the coming revolution in african health care

 

african power fist Pictures, Images and Photos

Before you have anything else, you have your health. Hopefully if you have nothing else, at least you have your health. Unfortunately, for millions across the African continent this is not an absolute fact. Even more unfortunate is the fact that many Africans have no ability to change their health status. They are trapped in a system that is driven by Western market based, profit driven health care systems. As the failures of Western development practices come to light, alternatives to what has been are becoming increasingly visible. These alternatives will form a revolution in African health care delivery. This revolution will be fueled by health care delivery models that will give local communities agency in the provision of their own health care. Community-based models involving cooperative financing, proven para-professional training, new information technology, and social enterprise for the social good will drive the revolution in African health care. People will be able to determine for themselves, their level of health.

What does “Health” mean anyway?
This is a question often left to remain ambiguous. For the purposes of my writing I will provide a comprehensive view of “health” and all that is entailed in sustaining and maintaining health. “Health” in all instances will refer directly to the “basic needs” of a person in regards to health care.

Healing, like health, is obviously rooted in the social and cultural order. […] To define dangerous behavior, and to define evil, is to define some causes of illness. As the definition of evil changes, so does the interpretation of illness. To understand change in healing, we must understand what it is that leads people to alter the definition of dangerous social behavior. It can easily be accepted that health and healing in Africa are shaped by broad social forces.

As Feierman and Janzen state, health (and healing for that matter) are directly linked to social forces. If a comprehensive understanding of health is to be understood, it must be studied in the context of politics, economics, and other societal structures.

Health is defined by the World Health Organization (WHO) as, “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” The WHO and many other international organizations recognize that this broad and encompassing definition of health. Where this definition becomes ambiguous is what qualifiers meet, “a state of complete physical, mental, and social well-being.” In 1978 the WHO made primary health care its number one objective with the Declaration of Alma Ata. However, even this statement had no clear definition of health or its qualifiers.

Feierman and Janzen provide a more clear definition of the qualifiers of health in the preface to their volume: The Social Basis of Health and Healing in Africa,

[…] it [health] is maintained by a cushion of adequate nutrition, social support, water supply, housing, sanitation, and continued collective defense against contagious and degenerative disease. Such a view is necessary if we are to understand those contexts in today’s Africa where health levels deteriorate, and where they improve.

These authors provide a complete set of qualifiers, or “basic needs,” of health that can be researched further to understand where political, economic, and social structures interfere with sustaining and maintaining health and where health care is inadequate.

Health care should thus be understood as the system and structure that works to provide the above defined “basic needs” to each individual. Often this role falls to governments, but sometimes is taken up by communities and organizations when government’s fail to provide these basic needs.

This blog series will cover four key areas identified that will fuel this revolution in African health care: cooperative financing, para-professional training, information technology, and social enterprise. SCOUT BANANA works to tackle social medicine (social, economic, structures) while enabling others to provide medical services. Be sure to follow closely to learn more!

Written for the SCOUT BANANA blog.

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!

Index:
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.
http://www.infoforhealth.org/pr/J45/j45chap3_1.shtml.

“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm.

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.
http://74.125.95.132/search?q=cache:4Oor9pRwaTkJ:pum.princeton.edu/pumconferenc 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.
http://www.anc.org.za/books/triumphs_part1.html#3back1.

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.

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

Appendix A

when in ghana. . .

This is a series of post that I wrote while completing an MSU Study Abroad program on “Disparities in Health Care” in Ghana. Our group was based in Accra at the University of Ghana, Legon and we stayed in a hostel in Shiashie. We traveled often: Volta Region, village of Klikor, Kakum National Forest, Volta Dam, Cape Coast, Kumasi, and Osu was a usual hangout. The posts are all pictures and reflections during that 6 week program in Ghana. The first post is a research paper I completed for a class about “development” in Ghana.

i. The Quest for Development: Aid to the Rescue in Ghana
ii. off to the continent of my dreams
In Ghana:
1. something you can taste
2. water by day, apples by night
3. for the love of america
4. scenery and speed bumps
5. aljazeera, acrobats, and aloe
6. imperialist footprints: the development story from the inside
7. the quest for the west
8. what is so important about ethnicity?
9. the value is the same
10. weekend of the obrooni [obruni]
11. two voltas, one ghana, three africas
12. the nature of africa: rhythm and socialism
13. image of america, the blinding lights
14. inside africa
15. definition of development
16. . . . keep your promise
17. the chinese influence
18. snapshot of health in ghana
19. a mixture of black, white, red
20. the longest driveway
21. when in ghana
Returned:
22. when not in ghana. . .
23. the land of culture, africa
24. the caramel apple of globalization
25. cynicism from a jaded summer
26. the crouching tiger and the curse of black gold
27. rastafarian confusion

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.

