![\"Richard](\"http:\/\/www.bmj.com\/site\/blog\/icons\/bmjh7648e.jpg\")
<\/p>\n<\/p>\n
South Africa suffers from a \u201cquadruple burden\u201d of disease\u2014infectious 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 \u201ctownship\u201d in Cape Town.<\/p>\n
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\u2014and the best bet is probably something like 600 000. Nobody likes the world slums, but most people live in very poor quality housing. Indeed, \u201chouse\u201d 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 \u201cgarden.\u201d 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.<\/p>\n
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\u2014waiting to see the two nurses with their two assistants who were gathering information and measuring blood pressure. People wait until it\u2019s 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.<\/p>\n
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\u2019t look miserable. They talked to each other, gossiped, and no doubt caught up with friends and the news of the township.<\/p>\n
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 \u201cprivate doctor on every corner\u201d and even more traditional healers. That must be an exaggeration, but there may be many private doctors\u2014because, we were told, they charge 200 to 250 Rand cash (some \u00a323 to \u00a329) 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\u2019s a very lucrative business for the doctors. The community clinic has met with the traditional healers and discussed how they might work together.<\/p>\n
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\u2014perhaps because they can\u2019t 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.<\/p>\n
I write that it\u2019s the third thing to hit you\u2014but 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\u2019s 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\u2014for fear of being thought to have HIV. Another factor shown in a study of causes of obesity among South African women is \u201ca memory of hunger as a child.\u201d Perhaps once you have experienced hunger you\u2019ll do all you can to avoid experiencing it again.<\/p>\n
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.<\/p>\n
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\u2019s because they have experienced effective programmes being mounted for HIV. Now the same needs to be done for NCDs.<\/p>\n