Public Health Problems in

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Alternative title Notes and Documents - United Nations Centre Against ApartheidNo. 7/79 Author/Creator United Nations Centre against Apartheid; Fullerton, Anne Publisher United Nations, New York Date 1979-03-00 Resource type Reports Language English Subject Coverage (spatial) South Africa Coverage (temporal) 1979-00-00 Source Northwestern University Libraries Description Morbidity and Mortality. Health services. Provision of health services. Financing of health services. Discrimination within health. Format extent 18 page(s) (length/size)

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http://www.aluka.org NOTES AND DOCUMENTS*

NOTES AND DOCUMENTS* MARCH 1979 PUBLIC HEALTH PROBLEMS IN APARTHEID 'I SOUTHAFRICA **by Anne Fullerton, School of Public Health, University of Michigan ** This paper was submitted to the Conference on Apartheid or Health held in London on 3 February 1979 under the auspices of the Anti-Apartheid Health Committee. The views expressed are those of the author. * All material in these notes and documents may be freely reprinted. 79-26135 Acknowledgement, together with a copy of the publication containing the reprint, would be appreciated. 7/79

Introduction In 1967, the world was amazed when South Africa announced that a young surgeon, Dr. Christian Barnard, had just completed the first successful human heart transplant at Hospital in . In 1967, the rate of kwashiorkor in the African population of South Africa was 66.6 cases per 100,000 although kwashiorkor ceased to be a notifiable disease that year because the white rate had dropped to 0.19:100,000. In 1967, a critically injured white man Jay unconscious on Ulazi Bridge near Durban 1 1/2 hours because the first ambulance sent to his aid was for non-whites and could not carry him. An ambulance for whites was later sent. The man died a few days after this incident. No single year in South African health history more clearly demonstrates the paradox of this country where 7 per cent of the population benefit from a health care system which rivals those of the developed world while the vast majority of the South African people labour under the heavy burden of largely preventable diseases combined with high infant mortality rates and woefully indadequate health services. The question "apartheid or health" has been posited precisely because the apartheid system in South Africa is antithetical to the production of a healthy society. Apartheid has created a structure which maintains most of the black South African majority in abject poverty with its concommitant disease burden: malnutrition illnesses, infections diseases aggravated by malnutrition, parasitic illnesses generated by poor sanitary conditions, and vaccine-preventable diseases due to inadequate preventive health services. Apartheid has also created created a stressful social structure. Forced population removals, migrant labour, lack of freedom of expression and the daily threat of Government harrassment have led to high rates of mental illness and stress-related chronic diseases. Apartheid has generated a dual pathology of poverty and violence which prevents South Africa from achieving an optimal level of health. Apartheid has also an impact on the availability of health care. White South Africa enjoys a health care system similar to those of Western nations. Most South Africans, however, must be content with a system characterized by overcrowded facilities, a chronic shortage of medical personnel, and numerous other barriers to access, both financial and structural. As with other professions, apartheid affects the health field. The African does not have equal access to medical education and this

-2- differential persists throughout his/her career in the form of wage discrimination. Finally, petty apartheid remains pervasive in the health area and particularly affects the system's ability to provide rapid and efficient emergency services to all groups. If apartheid is incompatible with the production of a healthy society then it follows that the pursuit of bantustanization (as a fulfilment of separate development) can only exacerbate the existing problems. With bantustanization, migrant labour and familial separation become the norm. With bantustanization, the dual economy of health services achieves its fullest expression in the complete geographic separation of black and white health facilities. With bantustanization, a horrific scenario emerges: apartheid may wash its hands of the diseases it has wrought by dumping the diseased back on the bantustan health services whose strained resources cannot bear the burden. With bantustanization, labour is not only cheap but disposable. This paper will examine the impact of apartheid on health and health services in South Africa. We will show first that apartheid has an impact on health and disease and we will look generally at the morbidity and mortality patterns, then more specifically at three public health problems: malnutrition, occupational illness and mental disease. This will be followed by an examination of the impact of apartheid on delivery of health services in South Africa. Apartheid, we will conclude, cannot produce an adequate functional level of health, let alone optimal experiental health.

