As rain batters the streets of Kayamandi, a township near Stellenbosch in the South African winelands, 66-year-old Judith Maqhashu stands in line in a restaurant with two dozen women, waiting for nurses to measure their blood sugar levels. Tuna sandwiches, bottles of apple juice and pamphlets in the IsiXhosa language have been laid out to welcome members of the Ikhaya diabetes support group.
Maqhashu has been diabetic for five years. Soon after retiring, in 2018, she was taken to hospital with a persistent fever. “In the ambulance, they told me my blood sugar was very high,” she remembers.
She is one of the 4.2 million South Africans living with diabetes, according to 2021 estimates from the International Diabetes Federation. The prevalence has more than doubled between 2011 and 2021 and is by far the highest in sub-Saharan Africa: by 2045, more than 7.4 million South Africans could be diabetic.
The condition has been labelled a “defining disease of the 21st century” by the Lancet scientific journal, which warned in June that 1.3 billion people worldwide could be living with diabetes by 2050.
In South Africa, diabetes has already reached a crisis point: it is the country’s leading underlying cause of death in women and second in the general population. Worryingly, nearly half of diabetics don’t know they have it.
“Diabetes could be fairly easily managed or even prevented, and instead it’s killing more women than anything else. It’s like a slow-moving car crash,” says Bridget McNulty, co-founder of Sweet Life, an online community of more than 35,000 South Africans with diabetes.
McNulty has hundreds of messages every month from patients across the country. Healthy living seems unattainable to many, and although free insulin is accessible, the complexity of the condition can make it difficult to get the right treatment.
The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
'A common condition' is a Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
Khokhela Sipambo, a 26-year-old with type 1 diabetes, recently wrote to McNulty in a “last recourse” after struggling with hospital limitations on testing strips and needles. “I end up reusing my needles because I have no other option, and I have to take my insulin,” she said.
Unlike HIV and tuberculosis, which are slated to receive 45bn rand (£1.9bn) in combined spending in 2023-24, “diabetes hasn’t received the attention it deserves”, says Patrick Ngassa Piotie, public health expert and chairperson of the South African Diabetes Alliance. “Diabetes and its complications are extremely expensive: if nothing is done, the car will definitely crash.”
Mobile clinics and government-sponsored awareness campaigns are scarce. Community groups such as Ikhaya – “home” in isiXhosa – are often the only support patients can turn to. Luleka Mzuzu, 40, founded the group in 2016 after noticing “a huge lack of information for diabetics” in her community. “When I was diagnosed, I couldn’t go to anyone,” she says.
Now, in the restaurant in Kayamandi, the women cheer as a member explains how to get free screenings for eye complications through the nonprofit Diabetes South Africa. During the Covid pandemic, the NGO also gave members glucometers to measure their sugar levels at home.
About 30 regular members meet every month and are in daily contact on WhatsApp. “In the beginning, I was alone. But with this group, if you’ve got a problem, you can ask everyone,” says Maqhashu.
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In line with a rising global movement to tackle diabetes, the South African government last year released a five-year strategic plan on non-communicable diseases. By 2030, 90% of adults should be screened for raised blood glucose, 60% of those diagnosed should be receiving treatment and half of those should be “controlled”.
“We now have goals we can look towards: this calls for improving diabetes surveillance,” says Ngassa Piotie, who is “optimistic”. However, McNulty has concerns about achievability. “There is no diabetes registry: the system is paper-based, so there is no way to know how these targets are doing. How do you fix a problem you can’t see?”
In the country’s top diabetes centre, at Groote Schuur hospital in Cape Town, doctors are similarly hesitant. “Politically, it all sounds great, and it’s voicing an intent to do something. But we don’t see anything massively changing on the ground,” says Dr Joel Dave, head of endocrinology at the hospital. “With HIV, they made huge investments upfront and we are now reaping the rewards. That’s what we need: a huge, cohesive, collaborative plan over the next 10 to 15 years to help change the direction things are going.”
The state-of-the-art diabetes centre opened to patients in January 2022. Walls are decorated with peaceful beaches and forests, contrasting with the rest of the public hospital. Eye screenings are available, a “foot room” diagnoses foot complications and three diabetes educators are on call to treat serious cases.
But eight miles away, in the underprivileged neighbourhood of Hanover Park, the inequalities of South African society are starkly visible. Here, diabetes impacts an already vulnerable population. “It is food insecurity, gang violence, patients who are sometimes afraid to walk to the clinic out of fear of being shot … people’s lives are extremely complex,” says Dr Rosa Jansen, a medical officer at Hanover Park community health centre.
The clinic sees about 3,600 diabetes patients a year. Jansen says: “We unfortunately see patients too late, knowing that strokes, heart attacks, amputations and other horrible complications are preventable. It feels like we’re dealing with more and more, with dwindling resources.”
At Groote Schuur, Dave is acutely aware of only seeing “the tip of the iceberg”. The Lancet studies published in June point to structural racism and “geographic inequity” in accelerating rates of diabetes. “The tsunami is coming, but we’re on quite high ground,” says Dave: “Primary health care is going to receive the brunt of it.”
By 2045, diabetes-related health expenditure could cost South Africa the equivalent of over £8.2 bn. But even that shouldn’t be “as expensive as treating complications”, Dave explains. The country needs to tackle the main root of the diabetes crisis: lifestyle.
South Africa has the highest obesity rates in sub-Saharan Africa: about half of the population is either overweight or obese. “We eat a lot of fast foods,” says Mzuzu. Exercising or going for a walk after work is not enough to compensate for this, she says
Campaigners point to a more systemic issue. For Nzama Mbalati, who heads Heala, a coalition of organisations advocating for access to healthy food, labelling diabetes as a “lifestyle disease” is problematic in itself. “The bigger problem is that we are living in a society where the food environment has been under attack for years. The fast-food industry has been targeting working and middle-class people,” he says.
Across the street from the Ikhaya group’s meeting, a store advertises Coca-Cola and other sweet drinks. “If people are surrounded by unhealthy food, they will buy that because they have to survive day by day,” says Mbalati.
Heala has been pushing for large-scale nutrition awareness campaigns. In a “big victory” earlier this year, the Department of Health announced a bill that would impose warning labels on foods high in sugar and fat. A 2018 tax on sugary beverages has also shown encouraging results, bringing down purchases by nearly 15%.
For Mbalati, this is not enough: the sugar tax was “watered down” to 11% after input from the industry, he says. “The initial proposal was 20%. You want unhealthy products to be unaffordable.”
“The food industry needs to come to the party,” agrees Prof Bob Mash, head of family medicine at Stellenbosch University. “We have to change the environment in which people are trying to heal: make healthier food more affordable, physical activity safer and provide medication and empower people so that living a healthier life becomes easier.”
