Current policies to confront South Africa’s health crisis must address key Social Determinants of Health

SaSa

A WHO Collaborating Centre for Research and Training in Human Resources for Health

David Sanders Emeritus Professor

School of Public Health University of the Western Cape

Member of Global Steering Council Peoples Health Movement

Outline of Presentation

The significance of nutritional status in South Africa’s health situation

The role and extent of undernutrition and ‘overnutrition’ in health and disease

Prevalence, trends and determinants of undernutrition and hunger

Prevalence trends and determinants of overweight/obesity

Dietary factors in overweight/obesity food sytems and their structural determinants

Possible interventions to address the ‘double burden’ of malnutrition

CHILD HEALTH STATUS IN SOUTH AFRICA

MDG4: SA progress

http://www.thepresidency.gov.za/learning/me/indicators/2009/indicators.pdf

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MRC

ASSA 2002

ASSA 2003

HST

U-5MR projections from various sources

Goal for U-5MR: 20 by 2015

Department of Health (2012)

Causes of under-five deaths in South Africa

• Neonatal causes; pneumonia, diarrhoea and other child illness; and HIV/AIDS each account for 30% of U5 deaths

• According to Child PIP 60% of children were underweight and a third were severely malnourished

Based on SA Burden of Disease estimates for 2000

Lancet Vol 371 April 12, 2008, 1294-1304

Children under 5: Nutritional Status

• Overall, 12 percent of children are underweight, 27 percent are stunted and 5 percent are wasted (DHS 2003).

• NFCS (2005) showed 18% stunting

• There are no indications that the nutritional status of children has changed substantially over the past 10 years.

Benefits of Breast Feeding

•Exclusive breastfeeding (ie giving nothing but breastmilk to the infant) reduces under-five mortality by 13 percent (Jones et al., 2003).

Breast Feeding in South Africa

Duration of Breastfeeding

• Prevalence of exclusive breastfeeding is low in South Africa and there has been little change since the previous survey.

• Addition of other liquids whilst breastfeeding starts very early in South Africa.

• Only 8 percent of infants under 6 months are exclusively breastfed and a further 19 percent are almost exclusively breastfed with the addition of water only. DHS 2003

Nutrition and Dietary Intake

The National Food Consumption Survey (2005) showed:

• 1 in 3 women and children are anaemic

• 1 in 3 children and 1 in 4 women have Vit A deficiency

• 45% of children are Zinc deficient

Imagine a stroll by the river …

You notice a movement in the water, it is a baby, drowning!

… then another infant, half-submerged, floats down in the water struggling for life

… followed by 5, 10 more -- and more and more and more

You become very good at saving drowning children, develop new methods & technology, teach others, attend international conferences

but more and more and more and more come struggling down …

Photo: L Reynolds

Structural Societal

Behavioural Biological

Burden of Disease study, PGWC

DOWNSTREAM UPSTREAM

The example of diarrhoea and environmental factors in South Africa

Trends in diarrhoea deaths

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East Khay Klipf M/Plain North South Tyger West

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num

bers

of

child

death

s

Numbers increasing, but fewer die

Source: Tony Westwood

Diarrhoea in Cape Town

Numbers increasing, but fewer dehydrated

Source: Tony Westwood

SOCIAL DETERMINANTS

Good paediatrics & health system

performance is not enough

Selective PHC:

Access to good health care

Dealing with the causes?

✓

✗

These (& the causes of the causes)

lie outside the domain of the DoH …

and the dominant 'narrow' paediatric

vision of child health

Dimension of deprivation Poorest

20%

Richest

20%

Income povertya 100% 0%

Food insecurity a 28% 3%

Inadequate water a 54% 9%

Inadequate sanitation a 47% 9%

Overcrowding a 28% 5%

Educational attrition a 46% 17%

Travel far to clinic a 46% 25%

Infant mortality b 22% 87%

• a Statistics South Africa (2011) General Household Survey 2010. Analysis

by Katharine Hall, Children’s Institute, UCT

• b Department of Health (publication date?) Demographic & Health

Survey 1998 (analysis by Debbie Bradshaw)

Child poverty in South Africa remains extremely high. In 2010, six out of every 10 children lived in households with an income of less than R575 per person per month. Stark racial disparities persist, with 67% of African children living in poor households compared to only 4% of White children

Statistics South Africa (2011) General Household Survey 2010

Wealth in SA: Income

share by decile

Leibbrandt, Finn & Woolard (2012).

