CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 38, No 4 December 2025
- Modal fragility of bare statistical generalisations in medicine
- Role of traditional healers in healthcare in the 21st century
- Minors and the termination of pregnancy
- The ethics of neonatal male circumcision
- Ethical issues associated with immunotherapy for allergic rhinitis
- Doctor, what would you do?
- Allergic and non-allergic skin conditions in the different mining industries
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EDITORIAL
Author: Sharon Kling
Abstract: It is my privilege to be guest editing this ethics-themed issue of Current Allergy and Clinical Immunology. The editors of the journal, Professor Eugene Weinberg and Dr Di Hawarden, provide their unstinting support for the Ethics section of this journal and I wish to thank them for their backing and encouragement. Thank you, too, to Mrs Robyn Marais, the production editor of our journal, for her professionalism, knowledge and enduring patience. I also wish to thank our longstanding language editor for his meticulous editing of the contributions to each issue and in particular for incorporating footnotes into the article by Ganya and Ganya.
Review article
MODAL FRAGILITY OF BARE STATISTICAL GENERALISATIONS IN MEDICINE
Authors: Wandile Ganya, Wanele Ganya
Abstract: This article argues that bare statistical generalisations, understood as population-level frequency – that is, claims that lack causal or explanatory grounding – exhibit a form of modal fragility that renders them epistemically inadequate in guiding inference in individual clinical contexts.a A generalisation is modally fragile when it fails to support a stable inference under plausible background variation, that is, across nearby possible worlds. In the absence of intentionally relevant evidence – which is evidence that is connected causally or explanatorily to an individual case – such generalisations lack counterfactual robustness and therefore cannot justifiably be applied directly to particular instances. Despite its stated commitment to rigour and objectivity, evidence-based medicine (EBM) lacks the operational criteria required to select reference classes or to evaluate intentional relevance. Its prevailing frequentist paradigm is structurally prone to modal breakdown. This fragility is especially apparent in ethically sensitive domains such as race-adjusted diagnostics, but it also arises in ostensibly neutral practices. This article argues that epistemic legitimacy requires a methodological shift towards modal and causal epistemology, particularly one informed by interventionist accounts of causal relevance. Although Bayesian frameworks may mitigate fragility when they are grounded in causally structured precedents, EBM as currently practised rarely satisfies this condition. This analysis targets the frequentist structure of EBM rather than statistical reasoning itself.
Keywords: evidence-based medicine, EBM, modal fragility, statistical generalisations, interventionism, Bayesian epistemology
Review article
ROLE OF TRADITIONAL HEALERS IN HEALTHCARE IN THE 21ST CENTURY
Authors: Ntombizanele Menze, Thembelihle Mashigo
Abstract: South Africa is a diverse society in which a variety of different cultural and religious belief systems pertain and are consulted. This means appreciating that each client is likely to articulate their diseases, and the cures, differently. In a struggling economy such as South Africa’s, the lack of essential healthcare services and a shortage of staff and essential resources call for integrative care that not only validates an individual patient’s culture and belief system, but will also ensure the delivery of these services in accordance with the biological-psychological-social-spiritual model. The majority of the patients in poor black communities use the services of traditional healers as their first line of treatment. This could be because traditional healers are more accessible and affordable and also because they validate the cultural perspective of their diseases. In order to offer safe collaborative and/or integrative care, we need to bridge the knowledge gaps between the traditional and biomedical healthcare systems by means of ongoing education and dialogue. The two systems should not be in competition with each other but should instead work in unity to ensure better outcomes for patients.
Keywords: traditional healer, healthcare, cultural belief system, religious belief system
Review article
MINORS AND THE TERMINATION OF PREGNANCY IN SOUTH AFRICA: LEGAL CONSIDERATIONS
Authors: Anita Kleinsmidt, Michael Urban
Abstract: The Choice on Termination of Pregnancy Act 92 of 1996 gives a pregnant female of any age the right to consent to an abortion without the assistance of a parent or a guardian. Counselling should be offered, but is not mandatory. Despite this liberal abortion law, there are significant obstacles to access, including intentional obstruction by clinic staff. The literature indicates that teenage childbearing is very likely to have negative effects on a woman’s mental health with educational and socio-economic ramifications. Medical practitioners should accept pregnant women’s accounts of the effect of childbearing on their lives. We mention a High Court case on abortion and minors which highlights the constitutional imperative of giving effect to women’s autonomy by supporting their constitutional rights to reproductive choice.
Keywords: minors, abortion, Choice on Termination of Pregnancy Act, conscientious objection
Review article
THE ETHICS OF NEONATAL MALE CIRCUMCISION
Author: Sharon Kling
Abstract: Non-therapeutic male circumcision (NTMC), the surgical removal of the prepuce or foreskin covering the glans of the penis, is frequently carried out on infants for religious or cultural reasons. The prophylactic circumcision of male infants may reduce the incidence of urinary tract infection, especially in the first year of life. It may also protect against the transmission of the human immunodeficiency virus (HIV), reduce human papilloma virus (HPV) infection and prevent penile cancer. However, it is a concern that circumcision removes a healthy part of the male infant’s body – a procedure that is not clearly in the infant’s best interests and which is performed at an age at which the child is too young to provide consent. Evidence shows that the procedure is not as innocuous as its proponents suggest but carries long-term physical and psychological sequelae. The question is whether parents can legitimately provide consent for circumcision of their infant male child, given that the best interests standard is not met, but the harm standard is used instead. Adequate anaesthesia and analgesia for the procedure are non-negotiable essentials.
