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Why there is No Doctor

the Impact of HIV/AIDS in the post-Apartheid Health Care System of South Africa

Alex B. Hill
4 May 2009
Introduction to an Epidemic

Everyone in the car remained silent as we passed a sea of gravestones on the way to

Zonkizizwe, an informal settlement south of Johannesburg.1 The cemetery seemed to extend for

miles. This was the reality of HIV/AIDS in the peri-urban, informal settlements. It is a reality

that is not far departed from scenes in rural homelands as well as the urban townships of South

Africa. I was not new to the HIV/AIDS epidemic, but I was new to the experiences of those

living in an informal settlement under apartheid, struggling with the crippling impact of HIV in

an area where I never even saw a doctor. Why were there no doctors?

It is estimated that one in five South Africans aged 15-49 are infected with HIV. Since

the last UNAIDS report in 2008, 5.7 million people are living with HIV in South Africa and

1000 people die everyday from HIV/AIDS related causes. 2 The cause of death for 71% of people

aged 15-49 is now AIDS.3 Some people have even noted that South Africans spend more time at

funerals than they do at weddings. There are an estimated 1,400,000 orphans as a result of

HIV/AIDS.4 The numbers of those infected does not reflect the real impact of disease because

the impact of HIV/AIDS extends further into families, friends, and communities.

Life expectancy has fallen considerably in South Africa as the prevalence of HIV/AIDS

spread rapidly from 1990-2003.5 This time period is marked by violent, but positive changes in

government rule and policy. The first case of AIDS in South Africa was diagnosed in 1982

Personal account of Alex B. Hill who interned at Vumundzuku-bya Vana ‘Our Children’s Future’ in Zonkizizwe
(Proper), South Africa from May-August 2008.
UNAIDS 2008 Report on the Global AIDS Epidemic
Centre for Actuarial Research, South African Medical Research Council and Actuarial Society of South Africa
(2006, November), 'The Demographic Impact of HIV/AIDS in South Africa - National and Provincial Indicators for
HIV & AIDS in South Africa: The history of AIDS in South Africa
UNAIDS 2006 Report on the Global AIDS Epidemic, Chapter 4: The impact of AIDS on people and societies

among the gay population, so why was the most rapid spread during this time period?6 Many

experts and professionals posit that this rapid spread of HIV and the lack of a response to the

epidemic in South Africa is due to the political turmoil of the 1980s into the 1990s. However,

this represents a failure to look deeper into the history of South Africa and its health care


While violent conflict had a direct effect on the response to HIV/AIDS in South Africa, a

number of other factors with greater impacts based in apartheid policy led to the rapid spread and

limited possibility for a comprehensive government response even if there were an absence of

violence. South Africa has a difficult history of formulating a response to HIV/AIDS: from

apartheid health policy to AIDS denial, from a failed treatment program to the absence of doctors

and adequate health infrastructures.

In the March 2009 elections, health was a driving factor for many voters and appeared on

many political party platforms. The African National Congress (ANC) ran with promises to cut

HIV infections by 50%, launch a National Health Insurance program, and ensure decent wages

for health workers.7 With such a far-reaching crisis at hand, politicians must formulate a better,

more comprehensive plan to address the effects of apartheid history combined with the current

strains on the health care system if they are to effectively combat HIV/AIDS. Why has the

response to HIV/AIDS been so poor? Why was HIV able to spread so quickly in South Africa?

Why is there no comprehensive treatment program? Why are there no doctors?

The Health System via Apartheid

HIV & AIDS in South Africa: The history of AIDS in South Africa
Cullinana, Kerry. “Healthy election promises.” 31 March 2009

In order to fully understand the extent of the HIV/AIDS crisis in South Africa and the

reasoning for its rapid spread without a response, the history of the health care system and

apartheid must be researched. Creating a timeline (see Appendix A, Page 31) of the health care

system in South Africa will be critical to understanding current inadequacies and failures.

Looking more critically at the policies of apartheid will also allow a better understanding of their

effects on the health of the population, especially the Black majority.

Looking back to the Union of South Africa under Jan Smuts8, the beginnings of

government control of health care systems can be seen. In 1919, the Public Health Act marked

the beginning of health service structure in South Africa where policy and procedure is delegated

to specific provincial authorities by the central government.9 In the early 1940s there was talk of

creating a National Health Service.10 However, when the National Party (Afrikaaner) came to

power in 1948, apartheid laws were enacted and the health budget was cut “drastically.”11 This

may seem a minor note, however this translated into the policy of “separate development” that

left traditional homelands or “Bantustans” as well as Black townships to come up with their own

health care services.

[…] the health services aid in the reproduction of the Black labour force according to
White economic needs. The provision of health care for Blacks outside the bantustans is
geared towards the urban population as the supplier of a large and increasingly skilled,
Black workforce, rather than the Black population at large. Secondly, the health services
support the commitment to ‘separate development’ in various ways. […] They help
to establish the credibility of the bantustans and their leaders, and of the representatives
in the new segregated parliament. They also provide a lever with which the government
can pressurize bantustan governments into accepting ‘independence’. […] Thus health
policy is shown to be an instrument of the state's twin imperatives: reproducing the
conditions of capitalist accumulation and maintaining White supremacy.12
“History of South Africa.”
Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 63.
Price, Max. “Healthcare as an instrument of apartheid policy in South Africa.” 1986.

Following the legal creation of apartheid, the health system continued to evolve. The year

1951 brought the Bantu Authorities Act, which established traditional homelands for the

majority of South African citizens. This action took away the rights and citizenship of 9 million

Blacks. In the same year the Prevention of Illegal Squatting Act continued the forced removal of

Black South Africans and began the destruction of basic health services that had been

established. 13 Up until 1970, health services run in Bantustans by mission stations and churches

were under the control of ‘local government’ authorities.14 However, following 1970 all health

services were placed under the control of the South African Department of Health.15 Along with

the removal of people living in the wrong areas and the destruction of health services in those

areas, the South African apartheid government was slowly taking control of all aspects of health

service to the Black population. In 1973, the Department of Bantu Administration and

Development began to gradually take control of all mission hospitals.16 This increased

government control led to severe staff shortages as mission doctors did not want to be under the

authority of the South African government. This was called an intermediate progress step before

completely handing over financing of health services to ‘homeland’ governments. Within the

health care system of apartheid South Africa, the notion of “separate development” quickly came

to mean absolute government control.

