ArticlePDF AvailableLiterature Review

Health, apartheid and the Frontline States

Authors:
Sm. SC;. Med. Vol. 27. No. 7, pp. 661465. 1988
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Copyright C 1988 Pergamon Press plc
INTRODUCTION
HEALTH, APARTHEID AND THE FRONTLINE
STATES
ANTHONV Zwr,’ SHULA MARKS’ and NEIL ANDERSSON’
‘Department of Community Medicine, University College and Middlesex School of Medicine, 6672
Gower St., London WClE 6EA, %stitute of Commonwealth Studies. University of London, 27 Russell
Square, London WC1 BSDS and )Department of Occupational Medicine, London School of Hygiene and
Tropical Medicine, Keppel St., London WCIE 7HT, England
This special issue of Social Science and Medicine is
devoted to health in contemporary southern Africa.
Approximately 100 million people live in southern
Africa, a region comprising 11 countries with very
different but linked economies: the Republic of South
Africa (RSA), Namibia, Lesotho, Swaziland, Bot-
swana, Mozambique, Zimbabwe, Malawi, Zambia,
Tanzania and Angola. Nine of these countries, ex-
cluding South Africa and Namibia, have grouped
together to form the Southern Africa Development
Co-ordination Conference (SADCC), an or-
ganisation committed to diminishing their political
and economic dependence on South Africa. Together
these countries are referred to as the Frontline States.
This issue of Social Science and Medicine draws
attention to the state of health in the southern
African region, including that of the people of South
Africa and the communities in the Frontline States.
Given the vast scope of the subject, we cannot hope
to provide a comprehensive account of all the prob-
lem areas in the political economy of health in this
region. The main focus of the issue is therefore on the
effects of apartheid on health in the RSA itself,
although this issue makes clear that apartheid affects
not only the communities within the RSA, but also
those in the surrounding Frontline States.
The purpose of this introduction is to explore some
of the relationships between developments in the
RSA and health and ill-health in the region, to link
the articles published here with the socio-political
environment in the region, and to point to some
current regional health concerns which have not been
covered elsewhere in this volume.
Social, economic and political institutions in the Republic
of South Africa are structured along legally defined
racial categories. Health services and health status
cannot be described without recourse to such racial
terminology which does not imply their legitimacy.
Official data on health patterns are quoted using the
official terminology: white, black, Asian and coloured.
‘African’ is used in the place of ‘black’ when reference
is not made to data using the official classification.
Although we recognise that the popular movements
refer to people classified by the State as Asian, coloured
or black collectively as ‘black’, we have chosen to name
each group separately in order to avoid confusion
between this general usage of the term ‘black’ and the
official classification.
The determinants of health in the sub-continent are
closely interwoven; this is not simply to restate the
truism that epidemic and infectious diseases do not
recognise man-made political frontiers, but to draw
attention to the fact that health patterns are closely
linked to the political economy within each country,
the relationships between countries, and the migrant
labour system. A particularly strong influence is the
military conflict between South Africa and its neigh-
bours: a confrontation that is likely to continue as
long as the Republic pursues its apartheid policies.
While South Africa’s invasions of its neighbours
have recently had dramatic impacts on morbidity and
mortality. the influence of South Africa on the health
of communities in the Frontline States has a longer
and deeper history. The movement of workers across
national frontiers in search of employment on the
South African mines and farms has linked the Front-
line States to the Republic for over a century, with
both short-term and long-term results for the health
of these workers and their families. At the same time,
health in the region has been and still is also pro-
foundly affected by the penetration of colonialism
and capitalism, much of it spearheaded from South
Africa. by food supply and redistributive policies,
and by trade atid customs agreements.
For all these reasons, it is essential to have some
understanding of the regional relationships and
conflict.
The particular colonial legacy of southern Africa,
the continuing ties through trade and migrant labour
and, more specifically, the division of labour between
the countries in the subregion, are all crucial to an
understanding of the issues surrounding health in the
Frontline States. Within the region, the countries
around the RSA can be seen as the ‘periphery’ to the
epicentre of capital in South Africa.
