Copyright New York Times Company Dec 19, 2000Dr. Thandi Puoane arrived several months ago at one of the clinics that serve this vast settlement of shacks south of Cape Town with a mandate to make obesity a health priority here.
A team of veteran community health educators, almost all of them women, were to meet her.
Dr. Puoane knew it would be a long, difficult mission, but only when she walked into the clinic and met them did she realize how hard a road she faced.
Nearly every one of the health workers was fat, most of them, in fact, obese -- hardly the sort of models to preach the message that heavy is not healthy. And worse, most of the workers were not the least bit worried about their weight.
Such attitudes certainly are not rare in a country where a hefty girth has long been a sign of well-being and a slim woman is the often the subject of nasty gossip (Is her husband neglecting her? Has she come down with H.I.V.?). Yet even Dr. Puoane, a black South African well acquainted with the social norms of her society and a public health expert, was stunned to see that women with years of experience as health educators could be such glaring examples of the country's growing obesity problem.
Alarmed, she went back to the doctors running the clinic.
''You can't take these people and send them into the community,'' she told them. ''They need to be examples. We need to change their behavior before we can change the community's behavior.''
So, for now, instead of talking to the people of Khayelitsha about losing weight and changing diets, the community health workers are talking among themselves about the cultural traditions and expectations that have shaped their own bodies and about the social and economic changes that are reshaping their world into an increasingly unhealthy place.
It is an urgent discussion.
The country's first national health survey, conducted by the Medical Research Council of South Africa two years ago and now being analyzed, shows that obesity is widespread here, affecting nearly 20 percent of the population over the age of 15. Black women over the age of 15 are most at risk, with almost 30 percent of them obese, the study found.
Never before had South Africa taken a comprehensive look at the health of its people, particularly its blacks. And for a country with a staggering AIDS problem and an array of other social ills, obesity was yet another to add to the list.
So nascent are the country's efforts in this area that charting the history of the condition among South Africans is an inexact exercise at best. Small-scale studies were identifying it as a problem for some groups in some places more than a decade ago. And many experts trace the rise of the problem to the wrenching social changes that began in the 1980's and intensified in the mid-1990's with the end of apartheid.
With access to better-paying jobs and the end of legal segregation, blacks have been able to live wherever they can afford. For many people, that has meant the cities, where fatty foods at the local supermarket and fast food on every other corner have made have made becoming fat almost a rite of urban passage.
Obesity appears to have crept up on the country. Only in the last few years, as the government turned to the health of its black citizens and conducted its national study, has it been confirmed that obesity is a widespread problem, and one that has already reached alarmingly high levels with no sign of abating.
''We are looking at an emerging pandemic,'' Dr. Krisela Steyn, the chief of chronic disease research for the Medical Research Council, said in an interview.
Diabetes, which was rarely diagnosed in black South Africans 25 years ago, now affects 8 percent of the black population between the ages of 30 and 65. While the incidence of diabetes, a common effect of obesity, is still considerably higher among whites here, the surge in the disease among blacks is an ominous sign, researchers say. Hypertension, another condition linked to obesity, is rising as well among blacks, and increasing levels of heart disease are inevitable, researchers say.
Indeed, as it has elsewhere, obesity here is laying the groundwork for a health care crisis, experts say. Eventually, they say, the crisis will manifest itself in myriad chronic diseases that will cost many millions of dollars in lost productivity and additional health care.
''Although we don't have the severe levels of cardiovascular disease yet in the black community, given the levels of hypertension and diabetes and so on for 20 years, there's no way we can escape it, like the African-American community,'' Dr. Steyn said. ''We are actually in the incubation period and people are very laissez-faire about it.''
Whether it is poverty, education or physiology, obesity here draws on a jumble of factors, and the science of it in South Africa remains the least understood. Many questions are only starting to be asked in earnest.
Researchers want to know whether the relative scarcity of food that has confronted rural blacks for centuries gradually altered their genetic makeup in a way that allows them to live with less. If so, have they been more susceptible to weight gain as they have encountered the relative abundance of food available today in urbanized South Africa.
Another question confounding researchers is whether the physiology of blacks here has evolved to use less energy and therefore fewer calories to accomplish the long walks and strenuous labor that are a fact of life for many blacks.
South Africa is not alone in following the Western world's lemming-lunge toward fatness. Across the developing world, from Brazil to China, obesity is rising as incremental improvements in living standards collide with the persisting effects of deprivation.
What that frequently means, researchers say, is that while many people may have a few more dollars to spend and a few more places to spend it, many remain poor in all too many ways, still ignorant of good nutritional habits and still deprived of adequate recreation space and good medical care.
The World Health Organization has predicted that within the next quarter century, chronic diseases will overtake infectious ones as the major disease burden for the developing world, and obesity is a large reason why.
''Very often, people think that overweight and obesity are a problem of the rich, and we're trying to clarify that misconception,'' said Chizuru Nishida, director of the obesity and nutrition disease program at World Health Organization. ''In all of the countries of the world that are undergoing rapid transition, we are seeing similar trends.''
