tag:theconversation.com,2011:/uk/topics/agincourt-21870/articlesAgincourt – The Conversation2024-02-18T07:07:22Ztag:theconversation.com,2011:article/2229542024-02-18T07:07:22Z2024-02-18T07:07:22ZHIV among older South Africans in rural areas: big study shows there’s a problem that’s being neglected<p>South Africa continues to have a high prevalence of HIV among all age groups. About 8.2 million people or <a href="https://link.springer.com/article/10.1007/s10461-023-04222-w">13.7%</a> of the population live with HIV, one of the highest rates in the world. </p>
<p>The country also has one of the world’s most impressive antiretroviral therapy programmes. Over <a href="https://www.phc.ox.ac.uk/blog/the-importance-of-primary-care-in-south-africa2019s-hiv-treatment-programme">5 million people</a> living with HIV are currently on chronic treatment. Widespread access to antiretroviral therapies since 2008 has led to millions of people <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9851406/#:%7E:text=The%20widespread%20roll%2Dout%20of,aging%20in%20the%20ART%20era.">ageing with chronic HIV infection</a>. Consequently, people with HIV are older on average than they were just a decade ago. </p>
<p>Most HIV prevention and treatment programmes and policies in South Africa remain focused on adolescents and young adults. A growing group of middle-aged and older adults with HIV, or at high risk, are being left behind. </p>
<p>To date, there has been little research about sexual behaviour, risk of HIV transmission, HIV stigma and HIV prevention for adults over 40 years old. </p>
<p>The <a href="https://haalsi.org/">Health and Aging in Africa: Longitudinal Studies in South Africa</a> study – or Haalsa as it is commonly known – is an exception to this trend. It seeks to better understand both the risk of getting HIV and the health of ageing adults with HIV in South Africa. </p>
<p>This project, a collaboration between the University of the Witwatersrand and Harvard University, has followed a cohort of over 5,000 adults older than 40 in the Agincourt region in north-east South Africa for more than 10 years. </p>
<p>Throughout this decade of research, the team has been gaining a deeper understanding of this “greying” HIV epidemic. Numerous important insights about HIV in older populations have already been achieved. Here we present some of the findings. </p>
<h2>Sexual activity is common</h2>
<p>Research conducted in 2017 uncovered a <a href="https://pubmed.ncbi.nlm.nih.gov/27926667/">high</a> prevalence of HIV in this older population. Nearly 1 in 4 people over 40 years old were living with HIV. </p>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/27926667/">study</a> found that 56% of respondents, across all HIV status categories, had had sexual activity in the past 24 months. Condom use was low among HIV-negative adults (15%), higher among HIV-positive adults who were unaware of their HIV status (27%), and dramatically higher among HIV-positive adults who were aware of their status (75%).</p>
<p>In another <a href="https://pubmed.ncbi.nlm.nih.gov/32516151/">investigation</a> in this cohort, the team found that over the period from 2010 to 2016 the incidence rate of HIV for women was <a href="https://pubmed.ncbi.nlm.nih.gov/32516151/">double</a> that of men.</p>
<h2>Feeling the stigma</h2>
<p>There are relatively few studies of HIV-related stigma among older adults, despite the <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(22)00041-1/fulltext">increasing number</a> of older adults living with HIV.</p>
<p>The majority of research excludes, or ignores, age as a variable. Understanding HIV-related stigma in older adults remains crucial and can inform interventions to support their mental health and overall well-being. </p>
<p>Our <a href="https://pubmed.ncbi.nlm.nih.gov/38286975/">research</a> suggests that social stigma poses a significant barrier to testing behaviour among older adults. A quarter of our respondents reported social stigma related to HIV infection.</p>
<p>This stigma was found to have important implications for HIV care: those experiencing high social stigma were <a href="https://pubmed.ncbi.nlm.nih.gov/38286975/">less likely</a> to engage in HIV testing and less likely to be linked to treatment.</p>
<p>A recent pilot study examined home-based HIV testing options for older adults and showed a preference for <a href="https://pubmed.ncbi.nlm.nih.gov/37696252/">self-testing</a>. More privacy may encourage more adults to establish their HIV status.</p>
<h2>Treatment targets</h2>
<p><a href="https://haalsi.org">Haalsa</a> is uniquely positioned to understand how older adults with HIV are faring in terms of achieving HIV treatment targets, including viral <a href="https://pubmed.ncbi.nlm.nih.gov/31243144">suppression</a>. </p>
<p>In 2014-2015, 63% of older adults with HIV in the study were taking antiretroviral therapy and 72% of those on therapy were virally suppressed. More recent updates have suggested that as of 2018-2019, many more older adults with HIV were virally suppressed. </p>
<p>To further highlight the critical importance of viral suppression for healthy ageing, the Haalsa team explored the impact of viral suppression on <a href="https://pubmed.ncbi.nlm.nih.gov/36179754/">life expectancy</a> in older adults. </p>
<p>Here, they found large gaps in life expectancy based on viral suppression <a href="https://pubmed.ncbi.nlm.nih.gov/36179754/">status</a>: a 45-year-old man without HIV could expect to live about another 27 years; a man with virally suppressed HIV could expect to live 24 years. One with unsuppressed HIV could expect to live 17 years.</p>
<p>Similarly, a woman aged 45 without HIV could expect to live another 33.2 years compared with 31.6 years longer for a woman with virally suppressed HIV. A woman with unsuppressed HIV could expect to live a further 26.4 years. </p>
<h2>Looking to the future</h2>
<p>Taken together, these new insights are critically important to inform the design of interventions and policies to ensure healthy ageing in South African society, and particularly among those with or at high risk of HIV. </p>
<p>Tailored strategies to prevent new HIV infections, awareness programmes and support to ensure that more people living with HIV in older age groups achieve and maintain viral suppression are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.</p><img src="https://counter.theconversation.com/content/222954/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jen Manne-Goehler receives funding from the US National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Julia Rohr receives funding from National Institute on Aging of the National Institutes of Health (NIH). </span></em></p><p class="fine-print"><em><span>Till Bärnighausen for this work my institution has received a grant from the National Institutes of Health/National Institute of Aging (NIH/NIA), which is the HIV component NIH/NIA of the overarching NIH/NIA HAALSI
Unrelated to this work, I also receive funding from a wide range of public science funders, including the NIH (other institutes), the German National Research Foundation , the European Union (within the Horizon science funding programme, the Alexander von Humboldt Foundation, the Volkswagen Foundation, the German Federal Ministry of Education and Research, the German Federal Ministry of the Environment, Wellcome (the British Medical Research Foundation), and the Else Kröner Fresenius Foundation.</span></em></p><p class="fine-print"><em><span>Francesco Xavier Gomez-Olive Casas, Kathleen Kahn, and Nomsa Mahlalela do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A significant number of older adults in rural South Africa are HIV-positive. Awareness programmes and self-testing would reduce cases.Jen Manne-Goehler, Physician-scientist, Harvard T.H. Chan School of Public HealthFrancesco Xavier Gomez-Olive Casas, Research Manager at MRC/Wits Agincourt Research Unit, University of the WitwatersrandJulia Rohr, Research Scientist, Harvard UniversityKathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandNomsa Mahlalela, Researcher, University of the WitwatersrandTill Bärnighausen, Professor, University of HeidelbergLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2227262024-02-06T15:20:45Z2024-02-06T15:20:45ZMoney and ageing: South African study shows cash grants help people live longer and have better memory function<p>Nearly <a href="https://theconversation.com/47-of-south-africans-rely-on-social-grants-study-reveals-how-they-use-them-to-generate-more-income-203691">half</a> of South Africa’s 60 million people receive social grants, ranging from child support to pensions. The grants are designed to provide financial assistance to people living in poverty.</p>