From the time of the mineral discoveries in the last
third of the 19th century, the development of mining
in South Africa depended upon the recruitment of
huge numbers of migrant labourers from all over the
sub-continent, affecting both them and their families.
The nature of deep-level hard rock drilling, in the
context of weak or absent labour organisation and
poorly controlled work conditions, meant an ex-
tremely high incidence of respiratory diseases, includ-
ing pneumoconiosis (‘phthisis’), tuberculosis (TB)
and pneumonia. African workers from northern
661
662 ANTHONY ZWI et al.
Mozambique and British Central Africa (Malawi)
suffered most heavily from these and other diseases,
leading to a ban on recruiting from north of latitude
22” south after 1913.
The rest of the region continued to supply young
men in their prime to South African mines and farms,
with far-reaching health costs. High accident rates (in
part a function of the very deep levels of the mines
and the disregard for safety where African lives were
involved) plagued those working on the mines; respi-
ratory and sexually transmitted diseases (STDs)
affected not only migrants to the mines, but also their
families in both urban and rural areas. TB and STDs
were taken by mine workers from the mines and
urban areas back to their rural homes, where the
impoverishment of the agrarian economy meant that
they found a ready breeding ground. There can be
little doubt that the ‘epidemic’ of TB in the region
today, discussed in these pages by Yach specifically
for the Western Cape and by Andersson and Marks
more generally for the RSA, are historically related
to the development of South Africa’s mining industry
and the underdevelopment of its rural hinterland [I].
Despite the political independence of the majority
of the Frontline States in the 1960s many of these
countries still depend, to a greater or lesser extent, on
the income of migrant labourers working in the RSA
and income from their customs agreements with
South Africa in the case of Botswana, Lesotho and
Swaziland. Most dependent is Lesotho, with 70% of
its GNP derived from remittances from migrants in
the RSA [2], and up to one half of all adult men away
from home during the year, seeking employment in
the Republic. Other countries are less heavily de-
pendent on the RSA for employment, but there are
still approx. 300.000 officially registered migrant
workers from SADCC countries in the RSA [2]. Up
to a further 1.3 million ‘illegal’ (according to the
South African authorities) migrants also work in
South Africa and if one includes the families of
migrants, then up to 4 million people, or about 7%
of the population of the SADCC countries, are
affected by migrant labour [2].
South Africa’s heavy dependence on migrant
labour means that the burden of disease is not only
felt at the point of production. Employers and the
South African state have been, and are still able, to
slough off their responsibility through repatriation of
ill and disabled workers, to their so-called ‘home-
lands’-whether to the Bantustans within the RSA,
or to the Frontline States-whose weaker economies
then have to carry the health repercussions of the
poor work conditions within the RSA.
Given the large number of people affected, it is
salutory to note that the absence of employment
opportunities may now have even more serious con-
sequences than the adverse conditions found in many
mines. Lesotho, for example, has very high un-
employment among ex-miners, and is one of the few
countries in the world to experience higher
psychiatric morbidity among males than females, a
characteristic quite possibly related to unemployment
[3]. The desperation of these ex-miners for work was
demonstrated by the ability of the Chamber of Mines
to recruit scab labour in Lesotho during the miners’
strike in South Africa in August 1987 [4].
Migrant labour thus provides a mechanism for the
South African state to exert control over the other
southern African countries. By 1985, for example. the
RSA had radically reduced the number of Moz-
ambicans and Basotho recruited to work in the
country, a factor which itself played a part in the
economic destabilisation of the region. In response to
the proposed imposition of international sanctions,
the RSA has threatened to take further action against
‘foreign’ migrants, indicating the ability of the RSA
to cast off unwanted workers when necessary. As
ominously, the government has recently declared that
it is to “take steps to repatriate foreign workers
infected with AIDS or those who carry the virus”.
