Our Unhealthy Condition.

So the doctors are on strike for more pay. Who can criticise people for wanting more pay? Especially when we aren’t the ones forking out the extra cash. (Well, we are, but indirectly, which is as good as not having to pay — or seems to be, when you’re hypnotised.)

But wait — what is the source of the problem? The might of the South African punditocracy was mobilised, and in a minute their giant brains found the solution. It seems that it is all Thabo Mbeki’s fault. He, and maNtombazana Tshabala-Msimang, destroyed the South African health care system which previously was working so brilliantly. Having established someone to blame, the punditocracy has fulfilled its function and need not ask any further questions. All that is necessary is to pay up.

All right, then. But . . . since Mbeki took over the management of health care in South Africa in 1996, which is well before any of the changes made by the ANC took effect, that means that this solution to the problem is actually a praise-poem to apartheid. Things were better back then, says the punditocracy. What we need to do is to go back there.

Of course, we cannot. Also, we should not, for things were not really better back then for most people (although they may have been better for the people whom the punditocracy care about). But all that this shows is that the issues are not being seriously looked at in the customary rush to justify Zuma’s accession and promote white-dominated reactionary politics. What are the doctors’ grievances, and what is the real source of the problem?

If you remember, in 1994 the ANC inherited a health-care system which was in a very dire state. In South Africa itself, the urban public health-care hospitals were steadily running down because of fiscal mismanagement. Rural clinics in South Africa barely existed — certainly not to serve black interests. Ironically, some homelands, such as KwaZulu, were better administered in terms of healthcare, but even there, the situation was gradually disintegrating.

The goal of the ANC under the RDP was to prop up the existing system while introducing a national network of small-scale healthcare clinics. Primary care was supposed to be the goal, and this was pursued by Nkosazana Dlamini-Zuma. However, this took money away from the big hospitals, and it also undermined big pharmaceutical corporations, so Dlamini-Zuma was smeared and undermined by everyone with a stake in the destruction of the country, including the whole of the press (familiar, isn’t it)? Eventually, when Mbeki took over, he shifted her to Foreign Affairs where she would be less vulnerable and could do work which particularly interested him while she was groomed for the Presidency.

But meanwhile, the economic condition of the country turned out to be more dire than the ANC had realised, and it also appeared that the global political situation did not favour any kind of radical redistributive agenda. (In any case, the South African Left were actually more concerned with feathering their own nests than with real redistribution — their calls for redistribution were almost entirely rhetorical.) So there was a big financial cutback, which stalled the clinic-building programme without doing anything to improve the situation of hospitals.

What was to be done? Politically it was impossible to sack lots of workers — and, besides, that would have calamitous consequences for healthcare, and a massive loss of doctors and nurses would be hard to replace (especially since the higher education system was under attack at the same time). Therefore, what was done was to cut back on infrastructure spending. Don’t maintain equipment or replace broken equipment, don’t repair the buildings or ask for new ones, and freeze new posts. A penny-pinching culture overwhelmed the provincial systems — and the provincial governments responsible for healthcare, and the municipal governments in the rural areas, were new, inept and potentially corrupt. It was a recipe for bad management.

Which was what we got. And, of course, in the background there was HIV/AIDS, the half-hidden horror for every health-care administrator:


          Like one, that on a lonesome road

          Doth walk in fear and dread,

          And having once turned round walks on,

          And turns no more his head;

          Because he knows, a frightful fiend

          Doth close behind him tread.


Anyone who wonders why the South African government did so little about HIV/AIDS during this period need only notice the budgetary problems (along, of course, with the undermining of ministerial authority).

There is another problem which wasn’t thought about too much at the time. The fact that the government had consciously decided not to cut staffing or slash salaries was a good thing and contradicts the claims that its policies were neoliberal. However, this fact also meant that the health-care workers, who were better paid than most workers, were cushioned against economic crisis. But they didn’t feel cushioned, because they were operating under deteriorating conditions with inadequate resources. They wanted better treatment, regardless of the fact that the treatment they were getting was better than economic conditions warranted. They became resentful.

Fast-forward a bit. Around 2003 it was obvious that the government’s economic policies had succeeded insofar as the budget deficit had been eliminated and economic growth sustained. Now there would be more money available. Of course, not all of it could be ploughed into healthcare, because so many other areas of government had been starved of funding for half a decade, but some could. What was to be done?

