NCD burden is killing health system
As a South African-trained doctor who grew up in apartheid South Africa, most of my childhood was spent in the picturesque town of Brits in the North West province, a place of great natural beauty, divided by prejudice. But nonetheless a lovely place to grow up. attended what was then termed a ‘black’ school. It didn’t bother me that I couldn’t attend the cinema on the other side of town. I developed an affinity for the natural beauty of this land and all its people.
We played outside, ran freely in the veld. Our food was healthy sandwiches packed by our parents. Often we would share our spoils with those less privileged. Fruit was in abundance from farms nearby and cheaply available from vendors. We drank water from taps, often queuing up after a game of cricket or soccer to quench our thirst with this life-giving fluid. And we felt good.
Time and tide would lead to many adventures. But becoming a doctor was written in my destiny from a young age. It was a single-minded pursuit despite similar difficulties that students today experience.
After graduating in 2002, I had the privilege of working across this country, from Groote Schuur and Mowbray Maternity hospitals in Cape Town, to King Edward Hospital in Durban, Voortrekker District Hospital in Mokopane in Limpopo, clinics in Roedtan, Naboomspruit, Elim and Lebowakgomo to the great giant hospitals in Johannesburg – Charlotte Maxeke Johannesburg Academic Hospital, Chris Hani Baragwanath Hospital and Helen Joseph Hospital. Even a one-year stint in the United Kingdom was a great learning opportunity, but my heart remained at home here in South Africa and with its people.
Fast forward to 2017. The boy from Brits is now a consultant endocrinologist, associate lecturer (University of Witwatersrand), honorary consultant (Charlotte Maxeke Johannesburg Academic Hospital), executive committee member of the Society for Endocrinology Metabolism and Diabetes of South Africa (SEMDSA) and spokesperson for the Healthy Living Alliance (Heala).
Having spent many years treating the spectrum of non-communicable diseases (NCDs) and their complications throughout SA frustration mounted at what was initially a rewarding exercise. The prevalence of these diseases has become overwhelming. Our hospitals are too overburdened and under-resourced to cope. We faced full clinics and a lack of basic medicines such as insulin to treat patients. Inpatient mortality rates are high from the complications of diabetes and obesity.
The poor education and lack of understanding of many patients has made preventive measures difficult. Post-democracy has left a lot wanting in the health sector. Hospitals practically collapsed and with them patient care. Our medical interventions seemed to have little impact on the course of disease so I realised that prevention of these NCDs had to be pursued.
Junk food industry
In the world outside the hospitals, the soft drink and other junk food industries capitalised on the post-democratic landscape. Industry punted “economic growth” as the holy grail of success in post-democratic South Africa. What saddened me was the mass manipulation, through advertising, of a vulnerable population still reeling from the impact of apartheid.
Just as people are finding their feet post-apartheid, we are now faced with the burdens of diabetes, obesity, tooth decay and other fallout driven by the excessive consumption sugary products – all on the shoulders of epidemics of HIV and TB.
Large billboards appeared across the country, even as far as the rural village of Roedtan, advertising the “enjoyment” to be derived from drinking soft drinks. These areas always had shortages of basic medicine in their clinics, yet soft drinks were readily available and cheap. Prices of these products went down over time, while prices of the food grown in those areas went up.
As the palate of the locals changed towards the sweeter, more addictive soft drinks and junk food products, they abandoned local produce for the cheaper more ‘attractive’ options. A two-litre coke and a loaf of bread with chips suddenly became the norm.
If this was the situation in rural areas, then the cities have become hives of gluttonous consumption. Advertising of soft drinks in cities took on a whole new pattern with the rise of social media and easy access to television and other electronic media outlets. The association of soft drinks with wealth, fame, sexiness and ‘having arrived’ has become rampant.
How were the people to know that the instrument of their enjoyment was bound to contribute to disease and death later? How were they to know that every can of soft drink has, on average, 10 teaspoons of sugar? That this liquid energy doesn’t fill you but leaves you feeling hungrier? They didn’t know that it has the same effect on the brain as consuming cocaine or other drugs of addiction. They couldn’t know that this liquid sugar dumps calories into the body that gets converted to visceral fat in the liver and other organs.
They couldn’t know that this would lead to abnormal cholesterol, hypertension, inflammation and pancreatic stress, ultimately leading to diabetes, higher risk of cancer, dementia and heart disease and stroke amongst the many other complications.
It is a scientific fact that diabetes, obesity and overweight are driven largely by excessive consumption of sugar. Independent studies and evidence have proven this without any doubt. It has also been shown that any evidence to the contrary is due to industry sponsored biased research.
How much sugar?
So, how much of added sugar do we need? For the purpose of health, the optimum consumption is zero. As Dr Aseem Malhotra notes ‘added sugar has no biological requirement and is, therefore, not by any definition a “nutrient.” It is the fructose component (sucrose is 50% glucose and 50% fructose) that fulfils four criteria that justify its regulation: toxicity, unavoidability, the potential for abuse, and its negative impact on society.’