-3- PART I Morbidity and mortality The vital statistics for the Republic of South Africa give the impression of two completely different societies. While the crude death rates for the white population has remained low and fairly constant over the last two decades (indicating that they have achieved a minimum possible mortality rate), the African and Coloured rates have declined (with the control of infectious diseases) but continue to be substantially higher than the white rates. White life expectancy (male) stands at 64,5 years while African life expectancy has been estimated at 52 years. The infant mortality rates, however, are most indicative of the difference in black and white health status. Infant mortality for in 1974 was 18,4 deaths per 1,000 live births. had an infant mortality rate (imr) of 115.5 in 1974. For Africans, the most recent figures range from 77 in Durban to 216 in the Transkei. 1/ The causes of infant mortality are conmpletely diferent as well. Prematurity is the leading cause of white infant deaths while diarrhoeal disease is the leading cause of Coloured infant mortality. Diarrhoeal disease is not a leading cause of death for white infants; neither is measles - although it is a leading cause of death in Coloured and Asian infants. This pattern can only be attributed to apartheid. Diarrhoea and measles are normal diseases of childhood across the world but combined with malnutrition, poverty and inadequate health care, they can be fatal. Diarrhoea leads to further nutritional malabsorption and death from dehydration in children already weakened by malnutrition; measles can develop into pneumonia in the malnourished child. Many of the infant deaths in the black population may probably have malnutrition as their secondary cause. A survey of the post mortem records from King Edward VIII and Addington Hospitals from 1973-75 shows that while 30 per cent of African and Asian deaths in children under 10 years were due to malnutrition, no white children died from malnutrition during those years.2/ As infant mortality rates are high for black South Africans, it also follows that infant deaths represent a high proportion of all deaths. Perinatal diseases is a leading cause of death in the Coloured and Asian population but not among the whites. The adult white mortality pattern is similar to those in developed countries with a preponderance of heart disease, strokes and neoplasms. I/ 'Implications of apartheid on health and health services in South Africa", Notes and Documents No. 18/77,June 1977.

Cardiovascular diseases account for 46.4 per cent of white (male) deaths but only 17,5 per cent of Coloured deaths. Infections and parasitic diseases account for 24,6 per cent of Coloured deaths but only 1,9 per cent of white deaths. Cancers account for fewer deaths in the Coloured community but this is due primarily to the fact that many cancers have a latency period of over 20 years and with the low life expectancy, many black South Africans do not live long enough to die of cancer. The King Edward VIII and Addington Hospital survey also shows that while adult Africans and Asians died of turberculosis and typhoid (which are vaccine preventable) there were few white deaths from these diseases. The morbidity patterns are also different across the different racial groups. Some diseases, such as polio, have changed in their relative incidence rates. Prior to the major 1961 polio immunization campaign, the white rates for polio were higher than the rate for Africans, while the African rate at present is higher. This indicates that South Africa spent fewer resources on immunization of the African population and it could be hypothesized that vaccination was carried out only to the extent where African immunological status would not constitute a threat to the white population. For most diseases, however, the incidence rate for Africans has remained consistently higher than for whites. In 1974, the African rate of tuberculosis was approximately 15 times greater than the white rate. Similar differences exist for typhoid and diptheria. All three of these diseases are vaccine-preventable and their prevalence and spread is also heavily influenced by the nutritional and sanitary conditions of the population. Trachoma, a leading cause of blindness in South Africa, has been virtually eliminated from the white population while the incidence rate for Africans is 3 cases per 100,000 population. The African rate for malaria is twice the white rate and while there is no vaccination against malaria, it can be prevented through the use of quininebased drugs. It must be stressed again that Africans are sif fering significantly higher rates of disease which are preventable through vaccination, quarantine (in the case of leprosy), or drugs (malaria). This is to say that these disease patterns. are not caused by some difference in genetic susceptability but by the apartheid systemwhich systematically deprives black South Africans of adequate preventive health care.

