Apartheid's Colonial Health and Mental Disorders: Fractured Consciousness and Shattered Identities Whenever I write about the past Apartheid regime's deeds on the African people, these are not merely notes as to the evilness or badness of the system, which it was, it is about the long term effects and affects these deeds, mistreatment or however one chooses to characterize, on the African population for generations and centuries on end, up to until today; also, a very important point worth noting is that this is written from an African point of view. When we deal with the History and story of African people in South Africa or anywhere in the world(Diaspora) we ought to listen to their accounts from their own perspective, maybe in so doing, this will hasten the healing of societies,and restore humanities and being human of the poor and oppressed. Little is known and understood about the social trauma and pathology that African People in South Africa had to go through and what this experience has been like and continues to be like, whenever they have to deal with Africans, health and the health institutions. The people have something to say, and they have their own way of saying it and how it affected them. The detractors of Africans in South Africa need to pause and begin to learn anew who their African neighbors are and what do they have to say bout their 'own' experiences under Apartheid, and what they hope for in the future, with their new ANC government. By going at such lengths to unfold the restrictive patterns of the Apartheid legacy, it is also important that those who were on the receiving side of Apartheid, and one should tell it exactly as it happened, and in the process help expand the knowledge about the subject matter before one indulges too deep and accuses them or any one of Making Afrikaners look bad, conveniently leaving out what the Africans are saying. The movie, Cry Freedom, form the eyes of Donald Woods, tells of the struggle that erupted in South Africa on June 16 1976; some say he was a liberal, but he told it as close as possible as Africans would tell it themselves. There is the problem of writers and readers within the African communities. This is not to say there are no educated people in South Africa or those in the fields of health, it is the paucity of material, written by and for African people, out of their own will and knowledge without being intimidated by either Apartheid rulers of the new ANC government, that we are talking about. This is so that we might see or have better understanding amongst the races, more especially on issues of health and African people's mental health in general. The Apartheid Censorship board has done a good job in leading to this shortage, and the poverty stricken masses would rather spend what they have scrounged on the meal for the day or evening, than buy books. It is the unchanging nature and the consistency at which these imposed life-styles ' and realities function amidst and within the country of South Africans, mostly as they affect and effect Africans, that their history should be written down and told about. It is important to see their life from their mouths, through their experiences and what their here-and-now is all about. When people come for the 2010 World Cup Finals, they are going to find a people who are happy to have them around, a people whose humanity is to recognize the humanity of others in others. But knowing the people as to how they got to where they are today, is important to help other people to be able to understand them when they visit the Townships, and the Townhouses and Mansions.
They will then tell their stories, the listener would be familiar with the reality they will be seeing. As of now, places like Soweto and elsewhere are being well manicured, but mashed-up with run-down shacks and some old houses since built by the Apartheid rulers. The Township people have tried to fix up some of their houses. There are things that are happening in preparation for the World Cup event, that they are cosmetically infrastructure, but the underlying social structure is deteriorating. So does the day-to-day existential realities of the people not change as we speak. As President Zuma told de Koc, that he needs to tell all what did without leaving out anything, because Zuma knows that the truth will be but one path towards healing the wounds and partly the psyches of Africans as they slowly reclaim their humanity, after living under a system that committed crimes against humanity on them. Why this is important, it is to help people of whatever ilk, to grasp the magnitude of the abuses and atrocities committed on Africans perpetuated by the Apartheid regime, and as these are put into perspective, using the narratives from their own point of view, it will more help heal the Africans, and make those who want to read this material more informed and be enabled to deal with the physical health and mental problems that are still persisting within the African community; and this suffering is more than four centuries old, and this consistently continues to plague African people and their descendants, truly speaking, since 1652 to the present as duly and doubly noted above. Apartheid's Colonial Mental Disorders is a very rarely discussed or a seriously talked about subject and phenomenon as to its effects and affects on both the African and Colored people. Today, those who were oppressed by Apartheid, have mental illnesses that have not yet been fully or seriously addressed, even today. Some structures have been set up throughout the land, but these do not really begin to address the myriad manifestations of many types of illnesses, mental health diseases and mental disorders prevalent within the African milieu. Not Every person of African or Colored Ancestry is mentally hurt, but are fully stressed, assailed by the silent killer sugar diabetes, murderous strokes, and seismic heart attacks, malfunctioning kidneys, with constant and recurrent TB consistently presently affecting and killing multitudes, scurvy, leprosy and many maladies that are consistently affecting and killing millions of Africans and Coloreds throughout South Africa. For expediency, although we will be alluding to the Africans and Colored throughout the narrative, we will use the generic name, "African" to refer to Indigenous Africans and Coloreds. There is also a newly added fixture of making Africans sick, these come in a form of drugs like Cocaine, Mandrax and so forth, which are mesmerizing and disabling Africans mentally and contributes to the rampant crime waves that are besieging them. The South African society does not just consist of 45 million or so people. There are added foreigners that have sojourned there with the Advent of Democracy, but it is also made up of social classes, of political parties, trade unions, schools, churches and many other social institutions, structures all of which play a particular role. Most importantly, society is made up of relationships that exist between all these different elements and societies. These relationships can only be understood if we look at their history as well as well as their current appearance and manifestations. Just because the Apartheid rulers were cast aside, does not mean the conditions on the ground changed just as quickly, nor did the machinations of apartheid seize and that new ones implemented by the new government struggle to emerge. If one wants to know why someone is ill, it's not enough to look at him or her individually, as a mechanical body that is malfunctioning. We must also understand the social and physical environments in which they live, and how this environment has been created and is affecting them. Any explanation of ill health which ignores or
