COVID-19 and South Africa: The coming storm in health and state

30 March 2020: Cramped housing, overcrowding and unemployment meant some residents of Kliptown were forced to be outside on day four of the Covid-19 lockdown. Photographer: Oupa Nkosi

From the UK site Left Horizons. This article was originally published here

South Africa in crisis, Part 1

By David Hemson

There are voices, some hidden, others vocal, saying that South Africa is heading straight to the abyss because of the staggeringly high levels (20.4%) of the population living with HIV/AIDS and that everything is in a state of collapse. Government responses to past epidemics have been ambiguous and piecemeal changes have not substantially changed health system inequality.

This is a firmly factually-based interpretation of our manifold inequalities, wasted state reserves and other resources. These are also some pointers to resilience: somewhat counter-intuitively, those who are on anti-retroviral drugs (ARVs) will be more resilient than those who are not and the battle-hardened front ranks of personnel in the facilities against HIV are a major resource.

Against this are the brutal contradictions of wealth and poverty, safety and violence. All the unfinished business of the South African revolution is now outlined against the dark sky of disease; the question is how the labour and social movements can forward a bold public health initiative and socio-economic plan to progress towards the once-promised stage of socialism. This crisis provides the opportunity to re-energize the creative energies of working people as in the victorious struggle against apartheid.

“Disasters are political. Disease is also political. Class determines who has medical aid and who does not, who has access to water, sanitation and safe means for heating and lighting and who does not.” – Shack dwellers’ movement Abahlali baseMjondolo, 22 March 2020

Working people already grappling with survival

With a declaration of a state of disaster by President Ramaphosa followed by lockdown on 26 March of all non-essential movement, the South Africa government acknowledged the threat and force of the pandemic. With a weakened state and an economy already in recession, working people are already grappling with strategies for personal and family survival. The question is how effective government measures will be to restrain and control the onrush of Covid-19 and provide for human survival. In the post-pandemic period there will be demands for redress for the stunted conditions of life under capitalism.

Covid-19 initially appeared in the enclaves of prosperity of the well-travelled elite. It seemed foreign to the African context. For some weeks South Africa was frozen in time, as infection raged in Italy and Iran. It appeared to be somewhat similar to the rest of Africa with cases in the units rather than hundreds. All this is now changing rapidly.

Virus might overwhelm fragile health system

This phenomenon of sick rich appeared to contradict the terms of inequality of black and white, poor and rich. The early numbers were carefully monitored and those tested positive were isolated. Now, however, the new cases are unrelated to foreign contact as the virus finds a place within wider SA society. Covid-19 infections have been spreading unpredictably and rapidly from the enclaves of prosperity to the population of 56 million which has a particularly vulnerable health profile. Potentially, the pandemic could overwhelm the deeply unequal, poorly administered and fragile health system.

Although the African National Congress (ANC), the dominant liberation movement, has ruled for 25 years, post-apartheid reforms have not included a fully-funded national health service. Instead, there have been piecemeal changes which have not substantially changed health system inequality. Indeed, greater income inequality – particularly rising incomes among the upper 10% – has encouraged growth of the private health sector in which the rising black elite participate.

In the recent period there has been little concern for conditions in public hospitals, despite many exposés of mismanagement in hospitals and, in some provinces, deep corruption and mismanagement of health systems. Despite these necessary reservations, there are public hospitals and clinics which are competently managed and are committed to meeting the rising burden of disease. In the midst of demanding conditions, dedicated health workers are undertaking competent and caring work under, often, very difficult conditions.

The state of the nation’s health

South Africa is no stranger to pandemics; its people suffered great losses in the 1918 flu epidemic and a hundred years later has the largest concentration of HIV positive people in the world as well as high levels of tuberculosis. The country also had a large-scale cholera epidemic in 2000-2001 which was shorter-lived but extensive in rural areas. The continuing HIV pandemic, tuberculosis and the year-long cholera epidemic severely tested the post-apartheid health system. There is some advantage: it has also helped prepare for the mass testing and emergency interventions now required.

The epidemics of HIV and tuberculosis overlay each other, infecting the same vulnerable communities and individuals. South Africa has the biggest HIV epidemic in the world, with 7.7 million people living with HIV and half of those HIV positive also suffer from tuberculosis. HIV infection is increasing at a rate of 4,285 a week and tuberculosis at 8,654 a week. These diseases have peaked but prevalence is not declining; these epidemics are kept at bay rather than declining. Massive interventions are at this stage partly effective, not decisive, in reducing these debilitating epidemics. Despite this, the infrastructure of testing and treatment is a resource for responding to Covid-19.

Government response to past epidemics has been ambiguous. The rapid advance of HIV infection in the mid-1990s was denied by then president Thabo Mbeki. Indeed, he vigorously argued that HIV virus did not exist and opposed anti-retroviral drugs being used in hospitals. The delayed intervention resulted in life expectancy plunging from 63 in 1994 to 53 years in 2004 and is only now rising beyond the levels of the early 1990s.

Anti-retroviral drugs labelled ‘poisonous’

His labelling of ARVs as “poisonous” clouded treatment with controversy and racial innuendo. Although South Africa has alarming levels of infection, visiting health specialists feel there is no sense of crisis and urgency in lowering the prevalence of people living with HIV. The mass treatment programmes for HIV and TB have been a priority in spending leaving an infrastructure in place but they leave fewer additional resources for this pandemic.

These epidemics have drawn heavily on available funds for investment in health facilities. It is estimated that the allocation to the health department for HIV/Aids has amounted to R537 billion ($36 billion) over the period since 2004. This spending is focused on HIV and TB prevention, care, and treatment interventions. Since 2004, PEPFAR (a US government fund) has contributed over $8 billion to support this initiative. While SA now has the largest treatment programme in the world, HIV appears to be accepted as a chronic disease along with obesity, hypertension, diabetes and cardiovascular disease. South Africa has the highest levels of obesity in sub-Saharan Africa.