-5- Apartheid has also affected the disease process itself. We have already noted that turberculosis is largely affected by various social factors. M.E. Edington and his colleagues observed this in their study of a rural African population: "The high frequency of turberculosis and non-tuberculous respiratory conditions in Sekhukhuneland probably reflects poor socio economic conditions". 3,/ These poor socio economic conditions included: malnutrition which reduces host resistance to tuberculosis (TB), overcrowded housing conditions, insufficient immunization and failure to provide adequate health education. It's spread is governed by inadequate screening and shortage of treatment facilities. Fatality from tuberculosis is influenced by all these conditions and the failure to diagnose tuberculosis in its early stages especially in black workers who may lose their jobs and be forced to subsist on inadequate workman's compensation if they are found to be turbercular. The case of syphilis, is also interesting. In Zulu, syphilis is known as "disease of white men" or "disease of the town". Both terms are descriptive. Syphilis was brought to South Africa by the Dutch East India company settlers where it quickly spread to the African population. Today Africans suffer a higher rate of venereal disease (VD) than whites. In 1973 the attack rate for VD was 0.21/100 for whites, 0,28 for Asians, 0.34 for Coloureds and 6.50 for Africans./ If the spread of venereal disease was primarily related to poverty, we would expect the Coloured rate to be similar to the African one. However, as the second Zulu name indicates, VD is spread through the migrant labour system. The working conditions in the urban areas, the crowded single-sex hostels, the forced break-up of the family conspire to create an environment favouring prostitution and promiscuity and, hence, the spread of syphilis. Syphilis, in South Africa, is a disease both of colonialism and of apartheid. Because it is generally not reported in the official Government statistics, the level of chronic illness in the South African population is difficult to ascertain. The best survey to date was recently conducted by Dr. Bruce Dick and his colleagues in Cape Town. Dick et al found prevalence rates of 24.7/1,000 for Africans, 37.4/1,000 for Coloureds, and 11,6/1,000 for whites. / The most frequent diagnoses in whites were / Edington, "Disease patterns in a South African rural Santu population," South African Medical Journal, 1972. Notes and Documents, No. 18/77. / Dick, B. et al.,"Chronic illness in non-nstitutional.zet.. pe:rso:ns," part Prevalence and epidemiology, South Jo. rnal, 1070.

-6- arthritis and ischaemic heart disease. Among Coloureds, mental retardation was the primary chronic illness and in Africans tuberculosis was the most important. Dick et al also found some major distinctions in the characteristics of black and white chronically-ill people. The white chronicallyill were substantially older than the black persons. In terms of disability caused by chronic illness, Africans experienced more unemployment than other groups while whites experienced primarily lack of mobility and dependency rather than any significant economic consequences. It is difficult to draw any specific conclusions about the impact of apartheid on chronic illness since the etiology of these diseases is complex. Most can be attributed to a combination of hereditary national environmental, and psychological factors. More recent research (notably the work of Hans Selye) points to the importance of stress. This should be considered critical in South Africa where the violence of apartheid makes a major contribution to the level of stress in that society. Certainly it is an area which deserves more research. Malnutrition:Dr. John Reid's statement that over 50 per cent of the children in a native reserve die of malnutrition and related diseases before the age of five / has become very familiar to anti-apartheid activists. Malnutrition in South Africa involves primarily protein-energy malnutrition, marasmus, kwashiorkor, pellagra and some anaemia. There is also some beri-beribut this persists mainly among hostel-dwellers in the urban areas. There is no malnutrition in the white population. There have been numerous studies of malnutrition in South Africa. Some more recent ones include: - Ahneyane et al. A study of Soweto/ which found rates of protein-energy malnutrition (PEM) ranging from 18.9 per cent in the less than two year olds to 45.4 per cent in the 10-12 year olds. Over half of all: children exhibited stunting. - Westcott and Scott's study of Tsolo (Transkei) §/ which found that 36 per cent of children under five years were suffering from malnutrition. For children age 1 1/2 - 2 1/2 the PEM rate was 57 per cent. - Margo et al. 's survey of Coloured children in Western Township, Johannesburg, 2/ found that one third of the children suffered from malnutrition. 6 South African Institute of Race Relations, 1969. 7/ Ahneyane F. Iet al.,"A socio-economic, health and cultural survey of Soweto",South African Medical Journal, 1977. 2/ Wescott, G.M. and R.A.P. Scott,"The extent and cause of malnutrition in children in the Tsolo District of Transkei",South African Medical Journal, 1976. 2/ Margo, G. et al.,"Protein energy malnutrition in colo red children in Western Townshiv", South African Medical Journal, 1977.

