1. Dr Energy Balance

At the top of the escalators that lead from the third-floor parking lot in the Charlotte Maxeke Johannesburg Academic Hospital to the fifth-floor foyer you are faced, as you turn right through the entrance, with a Coke dispenser. You don’t register it because your brain is hardwired to filter out all background noise and a Coke machine, whatever else it is, is about as background as the hum in your ears. You wait five minutes, checking your phone, stealing glances at the poor bloke in the slippers and gown who’s sucking on a cigarette in the outdoor atrium. Your contact, Dr Sundeep Ruder, comes striding down the corridor to fetch you. “Sometimes I’ll just put an ‘out of order’ sign on there,” he says.

Huh? Aah, he means the Coke machine, not the dude out of daytime television central casting. You associate freely from the mistake: if tobacco is estimated to have caused 100-million deaths in the 20^th century, processed sugar is all set to sail past that harvest well before the middle of the 21st. The seven-fold increase in the worldwide incidence of type 2 diabetes between 1975 and 2005; the doubling in the worldwide incidence of obesity since 1980; the fact that the latter (due in part to the global food trade) is no longer confined to rich countries; the fact that up to one in five South Africans is either a confirmed type 2 diabetic or in the pre-diabetic stage — why is it, you wonder, that you aren’t legally obliged to consume your Coke in a room safely quarantined from society?

One of only 50 working endocrinologists in the country (the US, at around six times South Africa’s population, has between 6,500 and 7,000), Ruder has made it his life’s mission to expose and correct the structural fault in the diet of the postmodern human. He uses phrases like “absolute positive energy balance”, which is less about having a sufficient energy store to get through your day than it is about a conscious and sustained conversation with your best volitional self: “What is my intention for the day? How do I apply the energy balance I need?”

A highly trained specialist in the functioning of a select network of hormone-secreting organs – “endocrine” comes from two Greek words meaning “to separate within” – there are few South Africans better placed to tell us why, as a nation, we are failing to regulate our metabolisms. “The human body evolved a mechanism to store energy easily in anticipation of scarcity,” Ruder says of our early history as a species, when we would stumble across the odd fruit tree on the prehistoric African veld. “Fast forward to 2015, the same evolutionary physiological advantage in the setting of an energy-rich environment, which is also sedentary, causes things like obesity and type 2 diabetes.”

And so here we are, a Thursday morning in the diabetes clinic of the Charlotte Maxeke Johannesburg Academic, where the patients who came late don’t have a place to sit, and where energy levels are sagging. Into the consulting room steps Mr Botha, 49, who was diagnosed with diabetes in 2000. “You know, I’m on the road a lot,” he admits sheepishly to the doc. “I’m drinking Tab, a burger here, chips there.” His sugar-monitoring diary has been stolen, he says, before lamenting that healthy food is near impossible to find outside the big cities, and that anyway it’s “hellish expensive”.

2. ‘Buy the World’

Purveyors of high-fructose corn syrup, which was developed in the 1970s as a cheap replacement for sugar and which can currently be found in everything from salad dressing to bread to cereals to chips (Coca-Cola uses it in their recipes in some countries, in others it uses sucrose), all have their procedures for dealing with dissent. Since these procedures also have their pet names, and since these pet names don’t necessarily apply industry-wide, we at Daily Maverick have decided to lump the most common defensive manoeuvre under the epithet “couch potato counterattack”. It goes thusly. If you, dear diabetic or obese person, can’t deal with the fact that you ingest too many calories and that your exercise regimen stretches about as far as the recliner handle on your Lay-Z-Boy, how convenient for you that we are here to take the blame. What Big Corporate is doing with this reverse piece of psychological espionage is nothing short of genius, mainly because it lays the emphasis on the sugar addict’s version of the alcoholic’s (eternally dubious) ‘disease’, self-justification: I was born this way, genetically predisposed to be a sufferer, and my only chance would’ve been if the drink wasn’t there.

In other words, for endocrinologists and activists and the anti-sugar lobby in general, it’s a tough one to beat. As my morning on the ward with Ruder demonstrated, even amongst people in the acute stages of type 2 diabetes, people who have no doubt that the onset of blindness they’re experiencing is directly related to their past and present intake of processed junk, there’s a tendency to indulge in futile self-recrimination. “Yes doctor, I’m sorry doctor, I couldn’t help it doctor.”

But to go no further than the agency and free choice of the consumer is to risk falling prey to willful obfuscation. Would these sufferers have stood a better chance if the Coca-Cola Company really wasn’t there? That, it would appear, is the $50-billion question. Not only do we have the abovementioned seven-fold increase in the worldwide incidence of type 2 diabetes between 1975 and 2005 – a 30-year period, incidentally, when certain American brands came to be associated with smiles and happiness across the entire planet – we also have the fact that Big Corporate, when confronted in 1999 with their culpability by one of their own and offered a chance to repent, chose to stick with the profits. Why? Because, as New York Times journalist Michael Moss wrote in 2013 in a groundbreaking investigative feature entitled Junk Food America: “What I found, over four years of research and reporting, was a conscious effort – taking place in labs and marketing meetings and grocery-store aisles – to get people hooked on foods that are convenient and inexpensive.”

