Prof Karen Hofman, one of this year’s two recipients of the top South African Medical Research Council (SAMRC) award, says that if she could wave a magic wand, she would eradicate harmful food and drink advertising aimed at children.
Hofman, a political and lifestyle activist, also describes herself as “a health researcher who cares about policy impact and policy change”. She says commercial influences on health are driving South Africa’s noncommunicable diseases to epidemic levels.
“The advertising campaigns are relentless and are focused on the poor,” she says. “In many countries, ads aimed at kids have been taken off the airwaves — but not in South Africa.
“We also have street vendors selling processed foods and sugary drinks close to schools. It’s not just about safety in the short term, such as preventing diarrhoea and vomiting … food safety in South Africa is viewed in a limited fashion, protecting people from contaminated food, which, of course, is important. But ubiquitous products high in sugar and salt need to be included in the unsafe category in the long run with premature deaths occurring 20 to 30 years later [from habitual consumption].”
As the founding director of the SAMRC/Wits University Centre for Health Economics & Decision Science Research Unit, Hofman has worked in public health for 30 years, shaping government salt and sugar content legislation. Its original name is an acronym: Priceless — priority cost-effective lessons for systems strengthening, South Africa.
In her focus on food and beverage policies, Hofman compares the sugar and processed fast-food industries to the tobacco and alcohol industries, urging the media to “wake up” to “the sophistication of these industries”.
More than half of all adults in South Africa are obese or overweight
— Karen Hofman
“More than half of all adults in South Africa are obese or overweight, and the prevalence of diabetes mellitus is linked to a high intake of sugar-sweetened beverages, especially among the most vulnerable, lower socioeconomic groups,” she says.
In 2014, at one hospital in KwaZulu-Natal, she says the cost of foot amputation resulting from diabetes was estimated at R213m for 660 patients. “Across all provinces, this cost is estimated at R68bn, with the socioeconomic price tag estimated at R5m per amputee.”
Hofman, also a paediatrician, says in low- and middle-income countries, the consumption of sugar-sweetened beverages has risen in line with noncommunicable diseases such as diabetes mellitus, cardiovascular disease, and earlier-onset cancer. “Not diseases of choice, but [ones] imposed on us by industries.”
These are, she says, the biggest killers, “more than HIV and TB”.
She sees her lifetime achievement award as recognition not just of her work but also of her team at the Wits School of Public Health. Over 16 years, they have reshaped the approach to public health research in South Africa, expanding the vision for achieving wellness and health.
“If we can focus a bit more on making our citizens healthier and decreasing the pressure on the public purse and the health-care workforce, it makes it easier to drive the kind of quality health care that’s so urgently needed. There are areas, such as maternal and child health, where we’ve done work. The focus has been on hospital and primary care settings, but our research shows there are other instruments we can leverage, regulations as well as legislation that affect health in ways that weren’t being done before.”
She cites the unit’s research from a decade ago, which showed how many lives could be saved by putting in place maximum salt-level regulations governing processed foods. “The levels should be even lower. Processed foods in general are terrible for people, but they’re cheap. Even bread, which was the original processed food, had a lot of salt, so those new regulations had a big impact on high blood pressure in South Africa.
“The other thing we did was model the possibility … of legislation that would tax sugary beverages. That became what the [National] Treasury called the health promotion levy.” The unit proposed a 20% tax, and the government opted for half that, with no inflationary-linked increases since 2019.
These sugary beverages lack nutritional value, and most South African children consume some of the highest amounts of sugary drinks in the world. Mexico ranks the highest, but South Africa is in the top 10. Diet drinks are harmful in a different way, she says, because they contain other toxic additives, now linked to both stroke and Alzheimer’s.
Contrary to popular belief, the sugar-drink industry is still making profits at the expense of health, hand over fist
— Karen Hofman
“Contrary to popular belief, the sugar-drink industry is still making profits at the expense of health, hand over fist. Yes, the industry did switch to smaller volumes, but now they’re promoting zero-sugar drinks, [which contain] other harmful additives — so we have a long way to go.”
She suggests using some of the billions of rand brought in by the health promotion levy to address the funding gap left in the SAMRC by US President Donald Trump’s ban on foreign health aid. The levy disappears into the Treasury “pot” and, according to Hofman, should at least be partly ring-fenced.
“We’re not the only unit that does this work, but focusing on preventing ill health and promoting good health is a key step to addressing poverty and inequality, which lie at the core of our post-apartheid democracy. It gives people an opportunity to stand up to commercial actors who make profits at the expense of our health, in our workplaces [through] vending machines and in our communities where these products are promoted as making you ‘cool or happy’.
“You even see research conference venues stocked full of these products,” she says.
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