What affects people’s brain function as they grow older? We sought answers in rural South Africa

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The world’s population is aging and for the first time ever there are more people over the age of 65 than under the age of 5. This global trend is reflected in many sub-Saharan African countries, including South Africa.

As people age, they experience a number of biological changes. These can include cognitive decline such as the ability to recall certain facts, concentrate or make decisions. Some cognitive decline is normal. But a more rapid or severe decline that affects activities of daily living is not. This can be a result of certain conditions such as stroke, Alzheimer’s disease or other related dementia.

Certain health and behavioural factors can influence the trajectory of cognitive decline. A healthy, balanced diet and regular physical activity make a difference in a positive way. Health conditions that have a negative effect include cardiovascular disease risk factors, such as hypertension and high cholesterol.

Most of the research that’s been done on dementia has been conducted in high-income countries. Little work has been done in Africa. Yet by 2050 the continent is expected to be home to an estimated 72 million people with Alzheimer’s or related dementia.

We set out to measure the prevalence and predictors of cognitive impairment in older rural South Africans. We found that the levels were strongly associated with age, and were similar to those reported by other studies from sub-Saharan Africa and around the world.

We also found that the key factors related to a decline in cognitive function in people over 40 years of age were being a woman, levels of education, marital status and being poor.

What we learned

Our study is the largest ever undertaken on cognitive function in older rural South Africans.

The work was carried out as part of the health and aging in Africa study (HAALSI): a larger study on aging in rural South Africa. The study took place within the Agincourt Health and Demographic Surveillance System, which is located in rural northeast South Africa and run by South Africa’s Medical Research Council and the University of the Witwatersrand’s Agincourt Research Unit.

The site is representative of much of rural South Africa and the cohort is currently one of the largest, most well-defined active groups of older people on the African continent.

All participants provided written, informed consent to participate in the study. Participants with treatable medical conditions, such as high blood pressure, were referred to local health facilities.

We interviewed 5,059 adults 40 years and older. We assessed orientation (whether a person recognised who they were, where they were, and what time it was), and immediate and delayed recall of 10 words read out loud.

Overall, 8% of the population had cognitive impairment, with a significant increase in prevalence by age (2% in those 40-44 years older compared to 24% in those 75 years or older). This is similar to the limited number of other studies in sub-Saharan Africa. The same trends are seen around the world. But direct comparison can be difficult due to differences in the tools used to measure cognition and the different composition of study participants.

Drivers

We found that the factors that made the biggest contribution to people’s cognitive function included being a woman. Nine percent of the women had poor cognition, versus 7% of men. Other factors included being poor and the person’s level of education.

Other studies have shown that formal education creates “cognitive reserve”. This is the idea that people’s ability to deal with cognitive tasks differs. People with increased cognitive reserve may have better cognition later in life. We wanted to see what the effect of limited or no education was on cognition in the South African context.

We found a strong correlation between the level of formal education and cognitive score. Those with no formal education performed worse than those with some primary education. This was true of both men and women at all age groups. Those with some primary education, at all ages, performed worse than those with some secondary education.

Women with no formal education had lower cognitive scores than men. However, the difference in cognitive scores between women and men disappeared in those who had any form of formal education. This suggests that even poor quality education may positively affect later life cognitive function.

When it came to health factors, we did find an association between HIV and hypertension and higher cognitive scores. This surprising finding needs further research. A history of physician-diagnosed stroke, angina or heart attack was associated with lower cognitive scores.

What next?

Over the next four years, we will continue to follow the participants. Our aim is to characterise the cognitive function and trajectory in the cohort more carefully. We will do this by using technology such as neuroimaging. This involves looking at changes to brain structure and size. We will also be using more refined cognitive assessments delivered on a tablet.

And we will look at the effect on cognition of social factors, such as the size of social network and amount of social interaction, and biological factors, such as changes in brain size and structure as well as the presence of certain biomarkers.

By understanding the rate of decline and the factors affecting it, we can begin to think about possible ways of intervening.

As the global and African population ages, levels of cognitive decline and dementia will increase. Studies such as ours can provide useful information that will allow clinicians, researchers and policymakers to understand the burden better. Importantly, interventions can be developed with the aim of enabling every person to age more gracefully.

Ryan G Wagner, Research Fellow, Wits School of Public Health, University of the Witwatersrand and Darina Bassil, Research associate, Harvard T.H. Chan School of Public Health

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

South Africa's main opposition party shows signs of serious strain

Helen Zille’s election as head of the Democratic Alliance’s federal council has rattled many.
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South Africa’s main opposition party, the Democratic Alliance, elected a new chairperson of its federal council this past weekend. Its choice – Helen Zille, former leader of the party, and former Premier of the Western Cape province – has sent shock waves through the party.

