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Pat Sidley on South Africa after Mbeki

26 Sep, 08 | by BMJ

South Africa’s newly elected president, Mr Kgalemo Mothlante, acted swiftly to end an era of ugly controversy and extreme incompetence in the health ministry by appointing a highly regarded, new health minister and effectively demoting the previous one, Dr Manto Tshabalala-Msimang, who implemented all of former president Thabo Mbeki’s eccentric AIDS beliefs, which has laid the foundations for the increased burden of disease that South Africa now has.
Within hours of his inauguration he appointed to cabinet, Ms Barbara Hogan, one of very few white women sentenced to a long stretch (10 years) in prison for treason by the apartheid government. Since then, she has chaired parliamentary committees on finance and on the auditor general, as a member of the ruling party, the African National Congress, has been noted not only for efficiency and intellectual astuteness, but for not being afraid to challenge the former president’s views on AIDS and make her own views known by siding with the activist groups trying to change AIDS policies.
As one of very few high-profile changes to government, her appointment signalled the urgency with which the new government needed to rid itself of what has been repeatedly referred to as destructive and divisive era of health policy and care. It has not been limited to a few disgruntled voices to criticise the previous president and his health minister – political commentators, journalists, broadcasters, trade unionists, and others have all clamoured in this recent fortnight of turmoil to be heard noting Mr Mbeki’s AIDS legacy.
It would not have gone without notice either, that on the day of the inauguration, and effective demotion of the previous health minister, yet another TV news item showed a community’s discontent with its large, but ill-equipped hospital. The Carltonville hospital, serving a large and impoverished population outside Johannesburg and close to many gold mines, had seen the deaths of three patients who had fallen out of a broken window with, it was alleged, insufficient reason for this. Protesters and patients outside the hospital complained that a doctor was available only once a month and that nurses beat patients. It is another unfortunate legacy of the Mbeki-era that patients’ complaints of failing services have fallen on deaf ears and resulted in frequent similar stories in the media. In the TB arena, viewers used to thinking of the occupants in hospitals as “patients” have become used to stories in the media, of patients who have “escaped” their quarantine facility and are being hunted down by police, like criminals.
While nobody has diminished the enormity of the task of repairing the damage to the health of all but the small white minority population, caused by apartheid, the small hints at improvements to the country’s vital statistics during the tenure of president Nelson Mandela (among them a small drop in the infant mortality rate) were rapidly undone when Mr Mbeki assumed office in 1999, announcing shortly afterwards his intention to follow up his inquiries into already well accepted AIDS science. His health minister, Dr Manto Tshabalala-Msimang, although struck off the professional register in Botswana for her theft of patients’ belongings while in exile, became his loyal hatchet-man when after several years of blunt refusals to listen to wiser counsel, Mr Mbeki was eventually forced to keep quiet on health issues.
Ironically, had he but listened to Mr Mandela in one of several meetings within the ANC on the AIDS issue and anti-retroviral therapy, and heeded a very pointed warning, Mr Mbeki may well have avoided his sacking. On that day, Mr Mandela told the meeting that it was not unprecedented within the ANC for it to depose a leader who had lost favour. He cited the one little known instance when this had happened as a way of warning the president that his party was capable of running out of patience and loyalty and sacking him too . However, it was not only the president who failed to heed the warning, but the majority of his cabinet and the national executive committee of the party. Almost nobody spoke or voted against the president at that time – but this trickle began to develop into what became a torrent of irritation when activists with doctors, trade unionists and others began using the courts and the constitution to force the government to begin providing ARV treatment. More importantly for a president who was fired in part for letting go of the ANC’s policy of alleviating poverty and creating jobs, the government found itself baring the brunt of démarches from Western embassies, deputations from multinational pharmaceutical companies, threats from prospective donors to his pet projects within Africa to withdraw their backing, and finally his own ambassadors and a large and influential grouping of black businessmen. While he became quiet, his health minister took over startling and dismaying local and foreign experts with her preference for beetroot and traditional medicines to treat AIDS.
Mr Mbeki’s legacy, from one of AIDS denialism, also incorporates after the long battle, the fact that the country now has the largest anti-retroviral programme in the world. It took subterfuge within the Treasury and certain people in the health departments to ensure that enough would be found to budget for the programme so that resources could not be used as an excuse to continue to deny ARVs to people in need of them.
However, the health system has been bleeding professionals with doctors and nurses trained in South Africa, leaving the country in droves and doctors from Tunisia and Cuba among other countries, being recruited to work in South Africa. This has left less skilled and sometimes incompetent people in the country. The same pattern has been mirrored in the health department itself with those able to get jobs leaving and those remaining not able to make headway in improving health.
At a recent conference in Cape Town of several United Nations groups on mother and child survival, it was noted that in the area of child deaths, South Africa was one of the 10 worst performing countries in the world and would not meet its Millennium Goals for the Countdown to 1015 for Maternal, Newborn and Child Survival in health.
The conference heard that at least 260 women babies and children died daily in South Africa and no progress had been made to reduce this. Making matters worse, many of these deaths were caused by inadequate care by health care workers. The figures were worse than those during apartheid.
There are few if any experts who would now jump to the defence of former president Mbeki’s health legacy, partly because so many people are part of communities robbed of young lives from AIDS and because it is likely to become as unfashionable to defend his policies as it suddenly became to defend apartheid in 1994.

Pat Sidley is a medical journalist in Johannesburg.

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  • Paul

    Pat Sidley fundamentally misstates how South AFrica’s black government makes its decisions on issues like AIDS. As President Motlanthe said yesterday, these decisions are made by the collective,not by any individual. Sidley confuses the authorities of the President of the United States or some other strong presidential system with the South African system in which the president is basically a prime minister with a presidential title and who is accountable to the cabinet and the party caucus in the National Assembly. To personalize policy decision on Mbeki is to be fundamentally misinformed about how South AFrica’s government is run.

    The new minister of health will be part of the same collective decision making system as Tshabalala-Msimang and will have to get a consensus in cabinet for any new policy. It is not even clear that the new minister wants any change in policy. But, being from the white English-speaking community, perhaps the white English speakers who viciously attacked her two black predecessors will lay off. At least for a while.

  • Ravi

    Pat is spot on in her article. Mbeki imposed his views on government leadership, which he had filled with yes-men. Ministers, such as the former deputy Minister for Health, who disagreed with him didn’t last long in their post. (But no one ever got fired for incompetence.)

    Paul needs to get over his race hangups. Mbeki had the same problem hence he mistook AIDS as a race issue and refused to deal with it, with genocidal consequences for South Africa.

  • Andrew

    Paul states that decisions are made by the “collective”; in the case of the Ministry of Health, this grouping consisted of a small cabal with a bizarre agenda that attempted to politicise science. The steadfast opposition (and forced change that occurred as a result) by a growing number of incensed ordinary South African health workers and activists was one of the major factors that prevents Mbeki and Msimang being remembered as the Pol Pots of the medical world. I very much doubt if they have the insight to be grateful to them.

  • Vishen

    Finally after years of Dr Manto Tshabalala-Msimang’s poor handling of what is an AIDS crisis in South Africa, we can finally look forward to some sensible national policy which will deliver appropriate care at the grassroot level.

  • Mobin

    Mr Mbeki’s legacy, from one of AIDS denialism, also incorporates after the long battle, the fact that the country now has the largest anti-retroviral programme in the world. It took subterfuge within the Treasury and certain people in the health departments to ensure that enough would be found to budget for the programme so that resources could not be used as an excuse to continue to deny ARVs to people in need of them.

    ———
    Mobin

    Promoter

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