According to the Minister of Health, his department
had prepared draft measures providing for the
identification of any contagious disease (including
AIDS) which allowed for the “isolation and compul-
sory treatment of sufferers and carriers of the dis-
ease” [S], despite the fact that such measures, in the
case of AIDS, for example. are generally considered
to be of no value whatsoever [6]. The full impact of
AIDS has yet to be felt in the rural areas of southern
Africa; what is certain is that its impact in combina-
tion with economic destabilisation, dependence and
migrancy is likely to be substantial.
Besides the migrant labour system, the escalating
violence in southern Africa has a profound influence
on health. As Glen Moss has pointed out: “De-
stabilisation in Southern Africa. [the] creation and
maintenance of ‘puppet’ regimes, and a merciless
commitment to anti-democratic social engineering
continue as essential themes in South Africa’s re-
gional strategies. These policies have effects in the
peripheries and rural areas of South Africa, as well as
in neighbouring states often subject to the dictates of
the regional power” [7].
The RSA with its massive economic and military
presence, exerts a degree of control over the entire
sub-continent. The entire region has been militarised
as a result of the RSA’s attempts to maintain control
of Namibia, the last colony in Africa; to undermine
the socialist government of Mozambique; to limit
Zimbabwe’s freedom of action; to perpetuate the
dependence of Swaziland, Lesotho and Botswana;
and to ensure that internal revolt is suppressed and
power maintained in white hands.
The Republic fosters and supports the terrorist
forces of the Mozambique National Resistance
(MNR) which seek to undermine the FRELIMO gov-
ernment of Mozambique, as Cliff and Noormahomed
show; it also supports UNITA, the dissident move-
ment which threatens the integrity of the Angolan
state. Throughout southern Africa, South African
forces have sought to destroy popular support for
progressive organisations and have used covert oper-
ations to undermine democratic opposition forces [8].
There can be little doubt that part of the motivation
for its destabilisation policies has been the fear that
the establishment of strong and successful African
states in the region encourage alternative visions of
the future for its own suppressed populace.
Cliff and Noormahomed vividly portray the grim
health implications of this escalation of violence in
Mozambique. The MNR have not only been re-
sponsible for the deaths of thousands of people in
Introduction 663
Mozambique. both directly through military action
and indirectly through the disruption of food supplies
and the resultant famine. but incessant war also
disrupts and reduces rural production and leads to
political instability, both of which have health con-
sequences. In addition, as these authors point out.
organisations like the MNR have looted, kidnapped
and killed numerous health workers and destroyed
clinics and hospitals. This has also occurred in An-
gola where UNITA, which has South African and
United States support, has been responsible for the
widespread destruction of health services [2].
Rural villagers in Mozambique have been terror-
ised and thousands have taken refuge in neigh-
bouring Malawi, Zimbabwe and the RSA. At the
same time South Africa’s internal violence generates
its own refugees and exiles, who arrive almost daily
in the neighbouring states. The hundreds of thou-
sands of displaced persons in the region create nu-
merous health problems as services are destroyed,
preventive programmes disrupted, and the control of
infectious disease ceases. Furthermore, war invari-
ably consumes resources which otherwise could be
available for health and social welfare [9]. It is
virtually impossible to calculate the sums of money
which have not been invested in community services
because of the need for expenditure on the war, but
there is no doubt that vast amounts are involved. In
addition, young and potentially creative and prod-
uctive men and women are drawn into military
conflict rather than devoting their skills and commit-
ment to building a better society. Besides injuries and
deaths, the emotional and psychological costs of this
violence and conflict are exceedingly difficult to quan-
tify, as are the burdens for future generations. What
is clear, however, is that they are imposing un-
desirable and, ultimately intolerable strains.
Of course, not all the problems of disease in the
region can be blamed on the South African con-
nection or the colonial inheritance. The dominance
of the RSA in the subregion as well as the impact of
the international economic order is mediated
differently by the internal processes of each of the
surrounding countries. and the consequent
differences are illuminating [IO]. The health strategies
adopted by individual countries and their priorities
can have a significant impact on health and welfare.
