the barking dogs

As well as posting sections of my research based on my experiences in South Africa I will also begin posting old journal entries from my time there to give some context with pictures included.
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(photo: Zonkizizwe at sunset.)

15 May 2008
It is never quiet here. There is always noise during the day; children going to school, women cooking and cleaning, traffic outside, chickens, men arguing, whistling, people gambling, anything – and especially Zonke lights up after school and work; loud music, flying kites, children running around everywhere at the center, adults trying to relax with friends and relatives – and then there are the dogs. . . Oh the dogs, how they incessantly bark at night, a constant. If there are no other constants in South Africa, here it is: the dogs, searching and fighting for food scraps among the rubbish.

Today we went to Pretoria, administrative [Executive] capital of SA (South Africa) to take care of errands and pick up the long awaited NPO certificate for VVOCF. There have been many setback and long waits, but now it is here! Now officially an NPO, growing community connections, this center will be ready for the future!

In Pretoria we went to five different banks before finding one since arriving at the airport that does foreign exchange, however we forgot our passports! Is that really needed to change money? At any rate we are going to Alberton tomorrow where we can change money. So we were able to see much of Pretoria by walking from bank to bank. We stopped to have some pizza at a shady looking shop run by a white Afrikaner, but it was terrible (not even comparable to the delicious pizza of Ghana prepared by the Lebanese businesses) – better luck next time I hope.

Yesterday, one of the VVOCF staff members was able to tell us about growing up during apartheid, the political violence, and the divide of peoples in Zonkizizwe. We asked if he knew the toyi-toyi dance march from a song on the computer. He knew it well and remembered from there the divisiveness of the ANC, which was majority Xhosa people and the IFP, dominated by Zulu people. The violence between the groups was very intense in Zonke until just after 1996. He had to be dressed as a girl so that he would not be killed. Boys were expected to fight or be killed. He guessed that most of his family would be dead if the violence had not stopped when it did.

A few days ago ‘China’ (nickname of a volunteer at the center) was able to give me a near complete rundown of South African history in brief, he loves history and historic name dropping, but we have heard little of his own experiences. It is crazy to think about how those living now in Zonke around my age lived through apartheid and witnessed such terrible acts of violence.

I also learned more about the extent of HIV/AIDS in Zonke. The intern coordinator reminded us that the statistic of students at MSU that have an STD is 1 in 4. We are only lucky that HIV/AIDS did not enter the mainstream population. Here in Zonke 1 in 4 people is HIV positive. The family at the center is more so affected by HIV/AIDS and now they work to care for children who come the center affected by the virus. There is still a very high stigma and a terribly ineffective ARV program. Many people refuse to get tested or even consider the idea. Each child at the center either has HIV (we went to the Natal-Spruit Hospital to get ARVs for one), has lost parents from AIDS or related illnesses or has not yet been tested to know. There are many who should be tested, but are not. My pen pal’s family has stopped coming to the center because they are so sick – I can only assume related to HIV/AIDS. We discovered the “2006-2008 Response Plan for HIV/AIDS” of the South African government. It has come to my attention that much of what the government does here looks good on paper and on banners, but there is a huge, massive disconnect in implementation.

I have learned so much Zulu tonight. Again, I have been able to naturally pick up a language. I think this stems from my childhood of sound/ noise making. I can make a loud clicking sound from the roof of my mouth that no one I know can replicate. It turns out to be how you make one of the clicking syllables of Zulu.

First entry in this series:
what are we to do when our children are dying?

why there is no doctor: what happened to reconstruction and development? (8)


(photo: This office in Zonke is responsible for RDP work – not much happens here)

Beyond AIDS denialists creating inadequate treatment programs, the rebuilding and scale-up of South Africa’s health care system has been very slow since the ending of apartheid. The main driver of scale up of health service infrastructure was the ANC’s Reconstruction and Development Programme (RDP). In its first White Paper of 1994, the RDP noted: “Health services are fragmented, inefficient and ineffective, and resources are grossly mismanaged and poorly distributed. The situation in rural areas is particularly bad” (66). Between April 1994 and the end of 1998, the RDP built 500 new clinics which gave an additional 5 million people access to primary health care facilities (67). The RDP had an incredible set of goals to match the incredible odds the country was up against, but many still had criticisms. Many note that the successes of the RDP are overshadowed by the enormity of the HIV/AIDS crisis.

