Let’s look at two lifelong diseases common in South Africa: HIV (South Africa has the largest number of people living with this infectious disease in the world) and diabetes (a larger share of South Africans have this non-infectious disease than any other African country). You’ll notice in the Table below that all groups of South Africans have some cases of HIV and diabetes. But you’ll also see that the poor (“low socio-economics”) have a larger share of HIV and the rich (“high socio-economics”) have a larger share of diabetes. Women have a larger share of HIV and of diabetes compared to men. A larger share of Black Africans have HIV than other races. Clearly, disease is not equal between groups of South Africans. Countries also have disease patterns different to other countries.

Is it bad luck or choice when some diseases affect some groups of people more?

Disease differences seem unfair. More poor people have HIV, but they have the least time and resources to visit clinics because they often have to prioritize survival needs of shelter, safety and food over health. More rich people have diabetes (type 2) even though they could buy healthier food.

Someone once told me his opinion that HIV prevention research is unnecessary because people are “choosing” not to use condoms. Interestingly, he and his partner had never used condoms nor gotten tested, probably because consistent condom use is not only a personal choice: it is shaped by complex forces. Incidentally, condoms prevent HIV by 80% or more, but are not failsafe.⁵ Although people make decisions, it might be too simple-minded to think that a person controls everything behind their health. The way today’s societies and economies have been set up helps spread disease, whether it is an infectious disease or not. Power and money affect what groups of people can access. For example, advertisements and shops expose people to products that help spread non-infectious diseases: many cheap unhealthy processed foods and drinks contribute to obesity and related conditions, alcohol and tobacco products can lead to addiction, cancers, and other conditions. We may judge the “personal choices” driving diabetes, but they are rooted in a system of industries that are enriched by selling these products, even though they can damage health.⁶

Preventable unfairness?

Health stretches beyond clinics managing disease, or research exposing issues behind disease and finding treatments. It is one task to educate each person on better health, but communities also organize to find, advocate for, and apply preventive solutions to issues in the system. Especially when taxpaying citizens are paying for healthcare systems to care for people who get diseases rooted in unhealthy industries, communities could ask industries to use simple product labels stating how many teaspoons of sugar have been added, could demand more taxes on products that add to disease burden while lifting taxes from products that improve health, or could call to ban harmful and unnecessary chemicals. If some humans created  unfair systems that ignore some groups of people, then perhaps communities’ main work for health must be improving those same unequitable social, economic, gender, and racial systems.

References:

1. Wabiri, N., Taffa, N. Socio-economic inequality and HIV in South Africa. BMC Public Health 13, 1037 (2013). https://doi.org/10.1186/1471-2458-13-1037
2. Sidahmed, S., Geyer, S. & Beller, J. Socioeconomic inequalities in diabetes prevalence: the case of South Africa between 2003 and 2016. BMC Public Health 23, 324 (2023). https://doi.org/10.1186/s12889-023-15186-w
3. Mutyambizi C, Booysen F, Stokes A, Pavlova M, Groot W (2019) Lifestyle and socio-economic inequalities in diabetes prevalence in South Africa: A decomposition analysis. PLoS ONE 14(1): e0211208. https://doi.org/10.1371/journal.pone.0211208
4. Grundlingh, N., Zewotir, T.T., Roberts, D.J. et al. Assessment of prevalence and risk factors of diabetes and pre-diabetes in South Africa. J Health Popul Nutr 41, 7 (2022). https://doi.org/10.1186/s41043-022-00281-2
5. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255. doi: 10.1002/14651858.CD003255. PMID: 11869658
6. Allen L. Are we facing a noncommunicable disease pandemic? J Epidemiol Glob Health. 2017 Mar;7(1):5-9. doi: 10.1016/j.jegh.2016.11.001. Epub 2016 Nov 22. PMID: 27886846; PMCID: PMC7103919. 

Dr. Fatima Laher is the Clinical Research Site Leader of the HVTN Soweto-Bara site in South Africa.