It was the deaths of Zinhle Maama, Isago Mabote, Njabulo Msimango, Katlego Olifant, Karabo Rampou and Monica Sebetwana that were the final straw. The children, all under the age of 9, died after eating a packet of chips tainted with a dangerous pesticide, which has since been found in three spaza shops not far from their home in Naledi, Soweto.

Their deaths — and the deaths of 16 other children and the nearly 900 people who were sickened from foodborne illnesses across the country over just two months — sparked outrage and the declaration of a national disaster.  

President Cyril Ramaphosa pulled together the departments of health; trade and industry; agriculture; basic education and small business development, as well as the police and military health services, the National Consumer Commission and National Institute for Communicable Diseases. A ministerial task force rolled out plans for rodent infestation clean-ups, community education programmes and a major push for the registration of small businesses and spaza shops. 

But the government response underscored the complex and sprawling, multi-agency way the nation’s food system is set up. Could part of the fix be a single food safety agency?

Not fit for purpose

Since the start of 2023, more than 3 000 people have got sick with suspected foodborne illnesses, which happen when someone eats contaminated food, whether because of germs or chemicals, including toxic substances. In South Africa, infections from bacteria like Salmonella — usually from meat, poultry, eggs or milk — and Clostridium perfringens, often linked to improperly heated gravy, poultry or other meat, are some of the more common causes of foodborne diseases.

Listeriosis, a disease caused by the microbe Listeria monocytogenes, which had contaminated ready-to-eat meat products, sickened 1 060 people and eventually caused 216 deaths in the country between January 2017 and July 2018.  

A study looking at the government’s response to the outbreak found that South Africa’s food safety system wasn’t “fit for purpose” because of a disjointed handling of the issue, with little interaction between different state bodies and confusion over whose responsibility it was to check that safe food is sold, including by informal traders. 

At the time, Ramaphosa announced plans to create a single agency for food safety. 

But more than six years later, this body has yet to be set up. 

“The work to establish a single food agency requires legislative changes and this will take some time to arrive at the final destination,” says Foster Mohale, spokesperson for the health department.

Work on this began in 2018 when a team from the health, agriculture and trade and industry departments submitted a report to parliament. But the government lawmakers’ term ended before a decision was made and the department will wait to see if the new committee will use the report or start over, says Mohale.

Food safety oversight

For now, making sure the food we eat is safe before it lands on shelves is the job of the health, agriculture and trade and industry departments, with support from the fisheries, forestry and environment department, border management authority and National Consumer Commission.

The health department checks that places that make, serve and sell food follow hygiene and safety rules and respond to foodborne outbreaks. The agriculture department handles the registration of pesticides and imports and exports of animal products, while the trade and industry department oversees the food products entering and leaving the country, ensuring they meet local and international standards. 

One of the authors of a study published in BMC Public Health in July that looked at food fraud in South Africa — when food suppliers deliberately sell goods they know aren’t safe for consumption — says it is that lack of coordinated oversight that allows unsafe food to enter the system. A single control authority, like the Food and Drug Administration in the US, or the Food Standards Agency in the UK, Phoka Rathebe, associate professor of environmental health at the University of Johannesburg, says, would help ensure coordination across the whole supply chain.

Below target

Much of the enforcement of rules meant to ensure that people can trust that their food is safe comes from environmental health practitioners (EHPs). But last year there were just 1 712 of these health inspectors across the country which, for a population of around 63 million, works out to about one for every 37 000 people. That’s far below the health department’s target of one for every 10 000 people, which they say is the norm.  

EHPs are responsible for everything from checking that public water supplies are safe and waste isn’t dumped in places it shouldn’t be to running campaigns to teach communities about things like how to clean their water and use paraffin to heat their homes and cook safely.

Enforcing safety rules that help prevent foodborne outbreaks coming from the informal sector, which is particularly difficult to regulate, is another part of their job.

But in a study among EHPs working in Ekurhuleni, a municipality in Gauteng, less than half of the 61 respondents said that they felt properly trained to handle foodborne outbreaks.

Blame game

Since November, inspections of spaza shops throughout the country found food stored alongside pesticides and fake and expired foods. More than 1 000 outlets, from spaza shops to warehouses, have been shut down since, for running without a licence and not following rules for storing and preparing food.

With a major small business and spaza shop registration drive, the government plans to create a database of informal shops, a move they say will help with regulation. 

“The biggest challenge,” says Mohale, “is that community members would just open [stores] without notifying the municipality. [These cases only] get picked up when there are joint operations or [when] incidents are reported.”

But Leslie London and Andrea Rother from the environmental health division of the University of Cape Town’s School of Public Health don’t believe the problem is solely rooted in informal shops but rather in weak regulations on toxic chemicals and badly run municipalities.

“Everyone wants to assign blame for this tragedy, but spaza shop owners are not the culprits,” they wrote in the Mail & Guardian in November. 

Many townships deal with rodent infestations because municipalities don’t collect rubbish, which builds up in the streets. Residents and business owners turn to cheap pesticides sold at train stations and taxi ranks to keep their homes and shops rat-free.

Rother has been studying these “street pesticides” — chemicals registered only for agricultural use, or banned outright, but sold in old beverage bottles or small packets as a cheap and quick fix to kill rodents — for more than 15 years.

In an op-ed published in The Conversation, she writes that these products end up on the streets because of poor enforcement, a lack of measures to keep children safe (who are especially vulnerable to the harmful effects of contact with pesticides), outdated legislation and the pay-to-access database of registered pesticides, which is run by the pesticide industry.

The agriculture department is inspecting the five manufacturers registered to sell organophosphate, the pesticide that killed the children from Naledi, to find out how it is making its way onto the streets. 

But that won’t take away the pain of the families of the 22 children who died.

“We are hurt as parents, Otlotleng Msimango, the mother of seven-year-old Njabulo, told the SABC. “Even Njabulo’s father, he can’t speak or utter a word.”

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Today, five baby boys from KwaZulu-Natal have continued Nkosi’s message of hope for an end to HIV. Their participation in a groundbreaking study, published in Nature Medicine in June, have given researchers a glimpse of what an HIV cure could look like during infancy. 

