It’s sobering to reflect that “neglected tropical diseases” are referred to as “neglected” because they persist in the poorest, most marginalised communities even after being wiped out in more developed parts of the world.

A variety of pathogens, including viruses, bacteria, parasites, fungi and toxins, cause neglected tropical diseases, which include dengue, chikungunya, leprosy, lymphatic filariasis and yaws.

They inflict tremendous suffering because of their disfiguring, debilitating and sometimes deadly impact. Patients often experience stigma, social exclusion and superstition.

The good news is that there is reason for hope as some African countries have made significant progress in eradicating these diseases.

We have put together some essential reads from The Conversation Africa over the past year highlighting a scourge that still affects more than 1 billion people today.

Patients’ beliefs about illness matter

Would you take medication for an illness you didn’t believe you had? Or if you disagreed with healthcare workers about the cause of your condition?

This is the dilemma of many people who live in rural areas of Ghana where a mosquito-borne disease called lymphatic filariasis, often referred to as elephantiasis, continues to spread. Researchers found that only 18% of respondents understood lymphatic filariasis as a disease. Fewer than 7% believed it to be a disease spread by mosquitoes.

Instead, people held a range of alternative beliefs attributing the condition to spiritual causes (curses, witchcraft, evil spirits), cold or rainy weather, and other illnesses.

The team of experts, that carried out the research, suggest that understanding patients’ belief systems would help healthcare workers treat patients more effectively.

100 million Nigerians are at risk

A quarter of the people affected by neglected tropical diseases in Africa live in Nigeria. An estimated 100 million Nigerians are at risk for at least one of these diseases and there are several million cases of people being infected with more than one of them.

There has been progress, writes Uwem Friday Ekpo. By January 2023 the country had eradicated Guinea worm disease and two states had eliminated onchocerciasis.

One of the interventions was door-to-door visits by volunteers to administer medicines. Teachers also played a similar role when medicines were distributed in schools.

Leprosy, scabies and yaws: Togo’s neglected skin diseases

Skin conditions caused by some bacteria, viruses, mosquitoes or mites are common neglected tropical diseases.

Research in schools and rural areas in Togo, west Africa, found a large number of these infections including scabies, leprosy, yaws and Buruli ulcer.

These are stigmatised and can be difficult to diagnose. There are typically few, if any, dermatologists in areas where they are common. Children with these diseases often refuse to go to school.

Michael Head, Bayaki Saka and Palokinam Pitche suggest authorities make the treatment of these diseases free of charge. Health promotion and education are also critical.

Reasons for hope

Togo did have reason to celebrate though. In 2022 it became the first country in the world to have eliminated four neglected tropical diseases. The country stamped out Guinea worm disease in 2011, lymphatic filariasis in 2017, sleeping sickness in 2020 and trachoma in 2022.

It achieved its milestone through a combination of measures. These included door-to-door mass drug administration, training of healthcare staff, sustained financing and strong political support.

Other African countries also made significant progress in tackling neglected tropical diseases in 2022. Benin, Rwanda and Uganda managed to eliminate sleeping sickness. Malawi eliminated trachoma and the Democratic Republic of Congo eliminated Guinea worm disease.

But the global health community and African governments cannot rest on their laurels. There is still a long way to go, writes Monique Wasunna.

Cape Verde has been certified malaria-free by the World Health Organization.

The archipelago to the west of Senegal consists of 10 islands, and has a population of over 500,000 people. It is the third country in Africa to be declared malaria-free, after Mauritius (in 1973) and Algeria (in 2019).

This brings the total of malaria-free countries to 43 worldwide.

Achieving malaria-free certification is no simple feat. As specialists in malaria prevention and control, we explain Cape Verde’s long journey to eliminating the disease that killed over 600,000 people worldwide in 2022.

How Cape Verde achieved its goal

Malaria, endemic since settlement of the previously uninhabited islands in the 15th century, affected all 10 islands before 1950.

During the 1940s, malaria posed a serious health threat. Severe epidemics resulted in over 10,000 cases and 200 deaths annually until targeted interventions were implemented.

The country was close to eliminating malaria twice but these gains were not sustained.

Indoor residual spraying with DDT was done on each island until transmission ended nationwide in 1967. The residual effect of the insecticide helped kill mosquitoes over a longer period. Larviciding, the use of chemicals to target mosquito larvae at breeding sites, and active case detection were also undertaken.

The indoor residual spraying campaigns were stopped in 1969. The result was a recurrence of local transmission on Santiago island in 1973, followed by a large epidemic in 1977.

The second attempt to eliminate malaria started in 1978, and resulted in transmission interruption in 1983. Case numbers were maintained at low levels from 1989, confining malaria to Santiago and Boa Vista islands. But by 2006, rising cases threatened tourism.

A political decision was made to boost nationwide elimination efforts. This led to a change in the country’s national health policy in 2007.

The focus was on expanded diagnosis, early and effective treatment, and management of all cases.

Cape Verde was on track to eliminate malaria, but in 2017 recorded its “worst malaria outbreak” since 1991 with 423 cases.

The outbreak prompted a strategy adjustment. A refocusing on vector control, targeting affected neighbourhoods and malaria infection-prone communities, prevented increases in cases. Transmission was successfully interrupted for four years.

Process to get certified malaria free

The WHO reported 249 million malaria cases and 619,000 malaria-related deaths globally in 2022.

The African region accounted for 94% of all cases and 96% of all deaths.

Achieving malaria-free status highlights a nation’s determination and commitment. Countries must meet the WHO’s stringent criteria to reach this goal. Firstly, there must be zero indigenous (locally) transmitted cases of malaria for at least three consecutive years.

Secondly a country must show that it has the ability to prevent reintroduction of disease transmission.

Only then may countries request certification from the WHO, working with regional offices to develop a certification plan and timeline.

If a country fails, it can reapply after three years.

To maintain malaria-free status, countries must continue to prevent transmission and submit annual reports to the WHO.

Predictions for the next countries to take the leap

The WHO’s E-2025 initiative focuses on 25 countries targeting elimination by 2025.

Belize achieved elimination in 2023. Malaysia reported zero local transmission for the fifth consecutive year, while Timor-Leste and Saudi Arabia achieved two consecutive years without local transmission (2021 and 2022). If maintained, they may be declared malaria-free soon. For the first time, both Bhutan and Suriname reported zero indigenous cases in 2022.

In the Africa region, several countries reported significant reductions in indigenous transmission in 2022. These included Botswana (43.5%), Eswatini (57.6%) and South Africa (31.3%). The Comoros saw a doubling in cases in the same year. São Tomé and Principe noted a 46% increase.

Despite country efforts, extreme climate events and cross-border movement may have an impact on transmission or recurrence.

Attaining certification holds importance, and Cape Verde’s success will drive positive development in the country.

Tourism plays an important role in the country’s economy. It accounted for a substantial share of the country’s GDP pre-COVID (24%), formal employment (10%), and the majority of foreign investment. Malaria-free status can potentially draw more visitors to the country.

The infrastructure established for malaria elimination has bolstered the country’s health system. This can be beneficial against other mosquito-borne diseases such as dengue fever, which also affects tourism.

A country’s “personal” milestone can help drive global malaria elimination efforts. Cape Verde’s achievement is a call to action for the malaria community to not give up. We must push harder to end malaria for good.

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

In 1992 a group of academics from the University of the Witwatersrand introduced a health and socio-demographic surveillance system in remote, rural South Africa to track and understand health and wellbeing in these environments. This initiative built on pioneering work by a Wits team to establish a health systems development unit in a typical rural setting. Agincourt, in the Bushbuckridge district in rural north-eastern South Africa adjacent to Mozambique, was a microcosm of the neglected health and socioeconomic systems in rural areas during apartheid.

The Agincourt research centre now covers some 31 villages and 120,000 people. It is one of the longest-running research centres of its kind in sub-Saharan Africa, attracting multidisciplinary scholars and researchers from around the world. The scale of data collection has led to groundbreaking research in many fields, including genomics, HIV/Aids, cardiovascular conditions and stroke, cognition and ageing. Stephen Tollman and Kathleen Kahn talk to Nadine Dreyer about what makes this Wits and Medical Research Council Unit different, particularly its focus on health and ageing.

Why is this work so important?

Before the end of apartheid in 1994, healthcare provision was skewed towards a minority population who represented only 13% of the country’s people. Healthcare for the majority of South Africans was woefully neglected.

As academics focusing on public health we wanted to understand rural South Africa, the people living away from the hospital, away from the train line, away from the supermarket or the town. Key to this was establishing a relationship of mutual trust and understanding between ourselves and those communities.

Drawing on early experiences with community-oriented primary care, we resolved to establish a longitudinal research and development platform. Today it covers some 31 villages in the Bushbuckridge area 500km from Johannesburg. This involved recording every member of every household – residents and temporary migrants.

We gathered valuable data on age, sex and gender, household type and income – producing a robust population “denominator”. To better understand evolving population dynamics, local field staff walked house-to-house meeting residents and recording data on vital events: who is born, who dies, who moves. In other words births, deaths and migrations.

We apply a simple concept called “person years”. At baseline, and with their consent, a person is enrolled. After five years, the person will have been there for five “person years”. Given a population of some 120,000 people, all followed up (including labour migrants) over 30 years, we can analyse and interpret data in a way that is not really possible with one-off, cross-sectional studies.

Today, the data generated over the past couple of decades is enabling work that was not possible in the early years.

In 2013 a project was launched to focus on ageing. Why?

Health and Aging in Africa: Longitudinal Studies in South Africa (Haalsa) was started to build understanding of the social, economic, biological, behavioural and mental health features that characterise rural people aged 40 years and above.

Ageing is not only about old people; it starts at birth, even earlier, because experiences at key periods influence a person’s life.

Some time ago, we noticed a reversal in mortality was under way. People were dying at a younger age during the height of the HIV/Aids epidemic.

For women living in Agincourt, life expectancy dropped from about 74 years in 1993 to around 57 years in 2005, a loss of 17 years. For men, it dropped from about 68 years in 1993 to 50 years in 2007.

As a result, fostering orphans became a norm. The importance of the older generation – especially of women – stood out. Far from seeing older adults as simply requiring healthcare and support in their later years, it became clear that older rural women played fundamental roles in childcare and household food security.

Of course men were involved too, but because of the way in which apartheid was engineered, women were generally expected to remain in the rural reserves while men migrated to work in the mines and cities.

What makes research in Agincourt so interesting and relevant is the rapidly changing socio-economic profile of the area.

Today we see an increase in life expectancy thanks largely to the widespread uptake of antiretroviral therapies for HIV/Aids. For women, life expectancy had returned to around 70 years by 2013. For men it had increased to around 61 years by 2013.

This means that South Africa is also a “greying society” and more people face an increased risk of developing multiple chronic conditions along with cognitive impairment associated with growing older.

The changes in older people kick in far earlier in situations of adversity. In all probability, signs of ageing you might encounter in a 65-year-old in a high-income country would start to manifest in people aged 45 to 50 in situations of pervasive poverty.

What stands out when you look back over 30 years?

When Agincourt started, life was very different.

In the early 1990s when we worked in a small suite of offices at Tintswalo Hospital, there was simply a “wind-up” phone in the entrance to the unit. Now we’re all on email and using mobile phones.

Bushbuckridge has become the land of the shopping mall. Even a person living in what previously was talked about as a deep rural area can now easily reach a mall by taxi or walking.

The pace of social change has been extraordinary.

There’s tremendous poverty. But people are spending money. Some of it may be on credit, some may be earned income or from other sources.

The proportion of households with dwellings built with either brick or cement walls increased from 76% in 2001 to 98% in 2013. The use of electricity for lighting and cooking respectively increased from 69% and 4% of households in 2001 to 96% and 50% of households in 2013.

Migrant labour today involves large numbers of women, especially younger adults.

Our research identified a high prevalence of HIV/Aids among older people. As a result we piloted a home-based testing option for middle-aged and older adults, with promising results.

We are seeing an association between formal education and cognition. At a population level, formal education protects against conditions like dementia later in life – an insight that is important in an area with historically poor educational opportunity and attainment.

Another surprising – and welcome – finding is that levels of hypertension are falling. This is especially encouraging because sub-Saharan Africa is in the midst of a profound health transition with infectious diseases paralleled by rapidly rising cardiometabolic conditions.

Despite all these changes, we’re still asking the question that’s guided us from the start: How do you build flourishing societies in a context where jobs are scarce, migrant labour is deeply embedded, but where aspirations and the desire to live a life of meaning are evident?

Stephen Tollman receives funding from the SAMRC, Dept of Science and Technology SA, National Institutes of Health USA, UK Medical Research Council, and, previously, Wellcome Trust UK. He is affiliated with the SA Population Research Infrastructure Network and INDEPTH Network of population-based health and socio-demographic information systems.

Kathleen Kahn receives funding from the South African Medical Research Council, Dept of Science and Innovation SA, and the National Institute on Aging, USA.

Nearly half of South Africa’s 60 million people receive social grants, ranging from child support to pensions. The grants are designed to provide financial assistance to people living in poverty.