- Margo et al's survey of black pre-schoolers in Muldersdrift iQ/ found that 27.6 per cent had PEM and 32.5 per cent were iron-deficient. There are also a number of hospital studies which show that malnutrition is a major cause of death in African pediatric patients. The South African Government has attempted to combat malnutrition primarily by distribution of skimmed milkpowder and P.V.M. concentrate and literature on economic food purchasing and infant feeding. The Theron' Commission report on health for Coloured people requested that the Government introduce feeding programmes in the schools. These measures do not address the real problem. First, the same families in which malnutrition is a problem probably also suffer from illiteracy. Second, the children most at risk are (a) pre-schoolers or (b) cannot afford to go to primary school. Nutrition education is a problem but this is primarily because it is usually undertaken by the school health services and thus is inaccessible to many South Africans. The major problem, however, is lack of income to buy food. The average income of households in the Tsolo survey was R 25 per month. In the Soweto survey inadequate finances was identified as one of the causes of kwashiorkor and marasmus. The MuJldersdrift survey found that children ate meat less than twice a week and fruit and vegetables only 2-3 times per week. The average diet is composed primarily of maize or mealie-meal, the starchy staples of most South Africans. Most Africans live below the poverty datum line and cannot afford a balanced diet. Migrant labour compounds the problem by separating the wage earner and encouraging abandonment of children who are left in the bantustans to starve. Malnutrition leads to increased illness and debilitation and perpetuates the cycle of poverty. Malnutrition is, without doubt, the single greatest cause of the high rates of mental retardation. Malnutrition will not be solved by feeding schemes,but only by the elimination of apartheid and concommitant inequalities in distribution of wealth. White children do not die of hunger in South Africa. Mental health It is very difficult to determine the actual extent of mental illness in South Africa. In 1976 there were 38,000 known mentally disordered people of which 70 per cent were black. The rates of mental illness by population group are substantially higher for whites, indicating that most mental illness in black groups remains undiagnosed. 10 Margo, G. et al. ,"Protein caloric malnutrition and nutritional anaemia in black pre-school children in a South African semi-rural community," South African Medical Journal, 1976.

-8- The World Health Organization, l_1l has succinctly stated the impact of iartheid tn the production of stress and mental illness in black South Africans: (1) Forced mass uprooting caused primarily by bantustan and resettlement policies and legally enforced under such laws as the Group Areas Act. (2) Forced splitting of the family caused by the bantustan policy, migrant labour, laws which specifically separate children from parents at a given age, a system which does not compel the employer to house the employee's family with him/her. (3) Enforced econonic deprivation caused by the bantustan policy, a minimum wage that barely allows for survival, a basic education system which is neither free nor compulsory for blacks and thus inaccessible to many of them, job reservation laws which deny the African access to better jobs. (4) Enforced inferior status and de-individuation caused by the pass laws, the petty apartheid laws, the job reservatibn laws. (5) Harassment and basic insecurity caused by the pass laws, the resettlement policies, the catch-all laws like the Terrorism Act. (6) Denial of means of self-expression and coping with stress caused by all the laws which restrict black freedom to vote, to form political parties, to express themselves verbally or in writing against apartheid, to act freely within black trade unions, and, if banned, even to associate freely with neighbours. In some cases mental illness seems to mirror the political events in South Africa. The World Health Organization (WHO), found that suicide rates for Africans jumped from 8,8 in 1947 to 18,1 in 1948 (15,8 to 36,3 for Coloureds) the year the Nationalist Party came into power. As we have said however, much African mental illness remains undiagnosed. This is due primarily to the lack of psychiatric services and to the fact that there are no African psychiatrists. European professions cannot consistently recognize mental illness in a culture alien to their own and are often not able to distinguish between mental symptoms "Apartheid and mental care",report by World Health Organization (WHO), otes and Documents, No. 11/77, April 1977.

