Prevention matters for a healthier SA

Last month’s United Nations session on non-communicable diseases (NCDs) has finally alerted the world to the threat posed to social and economic development by four major NCDs: cancer, heart disease, diabetes and chronic lung disease.

Not only do the costs of managing these so-called lifestyle conditions (because they are a result of lifestyle) disproportionally affect household savings for individuals, but they also impact the next generation, which undermines income security.

The intergenerational impact of NCDs is most pronounced for families in low and middle income countries like South Africa. The potential future costs are daunting and without serious attention are set to balloon. While strong health systems will be critical to ward off this growing epidemic, fortifying the health care infrastructure will take several years.

We cannot afford to wait to address an epidemic that is as serious as HIV/AIDS. We must start by focusing on prevention efforts that target actors outside the healthcare system. Some NCDs are caused by invisible viruses that lead to liver and cervical cancer, but many are visible in our daily lives.

The vectors of this epidemic can be purchased in the supermarket, the local fast food outlet and the school cafeteria. For example, two-thirds of households in rural SA now buy their food from supermarkets, where access to cheap nutritious food remains a challenge.

Therefore, even as people have access to a wider variety of foods, their choices are limited to highly processed products, which carry the very ingredients that cause non-communicable diseases. Other risk factors for conditions like diabetes, cancer, heart disease and chronic lung disease include poor diet, lack of physical activity, smoking and the harmful use of alcohol.

Preying on the poor
Still, the most important risk factor is poverty. For most poor people, cheap, nutritious foods and safe areas to exercise, walk, bike or play are in short supply. Recreational centres and swimming pools are off the radar entirely. While heart disease is often thought of as a disease of the wealthy, in South Africa stroke resulting from hypertension is more strongly linked to poverty.

This is largely because many people living in rural and informal urban areas remain undiagnosed and untreated. Sadly, the risk of stroke for an untreated hypertensive patient is triple that of someone who is on the necessary medications.

In a country where roughly half of all individuals are living below the poverty line, the impact of these diseases is particularly pronounced. Close to 25% of all schoolchildren in SA are now overweight. Many of them are poor and the majority of them are female — despite persisting under-nutrition in some communities.

In the next 20 years, deaths from heart disease alone are projected to increase by 40%. In the Western Cape, there are three to four amputations a week from preventable diabetes complications. These numbers are made worse by the fact that many patients die prematurely without ever knowing they were suffering from one of these silent killers.

In South Africa, 35% of these deaths occur before the age of 60. The economic toll of this epidemic on the healthcare system and on families is already tremendous.

Creative approaches
We need urgent solutions for South Africa to reach its stated life expectancy goals of 58 years for men and 60 for women by 2015. At a time when there are competing pressures for scarce healthcare resources, we need to focus on finding creative approaches that provide good value for money.

At the same time that government officials are improving primary care to better treat non-communicable diseases, we must invest resources into preventing these conditions in the first place. While the healthcare system itself is important to fighting these diseases, there are a number of reasons to look beyond the traditional tools of hospital, doctors and nurses.

First, building fully functioning and efficient health systems will take time. Second, interventions outside the healthcare infrastructure allow policy makers to engage in large-scale prevention measures for a relatively small amount of money. For example, the WHO puts the price tag for NCD population-based measures for upper middle income countries like South Africa at approximately R150-million per year.

This is a mere fraction of the estimated annual R1 125-billion for individually targeted interventions. (Population-based measures are typically instituted outside the health care system and target groups of people, while individual-based measures are typically delivered in primary health care settings and target a single patient). With a raging HIV/ TB epidemic and high rates of child and maternal mortality, policymakers face tough choices in terms of how to invest scarce resources.

Thinking beyond the health system itself, our prevention efforts must focus on the nexus between NCDss and agriculture, education the workplace and the political arena. A number of countries have already begun to do just that. Successful policies to tackle population-wide prevention include bans on food adverts that target children and instituting nutritious school food policies.

