The upheaval of South Africas apartheid government and the subsequent transition to a post-apartheid government ushered in a neoteric epoch of liberation and egalitarianism for non-White South Africans. However, postulations of White pre-eminence and physical segregation, lasting aspects of an apartheid hangover, inhibit the South African government's endeavours to reorient its health system. Additionally, new economic accelerants toward privatisation functions as a new impediment to reaching equitability in their domestic health system. The enduring imbalance in the transmission of healthcare within South Africa is depicted by the distribution of HIV/AIDS; Black South Africans constitute by far the largest burden of disease. This rapid spread of HIV/AIDS among the Black community was compounded by Apartheid policies that enacted the creation of homelands and forced relocation of non-Whites to rural areas, implementing these policies with little concern for the capacity of these regions to maintain a population or establish an economic base. Often the government did not provide adequate housing, water, sanitation, schools, hospitals and other public services, seriously damaging the health of the majority of non-White South Africans. This chapter argues that the current inability of the South African government to sufficiently address the HIV/Aids epidemic is indicative of lasting apartheid divisions of in the healthcare system. The entrenched division within the health system, a monumental gap between world class private health care and a corrupt, neglected public health system, alongside government inaction, pseudoscience and conflicts between HIV/AIDS organisations, politicians and scientists have served to further the foundation of neglect implemented by apartheid policies. Despite significant progress in recent years
Backdrop
Beginning in 1948, Black South Africans began to be subjected by exploitative and interdicting laws that divided South African geography, and therefore healthcare, into compartments based on race. The separate, designated areas for Black South Africans were situated in rural areas and highly neglected by the exclusionary apartheid government policies. These areas, known as Bantustans, were comprised of 13% of South African in geographical terms but were home to over 80% of population (Price, 1986). In these cases, healthcare was largely provided by non-profit missionary hospitals and overseen by local gentry. By handing over the reigns of control to the Bantustans, the apartheid government of South Africa virtually absolved itself of its responsibility to supervise and keep track of the standard and quality of health care in the designated areas. As a result, the health care system began to oft ignore the quality-of-care guidelines, creating an environment of abuse and maltreatment, including falsification of medical reports, refusing those in need of urgent treatment as well as the possibility of the mistreatment of the mentally ill. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636545/).
Despite healthcare services within Bantustan areas already being exposed to limited funding and inferior medical services, the configuration and application of the healthcare system within rural areas further entrenched racial discordance. Hospital employees were hired based on what ethnic group they belonged to, with each hospital being ethnically segregated and staff only being allowed to treat other patients of their common ethnic group, meaning the segregation of health services wholeheartedly reinforced apartheid axioms of racial division (Price, 1986). This "bureaucratic fragmentation"(?) fostered the growth of ubiquitous racial discrimination in health care, separating the national medical services into a matrix of bureaucratic entities which were applied and monitored by various levels of government employees and medical administrators. The medical establishment in South Africa became subsumed by apartheid policy, giving legislative and administrative policy-makers the freedom to maintain arrangements of discrimination by gaining control of the budgeting tools and subsequent finances. Due to the extreme imbalance of economic status between Whites and Blacks in South Africa, the apartheid government was able to rely on markets to automatically enforce principles of medical apartheid by making costs of private health services and insurance high enough to prevent almost all Black people from access to an acceptable level of medical care (Rubinstein, 1998).
Reflections of a divided healthcare establishment
As a result of the growing needs of the South African middle class during the 1980's, the development of the private healthcare system has made it progressively more problematic to gain access to health care and treatment of a high standard. As of 2010, only 15 percent of the South African citizenry had the means of entry to private health care facilities, while the rest of the population, most of whom are black, relied the on an understaffed and overburdened public health service (Hunter, 2010). Contribution to the private health care sector allows patients to receive subsidies and tax benefits, despite the fact that only 15% of citizens possess the means to access private care (Kon & Lackman, 2008). Although the majority of indigenous, Black South Africans cannot afford the high costs of private health care, most of the private health facilities are situated in urban, metropolitan areas, meaning the private health facilities were for the most part inaccessible to the people of the Bantustans. This issue has been compounded by the influx of capital into the private sector, drawing medical experts away from the public healthcare sector as a result of the temptation of well established infrastructure and greater profit hauls. Between the mid-1980's and mid-1990's, the number of South African healthcare professionals rose by 26%, meaning 66% of these professionals were employed in the private sector whilst South Africa had only just begun to transition away from apartheid and towards democratization (Kon & Lackman, 2008).
After the fall of apartheid, South Africa's high hopes for social justice with regard to healthcare equity were manifested in the ANC's commitment to health care for all since the 1955 Freedom Charter, outlining redistributive plans with social tendencies that aimed to prioritize the health of the poor and vulnerable as part of their Reconstruction and Development Programme. The 1996 Constitution and Bill of Right's compounded this objective, setting out a clear vision for a health care system based around equality and humanity. However, after 1997 new macroeconomic strategies were adopted, leading to more orthodox, neoliberal economic strategies to be employed. As a result, the focus on tight fiscal policy and minimizing the role of the state overrode the initial goal of redistribution and equitable, human-rights based health-care policies. (Baker, 2010).
Tackling the issue of the distributive imbalance of human resources with regard to the public and private healthcare systems continues to be a significant issue in South Africa. Health care professionals in rural clinics usually have inadequately developed skills and a lack of management experience, further extending the detrimental impacts of a public health system that is understaffed and overcrowded (Coovadia et al, 2009). Spending per private medical scheme member in 2005 was nine times greater than public arena expenditure, with one specialist doctor serving fewer than 500 people in the private sector but around 11 000 in the public sector (Mcintyre, 2007). The presence of hundreds of health workers sponsored by NGO's highlights the lack of standardization with regard to tutelage, supervision and oversight of the South African healthcare workforce. As a result, key programs in the areas of child health, maternal health, tuberculosis and HIV/AIDS have been compromised as there is no uniformity of implementation with regard to delivery of specialised care and treatment (Coovadia et al., 2009).