The South African Institute of Race Relations made a Survey of Race Relations in 1982

and quoted a doctor talking on rural health services in the Bantustan homelands,

[…] gave some credibility to the homeland administration itself by enabling it to promote
services to local communities. The separation of rural health services into homeland
Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 63.

health services allowed the government to manipulate health statistics to give the
impression that the health status of SA’s people was improving. An apparent fall in the
rate of tuberculosis notifications between 1975 and 1980 was a result of the exclusion of
statistics from Venda, Bophuthatswana and the Transkei. […] the separation of statistics
also allowed the SA government to claim that most infectious diseases were occurring
‘outside of SA’ and were the responsibility of the appropriate homeland authority, not the
SA Department of Health.17

The quote from this doctor working in the Bantustan health services shows the direct

contradictions of the “separate development” policy within the health care system of South

Africa. The doctor talks about how the South African Department of Health takes no

responsibility for health statistics in Bantustans (1982), but since 1970 the Department of Health

had controlled health services. This contradiction is an excellent example of the apartheid

policy’s effect on health, an effect with a planned negative outcome. In interviews in 1983,

doctors in the Department of Medicine at Baragwanath hospital in Soweto, Johannesburg noted

the inadequacies of health services for the Black population:

[…] described the overcrowding and shortage of medical staff as having reached a
‘breaking point.’ Journalists who visited Ward 21 found that its 40 beds were occupied
by 89 women and one child. […] ‘There are not enough doctors and too many patients to
do things any other way here.’ Bedletters, giving the crucial medical and drug history of
each patient, often got lost in a confusion of movement as patients moved outside the
wards during the day to give the doctors greater freedom to work inside. ‘Sometimes I
haven’t been able to find out what medication a patient was receiving,’ on doctor said,
‘People are not being treated properly here.’

Health, access to health services, and control of health services was an active aspect of

the apartheid government policy. The greatest impact of apartheid policy on health infrastructure

for South Africa was denying proper training for Black health workers. At the end of 1981, it

was estimated that 93% of the medical practitioners in South Africa were White and the ratio of

Black doctors to patients was 1 to ever 91,000 people.18 While these numbers do not reflect the

Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 69.
Ibid, 84.

direct availability of health services, as much can be gathered. The numbers do show the

availability of medical training for certain populations. Along with issues of access to training,

there was also the issue of distribution of doctors. Approximately 60% of the population lived in

rural areas, but only 5% of doctors practiced in those rural areas.19

The medical profession of South Africa is White dominated. Medical training was

offered at the major provincial universities. Black Africans were allowed to train at just three of

these universities until a new medical training center was established in one of the Bantustans as

a way to phase Blacks out of the White medical universities. Under the provisions of the

Extension of University Education Act of 1959 a new medical training center was establish and

the Minister of Education and Training (formerly Bantu Education) had the power to vet all

applicants.20 It was policy to limit the number of Blacks as part of ‘Bantu Education.’21 As Dr.

Verwoerd stated in 1954:

The education of a white child prepares him for life in a dominant society and the
education of a black child for a subordinate society [. . .] The limits (of Native Education)
form part of the social and economic structure of the country.

This unequal access to facilities translated even deeper into medical education as there were

restrictions for Black medical students even at the ‘mixed’ universities. The discriminatory laws

translate into an inadequate medical training: Black students cannot attend post mortems of

Whites, were not allowed to attend ward rounds in White hospitals, and Black students were

asked to leave the room when White patients were used for clinical demonstrations. These issues

related to access to training were seen across the board for doctors, nurses, pharmacists, and

Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 84.
Ibid, 86.

within professional medical organizations. The issues ranged from access to training, lower

salaries, and lack of promotion.

Health in South Africa was not departed from the apartheid policy and was an active tool

in ensuring political, economic, and social control by the White minority government. The only

way to fix health care in South Africa depended on ending apartheid and discrimination and

increased government attention to health problems.22 The effects that apartheid policy had on the

health system of South Africa, specifically for Black South Africans, laid the groundwork for

HIV/AIDS to rapidly spread and take such a heavy toll. Some of the active policy actions that

contributed to HIV’s spread were forced removals and migrant laborer movements, both internal

and international.

Cleaning Black Spots off of a White Land?

Forcing people to live in separate racial areas of South Africa was the driving piece of

apartheid’s “separate development” policy. The pockets of the Black population that lived

among and near White city centers were called “Black spots” and the government actively

worked to clean them out. During the 1950s and 1960s the first “forced removals” occurred after

the passing of the Group Areas Act established these racial areas. More than 860,000 people

were forcibly removed as a way to divide and control racially separate communities as resistance

grew towards apartheid policies.23 Sophiatown of Johannesburg and District Six of Cape Town

E. O. Nightingale, K. Hannibal, H. J. Geiger, L. Hartmann, R. Lawrence and J. Spurlock. “Apartheid Medicine.”
Committee on Health and Human Rights, Institute of Medicine, National Academy of Sciences. Vol. 264 No. 16,
October 24, 1990.
“Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.

are just two examples of vibrant multi-racial communities that were destroyed by South African

government bulldozers once they were deemed “White” areas.24

Between 1960 and 1983, over 3.5 million South Africans were forcibly removed25 and

until 1984 another 1.7 million were under threat of removal.26 Blacks were removed to distant

segregated townships, sometimes 30 kilometers away from places of employment in the central

towns and cities.27 As a result ‘informal settlements’ formed as shantytowns closer to places of

work, but many were destroyed. Farm laborers were also displaced by mechanized agricultural.