These destructive combinations have brought the unwelcome description of South Africa as the unhealthiest society in the world. This heavy burden of disease rests on the black working class which suffers high unemployment, poor housing and violent crime.

Public decline, private expansion

While health services are at the centre for effective treatment, they are fractured by staggering inequality. In the post-apartheid era, class allocation of resources has accelerated private health infrastructure. As access to the full range of public health services opened to all citizens, public funding faltered and private hospitals were built at an increasing rate. Health insurance companies such as Discovery, based in South Africa, grew rapidly and now range internationally.

As funding of the public sector has stalled, health has become a private and personal vocation supported by expensive medical insurance. The private healthcare system it supports opens access to private hospitals, gyms, doctors and other health professionals. This meets some 16% of the population’s needs and the overwhelming majority of health personnel follow this expenditure: about 79% of doctors work in the private sector. All medical training takes place in the public sector, but 70% of doctors go into the private sector.

21% of doctors for 84% of the population

Such huge dynamic disproportions distort the health services available to the majority: by comparison the public health sector has to meet the needs of 84% of the population with 21% of the doctors! There are radical divisions between the private urban and public rural hospitals; just under half the population live in rural areas, but only 3% of newly qualified doctors work there.

Improvement of the health of the majority has depended largely on the collective; public housing, water and sanitation services rather than drugs, even though these have been critically important in treatment of HIV. Despite this, the considerable post-apartheid advance in housing and social services has yet to be realised in improved health and life expectancy. Where services have faltered, however, the effects are clear. The disconnection to safe drinking water to rural communities resulting from neoliberal cost recovery in the 1990s led directly to the outbreak of the cholera epidemic of 2000-2001.

Health services show the blunt edge of reform; the new elite does not use public health facilities and has little concern for the actual conditions in clinics, hospitals and in the small private practices orientated to poor people. National budgets have consistently allocated less than the targeted 15% of the budget to health services. A regime of budgetary austerity (accompanied by profligacy and corruption in state enterprises) has further accentuated the public/private divide as the private sector rises in comparison.

Rising demand is not met

The latest available statistics show there are 407 public hospitals (with about 158,000 beds) and 203 private hospitals. The provincial health departments directly manage the larger regional hospitals. Smaller hospitals and primary care clinics are managed at district level. There are over 401,000 practicing nurses in South Africa; their number has been limited by the closing of nursing colleges during the late 1990s in implementing the GEAR neoliberal programme. Unfortunately, the rising demand is not met (even in conditions of mass unemployment) as there is a high drop-out rate of candidates in training.

Large public hospitals will be in focus as the pandemic grips South Africa. The Chris Hani Baragwanath Hospital is the third-largest hospital in the world and it is located to serve concentration of population in Johannesburg. There have been critical reports on its management but given its location to the centre of population in Johannesburg it will be the key hospital in the defence against Covid-19. High levels of wastage, theft and corruption are reported in the public hospitals.

The immediate focus will be on the ICUs. Although there are offers of cooperation from private hospitals, how will the 4,960 critical care beds in the private sector in 2017, with 60% availability, be jointly coordinated with the fewer 2,240 critical care beds in the state sector, with 20% availability? How can this resource be equitably used when there are conflicting claims from members of medical insurance and from the majority of desperately ill non-members?

Feedback loop and prognosis

The shack settlements are at one pole of interventions to contain Covid-19, at the other are the enclaves of well-travelled. Surveillance and intervention has initially focused on the latter. In other the epidemics in other countries, such poles of poverty and wealth have also been linked by feedback loops as domestic workers from poor communities work daily in the houses of the elite and return home at night. Local transmission of disease operates in both directions; studies of flu in India show such loops from the slum areas to the cities. It is hardly possible for the shack settlements of South Africa not to become more infected than privileged areas over time.

South Africa has a highly mobile population; the historically ingrained cheap labour system involving migration between the urban and rural contexts has drawn both closer together. During a period of crisis migrants return to rural areas potentially carrying disease.

Infections have risen relatively slowly within the enclaves of the privileged until local infections have risen sharply. From the first positive registered on 5 March there are now over 1,000 at the time of writing (26 March); the exponential increase has undoubtedly spurred the lockdown. [There were 1,655 cases on 6 April 2020.]

Systematic modelling of disease

There does not appear to have been any systematic modelling of disease taking South African social conditions into account. It is possible that the high temperatures may retard the advance of Covid-19. Presently its momentum appears exponential and not determined by temperature conditions. The difficulty is South Africa’s flu season only starts in April when it gets colder. It is unsure whether Covid-19 is a seasonal disease but that might not offer comfort.

Somewhat counterintuitively, most experts think those on antiretroviral therapy whose viral loads are suppressed will be more resilient than those who are not on this therapy. The ARVs may make the body more resistant to infection and the spread of the virus if HIV medications are maintained without disruption. Such defence could account for 54% of those living with HIV, taking treatment and who have achieved viral suppression.

This leaves 46% or 3.5 million of those living with HIV who are untreated with a potentially high viral load and low levels of immunity, a group which will be particularly vulnerable. Most of this group are the “missing men” who know they are HIV positive but decline to take the free ARV treatment. They may continue to be sexually active and could have a high viral load and infect others. Since partners and networks of infection are not known as this is not disclosed there are gaps in treatment and continuing infection. The millions involved in refusing treatment give some dimension to a problem which is not found in other African countries and is unique to South Africa.

April 14, 2020

From www.newframe.com, the original can be found here