by Tim Noakes
A number of factors jumped out at me as I read the CV4 of UCT’s newest, and soon to be shortest-reigning, dean of medicine. De Villiers had matriculated as the top student in the then Cape Province, hence the nickname Slim Wim. He had trained at the universities of Stellenbosch, Oxford and Harvard before ending up at the University of Kentucky Medical Center in 1996. In 2016, the University of Kentucky Medical Center was ranked 67th best in research and 74th best in primary care among US institutions. Harvard, Stanford, Johns Hopkins, the University of California, San Francisco and the University of Pennsylvania were ranked the top five medical institutions. Why, I wondered, had Slim Wim not pursued his academic career at one of these more academically challenging medical institutions?
Perhaps it was because academic research was not De Villiers’s real passion. In the two decades since receiving his PhD in 1995, De Villiers had supervised and co-supervised a total of just four successful doctoral candidates. During the same period, he had found time to work as a consultant to 18 pharmaceutical companies, nine of which have been fee-paying affiliates of the ILSI.*
De Villiers’s CV also records that during his career he was the principal investigator in ‘35 Inflammatory Bowel Disease industry sponsored studies’. I would guess that none addressed the possible role of specific dietary factors such as gluten in the causation of inflammatory bowel conditions.
Before she went home on Friday 22 August 2014, Linda Rhoda, head of marketing and communications for the UCT Faculty of Health Sciences, completed a last action: she sent an email to the Cape Times titled ‘Noakes’ diet and health implications’, cc’ing me, National Assembly Speaker Baleka Mbete, minister of health Dr Aaron Motsoaledi, Western Cape MEC of health Dr Theuns Botha, and members of the South African Committee of Medical Deans. The latter would have included the deans of all the South African universities charged with the responsibility of training medical doctors.
At the time, I was en route to the Western Cape nature reserve Bartholomeus Klip, near the village of Hermon. Early the next morning, I opened my email and read the attached letter with growing incredulity. It carried the names (but not signatures) of four UCT academics, as well as – importantly – the logos of UCT and the UCT Faculty of Health Sciences. It therefore, in effect, signalled my ultimate academic rejection by all members of the university, and especially the medical faculty that I had served with distinction for 35 years. Only the deaths of my parents, Bob Woolmer and a few other close friends surpassed the emotional devastation this email caused me. It is published here in full on pages 90–91.
As I read it, I pondered all the lessons I had learnt from the great coaches with whom I had worked, such as Bob Woolmer, Jake White, John Dobson and Kevin Musikanth. They all taught me that team success begins with developing personal relationships.
As the exceptional football coach Carlo Ancelotti explains:
First you have to build good relationships, good chemistry with the group you’re working with. After that, you can add the strategy. I think that the most important thing is the relationship with the people, and the relationship with the people makes a better organization. I’m sure of this. I speak with my players but I know that first of all they are people. So you have to treat them with respect. It’s important to have a good relationship on the same level, not them looking up to me or me looking down on them.5
How could my senior medical colleagues not understand these fundamental truths? Why, despite their education, were they so lacking in these basic human skills? Did they not understand that to build successful teams, you begin by respecting those with whom you work? Why, instead, had they resorted to the lowest forms of academic discourse – bigotry and harmful academic bullying?
My initial response when reading the email was that, besides its poverty of honesty and intellectual content, it was wholly inappropriate. If this were purely an academic disagreement, then the correct forum for its resolution lay within the moderating halls of UCT, not in the columns of a local ‘tabloid’ newspaper.
Why, I wondered, had these academics not called me in for a discussion first? That would have given me the opportunity to explain my views and answer their criticisms directly. The fact that De Villiers and his colleagues had chosen this bizarre route indicated that this was not a matter simply of academics and science. It had become much more. I believe that these professors were dancing to someone else’s tune, and that this letter and De Villiers’s subsequent actions were essential drivers for the HPCSA charges against me. Without this letter, the HPCSA hearing might never have happened.