Keywords: ethics of circumcision, non-therapeutic male circumcision, NTMC, parental decision-making, religious circumcision, cultural circumcision
Review article
ETHICAL ISSUES ASSOCIATED WITH IMMUNOTHERAPY FOR ALLERGIC RHINITIS IN SOUTH AFRICA
Author: Marinda McDonald
Abstract: Allergen immunotherapy (AIT) is the only disease altering treatment available in allergic disease; not only does it alter the course of allergic rhinitis, but it may also prevent asthma. Given South Africa’s high asthma burden and mortality rate this obligates further exploration. AIT significantly improves disease control but is available to very few people in South Africa and worldwide. Using the four biomedical ethics principles to frame the ethical dilemma, beneficence and patient autonomy are in conflict with distributive justice. Significant obstacles to access AIT in South Africa exist, like the need to apply for Section 21 approval and the availability of trained medical personnel. This calls for advocacy on behalf of patients. A locally manufactured vaccine might also resolve the lack of access to AIT.
Keywords: allergen immunotherapy, IgE-mediated allergic conditions, allergic rhinitis, subcutaneous immunotherapy, sublingual immunotherapy
Review article
DOCTOR, WHAT WOULD YOU DO?
Author: Sharon Kling
Abstract: Patients and their family members faced with difficult medical decision-making may resort to asking health professionals (HPs) what they would do if faced with a similar situation. HPs struggle with knowing how to approach this question and may hedge or refuse to answer. The situation shows patients’ and families’ trust in the HP, and generally the HP is advised to answer as honestly as possible, after clarifying exactly what they are being asked.
Keywords: Doctor what would you do, medical decision-making, shared decision-making, patient preferences, doctor-patient relationship
Allergies in the Workplace
ALLERGIC AND NON-ALLERGIC SKIN CONDITIONS AMONG WORKERS EXPOSED TO VARIOUS SUBSTANCES IN DIFFERENT MINING INDUSTRIES: THE VALUE OF PATCH-TESTING
Authors: Munyadziwa Muvhali, Anna Fourie
Abstract: The mining workforce is potentially exposed to skin hazards that range from air conditioners to solvents, chemicals, minerals, mining dust and other substances; these hazards can result in a variety of skin conditions, including both allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD), among other disorders. In the present study, the records of patients referred to the National Institute for Occupational Health (NIOH) occupational skin disease clinic from the mines between the years 2010 to 2023 were analysed. Of the 142 records retrieved, nine were excluded and a total of 133 were included in the study. Microsoft Excel was used for analysis. The median age of the participant workers was 39 years; workers within the age range 30–39 years were more commonly referred to the NIOH (35%) and the majority of workers were male (87%; 116/133). Platinum mines accounted for most of the workers (64%), followed by coal mines (13%). Atopy was reported in 28.6% of the workers; ICD accounted for 41% of the occupational skin disease (OSD) diagnoses, followed by ACD (32%). Metals accounted for 41% of the contactants, with mine dust accounting for 30% and explosives for 29% of them. Hands were the most common primary site for reactions (33%), followed by arms at 18%. The majority (98%) of the workers reported the use of personal protective equipment (PPE) such as rubber boots, gloves, masks or respirators. The European Standard Series (ESS) of patches was the most frequently used patch-test series (62%) in this study. The commonest allergens detected were nickel sulphate at 13%, with the second commonest being potassium dichromate (at 9%). Although occupational health measures have been put in place, the mining environment contains multiple irritants and allergens which can cause OSD; therefore, it is important to identify the cause of the OSD or to determine whether the skin disease is not occupation-related. This study highlights the value of patch-testing in the diagnosis of OSD among mine workers. Patch-testing was found to help with diagnosis by identifying an allergic cause of the OSD, particularly among workers exposed to various substances (both allergens and irritants). Patch-testing is an integral part of the assessment of OSD and should be considered in the assessment of workers exposed to various substances in the workplace, such as the mining industry.
Keywords: mine workers, allergens, contact dermatitis, patch test, occupational skin disease
ABC of Allergy
The hypersensitivity cells
Authors: Shaunagh Emanuel, Di Hawarden
Introduction: Dr Do-a-lot continues her lecture series on the immune system. She explains that, although it does a commendable job of consistently curbing invasion by microbes, sometimes the immune system becomes over-excited and mounts an exaggerated response against harmless molecules such as pollen, peanuts or pet dander.
DR SPUR’S MYSTERY CASE
The Case of the Silent Macrophage
Authors: Lizelle Nagel, Miguel Jose Teixeira, Barend Mitton, Sylvia van den Berg
Introduction: In the late 20th century, it was commonly believed that inborn errors of immunity (IEI) affect only leukocytes and that IEI patients are susceptible to infection by a wide range of microorganisms.1 These infections are usually Serious/severe, Persistent, Unusual and/or Recurrent (SPUR) and usually require medical intervention/hospitalisation. These patients usually also Return In Bad Shape (RIBS) after completing a standard course of treatment.
Nutrition Tuition
SUMMER FRUITS: NOT EVERYONE’S TREAT
Author: Jandri Barnard
Introduction: Fruit is promoted as a health food, stuffed as it is with antioxidants, minerals and other vitamins. During the summer months in South Africa (tropical) fruits are more freely available and the rest of the year they are available as dried fruit or as an ingredient in fruit juices. These tropical fruits include mangos, kiwis, watermelon, melons, bananas and coconut. But there are also those individuals who present with an allergic reaction to these fruits and so they prefer to avoid them for their own well-being, even their survival. Kiwis fall within the top 20 delayed-onset IgG food allergies and have been found to be the most commonly allergenic fruit, but not exclusively so.