(This post picks up from another, Mbeki's AIDS Legacy and Ours)
Mini-Skirts, Public Health & Mbeki
It should have been no shock last summer when President Mbeki, a man who has not recently
tolerated dissenting views, sacked Nozizwe Madlala-Routledge, the assistant health minister who very publicly tried to advocate for stronger action on South Africa's AIDS epidemic. Madlala-Routledge had taken
the helm of the health ministry from Dr. Manto Tshabalala-Msimang, who was out on medical leave. But after a short stint at the post, Madlala-Routledge was fired for "unsubordination", when Mbeki disapproved of her decision to attend an AIDS meeting in Europe.
If outspokenness and a maverick nature were Madlala-Routledge's transgressions, one might wonder, than why wasn't she dismissed earlier - or why was she ever assigned to the post? How did she so suddenly cease being a "team player"?
International media outlets checked their surprise -- the South Africa's government wasn't turning around on AIDS? -- before perfunctorily broadcasting dissapproval and a polite request that the South African government pay attention to AIDS. Mbeki is quite used this cadre of international critics who gripe about his refusal to deal with AIDS and he adeptly fended off the outcry. It's well-rehearsed, Mbeki and his naysayers, an almost monotonous dance...Mbeki forever lets the AIDS crisis in South Africa gain momentum, his compatriots die.
Predictably, the international spotlight on Mbeki's perennial denial of his country's AIDS crisis illuminated the problems with all the intensity of firefly on a summer's night, fluttering briefly here, flitting off there. The press reacted quickly and instinctively to AIDS news, but it was not the only issue about which Madlala-Routledge was outspoken. She was also starting to raise a warning flag about public hospitals.
A six week investigation by the (famous) Eastern Cape paper, the Daily Dispatch reported that despicable sanitary conditions, understaffing, underfunding and lack of equipment at the Frere hospital in East London were causing high rates of infant and neonate deaths. The South African national press riveted its attention on public health problems that were perhaps more germaine to Mbeki's prospects for continuing to lead the African National Congress (ANC) party once his second term is up in 2009.
Although the Unicef reports infant mortality figures for South Africa are about 45 deaths per 1000
babies, and 21 deaths per 1000 neonates, the reporters spent weeks in the hospital wards, manned the morgue, and conducted interview after interview before publishing their expose and claiming that the mortality figures were higher than reported and worsening:
"Minutes from weekly management meetings reveal damning admissions by doctors that
patients were dying because of outright negligence...Mothers and babies die at an alarmingly high rate, confirmed a former hospital gynaecologist....Last year's figures appear to be the highest on record, when at least 199 babies were stillborn [at Frere]......'I once saw a cleaner doing a delivery while there were students in the ward and she chased the students out because she said they don't know what they're doing,' said a student nurse, a claim corroborated by a veteran of Frere's maternity wards."
Assistant health minister Madlala-Routledge visited the hospital upon hearing of the report, and declared the situation deplorable. She was promptly fired. A resuscitated health minister Tshabalala-Msimang then returned to her post in time to summon a committee and report that the conditions at the hospital were fine. Containment achieved?
The press dug in, lambasting Mbeki for reigning over the now apparent public health crisis. Mbeki arguably expended more personal effort addressing this issue than the accusations from the AIDS activists. In his weekly newspaper column, he wrote a 3000 word essay titled, "Facts, Fiction and Mini-skirts", dismissing the paper's claims. The many threaded column wove through post-modernism, Charles Dickens, Marx, "the truth", and an interpretive course in statistics, not to mention the central mini-skirt theme:
"Mini-skirts achieved their high point as an indispensable item of women's
fashion and an iconic representation of the ethos of an age during the 1960s.
Even at the height of the craze, when it was virtually a social offense not to
show a considerable part of women's thighs, the statisticians remained loyal to
their profession.
They spread the notion, not difficult to understand even by the most discreet
observer, that mini-skirts showed or suggested more than they revealed..."
The thrust of the mini-skirt-memo was to assure readers that the newspaper's six week investigation on Frere's infant deaths was wrong, statistically spurious, not to be believed. The piece set to sooth the potentially volatile public, but also outlined in so many words the political confines that frame the president's stance on AIDS and emphasized his steadfast commitment to a neoliberal economic agenda.
