Public Health, AIDS, Mbeki, and the Media

(This post continues from another, Mbeki's AIDS Legacy and Ours)

Madlala-Routledge's Sacking and the European AIDS Convention

It should have been no shock last summer when President Mbeki, a man who has not tolerated dissenting views in his administration, 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 left on medical leave. But after only a short stint at the post, Madlala-Routledge was fired for "unsubordination". Mbeki disapproved of her decision to attend an AIDS meeting in Europe and her outspoken methods for attacking the AIDS problem.

One might wonder though, if outspokenness and a maverick nature were Madlala-Routledge's offensive transgressions, as Mbeki charged, why wasn't she dismissed earlier? How was she ever assigned to the post? How did she so suddenly stop being seen as a "team player"?

The press reacted quickly and instinctively to AIDS news. Predictably, the international spotlight on Mbeki's perennial denial of his country's AIDS crisis illuminated the problems like a firefly on a summer's night, fluttering briefly and intensely to capture everyone's attention, before flitting off over there. International media outlets checked their surprise -- the South Africa's government wasn't turning around on AIDS? -- before perfunctorily broadcasting dissapproval and polite requests that the South African government pay attention to AIDS. Mbeki is quite used to the international critics who gripe about his refusal to deal with AIDS. and he adeptly fends off the outcry.

Mbeki and his naysayers have rehearsed this dance for years. Throughout the charade, Mbeki continues to let the AIDS crisis in South Africa gain momentum, as his compatriots continue to die.

Madlala-Routledge & the Decrepit Public Hospitals

But the HIV/AIDS crisis was not the only issue about which Madlala-Routledge had been outspoken. She had also raised warning flags about the 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 focused its attention on these public health problems that were probably more germane to Mbeki's prospects for continuing his leadership of the African National Congress (ANC) party once his second presidential term was up in 2009.

Unicef reports that infant mortality figures for South Africa are about 45 deaths per 1000 babies, and 21 deaths per 1000 neonates. The reporters at Frere hospital spent weeks in the wards, manning the morgue and conducting interview after interview before publishing their expose. They reported that the mortality figures were higher than the official figures 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. The Mbeki fired her. The health minister Tshabalala-Msimang had undergone her liver transplant and she returned to the Health post just in time to summon a committee and report that the conditions at the hospital were just fine.

The press dug in, lambasting Mbeki for reigning over a public health crisis. Mbeki arguably expended more personal effort addressing this issue than he did responding to the perennial accusations from the AIDS activists.

Mbeki's Stand Against the Media "Facts, Fiction & Miniskirts"

In his weekly newspaper column, he penned a meandering 3000 word essay titled, "Facts, Fiction and Mini-skirts", which dismissed the paper's claims. The many-threaded treatise 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 seemed to be an attempt to assure readers that the newspaper's six week investigation on Frere's infant deaths was wrong, statistically spurious, and not to be believed. The piece set to sooth the potentially volatile public, but also outlined in so many words the political confines that trademark the president's stance on AIDS. Part of that was Mbeki's steadfast commitment to a neoliberal economic agenda.

"Hoist By His Own Petard?"

The mini-skirt memo didn't silence the tenacious paper, instead the Dispatch counterattacked, charging Mbeki with concocting faux mortality figures that would be uncovered in time, leaving him "hoist by his own petard."

The fray surrounding Frere hospital and other public hospitals in the East Cape roiled in the national headlines -- and the exchange 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", 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, and operations and surgeries that would be more expensive in Europe or the US. This doesn't sound like the most enticing holiday. 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 to spend a day bumping over grasslands looking for tigers running down wildebeests, then catch a quick dinner and the 12 hour flight back to London? Fun, fun. But anyway, to our point.

The safari goers and international investors chauffeured to the shinier places may not know of the economic disparities in Africa, acutely visible in the differences between public and private health systems, and even more apparent to anyone who falls ill and enters a public hospital on the Eastern Cape.

Places of Death

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 while 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 outdoors. 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 went on to describe the bathrooms at Mjanyana as:

"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 capture our attention by focusing on one specific issue in order to galvanize attention and raise money. Many agencies fundraise in the name of IDS and children, orphans or babies, to great reward. Children's health programs can make great 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 for such a worthwhile cause - 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, nebulous 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 that was then criminally 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 basic public health problems by a country's leaders led to an AIDS epidemic and tragedy. Conversely, every country where there has been a successful AIDS campaign there has been a public health campaign driven at the highest level of government.

In South Africa, 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 all of public health when the results 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". The country that has one of the highest GDP's in the world, has one of the lowest HDIs (human development indexes) For several months, the spirited South African media diligently kept the hospital 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 the ANC. In August, news of 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. In one report, "Manto: A Drunk and a Thief", the paper told of the Health Minister's drinking, alcoholism, liver cirrhosis, kleptomania, and verbal abuse of hospital staff during a hospital stays. The Times questioned whether favoritism and power allowed her to receive a recent liver transplant ahead of others. The Times quoted hospital staff who said that Tshabalala-Msimanga's antics were common knowledge among staff, and that 'Everyone here thinks its hilarious that she is today a health minister in South Africa'".

Mbeki responded to the paper's account by publishing another memo in ANC Today, August 31 defending Tshabalala-Msimang as a loyal member of the "democratic revolution". Her approach to nutrition and AIDS was that of the ANC, which he said was dedicated to the "scientifically based pursuit of the goal of health for all". He berated anyone who had the:

"audacity publicly to argue that nothing should have been done to attend to the health of [the sobriety challenged Tshabalala-Msimang] 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?

Since the media has been taking government to task, now the South African government is showing heightened interest in 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 and 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 from 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.

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