Cape Argus (Cape Town)
1 September 2007
Posted to the web 1 September 2007
By David Pienaar and Chris Colvina
Health has received prominent coverage in the media over the last few weeks, and often not for the right reasons. Thirteen years after the advent of genuine democracy in our country, this is the true state of the nation as measured by genuine experts in the field.
HIV and Aids
South Africa has more than 5 000 000 HIV-positive people. It is estimated that in February more than 700 000 needed anti-retroviral treatment while just over 250 000 were on treatment in the public sector. This is nothing short of genocidal neglect.
The most urgent long-term priority our country faces is to stop new HIV infections. This requires a massive change in national consciousness. Everyone needs to be made aware of the reality of the epidemic, and leaders have a critical role to play in this. Positive role models need to occupy people's minds. We're talking about media coverage that far exceeds the feeble attempts we've seen up to now.
We need soap stars "coming out" with their HIV status in real life, we need politicians talking about themselves and their families in Parliament, we need newsreaders swallowing their ARVs during the 7pm bulletin, we need sports people speaking out after games, and so on.
Protected sex needs to become the new cool, the new symbol of empowerment. The men and women on the street have to become the ones who demand condoms. We're talking about a massive effort to deliver vital public health messages on a scale we have nowhere near reached yet, and are unlikely to while our leadership insists on misreading reality.
And that's just point one in the HIV plan. At the same time, those of the 5 000 000 who are unaware of their status (the majority) need to become familiar with it. This is a potentially life-saving action, because knowledge in this case really is power. With modern testing and life-saving drugs, there is no need for people to start treatment belatedly when their body is ravaged by end-stage HIV. Testing early will, quite literally, save lives.
Finally, ARV drugs need to get out more quickly and to more people. This is an enormous logistical challenge. It can be helped by enacting policies that retain health-care personnel in the country, that enable the rapid local production of cheap, generic anti-retroviral medication, and that unfailingly support adherence to ARV medication.
A TB wildfire is fanning through the country. Registered cases across South Africa have increased by 80% in the last five years, from 190 000 in 2001 to over 340 000 last year.
Many of those who are diagnosed with TB don't finish their six-month course of treatment, causing drug resistance and spreading it further in their communities. Multi-drug resistance and extreme drug resistance, with prognoses worse than some cancers, are on the rise.
TB can be reduced though simple steps like reducing HIV infections, dispensing early TB treatment, living in well-ventilated, low-density dwellings and eating good food.
No scientist will dispute that adequate nutrition is a very important contributor to a healthy immune system. It is not, however, a cure for an immune system ravaged by HIV or TB. These are specific diseases with specific, effective medications.
More than 70 000 children die every year due to preventable diseases like diarrhoea, pneumonia and malnutrition. To stop diarrhoea one simply needs some quality food, clean water and adequate disposal of human waste. In such cases, the disease is self-limiting, and even contributes to building up the immune system of a child.
Nutrition is especially important in children. Food is literally the building blocks of their future. Malnutrition is the most frustrating diagnosis to make because it is the most unnecessary.
For many reasons, mostly to do with global trade restrictions and the artificial scarcity of money, mothers are unable to get healthy food for their families and themselves. This is an entirely avoidable event in our wealthy country and is having a huge knock-on effect on our nation's health.
Unnecessary injuries are placing an enormous load on an already failing health system. Homicide and violence are second only to HIV/Aids as a cause of premature death. If we could somehow get alcohol and firearms to disappear, our casualty units and hospital wards could concentrate on real medicine and health workers might rekindle motivation and job satisfaction.
The reasons for such high levels of male violence and alcohol abuse are complex but are related to the value systems of our society; a society where a man is viewed as a "breadwinner" yet, for reasons not of his own making, has limited opportunities to "win bread"; a society where the "dog-eat-dog", "survival-of-the-fittest" stereotype is touted as a success, despite ground rules that ensure that financial well-being is available to only a select few.
This can create poor self-esteem in the soundest of minds; throw alcohol and other mind-altering substances into the mix, and insecurity rapidly crescendos into violence.
The decay of social and economic systems in rural areas is creating a generation of urban migrants. And the resultant rapid urbanisation is replicating the squalid conditions that breed the above health problems. To assume economic growth, in and of itself, will solve this particular problem is naïve in the extreme. Such an assumption is based on the belief that we will follow Britain's trajectory of the late 19th and early 20th century, when their urban slums were gradually eradicated as they became wealthier as a country.
Unfortunately for us, this was a 100 years ago, when Queen Victoria had an empire of other nations' wealth to draw upon. Global financial rules have also changed drastically and therefore our "developing" country lacks a lot of the autonomy Britain had then.
Good Health is More Than Clinics and Hospitals
Although important, clinics and hospitals are not the absolute determinants of good health. They are end-of-the-line, response-to-need services, and much of that need is a consequence of us not having got fundamental living conditions right.
Truly good health management is preventing most of the burden of disease happening. This requires sound policies, equitable redistribution of resources and powerful methods to defend social justice.
We ought not to be so obsessed about measuring how many wealthy people our economy is generating. As it is a relative measure of resources, by definition, not everyone can be wealthy.
A lot more people could be healthy though. And besides, with the "trickle-down" economic theory having long since been discredited, our search for genuine equity needs to be grounded in other principles.
We should be caring about the child who dies because her mother cannot get access to our "fabulous" economy. About the woman who gets Aids because no one cares enough to give her simple, non-contradictory advice. About the man who dies by the gun because he had the misfortune to be born in the suburb on the "wrong side of town".
Time for a People's Health Movement
The People's Health Movement believes a healthy nation is a reflection of enlightened and equitable social policies, compassionate communities, a caring leadership and a social system based on humanitarian principles and the indisputable value of human life.
We need to realign our priorities. Health, rather than wealth, is a much truer lens through which to view the status of our nation. Ignoring what health statistics tell us about our country would be a short-sighted and contemptuous dereliction of duty.
Dr David Pienaar and Dr Chris Colvin are members of the steering committee of the People's Health Movement (South Africa) which will launch its Right to Health Campaign next Saturday in Khayelitsha. Pienaar is a registrar in public health at the University of Cape Town and Colvin is a post-doctoral fellow in public health at UCT.