Equity lies close to Dr Ivan Toms’€™ heart. Recently appointed as the health director in the City of Cape Town, Toms states unequivocally that the commitment from the city is towards equity, not just in the health department, but in general.

“Equity is not equality ‘€“ that’€™s the difference,” Toms says.

“So, if you have five people and you have R100, then equity doesn’€™t give each of them R20. Equity gives the single parent, woman headed household with no employment and five kids maybe R50 and the others ten.

“It’€™s to relate resources to need. That’€™s the key link and that’€™s what the city is trying to do,” Toms explains.

“And we’€™re managing what is a post-apartheid city, designed like an onion from the mountain outwards in terms of race and socio-economic level,” he says.

Toms is adamant that the city needs to be addressing these issues from a health point of view, with a particular need to deal with “the festering urban edge that you find in these informal settlements where there is nothing in terms of basic services”.

“One of the difficulties around it is that almost all of the informal settlements that have no services are on private land, so it becomes a question of who pays and whose legal responsibility it is and I think that is where we are battling together in a multi-sectoral approach ‘€“ there are now task teams to look at these issues that have housing people, that have people from sanitation, water, health participating. Often these teams are driven by health.”

Toms views it as extremely positive that the health sector is driving the equity issues in the city.

“There is this commitment to the poor ‘€“ one is seeing it in the province as well ‘€“ trying to get service delivery speeded up.

“It’€™s taking the process and saying you’€™ve got a city where you have to service the whole city, but you’€™ve got to have a particular focus to make a difference in the areas of poverty”,” Toms explains.

Toms firmly believes that if in Cape Town they could create jobs they would be making a huge impact on health and on everything else.

“Nobody likes being poor, nobody likes being given services. Ideally, we need to affirm people and for people to have a job so they can progress, have their little house and add to it, develop it, get out of the cycle of poverty ‘€“ that’€™s the first prize.”

Toms smiles when asked why TB is so high in Cape Town, but he ventures a few theories.

“One would suggest that overcrowding is a key issue, damp is a Cape Town phenomenon that perhaps suggests why we have a higher incidence than other places. (The TB bacteria lasts longer when coughed up in the damp weather)

“Prolonged periods of infectiousness ‘€“ long delays before clients present to the health services and presently poor treatment outcomes in the TB control programme due to interruption driven by high mobility of recently urbanised populations.

“At one stage we were probably making TB worse because of our poor outcomes. Because we keep people who are infected alive and they are then infecting others whereas in a normal epidemic they would have died,” Toms explains.

But he says that there is also a feeling that the rate is higher in the Western Cape because it has a better health infrastructure and picks up more of the TB cases than in other parts of the country.

“Because it is very strange to explain why a province with nearly the highest human development index also has the highest incidence of TB. And it is continuing to increase at the moment, even though we’€™re getting much better outcomes.”

Cape Town’€™s cure rate is currently at over 70% for the whole city and the success rate is about 80%. “That’€™s fantastic. But the incidence is still going up because of HIV. And both are diseases particularly linked to poverty.”

When asked to explain why a person in, for example, Bothasig should be concerned about the TB rate and levels of services in Uitsig, Toms is clear.

“I think in the rich areas of Cape Town, people’€™s biggest problem would probably be crime and grime. It’€™s usually what they moan about from a health point of view. I think most of people in those areas can quite clearly make the link between crime and poverty,” he says.

“The rich and the poor can make that link. I think we need to work on it as a city. If people in the leafy areas start demanding we want this, we want that, we need to talk to them about the needs coming from Phillipi East or Browns Farm where people have nothing.

“How can we start worrying about whether your trees have been clipped properly in your roads when people don’€™t have toilets and people don’€™t have water. People need to talk.

“Apartheid worked so successfully because people were never able to mix as equals and could always be indoctrinated about what they thought the other person felt. When we meet each other we find we are all very similar.”