<p>The largest components of the South African social grant system were introduced, or expanded to include the full population, in the 1990s. Since then, the system has <a href="https://asq.africa.ufl.edu/wp-content/uploads/sites/168/V19I1a3.pdf">evolved</a> into one of the most comprehensive in the global south.</p>
<p>In addition to their direct financial benefits, the grants have been found to have a wide range of positive effects. These include improvements in <a href="https://opensaldru.uct.ac.za/bitstream/handle/11090/46/06_08.pdf?sequence=1">child nutrition</a> and <a href="https://www.tandfonline.com/doi/full/10.1080/03768350500322925">education</a>, and increased participation of women in the <a href="https://theconversation.com/47-of-south-africans-rely-on-social-grants-study-reveals-how-they-use-them-to-generate-more-income-203691">labour force</a>. </p>
<p>But the effects of social grants on the health of older adults have not been extensively explored. Until now. </p>
<p>Across a series of recent studies conducted as part of an extensive research project in a rural part of South Africa, we have established that social grants can help older South Africans protect their cognitive health and live longer. Cognitive health is the ability to clearly think, learn, and remember. </p>
<p>Using our collective expertise into cognitive and population health, we studied the health effects of three different cash transfer programmes in a sample of 5,059 adults 40 years and older in rural Mpumalanga province.</p>
<p>Our results consistently found strong and positive effects thanks to these programmes. </p>
<p>Older people will make up a much bigger portion of South Africa’s population over the next <a href="https://afrique.maisonphilo.com/doc/aging.pdf#page=20">20 years</a>. Our results provide good news about a social intervention programme the country already has in place to promote health and well-being among older adults. </p>
<h2>How we did the studies and what we learnt</h2>
<p>The <a href="https://www.agincourt.co.za/agincourt-maps-2">Agincourt Health and Demographic Surveillance System</a> has been collecting data on more than 120,000 people living in 31 villages in north-east South Africa since 1992. </p>
<p>This rural campus of the University of the Witwatersrand was established to track and understand health and well-being in these rural environments. </p>
<p>The Agincourt project is also a platform for other studies to collect more detailed information on certain community members.</p>
<p>We used data from an experimental <a href="https://www.sciencedirect.com/science/article/abs/pii/S027795362300240X">cash transfer</a> trial within the larger Agincourt research platform that paid monthly cash transfers to households from 2011 through 2015 and compared them to control households with no payments. Just over 2,500 households originally enrolled in the trial. Monthly payments of R300 were split between a school-age female and her caregiver. </p>
<p>We also used data from Health and Aging in Africa: Longitudinal Studies in South Africa. This is a smaller Agincourt cohort of 5,059 men and women aged 40 and older with detailed information on memory function and dementia probability collected every three years from 2014/2015 through to 2021/2022.</p>
<p>We tested whether being in the group that received the cash transfers led to better cognitive health later in life, up to seven years after the trial concluded. </p>
<p>We found that people who received the cash were better off than those who did not. They had slower ageing-related memory decline and lower dementia probability in 2021/2022, the most recent wave of <a href="https://haalsi.org/">data collection</a>. </p>
<p>For some groups, we also observed an impact on mortality. In those who were relatively better off at baseline with regard to education and wealth, the addition of the cash transfer led to significantly reduced risk of mortality.</p>
<p>In a second study we examined the <a href="https://www.tandfonline.com/doi/full/10.1080/08959420.2023.2195785">impact</a> of the older person’s grant, a public pension, on men’s later-life cognitive health. </p>
<p>From 2008 to 2010, the older person’s grant expanded its <a href="https://www.social-protection.org/gimi/Media.action;jsessionid=bEt4_DojTu9wWIPBWbJTZ0k4vDXkszJ2EpvEJTFXyjUV31SZ3GJL!1393577045?id=15519">age eligibility</a> for men from 65 to 60 years. This meant that men aged 60 through 64 at the time of expansion were newly eligible for between one and five “extra” years of pension income prior to turning 65. </p>
<p>Women had always become eligible at <a href="https://www.social-protection.org/gimi/Media.action;jsessionid=bEt4_DojTu9wWIPBWbJTZ0k4vDXkszJ2EpvEJTFXyjUV31SZ3GJL!1393577045?id=15519">60 years</a> of age, so they were not included in this analysis. </p>
<p>We found that men who received the full five extra years of pension income eligibility had significantly better cognitive function than expected if the grant had not expanded its eligibility. </p>
<p>We also observed a “stair step” pattern, where cognitive function was progressively better for each extra year of pension eligibility.</p>
<p>In our final study, we examined the impact of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9949209/">child support grant</a> on women’s later-life cognitive health. </p>
<p>When the child support grant was introduced in 1998, it was available only for children under <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0037-80542017000300006#:%7E:text=The%20CSG%20was%20introduced%20in%201998%20to%20cover%20children%20below,Toit%20%26%20Lues%2C%202014">seven</a> years old. Since then, a series of policy changes expanded the ages that children were eligible for the grant, eventually rising to age <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0037-80542017000300006#:%7E:text=The%20CSG%20was%20introduced%20in%201998%20to%20cover%20children%20below,Toit%20%26%20Lues%2C%202014">18</a> in 2012. These expansions over time mean that two women with the same number of children could have had access to very different amounts of child support grant income, depending on when those children were born.</p>
<p>Consistent with what we found for the older person’s grant expansion, higher access to child support grant income was associated with higher later-life cognitive function for maternal beneficiaries of the grant. </p>
<h2>Looking forward</h2>
<p>Our results so far clearly point to the benefits of South Africa’s social grant programmes for older adults as they are currently structured. </p>
<p>They suggest that as South Africa ages in the upcoming decades, sustained investments in these programmes will pay off in better health and well-being of the country’s most vulnerable older adults.</p><img src="https://counter.theconversation.com/content/222726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Molly Rosenberg receives funding from the United States National Institute on Aging of the National Institutes of Health (grant number R01AG069128)</span></em></p><p class="fine-print"><em><span>Lindsay Kobayashi is supported by the National Institute on Aging of the US National Institutes of Health (grant numbers R01 AG069128 and R01 AG070953).
