Community Health Needs in South Africa

Ntombenhle Protasia Khoti Torkington

• Publisher: Routledge
• Year: 2017
• Topic: Social Sciences
• eBook ISBN:
  9781351769082
• Subtopic: Social Work
• Index: Social Sciences

This title was first published in 2000:  Although the apartheid regime has now been abolished there is still a great deal of work to be done in order to eliminate the disadvantages it created for the health of black people at both micro and macro levels. This book presents the findings of a study commissioned to assess and respond to the health needs of black people in South Africa. The hope expressed by those who participated is that the study is considered within the wider context of understanding the apartheid system and the scars it left behind. Community Health Needs in South Africa represents an excellent example of how action research can be used as a tool to make a difference in people's lives.

1 The Historical Development of South African Society

A doctor who genuinely wants to heai her patient will look beyond the physical symptoms, and examine everything in the patient's environment which is a likely cause of the symptoms. Similarly, the social analysis of diseases requires that we should examine the society to see which aspects of it are responsible for causing ill health, and then work for whatever changes are necessary and possible to improve the situation. This takes us out of the world of pure medicine and into that of politics - a necessary step. The barriers that have been erected between health and politics are artificial. They must be broken down before we can even begin to think what a healthy society might look like (De Beer, 1984).

As De Beer points out, it is important that we have some idea of the society within which South Africa's present health system developed in order to understand the enormous task faced by the government in its attempt to improve the health of the nation. Such understanding will also be useful for those who are interested in contributing to the development of good health for people in South Africa. They too need to know that current health issues have their roots in a history that predates the apartheid era. If good health is to be realised it matters that the focus is not only on illness and disease but also on the well-established roots that feed illness and disease.

Theoretical Perspectives in the Development of South African Social, Political and Economic Structure

The history of South Africa, which is relevant in explaining present patterns of disease and health care, has roots reaching back to 1652 when the first white settlers from the Netherlands landed in the Cape of Good Hope. From the time the settlers arrived contact between black and white people was characterised by wars over the possession of land and cattle. As De Kiewiet (1950) points out however, this era was skewed by more than just the desire to have land. It was primarily a process which gave the white community more than the bulk of the best land. They gained a considerable measure of control over the labour power of black people. Black people lost access to their land and were only allowed to work on it as labourers, tenants or herdsmen.

The control of land was finally legalised by the Land Tenure Act of 1913 which gave 87 percent of the land to white people and 13 percent to black people. This disproportionate distribution of land, many analysts have argued, is the heart of all developments which have impacted negatively on the health of black people. To many, racism was the impetus for these developments, but others maintain that racism was less influential in pursuing its own interests than the pursuit of capital. One such theorist is Wolpe who traces these developments back to the early phases of capitalism.

Wolpe (1972) proposes that during the early phases of capitalist development, when extractive industries and agriculture were the main employers of labour, the rural economy subsidised capitalism by making it possible for the extended family to perform 'Social Security' functions for the reproduction of the migrant labour force. It was the work of the family to care for the young, the old, the sick and the migrant workers when they were not at work. Thus, rural black families were crucial for capitalism since it was through the network of reciprocal obligations between the migrant workers and their rural families that a system of cheap labour through migration was maintained. This rural 'subsidy' enabled the white employer to fix wages at persistently depressed levels to provide subsistence to the migrant workers and only during their period of actual employment. Wages were woefully inadequate to maintain labourers and their families.

By 1920 the pre-capitalist forms of production surviving in rural areas began to show signs of decline for a number of reasons, e.g. the absence of able-bodied migrants, the increasing pressure exerted by population expansion and the incapacity of rural land to Increase agricultural production as a result of inefficient farming methods. Such factors made agricultural production so precarious that the slightest drought such as that which occurred between 1934 and 1936, could cause a serious deficit in the production of African staple foods, i.e. the production of maize dropped from 3.7 million bags in 1934 to 1.2 million in 1936 and sorghum production fell from 1.2 million bags to 0.5 million bags m the same period. Rural poverty prevailed and as a result many people left to seek work in the cities.

