Richard Smith: Managing hypertension in a South African township

Richard Smith

South Africa suffers from a “quadruple burden” of disease—infectious disease, particularly AIDS and TB; trauma from road traffic injuries and violence; perinatal and maternal health problems; and non-communicable disease. I thought of this burden as we visited the community clinic in Khayelitsha, the largest “township” in Cape Town.

Khayelitsha is as big as Bristol but has only three public clinics. Nobody knows exactly how many people live there: the last census showed 350 000, but some say a million—and the best bet is probably something like 600 000. Nobody likes the world slums, but most people live in very poor quality housing. Indeed, “house” is not the right word for most of the habitations. Most are shacks put together from tin and whatever is to hand. If people manage to get jobs and make some money they improve their houses, with some of them brick and even two storey, but then relatives might arrive and build a shack in the “garden.” Many houses do have electricity, and televisions are common and mobile phones almost universal. Sewerage is much rarer, but townships are often surrounded by rings of portable toilets, like those seen at pop festivals in Britain.

The community clinic is very familiar with HIV and TB, and huge numbers of patients attend and are methodically treated with free drugs. The clinic staff have long recognised, however, that non-communicable disease is also a problem. We walked into the clinic where patients with hypertension were being treated. The first thing that strikes you is the huge numbers. People queue to enter the room where we stood, and perhaps 50 people were packed into the room—waiting to see the two nurses with their two assistants who were gathering information and measuring blood pressure. People wait until it’s their turn, and then if they need to see the doctor they wait some more. People set a whole day aside to attend the clinic, and some arrive before dawn.

The clinic is called a club by the clinic staff, but when I asked they said it was really just a clinic. But the room had the feeling of a club. People didn’t look miserable. They talked to each other, gossiped, and no doubt caught up with friends and the news of the township.

Although the numbers seemed huge, they must be only a tiny fraction of the people in Khayelitsha with hypertension. Nobody has done a large prevalence study (and you can imagine how difficult such a study would be), but the best bet is that about a third of adults have hypertension and a third diabetes. Perhaps half of the township is under 15, but there might be 100 000 people with hypertension in the township. Many of these people are undiagnosed, but many go to traditional healers and to private doctors. One nurse told us that there is a “private doctor on every corner” and even more traditional healers. That must be an exaggeration, but there may be many private doctors—because, we were told, they charge 200 to 250 Rand cash (some £23 to £29) for each consultation. They often have no staff, operate from very primitive premises, and see dozens of patients a day. The cost to the patients is huge, but it’s a very lucrative business for the doctors. The community clinic has met with the traditional healers and discussed how they might work together.

The second thing that struck me was that almost all the patients were women. I could see two men among the 50 in the room. Hypertension is common in both genders, and clearly the men are not being treated or are going elsewhere. Many are, the staff thought, attending traditional healers and private doctors—perhaps because they can’t spare a whole day to attend the public clinic and perhaps because the clinic/club is so female dominated that they feel out of place.

I write that it’s the third thing to hit you—but you notice straight away that many of the women are huge, with BMIs well over 30. (In case you have forgotten, you are deemed overweight with a BMI of 25 and obese if it’s over 30.) As with all obesity, the reasons for the high levels of obesity among the women are highly complex, but one factor is that the preferred BMI for women is 29. The preferred BMI is lower for men, but nobody wants to be thin—for fear of being thought to have HIV. Another factor shown in a study of causes of obesity among South African women is “a memory of hunger as a child.” Perhaps once you have experienced hunger you’ll do all you can to avoid experiencing it again.

We were told that adherence to the drugs for hypertension is a huge problem. Again there are no studies, but the sense of the doctors and nurses is that only a minority of patients take their drugs regularly.

It might be easy to feel overwhelmed by the challenge of establishing effective prevention and treatment of hypertension in Khayelitsha, but the staff gave no sign of that. Perhaps it’s because they have experienced effective programmes being mounted for HIV. Now the same needs to be done for NCDs.

Competing interest. RS was visiting Cape Town to visit the Centre of Excellence for Chronic Diseases in SubSaharan Africa which is funded by the UnitedHealth Group, for whom RS works, and the National Heart, Lung, and Blood Institute. The centre is doing work in Khayelitsha.

  • Kirsten Patrick

    Adherence is a problem because the cheaper antihypertensives that these patients are prescribed are also the ones that have to be taken three or four times daily. Hard to remember to do… for anyone in any setting and particularly for people who live in 'informal' settings and don't have fixed daily routines. Would you want to take hydrochlorothiazide if it was hard for you to get to a toilet to pee?

  • Richard Smith

    You're quite right. Adherence only makes sense if you see it in a social context. That's one of the reasons that people have moved to the term concordance, where there is deep agreement between clinician and patient about the drugs, including perhaps that the patient won't take them. I learnt today in Eldoret, Kenya, how patients with HIV must achieve 95% adherence or resistance develops. I also learnt that PEPFAR will not pay for third line drugs and how in Eldoret 38 patients need them. They will die.