Debbie Bradshaw

The burden of non-communicable diseases in South Africa

15 years after its first democratic election, South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders. Non-communicable diseases are emerging in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Major factors include demographic change leading to a rise in the proportion of people older than 60 years, despite the negative effect of HIV/AIDS on life expectancy. The burden of these diseases will probably increase as the roll-out of antiretroviral therapy takes effect and reduces mortality from HIV/AIDS. The scale of the challenge posed by the combined and growing burden of HIV/AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-effectiveness in the primary and secondary prevention of such diseases within populations and health services. We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess, and implement integrated care interventions for chronic infectious and non-communicable diseases.

Initial burden of disease estimates for South Africa, 2000

BACKGROUND This paper describes the first national burden of disease study for South Africa. The main focus is the burden due to premature mortality, i.e. years of life lost (YLLs). In addition, estimates of the burden contributed by morbidity, i.e. the years lived with disability (YLDs), are obtained to calculate disability-adjusted life years (DALYs); and the impact of AIDS on premature mortality in the year 2010 is assessed. METHOD Owing to the rapid mortality transition and the lack of timely data, a modelling approach has been adopted. The total mortality for the year 2000 is estimated using a demographic and AIDS model. The non-AIDS cause-of-death profile is estimated using three sources of data: Statistics South Africa, the National Department of Home Affairs, and the National Injury Mortality Surveillance System. A ratio method is used to estimate the YLDs from the YLL estimates. RESULTS The top single cause of mortality burden was HIV/AIDS followed by homicide, tuberculosis, road traffic accidents and diarrhoea. HIV/AIDS accounted for 38% of total YLLs, which is proportionately higher for females (47%) than for males (33%). Pre-transitional diseases, usually associated with poverty and underdevelopment, accounted for 25%, non-communicable diseases 21% and injuries 16% of YLLs. The DALY estimates highlight the fact that mortality alone underestimates the burden of disease, especially with regard to unintentional injuries, respiratory disease, and nervous system, mental and sense organ disorders. The impact of HIV/AIDS is expected to more than double the burden of premature mortality by the year 2010. CONCLUSION This study has drawn together data from a range of sources to develop coherent estimates of premature mortality by cause. South Africa is experiencing a quadruple burden of disease comprising the pre-transitional diseases, the emerging chronic diseases, injuries, and HIV/AIDS. Unless interventions that reduce morbidity and delay morbidity become widely available, the burden due to HIV/AIDS can be expected to grow very rapidly in the next few years. An improved base of information is needed to assess the morbidity impact more accurately.

Health in South Africa: changes and challenges since 2009

Since the 2009 Lancet Health in South Africa Series, important changes have occurred in the country, resulting in an increase in life expectancy to 60 years. Historical injustices together with the disastrous health policies of the previous administration are being transformed. The change in leadership of the Ministry of Health has been key, but new momentum is inhibited by stasis within the health management bureaucracy. Specific policy and programme changes are evident for all four of the so-called colliding epidemics: HIV and tuberculosis; chronic illness and mental health; injury and violence; and maternal, neonatal, and child health. South Africa now has the worlds largest programme of antiretroviral therapy, and some advances have been made in implementation of new tuberculosis diagnostics and treatment scale-up and integration. HIV prevention has received increased attention. Child mortality has benefited from progress in addressing HIV. However, more attention to postnatal feeding support is needed. Many risk factors for non-communicable diseases have increased substantially during the past two decades, but an ambitious government policy to address lifestyle risks such as consumption of salt and alcohol provide real potential for change. Although mortality due to injuries seems to be decreasing, high levels of interpersonal violence and accidents persist. An integrated strategic framework for prevention of injury and violence is in progress but its successful implementation will need high-level commitment, support for evidence-led prevention interventions, investment in surveillance systems and research, and improved human-resources and management capacities. A radical system of national health insurance and re-engineering of primary health care will be phased in for 14 years to enable universal, equitable, and affordable health-care coverage. Finally, national consensus has been reached about seven priorities for health research with a commitment to increase the health research budget to 2·0% of national health spending. However, large racial differentials exist in social determinants of health, especially housing and sanitation for the poor and inequity between the sexes, although progress has been made in access to basic education, electricity, piped water, and social protection. Integration of the private and public sectors and of services for HIV, tuberculosis, and non-communicable diseases needs to improve, as do surveillance and information systems. Additionally, successful interventions need to be delivered widely. Transformation of the health system into a national institution that is based on equity and merit and is built on an effective human-resources system could still place South Africa on track to achieve Millennium Development Goals 4, 5, and 6 and would enhance the lives of its citizens.All the authorsKarim QA, Karim SS, Barron P, Bradshaw D, Chopra M, Churchyard GJ, Coovadia HM, Jewkes R, Lalloo UG, Lawn JE, Lawn SD, Mayosi BM, Pattinson R, Seedat M, Sitas F, Suffla S, Tollman SM, Van Niekerk A.

