Statistics South Africa (Stats SA) recently released its report on deaths that occurred in 2024. The headline findings contain a sobering, recurring truth: diabetes was once again the country’s leading underlying natural cause of death.In 2024 alone, 28,767 people died from complications caused by diabetes, accounting for 6.1% of all deaths nationwide. That is an average of nearly 79 deaths every day.Diabetes also claimed the top spot in 2022 and 2023.These numbers cannot be accepted as South Africa’s new normal. Behind every data point is a human life, a grieving family and, all too often, years of encounters with a health system that missed opportunities to diagnose, treat and support people in time.As a public health specialist and chairperson of the non-profit organisation Diabetes Alliance, I view this three-year trend as an unacceptable tragedy. Diabetes is manageable. With timely support, people can lead long, healthy lives free from preventable complications. Acknowledging this crisis is the start, but recognition must give way to political action. The Department of Health must establish a national diabetes strategy with clear targets for prevention and care. The finance minister must resource it. And the Presidency must lead a coordinated, whole-of-government response.The broader health landscape is equally stark. Noncommunicable diseases accounted for 60.7% of all recorded deaths in 2024. The top three causes of natural death – diabetes, hypertensive diseases and cerebrovascular diseases – frequently overlap in the same individuals. Managing these interconnected conditions through isolated disease programmes makes little sense for primary care clinics or the patients navigating them.Reading beyond the numbersAt first glance, the 2024 total is 800 deaths higher than the revised 2023 figure of 27,967 (5.8% of recorded deaths). Stats SA compiles these mortality figures from death notification forms filed through the Department of Home Affairs. Medical practitioners record the cause of death, which Stats SA then classifies using international coding standards. Late death registrations and administrative backlogs are processed retroactively; this leads to revision or updating of prior years’ totals. The updated count for 2022 stood at 33,126, higher than diabetes deaths recorded in 2023 and 2024. Diabetes has remained South Africa’s single largest natural killer for three consecutive years.The diabetes burden is also deeply unequal:Women bear the heaviest loss: diabetes was the leading recorded natural cause among women, claiming 17,429 lives (7.9% of all female deaths) and 11,334 or 4.5% of all male deaths.Working-age adults are hard hit: it ranked first among people aged 45-64, accounting for 9,364 deaths (7.9% of deaths in this group). Geographic split: diabetes ranked as the top natural cause in five provinces, Western Cape, KwaZulu-Natal, Limpopo, Eastern Cape and Gauteng, while hypertensive diseases led in the remaining four provinces. These provincial rankings are not a measure of individual care quality or residency. They are a starting point for region-specific questions about access and system performance.The geographic split shows the need to investigate whether access to diagnosis, treatment and good quality care differs between and within provinces.A death certificate is only the final chapterMortality statistics record the primary cause listed on a death notification, but remain blind to what happened along the way.They cannot tell us how many South Africans live with undiagnosed diabetes. They cannot show whether a patient had consistent access to insulin and testing supplies, whether their blood sugar was adequately controlled, or whether a simple follow-up could have prevented a fatal complication. Nor do they capture the full toll of diabetes when another condition is listed as the underlying cause.Those are the questions we must answer while patients are still alive.In my work on strengthening diabetes care, including the Tshwane Insulin Project – a nurse-led programme that helped people with type 2 diabetes start and adjust insulin treatment in primary care, with follow-up support at home – I have seen where care pathways break down, and where they succeed. Survival rarely hinges on high-tech interventions. It depends on the links in primary healthcare:a trained clinic nurse with the time to act a reliable supply chain for medicines and diagnostics routine follow-up mechanisms when a patient misses an appointment regular screening for kidney, eye and vascular (blood vessel) complications support systems that respect the economic reality of a person’s daily life.We need real-time clinical data that helps a facility respond today, not a national death tally published two years later.Turning policy into frontline careSouth Africa already has a framework: the National Strategic Plan for Non-Communicable Diseases and its 90-60-50 targets. This cascade aims to ensure that 90% of adults know their blood pressure and blood glucose status, 60% of those with elevated levels receive treatment, and 50% of those receiving care achieve clinical control.The challenge is making policy work in practice.Tools like the National Health Laboratory Service diabetes dashboard offer valuable insights into blood sugar levels control across districts. But to close the loop, South Africa urgently needs a national diabetes registry and integrated digital tracking to understand who enters care, who remains in care, and who is being left behind.From declaration to deliveryAfter the 2025 Diabetes Summit, the Diabetes Alliance launched the Johannesburg Declaration for Accelerated Action on Diabetes. The declaration calls for coordinated national leadership, sustainable financing, decentralised primary care, and direct participation by people living with diabetes. It asks the Presidency to lead a multisectoral response and calls on the National Treasury and health sector to match policy commitments with financial resources.The latest mortality report gives this agenda even more urgency. There are three practical priorities:Connect early diagnosis to sustained care. Screening is only useful if a positive result leads to uninterrupted treatment, reliable medicines, blood glucose monitoring and clinical review. Measure quality of care: publish a picture of diagnosis, treatment, retention and complication rates by district and province. Address the conditions in which health choices are made. Food prices, transport barriers and economic hardship shape health outcomes. People living with diabetes must help define what quality care looks like. Their experience should guide national policy and daily clinic operations alike.Patrick Ngassa Piotie is the Chairperson of the Diabetes Alliance in South Africa.