deliberately conceals the impact of isolated heath and social structures on the health of the African population, is helping to keep those structures intact, and prolonging the creation of unnecessary illness. The primary thrust of this Hub is to look at how Apartheid created this mental health crisis, and what steps are being built making for a healthy society and to try to understand what makes the present one so unhealthy, and that depends if those steps are being taken care of; also, what was, still is and might continue to be, debilitating diseases imposed on African people. So that it will also be important to look at the aspects of disease in South Africa in the context of the Apartheid system -- the dominant social reality, then and now, in South Africa- and the facilitation of these by the present ANC government and how this is worsening the mental health of Africans today. As with mental illness, these institutions that deliver health services... are also branded with the stamp of society in which they operate and exist -- they are apartheidized health structure, and continue up to this day. They cannot be understood simply as institutions responding to disease: they have been shaped by the apartheid state to the same extent as Bantu Education or the practice of housing people in separate 'group areas' Act .(You can read on both the former in my hub: "The Miseducation of the Africans: Savage Inequalities in four part Harmony", and the latter, "Group Areas Act in my hub, "South African Apartheid; So Where To Now?") The fight against this type of disease will not be simply a technical one. The best possible health for all will not be achieved by medical science alone; it will only arise out of a thorough understanding and critique of the existing services, and continuing a struggle to create a better one. It is only now 18 years that African people installed a government they chose in a democratic manner. It has bee over 400 years since they lost their lands and freedom; this article will try to trace the historical evolution of the coming of diseases amongst Africans and what happened from then onwards. The coming of mining, industry and the resettlement environment that have negatively impacted African families, communities and society. It will also in short trace the origins of the creation of migrant labor and take a look at the Apartheid systems as they operated and affected millions of Africans in multiple ways close to 400 centuries. As to the White community, they have always gotten first class treatment and healing institutions with state of the art equipment and excellent doctors and a hard working nursing staff(mostly African) and clerks and porters, cookers and so forth. This is still the case with the state of Public Health in south Africa. Sad to say that this goal will not be reached amongst the millions of the army of the poor, until South Africa as a whole has been thoroughly and completely transformed. Creation of Health Services From the 1600s In the Transvaal and the Free State, farmers tried to get new pass laws enacted to include women in the rural areas. But the British colonial authorities, reflecting the European sexual stereotypes, and ignorant of platteland labor practices, intervened, claiming it was unnecessary. In addition to freedom from rural pass laws, Free State African women enjoyed a degree of freedom and mobility not available to their sisters in the other provinces. In the Free State, Africans were not subject to a separate set of "Native Laws" as in Natal. When Africans and their families and societies were being broken up, there is a lesser known and
not seriously discussed history of the early colonies and their health practices. When the twentieth century was ushering itself in, development of modern medical techniques were developed, and hospitals were now regarded as places where a person could receive possible treatment in the safest conditions... This is questionable and even not true today. When the colonization of South Africa began in 1652, the Dutch East India Company's sailors had succumbed to illnesses like scurvy whilst at sea, hospitals were built for the purpose Harboring sick sailors who had succumbed to all the illnesses at sea. Medical practices at that time were primitive and "Blood letting," "Blistering," and "Sweating" were the favorite measures and vast quantities of purgatives and emetics were prescribed. And anyone who had a decent home stayed at home when sick, or if they could afford it, paid private doctors for the above mentioned dubious practices.Gail Gerhart informs us that: "On the eve of World War II, although the townward movement of Africans was well underway, some 80 to 85 per cent of South Africa's 6,6 million Africans still lived on land. Of these, about 2.2 million lived as laborers on white farms. The rest... who were the majority of rural Africans or some 3.2 million, eked out a living in the increasingly impoverished reserves, supplementing their resources with wages earned by migrant relatives. By any kind of political reckoning, the typical South African peasant of the late 1930s was still parochial in his orientation and quite thoroughly interested in the social and political causes which were increasingly capturing the attention of urban Africans. Yet, if any stratum of Black South African society could have been described as porto-nationalistic in outlook, it was the peasantry, for it was the peasant who, more than any other African, felt the most deeply and immediately the sting of dispossession and the injustice of conquest. Land occupied by his parents and grandparents within living memory was now in the possession of whites; where African herds had once wandered freely, fences now barred the way. Aspects of material culture brought by the Europeans-cooking pots and bicycles, medicines and even white religion could be accepted and appreciated, but the White man himself was forever a conqueror, and invader whose presence was tolerated because Africans lacked the power to expel him." Gerhart adds: "In between the peasant and the townsman proper, there were Africans in many stages of semiurbanization, from the tradition-bound migrants to men, perhaps with some formal education and perhaps accompanied in town by their wives and families, who aspired to become permanent townsmen but still had ties to the countryside and expected to return their in their old age. Well into the 1930s and '40' migrants and semi-migrants tended to predominate, but the number making the permanent transition to city life also rose steadily. Women, who in 1912 made up only 19 percent of all Africans in towns, by 1936 comprised 36 percent of the urban African population, an indication that large numbers of families had shifted their principal homes from country to town. These specific patterns of urbanization varied from city to city, as did the major types of work available to Africans-mining on the Reef, factory work in Port Elizabeth, East London and Johannesburg, stevedoring in Cape Town and Durban, service and domestic jobs everywhere-but whatever the particular the particular pattern, the transition from old existence to new was an arduous one, calling for many social adjustments and much endurance of hardship. In Johannesburg on the eve of World War II, for example, according to de Ridder, one City Council house existed "for every estimated twenty-eight Africans living in the city, The rest ... were living in shacks and squatter camps, without water or sanitation. Today, in they
year of 2012, the majority of africans in south Africa are still living under the conditions of squatter camps as they did in the 1930, and before them in the 19 century. Even with their temperament of "Ubuntu," as we speak, mental diseases are widespread amongst the African population because care has not yet been taken to give the whole nation a serious psychiatric help from the conditions that they have endured for so long, with respite or change. In 1755 South Africa a serious smallpox epidemic broke out in the Cape and 963 White settlers and 1000 African slaves were affected. The small pox victims were isolated by the authorities and they opened temporary hospitals, one for Africans and one for whites. Their purpose was to isolate the sick,not treat them, and when the epidemic ended, the hospitals were closed. The theme of isolation runs through much of South Africa's medical history. For instance, in early 1800s a leper colony opened in a place called "Hemel Aarde" (Heaven and Earth). By 1822, 120 lepers were confined there in conditions described by a doctor of the time as "squalid and wretched beyond description". By 1845, applying this policy of isolation, Robben Island, which later became a prison where Mandela was incarcerated, was opened up as a colony for lepers and lunatics. Wherever the White population settled in South Africa, jails were constructed before hospitals. The sick poor and the mentally ill were confined in these jails.(P.W. Laidler and M. Gelfand). In the modern In the middle of the nineteenth century hospitals for Africans were opened in Pietermaritzburg and Kingwilliamstown, along the east coast of South Africa. Both hospitals were named after Sir George Grey, governor of the Cape Colony at the time. In the eastern Cape, White settlers had waged a war against the Xhosa-speaking people and inhabitants of the so-called 'frontier areas' and the British finally came and took over. In Natal, the African population was also resisting encroachment on their land. The two Grey's hospitals marked one of the first attempts to subdue resistance through "winning the hearts and minds" rather than by military conquest. Dr. Fritzgerald of the Hospital in Kingwilliamstown stated his intentions explicitly: "Give me only one institution like this, give me talent and ability combined with kindness and mildness ... let pure untainted charity have free play ... let the heathen feel as free as in his kraal ... such as institution will draw the savage from the remotest part of South Africa and attach him forever to that government which entered in spirit into his sickness and provided a remedy." This was the Apartheid rulers mindset, and in fact it turned out bad for Africans who are still affected by this logic of Apartheid forced 'civilization' they had set in motion-still clearly apparent amongst the African population today. TB, Miners And Their Families Initially, Africans were not interested in working in the mines for low wages and under dangerous conditions. But the gold mining companies promised untold wealth to the mine owners whom they would pay tax. If a labor-force did not exist it had to be created. This was done in two ways: by limiting the amount of land available to Africans for farming, and by imposing cash taxes which forced people to earn money. During the early days of the finding of gold in South Africa, the mine owners needed skilled workers with experience to work underground. And a large proportion of these were recruited from mines in Britain and Europe. Secondly, they also needed a large, cheap, unskilled work force. These workers had to be prepared to work for low wages, doing the hardest work in dangerous and unpleasant