In the UK and Australia, industry is spearheading an effort to gradually reduce salt in processed foods. In 2011 Denmark imposed a “fat tax” on fatty foods in an effort to convince Danes to eat more healthily. The tax is structured so that rates correspond with the percentage of fat in a product. Brazil’s “Zero Hunger” programme features subsidised produce markets and state-sponsored low-cost restaurants.

Progress?
South African policy makers have developed a number of promising strategies along these lines, especially- with regard to tobacco control. Over the past two decades, legislation which raised tobacco taxes and banned indoor smoking led to a significant drop in smoking and concomitant reductions in illness and premature death.
Unfortunately, tax rates are not keeping pace with market demand and a shocking 25% of 15-25 year olds are now smokers. There is still much more to be done.

Food industry chiefs need to explore ways to engage with the government and to deliver products to stem the tide of non-communicable diseases. This may not be so simple. For example, a move by the French government to impose a tax on soft drinks has met with resistance from the beverage industry.

In the packaged food industry, because the top 10 food companies only account for 15% of sales, corporate leaders may need to build a coalition of multi-nationals and smaller enterprises to produce healthier products. We must also engage teachers and principals in the fight against NCDs in schools. This means doing more than just providing healthy options in the cafeteria.

Educators need to create a curriculum that produces a generation that understands nutrition. Bosses and managers across all sectors can promote healthy habits through the workplace. They must provide healthy food choices in canteens and breaks to encourage physical activity.

Studies suggest that putting in place innovative health policies like these boost morale and improve the reputation of the business. Executives should also establish facilities for working mothers to express breast milk. This would go a long way to improving outcomes for the next generation. Research shows that breast-fed children are much less likely than their formula-fed counterparts to grow into obese adults.

Engage on all levels
Finally, policy makers need to fully engage in this crisis. They need to build governance structures that allow multi-sectoral engagements to occur. For example, the national planning commission could ensure that all relevant ministries — from sports and recreation to trade and industry — coordinate around needed prevention interventions.

Equally important, policy makers will need evidence on which to launch their policies. While global and regional research on best buys in the fight against NCDs provides some guidance, we need data specific to South Africa. Not all prevention is cost effective or effective; we need to build a context-specific evidence base for prevention interventions.

These must be informed by local realities and drivers that include demographic changes, the rising demand for food and competing economic developments in the region. Effective prevention of obesity, for example, may need to account for post-apartheid internal migratory patterns or the impact of food products that are sold in the informal sector.

As health minister Aaron Motsoaledi has noted, we face tough choices and tackling NCDs cannot be done by the health sector alone. Just as the causes of these diseases are found in our supermarkets, our cafeterias and our kitchens — indeed, in all sectors of society so too are the solutions. While we cannot forget the role of the health sector, we must also look beyond to identify efficient approaches.

By focusing on prevention and non-health sector interventions that target lifestyle conditions, South Africa can achieve good bang for its buck. While these diseases may be non-communicable, by joining forces to address them, the solutions can be contagious.

Karen Hofman and Stephen Tollman are based at Wits University’s School of Public Health and lead an initiative on priority cost-effective lessons for systems strengthening. Contact [email protected]

What is a best buy?
A best buy can be defined in two ways:

If you had a million rand for health what would be the best way to spend it? How many lives could be saved?

Identifying low cost effective interventions to prevent death and disability, strategically planning how and where to invest scarce health care resources

Note: A best buy can be in the health system and focused on the individual or may be population-based and outside the health system

HIV Best Buys: Copenhagen Consensus Center — September 2011

Safer blood supplies cheapest and most cost-effective intervention

Mass infant circumcision

Preventing mother to child transmission

More investment in vaccine research

Maximising treatment coverage for people with low CD4 counts

Note: Over the next five years, neither treatment nor prevention alone will have sufficient impact on new infections.
Best Buys for tackling diet, physical activity and obesity ( Lancet — Cecchini et al 2010)