Day 1: Health is a Human Right. Right?

Activity 2: Why is health political? Preparing for site visits

Task 1
Journaling work: What does South Africa’s handling of the Covid-19 pandemic tell us?

(10 minutes)

Working alone at first, watch this short video clip on the political determinants of health inequities

Now take 5 minutes to gather your thoughts and write in your journal on how you rate South Africa’s handling of Covid-19 from a health equity vantage point. Give examples to explain your argument.

Task 2
Group work: Examples that show health is political through a Covid-19 lens

(35 minutes)

Working in three groups, first read the 4+ page extract below. It should take around 10 minutes if each person reads alone. The extract is from a research study that Tekano commissioned in 2020, on the impact of Covid-19 and its implications for health equity in South Africa. 

You then have 20 minutes in your group, to agree three examples of how South Africa’s treatment of Covid-19 shows how health is political. Write your three examples onto a flipchart and elect someone in your group to present in plenary.

Task 3
Plenary: So why do we say that health is political?

(15 minutes)

Groups will present their examples very briefly, and the facilitator will highlight from the examples, whether we can say without doubt that ‘health is political’. 

Health is Political
Extracts from a Tekano Covid-19 Research Study

October 2020

The Covid-19 pandemic strikingly illustrates the intersection of politics, economics, and other considerations. This extract, from a 2020 Tekano commission research study, helps illustrate this.

What are the impacts of the Covid-19 pandemic and the lockdown on health equity in South Africa?

To answer this question Tekano commissioned context analysis research that was carried out by a team of researchers brought together by Beneficial Technologies (Bentec).

The research for the context analysis has mostly been conducted between 15 July and 15 August. It was possible to do this research in such a short time because the members on Bentec’s research team were already involved in Covid-19-related civil society and activist responses

The analysis differentiates between the impact of the disease Covid-19 and the lockdown measures taken in response to it. The latter we found had a more negative impact on health equity. The evidence indicates that the lockdown failed to reach its own objectives which were to prepare the healthcare system and control the spread of Covid-19. This failure is reflected in the imagery of, on the one hand, poor people queueing to access services and, on the other hand, empty quarantine beds during the height of the pandemic in the Western Cape. This picture captures the essence of our story about the impact of the pandemic on health equity.

The health impact of Covid-19 

Covid-19 is a highly contagious, life-threatening disease caused by the novel coronavirus. Most infected people have mild to moderate symptoms and one in five require hospitalisation, mainly due to difficulties in breathing and other respiratory problems. The first case in South Africa was recorded on 5 March 2020. At the start of the lockdown on 26 March there were 927 confirmed cases mainly concentrated in Gauteng, the Western Cape and KwaZulu-Natal. This pattern is explained by the initial spread through international wealthy travellers followed by the spread to townships populated by poor black communities. On 12 August, South Africa had 568,919 recorded infections, with 432,029 recoveries and 11,010 deaths. We discuss four health-related dynamics of Covid-19 that impacted on health equity, namely, the quadruple burden of disease, comorbidities, the health system and testing and contact tracing.

Covid-19 directly threatened the management of South Africa’s quadruple burden of disease due to the reprioritisation of health services towards the C19 disease burden. The existing burdens include maternal, new-born and child health; HIV and AIDS and TB; non-communicable diseases (NCDs), and violence and injury. Before the pandemic the public health system did not have adequate resources and infrastructure to manage this situation, which has now worsened. The future impact is expected to be devastating. Experts predict an increase in child deaths, HIV-related deaths and general poorer health outcomes in the coming period as a result of disrupted healthcare services. 

People with pre-existing chronic conditions like diabetes, hypertension, lung disease, obesity, kidney disease and HIV and AIDS are at higher risk of serious illness and death when infected with the coronavirus. Age has also been identified as a comorbidity. In the Western Cape, 65% of people who died had more than one comorbidity. In August, the Medical Research Council (MRC) reported there had been more than 33,000 excess deaths, of which a significant proportion is likely caused by Covid-19. Taking existing disease burdens into account, Covid-19 does not present everyone with the same risks. Poor black people have a much higher chance of getting sick and dying of Covid-19 than white and privileged populations. 

The focus on strengthening the healthcare system to prevent and treat Covid-19 has created a backlog of patients with non-Covid-19 diseases who are not able to access care, treatment or life-saving medications. The pandemic exposed and exacerbated conditions in the existing overburdened public healthcare system and great disparities between the private and public sectors. There has been a devastating impact on physical and psychological health of healthcare workers at the forefront of the pandemic whilst facing the realities of inadequate resources, lack of personal protective equipment (PPE), and overcrowded facilities. 