working conditions. This work-force was to be violently fashioned from the African population by the European colonizers. Over the years a number of laws were passed in the different South African territories prohibiting Africans from owning or hiring land in the 'white areas' and restricting the size of the reserves where they could farm. These laws were revised by the 1913 Land Act which made just more than 12% of the country's land available for African residence and agriculture. Land became overcrowded, farming became more difficult and some men were forced to go the mines to earn a living. This process was speeded up by the imposition of a number of taxes: poll taxes, hut taxes, even dog taxes. The only way to earn money for taxes was to become a wage laborer.(TFB Collins) It is through these tactics that African labor was coerced and compressed into the mining compounds. See the pictures in the Photo Gallery on the right. The Advent of TB Within The African Milieu Mining of gold and diamonds in South Africa helped and hastened the break-up of African families and societies, along with the African spirit and mind. Dr. Macvicar did an extensive research on TB in Southern Africa in the first ten years of the twentieth century. In his discoveries, he was able to glean that until the mid nineteenth century the disease was unknown or very rare in the Transvaal and the territories then known as Southern Rhodesia, Botswana(Bechuanaland) and Lesotho. Dr. Neil MacFarlane, who was chief medical officer for Lesotho(Basotholand) says that TB was rare until the 1880s. A 1944 South African Medical Journal article states that TB was almost unknown in the Transkei 40 years before. By 1860 there were outbreaks in places like Butterworth and Queenstown(Both in the Eastern Cape, South Africa), and wherever military, trading or missionary outposts existed. It was in such places that the African population came into close contact with White settlers and began to contact their disease. These outbreaks however were isolated, and the disease did not spread. (E. Glatthaar) From all of these two things became clear: until it arrived, TB was not a disease known to the African population. Secondly, where isolated cases occurred, it did not spread. The only explanation is that conditions at that time did not favor the spread of disease. In other words,the population as a whole, more specifically African society, was reasonably healthy. This then means something must have happened between the middle of the century and the presentday life and sickness amongst Africans, that must have changed the situation completely. When gold was discovered in South Africa on the Witwatersrand (Present Johannesburg Area and the outlying areas) in 1886 that's when the disease took hold. The history of South Africa and health conditions changed radically and dramatically at this point, and along with the latter change, was also the change in the history of TB. It is important to note that one can be infected with the TB bacilli (germs) and never be sick. One gets contaminated by breathing germs from another sick person,but if that person who is not sick is well fed and not overworked or emotionally strained, their bodies can fight the disease. These people developed no symptoms and they cannot pass it to anyone. But if they are later become sick from another illness, or they do not get enough food and suffer great emotional and physical stress, then one's body weakens, and TB settles in or is activated. One cannot fight the TB germs which are still in one's body, and will probably get TB in its active
form. If there is a lot of malnutrition in society, there is a lot of TB. Overcrowding also helps the disease. In South Africa , as noted above, when land was taken away from the Africans, they were given small land to farm and overcrowding began in their homes and amongst the majority of poor africans who were crowded in mine compounds[see photo gallery], shack houses or those built in the ghettoes like Soweto, called "matchbox houses" with a few rooms for huge families were exposed to and likely to breathe in the germs coming from people who were already sick. If some tourists were to visit South Africa, they must try and visit Santa Hospital next or the present hospitals that deal with TB to get a better picture of what I am talking about, as the reader is now informed, came around the time when Gold was found and Crown Mines and other mines were opened on the fringes of Johannesburg-and these man-made yellow mountains of the extracted gold(which can still be recycled from that soil, although the government has stopped that practice)today in South Africa. Dr. E. Glatthaar of the Media University of South Africa has given an estimate that close to 10 million Africans who were infected, and most of them did not have it in an active form, but could get TB if their condition deteriorated, He also added that at least one hundred thousand people developed TB every year in South Africa leading up to 1982. A significant amount of people in the African community in South Africa has ben infected by TB in an inactive or active form. Today, with opportunistic diseases like HIV/AIDS and many others with poverty to go with it, repetitively over hundreds of years, must really make one pause and think about what I am saying. Along with these obstacles, Gerhart shows us what other deep underlying effects that were imposed on Africans by Apartheid were like, and we should count theme into the calculation as to how these affect mental states of Africans in south, since, as duly noted, have going on from the 17 century to 2012, and promise to that they are going to go beyond that time, and date frame. In the Eye of the Germ TB then is a very common disease among the poorer sections of the African South Africans. This has not always been the case. TB, as noted, was a relatively new disease in this country, and it became a problem around the beginning of the century. Now that we are able to trace its origins, we can now see a close connection between economic and political factors, and the development of TB as a major problem. Glatthaar paints the following statistical picture" "Only 1% of all reported cases occur amongst Whites, and the real proportion of whites with the disease must be even smaller. 'Each year about 50,000 cases new cases are reported. The actual number of new cases is about three times that amount. This means that about one hundred thousand cases a year are not reported and therefore not treated. Almost all of these were African people with no easy access to health care services or to doctors in private practice. So in fact, white probably make up less than 0.5% of people with TB in south Africa." During the Apartheid era, the government gave the official statistics for TB as dropping since around 1970s... This claim has been treated with suspicion because in Cape town, which has the best health statistics in the country, the number of notified cases was rising . In 1978, 8.8 out of every 1000 people had TB. In 1981 this figure had risen to nearly 12 in every 1000. One other thing that that explains the risen rate is that a number of people from the Transkei and Ciskei went to Cape Town "Illegally". There is the possibility that some of them came to the city as carriers or active carriers of TB. The breaking up of African society and families was inevitable. The culture and customs were shattered