The period between 1940 and 1960 was characterised by diverse industrial and political conflicts which were met and suppressed by oppressive political measures which formed the nucleus of apartheid. These conflicts coincided with a rapid expansion in the secondary and tertiary sectors of industry most of which were owned by British capital or English speaking South Africans. Since these industries needed a larger skilled work force, more than that provided by the white working class, the owners sought to solve their employment problems, and at the same time resolve the conflicts, by relaxing the political and the economic constraints on black workers. However, this had to be done without a corresponding fall in profits, and since this could only be achieved by reducing the wages of white workers, most of whom were of Afrikaner stock, the Afrikaners opposed this solution and their feelings were reflected in the victory of the Nationalist Party in 1948. This heralded a comprehensive repression of black people. By protecting white workers from the competition of black workers it guaranteed cheap labour to the Afrikaner industrialists as well as to the capitalist farmers. This was the beginning of apartheid which provided a base for cheap labour:

.. .Apartheid, including separate development, can be best understood as the mechanism specific to South Africa in the period of secondary industrialisation, of maintaining a high rate of capitalist exploitation through a system which guarantees a cheap and controlled labour force, under circumstances in which the conditions of reproduction (the redistributive African economy in the reserves) of that labour force is rapidly disintegrating (Wolpe, 1972, p.433).

Desmond (1978) highlighted the myopia that afflicted even those who opposed the apartheid system. They did not see the role of capitalism in the origins of apartheid. The reason was that such people:

...accept the capitalist form of society as the normative one and the most obvious way in which South African society deviates from that norm is the racial nature of the forms of oppression; 'racism' is therefore presumed to provide the explanation for everything that is wrong with the system. It cannot be 'capitalism' because they start from the assumption that there is nothing wrong with 'capitalism', it can therefore only be 'racism'. That this does not in fact provide an explanation escapes their attention because they unquestioningly accept the capitalist analysis of the South African social system. But it is also the consequence of their 'idealist' understanding of the truth which assumes that people's behaviour is determined by their knowledge or beliefs. This understanding leads them to be primarily concerned about people's mental attitudes. Since 'race' is the cause of the problem and since behaviour is determined by attitude, the whole problem is one of racial attitudes and the solution is to persuade them to change these attitudes (Desmond, 1978, p.20).

If Desmond is critical of idealists, he is equally critical of Marxist interpretations of the apartheid system:

Radicals on the other hand, tend to dismiss all ideological factors and attempt to fit the "facts" into rather rigidly preconceived theoretical frameworks. Much of the debate centres around the conceptualisation of the problems and less attention is paid to new empirical evidence. Indeed many of the facts adduced by these authors are somewhat over-simplified (Desmond, 1978, p.25).

Desmond viewed South African capitalism as having two faces. There was the face of state capital which was under the control of the Nationalist Party and private capital controlled by Anglo-American industrialists, most of whom were members of the Progressive Party. In contrast, the face of private capitalism was not dependent on government intervention to maintain economic domination, and the growth of African political power was not a threat to them since they could have used other means to advance their interests. More important to private capitalists was the fact that a strong black middle class in urban areas would not only increase the market for consumer goods but would also act as a strong buffer between the rest of the working class, both black and white, and the capitalist class. This is why, Desmond asserts, from as early as the 1920s these industrialists started campaigning for African urbanisation and were opposed to forced removals. In contrast, state capital, mainly Afrikaner business, greatly expanded under the patronage of the Nationalist government. The position of the white working class was protected by purposive government intervention, not least the colour bar in employment which reserved certain jobs for white workers. The growth of the African political power would have inhibited the State from maintaining these interests hence the need to suppress all forms of African protests through extra-economic measures enshrined in the apartheid laws and regulations. The Nationalists encouraged the emergence of a black middle class, not in urban areas, but in the 'homelands'. Since this middle class would be composed of African employees in government service, it was hoped that it would support the status quo and act as a buffer between the rest of the black population and the white community. Desmond stressed that the resettlement policy was not:

...on the one hand, the work of demented racists, nor on the other, is it simply a result of the development or production in the dominant sectors of the economy. Rather it is a complex, comprehensive and effective way of exercising political control, arising from the present form of South African capitalism as a whole (Desmond, 1978, p. 10).

