Unpacking South Africa’s excess deaths. What is known and where the gaps are

 

A pop-up site in Johannesburg aimed at encouraging mini-bus taxi operators and commuters to vaccinate on site. Luba Lesolle/Gallo Images via Getty Images

In the 2000s experts from the University of Cape Town and the South African Medical Research Council built a system to track AIDS mortality on a monthly and a yearly basis, using data from the Department of Home Affairs. In 2020 researchers built on this system to track COVID-19 deaths in South Africa. Now, South Africa is one of few countries in the developing world that have managed to build a near-real time mortality tracking system. The South African Medical Research Council publishes a weekly report on deaths in the country. The Conversation’s Ina Skosana spoke to demographer Tom Moultrie about what the data shows.

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Who, according to your figures, is dying, and where are they?

The weekly mortality report provides information on deaths registered in almost real-time on the National Population Register. These are used to determine the actual number of deaths that have occurred in the country and calculate the number of excess deaths over and above the numbers that would be expected had the historical mortality trends before the COVID-19 pandemic continued.

In South Africa between May 2020 and early September 2021, over a quarter of a million more people have died from natural causes than was predicted for that time period.

The vast majority – three quarters – are over the age of 60.

The burden of this has been very heavily felt by those at older ages. But it is not completely unaffecting those aged under 60. And that is because of the high prevalence of noncommunicable diseases. South Africa has a high incidence of diseases and conditions such as diabetes, hypertension and obesity. These are all known cofactors for COVID-19 related mortality

The geography of where people are dying is largely a reflection of where people are living. The actual count of excess deaths is lower in the sparsely populated Northern Cape than more densely-populated provinces such as the Western Cape or Gauteng. Allowing for population size and age-distribution, the three most-affected provinces are the Northern Cape, KwaZulu-Natal, and the Eastern Cape; while the three least-affected provinces are the Western Cape, North West, and Gauteng.

What are the leading causes of death?

This is the real problem we have with trying to understand COVID-19 deaths in the country. We get the data we use from the Department of Home Affairs, which only classifies deaths by natural or unnatural causes.

Unnatural causes of death would be homicides, suicides and accidents. Natural causes refers to medical causes of death.

At the time of death, a doctor or medical attendant records the chain of causes leading to death on an official death notification form. But that information is not captured in real time by the Department of Home Affairs. This data is only released by Statistics South Africa many years after the fact. For example, the mortality and causes of death report release in 2021 reflects deaths recorded through to 2018. However, the actual data are still only available through to 2017.

The numbers reported by the national Department of Health every night reflect those known to have died from COVID-19 and who were known to have been infected with the virus. But those reports miss many deaths, especially of those who do not die in a health facility.

In the meantime, however, we can look at the proportions of people testing positive, the excess deaths (above what was expected) as well as the officially reported COVID-19 deaths to get a sense of how these relate to each other. The estimates of excess deaths produced every week show that the peaks of the excess deaths follow almost exactly the peaks of reported COVID-19 deaths, as well as the cases reported a week or so earlier.

The South African Medical Research Council and University of Cape Town collaboration, who produce the estimates of excess deaths every week, has come to the view that between 85% and 95% of the excess natural deaths in the country are related to COVID-19.

But we do not know for certain. That’s one of the great tragedies of vital registration systems in sub-Saharan Africa and the developing world generally.

How can this information be used in the COVID-19 response?

The excess deaths shows that the effects of COVID-19 are far more severe than that reflected in the national data. We can see that even at a more granular level by looking at the provincial data. The number of COVID-19 deaths reported in the Western Cape – which has the best-functioning health data system in the country – is about 70% of the number of excess deaths estimated for the province. Based on this information we can be fairly certain that other provinces are missing COVID-19 deaths.

But even if we can’t attribute all of those excess deaths to COVID-19, we can say with a high degree of certainty that a lot more people have died from COVID-19 than has been reported by the National Department of Health.

Another thing that we’ve managed to do during this period of repeated lockdowns and changes in regulations has been to try and tease out the effects of the various alcohol bans and curfews on the number of unnatural deaths. Unnatural deaths – as a consequence of homicide, suicide, and accidents – tend to be strongly associated with alcohol. And one of the things which we have managed to show in the paper, which we published in the South African Medical Journal, was exactly how extreme the effects of banning alcohol are in terms of their impacts on the number of unnatural deaths. We also showed that the partial restrictions on the sale of alcohol are largely ineffective.