The immediate fallout from her reelection to the top DA post was the resignation of Herman Mashaba, the DA mayor of South Africa’s largest city, Johannesburg. He decried Zille’s win as signalling a takeover of the party by rightwing elements.

Mashaba’s resignation is puzzling. A self-made businessman as well as a former chairman of a rightwing think tank, the Free Market Foundation, his criticism of Zille seems misplaced. His views on economic issues are on the right of the political spectrum. And Mashaba sounds even more conservative than Zille on the issue of undocumented immigrants.

Zille was elected to the party’s top post because she remains popular among the DA’s membership base. She is also the last top DA leader with anti-apartheid struggle credentials dating back to the 1980s End Conscription Campaign and the veteran human rights organisation the Black Sash.

But she’s also a hugely controversial figure. The reasons for this stem from comments she has made on Twitter in recent years, including a series in which she defended the legacy of colonialism.

Her posts prompted stinging criticism from the DA’s national leader, Mmusi Maimane, as well as other black members of the party.

Zille’s appointment, Mashaba’s resignation and signs that there is a concerted campaign within certain quarters of the party to get rid of Maimane all point to a political party that’s in deep turmoil. This affects the DA’s strength as official opposition nationally.

Tensions in the DA

The DA can best be described, mostly, as a broad church of liberals. One point on its spectrum are what could be called “equal-opportunity liberals”. Mainly white liberals, this group tends to oppose affirmative action, arguing that it violates the principle that opportunities should be allocated on merit.

Another faction comprises “affirmative action or diversity liberals”. The group is mainly black and supports race-based affirmative action as a way of addressing the past injustices of apartheid.

These camps are divided – not entirely, but significantly – along colour lines.

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Read more:
Liberalism in South Africa isn't only for white people -- or black people who want to be white

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As well as policy, there are other dimensions to tensions within the party.

One is around the coalitions it established in three cities after elections in 2016 when neither the ANC nor the DA won sufficient support to run the councils.

In Nelson Mandela Bay the DA took over running the highly corrupt council by establishing a coalition with a much smaller party, the United Democratic Movement. The partnership was fraught and finally collapsed in 2018 amid a great deal of acrimony.

In the cities of Tshwane, home to the country’s capital Pretoria, and Johannesburg, the DA’s toehold on power has been even more fragile. The DA is in a tactical alliance in both councils with the Economic Freedom Fighters (EFF) – the third largest party in the country, which presents itself as politically radical and to the left of the DA and ANC.

The DA and EFF’s tactical alliance involves the EFF supporting the DA’s mayors on a vote-by-vote basis, or abstaining from voting.

This appears to limit the DA from completely instituting the clean governance which it has made the showcase of its rule.

Another dimension to the DA’s current situation is that the party has two centres of power. Zille, as the newly elected chair of the federal council, the party’s highest decision-making structure in between its federal congresses, holds arguably the most powerful post in the DA. Maimane, as leader of the party, will be bound by the policy and strategic choices of the federal council led by Zille.

What next

It would be strategic for Zille and Maimane to immediately and seriously negotiate the relationship between themselves and between their posts. It will also be strategic for Zille to let a professional public relations officer handle her Twitter account in future.

Part of leadership is about making tough choices. One of these will be: does the DA relinquish power in Nelson Mandela Bay, in Johannesburg and in Tshwane, rather than taint its brand as the clean-up party?

If it fails to make these hard decisions it risks sliding even further in the polls. The party secured only 20.8% of the national poll in elections earlier this year.

This result is no doubt what’s brought the present tensions to a head – and not only about the future of Maimane. Other failures that have been pointed out include the DA losing Afrikaner voters to the rightwing Freedom Front Plus (FF+).

In 15 months the party will be in full campaigning mode for the local government elections in 2021. It will therefore need to finalise its leadership posts, its candidates, and its policies in the intervening months.

As well as preventing Afrikaner voters from swinging back to the Freedom Front Plus, the DA also needs to strategise how it plans to win back black votes, and win more of them than ever before.

For example, it needs to spell out its alternative options to affirmative action and black economic empowerment. This debate often goes under the title of “race as a proxy for disadvantage” – mostly economic disadvantage.

All told, the 60-year-old DA faces an interesting and complex year ahead. As the party grows larger, the coalition of viewpoints within it must also grow. Maybe it could learn a few lessons from the governing African National Congress, which brings together nationalists, communists and the labour movement, among other persuasions, in a veritable broad church.

