Lethal cocktail of epidemics

Lethal cocktail of epidemics

A special series of the Lancet focusing on South Africa spells out in painful detail how many of our health indicators are the worst in the world. But while our health system is littered with lost opportunities, the Zuma government brings the possibility of real progress, argue the series authors. Kerry Cullinan reports.

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South Africa has a ‘€œcocktail of four epidemics’€ ‘€“ HIV/AIDS, tuberculosis, violence, poor maternal and child health and increasing chronic diseases.

This is according to a special edition of The Lancet, the respected UK-based medical journal, focusing on health in South Africa which is being released in Johannesburg today (Tuesday, 25  August).

The Lancet makes depressing reading. Some of our statistics ‘€“ such as for HIV, TB and interpersonal violence ‘€“ are among the worst in the world. We are beset by racial and gender inequity ingrained by decades of colonialism and apartheid.

‘€œRacial and gender discrimination, income inequalities, migrant labour, the destruction of family life and persistent violence spanning many centuries but consolidated by apartheid in the 20th century’€ are to blame for the current health problems, according to Professor Hoosen Coovadia and others, who wrote the introductory chapter.

The poorest 10% of households (mostly black) have an average annual income of R4 314 (mostly from grants) while the richest 10% get over ninety times this ‘€“ some R405 646.

Health indicators are still badly racially skewed. In 2002, the infant mortality rate among whites was seven per 1000 babies born. For African babies, it was 67 per 1000.

There are also inequities between provinces. Western Cape children under five have a mortality rate of 46 per 1000 in comparison to KwaZulu-Natal’€™s 116 per 1000.

Sexual entitlement of boys is ingrained, with almost 40% of girls reporting that they were sexually abused before the age of 18.

Teen pregnancy is widespread, and half of all South African women have had at least one child by the age of 21.

The role of alcohol abuse is raised over and over throughout all the six chapters. It plays a major role in violence, including murder and rape, road accidents, unsafe sex.

‘€œRudeness, arbitrary acts of unkindness, physical assault and neglect by nurses have been widely reported’€ during the post 1994-era, according to the authors.

Aside from rudeness, there is also a shortage of skilled health staff. Thanks to the ill-conceived decision to close a number of nursing colleges to save money during former President Thabo Mbeki’€™s era and migration, the rate of skilled professional nurses has dropped from 149 per 100,000 people in 1998 to 110 per 100,000 in 2007.

‘€œAs many as 40% of nurses are due to retire in 5-10 years and nursing remains the most crucial area for urgent policy intervention,’€ note authors

Poor leadership and stewardship (taking responsibility) also run like a ruinous cancer through the public health system.

Post-1994, many inexperienced managers were placed in positions of seniority and they have struggled to deal with major challenges, particularly human resource management.

Unfortunately, ‘€œincompetence within the public sector is widespread’€ and government has lacked the ‘€œpolitical will and leadership to manage underperformance in the public sector’€. Loyalty rather than the ability to deliver has been rewarded.

There is no personal accountability. Leaders and managers have not been held accountable when mistakes have been made.

‘€œWithout concerted efforts to change national thinking on accountability, South Africa will become a country that is not just a product of its past but one that is continually unable to either address the health problems of the present or to prepare for the future,’€ assert Coovadia and others.

Former President Mbeki’€™s ‘€œbizarre and seemingly unshakeable belief that HIV did not cause AIDS’€ resulted in hundreds of thousands of lives lost and a substantial burden of ill health.

While ‘€œthe public health system has been transformed into an integrated, comprehensive national service’€ the ‘€œ failures in leadership and stewardship and weak management have led to inadequate implementation of what are often good policies’€, conclude the authors.

Lancet UK editors Dr Richard Horton and Dr Sabine Kleinert conclude: ‘€œThe South African people have shown extraordinary resilience during difficult times. The current leaders have survived apartheid, and often imprisonment, to fight for the future of their country. Civil society, with its strong voice, has brought about many important changes in health.

‘€œSouth Africa is a young democracy with pride and hope, and above all with high expectations for a fair, equitable, and peaceful society. Its people deserve a healthy future.’€

* Professor Hoosen Coovadia, Rachel Jewkes, Peter Barron, David Saunders and Di McIntyre wrote Chapter 1, tracing the roots of current health challenges. http://press.thelancet.com/saser1.pdf

Click here to access the full series.

Related stories:

Massive twin burden of HIV and TB
A nation killing itself
‘The paradox of apparent progress yet worsening health outcomes’€™
Steady growth in chronic diseases
Finding solutions