The largest components of the South African social grant system were introduced, or expanded to include the full population, in the 1990s. Since then, the system has evolved into one of the most comprehensive in the global south.

In addition to their direct financial benefits, the grants have been found to have a wide range of positive effects. These include improvements in child nutrition and education, and increased participation of women in the labour force.

But the effects of social grants on the health of older adults have not been extensively explored. Until now.

Across a series of recent studies conducted as part of an extensive research project in a rural part of South Africa, we have established that social grants can help older South Africans protect their cognitive health and live longer. Cognitive health is the ability to clearly think, learn, and remember.

Using our collective expertise into cognitive and population health, we studied the health effects of three different cash transfer programmes in a sample of 5,059 adults 40 years and older in rural Mpumalanga province.

Our results consistently found strong and positive effects thanks to these programmes.

Older people will make up a much bigger portion of South Africa’s population over the next 20 years. Our results provide good news about a social intervention programme the country already has in place to promote health and well-being among older adults.

How we did the studies and what we learnt

The Agincourt Health and Demographic Surveillance System has been collecting data on more than 120,000 people living in 31 villages in north-east South Africa since 1992.

This rural campus of the University of the Witwatersrand was established to track and understand health and well-being in these rural environments.

The Agincourt project is also a platform for other studies to collect more detailed information on certain community members.

We used data from an experimental cash transfer trial within the larger Agincourt research platform that paid monthly cash transfers to households from 2011 through 2015 and compared them to control households with no payments. Just over 2,500 households originally enrolled in the trial. Monthly payments of R300 were split between a school-age female and her caregiver.

We also used data from Health and Aging in Africa: Longitudinal Studies in South Africa. This is a smaller Agincourt cohort of 5,059 men and women aged 40 and older with detailed information on memory function and dementia probability collected every three years from 2014/2015 through to 2021/2022.

We tested whether being in the group that received the cash transfers led to better cognitive health later in life, up to seven years after the trial concluded.

We found that people who received the cash were better off than those who did not. They had slower ageing-related memory decline and lower dementia probability in 2021/2022, the most recent wave of data collection.

For some groups, we also observed an impact on mortality. In those who were relatively better off at baseline with regard to education and wealth, the addition of the cash transfer led to significantly reduced risk of mortality.

In a second study we examined the impact of the older person’s grant, a public pension, on men’s later-life cognitive health.

From 2008 to 2010, the older person’s grant expanded its age eligibility for men from 65 to 60 years. This meant that men aged 60 through 64 at the time of expansion were newly eligible for between one and five “extra” years of pension income prior to turning 65.

Women had always become eligible at 60 years of age, so they were not included in this analysis.

We found that men who received the full five extra years of pension income eligibility had significantly better cognitive function than expected if the grant had not expanded its eligibility.

We also observed a “stair step” pattern, where cognitive function was progressively better for each extra year of pension eligibility.

In our final study, we examined the impact of the child support grant on women’s later-life cognitive health.

When the child support grant was introduced in 1998, it was available only for children under seven years old. Since then, a series of policy changes expanded the ages that children were eligible for the grant, eventually rising to age 18 in 2012. These expansions over time mean that two women with the same number of children could have had access to very different amounts of child support grant income, depending on when those children were born.

Consistent with what we found for the older person’s grant expansion, higher access to child support grant income was associated with higher later-life cognitive function for maternal beneficiaries of the grant.

Looking forward

Our results so far clearly point to the benefits of South Africa’s social grant programmes for older adults as they are currently structured.

They suggest that as South Africa ages in the upcoming decades, sustained investments in these programmes will pay off in better health and well-being of the country’s most vulnerable older adults.

Molly Rosenberg receives funding from the United States National Institute on Aging of the National Institutes of Health (grant number R01AG069128)

Lindsay Kobayashi is supported by the National Institute on Aging of the US National Institutes of Health (grant numbers R01 AG069128 and R01 AG070953).

Chodziwadziwa Whiteson Kabudula and Kathleen Kahn do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

In 2021, almost 33 of every 1,000 South African children under five years old died.

This under-five mortality rate is far worse than in similar middle-income countries such as Brazil (14.4 per 1,000 births), Cuba (5 per 1,000), India (30.6), Indonesia (22.2) and Egypt (19.0).

South Africa’s under-five mortality rate also lags behind the UN’s Sustainable Development Goal of reducing these figures worldwide by 2030 to 25 deaths per 1,000.

Significant progress has been made. In 1994 South Africa’s under-five mortality rate was 60.4 per 1,000. The government’s Expanded Programme on Immunisation was one health intervention that made a difference.

However, inequalities persist. The underfunded public health sector has been stretched to serve 71% of the population.

Worldwide, many people, particularly those in rural settlements, depend on medicinal plants for their health. In August 2023, the World Health Organization held the first global summit on traditional medicine, in India.

As researchers with an interest in indigenous knowledge, we explored the use of medicinal plants as remedies against diseases among children in the North West province of South Africa.

Of the province’s population, 49.2% live below the poverty line with no access to proper housing, water and sanitation. These conditions have an impact on children’s health.

Despite the high reliance on traditional medicine by rural populations, the role of medicinal plants for the treatment of childhood diseases remains speculative and lacks systematic documentation.

Our study yielded the first comprehensive inventory of medicinal plants and indigenous knowledge related to children’s healthcare in the area.

In total, 61 plants from 34 families were recorded as medicine used for managing seven categories of diseases. Skin-related and gastro-intestinal diseases were the most prevalent childhood health conditions encountered by the study participants.

Capturing local wisdom

Evidence shows traditional health practitioners continue to play an important role in managing childhood illness in sub-Saharan Africa.

South Africa is endowed with a rich wealth of flora and is often acclaimed as a biodiversity hotspot. Thousands of plants are used for traditional medicine for the management of diverse health conditions.

In the North West, we interviewed 101 participants, including traditional health practitioners, specifically those with expertise in managing and treating diseases among children, and herbal vendors operating in the selected study areas.

Gender distribution among the participants was 78% female and 21% male. This signifies the importance of women as active custodians of indigenous knowledge related to childhood health needs.

Of the participants, 63% had completed a secondary level of education, 21.8% had no formal education and 5% had attended primary school. Although 79% of the participants lived in villages, 15.8% were based in urban areas.

The participants were asked which plants they used to treat children. Of the 61 plants identified, 89% were recorded for the first time as botanicals used for childhood-related diseases by traditional health practitioners.

Carpet plant (Geranium incanum), common yellow commelina (Commelina africana) and elephant’s root (Elephantorrhiza elephantina) were the most popular medicinal plants.

Carpet plant was used as a treatment for diverse health problems such as umbilical cord conditions, muscle fits, measles, weight loss and appetite loss.

Common yellow commelina was used as a remedy to treat skin conditions, while elephant’s root was used to treat gastrointestinal and skin diseases.

Roots and rhizomes were the parts most frequently used as treatments (40%), followed by leaves (23%) and whole plants (20%).

Boiling plants or softening them in liquid were the main preparation methods. The plant remedies were mainly administered orally (60%) and used on the skin (39%).

The study also confirmed there are similarities in indigenous practices, techniques and plant matter for specific conditions that were previously reported in other provinces: KwaZulu-Natal and the Eastern Cape.

The way forward

There is increasing support from governments for promoting traditional medicine as part of primary healthcare in African countries such as Cameroon and South Africa.

We recommend that:

Government provide institutional and financial support to determine the role of herbal medicine in primary healthcare. Working with traditional health practitioners, medicinal plants must be documented and testing laboratories need to be set up to establish their efficacy and to determine appropriate dosages.
Botanical gardens should be created to ensure the sustainability of plants and their continued role in providing much-needed medical care. In the North West province, 40% of the ecosystems are under severe stress, with 11 of the 61 vegetation and 14 of the 18 river types classified as threatened. Medicinal plants are mostly harvested from the wild, so it’s possible that many could face extinction from uncontrolled harvesting.

Tshepiso Ndhlovu received funding from the National Research Foundation Pretoria, South Africa (NRF; Thuthuka Grant (UID: 121525), and nGAP programme for funding this study. He is a member of the South African Association of Botany (SAAB). We are grateful to our participants for their willingness to be part of this study. We extend our sincere gratitude to the North West Dingaka Association, Traditional Council (Barolong Boo Rra Tshidi) for granting permission and access to conduct this study, and the North West Department of Economic Development, Environment, Conservation, and Tourism for the plant collection permit. We appreciate the support from the South African National Biodiversity Institute (SANBI), Pretoria, for assisting with plant identification and Ms Almari Van Niekerk for creating the map.

Abiodun Olusola Omotayo receives funding from The Climap Africa programme,German Academic Exchange Service (DAAD-Grant Ref: 91838393), Germany and the National Research Foundation’s (NRF), Incentive Funding for Rated Researchers (Grant number: 151680), South Africa.

Adeyemi Oladapo Aremu receives funding from National Research Foundation, Pretoria, South Africa. He is a member of the Global Young Academy (GYA), Young Affiliate of the African Academy of Sciences (AAS) and South African Young Academy of Science (SAYAS).

Wilfred Otang-Mbeng receives funding from the National Research Foundation, South Africa (Grant # 135452)

South Africa continues to have a high prevalence of HIV among all age groups. About 8.2 million people or 13.7% of the population live with HIV, one of the highest rates in the world.

The country also has one of the world’s most impressive antiretroviral therapy programmes. Over 5 million people living with HIV are currently on chronic treatment. Widespread access to antiretroviral therapies since 2008 has led to millions of people ageing with chronic HIV infection. Consequently, people with HIV are older on average than they were just a decade ago.

Most HIV prevention and treatment programmes and policies in South Africa remain focused on adolescents and young adults. A growing group of middle-aged and older adults with HIV, or at high risk, are being left behind.

To date, there has been little research about sexual behaviour, risk of HIV transmission, HIV stigma and HIV prevention for adults over 40 years old.

The Health and Aging in Africa: Longitudinal Studies in South Africa study – or Haalsa as it is commonly known – is an exception to this trend. It seeks to better understand both the risk of getting HIV and the health of ageing adults with HIV in South Africa.

This project, a collaboration between the University of the Witwatersrand and Harvard University, has followed a cohort of over 5,000 adults older than 40 in the Agincourt region in north-east South Africa for more than 10 years.

Throughout this decade of research, the team has been gaining a deeper understanding of this “greying” HIV epidemic. Numerous important insights about HIV in older populations have already been achieved. Here we present some of the findings.

Sexual activity is common

Research conducted in 2017 uncovered a high prevalence of HIV in this older population. Nearly 1 in 4 people over 40 years old were living with HIV.

The study found that 56% of respondents, across all HIV status categories, had had sexual activity in the past 24 months. Condom use was low among HIV-negative adults (15%), higher among HIV-positive adults who were unaware of their HIV status (27%), and dramatically higher among HIV-positive adults who were aware of their status (75%).

In another investigation in this cohort, the team found that over the period from 2010 to 2016 the incidence rate of HIV for women was double that of men.

Feeling the stigma

There are relatively few studies of HIV-related stigma among older adults, despite the increasing number of older adults living with HIV.

The majority of research excludes, or ignores, age as a variable. Understanding HIV-related stigma in older adults remains crucial and can inform interventions to support their mental health and overall well-being.

Our research suggests that social stigma poses a significant barrier to testing behaviour among older adults. A quarter of our respondents reported social stigma related to HIV infection.

This stigma was found to have important implications for HIV care: those experiencing high social stigma were less likely to engage in HIV testing and less likely to be linked to treatment.

A recent pilot study examined home-based HIV testing options for older adults and showed a preference for self-testing. More privacy may encourage more adults to establish their HIV status.

Treatment targets

Haalsa is uniquely positioned to understand how older adults with HIV are faring in terms of achieving HIV treatment targets, including viral suppression.

In 2014-2015, 63% of older adults with HIV in the study were taking antiretroviral therapy and 72% of those on therapy were virally suppressed. More recent updates have suggested that as of 2018-2019, many more older adults with HIV were virally suppressed.

To further highlight the critical importance of viral suppression for healthy ageing, the Haalsa team explored the impact of viral suppression on life expectancy in older adults.

Here, they found large gaps in life expectancy based on viral suppression status: a 45-year-old man without HIV could expect to live about another 27 years; a man with virally suppressed HIV could expect to live 24 years. One with unsuppressed HIV could expect to live 17 years.

Similarly, a woman aged 45 without HIV could expect to live another 33.2 years compared with 31.6 years longer for a woman with virally suppressed HIV. A woman with unsuppressed HIV could expect to live a further 26.4 years.

Looking to the future

Taken together, these new insights are critically important to inform the design of interventions and policies to ensure healthy ageing in South African society, and particularly among those with or at high risk of HIV.

Tailored strategies to prevent new HIV infections, awareness programmes and support to ensure that more people living with HIV in older age groups achieve and maintain viral suppression are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.

Jen Manne-Goehler receives funding from the US National Institutes of Health.

Julia Rohr receives funding from National Institute on Aging of the National Institutes of Health (NIH).

