Longer lives – for some
Life expectancy in South Africa is increasing rapidly. Deaths from HIV and TB are declining because of the antiretroviral treatment programme and improved TB treatment outcomes. This is the essence of what we learn from two recent reports and a National Department of Health (NDOH) slideshow.
In March, Statistics South Africa (Stats SA) 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 rich data, a presentation by Norbert Ndjeka of the National Department of Health has been made available on the Health-e website.
The Stats SA publication reports the registered deaths in the country. It shows a continuing trend of declining annual deaths in South Africa. It estimates that well over 90% of adult deaths are registered but more time is needed to estimate the percentage of recorded child deaths.
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 declining. In 2011 there were about 505 000 deaths, about the same number as 2002.
In 1997, the median age of death was 51. This dropped steadily to a low of just under 43 in 2004, and then began increasing again. In 2011 it crossed 50 for the first time since 1997.
This good news is echoed by the MRC report. Monthly, since 1999, the MRC has collected the deaths registered on 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. As with the Stats SA data, the adult death data is much more complete than that for children. Various technical adjustments, beyond the scope of this article, have been made to the data.
“Survival rates are poor for DR-TB: nearly 20% of MDR-TB patients die of their illness.”
Using the census data to estimate the total population, the MRC calculates life expectancy at birth. The report states, ‘The estimates for 2012 show that the average life expectancy in South Africa has reached 61 years, an increase of seven years since the low in 2005.’ On average, women live 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 declined from 46% in 2009 to 38% in 2012.’
The report explains that this is because of a ‘significant decline in the mortality of those under the age of one, but it is also due to a decline in adult mortality, probably as a result of greater than expected roll-out of ARVs.’
Although not stated in the report, the decline in mortality in infants is likely because of the programme to prevent transmission of HIV from mother-to-child and because in recent years, guidelines have provided for infants diagnosed with HIV to start treatment immediately, which significantly reduces mortality.
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 and life expectancy has still not reached 1990s levels. The other worry is TB. It is the biggest cause of death in the country; mortality due to this disease rose through the late 1990s and 2000s because people with HIV are so prone to becoming deathly ill with it.
For the most part, the news on TB is improving. 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, even lower than in 2007. 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 this: In 2007 there were 7 350 confirmed cases of MDR-TB. This rose to 14 161 in 2012, of which fewer than half had started treatment, according to Ndjeka’s slides.
Data of interest
Interesting facts in the Stats SA and MRC reports include the following:
- Unnatural deaths (violence, suicides, accidents) were just under 46 000 in 2011, the lowest since at least 1997, the earliest year for which the report gives this statistic. The highest in this period was nearly 54 500 in 2007.
- Recorded diabetes deaths have been steadily climbing, reaching 21 612 in 2010. But in 2011, diabetes deaths
dropped slightly. Is this an indication that diabetes deaths, as a proportion of the population, have reached a plateau?
- The World Health Organization defines a maternal death as a woman dying while pregnant or within 42 days of the termination of pregnancy, from any cause related to the pregnancy, but excluding accidents or ‘incidental causes’. If that’s a mouthful, it’s edited; the actual definition is even wordier. It’s hard to estimate maternal mortality, in part because it’s hard to classify and also because the number of pregnancies and live births is not easy to calculate. Nevertheless, the MRC does its best. In 2008 there were 280 maternal deaths for every 100 000 live births. This rose to 304 in 2009 and then dropped to 269 in 2011. The Health Department’s target for 2014 is 252 per 100 000 live births. Whatever the real figure, maternal deaths are far too high.
For extensively-drug-resistant TB (XDR-TB), the number of laboratory confirmed cases rose from 85 in 2004 to 1 574 in 2011. There was a tiny drop in 2012.
Survival rates are poor for DR-TB: nearly 20% of MDR-TB patients die of their illness, and nearly half of those with XDRTB, according to Dr Ndjeka’s presentation. But it’s possible that these are underestimates. Mortality from DR-TB is hard to gauge and some studies report higher rates than this.
The number of DR-TB patients is still not large, based only on confirmed cases. The growth of drug-resistant TB is clearly happening. While there are new TB drugs in the pipeline and completely new TB treatment regimens on the horizon, progress is slow. In the meanwhile, people with DR-TB have to face about two years of treatment on drugs with awful side effects, including deafness, and limited evidence of efficacy.
Dr Ndjeka’s presentation shows the response to TB in Umzinyathi district in KwaZulu-Natal in a positive light. But, with a plethora of reports on stock outs, the NHLS is again in the news for being in financial crisis and for a multitude of problems in the health system. It is hard to be confident that we are adequately confronting the drug-resistant TB problem.