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Daily Maverick
2 days ago
- Business
- Daily Maverick
Electronic death registration is a win-win for SA — let's make it happen
Several studies have flagged problems with South Africa's death registration processes. To address it, a critical first step is to replace our paper-based process with an electronic one. A recent report by the South African Medical Research Council (SAMRC) highlights the underreporting of HIV in official mortality statistics. Official cause of death statistics are based on what doctors write on death notification forms. As part of the process of death registration, medical practitioners are required by law to provide information about the medical conditions resulting in each death. Multiple studies have identified concerns about the quality of the information provided by doctors and the Department of Health has been urged in a policy brief to address them as it clearly undermines the quality of data used by our government for health planning and resource allocation. The recently reported study found extensive underreporting of HIV as a cause of death. Only 28% of deaths that occurred in a national sample of public sector hospitals where the medical record had clear clinical indications of HIV, had HIV specified on their death notification form. Aside from ensuring that medical certification of the cause of death is part of the medical training curriculum, and that additional training is provided during internship periods, another key issue to address is that many doctors are reluctant to record HIV/Aids as a cause of death due to concerns about maintaining patient confidentiality. In 2014, a self-sealing section was added to protect information about cause of death on the death notification form, but this has clearly not had the desired effect. Following the deaths of at least 22 children from contaminated food in 2024, President Cyril Ramaphosa announced that the Department of Health would develop an electronic system for recording causes of death as one of several responses to the emergency. The move to an electronic system offers a strategic opportunity to address the challenge around confidentiality and promises a lot more. It allows for secure, institution-based data management that protects confidentiality, encourages accurate reporting and strengthens the integrity of vital statistics. Benefits of this digital transition will include: Improved data quality and confidentiality, encouraging accurate reporting of sensitive conditions like HIV/Aids; Automated validation checks, reducing certification errors at the point of data entry; Real-time access to mortality data, enabling rapid public health responses; and A platform for quality assurance and feedback, currently not possible in the paper-based system. Ultimately, moving away from a paper-based process of death registration will reduce the administrative burden and improve efficiency across the system. This presents a timely and valuable opportunity to collaborate across departments, including health, home affairs and Statistics South Africa, to modernise the country's civil registration and vital statistics system. We are at a pivotal moment for such coordinated policy action. Investing in a robust electronic system for cause-of-death certification will strengthen South Africa's public health planning, improve disease surveillance and increase accountability. The long-term returns – through faster, more reliable data – are substantial for both governance and health outcomes. It is a win-win. DM Dr Pam Groenewald and Professor Debbie Bradshaw are with the South African Medical Research Council's Burden of Disease Research Unit. Note: Spotlight previously reported on the issues discussed in this opinion piece. That reporting included the sentence: 'In the meantime, routine mortality data from Stats SA should clearly be taken with a pinch of salt.' That sentence may have been construed as reflecting Groenewald and the SAMRC's views. Groenewald has asked us to clarify that it does not. She points out that Stats SA is obligated to process the data it receives and the quality issues stem from what doctors report.
