PHA-Exch> Public Health Crisis in South Africa is more than just TB and HIV

[Claudio Schuftan]

Public Health Crisis in South Africa is more than just TB and HIV

David Pienaar

* *

*South Africa**'s public health crisis is deep-rooted in systemic problems.
Progress will require far-sighted, sustainable solutions.***



South Africa has more than 5 000 000 HIV-positive people. An estimated 1 000
000 need ARV treatment but only somewhere in the order of 2 00 000 people
are on treatment.



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 critical role to play in this. Positive role models need to occupy
people's minds at every opportunity. We're talking 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 news-readers swallowing their ARVs during the 7PM bulletin, we need
sportspeople talking out after games, and so on, and on…pervasively and
persistently. People from all walks of life need to destigmatise HIV
infections.



Protected sex needs to become the new cool, the new symbol of empowerment.
Men and women in the street have to become the ones who demand condoms,
because that is what they see their role models doing. We're talking real
scale of message delivery here, scale we've nowhere near reached yet, and
are unlikely to, whilst key people insist 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 immune system monitoring
tests, 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.



Thirdly, ARV drugs need to get out quicker and to more people. This is
obviously an enormous logistic 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 antiretroviral medication and that
unfailingly support adherence to ARV medication.



*Tuberculosis*

A TB wildfire is fanning through the countryside. Registered cases across
the country have increased by 80% over 5 years. TB cases have increased from
190 000 in 2001 to over 340 000 in 2006. Many of those that are diagnosed
with TB don't finish their curative course of 6 months, causing drug
resistance and spreading it around their communities. Multi-drug resistance
and extreme drug resistance, with prognoses worse than some cancers, are on
the up.



TB can be reduced though simple steps. Things 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 that is ravaged by HIV or TB. These
are specific diseases with specific, effective medications.



*Childhood disease*

More than 70 000 children die in this country 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 entirely self-limiting, and even
contributes to building up the immune system of a child.



Nutrition is especially important in a child, where food is quite literally
the building blocks for their future. Malnutrition is the most frustrating
diagnosis to make because it is the most unnecessary.



In the malnourished child with no clean water, diarrhoea is an unfair death
sentence. So too with pneumonia.



*Violence*

Injuries and violence are placing an enormous load on an already failing
health system. Violence and road accidents are second only to HIV/AIDS as a
cause of death in South Africa. If we could somehow get alcohol and firearms
to disappear, our casualty units and hospital wards could concentrate on
real medicine again and health workers might rekindle some motivation and
job satisfaction.



The reasons for such high levels of male violence and alcohol abuse are
complex but somehow relate to the value systems of our current society. We
live in a society in which it appears as if economics is the only thought
system required to describe the sum of all human activity. 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 "self-made man"
stereotype is touted as a success, despite ground rules that ensure that
financial success 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.



*Economics and the environment*

Rural mismanagement is creating a generation of urban migrants. The
resultant rapid urbanization is replicating the squalid conditions that
breed all of the above health problems. To assume that economic growth alone
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,
this was a hundred years ago, when Queen Victoria had an empire of other
nation's wealth to draw upon. Unfortunate too, is that the global financial
rules have changed drastically, and we as a "developing" country lack a lot
of the autonomy Britain had then.



As health activists we need to ask ourselves whether, by keeping health
within the economic paradigm, we are not complicit in overseeing its
deterioration. We can't be in the position where we keep deferring to
politicians and economists and accept their mantra, "Next year, economic
growth will reach the magical x% mark, and everything (including poverty and
its related health effects) will be fine".



We need an honest acknowledgement of the fact that even if "economic growth"
were to succeed nominally, the timeframes in which it operates are
incompatible with those of biology. A young mother in deep rural parts of
the country would be unlikely to access the benefits of such an economy
before her child starves. And this will happen despite the fact that there
is food for all in this country.



The notion that "economic growth" will improve the health of the poor
ignores other links in the causal chain of ill health and distracts
attention from the need to develop long-term sustainable solutions to health
problems. An "economic-growth-at-all-costs" policy could easily destroy the
environment in which it finds itself and, if current trends are anything to
go by, could end up benefiting only a select few.



The GINI coefficient measures income inequality in countries (a country with
a score of 0 has perfect equality, with everyone having equal income, while
a country with a score of 1 is the exact theoretical opposite, where one
person has all the income, and everyone else has none). It is no surprise
that countries with high GINI coefficients (South Africa has one of the
highest in the world) have some of the worst health statistics in the world.
Other states, like Kerala in India, or Sri Lanka have much greater
coefficients of equality (which is not necessarily the same as being
wealthy) and as a result have much better health outcomes than South Africa.




So, it is not absolute wealth that matters in terms of health outcomes,
rather, it is how fairly resources are distributed.



Economic growth tells us nothing about the state of our nation on the human
level. It just tells us about the amount of money in circulation, and this
is often in the hands of the already wealthy.

A lot more could be gained from focusing on the fair distribution of
resources and, importantly, measuring the impact of this on the quality of
human life.



We suggest therefore that one of the better measures of the state of a
nation is, quite simply, its burden of disease. Health statistics are never
just reflections of physical health alone. Instead, they also reflect, often
quite precisely, issues like regional poverty, national inequity, unsound
governmental policies, the fair distribution of resources, the quality of
our leadership and the state of health services, amongst other things.



There are many powerful interests vested in making a particular assessment
of 'economic growth'. This has a potential to generate biased results. The
annual burden of disease, by contrast, presents a very clear picture. It is
absolute, it is measurable, it has established and validated information
systems already in existence and it shows trends clearly. And currently it
is getting worse.



What's more, the determinants of good health appear in our Constitution as
basic rights. We are entitled to them by virtue of the simple fact that we
are citizens of this nation. So measuring improvements in health status will
be a very good proxy measure for our development as an enlightened
democracy.



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 inarguable value of human life.
When measured by this comprehensive approach, South Africa is failing
dismally. We can, and must, do better. In order to do so, we need to put
pubic health before private wealth.
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