After going without antiretroviral treatment for three to 10 months the babies, who were all born with HIV, were not ill nor did they have detectable levels of the virus in their blood. 

Usually, when people (especially babies) stop taking their antiretrovirals (ARVs), they become seriously sick because the virus has free rein to weaken their immune systems. 

The disease and treatment free state the babies achieved is also called “remission”.  It means the virus is no longer causing problems in your body, but not necessarily that it has disappeared. Scientists can only determine that the virus is not lurking somewhere by testing people’s tissues after they’ve died, said the study’s lead author, Philip Goulder. 

The five babies all had one thing in common: they were all boys, they were all infected with HIV in the womb, and they’d all been given antiretroviral treatment minutes after their first breath. Most infants start treatment in the first two days of life.

Scientists have long suspected the early HIV treatment for infants could lead to remission but the new study also reveals clues about why and how this happens. A crucial finding of the new research is that curing HIV in infants will probably look different for baby girls and boys and that getting ARV treatment immediately could be a part of it. 

Here’s everything you need to know about the study and what it reveals about the virus that has evaded researchers for decades and still infects 150 000 people in South Africa every year. 

How did researchers find the five boys? 

From 2015 to 2023, the researchers enrolled 284 children who were infected with HIV in the womb in a study.  The cohort was dubbed Ucwaningo Lwabantwana (which means “learning from children” in isiZulu). 

It was observational research, which means that there was no intervention; researchers were simply watching what happens under usual circumstances. In other words, all the children in the study were subject to the same treatment protocols and got the same medicines as would any other child in the care of South Africa’s public sector. 

Of the 284 children the researchers monitored, 25 were taking ARVs well enough for the virus to be undetectable in their blood by the time they reached their second birthday. It’s also called “viral suppression” and it means the person can no longer infect others. 

There’s nothing unusual about this group. They were taking their medicine 90% of the time, so researchers weren’t surprised that they were virally suppressed. About 94% of people who take HIV treatment in South Africa are virally suppressed, shows household data presented at the International Aids Society conference in Germany in July.  

Beyond the 25 typical virally suppressed babies, the five baby boys stood out because they were virally suppressed but they weren’t taking ARVs, and they hadn’t been for months. 

Four of the five boys had gone without treatment for periods of three to 10 months. These mothers explained that for various social reasons, they weren’t able to keep collecting HIV medicine to give to their children, Goulder says. 

The fifth baby hadn’t stopped getting medicine completely; instead he was given ARVs on and off for just under a year and a half. 

The researchers are relatively sure that the children likely achieved viral suppression without treatment, because blood tests showed low or no sign of ARVs. Clinic records confirmed that their caregivers hadn’t been given HIV medicine in those months either. 

Why were only boys cured? 

There were more baby girls enrolled in the study than boys (60% were girls), yet only baby boys were cured. The reason for this has to do with the difference between the male and female immune systems, and how they interact with the mother’s immune system during pregnancy, Goulder explains. 

Female foetuses have more of the immune fighter cells called “interferons” than males do right from conception.  Interferons help to fight diseases by stopping a virus from replicating. 

One would imagine that a strong immune system would be a good thing. But when it comes to HIV, female foetuses are instead at a disadvantage. 

The reason is that the specific kind of interferons that are present in abundance can also make it easier for HIV to infect cells. These interferons can come with an increase in one of the proteins that HIV uses to enter cells. 

Goulder and his colleagues ran immune system tests on mothers and their babies to understand what was happening. 

What did the immune system test results show? 

Consider a woman who is pregnant with twins, a boy and a girl (there were such instances in the Ucwaningo Lwabantwana cohort). 

If the mother becomes infected with HIV and she doesn’t get treatment, the virus will be free to infect both babies. 

Since the two foetuses have slightly different immune systems, the virus will have to launch subtly differing attacks to get around their defences. 

In the case of the female foetus, the virus is met with a far fiercer offensive particularly from interferons. This pressure forces the virus to evolve into a version of itself that can survive the attack.

 As a result, it’s a much meaner, tougher and, most importantly, interferon-resistant virus that infects the female foetus. 

When the virus reaches the male foetus, his immune system isn’t yet able to use interferons to put up a fight, so the virus can infiltrate his cells easily without any interferon-specific defences. 

But it’s not that the baby boy has no immune system at all, so even without the threat of interferons, the virus will still need to be able to replicate quickly enough to make sure it survives long enough to maintain an infection. 

In most cases, baby boys will get infected by an HIV that is bad at blocking interferons, and good at making copies of itself. 

In Goulder’s study, though, the baby boys who beat the virus had been infected with a strain of HIV that is bad at blocking interferons and bad at making copies of itself

Once the baby boy is born, his body begins to make interferons, which the virus can’t handle, and it’s also not able to replicate enough to maintain an infection. That means the virus circulating in the baby boy is toast. 

The baby girl’s strain of HIV, on the other hand, will be specifically evolved to sidestep interferons, so her body will battle to clear the infection. 

Why would such a weak virus survive to infect a male fetus? 

The virus is always looking for the easiest way to survive the body’s defences. It does so by outsmarting the immune system, but the mutations can lead to trade-offs. 

When the pregnant mother is infected, researchers think that the severe defence her body puts up forces the virus to change in a way that gets it into the body by any means, even if it means it’s no longer as good at making copies of itself. 

“Ideally, the virus would like to be as fit as possible, but if it’s going to be transmitted it just has to take the hit and become a feeble virus.” 

Once the virus is past the mother’s system, it will have to mutate again to infect the baby girl but will sail past the male twin’s defences largely unchanged. 

The result is a form of the virus that the baby boys’ immune system can clear easily after he’s born. 

Does this mean baby girls can’t be cured? 

No. Infant boys up to the age of two seem to have a better chance at beating HIV into remission than girls of the same age, Goulder explains. But that benefit fades for boys by their second birthday. 

Goulder’s previous research has shown that after the age of two, baby girls have a better shot at remission. 

It’s not because of a change in the way their immune system works. Rather, it’s  that the virus changes in a way that makes the female immune system’s strategy more effective, Goulder says. 