So this data contributes to the evidence base which government can draw on to determine what their COVID-19 response should be.

Tom Moultrie, Professor of Demography, University of Cape Town

This article is republished from The Conversation under a Creative Commons license.

How poverty and violence are linked with anxiety in young South Africans

 

Young people living in urban informal settlement are exposed to high levels of violence and poverty. Darren Stewart/Gallo Images via Getty Images

Over the past 10 years there has been increasing awareness of the importance of promoting good mental health in South Africa. Most of the mental health awareness campaigns have been around depression, suicidal thoughts and suicide, and alcohol abuse.

Important and often overlooked forms of poor mental health are anxiety disorders. The most recent estimates of anxiety disorders in South Africa are from a 2009 nationally representative study. Anxiety disorders were the most common form of poor mental health reported by South Africans in the research. More than 8% reported anxiety disorder in the past year. Anxiety disorders include agoraphobia, which is the fear of places or situations that may cause embarrassment, as well as panic attacks. A broader form of anxiety is generalised anxiety disorder. It manifests itself as ongoing generalised worry.

This worry can be about many things – from money to how to provide for children and hopes for the future. Such generalised anxiety is associated with increased substance misuse, greater risk of acquiring HIV, as well as other mental health disorders. It may also reduce people’s economic well-being through limiting their ability to look for work, or go out and work.

Studies globally have broadly identified two main structural drivers of anxiety: poverty and violence.

In South Africa half of adults are living below the poverty line, defined as earning an income of less than R1,183 per month. Similarly, experiences of violence in childhood and later life are common. A study among 15-17-year olds found that 10% of boys and 15% of girls had experienced sexual violence in their lifetime. Violence and injuries are the second leading cause of lost disability-adjusted life years in South Africa.

Yet the challenges of poverty, violence and chronic stress experienced by many South Africans daily and for many years are not uniform. Young people, particularly those living in the challenging contexts of urban informal settlements, may be more at risk of experiencing generalised anxiety disorder. This is because poverty and community violence are more common in these spaces than in other communities.

Few studies look at anxiety. But it remains the most common form of mental health disorder in South Africa.

Understanding the causes is important for starting to understand how to address generalised anxiety disorders. In our recent research we spoke to young people living in informal settlements in eThekwini Municipality, in KwaZulu-Natal. We asked them about their symptoms of anxiety, as well as potential risk factors for anxiety. These included abuse in childhood, interpersonal violence, food insecurity and stress related to poverty.

Symptoms of generalised anxiety disorder were higher in respondents who reported experiencing particularly extreme levels of poverty and experiencing violence. Addressing these two factors is critical for reducing poor mental health and its future impacts on individuals and potentially their children.

Anxiety in urban informal settlements

Our study was conducted in 2018. The study participants were young women and men (ages 18-30) who were already part of an intervention trial called Stepping Stones and Creating Futures. This intervention was run by the South African Medical Research Council and Project Empower, and sought to reduce poverty and violence among young people living in urban informal settlements.

We asked the respondents (488 women and 505 men) about their own experiences of symptoms related to generalised anxiety disorder. These are symptoms such as feeling nervous, not being able to stop worrying and being restless. In our study we found a high rate of women and men reporting moderate or severe symptoms of generalised anxiety disorder – 18.6% and 19.6%, respectively – as assessed through seven questions which comprised the Generalised Anxiety Disorder 7 Scale.

We asked women and men a range of questions about their experiences of poverty, violence and stress. We also looked at multiple potential risk factors for anxiety. Women with more severe symptoms of generalised anxiety disorder, as compared to those with few symptoms, were more likely to have stolen because of hunger in the past month, and be stressed about lack of work. They were also likely to have experienced more adverse events such as witnessing the death of someone or being robbed at knife or gunpoint, and to have experienced violence from a partner in the past year.

For men, a similar pattern to women was seen. More severe generalised anxiety disorder symptoms were associated with poverty and experience of violence. Specifically, men with more anxiety symptoms, as compared to those with fewer symptoms, had stolen in the past month because of hunger, reported more adverse experiences as children, and had more adverse experiences in adulthood.

