OP-ED: The Canary and the Coal Mine – The State of Public Health (Part 1)
In Part 1 of a two-part series, Harbingers of the State of our Nation, which analyses what recent health research reports tell us about our nation, we look at what they are saying about the state of public health. Right now, South Africa is being confronted by four worsening intersecting epidemics – maternal and infant mortality deaths; TB and HIV; non-communicable diseases such as strokes and obesity; and inter-personal violence.
In the early days of coal mining in Britain mine workers carried caged canaries into the mine shafts. Coal being carbon, gives off carbon monoxide (CO) and other gases on reacting with oxygen in the air. Carbon monoxide kills when it reaches a certain level of concentration. But the birds would die first of CO poisoning before human beings.
So the canaries were used as an early-warning system to test the quality of the air in coal mines. If they died then the mine workers should get out of the shafts immediately, otherwise they too would die. The deaths of the canaries were the harbingers of our own disaster if we did not react in time.
South Africa’s wealth was built on the back of mining and the cheap black labour that apartheid and segregation’s systems of forced migrant labour produced. Gold mining was the epicentre of that wealth. Coal mining was however at the centre of the generation of the energy needs of mining and the system of rail road transportation to take South Africa’s inland resources to the ports. So coal mining is part of our history.
But this is not a story of mining and its role in SA’s industrial and political history. This is a story of the canary in the cage. Today the canary giving us advance warning of a serious crisis if we do not respond appropriately, is the state of South Africa’s Health – both the social determinants of health and the state of healthcare.
We are aware that public commentary and policy is currently dominated by economic indicators such as unemployment, growth, investment and inflation. We would not contest that these are important …but they are at best proxies and, possibly, vehicles for human well-being. The state of the nation’s health, however, is a direct measure of our existence and frames whatever political and economic choices we may make. And yet current policies and economic orthodoxy are taking us in the opposite direction to that required to address what the reports are signalling.
The State of Public Health
Today, South Africa is being confronted by four worsening intersecting epidemics – maternal and infant mortality deaths; TB and HIV; non-communicable diseases such as strokes and obesity; and inter-personal violence.
In each of these categories South Africa’s statistics are amongst the highest per capita in the world. Mothers and new-born babies in South Africa die at 2 to 3 times more than the average for comparable countries and we have almost 1% of the global burden. We have the highest HIV (17% of the global burden) and TB deaths (5% of the global burden) in the world. Our non-communicable deaths are 2 to 3 times more than any than average for developing countries and we suffer 1.3% of the global burden of violence and injury deaths. The 10 highest killers in this country include TB and HIV, strokes, lower respiratory diseases such as pneumonia, non-communicable diseases like diarrhoea, and violence and injury deaths.
In the case of maternal, new-born and child health the increasing trend in maternal mortality was reversed in 2010 and Maternal Mortality Rate reached 152 per 100,000 live births in 2015. The under-five Mortality Rate has also declined from 80 per 1,000 live births in 2003 to 34 per 1,000 live births in 2016. But the persistent challenges of neonatal conditions, HIV/Aids, diarrhoeal disease and lower respiratory infections, such as pneumonia, have not been addressed.
Non-communicable diseases (such as strokes, diabetes and heart disease) as a group, now account for the highest number of deaths in South Africa. The leading risk factors for non-communicable diseases are – smoking and alcohol-use, the absence of physical activity and poor diet and the lack of primary healthcare.
While HIV/Aids and TB remain the leading cause of death, marked changes in mortality have been experienced with declines corresponding with the roll-out of ART and the earlier PMTCT intervention – 153,000 people died from the HIV/Aids in 2012 compared to 300,000 in 2006.
Interpersonal violence and road traffic injuries continue to account for considerable premature loss of life. We need Inter-sectoral actions which change norms in society and build social cohesion. While there was a 52% reduction in the death rate from interpersonal violence (murder) between 1997 and 2012, accompanying the political stabilisation in the country, and the Fire Arms Control Act of 2000, murder rates in South Africa remain much higher than the global average.
The World Health Organisation’s (WHO) Commission on Macroeconomics and Health reviewed the evidence on the relationship between poverty and health and highlighted the essential role of investing in health to promote development and reduce poverty. Its subsequent Commission on the Social Determinants of Health drew attention to the social determinants of health: including the social and economic environment, the physical environment and the access to basic services as the bedrock of health.
Collectively the epidemics of South Africa’s burden of disease are eminently solvable. They are not diseases requiring high-tech solutions and advanced interventions in medical science. They are diseases associated with poverty, poor living conditions, diet, poor quality water and sanitation.
