The crisis in health triggered by cheap food that's high in fat and sugar is now well documented. Obesity related diseases such as cancer, heart disease and diabetes are rapidly overtaking HIV as the top causes of death in South Africa. A bad diet is a major contributor to this epidemic because people increasingly opt for unhealthier, processed and fast foods.
But how should countries like South Africa go about making sure that people - particularly poor people (where the burden of non-communicable diseases is highest) - have access to healthy food?
Recent research from the Wits School of Public Health, the Health Systems Trust and the University of KwaZulu-Natal sheds fresh light on the problem, showing a proliferation of unhealthy food, particularly in poorer communities.
This demonstrates the need for the government to intervene urgently. One possibility is to create new policies or adapt existing policies to promote the creation of healthy food environments. In particular, local governments have a unique opportunity to intervene.
What food's available where
The research used a distinction between unhealthy and healthy foods drawn up by the Centres for Disease Control and Prevention. This categorises grocery stores and supermarkets as "healthy" and fast-food restaurants, for example, as "unhealthy".
The research set out to assess differences in food environment based on socio-economic status. It focused on grocery stores and fast-food restaurants only, with full service restaurants excluded. The analysis used a tool called the "modified retail food environment index" and show the proportion of food retailers in Gauteng that were "healthy" and what proportion were "unhealthy".
The results showed how fast-food outlets, and the unhealthy foods they serve, vastly outnumbered formal grocery stores. In November 2016, there were 1559 unhealthy food outlets in Gauteng compared to only 709 healthy food outlets.
Strikingly, the distribution of these outlets are income-based. Most of the poorer wards had only fast-food retailers with no healthy food outlets. Conversely, grocery stores are concentrated in wealthy areas.
The research shows that many wards in Gauteng have high concentrations of unhealthy food - in other words, they have "obesogenic" food environments. This means the type of food available in this environment promote obesity, leaving their residents little choice.
This is a big problem. But it can be fixed.
One possible strategy is to introduce policies that limit the number of fast-food outlets in communities. But what would these policies look like, and who would implement them?
Local as well as national government structures have the authority to license and control food retailers.
In addition, local governments have extensive powers over planning and zoning. They could be required to consider the impact on the food environment when granting zoning approvals or business licenses.
This would require filling a gap in municipal bylaws. For example, the City of Johannesburg municipality has passed two bylaws regulating informal or street trading and one on spatial planning. But neither of these link municipal planning obligations to the placement of food retailers. This gap can be filled by explicitly taking saturation or scarcity of different food retailers into account. This could include, for example, creating a zoning exemption or special approval for healthy retailers.
Alternatively, national level policies can better guide implementation at a local level. This would require governments to adapt existing business licensing and planning frameworks to take into account the lack of healthy food retailers in a particular area. For example, the framework used to grant business licenses is set out in national legislation, the Business Act, but implemented by local governments. This framework might require conditions that are more stringent for food retailers before they set up shop.
Currently, businesses are required to submit a copy of the menu of a food trader and a zoning certificate when applying for a license. This means that municipalities are aware of what kind of retailer is applying for a licence and the nature of their food offerings. Municipalities could use this information to control the number of fast-food retailers in a given area.
Additionally, municipalities could streamline the process for licensing healthy food retailers, making it easier and faster for them to open in areas most in need. By creating a separate, simpler process of approval for healthy retailers, it would potentially encourage more of them to open. Alternatively, they could introduce a certificate of "need exemption". This system could then allow a waiver of some requirements for a license if that business can demonstrate a need for healthy food retailers in an area.
Local governments have already exercised this kind of power to further public health. Cape Town passed a law that prohibited smoking within a certain distance of doors and open windows.
Municipalities could also put regulations in place that restrict the sale of unhealthy food near schools. In addition, they could incentivise retailers to move to under-served areas. Steps like this are already being explored and are set out in detail by the World Health Organisation guidelines.
The research shows that poor South Africans have little choice when it comes to purchasing healthy food in their own neighbourhoods. In addition, municipal governments aren't doing enough to preserve and improve access to healthier foods.
This must change. There's a plethora of options to select from if municipalities want to improve their food environments and can facilitate the right to access to healthy foods for the poorest and most vulnerable. A good place to start in South Africa would be Gauteng.
Noluthando Ndlovu, a public health researcher at the Health Systems Trust was a leading member of the research team.