IOL News
21-05-2025
- Health
- IOL News
Unsilencing the struggle: men's mental health and the fight against GBVF in South Africa
Sandile Mlangeni is a 2019 GP-based Activator, he is passionate about youth activism. Sandile regards it as important to contribute his views and experiences to recognised entities seeking to develop communities. He started his journey as an activist in 2012 when he started collaborating with community-based organisations in his hometown in Tsakane and Kwa-Thema Ekurhuleni. Kunzima, bafwethu. Being a man in South Africa means carrying silent battles, pressures to provide financially to your family, expectations to remain strong, and we're told to bury even our deepest pains. We were taught to 'man up, not to open up!' And so, we bottle things in '(sifela ngaphakathi),' a usual setting among men. The statistics are grim: men account for the vast majority of suicides in South Africa, a stark reflection of a mental health crisis festering in silence. As men, we don't talk because we're scared of being judged. We don't seek help because we're afraid of looking weak. This silence isn't just killing men it's fuelling the epidemic of gender-based violence and femicide (GBVF). It's time to challenge this narrative and redefine strength as vulnerability, because every man's life matters, and so does every woman and children's safety associated with men who are emotionally wounded. South Africa faces a suicide crisis disproportionately claims men. According to The South African Medical Research Council (SAMRC) estimates a suicide rate of 11.5 per 100 000 people in 2020/21, with men making up 75% of cases. The South African Depression and Anxiety Group (SADAG) reports 23 known suicides daily, with men consistently making up three-quarters of these deaths, based on data from 2019. For every suicide, ten others have attempted it, pointing to widespread untreated mental distress. Men are five times more likely to die by suicide than women globally, and in South Africa, this gap is even wider. Behind these numbers are stories of despair: 9.7% of South Africans 4.5 million people experience depression in their lifetime, and 70% of those who attempt suicide have a mental health condition. A 2020 report by the World Health Organization (WHO), highlighted that 75% of those with mental illnesses lack access to adequate care, constrained by an underfunded health system, and a culture that stigmatises weakness. Poverty, unemployment, and violence hallmarks of South Africa's socio-economic landscape deepen this crisis. With a Gini coefficient of 63.0, in 2020 the World Bank reported that South Africa is the world's most unequal society, with economic hardship driving suicide risk, particularly for men expected to be providers in their families. The 2024 unemployment rate of 32.9%, as indicated by Stats-SA intensifies this pressure, especially in urban areas where financial instability is severe. Continuous traumatic stress from living in high crime areas or witnessing violence further erodes mental resilience, leaving men feeling trapped and hopeless. According to the South African Medical Research Council (SAMRC), the silent struggles of men are inseparable from South Africa's GBVF crisis. The country has one of the highest femicide rates globally, with 5.5 women killed per 100 000 by intimate partners in 2020/21. Three women die daily at the hands of someone close to them, and 60% of femicides are committed by intimate partners. Unchecked mental health issues can escalate into violence, with a 2008 study revealing that 19.4% of intimate femicide perpetrators in South Africa died by suicide within a week of the murder. Legal gun ownership, often tied to notions of masculine control, significantly increases this risk. Are patriarchal norms the root of these crises? South Africa's culture equates masculinity with dominance, leaving men unable to process emotions healthily. A 2019 study in Culture, Health and Sexuality noted that practices like lobola, while they are culturally significant, can blind notions of consent, reinforcing ideas of ownership over women. Men need to be re-educated that, they don't have ownership over their wives and they cannot claim them as their property, marriage is an agreement between two people who decided to build their lives together, and start a family. Patriarchy is a double-edged sword, it demands that men must be confident, in control, must have money, and unyielding, yet punishes vulnerability. 'The 'macho male stereotype' expects men to 'man up' and adopt the 'boys don't cry' mentality,' says Dr. Talatala of the South African Society of Psychiatrists. This stigma drives men to suffer in silence, particularly in African contexts where stoicism is a cultural cornerstone. The legacy of apartheid adds another layer. A 2017 study by SAMRC noted historical disenfranchisement and systemic racism have left lasting mental health disparities, with white males overrepresented in suicide statistics due to access to lethal means like firearms. Meanwhile, Black men face unique pressures from intergenerational trauma and economic marginalisation, often without the resources to cope. As a new generation of men, we must rewrite this narrative. Real strength lies in vulnerability in reaching out and asking for help, in saying, 'I'm not okay.' By addressing men's mental health head on, we can dismantle the toxic norms that fuel despair and GBVF. Here's how: Expand Mental Health Access : Integrating mental health services into primary care is cost effective and scalable. Community based programs in low-income areas can reach men where they are, breaking cycles of untreated illness. Organisations like SADAG (0800 567 567) and LifeLine (0861-322-322) offer free counseling and should be amplified. Normalise Help Seeking : Public campaigns can shift perceptions, showing that vulnerability is strength. Social media, radio, and community events can share stories of men who sought help, inspiring others to follow suit. Decriminalising attempted suicide, as advocated by the Southern Africa Litigation Centre, would further reduce stigma. Address Root Causes : Implement policies tackling poverty, unemployment, and gender inequality, as highlighted in the 2020 National Strategic Plan on GBVF. Economic empowerment programs for men can alleviate the pressure to provide, while gender equality initiatives can challenge patriarchal norms. Join the movement. Share your story, support a friend, or reach out for professional help. The silent struggles of men are a crisis we can no longer ignore. If you're reading this and going through the most, you don't have to be alone. Talk. Cry. Pray. Reach out to someone, it could be a friend, a colleague or a pastor. You matter. By breaking the silence, we save not only men's lives but also the families affected by the ripple effects of untreated pain. Let's redefine strength, one conversation at a time, and build a future where no one suffers in silence. This is also a collective fight for men to heal, for women to be safe, and for South Africa to thrive. *Sandile Mlangeni is a 2019 GP-based Activator, he is passionate about youth activism. Sandile regards it as important to contribute his views and experiences to recognised entities seeking to develop communities. He started his journey as an activist in 2012 when he started collaborating with community-based organisations in his hometown in Tsakane and Kwa-Thema Ekurhuleni.