</span></em></p><p class="fine-print"><em><span>Chodziwadziwa Whiteson Kabudula and Kathleen Kahn do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nearly half of South Africa’s 60 million people receive social grants. Health experts say they improve cognitive health among the elderly.Molly Rosenberg, Associate Professor of Epidemiology, Indiana UniversityChodziwadziwa Whiteson Kabudula, Senior Researcher Rural Health in Transition and Agincourt Research Unit, University of the WitwatersrandKathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandLindsay Kobayashi, Assistant Professor, Department of Epidemiology, University of Michigan, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2226242024-02-05T14:20:21Z2024-02-05T14:20:21ZThirty years of rural health research: South Africa’s Agincourt studies offer unique insights<p><em>In 1992 a group of academics from the University of the Witwatersrand introduced a health and socio-demographic surveillance system in remote, rural South Africa to track and understand health and wellbeing in these environments. This initiative built on pioneering work by a Wits team to establish a health systems development unit in a typical rural setting. Agincourt, in the Bushbuckridge district in rural north-eastern South Africa adjacent to Mozambique, was a microcosm of the neglected health and socioeconomic systems in rural areas during apartheid.</em></p>
<p><em>The Agincourt research centre now covers some 31 villages and 120,000 people. It is one of the longest-running research centres of its kind in sub-Saharan Africa, attracting multidisciplinary scholars and researchers from around the world. The scale of data collection has led to groundbreaking research in many fields, including genomics, HIV/Aids, cardiovascular conditions and stroke, cognition and ageing. Stephen Tollman and Kathleen Kahn talk to Nadine Dreyer about what makes this Wits and Medical Research Council Unit different, particularly its focus on health and ageing.</em></p>
<h2>Why is this work so important?</h2>
<p>Before the end of apartheid in 1994, healthcare provision was skewed towards a minority population who represented only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636545">13%</a> of the country’s people. Healthcare for the majority of South Africans was woefully neglected. </p>
<p>As academics focusing on public health we wanted to understand rural South Africa, the people living away from the hospital, away from the train line, away from the supermarket or the town. Key to this was establishing a relationship of mutual trust and understanding between ourselves and those communities.</p>
<p>Drawing on early experiences with community-oriented primary care, we resolved to establish a longitudinal research and development platform. Today it covers some 31 villages in the Bushbuckridge area 500km from Johannesburg. This involved recording every member of every household – residents and temporary migrants.</p>
<p>We gathered valuable data on age, sex and gender, household type and income – producing a robust population “denominator”. To better understand evolving population dynamics, local field staff walked house-to-house meeting residents and recording data on vital events: who is born, who dies, who moves. In other words births, deaths and migrations.</p>
<p>We apply a simple concept called “person years”. At baseline, and with their consent, a person is enrolled. After five years, the person will have been there for five “person years”. Given a population of some 120,000 people, all followed up (including labour migrants) over 30 years, we can analyse and interpret data in a way that is not really possible with one-off, cross-sectional studies. </p>
<p>Today, the data generated over the past couple of decades is enabling work that was not possible in the early years. </p>
<h2>In 2013 a project was launched to focus on ageing. Why?</h2>
<p>Health and Aging in Africa: Longitudinal Studies in South Africa (<a href="https://haalsi.org/data">Haalsa</a>) was started to build understanding of the social, economic, biological, behavioural and mental health features that characterise rural people aged 40 years and above.</p>
<p>Ageing is not only about old people; it starts at birth, even earlier, because experiences at key periods influence a person’s life. </p>
<p>Some time ago, we noticed a reversal in mortality was under way. People were dying at a younger age during the height of the HIV/Aids epidemic. </p>
<p>For women living in Agincourt, <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4312-x">life expectancy</a> dropped from about 74 years in 1993 to around 57 years in 2005, a loss of 17 years. For men, it dropped from about 68 years in 1993 to 50 years in 2007. </p>
<p>As a result, fostering orphans became a norm. The importance of the older generation – especially of women – stood out. Far from seeing older adults as simply requiring healthcare and support in their later years, it became clear that older rural women played fundamental roles in childcare and household food security. </p>
<p>Of course men were involved too, but because of the way in which apartheid was engineered, women were generally expected to remain in the rural reserves while men migrated to work in the mines and cities. </p>
<p>What makes research in Agincourt so interesting and relevant is the rapidly changing socio-economic profile of the area. </p>
<p>Today we see an increase in life expectancy thanks largely to the widespread uptake of antiretroviral therapies for HIV/Aids. For women, <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4312-x">life expectancy</a> had returned to around 70 years by 2013. For men it had increased to around 61 years by 2013.</p>
<p>This means that South Africa is also a “greying society” and more people face an increased risk of developing multiple chronic conditions along with cognitive impairment associated with growing older.</p>
<p>The changes in older people kick in far earlier in situations of adversity. In all probability, signs of ageing you might encounter in a 65-year-old in a high-income country would start to manifest in people aged 45 to 50 in situations of pervasive poverty. </p>
<h2>What stands out when you look back over 30 years?</h2>
<p>When Agincourt started, life was very different. </p>
<p>In the early 1990s when we worked in a small suite of offices at Tintswalo Hospital, there was simply a “wind-up” phone in the entrance to the unit. Now we’re all on email and using mobile phones. </p>
<p>Bushbuckridge has become the land of the shopping mall. Even a person living in what previously was talked about as a deep rural area can now easily reach a mall by taxi or walking. </p>
<p>The pace of social change has been extraordinary. </p>
<p>There’s tremendous poverty. But people are spending money. Some of it may be on credit, some may be earned income or from other sources. </p>
<p>The proportion of households with dwellings <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4312-x">built</a> with either brick or cement walls increased from 76% in 2001 to 98% in 2013. The use of <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4312-x">electricity</a> for lighting and cooking respectively increased from 69% and 4% of households in 2001 to 96% and 50% of households in 2013.</p>
<p>Migrant labour today involves large numbers of <a href="https://www.jstor.org/stable/90009869">women</a>, especially younger adults. </p>
<p>Our research identified a high prevalence of HIV/Aids among <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417014/#:%7E:text=Disease%20acquisition%20seems%20to%20stop,high%20risk%20of%20HIV%20">older</a> people. As a result we piloted a home-based testing option for middle-aged and older adults, with promising results.</p>
<p>We are seeing an association between formal education and cognition. At a population level, <a href="https://karger.com/ned/article/55/2/100/226666/Incidence-of-Cognitive-Impairment-during-Aging-in">formal education</a> protects against conditions like dementia later in life – an insight that is important in an area with historically poor educational opportunity and attainment. </p>
<p>Another surprising – and welcome – finding is that levels of hypertension are <a href="https://pubmed.ncbi.nlm.nih.gov/36752095/">falling</a>. This is especially encouraging because sub-Saharan Africa is in the midst of a profound health transition with infectious diseases paralleled by rapidly rising cardiometabolic conditions. </p>
<p>Despite all these changes, we’re still asking the question that’s guided us from the start: How do you build flourishing societies in a context where jobs are scarce, migrant labour is deeply embedded, but where aspirations and the desire to live a life of meaning are evident?</p><img src="https://counter.theconversation.com/content/222624/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Tollman receives funding from the SAMRC, Dept of Science and Technology SA, National Institutes of Health USA, UK Medical Research Council, and, previously, Wellcome Trust UK. He is affiliated with the SA Population Research Infrastructure Network and INDEPTH Network of population-based health and socio-demographic information systems.
