Holding state healthcare discrimination accountable

A study by organisations representing people living with HIV exposes deep-rooted prejudice against ‘key populations’ by healthcare workers at South Africa’s state facilities.

It has been more than five years since Melody Seherrie last visited her local clinic in the Northern Cape town of Petrusville, but the 30-year-old transgender woman still recalls what “a very traumatic experience” it was trying to access health care at the state facility. 

“It’s very daunting,” she says. “Very difficult. I would get deadnamed and misgendered. And every single time that happens, I feel out of place. I feel publicly outed and humiliated. But I didn’t have the luxury of finances or access to private health care.” 

Seherrie’s experiences are not unique. A recent report shines a light on the discrimination key populations across South Africa face when trying to access health care at public health facilities. Key populations (KPs) are defined by the World Health Organization as “groups who, due to specific higher-risk behaviours, are at increased risk of HIV [and] also often have legal and social issues related to their behaviours that increase their vulnerability to HIV”.

The report was put together by Ritshidze, a body made up of organisations representing people living with HIV. These include the Treatment Action Campaign, the National Association of People Living with HIV, the Positive Action Campaign, the Positive Women’s Network and the South African Network of Religious Leaders Living with and affected by HIV/Aids.

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It was compiled after surveying close to 6 000 people in key population groups and in 18 districts across South Africa. Key populations surveyed for the report were sex workers, transgender people, men who have sex with men and people who use drugs. 

The report found that while the overwhelming majority of key populations accessed state facilities – 86% of men who have sex with men, 85% of people who use drugs, 76% of sex workers and 75% of trans people – they were often “treated poorly” by clinic staff.

“What we found highlighted the extent of the crisis that sees key populations ridiculed, abused and even chased away from clinics,” the report noted. “During the data collection, many told us they had been refused access to services at the clinic for being a KP – a complete violation of the constitutional right to access health services. People using drugs reported being turned away for being ‘too dirty’ … Many queer and trans people spoke of feeling humiliated during medical consultations because more and more healthcare workers are brought in to look, mock or judge them.” 

Forced to stay away

The report also found that most people who had stopped going to the clinic confirmed it was because of poor treatment, a fear of exposure and the lack of privacy and safety. 

Treatment Action Campaign’s Sibongile Tshabalala says she is “not surprised” by the study’s findings. 

“Because our healthcare system, the way it is, doesn’t cater for all kinds of people, especially key populations,” says Tshabalala. “The nurses are not sensitised and are always bringing their [religious] beliefs to work. Like with the issue of safe abortion – where women are discriminated [against] just because they want to terminate – this is the same situation that we are facing. [But] when it comes to key populations, it’s worse [because] from the gate until the consulting room with a nurse or a doctor, they are discriminated against. ” 

The study found that 28% of sex workers thought their privacy was not well respected at facilities, while 45% of trans people said unfriendly service was the reason they do not access healthcare at all.

10 June 2020: Dulcy Rakumakoe, a medical doctor committed to helping marginalised people access healthcare, photographed in Alexandra, Johannesburg. (Photograph by Madelene Cronjé)

It also found that the overwhelming majority of those surveyed – 87% of men who have sex with men, 81% of people who use drugs, 74% of sex workers and 83% of trans people – were “not aware” of drop-in centres, such as the WITS Reproductive Health and HIV Institute, which are dedicated to providing care to trans people and sex workers. But those who are aware of drop-in centres “often live too far away from these centres and cannot afford the cost of transport to access them”. 

Dulcy Rakumakoe is a Johannesburg-based general practitioner and executive director of Queerwell, which ​​provides mental-health care and support to the queer community. Rakumakoe says she regularly treats patients who, despite being unemployed, would “rather try their best to raise money” to access private healthcare “because of that discrimination that they go through” in state facilities. 

“I’ve seen a patient who had lesions for a long time and they were very septic by the time they presented to me. They said they wanted to rather wait until they had money before accessing care – even if it took weeks – because of the negative language that they knew they would experience in a public setting. I’ve had a patient, a trans woman, who was raped and refused … to go to a public hospital because they know they were not gonna be treated well.” 

Offensive discrimination

For Rakumakoe, part of the problem lies in discrimination against key populations not being considered a serious offence. 

“We don’t treat discrimination against the LGBTI the same way we treat discrimination against other groups. For instance, someone who’s openly racist will get an immediate dismissal in government. But [when] someone is openly homophobic and transphobic, people will giggle or whatever. So I think that in terms of HR [human resources] policies, people should know that those are level-five offences. And they would get immediately dismissed for that. So that people don’t use their own personal prejudices to justify treating people in a terrible way.” 

Speaking during the launch of the report, deputy health minister Sibongiseni Dhlomo acknowledged the need to sensitise health care workers to the needs of those in key populations and pledged to meet for further discussions around this with non-governmental groups and affected parties.

Tshabalala added that although no dates have been set, “every space we get, every chance we get, we will engage” the government on this issue. 

Now employed and living in Cape Town, Seherrie is able to afford private healthcare, something she laughingly describes as “moonlight and roses”. 

Advising those who have little choice but to rely on public health facilities that discriminate against them, Seherrie says: “Keep knocking on those closed doors. And if those doors don’t want to open, there are a bunch of organisations out there that can link you up with service providers that are actually able to give you what you need.”

Rakumakoe takes a harder line. “We need to take up that culture of reporting,” she says. “Let’s not watch wrong things being done. Because our Constitution is very clear on non-discrimination. If you are discriminated against in a hospital, find out who the hospital manager is and report it. And if they don’t do anything, we have the power of social media as well. We need to expose these institutions so that people get used to knowing that this is wrong and not acceptable.”

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