By far the most memorable character in Moss’s gallery of sugar rogues was one Howard Moskowitz, a food industry consultant with a PhD in experimental psychology from Harvard University. Moskowitz earned his stripes as an industry legend for ‘optimising’ any product that General Foods or Kraft or PepsiCo (or any company who could afford him) threw his way – spaghetti sauce, pizza, pickles and Dr Pepper among them. The mathematical model that he invented to engineer the optimum consumer response reached its apotheosis in what he proudly named the ‘bliss point’: a concept revered for its ability to create a sure-fire winner, given that it calibrates the fine line between maximum taste bud stimulation and the desire to keep quaffing. On the back of Moskowitz’s application of this bliss point to the creation of Cherry Vanilla Dr Pepper, Cadbury Schweppes launched a standalone soft drinks company currently valued at more than $11-billion.

And if, after that, you remain intent on condemning the weak of will to a slow and painful death by sweetness, if you are still saying caveat emptor and going your merry un-addicted way, just consider for a moment what is arguably the most successful advertising extravaganza of all time. You are considering, of course, the ‘Real Thing’ campaign, conceived and co-written by Bill Backer of McCann-Erickson close on 45 years ago. A genre-defying masterpiece that borrowed the concept of utopian post-racialism and branded it with the colours and taste of a soft drink, it was the archetypical feel-good anthem, an object lesson in the vulnerability of the human psyche to gushing sentimentalism. With innocent young Spanish, Swedish, Nigerian, Nepalese, Thai, etc., singers standing in traditional dress on a green hillside to greet the rising sun, the chorus went like this:

“I’d like to teach the world to sing/
?In perfect harmony/
?I’d like to buy the world a Coke/
?And keep it company/?
That’s the real thing.”

The campaign’s codename was ‘Buy the World’, and its success was in no small way attributable to the historical context of the early 1970s: Watergate, the Pentagon Papers, the Vietnam War, race riots, and approximately zero conclusive studies available to the general public on the link between excess sugar intake and terminal metabolism meltdown. In the wake of the campaign, Coca-Cola clearly did buy the world. In 2013, products of the Coca-Cola Company were available in more than 200 countries, with the human species consuming on average 1.8-billion servings per day, and the abovementioned studies available by the (peer-reviewed) journal-load.

“We’re all addicts,” Ruder had said to me, the night before I was due to meet him at the clinic. “These products are so close to us that we don’t even see them.” He had also spoken to me about ‘epigenetics’, the phase, to borrow from the theologian’s cheat-sheet (the author’s borrowing, not the doctor’s), following Lutheran-type genetic fatalism. We used to think our genes predefined our hormonal response to the world, but that, said Ruder, “turned out to be naïve”. We know now that we can have a real impact on our genes. Put another way, our personal genetic map may predispose us to a number of diseases, but we would have to do a whole bunch of things wrong to activate those diseases.

3. The cheap, healthy option? What universe, mate?

The next two diabetic outpatients to walk into the consulting room at the Charlotte Maxeke Johannesburg Academic are men in their late 70s, both of whom have had the disease for less than 10 years. Ruder asks them, for my benefit, what their diets were like when they were younger – until about the age of 40, they each say, they ate mostly healthy food because that was the food available. “There you go,” says Ruder, “it’s that pattern I was telling you about. What we’re seeing is that people are getting diabetes younger and younger.”

The men are pensioners, they receive R1,300 per month from the state, and this visit to the hospital sets them back R120 on transport. They need to travel to the clinic once a month for their meds – if the clinic is out of meds, a fairly regular occurrence, they’ll spend R240 a month. “The costs add up,” says Ruder. “One of the complications from this disease is gangrene of the feet. So you’ve got amputations, disability grants, losses to the economy, expenditure to the state. Which would be fine, in a sense, if these were isolated cases, but again, there are 4-million to 5-million ‘known’ diabetic cases in South Africa, with another 4-million to 5-million in the pre-diabetic range.”

Before us now sits Mrs Tswane, a 69-year-old pensioner, whose blood-sugar numbers don’t make sense to Ruder – either she’s not injecting herself with (the blood-sugar-lowering hormone) insulin as often as she should, or she’s eating really badly. “Low sugar feels like death,” he explains to me. “Your body reacts violently against the potential onset of hypoglycemia, which can kill quickly if glucose doesn’t get to the brain. So she might be trying to manage that, and then her sugar goes too high. What I’m going to do is counter-intuitive, I’m cutting back on the insulin.” He turns to her. “No more Coca-Cola. No more, ma.”

The following two hours pass in a whirl of revelatory and altogether frightening encounters, during which the scale of this wholly preventable national epidemic becomes clear. Ruder lectures patient after patient about the sugar content of various soft drinks, fruit juices, yoghurts, breads and cereals, but, time after time, the patients complain about the cost and availability of the ‘healthy’ option. Then, after the last patient has left, he walks me to the podiatry unit, where I am introduced to Mr de Freitas.

A diabetic for the last 20 years, Mr de Freitas had his right small toe amputated in 2012. He is lying propped up against the pillows with the gap from the missing toe exposed and a bandage wrapped around his left foot. There is a look of sheer terror on his face as podiatrist Thami Kubeka removes the bandage so Ruder can inspect the foot. The foot has swollen to twice its normal size, and due to the vascular condition brought on by the diabetes the infection isn’t healing; the stench says it all.

It’s plain to everyone, including Mr de Freitas, that the entire left foot will need to be amputated. “This is the end point of diabetes,” says Ruder, “it starts all the way back with the diet.” Kubeka, for his part, has only one word to offer the readers of Daily Maverick. It’s a good one, a composite, perfectly suited to the African continent. The word is “Coca-Colanisation”. DM

Photo by Moyan Brenn.