</span></em></p><p class="fine-print"><em><span> Kathleen Kahn receives funding from the South African Medical Research Council, Dept of Science and Innovation SA, and the National Institute on Aging, USA.
</span></em></p>Agincourt, the University of the Witwatersrand’s rural research centre 500km from Johannesburg, has documented the lives of 120,000 people over decades.Stephen Tollman, Director: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the WitwatersrandKathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1252812019-10-17T08:02:56Z2019-10-17T08:02:56ZTaking the long view on health: tracking the impact of ageing in rural South Africa<figure><img src="https://images.theconversation.com/files/297329/original/file-20191016-98653-1cr6b5k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ageing increases the risk of non-communicable diseases.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Population ageing is a growing challenge worldwide, and African is no exception. The World Health Organisation estimates that the continent is home to almost <a href="https://www.who.int/news-room/fact-sheets/detail/ageing-and-health">65 million people aged 60 </a>years or older, and that this number will increase to over <a href="https://blogs.worldbank.org/developmenttalk/aging-problem-africa-well">100 million by 2050</a>. </p>
<p>This rapid population ageing will certainly lead to an increase in non-communicable diseases. This, in turn, will present important challenges for countries – including South Africa – and their national health systems in the coming decades. </p>
<p>These health and demographic changes have prompted researchers to study disease trends in older South Africans. The aim is to understand the role that specific health conditions will play in ageing among rural people.</p>
<p>One of the key studies about these trends is called <a href="https://haalsi.org/">Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa</a> (HAALSI). The study is a collaboration led by researchers at the University of the Witwatersrand in Johannesburg and Harvard University in the US. </p>
<p>The team followed 5,059 adults over 40 years of age who live in the Bushbuckridge sub-district of Mpumalanga province in the northeast of the country. The <a href="https://www.agincourt.co.za/">South African Medical Research Council/Wits Agincourt Research Centre</a> has been running a wider project in this area for 26 years, and the <a href="https://www.agincourt.co.za/">Agincourt Health and Demographic Surveillance System</a> is the longest running surveillance survey in Africa. </p>
<p>As part of the study, we interviewed older adults periodically about their health and experience of ageing, and assessed key laboratory markers and clinical measurements. </p>
<p>The first set of interviews was conducted between November 2014 and November 2015. Our team recently returned to the homes of these same people to follow-up on how their health has changed. We’ve already <a href="https://academic.oup.com/ije/article/47/3/689/4791962">uncovered</a> several key health trends. For example, diseases beyond HIV and tuberculosis (TB), such as heart disease and diabetes, are beginning to affect peoples’s health. We have also been able to track how growing older affects peoples’ ability to function both physically and mentally. </p>
<h2>Health threats</h2>
<p>For many years, HIV and TB have been central health worries for South Africans of every age. But, thanks in part to the success of South Africa’s national HIV treatment programme, people taking antiretroviral therapy are living longer. </p>
<p>Our research on ageing and health shows that while HIV and TB remain important, even in older ages, other age-related conditions such as obesity, heart disease, diabetes and cognitive impairment also play an increasingly important role in the function and quality of life in older people. </p>
<p>For instance, HAALSI <a href="https://academic.oup.com/ije/article/47/3/689/4791962">research</a> has found that as many as two out of every three South African women, and one out of every two men are overweight or obese. Our additional <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4117-y">research</a> found that more than half of people over 40 have high blood pressure, and one in every ten has diabetes. The rates of these major cardiovascular risk factors are about the same in people who are HIV positive and those who do not have HIV infection. </p>
<p>Analysis of multi-morbidity in the HAALSI study <a href="https://gh.bmj.com/content/4/4/e001386.abstract">shows that</a> more than half of older people were found to have at least two of ten common health conditions at the same time. This is known as “multimorbidity” and has been linked to poorer overall functioning as people age. </p>
<p>In addition to heart disease, <a href="https://www.karger.com/Article/Abstract/493483">cognitive decline</a> is another important age-related condition that older South Africans are facing in increasing numbers. HAALSI has shown that one in four adults over 75 years old has cognitive impairment, or difficulties with memory, thinking and judgement, that can affect their daily lives. Even more importantly, many of these people report that this decline limits their ability to perform usual activities at home. </p>
<p>Finally, half of older adults with <a href="https://academic.oup.com/psychsocgerontology/advance-article/doi/10.1093/geronb/gby013/4953803">cognitive decline</a> who need assistance with such activities do not receive the help they need. </p>
<p>Older people also still face a high risk of HIV infection and the challenges associated with HIV treatment. Nearly <a href="https://sti.bmj.com/content/sextrans/early/2019/06/26/sextrans-2018-053925.full.pdf">one-quarter of both older men and older women in Agincourt had HIV</a>. Many older adults, including many of those who do not have HIV, report that they do not use condoms, despite moderate levels of casual sex and multiple concurrent partnerships. Among those who have HIV, almost 70% were taking antiretroviral therapy and the majority of these people were virally suppressed. Despite this relatively high treatment uptake, only half of people with HIV were willing to disclose their HIV status in these interviews. </p>
<h2>What needs to be done</h2>
<p>For one, it is important for the government to have information about these diseases so policymakers can develop strategies to take care of people as they age. </p>
<p>Interestingly, our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516957/">research</a> has also found that people who were participating in the national HIV treatment programme were more likely to receive care for high blood pressure and achieve control of both blood pressure and blood sugar. This finding suggests that strong primary care systems are an important part of the answer to the disease trends of older adults, and also that South Africa’s very successful national HIV treatment programme may offer a great platform for expanding primary care for all South Africans.</p>
<p>Lastly, it’s important for people to be aware of the diseases that may affect them when they are older and to prepare for how they will deal with these possible problems. Good health habits formed in childhood and in young adulthood – including avoiding smoking and alcohol overuse, engaging in physical activity and eating a nutritious diet – will be crucial to healthy ageing of the society of a whole.</p><img src="https://counter.theconversation.com/content/125281/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Manne-Goehler is supported by grant number T32 AI007433 from the National Institute of Allergy and Infectious Diseases. The contents of this research are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.The HAALSI study is funded by grant number NIH 2P01AG041710 (PI: Lisa Berkman).</span></em></p><p class="fine-print"><em><span>Kathleen Kahn receives funding from the South African Medical Research Council, Dept of Science and Innovation SA, and the National Institute on Agin, USA.</span></em></p><p class="fine-print"><em><span>Chodziwadziwa Whiteson Kabudula and Francesco Xavier Gomez-Olive Casas do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rapid population ageing has prompted researchers to study disease trends in older South Africans. The aim is to understand the role that specific health conditions play in ageing among rural people.Jennifer Manne-Goehler, Research Fellow in Medicine, Harvard UniversityChodziwadziwa Whiteson Kabudula, Senior Researcher Rural Health in Transition and Agincourt Research Unit, University of the WitwatersrandFrancesco Xavier Gomez-Olive Casas, Research Manager at MRC/Wits Agincourt Research Unit, University of the WitwatersrandKathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253202019-10-16T13:45:26Z2019-10-16T13:45:26ZQuarter century study on ageing in South Africa offers new perspectives<figure><img src="https://images.theconversation.com/files/297290/original/file-20191016-98670-16cayho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In 1992 a decision was taken to establish a health and socio-demographic surveillance system in a remote rural area in South Africa. The idea was to try and anticipate the kinds of health system reforms the country would need as it prepared for the end of apartheid, and the building of a new democratic state. </p>