How much sugar is safe? The consumption of small amounts of free sugar, which includes all added sugar and sugar present in fruit juice, syrups and honey, on a daily basis, has a deleterious impact on the most common non-communicable disease globally: tooth decay. Treatment of dental disease is responsible for 5%-10% of health expenditures in industrialized countries. A nutrient is defined as a substance that maintains life and growth, these products do not fit those criteria.
We had arrived in what we thought to be a free country, but we were not free from ill health. It saddened me to see young students marching last year for free education while carrying sugary beverages. Some tweeted about achieving free degrees and earning money so they could take these products back to their homes, in rural South Africa, for their families to consume.
I remembered how my physical health helped me pursue my higher goals in life as a young student. As a teacher at Wits University, I see fatigued students consuming soft drinks to get through the day. It concerns me that these students, who are fighting for a higher ideal of free education, will end up fighting for their lives because they never saw the health complications coming.
The food landscape has changed. Acquisition and enjoyment has become the order of the day. Children no longer run freely. The farmer is no longer revered as an essential component of the health of the nation. And the soft drink industry is profiting immensely.
As a physician (and I speak for many), there is despondency about our approach to treating diseases that are totally preventable. The treatment of NCDs and their complications ultimately becomes a costly salvage operation.
At the microcosm, the rise of NCDs affects the poor most. It is the poor of this country that have to use the public health sector, which is already overburdened and stretched to capacity. Think of the poor farm worker in rural Roedtan, walking miles to a clinic that does not have insulin to treat his diabetes. Not an uncommon occurrence.
Disability from stroke, amputations
At the macro level, it impacts adversely on the economy. The cost of treating NCDs and complications has the potential to stunt a country’s economy – not to mention the dependency on state disability grants as a result of complications of NCDs, such as amputations and strokes.
The world today faces an epidemic of approximately 420 million people with diabetes. If you add to this the number of overweight and obese patients, this involves close to 2 billion people. The burden of disease caused by this large number of patients has reached catastrophic proportions. Even first world countries with large economic resources are failing to cope. The number of diabetics in SA is estimated at around three million people, but many are undiagnosed so the true number is much higher. We are rated as the most obese nation in Sub Saharan Africa.
Post-apartheid South Africa has continued to face many challenges on every level and the resilience of its people is beginning to wane through ill health. Young people pursue bright ideas in an unwritten future. But this is threatened by an enemy with a mask of a friend. It has been said that the greatest trick the devil ever pulled off is making the world believe it didn’t exist.
If a people are to change its destiny and create a revolution, the vehicle of that revolution – the human body – must be sustained in a healthy way. Health is the intrinsic nature of a human being. From the placenta and amniotic fluid of a mothers womb and all its nutrients, to the fresh air and breast milk outside, to the plants and animals that sacrifice of themselves to nourish us, nature has always been sustaining us, giving selflessly. Food is information we put into our bodies, and we must consider the long term impact of filling ourselves with the incorrect information from sugar sweetened beverages.
Animals eat for purpose – for survival and reproduction. It is rare, if not impossible, to find an overweight or underweight zebra in the wild, untouched ecosystems of this beautiful country. However, it is only the human being that has been endowed with the capacity for choice. We can eat for a purpose or we can eat for instant gratification. How we choose is dictated by our intellectual development, individually and collectively. For the human being, the eternal battle is against desire. Unfortunately this trait is being manipulated and capitalised on by the sugary drinks industry.
Some people are strong at choosing the correct path, and others are weak. There is no doubt that knowledge and intellect (the ability to reason, discriminate and display logic) help in making choices against desires that are to our detriment.
For those that are less capable of making the right choices, government must step up to assist. The implementation of the sugar tax is a step in this direction. It is policy that will not only help people change behavior, but can help change pathophysiology. It is a macrocosmic policy intervention that will have an impact on the microcosmic physiological level thus improving the health of individuals and the population at large.
Evidence from other countries has shown that the implementation of a sugar tax leads to behavior modification and reduced consumption of sugary beverages, resulting in a decline in obesity and diabetes rates.
Success of tobacco decline
The substantial decline in tobacco consumption over the past two decades – the single most important factor driving a decrease in cardiovascular mortality during that period – only happened after legislative measures that targeted the affordability, availability, and acceptability of smoking.
Revenue generated should be put back into the health care sector to fund poorly resourced hospitals and public health interventions such as education campaigns aimed at prevention of NCDs. With behavior changes enforced by policy and provision of correct information on the adverse impact of sugary drinks, South Africans can work to find their footing again in this turbulent landscape. With better health, we can pursue our individual and collective goals, ensuring our country’s prosperity.
*This is an edited version of Sundeep Ruder’s submission to Parliament in support of the tax on sugary beverage.
An edited version of this story was also published by Daily Maverick