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1991 – Apartheid laws repealed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 1) (10)


(photo: Clinic #1 in Zonkizizwe, serving zones 1-4)

From May to August of 2008, I interned with an organization called Vumundzuku-bya Vana ‘Our Children’s Future’ (VVOCF). The organization is located in Zonkizizwe (Zonke), an informal settlement south of Johannesburg closest to Germiston. The informal settlement is best described as a peri-urban area much like a shantytown with convenience stores. Some live at a lesser degree of poverty than others, but everyone is impacted by HIV/AIDS.

I […] 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 […] 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. […] 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 (78).

Zonkizizwe is a snapshot of post-apartheid health care development failures. It was founded when a group of displaced people set up shacks on a farmer’s land so that they could live closer to potential places of work. Many times the South African government tried to remove them, but they kept rebuilding. This is a story different than that of the Black townships or Bantustan “homelands.” Zonkizizwe was an area not meant to be inhabited by anyone, let alone poor Blacks. Understandably the story of health care here is one of an even greater lack of access. Informal settlements had no budgets of their own to even attempt to build their own health infrastructure and even if they did it would likely have been destroyed during forced removals. Under apartheid, health services would have been incredibly difficult to come by.

Everyone waves from their steel-corrugated shacks, children smile and get excited, parents and elders are welcoming – looking out over the shanty town roof tops that extend as far as the eye can see in each direction, you can’t help but wonder that within this poverty and desolation mixed with laughter and happiness – what potential can be harnessed, what community action can be inspired to make South Africa’s future brighter by and for those who live here (79).

My goals as an intern with VVOCF were HIV/AIDS education, HIV/AIDS peer educator training, and assistance with nonprofit organizational development. I was very glad to be able to focus my strengths and interests in the work I did. I also worked to formulate a rough community health assessment based on my interactions with people at the VVOCF center, neighbors, visits to the clinics, and interactions with Zonkizizwe residents.

Now Zonkizizwe has two primary health care clinics to serve its roughly 250,000 people. Health services are all free through government funding, including immunizations and treatments. However, the issue does not become access to treatments, but rather quality of care. The director of VVOCF, Celumusa, said that all the health clinics do is give out painkiller tablets for everything (80). She said she often just goes to the chemist [pharmacist] to tell them what is wrong and get something that will actually help. This appears to be a direct outcome of apartheid health policy. The lack of trained medical professionals, notably doctors, leaves local health workers with no better option than handing out painkillers. Quite possibly the training of these health workers remains inadequate as well. Zonke is an area much in need of the RDP’s action, but all that can be seen here are RDP building supplies for new houses.

“You can see people die, sitting at Natal-spruit.” – Celumusa (81)

The closest hospital to Zonke is in Natal-spruit, about a 30-40 minute taxi ride away. If you live in Zonke, this is the closest place to get ARV medications since the clinics are “not certified” yet to distribute (82). There is another hospital nearby, but the taxi fare is more costly and it takes longer to get there. Residents of Zonke don’t necessarily have the time or money to take a day to travel to the hospital even if it is critical to their health. Those who go to Natal-spruit notice a different level of care. People die waiting, people in great pain are not attended, people in need of good health care cannot access it. At Heidelberg I was told the staff rush to help you and are much more caring (83). The Natal-spruit hospital is set to be closed soon and a new hospital will be built in Extension 6, which is in Sandonga, much closer to Zonke. Maybe with this new hospital the level of care and access to care will increase, especially in regards to ARVs accessibility.

Notes:
78. Hill, Alex B. Journal Entry. 15 May 2008.
79. Ibid, 13 May 2008.
80. Ibid, 6 June 2008.
81. Ibid, 29 May 2008.
82. Ibid, 10 June 2008.
83. Ibid.

Coming next: Harsh Realities in Zonkizizwe (part 2)

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?

the week in african health

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“No weapons” MSF in Nasir, Upper Nile State, South Sudan

More:
A Tale of Two Refrigerators
Fighting has renewed in southern Sudan, but its not just between militant groups – aid groups fall victim to needless fighting as well. Diane Bennet writes on William Easterly’s Aid Watch blog about the 2001 peace in Sudan and how it was a ripe time to treat disease and build health infrastructure. Unfortunately internal bureaucracy and politics became the largest hurdle.

Sudan: Darfur – Thousands Flee to African Union Safety
More recently, South Darfur has become the seen of violent clashes between government forces and militants. It is important to never forget the impacts that conflict has on health services.