As a result farm laborers were segregated into desperately poor and overcrowded rural areas and

were not permitted to travel to towns to find new jobs.28

Removals represented the “essential tool” for apartheid to work. Creation of the

Bantustans stripped Black South Africans of all legal rights in South Africa and their welfare

was no longer the problem of the South African government. Hundreds of thousands of other

Blacks were dispossessed of land and homes where they had lived for generations in these

“Black spots” now designated as part of “White” South Africa. Entire townships were destroyed

and their residents removed to just inside the borders of Bantustans where they now faced long

commutes to their jobs.29

In other words, removal of people is not simply a physical act; it is part of a process and a
strategy that seeks to push increasing numbers of South Africa's people into ever more
remote and inhospitable areas where, broken and fragmented by the experience of

“Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.
“The uprooting of millions, forced removals.” For their Triumphs’ and Tears. ANC, 1983.
“Forced removals” South Africa: Overcoming apartheid, building democracy. MSU African Studies Center.

removal and all that it means, people are left to exist under conditions of increasing
apathy and powerlessness. 30

One UN report on the forced removals noted, “that the demolition was executed in total

disregard for the health and well-being of every individual concerned, in the most inhumane

manner.”31 The forced removals created poverty situations where the infertile Bantustan lands

had to sustain an overcrowded population. This policy of removal, coupled with the apartheid

policies on health services in Bantustans and for Black medical training, shows the dire health

effects on the Black population. These terrible health conditions later translate into environments

easily susceptible to the spread of HIV/AIDS.

High-Risk Migration Patterns

Apartheid worked on a model of strict population control for increased economic gains.

Removing millions to overcrowded townships and Bantustans far from city centers developed a

system of forced migrant labor. Both men and women had to leave these areas to find any

economic stability for their families.

It has been estimated that one third of the adult male population in the Bantustans is
absent at any one time, contributing to the low level of farming. Many women are also
forced to seek work elsewhere to support their families. In general they are excluded
from seeking work on the industrial areas of South Africa and the majority work as
domestics or in agriculture.32

The migration of Black populations to find work had adverse effects on the health of individuals,

families, as well as communities. The movements of people from rural to urban areas became

entrenched in the economic system where state interventions actively controlled and mobilized

J Yawitch, Betterment. “The myth of homeland agriculture” SAIRR: Johannesburg, 1981, p.86.
'Forced removals in South Africa 1977-1978', paper prepared by IDAF for the United Nations Centre Against
Apartheid, No. 44/78, Oct. 1978, p.9.
Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 18.

labor migrations.33 In 1990, a study in KwaZulu-Natal province found that men who were

migrant workers in the mines had twice the HIV rates as non-migrant workers, while women

who attended prenatal clinics in the province had twice the national level of HIV infection.34

During the period of 1993-1999, there was a significant increase in migrant labor. This

can be explained by the ending of apartheid laws creating an increased mobility of populations of

workers. In 1993, 32.6% of rural Black Africans were migrant laborers.35 In 1999, almost 40% of

rural Black Africans were migrant laborer and 34% of all these migrant workers were women.36

This period also marked the ending of apartheid laws, the first democratic elections in South

Africa as well as the doubling of HIV prevalence rates.37 Recent studies have shown that labor

migration patterns did not change with the ending of apartheid, but rather increased. A 2003

study concluded that,

Migration continues to play an important role in the spread of HIV-1 in South Africa. The
direction of spread of the epidemic is not only from returning migrant men to their rural
partners, but also from women to their migrant partners. Prevention efforts will need to
target both migrant men and women who remain at home.38

Professor Lurie and researchers from Brown University, Harvard Medical School and Imperial

College London used data collected from nearly 500 men and women living in bustling towns

and rural villages to create a mathematical model that shows that migration of South African

workers played a major role in the spread of HIV mainly by increasing high-risk sexual

behaviors.39 Very often young men would leave the rural Bantustans in order to earn a living in

Posel, Dorrit. “Have migration patterns in post-apartheid South Africa changed?” 4-7 June 2003.
“HIV and other STDs. Chapter 3, Part 1” Population Reports. November 1996, 20.
Posel, Dorrit. “Have migration patterns in post-apartheid South Africa changed?” 4-7 June 2003, 3.
“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
Lurie, Mark N; Williams, Brian G; Zuma, Khangelani; Mkaya-Mwamburi, David; Garnett, Geoff P; Sweat,
Michael D; Gittelsohn, Joel; Karim, Salim SAbdool. AIDS:17 October 2003 - Volume 17 - Issue 15 - pp 2245-2252.

the urban areas and mines only returning home once a year. With the lifting of travel restrictions

on Black South Africans after apartheid this “circular movement” increased.40 Professor Lurie


Our model showed that migration primarily influences HIV spread by increasing high-
risk sexual behavior. Migrant men were four times as likely to have a casual sexual
partner than non-migrant men. So, when coupled with an increase in unprotected sex, we
found the frequent return of migrant workers to be an important risk factor for HIV.41

Scapegoating “tropical workers”

As early as 1913, international migrant workers have been brought into South Africa to

fill out the labor supply, especially in the mines.42 These workers were called “tropical workers”

because they came from countries like Malawi and Mozambique that had more tropical climates

and diseases. The mines faced a labor shortage starting in the 1930s and by 1934 over 2,000

“tropical workers” had been brought in on an experimental basis.43 The South African

government had difficulties with “tropical workers” bringing in disease and spreading it before

1930 and so there was a certain stigma associated with international laborers. Early tropical

workers were blamed with bringing tuberculosis and spreading it within the mines. However,

working conditions in the mines and biological susceptibility were not taken into account.

Regardless, tropical workers were associated with tuberculosis and that reasoning led the South

African government to be wary about reintroducing tropical workers in 1934. The success of

these workers and lack of increased disease inspired the South African government to lift the ban

Lurie, Mark N; Williams, Brian G; Zuma, Khangelani; Mkaya-Mwamburi, David; Garnett, Geoff P; Sweat,
Michael D; Gittelsohn, Joel; Karim, Salim SAbdool. AIDS:17 October 2003 - Volume 17 - Issue 15 - pp 2245-2252.
Packard, Randall. White Plague, Black Labor: Tuberculosis and the political economy of health and disease in
South Africa. University of California Press. 1989, 229.
Ibid, 230.

on hiring workers above the 22nd parallel in 1937.44 With the lift of the ban, the numbers of

tropical and international migrant workers increased significantly.

