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

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: high-risk migration patterns (4)


(photo: traffic in Johannesburg)

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

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

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

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

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

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

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

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

Coming next: Scapegoating “tropical workers”