Notes:
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: 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: the health system via apartheid (2)

In order to fully understand the extent of the HIV/AIDS crisis in South Africa and the reasoning for its rapid spread without a response, the history of the health care system and apartheid must be researched. Creating a timeline (see Appendix A) of the health care system in South Africa will be critical to understanding current inadequacies and failures. Looking more critically at the policies of apartheid will also allow a better understanding of their effects on the health of the population, especially the Black majority.

Looking back to the Union of South Africa under Jan Smuts (8), the beginnings of government control of health care systems can be seen. In 1919, the Public Health Act marked the beginning of health service structure in South Africa where policy and procedure is delegated to specific provincial authorities by the central government (9). In the early 1940s there was talk of creating a National Health Service (10). However, when the National Party (Afrikaaner) came to power in 1948, apartheid laws were enacted and the health budget was cut “drastically” (11). This may seem a minor note, however this translated into the policy of “separate development” that left traditional homelands or “Bantustans” as well as Black townships to come up with their own health care services.

[…] the health services aid in the reproduction of the Black labour force according to White economic needs. The provision of health care for Blacks outside the bantustans is geared towards the urban population as the supplier of a large and increasingly skilled, Black workforce, rather than the Black population at large. Secondly, the health services support the commitment to ‘separate development’ in various ways. […] They help to establish the credibility of the bantustans and their leaders, and of the representatives in the new segregated parliament. They also provide a lever with which the government can pressurize bantustan governments into accepting ‘independence’. […] Thus health policy is shown to be an instrument of the state’s twin imperatives: reproducing the conditions of capitalist accumulation and maintaining White supremacy. (12)

Following the legal creation of apartheid, the health system continued to evolve. The year 1951 brought the Bantu Authorities Act, which established traditional homelands for the majority of South African citizens. This action took away the rights and citizenship of 9 million Blacks. In the same year the Prevention of Illegal Squatting Act continued the forced removal of Black South Africans and began the destruction of basic health services that had been established (13). Up until 1970, health services run in Bantustans by mission stations and churches were under the control of ‘local government’ authorities (14). However, following 1970 all health services were placed under the control of the South African Department of Health (15). Along with the removal of people living in the wrong areas and the destruction of health services in those areas, the South African apartheid government was slowly taking control of all aspects of health service to the Black population. In 1973, the Department of Bantu Administration and Development began to gradually take control of all mission hospitals (16). This increased government control led to severe staff shortages as mission doctors did not want to be under the authority of the South African government. This was called an intermediate progress step before completely handing over financing of health services to ‘homeland’ governments. Within the health care system of apartheid South Africa, the notion of “separate development” quickly came to mean absolute government control.

The South African Institute of Race Relations made a Survey of Race Relations in 1982 and quoted a doctor talking on rural health services in the Bantustan homelands,

[…] gave some credibility to the homeland administration itself by enabling it to promote services to local communities. The separation of rural health services into homeland health services allowed the government to manipulate health statistics to give the impression that the health status of SA’s people was improving. An apparent fall in the rate of tuberculosis notifications between 1975 and 1980 was a result of the exclusion of statistics from Venda, Bophuthatswana and the Transkei. […] the separation of statistics also allowed the SA government to claim that most infectious diseases were occurring ‘outside of SA’ and were the responsibility of the appropriate homeland authority, not the SA Department of Health. (17)

The quote from this doctor working in the Bantustan health services shows the direct contradictions of the “separate development” policy within the health care system of South Africa. The doctor talks about how the South African Department of Health takes no responsibility for health statistics in Bantustans (1982), but since 1970 the Department of Health had controlled health services. This contradiction is an excellent example of the apartheid policy’s effect on health, an effect with a planned negative outcome. In interviews in 1983, doctors in the Department of Medicine at Baragwanath hospital in Soweto, Johannesburg noted the inadequacies of health services for the Black population:

[…] described the overcrowding and shortage of medical staff as having reached a ‘breaking point.’ Journalists who visited Ward 21 found that its 40 beds were occupied by 89 women and one child. […] ‘There are not enough doctors and too many patients to do things any other way here.’ Bedletters, giving the crucial medical and drug history of each patient, often got lost in a confusion of movement as patients moved outside the wards during the day to give the doctors greater freedom to work inside. ‘Sometimes I haven’t been able to find out what medication a patient was receiving,’ on doctor said,‘People are not being treated properly here.’

Health, access to health services, and control of health services was an active aspect of the apartheid government policy. The greatest impact of apartheid policy on health infrastructure for South Africa was denying proper training for Black health workers. At the end of 1981, it was estimated that 93% of the medical practitioners in South Africa were White and the ratio of Black doctors to patients was 1 to ever 91,000 people (18). While these numbers do not reflect the direct availability of health services, as much can be gathered. The numbers do show the availability of medical training for certain populations. Along with issues of access to training, there was also the issue of distribution of doctors. Approximately 60% of the population lived in rural areas, but only 5% of doctors practiced in those rural areas (19).

The medical profession of South Africa is White dominated. Medical training was offered at the major provincial universities. Black Africans were allowed to train at just three of these universities until a new medical training center was established in one of the Bantustans as a way to phase Blacks out of the White medical universities. Under the provisions of the Extension of University Education Act of 1959 a new medical training center was establish and the Minister of Education and Training (formerly Bantu Education) had the power to vet all applicants (20). It was policy to limit the number of Blacks as part of ‘Bantu Education’ (21). As Dr. Verwoerd stated in 1954:

The education of a white child prepares him for life in a dominant society and the education of a black child for a subordinate society [. . .] The limits (of Native Education) form part of the social and economic structure of the country.

This unequal access to facilities translated even deeper into medical education as there were restrictions for Black medical students even at the ‘mixed’ universities. The discriminatory laws translate into an inadequate medical training: Black students cannot attend post mortems of Whites, were not allowed to attend ward rounds in White hospitals, and Black students were asked to leave the room when White patients were used for clinical demonstrations. These issues related to access to training were seen across the board for doctors, nurses, pharmacists, and within professional medical organizations. The issues ranged from access to training, lower salaries, and lack of promotion.

Health in South Africa was not departed from the apartheid policy and was an active tool in ensuring political, economic, and social control by the White minority government. The only way to fix health care in South Africa depended on ending apartheid and discrimination and increased government attention to health problems (22). The effects that apartheid policy had on the health system of South Africa, specifically for Black South Africans, laid the groundwork for HIV/AIDS to rapidly spread and take such a heavy toll. Some of the active policy actions that contributed to HIV’s spread were forced removals and migrant laborer movements, both internal and international.

Notes:
8. “History of South Africa.” Wikipedia.org.
9. Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 63.
10. Ibid.
11. Ibid.
12. Price, Max. “Healthcare as an instrument of apartheid policy in South Africa.” 1986. http://heapol.oxfordjournals.org/cgi/content/abstract/1/2/158
13. Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 63.
14. Ibid.
15. Ibid.
16. Ibid.
17. Ibid, 69.
18. Ibid, 84.
19. Ibid.
20. Ibid, 86.
21. Ibid.
22. E. O. Nightingale, K. Hannibal, H. J. Geiger, L. Hartmann, R. Lawrence and J. Spurlock. “Apartheid Medicine.” Committee on Health and Human Rights, Institute of Medicine, National Academy of Sciences. Vol. 264 No. 16, October 24, 1990.

Coming next: Cleaning Black Spots off of a White Land?

when not in southern africa. . .

I will now begin filling in the gaps from my summer travels. I was only able to post four times during my three months in southern Africa.