The papers in this special issue by Cliff and
Noormahomed and Sanders and Davies examine
aspects of post-independence health care in Moz-
ambique and Zimbabwe respectively. Both papers
show how according priority to the delivery of pri-
mary health care (PHC). particularly in the rural
areas. can have a discernible impact on health and
nutritional status, even in conditions of considerable
poverty. Vaughan and Moore make a similar point in
their research note concerning Zambia. Their work
illustrates the possibilities and limitations for real
transformations in health status in the region as a
result of health sector interventions, Difficulties arise,
however, from the decline of the economy as a result
of the international recession, drought, domestic
macroeconomic policies and, particularly in the case
of Mozambique, South African destabilisation.
Loewenson deals with the impact of plantation
agriculture on the health of agricultural workers in
Zimbabwe, showing that the development of large
scale private farming has led to poor health condi-
tions in general. Furthermore. casually employed
temporary workers. primarily women. who have the
least access to health care and the least security of
employment, have the poorest health status. This
paper is especially important as far less is known
about rural than urban health. Evidence of condi-
tions on white owned farms and plantations is partic-
ularly hard to come by.
Even where commercial agriculture is in African
hands, it can have unforseen and unfortunate con-
sequences for the health of the vulnerable, especially
women and children. As Vaughan and Moore point
out, in the 1930s when social scientists and adminis-
trators sought the causes of childhood malnutrition
in what is now northern Zambia, they attributed it to
the absence of men and a consequent shortage of
labour. Yet today it is primarily in the households
of the more ‘progressive’ farmers who are producing
maize for the market that childhood malnutrition
seems more prominent. Recent research suggests “it
seems that in these households the problem for
women is not the absence of men . but the presence
of men in conjunction with a new system of prod-
uction with no culturally predetermined sexual
division of labour”. Thus women find themselves
working on commercial maize production and
cultivating millet for food, in addition to carrying out
their ‘normal’ domestic and child care duties. Under
the circumstances it is hardly surprising that they are
short of time and their children suffer.
In the Bantustans and elsewhere in the rural
periphery, those still dependent on remittances from
migrant labourers have little economic bargaining
power and their rights, their health, and that of their
children is least known and probably most vulner-
able. In addition to physical stress, the migrant
labour system means that women frequently have to
take on additional work and household management
responsibilities, despite the fact that men still con-
sider themselves heads of the household. The
modified and weakened family/kinship system has
increased the work load and health risk of women
[I 11. This can lead to psychological stress for both
partners [ 121. and warrants further research.
Within the countries in the region, specific
conditions shape the nature and extent of health
problems. Zwi and colleagues show that industrial
accidents and the disregard for safety regulations are
not a matter of the past, but continue both in mining
and more widely. As their article shows, neither the
South African state nor employers have been over-
concerned with the welfare of workers; the former is
interested in minimising conflict and avoiding con-
frontations as a result of deteriorating conditions at
the workplace; the latter with maximising prod-
uctivity and profits. In the mining industry, the early
muscle of the white working class and fears for the
reproduction and recruitment of the migrant work-
force led to a degree of concern with occupational
health and workers’ compensation. Yet African
workers disabled by occupational lung diseases still
receive only about a tenth of the compensation paid
to white workers. It is only relatively recently, with
the growth of progressive trade unions, that African
664 ANTHONI
workers have been able to negotiate around safety at
work. Yet there is evidence, for example, from the
recent failed widespread strike of some 300.000
African miners, that there are setbacks in even these
preliminary steps. The conditions of work remain
extremely dangerous, as has been revealed by the
numbers killed in accidents in the gold mines in the
past year alone [ 131. In the wake of the disaster on the
St Helena Gencor gold mine in the Orange Free
State, the South African National Union of
Mineworkers roundly declared that the Republic’s
mines were the most dangerous in the world [5, p. 51.
<Within South Africa, repression continues under
the State of Emergency, with security legislation
allowing indefinite detention and the banning of
political opponents [14]. Popular uprisings in com-
munities have been suppressed, using military and
police forces and state supported ‘vigilantes’ [I 51.