Mail & Guardian
16-05-2025
- Health
- Mail & Guardian
Hypertension in Africa: An Escalating Public Health Crisis
As the world marks World Hypertension Day on 17 May and observes May Measurement Month, the South African Medical Research Council (SAMRC) is calling on healthcare providers to make blood pressure checks a routine part of every patient visit. The SAMRC is also urging the government to integrate regular screenings into school health programmes, laying the foundation for a healthy generation and reducing the growing burden of hypertension in communities across the country. Hypertension, commonly known as high blood pressure, remains one of the leading risk factors for cardiovascular disease (CVD) and global CVD-related deaths. It causes a series of cardiovascular disorders, including ischemic heart disease, heart failure and stroke with 50–60% of strokes being attributable to elevated blood pressure. Clinically defined as a systolic/diastolic blood pressure ≥140/90 mmHg, hypertension affects an estimated 1.4 billion adults aged 30–79 worldwide, with more men likely to have hypertension than women before the age of 55. Over the past two decades, the burden of hypertension has shifted markedly from high-income countries (HIC) to low-and middle-income countries (LMICs) with nearly two-thirds of affected individuals residing in LMICs. Regions such as South Asia, parts of Latin America and sub-Saharan Africa (SSA) have seen particularly steep increases. In South Africa (SA), hypertension affects 48% of women and 34% of men, according to 2019 data. More worryingly, there is a rising prevalence of childhood hypertension, often linked to early life exposure as well as increased rates of overweight and obesity. This suggests a looming public health crisis, especially given the long-term cardiovascular risk associated with early-onset hypertension. Despite multiple calls to action strategic roadmaps from regional and international bodies, awareness, treatment, and control of hypertension remains suboptimal, both globally and in SA . A recent study by Dr. Lebo Gafene-Matemane reports that fewer than 10% of hypertensive men and only 13% of women in SA are aware of their condition. Among those diagnosed and treated, just 14–21% achieve adequate blood pressure control. Regarding childhood hypertension, there is a lack of African-specific blood pressure nomograms for children, and no adequate data exists to evaluate the long-term effectiveness of pharmacological treatment for high BP in children and adolescents. This is particularly concerning given the evidence that individuals of African descent often experience more severe hypertension phenotypes, requiring more aggressive treatment regimens. Yet regional variability is high, and factors such as rapid urbanisation, lifestyle transitions in rural communities, limited access to health education, and the obesity epidemic continue to fuel the disease burden, especially in SA. South Africa, already grappling with the quadruple burden of disease, infectious illnesses, non-communicable diseases (NCDs), maternal and child health issues, and trauma, faces a growing hypertension epidemic that threatens to overwhelm an already stretched healthcare system. The socio-economic consequences are substantial, including lost productivity and escalating healthcare costs. In response to this global crisis, initiatives like May Measure Month, a public health campaign spearheaded by the International Society of Hypertension (ISH), aim to raise awareness and increase screening. This effort underscores the importance of 'knowing your numbers,' as hypertension is often asymptomatic yet profoundly increases the risk of heart disease, stroke, kidney failure, and premature death. Once identified, lifestyle modification remains a cornerstone of management. Some evidence-based recommendations include: Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week (e.g., 30 minutes of brisk walking five days a week). Sleep: Prioritising 7–8 hours of quality sleep nightly. Stress reduction: Incorporating deep breathing, mindfulness, or social connection strategies. Dietary changes: Limiting salt and sugar intake, increasing hydration, replacing alcohol with herbal teas or sparkling water, and swapping sugary beverages for fruit-infused water. These accessible interventions can improve both blood pressure control and overall well-being. The 2024 European Society of Hypertension (ESH) guidelines present significant advancements in pharmacological management aimed at simplifying treatment regimens and adherence. In addition, according to the new guidelines, an aggressive blood pressure target of <130/80 mmHg is now advocated for most patients, to reduce CV events. Nevertheless, despite these interventions, a significant portion of hypertensive individuals struggle with uncontrolled blood pressure due to inadequate drug response, rendering them vulnerable to CVD events. As such, 'therapeutic trial and error' becomes a challenge as medications are based on a 'one drug fits all approach', but adjustments are needed as the individuals' comorbidities, diet, body mass index, and genetic makeup affect how one respond to antihypertensive medications. African populations, though genetically diverse, have historically been underrepresented in