Despite 18 years of democracy, inequalities in gender, race, income and geographical location still remain the key markers of poor health in South Africa according to the 2012/2013 South African Health Review released on 2 April 2013.
The Review contains commentary from a range of experts on topics such as the social determinants of health, non-communicable diseases, climate change and occupational health. It further states that overcoming these increasing inequities between the rich and the poor is necessary in order to reduce the country’s quadruple burden of disease and transform the public and private healthcare landscapes.
South Africa is currently in the grips of 4 simultaneous epidemics referred to as the country’s ‘quadruple burden of disease’. This includes HIV and AIDS, diseases relating to poverty and under-development, chronic diseases, injuries and interpersonal violence.
The Review’s findings come amid a burgeoning volume of recent research which shows a direct correlation between social inequalities and poor health. Although there has been overall growth in the economy since 1994, South Africa still has one of the highest income inequalities in the world, with a Gini coefficient (the measure of inequality within a country) that has remained at 63.1.“Despite increased provision of social grants, extreme wealth inequalities and high unemployment likely play an important role in poor health outcomes” says Debbie Bradshaw, director of the Burden of Disease Research Unit at the South African Medical Research Council. Inequality is thus a far more useful determinant for assessing South Africa’s health status than material deprivation in the form of poverty.
An understanding of poverty in the form of material deprivation such as dirty water or poor nutrition is inadequate because relief of such material deprivation such as providing clean water can be reduced to merely a technical matter, asserts Michael Marmot, Professor of Epidemiology and Public Health at University College London. This understanding fails to take into account the socially determined nature and skewed allocation of these resources. “In fact, there are many examples of relatively poor populations with similar incomes but strikingly different health records,” Marmot further adds.
The Spirit Level: Why More Equal Societies Almost Always Do Better, published in 2009 by Richard Wilkinson and Kate Pickett argues that inequality is socially corrosive and leads to more violence, an erosion of trust, increased anxiety and illness, chronic stress and risky behaviour such as increased consumption of alcohol and smoking. These in turn lead to poor health outcomes in terms of physical and mental health, drug abuse, obesity, violence, infant mortality and lower average life expectancy.
According to the Review, violence, alcohol misuse and mental disorders are leading contributors to the burden of disease in South Africa. South African homicide rates are estimated at more than 8 times the global average among males and five times the global average among females. South African drinkers also rank in the top five riskiest drinkers in the world. These are all risk factors compounded by South Africa’s high levels of inequality and income disparities.
Government’s annual death report released on 10 April 2013 confirms that fewer South Africans are dying from HIV/AIDS-related diseases. This is likely a reflection of the success of the antiretroviral programme, says University of Cape Town (UCT) actuary and epidemiologist, Leigh Johnson, in an article for Health-e News Service. However, more people are dying of non-communicable diseases (NCD’s) such as diabetes. The World Health survey shows that socio-economic inequalities are risk-factors for non-communicable and chronic diseases in low to middle income countries such as South Africa. This could explain the high contribution of NCD’s to the country’s disease burden.
However, the scale of whether a society’s income inequality is a determinant of population health still remains a controversial issue. Critics argue that measuring a nation’s health according to the level of inequality within that country is statistically flawed and does not explain homicide rates, women’s status, life expectancy or obesity.
In spite of this, South Africa has displayed a commitment to reducing the level of inequality within the country by signing the United Nations Millennium Declaration in 2000 which is a global attempt to address unacceptable inequalities within and between countries by the year 2015. These goals include eradicating poverty and hunger, promoting gender equality, reducing child mortality, improving maternal health, combating HIV and AIDS and ensuring environmental sustainability. Unfortunately with only 2 years to go, achieving these goals is proving to be elusive, and in many cases impossible for the country.
The implementation of the proposed National Health Insurance will also attempt to make inroads into reducing the level of inequality in the country’s health but whether this will be a success remains to be seen as many challenges still confront the planning committee.
The Review shows that more needs to be done to address the ‘causes of the causes’ of ill-health, namely those directly influenced by inequality and social stratification. After all, prevention is always better than cure.
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