and they could no longer act as a social glue or deterrent of foreign assailment. The urbanization of African women added to the dissolution of African family and social fabric. The prevailing social perceptions of women had their historical roots in the rural experience of the platteland . The custom on the farms was for African women to do all the domestic service in the white households and to help with other aspects of the farm work when required. The use of their labor was unpaid, casual, erratic and irregular, leaving a great deal of uncertainty in the lives of the women. Women could be called upon without notice to perform a wide variety of tasks required by the White masters. It was often assumed that young African girls would spend several years of "apprenticeship" in the white household. But during the first decade of the twentieth century this labor pattern was seriously challenged. Rather than face a lifetime of subordination, many women chose to leave the rural areas altogether. Many of them acted against the wishes of their own families, but, ironically, were protected in doing so by the laws of the land(Dorothy Hammond) This break-up drastically altered and changed the African family formation forever, to what we see it to be today. My Hub, which is about to answer all these broken strands of African families, customs, tradition, languages, traditions and practices, are reassembled with a new addition that anchors and embeds African South African history with the rich history of Mapungubwe. The period of reconstruction following the Anglo-Boer War brought dramatic changes in the countryside. The sudden influx of large amounts of British Capital into the agricultural sector had a negative impact on relationships between white farmers and black workers. Workers who had previously enjoyed some degree of independence lost such rights and the real value of the compensation for their labor depreciated. As the terms of service declined, many African women simply refused to serve, leading farmers to begin clamoring for more control. Male farm workers were quite restricted in their movements by a baffling array of pass laws and efforts were made to extend the system to cover women. The problem was explained by a rural policeman: "At certain seasons of the year it is almost a daily occurrence for me to receive a complaint from one of the farmers to the effect that the wives and daughters of his native squatters have, in defiance of him, their husbands and fathers, gone away to visit or attend a beer party on a neighboring farm and left the agricultural work which required immediate attention to be taken. The same applied to daughters of squatter, who the farmer permanently employs as domestic servants." As the conditions of squatting are made with the head of the family, the police cannot take any legal action ... If the native females had to have passes, it would not only assist the police in the prevention of this, but would give the farmer absolute control over the wives and daughters of his native squatters."(Transvaal Native Affairs Department(TNAD) Report, 1908; Tim Keegan) These are some of the restrictive laws that were imposed onto Africans and were rigidly controlled by the Apartheidizers, without let-up, for hundreds of years-more intensely from 1948 to the take over of the ANC-led government. The Scourge of TB For us to fully understand and appreciate how these affects affect Africans, it is better to have started in the beginning, and from what we can eke out of those experiences will better help Africans to understand themselves better and be more pro-active in their day-to-day survival of the disease . It should be understood that about conditions on the ground within the African milieu,
change has not been for the better, especially in the realm of health. The stress that comes with the environment African people had been relegated to today, is important to Africans because this existence is an inherited degradation. Biko once put it that, "The lie perpetuated by the White rulers has made Africans to not love themselves and see themselves their self-worth." Biko adds that, "The most genius thing that White rulers was to make Africans see themselves as such and believe it." Articles such as this one is an attempt to equip African with written records of their suffering and try and reveal their humanity in the process of undergoing dehumanization, in any form. Afrikaners and other nations all over the world write their own history as they see fit. Yet, the fact that Africans are ruling and are setting their history straight, this in turn becomes interpreted as 'misinformation,' 'propaganda,' blemishing the image of the "Minorities((and yet this is supposed to be a Rainbow Nation - as someone averred virally, ("Is it because there is no black in a Rainbow?") The past informs us about the present so that we can make informed decisions about the future. The historiography of South Africa is having added to it the African History from the African people's point of View. We are history because we live with it and in it. The health conditions in the townships today are atrocious. But while the tendency is to focus on the health institutions, we need to understand its historical evolution for us to better understand Africans today, and maybe help them make wiser decisions about their health and health institutions. This other point which is not yet considered a fact is what is affecting African people: the paucity of books and reading material; the degraded and poor classroom and, lack of direction as to education for a new African society; dire financial and material poverty has created an army of uneducated Africans, and, the HIV/AIDS, TB, drugs and lax social services, have all contributed to the lack of books, causing zero social awareness and knowledge cultural cohesion and tumult in the customary practices; African people's inability to afford computers, let alone install the internet therein, has been prohibitive and created those pockets and vacuum of ignorance that bedevils Africans today. These effects attained their origins from the history of Africans facing and colliding with European Colonization. They(Europeans) invented have maintained the notion that there was an uninhabited country they took and 'made' it what is today-when the landed and made their 'Great Trek' from the Cape[in the process built the country on the back of millions of African men, women elderly and children]. TB because it is a social disease, is not a natural illness, caused by bad overcrowded living conditions, stress of being oppressed, poor food, and can be cured with some medicine,means that the eradication of the aforementioned ground conditions need to be erased/resolved, and could be managed by eliminating poverty and social foisted upon the Africans all these centuries... Many of the skilled mine workers that from England and Europe were infected with TB, although few suffered from the disease in active form. At that stage, because of the poverty, overcrowding and poor working conditions which resulted from the industrial revolution. TB was still common throughout Europe. These miner also developed silicosis, a disease of the lungs which encourages active TB. Silicosis is cause by a special kind of dust in the mines, and this disease affected a large number of workers on the mines, especially when dust control techniques had not been properly developed. Statistics for the years 1903-6 shows that the majority of white mine workers who developed TB were immigrant workers.
Underground and its Effects Mining for Africans has always been hazardous from the beginning of the imposition of taxes on huts, dogs and the like. In the mine itself underground, it was poorly lit and poorly ventilated in its tunnels, these tubercolotic immigrants worked closely with unskilled African workers from the reserves. In the long run Africans were infected and encountered the two conditions necessary for the spread of TB. One of the conditions that contributed to TB was the presence of the bacillus which caused the infection. The other contributory factor was the people who were weakened by poor diet(which was eventually somewhat improved), stressed, overworked. These two factors collided in the mines, and thus begun a TB epidemic that is still ruining the health of thousands every year, to date. "Around 1900 and 1910 was when TB became critical," report of a Johannesburg officer of health said in his report that, 'there was a very noticeable increase of TB among the natives of Johannesburg. One researcher says that by 1903 about 70 out of every African mine workers were dying of TB." In 1905 the South African medical Congress appointed a special committee to look into the spread of TB. Dr. Macauley gave the following evidence to the Commissioner of Mines in 1906 and said: "It is apparent to us from statistics which we have been able to gather that Tuberculosis has enormously increased on the mine(fields), not only among whites, but largely amongst natives. Because TB was so devastating that number of commissions were created to try and deal with the problem. The Commissions were clear that people who were susceptible other decease were falling victim to TB once they arrived in the mines. In 1905 the Commissioners were unanimous that the spread of TB amongst Africans in the towns was due to the 'unhealthy manner in which they lived .... overcrowding, poorness of diet and want of ventilation and sunlight too often found in the town locations, compounds and barracks in which Africans congregated.