The South African Department of Death

Over the last few years I have watched, with increasing despair and anger, the backward ass circa 11th century response of the South African Department of Health (and the archaic/demented Minister of Health, Dr. Manto Tshabalala-Msimang) to the critical health needs of South Africans. What has prompted me to blog about this situation is the apocalyptic crisis (alas my use of hyperbole is well justified in this case) that I see occurring over the next few years where all the king's horses and all the king's men will not put South African health back together again. Unfortunately, the irresponsible posturing of the South African government and its continuing lack of a timely and well-executed plan to deal with the health needs of its citizens will also have direct and dire consequences for its small and vulnerable neighbors (i.e. Lesotho and Swaziland). I will spare my readers a grim history of the South African government's response to HIV/AIDS and its shocking amount of heel dragging re: the availability of antiretrovirals to its HIV positive citizens ( for those that are interested in learning a bit more here is a website that has a quick overview of the history of the HIV/AIDS epidemic in South Africa: http://www.avert.org/aidssouthafrica.htm), but I will let you know what I see in my crystal ball for the state of South Africa's health over the next decade.

There are four major problems with the current health care system in South Africa: 1) a brain drain of professional staff; 2) lack of a coordinated, evidence-based medicine approach to a host of health problems;3) a crumbling public health infrastructure in both rural and urban areas; and last but certainly not least 4) little or no accountability on the part of local, provincial, and national officials when it comes to health care delivery and services.

Staffing is a huge problem in South Africa and this is readily apparent when it comes to public hospitals and clinics where nurse clinicians and physicians are few and far between and the ones that are available are typically overworked young interns or doctors recruited from more volatile corners of Africa (e.g. Democratic Republic of Congo, Nigeria) whose training and experience are often quite variable (as I witnessed first-hand in Lesotho). Even the private health sector in South Africa is suffering with staff shortages, particularly in the specialist areas areas of medicine. Whither go all the South African doctors? Australia, New Zealand, Canada, the UK, and the USA are the recruitment hotspots that offer more money, more security (no more sending out the hounds and securing your mini-fortress before you go to bed when you migrate to rural Canada), and more opportunities for advancement and education. The situation is only going to get worse over the next decade as more nurses and doctors immigrate to greener pastures; a new intern scheme recently instituted in medical schools drastically reduces the numbers of available interns for staffing public hospitals and clinics; and more foreign staff, some with questionable training and experience (note: I'm not saying all foreign doctors in South Africa are under trained but there has to be stricter regulations, education, and supervision in place for foreign trained medical staff to safeguard South African citizens) are recruited to fill in the gap.

As for the lack of a coordinated, evidence-based medicine approach and accountability to deal with the juggernaut of health problems that South Africa faces today, I could write a seven-volume work, but I will give you one alarming example which should suffice: Extensively Drug Resistant (XDR) Tuberculosis. So far, by the questionable epidemiological tracking standards of the Department of Health, there have been 330 reported cases of XDR-TB in 39 hospitals across South Africa with the largest cluster in the province of Kwa-Zulu Natal (which not so coincidentally, also has the highest provincial prevalence rate of HIV in the country). XDR-TB is a nasty and very virulent form of TB especially for folks that are immunocompromised like HIV + patients. First and second line treatments are useless and the mortality rate is spectacularly high. South Africa's Ministry of Death...err..I mean Health is just beginning to get it's collective self together along with its minions at the local and provincial levels to properly diagnose, document, and track XDR-TB cases and booster local responses to the epidemic. The irony is that most of the burden has fallen on outside sources (e.g. NGOs, private research consortiums) to treat and report these cases and raise the alarm at the international level. Now the World Health Organization and the CDC among others are willing to send in experts to assist the Department of Health in its herculean task but the department will only allow their presence on a consultative basis and will shackle them from making any needed immediate changes they see fit at the local or provincial levels. I understand the need to maintain state control, especially in the face of a colonial and apartheid past, but when it comes to the health of your citizens and poor neighbors and your well-documented history of wacko and unscientific health decisions (Hello Minister Tshabalala "just take garlic and herbs to control HIV" Msimang!) it's time to bring in the A-Team!! Now it is almost certain XDR-TB has crossed the border of South Africa and the toll it will take on the overburdened and underfunded health services and staff of South Africa's neighbors is almost too horrific to think about.

Finally the crumbling public health infrastructure also speaks volumes for the lack of accountability that I see from the Department of Health and the South African government in general when it comes to providing health services (or heck any services to its people). One prime example which recently came up in the news (and my dear readers I can provide many examples if you need more substantial evidence) is the delay in funding two 200 bed hospitals in the Northern Cape Province because money was diverted for funding South Africa's 2010 World Soccer Cup ambitions. What???? Correct me if I'm wrong, and yes I'm biased because I work in public health, but isn't the role of any government to provide basic services for its citizens way above and beyond its role to support international sporting events (and by the way I am a huge soccer fan) in order to boost its image abroad?? Call me a dreamer but hospitals are extremely important (yes, even in bumblefuck Northern Cape Province) especially in a country with one of the highest prevalence rates of HIV in the world!!

My simple solutions to this impending apocalyptic health crisis: 1) cut bureaucratic staff and ANC toadies at the Department of Health and reroute funds to primary health care clinics and hospitals; 2) expand the training capacity of current medical and nursing schools (read: $$$); 3) set up a simple epidemiological reporting system and TRAIN people at all levels at the work site (no more bloody workshops!) to use it or they lose funding; 4) boost ARV and TB drug defaulter tracking services; 5) use on site 6 month performance evaluations for all health staff with pay bonuses for improvements and penalties for shoddy work; 6) make primary health care services the #1 concern of the government (reducing violent crime being the # 2 concern) and "put your money where your mouth is" and finance the maintenance and rehab of existing facilities and recruitment of health care staff; and finally 7) for the love of God and the people of South Africa please FIRE Minister Tshabalala-Msimang!!