Apart from the death and mortality from coercive
action in the townships and the psychological trauma
as a result of the emergency (discussed by Andersson
and Marks below), the state of undeclared war in the
townships has indirect consequences on health and
health care. Thus during the upheavals in Crossroads
and the nearby KTC squatter camp outside Cape
Town, between May and July 1986, health services
were gravely disrupted: “water supplies and sewage
bucket collections were affected, carrying the risk of
a major epidemic. Midwives could not make follow-
up visits. The impact of the loss of preventive
services-immunisation, family planning, tuber-
culosis and hypertension treatment--could not be
measured” [5, p. IO].
The health consequences of apartheid are not
necessarily worst where the pressure from the apart-
heid state is felt most intensely. As a result of the
increasing organisation of workers and communities
in the RSA, the government has attempted to
defuse urban resistance and to coopt the African,
Asian and coloured middle classes through the pro-
vision of social welfare services. This has taken a
number of different forms. Thus specific health mea-
sures have been introduced that have effectively
reduced infant mortality in some urban areas (no-
tably Soweto and parts of Cape Town), as is dis-
cussed by Andersson and Marks. In these urban
areas. infant mortality is now well below that of most
of the Frontline states-as well as that in South
Africa’s own rural areas.
The high levels of infant mortality and disease in
the Frontline States are frequently used by apologists
of apartheid to argue that high levels of morbidity
and mortality would occur in any case among Afri-
cans in the RSA, and have nothing to do with the
apartheid system. They point with pride to the num-
bers of African nurses and clinics in the RSA and
argue that the South African government has actually
improved conditions for African health in the RSA,
particularly over the last few years. While the claims
themselves can be disputed, these arguments also do
not take into account the fact that health conditions
in the townships and rural areas should be weighed
against the health possibilities in South Africa, given
its overall wealth. There is no logical basis for the
comparison with poorer countries in Africa. The
papers in this issue by Andersson and Marks, Yach,
Zwl el al.
Zwi et al. and Price in their different ways powerfully
illustrate how social inequalities lie behind the
differential disease patterns and the distribution of
health resources in the RSA.
In addition to social inequalities based on skin
colour gender inequalities are also present. While the
exploitation of minerals in the RSA depends on the
labour of younger men. an increasing number of
African, Asian, and coloured women from within the
Republic have also been incorporated into the service
and industrial workforce. They tend to be employed
in the worst paid and least attractive jobs although,
as Zwi er al. point out in this collection, in some
sectors of the economy women are becoming in-
creasingly unionised and have won significant mater-
nity and other welfare benefits from their employers
1161.
Price discusses the expansion of private health care
schemes to urbanised Africans and shows that in-
creasing private sector involvement in health is par-
ticularly attractive to the state at a time of financial
stringency. Through private health care the state is
able to pass a considerable financial burden in the re-
production of the workforce to capital. At the same
time, apart from the gain individual capitalists hope
to make from the privatisation of health care, they
also hope that a racially non-discriminatory private
health care service will serve to capture support from
urbanised Africans for the ‘free enterprise’ system. Yet,
as Price points out, this strategy has several long-term
costs. Medical aid schemes are limited to a minority
of Africans and effectively increase inequalities of
care among the population, Furthermore, the African
middle class, at whom such reforms are directed,
comprise a tiny fraction of the overall African popu-
lation. Thus, private medical insurance is unlikely to
solve the health needs of the majority of the people.
The thrust towards the privatisation of health
services in the RSA is an issue which will have
important ramifications in coming years. Price has
gone some way towards addressing these issues in the
present collection, as have authors such as Dor-
rington and Zwarenstein [17] who provide empirical
data concerning the cost and distribution of services.
The state, in its attempts to shrug off responsibility
for a range of health and social welfare services, tries
to ‘pass the buck’ onto the private sector. However,
this opportunity for the private sector will only be
seized where the possibility for profit exists, amongst
the urban and Bantustan middle classes of all races
or where employers are prepared to pay health
insurance for highly skilled workers.