((Report of the Miners Commission, 1902-03, Pretoria, 1903) The facts above are the reality of today in south Africa, with overcrowding, tin-shack dwellings, depressed conditions still persisting even as I write this Hub; and yet, the reports and commissions were formed as far back as the 1900s. Miners lived in compounds to which they were effectively confined. They lived in large rooms 'housing twenty to fifty workers who sleep on concrete bunks built one above the other like shelves. Many of the huts had earth floors which turned muddy in wet weather. When the huts were crowded, workers had to sleep on these damp floors. The diet consisted largely of porridge, some meat, mainly offal, and beer. Almost all food was consumed in one large meal at the end of the day, which was dished into their plates with a shovel [see these pictures in the Photo Gallery]. Miners ended having to spend their money outside the mine for additional food, yet the mine had promised to provide all the food needs of their workers. Hunger and wretched working conditions were some of the issues the African miners had to contend with. Miners during those days woke up at 4:30 a.m. , and in some mines bread(Mbonyama) was provided, some coffee, some soup and others no food at all. Journeying to work took two hours. Then followed a shift of 10-11 hours with no real break and no food. The wok was physically very tiring, the mine shafts hot, dusty and damp. Then the trip home, which might include long waits for the cage, waiting for work tickets to be stamped and food tickets to be issued. The workers returned to their
compounds in the late afternoon, and were provided with their one main boring meal for the day. These were conditions perfect for breeding TB and made the mine workers susceptible to the disease. TB grew from the mines, to the towns surrounding the mines, and now it was more common in the reserves. A Brief Case Study: Transkei The statistics do not give us a complete picture until we meld and merge the multitudes in the grip and grid of poverty and draconian laws that stripped them off their humanity and their reality(statistics too). That is stress enough. Then in the mix we have a disease that is affecting large swaths of communities, who were not infected, but for the men who returned from the mine, those that lived in the Kingdom of Lesotho,and those in the reserves like the one in the Transkei. Dr. Neil McFarlane, chief medical officer for Basotholand(Lesotho) wrote that TB was rare until 1890s: "It[TB] has not been indigenous to these parts, and cases seen were boys who had been working on the mines and in Johannesburg. But now it's attacking others who had never left the country". In 1908 a surgeon in Flagstaff opined: "Time and again one Native who returned from the mines infects the entire occupants of a hut previously healthy." In order to fully understand what makes Africans in South Africa tick, some of the descriptions about their conditions and existence or survival, (today they say they are "Coping"), under Apartheid to appreciate why it is important to begin to understand that the mind-set and state of sanity of Africans in South Africa today is due to these conditions which have not ceased, and have morphed into different attack modes, rendering mental illness a huge and fast-growing sickness amongst Africans in South Africa. Let's look at these stats: Surveys in the Transkei, Ciskei and Basotholand(Lesotho) around 1930 shows that between 69% and 88% of men aged about 20 were infected with TB and 72% of African workers applying for jobs on the mines was infected. The ,majority of them did not have TB in an active form. The figures show us that the people with the disease in its active form passed in the reserves on to a very large proportion of the African population. The mine owners and the White authorities did not intended to allow a large Township to develop next to the mines(but in the case of Crown Mines, it is not far off the ghetto of Soweto, and Soweto is out-of-sight for those living in downtown Johannesburg whose view of Soweto is blocked by manmade Gold dust and mine dust mountains). In fact, these Yellow/White man-made mines are just a walk away, the ANC-has in fact built many of these houses just a stone-throw from the foot of this poisonous hillocks-or Mine-Waste-Dumps.This point about the White-man-made mine dumps created by the mines, T The new government has put people there, and they did so knowing how the dust affects the People of Soweto, during the August windy day , is something that needs to be discussed in depth later on. Pass laws ensured that the Africans were in 'White areas' to work. Whenever an African immigrant had completed his contract and was found to have developed TB, he had to return to the Native Reserves. This facilitated for a constant flow of tuberculosis infected African workers returned to their families in the Reserves. Here is one example: in 1916 there were 60,000 men from the Transkei on the mines. That year, 14 out of every 1,000 miner got TB. This meant that about 850 men returned to the Transkei coughing out TB germs. (South African Institute of Medical Research, Johannesburg, 1932) This was a known
fact, hidden from the world since the 1900, and today, without much improvement in the social and living conditions of Africans, is it not any wonder that African people, who have had no respite from such Apartheid Shenanigans described above, that Africans within their societies should be having many people with mental problems? Clearly the mine owners would have liked TB epidemic nipped in the bud. After all, an increasingly sick work-force, and the need to provide for sick workers was "too expensive" for them and would eat into the profits of the mines. Also, they were not determined to consider a long term solution; to improve the living conditions of the miners; to feed the African mine workers better and to shorten the working day lightening the physical strain suffered by all miners. High standards of life and high standards of prosperity in general and lack of overcrowding combined to render the White population of South Africa in a good measure, secure from TB- and dreadful and appalling inhuman conditions for the African populace at the mercy of Miners, and the government of the day, since the 1900, and so far as has been attested in this hub, that made them have TB and other diseases. Health From 1950s To The 1970s In South Africa. The African people have been the majority of South Africans suffering from TB rose steadily from the middle of the century until the late 1950s. This increased rapidly after the World War II, when South Africa was industrializing rapidly. This infected and physically stressed the African people who saw the rise of TB amongst men from the age of twenty, an age most were entering the labor market. From 1940s to 1960s some drugs were discovered, and there was a spike in TB cases... this discovery helped a lot of people from dying , but could not stop the disease from spreading. With these technical advancement, the officials claimed that the number of TB infections was declining. But, in 1976 four Homelands"(Bantustans), were listed as the most affected areas. By 1976 "Homelands became 'Independence Granted' entities on the purse-strings of the Apartheid regime. Their statistics were removed form the official statistics about he extend of the disease in South Africa. For Instance, Transkei, about 6% of that population suffered from active TB. Official stats for other independent states were inaccurately lower, that for instance, Kwazulu Natal had 8 out of 1,000 infected with TB. Four miles down the road there were more people infected with TB that were not counted. In the end, the official figures reflected the inadequacy of the health services more accurately than they do the number of people suffering from TB. (N. White) So, The conditions for disease was exacerbated by industrialization and migrant labor, the creation of Bantustans and the destruction of rural subsistence economy: All factors which hastened the spread of disease. Miners who worked and lived in overcrowded, dusty hot conditions, and worked hard got TB. These are the lowest on the social rung and do not have political power to improve their condition. During the 1900 in south Africa, White miners mobilized and called for the 'Workers of the World to unite with White miners'. They were able to ensure for themselves a level of economic privilege and social security which protected them from the disease. But they never fought for the rights of the African mine workers nor considered them at all. Over the short historical periods viewed above, it is clear that medical science could not deal with employment, poverty and misery faced by the workers, which they had imposed on them through Apartheid.