Keith Gottschalk, Political Scientist, University of the Western Cape

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

Two crime hotspots still without permanent police stations

Five years after Khayelitsha Commission of Inquiry, recommendation to build new station still not implemented

The Khayelitsha Commission of Inquiry in 2014 recommended a new police station for Makhaza. But there is still no clue when the area will get a permanent one. Photo: Masixole Feni

Residents living in two areas whose recorded murders are among the highest in the country are still without permanent police stations.

In Makhaza residents told GroundUp they spent at least R40 for a round trip to the nearest police station in Harare. The land earmarked for the construction of a new police station in Makhaza remains empty. While in Samora Machel, the Community Policing Forum spokesperson said he is satisfied with the temporary station placed there ten months ago, which serves thousands in the area.

In the 2018/19 crime statistics, Samora Machel falls under Nyanga and Makhaza falls under Khayelitsha. Nyanga is the precinct with the highest number of murders in the country at 289. Not far behind, in third, was Khayelitsha with 221 murders.

Makhaza

The land where the police station is meant to be built is still vacant. Despite attempts to find out more about the expected construction, the South African Police Service (SAPS) has been tight-lipped about exactly when building would start. This comes nearly five years after the Khayelitsha Commission of Inquiry made findings and recommendations.

Recommendation 19 of 20 made by the Commission stated that a new police station should be established at Makhaza. The community has been waiting for its station since 2004.
But in 2019 Makhaza residents still have to travel by taxi to the nearest station in Harare — more than 5km away — to report a crime.

National police spokesperson Colonel Athlenda Mathe said: “Makhaza police station is in the planning and design phase, at a very advanced stage.” She provided no time frames for the construction of the building.

The Social Justice Coalition (SJC) has been at the forefront of campaigning for the implementation of the Commission’s recommendations. The SJC’s head of policy and research, Dali Weyers, said the organisation had “no correspondence with or from SAPS” about the construction of the Makhaza police station.

Weyers said that the SAPS annual report for 2016/17 stated that it had failed to acquire the land in Makhaza for the station. But a more recent report for 2017/18 stated that the land acquisition had been finalised by 20 February 2018. “The ‘very advanced stage’ response from SAPS, without additional and clear time frames is problematic,” said Weyers.

Samora Machel

In December 2018, GroundUp reported that a temporary police station had been placed in Samora Machel. This after Minister of Police Bheki Cele announced in May last year that the area would get a permanent police station by 2023. But some residents in the area say the temporary station has already brought much-needed relief.

“Let us get one thing straight, Samora does not have a temporary or mobile police station; we have a fully fledged police station with a full complement of staff members,” said Samora Machel’s community policing forum spokesperson Bongani Maqungwana.

He said it was important to mention that Samora Machel stopped falling under Nyanga since December. “Our police station services Sweet Home Farm, Kosovo and Heinz Park. The recent crime statistics are a reflection of 2018/2019 when Samora was still under Nyanga,” he said.

Maqungwana said that since the station was opened, there has been a significant decline in crime. “Even though we are still struggling with the increment of officers and vehicles, I have to compliment them because our police are visible. They have an open door policy so the community feels free to report crimes.” He said the brick building, expected next year, is still needed. The current station consists of prefabricated structures.

Colonel Mathe told GroundUp that the prefabricated structures are an “interim solution” but did not say when the permanent station would be built.

© 2019 GroundUp.
 27 September 2019   By Mary-Anne Gontsana

Cape Town's bloody gang violence is inextricably bound up in its history

Today’s gang violence on the Cape Flats can’t be divorced from Cape Town’s history of forced removals.
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When the apartheid government decided to evict people it called Coloured from Cape Town’s inner city, it set off a chain reaction that now requires military intervention.

More than 50 years on from the mass evictions that drove anyone who wasn’t white from the city centre, the South African National Defence Force has moved in to guard the areas known collectively as the Cape Flats. It was to these places that Coloured people were pushed by the Group Areas Act. So it’s necessary to look to history – which I’ve explored in a number of my books, most recently Gang Town – as violence in suburbs far from the city centre escalates.

Given the framework within which removals under the Group Areas Act took place in Cape Town, a social disaster was inevitable. As the familiar social landmarks in the closely grained working-class communities of the old city were ripped up, a whole culture began to disintegrate.

Networks of kin, friendship, neighbourhood and work were destroyed. The streets, houses and corner shops that also formed networks were torn away. With this destruction the mixture of rights and obligations, intimacies and distances, solidarity, local loyalties and traditions that bound established communities dissipated.