Tropical workers entering South Africa numbered 40,000 by 1948, the start of

apartheid.45 Between 1988 and 1992, around 13,000 tropical migrant workers from Malawi were

repatriated because over a two year period 200 of them had tested positive for HIV.46 The

tropical worker who was scapegoated for the spread of tuberculosis was now labeled as the

culprit for the spread of HIV to South Africa. Later it was understood that the South African

mining industry was working on stabilizing its mining labor supply and HIV/AIDS was used as a

way to clear out international migrant workers.

Nevertheless, the increase in numbers of tropical or international migrant workers to

South Africa expanded the area where high-risk behavior related to HIV/AIDS could have an

impact. The international migrant worker movements from the mines to their home countries and

any locations in between likely contributed to the increased prevalence of HIV similar to studies

that have proven the same for internal labor migrations. The reach of apartheid’s policies

stretched beyond South Africa’s borders and contributed to the deepening of the HIV/AIDS

crisis within the country as well as the southern African region.

HIV/AIDS in South Africa

The first case of AIDS was diagnosed in South Africa in 1982 among the gay

community.47 The apartheid government took minimal actions in response to the virus’ coming.

Packard, Randall. White Plague, Black Labor: Tuberculosis and the political economy of health and disease in
South Africa. University of California Press. 1989, 230.
Chirwa, Wiseman Chijere. “Aliens and AIDS in Southern Africa: The Malawi-South Africa Debate.” The Royal
African Society. African Affairs 97:53-79, 1998.
“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.

This could be in part due to the violent political turmoil as well as discrimination against the gay

community. In 1986 the AIDS Advisory Group was established to respond to the epidemic,48 but

nothing of significance can be associated with the Group. HIV/AIDS quickly spread to the

heterosexual populations and by 1990 antenatal tests showed that up to 120,000 people were

living with HIV/AIDS.49

It wasn’t until after apartheid laws were repealed that a government response was crafted.

In 1992, the same year that a referendum was held on apartheid policies, Nelson Mandela

addressed the National AIDS Convention of South Africa (NACOSA), which was to develop a

national strategy to cope with the epidemic.50 The National Health Department reported in 1993

that HIV rates had increased by 60% in the last two years and this number was expected to

double in the next year.51 This was the groundwork that apartheid had lain for the rapid spread of

HIV/AIDS in the next seven years.

The period from 1993-2003 marked the freedom of mobility of more people, which was

evidenced by the increase in internal labor migration patterns as well as a severe increase in HIV

prevalence. Seedat’s book is rightly named “crippling a nation” because when the government

was stabilized and working to develop a response to the HIV/AIDS crisis it was already too late.

The HIV/AIDS crisis was poised to take its toll from the detrimental apartheid policies that

limited health services, medical training, forced mass migrations of people, and established

environments prone to high-risk behaviors.

During this time period, a number of government actions were meant to stem the

increasing prevalence rates. In 1994, the Ministry of Health adopted its first national AIDS
“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.

strategy based off of NACOSA’s work.52 Unfortunately the plan was considered inadequate,

poorly planned, and disorganized. In 1995, the International Conference for People Living with

HIV and AIDS was held in South Africa and then Deputy President Thabo Mbeki acknowledged

the seriousness of the epidemic.53 That same year the Ministry of Health announced that 850,000

people (2.1% of the population) were living with HIV.54 In 1998, The Treatment Action

Campaign (TAC) launched partly in response to the failures of the South African government to

provide adequate resources to people affected by the crisis.

Denial is the First Step

Since the early 1990s, Mbeki had turned his back on scientific evidence linking HIV as

the cause of AIDS. Mbeki’s stance on the cause of AIDS is the largest contributing factor in the

South African government’s failure to scale-up treatment. In 2000, Mbeki called together a

group of scientists including a group of ‘dissident scientists’ to discuss the cause of AIDS.55

Later that year at the International AIDS Conference in Durban, he spoke publicly rejecting the

accepted science that HIV causes AIDS and instead focused on the need to alleviate poverty in

Africa as a way to combat AIDS.56 He said the cause was poverty, bad nourishment, and general

ill health while also noting that more Western medicine was not what Africa needed.57

Since his public statements, Mbeki and the South African government have been hit by a

backlash of criticism from the international community and Mbeki has remained silent on the

topic. The year 2000 was the same year that the Department of Health launched a five-year plan

“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
Boseley, Sarah. “Mbeki Aids denial ‘caused 300,000 deaths.” Guardian News UK. 26 November 2008.

to combat HIV/AIDS. However, Mbeki’s statement and the lack of strong governmental support

led to much “foot-dragging.”58 Mbeki had turned down grants, funding, and free medicines to

scale-up the treatment program as a result of his denial. Now a recent Harvard study has placed

impact numbers with Mbeki’s denial claims. The authors of the study estimate that more than

330,000 people died unnecessarily in South Africa and that 35,000 babies could have been

protected from HIV-infection as a direct result of Mbeki’s HIV/AIDS policy and denial.59

In 2002, with international pressure growing, the South African High Court ordered that

nevirapine, which combats the spread of HIV from mother-to-child, be made available.60 Sadly

despite offers of free and cheap antiretrovirals (ARVs), the South African government was

hesitant to offer the medicines and only distributed in two test sites. In 2003, the government

approved a plan to make antiretrovirals publicly available and by 2005 there was at least one

service location for AIDS-related illness in each of the 53 districts.61 However the program did

not reach enough people and the HIV prevalence rate among pregnant women was recorded at

30.2%, a steady increase since 1990.62 The treatment program was beyond inadequate.

The case for HIV/AIDS treatment and prevention suffered another blow at the hands of

South African government leadership in 2006. Former Deputy President Jacob Zuma went on

trial for the rape of an HIV positive woman and claimed that having taken a shower afterwards

protected him from HIV transmission.63 This only heightened international outrage and pressure

on South Africa’s HIV treatment programs. At the 2006 International AIDS Conference in

Boseley, Sarah. “Mbeki Aids denial ‘caused 300,000 deaths.” Guardian News UK. 26 November 2008.
“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.