Medical science by itself has not been able to control the epidemic. All the drugs, plus the level of poverty, unemployment and misery, couldn't be the only panacea to curing TB, because TB is a social disease, those who are disempowered and have the disease are going to have to be included in the major improvement of their economic and political position in the society, or has already happened in south Africa, the regime was eventually partly overthrown, and now African have to deal with the health and mental health in their midst for stress-overload that has bee there for hundred or more years without respite. Other Health Diseases It is often easy for the critics of African Studies to overlook the ramifications and impact of diseases such as TB have on the African continent and its people. It's not only the social illness that manifests itself within the African community and kills, but if is the national social trauma that dislocates homes, families, and society whereby those sick end up being interned in hospitals like Santa, and elsewhere in the ghettoes throughout South African that is effective. Migratory laborers brought the disease with them, and decimated their families and societies without their intentions, being aware or having any knowledge of it. The history of the negative effects of inadequate or lack of health institutions has been the most damaging things in relation to an on the African people and African society. This is important to note here that what constitutes African society in all its variations has been a pre-determined and created entity. It is deconstructing and dislodging this ready-made image and reality that is the African society that should be of primary concern here. In informing this society as to what creation went into their being a society that they are today, it would be important for the African Community to take a true and hard look as to its formative years, what happened then, and learn from the past in order to begin to transform their present and making sure that Apartheid created mental disorders, how this was created, what they need to really know about the earlier intentions how and why mental disorders exist with such ferocious frequency within the african communities and Society, and what should be done about it. Now that Africans rule their own society in tandem with other races, it is important to interrogate the History of the diseases, and the health system's and institution and their delivery systems: how these were set up during Apartheid, and how they are functioning now in the present ANC-led government. Looking At Health TB makes for quite an interesting Case study, but it would be a mistake to make it a special case study. But by learning from the history of the TB in South Africa, we can apply those lessons learned from TB to may aspects of ill-health and diseases in South Africa. What the ANC inherited as their power-base(the African Community) was shocking and still needs to be unearthed in order to be unIt has understood better and more fully: It has been estimated that between 15,000 - 30,000 children were dying each year in south Africa as a result of starvation or illness-related malnutrition. There are no official figures, which is shocking, but not surprising, since above we have noted that with TB, those in the reserves and "Homelands" were omitted from the official counts, although they might have lived four miles away from the counted community. The numbers among experts differed, and some gave calculation closer to the official figures.
Measles and gastroenteritis are some of the most common childhood diseases There are those to who it is an irritant. But for many others it meant weakened by malnutrition and unable to get good medical care, these diseases are killers, and thousands, as a result of an apartheidized medical care and delivery, die from them each year . Cholera arrived in South Africa around the early 80s. It first took root at Kangwane, a newly create "Homeland"(Apartheid's created Nation State), not more than a massive resettlement camp. Apartheid was spread to other such settlements in Lebowa,(Pedi people), Gazankulu(Shangaans), KwaZulu(Zulus) the Transkei(Xhosas) and Bophutatswana(for the Tswana peoples), and all were the homelands areas. The press reacted hysterical to the first appearance of cholera, but is currently less covered now from the establishment press, although is widespread. It has not spread to urban populations as a pandemic yet, but now it is being recognized one of the many health threats and hazard to many people who, many of them, are still confined to the rural ghettoes, which were then known as "Homelands/Bantustans." It is also postulated that Hundreds of thousands of workers are exposed to dangerous chemicals, dust or working conditions which affect the health of many over a period of years. There are over two thousand or so die from Industrial accidents each year. And the laws that were set then in the apartheid times were there to protect workers, but were lax compared to other industrialized countries. The Debilitating Picture of Health It has been hard to come by health statistics in the South Africa before the present ruling ANC. Fortunately there is enough seeping through the concealment for us to know that if one were born into an African family, or into the African working class was to be born into a dangerous life. Statistics show that: "More than 250,000 workers injured each year in industrial accidents; about 800 people died from mining accidents each year; in 1976 the Erasmus Commission reported that more than 1.2 million worker came into contact with ammonia or benzine, and both these substances are potentially dangerous and harmful; Another 160,000 have been exposed to lead; some alternative researches state that 22,000 mine workers and 6,000 factory workers work with asbestos, an important cause of a variety of lung diseases and cancer. The Erasmus Commission noted that the employers had a casual attitude to occupational safety. The Commission said: "industrialists have put very little time, money and organization into the prevention of occupational diseases". Four years later, Professor Webster of the National Council for Occupational Health did not see any improvement: 'I wouldn't say that the regular monitoring [of industrial health hazards] has increased very much since the Erasmus report'. The regulations for occupational hazards were not enforced with zeal.((D. Horner;) For instance, in 1974 there were only 32 factory inspectors available to watch over the safety procedures of some 30,000 factories throughout South Africa. Also, workers had no way of checking their employers if they are putting right any malpractice that might have been turned up in the investigation. Another useful measure of the health of a community is its infant mortality rate, which measures the number of babies who died before they reached age one. By using this measure, it became clear that ill health was divided unevenly in South Africa's urban population. In Cape Town in 1981, the infant mortality rate for whites was 9.4 deaths for every thousand live births; for Africans in the same city, the rate was 34.6 per thousand. In Pretoria the difference was even greater. In Pretoria, for Whites, the rate was 10.08/1000. Compared to 53.3/1000 for Africans. In Durban, 45% of African children admitted to King Edward VII Hospital for any reason were found
to be malnourished. A quarter of those who had malnutrition as their major problem, died. (Guide to the Health Act, 1978) Several Commissions, like the Fagan Commission, recommended that, with some exceptions, the migrant labor system should end. The Gluckman Commission represented what may be called reformist response to the social tensions of the 1940s. They advocated that social conditions, housing, medical services, education and wages. The Gluckman Commission report itself recommended a humane concern at the extent of ill-health, and its recommendations went far beyond those which might have been expected in a narrowly reformist document. The Gluckman report of the 1940s was ahead of its time when it was chronicled the impact of industrialization and urbanization on the health of the working class and shows great sensitivity to the relationship between peoples health and the social conditions in which they were living. The report stated: "First and foremost among the causes of ill health are the economic poverty and social backwardness of the greater part of the Union's[South Africa] population. Vast numbers of people in this country do not earn enough to purchase the minimum food, shelter and clothing to maintain themselves in health. Malnutrition is rife throughout the land and hitherto the services for its prevention appear to be ineffective. Housing is a problem which, despite the Housing and Slum Acts steadily becomes graver, nor does any effective solution appear to be in sight. Environmental Services ... leave as much to be desired in many small local authority areas, in nearly all urban Native locations, in periurban areas and in rural areas generally. (Gluckman Commission) Right through to the 1940s, the above stats show the intensity with which the regime operated and affected people in other various ways. The Commission had found out that all the pre-conditions existed for a high incidence of disease and health. In their investigations they found and