The explosive growth of chronic lifestyle diseases in South Africa has put even more strain on a health system already dealing with the double burden of tuberculosis (TB) and HIV. The increase in the number of people developing kidney failure - and the high cost of treating it - is just one example of this deadly trend.
The growth of non-communicable diseases (NCDs), such as cancer, diabetes and hypertension, in developing countries has gone almost unnoticed, as they are largely perceived as a problem affecting affluent countries. But NCDs have overtaken infectious diseases as the leading cause of death worldwide, with nearly 80 percent of these deaths occurring in low- and middle-income countries, according to the World Health Organization (WHO).
In August, South Africa’s Human Sciences Research Council (HSRC) and the Medical Research Council released a survey showing that 70 percent of women had a dangerously large waist circumference that increased their risk of developing chronic illnesses, and that the percentage of children who are overweight had almost doubled from 11 percent in 2005 to 18 percent in 2012. Researchers also noted that the burden of NCDs in South Africa was on the rise in rural communities and was disproportionately affecting poor people living in urban settings, resulting in higher demands for chronic care.
About 15 percent of the country’s population has chronic kidney disease. According to the National Kidney Foundation of South Africa, an NGO that raises awareness about kidney diseases, an estimated 25,000 people needed to be treated for kidney diseases in 2012. But unlike patients in Europe and the US, who usually experience kidney failure - an advanced stage of kidney disease - in their 60s, South Africans get it at a much younger age, mainly as a result of hypertension.
Treating kidney failure requires a dialysis machine, which removes waste from the blood. There are currently fewer than 500 dialysis machines used to treat more than 4,000 patients with end-stage kidney failure in South Africa’s public healthcare sector, which serves the vast majority of the country’s patients. The health ministry says it has no plans to procure more machines to meet the growing demand, as most kidney diseases are preventable by simply leading healthy lifestyle.
“The state spends about R200,000 [US$19,500] treating a single patient on dialysis per year, and that is a lot of money when you look at our annual budget. So instead of buying more machines, we should be investing on raising awareness about the risk factors of kidney disease,” said Health Minister Aaron Motsoaledi.
Waiting for treatment
The limited number of dialysis machines in South Africa has meant that hundreds of people are denied access to treatment. Statistics from the department of health showed 218 people in Gauteng, one of the country’s nine provinces, were on the waiting list to begin dialysis in 2012.
Nosipho Madlala*, 36, is an unemployed mother of two from Braamfischerville in Soweto, south of Johannesburg. She has been on the waiting list for dialysis for more than four months, and is also HIV-positive and taking antiretroviral medication.
“Every time I go to the hospital for [a] check-up, I pray that I will be told a slot has opened up in the renal clinic. The thought of dying and leaving my babies behind is killing me inside. Sometimes I wish I could win [the] lotto so that I can go to the private [healthcare sector],” she told IRIN.
The limited resources have meant that patients are added to the waiting list until a slot opens up. Brian Rayner, head of the division of nephrology and hypertension at Groote Schuur Hospital, a public healthcare facility situated in Cape Town, acknowledged that this was not an ideal situation. “Patients will receive dialysis if a space is available. If not, they go on a waiting list, and some will die waiting. Then there are patients who are not accepted [due to underlying conditions like diabetes] and account for 30 to 40 percent of patients, and as a result all of them will die of kidney failure.”
The few who are fortunate enough to have dialysis still face an uphill battle: many require a kidney transplant, but the waiting list for kidney transplants is also long, and it is growing as more people reach end-stage kidney failure, according to Sarla Naicker, head of nephrology at Charlotte Maxeke Academic Hospital in Johannesburg.
The department of health has strict guidelines for dialysis. For a patient to be accepted for dialysis, they must be a suitable transplant candidate. If a patient receives dialysis only, then that spot remains blocked until the patient dies, while a successful transplant will free a space for a new patient.
The final decision about who gets renal replacement therapy, a combination of dialysis and kidney transplant, is made by a hospital clinical committee in the public sector. Doctors have to justify to the committee why a certain patient deserves to be treated. They also face the daunting duty of informing patients they did not qualify for treatment because they are old; have underlying conditions, like diabetes or cancer, that complicate treatment; or just because there are not enough dialysis machines to permit everybody to receive this kind of renal therapy.
Rayner and Naicker have to deal with this dilemma every week. “Patients are devastated knowing that they are denied life-saving treatment. Some of the letters we receive from patients and their family are heartbreaking. But there is not much we can do because the public sector is unable to cope with the increasing numbers of patients. Only a limited number of people are accepted,” Rayner told IRIN.
“This is the most difficult part of nephrology practice, as we wish to treat everyone who requires renal replacement therapy,” said Naicker.
There are currently more than 2,500 patients waiting for kidney transplants in South Africa. According to WHO, transplantation tends to be more cost-effective than dialysis, producing better outcomes in terms of quality of life.
Although it is a fairly straightforward and generally highly successful procedure, the chances of finding a donor, let alone a match, are rare in South Africa, as most people do not believe in organ donation due to their cultural or religious beliefs. Kidney transplants from living donors are relatively common in much of the world, but in South Africa 60 percent of the kidneys come from deceased donors.
Yet in many cultures, it is taboo to donate the organs of the deceased. “There is a belief that if a deceased [person] is buried with some of his organs missing, he or she won’t find rest because the ancestors will not accept him,” explained Johannesburg-based traditional healer Bhekokwakhe Hlatshwayo.
Many Muslims also do not believe in organ donation. In Islam, the human body, whether living or dead, is considered inviolable.
As a result, many people who require kidney transplants often die before they get a donor kidney.
With all these odds stacked against patients with kidney failure, nephrologists say the only way South Africa can decrease the incidence of kidney disease is with prevention.
“Kidney diseases can be prevented by quitting smoking, following a low-protein diet and maintaining healthy levels of cholesterol in the blood stream. Other preventative methods include having the regular blood pressure check-ups, making sure that your diabetes is under control, avoiding indiscriminate use of non-prescription medication, especially painkillers. And if you are HIV positive, have a blood test to check your kidney function annually,” Naicker added.
*not a real name