Rampant profit-making in the health care industry
is now an international phenomenon of considerable
importance [18]. The private health sector effectively
helps undermine attempts to set up or to protect
national health services in a number of insidious
ways. First, it removes a particularly influential and
articulate group of consumers-the middle classes.
Secondly, it diverts potentially income-generating
patients away from the public health service and into
the private services, thus further depleting already
strained resources. Staff trained at the public’s cost
are also siphoned into the for-profit sector. The loss
of revenue and staff further exacerbates the demands
placed on an under-resourced public service and thus
Introduction 665
weakens the service. Finally, the presence of efficient,
albeit often inappropriate, private sector hospitals,
places additional strains on the public service and
creates demands for services which may be both
unnecessary and costly. The South African and busi-
ness enterprises are also likely to seize opportunities
to expand the profit-making health sector elsewhere
in southern Africa. This is bound to cause havoc
within the primarily state-provided health services
elsewhere in the region. Thus, once again, the poorer
parts of the region will be left with second rate care,
provided by state health services, which are
financially squeezed.
The South African state has also adopted an
insidious use of health jargon. Terms such as primary
health care (PHC), ‘community involvement’ and
‘self-help’ appear frequently in South African official
publications, yet the principles behind such terms are
rarely, if ever, addressed by the official services. Buch
[19] and De Beer [20] have shown how such
terminology has been appropriated and is being used
quite differently from its true meanings. Few
resources go into providing PHC and even less
attention is devoted to overcoming those political
issues which have an impact on health. PHC thus
plays a role in the ‘rationalising’ of health care,
ensuring that the burden of actually providing ser-
vices is shifted onto communities under the guise of
‘community participation’. Thus, in South Africa,
PHC becomes an opportunity for the South African
state to provide second rate care for what are
effectively ‘second rate citizens’-the urban and rural
poor.
These South African policies of inadequate PHC,
and an emphasis on privatisation and profit-making
through health services, play a part in undermining
genuine attempts at providing appropriate health
services in many other parts of the region.
This introductory section has not set out to deal
comprehensively with the political economy of health
in the region. Rather, it has attempted to provide a
context for the reading of the individual papers
presented here. However one approaches the issues,
it is clear that the RSA dominates the southern
African region in many crucial respects and that it
exerts enormous power over the health and health
services of the 100 million people who live there. In
the past and present, the nature of the apartheid state
and its relationships with its neighbours have been
the major determinants of health in the region. In the
future too, the nature of apartheid and whatever
replaces it ultimately, will continue to dominate the
political economy of the region, thereby influencing
the health status of millions of people in a multitude
of ways.
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and Health Services. CIIR. London, 1986.
... Badly designed, ill ventilated, and overcrowded mine compounds and barracks for workers caused a number of diseases (Gottschalk, 1988). High incidences of respiratory diseases, inclusive of pneumoconiosis, tuberculosis and pneumonia affected the working class due to poor working conditions (Gottschalk, 1988;Zwi et al., 1988). Workers diagnosed with the abovementioned and other infectious diseases upon recruitment, continued working without treatment or being separated from non-infected workers (Gottschalk, 1988). ...
... First, (in South Africa, which is similar to Namibia) the private hospitals were a creation of medical specialists who were largely working in public health facilities (Van den Heever, 2012). The likelihood of diverting "medical scheme covered patients into their private practices and associated private hospital services" was very high (Van den Heever, 2012, p. 5), thus diverting resources that were supposed to be used to improve services in the public healthcare sector to private and profit-oriented individuals (Zwi et al., 1988). Medical personnel trained in public health facilities were absorbed by the better-remunerated private health sector (Zwi et al., 1988) leaving the public hospital under-resourced and weakening public service delivery. ...
... The likelihood of diverting "medical scheme covered patients into their private practices and associated private hospital services" was very high (Van den Heever, 2012, p. 5), thus diverting resources that were supposed to be used to improve services in the public healthcare sector to private and profit-oriented individuals (Zwi et al., 1988). Medical personnel trained in public health facilities were absorbed by the better-remunerated private health sector (Zwi et al., 1988) leaving the public hospital under-resourced and weakening public service delivery. ...