Does this mean an HIV cure is around the corner?

No. This study is small and much more research will have to be done, Goulder says. 

Scientists are looking into a range of cure options. Some of them try to attack the virus and others try to coax the body’s immune system to attack the virus and keep it out of someone’s system for good. HIV experts told Spotlight that a combination of approaches will likely be necessary to eliminate the virus completely. 

What Goulder’s study does show, though, is that starting HIV treatment early (right after birth) in combination with other immune system therapies will likely be part of achieving remission in infants, and that infant cure will be different for males and females. 

There’s a small group, such as these five babies, who may be able to beat HIV with regular ARVs under very specific circumstances. 

What will happen next? 

Goulder and his colleagues have already started work to set up a study to find more cases like the KwaZulu-Natal five. Some of the boys from the Ucwaningo Lwabantwana will be included, but one of the mother-baby pairs has already been lost-to-follow up.

Such research will include a step called “analytical treatment interruption” or ATI. This is a feature of HIV cure research in which scientists stop giving people antiretrovirals to see if the virus bounces back. 

Researchers involved in ATI studies have a responsibility to make sure participants know about the risks that come along with stopping treatment. They’ll be more likely to infect others and more likely to develop both the mild and serious signs of untreated HIV. They might also become resistant to the HIV treatment they were using before ATI. 

Community advocates have pushed for careful monitoring and support during this part of the study. 

A study co-designed with community members found that people who agree to participate in ATI studies worry about their HIV medicine becoming ineffective, but their sense of contributing to a greater good fuelled their continued excitement and participation.  

As for the KwaZulu-Natal babies, if they remain HIV and treatment-free until adolescence, it’s likely that researchers will study their immune systems once more to find out if the virus may still be hiding somewhere in their tissues. 

This research is an important step toward the future Nkosi dreamed of, in which children no longer have to fight HIV and can get back to the playground. — Additional reporting by Joan van Dyk. 

Tian Johnson is the founder and strategist of the pan-African health advocacy nonprofit, African Alliance.

In July 2000, then president Thabo Mbeki opened the International Aids Conference in Durban with a speech that ignored well-established facts and doubted that HIV caused Aids. With the world watching, he walked out on 11-year-old HIV activist Nkosi Johnson, who from the stage was pleading with him for access to antiretroviral (ARV) treatment.

At the time, a month’s supply of ARVs cost about R2 400, an amount out of reach for most people who needed medicine — like Johnson. Experts estimate the Mbeki administration’s Aids denialism and delayed response cost roughly 330 000 people their lives unnecessarily between 2000 and 2005.

But the government’s HIV dissidence at that fateful meeting achieved exactly the opposite of what Mbeki intended: instead of leading to delegates casting doubt on HIV science, it started a “treatment revolution”, with experts vowing to get treatment to everybody. 

Twenty-five years later, after long-standing activism and a famous 2002 court case that forced the government to provide HIV-positive pregnant women with medicine that stopped them from infecting their unborn babies, and which in the process mobilised access to treatment for everyone, we’re there.

South Africa now has the biggest HIV treatment programme in the world, with around 6-million people on anti-HIV medication — and it’s free. New HIV infections have dropped by 75%, from about 1 463 a day in 2000 to roughly 370 daily infections now.

In a quarter of a century, our understanding of HIV science has evolved — and along with it our toolbox to fight the epidemic. 

Learning about different ways in which the virus attacks the body meant newer, better drugs with fewer side effects could be developed. ARVs became cheaper as generic licenses were issued to companies who started to compete for the market.  

U=U — having undetectable levels of virus in your body because of sticking to treatment, and it therefore being untransmittable — became a thing. Medical male circumcision helped to slash infections in men (because it removes tissues with the cells the virus loves to invade). And medicine to prevent HIV-negative people from getting infected became available — first a pill, a monthly ring, then a two-monthly jab and now a six-monthly shot that’s in the process of being registered with regulators. 

But the epidemic is not over, Mitchell Warren of the international HIV advocacy organisation Avac told Bhekisisa this week. 

“HIV is still an issue,” he says. Despite three-quarters of people with HIV being on treatment, “we still have 1.3-million new infections [in the world] every year”. Although that’s about half of what it was 15 years ago, “the worry is that the declines in the past five or so years have begun to plateau”, so the number of new infections isn’t coming down fast enough to end Aids as a public health threat by 2030 — and that’s “a cause for great concern”. 

That’s why, says Warren, the six-monthly anti-HIV injection needs to become widely available. “The world cannot afford to squander” this chance, he says.

For World Aids Day 2024, we’ve put together a timeline of how South Africa’s HIV response has evolved over the past 25 years — and 15 years since the government vowed to “start to turn the tide in the battle against Aids”.

Click on and drag the event showing on the timeline or use the scroll bar below the cards. Hovering over a card will show our stories linked to events from the past 15 years. 

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They teeter on a narrow, unstable bridge with the hope of making it to the other side — a sunbaked island where life is good. But the journey will be treacherous. If they fall off the bridge, there is a menacing shark, crocodiles ready to snap and hippos about to charge.

It’s game day at the Eersterust Community Health Centre in Pretoria and Portia Mazo, an HIV counsellor, explains the lay of the land.

The photo of the island represents the hopes and dreams of a bright future, she tells the participants. The ropes are the support systems that will help get them there — things like abstinence, mutual faithfulness and condom use. The sharks, crocodiles and hippos — fellow participants wearing masks — represent HIV, sexually transmitted infections and unintended pregnancies.

Today’s game is helping Mazo teach her patients about sexually transmitted infections. She uses the same approach to show people who have HIV why sticking closely to their treatment will allow them to live a healthy life and get to the island with a beautiful future. 

According to a study published in the Southern African Journal of HIV Medicine, it’s an approach that works.

The countdown to ending Aids

Adherence to antiretroviral treatment (ART) — properly taking medicines that help people with HIV reach viral levels so low that they can’t infect someone else — is a big barrier to ending Aids.

“Adherence is the be-all and end-all of successful HIV treatment, especially as side effects are so limited and far less common,” says Francois Venter, executive director of the Ezintsha research centre at the University of the Witwatersrand. “The struggle is to swallow the tablet every day and that is a real issue for almost all of us taking medication.”

