South Africa: The coming storm in health and state

Government response to past epidemics has been ambiguous and piecemeal changes have not substantially changed health system inequality. Covid-19 will put extreme pressure on this system.


“Disasters are political. Disease is also political. Class determines who has medical aid and who does not, who has access to water, sanitation and safe means for heating and lighting and who does not.” – Shack dwellers’ movement Abahlali baseMjondolo, 22 March 2020

With a declaration of a state of disaster by President Ramaphosa followed by lockdown on 26 March of all non-essential movement, the South Africa government acknowledged the threat and force of the pandemic. With a weakened state and an economy already in recession, working people are already grappling with strategies for personal and family survival. The question is how effective government measures will be to restrain and control the onrush of Covid-19 and provide for human survival. In the post-pandemic period there will be demands for redress for the stunted conditions of life under capitalism.

Covid-19 initially appeared in the enclaves of prosperity of the well-travelled elite. It seemed foreign to the African context. For some weeks South Africa was frozen in time as infection raged in Italy and Iran. It appeared to be somewhat similar to the rest of Africa with cases in the units rather than hundreds. All this is now changing rapidly.

This phenomenon of sick rich appeared to contradict the terms of inequality of black and white, poor and rich. The early numbers were carefully monitored and those tested positive were isolated. Now, however, the new cases are unrelated to foreign contact as the virus finds a place within wider SA society. Covid-19 infections have been spreading unpredictably and rapidly from the enclaves of prosperity to the population of 56 million which has a particularly vulnerable health profile. Potentially the pandemic could overwhelm the deeply unequal, poorly administered and fragile health system.

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Although the African National Congress (ANC), the dominant liberation movement, has ruled for 25 years, post-apartheid reforms have not included a fully funded national health service. Instead there have been piecemeal changes which have not substantially changed health system inequality. Indeed, greater income inequality – particularly rising incomes among the upper 10% – has encouraged growth of the private health sector in which the rising black elite participate.

In the recent period there has been little concern for conditions in public hospitals despite many exposés of mismanagement in hospitals and, in some provinces, deep corruption and mismanagement of health systems. Despite these necessary reservations, there are public hospitals and clinics which are competently managed and are committed to meeting the rising burden of disease. In the midst of demanding conditions, dedicated health workers are undertaking competent and caring work under, often, very difficult conditions.

The state of the nation’s health

South Africa is no stranger to pandemics; its people suffered great losses in the 1918 flu epidemic and a hundred years later has the largest concentration of HIV positive people in the world as well as high levels of tuberculosis. The country also had a large-scale cholera epidemic in 2000-2001 which was shorter lived but extensive in rural areas. The continuing HIV pandemic, tuberculosis and the year-long cholera epidemic severely tested the post-apartheid health system. There is some advantage: it has also helped prepare for the mass testing and emergency interventions now required.

The epidemics of HIV and tuberculosis overlay each other, infecting the same vulnerable communities and individuals. South Africa has the biggest HIV epidemic in the world, with 7.7 million people living with HIV and half of those HIV positive also suffer from tuberculosis. HIV infection is increasing at a rate of 4 285/week and tuberculosis at 8 654/week. These diseases have peaked but prevalence is not declining; these epidemics are kept at bay rather than declining. Massive interventions are at this stage partly effective, not decisive, in reducing these debilitating epidemics. Despite this, the infrastructure of testing and treatment is a resource for responding to Covid-19.

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Government response to past epidemics has been ambiguous. The rapid advance of HIV infection in the mid-1990s was denied by then president Thabo Mbeki. Indeed, he vigorously argued that HIV virus did not exist and opposed ARVs (antiretroviral drugs) being used in hospitals. The delayed intervention resulted in life expectancy plunging from 63 in 1994 to 53 years in 2004 and is only now rising beyond the levels of the early 1990s.

His labeling of ARVs as “poisonous” clouded treatment with controversy and racial innuendo. Although South Africa has alarming levels of infection, visiting health specialists feel there is no sense of crisis and urgency in lowering the prevalence of people living with HIV. The mass treatment programmes for HIV and TB have been a priority in spending leaving an infrastructure in place but they leave fewer additional resources for this pandemic.

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These epidemics have drawn heavily on available funds for investment in health facilities. It is estimated that the allocation to the health department for HIV/Aids has amounted to R537 billion ($36 billion) over the period since 2004. This spending is focused on HIV and TB prevention, care, and treatment interventions. Since 2004, PEPFAR (US government fund) has contributed over $8 billion to support this initiative. While SA now has the largest treatment programme in the world, HIV appears to be accepted as a chronic disease along with obesity, hypertension, diabetes and cardiovascular disease. It has the highest levels of obesity in sub-Saharan Africa.