Above all, what the Group Areas Act’s inroads into the culture of the older districts fundamentally disturbed was the organisation and role of the working-class family. One of the major problems that arose from all this was the collapse of social control over the youth. One of the greatest complaints about Group Areas removals was that individual families rather than whole neighbourhoods were moved to the Cape Flats.

Amid these complex developments and realities, gangs emerged. There had been smaller, less hierarchical and organised gangs in areas like District Six from which people were forcibly removed. But harsh conditions on the Cape Flats saw much fiercer gangs forming and increasing use of knives and, later, handguns.

Isolation and fear

The first effect of the removals into the high-rise schemes on the Cape Flats was to destroy the way the street, the corner shop and the shebeens in the “old” areas had provided the residents with a great measure of communal space. The new areas contained only the privatised space of small, nuclear family units.

These were stacked on top of each other in total isolation, juxtaposed with the totally public space surrounding them – a space that lacked any of the informal social controls generated by their former neighbourhoods. A key control was that houses in the old areas had verandas where older people would sit and informally police the streets. On the Cape Flats you were either behind a door or on the street.

The destruction of the neighbourhood street also blew out the candle of household production, craft industries and services. The result was a gradual polarisation of the labour force into those with more specialised, skilled or better paid jobs; those with the dead-end, low-paid jobs; and the unemployed.

As the new housing pattern dispersed the kinship network, so the isolated family could no longer call on the resources of the extended family or the neighbourhood. The nuclear family itself became the sole focus of solidarity.

This meant that problems tended to be bottled up within the immediate interpersonal context that produced them. At the same time, family relationships gathered a new intensity to compensate for the diversity of relationships previously generated through neighbours and wider kinship ties.

Pressures gradually built up, which many newly nuclear families were unable to deal with. The working-class household was thus not only isolated from the outside, but also undermined from within. The main, and understandable, product of this isolation was fear: fear of neighbours, of unknown people, of gangs and of the strange dynamics of the new environment.

The author discussing his book “Gang Town”

These pressures weighed heavily on the house-bound mothers. The street was no longer a safe place for children to play in and there were no longer neighbours or kin to supervise them. The only play-space that felt safe was “the home”, the small flat. As stresses began to build up within the nuclear family, what had once been a base for support and security now tended to become a battleground, a major focus of all the anxieties created by the disorganisation of community.

One route out of the claustrophobic tensions of family life was the use of alcohol and drugs. This became the standard path of many men. Children were shaken loose in different ways. One way was into early sexual relationships and perhaps marriage.

Another was into the fierce youth subcultures on the streets which became ritualised in the violent youth-gang culture, reinforcing the neighbourhood climate of fear. The situation was to be compounded by rising unemployment at the younger end of a potential labour force and the consolidation of illegal markets that required “soldiers” to protect.

What these gangs did in order to survive in the face of tremendous odds was to rebuild the lost organisation and domestic economy in the new housing-estates. This time, however, their customers and they themselves were often also their victims.

Then came 1994 and the newly elected African National Congress (ANC) government inherited, in Cape Town, a working class that was like a routed, scattered army, dotted in confusion about the land of their birth.

The ultimate losers in this type of claustrophobic atmosphere are the working-class families. For those scattered across the Cape Flats, the emotional brutality dealt out to them in the name of rational urban planning has been incalculable. The only defence the young people have had has been to build something coherent out of the one thing they had left – each other.

Too little too late

Bringing soldiers onto the Cape Flats is too little and too late to unscramble the political omelette. What’s needed is not repression but contrition, better intelligence and the rebuilding of damaged communities whiplashed by gunfire.

Don Pinnock, Research fellow, criminologist, University of Cape Town

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

South Africa's finances are in bad shape. It's running out of time to fix them

Under President Jacob Zuma the economy didn’t recover as much as it should have from the global financial crisis.
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South Africa’s public finances are in a perilous state. There are four main reasons for this. First, economic growth is low or non-existent. Second, tax revenue collection is repeatedly below forecasts. Third, debt levels have risen rapidly and are now at their highest levels in the post-apartheid era. Fourth, the poor performance of state-owned enterprises is necessitating large-scale government support.

Recent developments since the tabling of the 2019/20 Budget in February 2019 have only made the situation worse. A downgrade of government debt to ‘junk’ by a third ratings agency will lead to an outflow of investment and exacerbate matters further. South Africa is, in fact, fortunate that this has not already happened.

The state of South Africa’s public finances is the outcome of different dynamics in three, overlapping periods. The first was the period after the 2008 global financial crisis. The second was the period under the continued presidency of Jacob Zuma. And the third has been the period since Zuma was succeeded by Cyril Ramaphosa. Careful consideration of these periods contradict widely-circulated claims in the political space.

