Burden of Health & Disease in South Africa: Medical Research Council briefing

Meeting report

Briefing by South African Medical Research Council

Dr Marlon Cerf, Chief of Staff, South African Medical Research Council, said the SAMRC was a world class science council with a global footprint, and a national science body with influence. The SAMRC conducted and funded cutting edge medical research, and collaborated with other science councils and national institutes.

The strategic goals of the SAMRC were to administer health research effectively and efficiently, lead the generation of new knowledge, support innovation and technology development to improve health, and build capacity for the long-term sustainability of the country’s health research.

The quadruple burden of disease in South Africa was a cocktail of four colliding epidemics: maternal, newborn and child health; HIV/AIDS and tuberculosis (TB); non-communicable diseases; and violence and injury. There were 11 intra-mural units that focused on the national health priorities, and over 20 extra-mural units at universities throughout the country that were aligned to the council’s research strategies. The innovation platforms and grants were focused on growing the next generation of scientists, particularly at previously disadvantaged universities.

The council would have a deficit of R38 million in the coming financial year, but would continue to work to achieve its objectives.

Prof Debbie Bradshaw, Unit Manager, South African Medical Research Council, gave an overview of the trends in diseases and burden of health from the work that the MRC had been doing. The rapid mortality report was shared with the Committee, a burden of disease study, and a cancer registry that had been run in the Eastern Cape.

The rapid mortality surveillance report was based on the information received on a monthly basis from the Department of Home Affairs, which kept the population register, and adjustments were made to the numbers to account for under-registration of deaths and the proportion of population without identity documents (IDs). The key health indicators were determined from these numbers, and the life expectancy at birth and at age 60 was calculated, the adult mortality rate, the under-5, infant and neonatal mortality rates, and maternal mortality ratios.

There had been a rapid increase in young adults’ mortality rates since the year 2000, and this had peaked in 2006. There had been on average a nine-year increase in average life expectancy since 2005, and this could be attributed to the provision of anti-retrovirals (ARVs). The life expectancy of males was lower than that of females, with males having a life expectancy age of 60, and females 65 to 66 years. Males had a higher mortality from smoking, injuries and alcohol. If men’s lifestyles were changed, they would catch up to women.

The premature adult mortality rates of 15-year-olds not surviving until the age of 60 had decreased since 2005, and on average it was now sitting at 34%. Life expectancy for older people, of 60 years upwards, had been steady and not much change had taken place. The changes in child mortality rates showed that the under-5 mortality rate and infant mortality rate had increased to a peak in 2003 and declined until 2011. Levels had stagnated at 40 and 28 deaths per 1 000 live births for under-5 and infant mortality rates respectively. Neonatal mortality rates had declined to 11 per 1 000 live births.

Maternal deaths were relatively rare and uncertainty about true values remained. The rates had declined from 2010, to 155 per 100 000 live births in 2013, which was an estimation and was similar to what the level had been in the 1990s.

Dr Victoria Pillay-van Wyk, Specialist Scientist, South African Medical Research Council, said that the Council was currently busy with the second National Burden of Disease study and cause of death profile. This would show the mortality estimates by broad cause group and disease categories, age distribution of deaths by broad cause group, leading causes of death for SA between 1997 and 2010, and mortality estimates by broad cause group by population, sex, and province until 2010.

The data sources used to get the mortality estimates were Statistics South Africa and injury mortality surveys from mortuaries across the country, and these had been adjusted for completeness to identify misrepresented HIV-related deaths. The estimated number of AIDS deaths reported by cause of death and age for the period 1997-2010 showed that most of the deaths had been attributed to tuberculosis or HIV-pseudonyms. An estimate of under three million deaths for the study period were from AIDS.

The four broad causes of death in South Africa were HIV/AIDS and TB, non-communicable diseases, injuries, and other Type One conditions, such as nutritional deficiencies. There had been a rapid increase in deaths from HIV/AIDS until 2006. Cardiovascular disease was the leading cause of death prior to 1999, then HIV/AIDS and TB had come along and taken over. All cancers were responsible for an estimated 7% of deaths in 2010.