These destructive combinations have brought the unwelcome description of South Africa as the unhealthiest society in the world. This heavy burden of disease rests on the black working class which suffers high unemployment, poor housing and violent crime.

Public decline, private expansion

While health services are at the centre for effective treatment, they are fractured by staggering inequality. In the post-apartheid era, class allocation of resources has accelerated private health infrastructure. As access to the full range of public health services opened to all citizens, public funding faltered and private hospitals were built at an increasing rate. Health insurance companies such as Discovery based in South Africa grew rapidly and now range internationally.

As funding of the public sector has stalled, health has become a private and personal vocation supported by expensive medical insurance. The private healthcare system it supports opens access to private hospitals, gyms, doctors and other health professionals. This meets some 16% of the population’s needs and the overwhelming majority of health personnel follow this expenditure: about 79% of doctors work in the private sector. All medical training takes place in the public sector but 70% of doctors go into the private sector.

Such huge dynamic disproportions distort the health services available to the majority: by comparison the public health sector has to meet the needs of 84% of the population with 21% of the doctors! There are radical divisions between the private urban and public rural hospitals; just under half the population live in rural areas, but only 3% of newly qualified doctors work there.

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Improvement of the health of the majority has depended largely on the collective; public housing, water and sanitation services rather than drugs, even though these have been critically important in treatment of HIV. Despite this the considerable post-apartheid advance in housing and social services has yet to be realised in improved health and life expectancy. Where services have faltered, however, the effects are clear. The disconnection to safe drinking water to rural communities resulting from neoliberal cost recovery in the 1990s led directly to the outbreak of the cholera epidemic of 2000-2001.

Health services show the blunt edge of reform; the new elite does not use public health facilities and has little concern for the actual conditions in clinics, hospitals and in the small private practices orientated to poor people. National budgets have consistently allocated less than the targeted 15% of the budget to health services. A regime of budgetary austerity (accompanied by profligacy and corruption in state enterprises) has further accentuated the public/private divide as the private sector rises in comparison.

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The latest available statistics are there are 407 public hospitals (with about 158 000 beds) and 203 private hospitals. The provincial health departments directly manage the larger regional hospitals. Smaller hospitals and primary care clinics are managed at district level. There are over 401 000 practicing nurses in South Africa; their number has been limited by the closing of nursing colleges during the late 1990s in implementing the GEAR neoliberal programme. Unfortunately, the rising demand is not met (even in conditions of mass unemployment) as there is a high drop-out rate of candidates in training.

Large public hospitals will be in focus as the pandemic grips South Africa. The Chris Hani Baragwanath Hospital is the third-largest hospital in the world and it is located to serve concentration of population in Johannesburg. There have been critical reports on its management but given its location to the centre of population in Johannesburg it will be the key hospital in the defence against Covid-19. High levels of wastage, theft and corruption are reported in the public hospitals.

The immediate focus will be on the ICUs. Although there are offers of cooperation from private hospitals, how will the 4 960 critical care beds in the private sector in 2017, with 60% availability, be jointly coordinated with the fewer 2 240 critical care beds in the state sector, with 20% availability. How can this resource be equitably used when there are conflicting claims from members of medical insurance and from the majority of desperately ill non-members?

Feedback loop and prognosis

The shack settlements are at one pole of interventions to contain Covid-19, at the other are the enclaves of well-travelled. Surveillance and intervention has initially focused on the latter. In other countries’ epidemics, such poles of poverty and wealth have also been linked by feedback loops as domestic workers from poor communities work daily in the houses of the elite and return home at night. Local transmission of disease operates in both directions; studies of flu in India show such loops from the slum areas to the cities. It is hardly possible for the shack settlements of South Africa not to become more infected than privileged areas over time.

South Africa has a highly mobile population; the historically ingrained cheap labour system involving migration between the urban and rural contexts has drawn both closer together. During a period of crisis migrants return to rural areas potentially carrying disease.

Infections have risen relatively slowly within the enclaves of the privileged until local infections have risen sharply. From the first positive registered on 5 March there are now over 1 000 at the time of writing (26 March); the exponential increase has undoubtedly spurred the lockdown. [There were 1 655 cases on 6 April 2020.]

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There does not appear to have been any systematic modelling of disease taking South African social conditions into account. It is possible that the high temperatures may retard the advance of Covid-19. Presently its momentum appears exponential and not determined by temperature conditions. The difficulty is South Africa’s flu season only starts in April when it gets colder. It is unsure whether Covid-19 is a seasonal disease but that might not offer comfort.

Somewhat counterintuitively, most experts think those on antiretroviral therapy whose viral loads are suppressed will be more resilient than those who are not on this therapy. The ARVs may make the body more resistant to infection and the spread of the virus if HIV medications are maintained without disruption. Such defence could account for 54% of those living with HIV, taking treatment and who have achieved viral suppression.

