Why There is No Doctor: the Impact of HIV/AIDS on the Post-Apartheid Health Care System of South Africa

Empty waiting room at Clinic 2 in Zonkizizwe, the doctor was not in (photo credit: Alex B. Hill, 2008)

This research was the culmination of my three month long internship at Vumundzuku-bya Vana “Our Children’s Future,” a center in Zonkizizwe, Katlehong, South Africa (Gauteng Province) for children and youth affected by HIV/AIDS. During my time there I developed an HIV Peer Educators curriculum and taught HIV/AIDS information sessions to the youth. The piece that I am most proud of was the planning and organizing of a area-wide HIV Testing Day where over 80 people were tested in a settlement where there was a very high testing stigma.

What I noticed during my time in Zonkizizwe was the lack Doctors (at government clinics, private clinics, etc.) as well as the lack of a working health system in an informal settlement not far from Johannesburg and Germiston. The research focuses on how and why apartheid and HIV/AIDS impact South Africa’s current post-apartheid health system.

Related blog posts:


why there is no doctor: the impact of hiv/aids in the post-apartheid health care system of south africa

This is a series of posts based on the lengthy research paper that I completed as part of my “field experience” requirement for my International Relations major at James Madison College, as well as my Global Area Studies: Africa major and International Development specialization through the College of Social Science at Michigan State University. I was supported by the Young People For internship program as well as my friends and family. My field experience was completed as a three month long internship at Vumundzuku-bya Vana ‘Our Children’s Future’ (VVOCF) in the peri-urban settlement of Zonkizizwe, just south of Johannesburg. My tasks as an intern were to conduct health classes, run the HIV/AIDS Peer Educator courses, help with day-to-day programming, as well as assist in the nonprofit development and paperwork. The highlight of my work was organizing an HIV Testing Day with the clinics for the whole community. In all 80 people were tested in an area where stigma around HIV/AIDS and testing is very high. Please feel free to send comments and recommendations to help improve my work. Thanks!

i. Why are there No Doctors?
Academic Paper:
1. Introduction to an Epidemic
2. The Health System via Apartheid
3. Cleaning Black Spots of off a White Land?
4. High-Risk Migration Patterns
5. Scapegoating “tropical workers”
6. HIV/AIDS in South Africa
7. Denial is the First Step
8. What happened to Reconstruction and Development?
9. Post-Apartheid Health: the Burden Continues to get Heavier
10. Harsh Realities in Zonkizizwe (part 1)
11. Harsh Realities in Zonkizizwe (part 2)
12. Conclusion & Works Cited
13. Appendix A: Timeline of Health Care and HIV/AIDS in South Africa

why there is no doctor: conclusion & works cited (12)

The sea of gravestones near Zonkizizwe was almost unimaginable. I would not have believed it myself if I had not seen it firsthand. This scene conveys the real implications and impacts of HIV/AIDS on a health care system and a country that has been stripped, divided, and neglected by apartheid.

While I often asked why there is no doctor, I was able to track down a traditional medicinal doctor who seemed to see no patients as well as the private clinic doctor who did not seem to care about providing real health care to the residents of Zonke. Writing has been done on where there is no doctor and what to do when there is no doctor, but the number one question in South Africa is why there is no doctor. This question is answered through history: apartheid, oppression, denial, and failure to recognize a crisis. The reality of apartheid health policies continuing to affect Black populations and responses to HIV/AIDS can be seen firsthand in the Zonkizizwe informal settlement.

Health was a weapon of apartheid and it worked. Denying medical access and training to the Black majority has kept the population in submission even 16 years after the end of apartheid. The critical period of 1993-2000 saw the new democratic government with its hands tied behind its back. There was no way that the health care system could be so dramatically scaled-up to meet the human and social needs of the HIV/AIDS crisis. As Seedat stated in Crippling a Nation, 1984, “Health in South Africa is inseparable from the economic, political and social structure of the apartheid state.” The health and HIV/AIDS realities that can be seen Zonkizizwe are direct result of apartheid’s legacy. HIV/AIDS in South Africa is not a direct result of apartheid policies, but the impact of HIV/AIDS and the health care system of South Africa is still inseparable from its apartheid past.

