When it transpired that comorbidities constitute a risk factor for severe illness and death from Covid-19, the biggest concern was for the large proportion of the population living with HIV and tuberculosis. However, after a few months since the first case and a few thousands deaths later, noncommunicable diseases, diabetes in particular, is the leading risk factor for severe illness and death from Covid-19.
It is important to note that the pandemic has merely amplified an existing problem. Pre-Covid-19, NCDs accounted for the biggest proportion of deaths globally and, in South Africa, diabetes and cerebrovascular diseases, such as strokes, are in the top three leading causes of death.
What does the role of noncommunicable diseases in Covid-19 mean for NCD prevention efforts going forward? Will the increased understanding of the severity of NCDs translate to better prevention policies? The answer to this will depend on how the effects of Covid-19 are framed.
Best practices for NCD prevention include regulating harmful commodities such as alcohol, tobacco and ultra-processed foods. From a public-health perspective, it would make sense to expect that the increased understanding of the effects of noncommunicable diseases will increase the appetite for prevention policies.
However, we know that the existence of problems and evidence alone do not lead to adoption of policies. Policy agendas are influenced by the stakeholders involved and the strategies they use, including how they frame the problem. These factors, in turn, shape policy priorities.
The role of framing
Although there are many stakeholders involved in policies, it is often those stakeholders with some form of power that are able to influence policy agendas. Power can be in the form of economic resources, access to decision-makers or having the capacity to shape public discourse on issues. In this piece I am mainly focusing on the latter, specifically the role of framing.
By framing, I mean how different stakeholders shape what the problem is perceived to be and, therefore, which policy solutions are warranted. For example, in the food-policy space, the framing of obesity as a “lifestyle” or “individual problem” plays a role in whether the government institutes nutrition policies, such as taxes, that affect the entire population, or leaves eating healthy food to individual choice.
In the transition to a post-Covid-19 world, the framing of the effects of the coronavirus will likely play a role in shaping policy priorities. Given that Covid-19 is a public health crisis, it is logical to expect health to be the dominant frame that will shape post-Covid-19 policy agendas. This would mean a post-Covid-19 policy agenda that prioritises sustainable policy solutions for NCD prevention, including regulation.
However, there is also a perspective of the economic effects of Covid-19 on industries such as alcohol, tobacco and big food, all of which are commodities associated with risk factors for noncommunicable diseases. If the economic framing of the effects of Covid-19 is more dominant, policy priorities will more likely emphasise economic recovery, which — for the alcohol, food and tobacco industries — may be at the expense of public health.
These two frames are often at odds with each other: whenever a public-health policy has been introduced in South Africa — think tobacco and sugar tax — the effects of the policy on jobs has been used to counter it.
The discourse around the alcohol ban
The economic framing of the effects of Covid-19 is already evident in the public discourse in South Africa, especially through the framing of the Covid-19 alcohol ban. The discourse on the banning of alcohol during the Covid-19 lockdown has been dominated by the economic implications of these bans on the already ailing South African economy.
A typical example of the alcohol industry directly shaping the debate was the #savemylivelihood social-media campaign by the #savemylivelihood coalition. This campaign entailed sponsored social-media posts that shared personal and heartfelt stories about the negative effects of the alcohol ban on livelihoods and the economy. In addition, information about Heineken halting a R6-billion brewery and withdrawing from South Africa, was later proven to be misleading. These are only two examples of the many ways different stakeholders shape public debate and, thus, influence policies.
Although the economic concerns are valid, the harsh reality of the harm of alcohol must also be acknowledged. In South Africa, alcohol consumption is one of the highest risk factors for death and disability; alcohol not only increases the risk for noncommunicable diseases, but also death and injury, because of personal injury and road accidents. One in 10 South Africans die from alcohol-related diseases, and the country has the highest rate of alcohol-related road deaths in the world. Noncommunicable diseases and injury or trauma constitute two facets of South Africa’s quadruple burden of diseases, and both intersect with the care and management of the Covid-19 pandemic.
The alcohol ban was instituted during the Covid-19 lockdown to relieve the pressure of trauma cases on the health system and, judging by the decrease in deaths from unnatural causes, as well as the reduction in trauma cases, the ban was effective. Although, perhaps, it was extreme and not sustainable, the prohibition of alcohol sales was neither the first nor the last noncommunicable-diseases prevention policy we shall see.
A real-world experiment
Covid-19 has not only given us a real-world experiment of what reduced alcohol consumption would look like for the South African health system, but it has also highlighted the need for sustainable policy solutions to prevent noncommunicable diseases. Such policy solutions go beyond Covid-19: they would address problems that existed before — and will continue to exist after — the coronavirus pandemic.
With regards to alcohol, South Africa is in dire need of policies that reduce the supply and consumption of alcohol, such as regulating sales, and instituting warning labels and restrictions on alcohol advertising. But there is a very high likelihood that the same arguments about the negative effects of the lockdown regulations on the economy will be used to counter such policies, especially after the much-publicised effects of Covid-19 on businesses.
To counter this, public-health interest groups, civil society, and academics must continue to highlight the intersections between the alcohol, tobacco and big food industries, noncommunicable diseases and Covid-19, using the experience generated from the implementation of the tobacco and, most recently, the sugar tax.
Civil society organisations such as the Healthy Living Alliance and the Rural Health Advocacy Project are already taking the lead in keeping noncommunicable diseases at the forefront of the Covid-19 discourse in the food-policy space, but countering the already dominant economic framing of the effects of Covid-19 will require a stronger effort from more public-health stakeholders.