This leaves 46% or 3.5 million of those living with HIV who are untreated with a potentially high viral load and low levels of immunity, a group which will be particularly vulnerable. Most of this group are the “missing men” who know they are HIV positive but decline to take the free ARV treatment. They may continue to be sexually active and could have a high viral load and infect others. Since partners and networks of infection are not known as this is not disclosed there are gaps in treatment and continuing infection. The millions involved in refusing treatment give some dimension to a problem which is not found in other African countries and is unique to South Africa.

The mantra of the WHO is currently “test, test, test” combined with a strategy of social distancing and hand washing. The procedure is that those tested positive are required to cooperate in contact tracing; those named are also then quarantined. Containment would not be possible without such intrusive questioning. Such a strategy has not succeeded in HIV-Aids treatment as it has been contested as an intrusion on privacy even though it would lead to much greater effectiveness in reducing infection.

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The liberation struggle drove people to be deeply distrustful, to be defiant, of the state. “Ungovernability” characterised the culture of resistance then and into the post-apartheid period. This tradition and denialism could be a factor in the poor response to the key strategy of interviewing the “zero patient” to identify networks of infection. This is how those infected have been isolated.

In the coming period there will be a drive among treatment groups in clinics and hospitals to reach this group and develop a defensive shield against Covid-19 infection. The urgency of this intervention could also help health services reach the service targets for HIV/Aids; unfortunately this “catch up” strategy is late.

Identifying networks in Covid-19 is critically important to tracing and isolating the infected. The question is whether the flurry of daily contacts between people living in poor communities can be unpacked, separated and identified and the pandemic contained and ended. There is resistance to tracing in HIV interventions. It is also very difficult to trace infections in dense settlements. If tracing fails, the alternative offered is broad interventions hoping that “herd immunity” is achieved as infection sweeps through communities.

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The course of seasonal influenza may offer something of an indication of the profile of mortality and hospitalisation. Flu kills between 6 000-11 000 annually. About half of those deaths are among seniors, and about 30% in people living with HIV. These also represent groups with the highest rates of hospitalisation. Existing conditions will make Covid-19 worse. According to an authoritative source, people living with HIV are eight times more likely to be hospitalised for pneumonia resulting from influenza than the general population and are three times more likely to die from it.

There are no general models of infection and hospitalisation publicly available in South Africa. As in other African countries it is anticipated that the slow initial rates of infection will rise exponentially and put extreme pressure on weak health systems. Through heroic interventions, African health workers with international support have controlled the spread of Ebola. Unfortunately Covid-19 appears to be more infectious, if less deadly.

The challenge of lockdown

The current lockdown is enforced in an urban society which varies considerably from the cities of China, Europe and the United States. The spatial planning of apartheid which segregated black people to the urban periphery has altered, but not substantially changed. Many city centres are now occupied by black people with “townships” (state housing) many kilometres distant on the periphery. There are many small and substantial shack settlements sandwiched between these two extremes. Extensive suburbs provide for the white and some of the black middle class.

With the exception of the suburbs, in all three types of urban settlement, there is overcrowding and a poor living environment; there are few parks, sports fields or libraries in townships and none in shack settlements. The open areas are often strewn with rubbish without grassed spaces to walk. These areas are certainly not excluded from South Africa’s extreme crime levels with high levels of murder and women and child abuse. Many households are women-headed and multi-generational often based on income from a grandmother’s pension and child allowances. Services in water, electricity and rubbish removal are frequently interrupted by poor service levels or disconnections for non-payment. Rubbish collection is either absent or not at the level of former white areas. Devastating fires in shack settlements are also not infrequent.

Hand washing is a challenge as access to water services is uneven. The highest level of service providing indoor plumbing is available to 46% of the population in middle-class housing and many townships. Fetching and carrying for domestic use is needed for households with outdoor yard connections (29%) and communal taps (12%). These households have much reduced consumption and do not have flowing water for hand washing.

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A social activist recently described the conditions which school children will now be experiencing:

“A number of children return from schools that mirror their neighborhoods – with pit toilets and no water, libraries, laboratories or sports-fields. They live in areas ruled by gangsters who peddle drugs and rape schoolchildren. They lack access to clean water to drink or wash with. They have few books or toys. Their homes are not in safe, wide-open spaces. Fresh air, clean water and nutritious meals are not guaranteed. There is no space to self-isolate in crowded homes where infection spreads like wildfire. Those who take care of them are often grandparents, who are most susceptible to Covid-19, yet have little access to emergency treatment or hospitalisation in far-away, over-extended public hospitals.” 

These are the conditions which children and their parents will be locked into, cheek by jowl with their neighbours. Power outages are not infrequent as the mismanaged electricity provider, Eskom, fails to maintain supply. There will not be much relief from isolation, most houses don’t have internet hubs; although most people have cellphones, data access is expensive. This is hardly a rich environment for tutoring children or keeping in touch with family. There will be a strong temptation to escape enclosure particularly in the one-roomed shacks.

