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 terminal decline in the case against him. Whether you see signs as auspicious or ominous – or see any at all – 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 achieved not a single major concession from Noakes. When he wasn’t accusing Noakes of having brought the case on himself, Bhoopchand tried and failed to poke serious holes in the science of low-carb, high-fat (LCHF) 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.
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 evidence as new additions to the witness list. Zinn was on the list and attended the November 2015 session. The HPCSA took up all the time, which meant she could not give her evidence.
Noakes’ legal team drew their arguments mainly from the HPCSA’s own submissions. They applied successfully to call surprise and secret witnesses at the November 2015 and February 2016 sessions.
Pretoria advocate Joan Adams, chair of the HPCSA independent disciplinary committee hearing the charge against him, 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 saying good first foods for infant weaning are low-carb, high-fat (LCHF).
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.
As it turned out, Harcombe was able to begin giving evidence late on Friday, though only for 45 minutes. However, the fast-talking Harcombe got lots in. (She 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.
The second is the “diet-heart hypothesis” that saturated fat causes heart disease. That hypothesis lies at the heart of the guidelines.
Harcombe said the diet-heart hypothesis had no evidence to support it then. It has none now.
On Monday, she will present evidence undermining a key pillar of the HPCSA case against Noakes: the so-called “Naudé Review”, after lead author and Stellenbosch University academic Dr Celeste Naudé . The evidence suggests that this review is “fundamentally flawed”.
Interestingly, the HPCSA case against Noakes appears to be growing his friends. Doctors have attended the hearing to show support. I overheard one introduce 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 allude to vested interests keen to see the case against LCHF 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 disciplinary committee finds in Noakes’ favour.
Certainly, Strydom is just one of many dietitians involved directly or indirectly in this case. Many are ADSA members. ADSA president Maryke Gallagher and her executive have voiced loyal support for Strydom and her case against Noakes. Gallagher even issued a public statement last year saying that the case against Noakes was “only about Twitter”.
Noakes’ Cape Town lawyer Adam Pike, of Pike Law, dismissed that. He said Strydom’s own evidence shows she objected to the information he gave. Click here to read: It’s not about Twitter.
Two other dietitian academics with vested interests against Noakes and LCHF have been present throughout the hearing. They are retired North-West University Prof Hester “Este” Vorster and University of Cape Town dietetics professor Marjanne Senekal.
They’ve beavered away to assist the HPCSA’s very expensive outside legal team. The team and the HPCSA have declined to confirm or deny reports that Bhoopchand’s first bill for the February hearing alone was for around a cool R1 million.
Vorster wrote a report for the HPCSA Preliminary Inquiry Committee that it used to charge Noakes, without letting him see it beforehand. In that report, she refers to the Naudé review. She then appeared as an expert witness against Noakes at the November 2015 hearing.
Vorster also wrote the South African guidelines. She’ll be none too happy with the demolition job Noakes and his experts are busy doing on the science behind the guidelines.
Click here to read: LEGAL TEAM FIGHTS ‘TRIAL BY AMBUSH’, PART 1
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 he was developing his strategy according to Vorster’s intermittent instructions.
Senekal is a consultant to the HPCSA in this case. She is a co- author of the Naudé review. She is also co-author of a letter Noakes’ UCT colleagues wrote to the press in 2014, which Noakes has repeatedly said is defamatory.
In it, the authors attack Noakes, inter alia for making “outrageous, unscientific” claims on diet and disease. The HPCSA has 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 distances himself from the letter’s contents and says the authors should retract it and apologise to Noakes.
The letters’ authors have remained resolutely mum. I’ve emailed them again, including UCT vice chancellor Dr Max Price, for comment on the ethics of the letter. I have also asked about the ethics of a UCT academic assisting the HPCSA, a statutory body, to prosecute a distinguished colleague. (Watch this space.)
Bhoopchand may not have intended it, but his cross-examination may have buttressed evidence 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 has testified in his “dogs that don’t bark” analogy that this case was never about breastfeeding, babies, weaning or even Twitter.
It is and always has been about the safety and efficacy of LCHF to treat and prevent serious disease, in particular, obesity, diabetes and heart disease. The diet-heart hypothesis is clearly also very much on trial.
Bhoopchand focused much of his cross-examination on Twitter. He insisted at length that was an “inappropriate forum” for doctors to give out any medical or nutrition-related information. Noakes disagreed. He said Twitter’s “ self-correction” mechanism doesn’t 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.
Bhoopchand tried hard to get Noakes to concede that he gave Leenstra medical advice rather than information on Twitter.
However, Noakes dismissed that, saying doctors and dietitians regularly dish out information on and off social media. He argued that a lack of information, not access to information, was the real danger. He said Twitter’s “natural democracy” means that “what works percolates to the top. What does not work falls to the bottom”.
Bhoopchand said even if there were no doctor-patient relationship with Leenstra, “ as a responsible human being”, Noakes should have amplified the information.
Noakes replied: “ Sir, I am a very responsible human being. 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.
“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.
“Now for you to say I am responsible for being unethical, badly behaved, etcetera, and breaking the ethics of medicine because I do not respond to one question from this lady, I find that not very helpful, sir.”
Bhoopchand insisted that Noakes had contravened the HPCSA’s rules on ethical conduct for medical professionals on Twitter. The only problem is the HPCSA doesn’t have any ethical rules governing doctors’ conduct on social media.
Full marks for initiative in covering all bases, though. Bhoopchand suggested that what rules the HPCSA did have, applied to doctors’ conduct apply anywhere, anytime. That includes in cyberspace. Thus, 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 – many times. He said Noakes had gone against the the Tshwane declaration of support for breastfeeding in South Africa by telling the breastfeeding mother, Pippa Leenstra, to stop breastfeeding.
Noakes pointed out that his tweet doesn’t say that the breastfeeding mother should to stop breastfeeding. With one of many Kafkaesque flourishes that have characterised this trial, Bhoopchand said: “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 tried to suggest that Noakes told the breastfeeding mother to put her infant on a dangerous “ketogenic” diet. However, his tweet does not mention the “k” word and “ketogenic diet”, dangerous or otherwise, isn’t in the charge.
Bhoopchand said Leenstra might have thought that was what Noakes meant. And so it went on in similar vein.
He seemed to do what most of the HPCSA’s witnesses did, including Vorster, Kruger, paediatrician Dr Mohammed Dhansay and Strydom herself. All conflated LCHF not just with ketosis but 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 extreme medical ketogenic diets, nutritional ketosis and low-carb.
Noakes made the point that breastmilk is ketogenic, despite having a moderate carbohydrate content.
“There is something in breastmilk that increases ketosis and we have never been able to reproduce that in standard milk that is provided to babies,” he said. Humans fed breastmilk and moderate carbohydrates would still be producing “lots of ketones for the brain”, he said.
Bhoopchand pounced and asked Noakes if had any science to back up that view. Noakes smiled and said he had presented it. He reminded Bhoopchand that the HPCSA’s own witness, paediatrician Dr Mohammed Dhansay, had confirmed that breastmilk was ketogenic.