Feature

No easy walk to health

The end of apartheid has brought much optimism to South Africa, yet the challenge of improving the health of the population is almost overwhelming. Rachael Dixey reports

An invitation to give a paper at a conference in Cape Town in January 1996 provided an opportunity to return after an interval of 16 years. The changes, as everyone knows, have been dramatic, not only the historic elections in 1994 and Mandela’s presidency, but before that also, with a steady trickle of change since the late 1980s. It was still a shock, though, to see the changes first hand, and to hear the liberation struggle song ‘Nkosi sikel iAfrica’ (‘God Bless Africa’) sung as the national anthem.

While there is much to feel optimistic about, the enormity of the reconstruction task did leave me feeling somewhat overwhelmed, if not depressed. The massive informal settlement which has sprung up by Cape Town airport, home to thousands of desperately poor black families, now free to move into the town to seek a living, is the most obvious sign to outsiders that millions of black South Africans live in the most appalling conditions. Such a clear signal that South Africa is both a first and third world country is something that the Olympic Committee organising Cape Town’s bid to host the Games in 2004 want to tackle; some see this as a cynical and cosmetic move, part of the rehabilitation of South Africa into the league of industrialised nations. I didn’t meet many who agreed with the publicity slogan ‘If Cape Town wins, we all win’.

Two further visits, in April and June of this year, have allowed more time to see and to reflect on the challenges facing Mandela’s government. It is difficult to be precise about the health status of South Africans. There is a lack of data on black, Indian and Coloured South Africans — to use the apartheid era classifications. Some of this lack is related to the deficiency of black researchers and the poor resourcing of traditionally black universities. These deficiencies are now beginning to be addressed, and the Medical Research Council (MRC) is playing a lead role. For example, the historically black University of Medunsa has recently been helped to establish a research unit which will focus on diarrhoeal diseases. This is the major cause of death in South African children under five, accounting for up to 28 per cent of deaths in this age group, but it has been a neglected area of research. Its director comments that ‘the unit has enormous importance for the whole of Africa. We will be addressing African problems in an African context, instead of adapting European and American solutions which do not always apply. With the existing collaboration that we have with other African countries, such as Kenya and Zimbabwe, I hope that the unit will become a centre of research for the whole of Africa.’¹This new relationship with the rest of Africa is exciting and should give greater prominence to the health issues faced by the majority in the whole of sub-Saharan Africa.

The combination of first and third world patterns of disease is dramatically shown by the spread of HIV: gay men are affected as in other developed countries, but there is also a massive spread to poor, black communities through heterosexual contact, as in other developing countries. But South Africa’s response is its own: it has an organised lesbian and gay movement, and is the only country in the world to have gay rights in its constitution. Support came from various quarters, including Archbishop Desmond Tutu, who wrote in a submission to the Constitutional Assembly: ‘It would be a sad day for South Africa if any individual or group of law-abiding citizens were to find that the final constitution did not guarantee their fundamental human right to a sexual life, whether heterosexual or homosexual.’²

The opportunity to write a new Constitution has been seized in order to redress many wrongs, not just those perpetrated on racial grounds. This is in contrast to Zimbabwe, where ex-freedom fighter President Mugabe has reputedly said that gays — who are being blamed for the spread of HIV — have ‘no rights at all’. South Africans are concerned when other African governments describe homosexuality as ‘unAfrican’ (as Namibia has recently done), and argue that there cannot be a separate African conception of human rights, which should not vary according to geographic location.³

The South African response to its HIV/AIDS epidemic is as sophisticated as one would expect from a country with a relatively well-resourced healthcare service (compared to other African countries) and an organised gay community. The size of the problem is mind-blowing, however, with an estimated 2 million people infected, and with estimates of caring for people with AIDS taking anything between a third and three-quarters of the healthcare budget by 2005.⁴ The HIV epidemic has also exacerbated the existing problem of TB, which is now the most common opportunistic infection associated with HIV.

Although the diseases associated with low levels of development, such as diarrhoeal disease, infectious diseases and now HIV, clearly need to be tackled, many would argue that the main health problem facing South Africa is violence. In Kwa-Zulu Natal, where rates of violence are high, the Guardian and Mail newspaper noted for June: ‘Although more than 50 people have died in the province so far this month, and intimidation and tension are still widespread, peace monitors report a drop in violence in recent months.’ (Emphasis added). Violence associated with political events such as local elections rests amid a high level of general violence. MRC research shows that in the Western Cape (a relatively ‘peaceful’ area), 60 per cent of ambulance trauma cases were victims of violence, and in a Cape Town tertiary hospital, 42 per cent of beds in the surgical division were occupied by trauma cases.

Alcohol is also a key factor in violence and accidents; MRC research again shows that 75 per cent of adult pedestrian deaths in Cape Town are alcohol related.⁵ The restoration of social stability would free healthcare resources for other problems, but violence has been part of South African life for many decades, and restoring ‘normality’ may be the biggest challenge the Government of National Unity faces.

One attempt to move forward is the Truth and Reconciliation Commission (TRC). South Africa debated which form of reconciliation and/or retribution it wished to follow, and there is still much disagreement among ordinary South Africans about this. Anyway, the TRC sits, with 17 commissioners under the leadership of Archbishop Desmond Tutu. These commissioners have the unenviable task of listening day after day to the testimonies of victims of racial violence and their relatives, and those victims themselves are reliving the horrors of their pasts. I met one commissioner, Dr Maphule Ramashala, in a scheduled meeting in her role as MRC group executive for research capacity development. (She is temporarily seconded to the TRC.) Prior to the main purpose of the meeting, she shared with us some of the burden of her TRC work, having come straight from the hearings. She spoke of how her life had altered, and how others commented on her personality change due to the strain of what she was hearing, and of how she thought that story was the most horrific — until she heard the next one.

It was easy, when relaxing recently in False Bay on a friend’s sailing boat, accompanied by a dozen friends and colleagues of all races — white, black, ‘coloured’ — to imagine that one was truly in the Rainbow Nation, and that everything could eventually be put right. But my small circle of enthusiasts, all working in the health field and committed to the reconstruction process, are clearly not typical. The newspaper on the plane back to the UK carried a story about increasing white interest in emigration; friends spoke of their increased vigilance about personal safety in the face of dramatic crime rates, and of the unspoken but evident racism of neighbours and colleagues. And of course, the shanty towns where the settlers have no water or sanitation and live in tiny shacks are still there too, now it seems almost to the perimeter of the airport itself, a reminder and an embarrassment to the authorities. Meanwhile the wealthy white suburbs of Cape Town appear to be carrying on life as normal.

But an astonishing transformation is taking place. There has truly been a revolution — and it will take time to change the deeply embedded injustices and inequalities which the apartheid regime painstakingly and violently built. South Africa does need appropriate and sensitive outside support, and I would urge everyone to consider how they can make a personal contribution, even if this only means taking time to inform themselves about the transformation facing all South Africans.