The government’s stated intentions and expected gains from screening and testing were not realised. There has not been enough laboratory capacity to deliver results in time to prevent further infections, especially in rural areas where the turnaround time has been 14-20 days. Again, disparities in the private and public sector impacted on the effectiveness of testing as well. Contact tracing has not happened successfully in South Africa although it has been a demonstrated effective method for containing the spread of infections, for example, in South Korea and China. Although the government received initial international praise for the original lockdown, this analysis shows that the inadequate public healthcare system, and the existing disease burden and poverty levels caused immediate devastation for the majority of people in South Africa who are not privileged.

Covid-19 state policy measures

Managing the response to the Covid-19 pandemic became the state’s main focus. The measures and interventions of the state included infection control, health services, enforcement, economic stimulus and social welfare and protection. This analysis presents the issues that emerged in relation to the state measures and their impact on health equity. 

The main objective of the state in the beginning stages of Covid-19 was to control, slow and prevent coronavirus infections. As part of the National State of Disaster declared on 15 March 2020, the state established the National Coronavirus Command Council as the centre of government decision-making. On 29 March the state declared a general lockdown and gave a stay-at-home order for all but essential workers. From 1 May 2020, subsequent lockdown levels eased the restrictions of movement and economic activity. The state ordered mandatory personal protection measures and banned the trade in tobacco products and alcohol. From the start there have been critical voices questioning the validity, feasibility and legal status of these measures.

In line with some of the critics, we found that the state’s measures for the control of infections have failed and caused a breakdown of trust in government. This is shown in the fact that community transmissions were not stopped and are now concentrated in black, low-income areas like Mitchell’s Plain, Khayelitsha and Soweto. This negative impact on health equity has been inevitable given the government’s commitment to neoliberal policies and contempt for the views, situation and interest of people in townships and informal settlements. For many people it was not possible to implement protections such as social distancing, isolation and personal infection control. The lack of access to food and cash forced people to break lockdown rules. The exemption from the lockdown for the goldmines and export wine farms came at the cost of increased risk of infection for workers and spread of the disease to their communities. 

An important part of the Covid-19 response of the state was to strengthen, repurpose and prepare the capacity of healthcare providers. The resource allocation for the private and public sector is extremely unequal, with 84% of the population depending on services in an under-resourced, stretched and overwhelmed public sector. Given this situation, we found that the impact of government’s intervention around health services was skewed and undermined health equity. The scaling down of general services disproportionately affected the users of public facilities. The private sector received payments from the government to admit state patients while the public sector suffered from underfunding and corruption. Mass testing was never fully implemented and tracking abandoned due to lack of capacity. Public quarantine facilities were avoided because people did not trust they would be taken care of, especially after the death of entrepreneur, Shonisani Lethole. Some expenditures were wasted due to lack of staff and equipment at public facilities. 

As part of the enforcement of the lockdown regulations, the state restricted certain human rights like freedom of movement, instituted a curfew and travel restrictions, and used the police, army and private security to arrest, sentence and fine people who were breaking lockdown rules. Great concerns have been raised about the use of armed forces to respond to a health crisis as it soon became clear violent forms of enforcement were concentrated in poor black communities. The enforcement practices directly undermined health equity and the constitutionality of the measures have been questioned. Black people experienced police brutality to the extent that they were more scared of the armed forces than the virus. Within five weeks of the lockdown, 11 deaths resulted from army and police actions. All the deceased were black men except one transgender black woman. By June, more than 230,000 people were arrested. Lockdown enforcement was prioritised over enforcement of other rights and laws. These undermined effective responses to the surge in gender-based violence during this period. The violence linked to enforcement of the lockdown followed a racist and classist pattern with weak recourse options for victims. 

The government’s economic stimulus package in response to the crisis resulting from closing down most of the economy followed the logic of neoliberal economic policies. Calls on the government to break from this direction and adopt a more redistributive stance are expected to have little chance of success. Economic stimulus has been mostly directed at tax breaks, subsidies and soft loans for business. The decision to take out loans from the IMF and the World Bank most likely means a commitment to neoliberal austerity and cuts to social services which directly undermines health equity. Existing socio-economic divisions have deepened due to job, business and income losses of working-class people on the one hand and benefits for capitalists owning the mines, banks and supermarket chains that continued to operate on the other hand. 

When it became apparent that the lockdown was causing widespread hunger and distress for the poor, the government instituted a number of temporary social welfare and protection measures. The administrative requirements to access food parcels and the temporary Covid-19 relief grants prevented many vulnerable from accessing these resources and services. Other problems with state relief were corruption, the grant amounts were not enough to meet needs, and conflict between communities and civil society with the state who treated self-activity under lockdown as a problem instead of a solution. This analysis of the Covid-19 policy responses of the state indicate that the response was framed in the government’s neoliberal policy model which worsened existing health inequities. 