Some have claimed that South Africa’s woes began with Zuma but this is not true. The first shock to the economy under public finances was the global financial crisis. Others have claimed that Zuma is not responsible for poor economic and public finance performance, but this is also not true. South African economic performance should have been able to recover to a much greater degree than it did under the era of his leadership. Government revenue collection seems to have been negatively affected by institutional destabilisation of the South African Revenue Service.

Finally, the deterioration of economic indicators (growth and employment), along with further underperformance of revenue collection and public finances more broadly, is being laid at the door of Ramaphosa’s presidency. That is simply implausible.

The deterioration can often be linked to factors that preceded Ramaphosa’s replacement of Zuma in early 2018. Admittedly, Ramaphosa has not helped his case by making promises about job creation, for instance, that may be outside the ability of the state to deliver.

Understanding why such claims are likely to be wrong is important not just because of attributing blame, but in order to understand what the fundamental drivers are behind the country’s current state and future trajectory.

Recycled disagreements

Unfortunately, beyond blame, much of the policy discussion is characterised by recycled disagreements. These date to the era in which the African National Congress (ANC) government adopted the Growth, Employment and Redistribution (GEAR) strategy – which was opposed and resented by left-wing parts of the ANC alliance. That strategy was largely concerned with reducing the debt levels the new democratic government inherited from its apartheid predecessors.

For example, left-wing commentators have argued for expansionary fiscal policy. This basically means increasing government spending to a significant degree. They have also claimed that National Treasury implemented ‘austerity’ after 2008. This is incoherent. First, South Africa actually adopted a ‘countercyclical’ approach after 2008: government spending increased faster than revenue. That is how the country’s debt initially escalated.

Second, increasing government expenditure in the manner proposed is, at best, a very high risk strategy. With the country’s public finances already under strain, an increase in expenditure that does not deliver significant increases in economic growth and tax collection will lead to a dramatic deterioration in public finances. That could cause harm for generations to come. These risks, which seem more likely than the benefits, are never mentioned by populists who simply regurgitate arguments from earlier eras.

The reality is that even though Treasury attempted to maintain government spending to support the economy during the aftermath of the global financial crisis, and then attempted to stabilise debt levels using a policy of ‘fiscal consolidation’, it has been unable to do either. The economy has not recovered, arguably due in significant part to the ravages of state capture and other state failures in the Zuma era. Debt targets have been regularly missed. At one point national government debt was expected to stabilised below 45% of GDP, now it has gone above 60% and may reach 70% of GDP within a few years.

There is no consensus among economists or other public finance experts on a specific threshold that is tolerable. What is clear though is that the higher the amount of debt relative to the size of the economy, the greater the risk. This is especially true where economic growth is lacklustre, as it has been in South Africa for some years.

Recent developments have only made the situation more dire. In the 2019 Budget, Treasury indicated that it would have to breach its expenditure ceiling for the first time in order to give support to national power utility Eskom amounting to R23 billion per year for an intended 10 years. That was despite planned cuts to public service employment and additional tax measures.

Since then, Eskom was given a lower-than expected tariff increase by the National Energy Regulator (NERSA). National government has also tabled an additional proposal to give Eskom a further R59 billion over two years.

It seems unlikely that government will be able to cut such vast sums in other parts of the state, not least at such short notice, with the result that debt targets will be exceeded again. And despite the money being poured into Eskom, there is no clear indication of the overall plan to stabilise the utility’s finances.

Meanwhile various other risks, like South African Airways, the Road Accident Fund and medical negligence lawsuits, continue to linger in the background. Economic growth and job creation are virtually non-existent, and both are below population growth. This means a higher unemployment rate and less national wealth per person.

In the face of the crisis with Eskom, public finances and economic growth, the only way to proceed is to secure a societal agreement on the way forward that recognises the need for sacrifices in the face of the crisis. Ramaphosa is uniquely equipped to secure a ‘social compact’ of this kind. But he is moving too slowly. This may be due in part to incessant factional battles in the ANC and an unprecedented assault on Ramaphosa and close allies like Public Enterprises Minister Pravin Gordhan that is being conducted through the Office of the Public Protector.

The president is also heavily reliant on advisers, his Cabinet and senior government officials – few of whom have shown that they can deliver on such a weighty responsibility. But as others have noted: if the country fails to agree in time, decisions will be forced upon it. And under such dire circumstances there will be less opportunity to protect vulnerable citizens with the least to sacrifice.

Seán Mfundza Muller, Senior Lecturer in Economics and Research Associate at the Public and Environmental Economics Research Centre (PEERC), University of Johannesburg

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