Till Bärnighausen for this work my institution has received a grant from the National Institutes of Health/National Institute of Aging (NIH/NIA), which is the HIV component NIH/NIA of the overarching NIH/NIA HAALSI Unrelated to this work, I also receive funding from a wide range of public science funders, including the NIH (other institutes), the German National Research Foundation , the European Union (within the Horizon science funding programme, the Alexander von Humboldt Foundation, the Volkswagen Foundation, the German Federal Ministry of Education and Research, the German Federal Ministry of the Environment, Wellcome (the British Medical Research Foundation), and the Else Kröner Fresenius Foundation.

Francesc Xavier Gomez-Olive Casas, Kathleen Kahn, and Nomsa Mahlalela do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Farmers often use antibiotics to keep their livestock healthy. They’re sometimes used as “quick fixes”, to avoid more costly management measures like regular disinfection, waste management, routine vaccination or provision of clean drinking water.

Animal husbandry now accounts for about two thirds of the global consumption of antibiotics. As livestock and fish production grows, by 2030 the consumption of antibiotics is projected to increase by 67%.

Worryingly, this overuse in food animal production can create problems for both animals and people.

It can contribute to the development of antibiotic-resistant bacteria which, through food or environmental exposure such as drinking contaminated water, can be transmitted to people.

This means that some antibiotics may become ineffective in treating human infections. Antibiotic resistant infections are associated with 4.95 million deaths globally every year. Sub-Saharan Africa accounts for 22% of these.

Similarly, animals can also become infected with antibiotic-resistant bacteria. This leads to infections that are difficult or impossible to treat.

Our latest study, which focused on the central Kenyan highlands, looked at antibiotic use on smallholder dairy farms as well as antibiotic quality (substandard or counterfeit antibiotics).

Kenya is one of the largest milk producers in Africa and one of the countries with the largest per capita consumption of milk. About 80% of the milk produced in Kenya comes from smallholder farmers.

We found that smallholder farmers weren’t using antibiotics properly and were buying poor quality products. Also, traces of some antibiotics were found in milk.

This puts the health of both people and animals at risk.

Antibiotic access and use

For our study, we collected data from 248 dairy farms and 72 veterinary drug stores between February 2020 and October 2021. This included milk samples and the antibiotics themselves.

Most dairy farms surveyed reported using antibiotics at least once in the past year. This is not unusual – cows get sick. Dairy cows are especially prone to getting udder infections.

Antibiotics were used to treat and to prevent infections. Most were obtained through animal health service providers. A small number (6%) were bought directly from veterinary drug stores or other farmers.

Antibiotics were often sold without a prescription, and based on farmers’ own diagnosis. These are imprudent practices – the wrong antibiotic could be used to treat an infection or antibiotics could be overused.

The improper or excessive use of antibiotics in dairy farming can lead to the development of antibiotic-resistant bacteria. This then leads to economic losses for farmers, because animals will be less productive and the cost of treatment will grow.

It’s estimated that, as a result of antimicrobial resistance, livestock output could fall by 11% by 2050, with the highest decline in low income countries.

There’s also the risk of these antibiotic-resistant bacteria being transmitted to humans, either directly through contact with animals or indirectly through the consumption of milk and dairy products. This can lead to infections that are difficult to treat, posing a public health risk.

Antibiotics found in milk

Also worrying, in this study we detected nine antibiotics in milk. Three samples exceeded global standards. Antibiotics can get into milk supplies when withdrawal times are not strictly followed.

The presence of antibiotic residues in milk – even at low levels – can pose health risks to consumers, particularly those who are allergic to specific antibiotics.

Even for those who aren’t allergic, prolonged exposure to low levels of antibiotics may contribute to the development of antibiotic-resistant bacteria.

Quality of antibiotics

The study also examined the quality of antibiotics available in veterinary drug stores in central Kenya.

Poor quality, substandard, or counterfeit antibiotics can lead to ineffective treatment and prolonged illness. Low-quality antibiotics are even more likely to contribute to the development of antibiotic-resistant bacteria. This is because they won’t fully eradicate the pathogen (disease-causing bacteria), allowing them to adapt and become resistant.

Almost 44% of the antibiotics we tested were of poor quality. This has considerable implications for the efficacy and safety of these drugs. It can also contribute to antibiotic resistance.

Implications

The findings of the study underscore the need for better management practices on Kenya’s dairy farms. This includes:

stricter regulation of antibiotic sales
improved veterinary oversight
education of farmers about the risks of antibiotic misuse.

For a country like Kenya, where agriculture plays a significant role in the economy, ensuring livestock is healthy and productive is crucial for both farmers and the country.

We recommend a few steps for policymakers to take:

strengthen regulations around antibiotic use in livestock
enhance surveillance and monitoring systems for antibiotic residues in milk
improve the quality control of antibiotics sold in veterinary drug stores
educate farmers about the responsible use of antibiotics
promote better animal husbandry practices that reduce the reliance on antibiotics.

Dishon Muloi receives funding CGIAR Trust Fund, the Fleming Fund, the German Federal Ministry of Economic Cooperation and Development, and the Danish International Development Agency.

Arshnee Moodley receives funding from the CGIAR Trust Fund, the Fleming Fund, the German Federal Ministry of Economic Cooperation and Development, Danish International Development Agency, and International Centre for Antimicrobial Resistance Solutions.

Worldwide in 2020 a baby died every 40 seconds because of complications of prematurity. Preterm birth is the leading cause of death among children under 5 years old.

The burden of preterm birth is heavier in in low- and middle-income countries, where around 80% occur. The countries with the highest recorded preterm rates in Africa are Malawi, South Africa, Ethiopia, the Democratic Republic of Congo and Botswana. In Ethiopia 12.9% of babies were born preterm in 2020. In Nigeria the figure was 9.9%.

Preterm birth occurs when a baby is born before 37 weeks’ gestation. Preterm babies are more at risk of severe neurological problems, like cerebral palsy, poor lung function and long-term problems with their guts. But around 95% of babies born preterm are born after 28 weeks. They often survive with relatively less complex medical interventions.

Given the scale of the problem, the preterm birth committee of the International Federation of Gynaecology and Obstetrics selected five key interventions known to save lives.

We co-authored a recent paper in which we discussed the five measures. There are many other interventions that may improve outcomes at the time of labour and after preterm birth. But the five selected are clinically effective and relatively inexpensive options that can be practised in most settings.

Five interventions

The five interventions are:

1.) Giving a course of steroids before the baby is born. This triggers changes in the baby’s lungs, allowing them to expand, and so makes breathing easier. Additionally, it reduces the risk of brain bleeds, bowel complications and death.

A study run by the World Health Organization in low- and middle-income countries estimated 370,000 babies could be saved each year if steroids were administered.

The drug is on the WHO List of Essential Medications. It is relatively easy to administer and carries a low risk of causing the mother any problems. It is also heat stable and does not require refrigeration, which is very important for environments where electricity is in short supply.

2.) Mothers can be given magnesium sulphate soon before delivery. This is known to stabilise cell membranes in the baby. This protects neurons and therefore reduces brain damage. Magnesium sulphate given to a mother in preterm labour can be lifesaving.

This drug is also on the WHO List of Essential Medications and appropriate for low income environments.

3.) Delayed cord clamping for at least a minute postnatally at delivery.

When a baby is born their umbilical cord is clamped and then cut. However, a delay of around a minute before clamping is associated with a reduction in neonatal death. It also reduces the need for medications to support blood pressure in the baby – something that cannot be offered outside highly specialist medical facilities.

4.) Encouraging breast feeding within one hour of delivery.

Breastfeeding is particularly beneficial for premature babies, reducing the risks of serious complications of prematurity like severe infection or a serious bowel condition called necrotising enterocolitis that often requires surgery as a lifesaving measure.

5.) Strongly encouraging immediate “kangaroo care”.

Kangaroo care involves a baby being placed skin-to-skin on the chest of its mother or another family member for extended periods of time – at least eight hours a day, but for as long as possible.

Premature babies are very prone to getting very cold. Kangaroo care reduces the risk of death. This has been found to be the case even if there aren’t other options to stabilise the baby.

Kangaroo care also reduces the risk of infection and improves rates of breastfeeding.

Beyond the benefits for the baby, both kangaroo care and breastfeeding play an important part in involving parents in the care of their infant, and in reducing rates of maternal postnatal depression.

The risk of postnatal depression is known to be higher following a preterm birth.

Looking to the future

All these interventions have a track record of being effective in low- and middle-income settings. But there has been no coordinated effort to make them better known worldwide.

Using multimedia and other training methods, the FIGO PremPrep-5 initiative provides initial training to national obstetrics and gynaecology societies so that they can pass on the skills to other professionals.

Five simple ways to prevent preterm deaths.

A baby’s first 1,000 days, from the time of conception until their second birthday, is a crucial window of opportunity to optimise their potential– through healthy nutrition for the mother during pregnancy, and then for the child after birth.

Undernutrition during this early period can cause stunting, which has major health and social effects later in life. Stunted children may never reach their full potential, and may suffer from obesity and related diseases for the rest of their lives. This costs the individual their health and their future, and costs governments billions in healthcare spending.

Many studies have shown that pregnancy support grants or vouchers improve women’s nutritional status and their ability to access and benefit from antenatal care. Globally, around 41% of mothers with newborns receive a maternity benefit of some kind. This rises to more than 80% in Europe and Central Asia, but drops to 16% in Africa.

Currently, pregnant women in South Africa receive no such benefits. The child support grant, which amounts to R510 (approximately $27) a month, is only paid after a child is born and has a birth certificate.

In South Africa, more than a quarter of children under five (27%) are stunted. Improving pregnant women’s nutritional status – and thus the health of their babies – should be high on the list of priorities for South African policymakers. It would contribute to ending childhood malnutrition, reducing poverty and unemployment and raising future generations of healthy, productive children who, as adults, will drive economic growth.

As health economists we wanted to establish whether extending the child support grant to pregnancy would be cost effective for the South African government.

Our research found that it would decrease healthcare costs by R31,200 ($1,600) per baby over the first 1,000 days of life, largely as a consequence of mothers attending antenatal care more regularly and reduced neonatal complications.

Applied to the whole population, this would save the government about R14 billion (US$720 million) over the first 1,000 days of children’s lives.

Mothers in need

A large proportion of pregnancies in South Africa (69%) occur in impoverished households. Almost half of all pregnancies (46%) occur in female-headed households. More than one third (35%) of pregnant women run out of money to buy food, and one quarter of them (25%) experience hunger.

Given that 13 million children now receive the child social grant, the number of mothers potentially eligible for a pregnancy support grant is likely to be sizeable.

Making healthy food choices

A 2021 pilot study by GrowGreat, an organisation dedicated to achieving zero stunting by 2030, gave 2,618 poor pregnant women in the Western Cape province a R300 ($15.40) digital food voucher every two weeks for 16 weeks and showed that the women used the grant money to buy nutritious foods.

The pilot also highlighted the grant’s psychological benefits. Having the power to make healthier food choices for themselves and their unborn babies not only relieved their financial burden but also gave them hope for the future.

Policy on a pregnancy support grant

A pregnancy support grant has already been proposed by the SA Law Reform Commission and would prioritise support for the most impoverished and vulnerable people.

Some people argue that the child support grant encourages women to get pregnant. Numerous studies have shown that this is not the case. In fact, many women with children who need the grant do not access it – especially teenagers.

Across the globe low- and middle-income countries, such as India, Bangladesh, Mexico, Nepal, Nigeria, Kenya and Brazil, have tried to address the financial burden placed on pregnant women by providing them with pregnancy support grants. These studies found that such grants promote weight gain during pregnancy, reduce maternal anaemia, increase access to services during pregnancy and childbirth, reduce maternal mortality, and prevent low-birthweight births and infant mortality.

Benefits of extending the child support grant into pregnancy have the potential to enhance the lives of families and communities as well as individual children and save the South African government billions. The knock-on effects in terms of hope, motivation, learning and employment of women – and thus for the economy – are likely to be immense.

Susan Goldstein receives funding from NIHR, UKRI, and the SAMRC. She is on the board of the Southern African Alcohol Policy Alliance SA.

Aisha Moolla received funding from the UK's NIHR with additional support from the SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA

In February 2024 the World Health Organization announced southern Africa was suffering the deadliest regional outbreak of cholera in at least a decade. At the epicentre of the disaster were Malawi, Zimbabwe and Mozambique, where cholera cases surged more than four-fold between 2022 and 2023. Over 1,600 deaths were reported in the three countries.

Already 2024 is threatening to be another devastating year for cholera in the region as warmer weather and unusually heavy rains and storms have fuelled the disease’s spread. Zimbabwe, Mozambique and Malawi have reported more than 13,000 cases of the disease so far in 2024.

Cholera bacteria are spread by eating or drinking food or water contaminated by the faeces of an infected person. Oral vaccines help contain outbreaks and limit the spread of the disease. But there is a worldwide shortage of the vaccines.

From January 2023 to January 2024 there were urgent requests for 76 million doses of the oral cholera vaccine from 14 nations. Only 38 million doses were available. Stockpiles ran dry at the beginning of 2024.

Nadine Dreyer spoke to vaccinologist Edina Amponsah-Dacosta about the impact of the vaccine shortages and what is being done to secure stockpiles for future outbreaks on the continent.