In the first place, I found it difficult to believe that Lionel Opie, a man of honour and integrity, as I believed him to be, would dignify what I see as scurrilous drivel with his signature. Just three months earlier, at a Franschhoek Literary Festival debate with me on 17 May 2014, Opie had confirmed to my wife that, while he was happy to participate in that event, he did not wish to do anything to damage the special relationship we had enjoyed since 1972.
Opie had also written a letter to the Sunday Times on 27 July, in which he sought to clarify some attributed statements in an article published by the paper the previous week. In this letter, he expressed opinions quite different from those that would appear in the UCT professors’ email, and included a partial endorsement of the Banting diet:
I regard the New Atkins low-carbohydrate diet as a good starting point for weight reduction because it has a two-year placebo-controlled study to its credit. I will not propose that Noakes is ‘dangerously wrong’, as stated in your subheading, as his diet also induces weight loss. But we must face facts. The Noakes diet, although related to the Atkins diet, crucially differs by emphasising the high-fat diet that has no supportive trial data. Note a long-term danger after short-term weight loss, namely the increased risk of breast cancer.6
Crucially, Opie was refusing to state publicly that I was ‘dangerously wrong’; instead he endorsed LCHF as a reasonable initial diet for weight loss. He limits any further endorsement only because of concerns about a lack of long-term trials. This was essentially what he had said at our debate at the Franschhoek Literary Festival: begin your weight-loss journey on the LCHF diet and then switch to the ‘Mediterranean diet’ (whatever that is) for long-term health.
How could he have changed his opinion so drastically in the space of a few weeks? How could our relationship of more than 42 years suddenly mean so little to him? Would he really add his name to an email that was so intellectually and ethically deficient and so professionally degrading for all involved? My instinct told me no, this is not what Professor Lionel Opie stands for.
I did not know quite what to make of it, but I knew I had to at least try.
What struck me most about the letter was its cruelty and inhumanity, and that the authors showed not the slightest hint of conscience in publicly shaming me. Medicine is meant to be a caring profession in which we are concerned with the emotional health and needs of not just our patients, but also our colleagues and students. De Villiers appears to understand this. When he was eventually appointed rector and vice chancellor of the University of Stellenbosch in December 2014, his university profile stated: ‘He believes the University should offer an experience that is pleasant, welcoming and hospitable – in an inclusive environment.’7 Those admirable sentiments were remarkable for their absence from the Cape Times professors’ letter.
Instead, the letter is a textbook example of academic bullying, a topic recently reviewed by Dr Fleur Howells, senior lecturer in psychiatry at UCT. Howells writes that there are three forms of academic bullying. The third, ‘social bullying, also known as relational aggression, is the deliberate or active exclusion or damage to the social standing of the victim through, for example, publicly undermining a junior academic’s viewpoint’.8 The four key components of bullying are intent to harm, experience of harm, exploitation of power and aggression. The professors’ letter thus neatly fulfils all the diagnostic criteria for academic bullying.
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Jacqui Hoepner is currently completing her PhD thesis at the Australian National University, studying the use of these bullying tactics to suppress or silence dissenting scientific opinions.9 In a discussion with Daryl Ilbury, author of Tim Noakes: The Quiet Maverick, Hoepner disclosed her original assumption that most cases of academic suppression or silencing arise from outside academic circles. To her surprise, she discovered the opposite – ‘the bulk of suppression or silencing came from within academia, from colleagues and competitors’, she told Ilbury. ‘This suggests that the assumed model of respect and disagreement between academics is inaccurate.’
Hoepner was astonished to uncover 43 different ‘silencing behaviours’ that fly in the face of the concept of academic freedom: ‘Every policy and university guideline I looked at suggested that academic freedom was absolutely central to what academics do and their place in society … [But] there’s a real disconnect between what academics think they are guaranteed under academic freedom and what the reality is for the life of an academic.’
She also discovered that the nature of these silencing attacks was ‘more of a personal gut response: that someone has crossed a boundary and we need to punish them. The exact motivation differed from case to case, but it seemed very much a visceral response.’
