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.

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?

the greatest youth movement in history: mandela’s disciples

The beginning of arguable the greatest youth activism movement all began with twelve. Twelve young boys inspired by the ideas of Nelson Mandela left on a journey that would change their lives and so many others for years to come. This is the story of how Nelson Mandela’s movement began. Social movements often have symbolic leaders, but they are really comprised of thousands, thousands and thousands of local leaders and supporters. The first of these unsung heroes came from Bloemfontein. Most people have never heard of Bloemfontein, but they have heard of Soweto or Johannesburg or Cape Town. Bloemfontein is where the twelve came from.

After recently seeing the documentary ‘The Twelve Disciples of Mandela’ I began to learn about the real history of the anti-apartheid movement and its deep roots in youth activism. “Less well known is the experience of a generation of young men who left their country clandestinely to build the African National Congress (ANC) and spread its liberation message in places as far-flung as Dar Es Salaam, Belgrade, London, Havana and New York. Left to their own devices, hunted by the Afrikaner regime (and considered terrorists by the U.S. government), lacking legal status and often socially isolated, these foot soldiers of the anti-apartheid cause forged ahead as one of the century’s great freedom struggles stretched into 30 years of brutal conflict.” – this is the brief synopsis that is given about the compelling documentary. The film outlines the struggles for independence all across the continent and tells of how this group of twelve students blazed the trail for so many freedom fighters starting in the 1960s.

Beginning in 1952 the anti-apartheid campaign was defined as the ANC staged its first act of civil disobedience against the pass laws. In 1958 the Bantu education policy was imposed, where basically black South Africans were taught nothing of value, except how to serve their white counterparts. This is the where the journey of the twelve began. The burned their pass cards in response to the Bantu education law and set out on what would be a quest that would alter their lives forever. With the passage of the Bantu education, riots sprung up in Sharpville in 1960, where many innocents were killed and the concept of human dignity was questioned. As quoted from one interview, “[…] whether educated or uneducated, all realized they had to rise up against the system.”

The twelve began their journey from a jump point in Botswana, where many left and were deported back to start again. They had a desire to reach the newly independent Ghana. My class, ‘Africa and the World’ watched a documentary today on the rise of nationalism in Africa and how Ghana represented a great hope for the rest of the continent. Ghana’s independence raised hope everywhere especially in South Africa. The twelve sought education to build the movement and some made it to Tanganyika (before Tanzania was formed) through Sudan, where they met Mandela. They began studies in the capitol, Dar es Salaam. Others traveled to Cuba to be trained militarily and were mobilized for the October crisis. Around 1967, some members of the twelve made it to the US to continue studies in journalism, where the ANC was considered a communist, terrorist group. At Lincoln and Temple University members of the twelve grew in knowledge to fight apartheid.

1976 – the Soweto student marches and massacre, “We still have a long way to go.” This one event led to the uprising of young people all over the world in a hope for peaceful change. David Basilson stated in his documentary on the rise of nationalism that, “Freedom will bring peace.”

The ‘Twelve Disciples of Mandela’ documentary was extremely compelling and educational with its history aspects. The story of this youth movement is told by a son of one of the twelve. Thomas Allen Harris tells the story of his stepfather, Benjamin Pule Leinaeng, who met his mother in the Bronx while studying journalism. He always remembered his stepfather in his depression and drinking and often rebelled against his authority, but nothing prepared Harris for his father’s funeral in South Africa, which was the inspiration for the documentary. “In Bloemfontein, however, Harris discovered an image of Lee dramatically different from that of the moody, foreign stepfather. He was especially affected by the recollections of two of Lee’s associates, Moses Medupe (Dups) and Mochubela Seekoe (Wesi), who were among the group of 12 students, including Lee, who left Bloemfontein in 1960. Dups and Wesi spoke fondly of Lee as a young man and described what life was like for blacks in Bloemfontein under apartheid and during the long years of exile. Family and friends who gathered at the funeral to eulogize Lee spoke of a brave and cheerful youth setting out to battle apartheid, a comrade who never wavered in that struggle even as it wore him down. They all told stories of the ANC’s beginnings in Bloemfontein, in the heart of Afrikaner country, and of the terrible repressions that drove the organization underground and to establishing centers of resistance outside the country.”

This documentary runs through all these stories and more. Interviews with original members of the twelve and those who supported them inspires, recreations of actions taken by the twelve captivate, and the history of a young generation inspired to fight oppression motivates the mind to take action even today. Youth trapped in an oppressive world were able to battle the odds and pave the way for so many others to make a difference for South Africa, what is holding us back now?