noakes. “ Sir, I am a very responsible human being,” he told Bhoopchand. ” I’m a teacher. I have spent my life, 40 years of it, educating people at my cost. Answering emails. Answering letters. Writing articles. Writing books.
Breaking invisible rules
“I have made essentially nothing out of it. I am here to help the public. That is my mission, that is what I have done. I dedicated my life to that.”
Bhoopchand insisted that Noakes had contravened the HPCSA’s rules on ethical conduct for medical professionals on Twitter. The only problem is that the HPCSA has no ethical rules governing doctors’ conduct on social media.
Full marks to him for trying to covering all bases, though.
Bhoopchand suggested that what rules the HPCSA did have applied to doctors’ conduct apply anywhere, anytime. That included in cyberspace. Thus, he claimed that Noakes was unethical in the breach.
Noakes disagreed. “You don’t make someone ethical by writing rules,” he said.
“It’s how you live your life that makes you ethical. I’m a scientist and a very ethical person. I would be horrified if I ever did anything unethical.”
Breastfeeding was never part of the charge but Bhoopchand went down that path anyway and many times. He said that Noakes had gone against the Tshwane declaration of support for breastfeeding in South Africa. And that he did so by telling the Leenstra to stop breastfeeding.
Noakes reminded Bhoopchand that his tweet said nothing about breastfeeding at all. Neither did he tweet that she should stop breastefeeding With one of many Kafkaesque flourishes that have characterised this trial, Bhoopchand replied: “But you didn’t tell her to continue breastfeeding.”
Noakes pointed out that he is on record in print and in lectures regularly recommending that mothers breastfeed for two years if possible. He said his view has always been that breastmilk is high-fat and the healthiest food for newborns.
— Marianne (@Mariann58168113) October 23, 2016
Bhoopchand also suggested that Noakes’ tweeted to Leenstra to put her infant on a dangerous “ketogenic” diet. However, Noakes’ tweet made no mention of a ketogenic diet. The HPCSA’s charge against him does not include advising a keto diet.
Bhoopchand said that Leenstra might have thought Noakes meant a keto diet. Yet the HPCSA did not call her as a witness to her thoughts. And so it went on in similar vein.
Bhoopchand effectively did what all the HPCSA’s witnesses did. All confused and conflated LCHF ketosis with ketoacidosis. The latter is a rare but potentially fatal condition seen mostly in type 1 diabetics. LCHF is a broad spectrum of diets that includes safe, medica-therapeutic ketogenic diets, nutritional ketosis and low-carb.
Noakes made the point that breastmilk was ketogenic with a moderate carbohydrate content.
“Something in breastmilk increases ketosis and we have never been able to reproduce that in standard milk provided to babies,” he said. Humans fed breastmilk and moderate carbohydrates would still produce “lots of ketones for the brain”, he said.
Bhoopchand demanded that Noakes give science to back up that view. Noakes smiled and said he had already presented it. He reminded Bhoopchand that his own witness, paediatrician Dr Mohammed Dhansay, confirmed that breastmilk was ketogenic.
- Part 2
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