The country's near-total focus on HIV over the past 15 years has saved countless lives but starved other diseases of resources.
It was in late 2016 that Goodman Gwala noticed an itch on his left foot. His local clinic in Inanda, a township in Durban, South Africa, gave him bone-chilling news. "The doctor told me: 'Your toes are rotten, Goodman, there's nothing we can do. We have to take this thing out.'"
In April, doctors amputated half of Gwala's left foot to halt the source of the itch—a gangrenous ulcer caused by diabetes. If caught early and treated carefully, such wounds can heal. But in South Africa, where diabetes is an overlooked condition, many seek help too late. Type 2 diabetes, which is what Gwala has, can often be prevented by a healthy lifestyle. But his job as a supermarket baker put him in the way of too much temptation. "I used to make birthday cakes, donuts…Most of the time I was eating them," he says.
Today the 51-year-old has given up sweet cakes and sugary drinks, but the damage is already done. "My life is difficult. It's not like before," he says. He rarely goes out, as it hurts to be on his crutches too long. Mostly, he sits at home watching TV. He survives on a meager disability grant of R4,000 a month—around $310—and he reckons he'll never work again. He hopes retirement age will bring more money—enough to build a bigger house for himself and his young son.
Gwala's illness is one case among more than 2 million South African adults who were shown to have diabetes in 2015 (the most recent year on record); this is around 7 percent of the country's adult population. In fact, only tuberculosis killed more South Africans, and diabetes deaths overtook those caused by HIV as well.
Although the usual suspects—a poor diet and lack of exercise—play a part, there are other reasons for South Africa's diabetes epidemic. One of them, ironically, is the gains the country has made against its HIV/AIDS. Since scaling up antiretroviral (ARV) treatment in 2005, life expectancy has increased by six years, causing a rise in diseases associated with aging, including diabetes.
But HIV could also be directly fueling the diabetes crisis. People with HIV are more likely to develop diabetes, and some HIV drugs even predispose patients to Type 2 diabetes. While scientists don't know to what extent this phenomenon is to blame for South Africa's diabetes rise, the numbers alone give cause for concern: More than three million South Africans take ARVs drugs each day, and an estimated seven million live with the virus.
The effect on the country's health system is overwhelming. Even though it has been months since Gwala had his operation, he has to visit the hospital every week to have his wound cleaned and checked. And he's lucky—his old job pays his medical insurance, giving him access to top-of-the-line private healthcare, unlike most of the country's 50-odd million people, who have to rely on the threadbare public system. "Without medical aid, I [would] be dead," he says.
At the hospital, Gwala visits the surgeon who operated on his toes, Vishnu Padayachee, who sees the devastating consequences of diabetes every day. "Diabetes affects your eyesight, it affects your heart, it affects your kidneys, your feet, your nerves," Padayachee says. Foot ulcers are just one complication—others include blindness, kidney failure and heart disease. "That equates to numerous visits to hospitals, numerous procedures, numerous medications," he adds. "And the cost is astronomical."
Prevention could help, but there is often little opportunity for it. "You can actually smell the infection from a mile away," podiatrist Nikita Sahadew says as she gouges with her scalpel into a quarter-sized callous. The foot belongs to an elderly Indian man who is lying on the paper-covered chair with a surprisingly quiet air of resignation. This is his first visit in months, and there is a lot of work to do. "It's really important that we cut, clean and excavate that wound, and dress it so it has a chance to heal," she says.
The diabetic foot care that Sahadew performs could cut amputation rates by 85 percent. But few can afford her private rates. Medical insurance plans don't cover it either, saying that what she does is "cosmetic." She only knows of two podiatrists in the public sector that serves the majority of the province's 11 million people. The result is a gut-wrenching loss of limbs. There were around 1,200 diabetes-related amputations in her province in 2014—more than three a day. And South Africa has eight more provinces.
But the cost doesn't end there, she says. "After having their feet amputated, these people go on social grants, their family loses a breadwinner, and their quality of life is severely reduced." Most of the people who end up having amputations are men. "They don't like to fuss over their feet, perhaps it makes them feel less masculine," she adds.
It's a bittersweet fact that South Africa's near-total focus on HIV over the past 15 years, which has saved many lives, has also ended up starving other disease areas of resources. But some doctors are now taking lessons from the playbook that curbed the HIV crisis to tackle other threats.
Cathy Kolombo is one of them. She works in Cape Town's Gugulethu Community Clinic, one of the first facilities in the country to offer free ARVs to those who can't afford them. Today, the clinic provides treatment for 5,800 patients—a huge burden, were it not for the "HIV clubs" that stretch the public sector's budget.
The HIV clubs were conceived as a way to rapidly scale up South Africa's ARV programs without breaking the bank. Each club has around 30 patients who meet in an out-of-clinic location every two months to collect meds and undergo health assessments. This allows the clinic's doctors to focus on patients who aren't doing well, while also saving stable patients hours of queuing.
The clinic's HIV clubs grew in number and Kalombo saw that while their members were able to access their HIV drugs quickly and painlessly, a significant number had other chronic diseases like diabetes or hypertension. And they still had to go back to the clinic's long lines to fetch their other meds.
Since early 2016, Kalombo has experimented with joint clubs for patients with HIV and a non-communicable disease: a one-stop shop for all their chronic health needs. She thinks there are other lessons from HIV, too; Strong public information drives, mobile testing clinics, and better counseling services.
Stigma remains an issue for getting people to test and seek treatment for HIV, Kalombo says. But integrating HIV care with other chronic care could lessen it, she hopes. Besides, people have the wrong idea about what diseases they should fear the most: "Everyone knows that HIV kills you. But some people who hear they have diabetes are happy because they think they can get disability pay," she says.
That's an assumption that needs to be turned on its head, she says. Today, people living with HIV have better access to healthcare than those who don't, particularly the poor who rely on the ramshackle public health system. In South Africa right now, an HIV diagnosis would probably be preferable to diabetes, she says.
Some reporting for this article was supported by South Africa's Health-e news service.
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