The world’s oral cholera vaccine stockpile has run dry. Why?

Unlike routinely administered vaccines, such as those for measles, the cholera vaccine is developed on a needs basis: during outbreaks and humanitarian crises, for example.

There’s limited funding to purchase cholera vaccines, and as a result there’s limited production.

There is only one vaccine recommended for mass vaccination during cholera outbreaks, Euvichol-Plus.

The vaccine is manufactured exclusively by EuBiologics, a global biopharmaceutical company based in Seoul in South Korea.

The company has limited manufacturing capacity. So when there is a spike in the need for the vaccine, demand outstrips production.

So there is usually only a limited stockpile available.

Traditionally we haven’t had several countries experiencing outbreaks at the same time like we are currently seeing in southern and eastern Africa as well as in parts of the eastern Mediterranean, the Americas and south-east Asia.

This is one of the main reasons for the current shortage.

EuBiologics has identified certain steps in the manufacturing process that could be refined and shortened, while ensuring that the vaccine remains safe and effective.

A low-cost, simplified version, Euvichol-S, has been approved by the World Health Organization and will help ease the shortage. Over 15 million doses of Euvichol-S are expected in 2024.

What is being done about the vaccine shortage in southern Africa?

There have been several strategies to fight the outbreak.

Firstly, in October 2022 the WHO temporarily suspended the standard two-dose vaccination regimen in favour of a single dose to stretch existing supplies.

Two doses provide up to two or three years’ protection, but one dose is still safe and effective. With one dose we’re able to deliver some level of safety up to one year or just a little bit more, hopefully enough time to beat the current outbreaks.

Secondly, countries like Zambia and Zimbabwe have taken steps to prioritise vaccine distribution to areas that need them the most.

An example of a priority area would be one devastated by droughts or floods with a high transmission rate and no access to safe drinking water and sanitation.

Last year, cholera cases surged in Malawi and Mozambique following Cyclone Freddy, the longest-lived tropical cyclone in history. It traversed the southern Indian Ocean for more than five weeks in February and March.

Is progress being made to develop more cholera vaccines?

In Africa less than 1% of doses of all vaccines are locally manufactured.

During the COVID-19 pandemic African countries were forced to the back of the queue for life-saving COVID-19 vaccines. It taught us that we need to have our own local manufacturing capacity.

In the case of cholera we are seeing that we cannot rely on just one manufacturer in South Korea when most of the outbreaks are happening in several African countries.

The problem has been recognised and there are steps to rectify it. There has been a lot of investment in expanding the cholera vaccine manufacturing capacity.

Two manufacturers are coming into play globally, one in South Africa and one in India.

Biovac, a biopharmaceutical company based in Cape Town, has received investment capital to develop vaccinations for cholera and other diseases.

It has concluded a ground-breaking licensing and technology transfer agreement with the International Vaccine Institute, a non-profit international organisation headquartered in South Korea, for the manufacture of the vaccine.

The first batch of vaccines will undergo clinical trials from 2024 to 2025, with licensing expected from 2026. This means we won’t see locally manufactured cholera vaccines until after 2026.

In India, pharmaceutical company Biological E plans to manufacture the simplified version of Euvichol-plus.

But vaccination is not a replacement for the provision of safe drinking water, adequate sanitation and good hygiene practices.

Edina Amponsah-Dacosta receives research funding through Gilead Sciences' Research Scholars Program.

Sleep is as essential to our health as food and water. It is important to a number of brain functions, including how nerve cells communicate with each other. We sleep for a third of our lives and there are many restorative processes going on during sleep that are needed to stay healthy.

Why do we usually sleep at night? What happens when we don’t sleep? On World Sleep Day, Nadine Dreyer asks a group of experts to tell us more about this essential part of our lives.

Why do we need sleep and why do we sleep better at night?

We sleep for a third of our lives, yet it is only when we cannot sleep or when we experience poor quality sleep that we really start noticing it.

During sleep, our muscle activity drops, our breathing slows down, and our heart rate and blood pressure decrease. At the same time our brain actively clears toxins, which cause neurodegenerative diseases.

It also consolidates memories, wiping out “useless” ones during deep sleep, known as slow wave sleep.

All this allows us to start afresh the following day.

Our lives are organised around our sleep-wake schedule. As we’re a diurnal species, our master clock in the brain, which maintains many of our 24-hour rhythms, schedules our period of activity with daylight, and our period of rest with the night.

In some other animals, like rodents, evolutionary pressure has pushed those species to become nocturnal, which allows them to scurry and feed outside the view of their diurnal (daytime) or crepuscular (twilight) predators.

Not sleeping at the right time has been associated with poor health. Some of the side-effects are poorer cognitive performance, lower energy and worse mental health.

There’s also a higher risk of developing neurodegenerative diseases such as Alzheimer’s and a higher risk of developing high blood pressure and diabetes.

After a poor night’s sleep, we try to get on with our lives but research has shown this is not so easy. During the COVID-19 pandemic and the strictest lockdown, South Africans rated their sleep quality as poorer, with more insomnia symptoms. These were were both in turn associated with worse levels of depression and anxiety.

What happens when we don’t sleep?

Sleep is a state of vulnerability where a “rest and digest” state dominates over the “fight and flight” state when we are awake.

Our early sleep “scans” the environment before allowing us to dive into deeper stages of sleep.

When a rupture in this consolidated bout of sleep happens, we will start complaining “I haven’t slept enough” or “I slept really badly last night”.

Such ruptures include those induced by specific sleep disorders like sleep apnoea or insomnia.

Sleep apnoea leads to unconscious sleep interruptions due to upper airways obstruction and can lead to hypertension and increased risk of diabetes.

Research in rural Mpumalanga province in South Africa found one out of three older adults had moderate to severe sleep apnoea and this was associated with a higher risk of cardiovascular disease. Yet there is no treatment in the public health system for this common sleep disorder.

Certain situations disrupt sleep: parents tending to their young children, doctors being awake while on call, loud generator noises during night-time electricity cuts, mosquitoes, or worse, gunshots or sounds of violence waking us up from our slumber, signalling danger.

Sleep health inequity in South Africa is also driven by socioeconomic status.

A recent study on sleep in men and women living in the urban township of Khayelitsha in South Africa’s Western Cape province showed that poor sleep quality was associated with fear of falling asleep in a violent environment. Sleep was disturbed by strange noises, fear of attacks and dreams about past traumatic experiences.

Electronic devices make it difficult to sleep. Why?

Even though our biology is meant to make us sleep at night, several societal, technological changes have progressively decreased our sleep opportunity.

Our sleep timing is controlled by our master circadian clock. This clock is exquisitely sensitive to light, so exposure to bright light and blue light such as that emitted from electronic devices such as smartphones shifts our bedtime to a later time.

In our recently published study of adolescent sleep in Nigeria, adolescents in urban areas slept less and sleep quality was worse.

Sleep duration was shorter, due to bedtimes being later but waking times in the morning similar to those of adolescents in rural areas. The use of electronic devices at night by urban Nigerian adolescents was associated with shorter sleep duration.

This is one example of a growing body of research that highlights the negative consequences of nocturnal tech use on sleep, even in African societies.

What are key habits to help people sleep better?

The most important habit is to take sleep as seriously as a healthy diet and regular exercise.

We advise the following:

Keep regular wake times and bedtimes. This helps us sleep at the best time with respect to our master clock’s rhythm. This in turn helps ensure a consolidated bout of sleep.
Aim for an average of 7 to 9 hours of sleep each night.
Avoid watching screens one hour before normal bedtime. If this is unavoidable, choose the lowest brightness and add the orange night screen setting. Rather read a book under a bedside light.
Get outdoor light during the day to strengthen the master clock’s circadian (near 24-hour) rhythm.
Do some form of physical activity once a day. This helps build sleep pressure and also strengthens the master clock’s rhythms.
Avoid alcohol before bedtime as this is associated with disrupted sleep.
Avoid caffeine and stimulants after noon.
Try to sleep in a quiet, cool and dark or dimly lit environment.

For more information please visit the South African Society for Sleep and Health.

Karine Scheuermaier receives funding from National Institutes of Health (Bethesda, MD, USA), South African Medical Research Council, South Africa's National Research Foundation, and the Wellcome Trust (London, UK). She is affiliated with the South African Society for Sleep and Health and the World Sleep Society.

Dale Rae works for Sleep Science and is currently funded by the Wellcome Trust UK. She is affiliated to the South African Society for Sleep and Health, World Sleep Society and European Society for Sleep Research

Gosia Lipinska receives funding from the Wellcome Trust and the National Research Foundation. She is affiliated with the South African Society for Sleep and Health and the World Sleep Society.

Jonathan Davy receives funding from Wellcome Trust. He is affiliated with the South African Society for Sleep and Health and the Ergonomics Society of South Africa.

Dr Joshua Davimes receives funding from the National Research Foundation. He is affiliated with the South African Society for Sleep and Health.

Dr Nomathemba Chandiwana has received research funding from Unitaid, USAID, Shin Poong Pharm, Merck, ViiV Healthcare, Gilead Sciences, Johnson & Johnson and is currently receiving research support from the Bill and Melinda Gates Foundation,, Novo Nordisk and Merck

Oluwatosin Olorunmoteni receives funding from the Obafemi Awolowo University, the Consortium for Advanced Research Training in Africa, Uppsala Monitoring Center, Norwegian Agency for Development Cooperation, the Wellcome Trust and the UK Foreign, Commonwealth & Development Office.

Alison Bentley and Francesc Xavier Gomez-Olive Casas do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

Malnutrition, in all its forms, includes undernutrition (wasting, stunting, underweight), inadequate vitamins or minerals, overweight and obesity.

South Africa has undergone a nutritional transition over the past 30 years characterised by the triple burden of malnutrition: households are simultaneously experiencing undernutrition, hidden hunger, and overweight or obesity due to nutrient-poor diets.

Results of the first in-depth, nationwide study into food and nutrition since 1994, the National Food and Nutrition Security Survey, found almost half the adult population of South Africa were overweight or obese.

While there was sufficient food to feed everyone through domestic production and imports, many families and individuals went to bed on empty stomachs.

Due to high unemployment figures, families relied on social grants to buy basic food items. Many tended to buy food with little nutritional value to avoid hunger.

The survey, conducted by the Human Sciences Research Council, was commissioned by the Department of Agriculture, Land Reform and Rural Development to map hunger and malnutrition hotspots in the country.

Data was collected from more than 34,500 households between 2021 and 2023. Close to 100 indicators were used to compile the report.

Overweight or obese: what’s the difference?

Carrying excess weight poses a number of health risks. It increases the dangers of high blood pressure, high triglyceride levels, coronary heart disease, stroke, type 2 diabetes, osteoarthritis, sleep apnoea, and respiratory problems.

People are overweight if their body mass index, a measure of body fat based on height and weight, is greater than 25.

Obese adults have a body mass index greater than 30.

Key facts

Some of the significant findings were:

69% of obese adults lived in food insecure households where families had little dietary choices and were forced to eat food with little nutritional value.
More than two-thirds (67.9%) of females were either overweight or obese. There were higher incidences of obesity among women than men.
Adults aged 35 to 64 years had a significantly greater prevalence of obesity than younger age groups. This could be explained by differences in metabolism and the fact that youngsters are more active than adults.
KwaZulu-Natal reported a higher prevalence of obesity (39.4%) compared to the other provinces. More research is needed to explore this finding and whether cultural factors are behind this.

The survey period overlapped with the tail-end of COVID-19. Focus group discussions took place in all districts where data was collected to assess the effects of the pandemic.

The survey found that the swift responses by government through various relief programmes significantly reduced the exposure of families to extreme poverty and food insecurity during this period.

Moving forward

Obesity is a global problem. A new study released by the Lancet showed that, in 2022, more than 1 billion people in the world were living with obesity.

Worldwide, obesity among adults had more than doubled since 1990, and had quadrupled among children and adolescents (5 to 19 years of age).

The Human Sciences Research Council made the following recommendations to help address malnutrition in South Africa:

focus on areas with high levels of malnutrition
encourage families to produce their own food to supplement social grants
invest in food banks at fruit and vegetable markets strategically located close to vulnerable households
help extremely poor households survive seasonal hunger
launch campaigns to educate the public on the benefits of consuming nutrient-rich foods and dietary diversity.

Thokozani Simelane does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Dehydration is a big issue during unusually hot weather and outbreaks of diseases such as cholera that lead to life-threatening diarrhoea. Anastasia Ugwuanyi is a family physician and clinical educator at the University of the Witwatersrand. We asked her four questions designed to be useful in avoiding or managing dehydration.

What causes dehydration?

Dehydration can be defined as loss of intracellular body water. To understand the causes it’s important to set out some basic information about our bodies in relation to water physiology. Water contributes 55% to 65% of total body mass. Most of this is in lean tissue. The other third is extracellular.

Dehydration can be either water loss or salt and water loss. The body’s “water ecosystem” is regulated by responses to salt and water levels. Organs such as the brain, skin, gastrointestinal tract and kidneys are involved in water regulation.