It’s also a big part of the UN 95-95-95 plan to end Aids around the world. By 2025, the goal is for 95% of people in those states to know if they have HIV. Of those who tested positive, 95% should be on ART and, of that group, 95% should have viral levels low enough that they can’t infect someone else.

Although South Africa has come a long way, reaching the middle 95 could be a problem. The country’s latest figures — from the Thembisa model, which the government uses to report on its UNAids targets, show that 95% already know whether they have HIV. 

But of those — in other words, the group for the middle target — only 78% are on treatment.  

Workshopping the game

Mazo learned about using a game as a teaching tool at the South Africa Aids Conference in Durban in 2023. 

Peter Labouchere, the social and behaviour change specialist who came up with the game, held an interactive workshop to show how it works. 

With Labouchere acting as the director of a sort of microbiological play, he instructed Mazo and her fellow participants to put on masks to represent different characters. They would play the roles of white blood cells, HIV and ART.

Labouchere then instructs the players when to move into or out of a square marked out on the floor which represents the body. The White Blood Cells wait inside the square. Then, the HIV invaders move into the block. They attack the White Blood Cells, pushing them out of the square until there aren’t many left. 

Then the ART players move in, coming to the rescue. White Blood Cell characters then start moving back in and HIV players get kicked out. The White Blood Cells celebrate.

The game helps participants understand how the body responds to infection and treatment. But, more than that, it also shows why it’s important for someone to take their pill at the same time every day, how to deal with the stigma of being HIV positive, how to ask for the support of family and friends and the importance of people telling others about their status. 

Labouchere, who started the Bridges of Hope Training programme, says physical experiences that use different senses — seeing, hearing and feeling — tap into emotions, which is better at changing behaviour fast than just teaching someone the facts.

He says it comes down to people saying: “As I hear and see and do, I really get it, internalise it, and apply it.”

The University of Pretoria’s Sanele Ngcobo led the research team that found the approach works. 

They tracked 467 participants in Tshwane over 12 months and found that those who used games to learn about ART stuck to their treatment 97% of the time, while those who were taught using more traditional methods adhered to treatment only 78% of the time.

Mazo, who is now a trained Bridges of Hope facilitator, has seen its success first hand.  

“It’s difficult to explain to someone what antiretroviral drugs do, why they need it and how it works,” she says. “It’s also difficult to understand. But armed with the knowledge, disclosure becomes easier, and so does accepting that you can still have dreams and goals in life.”

Why people don’t take their medicine

There are many reasons why people don’t stick to ART — from fear of being discriminated against and the stigma of having HIV to high transport costs to get to a clinic for refiling a script, side effects and not having support from family or friends. Issues such as long queues at a clinic or negative attitudes of health workers towards people with HIV can also be a problem. 

Ezintsha’s Venter puts it down to the “chaos of everyday life”. 

“There are so many reasons for interrupting therapy, and the system doesn’t make it easy to move clinics or to come back after you’ve stopped your treatment. The healthcare workers routinely yell at you. It’s a huge disincentive to come back.”

Despite studies having shown that young men who have sex with men and teenagers and young adults are willing to try online or video games to help them learn about HIV transmission or stick to treatment, Venter isn’t convinced that it’s the fix. 

Discussions that help people stick to treatment can play a positive role, but he is doubtful that patients will stick with it in the long term. Adherence, he says, is influenced by everything from moving and losing a job to a relationship that breaks down, taking alcohol or drugs, having mental health issues and the occasional “I forgot”.

But Ngcobo and his team found that using a physical game like Labouchere’s is particularly important where “access and knowledge of digital technology are limited”.

Sticking to ART

Patricia* had been living with HIV for many years. But it wasn’t until she came to some of Mazo’s groups that she finally understood the importance of adherence. After telling her three children and her mother that she was HIV positive, taking her medicine regularly became a lot easier.

Adherence also helps the clinic, says Mazo.

Women who stick to treatment can enrol in the government’s chronic medication dispensing and distribution programme. It allows those who have repeat prescriptions to use pick-up points that are closer to their homes or work than the clinic. 

Patricia is now one of them. She gets her medication from the pharmacy and only comes to the clinic once a year for check-ins and blood tests. 

She’s far better at sticking to her treatment than she’s ever been in the past. But she still struggles with telling others about her status — like her new partner, who she’s not yet had that conversation with. 

That’s a problem, says Mazo.

“If they don’t disclose their status to their partners, they hide their medication and don’t take it as prescribed,” she says. “If children don’t know, it’s difficult to convince them to take their medication … the 10-to-12-year-old group is not adhering, often because the mothers did not inform the children of their status.”

A future with HIV

Back at the health centre, Mazo turns to the participants and the sunbaked island of life ahead.

“Tell me about your future. Where do you see yourself in five years’ time?” she asks.

One young woman says she sees herself in a house with her husband and children, running her own business, happy and content. A woman in a floral dress says she’ll also be working and self-employed. A girl in a pink shirt sees herself living abroad. 

“We do not have to abort our goals,” Mazo tells the women. “Even with HIV.” 

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Nearly 5% of the world’s carbon emissions come from the healthcare sector, according to a report launched last week at COP29, the UN’s annual climate change conference — and money for dealing with the disastrous effects of changing weather patterns on people’s health is “urgently needed”. 

South Africa is not yet a member of the Alliance for Transformative Action on Climate and Health, a World Health Organisation (WHO) group, whose plans were put in place in 2021 at COP26 in Glasgow, as a way to help countries make their health services greener. 

Keeping hospitals running adds to the rising level of greenhouse gases, because of the electricity used to power buildings and equipment; fuel needed to transport patients and get supplies delivered and dealing with waste, says Azeeza Rangunwala, coordinator for Africa at Global Green and Healthy Hospitals, a network of people who help healthcare facilities around the world to be more environmentally friendly. 

Burning fuels such as coal and oil to generate electricity releases carbon dioxide. This forms a layer in the atmosphere that traps heat. Because the heat can’t escape, the air heats up — much like in a greenhouse — and, over time, the air gets warmer and warmer.  

