Brendon Barnes

Inequity in poverty: the emerging public health challenge in Johannesburg

In 2005, in recognition of the role of social factors in increasing health inequities, the World Health Organisation established the Commission on the Social Determinants of Health. South Africa is among the most unequal societies in the world. It faces serious public health challenges, including an elevated burden of chronic disease, and high levels of violence. This paper presents data from a cross-sectional study of socio-economic and health status conducted in five Johannesburg housing settlements in 2006. The findings paint a picture of health inequities across and within the study sites, and socio-environmental conditions that undermine the prospects of protecting and promoting health. The authors suggest the need for a new approach to public health in areas of urban impoverishment in Johannesburg and elsewhere.

Environmental lead--a public health challenge in South Africa.

© 2013 Lippincott Williams & Wilkins www.epidem.com | 621 To the Editor: Blood lead levels in developing countries are generally higher than international guideline levels due to the unabated use of lead in formal and informal industries.1 this is especially worrisome in countries such as south Africa, where there are limited public resources to regulate exposure and mitigate adverse effects. In 2002, a cross-sectional survey had assessed lead exposure in elementary-age children in three south African cities (Kimberley, Cape town, and Johannesburg), documenting high levels of lead exposure. In 2007, we conducted a follow-up study in elementary-age children attending the same schools in the same cities. Finger-prick blood tests were conducted using the LeadCare 1 analyser system (esA Biosciences Inc, Chelmsford, MA). Although this was not the method used in the 2002 survey, this system has been shown to be reliable and with similar results to more formal analytic methods.2,3 the Us Centers for Disease Control and Prevention has recently recommended a reference level of 5 μg/ dL, based on the Us population of children aged 1–5 years. We used this level to dichotomize blood leads.1 A total of 1349 elementary-age students (51% boys and 49% girls) participated in the survey. the mean age was 7.6 years, with ages ranging from 5 to 12 years. twelve percent were from the smaller city of Kimberley, 36% from Cape town, and 52% from Johannesburg. the majority of households were impoverished, with 33% earning less than r1000 (UsD 125) per month. Mean blood lead in the total sample was 8.0 μg/ dL, with a median of 7 μg/dL. Individual blood lead levels ranged from 0.8 to 32.3 μg/dL; 74% of the sample had blood lead levels at 5 μg/dL or higher, and 25% had levels above 10 μg/dL. In Johannesburg, 84% of children had blood lead levels of 5 μg/dL or higher, whereas the proportions were 57% in Kimberley and 66% in Cape town (table). In the 2002 survey, 35% of children in the same schools in Johannesburg had had blood lead levels of >10 μg/dL compared with 33% in 2007. this minimal reduction in exposure may reflect the discontinuation of leaded gasoline. similar decreases have been found in other countries.4–7 However, there was an apparent increase in blood lead levels in Cape town and Kimberley. In 2002, only 10% of children in the same schools had had blood lead levels in excess of 10 μg/dL, compared with 18% and 13%, respectively, in 2007.8 In just 5 years, an additional 8% of children in Cape town and an additional 3% of children in Kimberley were classified in the most heavily lead-exposed category. this suggests there are pockets of children in urban south Africa who continue to experience substantial lead exposure, despite the removal of major lead sources. It must be noted that different methods were used to assess blood lead levels in the two surveys; however, previous studies have found results from LeadCare to be comparable to formal laboratory analytical methods.3 We find that 1 to 2 years after discontinuation of leaded gasoline, children’s blood lead levels in urban south Africa remain high, and in some areas are increasing. the disabilities related to childhood lead exposure are well documented and preventable. More attention to this public health problem is urgently needed.

The prevalence and health implications of violence in impoverished communities in Johannesburg.

The experience of violent crime can have a significant impact on the physical and psychological well-being of victims and their families. This paper looks at household experience of violence in five impoverished sites in the city of Johannesburg, South Africa. Five sites were purposefully selected to reflect the prevailing housing profiles in settings of relative impoverishment in Johannesburg. A structured questionnaire was used to obtain information on demographic profiles, socioeconomic data, environmental conditions and health status. Bivariate analyses were conducted to assess the relationship between household experience of violence, and potential risk factors and health/social outcomes. Overall, members of 28% of households had been a victim of violence in the year preceding the study. Across sites, experience of violence within households ranged from 21% to 36%. Perceptions of drug abuse (p=0.01) and drug peddling (p=0.03) as being major problems in the neighbourhood, and living in a house of poor quality (p=0.01), were significantly associated with household experience of crime. In households with experience of violence, fear of crime (p=0.03) and depression (p<0.001) were elevated, and levels of exercise in men were decreased (p=0.05). This paper highlights the high prevalence of violence in impoverished urban areas in South Africa, and contributes to existing evidence regarding the associations between experience of violent crime and psychological ill health in affected communities. The high prevalence of violent crime, and the resultant health and social effects, demand a cross-sectoral intervention to reduce violence, with the health and social sectors playing key roles.