Social support for shack settlements

The growth of shack settlements has been a desperate response to delayed public housing; they were thrown up to find some accommodation at a place as close to possible work. These settlements are at the centre of the dispossessed; some 3.6 million people or 14% of the total population live in shacks. Many are in floodplains, near the stench of waste disposal areas or in crevices between private housing. Local governments wage war against them to destroy the structures, evict the people and disconnect their “informal or illegal” connections to water and electricity. Again, these connections are acts of desperation even if they can lead to a failure of services. The dispossessed of the shacklands are represented by local community leaders, interconnected nationally by the Abahlali baseMjondolo (Shack Dwellers) Movement.

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The question is what provision can be made for these communities. During the cholera epidemic of 2000-2001 the SA Military Health Service (SAMHS) was deployed and set up mobile hospitals and 70 rehydration centres in remote rural areas. This was a high-cost intervention with ambulances, hospitals and medication. Helicopters were used to transport medical teams and patients. On average a thousand patients were treated a day; in total some 98 000 cases were seen. This intervention brought down mortality quite dramatically.

The question is whether the military will be deployed to police poor communities or provide services. Will we now see mobile hospitals set up in sports fields near shack settlements and in densely populated rural areas to meet the needs of the dispossessed? Or will its role be that of force and constraint?

The basics for survival

Sections of civil society and trade unions have put forward an immediate programme for survival in a set of demands to make life possible during the current lockdown:

End all evictions and disconnections from water and electricity, shack settlements must be included in refuse removal, workers given paid leave, small traders included in relief and provided with guaranteed income, free food parcels, hand sanitisers provided, places for those tested positive to self-isolate, free data available for cellphones, the release from prison of those detained for making “illegal” connections, health facilities available to the undocumented.

The current mood is reflected in the possibility of “rebellion born of extreme desperation” and reports of a “death wish” among working-class youth facing long-term unemployment. The labour movement has, for a period, been quiet in the face of the economic downturn.

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The overcrowded and impoverished conditions of life could provide fertile ground for social explosions. It seems some employers are adopting a “no work, no pay” policy during the lockdown. Others are expecting workers to take their annual leave during the lockdown. For 85% of black working people (in agriculture, services, industry and transport) it will not be possible to work from home. There is desperation within the lockdown.

The prevailing mood is, however, uncertain. There is broad acceptance of the need for the lockdown but also a keen awareness of the use of the police and army historically in repression. There is also concern about the existing high levels of abuse of women and children rising in closed conditions. In desperate times there could be swings between solidarity and xenophobia against undocumented black people.

Accumulating crises and a socialist way out

The international Covid-19 crisis is devastating the lives of working people in South Africa as it is worldwide. However, the economy, the people, the health systems are all more vulnerable than elsewhere. Every crisis, from the Great Recession to the present disaster has also reinforced South Africa’s semi-colonial place in the world economy and deepened its dependence.

The labour movement watches in awe as governments in advanced countries roll out “whatever it takes” recovery plans of trillions of dollars compared to a pathetic trickle at home. Decades of corruption have used up government surpluses and devastated public finances and SA’s position in the world economy and likely defaults have resulted in high interest rates for loans. In crisis, capital absconds to safe centres and to the dollar, draining the economy of resources.

The virus is shaking the foundations of South African politics. The country has just been starting to emerge from a period of mismanagement and corruption which has left state-owned enterprises reeling from a crippling burden of debt. Before the pandemic Ramaphosa represented a fairly weak presidency attempting the restoration of state finances. By acting decisively and giving an authoritative speech before the lockdown, he has now won respect from large sections of the population traumatised by the sweep of the pandemic. Working adroitly to assemble political consent he appears presidential.

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This rising political capital will be used to bring resources and focus to interventions. The immediate priority is the creation of a robust public sector and health system as an emergency measure. If the Covid-19 health crisis cannot be resolved the economy will continue to crash. Every crisis has, however, also led to concessions to capital.

All the unfinished business of the SA revolution is now outlined against the dark sky of disease; the stalled housing programme, indecisive health investment, mass unemployment and declining incomes, rising poverty, and the stark inequality of economy and society. The weak support offered to the newly unemployed and struggling families touches on these issues but without leading to resolution.

The question is how the labour and social movements will rise to put a bold public health initiative, mass housing programme and job creation back on the political agenda; progress towards the once-promised stage of socialism. This crisis has to re-energise the creative energies of working people as in the victorious struggle against apartheid.

The article will be carried in the forthcoming special issue of Transform, a Journal of the European Left, linked to Public Reading Rooms where it appeared online.

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