Last year, the air temperature was 1.45°C higher than about 150 years ago, when the world started burning coal and oil at a large scale to run factories and fuel cars and planes. It’s dangerously close to the 1.5°C rise in temperature that 196 countries, including South Africa, who signed a legally binding agreement in Paris in 2015, pledged not to exceed to avoid the catastrophic consequences of more floods, droughts and illness.

In South Africa, rules about how many types of modern healthcare products are used are essentially blocking simple ways in which hospitals — of which the government runs about 395 — can cut down on how much greenhouse gases caring for patients puts into the air. 

Here’s why this is a problem.

Waste from hospitals 

The amount of greenhouse gases the South African economy produces is close to 400 million metric tonnes of carbon dioxide a year (a metric tonne is 1 000kg) and makes up about 1% of the world’s carbon emissions. As a signatory to the Paris Agreement, the country has committed to reducing its carbon emissions to between 350 and 420 million metric tonnes by 2030. 

Research shows that hospital buildings are big energy users because they need a constant power supply to keep the lights and equipment on, keep wards and theatres at the right temperature and to heat water. 

In South Africa, coal for generating electricity makes up 70% to 80% of the fuel the country needs to run, adding about 188 million metric tonnes of carbon dioxide to the air a year. 

Another big contributor to carbon emissions is waste from hospitals, says Rangunwala, because it gets collected from facilities by trucks, travels over long distances, and then, by law, is incinerated at high temperature — both being things that run on diesel. Such items include waste like needles, medicine vials and bandages that have come into contact with blood.

Food and supply deliveries, together with transport for staff to get to a health facility, add still more greenhouse gas emissions. 

And food that’s left uneaten or thrown away, and which can make up 20% to 30% of a hospital’s waste, adds extra pressure. Not only were the emissions from making and delivering the food unnecessary but the waste has to be collected and driven away by trucks and then usually gets dumped on landfill sites. Here it breaks down and releases methane, another powerful greenhouse gas, into the atmosphere. 

What is SA doing about it? 

Research from the Food and Drug Administration shows that devices such as forceps used during biopsies, drill bits and bite blocks for dental work and some fittings attached to instruments used in surgeries done by camera can be safely sterilised and reused. 

But the South African Health Products Regulatory Authority does not allow this because the manufacturers’ instructions say that the devices can be used only once.

John Lazarus, head of urology at the University of Cape Town, has, together with other healthcare workers, called for reusing these devices. But without support from the regulator, he says “our hands are tied”.

“Hospitals and individual clinicians would not want to work outside the rules,” he says, and despite the group having met with the regulatory body on the issue, it “has been slow to make a decision”.

Another way to lower the health sector’s carbon emissions is to build so-called green hospitals. These are buildings that run on, for example, solar power instead of electricity generated from coal, or have been designed to benefit from sunlight instead of having to switch on lights or use materials that keep buildings naturally cool in summer and warm in winter. 

New public health facilities such as the Khayelitsha and Mitchells Plain hospitals in Cape Town are examples where this works.

The spokesperson for the Western Cape’s health department, Dwayne Evans, says through their energy-saving programme at pilot sites such as the Red Cross Children’s Hospital and Paarl Hospital, the department has saved about 4 000 tonnes of carbon dioxide emissions since 2022 — the same as about 13 750 homes not having to rely on electricity from coal for a year.

But getting the health sector on board to change how they work and so help slow climate change might prove difficult. 

Says Lazarus: “In general the motivation to transform health for sustainability is not well established in South Africa.” 

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Along with touch, it is the way we are invited into our physical bodies moments after we are born.

We are designed to seek nourishment in its many forms — for pleasure, fortitude and growth and development. It’s fascinating that this primal, simple fact of life has evolved with modernity to be the root of much of our well-being undoing.

And while our waistlines are so much wider, our nutrient deficiencies are equally a heavier burden of disease. 

In the most recent investigation into food intake and nutrition of South Africans, the Human Sciences Research Council looked at 100 variables affecting a cohort of 34 000 people.

It found that 69% of obese adults lived in resource-constrained households where food choices were devoid of nutrients. 30% of women of reproductive age are iron deficient.

More than half of the global population is vitamin D deficient. More than two thirds of women are either obese or overweight. KwaZulu-Natal had the highest incidence of obesity, at 39.4%. 

At the same time, 4% of women will be diagnosed as anorexic in their lifetimes, and a much larger percentage will fall on a spectrum of disordered eating habits and body dysmorphia. 

Too much of anything is never a good thing. Your fat cells are metabolically active, and while we all need some subcutaneous fat for warmth and scarcer days, and a cushion to break a fall, an excess of adipose tissue contributes to an inflammatory soup coursing through your veins and affecting your every organ.

Nervous system regulation is a central concept in popular wellness culture today. Everyone is contemplating their vagus nerve.

We are all familiar with the accelerators and decelerators of the nervous system. What the body winds up, it also winds down and somewhere on that fulcrum is a harmonious balance that keeps your heart beating and your psyche mostly serene. 

This, of course, is in ideal circumstances or in a mind where psychic maturity and perspective reign. The mental health crisis, with more than a third of South Africans having been diagnosed with a common mental health diagnosis in their lifetime, suggests that the serenity of this balance is becoming more elusive. 

There are many pieces that contribute to this great undoing, but a collective response to physical and psychological dis-ease is reaching for crisps and a chocolate.

With fast and junk food being the cheapest and easiest to get, self-soothing with refined carbohydrates is even easier than self-soothing with alcohol. 

I feel like a broken record perseverating about the food and advertising industry and how they feed into this burden of disease.

How often do you see a billboard of a muscular, vibrant human body enjoying a bowl of organic spinach or munching on a carrot? No, the images idealise alcohol, burgers, chips, sugary drinks and vapes. They are even beginning to glamourise bodies that carry unhealthy extra adipose tissue. 

Cultural norms should not be shifting towards diabetic bodies with hypertension and heart disease. I know this is sensitive ground. There are so many factors that contribute to body shape, but if we rewind just 50 years and compare, we really are shape-shifting — and not in a healthy way. 