Works Cited
Beinart, William. “Labour Migrancy and Rural Production: Pondoland c.1900-1950.” In
Black Villagers in an Industrial Society, edited by Philip Mayer, pp. 81-108. Cape Town: Oxford University Press. 1980.

Boseley, Sarah. “Mbeki Aids denial ‘caused 300,000 deaths.” Guardian News UK. 26 November 2008. .

Chirwa, Wiseman Chijere. “Aliens and AIDS in Southern Africa: The Malawi-South Africa Debate.” The Royal African Society. African Affairs 97:53-79, 1998.

E. O. Nightingale, K. Hannibal, H. J. Geiger, L. Hartmann, R. Lawrence and J. Spurlock. “Apartheid Medicine. Health and Human Rights in South Africa.” Committee on Health and Human Rights, Institute of Medicine, National Academy of Sciences. Vol. 264 No. 16, October 24, 1990.

‘Forced removals in South Africa 1977-1978’, paper prepared by IDAF for the United Nations Centre Against Apartheid, No. 44/78, Oct. 1978, p.9.

“HIV and other STDs. Chapter 3, Part 1” Population Reports. Population Information Program, Center for Communication Programs, The Johns Hopkins School of Public Health. Volume XXIV, Number 3. November, 1996.

“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.

J Yawitch, Betterment. “The myth of homeland agriculture” SAIRR: Johannesburg, 1981, p.86.

Kon, Zeida R. and Nuha Lackan. “Ethnic Disparities in Access to Care in Post-Apartheid South Africa.” American Journal of Public Health. December 2008, Vol. 98, No. 12.

Lodge, Tom. “The RDP: Delivery and Performance” in “Politics in South Africa: From Mandela to Mbeki”, David Philip:Cape Town & Oxford, 2003.

Lurie, Mark N., Brian G Williams, Khangelani Zuma, David Mkaya-Mwamburi, Geoff P Garnett, Michael D Sweat, Joel Gittelsohn, Salim SAbdool Karim. AIDS:17 October 2003 – Volume 17 – Issue 15 – pp 2245-2252.

Packard, Randall. White Plague, Black Labor: Tuberculosis and the political economy of health and disease in South Africa. University of California Press, 1989.

Palitsza, Kristin. “A Burden that Will Only Become Heavier.” Inter Press Service News Agency. May 28, 2006. http://www.ipsnews.net/africa/nota.asp?idnews=33396.

Posel, Dorrit. “Have migration patterns in post-apartheid South Africa changed?” 4-7 June 2003. e/papers/1-Posel.pdf+the+economic+of+apartheid,+labor+migrations&cd=1&hl=en&ct=clnk&gl=us&client=firefox-a.

Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa. International Defence Aid Fund for Southern Africa, London, April 1984.

“The Demographic Impact of HIV/AIDS in South Africa – National and Provincial Indicators for 2006” Centre for Actuarial Research, South African Medical Research Council and Actuarial Society of South Africa. November 2006.

“The uprooting of millions, forced removals.” For their Triumphs’ and Tears. ANC, 1983.

UNAIDS 2006 Report on the Global AIDS Epidemic, Chapter 4: The impact of AIDS on people and societies

UNAIDS 2008 Report on the Global AIDS Epidemic. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/.

