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)

the barking dogs

As well as posting sections of my research based on my experiences in South Africa I will also begin posting old journal entries from my time there to give some context with pictures included.
———————————————————————————

(photo: Zonkizizwe at sunset.)

15 May 2008
It is never quiet here. There is always noise during the day; children going to school, women cooking and cleaning, traffic outside, chickens, men arguing, whistling, people gambling, anything – and especially Zonke lights up after school and work; loud music, flying kites, children running around everywhere at the center, adults trying to relax with friends and relatives – and then there are the dogs. . . Oh the dogs, how they incessantly bark at night, a constant. If there are no other constants in South Africa, here it is: the dogs, searching and fighting for food scraps among the rubbish.

Today we went to Pretoria, administrative [Executive] capital of SA (South Africa) to take care of errands and pick up the long awaited NPO certificate for VVOCF. There have been many setback and long waits, but now it is here! Now officially an NPO, growing community connections, this center will be ready for the future!

In Pretoria we went to five different banks before finding one since arriving at the airport that does foreign exchange, however we forgot our passports! Is that really needed to change money? At any rate we are going to Alberton tomorrow where we can change money. So we were able to see much of Pretoria by walking from bank to bank. We stopped to have some pizza at a shady looking shop run by a white Afrikaner, but it was terrible (not even comparable to the delicious pizza of Ghana prepared by the Lebanese businesses) – better luck next time I hope.

Yesterday, one of the VVOCF staff members was able to tell us about growing up during apartheid, the political violence, and the divide of peoples in Zonkizizwe. We asked if he knew the toyi-toyi dance march from a song on the computer. He knew it well and remembered from there the divisiveness of the ANC, which was majority Xhosa people and the IFP, dominated by Zulu people. The violence between the groups was very intense in Zonke until just after 1996. He had to be dressed as a girl so that he would not be killed. Boys were expected to fight or be killed. He guessed that most of his family would be dead if the violence had not stopped when it did.

A few days ago ‘China’ (nickname of a volunteer at the center) was able to give me a near complete rundown of South African history in brief, he loves history and historic name dropping, but we have heard little of his own experiences. It is crazy to think about how those living now in Zonke around my age lived through apartheid and witnessed such terrible acts of violence.

I also learned more about the extent of HIV/AIDS in Zonke. The intern coordinator reminded us that the statistic of students at MSU that have an STD is 1 in 4. We are only lucky that HIV/AIDS did not enter the mainstream population. Here in Zonke 1 in 4 people is HIV positive. The family at the center is more so affected by HIV/AIDS and now they work to care for children who come the center affected by the virus. There is still a very high stigma and a terribly ineffective ARV program. Many people refuse to get tested or even consider the idea. Each child at the center either has HIV (we went to the Natal-Spruit Hospital to get ARVs for one), has lost parents from AIDS or related illnesses or has not yet been tested to know. There are many who should be tested, but are not. My pen pal’s family has stopped coming to the center because they are so sick – I can only assume related to HIV/AIDS. We discovered the “2006-2008 Response Plan for HIV/AIDS” of the South African government. It has come to my attention that much of what the government does here looks good on paper and on banners, but there is a huge, massive disconnect in implementation.

I have learned so much Zulu tonight. Again, I have been able to naturally pick up a language. I think this stems from my childhood of sound/ noise making. I can make a loud clicking sound from the roof of my mouth that no one I know can replicate. It turns out to be how you make one of the clicking syllables of Zulu.

First entry in this series:
what are we to do when our children are dying?

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: denial is the first step (7)


(photo: downtown Zonkizizwe, South Africa)

Since the early 1990s, Mbeki had turned his back on scientific evidence linking HIV as the cause of AIDS. Mbeki’s stance on the cause of AIDS is the largest contributing factor in the South African government’s failure to scale-up treatment. In 2000, Mbeki called together a group of scientists including a group of ‘dissident scientists’ to discuss the cause of AIDS (55). Later that year at the International AIDS Conference in Durban, he spoke publicly rejecting the accepted science that HIV causes AIDS and instead focused on the need to alleviate poverty in Africa as a way to combat AIDS (56). He said the cause was poverty, bad nourishment, and general ill health while also noting that more Western medicine was not what Africa needed (57).

Since his public statements, Mbeki and the South African government have been hit by a backlash of criticism from the international community and Mbeki has remained silent on the topic. The year 2000 was the same year that the Department of Health launched a five-year plan to combat HIV/AIDS. However, Mbeki’s statement and the lack of strong governmental support led to much “foot-dragging” (58). Mbeki had turned down grants, funding, and free medicines to scale-up the treatment program as a result of his denial. Now a recent Harvard study has placed impact numbers with Mbeki’s denial claims. The authors of the study estimate that more than 330,000 people died unnecessarily in South Africa and that 35,000 babies could have been protected from HIV-infection as a direct result of Mbeki’s HIV/AIDS policy and denial (59).