Medical Apartheid
The health policies of the apartheid government established a network of bureaucratic mechanisms, institutions and individuals who all served the domineering objective of sustaining fiscal and constitutional power for the white population. It was designed to accommodate different levels of living standards for separate population groups, and therefore acted as a tool for the promotion of support for the National Party (Price, 1986).
Towards the end of 1997, the South African Truth and Reconciliation Commission released a 3500-page report on the human rights offenses committed under the apartheid regime of South Africa. The chapter regarding the health sector - the subject of Truth and Reconciliation Commission hearings in June of 1997, witnessed numerous individuals and groups presenting their perspective, supplemented by written submissions and a detailed survey of health care under the apartheid system by the Health and Human Right Project. (?).
The failings within the medical profession that were revealed fell under two categories: toleration or endorsement of inequalities in the health system and involvement in egregious offenses of individuals' human rights. The foundation of this disparity was a racially segregated health care system, where in which the provided facilities and services for the White community were vastly superior to those of non-Whites. By 1985, per capita spending on health care was triple for Whites than for Blacks, resulting in instances such as ambulances reportedly leaving the scene of an accident if they did not belong to the correct racial group. (TALK ABOUT BIKO INCIDENT.
In 1996, the Medical association of South Africa collectively apologized for its role in maintaining and in some cases endorsing apartheid. This extended beyond segregated medical facilities - with racial restrictions on admission to medical schools, colluding with police by breaking doctor patient confidentiality and allowing the interference of police in the treatment of detainees. The ethics and code of medical professionals had been eschewed by the institutional and ideological penetration of apartheid (
Impact of Apartheid and Politics of HIV/AIDS - A Neglected Nation
Partially due to the neglectful policies of the apartheid regime, South Africa is one of the countries most severely affected by the AIDS epidemic. Approximately 5.6 million people are currently living with HIV/AIDS in South Africa, the highest number anywhere in the world (http://www.kff.org/hivaids/upload/3030-17.pdf). Within this group, 2.9 million are women and 460,000 are children ranging from the ages of 0-14 living with HIV. 17.3% of adults aged 15 to 49 are currently living with HIV, as well as there being 2.1 million orphans due to HIV/AIDS under the age of 17 (UNAIDS).
In the post-apartheid era, the addressing of the pandemic of HIV/AIDS harmfully became a subject of political disagreement. Thabo Mbeki, the former president of South Africa from 1999-2008, supported and drew attention to the theory of AIDS denialism, probing the notion that HIV was the cause of AIDS. According to Jamie Gates, this idea went unopposed by the majority of South Africans, who had become suspicious of the European utilization of science and medicine as it had been used to the "detriment of black South Africans" (http://www.ethicscenter.net/files/u573/lacks.gates1_.pdf ). Gates elaborates by exploring the historical use of science in South Africa, stating that European science in South Africa was linked to white dominance in two ways - firstly, the relationship between science, the pharmaceutical industry and the extraordinary profits being made, and secondly, the legacy of scientifically-enhanced racism in South Africa. Black South Africans were also victimised by experimental medical trials that were common during the apartheid era, entrenching suspicion of the scientific community and its relevant institutions in the context of healthcare among the black community (2008).
In the early 2000's, Mbeki began to implement policies denying certain effective HIV/AIDS drugs, such as antiretroviral drugs, on the basis of Berkeley scientist Peter Duesberg's findings, one of the leading and only scientists who subscribe to the concept of AIDS denialism. Duesberg maintained this position even after evidence proved drugs had been successfully designed to cripple the virus and control the infection (http://healthland.time.com/2012/08/21/legitimate-rape-todd-akin-and-other-politicians-who-confuse-science/slide/questioning-the-origin-of-aids/). Due to government inaction and failing to provide an appropriate antiretroviral treatment program, it is estimated that over 330,000 people lost their lives between 2000 and 2005 (http://journals.lww.com/jaids/fulltext/2008/12010/estimating_the_lost_benefits_of_antiretroviral.10.aspx#).
Due to government inaction with regard to HIV/AIDS, the issue itself was left in the shadow of debates and disagreement surrounding the nature of the virus, despite the overwhelming majority of the scientific community accepting HIV as the cause of AIDS for over 20 years ( ). As a result, the South African government itself became a barrier to the distribution of medicine for those suffering from HIV/AIDS. To a particularly vulnerable majority of uneducated South Africans who maintain the highest number of individuals living with HIV/AIDS anywhere in the world, presidential leadership is crucial to lead by example and search for avenues of progress. In 2006, Jacob Zuma the current South African president, stood trial for raping a woman and stated that although it was consensual, he had taken a shower afterwards to reduce the chance of contracting HIV. In the highly publicised trial, the former head of the government's National Aids Council and the Moral Regeneration Campaign, also admitted to not using a condom (http://news.bbc.co.uk/1/hi/world/africa/4879822.stm). This disregard for his influential position and the HIV/AIDS pandemic in South Africa epitomises the lack of urgency and action with regard to the ANC and the HIV/AIDS issue.
Due to the historical legacy of apartheid and European domination, the ANC is held in extremely high regard by those liberated by its cause. As a result, occurrences such as Mbeki's support of AIDS denialism and Zuma's disregard for the severity of HIV/AIDS negatively consequence the consciousness of the impoverished South African majority. Over the years, support levels have largely been maintained, illustrating the need for South African leadership to be more responsible and progressive, guiding the country in a beneficial direction for the sake of the people that are in dire need for their support.
