Tackling non-communicable diseases: Critical beyond COVID-19
Evidence suggests that COVID-19 patients with diabetes and hypertension are more likely to face poorer outcomes. Both of these health conditions are widespread in South Africa — and often untreated. Expanding health care and creating healthier environments will be critical to South Africa’s resilience against COVID-19 and future epidemics. By Andrea Teagle
Patience Ndou (37) lives in Mandalay in Cape Town with her husband and two children. She was diagnosed with severe blood pressure last year. “My heart beats faster like someone scared me. Then I feel hot from the legs, going up, up, upwards. If I’m in a taxi, I have to remove my jacket. I didn’t want to sit in between people because any time those hot flushes would start.
“When they tested me, my blood pressure would be 165/115 and my heart would be beating very fast. They decided that I had to start on the medication because I was going to [have a] stroke.”
Eight months after her diagnosis, Ndou is doing much better: her blood pressure is under control and she is a healthier weight. However, although aware which foods she needs to eat — particularly wholegrains and certain fruits and vegetables — she cannot always afford them on her domestic worker’s salary. Like many, Ndou and her family have been struggling to make ends meet since South Africa went into lockdown: “I’m really worried, because things are not going well food-wise. We’re eating, eating, eating and not making any money. I have to be on a certain diet, so it’s really tight. It’s really affecting us.”
Rising rates of diabetes and hypertension
On 26 May 2020, the Western Cape government conducted a data review of underlying diseases associated with COVID-19 deaths in the province; at the time, the province had recorded 403 deaths. The review revealed that the most prevalent comorbidities were hypertension and diabetes.
These early data showing that South Africans with diabetes and hypertension are at higher risk of more severe cases of COVID-19 support research from elsewhere. The largest study on risk factors to date, using health data from 17.4 million adults in the United Kingdom, points to uncontrolled diabetes being one of the major risk factors associated with death from COVID-19. Other factors included being a man, suffering from asthma, and older age. Black and Asian people also had a higher risk of death, even when controlling for other factors such as poverty.
In the United States of America, half of all COVID-19 patients hospitalised in March had hypertension (49.5%), while over a quarter had diabetes (28.3%). Obesity, chronic lung disease and cardiovascular disease were also common underlying conditions (48.3%, 34.6% and 27.8% respectively).
In China, a systematic review found that diabetes and hypertension were twice as common among hospitalised COVID-19 patients in intensive care as among general COVID-19 hospital patients.
As many as 1 in 4 adults in South Africa have hypertension, and more than 1 in 10 have diabetes. Also, according to HSRC research, 1 in 4 diabetes cases are undiagnosed. These individuals may be even more vulnerable due to the socioeconomic impacts of lockdown.
In an HSRC survey conducted between 7 and 14 April on perceptions of the impact of COVID-19 nationally, 13.2% of respondents indicated that their chronic medication was inaccessible during the lockdown. In informal settlements and rural areas and on farms this figure ranged between 13% and 25%.
Ndou said that her nearby clinic was closed after staff members tested positive for COVID-19: “I’m worried about where I will go and collect [my medication], because I don’t know if I can buy it over the counter at a pharmacy.”
More than half (55%) of respondents from informal settlements also experienced food shortages, a situation that may have worsened due to the economic impact of the pandemic, despite the easing of restrictions. For people with diabetes, food shortages or limited access to nutritious food may make it more difficult to regulate glucose levels, which is important for the body’s ability to fight off infections.
Expanding health care and healthy food accessibility
In the long term, addressing rising rates of non-communicable diseases (NCDs) will be critical to mitigate the damage caused by pandemics - which are predicted to become increasingly common due to globalisation and climate change. COVID-19 itself might become a seasonal menace.
“There’s been a shift in the last 20 years in what South Africans eat,” explains researcher Ronel Sewpaul of the HSRC. “Much less fibre, much more calorie-dense, much high-fat food, swinging away from more traditional diets and towards more westernised diets, more fast foods.”
Sewpaul says that as a first step towards a more robust population, screening for NCDs and other conditions needs to be increased. “The first step would be inching through that cascade of care, which is having your blood sugar or having your blood pressure measured, and then getting screened. And then [the health-care sector] would at least be able to differentiate who the immunocompromised and the at-risk people are. Because at the moment, they don’t know — it’s just the general population.”
The pandemic has underscored the need for equitable and ultimately universal health care.
Scaling up treatment for cardiovascular risk factors, like diabetes and hypertension, would be cost-effective from a health-care perspective, according to a 2018 study in The Lancet. The team of researchers — which includes the HSRC’s Prof Priscilla Reddy - modelled two viable treatment expansion options.
The first was the WHO’s package of essential non-communicable disease interventions and the second was South Africa’s Primary Care 101 guidelines. Both involved greater prioritisation of medications used to treat high blood pressure compared with blood sugar medications. The researchers found that both models would disproportionately benefit black, male and low-income South Africans.
Other, non-clinical interventions towards a healthier population seek to make fresh produce and exercise more accessible, affordable and appealing. As the COVID-19 pandemic has underscored, many households struggle to get enough — let alone nutritious — food.
The HSRC is exploring the possibility of research into the impact of subsidising nutritious food baskets, Sewpaul says, as a possible complement to existing measures such as the sugar tax. “It’s not just up to the individual [to eat healthily] — the individual has to be enabled. That can come from the government, it can come from schools, it can come from the community.”
Author: Andrea Teagle, science writer in the HSRC’s Impact Centre