Water in the body ecosystem is useful to maintain certain functions. These include:

transporting nutrient, biological and chemical materials around
part of the support system in joints, including the spine
an environment for the normal chemical processes of the body to function.

Dehydration can be caused by several factors that tilt the regulatory mechanisms to a water loss mode. These can include:

environmental or external causes such as heat waves (climate change factors)
droughts and long-standing water deprivation
reduced fluid intake – in elderly people, children or people with certain mental health challenges
municipal shortages affecting availability or access to potable drinking water
increased fluid loss through urinating excessively such as in conditions like diabetes
increased loss of fluids from diarrhoea
increased loss of fluids from sweating or hyperventilating.

How do you know if you’re dehydrated?

Shifts of between 5% and 10% loss of body water are symptomatic especially among very old and very young people. Signs to look out for include: headaches, fatigue or lassitude, confusion that cannot be immediately explained, a dry mouth (not immediately explainable), skin that’s dry when you pinch it and sluggish in the normal elastic return, sunken eyes and in infants sunken fontanelles, no tears when crying particularly in children, concentrated urine – deep amber to dark, and decreased frequency of urination as the body switches to conservation.

Other signs to watch out for include heat exhaustion symptoms. These indicate that the cardiovascular system is taking a hit. Here the signs can include: cold, clammy skin; unusually heavy sweating; weak, fast pulse; dizziness; muscle cramps; nausea.

What happens to your body when you’re dehydrated?

Several of our body’s systems are affected by dehydration. This can be acute and in the long term.

What happens is also a function of the level of dehydration. Dehydration is classified from mild to severe depending on the percentage body weight of water lost. In children and infants it’s particularly problematic because water makes up a bigger part of their body mass.

With up to 15% loss, symptoms include a drop in blood pressure that affects circulation dynamics and signs of decompensation – systems not being able to cope (think of an overheating car engine).

The cardiovascular system, gastro-intestinal system, renal system, central nervous system, skin and outer layer of your body, musculoskeletal system, are all adversely affected by dehydration depending on the level of total body water lost.

The effects of dehydration on the body can include: weight loss, constipation, delirium, renal failure, greater propensity for respiratory infections and urinary infections, hearts attacks and seizures as a result of blood thickening

These effects are all more debilitating in very old people and those with existing conditions like diabetes.

How can you stop dehydration?

To stop dehydration, it is important to consider every aspect of water demand and supply.

Environmental: Access to potable water supply always is a collective responsibility of government and the community. This can range from reporting and repairing municipality water supply leaks and breaks, to maintaining the water purification and supply distribution networks.

Personal: Don’t wait until you are thirsty before you drink. Thirst is your body saying you are becoming dehydrated. For every kilogram of body weight, drink about 30-35 millilitres (3 tablespoons) of water daily, especially in hot weather.

Be mindful of the signs of dehydration in yourself, or in the elderly, children, or incapacitated family or friends. Check that with simple steps such as replacement therapies made up of water, salt and sugar.

Be deliberate about drinking more water during physical activity, and when ill. Every home has salt, sugar and water. Knowing how to make this or having the prepackaged oral rehydration therapy at home is essential. There are a number of good guides to making homemade salt-sugar-water solution for treating dehydration before seeking medical help.

Create a habit of drinking water intentionally as opposed to cold drinks and beers that have water but are high in calories. These worsen dehydration.

Make sure you have the right balance of salts before, during and after excercise.

Keep cool in hot weather by wearing breathable clothes, taking a swim or cooling showers if there are no water restrictions. Water jets are available in some public places to help with cooling during particularly hot weather.

Lastly, there are several smart devices with health apps that can assist with tracking water intake.

Anastasia Ugwuanyi belongs to the South African Association of Family Physicians.

Every year, 10 million people fall ill with tuberculosis. Even though the disease is both preventable and curable, it kills 1.5 million people each year, making it the world’s deadliest infectious disease. Over 25% of these deaths occur in African countries. The World Health Organization has developed a strategy to reduce TB deaths by 95% by 2035. It’s a monumental task. But, global health and infectious disease specialist Tom Nyirenda tells health editor Nadine Dreyer, there are grounds for hope.

Effective tuberculosis treatment has been available for decades. What makes it difficult to contain?

Tuberculosis is a disease of poverty. It thrives in poor living conditions and overcrowding. It’s a respiratory disease and spreads through the air when people cough, sneeze or spit. Victims need only to inhale a few germs to become infected.

In 1882, when the eminent German scientist Robert Koch discovered Mycobacterium tuberculosis, the microbe that causes tuberculosis, the disease sent shock waves throughout the world as it killed rich and poor alike.

At that time one in seven people in the US and Europe died from the “white plague”.

The Industrial Revolution had resulted in the urbanisation of the poor, who were forced into overcrowded, squalid conditions.

Housing conditions improved and by the time effective antibiotic treatments were discovered in the 1940s, TB rates in the west had declined.

In poor countries the vicious cycle of poverty and disease makes it difficult to eliminate TB. Poverty leads to poor health and unemployment. Unemployment leads to poverty and poor health.

There has however been progress in fighting TB in several African countries.

Tell us more about those countries and their successes

Last year the WHO reported that seven African countries – Eswatini, Kenya, Mozambique, South Sudan, Togo, Uganda and Zambia – had reduced TB deaths by a third since 2015.

The WHO’s Africa office identified several common strategies, all of which can be used by other countries on the continent and elsewhere in the world.

1.) Countries with limited resources need to choose where to concentrate them, for example, among people with HIV/AIDS who have a high risk of contracting TB.

2.) Educating healthcare workers and the public to recognise symptoms is key. These include persistent coughs, phlegm, weight loss, night sweats and high temperatures.

3) The next step is to persuade the person suspected of having TB to get to a testing centre. There is a lot of stigma around TB, so this needs to be approached sensitively.

4.) Another challenge is making sure patients finish their medicine and get better. Treatment usually lasts for six months. There are some innovative ways to tackle this. For example roping in family members, community workers and even local neighbourhood shop owners to make sure patients take their pills.

As human beings we can make things possible using our own communities. We have lots of solutions.

Have there been advances in TB treatment?

For many years it took three days to diagnose patients with TB. Three sputum smears were examined under a microscope to confirm the diagnosis.

Then, in 2001, there was a series of anthrax attacks on the US postal service. Powdered anthrax spores were deliberately put into letters that were mailed through the US postal system. Twenty-two people, including 12 mail handlers, got anthrax, and five died.

The molecular technology developed to detect anthrax revolutionised the diagnosis of tuberculosis.

The GeneXpert system, launched in 2003, was at the heart of biohazard detection for the United States Postal Service.

In 2010 the WHO gave the green light for GeneXpert to be used to diagnose TB.

The GeneXpert test can diagnose patients in an hour. A sputum sample is collected from the patient with suspected TB. The sputum is mixed with a reagent and a cartridge containing this mixture is placed in the GeneXpert machine.

All processing from this point on is fully automated.

This was the first major breakthrough in tuberculosis diagnostics since the sputum smear microscopy was developed more than 100 years ago.

Another big development is that for the first time in a century we are closer to an effective vaccine.

The BCG vaccine for TB has been used for 100 years. It is largely effective for children under five, but less so in older people and can’t be used on patients who have certain medical conditions.

The emergence of multidrug resistant forms of tuberculosis has increased the urgency of developing an effective vaccine.

There are 17 vaccine candidates currently in different stages of clinical trials.

One of these is the M72 experimental vaccine. The late-stage trial of the vaccine is being rolled out in South Africa, Zambia, Malawi, Mozambique, Kenya, Indonesia and Vietnam. A total of 20,000 volunteers will take part in the trial, which is expected to run for five years.

Medical advances are an essential tool to fight TB, but without combating poverty this devastating disease will remain with us.

Tom Nyirenda does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Same-sex relationships are legal in South Africa and protected by the constitution. Unfair discrimination on the basis of sexual orientation is against the law.

But in practice many cultures don’t necessarily see this as a right.

Traditional Zulu culture, for example, perceives same-sex relationships and sexual intercourse as taboo and unAfrican. Statements like “real men are not gay” indicate some people’s ideas about masculinity and sexuality.

These cultural norms have profoundly negative effects on Zulu men who have sex with men.

This abuse often triggers depression, suicide and drug abuse.

As a public health specialist with an interest in marginalised groups, I conducted research looking into the role Zulu culture plays in discouraging men who have sex with men from accessing healthcare.

Stigma rooted in cultural beliefs was rife and many of the men we interviewed were too afraid to go to a health clinic.

This research is a tool for policymakers to use to ensure better healthcare for marginalised communities.

How we went about our study

In South Africa, men who have sex with men are categorised as a key population, a vulnerable group more likely to get sexually transmitted infections, due to their socio-economic isolation.

Our study participants were living in Umlazi, an urban area of least 400,000 inhabitants in the province of KwaZulu-Natal. The province is the home of the Zulu monarchy and the majority of Zulu people – the largest ethnic group in South Africa. More than 13 million people speak isiZulu as their first language.

Many Zulu people forced from “white” towns during apartheid ended up in Umlazi. Informal settlements have also mushroomed around Umlazi as those desperate for work flock to urban areas in search of jobs.

In our study we interviewed 25 participants, men who have sex with men, between the ages of 21 and 55. They were representative of different areas of KwaZulu-Natal as they had roots in Ulundi, Nongoma, uPhongolo, eDumbe and Vryheid.

They shared their experiences in a very emotional way. They described how they were frequently forced to conceal their sexual orientation to avoid being rejected or discriminated against. Study participants were representative of different areas of KwaZulu-Natal as they had roots in Ulundi, Nongoma, uPhongolo, eDumbe and Vryheid.

Culture is very stigmatising, discriminatory, and depriving. I grew up in a community where people see same-sex relationships as culturally taboo, so tell me, how would you come out in such a community? People create culture; instead of discriminating against same-sex relationships, these same people must accept and embrace them as cultural norms. (Funani)

For some participants, the traditional rite of passage from boyhood to manhood at the age of 21 was a source of alienation and pain.

At the age of 21 you are celebrated as a man in the Zulu culture … you are dressed like a Zulu warrior with skin, a spear, and a shield. I was deprived of this because they said I am not a man. … I became sick because of this and was admitted to the hospital for weeks. I almost lost my life because I was deprived of my rights. (Linda)

Yet another participant spoke about his experiences of not being accepted:

I don’t care about culture because the culture has let me down as a gay man. Culture does not respect me … I would have killed myself in the more conservative rural areas because the culture does not accept me. I have suffered so many mental health crises because of this. (Sanele)

‘I could hear them laughing’

The men consistently cited fear of discrimination and a lack of understanding among healthcare providers as reasons they avoided health clinics.

I went to my local clinic because I had a sexually transmitted infection and needed care. When being attended to by the nurse, I was asked some silly questions that did not feel like they were taking my medical history. Then I was reprimanded about my sexuality as being culturally wrong and needing to change, which made me decide never to use my local clinic again. (Lindani)

Most of the participants related to these experiences.

I had a sexually transmitted infection and went to my local clinic for medical care. Getting there, a nurse attended to me, and during the section, she walked away to a separate room, where she went to tell other nurses about me. I could hear them laughing. I took my bags and left the clinic and never went back. (Siyanda)

The impact on the men’s health could be critical:

I would rather die with my sickness than use such facilities. (Anele)

Another said:

Due to my outfit I was kept in the queue for a long time, and when I was finally attended to, the nurse asked me if I am male or female. I respectfully answered her, and she called her other colleagues to make fun of me. (Solomon)

Cultural sensitivity

Collaboration with cultural influencers and community leaders is essential to protect the rights of men who have sex with men while honouring cultural values.

Such interventions should be culturally appropriate, holding in esteem and respecting the Zulu traditions and values, as well as embracing the full spectrum of health matters encountered by men who have sex with men.

Similarly, healthcare providers should receive training to support this community and establish discrimination-free healthcare environments.

Efforts such as these would promote inclusivity and healthcare access for all.

Ikekhwa Albert Ikhile does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Mycotoxins are substances produced by mould that poison food. They are harmful to humans and animals when consumed. According to the Food and Agricultural Organisation (FAO), about 25% of the world’s agricultural harvests are contaminated by mycotoxins. Though reliable data is lacking, mycotoxin contamination is widespread in Africa. It often takes the form of aflatoxin in cereal crops and has led to health issues such as chronic gastritis, diarrhoea, kidney problems and liver cancer. Biologist Oluwadara Pelumi Omotayo studied how mycotoxins contaminate ginger in South Africa. We asked her to explain what they are and how to avoid the danger.

What are mycotoxins?

Mycotoxins are hazardous substances produced by certain microorganisms called toxigenic fungi (moulds).

One mould species may produce more than one type of mycotoxin, and a single mycotoxin may be produced by several mould species. Mycotoxins are ubiquitous. They can be found indoors and outdoors, thriving in warm and highly humid areas. They are usually toxic to living things.

Contamination can lead to variety of illnesses, and even death. They can cause cancer, hepatic diseases, deterioration of the kidneys, nephropathy, and alimentary toxic aleukia, a potentially fatal illness marked by nausea, vomiting, diarrhoea and skin inflammation. They can also impair an animal’s immune system, decrease milk production, cause stunted growth and weight loss, and induce gastroenteritis.