Achieving the health Millennium Development Goals for South Africa: challenges and priorities

15 years after liberation from apartheid, South Africans are facing new challenges for which the highest calibre of leadership, vision, and commitment is needed. The effect of the unprecedented HIV/AIDS epidemic has been immense. Substantial increases in mortality and morbidity are threatening to overwhelm the health system and undermine the potential of South Africa to attain the Millennium Development Goals (MDGs). However The Lancets Series on South Africa has identified several examples of leadership and innovation that point towards a different future scenario. We discuss the type of vision, leadership, and priority actions needed to achieve such a change. We still have time to change the health trajectory of the country, and even meet the MDGs. The South African Government, installed in April, 2009, has the mandate and potential to address the public health emergencies facing the country--will they do so or will another opportunity and many more lives be lost?

Rape of girls in South Africa

Child rape violates human rights and causes immediate and long-term health problems for the child. In the 1998 South Africa Demographic and Health Survey, we assessed frequency of rape in a nationally representative study of 11735 women aged 15-49 years. 153 (1.6%, 95% CI 1.2-1.9%) of these women had been raped (forced or persuaded to have sex against their will) before the age of 15 years. Our results show that younger women were significantly more likely to report rape than older women (p<0.0001). The largest group of perpetrators (33%) were school teachers. Our findings suggest that child rape is becoming more common, and lend support to qualitative research of sexual harassment of female students in schools in Africa.

Tobacco attributable deaths in South Africa

Background: In mid 1998, a question “Was the deceased a smoker five years ago?” was introduced on the newly revised South African death notification form. Design: A total of 16 230 new death notification forms from 1998 have been coded, and comparison of the prevalence of smoking among those who died of different causes was used to estimate, by case–control comparisons, tobacco attributed mortality in South Africa. Cases comprised deaths from causes known (from other studies) to be causally associated with smoking, and controls comprised deaths from medical conditions expected to be unrelated to smoking. Those who died from external causes, and from diseases strongly related to alcohol consumption, were excluded. Subjects: Reports were available from 5340 deceased adults (age 25+), whose smoking status was given by a family member. Results: Significantly increased risks were found for deaths from tuberculosis (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23 to 2.11), chronic obstructive pulmonary disease (COPD) (OR 2.5, 95% CI 1.9 to 3.4), lung cancer (OR 4.8, 95% CI 2.9 to 8.0), other upper aerodigestive cancer (OR 3.0, 95% CI 1.9 to 4.9) and ischaemic heart disease (OR 1.7, 95% CI 1.2 to 2.3). Conclusion: If smokers had the same death rate as non-smokers, 58% of lung cancer deaths, 37% of COPD deaths, 20% of tuberculosis deaths, and 23% of vascular deaths would have been avoided. About 8% of all adult deaths in South Africa (more than 20 000 deaths a year) were caused by smoking.