Critics of the RDP argue that access to healthcare only improved slightly under the RDP and that, even with moderately improved access, standards at many medical institutions declined rapidly. They cite, in the first place, that usage of healthcare facilities increased by just 1.6% between 1995 and 1999, and that even these modest improvements have been eclipsed by the advance of the AIDS pandemic and other health epidemics such as malaria. Between 1995 and 1998 life expectancy of South Africans fell from 64.1 years to 53.2 years, with AIDS patients sometimes occupying up to 40% of beds in public hospitals. This, say critics, is indicative of a “public health system… in crisis” rather than one undergoing positive transformation. Equally troubling has been declining quality of services […] for example, that in Soweto 950,000 patients attended primary healthcare clinics in 1994 where they were seen by 800 nurses — but by 2000 the number of patients had spiraled to about 2,000,000 while the number of nurses had fallen to just 500 (68).

The difficulties of apartheid have transferred over as the country has attempted to rebuild. There remain serious deficiencies in trained health workers, even regressions. More people are using health services, but more health services are not readily available. More and more people need access to treatment for HIV/AIDS, but the inadequacies in health service infrastructure combined with denial policies have limited that access. The RDP White Paper only had one small section on AIDS, Section 2.12.8 reads:

Sexual health and AIDS. A programme to combat the spread of sexually transmitted diseases (STDs) and AIDS must include the active and early treatment of these diseases at all health facilities, plus mass education programmes which involve the mass media, schools and community organisations. The treatment of AIDS sufferers and those testing HIV positive must be with utmost respect for their continuing contributions to society. Discrimination will not be tolerated. AIDS education for rural communities, and especially for women, is a priority (69).

The numbers speak for themselves and the RDP has failed to achieve its intended goals. The biggest difficulty seems to be that the RDP and health infrastructure were not taken seriously. When the new ANC government was elected the RDP was its own department, but then slowly was scaled back to its own program and now RDP programs exist within other governmental departments where priorities are not on health services or HIV/AIDS.

Notes:
66. “Health Care.” The Reconstruction and Development Programme. White Paper, 1994.
67. Lodge, Tom. “The RDP: Delivery and Performance” in “Politics in South Africa: From Mandela to Mbeki”, David Philip:Cape Town & Oxford, 2003.
68. Ibid.
69. “Health Care.” The Reconstruction and Development Programme. White Paper, 1994.

Coming next: Post-Apartheid Health: the Burden Continues to get Heavier

why there is no doctor: denial is the first step (7)


(photo: downtown Zonkizizwe, South Africa)

Since the early 1990s, Mbeki had turned his back on scientific evidence linking HIV as the cause of AIDS. Mbeki’s stance on the cause of AIDS is the largest contributing factor in the South African government’s failure to scale-up treatment. In 2000, Mbeki called together a group of scientists including a group of ‘dissident scientists’ to discuss the cause of AIDS (55). Later that year at the International AIDS Conference in Durban, he spoke publicly rejecting the accepted science that HIV causes AIDS and instead focused on the need to alleviate poverty in Africa as a way to combat AIDS (56). He said the cause was poverty, bad nourishment, and general ill health while also noting that more Western medicine was not what Africa needed (57).

Since his public statements, Mbeki and the South African government have been hit by a backlash of criticism from the international community and Mbeki has remained silent on the topic. The year 2000 was the same year that the Department of Health launched a five-year plan to combat HIV/AIDS. However, Mbeki’s statement and the lack of strong governmental support led to much “foot-dragging” (58). Mbeki had turned down grants, funding, and free medicines to scale-up the treatment program as a result of his denial. Now a recent Harvard study has placed impact numbers with Mbeki’s denial claims. The authors of the study estimate that more than 330,000 people died unnecessarily in South Africa and that 35,000 babies could have been protected from HIV-infection as a direct result of Mbeki’s HIV/AIDS policy and denial (59).

In 2002, with international pressure growing, the South African High Court ordered that nevirapine, which combats the spread of HIV from mother-to-child, be made available (60). Sadly despite offers of free and cheap antiretrovirals (ARVs), the South African government was hesitant to offer the medicines and only distributed in two test sites. In 2003, the government approved a plan to make antiretrovirals publicly available and by 2005 there was at least one service location for AIDS-related illness in each of the 53 districts (61). However the program did not reach enough people and the HIV prevalence rate among pregnant women was recorded at 30.2%, a steady increase since 1990 (62). The treatment program was beyond inadequate.

The case for HIV/AIDS treatment and prevention suffered another blow at the hands of South African government leadership in 2006. Former Deputy President Jacob Zuma went on trial for the rape of an HIV positive woman and claimed that having taken a shower afterwards protected him from HIV transmission (63). This only heightened international outrage and pressure on South Africa’s HIV treatment programs. At the 2006 International AIDS Conference in Toronto, UN Special Envoy on HIV/AIDS Stephen Lewis, called the South African government “obtuse and negligent” (64). By the end of the year the government had announced that it was drafting a framework to tackle AIDS and pledged to increase public access to antiretrovirals (65).