It’s no accident that the other big arms of the capitalist beast feeding this problem include Big Pharma, who are there with a side order of antidepressants and a needle full of appetite suppression. A salve for the ills spread by our food system. 

One of the challenges we face when treating psychiatric disease is the metabolic adverse effects associated with most of the drugs in this armoury.

For a patient whose mood symptoms might be linked to their body image or an underlying inflammatory problem, adding an antipsychotic or an antidepressant will often result in weight gain.

And what about endocrine disruptors? These molecules can mimic our endogenous hormones and stimulate or block the receptors that they act on. According to the Endocrine Society, there are nearly 85 000 human-made chemicals in the world, and 1 000 or more of these could be endocrine disruptors. 

This discovery began when studying an adverse effect of the drug diethylstilbestrol, which was administered to pregnant women to prevent miscarriage. The girl children of these women suffered from a rare form of vaginal cancer. 

Many links and associations have been drawn between conditions such as attention deficit hyperactivity disorder, cancer and certain chemicals that we are all exposed to through skin, diet, air and water.

What makes these associations so difficult to prove is the multi­faceted influences that conspire to make a disease profile express itself. 

Another contributor may be the steroid hormones we are exposed to through our water systems. Studies observing the feminisation of aquatic life have raised concerns about the levels of sex hormones excreted through sewerage. More and more data is being gathered to expose a new kind of pollution that many of us don’t think about. 

Designing hyperpalatable foods is a career choice that didn’t exist before the pandemic of adult and child obesity. Perfect combinations of unnaturally occurring fat, salt, sugar, crunch and carbs are messing with our satiety signals and tricking our brains into needing more. 

The jury is out on whether we can compare drug addiction to food addiction.

In rodent experiments, healthy and cocaine-addicted rodents will choose a sugary drink over a cocaine dose.

Our brain’s reward system is designed to seek out calories to fortify us against leaner times. Hyperpalatable food not only cultivates unhealthy bodies, but also reduces cognitive function, memory and learning — most notably in the developing brain.

According to the World Health Organisation, the worldwide prevalence of obesity more than doubled from 1990 to 2022. Other than our environment, what could have precipitated this escalation? Twin, family and adoption studies have estimated the heritability of obesity to be 40% to 70%. But it probably accounts for less than 5% of the increase in the current burden of disease. 

We also know that less than 5% of other chronic diseases are heritable, so it feels too convenient to blame obesity on evolution alone.

We know that our genes load the gun, but our environments and choices pull the trigger. We can switch off obesogenic genes by choosing lifestyles that support healthy bodies. 

When we use our bodies in the way that they were designed to be used (moving, exerting, dancing, leaping); when we seek nutrition for the amino acids and fatty acids that our bodies need for fundamental health, then we switch these obesogenic genes off and we stave off diseases such as hypertension, diabetes, depression and cardiovascular disease. 

Once a body has been obese for a prolonged period of time, it becomes almost insurmountable to lose the accumulated weight. The body holds on to fat. In the face of a reduced caloric diet, an obese body will increase its desire for extra calories and slow its metabolic rate. 

The uphill battle against weight loss for a very overweight body is real and measurable. The discomfort of carrying extra weight on your joints is real and measurable. The effect of obesity on a patient’s quality of life is overbearing and mammoth. 

We have a responsibility to our children and our species to halt the engines that feed this insatiable beast. Say no to Coca-Cola and fruit juice. Say no to deep-fried chicken and processed meat. Say no to microwave dinners in front of a television. 

Say yes to the Earth’s bounty and wisdom. What you feed your body designs your brain. We can’t afford any further dumbing down.

Dr Skye Scott is a family GP and co-owner of Health with Heart.

At his home in New Forest village, he mixes herbs “to treat psychiatric disorders, diabetes, constipation, cast out evil spirits and help estranged couples love each other again”.

About 70% of South Africans — mostly in rural areas — visit sangomas like Mawelele first before they go to a medical doctor, or they don’t go to a health clinic at all. 

But new rules “expected to start [being enforced] early in 2025” will see izangoma (diviners) and other traditional healers having to register with the Interim Traditional Health Practitioners Council, to align their work to a more formal system, says spokesperson and chairperson of the registration, education and accreditation committee, Sheila Mbhele. 

The council will oversee how traditional healers operate, in a similar way as the Health Professions Council of South Africa and the South African Nursing Council does for other health workers such as doctors, dentists, dietitians and nurses. 

The draft regulations, which were published in June, are meant to set standards for practitioners’ training and practice and closed for public comment on 21 September.

Practitioners will have to pay registration fees to the council every year and show proof of being appropriately trained for the type of service they offer. 

Health department spokesperson Foster Mohale said this week that “processes for finalisation [of the regulations] are ongoing” and that they “will be implemented on proclamation”, although when exactly this will be is not clear. 

The suggested rules come more than 15 years after the Traditional Health Practitioners Act was passed into law in 2007.

Moving away from traditional medicine being seen as witchcraft, the modern law is in line with the World Health Organisation’s (WHO’s) view of treating health problems based on indigenous know-how and customs passed on through generations being an alternative to Western medicine, which relies on evidence from scientific studies.  

And, says the health department, formalising traditional medicine will allow healers to work with doctors and nurses at the level of primary care.

This, says Mohale, links to the WHO’s Alma-Ata Declaration of 1978 about countries committing to offer everyone this type of health service and so working towards universal health coverage. 

He explains: “In working together like this, their role in fighting major diseases such as HIV can be identified.” 

Regulation, registration and reticence

But not everyone agrees with putting formal rules in place. 

Zanele Mazibuko, spokesperson of the Traditional Healers Organisation (THO), says although the regulations “will protect the sector against charlatan healers, more consultation is needed”.

At the heart of this reticence are the requirement for registration fees and practitioners’ having to submit proof that they are trained.

For example, under the new regulations, someone who wants to work as an isangoma or herbalist has to be at least 18 years old and will have to have had 12 months’ training in diagnosing conditions, collecting and storing herbs and preparing treatments, as well as doing traditional consultations.

Those who want to work as traditional birth attendants or surgeons must be 25 or older and have had one year (birth attendant) or two years (surgeon) of training to learn the ropes in their field of practice.

