Wide celebration and promise of a better life for all its citizens accompanied South Africa’s rise from apartheid rule. Two decades on, Adele Baleta and Fiona Mitchell report on the insidious threat of chronic morbidity and early mortality.

For health in the new South Africa the main threats are fourfold. First, the country has the highest number of people living with HIV and AIDS worldwide, and most are co-infected with tuberculosis. Second, there are soaring rates of trauma caused by motor vehicle accidents and interpersonal violence. According to South African police services, the murder rate is about 4·5 times higher than the global average of 6·9 murders per 100 000 population. Third, South Africa has high rates of maternal and infant mortality compared with other countries. Finally, industrialisation and economic transition are conspiring with population demographic change to produce a massive rise in non-communicable diseases.

This unwelcome combination of events is occurring in a health system that is already groaning under the high burden of communicable diseases, and fears are that without integrated health management systems, the rising tide of non-communicable diseases could lead to rife competition for scarce health resources.

There is nothing country-specific about the rise in many non-communicable diseases in South Africa. Here, as elsewhere, insufficient exercise and unhealthy diets are behind the inevitable increase in obesity and its associated diseases; the other two important risk factors are tobacco use and excessive alcohol consumption. The South African Medical Research Council reports that 61% of the population is overweight, obese, or severely obese. According to the International Diabetes Federation, an estimated 2 million people in South Africa have diabetes.

However, this is likely to be an underestimation of the true burden. Speaking with The Lancet Diabetes & Endocrinology, Demetre Labadarios from the Human Sciences Research Council (HSRC) states that the prognosis is “bleak”, and that “urgent action” is needed. The HSRC’s first South African Health and Nutrition Examination Survey (SANHANES) of more than 25 000 people in 2012, showed that 5% of all adult (older than 15 years) respondents had self-reported diabetes; in those over 55 years of age, the proportion was 16%.

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