Mbeki was ousted from his ANC leadership position in September of 2008 and the interim president appointed Barbara Hogan as the Health Minister. Many saw this as a major turning point in South Africa’s HIV/AIDS policy, especially as the government is working to get antiretrovirals to as many people as possible. Unfortunately, Zuma is set to win the upcoming presidential election and has not made any apology for his false statement on HIV prevention.

Notes:
55. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
56. Boseley, Sarah. “Mbeki Aids denial ‘caused 300,000 deaths.” Guardian News UK. 26 November 2008.
http://www.guardian.co.uk/world/2008/nov/26/aids-south-africa
57. Ibid.
58. Ibid.
59. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
60. Ibid.
61. Ibid.
62. Ibid.
63. Ibid.
64. Ibid.
65. Ibid.

Coming next: What happened to Reconstruction and Development?

Access all entries in this series: Index

why there is no doctor: introduction to an epidemic (1)

Subtitle: The Impact of HIV/AIDS in the Post-Apartheid Health Care System of South Africa

Introduction to an Epidemic

Everyone in the car remained silent as we passed a sea of gravestones on the way to Zonkizizwe, an informal settlement south of Johannesburg (1). The cemetery seemed to extend for miles. This was the reality of HIV/AIDS in the peri-urban, informal settlements. It is a reality that is not far departed from scenes in rural homelands as well as the urban townships of South Africa. I was not new to the HIV/AIDS epidemic, but I was new to the experiences of those living in an informal settlement under apartheid, struggling with the crippling impact of HIV in an area where I never even saw a doctor. Why were there no doctors?

It is estimated that one in five South Africans aged 15-49 are infected with HIV. Since the last UNAIDS report in 2008, 5.7 million people are living with HIV in South Africa and 1000 people die everyday from HIV/AIDS related causes (2). The cause of death for 71% of people aged 15-49 is now AIDS (3). Some people have even noted that South Africans spend more time at funerals than they do at weddings. There are an estimated 1,400,000 orphans as a result of HIV/AIDS (4). The numbers of those infected does not reflect the real impact of disease because the impact of HIV/AIDS extends further into families, friends, and communities.

Life expectancy has fallen considerably in South Africa as the prevalence of HIV/AIDS spread rapidly from 1990-2003 (5). This time period is marked by violent, but positive changes in government rule and policy. The first case of AIDS in South Africa was diagnosed in 1982 among the gay population, so why was the most rapid spread during this time period (6)? Many experts and professionals posit that this rapid spread of HIV and the lack of a response to the epidemic in South Africa is due to the political turmoil of the 1980s into the 1990s. However, this represents a failure to look deeper into the history of South Africa and its health care systems.

While violent conflict had a direct effect on the response to HIV/AIDS in South Africa, a number of other factors with greater impacts based in apartheid policy led to the rapid spread and limited possibility for a comprehensive government response even if there were an absence of violence. South Africa has a difficult history of formulating a response to HIV/AIDS: from apartheid health policy to AIDS denial, from a failed treatment program to the absence of doctors and adequate health infrastructures.

In the March 2009 elections, health was a driving factor for many voters and appeared on many political party platforms. The African National Congress (ANC) ran with promises to cut HIV infections by 50%, launch a National Health Insurance program, and ensure decent wages for health workers (7). With such a far-reaching crisis at hand, politicians must formulate a better, more comprehensive plan to address the effects of apartheid history combined with the current strains on the health care system if they are to effectively combat HIV/AIDS. Why has the response to HIV/AIDS been so poor? Why was HIV able to spread so quickly in South Africa? Why is there no comprehensive treatment program? Why are there no doctors?

Notes:
1. Personal account of Alex B. Hill who interned at Vumundzuku-bya Vana ‘Our Children’s Future’ in Zonkizizwe (Proper), South Africa from May-August 2008.
2. UNAIDS 2008 Report on the Global AIDS Epidemic http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/
3. Centre for Actuarial Research, South African Medical Research Council and Actuarial Society of South Africa (2006, November), ‘The Demographic Impact of HIV/AIDS in South Africa – National and Provincial Indicators for 2006’
4. HIV & AIDS in South Africa: The history of AIDS in South Africa
http://www.avert.org/aidssouthafrica.htm
5. UNAIDS 2006 Report on the Global AIDS Epidemic, Chapter 4: The impact of AIDS on people and societies
http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2006/default.asp
6. HIV & AIDS in South Africa: The history of AIDS in South Africa
http://www.avert.org/aidssouthafrica.htm
7. Cullinana, Kerry. “Healthy election promises.” 31 March 2009
http://allafrica.com/stories/200903310649.html

Coming next: The Health System via Apartheid

the greatest youth movement in history: mandela’s disciples

The beginning of arguable the greatest youth activism movement all began with twelve. Twelve young boys inspired by the ideas of Nelson Mandela left on a journey that would change their lives and so many others for years to come. This is the story of how Nelson Mandela’s movement began. Social movements often have symbolic leaders, but they are really comprised of thousands, thousands and thousands of local leaders and supporters. The first of these unsung heroes came from Bloemfontein. Most people have never heard of Bloemfontein, but they have heard of Soweto or Johannesburg or Cape Town. Bloemfontein is where the twelve came from.