Toronto, UN Special Envoy on HIV/AIDS Stephen Lewis, called the South African government

“obtuse and negligent.”64 By the end of the year the government had announced that it was

drafting a framework to tackle AIDS and pledged to increase public access to antiretrovirals.65

Mbeki was ousted from his ANC leadership position in September of 2008 and the

interim president appointed Barbara Hogan as the Health Minister. Many saw this as a major

turning point in South Africa’s HIV/AIDS policy, especially as the government is working to get

antiretrovirals to as many people as possible. Unfortunately, Zuma is set to win the upcoming

presidential election and has not made any apology for his false statement on HIV prevention.

What happened to Reconstruction and Development?

Beyond AIDS denialists creating inadequate treatment programs, the rebuilding and

scale-up of South Africa’s health care system has been very slow since the ending of apartheid.

The main driver of scale up of health service infrastructure was the ANC’s Reconstruction and

Development Programme (RDP). In its first White Paper of 1994, the RDP noted: “Health

services are fragmented, inefficient and ineffective, and resources are grossly mismanaged and

poorly distributed. The situation in rural areas is particularly bad.”66 Between April 1994 and the

end of 1998, the RDP built 500 new clinics which gave an additional 5 million people access to

primary health care facilities.67 The RDP had an incredible set of goals to match the incredible

odds the country was up against, but many still had criticisms. Many note that the successes of

the RDP are overshadowed by the enormity of the HIV/AIDS crisis.

“HIV & AIDS in South Africa: The history of AIDS in South Africa.” Avert.
“Health Care.” The Reconstruction and Development Programme. White Paper, 1994.
Lodge, Tom. "The RDP: Delivery and Performance" in "Politics in South Africa: From Mandela to Mbeki",
David Philip:Cape Town & Oxford, 2003.

Critics of the RDP argue that access to healthcare only improved slightly under the RDP
and that, even with moderately improved access, standards at many medical institutions
declined rapidly. They cite, in the first place, that usage of healthcare facilities increased
by just 1.6% between 1995 and 1999, and that even these modest improvements have
been eclipsed by the advance of the AIDS pandemic and other health epidemics such as
malaria. Between 1995 and 1998 life expectancy of South Africans fell from 64.1 years
to 53.2 years, with AIDS patients sometimes occupying up to 40% of beds in public
hospitals. This, say critics, is indicative of a "public health system... in crisis" rather than
one undergoing positive transformation. Equally troubling has been declining quality of
services […] for example, that in Soweto 950,000 patients attended primary
healthcare clinics in 1994 where they were seen by 800 nurses -- but by 2000 the number
of patients had spiraled to about 2,000,000 while the number of nurses had fallen to just

The difficulties of apartheid have transferred over as the country has attempted to rebuild. There

remain serious deficiencies in trained health workers, even regressions. More people are using

health services, but more health services are not readily available. More and more people need

access to treatment for HIV/AIDS, but the inadequacies in health service infrastructure combined

with denial policies have limited that access. The RDP White Paper only had one small section

on AIDS, Section 2.12.8 reads:

Sexual health and AIDS. A programme to combat the spread of sexually transmitted
diseases (STDs) and AIDS must include the active and early treatment of these diseases
at all health facilities, plus mass education programmes which involve the mass media,
schools and community organisations. The treatment of AIDS sufferers and those testing
HIV positive must be with utmost respect for their continuing contributions to society.
Discrimination will not be tolerated. AIDS education for rural communities, and
especially for women, is a priority.69

The numbers speak for themselves and the RDP has failed to achieve its intended goals. The

biggest difficulty seems to be that the RDP and health infrastructure were not taken seriously.

When the new ANC government was elected the RDP was its own department, but then slowly

was scaled back to its own program and now RDP programs exist within other governmental

departments where priorities are not on health services or HIV/AIDS.
Lodge, Tom. "The RDP: Delivery and Performance" in "Politics in South Africa: From Mandela to Mbeki",
David Philip:Cape Town & Oxford, 2003.
“Health Care.” The Reconstruction and Development Programme. White Paper, 1994.

Post-Apartheid Health: the Burden Continues to get Heavier

The South African health care system was in crisis during the apartheid years and that

fact has not changed almost 15 years later. According to the American Association for the

Advancement of Science and the Physicians for Human Rights organization, the South African

health care system not only limited access to health services for Blacks, but also created an

environment in which abuses could and did occur.70 The Bantustan homelands have been

incorporated back into the unified free South Africa and these areas remain the most

underserved. These areas had their own separate health departments under apartheid with 300

local authorities in charge.71 Now these separate departments are under the authority of 9

different provincial health services leaving health care in South Africa fragmented.

In essence there were, and still are, two different health care systems in South Africa.

One system is public and accessed by the majority of the population. The other system is private

and subsidized for the few who can afford it. During apartheid the majority of the health budget

went into developing this private health system for those living in urban areas and those privately

insured.72 This disparity remains true today, as Blacks still have limited access to health services.

Economics also continues to drive this disparity as most doctors choose to enter into the private

system for better pay and better facilities.

The lack of an adequate health care system for the majority of the population as a result

of apartheid policies has exacerbated the ability of medical practitioners in responding to the

Kon, Zeida R. and Nuha Lackan. "Ethnic Disparities in Access to Care in Post-Apartheid South Africa."
American Journal of Public Health. December 2008, Vol. 98, No. 12, 1.

HIV/AIDS crisis. "HIV patients might soon account for 60 percent to 70 percent of hospital

expenditure in medical wards," says HEARD researcher Nina Veenstra.73

Already, about half of all patients admitted to hospitals in South Africa seek care for
HIV-related illnesses, while the numbers of HIV-positive patients in paediatric wards are
even higher, she added. […] As the numbers of AIDS patients grow, there will be a
greater demand for skilled health workers, medication and hospital facilities.
South Africa already suffers a shortage of health workers, due in large part to unattractive
working conditions. Many posts for health workers remain vacant, notes a study by a
national research organisation, the Durban-based Health Systems Trust (HST).74

The HST and other researchers have estimated that only 13% of all patients who are in need of

ARV treatment are receiving it.75 This is in large part because of the lack of health workers.

