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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
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
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
0
5
10
15
20
25
30
35
40
45
East Khay Klipf M/Plain North South Tyger West
08/09 09/10 10/11 11/12 12/13
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
50
20
30
10
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)
0
50000000
100000000
150000000
200000000
250000000
300000000
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
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