Such a backdrop draws attention to the knowledge that the demise of apartheid, in itself, is not enough to bring about changes that would improve the health of the nation. The government has to tackle the fundamental causes of ill health and that is capitalism with its associated inequalities. In the health service inequalities date back to the arrival of white settlers when health services were developed to meet the needs of the ruling class.

References

De Beer, C. (1984), The South African Disease: Apartheid Health and Health Services, South African Research Services, South Africa.

De Kiewiet, C.W. (1942), A History of South Africa: Social and Economic, OUP, 1950.

Desmond, C. (1978), Lunehill Revisited, A Working Paper (later published by the University of Natal in 1978).

Wolpe, H. (1972), 'Capitalism and Cheap Labour Power in South Africa', Economy and Society, vol. 1, No.3, pp.425-454.

2 The Development of Health Services in South Africa

De Beer makes the compelling assertion that historically health services in South Africa had no rational development. They emerged in the process of meeting the particular needs of the ruling class. Hospitals, for example, were established for sailors who worked for trading companies that came via the Cape of Good Hope. They were also built to accommodate and segregate people who were suffering from diseases such as leprosy, smallpox and other plagues which, it was feared, would infect the residential quarters of the rich and the powerful.

The first hospitals for black people were built in the nineteenth century by Sir George Grey - one in Pietermaritzburg in Natal, and the other in Kingwilliamstown in the Cape province. The motivation however, as the superintendent of Kingwilliamstown explained, was less to provide a needed health service than to ensure the allegiance of black people to the government of the day:

Give me only one institution like this, give me talent and ability combined with kindness and mildness...let pure untainted charity have free play...let the heathen feel as free as in his own kraal...Such an institution will draw the savage from the remotest part of South Africa and attach himself forever to that Government which entered in spirit into his sickness and provided a remedy (De Beer, p.17).

Similarly, the development of a network of hospitals for mine-workers was a response to the prevalence of diseases such as silicosis and TB as well as industrial injuries among workers. Right up to the twentieth century the health of black people received very little attention. In 1920 the Government set up a Committee to 'Inquire into the Training of Natives in Medicine and Public Health'. Again here the concern, as the report from this Committee shows, was not the health of black people per se:

It cannot be denied that at present there are hordes of Natives in many centres who have little chance of medical treatment and the untreated sick become a menace to the community. Indeed, not just a menace but a double menace to South Africa. First, there is the immediate danger of the risk of infection and contagious diseases from areas where they may be said to be endemic. Second, there is the economic danger of the deterioration and eventual failure of the labour supply (De Beer, p.21).

The outset of the Second World War heralded further declines in the health situation for black people. In response to the war efforts the economy expanded rapidly with the national income increasing by 300 percent between 1933 and 1947. By 1939 the value of manufacturing had grown by 140 percent and by 1945 by another 140 percent. This expansion was accompanied by changes in the social structure with inherent pol...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Figures and Tables
• Preface
• Introduction
• Submission to the Truth and Reconciliation Commission Concerning Forced Removals
• Glossary
• 1 The Historical Development of South African Society
• 2 The Development of Health Services in South Africa
• 3 The Structure of the Present Health System
• 4 Children and Health
• 5 Women and Health
• 6 Women Making 'Herstory'
• 7 Care for Elderly People
• 8 Black People and Mental Illness
• 9 HIV/AIDS Epidemic
• 10 Care for Terminally Ill People - The Role of Hospices
• 11 The Orange Farm Study
• 12 Quantitative Research
• 13 Action Research
• Conclusion