<p>The decision followed the realisation that there was no reliable information for planning a health system that could service all South Africans. Under apartheid health provision was skewed towards white people who represented only <a href="https://www.ncbi.nlm.nih.gov/pubmed/12321499">13%</a> of the country’s population.</p>
<p>Leading academics set up the surveillance system which now covers 31 villages and 120,000 people in rural north eastern South Africa. The project involved recording every member of every household – residents and temporary migrants – and regularly updating every birth, migration in and migration out, and death, as well as cause of death. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297117/original/file-20191015-98644-rp9pnv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Agincourt health, social and demographic surveillance system site map.</span>
<span class="attribution"><a class="source" href="https://www.agincourt.co.za/?page_id=1896">Agincourt</a></span>
</figcaption>
</figure>
<p>We also recorded education and household assets as a measure of socio-economic status, social grants, labour migration, among others. </p>
<p>Known as <a href="https://www.agincourt.co.za/">Agincourt</a>, this project is now one of the longest running surveillance surveys on the African continent. The Agincourt Research Centre has developed a robust research infrastructure that undertakes work that is locally embedded and globally resonant, and is responsive to intractable health and development challenges confronting rural South and sub-Saharan Africa.</p>
<p>The centre has been producing interdisciplinary research aimed at addressing inequalities and enhancing health, well-being and economic prospects for people throughout their lives.</p>
<p>Research done over the past 26 years captures the dynamic transitions underway in the community. It provides insights into changes across people’s lives, helps to evaluate interventions, and provides information for local, provincial and national policy and planning.</p>
<p>As part of the project, a partnership was created six years ago to measure health and ageing specifically. Called <a href="https://haalsi.org/">Health and Aging in Africa: Longitudinal Study of an INDEPTH Community</a> (HAALSI), it involves the Harvard Centre for Population and Development Studies and South Africa’s Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt). The study is funded by the National Institute on Aging, of the National Institutes of Health in the US.</p>
<p>This project is nested within the Agincourt longitudinal research infrastructure that can capture trends at a population level, and changes over time at an individual level. This has helped provide critical insights into how health risks and social influences earlier in life affect the outcomes at later stages of live.</p>
<h2>Why it matters</h2>
<p>Health, population and social transitions are underway across the world. Africa too is being affected. Given that we are all living longer, healthy ageing has become an important goal. This is so that we remain socially and economically productive and engaged in society.</p>
<p>Less appreciated is that the quality of later life is largely determined by behaviours and experiences earlier in life. Hence the vital importance of the social determinants of health. These include schooling and education, employment and income, environment and access to natural resources as well as social networks.</p>
<p>In addition, pensions and other non-contributory social grants are critical policy instruments that carry benefits for the health and well-being of older people and their families, particularly children.</p>
<p>The nature and pace of change is proving to be rapid. This is particularly true in rural settings which is why it has been vital to build a strong evidence base for policy making. </p>
<p>It also matters because an ageing population affects countries in multiple ways. In South Africa, some of the biggest effects have been the increasing costs of health care. This is because longer life expectancy has meant that there are <a href="https://journals.lww.com/jaids/Fulltext/2017/08150/The_ART_Advantage___Health_Care_Utilization_for.10.aspx">growing numbers of people</a> on antiretroviral therapy. This, in turn, has led to many having co-morbid conditions that can be challenging to manage medically. These include noncommunicable conditions such as diabetes and hypertension. </p>
<p>This has put increased pressure on an already strained fiscus to sustain a growing community that is eligible to receive state-funded pensions. </p>
<p>There are other ways in which an ageing population affects a country. Older people play a critical role when families and communities are under severe stress. This has been particularly marked in South Africa during the HIV/AIDS epidemic. This was a time when older adults shouldered major responsibilities for child care, for school-going children and for sustaining household livelihoods. </p>
<p>The role of older people in child care in rural households remains vital. This is because an increasing number of women of child-bearing age are migrating far afield for employment (whether intermittent, seasonal or year-round).</p>
<h2>The research</h2>
<p>Community-based surveillance research rests on stable long-term relationships. These need to be nurtured and fostered. We’ve enjoyed the support of our host communities since the unit’s inception in 1992. Community consent for all research activities was obtained from both civic and traditional leadership, and verbal or signed consent continues to be obtained at household and individual level. </p>
<p>Our fieldworkers are trained to conduct informed consent and answer questions from potential participants with sensitivity. We have a public engagement office and staff hold village meetings every year. In these meetings they give feedback on village specific data from the community surveillance as well as results from specific research projects nested within the surveillance platform.</p>
<p>We strive hard to preserve and strengthen respectful working relationships with local communities, to reinforce productive local and provincial stakeholder interaction around research findings and to maintain the confidentiality of the data generated.</p>
<p>The research that’s been done has provided insights into all aspects of ageing.</p>
<p>In particular, insights have been gleaned on the impact that ageing has on health through the HAALSI project. The baseline survey and biomarker collection for the project was conducted in 2014/15 in men and women aged 40 years and older. A second round was completed in 2019, and a third wave of data collection is planned for 2021. </p>
<p>Baseline <a href="https://haalsi.org/data">data</a> was made publicly available in 2017, and can be analysed by researchers and students anywhere in the world. </p>
<p>This data has been integrated with cause of death data from the Agincourt longitudinal survey. This has enabled researchers to examine the interrelationships between physical and cognitive functioning, lifestyle risk factors, household income and expenditure, depression and mental health, social networks and family composition, HIV infection and cardiometabolic disease. </p>