Africa: Public Health Care Must Lead

Oxfam International has released a report [access here] “challenging the myths about private health care in developing countries.” The report emphasizes the role that private health care can play in developing countries, but reminds us that there is no way a scale-up of private health services will reach poor people in need. Key recommendations are to increase funding for free universal health care infrastructure, rejecting ineffective practices of the past, and combining efforts to fuel effective initiatives – sounds a lot like SCOUT BANANA

Global Health: Mobile Phones to Boost Healthcare

Revolutionizing access to health knowledge, the efforts of the Mobile Health Alliance (mHealth), supported by the Rockefeller Foundation, the UN Foundation, and Vodafone Foundation are making a mark across the African continent boasting 51 existing or to-be-implemented programs in 26 countries around the world. Harnessing the potential of growing technology in ‘developing’ countries for the purpose of health can only signal a major shift in access to health care across Africa.

Getting the Continent on Obama’s Agenda

It appears that Obama’s administration is stacked in the favor of Africa and in favor of better international development practices all around. With Susan Rice serving as Ambassador to the UN action against genocide may be bolstered, Gayle Smith more likely than not will be tapped as USAID Director, she was a major proponent of the HELP Commission creating a cabinet level position for foreign aid, and a well known name among insiders and outsiders in African affairs, Johnnie Carson, is expected to be named head of the Bureau of African Affairs of the State Department. The future of US relations in Africa has incredible potential and hope to change.

Zimbabwe: Staff Return to Hospitals, But Not to Work

As a massive cholera outbreak tears across the country, medical staff have returned to their posts, but the nature of their strike, that began in 2008 over poor working conditions and wages, is now “more like a sit-in.” In a country so crippled by Western exploitation and resulting politics, a strike of the health workers in the face of a rampant disease outbreak does not bode well for a vulnerable population.
More:
Too Much Cholera, Too Little Food
Over 80,000 Zimbabweans Infected with Cholera

Africa: U.S. Naval Engagement Offers Health Dividends

Imagine the potential of the US’ military might if it was dedicated to coordinating naval and health care workers from 13 countries to bring aid and health services to communities in need. This becomes a reality with the African Partnership Station Initiative and Project Handclasp. I can only dream of a day where initiatives like this are more a norm than a surprising gesture of good will.

Mali: Raising Money and Hygiene Standards

One of the most innovative programs that I have read most recently is the work the Dutch based Gender and Water Alliance which is employing women to make soap as well educate and use it to increase hygiene and combat preventable diseases. Health benefits, a source of income and empowering women!

Food Crisis Over, Say Experts

Supposedly the global food crisis of last year is over! Agricultural experts from Africa and Asia are saying that we are no longer in a food crisis and that there needs to be an increased production of rice in Africa in order to keep the food crisis at bay. In my opinion, as long as we continue our unsustainable and capitalist practices that commodify a basic human need, we will remain in a global food crisis affecting both the US and Africa.
More:
Rwanda: Food Production Up, Thanks to Green Revolution
Thankfully the increase is not due to the ‘Green Revolution,’ but instead to increase in practices that are focused on protecting the environment.

South Africa: Treasury Blamed for Shortage in Aids Drugs

Years of controversy seem to have brought the blame down on the South African Treasury. With an extensive bureaucracy, it is no wonder that the ARV roll-out program has taken much longer than it should – as many die without the proper medications. While the numbers of people enrolled in the ARV program has increased significantly there still exists a problematic policy of access. Access hinges on wealth, CD4 count, and location. To access the government’s ARV program your CD4 count has to be less than 300, which is at a point where you are already very vulnerable. This creates an issue of sustained treatment because it forces an irregular regimen. If your CD4 count is above 300, you will have to pay. Many cannot pay and if you live far from a government hospital access is just that much more difficult because of taxi fare and time sacrificed for travel. It seems the health and wellbeing of its citizens is not a high budget priority of the South African government.
More:
Rapid HIV evolution avoids attacks
Much like the flu virus, HIV mutates and evolves in response to treatments. This really exposes the South African ARV program as highly ineffective.
Duncan discusses HIV/AIDS in Morocco
Little known to the world, the HIV/AIDS crisis grows in Morocco.

Originally posted on the SCOUT BANANA blog. 

steel villages and concrete fences

13 May 2008

Everyone waves from their steel-corrugated shacks, children smile and get excited, parents and elders are welcoming – looking out over the shanty town roof tops that extend as far as the eye can see in each direction you can’t help but wonder that within this poverty and desolation mixed with laughter and happiness – what potential can be harnessed, what community action can be inspired to make South Africa’s future brighter by and for those who live here.

The government built lavatories and sinks for the informal settlement so sanitation is good. They provide building materials for brick houses through the Reconstruction and Development Program (RDP), but where are the education improvements? the health support? the food subsidies? A government can’t do it all and so places like VVOCF exist!

This all made me think more about the African health worker crisis as I see the direct result of it, the effectiveness of government funded health care, and the access to nutritional information and education.