A comparative risk assessment for South Africa in 2000: Towards promoting health and preventing disease

2on the basis of additional data to estimate the disability-adjusted life years (DALYs) for single causes for the first time in South Africa. DALYs are a comprehensive measure of the disease burden combining the years of life lost (YLLs) as a result of premature mortality and years lived with disability (YLDs) related to illness or injury. 3 Compared with the use of mortality as a measure of disease burden, DALYs also capture the contributions of conditions that do not result in large numbers of deaths. For example, mental health disorders have a large disability component relative to the number of deaths. The SA NBD study highlighted the fact that despite levels of uncertainty there is important information to guide public health responses to improve the health of the nation.

Estimating the burden of disease attributable to diabetes in South Africa in 2000

Objectives. To estimate the burden of disease attributable to diabetes by sex and age group in South Africa in 2000. Design. The framework adopted for the most recent World Health Organization comparative risk assessment (CRA) methodology was followed. Small community studies used to derive the prevalence of diabetes by population group were weighted proportionately for a national estimate. Population-attributable fractions were calculated and applied to revised burden of disease estimates. Monte Carlo simulation-modelling techniques were used for uncertainty analysis. Setting. South Africa. Subjects. Adults 30 years and older. Outcome measures. Mortality and disability-adjusted life years (DALYs) for ischaemic heart disease (IHD), stroke, hypertensive disease and renal failure. Results. Of South Africans aged ≥ 30 years, 5.5% had diabetes which increased with age. Overall, about 14% of IHD, 10% of stroke, 12% of hypertensive disease and 12% of renal disease burden in adult males and females (30+ years) were attributable to diabetes. Diabetes was estimated to have caused 22 412 (95% uncertainty interval 20 755–24 872) or 4.3% (95% uncertainty interval 4.0–4.8%) of all deaths in South Africa in 2000. Since most of these occurred in middle or old age, the loss of healthy life years comprises a smaller proportion of the total 258 028 DALYs (95% uncertainty interval 236 856–290 849) in South Africa in 2000, accounting for 1.6% (95% uncertainty interval 1.5–1.8%) of the total burden. Conclusions. Diabetes is an important direct and indirect cause of burden in South Africa. Primary prevention of the disease through multi-level interventions and improved management at primary health care level are needed.

Estimating the burden of disease attributable to smoking in South Africa in 2000

OBJECTIVES To quantify the burden of disease attributable to smoking in South Africa for 2000. DESIGN The absolute difference between observed lung cancer death rate and the level in non-smokers, adjusted for occupational and indoor exposure to lung carcinogens, was used to estimate the proportion of lung cancer deaths attributable to smoking and the smoking impact ratio (SIR). The SIR was substituted for smoking prevalence in the attributable fraction formula for chronic obstructive pulmonary disease (COPD) and cancers to allow for the long lag between exposure and outcome. Assuming a shorter lag between exposure and disease, the current prevalence of smoking was used to estimate the population-attributable fractions (PAF) for the other outcomes. Relative risks (RR) from the American Cancer Society cancer prevention study (CPS-II) were used to calculate PAF. SETTING South Africa. OUTCOME MEASURES Deaths and disability-adjusted life years (DALYs) due to lung and other cancers, COPD, cardiovascular conditions, respiratory tuberculosis, and other respiratory and medical conditions. RESULTS Smoking caused between 41,632 and 46,656 deaths in South Africa, accounting for 8.0 - 9.0% of deaths and 3.7 - 4.3% of DALYs in 2000. Smoking ranked third (after unsafe sex/ sexually transmitted disease and high blood pressure) in terms of mortality among 17 risk factors evaluated. Three times as many males as females died from smoking. Lung cancer had the largest attributable fraction due to smoking. However, cardiovascular diseases accounted for the largest proportion of deaths attributed to smoking. CONCLUSION Cigarette smoking accounts for a large burden of preventable disease in South Africa. While the government has taken bold legislative action to discourage tobacco use since 1994, it still remains a major public health priority.

Setting priorities in child health research investments for South Africa

Nearly 100,000 children under 5 years die annually in South Africa. This paper defines health research priorities to address this unacceptably high mortality rate.