Where apartheid denied Blacks adequate training for medical professions, there is now such a

lack of health workers that a government ARV treatment plan can’t even be carried out because

there are such limited human resources.76 Along with the lack of health workers, a recent study

found that 13% of health workers who passed away between 1997 and 2001 died of HIV/AIDS-

related diseases. 77

Harsh Realities in Zonkizizwe

From May to August of 2008, I interned with an organization called Vumundzuku-bya

Vana ‘Our Children’s Future’ (VVOCF). The organization is located in Zonkizizwe (Zonke), an

informal settlement south of Johannesburg closest to Germiston. The informal settlement is best

described as a peri-urban area much like a shantytown with convenience stores. Some live at a

lesser degree of poverty than others, but everyone is impacted by HIV/AIDS.

Palitsza, Kristin. "A Burden that Will Only Become Heavier." Inter Press Service News Agency. May 28, 2006.

I […] learned more about the extent of HIV/AIDS in Zonke. The intern coordinator
reminded us that the statistic of students at MSU that have an STD is 1 in 4. We are only
lucky that HIV/AIDS did not enter the mainstream population. Here in Zonke 1 in 4
people is HIV positive. The family at the center is more so affected by HIV/AIDS and
now they work to care for children who come the center affected by the virus. There is
still a very high stigma and a terribly ineffective ARV program. Many people refuse to
get tested or even consider the idea. Each child at the center either has HIV […] has lost
parents from AIDS or related illnesses or has not yet been tested to know. There are
many who should be tested, but are not. […] It has come to my attention that much of
what the government does here looks good on paper and on banners, but there is a huge,
massive disconnect in implementation.78

Zonkizizwe is a snapshot of post-apartheid health care development failures. It was

founded when a group of displaced people set up shacks on a farmer’s land so that they could

live closer to potential places of work. Many times the South African government tried to

remove them, but they kept rebuilding. This is a story different than that of the Black townships

or Bantustan “homelands.” Zonkizizwe was an area not meant to be inhabited by anyone, let

alone poor Blacks. Understandably the story of health care here is one of an even greater lack of

access. Informal settlements had no budgets of their own to even attempt to build their own

health infrastructure and even if they did it would likely have been destroyed during forced

removals. Under apartheid, health services would have been incredibly difficult to come by.

Everyone waves from their steel-corrugated shacks, children smile and get excited,
parents and elders are welcoming - looking out over the shanty town roof tops that extend
as far as the eye can see in each direction, you can't help but wonder that within this
poverty and desolation mixed with laughter and happiness - what potential can be
harnessed, what community action can be inspired to make South Africa's future brighter
by and for those who live here.79

My goals as an intern with VVOCF were HIV/AIDS education, HIV/AIDS peer educator

training, and assistance with nonprofit organizational development. I was very glad to be able to

focus my strengths and interests in the work I did. I also worked to formulate a rough community

Hill, Alex B. Journal Entry. 15 May 2008.
Ibid, 13 May 2008.

health assessment based on my interactions with people at the VVOCF center, neighbors, visits

to the clinics, and interactions with Zonkizizwe residents.

Now Zonkizizwe has two primary health care clinics to serve its roughly 250,000 people.

Health services are all free through government funding, including immunizations and

treatments. However, the issue does not become access to treatments, but rather quality of care.

The director of VVOCF, Celumusa, said that all the health clinics do is give out painkiller tablets

for everything.80 She said she often just goes to the chemist [pharmacist] to tell them what is

wrong and get something that will actually help. This appears to be a direct outcome of apartheid

health policy. The lack of trained medical professionals, notably doctors, leaves local health

workers with no better option than handing out painkillers. Quite possibly the training of these

health workers remains inadequate as well. Zonke is an area much in need of the RDP’s action,

but all that can be seen here are RDP building supplies for new houses.

“You can see people die, sitting at Natal-spruit.” - Celumusa81

The closest hospital to Zonke is in Natal-spruit, about a 30-40 minute taxi ride away. If

you live in Zonke, this is the closest place to get ARV medications since the clinics are “not

certified” yet to distribute.82 There is another hospital nearby, but the taxi fare is more costly and

it takes longer to get there. Residents of Zonke don’t necessarily have the time or money to take

a day to travel to the hospital even if it is critical to their health. Those who go to Natal-spruit

notice a different level of care. People die waiting, people in great pain are not attended, people

in need of good health care cannot access it. At Heidelberg I was told the staff rush to help you

Hill, Alex B. Journal Entry, 6 June 2008.
Ibid, 29 May 2008.
Ibid, 10 June 2008.

and are much more caring.83 The Natal-spruit hospital is set to be closed soon and a new hospital

will be built in Extension 6, which is in Sandonga, much closer to Zonke. Maybe with this new

hospital the level of care and access to care will increase, especially in regards to ARVs


While working in Zonke, a fact that shocked me was that an HIV-positive person can

only access ARV treatment [for free, otherwise it is very expensive] if their CD4 count is below

200. This is official South African government policy and numerous studies have shown that

accessing treatment earlier has greater long-term health benefits as ARVs are meant to be taken

life-long. A World Health Organization (WHO) study in 2008 outlined four clinical stages of

HIV progression. The WHO recommends that when a patient hits stage three with a CD4 count

below 350, life-long ARV treatment should be started.84 Starting patients earlier negates

complications later. However, in South Africa once the CD4 count goes above 200 again,

treatment is stopped, which allows for greater complications and the need for new strains of

ARVs. This year a push to increase the CD4 count threshold for treatment was rejected by the

National Health Council on the grounds of affordability.85

Prof Robin Wood, director of the Desmond Tutu HIV Centre at the University of Cape
Town, is among the clinicians who have been calling for the South African government
to raise the standard of treatment set out in its guidelines. However, he pointed out that
better guidelines would be meaningless without improving the quality of care and access
to services.86

Professor Wood brings everything back to perspective. Anyone can call for greater access

and more treatment, but if there is no distribution system for health services and care then what is

Hill, Alex B. Journal Entry, 10 June 2008.
“South Africa: Government urged to raise treatment standards. IRIN/PlusNews. 6 May 2008.
“South Africa: Funding shortfall threatens treatment programme.” IRIN/PlusNews. 2 April 2009.
“South Africa: Government urged to raise treatment standards. IRIN/PlusNews. 6 May 2008.

the point. It would be like having a big supply of pizzas and no delivery drivers. This is the

problem in many former “homelands,” townships, and informal settlements. There are

inadequate or non-existent delivery systems for health services and treatment and so in areas

where the HIV/AIDS crisis is most critical, there is no system to address the problem.