http://dx.doi.org/10.1080/0376835X.2012.645639

5 6 1 4 7 3 2 8 9 10

40

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30

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60

0

1993

2008

% share

of income

Non-communicable Diseases, overweight and obesity in South Africa

South Africa’s Double Burden of Malnutrition

NFCS, 1999; NFCS, 2005; SANHANES, 2012

Double Burden

Effects and Determinants of ‘Overnutrition’ in South Africa

Structural Societal

Behavioural Biological

Burden of Disease study, PGWC

DOWNSTREAM UPSTREAM

Overweight and chronic disease in rural S Africa In a 2005 study of a rural black population from Limpopo Province, South Africa: 51% of women were overweight or obese

Diabetes diagnosed in 8.8% of women and 8.5% of men

Hypertension was found in 25.5% of women and 21.6% of men Source: Alberts, M, P Urdal, and K Steyn. "Prevalence of

cardiovascular diseases and associated risk factors in a rural black population of South Africa." European Journal of Cardiovascular Prevention and Rehabilitation 12.4 (2005): 347-354.

Figure 2. Diabetes prevalence based on 1985 WHO criteria presented by age categories for men

and women in 1990 and 2008/09.

Peer N, Steyn K, Lombard C, Lambert EV, et al. (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans.

PLoS ONE 7(9): e43336. doi:10.1371/journal.pone.0043336

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043336

Consumption of sweet beverages and confectionery

Compared with a worldwide average of 89 in 2010

South Africans consumed 254 Coca-Cola

products per person per year, an increase from

around 130 in 1992 and 175 in 1997.

In 2010, up to half of young people were reported to

consume fast foods, cakes and biscuits, cold drinks,

and sweets at least four days a week.

Carbonated drinks are now the third most commonly

consumed food/drink item among very young urban

South African children (aged 12–24 months)—less

than maize meal and brewed tea, but more than

milk . Hawkes C. (2002), Coca-Cola Company (2010)

Theron et al (2007), Reddy et al. (2010)

• There is a shortage of healthy

low-fat food and little fresh fruit

and vegetables in the

townships.

• ‘Low-fat milk is not available in

our shops’, stated one of the

CHWs after she had tried to

cut down on the fat in her diet.

• ‘I am scared of exercising

because I will lose weight and

people may think that I have

HIV/AIDS.’

Chopra M, Puoane T. Diabetes Voice 2003; 48: 24–6.

Societal Factors in Obesity

Structural Factors in Obesity

Market Sizes - Historic - Retail Value RSP - R mn - Current Prices

Category 2004 2005 2006 2007 2008 2009

Packaged food 69475 74462 78929 84062 92671 101192

Source: Packaged Food: Euromonitor from trade sources/national statistics Source: Packaged Food: Euromonitor from trade sources/national statistics

Packaged Food Sales in South Africa

The largest ten packaged food companies account for 51.8% of total packaged food sales.

This is greater than the global average (globally in 2007, ten companies accounted for around 26%

of the processed foods market).

Euromonitor International, ETC Group (2008)

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Value of imports from world in Rand

Bread, Pastry, Cakes, Biscuits and Other Baker's Wares

Rapid growth of supermarkets in South Africa

• Supermarkets now share at least 50-60% of food sales in South Africa, with the majority of this growth occurring after 1994

• In a recent study, nearly two-thirds of households in a rural area in South Africa were now buying their food at supermarkets

Number of households in two rural areas in Transkei, Eastern Cape going to supermarkets

Xume Luzie Total

Percent of total

78.4% 50.0% 64.8%

Source: D'Haese, Marijke, and Guido Van Huylenbroeck. "The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area, South Africa." Food Policy 30 (2005): 97-113.