Places of Death
The Dispatch editors were not silenced by the mini-skirt memo, instead they counterattacked, charging that Mbeki's faux mortality figures would be uncovered and he'd be left "hoist by his own petard." The fray surrounding Frere hospital and other public hospitals in the East Cape roiled the national headlines. The demonstrative exchange (relative to some of the staid journalism we're so used to), was not merely drama to sell papers. The public health infrastructure in South Africa has been ignored for years.
This may surprise people outside of the country who have heard of the country's cutting edge hospitals and its modern private health care system. Medical tourism is part of the fast growing tourism business in South Africa, a booming, much ballyhooed sector. You've probably heard of 'adventure seekers' who travel to Africa on "medical safaris", or more hair-raisingly known as "silicon safaris" or "scalpel safaris". Prospective patients travel to South Africa's state-of-the art medical facilities to get plastic surgery, fertility treatments, treatments and surgeries that would be more expensive in Europe or the US. Sounds enticing. Fly the 12 hour, 9700 km (6000 mi) flight from London to Capetown on Virgin Airlines, get a nose job or tummy tuck, hop in a jeep with your safari cohort and spend the day bumping over the grasslands looking for tigers running down wildebeests, then catch a quick dinner and the 12 hour flight back to London.
The safari goers and international investors chauffeured to the shinier places can't necessarily know of the economic disparities in Africa, acutely visible in the differences between public and private health systems, even more apparent to anyone who falls ill and enters a public hospital on the Eastern Cape. Phyllis Ntantala, a former professor of History and English in the U.S., wrote about the Eastern Cape hospital conditions in 2006. The 80 year old woman, who lives in the United States but grew up in the Eastern Cape, South Africa, was rushed to the hospital when she collapsed visiting her family in South Africa. She documented the hazards of public hospital admission in an essay titled "Places of Death, not Life".
"The state of the public hospitals in the Eastern Cape is horrific", she wrote, after finding broken equipment, dirt, piled up garbage, patients who lay unattended in the hospital for days, and water shortages that forced nurses to dry urine soaked mattresses in the sun outside. Ntantala describes her stay at Nelson Mandela Hospital:
"I was stripped and lay naked in bed under an obviously used sheet for two days until a member of my family managed to bring me some night clothes. In all my 80-plus years I have never felt as insulted as I did for those two days and nights lying naked in that bed."
She also inadvertently locked herself in a bathroom on account of a broken door that automatically locked from the outside.The octogenarian reported pounding on the door yelling for help for 45 minutes before someone let her out. When she recovered from her illness she traveled in the Eastern Cape and documented the deteriorating conditions across the province. She relays the story of a young man admitted to Mjanyana TB hospital for suspected tuberculosis:
There was no doctor on duty when he was admitted and he stayed there for three weeks without being examined or having a chest X-ray taken because the X-ray machine was out of commission. His family finally removed him and he was referred to a doctor in East London where he was diagnosed with TB and treated.
She described the bathrooms at Mjanyana:
"filthy death traps where germs must be multiplying by the millions. Toilets do not flush, tiles are cracked and broken and there is moisture everywhere. In such an environment, it is difficult to imagine how anyone could come out alive."
We hear more about AIDS in Africa, than public health. International health campaigns that get our attention tend to focus on one specific issue in order to galvanize attention and raise money. Many an agency fundraises in the name of AIDS and children, orphans or babies, to great reward. Children's health programs especially can make use of a photo of a child dragging a teddy bear up a desolate looking stairwell, in the name of malaria, or AIDS. We commend these campaigning efforts, in Africa alone over 2 million children will be orphaned from aids by 2020. We very much understand the necessity of NGO's that understand the imperative of facing down pandemics. Marketing campaigns that isolate diseases are essential to fighting disease. Public health, on the other hand, is an unwieldy area that doesn't lend itself to private fund-raising, heart-tugging advertisements, or measurable endpoints. But while NGO's carve out a special place for AIDS (as well as malaria, tuberculosis, leishmania etc), in reality, an AIDS crisis cannot be so facilely uncoupled from general public health.