Mycotoxins have been reported to be responsible for numerous human deaths. For example, in 2004, Kenya recorded an outbreak of aflatoxin poisoning which led to the death of about 125 people.

Mycotoxins drastically suppress the immune system. And a single mycotoxin, even in minute quantities, can result in acute poisoning in humans and animals.

Over 300 types of mycotoxins have been identified so far, including the notable aflatoxin and other types like ochratoxin and fumonisin, which often contaminate grains like maize.

How do humans come in contact with mycotoxin?

People can be exposed to mycotoxins through eating contaminated food and through contact and absorption through the skin. Exposure can also happen through inhalation of polluted air, as they can be present in airborne particles such as fungal spores.

Human exposure to mycotoxins can come from plant-based food and from the carry-over of mycotoxins and their metabolites in animal products such as meats.

Food items that can be tainted include spices, grains (such as maize, rice and sorghum), nuts, fruits (dry or fresh), coffee beans, cocoa seeds, vegetables and rhizomes like ginger.

Why should we be concerned about mycotoxins?

Mycotoxin contamination is widespread, especially in African countries. The toxins exist even in medicinal plants and herbs. This was confirmed by our study, which investigated the presence of mycotoxin in ginger.

Ginger has been used since antiquity for the treatment of various ailments such as colds, migraines and gastrointestinal tract disorders. However, like other spices and herbs, it has been reported to contain mycotoxins. Ginger has been found to contain aflatoxin and ochratoxin A (which is known to be teratogenic: capable of causing developmental abnormalities in unborn foetuses).

From our study, aflatoxins B1, B2, G1 and G2 and ochratoxin A were found in ginger collected from the North-West province of South Africa in summer and winter. Though at varying concentrations, the highest concentration was observed in summer. This indicates that there’s no period when crops and plants, including ginger, would necessarily be completely free from mycotoxins.

How do farmers and consumers know that a crop has been contaminated?

Mycotoxins are not visible to the naked eye. The invasion of crops and foods by moulds is an indication that they are potentially contaminated with mycotoxins.

Farmers and consumers should inspect food crops for evidence of moulds, and discard crops and food that have mould growth.

What can be done to prevent mycotoxin contamination?

To minimise the risk of mycotoxin exposure and contamination, we recommend action before and after harvest and storage.

Prevent mycotoxin/fungi invasion while the crops are still in the field. This can be achieved by cultivating and harvesting at the appropriate time. Adopt techniques that reduce stress in plants, such as ensuring they get enough water and are well spaced. They also need adequate sunlight and should be cultivated on suitable soil. It is also important to avoid using agricultural residues as compost as they can produce toxigenic fungi and mycotoxins when decaying.
After harvest, reduce fungal contamination and mycotoxin production in foods during storage, handling, processing and transport. Facilities should be monitored and kept at temperatures that discourage mould growth. Crops with moulds should be sorted and removed before storage. Storage facilities must be aerated and dry. Reducing moisture content in crops before storage is important to prevent mould.
Avoid damage to grains before storing as damaged grain is more susceptible to mould growth and mycotoxin contamination.
Don’t store food too long before consumption. It is important to follow recommended guidelines for safely storing cooked and raw food in the refrigerator, fruits and vegetables, grains, nuts and seeds, and spices such as ginger.
Inspect and discard foods contaminated by moulds.
Ensure contaminated foods are not sold to consumers.
Improve awareness about mycotoxin contamination.

Oluwadara Pelumi Omotayo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Detecting tuberculosis early could play a significant role in eradicating the world’s most deadly infectious disease. The World Health Organization says 1.5 million people die from this devastating disease each year.

People infected with Mycobacterium tuberculosis, the TB bacteria that attack the lungs, often do not know that they have it until their symptoms become severe. Two out of every five cases of TB remain undiagnosed or hidden.

One of the dangers of this is unknowingly infecting others.

Current diagnostic methods are slow, often expensive, sometimes difficult to administer and not easily accessible in the low-income regions where TB is most prevalent.

The oldest test, the sputum smear, has been used for 100 years to detect TB. It is outdated, clumsy and can take three days to process.

GeneXpert technology, the current gold standard for TB diagnosis, can detect the disease in an hour but is expensive and not available in remote areas.

Improvements in screening and diagnosis could help eradicate this curable disease.

One of the new routes to better diagnosis may be through detecting TB on the skin.

Diagnosing a sickness

Diseases have tell-tale chemical signatures.

Some cancers, for example, produce signs which dogs, with a sense of smell anywhere from 1,000 to 10,000 times better than that of humans, can be trained to detect.

Our team at the University of Pretoria looked at whether a silicone rubber sampler could help us identify the chemical signatures of TB.

We developed a patch, similar to a plaster (adhesive bandage), that could detect some of the chemicals from the TB bacteria.

We found we were able to distinguish between TB-positive and TB-negative individuals.

Our research holds promise for an inexpensive test that could be easy to transport and simple enough so that it would not need a healthcare worker to administer.

It all started with the mosquito

In 2021 we looked into why mosquitoes bite some people and not others.

We investigated whether there was a chemical difference to the skin surface between individuals who perceived themselves as being attractive to mosquitoes and those who were not.

Using a silicone rubber sampler, we were able to test the skin surface of 20 individuals. These samplers were specially developed and could be worn as a bracelet or an anklet.

We found chemical differences between the volunteers who were attractive to mosquitoes and those who were not.

Turning to the TB test

We built on the mosquito test to develop our research into TB detection. Could the deadly respiratory disease be diagnosed by attaching a plaster to a patient’s skin?

Skin patches, similar to a plaster, equipped with small silicone rubber bands were attached to the wrists of 15 TB-positive individuals at the Steve Biko Academic Hospital and the Tshwane District Hospital in Pretoria. Likewise, the rubber bands were attached to 23 TB-negative individuals at the University of Pretoria.

The silicone rubber bands served as effective traps for semi-volatile and volatile organic compounds emitted by the body during the sampling period.

The bands were comfortable and non-restrictive and were worn for between 30 and 60 minutes. During this sampling period participants were free to go about their routines.

The bands were easily removed and sent to the laboratory.

In the laboratory we were able to separate the large number of chemical compounds found in the silicone rubber and were able to detect 27 compounds associated with TB.

Promise of easy, inexpensive results

As we refine and expand our findings, the human skin test for TB holds promise as a non-invasive screening tool in the fight against this infectious disease.

Our findings showed that:

it is feasible to detect TB through skin emanations
the small and lightweight rubber band sample would be particularly suitable for use in rural and remote regions
individuals would not have to travel to a clinic or a hospital for testing as the patches could be applied at schools, households and gatherings
no special arrangements would be needed to transport the bands.

This exciting breakthrough is not restricted to TB, but can also be repurposed to help detect other diseases such as malaria.

*Portia Makhubela and Egmont Rohwer co-authored the research on which this article was based.

Yvette Naudé does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

The world has declared a time-out on sugar consumption. The harmful link between disease and dietary sugar was recently outlined in a comprehensive assessment of published studies.

Recognising this link between widely consumed food and disease is essential in marshalling forces to change harmful outcomes. These include coronary heart disease, obesity, type 2 diabetes, tooth decay and some cancers. For over a decade, my research has focused on the mechanisms by which fructose intake plays into disease.

A growing number of African countries have joined the worldwide efforts to reduce sugar intake. For instance, in an attempt to address obesity, diabetes and other non-communicable diseases, South Africa introduced a tax on sugar-sweetened drinks in 2018.

It’s hard to avoid sugar when it’s become a normal part of diets and when we celebrate special times with sweet treats. But being more aware of what sugar is and how it can affect our health is the first step.

What is sugar?

Sugar is a class of naturally occurring sweet-tasting molecules found in fruits, vegetables, plants and the milk of mammals. It can be extracted from these natural sources and concentrated in processed foods.

The sweet-tasting molecules in sucrose (table sugar) are glucose and fructose.

Sucrose is a disaccharide. This is a molecule made of two simple sugars – glucose and fructose – in a 1:1 ratio and chemically bound. Sucrose is used in many processed foods.

High fructose corn syrup, also used in processed foods, is a mixture of the monosaccharides glucose and fructose. Usually the combination is 45% glucose and 55% fructose.

Sucrose and high fructose corn syrup are more concentrated in processed foods than in fruits and vegetables.

Both are considered added sugars when they are added to foods and drinks. Besides the sweet taste, they may be added for colour and texture, as a preservative or to aid fermentation.

There are other natural sugars found in the foods we eat. Lactose, or milk sugar, is a disaccharide made of two simple sugars – glucose and galactose – in a 1:1 ratio. It’s found in mammals’ milk and produced naturally to provide nutrition to offspring, and in other dairy products, such as cheese and ice cream.

Honey, made from nectar by honeybees, is primarily a mixture of glucose and fructose monosaccharides with some maltose, sucrose and other carbohydrates. Maltose, which is found in breakfast cereals and breads, is a disaccharide of two glucose molecules.

Naturally occurring sugars are made by plants, bees or mammals based on their needs.

The human body needs glucose as a fuel for every cell, especially brain cells. That’s one of the reasons why we need a stable blood glucose level throughout the day and night.

The way our bodies use fructose is different. It can be turned into glucose, used as fuel, or processed into fats, called triglycerides. Excessive fructose in our diets can lead to increases in blood triglycerides, liver fat, blood glucose, body mass index and insulin resistance (where the body cannot easily remove glucose from the bloodstream).

Increases in these markers can lead to an increased risk for metabolic dysfunction, type 2 diabetes and non-alcoholic fatty liver disease (or metabolic dysfunction-associated steatotic liver disease).

Because of the difference in how the body uses glucose and fructose, and evidence that a higher consumption of sugar leads to worse health outcomes, we must be mindful of the added sugar we eat.

What would happen if we quit eating sugar?

A group of scientists performed a study and published a set of research papers that detailed exactly what happened when over 40 children (aged eight to 18) stopped eating sugar and fructose for 10 days. The participants didn’t stop eating bread, hotdogs or snacks. They stopped eating fructose. These studies found significant reductions in:

newly made triglycerides (or fats)
fasting blood glucose
blood pressure
fat stored on organs, including the liver
AST, which is a marker of liver function
insulin resistance, as their cells were better able to remove glucose from the bloodstream
body mass index.

The participants also reported feeling better and were better behaved.

The World Health Organization has made recommendations for adults and children to reduce their sugar intake to about 58 grams, or 14 teaspoons, per day or between 5% and 10% of total caloric intake.

This is not a lot of sugar.

Consider that a 300ml bottle of Coca-Cola or 240ml cup of sugarcane juice contain about 30 grams of sugar. One piece of mandazi, a popular deep-fried Kenyan wheat snack, has about 4 grams of sugar, or about 6% of the WHO’s recommended intake contained in each small piece.

What can I do to lower my sugar intake to recommended levels?

First, keep track of everything you eat during a typical day, what you eat, when you eat and how much you eat. Secondly, give yourself a star for the fresh vegetables and whole fruits you eat, and identify the foods that have added sugars.

Now, set an attainable goal that details one thing you can change to either:

1) increase the whole fruits or vegetables you eat or

2) decrease the amount of added sugar that you eat each day.

This way, you can be mindful of the added sugar you consume and adjust what you eat accordingly.

Grace Marie Jones receives funding from The National Institutes of Health (US).

The challenge for universities is to produce graduates who can work with others to produce knowledge and research that can change institutions and societies for the better.

That is the basis on which the Consortium for Advanced Research Training in Africa (Carta) began developing an approach to teaching PhDs 12 years ago. The consortium supports faculty members of public universities and research institutes on the continent who want to pursue a PhD. The training covers a range of research methods to ensure graduates value multidisciplinarity. It also includes a focus on stakeholder and community engagement and prepares students for life after their PhD. To date 245 fellows have been through the programme. So far 160 have graduated .

We are members of the consortium. Since its inception it has run, evaluated, changed and reevaluated its curriculum. A body of evidence has accumulated that suggests its approach has merit.

In a recent paper we set out to understand what impact the programme had had on fellows. The survey was part of an evaluation process initiated by the consortium in 2019. There have been several publications about the different interventions that have been implemented as well as reflections on the impact of the programme.

In the most recent survey PhD fellows were asked what significant change in themselves they attributed to their experience under the programme. They reported changes in their sense of self; worldviews; beliefs about knowledge; their experience of life; behaviour; and capacities.

Their responses showed that the training had a positive impact on their lives in three critical ways. It improved their research capacities and their teaching; and it affected how they saw themselves and how they saw and experienced the world.

The findings suggest that it is possible to create a curriculum that can produce excellent graduates committed to making an impact in their worlds.

Approach to teaching

The results of the survey suggest that the consortium has achieved some of the challenges it set out to address. Among these were:

how to produce graduates with the potential to be researchers and use research to lead change at institutional or societal level, nationally or internationally
how to teach graduates to have an appreciation of and ability to work in a multidisciplinary way
how to teach graduates in a way that is value-based and instils a commitment to equity.

In setting up the programme, we hypothesised that the way the consortium designed its interventions could be transformational. Transformational learning is described as

a deep shift in perspective during which habits of mind become more open, more permeable, more discriminating, and better justified.