Training will be handled by experienced healers such as Mawelele. Mbhele says the council will work closely with amakhosi (local chiefs) to certify healers and confirm that “we know this healer, we’ve trained him, we’ve seen him practise and we’ve visited him”.

She notes that the health department will also be involved and that they “have their own processes to track the training of traditional healers”.

Having to pay yearly registration fees to get a practice number “similar to that of doctors” has also caused unhappiness among healers.

Applicants who can show evidence of their education will have to pay R1 000 for the first year and R500 a year afterwards. Amathwasa (student healers) will have to pay R200 at first and then R100 a year afterwards, while their tutors will have to pay R5 000 upon first registration and then a yearly renewal of R1 500. 

With the period for public comment now having closed, the council will start to formally accredit and register healers who qualify for registration. 

But in the THO’s view, the fees will be “unaffordable” and, says Mazibuko, although healers “are ready to be taken seriously and integrated in the healthcare sector, this must be without Eurocentric methods dominating and dictating our traditional practices”.  

Mbhele counters: “[Even though the period for public comment has closed], people can still ask the council to come [to them] to be shown areas where [we] need to do things right.”

Can sangomas help SA to tackle HIV?

Research shows that power struggles and mistrust are common in efforts to get traditional and Western medicine systems working together.

For example, in a study from KwaZulu-Natal that explored healers’ views on formal registration, practitioners said they were sceptical about the process and saw no benefits, except for their work being officially recognised. Moreover, registration fees were seen as a tactic to bolster the government’s tax revenue. 

Elsewhere in Africa ( 39 countries have policies around traditional healing in place), an analysis of 22 studies shows that when indigenous medicine is part of the formal health system, mistrust and rivalry between conventional doctors and traditional healers stem mostly from doctors considering themselves superior and seeing their role as having to teach healers, and not accepting the spiritual aspects of traditional healing.

But Ryan Wagner, a senior research fellow at Agincourt, a rural health research unit run jointly by the South African Medical Research Council and the University of the Witwatersrand, says this needn’t be the case. 

He is leading a five-year study on having traditional healers offer HIV testing and counselling to clients and connecting them to clinics for treatment if their result is positive.

Wagner has been working with practitioners in Bushbuckridge since 2015 to understand how the two health systems can work together to “improve patients’ health and finding common ground”.  

Mawelele is one of this group of 15 traditional healers. In the past year, he has referred more than 40 patients to local clinics for testing as part of the pilot project.

Getting tested is the first step towards achieving the 95-95-95 goals — the world’s strategy to end Aids as a public health threat by 2030 — because if someone tests positive for HIV, they can start taking ARVs immediately (this is the second number in the series of 95s).

The 95-95-95 goals aim to, by the end of 2025, have 95% of people with HIV diagnosed. Of those, 95% must be on treatment, and of the 95% people on treatment, 95% must be virally suppressed, which means the levels of HIV in their bodies have dropped to such low levels (as a result of treatment) that they can no longer transmit the virus to others. 

In the Ehlanzeni district, in which Bushbuckridge is located, about 75% of people with HIV were on treatment by the end of 2023, which is close to the national figure of about 78% for the second 95 of the series (according to the Thembisa model, which the health department uses).

Says Mawelele: “A lot of my patients come to me first as they don’t want to stand in long queues at the clinic. They say there’s more privacy here and no one judges them.” 

Working together

Having conventional and traditional systems work together is possible, research shows.

For example, a study from rural Uganda, where it’s easier for communities to access traditional services than an HIV clinic, found that when an indigenous healer offered people an HIV test, everyone agreed to, compared with only about a quarter of people who did so when they were sent to a clinic to get tested. 

For effective cooperation, Wagner says trust between traditional healers and medical doctors and nurses is essential.

“Distrust can only be broken down through frank engagement in safe spaces. Ultimately, both systems strive to improve the health and wellbeing of people, and by working together, we can get there faster.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Travelling around Nyandeni, a local municipality in the OR Tambo district in the Eastern Cape, is a bumpy ride. Here, like in most of the province, roads are mostly untarred. 

To get to a clinic, people have to either walk about 20km or take a guruguru (a bakkie that operates as a taxi), which travels to the health facility at 5am and back again at 5pm to take them home.

OR Tambo, which spans an area of about 12 140 square kilometres and has Port St Johns on the Wild Coast about halfway between its southern and northern borders, is deeply rural — and one of the poorest districts in South Africa. About 90% of people here live in so-called last-mile communities — villages and informal settlements that are far from services such as electricity, piped water and healthcare.

On the gravel roads of Nyandeni, you’re bound to see women like Nosizwe Peter, 58, walking in their bright green T-shirts.

Peter is one of 40 mentor mothers in OR Tambo, lay health workers employed by One to One (OTO) Africa, which is a nonprofit organisation that provides maternal and child health services in rural communities. 

But mentor mothers are different from community health workers employed by the health department — because they focus only on pregnant women and new mothers who, like they, are HIV positive. 

The idea behind this peer-support model, which has successfully been rolled out elsewhere in Africa such as in Malawi and the Democratic Republic of the Congo, is that because the mentors themselves have HIV, they understand the issues these new mothers grapple with and, in turn, clients feel more comfortable getting health advice from them. 

Could a programme like this help mothers, in a district where just over a third of pregnant women are HIV positive, stay healthy — and raise healthy children too?

We travel with some of these mentors to see how the system works. 

Twins, a mentor mother and a scale

When Peter arrives at a rondavel in KwaDontsa, she greets 21-year-old Aphiwe Tyhontsi, a mother of twins. 

The two girls, Alizwa and Aliziwe, are 11 months old, content while feeding at their mother’s breast. 

Peter praises Tyhontsi for breastfeeding and then asks her for their clinic cards. 

Breast milk is the best food for infants from birth up to six months, because it’s nutritious, easy to digest and contains antibodies that help protect babies against stomach bugs and ear infections. 

She pulls a scale out of her OTO-branded backpack, sets it on the ground and asks Tyhontsi to stand on it. 

Peter notes down her weight.