History bears this out. In the late 1980's Romania's many malnourished orphaned children were given blood microtransfusions using unscreened blood. Unsterilized equipment, poor public health, government poverty and denial of the problems caused outbreaks of AIDS among hundreds of the children. Libya arguably had a public health problem before it had the tragic AIDS epidemic among hospitalized children which was then blamed on foreign health workers. China's contaminated blood and plasma banks spread HIV virus to thousands of transfusion patients. In each of these cases, Libya being the most recent, a combination of issues plus political denial of the problem by the country's leaders, led to an AIDS epidemic and tragedy.
While people die in public hospitals at unacceptable rates, the tourism board promotes private hospitals in brochures abroad. South Africa is not just ignoring its HIV/AIDS populations, it's ignoring public health when the result can go unnoticed. A recent Unicef report notes that 5.4 million people were infected with HIV/AIDS as of 2006 in South Africa, amounting to almost one fifth of the total population. Moreover, South Africa is also not likely to meet the UN's Millennium Development Goal of cutting under-five mortality by two thirds by 2015. "Instead, child mortality rose by an annual 5.8 percent in the ten years between 1990 and 2000". For several months, the spirited South African media diligently kept public health debacle in the news.
You're Either With the Revolution....or with the Opposition
Underlying the failure on both (inseparable) issues is ambivalent leadership on the part of the president's party. In August, the African media's Frere hospital investigation merged with the African media's condemnation of Mbeki's coddling of Tshabalala-Msimang, as the Sunday Times broke a couple of stories based on leaked medical records from hospitalizations of the Health Minister. One report, Manto: A Drunk and a Thief, told of the Health Minister's drinking, alcoholism, liver cirrhosis, kleptomania, and verbal abuse of hospital staff during a hospital stays. The paper also questioned whether favoritism and power allowed her to receive a recent liver transplant in ahead of others. The Times quoted hospital staff reactions to her behavior, including an employee who "said Tshabalala-Msimang’s antics were common knowledge among staff: 'Everyone here thinks its hilarious that she is today a health minister in South Africa'".
Mbeki responded in the the paper's account in another memo in ANC Today, August 31. Mbeki defended his
compatriot, Tshabalala-Msimang, who had been a loyal member of the "democratic revolution". Her approach to nutrition and AIDS was that of the ANC he said, and followed a "scientifically based pursuit of the goal of health for all". Following on with an interesting argument, he said:
"anybody could have the audacity publicly to argue that nothing should have been done to attend to the health of another South African human being, allowing her to die instead as some in our society have argued"
The ubuntu culture which he grew up in, he explained "valued and values the sanctity of human life". He defended the Minister's place in "the movement" and her 45 years serving the people. Finally he noted that "recent events have brought to the fore the obligation our movement faces, to choose between either ecstatic media adulation, or the defense of the truth as it understands this truth."
Media Revelations...Then Hoist By Their Own Petard?
The media has been taking government to task, now the South African government has heightened interest the media. Police are investigating how Sunday Times editor Mondli Makhanya and senior journalist Jocelyn Maker obtained the Health Minister's medical records. Last week the Times reported the two were going to be arrested, then a couple of days later, the Times reported that they weren't yet going to be arrested.
Also, last week the Financial Times (October 16, 2007) reported that activist shareholder Brian Molefe was trying to purchase the company Johncom, which owns the Sunday Times. Molefe runs the Public Investment Corporation "which manages R720bn (Pounds 52bn, Dollars 106bn, Euros 75bn) of civil servants' pension funds he is the single largest investor on the Johannesburg Stock Ex-change (JSE)." He works to "force traditionally white-run companies to promote more black people on to boards and into top management". According to the Financial Times, this approach has drawn criticism form those who think he should spend more time managing assets, and less time being a "government hit man stepping outside his mandate to enforce black economic empowerment (BEE), which is the "African National Congress government's policy to redress the financial inequalities of apartheid by transferring a stake in the economy to black control." Molefe insists that while he does wish to change the employee incentive system of the paper, he doesn't intend to change the editorial direction of the Times.