genetic studies, resulting in significant gaps in understanding the genetic basis of diseases within these communities. This lack of empirical data limits insights into how African individuals respond to various antihypertensive medications, leading to the widespread use of a 'one drug fits all approach'. Prof Rabia Johnson said that 'while standard hypertension therapies may be effective for the majority, a more personalised approach is critical for individuals with distinct hypertension subtypes that do not respond as expected. Addressing this gap through pharmacogenetic research can optimise treatment strategies, improve patient outcomes, and advance precision medicine for African populations. Although promising strides are being made, we remain a long way from achieving truly personalised medicine, making sustained research efforts in this area more important than ever.' We call on healthcare providers across South Africa to make blood pressure measurement a routine part of every patient visit. A simple check could save a life. Early detection and management are key to preventing long-term damage. We urge the South African government and Department of Health to integrate regular blood pressure screenings into school health programs. Early screening and education can build a generation of heart-healthy citizens and reduce the burden of hypertension in our communities. And to every South African, take charge of your health, get your blood pressure measured. Whether at a clinic, pharmacy, or community health event, knowing your numbers is the first step to controlling them. Together, we can beat hypertension, one blood pressure check at a time.
Daily Maverick
29-04-2025
- Health
- Daily Maverick
Surprising new study reveals alarming HIV death rates, challenging official statistics in South Africa
It is widely acknowledged among health and demographic experts that relying solely on what is written on death certificates does not paint an accurate picture of what people in South Africa are actually dying of. Now, an SAMRC study has provided evidence that the undercounting of deaths due to HIV might be even greater than previously thought. Many in health circles were surprised by a recent South African Medical Research Council (SAMRC) study that found that 23% of deaths in a nationally representative sample drawn from 2017/2018 were due to HIV. By comparison, Stats SA data for roughly the same period puts the figure at only 5.7%. That Stats SA's HIV mortality figure differs from other sources is not new and not in itself surprising. This is because Stats SA reports a relatively straightforward count of what is written on death certificates — where it is known HIV is often not indicated, even if it is the underlying cause of death. By contrast, the new SAMRC study looked at autopsy reports, death certificates, medical records, and interviews with next of kin to come up with its much higher estimate. The thing that did come as a surprise, is just how much higher the SAMRC figures were than anticipated. Previously, the real number of HIV deaths were thought to be around double the Stats SA number, rather than four times as much. For example, according to Thembisa, the leading model of HIV in South Africa and the basis for UNAids' estimates for the country, about 12% of deaths in the country in 2018 were due to HIV. 'Accurate mortality data are essential for informed public health policies and targeted interventions; however, this study highlights critical gaps in our cause-of-death data, particularly in the underreporting of HIV/Aids and suicides,' says Professor Debbie Bradshaw, study co-author and Chief Specialist Scientist at the SAMRC Burden of Disease Research Unit, in a media statement. (The study also found substantial under-reporting of suicide on death certificates.) Multiple data sources The study was conducted in three phases, examining deaths that were registered in 27 randomly selected health sub-districts between 1 September 2017 and 13 April 2018. In addition to the examination of autopsy reports, death certificates, and medical records, trained fieldworkers interviewed next of kin to conduct verbal autopsies using a World Health Organization (WHO) questionnaire that had been translated into the country's nine official languages. Based on these various sources of data, the cause of each death was categorised into one or more of 44 categories and then compared to the cause of death indicated on the person's death certificate. (The process for ensuring accuracy, including a review shared by a team of 49 medical doctors, is described in detail in this report.) The researchers collected data for more than 26,000 deaths, although not all types of data were available for each death. Medical records were available for more than 17,600 cases, forensic pathology (autopsy) records for 5,700, and about 5,400 verbal autopsies were conducted. In the end, 'to save costs', not all medical records were reviewed. Overall, for just over 15,000 deaths, the researchers could link and compare their assessment of why a person died to what was written on death certificates. 