Appendix A

appendix a: timeline of health care and hiv/aids in south africa

1913 – “Tropical workers” migrating bring in high prevalence of tuberculosis (Packard, 230)
1919 – Public Health Act places government control over mission health centers (Seedat, 63)
1930 – Mines experience shortage of workers (Packard, 229)
1934 – 2000 “tropical workers” brought into SA on experimental basis (Packard, 230)
1937 – The number of “tropical workers” increases dramatically after government ends ban on recruiting mine workers above 22nd parallel (Packard, 230)
1948 – National Party takes control and apartheid laws are enacted
Health budget is drastically cut (Seedat, 63)
Over 40,000 “tropical workers” are entering SA (Packard, 230)
1950 – Population Registration Act required S. Africans be segregated into three racial categories
Group Areas Act establishes separate residential areas for different racial groups, “forced removals” began of those living in the “wrong” area
1951 – Bantu Authorities Act established “homelands” (Bantustans) taking away SA citizenship and rights
Prevention of Illegal Squatting Act began destruction of basic health services developed by individuals in the “wrong” areas
1960 – Black townships became areas of concentrated population far from towns and city centers
*Sharpeville massacre kills 69, wounds 187 protesting the pass laws
1963-1964 – Rivonia Trials
1970 – South African Department of Health takes over control of all health services from ‘local’ governments, including mission and church hospitals (Seedat, 69)
1973 – Department of Bantu Administration and Development begins takeover of all mission hospitals in the Bantustans (Seedat, 69)
1976 – Soweto uprising kills 23, wounds 500 in protest of Bantu Education policies
1976-1981 – Four “homelands” (Bantustans) de-nationalize 9 million Black South Africans
1982 – First case of AIDS diagnosed in SA, increased charges in governmental health services (Seedat, 71)
1983 – Doctors in the Department of Medicine at Baragwanath describe overcrowding and shortage of staff as having reached a ‘breaking point’ (Seedat, 65)
1985-1989 – SA declares ‘state of emergency’
1986 – First AIDS Advisory Group established to aid the government’s response to the growing problem
1990-2003 – Most rapid increase in HIV prevalence rates
1990 – Mandela released from imprisonment
First antenatal survey estimates that between 74,000 and 120,000 people are living with HIV
1991 – Apartheid laws repealed
1992 – Referendum on de Klerk’s policy
Mandela addresses the newly formed National AIDS Convention of South Africa (NACOSA)
Free National AIDS Helpline established
1993-1999 – Internal labor migration increases significantly, specifically among women
1993 – National Health Department reported the number of HIV infections had increased by 60% in the previous two years and was expected to double over the year
1994 – First democratic elections held, Mandela wins
Minister of Health accepts the basis of the NACOSA strategy as the foundation for the government’s AIDS plan
1995 – International Conference for People Living with HIV and AIDS was held in South Africa, Deputy President Mbeki acknowledges the seriousness of epidemic
South African Ministry of Health announces that 850,000 people (2.1% of population) are believed to be HIV-positive
1998 – Treatment Action Campaign is launched
2000 – Department of Health outlines five-year plan to combat HIV/AIDS
International AIDS Conference in Durban, new SA President Mbeki denies HIV causes AIDS, cites poverty as cause
2002 – SA High Court orders government to make nevirapine available
Government remains hesitant to provide treatment to people living with HIV
2003 – Government approves plan to make antiretrovirals (ARVs) publicly available
2004 – ARV treatment program launches in Gauteng Province
2005 – One service point in each of the 53 districts established for AIDS related care and treatment
HIV prevalence reported at 30.2% – a steady increase since 1990
2006 – Former Deputy President Jacob Zuma claims taking a shower prevented HIV transmission after “having sex” with an HIV-positive woman
UN Special Envoy on HIV/AIDS, Stephen Lewis attacks SA government at International AIDS Conference in Toronto over ARV treatment access
2007 – Mbeki is forced to resign, interim president appoints Barbara Hogan as Health Minister, activists welcome the change and expect greater government commitment to HIV/AIDS
An estimated 1,400,000 orphans of HIV/AIDS in SA
2009 – Apology for Mbeki ARV policy
Development of health services/ access to health services is a major issue in 2009 elections

why there is no doctor: harsh realities in zonkizizwe (part 2) (11)

(photo: Zonke Testing Day banner on the back of a van used to transport people to the clinics)

While working in Zonke, a fact that shocked me was that an HIV-positive person can only access ARV treatment [for free, otherwise it is very expensive] if their CD4 count is below 200. This is official South African government policy and numerous studies have shown that accessing treatment earlier has greater long-term health benefits as ARVs are meant to be taken life-long. A World Health Organization (WHO) study in 2008 outlined four clinical stages of HIV progression. The WHO recommends that when a patient hits stage three with a CD4 count below 350, life-long ARV treatment should be started. Starting patients earlier negates complications later. However, in South Africa once the CD4 count goes above 200 again, treatment is stopped, which allows for greater complications and the need for new strains of ARVs. This year a push to increase the CD4 count threshold for treatment was rejected by the National Health Council on the grounds of affordability (85).