The results of the latest survey suggest that this is indeed the case. Fellows reported a sense of empowerment and responsibility, and an appreciation of who they were in the world and how they might be able to have an impact on it. They viewed themselves as critical thinkers, change agents and committed to passing on their knowledge to the next generation of researchers.

They reported on what they had learnt and reflected on how it was taught to them, and shared examples of how they were applying those same methods to teaching and supervising the next generation.

We concluded in our paper that these positive outcomes were a result of the way in which the consortium developed its approach to teaching.

Those of us who developed the curriculum think that what sets the programme apart is that most of our teaching methods are interactive in nature, are participatory and use peer learning. This approach allows us to use the knowledge and skills that our students bring with them.

To give one concrete example of what we do, we make overt how we teach. At the end of a session we reflect on what we have done and how we’ve done it – we make our pedagogical approach clear to our PhD fellows. There are many more examples of our approach.

Key lessons

The theory of change that the curriculum was developed around includes the assumption that a natural network will arise from developing a critical mass of graduates in each member institution who meet regularly over a number of years and train as cohorts which include people from various disciplines, institutions and countries. That network will support them in fostering change in their home institutions and societies.

We believe that our approach has relevance internationally for those who want to produce multi-potential, multidisciplinary change agents who want to make a positive impact in their worlds.

All curricula are available to adapt and use. We believe this work can be adapted to multiple disciplines and have evidence that this approach – a taught component to all PhD training – is beneficial.

But the institutions in which the graduates are employed have to nurture and value them. They have to create an enabling environment in which graduates can, and want to, stay and work and lead.

Sharon Fonn is the co-director of the Consortium for Advanced Research in Africa (CARTA) and works at the University of the Witwatersrand, Johannesburg South Africa. CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand. At the time of the evaluation reported, CARTA was funded by the Carnegie Corporation of New York (Grant No. G-16-54067), Sida (Grant No. 54100113), Uppsala Monitoring Center, German Academic Exchange Service (DAAD) and the Wellcome Trust (reference no. 107768/Z/15/Z) and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the authors.

Marta Vicente-Crespo works at the African Population and Health Research Center as the program manager of the Consortium for Advanced Research Training in Africa (CARTA). The Consortium for Advanced Research Training in Africa (CARTA) is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:16604), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Science for Africa Foundation to the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme (Del-22-006) with support from Wellcome Trust and the UK Foreign, Commonwealth & Development Office and is part of the EDCPT2 programme supported by the European Union. The statements made and views expressed are solely the responsibility of the author.

Corruption comes in many forms in Ghana. Bribery, misappropriation of funds, extortion and administrative theft remain pervasive and affect key sectors of Ghana’s economy. In a 2023 Afrobarometer survey, 77% of Ghanaians surveyed responded that corruption was on the rise in the country.

Scholars have long studied the links between corruption and other facets of life. Political scientist Daniel Treisman tells us that every kind of corruption is unwanted in democratic societies because of its far-reaching negative consequences for the economic life and well-being of the population. Through legal scholar Jorum Duri, we know a great deal about the relationship between corruption and gender.

However, little is known about the psychological and mental health problems associated with corruption.

As scholars of psychology, we set out to examine the overall levels and effects of perceived corruption on mental health in Ghana.

We sought to answer the question: does the perception that wealthier people can influence state institutions or government officials for personal gain affect people’s mental health?

We found that people’s perception of corruption in Ghana had a negative impact on their mental health. This was measured in increased suicide risk, anxiety and depression symptoms. The perception that rich people in society could bribe and influence any state institution or government official was strongly associated with depression and anxiety symptoms among our participants.

Study method

We used a survey to collect data from 730 university students in Ghana. The participants’ average age was 22 years and they were studying for different degrees.

We measured their perception of corruption by asking them to respond to four statements. The responses ranged from “not at all” to “extremely likely”:

State institutions are corrupt (for example public universities, hospitals).
Politicians and other government officials are corrupt (for example, parliamentarians and ministers).
In this country, people who have money/resources can influence any state institution(s) or government official(s) for personal gain.
In the last 12 months, I have seen a person influence/induce state institution(s) or government official(s) with money or other thing for personal gain.

The mental health burden of witnessing corruption

We also investigated the question of what aspect of corruption had the greatest impact, and on what aspect of mental health. What we found was that witnessing corruption among state institutions and government officials, and the perception that the rich could influence these officials for personal gain, was strongly associated with depression and anxiety symptoms among our participants.

The explanation may be that when people become aware that corruption is a way of life, and that only a few have what it takes to live this way of life, they become helpless and hopeless and feel a loss of personal agency. These feelings are related to depression and anxiety symptoms. It should however be noted that we did not control for participants’ prior experiences and symptoms of depression and anxiety.

Why does corruption affect mental health in Ghana?

We offered two explanations. Firstly, witnessing corruption may reinforce the negative beliefs about harassment, uncertainty and arbitrariness that are associated with corrupt practices. It may also heighten people’s expectations that they or their loved ones could be unfairly involved or targeted for corruption. This may explain the relation with symptoms of depression and anxiety.

The work of scholars like sociology researcher Iona van Deurzen shows that harassment and arbitrariness by someone who represents the state or public authority can become a stressor that may elevate a person’s levels of depression.

We discovered that the links between witnessing corruption and mental health problems could also be traced to certain tendencies for people to:

remain silent to protect or save others from being caught in order to maintain relationships
report to get the corrupt person sacked and ruin relationships
conform to a culture of corruption either in solidarity or for fear of being victimised.

These tendencies can potentially create psychological discomfort that may lead to mental health outcomes such as anxiety and depression.

Corruption implies that rules regulating access and distribution of social and material resources are dysfunctional.

There is a need to rethink the effects of corruption perceptions and to redefine it as a social determinant of public mental health.

We advise that people who experience corruption-induced anxiety or depression should talk to a mental health expert and counsellors for professional assistance.

Intimate partner violence starts early.

Around one in four girls aged between 15 and 19 worldwide have already been subjected to physical or sexual violence.

Girls who experience abuse in their childhood face increased and disproportionate levels of intimate partner violence later in life.

Pregnant and parenting girls are even more exposed to intimate partner violence due to their young age and vulnerability.

As social scientists with a special interest in the traumas faced by adolescent girls, we carried out research into intimate partner violence among pregnant and parenting adolescents in the Blantyre district in southern Malawi.

We found that two out of every five pregnant and parenting adolescents had experienced intimate partner violence.

Our results point to the need for interventions that focus on girls aged 17 or younger and those who engage in transactional sex. Interventions are also needed to make violence less socially acceptable.

Transition to adulthood

Sexual violence and child marriage were among the main reasons for early pregnancy among participants in the study.

Research shows the period during the transition to adulthood is when the majority of adolescents in low-income countries first encounter dating, sexuality and partnerships, often with older adolescents or adults.

It is also when lifelong patterns of violence and beliefs about acceptable intimate partner violence are formed.

Abuse in different forms

A demographic and health survey done in 2016 showed that almost a third of girls in Blantyre aged 15 and 19 were either pregnant or had given birth.

Our survey used questionnaires to interview 669 participants within 66 randomly selected rural and urban areas in and around Blantyre.

Participants eligible to take part were between 10 and 19 years old, had been pregnant at any stage of their lives, were pregnant at the time of the study, or had given birth.

We included girls as young as 10 because of evidence from clinic records suggesting that more and more younger girls were presenting with pregnancy in clinics.

We asked 15 questions focusing on physical, emotional and sexual abuse.

1.) Emotional abuse: questions focused on whether intimate partners had said something to humiliate, threaten to hurt or insult the participants.

This form of abuse was reported by 28.8% of interviewees.

2.) Physical abuse: questions focused on whether intimate partners had pushed, slapped, arm-twisted, punched, beaten up, choked or attacked participants with a weapon.

Of the participants 22.2% reported being attacked violently.

3.) Sexual violence: participants were asked if their intimate partners had grabbed or fondled them, attempted to force them to have sex or forced them to have sex or perform sexual acts against their will.

Sexual violence was reported by 17.4% of the girls.

Age, education level, sex for money

Forty percent of the girls reported having suffered some form of intimate partner violence.

Some other trends:

Girls between the ages of 13 and 16 were much more likely to report exposure to violence than those aged 17 and older.
Girls with secondary education were 70% more likely to report intimate partner violence compared those with primary or no education.
Those who reported having exchanged sex for money, gifts or favours were more likely to experience intimate partner violence than those who did not.

Pregnant and parenting girls who believed it was culturally acceptable for wives to be beaten were more likely to talk about having experienced intimate partner violence. Qualitative studies done in Kenya show that these women equate being beaten as a sign of love and care.

Closing the gap in research

Studies on the experience of intimate partner violence among pregnant and parenting girls in Africa are scarce. This gap could result in issues affecting pregnant and parenting girls being neglected in policies and programmes.

Since these girls face a disproportionate level of intimate partner violence, there is a need for special policies and programmes to help them. These could included safe houses and awareness campaigns targeted at men and adolescent boys.

Health providers should screen pregnant and parenting adolescents for signs of intimate partner violence during antenatal and postnatal care. These victims should receive support from healthcare providers.

Malawi, like most African countries, has laws to hold perpetrators of violence accountable, but often victims are frightened to report abuse.

Survivors need greater support to increase safety and prevent further abuse.

Cities are growing faster in sub-Saharan Africa than elsewhere, with an annual urban population growth rate of around 4% compared to the world average of 1.5%.

Across the continent the urban share of the total population is projected to increase to 50% by 2030 and 60% by 2050.

Urbanisation is associated with lifestyle changes such as less physical activity and less labour-intensive work. This is often accompanied by an increased intake of high-calorie fast foods, snacks, and sugar-sweetened beverages.

This combination has contributed to rising obesity in cities in low- and middle-income countries. At the same time, undernourishment and micronutrient deficiencies remain a problem.

In Tanzania, about 37% of the population lives in urban areas. About 5.3 million people live in Dar es Salaam, 28% of the urban population.

As an agricultural economist focusing on nutrition, my latest research looks into the difference in dietary quality between rural areas, secondary towns and the commercial capital Dar es Salaam.

What people eat differs considerably depending on where they live. Any public health campaign to improve nutrition needs to target these areas differently.

Food diaries

Using data from food diaries recorded by 1,506 households over a two-week period, I calculated how many calories, macronutrients and micronutrients were consumed and compared them to the recommended requirements for a healthy life.

The data was collected in five regions of Tanzania, each representing a different ecological and economic zone. In our sample, 988 households lived in rural areas, 304 in towns and 214 in Dar es Salaam.

Besides food diaries, our data also included information on household characteristics and their socioeconomic status. This included details on educational level, assets and food production.

Homegrown or highly processed?

We found that people living in rural areas suffered from the highest deficiencies.

This was because they were not eating sufficient quantities of food.

Most food was home-grown, which provided beneficial nutrients, but diets were not diverse enough to provide all the nutrients needed for healthy living.

At the opposite end of the scale, residents of Dar es Salaam also ate unhealthy diets, but for very different reasons.

They relied heavily on processed cereal products and ready-made meals. This meant that they weren’t getting enough fibre and micronutrients and also ate too many saturated fats and sugar.

Comparatively the diets of households in secondary towns, those with a population of 500,000 or fewer, were the healthiest of the three.

Residents still produced some of their own food, and at the same time had more access to markets, more food choices to diversify their diets, and higher incomes to afford this diversity.

Calories, nutrients or a lack thereof

1.) Rural households primarily consumed starches, cereals, vegetables and fruit, making up 29%, 21%, 12% and 7% of their diet respectively.

Plantains, maize, cassava, sweet potatoes and spinach were the most consumed food items in rural areas.

These diets are considered healthy, but many still faced severe deficiencies. About 48% of households were not reaching the daily recommended calorie intake. Between 40% and 80% of households in these areas didn’t consume enough of the vitamins and minerals that are important for physical and mental development, such as folate, vitamin B12, calcium, iron and zinc.

Many of these nutrients are found in animal foods, which made up a small share of rural diets.

2.) In secondary towns, maize, rice, cassava, tomatoes and squash were eaten most frequently. In terms of quantity, these households tended to consume more, leading to lower levels of nutritional deficiencies than in rural areas.

About 26% of households did not meet the recommended calorie intake, but this was significantly better than in rural areas.

The additional consumption of foods such as groundnuts, beef and dried aquatic foods further improved the nutritional adequacy of their diets.

These households consumed about 20% more calories, fats and proteins, all necessary for a healthy diet. The consumption of thiamine, niacin, vitamin B12, magnesium, iron and zinc also increased by between 15% and 45% compared to rural diets.

3.) Dietary patterns changed a lot when we compared rural areas and towns to a megacity like Dar es Salaam. Cereals, including highly processed cereal products like bread and pasta, made up 25% of the bulk of the city diet.

Full meals bought outside the home were the next largest category. Vegetables made up only about 8.5% of their diet. The consumption of snack foods such as chapatis and doughnuts was also high.