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The purpose of this study is to identify barriers to contribution collection and compliance in the social insurance scheme in Namibia. Contribution collections and enforcement of compliance are important in ensuring the sustainability of social security schemes. It is from the contributions paid by employers and employees where social insurance benefits and administrative expenses are paid. Using a qualitative study, a purposive sampling method was used, and interviews were conducted with social security officials of the Social Security Commission Namibia who identified barriers in respect of contributors and the collecting agency. The findings suggest that barriers to contribution collections are embedded in the structural design of the social insurance scheme causing failures in collections and compliance. Barriers were found at all stages of the operational processes from registration of contributors, billing, and debt management to the enforcement of compliance.
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In the year 1966, the first government hospital, Oshakati hospital, was inaugurated in northern South-West Africa. It was constructed by the apartheid regime of South Africa which was occupying the territory. Prior to this inauguration, Finnish missionaries had, for 65 years, provided healthcare to the indigenous people in a number of healthcare facilities of which Onandjokwe hospital was the most important. This article discusses these two agents' ideological standpoints. The same year, the war between the South-West African guerrillas and the South African state started, and continued up to 1988. The two hospitals became involved in the war; Oshakati hospital as a part of the South African war machinery, and Onandjokwe hospital as a 'terrorist hospital' in the eyes of the South Africans. The missionary Onandjokwe hospital was linked to the Lutheran church in South-West Africa, which became one of the main critics of the apartheid system early in the liberation war. Warfare and healthcare became intertwined with apartheid policies and aggression, materialised by healthcare provision based on strategic rationales rather than the people's healthcare needs. When the Namibian state took over a ruined healthcare system in 1990, the two hospitals were hubs in a healthcare landscape shaped by missionary ambitions, war and apartheid logic.
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This contribution analyses and systematiscs apartheid as a phenomenon and as a problem in South African health and health care. It is assumed that apartheid is one of the most decisive forces moulding the South African health care system as well as the health of the people, resulting in grave race-related disparities, inequalities, fragmentation and discrimination on the one hand, and divergent, race-related health outcomes in the health indices and health statuses of the different ‘colour’ groups. The material presented. is systematised within a fourfold framework, differentiating between a structural/institutional component and a consequential/outcome component of apartheid, The former refers to both the racially segregated supply system and the racially divided clientele; the latter applies to both structural outcomes in the form of race-related deformities in the organisation and allocation of health care supply and racerelated inequalities and disparities in the health and health status of the different clienteles. The conclusion is that apartheid in health and health care is still firmly in place and will remain a decisive force in South African health and health care for many years. even generations. to come. More deliberate attempts have to be launched to eliminate both ‘apartheid in society’ and ‘apartheid in man’.
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Presents an extended review of recent writings on health under apartheid, focusing on the importance of health for rural development; social reproduction and struggle in the context of health; the characteristics of health under apartheid; and the future challenge. The paper contains a detailed statistical account of health status under apartheid and disparities in health care. The formidable challenges to developing a future comprehensive health care system are stressed. -R.House
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Community involvement in health (CIH), a central concept in health development, is a participatory approach to health care that is organized from the perspective of the recipient. Putting CIH into practice represents a learning experience for the community, the health professionals involved and those responsible for the national climate in which this change takes place. The CIH process was operationalized over a two-year period in a black township in South Africa. A community survey identified the health needs and capacities related to the elderly, their families and their support system. Community groups and individuals, in partnership with the researcher, prioritized the needs that had been identified and then implemented four programs related to those needs. A process model was developed that provided the structure for initiating and maintaining these programs. The model helped people who were new to the community organizing to focus on general principles. It was flexible so that programs could be interpreted and implemented in the context of local culture and resources. The model was functional in guiding community nurses, lay community members and employees in health-related programs through the process of starting new programs. This approach empowered participants to move beyond only hoping for change or being puzzled by its elusiveness.