-9- and elements in the traditional African belief system. (e.g.bewitchment). In the case of mental retardation, diagnosis is also inhibited since the African child may not be in the school system and the worker is likely to be in a job not requiring much mental effort. At other times it is difficult to determine exactly what constitutes mental illness in South Africa. In his 1975 proclamation on a rehabilitation institution in the Bantu homelands, Vorster stated: "The inmates of an institution shall be detained therein for the purpose of improving their physical, mental and moral conditions by (a) training them in habits of industry and work: (b) re-orienting them to the traditions, culture, customs and system of government of the national unit to which they belong; (c) generally cultivating in them habits of social adaptation in the community and of good citizenship including the fostering of an awareness in regard to the observance of, and the necessity for, the laws of the country. L/ It is clear from this Proclamation that the purpose of mental institutions shall be to reconcile the African with the apartheid policy so that he will docily accept his position as second-class citizen. Once mental illness is defined as the failure to accept these Government policies as the norm, the line between insantiy and political dissidence completely disappears and the way is paved for the use of the medical system to violate human rights. Apartheid has a major effect on mental health status of Africans through poverty- related malnutrition which causes mental retardation and through the production of an intolerable level of violence for most South African citizens. In addition, apartheid affects the ability of the mental health system to detect and treat illness in the African population, masks mental illness by maintaininga Africans in low status jobs, and ultimately defines mental illness as any state of mind which interferes with the existing order of society. Occupational health Occupational safety and health in South Africa has become a topic of increasing concern in the last few years in the international community. L2/ Ibid.

- 10 - Although blacks have traditionally held the lowest jobs in South African industry (and thus are more exposed to occupational illnesses), two factors have influenced the new concern over this issue: (1) There is an increased focus on the role of foreign corporations in South Africa and the concern for industrial health is a natural by-product of the divestment campAign; (2) This issue becomes increasingly important as South Africa proceeds with the bantustanization of health services. This bantustAnization raises the prospect that migrant labourers working in the mines, fields and factories of white South Africa will contract occupational diseases only to be sent back to their bantustans whose inadequate health services will bear the cost of chronic disabilities which apartheid has created. Occupational health statistics on South Africa are difficult to find and it is almost impossible to get any sort of breakdown by race. In most cases we can only assume that the rates for any given occupational illness are higher for blacks since many blacks are not screened whether by their own will or because of the embarrassment it might cause to the industry. The 1975 Erasmus Commission of Inquiry into Industrial Health has published some findings: (a) 500 miners have died of accidents in the South African gold mines every year for the last ten yearsi (b) in 1975, 257 whites and Coloureds and 1050 Africans were certified and/or died from pneumoconiosis. U/ The South African Department of Statistics (1976) shows a decline in the rate of industrial accidents for whites from 21.9/ 1,000 in 1960 to 20,8/1,000 in 1971. For all other groups, however, the rate has increased (from 9,8 to 13,2 in the case of Africans). 1/ Diana Ellis and Julian Friedman in their study of the socio-economic consequences of apartheid found that in 1973 the rate of accidents per 1,000 employed in the South African gold mines was 1,05 for whites and 1,57 for Africans. This was higher than the rates for other developed nations as well as for Kenya and Zambia. D/ "Workers health undermined by apartheid," The African Communist 1o. 72, January 1978 121/ Diane Ellis and Julian F. Friedman, "The depressed state of the South African population under apartheid: a comparative analysis". Notes and Documents, No. 24/76, December 1976.

- 11 - The asbestos industry has caused particular concern in South Africa. The Erasmus Commission reports that in one survey of three factories employing 1635 workers, 160 cases of asb'estosis were found. Dr. SluisCremer LJ/ states that 5 out of every 14 miners in Northern Transvaal suffer from asbestosis. In the case of the other major occupational diseases caused by asbestos, mesothelioma, the Erasmus Commission cites a survey which found 465 cases. It is difficult to ascertain the development upwards of twenty years after exposure to the carcinogenic substance. In the case of the African population, many Africans will die before the cancers are visible owing to the low life.expectancy and, in any case, the growing pattern of migrant labour can effectively mask the cause.effect relationship since Africans may be far away from the place of exposure once the cancer is diagnosed. Compensation for occupationally-induced illness is also offered on a discriminatory basis. The payments offered to Coloured workers under the Occupational Diseases in Mine and Works Act No. 78 of 1973, are exactly half of those offered to whites for pneumoconiosis and TB. Compensation for African workers is 1/12 that of whites with the additional proviso that it will be cut further in the case of death of the worker. Very little is known about occupational health in South Africa but from that which is known a few conclusions can tentatively be drawn: (1) The apartheid system has little concern for the welfare of the African workeras can be seen from the failure to gather data on the occupational health status of the African population; (2) Blacks, due to their lower occupational status are probably suffering a greater incidence of occupational disease than whites; (3) Although Africans are probably experiencing greater disability, they are definitely receiving less compensation than whites; (4) The bantustanization of health services will offer no incentive to South Africa to improve working conditions since sick workers will no longer be a burden to the South African health care system but can instead be "repatriated" when they contract occupational illnesses. 15 Sluis-Cremer, G.K.,"Pneumoconiosis in South Africa," South African Mda Journal, 1972.