These households were overconsuming fats, saturated fats and sugar. They were underconsuming fibre, key vitamins such as thiamine, folate, vitamin C and E and minerals such as calcium and potassium, exposing them to the risks of obesity and micronutrient deficiencies.

Next steps

A lack of essential nutrients has a host of knock-on health effects, such as decreased cognitive function, fatigue, intensified illness and infections.

At the same time, overconsumption of potentially harmful food substances such as fats and sugars can lead to health risks such as obesity, diabetes and cardiovascular disease.

The findings highlight the need for a varied approach to dealing with nutrient intake and tackling problems such as rising obesity rates. One size won’t fit all.

Hannah Ameye does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Play is how children learn about the world, explore their environments, and engage in physical activity.

It’s also essential in nurturing children’s social, emotional and cognitive capabilities and is an important component of bonding with caregivers.

Playtime for children is as important for their development as exercise is for adult health. Guidelines have been developed in South Africa, which closely follow international guidelines, for how much sleep, physical activity and sedentary time children should get each day from when they are born.

Children under the age of two should spend as much tummy time – time spent on their tummies while they learnt to lift their heads, roll over, and eventually crawl – and active play time with their parents as possible. They should spend as little time as possible restrained in car seats, strollers and rockers.

As I have found in my research, South African babies do not always meet these recommendations, and spend too much time restrained in devices or in front of the television.

Screen time is not recommended in the first two years of life at all. Children over two may watch up to an hour of television each day. Less is better.

Children who play a lot reach their developmental milestones, such as sitting, crawling and standing, quicker. They also have better social, emotional and cognitive development.

They are less likely to develop obesity too. All of these effects lead to better health and wellbeing during adulthood.

The amazing thing about play is that it is free. You serve as your child’s entertainment and are the best source of learning and growth for them.

Here are some simple ways you can help your baby’s development through play.

The magic of storytelling

Reading and storytelling are ideal ways to spend quiet time with your little ones rather than letting them watch television. Unsupervised television time can lead to language delays, and difficulties with focus and attention.

By the time your baby is one, they will have learnt sounds from you, and be starting to speak. The more stories you read aloud, the more words your baby will learn and the better they will be able to talk.

Between 6 and 12 months your baby is already starting to learn that a picture represents an object and by 12 months may start turning the pages and engaging with the story.

There are many other benefits of reading aloud to your baby, including improved brain development, specifically cognition.

Story time will encourage quietness and calm, which can work wonderfully as a bedtime routine to encourage better sleep. Make reading fun with lots of expression and different voices or by adding rhymes and songs and pulling funny faces.

Read the same thing over and over – this is how babies learn.

Every day is tummy time

Helping babies to roll, sit, crawl and walk provides them with the ability to explore their environment and develop both motor, and cognitive skills.

Tummy time is the first step to getting them mobile, and counts as their exercise for the day. Tummy time should start from the day they are born, with a few minutes at first, building up to longer stretches. Babies should be doing at least 30 minutes of tummy time each day.

Place babies on their tummies (on a safe surface or on your stomach) and use your voice to encourage them to lift their heads to look at you or to reach for a toy.

Babies use touch to learn, and they will develop better motor skills from having their hands and feet in contact with the ground, so take off socks and leggings during free play. During tummy time babies learn to push up on their hands and knees to start crawling.

Babies usually start crawling anytime between 6 and 9 months, but many babies will still be developing this skills beyond 9 months.

For babies who can crawl, create obstacle courses with safe, soft toys like teddy bears, pillows and blankets to encourage exploration and build core strength for standing. Get down on their level and explore the world with them.

Singing and funny dance moves

Have a dance party with your little one to keep them (and you) stimulated and active.

Small babies can be held while you dance, while older babies can get involved by holding onto objects and bouncing up and down.

Singing makes play time even more fun. Babies love to hear your voice, and singing can be energetic or soothing.

For older babies you can sing and make the movements at the same time to teach them while playing (think “heads, shoulders, knees and toes”).

Smaller babies will enjoy nursery rhymes such as “Eensy weensy spider” that go along with hand movements or clapping to keep them interested. Make lots of eye contact and try to make your baby laugh with funny dance moves.

Let your hair down and enjoy.

Everyday fun

Imagination helps children to understand the world by thinking about what they cannot see and imagining what comes next. Small babies will enjoy looking for hidden toys underneath a blanket or cushion, or watching you play peek-a-boo as they start to learn that you can go away from their view and will come back.

Mobile babies will enjoy hiding from you and listening to you search for them – make it fun by looking in silly places and telling your baby what you are doing. This develops their sense of “object constancy” – their ability to understand that they can spend short periods of time away from their parents safely, and that their parents still exist even when they can’t see them. Children who do not successfully develop a sense of object constancy may not form secure attachments, and may suffer from separation anxiety.

Older babies will love to copy what you are doing, play pretend, and explore homemade obstacle courses with you. Make everyday activities such as cooking and cleaning into a game by letting them copy along and “help you”. Have a baby-height drawer filled with safe objects for them to unpack and repack while you tidy up.

If you let your home become a safe area for children to explore, they will be free to move and play, becoming healthier, happier and more confident. So, embrace the mess, the laughter, and the learning that comes with play – it is one of the greatest gifts you can give your children.

Alessandra Prioreschi receives funding from The Wellcome Trust

In rural Kenya, 64-year-old John Kamau’s world of silence is about to change. For decades, isolated by hearing loss from the community’s vibrant life and his grandchildren’s conversations, he sees hope when a community health worker visits with a smartphone in hand.

This isn’t just any visit; it’s the gateway to Kamau’s reconnection with the world, facilitated by breakthrough digital health tools on a smartphone.

A revolutionary hearing test app on the smartphone conducts precise assessments, followed by the provision of low-cost, high-quality hearing aids right there and then.

With these aids, programmed to his specific hearing profile using Bluetooth, Kamau can take part in ordinary conversations and hear his grandchildren laugh.

Kamau is one of many whose lives are being transformed through a high-tech, soft-touch approach: advanced digital technologies delivered through trained members of a community.

Africa’s silent epidemic

In Africa, an estimated 136 million people are currently living with hearing loss, a figure expected to swell to 337 million by 2050.

This silent epidemic has profound social and economic repercussions contributing to a global cost of untreated hearing loss estimated at US$980 billion annually.

In Africa it is exacerbated by a dire shortage of audiologists, with fewer than one for every million people, and the prohibitive costs of hearing aids for many in low- to middle-income countries.

Only 2% of those who need hearing aids in Africa wear them.

There is also a widespread lack of awareness of the condition.

Revolutionising access to hearing care

I am a professor of audiology at the University of Pretoria where – working together with the World Health Organization and the hearX Foundation– we have developed digital devices being used to test hearing loss across Africa.

We are pioneering community-based hearing care initiatives in low-income communities in Kenya, as well as Khayelitsha, Gugulethu, Mbekweni, Atteridgeville and the Eastern Cape province in South Africa.

1.) A screening app for children

We have trained local community members to conduct hearing screenings in early childhood development centres. Close to 50,000 children have been tested at a cost of less than US$6 per child.

Hearing loss is especially traumatic for children as it hampers language development and learning and leaves them at a disadvantage for life.

Community health workers need minimal training to carry out screenings with a simple screening app on an Android smartphone with calibrated headphones.

The app monitors noise in real time to make sure the surroundings are quiet enough for the test. Parents receive a text message with their child’s results and next steps if further interventions are needed.

Community workers can also do eye tests on the same device in less than three minutes.

2.) Early child development training

We’ve launched a mobile health (mHealth) training programme focusing on ear and hearing ability for teachers in early childhood development centres.

Daily multimedia WhatsApp messages train teachers to identify hearing problems. Teachers are taught to assess if a child needs to move to the front of the class or to go for a hearing test.

The programme has already successfully trained thousands of teachers across South Africa.

3.) Screening adults

Our collaboration with the World Health Organization has led to the creation of the hearWHO app, an official tool for screening adults.

The app features an easy-to-use test that plays numbers with a background noise and asks users to press on these numbers. Taking just two to three minutes to complete, the test has reached nearly 500 million people in over 190 countries since 2019.

The app displays user results and keeps a personalised track record of their hearing over time. It is available in English, Dutch, Mandarin, Russian and Spanish.

4.) Hearing aids for communities

In a recent feasibility study for the WHO, we explored the provision of hearing aids in low-income communities to inform the recently released WHO guidelines.

Community health workers, aided by an artificial intelligence system, analysed images of an eardrum. If the eardrum appeared normal – and a hearing loss was detected – he or she could be fitted immediately with hearing aids.

We have also partnered with the Clinton Health Access Initiative to expand our screening technology to eight countries in Africa and Asia.

As we continue to confront the challenges of hearing loss, the path forward is clear: integrating these innovative models into existing healthcare systems is imperative.

De Wet Swanepoel consults to and owns shares in the hearX Group (Pty) Ltd. He receives funding from the National Institutes of Health, National Research Foundation, Newton Advanced Fellowship UK Medical Council, World Health Organization, Technology Innovation Agency, Oppenheimer memorial trust, Sonova Holding AG. He is affiliated with the hearX Foundation NGO.

In Sierra Leone almost 59% of the population live in remote, rural areas. Roads may be non-existent or in bad condition, making it very difficult for rural dwellers to access healthcare. This is one of the key reasons why COVID-19 vaccination rates in the country are low.

During an innovative vaccine programme mobile vaccine clinics were dispatched to the furthest parts of the country, sometimes on motorcycles and boats. The results showed COVID-19 vaccination rates tripled in three days.

Development Economist Niccolò F. Meriggi tells Nadine Dreyer about the programme’s potential to become a blueprint for future healthcare delivery in the country and other remote regions in Africa.

Why are vaccination rates low in Sierra Leone?

By 10 March 2022, more than a year after COVID-19 vaccines arrived on the market, 80% of people living in high-income countries had received at least one dose. In stark contrast, only 15% of people had been vaccinated in low-income countries.

Fast-forward to November 2023 and still only 33% of the population in Africa had received at least their first dose of a COVID-19 vaccine.

The hardships Sierra Leoneans face are typical of the obstacles people in low-income countries have to overcome to access healthcare.

In the early days of the COVID-19 vaccination campaign in Sierra Leone, it took the average Sierra Leonean living in a rural community three-and-a-half hours each way to the nearest vaccination centre.

Things improved as more clinics started offering the vaccine, but the cost of reaching clinics remained high and, in many cases, prohibitive. In Sierra Leone 60% of the rural population live on less than US$1.25 a day. Getting to a clinic would cost more than one week’s wages.

How did this vaccine drive tackle the problem?

A team of researchers designed a COVID-19 vaccination drive that was implemented in March and April 2022 by the Ministry of Health and Sanitation and their technical partner Concern World Wide, an international humanitarian agency.

The primary aim of this intervention was to take vaccine doses and nurses to administer vaccines to remote, rural communities, preceded by seeking permission and community mobilisation.

At the time, only 6% to 9% of the adults who took part in the programme were already immunised.

Just over 20,000 Sierra Leoneans, living in 150 rural towns outside the country’s national clinic network, took part in the vaccination campaign.

The first step was to approach village leaders including the chief and the mammy queen, the most important woman in the village. Youth and religious leaders were also consulted. They were briefed about the purpose of the visit and the vaccination team answered questions about the available vaccines.

The leaders were asked for their cooperation in encouraging eligible community members to take the COVID-19 vaccine.

That evening, when labourers returned home from farms, the health team talked directly to all villagers about vaccine efficacy and safety and the importance of getting vaccinated. They also addressed villagers’ questions and concerns.

Finally, vaccine doses and healthcare workers arrived at the villages to administer the doses. Some travelled on motorbikes or on boats because of the lack of any road access.

This last-mile vaccine intervention tripled vaccination rates within three days in treated communities.

Large numbers of people from neighbouring communities also showed up to receive vaccines at the temporary vaccination sites.

Looking forward

These results suggest that people who live far from clinics are less likely to seek healthcare and that last mile delivery is a cost-effective intervention capable of overcoming that problem.

The intervention cost in this campaign was US$33 per person vaccinated. This approach proved 76% more cost-effective than other vaccination campaigns.

Transport accounted for a large share of the costs, so the cost-effectiveness of last mile delivery can be increased by offering a “bundle” of health products. The bundle could include routine child immunisation, as well as human papillomavirus and malaria vaccines, combined with other important health supplies such as deworming tablets, vitamin A supplements, oral rehydration solutions and chlorine for drinking water.

The World Health Organization reported that between 2020 and 2021, 5.42 million people died of COVID-19.

Other estimates put the death toll for the same period at 14.83 million, which is 2.74 times higher.

Developing cost-effective strategies to make vaccines easily accessible to everyone, everywhere, is the most promising solution to prevent future pandemics. This blueprint could also be used to address obstacles to other life-saving medical care.

The research team has since been awarded funds from the International Growth Centre and the Social Science Research Council through its Mercury Project. These grants will be used to expand the model in this paper to a bundle of health products and services, including additional vaccines (HPV and Malaria) and maternal and child health interventions, and further explore its feasibility and cost-effectiveness

Niccolò Francesco Meriggi receives funding from Weiss Asset Management, UKRI and the International Growth Centre.