<p>The research produced through these combined projects has provided valuable insights into major policy interventions over the past 20 years. The most important contribution has been the research-based evidence that debunks the fallacy that future health and well-being is ordained by adulthood. The research output has enabled policy makers to understand where interventions – biological and social – can make a difference along the life course.</p><img src="https://counter.theconversation.com/content/125320/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathleen Kahn receives funding from the South African Medical Research Council, Dept of Science and Innovation SA, and the National Institute on Agin, USA.</span></em></p><p class="fine-print"><em><span>Stephen Tollman receives funding from the SAMRC, Dept of Science and Innovation SA, National Institutes of Health USA, UK Medical Research Council, and (previously) Wellcome Trust UK. He is affiliated with the SA Population Research Infrastructure Network (SAPRIN) and INDEPTH Network of population-based health and socio-demographic information systems.</span></em></p>Research done over the past 26 years
provides insights into changes across people’s lives, helps evaluate interventions, and provides information for local, provincial and national planning.Kathleen Kahn, Professor: Health and Population Division, School of Public Health, University of the WitwatersrandStephen Tollman, Director: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1249352019-10-15T13:13:08Z2019-10-15T13:13:08ZSouth African study shows how unhealthy ageing takes its toll on health and income<figure><img src="https://images.theconversation.com/files/296851/original/file-20191014-135513-rp018q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The relationship between income and health underlines the need for strong government policies to break the cycle.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Population ageing is often associated with health-related challenges. But its effects also reach other spheres of life. In particular, an ageing population has a big impact on countries’ economies. <a href="https://www.nber.org/papers/w16705">Research</a> shows how it can influence a country’s economic growth. And a similar effect can be found at the <a href="https://www.cambridge.org/core/journals/ageing-and-society/article/ageing-income-and-living-standards-evidence-from-the-british-household-panel-survey/3825CF5F118D6AFC9C3F0A9BFBFDE592">household level</a>. </p>
<p>This is of greater relevance given there is a greater share of the population reaching older age across the world. This had made it even more important to understand how ageing influences household well-being, what challenges exist, and – more crucially – how policies can be designed to improve general welfare. </p>
<p>Our <a href="https://www.sciencedirect.com/science/article/pii/S2212828X18300768">research</a> in South Africa seeks to understand how different social policies can influence health and income at older ages. The idea is to contribute to the development of evidence based policy making. We believe that our findings are relevant to other developing countries too. </p>
<p>Our research has been conducted under the umbrella of the <a href="https://haalsi.org/">Health and Aging in Africa: A Longitudinal Study of a community in South Africa</a>. It’s been conducted in 31 villages in rural northeast South Africa, close to the border with Mozambique since 2013. The study, which is ongoing, has involved collecting income and health information on older people approximately every two years. </p>
<p>This is the first study of its kind in Africa but joins a large family of studies that follow the same methodology to explore the links between ageing, income, and health across many countries.</p>
<h2>Ageing, jobs and health</h2>
<p>Ageing can influence a households’ economic well-being because it has a bearing on employment. In our study we have seen employment rates drop off even before people reach retirement age. In South Africa there is no legal retirement age, but men and women qualify for an <a href="https://www.sassa.gov.za/Pages/Older-Persons-Grant.aspx">old age grant at 60</a>.</p>
<p>This means that a large share of older people who are still in active age do not participate in the labour force. </p>
<p>There are two potential explanations for this. One is the very high levels of <a href="https://www.statssa.gov.za/publications/P0211/P02112ndQuarter2017.pdf">unemployment</a> in South Africa. This is affecting older people too. Being out of the labour force is strongly associated with lower incomes and thus a lower capacity to consume.</p>
<p>Health is the other factor affecting the economic well-being of households. This can happen in two ways. First, unhealthy ageing is strongly associated with greater need for health services. This, in turn, is often coupled expenditure that reduces the amount of income available for other needs like food. This can even lead to medical impoverishment – when a household’s income falls below the poverty line due to the fact that money has been spent on health services. </p>
<p>In our research we found that most of the people living in the study communities are already living below the South African poverty line. </p>
<p>Unhealthy ageing can also impact economic well-being by forcing other household members out of work to provide care for the elderly – compounding the burden on the household. </p>
<p>It’s also important to remember that economic well-being itself can have an impact on health. It’s evident from our research that while health influences economic well-being, the inverse is also true - economic well-being influences health. </p>
<p>Results from the baseline wave of the our study show that individuals in the highest wealth quintiles – defined either by wealth or consumption – are more likely to be in better health. For example, an individual in the <a href="https://www.sciencedirect.com/science/article/pii/S2212828X18300768">highest wealth quintile </a>is approximately two times less likely to be in the bottom quintile of disability. </p>
<p>And there’s <a href="https://link.springer.com/article/10.1007%2Fs00038-018-1173-8">evidence</a> that individuals in the lower wealth quintile are less likely to access health care or follow the correct guidelines for disease prevention. This can be either due to knowledge or financial capacity reasons. </p>
<p>This implies that already impoverished households can be made worse due to the health consequences of their economic position.</p>
<h2>Breaking the cycle</h2>
<p>The relationship between income and health underlines the need for strong government policies to break the cycle. </p>
<p>A myriad of policies could be considered. In South Africa the focus has been on establishing an extensive social grant net. The country’s old age pension system is one of the largest and <a href="https://www.oecd.org/finance/private-pensions/42052117.pdf">more generous</a> – in proportion to local income – in the developing world.</p>
<p>South Africa has three social grants to protect households from the financial consequences of ageing: </p>
<ul>
<li><p>Old age state grant provided to all individuals over the age of 60, </p></li>
<li><p>disability grant to those that have a disability that prevents them from working and,</p></li>
<li><p>carer grant which is provided to individuals that need to care for disabled adults. </p></li>
</ul>
<p>These grants have become strong pillars in the South African welfare system and most importantly a valuable tool for <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1754420">tackling poverty</a> among older people. Over <a href="https://www.sassa.gov.za/Statistics/Documents/Fact%20Sheet%20-%20Issue%20No.21%20-%20September%202018.pdf">17 million</a> grants are paid out every month.</p>
<p>But there are still important challenges. The main one is that administration isn’t perfect – some people who are eligible aren’t getting them. For example, around 10% of those eligible for the old age grant aren’t receiving it. This number increases to over 85% for both the disability and carer grant according to our estimates in the town of Agincourt, Mpumalanga province. The reasons for this sub-optimal uptake are either lack of knowledge, stigma, or lack of the required documentation such as a national identity card. </p>