Typically, attacks are ad hominem, with accusations of conflicts of interest ‘to undermine credibility … without any attempt by the claimant of the accusations to provide any evidence’; and with allegations such as ‘You’re doing real harm’, ‘You’re causing confusion’ or you’re undermining the public’s faith in science; and ending with summons that the researcher be ‘fired or disciplined in some way’.
Perhaps with direct relevance to my experience, Hoepner said: ‘If a scientist discovers evidence that contradicts decades of public health messaging and says that data doesn’t support the messaging, and that person is attacked, and publicly … that’s insane!’
Returning to the professors’ letter, it is also blatantly defamatory because it implies that I, as a medical practitioner: promote a diet that may cause harm (‘heart disease, diabetes mellitus, kidney problems … certain cancers’); make ‘outrageous unproven claims’; malign the integrity and credibility of peers who disagree with me; and undertake research that is not ‘socially responsible’ in the judgement of UCT.
The letter also breaches the HPCSA’s own ethical guidelines. Professor Bongani Mayosi, another signatory to the letter, was involved at that time in a review of the HPCSA management and functioning, and therefore should have been well versed in the ethical guidelines of the organisation he was investigating. According to section 6 of the HPCSA ‘General Ethical Guidelines for the Health Care Professions’:
Health care professionals should:
6.2.1Work with and respect other health care professionals in pursuit of the best health care possible for all patients …
6.2.3Refrain from speaking ill of colleagues or other health care practitioners.
6.3.4Not make a patient doubt the knowledge or skills of colleagues by making comments about them that cannot be fully justified.10
The four UCT academics therefore had an ethical responsibility, mandated by the HPCSA, to treat me with respect and dignity. In addition, the medical profession provides specific strategies for how medical colleagues are expected to communicate with one another when there are disagreements. These include:
Respectfully raising your concerns with your colleague.
Framing your words around achieving the best result for the patient.
Attempting to negotiate a mutually agreeable resolution.
Taking action until you are satisfied that the patient’s best interest is being served.
Thus, the initial responsibility of the four UCT academics was to negotiate with me directly to find a ‘mutually agreeable resolution’. They chose not to do this. Instead, they took their disagreement public in the pages of a local newspaper, and it subsequently spread via social media and radio to the rest of the world. And what of my ethical responsibilities? I believe one of my responsibilities is to provide patients with information that, as a result of my medical and scientific training, I believe will improve their health. This, too, falls within the requirements of the HPCSA, specifically that the medical practitioner shall at all times:
27A (d) provide … any other pertinent information to enable the patient to exercise a choice in terms of treatment and informed decision-making pertaining to his or her health and that of others.11
And how does the UCT Faculty of Health Sciences expect their graduates to act? At graduation, my colleagues and I, including the co-signatories of the Cape Times letter, made the following declaration:
I solemnly pledge to serve humanity.
My most important considerations will be the health of patients and the health of their communities.
I will not permit considerations of age, gender, race, religion, ethnic origin, sexual orientation, disease, disability or any other factor to adversely affect the care I give to patients.
I will uphold human rights and civil liberties to advance health, even under threat.
I will engage patients and colleagues as partners in healthcare.
I will practise my profession with conscience and dignity.
I will respect the confidentiality of patients, present or past, living or deceased.
I will value research and will be guided in its conduct by the highest ethical standards.
I commit myself to lifelong learning.
I make these promises solemnly, freely and upon my honour.12
It seemed the four UCT professors might have forgotten some aspects of their solemn oath.
Besides failing to treat me, their colleague, with respect and dignity, they clearly wished to restrict my ability to ‘value research’ and to provide patients with ‘any other pertinent information’ that would enable informed decisions. They also appeared to want to prevent me from fulfilling my most important professional responsibility, which is to the health of patients and communities, not to other special interests, including personal ego and the pharmaceutical and food industries.
In the 43 years since I first graduated as a medical doctor from the UCT Faculty of Health Sciences, I have observed a steady decline in the health of the communities that UCT serves. Surely my duty is to ask why this is so. And if I think I have a scientifically based answer, my responsibility – according to the UCT graduands’ declaration – is to do all in my power to promote whatever change may be necessary.
