South Africans living longer but drug-resistant TB a threat

AIDS has killed about three million South Africans so far. From the 1990s through the 2000s, national health took a nosedive. Instead of living till our early 60s, life-expectancy fell to the mid-50s. Thankfully, the rollout of the health department’s antiretroviral (ARV) treatment and prevention programmes turned this around. There are now over two million people on treatment and every year tens of thousands of infants are born without HIV thanks to ARVs.

In March, Statistics South Africa released the mortality data for 2011. A few days later the Medical Research Council (MRC) released its second Rapid Mortality Surveillance Data report. Adding to this, a presentation by Norbert Ndjeka of the National Department of Health has been made available on the Health-e website.

The Stats SA report shows a continuing trend of declining annual deaths in the country. In 1997, there were just over 317,000 recorded deaths. This rose to over 500,000 by 2002 and peaked at 613,000 in 2006. Then deaths began dropping. In 2011 there were about 505,000 deaths, about the same number as 2002.

A simple way to see how health is improving is to look at the median age of death. If you wrote down every person who died from youngest to oldest, the median would be the age of the person at the halfway mark. In 1997, the median age of death was 51. This dropped to a low of just under 43 in 2004 and then began increasing again. In 2011, it crossed to above 50 for the first time since 1997.

The MRC has, monthly since 1999, collected the deaths recorded in the National Population Register. This is a subset of deaths registered with Stats SA that includes only people who had South African birth certificates or identity documents. The MRC report has excellent news:

The estimates for 2012 show that the average life expectancy in South Africa has reached 61 years, an increase of 7 years since the low in 2005.

Women are living a lot longer than men. Life-expectancy in 2012 for women was 64 but only 58.5 in men. The odds of a person aged 15 dying before their 60th birthday dropped from 46% in 2009 to 38% in 2012.

In 2011, a Department of Health committee set 59 as the target life-expectancy for 2014. Unbeknown to the committee at the time, this had already been exceeded. All this is excellent news.

However, we can’t be complacent. Tens of thousands of people continue to die of AIDS yearly and life-expectancy has still not quite reached the peak of the 1990s.

Another worry is TB. It is the biggest cause of death in the country mainly because people with HIV are so prone to becoming deathly ill with it. For the most part, the news on TB is improving. TB is a notifiable disease, meaning that every case of a person being ill with TB has to be reported to the health department. Ndjeka’s presentation shows that in 2007 there were nearly 354,000 TB notifications. This peaked at just under 406,000 notifications in 2009 and has since declined to just under 345,000 in 2012.

The Stats SA report also shows a decline in recorded TB deaths, from nearly 70,000 in 2009 to just over 54,000 in 2010. While the death certificates used by Stats SA are not reliable for determining totals for cause of death, and actual TB deaths were certainly much higher than recorded, the decline in TB as a cause of death is consistent with the rest of the data.

The one disturbing TB trend is drug-resistance. It is very difficult to treat people when the best drugs against the disease no longer work and death-rates are high. Patients face about two years of treatment with medicines that have awful side-effects. In 2007, there were over 7,000 cases of multi-drug resistant TB. This rose to over 14,000 in 2012. These might not seem like large numbers, but these are only the confirmed cases; the stats show the problem is clearly getting worse.

Ndjeka’s presentation shows an apparently successful response to TB in Umzinyathi district in Kwazulu-Natal. But with a plethora of reports on stockouts, the National Health Laboratory Services again in the news for being in financial crisis and a multitude of reports of problems in the health system, it is hard to be confident that we are adequately confronting the drug-resistant TB problem.

New TB drugs, against which there is no resistance yet, are being researched. but the TB medical world, in contrast to the HIV one, is deeply conservative and moves at a glacial pace. TB drugs typically take well over a decade from discovery to market.

The news is mostly good. But South Africans still die too young and the gains of the last few years are not guaranteed to continue.