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As part of a larger study, medical practitioners working in Mamre, a 'coloured' village close to Cape Town, South Africa, were interviewed concerning their use of the term 'nerves' in interaction with their patients. Contrary to the initial perception of researchers and some clinicians, the term is not simply a folk category. It does, however, represent a medium through which psychosocial issues are discussed in the clinical encounter. Differences in the usage of the term by different practitioners seemed to indicate different attitudes towards patient care. The data are presented and discussed in the context of debates concerning the development of more accessible and responsive health services in a future South Africa, and the information gleaned has implications for future training of clinicians.
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The aim of this study was to assess the effect of 'population group' classification, as a specific instance of 'racial' categorization, on caesarean section rates in South Africa. Information on 'population group' classification ('Black, 'Coloured', 'Indian', or 'White', as defined under apartheid legislation) and place of delivery, together with basic obstetric, sociodemographic and perinatal data, were extracted from the birth notification forms of 5456 children who made up the birth cohort of the Birth to Ten longitudinal study. This cohort included all births that occurred to mothers resident in Soweto-Johannesburg during a 7-week period in 1990. After accounting for differences in maternal age, gravidity, birth weight and gestational age at delivery, the rate of caesarean sections at private facilities was more than twice that at public facilities. Although there were significant differences in the utilisation of private facilities by women from different 'population groups', there was an independent effect of 'population group' classification on caesarean section rates: caesarean section rates among women classified as 'White' and 'Coloured' were significantly higher (95% confidence intervals for odds ratios: 1.40-2.42 and 1.05-1.81, respectively) than among women classified as 'Black'. 'Population group' differences in caesarean section rates among South African women are not explained by differences in demographic risk factors for assisted delivery, nor by differences in access to private health care. Instead, the differences in section rates may reflect the effect of bias in clinical decision-making, and/or differences among women from different 'population groups' in their attitude towards assisted delivery, and their capacity to negotiate with clinicians.
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PIP Health policies worldwide have changed dramatically over the past few decades. Currently, practically every country is engaged in or considering health sector reform. The authors reflect upon those changes, highlight current trends, and identify key issues and challenges. They comment upon the concepts of health and policy and the historical developments which have influenced policy. The context in which health policies in low-income countries are formulated and implemented is discussed, including macropolitical and macroeconomic developments, health needs and determinants, financing, approaches to health planning and priority setting, and the key international health policy actors. An overview of the content of current health policy proposals in less developed countries is presented, with key issues identified for the future. Reference is made to the 1993 World Bank Development Report, Investing in Health, and other health sector reform efforts.
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The last 5 years have seen dramatic developments in South Africa, with wide-based internal political struggles and international pressure forcing the government into a well publicized if temporary series of reforms. Yet this has not been paralleled by any substantial improvement in the health conditions of the majority of the population. Apart from improvements in black infant mortality in some urban areas, the health gap remains, a material expression of the social inequality that is part of the definition of apartheid. Black children continue to die from preventible afflictions at about 10 times the rate of their white counterparts. Maternal deaths among women classified as black, coloured or Asian continue to occur, mostly due to septic abortions. At national level, blacks are nearly 30 times more at risk of being diagnosed to have tuberculosis than whites, with some age groups being at still worse risk. Black children under the age of 4 years in Cape Town in 1984 were 205 times more likely to have tuberculosis than their white counterparts. The last 5 years has also seen a revival of rhetoric echoing the international support for primary health care in the 1970s, but health care processes have not been modified to cope with the continuing racial stratification of disease and access to health care. A move towards privatization of the health services has only benefited a few.
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The expansion of United States for-profit hospital chains into the international arena is a new and important development. Experiences with contract management of middle eastern hospitals in the early 1970s gave the American firms impetus to pursue ownership of health facilities in other parts of the world. US companies now operate over 95 foreign hospitals. The reasons for this involvement include the political receptivity of the government of the host nation; the potential for rapid growth and profits; the lack of indigenous competition; and the ability to occupy a distinct niche within the extant health services organization. The political and ideological implications of the growth of private medicine, particularly in the United Kingdom, in terms of its effects on the National Health Service are discussed. Questions for future research are posed.
Industrialisation. rural change and the
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