The leading cause of death in children was still HIV/AIDS, with the highest percentage of 28%, followed by diarrhea at 18%, and pneumonia at 11%. The under-5 mortality rates for each of the provinces showed that the year 2005 had the highest under-5 mortality rates across all provinces in the country, except for the Northern Cape. Kwa-Zulu Natal, Free State and the Eastern Cape had the highest under-5 mortality rate for 2010, and had been higher than the national average. The Western Cape had the lowest mortality rate.

All the provinces had unique leading causes of premature deaths and had different profiles, indicating that they were at various stages of the health transition. The indicators would show provinces which areas they needed to target to improve their health status. Huge gains had been made with HIV/AIDS, but current programmes needed to be strengthened. There had been a notable decrease in interpersonal violence mortality, although the rates remained high. There were increased death rates for renal disease and diabetes mellitus, prostate cancer and breast cancer. The highest death rates among adults and children were in Kwa-Zulu Natal.

Dr Pillay-van Wyk handed over the presentation to Ms Nthutu Somdyala to present on the cancer registry in the Eastern Cape.

Ms Somdyala, Senior Scientist, South African Medical Research Council, said that the need for the cancer registry had been caused by the high incidence of oesophageal cancer amongst the Xhosa-speaking people of the former Transkei region of the Eastern Cape in the early 1950s. A register had been dedicated to record every cancer case in the area since 1955 in East London, and it was termed the “Bantu Registry”. The SAMRC had continued and expanded the cancer registry and it contributed to the international data base on cancers.

The data was collected from 15 collaborating hospitals in and around the registration area, one pathology laboratory, and through active and passive data collection from other hospitals outside the area. The area was rural, but tarred roads had made it easier to access. The data processing was done using geographic coding and International Classification of Diseases for Oncology (ICD-O) coding, capturing of data using CanReg5 -- an open source tool to input, store, check and analyse cancer registry data -- and data checking. The rates were calculated using census data, and age standardised using International Agency for Research on Cancer (IARC) world standards.

The most common cancers for males were cancer of the oesophagus, prostate cancer and cancer of the oral cavity and pharynx. Kaposi sarcoma, which was an HIV-related cancer, ranked fourth on the list. The most common cancers in females were cervix uteri, oesophagus and breast cancer, while Kaposi sarcoma was fourth on the list in this category as well.

The importance of keeping a cancer register was to note the trends as the years go by, so that the causes could be identified and addressed.

Prof Bradshaw ended the presentation by saying civil registration and vital statistics were well established in South Africa and had improved considerably since 1994. The quality of medical certification and the inclusion of information about the external causes of injuries needed to be improved. Morbidity data systems needed to be strengthened, as well as demographic, epidemiological and bio statistical skills and capacity.

Discussion

The Chairperson opened the floor for questions and asked the team from the MRC to send the answers in written form, in the interest of time and also so that they could provide detailed answers.

Ms L Zwane (ANC; KwaZulu-Natal) requested that at the next presentation, they should be mindful that not everyone they would be presenting to was a scientist, and therefore might not be able to understand some of the terms that were mentioned in the presentation. She also wanted know to what extent the Council was involved with the Department of Science and Technology in their research.

Ms P Mququ (ANC; Eastern Cape) asked a question about the meaning of oesophagus cancer, and whether there were awareness campaigns in the area, because the numbers clearly indicated that there was a high prevalence there. Did the research extend to KwaZulu-Natal?

Mr M Khawula (IFP; KwaZuluNatal) asked whether the findings were enough to generalize about the prevalence, and if not, why they were confined only to the Eastern Cape and not all the other areas of the country. He wanted to know why the data was six years behind, and if they would be presenting on very recent findings at the next meeting. He requested a breakdown of data in terms of race, rural versus urban areas, and economic status. Why was there limited information on the link between the age restriction on alcohol and road accidents, and what was being done about it?

Mr C Hattingh (DA; North West) asked about what was being done to combat the high prevalence of cancer in the area, since there was a lot of data which had been collected for more than 50 years. He asked if there was current research about the effect of heavy metals and the mortality rate in South Africa, and the detectability rate of prostate cancer.

Ms T Mpambo-Sibhukwana (DA; Western Cape) asked about the mortality rate and what had been done to combat it, and if the information was being shared with the provinces.

The Chairperson asked questions relating to the future of the country in relation to the mortality rate, the sharing of information between provinces, and whether the mortality rates per province had been calculated based on the population.

The meeting was adjourned.