Addressing anxiety in South Africa

Our findings show how poverty, experiences of violence and adverse events are key contributing factors for generalised anxiety disorder among young people living in urban informal settlements.

South Africa must address the wider structural drivers of poor mental health, specifically poverty, unemployment and violence. It is the only way to achieve the Sustainable Development Goals, and specifically Goal 3.4, which emphasises the need to promote mental health and well-being.

Andrew Gibbs, Senior specialist scientist: Gender and Health Research Unit, Medical Research Council, South African Medical Research Council

This article is republished from The Conversation under a Creative Commons license.

Why an amnesty for grand corruption in South Africa is a bad idea

 

Thuli Madonsela, professor of law and former Public Protector of South Africa. EFE-EPA

South Africa’s former Public Protector, Thuli Madonsela, provoked a political storm recently when she suggested that public servants implicated in grand corruption should be given the chance to apply for amnesty.

Many South Africans, weary of rampant, unchecked and unaccountable corruption, could be forgiven for asking: what on earth was she thinking?

Madonsela won the admiration of many South Africans because of her steely resolve in the face of malfeasance and breaches of the rules of integrity in public office. Her proposal suggested she might be going soft on corruption.

To be effective as the Public Protector Madonsela required many attributes, as I set out in my 2013 book, The Zuma Years. These included independence of mind, a very thick skin and a certain contrarian eccentricity that rendered her far less susceptible to the numerous attempts to intimidate her as she took on then president Jacob Zuma and his state capture network.

Her amnesty idea displays all of these characteristics.

It should be taken seriously, if only to affirm the merit of a diametrically opposed position.

It’s an inherently bad idea.

Bad timing

Madonsela’s timing is especially unfortunate. It is only in very recent times that the Hawks, the priority crimes investigating police unit, and other agencies of the criminal justice system appear to have recovered the institutional capacity to begin prosecuting those responsible for the deep-lying state capture project.

Recent developments have begun to suggest that the net is finally tightening around the bigger fish that are the true architects of systematic corruption in the country.

This has been widely welcomed. Accountability, at last.

Against the grain of this public view, Madonsela, a law professor, entered the fray to suggest that instead of being tough on the perpetrators, an olive branch should be extended.

This is an example of the “independent-mindedness” for which Madonsela was rightly acclaimed during her seven-year term as Public Protector from 2009-2016.

It is also not only contrarian, but also eccentric in that it makes so little sense.

To be fair to her, she tried to clarify later that she did not mean amnesty for every perpetrator, and certainly not the big fish. Her idea is targeted at those whose “status”, she says, “in the food chain is quite junior”.

But the first of a series of fatal flaws in her idea is about where to draw the line: on what basis should one distinguish the smaller from the bigger fish?

Those who had played a “minor but critical” role was how she framed her idea. There is already a problem here: is it possible for something to be both “critical” to a (criminal) enterprise and yet still “minor”?

I think not.

Half-baked idea

Madonsela confirmed that amnesty should be available on a legal rather than a moral basis. Yet, in a radio interview after she’d floated the idea, and drawn a lot of flak, she added to the confusion.

At first Madonsela spoke of people who may have “bent the rules” unwittingly, in which case, they may well have a legal defence to criminal conduct. Later, she clarified that she intended to cover individuals with “agency”, even to the extent that their palms have been “greased with money” (which, she argued, they would have to pay back in return for amnesty).

If the right to amnesty was indeed to be a legal entitlement, then the terms on which entitlement to amnesty applies have to be very clearly and carefully drawn. This much has been revealed in Constitutional Court decisions concerning the legal rationality of presidential amnesties or pardons in the case of women convicts and perpetrators of apartheid era offences.

Madonsela’s public policy rationale appears to be that without an inducement, the smaller cogs in the bigger wheels of state corruption may seek to hide and avoid prosecution when what is required is that they should come forward with information about the bigger fish.

Perhaps, then, an offer of amnesty – in effect, a legal right to indemnity from prosecution – deserves to be given serious consideration. This, especially if it is the case that the National Prosecuting Authority is struggling to pull together the evidence to bring strong prosecutions against the most powerful perpetrators of state capture corruption.