Unfortunately for the fiscal stability of health-care, there was a simple answer. Two years earlier, Glaxo-Wellcome had slashed the price of AZT for Africa in order to sidestep the growing tendency to pursue generic antiretrovirals. The previous year, the TAC had used the legal system to force the government to provide nevirapine for the prevention of mother-child HIV transmission (artfully concealing both the fact that nevirapine was dangerously toxic, and that the tests supposedly showing that nevirapine was useful for this purpose were all fake). It was obvious that the provision of AZT to people with AIDS was both financially practical and politically necessary. Hence the gigantic project was put in motion.

But it was indeed gigantic; AZT was “affordable”, but it wasn’t cheap. The cost of antiretroviral provision (even disregarding the absurd nevirapine programme) rapidly ballooned; within five years it was absorbing a tenth of the healthcare budget (while actually serving half of one percent of the population). As a result, the Ministry found that — unlike the situation at Safety and Security or Education — there was virtually no windfall from the end of GEAR. Hospitals continued to deteriorate, clinics remained absent or understaffed. What was to be done?

Well, the answer was obvious for any true South Africa — gimme, gimme, gimme! The public service went on strike demanding more money. Eventually they got their huge increases — NEHAWU, representing hospital workers here, was particularly benefited. As a result of this, enthusiastically supported by everybody who hated the government and loved to see them in trouble, the disproportion between personnel spending and infrastructure spending increased rather than decreasing. In short, the antiretroviral programme and strike action dealt the actual provision of adequate health care a double blow.

But this didn’t apply to everybody. A long, long time ago, a forgotten man named Thabo Mbeki said that South Africa was two nations, one rich and one poor. Well, he was roundly denounced for that by everybody who was rich and did not care about the poor, because nobody likes having the ugly truth about them revealed. (As it turned out, virtually nobody cared about the poor.) In fact, of course he was right. The rich have private health care. The middle class have medical aids, which are corporate scams pumping money out of middle-class bank accounts and into the pockets of the rich, but which the middle class tolerate because this means they can access the private hospitals of the rich. This all means that health care goes swimmingly for the 5% of the population who can afford it, and who spend about half as much on their health care as is spent on the other 95%. (A better ratio than it used to be — but since so much of the increased state spending goes on paying increasingly whopping salaries for personnel, it’s doubtful that this spending does much for health care.)

The trouble is that doctors and nurses in the private sector naturally get stratospheric salaries as compared with those in the public sector. However, there just aren’t enough jobs in the private sector for them. So they have to either emigrate or take employment in the public sector (invariably the worst performers go to the public sector, which exascerbates the problem). But they’re resentful; why do I get so little while they get so much? If only I could get more pay! If only I had high status! If only I had better working conditions!

Another problem is that nobody is there to tell them that more pay will almost certainly translate, over time, to worse working conditions. The media’s treatment of the health-care crisis is quite bizarre by practical assessment (but perfectly sensible if you assume that their goal is to gradually destroy the public health-care system, which is probably true). There is much justified criticism of public health care (although the only newspaper to actually investigate issues is the Eastern Cape Daily Dispatch).

So, for instance, it was found that at Frere Hospital in East London the management had been covering up for a disturbingly high death rate in the paediatric ward. Obviously management were at fault for covering this up — but also obviously, the doctors and nurses in the paediatric ward were not doing their jobs properly. The provincial health authorities should also have scrutinised the hospital more thoroughly. All these points are quite obvious, and all of them were concealed by the press, which blamed the President and the national Minister of Health, because this suited their political agenda. Nobody criticised the people actually responsible. In the same way, when babies in Sterkspruit were dying because the local municipality had stopped treating the water supply and the local clinics were failing to give rehydration therapy for diarrhoea, nobody blamed the municipality or the personnel at the clinics — instead they blamed the provincial Premier, because this suited their political agenda.

Hence there is no force seeking to improve the management of the health care system or to restore discipline and responsibility among health care practitioners. Instead, the recommendation is that dump-trucks full of money be shovelled out in their general direction. Meanwhile, the crisis remains unresolved, the divide between rich and poor grows daily greater, and the failure of our national health-care system grows ever more likely, even as the Zuma administration play silly games pretending that a national health insurance system (another massive scam, probably) is practically possible.

Conceivably the condition may be terminal.

One Response to Our Unhealthy Condition.

  1. akash rana says:

    nice work, you work a lot on your posts!

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