Today was the 2nd half of Prevention in the HIV/AIDS course. The kids are incredibly
receptive with questions, comments, and the desire to learn more. We will be covering
Treatment and resources this Friday. Celumusa did a great job of translating and really
getting the course lessons through to the kids. Later in the evening she talked with us –
her passion and drive to get people tested and aware and knowledgeable is amazing and
so admirable with all she has been through. She is so excited about a Zonke testing day,
the HIV/AIDS class, working with the staff and community to make more people talk
and not be afraid to talk. Today she told the kids that she was HIV positive and they all
did not believe her at all – they asked her to cross her heart that she was not lying. I could
tell from the first class that the kids were learning much more than they had before
beyond what HIV and AIDS stands for.87

Much of the work at the center and the work that needs to happen in Zonke is HIV

testing. Once tested you can learn how to take care of yourself, your children, and your

community. When I asked Celumusa why people don’t test she said that people don’t know that

they can live with HIV. So many people are involved in risky behaviors, she said, they have

family members die from HIV/AIDS, but don’t test themselves. She also noted that pregnant

mothers are tested and are given tablets, but not told their status. Testing is critical and we began

working on this by planning a Zonke Testing Day for July 31st.

As I began organizing for the Testing Day, I came into contact with more of the health

services available in Zonke. There are a number of traditional doctors and surgeries in Zonke. I

can only imagine that this is because there is such a lack of other health services. Celumusa and

others have bad perceptions of traditional medicine: evil, it kills people, and the traditional

healers are crazy people. I was still having no luck finding any doctors, until I finally caught a

Hill, Alex B. Journal Entry. 30 June 2008.

traditional doctor in his office. He ran a clinic that was more Western than others and was

supposedly trained by the government in traditional healing, but his office was empty every time

I visited – no patients.88 Why are there no doctors?

Across the road from his office was a private clinic run by a group of Indian doctors. I

also had a difficult time finding them, as did many Zonke residents. I was able to visit the private

clinic only when Celumusa had to schedule an appointment for her baby. The private clinic had

become her last option that she was sure to see a doctor. This says a lot for the health care system

in Zonke (and other overcrowded settlements and townships left over from apartheid era) that the

poor will pay to see a private doctor because the government health services are unreliable.

Celumusa said they always give injections at the private clinic. Yet again I wonder about the

quality of care. The clinics give painkiller tablets and the private clinics give injections

(antibiotics?). If care is inadequate and access to ARV medication is beyond the ability of most,

then the extended scenes of cemeteries become less shocking.

In the past 2 weeks, 3 people have passed because of HIV and AIDS that we have been
directly informed of because the Buthelezi family has been close to the deceased – a
father, an aunt, and a neighbor. Living in an HIV positive community is so different when
you can fully understand the impact of just one life.89

It was as if I had seen the walking dead. The prospect of death is so intertwined with life

in Zonkizizwe that the author who wrote that South Africans attend more funerals than weddings

was supported by my experiences this summer. The hardest hitting example was with the passing

of the father of one of the families at the center. Three of the children attended the center. The

oldest was 17 years old and was taking care of her frail father as he withered away, making sure

her younger brother and sister were going to school, and attending school herself. This small

Hill, Alex B. Journal Entry. 17 July 2008.
Ibid, 6 June 2008.

family had already lost their mother to HIV/AIDS. The burden of disease was not met by the

health care system or any the government response. The burden of disease rests completely on

those who are affected and they do not have the resources to help themselves.

A critical aspect of combating the effects of HIV/AIDS in South Africa is education. As

one of my goals over summer I developed an HIV/AIDS curriculum, based off of the Peace

Corps Lifeskills curriculum, that the youth could share with the friends and families as peer

educators. The spreading of knowledge is a powerful first step in giving people the resources

they need to prevent HIV/AIDS. It is especially important when there exists no other means to

access this information. The Zonkizizwe schools are under-funded and teachers are under-

trained. This translates to the lack of a teacher for the Lifeskills curriculum and therefore the lack

of knowledge on sexual health and HIV/AIDS. VVOCF is beginning to fulfill a service where

the government is horribly failing.

All of our kids were tested, plus about 20 others. In all over 60 people tested. […] The
community and guardian support was incredible. There were a few positives that we
expected from already young mothers […] and unexpected bad news surprise […] Many
good surprises came out of the day as we learned of many negative cases that were
expected to confirm our worst nightmares.90

The success of solutions driven by citizens was best evidenced by the culmination of the

HIV/AIDS peer education courses, health classes, and the death of a father in an area wide

Year Number of HIV testing day. I had taken the lead in organizing the testing day
*(from Clinic #2) with the clinics, MSU study abroad volunteers, and various
2006 128
local organizations. Because of the stigma attached and
2007 246
2008 412
sensitivity of the issue I was a bit nervous when the day came.

July 31st 2008, the first Zonke Testing Day was a day of success fueled by the youth at the

Hill, Alex B. Journal Entry. 31 July 2008.

center. And while the numbers of people testing have made steady increases, the reality remains

that the majority of those who need treatment after testing will not have access. Many in the

generation just older than these youth mocked or scoffed at the testing day, but our kids were set

on it.

We really are building a new generation of freedom fighters - not afraid of stigma, talking
about sex, ready to be tested, and not about to turn a blind to HIV/AIDS. These young
people stood today with a powerful support base of each other evidenced by yesterday's
action and the larger community is taking notice. The youth continue to give me hope and
pride in being allowed to take part in such a community action.91

The realities of Zonkizizwe paint a vivid picture of the effects of apartheid on health care for the

majority of the South African population. The health system operating in Zonke is the ground

zero of the failures of post-apartheid government policy to address the far-reaching impact of



The sea of gravestones near Zonkizizwe was almost unimaginable. I would not have

believed it myself if I had not seen it firsthand. This scene conveys the real implications and

impacts of HIV/AIDS on a health care system and a country that has been stripped, divided, and

neglected by apartheid.