examined a wide range of diseases including typhoid, tuberculosis, venereal diseases, malaria and bilharzia. The reported stated that far too man people, especially Africans, suffered from these illnesses. This reflected an appalling inadequacy of such(maternal and child welfare) services. Another report observed that, 'Bilharzia's high incidence among the children of the Union (South Africa) is yet another indictment against the present day health services.' The report did not simply hope that the people in health could be improved by simply being upgraded and extended. The report stated: "Unless there are vast improvements made in the nutrition, housing and health education of the people, the mere provision of more 'doctoring' will not lead to any real improvement in the public health.... It would be unreasonable and unsound to expect the health services forever to make good the deficiencies of the socioeconomic system. The Commission did not offer any recommendations as to what the long term policy should be. The major problem of health Act, Health Plan and health care in South Africa was that, the reforms that took place meant more tighter control by the State. They also meant that today, Africans are still not having enough health care and are struggling to pay private doctors who scalp their every penny with shoddy medicinal practices in many cases In the 1970s south Africa began undergoing rapid growth economically and this begun to create problems for the economic system as a whole. To start with, capital intensive industry resulted in
South Africa having to import substantial quantities of sophisticated technology. This created problems in the balance of payments, and then the deficit ensued. The point following up was that White workers, and the poor education and training available to African workers limited the possible extent of African advancement. This resulted in a shortage of skilled workers. Another thing was than South Africa encountered problems in finding markets for its manufactured items. This was caused by international isolation, and the fact that domestically their market was limited because of the low wages earned by the majority of the population. All these problems combined to slow down the rate of development, and by 1976, South Africa was experiencing a negative growth rate. Also, the African Township of Soweto revolted in 1976 and was effectively repressed with guns. But the revolt spread into the rest of the country and South Africa was no more the same. The oppressed Africans went on the offensive with political campaigns, community organizations, trade unions and student movements. the resistance grew so strong that Botha, the current President, called for the Afrikaners to "Adapt or Die" [see some of my Hubs on this subject] The Township revolution of 1976-77 forced the government onto the defensive for the first time in may years. The popular uprisings, combined with important economic changes, made the government cast and looked around for ways to adapt to new circumstances. Reform was in the air, and health care was chosen as one of the areas of possible reform. The 1977 Health act and subsequent policy statements from the department of health again raised the need to emphasize prevention rather than cure, and they even proposed the establishment of community health centers. These proposal that came 30 years after the Gluckman Commission and were in reality a dreadful parody of the plans laid out in the Commission's report. So many more years had to pass and are still going into an uncertain future regarding the health of Africans in south Africa. The "Bantustans Health Services The 'created' "Homelands," "Bantustans" or "National States," had no significant agricultural or industrial wealth, and they were simply concentration camps which added to the misery of Africans. As in the reserves with the mining companies, the Apartheid officials created the 'Bantustans' for migrant laborers for the development of the country's economy and to company profits. The laborers taxation went to the central government(Apartheid South Africa and not to the 'Bantustans' bureaucracies). In the final analysis, the 'homeland governments' had no source of revenue and they depended entirely on financial grants from the Pretoria government. In 1982 the budget of Gazankulu was over R98 million(over $13 million) of which R70 million($9.3 million) or about 70% was donated by the Apartheid government. The Regime tightly controlled this situation in varying degrees of all the "independent" and "self-governing" "Bantustans"(D. Hindson) This in turn created havoc to African societies and the bleak spaces that they were bundled into called "homelands" merely exacerbated the mental state of the African families and their societies The Same Foundations or New Facades and Mirages? In 1977, Gazankulu produced a five-year Health Plan which was going to pivot around 18 health centers. But only five health centers were built at the end of that five years and the problem was the shortage of funds. Between 1976 and 1977, the South African government contribution to Gazankulu dropped from R6.3-million to R5.7-million. In 1981, the health budget was &7-million of which 68% was earmarked for existing hospital services and another 10% for existing clinics and health centers. A senior health official in the Bantustan stated that in 1981 there were 400 villages without clinics. The Bophutatswana Bantustan government did not have sufficient funds needed to make-up this
backlog. A 1981 report by the head of the Department of Community Medicine at Natal Medical school stated that the Kwazulu 'Homeland' had 28 hospitals, 119 fixed clinics and 227 mobile clinics. There was a desperate need for 200 clinics, and yet in 1982, the entire health budget for KwaZulu was R60-million which was about the same amount Johannesburg Hospital spent in a year. After meeting the expenses in maintaining the existing services, Kwazulu had nothing left to take the healthcare to the people. None of these created 'Bantustans' had any medical school, and the few that are trained in South Africa, receive training that directs them towards lucrative private practices or to modern city hospitals. This was the 'normal' Africans were dealing with during the era of Apartheid and even with their present government post-Apartheid faced and are still facing the same state of affairs when it comes to their health and well-being. The situation described above created a serious shortage of medical personnel in the 'Bantustans'. There is only 3% of doctors practicing in south Africa that were found in the Homelands. In 1981 there were 70 openings for doctors, and in a letter to the South African Medical Journal, the Minister of Health in Lebowa complained that, 'In some cases(the Lebowa Homeland) hospitals were without full time or regular medical officers for more than four years'. He added that, "between July and December of 1980, only 40% of hospital medical posts were filled with full time doctors. In the period January-June 1981, Lebowa had only one doctor for every 20,000-30,000 residents. In August 1982, a newspaper reported that there was one doctor for the Qwaqwa Bantustan which had a population of 232,000. In 1981, Dr. Madide, KwaZulu's Minister of Health reported that recruiting doctors from outside South Africa was being obstructed [and in the present era of democracy doctors from outside came in droves, and most of them were fakes, which is costing Africans their lives and money]". People in the reserves lived far away form any health institutions, and many got to the clinics by walking long distances on foot, because they had no other transport available, and taxis charged high fees for transportation. And these clinics were usually staffed by one nurse. This is the South Africa Africans in South Africa have been living under and even today, the issues of health dominate and the Africans are becoming sicker and many have mental health issue which have not yet been dealt with appropriately by the duly elected officials. The hospitals that do exist were short staffed and overcrowded, and some were in urgent need of repair and extension, meanwhile the quality of health care suffered. Also the absence of wellorganized infrastructure reduced the effectiveness of health care services. During the 1982 Polio outbreak in the Northern Transvaal, the necessary vaccines were at times not available. What saved the health services from total collapse was the South African Defense Force who had a large number of doctors from within South Africa who did their National Service working in the Homeland hospitals, and these soldier/doctors performed a necessary service; nonetheless, their presence must served as a constant reminder to all concerned as to who the real boss was. The Sum of It All The Bantustans were eventually called 'National Sates' and the following three examples give a sense how deep the poison of ethnic thinking had seeped into the health services: - In 1982, it was reported that two nurses at Sebokeng Hospital in Vereeniging were expelled after it was discovered they had documentation form the Boputhatswana Homeland and the Homeland of the Transkei's travel documents, and they could not be accepted without prior permission from their