'Poor agreement' The researchers found that 'there was poor agreement between the underlying cause of death obtained from the study and the official cause of death data'. The cause of death was the same in only 37% of cases. In addition to the under-reporting of HIV, the researchers also identified 'severe under-reporting' of suicide as a cause of death. Some question marks As noted earlier, the new numbers are substantially higher than estimates from the highly respected Thembisa model. According to their data only 12% of deaths from mid-2017 to mid-2018 were due to HIV-related causes, with a further 9% of deaths occurring in persons with HIV but due to other causes. Dr Pam Groenewald, a co-author of the new study and also with the SAMRC, describes Thembisa as 'an excellent source'. She tells Spotlight they had a long discussion with the Thembisa researchers, 'but we weren't able to fully explain the differences'. The study authors cite several factors that might contribute to a higher proportion of HIV deaths in their study. Firstly, the weighted national causes of death validation sample aimed to represent the registered deaths in the country, and it was known that deaths in rural areas and child deaths were under-represented. Secondly, deaths that occurred in private sector hospitals were not represented. Groenewald says the HIV-linked deaths in private hospitals are 'definitely lower', but doubts they would have had a significant impact on their findings. One thing in favour of the study numbers is the fact that the cases they identified with HIV/Aids as the underlying cause of death were independently reviewed by clinicians. As Groenewald points out, they looked at medical records of people admitted to and who died in hospital, including CD4 cell counts and HIV viral loads. The suggestion is that if someone had a very low CD4 count and a very high HIV viral load at the time of death, then it is very likely HIV played a role in their death, unless of course they died of a clearly non-associated cause like injuries from a car accident. On the other hand, it might be argued that since HIV is very widely tested for in South Africa, it is more likely to appear on medical records than other less tested for diseases. Another interesting wrinkle is that the proportion of deaths from HIV/Aids from this study was higher than anticipated based on observed declines in adult mortality. It is widely accepted that the decline in adult mortality and the increase in life expectancy over the past two decades was driven by antiretroviral therapy keeping more people with HIV alive. While the new findings do not challenge this narrative, it does suggest the effect may be less pronounced than previously thought. What to do? The researchers suggest their study has immediate implications for the country's response to HIV and TB. 'The study recommends strengthening case finding, follow-up, prevention, and treatment for HIV, Aids and TB to reduce mortality rates, and underlines the importance of the government's rapid response to counter the recent abrupt withdrawal of Pepfar (American) funding,' Bradshaw commented in the media release. But more broadly, the findings put the spotlight on major problems in the country's death certification systems. 'Our findings highlight the need for improved record quality and adherence to testing guidelines within the medical community. Poor record keeping included incomplete documentation of clinical findings and results,' the study authors write. 'A lot of doctors' report HIV as 'retroviral disease', for example, and it's not coded as HIV,' Groenewald said. Urging doctors to record the actual underlying cause of death when writing up death certificates, she also called for improved training in death certification at medical schools. Doctors' reluctance to report HIV on death certificates probably has various reasons, including stigma related to HIV and the fact that some medical insurance policies used to exclude HIV, though policies now treat HIV like any other chronic condition. Overall, Groenewald said, we needed to step back and probe the rationale of compiling underlying cause of death statistics. 'The public health aim of the medical certificate of cause of death is to prevent premature deaths. We therefore need to record the cascade of events or causal sequence of medical conditions leading to death and target our interventions at the underlying cause of death. The coding rules focus on the underlying cause of death to compile the mortality statistics,' she said. Groenewald stressed that the law required doctors to provide accurate information on death causation. The Health Professions Council of SA's ethical rules also recognised that a statute requiring disclosure about a deceased person's health must be complied with and was not considered unethical. Contrary to common physician misconception, Groenewald said all this combined to show 'it is completely ethical to disclose on a death certificate that a person has died from an Aids-related illness'. In the meantime, routine mortality data from Stats SA should clearly be taken with a pinch of salt. As Groenewald pointed out, vital registration data should not be accepted at face value but should be interrogated and cross-checked with other data sources to get coherent and consistent estimates that fit within an envelope of all causes of mortality. DM
The Citizen
29-04-2025
- Health
- The Citizen
Why are some SA children still not vaccinated?
