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In 1971, epidemiologist Abdel Omran, published an influential article in which he declared that humanity was undergoing an ‘epidemiological transition.’ The world was no longer living in an age of pathogens and pestilence. Instead, humanity was on a one-way path towards longer, healthier lives. Rather than dying from violence, famine or pandemics; the vast majority of the global population would now die of slow, degenerative illnesses. This was public health’s own End of History moment:[1] we were beyond deadly contagion.
Already, Omran’s many blindspots are clear. Many considered the ‘epidemiological transition’ to be a marker of progress – a victory for medical science, and a reflection of improved food security, healthcare, and life expectancy.
But in reality, the trajectory of human health hasn’t been nearly this simple. Access to healthcare is uneven, infectious outbreaks continue, and the young find themselves evermore at risk of diseases once reserved for the old.
Since the seventies, those of us working on non-infectious, degenerative illnesses – technically termed non-communicable diseases (NCDs) – have sought to complicate Omran’s picture. In South Africa (and elsewhere on the continent), the experience is less a ‘transition’ and more a collision of both infectious and non-infectious illness. Here, NCDs compound, and are complicated by, the largest HIV and TB epidemics in the world.
The arrival of Covid-19 has shone a light on the ways in which chronic and contagious diseases collude – and, simultaneously, demystified the view that capitalist modernity is good for our health. To illustrate the point, it’s useful to draw from our recent fieldwork in Cookhouse, Eastern Cape. At first glance, this case study is neither about Covid-19 nor NCDs. Those connections will become clear later. Instead, this story is about a mother and child with scabies. An ancient disease, scabies has irritated human beings for more than 2,500 years. It’s among those ‘primitive’ contagions that Omran would have long relegated to our past. In theory, the disease is easily treated – caused by a small parasite which is easily killed by ointment.
‘It’s a gogga,’ the doctor explains to the mother in our presence. But she has a different explanation: ‘It’s these buckets’, she says -- by which she means the bucket system.
To prevent onward transmission of scabies, clothing and linen must be washed in hot water, on the same day the ointment is applied. But none of this was possible in Cookhouse. Many people had no access to running water, never mind hot water. Being winter, there was little sunlight to dry linen. To add to this, many residences housed migrant members who could not be treated along with everyone else. Unsurprisingly, scabies in Cookhouse had become a relentless epidemic. One can only imagine how vulnerable these neighbourhoods must be to Covid-19.
The mother was right: the bucket system was responsible for the scabies epidemic, along with the many other injustices that made her home, and many others like it, unable to defend their health.
In the face of contagious epidemics, some households and neighbourhoods are resilient, while others are near defenseless. It’s useful to think of bodies in the same way. Some bodies are more vulnerable to illness than others. With respect to Covid-19, the elderly and people with underlying conditions are classed as most at risk – including those with NCDs. In South Africa, this is no small number. Consider this: about 4.5 million South Africans have diabetes,[2] and more than a third are hypertensive.[3] Covid-19 has transformed NCDs – which many consider chronic, rather than imminent, challenges – into an acute threat.
Since the first case of Covid-19 in South Africa, much of the public focus has been on limiting viral transmission — a worthy goal. But there is another underlying question that demands urgent attention: the resilience of our population.
Those working on NCDs know that, rather than being inconvenient side-effects of ‘progress,’ NCDs are often symptoms of a sick society. They are the outcome of large corporations outplaying smaller ones, while flooding the market non-nutritious food; of mental illness and industrial pollution; and of a world more interested in profits than people. To this end, Percept is embarking on a year-long research project aiming to quantify and forecast the burden of NCDs in South Africa- triangulating data from a variety of sources to build a useful picture for planning and policy making.
Covid-19 is teaching us to prioritise health, and to do so systemically. This means improving access: not only to health services, but also to nutritious food, clean water, psychosocial support, and safe environments for working and playing. To combat pandemics, we must bolster our resilience to illness: not just within individuals, but also within our neighbourhoods and health systems.
We might think of this as a type of societal vaccination, to bolster the medical ones in-the-making. Indeed, health is as much a social question, as a medical one.
Maybe this is the transition we should hope for: A world in which health does not rest solely on scientific advancement, but on a sustained commitment to protecting and nourishing both people and the planet.
This piece forms part of a collaboration between myself, Dr Beth Vale, and Percept – a multi-disciplinary consultancy. Together, we are working to understand the trajectory and impact of ‘non-communicable diseases’ in South Africa.
[1] In 1991, Francis Fukuyama famously posited that, having overcome the Cold War, humanity had reached its final and ultimate form of government – Western liberal democracy. This, he described as The End of History; conflict would no longer be defined by ideology. [2] IDF’s 2019 Diabetes Atlas [3] World Health Organization. GHO | by category | raised blood pressure (SBP ≥ 140 OR DBP ≥ 90), age-standardized (%) - estimates by country.