0%

10%

20%

30%

40%

Japan U.S. South Africa

Percent increase:

1999- 2005

Source: Euromonitor International, 2007

Growth in Supermarket Food Sales

Expansion of Supermarkets in Cape Town

Battersby, AFSUN

The consequences…

• Rural consumers pay almost R6 more than urban consumers for the same food basket. The poor households spent 33% of their income on food, compared to 11% for the non-poor

• Healthier foods typically cost between 10% and 60%

more when compared on a weight basis (R per 100g) and between 30% and 110% more when compared based on the cost of food energy (R per 100 kJ)

• Children from the most food insecure households are

most at risk of under-nutrition whilst adult women in the same households are often most at risk of obesity (NFCS 1999, 2005; SANHANES 2012)

Total imports of soft drinks and processed snack foods into South Africa and other SADC countries

Source: FAOSTAT detailed trade data

Structural Determinants of ‘Overnutrition’ Regionally and

Globally

Regional trade and investment policies in SADC since 1990

• early 1990s: ongoing liberalization associated with multilateral trade negotiations

• 1996: SADC trade agreement signed

• 1997-2003: South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements

• 1999: South Africa signs bilateral agreement with European Union (EU)

• 2000: SADC trade protocol comes into effect; Government of South Africa strengthens support for regional export and investment

• 2002: new Southern Africa Customs Union Agreement completed

• 2007: Interim Economic Partnership Agreement concluded between EU and Botswana, Lesotho, Namibia, Swaziland and Mozambique

• 2008: SADC Free Trade Area completed (except for Angola, Democratic Republic of the Congo, Seychelles)

Liberalisation and growth of TNCs

• Growth of FDI in food industry –bilateral investment treaties increased from 181 to 2495 between 1980 and 2005 (UNCTAD 2000, 2006)

• TNCs now control seeds, fertilisers, pesticides, production, processing, manufacturing and selling of foods

• In 1980s TNCs expanded into manufacture of processed foods eg snacks, soft drinks, dairy

FDI and supermarkets

• From 1990 FDI penetrated supermarkets : FDI from US-based supermarkets increased from $4bn to $13bn between 1990 and 1999

• In LA supermarkets increased share of retail market from 10-20% in 1990 to 50-60% in 2000

• Between 1990 and 2001 foreign sales of world’s largest 100 TNCs increased from $88.8bn to $257.7 bn

From a Nestlé press release:

Vevey, February 21, 2008 “Popularly positioned products (PPPs). Products aimed at lower income consumers in the developing world, will continue to grow strongly in 2008 and beyond. Nestlé PPPs, which mostly consist of dairy products, Nescafé and Maggi culinary products, grew by over 25% to reach around CHF 6 billion in sales in 2007. The overall market for such products in Asia, Africa and Latin America is estimated at over CHF 80 billion.”

“Transnational corporations .have flourished as trade liberalization has

broadened and deepened. The revenues of Wal-Mart, BP, Exxon

Mobil, and Royal Dutch/Shell Group all rank above the GDP of countries such as Indonesia, Norway, Saudi

Arabia, and South Africa (EMCONET, 2007).

The combination of binding trade agreements .. and increasing

corporate power and capital mobility have arguably diminished individual countries’ capacities to ensure that

economic activity contributes to health equity, or at least does not

undermine it”.

Olivier de Schutter UN Special Rapporteur on the Right to Food

March 2012

Felicity Lawrence, The Guardian, 9 March 2012

“… trade policy that actively

encourages the unfettered

production, trade, and

consumption of foods high in

fats and sugars to the

detriment of fruit and vegetable

production is contradictory to

health policy …” (p 10)

It is important therefore that

ministers of health, supported

by the ministry, are strongly

equipped to play such a

stewardship role within

government”(p 111)

SUMMARY

In South Africa, as in other jurisdictions, ‘‘Big Food’’ (large commercial entities that dominate the food and beverage environment) is becoming more widespread and is implicated in unhealthy eating.

Big Food in South Africa involves South African companies, some of which have invested in other (mainly, but not only, African) nations, as well as companies headquartered in North America and Europe.

SUMMARY

These companies have developed strategies to increase the availability, affordability, and acceptability of their foods in South Africa; they have also developed a range of ‘‘health and wellness’’ initiatives. Whether these initiatives have had a net positive or net negative impact is not clear.

The South African government should act urgently to mitigate the adverse health effects in the food environment in South Africa through education about the health risks of unhealthy diets, regulation of Big Food, and support for healthy foods.

Policy Interventions to Combat ’Overnutrition’

• Raise awareness of deteriorating food environment amongst health workers and general population

•Review local government policies and regulations around vending eg in and around schools and advertising, especially to kids.

• Invest in school and community infrastructure for sport and recreation and improved personal safety

•Analyse pricing incentives/disincentives to tax unhealthy and subsidise healthy foods

•Review trade policy, especially wrt food trade

• Challenge inequitable national and global macroeconomic regime through evidence-based advocacy and social mobilisation