But there is no evidence that this is the situation. And, moreover, there are major downsides to be weighed in the balance.

The case against amnesty

First of all: deterrence.

The fact that amnesty has been granted in the past may encourage future corrupt actors to take the risk. The corollary is that the successful prosecution of corrupt officials is likely to discourage repetition.

Secondly, the arguments put forward by Madonsela would, in my view, provide grounds for mitigation in sentencing – not for amnesty. One example would be “small fish” cooperating with the investigative authority and providing evidence about the bigger fish. Another example would be if someone could show that they were bullied into bending procurement rules by a superior and more powerful individual in the system.

Another possible avenue – common practice in criminal justice systems around the world – is the use of a “plea bargain”. Here an accused person trades information in return for facing a less serious charge.

Amnesty would, in effect, deprive them of this opportunity and could thereby undermine the integrity of the whole criminal justice system.

The other major consideration is perception – both in the eyes of key stakeholders, such as the investment community and, secondly, the general public.

Investors are especially eager to see if South Africa has the capacity to hold to account those who contaminated the democratic state and so undermined fair competition by enabling a rent-seekers’ paradise. It is about the strength of the rule of law. Investors want to feel confident that this is one destination where the rule of law holds and where, because of state capture prosecutions, there is less risk of a repeat.

And surely, above all else, the public will feel cheated if perpetrators of state capture corruption, however “minor”, get away scot-free. This, more than anything, would encourage a lawless society, steeped in a culture of impunity rather than accountability.

A dangerous path to tread

Attempts to trade amnesty for information about state corruption have caused conflict as well as controversy in other countries. One notable example was in Tunisia in 2017.

But the biggest danger is that it simply sends the wrong message. This was aptly spelt out by esteemed South African artist William Kentridge reflecting on a previous attempt at taking the amnesty road in South Africa through the Truth and Reconciliation Commission process.

A full confession can bring amnesty and immunity from prosecution or civil procedures for the crimes committed. Therein lies the central irony of the Commission. As people give more and more evidence of the things they have done they get closer and closer to amnesty and it gets more and more intolerable that these people should be given amnesty.

Admittedly, Madonsela has a different purpose in mind than the national reconciliation ambition of the Truth and Reconciliation Commission process. But, no, Advocate Madonsela, a blanket amnesty would send the wrong message at the worst possible time.

Richard Calland, Associate Professor in Public Law, University of Cape Town

This article is republished from The Conversation under a Creative Commons license.

South Africans are revolting against inept local government. Why it matters

 

Failures by municipalities to do their work are forcing many residents to take matters into their own hands. EFE-EPA/Nic Bothma

A sea change is under way at local government level in South Africa, one which all political parties had better watch out for. Citizens’ groups are taking control of municipal functions, some with the support of courts, and are delivering services where this sphere is collapsing.

The trend is being driven by voters who are sick of corrupt politicians – as every poll makes clear. For example, a poll run in late 2019 showed growing mistrust in political parties and politicians. There was a deep-seated belief that the country was headed in the wrong direction. Over 80% of respondents thought corruption was increasing.

The sad state of the local sphere has been lamented by many, not least the late Auditor-General Kimi Makwetu. He noted in 2018 that “on average almost 60% of the revenue shown in the books will never find its way into the bank account”, raising the alarm that such rampant corruption and incompetence would inevitably result in a growing revolt against rates and taxes.

The consequence has been precisely that – talk of withholding rates and taxes, and going further to simply do what has to be done – but which government seems incapable of doing. The “gatvol” (fed-up) tipping point seems to be upon us.

Growing discontent

It is against this background that the country will have local government elections, currently scheduled for August this year.

Soon the media will be replete with pundits talking about the low turnout that generally affects local elections. Some will touch on the way all parties are commonly “punished” at local rather than national elections, others will talk to the winners, losers and likely coalition partners. All this will be pretty predictable. Some of it may even be correct. But something more subterranean and interesting is happening.

There has been growing discontent with many local authorities. In some this has gone as far as concerned citizens successfully calling for the municipality to be dissolved and put into administration, as happened in Makhanda in the Eastern Cape province in 2020.

Elsewhere, citizen groups have found other ways of simply taking matters into their own hands. Instead of just moaning, people are taking action.