In South Africa, the problem has many roots, some of them deeply embedded in cultural traditions. In particular, the way of thinking in the African countryside, where a big woman is good and a bigger woman is better, has migrated, along with millions of people, to South Africa's cities, which are more modern and more developed than cities anywhere else on the continent -- and consequently, more nutritionally perilous.
Fresh fruits and vegetables are rare here in the hardscrabble of one of South Africa's biggest townships, as black urban districts are called. Cheap, fatty meat, on the other hand, is everywhere, fresh off little pickup trucks and cooked on makeshift grills in street corner stalls like ones here in Khayelitsha on Solomon Tshuku Avenue, a few blocks from the clinic. A piece of umbengo, a sizzling slab of low-grade beef, with a glistening sliver of fat clinging to it, sells for 4 or 5 rand, or about 50 to 60 cents.
In the city centers, where most people with steady jobs make their living, McDonald's and 
KFC, and local imitators like Steers and Nando's, beckon. And even in the countryside, the city life is encroaching, fast-food outlets creeping closer.
While highest among black women, obesity among whites, especially white women, is also high, with just over 26 percent of them classified as obese. Mixed race and Indian women report only slightly lower levels of obesity. Yet the sheer number of blacks, who make up three-quarters of the population, the historical lack of attention to their needs and a host of other factors, like substandard education, appear to place them at greatest risk.
So in the new South Africa, where the problems of poor blacks have merited unprecedented attention, it would seem to follow that obesity and the chronic diseases that loom in its wake should have become something of a health priority, as they have in many countries.
But unlike many of the countries in the world that have already begun confronting obesity, South Africa is already facing a full-fledged health crisis. With more H.I.V.-positive people than any other nation, South Africa is watching its people die every month by the thousands in the prime of their lives.
So obesity and its attendant threats of hypertension, diabetes and heart disease, find themselves relegated to the recesses of the public conscience.
In the clinic's meeting room here where the township's health educators gather, Dr. Puoane is doing her best to make it a pressing problem, one person at a time. The health educators have been meeting periodically for several months, examining themselves, their lifestyles and their environments.
They have measured each other's body proportions. They have traveled around the township, photographing ''everything that makes them fat.''
''I realize that overweight is a health problem,'' one woman said during a recent session.
''If you are overweight you don't look nice,'' another said.
Yet when it was Novakue Sijeku's turn to speak, she voiced some of the sentiments many of the women were struggling to shake off about shedding weight.
''The community doesn't accept you,'' said Ms. Sijeku, 40, one of the health workers, who weighs 286 pounds and is 5 feet 6. ''The community gives you names when you lose weight.''
Such shame is a certain reality for many women here. Watching his wife lose weight, a man here is likely to think that he will be seen as falling short in his responsibilities, or their neighbors will suspect that she has contracted H.I.V., the virus that causes AIDS.
Nosizwe Cweya, a 35-year-old health educator who is about 5 feet 4, said she weighed 223 pounds when she decided to change her diet and her family's a few months ago. Eating lots of chicken and vegetables and eliminating red meat and rice, she has lost 24 pounds. Her husband is not happy, she said. ''Outsiders are going to say you have H.I.V., because you are becoming slenderer and slenderer, so you must stop,'' she says he told her.
Such sentiments run deep and die hard here in Khayelitsha, to judge by a study assessing local women's attitudes toward body size. The survey, conducted three years ago by a University of Cape Town epidemiology student, Ntombizodumo Mvo, found that when presented with images of a range of body types, from underweight to obese, the bigger body sizes won every time. Nearly 60 percent of the participants preferred the overweight image, nearly 62 percent picked the obese image as the healthiest and nearly 56 percent picked obese or overweight image as the most attractive.
Dr. Puoane sees those attitudes in the flesh when she looks out on her room full of health educators. Changing their minds will mean allowing them to find their own way, she said.
''We can't be authoritative,'' she said. ''They know what causes them to be overweight, but they don't want anybody to come and tell them that they need to lose weight, so we need to be careful, and my intention is to negotiate with them and ask them what they need to do.''
The Fat Epidemic
Previous articles in this series examined an extreme surgery for weight loss, exercise, chronic dieters, the diet business, the psychology of eating and discrimination. A coming story will look at families dealing with obesity. The series will remain available online:www.nytimes.com
/obesity
| [Photograph] |
| Geraldine Lewin, left, and Mary Marshall, right, attend an exercise class as part of a community anti-obesity program in Mitchell's Plain.; At her stand in Kayelisha Township, outside Cape Town, Victoria Matshayana sells the kind of meat favored by many South Africans: fat-laden cuts she garnishes with chunks of pure fat.; Dr. Thandi Puoane discusses anti-obesity efforts with health educators in Khayelitsha Township, many of whom are overweight. (Photographs by Lori Waselchuk for The New York Times)(pg. F6); To the dismay of health experts, many in South Africa regard a trim figure as a sign of illness. Monica Sithole competes a beauty competition in Soweto for heavy women. (Lori Waselchuk for The New York Times)(pg. F1) |
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