<p>What’s clear is that there’s a need to improve access.</p>
<h2>What’s needed</h2>
<p>As the population ages in developing countries like South Africa it is vital to remember the dual relationship between health and income. This can prove helpful in the development of strong social policies that contribute to healthy ageing as well as protect and improve the economic well-being of households. This is important given that that poverty rates and bad health are often greater for older people. </p>
<p>Evidence gathered in South Africa suggests where policy interventions can have a larger impact. And it can be a source of knowledge for other developing countries.</p><img src="https://counter.theconversation.com/content/124935/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carlos Riumallo Herl receives funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska Curie grant agreement No 707404</span></em></p><p class="fine-print"><em><span>David Canning receives funding from National Institutes of Health of the USA.</span></em></p><p class="fine-print"><em><span>Mark A. Collinson receives funding from the National Department of Science and Innovation</span></em></p>It’s evident from research that while health influences economic well-being, the inverse is also true, economic well-being influences health.Carlos Riumallo Herl, Assistant Professor, Erasmus University RotterdamDavid Canning, Richard Saltonstall Professor of Population Sciences, Harvard UniversityMark A. Collinson, Reader in Population and Public Health, MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/867332018-02-13T17:21:11Z2018-02-13T17:21:11ZMonitoring populations helps to put the right health services in place<figure><img src="https://images.theconversation.com/files/199247/original/file-20171214-27583-i52vca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Flickr/Isabel Sommerfeld</span></span></figcaption></figure><p>Fourteen years ago South African researchers <a href="https://www.sciencedirect.com/science/article/pii/S0140673608613999">first picked up</a> rising rates of high blood pressure in the population that led to people dying earlier than expected. </p>
<p>But it wasn’t in the bustling urban metropolis of Johannesburg in South Africa’s economic hub where this cardio-metabolic disease epidemic was first found. The trends – that people were increasingly dying from stroke – were picked up in one of the country’s most rural sub-districts.</p>
<p>The <a href="https://www.sciencedirect.com/science/article/pii/S0140673608613999">findings</a> contributed to South Africa’s National Department of Health drawing up a policy to introduce “integrated” primary health care. And through this policy, chronic conditions such as high blood pressure can be tested and treated at the clinics set up primarily to provide antiretrovirals to HIV positive people.</p>
<p>The discovery was not coincidental. It emanated from work done in a health and demographic surveillance system <a href="https://www.sciencedirect.com/science/article/pii/S0140673608613999">set up in 1992</a> in Bushbuckridge, Mpumalanga. The site is run jointly by the South African Medical Research Council and Wits University’s Rural Public Health and Health Transitions Research Unit.</p>
<p>The project collects population and health and socio-economic data on communities in an impoverished and developmentally constrained part of the country over a long period of time.</p>
<p>Health and demographic surveillance systems like these help researchers understand how factors around health, social and economic wellbeing affect people and the societies that they live in.</p>
<p>These systems are an important part of advanced population registration systems. And nations with complete systems are the world’s most developed. A key reason for this is that they can determine if services are meeting the needs of the population. </p>
<p>The site in Bushbuckridge is one of three surveillance systems running in South Africa. The other two sites are in rural Limpopo: <a href="https://academic.oup.com/ije/article/44/5/1565/2594575">Dikgale</a> at the University of Limpopo, and the <a href="https://www.ahri.org/research/">Africa Health Research Institute</a> in rural KwaZulu-Natal. These sites collectively follow a population of about 300 000 people.</p>
<p>The data being collected is expected to provide <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-741">deep evidence-based insights</a> into major health and socio-economic challenges facing the country which in turn will enable the government to design and evaluate targeted, evidence-informed policy solutions.</p>
<h2>Giving government a heads-up</h2>
<p>When surveillance systems work well, the information that is collected forms part of the national statistics platform of the country. It helps researchers understand detail and dynamics that they are unable to derive from a census. </p>
<p>This is because censuses are only able to see people at one point in time. Surveillance systems can provide detail on changing patterns and the processes affecting these changes. Together, the surveillance system data and census data give policymakers a sound basis to evaluate policies that are not working.</p>
<p>Surveillance system data provides deep and <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-741">granular insights</a> into the health and wellbeing of a community. They help governments understand the changing dynamics of a particular population. This, in turn, helps them understand what sort of interventions are needed. Here are some examples:</p>
<ul>
<li><p>Data will give a better idea of how and why people move between rural and urban areas and insights into what health and socio-economic services they are getting or being excluded from.</p></li>
<li><p>Tracking the number of pregnancies can provide valuable information about whether or not there are adequate maternal health and family planning services in place.</p></li>
<li><p>Looking at why people are dying is important to understanding if health services need to be adapted or preventative services strengthened.</p></li>
<li><p>Understanding how people’s levels of education and socio-economic status affect their wellbeing.</p></li>
</ul>
<h2>Falling through the cracks</h2>
<p>Surveillance systems do have challenges. One is that the data come from specific geographic locations. Researchers can’t easily tell what happens beyond these boundaries.</p>
<p>This is why it’s important to have surveillance systems in both rural and urban settings so that researchers can understand livelihoods and monitor bi-directional, migration flows linking poor, rural communities with urban centres.</p>
<p>With investment from the Department of Science and Technology, data and data systems from the current three centres are being harmonised, and <a href="http://saprin.mrc.ac.za/">four more surveillance systems</a> are being set up. Three will be in urban settings in Gauteng, eThekwini and the Western Cape and one in a rural setting in the Eastern Cape. This harmonised network is called the South African Population Research Infrastructure Network (SAPRIN), which is hosted by <a href="http://saprin.mrc.ac.za/">The Medical Research Council</a></p>
<p>The full SAPRIN platform will include 550,000 people –- around 1% of South Africa’s census population. The platform will form <a href="http://saprin.mrc.ac.za/SAPRINfactSHEET.pdf">a network</a> that will be able to generate high-quality evidence to respond to some of South Africa’s biggest issues, which include poverty, inequality, unemployment, education and poor access to effective health care.</p>
<p>It will do this by linking to the public sector’s health system records as well as public school attendance registers and have access to the statistics around social grants. This will help researchers understand how people are using the services that the government has made available.</p>
<h2>The bigger picture</h2>
<p>Inadequate or even misleading evidence for planning is a complex problem in all countries, but especially low and middle-income countries. It arises due to limitations in infrastructure, especially in poorer parts of the country, and the costs involved for people registering key events in their lives. </p>