In 2002, with international pressure growing, the South African High Court ordered that nevirapine, which combats the spread of HIV from mother-to-child, be made available (60). Sadly despite offers of free and cheap antiretrovirals (ARVs), the South African government was hesitant to offer the medicines and only distributed in two test sites. In 2003, the government approved a plan to make antiretrovirals publicly available and by 2005 there was at least one service location for AIDS-related illness in each of the 53 districts (61). However the program did not reach enough people and the HIV prevalence rate among pregnant women was recorded at 30.2%, a steady increase since 1990 (62). The treatment program was beyond inadequate.

The case for HIV/AIDS treatment and prevention suffered another blow at the hands of South African government leadership in 2006. Former Deputy President Jacob Zuma went on trial for the rape of an HIV positive woman and claimed that having taken a shower afterwards protected him from HIV transmission (63). This only heightened international outrage and pressure on South Africa’s HIV treatment programs. At the 2006 International AIDS Conference in Toronto, UN Special Envoy on HIV/AIDS Stephen Lewis, called the South African government “obtuse and negligent” (64). By the end of the year the government had announced that it was drafting a framework to tackle AIDS and pledged to increase public access to antiretrovirals (65).

Mbeki was ousted from his ANC leadership position in September of 2008 and the interim president appointed Barbara Hogan as the Health Minister. Many saw this as a major turning point in South Africa’s HIV/AIDS policy, especially as the government is working to get antiretrovirals to as many people as possible. Unfortunately, Zuma is set to win the upcoming presidential election and has not made any apology for his false statement on HIV prevention.

Notes:
55. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
56. Boseley, Sarah. “Mbeki Aids denial ‘caused 300,000 deaths.” Guardian News UK. 26 November 2008.
http://www.guardian.co.uk/world/2008/nov/26/aids-south-africa
57. Ibid.
58. Ibid.
59. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
60. Ibid.
61. Ibid.
62. Ibid.
63. Ibid.
64. Ibid.
65. Ibid.

Coming next: What happened to Reconstruction and Development?

Access all entries in this series: Index

why there is no doctor: hiv/aids in south africa (6)


(photo: Local staff and interns at VVOCF in Zonkizizwe)

The first case of AIDS was diagnosed in South Africa in 1982 among the gay community (47). The apartheid government took minimal actions in response to the virus’ coming. This could be in part due to the violent political turmoil as well as discrimination against the gay community. In 1986 the AIDS Advisory Group was established to respond to the epidemic (48), but nothing of significance can be associated with the Group. HIV/AIDS quickly spread to the heterosexual populations and by 1990 antenatal tests showed that up to 120,000 people were living with HIV/AIDS (49).

It wasn’t until after apartheid laws were repealed that a government response was crafted. In 1992, the same year that a referendum was held on apartheid policies, Nelson Mandela addressed the National AIDS Convention of South Africa (NACOSA), which was to develop a national strategy to cope with the epidemic (50). The National Health Department reported in 1993 that HIV rates had increased by 60% in the last two years and this number was expected to double in the next year (51). This was the groundwork that apartheid had lain for the rapid spread of HIV/AIDS in the next seven years.

The period from 1993-2003 marked the freedom of mobility of more people, which was evidenced by the increase in internal labor migration patterns as well as a severe increase in HIV prevalence. Seedat’s book is rightly named “crippling a nation” because when the government was stabilized and working to develop a response to the HIV/AIDS crisis it was already too late. The HIV/AIDS crisis was poised to take its toll from the detrimental apartheid policies that limited health services, medical training, forced mass migrations of people, and established environments prone to high-risk behaviors.

During this time period, a number of government actions were meant to stem the increasing prevalence rates. In 1994, the Ministry of Health adopted its first national AIDS strategy based off of NACOSA’s work (52). Unfortunately the plan was considered inadequate, poorly planned, and disorganized. In 1995, the International Conference for People Living with HIV and AIDS was held in South Africa and then Deputy President Thabo Mbeki acknowledged the seriousness of the epidemic (53). That same year the Ministry of Health announced that 850,000 people (2.1% of the population) were living with HIV (54). In 1998, The Treatment Action Campaign (TAC) launched partly in response to the failures of the South African government to provide adequate resources to people affected by the crisis.

Notes:
47. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
48. Ibid.
49. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
50. Ibid.
51. Ibid.
52. Ibid.
53. “HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
http://www.avert.org/aidssouthafrica.htm
54. Ibid.

Coming next: Denial is the First Step

why there is no doctor: scapegoating "tropical workers" (5)


(photo: At the Lesotho border)

As early as 1913, international migrant workers have been brought into South Africa to fill out the labor supply, especially in the mines (42). These workers were called “tropical workers” because they came from countries like Malawi and Mozambique that had more tropical climates and diseases. The mines faced a labor shortage starting in the 1930s and by 1934 over 2,000 “tropical workers” had been brought in on an experimental basis (43). The South African government had difficulties with “tropical workers” bringing in disease and spreading it before 1930 and so there was a certain stigma associated with international laborers. Early tropical workers were blamed with bringing tuberculosis and spreading it within the mines. However, working conditions in the mines and biological susceptibility were not taken into account. Regardless, tropical workers were associated with tuberculosis and that reasoning led the South African government to be wary about reintroducing tropical workers in 1934. The success of these workers and lack of increased disease inspired the South African government to lift the ban on hiring workers above the 22nd parallel in 1937 (44). With the lift of the ban, the numbers of tropical and international migrant workers increased significantly.

