South Africans are more likely to die from NCDs even though the country is threatened by a prolific HIV epidemic
Corn porridge, processed meat and convenience foods are staples in an average South African’s diet. These food choices, made out of necessity and ignorance, are the main driving forces behind the country’s growing epidemic of lifestyle diseases. Like other low- and middle-income countries, South Africa is experiencing a surge in non- communicable diseases (NCDs), including heart diseases, stroke, cancer, diabetes and chronic lung disease.
South Africans are more likely to die from NCDs even though the country is threatened by a prolific HIV epidemic (18.9 per cent of population is HIV-positive), coupled with tuberculosis (TB) co-infection in more than 60 per cent of HIV patients. The country’s latest mortality statistics of 2016 shows diabetes is just behind TB as the leading cause of death, with heart diseases and stroke (cerebrovascular diseases), in third and fourth places.
South Africans have a 51.9 per cent probability of dying from NCDs, suggests NCD Countdown 2030, a collaboration between the World Health Organization (WHO), The Lancet, NCD Alliance (a network of civil society organisations) and the Imperial College, London. It is also the most obese country in Sub-Saharan Africa with two-thirds of women and about a third of men overweight or obese. At the same time, 25 per cent of South African children are undernourished, indicating double burden of malnutrition where members of a family can suffer from undernutrition and obesity at the same time.
“Driving the rise in NCDs in South Africa is an obesogenic diet that is high in ultra-processed food,” says David Sanders, an emeritus professor of public health at the University of the Western Cape, South Africa. South Africans’ food energy rose by 397 kilojoules per person per day (equivalent to one extra candy bar a day) between 1998 and 2003 largely due to ultra-processed food products, says a 2015 study published in the bulletin of WHO.
Sibongile Nkosi, director of South African advocacy group Healthy Living Alliance (HEALA), blames junk food outlets for the current diet. “Fast food joints are popping up everywhere because they are perceived to be cheaper and more convenient than their healthy alternatives,” says Nkosi.
At the same time, land policies dating from the former Apartheid era have discouraged subsistence farming, which has further pushed fast food. “We have done surveys in remote rural areas and found that even these communities purchase nearly all their food,” says Sanders.
Socioeconomic factors have a large impact on the South African diet. Two-thirds of South Africans live on a household income lower than US $240 (3,500 ZAR) a month forcing them to buy cheap unhealthy food. A 2012 study by Sanders and his colleagues published in the medical journal PLOS Medicine found that healthy food cost South Africans between 10 and 60 per cent more than junk food. Elsie Malaza, a pensioner from the Mpumalanga province who suffered a stroke in 2013, says she continues to survive on junk food knowing well that it is increasing her chance of another stroke.
“I cannot afford the diet I have been prescribed,” she says. Frequent electricity outages and limited refrigeration facilities in the country further minimise the consumption of fresh food. Salome Kruger, professor with the Nutrition Centre of Excellence at the North-West University believes schoolchildren should be targeted to combat obesity. She says tuck-shops outside the school premises are a major source of unhealthy food to the children. “Efforts should be made to sell milk drinks, yogurt, maas (fermented milk) and fresh fruit in tuck-shops,” she says.
South Africa’s health minister Aaron Motsoaledi in his foreword to the National Strategic Plan (NSP) for NCDs says health services in the future will be overwhelmed with patients requiring acute, long-term support. The country has so far developed a Declaration for Prevention and Control of NCDs, which has 10 goals, out of which some need to be achieved by 2020 and the rest by 2030. The goals include reduction of premature mortality, tobacco use, alcohol consumption, salt intake, while promoting physical activity and better screening of cervical cancer, hypertension, diabetes, asthma and mental disorder.
In April this year, South Africa, which is among the top 10 consumers of sugary drinks in the world, became the first African country to introduce an 11 per cent tax on sugary beverages. The soft drinks market in the country had doubled from 2.3 million litres in 1998 to 4.7 million litres in 2012. The tax is expected to generate $130 million revenue. Though a move in the right direction, Tracey Malawana of HEALA says soft drinks should be taxed at least 20 per cent to make any significant impact. A 2014 report by Priceless-SA, a research unit of the Wits University School of Public Health, says a 20 per cent tax on sugary beverages would reduce obesity in over 220,000 South African adults.
Besides sugar, South Africans have high salt intake. While 65 per cent of South Africans consume more salt than WHO target of 5 grams per day, 40 per cent consume over 9 grams per day, states a WHO study on global ageing and adult health. The report adds that 53 per cent South African adults above 50 years suffer from hypertension. In 2016, the country introduced a legislation to reduce salt in processed food. The regulation has two reduction targets for individual items, one of which was to be implemented by 2016 and the other stricter target has to be adhered to by 2019. The legislation is expected to avert 11 per cent of deaths from heart diseases and save the government $50 million per year in healthcare costs.
South Africa has also banned advertisements of tobacco products and mandated that their packaging carry health warnings. “The legislation and annual increases in cigarette prices have led to a consistent decrease in the prevalence of smokers from 38 per cent in 1998 to 17 per cent in 2012,” says Savera Kalideen, executive director, South African National Council Against Smoking. The government also has a 2003 legislation to contain alcohol consumption. Health experts say the government should tax unhealthy food and use the revenue to subsidise healthy food. “This can make a packet of milk cheaper than a bottle of soft drinks,” says Sanders.
South Africa needs to be proactive if it wants to achieve the Sustainable Development Goal 3 (see ‘Reform policies, focus on prevention, p36) It has already included NCDs in the National Development Plan with a goal of 28 per cent reduction by 2030. But with just 0.1 per cent of the national health budget given to NCDs in 2017, it seems a difficult task. To ensure universal health coverage, the country is depending on the National Health Insurance (NHI). Though publicly funded, it would depend on delivery from both private as well as public providers. The green paper on NHI estimates that public health spending will increase from 4.2 per cent to 6.2 per cent of GDP by 2025.
“There is very little political will. The President attended and spoke at the UN high-level meeting on TB. But a day later not a single politician or high-level official attended the plenary session on NCDs,” says Victoria Pinkney-Atkinson, director, South African NCD Alliance. She added that NCDS received 0.011 per cent of the health budget in 2017. “With such low budgets it is common that even when NCD medication is available at the primary care level, diagnosis is poor due to insufficient equipment and training among health workers,” she says.
Sandhya Singh, acting chief director for NCDs at the National Department of Health, says that though prevention and control of priority NCDs like diabetes and hypertension are integrated into South Africa’s primary healthcare package, non-compliance by patients is an issue. “We find that people are struggling to maintain good health. Often, we have patients with uncontrolled diabetes who experience kidney failure, blindness and even amputation.” But she is optimistic. “We have leveraged many excellent lessons from the fight against HIV, which too is a chronic disease and they will benefit us in our fight against NCDs,” says Singh.
(This article was first published in the 1-15th December issue of Down To Earth under the headline 'Silent killer'. It is part of a series on healthcare in Africa).
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