Apartheid is dead! Long live apartheid!

On our rounds on Friday we were called to the adjacent ward to see a young lady, barely 40 years old. The curtains were pulled round the bed, which was itself unusual, as most consultations and examinations take place without screens. It predicted bad news. On arrival it became clear that we were not going to be able to help as she appeared to be already dead and a swift examination confirmed this. It was not that we had arrived too late to help; she had HIV infection and had been terminally ill with advanced cancer of the cervix. She had a large mass palpable in her abdomen, almost certainly the disseminated cancer.

Cervical cancer is another epidemic that is raging in Southern Africa on the back of AIDS. It is caused by a virus, the human papilloma virus (HPV). Related viruses cause the simple wart. HPV types 16 and 18 are the major culprits causing cancer, but others can do it too. They are sexually transmitted so they can travel with HIV but, more importantly, the immune system plays a major role in controlling and eradicating these viruses. In advancing AIDS, as the power of the immune system wanes, HPV infection can spread unchecked through the cervix. By infecting more cells the chance of a cancer developing increases dramatically. With no immune system to contain it, the cancer grows rapidly and spreads aggressively. In South Africa there are around 7,000 cases each year and almost half of these are fatal.

The tragedy of this case is that, unlike HIV, for which a vaccine is a distant dream (very distant I believe), cervical cancer is now a disease which can be prevented by vaccination. In many countries all young girls are now offered vaccination against HPV 16 and 18. The benefits for the individual are evident and the economics are also obvious since cervical cancer can be expensive to treat, and the loss of otherwise healthy young (taxpaying!) women is bad news. Add to that the unquantifiable damaging effects on children of the loss of their mother, commonly at a very young age, and the case for vaccination is compelling. In a country like this where HIV is rife it is unanswerable. The vaccine has been available here since 2008 but only in the private sector.

The big news story here is the miners’ strikes. At the first of these there was a violent clash between police and striking miners. Confrontations between miners and the police have occurred in the past in the UK, notably during the Thatcher years, but those pale into insignificance compared to this one where 34 miners were shot dead by the police. This provoked predictable and understandable outrage. The most jaw dropping moment however was the authority’s response in which they attempted to bring a charge of murder against the striking miners. The accusation was based on an old apartheid-era law rendering those who initiate such an action responsible for its consequences. The idiocy of this (but possibly not the irony) was eventually perceived and this preposterous legal action was withdrawn.

The strikes have now spread to other mines. They are all ‘wildcat’ which suggests the miners have an equal lack of faith in their employers and their Unions. Sadly they play into the hands of both the employers who then can (and do) dismiss strikers with impunity and, possibly more worryingly, they are fuel for activists like Julius Malema.

Malema was ejected from the ANC for ‘divisiveness’. This firebrand, who hobnobs with the wealthy when not tub-thumping, is now preaching that the deaths of his ‘fellow’ workers are all symptomatic of the underlying problem of South Africa which is white owned wealth. This is a potently seductive rallying cry but might be thought disingenuous from someone sporting a $34,000 Breitling watch.

The wealth of this country depends heavily on mineral exports so that the knock on consequences of the current industrial unrest will be significant and widely felt. Inevitably the folk at the bottom of the tree who are least able to hedge their welfare against adversity and who have no personal reserves will feel it most. One area that will certainly suffer even more is health. The financial resource available for healthcare is already stretched to the limit in South Africa as can be seen every day here in Zithulele, where, if we run out of a basic antibiotic, we don’t know when (if) it will be available again, and where the venerable ultrasound machine, our only radiology, and on which obstetric care is so dependent, sometimes inexplicably decides to stop working for days on end. Currently it is also on a wildcat strike.

In healthcare nationally South Africa is wrestling with the prospect of a possible withdrawal of PEPFAR, the US presidents fund which has underpinned so much of what has been achieved in making such huge inroads into stemming the AIDS tsunami. In passing it is an interesting thought that it will be a strange paradox if Bush is remembered for introducing PEPFAR and Obama’s legacy is its withdrawal.

The other big news here is that President Jacob Zuma is having 238 million rand spent on his house in KwaZulu Natal for ‘security’ reasons. Against what sort of threat this level of ‘security’ is required is difficult to imagine: – nuclear attack? Armed insurrection? Namibian expansionism? In what is known as ‘pork’ in the US, another town is also being built in his homeland at a cost of I billion rand, but at least that may benefit others. When the bill finally comes in it is a reasonable prediction that one quarter of a billion rand is going to be spent on this one man’s home.

The government is spending nothing on HPV vaccination.

With the money that is being lavished on the Kwa-Zulu bunker, a rough estimate suggests that the government could fund a vaccination programme against HPV for all the 10-12 year old girls in South Africa (ideally the boy as wells; vaccinating both is what is really needed to stop these viruses). There are of course other equally deserving health targets, but the principle is the same and the inequity in resource allocation is starkly and offensively visible when young people are dying of a disease that is preventable by an affordable vaccine. It was not us that were too late to help our patient on Friday it was this country that was far too late for her, and for thousands like her.

The departure of apartheid was welcomed worldwide. It was an abusive inequitable race based system, morally corrupt and with no virtues. Its legacy is still here in the persistence of large white-owned farms and businesses and a persistent maldistribution of wealth. According to the World Bank, the richest 10% of the population earns 58% of national income while the poorest 50%, earn just 8%. This is changing, but rather too slowly, and the plans to begin a redistribution of farmland (another major enthusiasm of Malema’s) have triggered serious fears of a Mugabe style populist eruption. There are far more sensible evolutionary schemes which could achieve the same ends while keeping the farming wealth intact and avoiding a repeat of a Zimbabwean style agricultural meltdown and the subsequent economic catastrophe.

If the government here really do want to erase what might be construed as remnants of a discredited political system then it is not the smartest of moves to invoke a Kafkaesque law from that era after shooting dead unarmed strikers. It also seems blindingly obvious that they will be far better able to achieve those ends, and gain international respect, as well as encouraging prolongation (and a desperately needed increase) of international aid for health if they can demonstrate that they themselves occupy the moral high ground. What will international aid agencies think as they look at the excesses of the Zuma ‘pork’?

Those of us who are exposed to the sharp end of health care here can only hope that international funding agencies will focus on the real issues facing the country. HIV has got to be held in check before its lethal partner in crime, tuberculosis, generates a plague to dwarf AIDS and one which doesn’t just affect those whose behaviour has put them at risk of infection. It may already be too late. The humanitarian impulse must outweigh reservations triggered by the appalling self-seeking behaviour of the (relatively) few.

Racial apartheid may be history but this situation is merely a different form – political apartheid. The new ‘haves’ are politicians hell-bent on a bloated lifestyle of privilege and giving themselves all the luxuries they can while turning a blind eye to the consequential creation of new inequities in the distribution of wealth, and ignoring the health needs that are screaming out throughout the country. Political apartheid also isn’t above considering the use of laws against which those currently in power campaigned so vigorously.

The current situation brings to mind the bleakest scene in Orwell’s ‘Animal Farm’ when, at the very end, the assembled animals are watching through the window as pigs and men are companionably drinking, joking and gambling. The poor South African black would be forgiven for looking from pig to man and man to pig and pig to man again and realising that they too could no longer tell the difference.


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