My travels began in South Africa;s largest city, Johannesburg and took me to a community development project (which became an official non-profit organization (NPO) this summer) in an informal settlement known as Zonkizizwe. Shortened to Zonke, the settlement was started during the apartheid years as a place for people commuting to live closer to their mostly inadequate jobs as farm hands, domestic workers, miners, and other menial jobs. The settlement is surrounded by farmland from which it owes its birth. The former Afrikaner farmland now houses close between 150,000 – 200,000 people (estimates are not clear). There are now other Zonkizizwe areas known as extensions. Where I was is called Zonkizizwe Proper as opposed to the five other extensions just nearby.

Zonke was a flash point of much police violence related to forced eviction from the settlement and inter-ethnic violence related to pitting African peoples against each other to keep the unrest away from the apartheid regime. As a result of this politics is a much deferred subject in the settlement and many people will tell you that they will have nothing to do with politics. South African apartheid police supported Zulu warriors, as members of the Inkatha Freedom Party (IFP), to attack settlement dwellers and take their homes and possessions. If you ask people on either side, the victim and attacker are always switched and just goes to show the ruthless nature of the apartheid government at the time.

As a direct result of the intense fighting, violence, and death witnessed by the residents of Zonke, the community came together during the xenophobic attacks to say that they would not tolerate any violence when they, as youth and young adults, had seen so much violence already. Zonkizizwe means “all the nations” in Zulu and was a term that held true when times got rough around the country and just 10 kilmetres away in nearby Thokoza (Tokoza).

As an African Studies major specializing in international development it was very interesting and powerful to be able to work directly with people on the ground in Africa and see the various stages of ‘development’ within an informal settlement becoming formalized with the new change of government pursuing liberal democracy. As part of the formalizing Zonke has a taxi rank, a new Library, and a new Secondary school. There are a few sections of paved road and street lights also present in the settlement. There is also a large police station (some things left over from the apartheid regime still remain – the overlarge and ineffective police force is just one example). Two health clinics exist in Zonke, however health care is extremely inadequate. I never saw a doctor, nurses and specialists without formal training often diagnosed patients and supplied them with a simple blue painkiller tablet (pill) for most ailments. There will be much more on this subject later. A large administrative center also existed with a Social Development office responsible for dispersing grants from the government and helping with social services. This administrative center used to be the South African police staging area during apartheid, utilized to execute raids on the undesired informal settlement.

The majority of my time was spent at a center for children and youth affected by HIV and AIDS. Most of the children had already lost either one or both of their parents to HIV/AIDS. Many were now living as orphans in child-headed households where their eldest sibling is now in charge or they live with guardians, some so indifferent it seemed that they wouldn’t care if the child died tomorrow. The center was a place where kids could be kids and try not to worry about running a house, taking care of a sick family member, and a place to learn and grow. I ran after school programs with the local staff of the NPO and two other students. The staff was so dedicated and passionate about their work that it was easy to get just as invested in the children of the center. I was able to get excellent workouts from lifting kids all day, up and down, spinning, throwing, catching, chasing, etc. . . whew children. We worked with ages 3 to 21 so I now feel more than ready when I have kids myself. Our programs included arts and self expression, writing, English, homework help, sports and fitness, health, HIV/AIDS, and anything else we could think of to do with kids. Never have I seen such difficult circumstances pushed aside with such desire and hope, that often the resilience of the children made me forget how hard their lives were – with an empty house, a new child, no food to eat, an abusive guardian, a dead parent. . .

I spent some time in the mountain kingdom of Lesotho and learn much from local people and Peace Corps volunteers. I also spent a week in Mozambique visiting a friend finishing a year in Peace Corps where I met many great Mocambicans, international development and aid workers, went to some great beaches, and tried out some Portuguese. There will be many insights and reflections on my experiences in these countries as well.

I saw many things that are difficult to articulate into words, I heard so many stories that I feel it is not my place to repeat, I experienced so much that I will not be able to share for the simple fact that I, myself, can not yet understand. I feel like I left South Africa with many things hanging and left undone, what was most painfully left hanging was my heart. . .

Be sure to check the highlighted dates to be sure to follow my travels in southern Africa over the past three months.

Check out the few posts from South Africa:
what are we to do when our children are dying? (before leaving)
ten hours from amsterdam
a first glimpse: zonke
eruptions from fault lines: race is class
hangin in joburg