HPV vaccination, which can prevent cervical cancer and other related diseases, remains an essential but underutilised intervention. As the African Vaccination Week concludes on Wednesday, 30 April 2025, serious concerns remain about the number of South African children and adolescents not receiving life-saving vaccines. According to the South African Medical Research Council (SAMRC), efforts to increase vaccine uptake must urgently address the complex reasons behind vaccine hesitancy. This comes as the continent commemorates African Vaccination Week, observed from 24 April to 30 April, a time that highlights the crucial role of immunisation in preventing disease and saving lives across the continent. ALSO READ: Gauteng Health and EMS on high alert for Easter flood emergencies Deeper issues behind missed vaccinations Findings from two recent reviews by Cochrane South Africa (Cochrane SA), a unit within the SAMRC, highlight why some parents and caregivers do not vaccinate their children. According to the unit's specialist scientist, DR Sara Cooper, the reviews draw on global qualitative studies to identify the personal, social, and systemic barriers to vaccination. '[Our findings] highlight that effective public health interventions must go beyond simply providing access to vaccines. They must also address the broader context in which vaccine decisions are made,' Cooper said. While vaccines are widely recognised as one of the most effective tools to prevent serious illness and death in children, the research shows that poor caregivers may be deterred by poor access to health facilities, transport challenges, and unaffordable indirect costs. 'Others experience distrust in vaccination programmes due to broader political concerns or past negative interactions with health systems. 'Cultural and social norms, as well as individual health beliefs, also play a critical role,' Cooper noted. ALSO READ: Health MEC says Tembisa Hospital still operational after fire, confirms no injuries [PICS] HPV vaccine under threat The research also examined Human Papillomavirus (HPV) vaccination among adolescents. HPV vaccination, which can prevent cervical cancer and other related diseases, remains an essential but underutilised intervention. Cooper added that limited knowledge about the vaccine, confusion over decision-making roles in families, and cultural attitudes about adolescence, gender, and sexuality all contribute to low uptake. 'Caregivers and adolescents are also heavily influenced by extended social networks, media messages, and their trust (or lack thereof) in institutions such as schools, governments, and the pharmaceutical industry,' she said. ALSO READ: Flexicare brings affordable healthcare within reach for South African communities No one-size-fits-all solution Cooper cautioned against one-size-fits-all approaches. 'Some parents in high-income countries may resist vaccination due to a belief in individual choice and risk management that conflicts with public health messaging,' she said. However, in lower-income areas, social exclusion and unreliable public services foster distrust in health programmes. The specialist scientist highlighted that information campaigns alone are insufficient. 'The most common interventions only target a narrow range of concerns, mainly around knowledge and risk. Yet the actual reasons for hesitancy are far more diverse and nuanced,' she added. Cooper concluded by urging policymakers, researchers and programme implementers to engage more deeply with the communities they serve. 'Tailoring vaccination efforts to local realities — including cultural norms, access barriers, and trust dynamics — will lead to more relevant, acceptable, and ultimately more effective interventions.' NOW READ: Zam Buk: The winter go-to