The 2016 Demographics and Health Survey – which compares 1998 with 2016 – shows that fewer than one quarter of South Africa’s children receives the MINIMUM level of nutrition. It also highlights the persistence of stunted growth of children; 27% of our children under five exhibit stunted growth and 10% are severely stunted.
The Saving Babies Report shows that South Africa’s birth rate is declining, and that infant mortality is also declining, but that the Low Birth Weight Rates persist – 12.7% in 2014 and 13% in 2016. And that this has a significant provincial spread, with the Northern Cape - the poorest province and the one with the highest Low Birth Rates in the country.
This shows a picture of our children suffering from malnutrition and that that picture is persisting, not improving.
We cannot even begin to speak about the efficacy of early-learning initiatives and improving educational outcomes if our children do not have adequate levels of nutrition.
In response to the outcry and HIV/Aids deaths in the early 2000s and the campaigns of social movements South Africa eventually made ARTs available in the public health care system. Now we have the biggest distribution programme of ARVs in the world – although the latest study tells us that HIV death rates are no longer declining but levelling out – albeit with being the biggest contributor to a decrease in mortality levels after 2008. But South Africa’s TB deaths per capita are still the highest in the world and hard to statistically separate from HIV deaths.
And TB is a disease of over-crowding, poor air quality and compromised immunity systems. It is a disease of the poor majority. Although systems of early diagnosis exist and treatment is possible and effective the regime of drugs requires consistency and support difficult for poor people to sustain. So Multiple Drug Resistant (MDR) varieties now stalk our country.
Some of the above epidemics, like strokes and diabetes, require personal changes in the diet and exercise patterns of our people. We have the perverse contradiction that have we problems at both ends of the dietary spectrum – of malnutrition, on the one hand, and obesity on the other, which will require public campaigns to change behaviours.
Violence such as gender-based violence or intimate partner violence requires campaigns to change the patriarchal attitudes which pervade South Africa men and which the migrant labour system did so much to institutionalise.
These require mass public behavioural campaigns and the passion and drive of social movements to make these political issues of social justice.
But addressing the epidemics, above all, requires the political will on the part of government to provide potable water, sewerage, decent housing and public health care. They cannot be outsourced to markets, whose interest is private profit and not public good. We have seen in the Life Esidimeni case what happens when the state abrogates its responsibility to citizens with mental illnesses and outsources their care to private companies and NGOs. We have also seen how there was – particularly from the mainstream economists - a shift from warning about the “unaffordable costs” of the social grants to the fiscus in 2016 and 2017 to the growing acceptance that this was all that was standing in the way of a social and political crisis.
The information about malnutrition and Low Birth Weight is instructive in that we have adopted policies that take us in the opposite direction of addressing food insecurity. We have freed up agriculture to global market forces without installing a basic or staple food policy protection provision. So South Africa’s staple food – maize – in which we were once self-sufficient, is now traded globally and priced primarily in dollars on the Chicago Futures Exchange. We have become an importer paying in dollars for a commodity that is domestically grown.
We are aware that there is acute sensitivity within government and across the political spectrum and even within the research community as to what is the actual state of basic public service delivery in South Africa. Whatever the validity of these various reports and studies, it has to be acknowledged that there has been some improvement in the provision of basic services. But the appalling health statistics do not leave us with any other conclusion but to say that the political will to provide decent basic public services and treat the burden of disease as a national crisis, and respond accordingly, is lacking.
Within government this cannot be seen as a “line department” issue or one that shifts within the framework of tiers of government (national, provincial, local). The commitment needs inter-ministerial co-operation and Treasury prioritisation. DM
Glenda Gray is the President of the SAMRC, Debbie Bradshaw is the Director of the Burden of Disease Research Unit at the SAMRC and Leonard Gentle is a consultant in Research Translation at the SAMRC
About the SAMRC
The South African Medical Research Council (SAMRC) is the statutory body which conducts and funds research on the state of the nation’s health, collates reviews on clinical practices, investigates environmental and epidemiological threats to South Africa’s health and seeks interventions to improve health systems and practices.
The SAMRC publishes the definitive studies of the trends in mortality and the causes of death – the Rapid Mortality Surveillance and the National Burden of Disease Study. In addition, the SAMRC – in partnership with StatsSA and the National Department of Health (NdoH) – has conducted a large-scale survey of some 14,000 households to understand South African’s health practices and outcomes – called the South Africa Demographics and Health Survey. We also draw from the 2014-2016 Report on Perinatal Mortality in South Africa published by the National Perinatal and Morbidity Committee. The most recent of these studies – reflecting the state of the nation as of 2016 – have been published this year.
Together these reports convey alarming information that needs public reflection and government attention if we are to avoid disaster.