All is not fair in the Cape

In 1993, Ntombekaya Philingane boarded a bus in Queenstown, leaving behind one of the poorest parts of South Africa and headed for Cape Town, hoping to find a better life.

But nine years later Ntombekaya, who has since become a mother to seven-month-old Sisonke, finds herself sharing a three-roomed shack with three adults, including her unemployed partner, next to Mew Way in Khayelitsha’€™s Section RR.

She fetches water from a disused shipping container next to the road. She fills a plastic drum almost every day and transports it back to her shack in a shopping trolley.

Sanitation is a foreign concept in her area with the family using a bordering stream as a toilet. Electricity is non existent.

When the rain arrives, the shack is flooded.

“I will do anything for a job, I will sweep, anything,” she says, cradling Sisonke on her arm.

At times Ntombekaya and the baby are forced to flee to a relative’€™s house in an attempt to escape the mosquito plague. “They sit all over the baby and bite her,” she says.

Ntombekaya says she is relieved that her baby has not been ill up to now, although other children are breaking out in a rash, possibly due to the unhygienic surroundings and polluted stream nearby.

“I wish we could be moved from here to a better place where there is water, sanitation and electricity. At times we don’€™t have food, but we manage to scrape enough together for half a loaf of bread when my boyfriend gets an odd job’€¦”

Listening to Ntombekaya’€™s story one needs to be reminded that this woman is living only a few kilometers from Cape Town suburbs where every house has a flush toilet, running water and electricity.

In an attempt to move a step closer towards a fairer distribution of resources – such as health services, water and electricity – for people such as Ntombekaya, the Health Equity Gauge has been introduced to the Cape Town Unicity.

Dr Mickey Chopra, senior lecturer at the University of the Western Cape’€™s School of Public Health and one of the driving forces behind the introduction of the Equity Gauge, believes the gauge could provide an active approach to monitoring equity (fairness) in health and health care.

In the Cape Town Unicity, as in the rest of South Africa, there has been a history of racially separate and grossly inequitable provision of health and other services, with those who least require the services having access to more varied and a greater proportion of services, than those who require them most.

“The vast inequity across the Unicity is obviously a legacy of its apartheid past, but it also reflects an unequal present. However, this inequity affects everybody in the Unicity. For example, we find children with worm infestation even in areas where there is good sanitation because the eggs get blown from areas with poor sanitation,” Chopra points out.

He adds that the rapid and unplanned growth of the city and the continuing inequitable distribution of resources mean that many residents live in very poor conditions. Poor housing and a contaminated environment coupled with poor nutrition and sometimes poor primary health care services result in the high number of infant deaths (children under one) in parts of the city.

“Such large differences in the number of deaths across the city is simply unacceptable,” Chopra says.

By measuring and drawing attention to the health inequities across the Unicity, the Equity Gauge hopes to establish shared values and targets to reduce these inequities.

It is hoped this in turn will lead to actions aimed at reducing such inequities.

But Chopra cautions that the monitoring of equity would have to take place through partnerships of key stakeholders such as councillors, community health committees and health managers.

Because good health is dependent upon having access to good health services as well as water, sanitation, housing and a safe environment, the Equity Gauge is planning to use health indicators as a way to facilitate the process of implementing a practical strategy for equitable allocation of resources, services and public health interventions, between the eleven proposed health districts in the Cape Town Metropole, based on their present and predicted future health needs.

For many years the infant mortality rate (IMR) has been considered the best indicator of a population’€™s overall health level.

IMR is the number of deaths per 1 000 live births in children under one year of age.

Not only are infants especially vulnerable to the ravages of ill health, but also their survival depends on a diversity of factors ranging from biological and environmental to economic and cultural.

Studies have shown for example that the under 5-mortality rate can be up to 60 times higher in poor than in rich nations, while the IMR is as much as forty times higher.

In 1993, the IMR in Mozambique was 164, while in Cuba and the United States it was 9.

Professor David Sanders, Director of the School of Public Health, agrees that health could be used as a mechanism to successfully draw attention to a range of inequities.

“We have got a slice of the Ciskei and Transkei (Eastern Cape) here in Khayelitsha,” says Sanders.

Sanders explains that most infant deaths in developing countries and in the Unicity are due to a small number of conditions.

These are peri-natal problems (problems associated with late pregnancy and child birth and complications in the first week of life) which are much more common in infants born with a very low birth weight; diarrhoeal diseases, lower respiratory infections (pneumonia); and HIV/AIDS.

For example, in 1999 in the Table View area 18 babies weighed less than 2,5kg at birth while in bordering Marconi Beam the figure was 34. More babies were born in Table View during that year.

Peri-natal problems are related significantly to poor maternal nutrition and health and inadequate ante-natal care.

Diarrhoeal disease is sensitively related to poor environmental hygiene (sanitation and water supply) as well as under- or poor nutrition of an infant that renders him or her more susceptible to serious and prolonged diarrhoea.

Respiratory infections are more common or serious in overcrowded and poorly ventilated housing and in the presence of under-nutrition.

In infants and young children the most common complications of HIV are respiratory and intestinal infections (diarrhoea).

These inequities are starkly highlighted by data gathered by the Unicity as well as Stats SA.

It does not take complex calculations to gather that the infant mortality rate in for example Table View, where there is on site access to toilets, clean water and education at all homes, is much lower than in Marconi Beam.

In fact, in 2000 about 8 out of every 1000 children under the age of one died in Table View, while in Marconi Beam the figure was closer to 130 ‘€“ fourteen times higher.

Needless to say, most residents in Marconi Beam have poor or no access to water, sanitation, electricity, housing and good education.

In parts of Khayelitsha where Ntombekaya lives, the IMR is well over 50.

South Africa is categorised as an upper middle-income country by the World Bank, with an average per capita gross national product of U$3160 in 1995.

Yet the 1998 Poverty and Inequality Report prepared for the South African government, indicates that just over 50% of the population is “poor” and 27% is “ultra-poor” assessed against consumption-based income poverty lines.

The report lists the Western Cape as one of the provinces well above the poverty line.

But despite this, pockets of Cape Town, such as Khayelitsha are as poor as many areas in the Eastern Cape where 71% of residents are classified as poor.

In the Western Cape 28% of residents are listed as poor.

Dr Lilian Dudley, acting head of Cape Town’€™s municipal health services, points out that the health department has control over health services, but it is other basic services which they don’€™t control that are impacting on health.

“We found major disparities on how money was being allocated when the Unicity was established,” she says.

Dudley says that most of the Unicity health resources are tied up with staff, but that they are trying to address issues of understaffing.

“We will also look at quality of care, but this is a long term issue.”

Dudley agrees that access to sanitation, electricity and clean water are the important factors influencing the IMR.

“But we need to either link IMR to housing development or find another route to influence trading services that seem more intent on collecting revenue at this stage,” she remarked.

“Unless we address it now, it is going to get worse.”

Other health indicators that could be used include to measure the level of service include the diarrhoea and TB rates in an area.

See sidebar : Social development restored health in Britain’s 19th century urban ghettos long before the arrival of drugs”

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