Prof Robin Wood, director of the Desmond Tutu HIV Centre at the University of Cape Town, is among the clinicians who have been calling for the South African government to raise the standard of treatment set out in its guidelines. However, he pointed out that better guidelines would be meaningless without improving the quality of care and access to services (86).

Professor Wood brings everything back to perspective. Anyone can call for greater access and more treatment, but if there is no distribution system for health services and care then what is the point. It would be like having a big supply of pizzas and no delivery drivers. This is the problem in many former “homelands,” townships, and informal settlements. There are inadequate or non-existent delivery systems for health services and treatment and so in areas where the HIV/AIDS crisis is most critical, there is no system to address the problem.

Today was the 2nd half of Prevention in the HIV/AIDS course. The kids are incredibly receptive with questions, comments, and the desire to learn more. We will be covering Treatment and resources this Friday. Celumusa did a great job of translating and really getting the course lessons through to the kids. Later in the evening she talked with us – her passion and drive to get people tested and aware and knowledgeable is amazing and so admirable with all she has been through. She is so excited about a Zonke testing day, the HIV/AIDS class, working with the staff and community to make more people talk and not be afraid to talk. Today she told the kids that she was HIV positive and they all did not believe her at all – they asked her to cross her heart that she was not lying. I could tell from the first class that the kids were learning much more than they had before beyond what HIV and AIDS stands for (87).

Much of the work at the center and the work that needs to happen in Zonke is HIV testing. Once tested you can learn how to take care of yourself, your children, and your community. When I asked Celumusa why people don’t test she said that people don’t know that they can live with HIV. So many people are involved in risky behaviors, she said, they have family members die from HIV/AIDS, but don’t test themselves. She also noted that pregnant mothers are tested and are given tablets, but not told their status. Testing is critical and we began working on this by planning a Zonke Testing Day for July 31st.

As I began organizing for the Testing Day, I came into contact with more of the health services available in Zonke. There are a number of traditional doctors and surgeries in Zonke. I can only imagine that this is because there is such a lack of other health services. Celumusa and others have bad perceptions of traditional medicine: evil, it kills people, and the traditional healers are crazy people. I was still having no luck finding any doctors, until I finally caught a traditional doctor in his office. He ran a clinic that was more Western than others and was supposedly trained by the government in traditional healing, but his office was empty every time I visited – no patients (88). Why are there no doctors?

Across the road from his office was a private clinic run by a group of Indian doctors. I also had a difficult time finding them, as did many Zonke residents. I was able to visit the private clinic only when Celumusa had to schedule an appointment for her baby. The private clinic had become her last option that she was sure to see a doctor. This says a lot for the health care system in Zonke (and other overcrowded settlements and townships left over from apartheid era) that the poor will pay to see a private doctor because the government health services are unreliable. Celumusa said they always give injections at the private clinic. Yet again I wonder about the quality of care. The clinics give painkiller tablets and the private clinics give injections (antibiotics?). If care is inadequate and access to ARV medication is beyond the ability of most, then the extended scenes of cemeteries become less shocking.

In the past 2 weeks, 3 people have passed because of HIV and AIDS that we have been directly informed of because the Buthelezi family has been close to the deceased – a father, an aunt, and a neighbor. Living in an HIV positive community is so different when you can fully understand the impact of just one life (89).

It was as if I had seen the walking dead. The prospect of death is so intertwined with life in Zonkizizwe that the author who wrote that South Africans attend more funerals than weddings was supported by my experiences this summer. The hardest hitting example was with the passing of the father of one of the families at the center. Three of the children attended the center. The oldest was 17 years old and was taking care of her frail father as he withered away, making sure her younger brother and sister were going to school, and attending school herself. This small family had already lost their mother to HIV/AIDS. The burden of disease was not met by the health care system or any the government response. The burden of disease rests completely on those who are affected and they do not have the resources to help themselves.