Events in Kgetlengrivier Local Municipality, in the platinum-rich North West province, have shown just how serious the situation has become.

In December 2020, in what was described as an “astonishing judgment”, a judge in the North West High Court ordered the imprisonment of the municipal manager of Kgetlengrivier for 90 days. The sentence was suspended on condition that sewage spilling into the Elands and Koster rivers be cleared up.

Remarkably, the judge also gave the residents’ association the right to take control of the area’s sewage works, and to be paid by local and provincial governments for its efforts.

The local residents duly took over the job of clearing sewage, successfully.

The legality of this will be tested on appeal, and may well be overturned by a more risk averse higher court. But the seeds have been sown, and national government seems to agree – national ministers were respondents in the case, and did not appeal. And the governing African National Congress (ANC) had better be careful – most of the places where these events are occurring are in ANC-held municipalities.

Take events in Harrismith in the Free State, were residents also took over fixing the sewerage; or Umdoni Municipality in Scottburgh, in KwaZulu-Natal, where residents are threatening to stop paying rates. In Graaff-Reinet, in the Eastern Cape, residents have objected to increases in municipal rates, frustrated by the broken down sewerage system and other municipal services.

This could be construed as anarchy. And it may well be. But anarchy is often criticised and used as a pejorative – a “descent” into anarchy – rather than analysed or understood as one possible “ascent” from a corrupt and coercive politics. It means something along the lines of a belief in abolishing all government, and organising residents on a voluntary, non-coercive, cooperative basis.

And this is happening, across the country, from withholding rates and taxes to taking over key service delivery functions.

South Africans may be leading themselves from the trough of corruption to something much more interesting, contested and dangerous to a young democracy. When an entire sphere of the state is close to dysfunctional and can have its power, functions and revenue turned over to citizen groups because of incompetence or malfeasance, something is very seriously wrong. Yet political parties still want voters to trust them, come election time.

Loss of trust

Trust in all spheres of government is close to rock bottom, as is trust in political parties. In the last Ipsos poll, no party was trusted by a third of its own supporters. The opinion voters have of politicians could not be lower, matched by pessimism: less than half of respondents felt the country was heading in the right direction.

The final straw may well have been watching with revulsion as the most politically connected stole money meant for life-saving COVID-19 protective equipment.

Talk of withholding rates and taxes has now become commonplace. Community groups have been seeking legal advice on withholding rates and are sharing legal opinions about the issue. Why pay, if your money is merely going to be “eaten”? This is now backed up the North West High Court ruling. Who needs government?

If pollsters want to understand where South Africa is going, it seems that measuring political parties and their campaigns is perhaps necessary – much as a visit to the dentist is necessary – but it may miss the point.

They should be polling those who no longer care about the local sphere, and who see themselves as constituting a more legitimate and, frankly, competent part of the governance infrastructure. And while taps run dry, power cuts continue due to corruption or incompetence, and no politician has yet been jailed, who is to say they are wrong?

David Everatt, Professor of Urban Governance, University of the Witwatersrand

This article is republished from The Conversation under a Creative Commons license.

Zuma's abuse of South Africa's spy agency underscores need for strong civilian oversight

 

Former South African President Jacob Zuma deployed spies in factional battles within the governing party. GCIS

If people who work for the government tell us our safety depends on us not knowing what they do, we might suspect that they wanted to cover up wrong-doing. Unless, it seems, they work for state security agencies.

South Africa’s media are awash with shock at “bombshell” revelations about the country’s security services at the hearings of a commission of inquiry into “state capture”. Testimony shows that the State Security Agency, which is meant to provide the government with intelligence on domestic and foreign threats, was used to fight factional battles in the governing African National Congress (ANC) and to engage in corrupt activity. The agency, the evidence suggests, served former president Jacob Zuma and his allies, not the country.

The revelations are of far less interest than the reaction of the media and the national debate to them. This is so not because the case against the security services is trivial. It is anything but: it shows that they did little to safeguard the country and much to protect a political faction and to funnel public money into private purposes.

But these allegations are not new. The fact that they are being treated as bolts from the blue shows how unprepared South Africa’s politicians, media and citizen organisations which shape the national debate are to deal with the threats posed by its security establishment.

