Ebola, Disease Outbreaks, and Inadequate Health Systems

I vividly remember the Kagadi Hospital run by the Ministry of Health. In 2002, I was visiting the communities that would benefit from an ambulance fundraiser project. That evening the need for emergency transportation in the Kagadi-Nakuulabye area of the Kibaale District could not have been made more clear to me. Driving back to our housing one evening, our pickup truck was flagged down to help at the scene of a bicycle accident where two riders had collided head on in the dark. One man was bleeding from his ears and obviously needed advanced medical attention. We drove him, lying in the pickup truck bed, to the Kagadi Hospital only to be turned away because the staff said they didn’t have any supplies to treat the man. I remember looking into the hospital windows and seeing nothing but empty walls.

It came as a shock to read news of the Ebola outbreak in that very same area where I had visited 10 years ago: Kagadi, Kibaale District. My first thought was that the health care system couldn’t possibly respond quickly enough, but hopefully things had improved over the last decade. Reports noted that the Red Cross, Doctors Without Borders, CDC, and the World Health Organization (WHO) were assisting with the response. This was a positive sign since the area is rural, difficult to travel to, and as far as I knew lacking a strong health care system.

“This outbreak is occurring in the same area where the Red Cross is already responding to the growing crisis caused by the influx of Congolese refugees fleeing violence in their country” said Charlie Musoka, Regional Operations Coordinator for the International Federation of the Red Cross.

On top of dealing with the Ebola outbreak, the Ugandan Red Cross was also managing the influx of refugees into the country. My initial thought was that Ebola is easily transmitted by close contact between people and usually kills 90% of those infected. With the regular movement of people across the Uganda/ DRC border it could be just days before an Ebola outbreak occurs in the DRC.

Shortly after the Ebola outbreak, news broke that the Ugandan Ministry of Health needed Sh3 billion to be able to contain and manage the disease and necessary health care facilities. I was also contacted by the local health center in Kagadi and told that were having difficulty responding to the outbreak as well. My fears seemed to have been true and the health system was feeling the pressure of responding to an Ebola outbreak in an area where there was very little health care capacity.

Roughly, two weeks after the request for supporting funds by the Ugandan Ministry of Health, the Ebola outbreak is reported as contained in Uganda and a Ugandan team would be sent to the DRC to help contain the new outbreak there. Reports said that it was a different strain of Ebola, but the first reports were in a Uganda/DRC border town that is a regular crossing point between the two countries. I had worried about the lacking health care system in Uganda, but the health care system in the DRC is in an even more strained. There are limited health care workers and facilities, which are usually filled by casualties from the ongoing violent conflict in the region.

Early this month, the WHO declared Uganda Ebola free after there were no new cases reported after August 3rd (24 confirmed cases, 17 deaths). The facilities in Kibaale District remain on alert, but the larger Ebola crisis is in the DRC. The WHO confirmed the Ebola outbreak is a different strain (see map above) and not connected to the Ugandan outbreak, however there have already been 72 confirmed cases and 32 deaths. Health workers were reported infected in the Ugandan outbreak, but in the DRC so far 23 of the 32 deaths have been health care workers. Representatives of Medicines sans Frontiers note that the death of health care workers at hospitals scares people away from seeking treatment and they are more likely to continue the spread of Ebola. It seems that the DRC has been less equipped to deal with the Ebola outbreak or its just the nature of the area where the outbreak occurred that made it easier to spread.

Both of these examples of Ebola outbreaks in a remote region of Uganda and in a transit town in the DRC demonstrate the critical need for adequate health care systems and health care workers. Before conflict started in the DRC, the health care system was already underfunded and in need of investment. The United Nations reported that militias raided almost all of the health care facilities in rural areas where 70% of the populations lives. The conflict also disrupted transportation and everyone must travel by foot to get treatment. NGOs have tried to invest in the health care system, but Doctors Without Borders report regular attacks on their compounds. In Uganda, there has been similar conflict, but greater investment in the health system. However, a recent report highlighted the inadequate staffing and space in many key hospitals. In some areas there is 1 doctor for every 178,000 people. Due to financial constraints the Ugandan government has banned recruitment of health care workers.

No one can afford to not invest in health care capacity building. In these two countries it seems that health crises need to be managed by outside NGOs with additional funding. How can the international community better work to build the capacity of individual country’s health care systems?

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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

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?