HIV solution: decentralizing treatment & patient empowerment

At the core of successful health programs are powerful community systems. Whether they are strong local governments, community-based organizations, or just informal groups of individuals – these types of community centered systems keep health programs focused on serving people and meeting needs in ways that will be most effective for the community.

In what has been called a model for Africa and US health programs by CDC Dr. Kebba Jobarteh, Mozambique is leading the way in restructuring how HIV treatment and support is delivered. Most countries in southern Africa have very high HIV prevalence rates as well as difficulties in providing treatment to those who need it. While there are many people in need of HIV treatment, there is a critical lack of adequate health infrastructure, clinics, hospitals, and health workers, to deliver the necessary services.

Providing treatment is just the beginning of the battle. Once an individual starts treatment with antiretrovirals (ARVs) they need to continue to adhere to a regular regimen of ARVs. Access to the medications and clinics along with regularly taking ARVs present a two-fold problem in areas where health services have long been weakened by a plethora of misfortunes: apartheid, structural adjustment programs, lack of development, under-investment, etc.

The new model developed by Doctors without Borders (MSF) puts communities at the forefront. By creating “patient groups,” treatment is decentralized to small health clinics in communities. This model spreads the responsibility to communities where there is the greatest need. The patient groups act as both a delivery system for ARV drugs as well as a support network for those with HIV. In many rural areas, people don’t have the time to travel long distances for extended periods of time to get their ARV drugs. The members of a patient group take turns traveling the distance to the health clinic. Likewise, members record whether each member of their group has taken their ARVs regularly and on time, which is then reported to the health clinic.

The model is very similar to that of “community health workers” (CHWs), who are members of the community that share knowledge and provide services when health systems can’t. As a solution to the inadequate health systems seen around the world, the “patient group” model puts those who need health services in control of their own treatment with the backing of a support network from their community. This may be a more effective model than CHWs since those who need treatment are providing the treatment. What better way to understand patient needs than to listen to the patients?

The CHW model has been popularized by organizations such as Partners in Health working in communities in developing countries. The model has now spread to urban areas and “developed” countries around the world. The patient model is yet another example of rural solutions from developing countries setting the bar for gaps in health care treatment in developed countries. A patient-centered/ people-centered approach to health delivery will make health systems more effective and successful around the world.

Featured on the Americans for Informed Democracy Blog, where I’m writing as a Global Health Analyst and reposted by Partners in Health.

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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

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.

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

modernizing traditional remedies


(photo: Traditional surgery, not in the sense of cutting people open – just means it is a place of traditional medicine practice.)

6 June 2008
There hasn’t been much that I have cared to write on for the past few days. I am building an HIV/AIDS curriculum for peer education from the Peace Corps Life Skills curriculum. The Peace Corps program is very good with excellent activities and info. The classes were supposed to start today, but will be pushed back a week because kids didn’t show up on time – so it became freedom of expression day with singing, drawing, and poetry reading. But I am excited to start and contribute to youth leadership development in such a critical and controversial subject.

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.


(photo: Traditional doctor’s office, 2 years of formal training)

Celumusa told us today that all the health clinics do is give out painkiller tablets for everything. She often just goes to the chemist (pharmacist) to tell them what is wrong and to get something that will actually help. I inquired about the herbalist and surgeon – same building that we passed in Zone 3 – Celumusa is skeptical of the herbalist. Today she returned from Sandonga with a paper flyer for a “traditional” healer who claims to help with 65 diseases including HIV/AIDS. Supposedly the South African government gives witch doctors certificates in the hopes of finding a cure for HIV/AIDS. Yet another example of their [the government’s] absurdity. Mr. Ndaba told us that Mbeki and Zuma are supposedly coming to Zonke for the upcoming elections. That should be interesting.

Reflections 6 July 2009:
This is a very different picture of traditional medicine than what I saw and studied in Ghana. Here traditional medicinal practice is more associated with the spirits and evil (muti in isiZulu) as opposed to healing processes that are trusted to work, like I saw in Ghana. There were plenty of stories about the frightening things that might happen to small children who upset a Sangoma (“witch” doctor), etc. However, I did see some traditional medicinal practices being employed by the grandmother (Goko) and mother. One such traditional remedy turned modern was using a ball of toothpaste or soap (inserted into the anus) to cleanse the body. Nothing like a little soap to clean out your system of sickness. Regardless of the views I received from neighbors and community members about traditional medicine and doctors there were plenty of locations to visit the practitioners of traditional medicine.

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)

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).

Notes:
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)