<p>South Africa is not the only country in the developing world to have surveillance systems like this. The three surveillance sites in South Africa are part of a <a href="http://www.indepth-network.org/">network of 37 health and demographic surveillance system sites</a> in sub-Saharan Africa, comprising the <a href="http://www.indepth-network.org/">INDEPTH Network</a></p>
<p>A combination of national census, vital registration and localised health and demographic surveillance data can be expected to fill the evidence gap in developing countries. </p>
<p>This will enable planners to have immediate and longer-run feedback on the impact of policies and programmes designed to improve health care and socio-economic status. </p>
<p>For this reason, we can expect to see more investment in surveillance over time and a bigger push to combine datasets to understand what is going on and what is needed.</p><img src="https://counter.theconversation.com/content/86733/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark A. Collinson receives funding from the South African Department of Science and Technology and the National Institute of Health in the US. </span></em></p><p class="fine-print"><em><span>Kobus Herbst receives funding from the South African Department of Science and Technology and the Wellcome Trust.</span></em></p>Health and demographic surveillance systems are important to understand people and the societies that they live in.Mark A. Collinson, Reader in Population and Public Health, MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, University of the WitwatersrandKobus Herbst, Chief Information Officer at the Africa Health Research Institute, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/495392015-10-22T09:54:36Z2015-10-22T09:54:36ZGore and glory: how Shakespeare immortalised the Battle of Agincourt<figure><img src="https://images.theconversation.com/files/99214/original/image-20151021-15414-lhg5xa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>Henry V’s 1415 victory against the French at Agincourt is a key point of pride in British memory, and as such celebrations for this week’s 600th anniversary are multiple and varied. Options include the Tower of London’s <a href="http://www.hrp.org.uk/TowerOfLondon/WhatsOn/battle-of-agincourt">exhibition</a>, featuring medieval arms and armour, experiencing “the sights and sounds of twenty thousand arrows darkening the battlefield skies” <a href="http://www.agincourt600.com/event/the-dark-sky-agincourt-600-leeds-castle-kent/">at Leeds Castle</a> or attending one of the many commemoration <a href="http://www.agincourt600.com/event/service-to-commemorate-the-600th-anniversary-of-the-battle-of-agincourt-on-29th-october-2015/">services</a> in churches around the country.</p>
<p>What Shakespeare might have thought of all this commotion is interesting to consider, as it’s largely down to him that Agincourt haunts British memory. His plays have kept “this glorious and well-foughten field” alive, championing its power as a myth of national unity and heroism. “King Henry the Fifth, too famous to live long” is given an afterlife which raises him to the status of a superhero in Henry VI Part I: </p>
<blockquote>
<p>His arms spread wider than a dragon’s wings;<br>
His sparking eyes, replete with wrathful fire. </p>
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<p>The statistical significance of the victory at Agincourt by “we few, we happy few” is advertised in Shakespeare’s listing of French and English casualties in <a href="http://www.shakespeare-online.com/plays/henryvscenes.html">Henry V</a>: 10,000 “slaughtered French” including 126 nobility, 8,400 knights, esquires and gentlemen and 1,600 mercenaries, contrast with just 29 English dead, whose names Henry reads: the Duke of York, the Earl of Suffolk, “Sir Richard Keighley, Davy Gam esquire / None else of name”, and 25 commoners. </p>
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<h2>Rousing rhetoric</h2>
<p>Henry V overflows with rousing patriotic speeches and these speeches have lent themselves remarkably well to versions of British patriotism over the years. Shakespeare’s dramatisation of the battle champions rhetoric, Henry inspiring his troops with dreams of glory. The fact that they are outnumbered by the French just means a greater share of honour for those present. </p>
<p>Henry V promises that fighting at Agincourt will eliminate class boundaries: “He today that sheds his blood with me / Shall be my brother” and that his soldiers’ names will “be in their flowing cups freshly remembered” by future generations. </p>
<p>The “wonderful” victory at the Battle of Agincourt has been especially invoked at times of national or political crisis to awake feelings of patriotism. The play was staged just at the point when the Earl of Essex was miserably failing to establish imperial control over the Irish, and, some thought, to lead a coup for Queen Elizabeth’s throne. Agincourt reminded spectators of the English victory over the Spanish Armada at a time when national stability and succession was precarious. </p>
<p>More recently, in Laurence Olivier’s <a href="http://www.imdb.com/title/tt0036910/">1944 film</a>, and Kenneth Branagh’s <a href="http://www.imdb.com/title/tt0097499/?ref_=nv_sr_1">1989 post-Falklands film</a>, Henry’s speech celebrating the “band of brothers” and “we few, we happy few” engaged with the patriotic political agendas of Winston Churchill in World War II and of Margaret Thatcher’s attempt to retain power. Indeed, Branagh’s delivery of the speech from a raised cart amongst his troops deliberately echoes Olivier’s which is shot from the same angle. </p>
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<h2>Not so glamorous</h2>
<p>So the seductive image of a “band of brothers” fighting against a common enemy is well remembered. But the play’s equally sound critique of Henry’s campaign has often been ignored.</p>
<p>Shakespeare does not depict the Battle of Agincourt as simply “glorious”. The play repeatedly punctures its own representations of national unity and glory. The four Captains of England, Scotland, Wales and Ireland are not as united as they first appear and doubts are raised about the number of Irish fighting for Henry. Before the army even leaves English shores, treason is uncovered amongst three noblemen, “English monsters” who have plotted to kill King Henry for French gold. </p>
<p>Although the Chorus proclaims that “all the youth of England are on fire”, the cast includes characters who do not want to be there or are fired by the desire of looting, “to suck, to suck the very blood to suck” as Pistol says. His boy servant is disgusted by English cowardice and petty theft.</p>
<p>The play insists on the brutality of war, in spite of Henry’s insistence that the French people, including the women, are not to be harmed. Burgundy’s plea for “naked, poor and mangled peace” hints at the damage done and tellingly observes that the French people “grow like savages, as soldiers will / That nothing do but meditate on blood”. Henry’s wooing of the French princess Katherine romanticises his conquest, but this scene can be played as a rape to heighten the cruelty of his imperialist power.</p>
<p>Most unsettling is the common soldier Williams who, in the wretched, mud-drenched English camp, challenges the disguised king by refusing to trust that his cause is “just and his quarrel honourable”. Henry rewards Williams after the battle with crowns, but Williams cannot be bought off so easily. The most powerful moment of the current <a href="http://www.rsc.org.uk/whats-on/henry-v/">RSC production</a> is when Williams punches Henry, “the mirror of all Christian kings” in the face, enraged by his deception.</p>
<p>Shakespeare’s celebration of Agincourt is thus also a critique of the process of memorialisation, which creates elite superheroes but conveniently forgets sceptics like Williams in its list of casualties with “none else of name”. On this 600th anniversary, we would do well to remember these less savoury elements of the play – and the battle.</p><img src="https://counter.theconversation.com/content/49539/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Findlay does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Shakespeare’s plays have kept “this glorious and well-foughten field” alive, championing its power as a myth of national unity and heroism.Alison Findlay, Director of the Shakespeare Programme, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.