Tropical workers entering South Africa numbered 40,000 by 1948, the start of apartheid (45). Between 1988 and 1992, around 13,000 tropical migrant workers from Malawi were repatriated because over a two year period 200 of them had tested positive for HIV (46). The tropical worker who was scapegoated for the spread of tuberculosis was now labeled as the culprit for the spread of HIV to South Africa. Later it was understood that the South African mining industry was working on stabilizing its mining labor supply and HIV/AIDS was used as a way to clear out international migrant workers.

Nevertheless, the increase in numbers of tropical or international migrant workers to South Africa expanded the area where high-risk behavior related to HIV/AIDS could have an impact. The international migrant worker movements from the mines to their home countries and any locations in between likely contributed to the increased prevalence of HIV similar to studies that have proven the same for internal labor migrations. The reach of apartheid’s policies stretched beyond South Africa’s borders and contributed to the deepening of the HIV/AIDS crisis within the country as well as the southern African region.

Notes:
42. Packard, Randall. White Plague, Black Labor: Tuberculosis and the political economy of health and disease in South Africa. University of California Press. 1989, 229.
43. Ibid, 230.
44. Ibid.
45. Ibid.
46. Chirwa, Wiseman Chijere. “Aliens and AIDS in Southern Africa: The Malawi-South Africa Debate.” The Royal African Society. African Affairs 97:53-79, 1998.

Coming next: HIV/AIDS in South Africa

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”

why there is no doctor: cleaning black spots off of a white land? (3)

Forcing people to live in separate racial areas of South Africa was the driving piece of apartheid’s “separate development” policy. The pockets of the Black population that lived among and near White city centers were called “Black spots” and the government actively worked to clean them out. During the 1950s and 1960s the first “forced removals” occurred after the passing of the Group Areas Act established these racial areas. More than 860,000 people were forcibly removed as a way to divide and control racially separate communities as resistance grew towards apartheid policies (23). Sophiatown of Johannesburg and District Six of Cape Town are just two examples of vibrant multi-racial communities that were destroyed by South African government bulldozers once they were deemed “White” areas (24).

Between 1960 and 1983, over 3.5 million South Africans were forcibly removed (25) and until 1984 another 1.7 million were under threat of removal (26). Blacks were removed to distant segregated townships, sometimes 30 kilometers away from places of employment in the central towns and cities (27). As a result ‘informal settlements’ formed as shantytowns closer to places of work, but many were destroyed. Farm laborers were also displaced by mechanized agricultural. As a result farm laborers were segregated into desperately poor and overcrowded rural areas and were not permitted to travel to towns to find new jobs (28).

Removals represented the “essential tool” for apartheid to work. Creation of the Bantustans stripped Black South Africans of all legal rights in South Africa and their welfare was no longer the problem of the South African government. Hundreds of thousands of other Blacks were dispossessed of land and homes where they had lived for generations in these “Black spots” now designated as part of “White” South Africa. Entire townships were destroyed and their residents removed to just inside the borders of Bantustans where they now faced long commutes to their jobs (29).

In other words, removal of people is not simply a physical act; it is part of a process and a strategy that seeks to push increasing numbers of South Africa’s people into ever more remote and inhospitable areas where, broken and fragmented by the experience of removal and all that it means, people are left to exist under conditions of increasing apathy and powerlessness (30).

One UN report on the forced removals noted, “that the demolition was executed in total disregard for the health and well-being of every individual concerned, in the most inhumane manner” (31). The forced removals created poverty situations where the infertile Bantustan lands had to sustain an overcrowded population. This policy of removal, coupled with the apartheid policies on health services in Bantustans and for Black medical training, shows the dire health effects on the Black population. These terrible health conditions later translate into environments easily susceptible to the spread of HIV/AIDS.

Notes:
23. “Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
http://www.overcomingapartheid.msu.edu/multimedia.php?id=5
24. Ibid.
25. “Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
http://www.overcomingapartheid.msu.edu/multimedia.php?id=5
26. “The uprooting of millions, forced removals.” For their Triumphs’ and Tears. ANC, 1983.
http://www.anc.org.za/books/triumphs_part1.html#3back1
27. “Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
http://www.overcomingapartheid.msu.edu/multimedia.php?id=5
28. Ibid.
29. Ibid.
30. J Yawitch, Betterment. “The myth of homeland agriculture” SAIRR: Johannesburg, 1981, p.86.
31. ‘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.

Coming next: High-Risk Migration Patterns

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?