government. - Dr. G. de Klerk, head of the Medical Association of South Africa blamed the epidemics on the breakdown of health services on the 'created black states'. According to de Klerk: "South African Health Services compared with the best in the world. But the health services of he neighboring states an of the "independent homelands/Bantustans/National states" were in either in a state of collapse, or totally inadequate. In 1982 the Government of south Africa experimented with new ways to force independence on unwilling Bantustans and it chose sector of health as its terrain. For instance, the Nursing Act of 1982 sought to prevent Bantustan nurses form belonging to the Nursing Association of South Africa. Although Kwazulu resisted, they were eventually forced out. In the same year nurses were forced out of the Nursing Association, the laws of separation were passed to enabled the Medical Research Council, the Medical and Dental council and the Pharmacy Board to carry on their activities inside the borders of the "independent black states". The health services were not for meeting the needs to the people, but rather their operations reflected the needs and policies of the Apartheid State. Although Apartheid as a governing entity has been removed from parliamentary and political power, the health effects linger even today, although the present government is working to improve them, but progress is sow. This had had some serious mental and physical devastating health outcomes for African people. In the next Hub, "Apartheid's Mental Diseases: An Educative Social TherapyReintegration of African Health and History," we look at the other causes of mental health like the history of torture and the continuation of slums and resistance that is building against it today. There needs to be a serous commitment to the health of the poor, and the equalizing of fair distribution of wealth and social services in order to begin to meet the dire needs of the poor and sick African South Africans. Looking in hindsight about what the article has been about, above, I would like to utilize an article written by Gavin H. Mooney and Diane E. McIntyre, which I think help to update the article above, and gives us a perspective of health in contemporary South Africa, but still resting and built of the Apartheid Modal and model. I Will defer to the two authors mentioned above: South Africa: a 21st century Apartheid in health and health care? Abstract The current crisis in health and health care in South Africa results from a combination of factors: the legacy of apartheid; issues of poverty, income inequality and AIDS; and the more recent influence of neoliberal economic policies and globalization. The legacy of apartheid has meant that both health and health care are skewed along racial lines, and 60% of health care expenditure goes largely to the 14% of the population who have private health insurance. A more equitable distribution of health care resources will result from the promised National Health Insurance, the details of which are still being debated. The AIDS epidemic in South Africa was exacerbated by the government not introducing antiretroviral treatment (ART) until the early 2000s. In 2005, it was estimated that more than 5.5 million South Africans were infected with HIV. Now all those with a CD4 count below 200 are eligible for ART.A better health service will not be enough to improve the health of South Africans. A
whole-of-government approach is needed to address the persistent problems of poverty and inequality. Grave concerns about the health of the people of South Africa are compounded by the inadequate state of the South African health care system. The main factors affecting health in South Africa are the legacy of apartheid and the pressing current issues of poverty, income inequality and AIDS. These same factors affect health care -- dealing with AIDS has severely diminished the funding and resources available for other diseases; income inequality is reflected in the split between private and public care; and poverty means that many South Africans have limited access to health care of any kind, and for those able to access services the quality is low. Health care problems are exacerbated by the fact that funding for health, while overall at a reasonable level for a country with a gross domestic product per head of $634, is skewed in favor of the private sector which mostly caters for the rich. Thus, inequalities in income are reflected in inequalities in health care and in turn in inequalities in health. Background to the current health crisis The democratic African National Congress (ANC) government was elected in 1994, after a half century of the nationalist government's racist policies under apartheid (the Afrikaans word for "separateness"), which included political, legal, social and economic discrimination against black people. This legacy of discrimination, one of the key social determinants of health, had a major impact on the health of black South Africans. From 1994 to 1996, the broad policy agenda of the ANC government headed by Nelson Mandela was the Reconstruction and Development Program (RDP). Efforts were made to improve health and health care and especially to tackle some of the problems arising from other social determinants of health -- poverty, inequality, inadequate housing and poor education. For example, a clinic building program greatly increased the number of primary health care facilities in previously underserved areas. In 1996, the RDP was replaced by a neoliberal macroeconomic policy -- GEAR (Growth, Employment and Redistribution) -- favored by the International Monetary Fund (IMF) and the World Bank. Neoliberalism has been defined by Harvey as a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets and free trade . . . State interventions in markets . . . must be kept to a bare minimum. Persistence of poverty and inequalityUnder the influence of neoliberalism, levels of poverty and inequality remain high. A 2004 report from the Human Sciences Research Council states that the proportion of people living in poverty in South Africa has not changed significantly between 1996 and 2001 . . . [but] those households living in poverty have sunk deeper into poverty and the gap between rich and poor has widened. According to Statistics South Africa, in 2001 "the 10% of the population in the lowest income decile shared R1.1 billion, whereas the 10% of the population in the highest income decile shared R381 billion". The Gini coefficient, the most commonly used indicator of inequality (the closer to 1, the greater the inequality) is 0.73 for South Africa, which makes it one of the most unequal societies in the world. Average real incomes actually fell from 1995 to 2000.3 In his history of inequality in South Africa, Terreblanche writes of his concerns about the problems it
is creating. The coexistence of a new political system (controlled by an African elite) and the old economic system (still controlled by a neoliberal white elite) constitutes a dual system of democratic capitalism which is morally unjust, dysfunctional, and also unsustainable. We are forced to ask: for how long can white wealth and elitism remain entrenched; for how long can the black elite continue to indulge in black elitism; and how far can the black bourgeoisie and the black lumpenproletariat [the lowest members of society or the underclass] extend before the system cracks? A similar concern is expressed by Gumede in his account of the rise of Mbeki and the "soul of the ANC". So far, the economic cost of South Africa's transition [from the apartheid years] has fallen disproportionately on those it was supposed to benefit most -- the millions of black poor . . . Unless the economy delivers to the country's poor, South Africa's democratic miracle could unravel. Implications of neoliberalism and globalization Fourteen years on from the democratic elections, nearly 60% of health care expenditure in South Africa remains private, largely for the 14% of the population who have private health insurance. The reason appears to be that, in essence, the democratically elected South African Government is caught in the web of neoliberal international politics and regulations supported by the IMF and the World Bank. The government has justifiable concerns that if it moves too fast to introduce reforms, in this case health care reforms, this will have financial repercussions for its relations with the IMF and the World Bank. Neoliberalism creates problems not only for the health of South Africans but also for the health of the peoples of many other low- and middle-income countries. The selfish individualism that neoliberalism engenders -- described as "the malaise of modernity" by the Canadian philosopher Charles Taylor -- increases inequality within countries, and spills over into global power relations between rich and poor countries. Accompanying neoliberal globalization has been a freeing up of trade, with a resultant movement of the workforce, especially doctors and nurses, from developing to developed countries. Mackintosh writes, Migration from Africa to high-income countries . . . worsens an already intolerable gulf. Its distributive effects may be measured by the perverse subsidy generated . . . Migrant African health care professionals were trained in sub-Saharan Africa at public and private expense; the benefits of that training always are then experienced in the UK [and other rich countries such as Australia] and lost to those dependent on African health services.