Public Health -- (nerd alert)

“The realities of apartheid are not to be found in segregated parks and separate lavatories, but in infant mortality rates, cholera epidemics and TB statistics.” ~Cedric de Beer

In September, I started a UW Public Health distance course on the internet thru the extended degree program, moving forward toward my eventual goal of a Masters in Public Health. I absolutely love chewing on the questions that arise out of the intersection of socio-political-economic issues with health and thinking about how we can use health as a point of leverage for creating a more equitable society. The class I'm taking is on International Health, and we've each had to select a country we've focused on for the course assignments. Obviously, South Africa was a pretty logical choice for me. For my final project, I'm looking at the disparity in infant mortality in South Africa - black babies still are 4 times more likely to die in the first year of life than their white baby counterparts, and largely due to the legacy of economic disparity left by apartheid, and the new government's inefficient response, cowtowing to the dominant global macroeconomic doctrines of fiscal restraint on public & social services while emphasizing foreign investment and privatisation. [Of course, fiscal restraint is very loosely interpreted by the government, which spent over 40 billion Rand (about 4 billion USD) on an arms deal in the late 1990s that was never approved by the Parliament, and which would have funded the building of houses for all but 300,000 of the millions waiting for homes to be built - more on this in my next post].

Below is a concept diagram I made of the influences on infant mortality here in South Africa. Above the blue dotted line are the social/structural influences on mortality, while below are individual behavioral choices, etc.

For those who are interested, I'm also including the situational analysis I wrote of the historical context of current health issues in South Africa, below the image.

[click on image to enlarge... but it's still pretty convoluted. MTCT = Maternal to Child Transmission, and refers to HIV]

Historical Context of Health in South Africa

In 1994, the world widely celebrated the end of Apartheid rule in South Africa. While genocide raged in Rwanda, the global public image of Africa focused on Nelson Mandela and the ascension to power of the long-exiled African National Congress (ANC) – the first black party to rule after decades of harsh oppression by the white minority. And with due cause; the depth to which “race” -based discrimination and violence permeated South African society is horrific, astonishing, and worthy of close attention and analysis. More than any single other contextual factor, the legacy of Apartheid unavoidably informs any analysis - whether contemporary or historical - of South and Southern African health.

Though the official system of apartheid (“apartness” in Afrikaans) wasn’t formalized until the Afrikaner National Party took power in 1948, discrimination and violence against the indigenous African population has characterized the region’s history since Europeans first arrived on the African continent. Afrikaners – settlers of primarily Dutch descent – dominated the area until the British arrived in the 19th century and began competing for control of the economic and human resources of the regions. In 1910, after years of bitter conflict, the two white settler groups agreed to unite to form the Union of South Africa, and racial discrimination was swiftly institutionalized by legislation in 1913 and 1936 that effectively prohibited Africans from owning 86 percent of the country’s land. The remaining 14 percent was established as “native reserves.”

The reality of separate and unequal health services is well documented and broadly characteristic not only of South Africa, but also of the entire Southern Africa region that had been colonized by European nations. A few highlighted health decisions illuminate the general dynamics of the political economy of health in South Africa during the apartheid era:
• 1938 – Department of Public Health decides “to establish a completely segregated health
service for Africans” to be “jointly administer[ed] with the department of Native Affairs.”
• 1963 – Bantu Administration Department takes over provision of health services in the
"Bantustans", or Bantu Homelands.
• 1970s and 80s – ten separate health authority and service delivery structures are erected
in the Bantustans. During this same period, greater degrees of social engineering to control
black South African labor yield the (forced) removal of as many as 3.5 million Africans from
the urban areas to the Bantustans, where “their health was no longer the concern of the
apartheid state.”
• 1986 – “Pass laws” repealed. Squatter camps proliferate on urban peripheries,
characterized by make-shift housing, unsafe water, lack of sanitation.

Statistics from the apartheid era, though poorly kept and often racially biased , point to major differences in life expectancy for blacks versus whites, as well as in maternal and infant mortality. Africans “suffered the brunt of malnutrition, tuberculosis, and venereal diseases.” So when the ANC ascended to power in 1994, what did they inherit? In the words of their National Health Plan, “a [health] system which is highly fragmented, biased towards curative care and the private sector, inefficient and inequitable. [...] There has been little or no emphasis on health and its achievement and maintenance, but there has been great emphasis on medical care.”
The infrastructural inadequacies not just of the health system, but also of other indicators of human development such as education, housing, sanitation, etc, have significant repercussions on the ability to effectively combat South Africa’s most significant health problems. Many of the deeply entrenched health inequities that existed during apartheid across different populations prevail today. Particularly with respect to infectious disease (HIV/AIDS being the most infamous, as well as the number one cause of death in South Africa ) the disease burden still falls most heavily by the poor, non-white majority.

However, the so-called “democratic transition” has brought significant changes in health policy which have greater potential to tackle the biggest health issues. The ANC, inspired by the ideals of Alma Ata, named Primary Health Care as “the underlying philosophy for restructuring the health system.” The Department of Health’s 1996 “White Paper for the Transformation of the Health System” further takes up the call to forge ahead with PHC, and openly acknowledges that it anticipates such a policy “will require continuous defence in the political arena” as resource redistribution “begins to bite.” The South African Constitution is arguably the most progressive in the world as far as human rights are concerned, and gives all citizens “the right to have access to health care services, including reproductive health care”. And though the South African government has been widely criticized for its grossly inadequate and ‘denialist’ response to the HIV/AIDS crisis, recent turnover of government in September 2008 brought the appointment of a new Minister of Health, and the government has finally issued a formal recognition of the causal link between HIV and AIDS. The political will to address South Africa’s health problems and inequities is certainly present, at least in the public rhetoric. It still remains to be seen whether the country will be able to mobilize the necessary resources to keep South Africa moving toward a comprehensive primary health care approach and to promote overall systems strengthening.