A critical aspect of combating the effects of HIV/AIDS in South Africa is education. As one of my goals over summer I developed an HIV/AIDS curriculum, based off of the Peace Corps Lifeskills curriculum, that the youth could share with the friends and families as peer educators. The spreading of knowledge is a powerful first step in giving people the resources they need to prevent HIV/AIDS. It is especially important when there exists no other means to access this information. The Zonkizizwe schools are under-funded and teachers are under-trained. This translates to the lack of a teacher for the Lifeskills curriculum and therefore the lack of knowledge on sexual health and HIV/AIDS. VVOCF is beginning to fulfill a service where the government is horribly failing.

All of our kids were tested, plus about 20 others. In all over 60 people tested. […] The community and guardian support was incredible. There were a few positives that we expected from already young mothers […] and unexpected bad news surprise […] Many good surprises came out of the day as we learned of many negative cases that were expected to confirm our worst nightmares (90).

Year – Number of HIV Tests (*from clinic 2)
2006 – 128
2007 – 246
2008 – 412

The success of solutions driven by citizens was best evidenced by the culmination of the HIV/AIDS peer education courses, health classes, and the death of a father in an area wide testing day. I had taken the lead in organizing the testing day with the clinics, MSU study abroad volunteers, and various local organizations. Because of the stigma attached and sensitivity of the issue I was a bit nervous when the day came. July 31st 2008, the first Zonke Testing Day was a day of success fueled by the youth at the center. And while the numbers of people testing have made steady increases, the reality remains that the majority of those who need treatment after testing will not have access. Many in the generation just older than these youth mocked or scoffed at the testing day, but our kids were set on it.

We really are building a new generation of freedom fighters – not afraid of stigma, talking about sex, ready to be tested, and not about to turn a blind to HIV/AIDS. These young people stood today with a powerful support base of each other evidenced by yesterday’s action and the larger community is taking notice. The youth continue to give me hope and pride in being allowed to take part in such a community action (91).

The realities of Zonkizizwe paint a vivid picture of the effects of apartheid on health care for the majority of the South African population. The health system operating in Zonke is the ground zero of the failures of post-apartheid government policy to address the far-reaching impact of HIV/AIDS.

85. “South Africa: Funding shortfall threatens treatment programme.” IRIN/PlusNews. 2 April 2009. http://www.irinnews.org/report.aspx?ReportId=83762
86. Ibid.
87. Hill, Alex B. Journal Entry. 30 June 2008.
88. Ibid, 17 July 2008.
89. Ibid, 6 June 2008.
90. Ibid, 31 July 2008.
91. Ibid.

Coming next: Conclusion

why there is no doctor: post-aparthied health, the burden continues to get heavier (9)

(photo: View of Zonkizizwe with mountains in the background)

The South African health care system was in crisis during the apartheid years and that fact has not changed almost 15 years later. According to the American Association for the Advancement of Science and the Physicians for Human Rights organization, the South African health care system not only limited access to health services for Blacks, but also created an environment in which abuses could and did occur (70). The Bantustan homelands have been incorporated back into the unified free South Africa and these areas remain the most underserved. These areas had their own separate health departments under apartheid with 300 local authorities in charge (71). Now these separate departments are under the authority of 9 different provincial health services leaving health care in South Africa fragmented.

In essence there were, and still are, two different health care systems in South Africa. One system is public and accessed by the majority of the population. The other system is private and subsidized for the few who can afford it. During apartheid the majority of the health budget went into developing this private health system for those living in urban areas and those privately insured (72). This disparity remains true today, as Blacks still have limited access to health services. Economics also continues to drive this disparity as most doctors choose to enter into the private system for better pay and better facilities.

The lack of an adequate health care system for the majority of the population as a result of apartheid policies has exacerbated the ability of medical practitioners in responding to the HIV/AIDS crisis. “HIV patients might soon account for 60 percent to 70 percent of hospital expenditure in medical wards,” says HEARD researcher Nina Veenstra (73).