While I often asked why there is no doctor, I was able to track down a traditional

medicinal doctor who seemed to see no patients as well as the private clinic doctor who did not

seem to care about providing real health care to the residents of Zonke. Writing has been done on

where there is no doctor and what to do when there is no doctor, but the number one question in

South Africa is why there is no doctor. This question is answered through history: apartheid,

oppression, denial, and failure to recognize a crisis. The reality of apartheid health policies

Hill, Alex B. Journal Entry. 31 July 2008.

continuing to affect Black populations and responses to HIV/AIDS can be seen firsthand in the

Zonkizizwe informal settlement.

Health was a weapon of apartheid and it worked. Denying medical access and training to

the Black majority has kept the population in submission even 16 years after the end of

apartheid. The critical period of 1993-2000 saw the new democratic government with its hands

tied behind its back. There was no way that the health care system could be so dramatically

scaled-up to meet the human and social needs of the HIV/AIDS crisis. As Seedat stated in

Crippling a Nation, 1984, “Health in South Africa is inseparable from the economic, political

and social structure of the apartheid state.”92 The health and HIV/AIDS realities that can be seen

Zonkizizwe are direct result of apartheid’s legacy. HIV/AIDS in South Africa is not a direct

result of apartheid policies, but the impact of HIV/AIDS and the health care system of South

Africa is still inseparable from its apartheid past.

Seedat, Aziza. Crippling a Nation: Health in Apartheid South Africa, 101.

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Africa." American Journal of Public Health. December 2008, Vol. 98, No. 12.

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to Mbeki", David Philip:Cape Town & Oxford, 2003.

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UNAIDS 2008 Report on the Global AIDS Epidemic

Appendix A:
Timeline of Health Care and HIV/AIDS in South Africa

1913 “Tropical workers” migrating bring in high prevalence of tuberculosis (Packard, 230)
1919 Public Health Act places government control over mission health centers (Seedat, 63)
1930 Mines experience shortage of workers (Packard, 229)
1934 2000 “tropical workers” brought into SA on experimental basis (Packard, 230)
1937 The number of “tropical workers” increases dramatically after government ends ban on
recruiting mine workers above 22nd parallel (Packard, 230)
1948 National Party takes control and apartheid laws are enacted
Health budget is drastically cut (Seedat, 63)
Over 40,000 “tropical workers” are entering SA (Packard, 230)
1950 Population Registration Act required S. Africans be segregated into three racial categories
Group Areas Act establishes separate residential areas for different racial groups, “forced
removals” began of those living in the “wrong” area
1951 Bantu Authorities Act established “homelands” (Bantustans) taking away SA citizenship
and rights
Prevention of Illegal Squatting Act began destruction of basic health services developed by
individuals in the “wrong” areas
1960 Black townships became areas of concentrated population far from towns and city centers
*Sharpeville massacre kills 69, wounds 187 protesting the pass laws
1963-1964 Rivonia Trials
1970 South African Department of Health takes over control of all health services from ‘local’
governments, including mission and church hospitals (Seedat, 69)
1973 Department of Bantu Administration and Development begins takeover of all mission
hospitals in the Bantustans (Seedat, 69)
1976 Soweto uprising kills 23, wounds 500 in protest of Bantu Education policies
1976-1981 Four “homelands” (Bantustans) de-nationalize 9 million Black South Africans
1982 First case of AIDS diagnosed in SA, increased charges in governmental health services
(Seedat, 71)
1983 Doctors in the Department of Medicine at Baragwanath describe overcrowding and
shortage of staff as having reached a ‘breaking point’ (Seedat, 65)
1985-1989 SA declares ‘state of emergency’
1986 First AIDS Advisory Group established to aid the government’s response to the growing
1990-2003 Most rapid increase in HIV prevalence rates
1990 Mandela released from imprisonment
First antenatal survey estimates that between 74,000 and 120,000 people are living with
1991 Apartheid laws repealed
1992 Referendum on de Klerk’s policy
Mandela addresses the newly formed National AIDS Convention of South Africa
Free National AIDS Helpline established
1993-1999 Internal labor migration increases significantly, specifically among women
1993 National Health Department reported the number of HIV infections had increased by 60%
in the previous two years and was expected to double over the year
1994 First democratic elections held, Mandela wins

Minister of Health accepts the basis of the NACOSA strategy as the foundation for the
government’s AIDS plan
1995 International Conference for People Living with HIV and AIDS was held in South Africa,
Deputy President Mbeki acknowledges the seriousness of epidemic
South African Ministry of Health announces that 850,000 people (2.1% of population) are
believed to be HIV-positive
1998 Treatment Action Campaign is launched
2000 Department of Health outlines five-year plan to combat HIV/AIDS
International AIDS Conference in Durban, new SA President Mbeki denies HIV causes
AIDS, cites poverty as cause
2002 SA High Court orders government to make nevirapine available
Government remains hesitant to provide treatment to people living with HIV
2003 Government approves plan to make antiretrovirals (ARVs) publicly available
2004 ARV treatment program launches in Gauteng Province
2005 One service point in each of the 53 districts established for AIDS related care and treatment
HIV prevalence reported at 30.2% - a steady increase since 1990
2006 Former Deputy President Jacob Zuma claims taking a shower prevented HIV transmission
after “having sex” with an HIV-positive woman
UN Special Envoy on HIV/AIDS, Stephen Lewis attacks SA government at International
AIDS Conference in Toronto over ARV treatment access
2007 Mbeki is forced to resign, interim president appoints Barbara Hogan as Health Minister,
activists welcome the change and expect greater government commitment to HIV/AIDS
An estimated 1,400,000 orphans of HIV/AIDS in SA
2009 Apology for Mbeki ARV policy
Development of health services/ access to health services is a major issue in 2009 elections