After recently seeing the documentary ‘The Twelve Disciples of Mandela’ I began to learn about the real history of the anti-apartheid movement and its deep roots in youth activism. “Less well known is the experience of a generation of young men who left their country clandestinely to build the African National Congress (ANC) and spread its liberation message in places as far-flung as Dar Es Salaam, Belgrade, London, Havana and New York. Left to their own devices, hunted by the Afrikaner regime (and considered terrorists by the U.S. government), lacking legal status and often socially isolated, these foot soldiers of the anti-apartheid cause forged ahead as one of the century’s great freedom struggles stretched into 30 years of brutal conflict.” – this is the brief synopsis that is given about the compelling documentary. The film outlines the struggles for independence all across the continent and tells of how this group of twelve students blazed the trail for so many freedom fighters starting in the 1960s.

Beginning in 1952 the anti-apartheid campaign was defined as the ANC staged its first act of civil disobedience against the pass laws. In 1958 the Bantu education policy was imposed, where basically black South Africans were taught nothing of value, except how to serve their white counterparts. This is the where the journey of the twelve began. The burned their pass cards in response to the Bantu education law and set out on what would be a quest that would alter their lives forever. With the passage of the Bantu education, riots sprung up in Sharpville in 1960, where many innocents were killed and the concept of human dignity was questioned. As quoted from one interview, “[…] whether educated or uneducated, all realized they had to rise up against the system.”

The twelve began their journey from a jump point in Botswana, where many left and were deported back to start again. They had a desire to reach the newly independent Ghana. My class, ‘Africa and the World’ watched a documentary today on the rise of nationalism in Africa and how Ghana represented a great hope for the rest of the continent. Ghana’s independence raised hope everywhere especially in South Africa. The twelve sought education to build the movement and some made it to Tanganyika (before Tanzania was formed) through Sudan, where they met Mandela. They began studies in the capitol, Dar es Salaam. Others traveled to Cuba to be trained militarily and were mobilized for the October crisis. Around 1967, some members of the twelve made it to the US to continue studies in journalism, where the ANC was considered a communist, terrorist group. At Lincoln and Temple University members of the twelve grew in knowledge to fight apartheid.

1976 – the Soweto student marches and massacre, “We still have a long way to go.” This one event led to the uprising of young people all over the world in a hope for peaceful change. David Basilson stated in his documentary on the rise of nationalism that, “Freedom will bring peace.”

The ‘Twelve Disciples of Mandela’ documentary was extremely compelling and educational with its history aspects. The story of this youth movement is told by a son of one of the twelve. Thomas Allen Harris tells the story of his stepfather, Benjamin Pule Leinaeng, who met his mother in the Bronx while studying journalism. He always remembered his stepfather in his depression and drinking and often rebelled against his authority, but nothing prepared Harris for his father’s funeral in South Africa, which was the inspiration for the documentary. “In Bloemfontein, however, Harris discovered an image of Lee dramatically different from that of the moody, foreign stepfather. He was especially affected by the recollections of two of Lee’s associates, Moses Medupe (Dups) and Mochubela Seekoe (Wesi), who were among the group of 12 students, including Lee, who left Bloemfontein in 1960. Dups and Wesi spoke fondly of Lee as a young man and described what life was like for blacks in Bloemfontein under apartheid and during the long years of exile. Family and friends who gathered at the funeral to eulogize Lee spoke of a brave and cheerful youth setting out to battle apartheid, a comrade who never wavered in that struggle even as it wore him down. They all told stories of the ANC’s beginnings in Bloemfontein, in the heart of Afrikaner country, and of the terrible repressions that drove the organization underground and to establishing centers of resistance outside the country.”

This documentary runs through all these stories and more. Interviews with original members of the twelve and those who supported them inspires, recreations of actions taken by the twelve captivate, and the history of a young generation inspired to fight oppression motivates the mind to take action even today. Youth trapped in an oppressive world were able to battle the odds and pave the way for so many others to make a difference for South Africa, what is holding us back now?