Already, about half of all patients admitted to hospitals in South Africa seek care for HIV-related illnesses, while the numbers of HIV-positive patients in paediatric wards are even higher, she added. […] As the numbers of AIDS patients grow, there will be a greater demand for skilled health workers, medication and hospital facilities.
South Africa already suffers a shortage of health workers, due in large part to unattractive working conditions. Many posts for health workers remain vacant, notes a study by a national research organisation, the Durban-based Health Systems Trust (HST) (74).

The HST and other researchers have estimated that only 13% of all patients who are in need of ARV treatment are receiving it (75). This is in large part because of the lack of health workers. Where apartheid denied Blacks adequate training for medical professions, there is now such a lack of health workers that a government ARV treatment plan can’t even be carried out because there are such limited human resources (76). Along with the lack of health workers, a recent study found that 13% of health workers who passed away between 1997 and 2001 died of HIV/AIDS-related diseases (77).

70. Kon, Zeida R. and Nuha Lackan. “Ethnic Disparities in Access to Care in Post-Apartheid South Africa.” American Journal of Public Health. December 2008, Vol. 98, No. 12, 1.
71. Ibid.
72. Ibid.
73. Palitsza, Kristin. “A Burden that Will Only Become Heavier.” Inter Press Service News Agency. May 28, 2006. http://www.ipsnews.net/africa/nota.asp?idnews=33396
74. Ibid.
75. Ibid.
76. Ibid.
77. Ibid.

Coming next: Harsh Realities in Zonkizizwe (part 1)

why there is no doctor: high-risk migration patterns (4)

(photo: traffic in Johannesburg)

Apartheid worked on a model of strict population control for increased economic gains. Removing millions to overcrowded townships and Bantustans far from city centers developed a system of forced migrant labor. Both men and women had to leave these areas to find any economic stability for their families.

It has been estimated that one third of the adult male population in the Bantustans is absent at any one time, contributing to the low level of farming. Many women are also forced to seek work elsewhere to support their families. In general they are excluded from seeking work on the industrial areas of South Africa and the majority work as domestics or in agriculture (32).

The migration of Black populations to find work had adverse effects on the health of individuals, families, as well as communities. The movements of people from rural to urban areas became entrenched in the economic system where state interventions actively controlled and mobilized labor migrations (33). In 1990, a study in KwaZulu-Natal province found that men who were migrant workers in the mines had twice the HIV rates as non-migrant workers, while women who attended prenatal clinics in the province had twice the national level of HIV infection (34).

During the period of 1993-1999, there was a significant increase in migrant labor. This can be explained by the ending of apartheid laws creating an increased mobility of populations of workers. In 1993, 32.6% of rural Black Africans were migrant laborers (35). In 1999, almost 40% of rural Black Africans were migrant laborer and 34% of all these migrant workers were women (36). This period also marked the ending of apartheid laws, the first democratic elections in South Africa as well as the doubling of HIV prevalence rates (37). Recent studies have shown that labor migration patterns did not change with the ending of apartheid, but rather increased. A 2003 study concluded that,

Migration continues to play an important role in the spread of HIV-1 in South Africa. The direction of spread of the epidemic is not only from returning migrant men to their rural partners, but also from women to their migrant partners. Prevention efforts will need to target both migrant men and women who remain at home (38).

Professor Lurie and researchers from Brown University, Harvard Medical School and Imperial College London used data collected from nearly 500 men and women living in bustling towns and rural villages to create a mathematical model that shows that migration of South African workers played a major role in the spread of HIV mainly by increasing high-risk sexual behaviors. Very often young men would leave the rural Bantustans in order to earn a living in the urban areas and mines only returning home once a year. With the lifting of travel restrictions on Black South Africans after apartheid this “circular movement” increased (40). Professor Lurie said,

Our model showed that migration primarily influences HIV spread by increasing high-risk sexual behavior. Migrant men were four times as likely to have a casual sexual partner than non-migrant men. So, when coupled with an increase in unprotected sex, we found the frequent return of migrant workers to be an important risk factor for HIV (41).

32. Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 18.
33. Posel, Dorrit. “Have migration patterns in post-apartheid South Africa changed?” 4-7 June 2003.
34. “HIV and other STDs. Chapter 3, Part 1” Population Reports. November 1996, 20.
35. Posel, Dorrit. “Have migration patterns in post-apartheid South Africa changed?” 4-7 June 2003, 3.
36. Ibid.
37. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
38. Lurie, Mark N; Williams, Brian G; Zuma, Khangelani; Mkaya-Mwamburi, David; Garnett, Geoff P; Sweat, Michael D; Gittelsohn, Joel; Karim, Salim SAbdool. AIDS:17 October 2003 – Volume 17 – Issue 15 – pp 2245-2252.
39. Ibid.
40. Ibid.
41. Ibid.

Coming next: Scapegoating “tropical workers”

why there is no doctor: cleaning black spots off of a white land? (3)

Forcing people to live in separate racial areas of South Africa was the driving piece of apartheid’s “separate development” policy. The pockets of the Black population that lived among and near White city centers were called “Black spots” and the government actively worked to clean them out. During the 1950s and 1960s the first “forced removals” occurred after the passing of the Group Areas Act established these racial areas. More than 860,000 people were forcibly removed as a way to divide and control racially separate communities as resistance grew towards apartheid policies (23). Sophiatown of Johannesburg and District Six of Cape Town are just two examples of vibrant multi-racial communities that were destroyed by South African government bulldozers once they were deemed “White” areas (24).

Between 1960 and 1983, over 3.5 million South Africans were forcibly removed (25) and until 1984 another 1.7 million were under threat of removal (26). Blacks were removed to distant segregated townships, sometimes 30 kilometers away from places of employment in the central towns and cities (27). As a result ‘informal settlements’ formed as shantytowns closer to places of work, but many were destroyed. Farm laborers were also displaced by mechanized agricultural. As a result farm laborers were segregated into desperately poor and overcrowded rural areas and were not permitted to travel to towns to find new jobs (28).

Removals represented the “essential tool” for apartheid to work. Creation of the Bantustans stripped Black South Africans of all legal rights in South Africa and their welfare was no longer the problem of the South African government. Hundreds of thousands of other Blacks were dispossessed of land and homes where they had lived for generations in these “Black spots” now designated as part of “White” South Africa. Entire townships were destroyed and their residents removed to just inside the borders of Bantustans where they now faced long commutes to their jobs (29).

In other words, removal of people is not simply a physical act; it is part of a process and a strategy that seeks to push increasing numbers of South Africa’s people into ever more remote and inhospitable areas where, broken and fragmented by the experience of removal and all that it means, people are left to exist under conditions of increasing apathy and powerlessness (30).

One UN report on the forced removals noted, “that the demolition was executed in total disregard for the health and well-being of every individual concerned, in the most inhumane manner” (31). The forced removals created poverty situations where the infertile Bantustan lands had to sustain an overcrowded population. This policy of removal, coupled with the apartheid policies on health services in Bantustans and for Black medical training, shows the dire health effects on the Black population. These terrible health conditions later translate into environments easily susceptible to the spread of HIV/AIDS.

23. “Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
24. Ibid.
25. “Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
26. “The uprooting of millions, forced removals.” For their Triumphs’ and Tears. ANC, 1983.
27. “Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
28. Ibid.
29. Ibid.
30. J Yawitch, Betterment. “The myth of homeland agriculture” SAIRR: Johannesburg, 1981, p.86.
31. ‘Forced removals in South Africa 1977-1978’, paper prepared by IDAF for the United Nations Centre Against Apartheid, No. 44/78, Oct. 1978, p.9.

Coming next: High-Risk Migration Patterns

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?

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
5. UNAIDS 2006 Report on the Global AIDS Epidemic, Chapter 4: The impact of AIDS on people and societies
6. HIV & AIDS in South Africa: The history of AIDS in South Africa
7. Cullinana, Kerry. “Healthy election promises.” 31 March 2009

Coming next: The Health System via Apartheid