Socioeconomic impacts 

The lockdown amplified existing crises around service delivery and labour relations in South Africa. The intensification of socioeconomic inequalities increased health inequity. We found that there was an immediate increase in hunger and food insecurity as the closing of the economy caused vulnerable working class people to run out of money for food in April already. Food price increases made the situation worse. In rural areas informal food markets and small holder farmers’ practices were disrupted which blocked rural people’s access to food. This paved the way for the government to later claim that reopening the economy is in the best interest of black workers who would otherwise die of hunger. 

The government’s stay-at-home order contradicted the realities of housing conditions like overcrowded residential areas and ongoing evictions of informal settlement dwellers and tenants. This made it impossible for poor black people to adhere to the lockdown rules. The resulting increase in homelessness contradicts the logic of the lockdown or its stated intention to protect people from infection. Lack of access to water and electricity during lockdown amplified existing health inequities as well. Water and sanitation are crucial for personal protection and Covid-19 prevention, but many poor and black communities have been excluded from access and use due to privatisation and lack of service delivery. During lockdown, vulnerable people like informal settlement dwellers or farm dwellers still experienced being cut off from water and/or electricity. In many places, people reported that water tanks promised by the government have never been delivered. Black women in Somkhele (KZN) demonstrating for their rights to water were arrested and detained. The continued failure of the government to deliver basic services such as adequate housing, water and electricity all impacted negatively on health equity. 

The impact of Covid-19 and the lockdown on labour has to be understood in the wider context of labour relations in the country. The three million job losses reported at the start of the lockdown were concentrated amongst already vulnerable groups in the labour market: women, black people, youth, less educated and informal/casual workers. Employers seem to have used the pandemic to legitimise an ongoing wave of retrenchments. The reopening of the economy under Level 3 of the lockdown has been presented as necessary relief for workers depending on income from jobs. However, working conditions of cheap black labour in mines, factories and on farms, combined with widespread non-compliance with labour law by employers created a reality of increased risks for personal infections and community transmissions. Access to labour rights institutions was limited and use of the public transport system disproportionately exposed the black working class to Covid-19 infection. 

Big sections of the mining sector were exempted from lockdown and continued operations. On 17 July, the sector counted 5,396 positive Covid-19 cases and 45 deaths. The Minerals’ Council of South Africa denies that mines are epicentres of infection, whereas mining communities are raising alarm about their observations and experiences with increasing numbers of sick people without access to necessary healthcare services. Sections of the agricultural sector were also exempted, meaning farm workers continued working during the pandemic. This sector relies heavily on seasonal migrant labour. The movements of farm workers during the pandemic caused anxiety and risks for rural residents. Women make up a big part of the workforce and reported not having access to UIF funds because labour offices were closed. Domestic workers lost income, were sent on unpaid leave or dismissed, and did not have access to employment benefits as only 20% are registered for UIF.

Healthcare workers have been on the frontline of the pandemic dealing with sick people whilst working in the understaffed and under resourced public sector or in the private sector. Community healthcare workers were called upon to assist with screening in vulnerable communities. Many of these frontline workers experienced a lack of PPE and general support which increased the risk of infection. We found that these experiences occurred in the context of precarious working conditions in all healthcare sectors where important work is done by outsourced nurses, cleaners, and security guards. Workers who protested and demanded better conditions met with violent responses from the police in the Eastern Cape. The realities of the working poor in South Africa, who rely on public transport and have often not been provided with PPE or their conditions of work make it impossible to socially distance, illustrate that in many instances their safety was compromised whilst going back to work. Black women who are at the bottom of the hierarchy in the country’s socio-economic relations, had to negotiate care work for children and community in addition to often precarious working conditions. This has likely increased stress and mental health problems of workers.

So as Tekano, we see health like almost all other aspects of human life, as political in numerous ways:

  1. Health is political because, while states have a key role in ensuring their populations’ right to health, many determinants of health are now beyond the control of single governments; rather, with globalisation, the inequities in health that exist both within and between countries are increasingly determined by transnational activities and global political interaction involving actors with different interests and degrees of power.
  2. Health is political because, like any other resource or commodity under a neo-liberal economic system, some social groups have more of it than others
  3. Health is political because its social determinants are amenable to political interventions and are thereby dependent on political action (or more usually, inaction).
  4. Health is political because the right to ‘a standard of living adequate for health and well-being’ is, or should be, an aspect of citizenship and a human right.
  5. Ultimately, health is political because power is exercised over it as part of a wider economic, social and political system. Changing this system requires political awareness and political struggle.