Spies behaving badly

The core of the evidence was the testimony of Sydney Mufamadi, an academic and former cabinet minister. It was damning but should have taken no-one by surprise. It was given because he chaired a panel which investigated the security agencies at the request of President Cyril Ramaphosa.

Mufamadi’s panel reported in December 2018 and its report was released by Ramaphosa in March 2019. It is a public document, available on the Internet. There were some media reports on its contents when it was released but it did not cause much of a stir.

Mufamadi’s evidence was supplemented by that of the acting director-general of the State Security Agency, Loyiso Jafta, and by a witness who conducted an internal investigation into wrong-doing at the agency and who, consistent with the security services’ penchant for secrecy, is identified as “Miss K”. While both added detail to Mufamadi’s account, everything they said reinforced his panel’s findings.

The factionalism of the security services has been evident for at least a decade. During the fight against apartheid, Zuma headed ANC Intelligence. So, he could command the loyalty of former ANC underground security agents who joined the government after 1994, many of whom continued to put his interests first. Years ago, a colleague valued for his understanding of the workings of the governing party who had joined me in a radio panel discussion explained how the security agencies would interpret what we said and pass on their view to the faction whose interests they served.

So why have media treated the contents of a two-year-old report which confirmed older suspicions as a “bombshell”? One reason may be that most of the country’s reporters do not read anything longer than a media release, ensuring that government reports are ignored unless their contents are revealed at a press conference. Another is that the media – and citizen organisations which take part in the national debate – do not see the security services as a threat to democracy.

This is illustrated by the controversy over the Protection of State Information Bill. It was passed by Parliament in 2013 but is still not law – Ramaphosa sent it back to Parliament last year because he believes parts are unconstitutional.

The bill, which would give officials power to classify documents to keep them out of the public eye, triggered a campaign by media and citizens’ groups who claimed it aimed to prevent reporting on corruption. They insisted that there was no problem with “legitimate” secrecy which protected national security.

Holding spies to account

This misunderstood why the bill was tabled and what it was meant to do. Ironically, it began as an attempt to ensure that apartheid-era laws were changed to align them with the values of the democratic constitution.

When drafts of the bill proposed ending most government secrecy, the security establishment, as securocrats are wont to do, painted lurid pictures of the horrors which would ensue if citizens knew what they were doing.

They demanded strong provisions to keep information classified. To emphasise the bill’s real purpose, an entire chapter was included which made it clear that it could not be used to prevent reporting on government corruption – its only role was to safeguard “genuine” state secrets.

The “bombshell” evidence shows what the security agencies wanted to be protected from: information on how they were abusing their power. If the bill had been phrased as the campaigners wished, the security establishment’s secrets would have been classified, hiding their partisanship and wrong-doing from public view, while the media and citizens’ organisations claimed victory.

The fact that the Mufamadi report was largely ignored when it appeared suggests that the debate has no great enthusiasm for holding spies to account because it remains convinced that they need to hide what they do to protect the people.

Even now, this is a theme in some reporting on the “revelations”. Spies are feeding reporters more lurid details of how the evidence to the commission threatens citizens’ security. Agents who now fear for their safety when their identities are revealed will now, the country is told, sell their services to other employers who will protect them better.

None of this is backed by a shred of evidence – security agencies are in the business of exaggerating both the threats to the country and their importance in thwarting them. But, since the default position of many journalists and campaigners is to believe the spies, loud voices will again insist that they be allowed to keep their secrets.

Democracy’s health depends partly on ignoring those voices.

Safeguarding democracy

It is open to question how much the country needs security agencies. Crime intelligence is essential but the country is not threatened by any other state enemies (except those invented by security operatives) and internal threats to security stem from issues, such as local tensions between citizens and local governments, which are no business of spies.

That said, the country probably needs security agencies to guard against future threats but, precisely because they do operate in secret, the interests of the people will be protected only if they are subject to strong oversight from elected representatives and citizens’ groups.

At the very least, oversight bodies need to know exactly what they are doing, how and why. This information, stripped of references to people and operations where Parliament thinks this is needed, must be available to all citizens.

If that does not happen, citizens’ rights will be eroded as they allow spies to prey on them while they claim to protect them.

Steven Friedman, Professor of Political Studies, University of Johannesburg

This article is republished from The Conversation under a Creative Commons license.