My concern, which I expressed to Parliament’s wellness group, is the imminent diabetes tsunami that will bankrupt South Africa’s medical services within the next 10 to 15 years. This is especially important for the Western Cape, which is the diabetes capital of South Africa. My message is that we cannot reverse this epidemic unless we change our national eating patterns by consuming more fat and less sugar, processed foods and carbohydrates, a point which now even the HSFSA fully endorses.
Interestingly, not once in my presentation to Parliament’s wellness group had I mentioned LCHF/Banting and The Real Meal Revolution, as the four professors clearly assumed I had done. My talk was about the biology of IR, the causes of the obesity/diabetes epidemic, the role of the processed-food industry and its addictive foods, and the evidence for the role of nutrition in fighting life-threatening diseases.
If the four UCT professors really believed that my message to Parliament’s wellness group was ‘dangerous’, they needed to explain why. Why did they find my main message that South Africans should eat less sugar, less processed foods and fewer carbohydrates so threatening? It cannot be because replacing sugar, refined carbohydrates and excess carbohydrates with real foods will lead to an epidemic of other diseases, as there is no evidence that this will happen. Why, then, were these academics so desperately concerned by this revolutionary advice, which millions of people in South Africa and globally had already come to accept as mere common sense
?
Let’s return first to the ‘academic’ issues in the letter and all the errors it contains.
Their first error is to label LCHF/Banting ‘the latest fashionable diet’; in other words, a fad. This is wrong. The Banting diet takes its name from an obese 19th-century undertaker, William Banting. First described in 1863, Banting is the oldest diet included in medical texts. Perhaps the most iconic medical text of all time, Sir William Osler’s The Principles and Practice of Medicine, published in 1892, includes the Banting/Ebstein diet as the diet for the treatment of obesity (on page 1020 of that edition).13 The reality is that the only non-fad diet is the Banting diet; all subsequent diets, and most especially the low-fat diet that the UCT academics promote, are ‘the latest fashionable diets’. Opie, who has such a grasp of the history of medicine, would never, in my opinion, attach his signature to a letter that included such an obvious misrepresentation.
The authors write with the certainty of dogmatic arrogance that they are deeply concerned about this ‘diet revolution’ and ‘the long-term impact this may have on the health of the very people they [parliamentarians] have been elected to serve’. They conveniently ignore the fact that the low-fat dietary guidelines they promote were adopted in the absence of any robust evidence for either safety or efficacy. And since the adoption of those dietary guidelines, there has been an unprecedented pandemic of obesity and T2DM, most especially in their area of influence, the Western Cape.
Surely these academics should be asking themselves why this has happened and what they should be doing about it. Surely they should be excited at the prospect of Parliament finally taking this issue seriously enough to ask me to address members on this topic.
The next point the authors reiterate is that ‘the long term safety and health benefits of low carbohydrate, high fat diets … are unproven’. This ignores two facts. Firstly, there is no long-term data showing the safety of the LFHC diet, which the UCT Faculty of Health Sciences has promoted for the past 50 years. Yet the professors demand scientific proof for a diet that modern humans have eaten safely for more than 150 years, and our ancestors for millions of years. Secondly, they fail to acknowledge that if a diet is ‘dangerous’, it must show that ‘danger’ within a reasonable period of time. The LCHF/Banting diet has consistently outperformed all other diets in the correction of the metabolic risk factors for arterial disease.14 This makes sense biologically, because arterial disease is caused by high-carbohydrate diets in those with IR and NAFLD, what I have termed the diet-liver-heart hypothesis. Furthermore, it is a general rule that two years is sufficient to determine whether or not an intervention is likely to be healthy or harmful. For how can an eating plan that corrects the metabolic abnormalities causing arterial disease suddenly become dangerous after two years and one day? There are at least four studies of this diet that have run for two years15 and another seven for one year without even a hint of harm.16