Soon one of the girls stretches out her little arms, motioning that she wants to be picked up. Tyhontsi heeds and steps onto the scale once more. After Peter has written down their combined weight, it’s her sister’s turn. 

Peter smiles as she looks at the reading on the scale. 

Both girls, who weighed less than 2.5kg at birth and which can be a sign of development problems, are now just over 9kg — right on target for a healthy weight at this age and showing that they’re growing well.

Then Peter looks at the girls’ clinic cards and says: “If there’s a measles outbreak your babies are at risk.” 

Why pregnancy checks and childhood shots are important

The first thing mentor mothers do is to help HIV-positive pregnant women understand why it’s important to start antiretroviral (ARV) treatment — and stick to it. Research shows that if soon-to-be mothers aren’t taking their anti-HIV medication, they could pass on the infection to their babies in up to 45% of cases.

But apart from that, these peer-support health workers also give women advice on staying healthy during pregnancy, tips on breastfeeding and nutritious foods, go with them to check-ups at clinics, and check that their babies are growing well and get their vaccinations on time. 

Mentors, who get six weeks of training, are recruited from the local area with the help of the chiefs and headmen of the villages — an important part of getting people to accept the programme, given the power these leaders have in their communities. 

Although Alizwa and Aliziwe have had their first doses of measles vaccine when they were six months old, they’re due for the final jab within the next month, by the time they’ll turn one. 

Check-ins like this can go a long way to boost childhood immunisation coverage in the district, which sat at only about 75% in 2022-23, well below both the national and provincial average of about 82%. (If enough children in a community aren’t vaccinated against diseases such as polio, measles and diphtheria, infections can spread quickly lead to a wide outbreak.)

With difficult access to clinics because of poor infrastructure and the rural nature of areas, last-mile communities often lag behind when it comes to things like antenatal clinic visits and childhood immunisations. OR Tambo is one of the worst performing districts in the country when it comes to kids getting their shots.

‘Sometimes the mobile clinic doesn’t come’

For this reason, the mentor mothers programme also has a mobile clinic, where “all of our services come together”, says Emma Chademana, programmes director at OTO Africa.

The truck, which stops at a different village each day, is on its way to Lucingweni today, about 80km southeast of Mthatha. 

Up on the hill on the other side of the bridge that crosses over the Mtakatyi River, waits the pregnant Carmel Vice, 32, with her toddler son. 

Vice, a teacher at a local school, isn’t at work today because she and her son have been feeling sick for a while, but she hasn’t had money to get transport to one of the local clinics. 

Since 2000, the government has been sending a mobile clinic to Lucingweni once a month, “but sometimes it doesn’t come”, says Aaron Makhabola, headman of the village.

But with OTO’s clinic-on-wheels being recognised by the provincial health department as a standalone facility, people are sure that they’ll be able to get medical care at least once every month. 

This is good news for someone like Vice, who can get her pregnancy check-ups at the truck instead of having to travel to the government clinic — or having to forgo a visit if she can’t get the money together.

Research shows that when women have regular check-ups during their pregnancy, there’s a lower chance of their babies dying shortly after birth. 

Early newborn deaths are particularly worrying in OR Tambo, where nearly 13 out of every 1 000 babies born in a hospital or clinic die in their first seven days of life. Compared with the national rate of just under 10 per 1 000, the district’s figure makes it one of the worst performers in the country for this indicator.

Why it’s important to work with the health department 

OTO works closely with the health department, says Chademana. Their mobile clinic offers the same services as what’s available in a state clinic, such as check-ups for patients with diabetes or high blood pressure, pregnancy care and teaching people about living healthy. 

Moreover, the app mentor mothers use to track their client visits is developed by the same company that made the government’s one for community health workers, and when they write a referral for someone to be treated at a hospital, the form shows the health department’s stamp, says Chademana.

“The relationship with the [health] department is critical. We can’t offer services that don’t exist in their system because who will service those clients [if] we leave? It’s important that we work to strengthen the existing system.”

To help with this, OTO has trained 27 of the government-employed community health workers in Nyandeni to support pregnant women or new mothers in the same way as mentor mothers do. Two of these are at Buchele Clinic in Lusikisiki, which has to look after more than 8 400 people in the surrounding villages. 

With the extra training, these community workers help with more than just making sure HIV-positive mothers stay on treatment — they also track their babies’ growth; give shots for vitamin A (which is important for a strong immune system and keeping cells healthy but often lacks in the diet of children growing up in poor households); and help families with eating healthy and getting social support. 

“Before I would just give a child deworming and check their card to see if they’ve been to the clinic. But now I can do more things, like give education on nutrition and take their blood pressure,” says Bukiwe Mpaceka, a community health worker who adopts the mentor mother model.

“If I come into a house and see that there are no vegetables, I advise [the family] on the importance of planting these for nutrition,” she adds. 

OR Tambo is especially hard hit by food insecurity. In 2022, the district had the most deaths and hospital admissions of children under five in the province because they have too little to eat in critical development periods and become very thin (a condition called severe acute malnutrition). 

Moreover, not having a good balance of nutrients such as vitamins, minerals and proteins at a young age can lead to children’s brains not developing well, which makes it hard to concentrate or do thinking tasks like understanding stepwise instructions, and can up the chance for health problems like obesity and diabetes later in life.

First-hand change

Peer support for pregnant HIV-positive women by mothers who also have HIV has been shown to work really well. 

In Nigeria, about 1.2 million women and girls older than 14 have HIV but only a third of those who are pregnant are on treatment to prevent the virus from being passed on to their babies. A study found that women from rural areas who got advice from mentor mothers were almost five times more likely to have stuck to their treatment so well that they were virally suppressed six months after giving birth than those who had help from only general community health workers.

In KwaZulu-Natal, more pregnant women who had support from mentor mothers started taking ARVs than those without such backing. Moreover, women in the programme knew more about how to prevent their babies from getting infected and were also more likely to know their CD4 count. 

But the effect of this support model doesn’t exist on paper alone; communities see the change first hand.

Says headman Sigcau of the Mankosi village: “You won’t find a child born with HIV or malnourished in this village — because of the mentor mothers.” 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.