-12- PART II Health services Although, as is apparent from part I of this paper, much of the differential in black and white disease burdens stems from the apartheid system and associated socio-economic disparities, there are still differences in the health care provided to blacks and whites in South Africa. Apartheid affects the quantity of services provided, the structure of delivery, access to the medical profession, and remuneration of health personnel, apartheid has meant that although blacks have a higher rate of illness than whites, they have fewer health services. We will now discuss these differences in greater detail. Provision of health services There is, first of all, a difference in the quantity of services provided to the different racial groups. The most recent estimates (1975) show a physician/population ratio of 1:400 for whites and 1:40,000 for Africans. 1/ The nurse/population ratio is 1:256 for whites and 1:1,581 for Africans. !I/ When we contrast the bantustans with South Africa as a whole it becomes worse. In 1976, only 2,8 per cent of all registered doctors practiced in the bantustans whereas approximately 46 per cent of the African population live there. Beaton and Broune's paperlJ shows rates for doctors in the bantustans which range from 2,2/100,000 population for Bophuthatswana to 12.2/100,000 for Swazi. For Transkei (the first so-called "independent" bantustan) the rate is 4.3/100,000. The doctors practicing in the bantustans remain predominantly white. There are no racial breakdowns available by specialty although most doctors in South Africa are general practitioners. i/ In terms of hospital services, in 1975 the bed/population ratio for whites was 1:96 while for blacks it was 1:186. In 1974 the white bed occupancy rate was 64 per cent while the black occupancy rate was 95 per cent.jQ/If these figures are accurate, the maldistribution of health services under apartheid is not only unjust but uneconomical since unused beds are expensive to maintain. It is also necessary to break down the African bed/population ratios by different categories. In 1976 there were 71,491 hospital beds for Africans in white areas and 26,024 beds in the bantustans.2 16/ Notes and Documents No. 18/77. L/ Ibid. L/ Beaton and Bourne,"Some notes on the distribution of doctors in South Africa, 1975"(mimeo) 978. Tim Uilson,"The need for health professionals in South Africa'(mimeo),l978. 191cGrath,"Health expenditure in South Africa"kmineoI1978. 2l' South African Institute of Race Relations, Survey of Race Relations, 1977.

- 15 - Since 46 per cent of the Africans live in the bantustans, they remain significantly underserved. In terms of mental health services, overcrowding remains a problem. The Observer (London) of 22 June 1975 reported that 3,000 mental patients slept on mats due to overflowing facilities and up until the mid 1960s mental health patients were detained in prison until accomodation could be found for them. The World Health Organization report on mental health care. 22; found ratios of 2,55 psychiatomic beds/ 1,000 population for whites and 0,76/1,000 for other races. in the case of mental retardation there were 15,000 known mentally retarded whites in 1975 and 56,000 mentally retarded Africans. That same year there were 1384 beds for white retarded persons, 660 beds for Africans, and 2601 multi-racial beds. A further 2654 whites and 186 Africans were in State subsidized home care. The information available on quantity of health services available to each racial group and to the bantustans in comparison to white South Africa indicates overwhelmingly that black South Africans are receiving an inferior quantity of health care. Data on the quality of health services to Africans is difficult to obtain. Certainly the high infant mortality rates would lead one to question the quality of obstetric/pediatric services. Another critical piece of information, for example, would be the p6int of entry of Africans into the medical process, ie. given the lack of health care, do most Africans use preventive services, enter the process at the curative point, or come to the hospital to die? The point of entry into the medical process is significant in determining the outcome of that process. All that can be said is that, though modern health services were extended to Africans to break the power of the witch-doctor ("conquest by civilization"),traditional medicine still flourishes today. Edington and his colleagues found that 80 per cent of the population from Sekhukhuneland which they sampled consulted witch-doctors and 75 per cent used folk medicine. 24/ Financing of health services Health expenditure in South Africa is divided fairly evenly between the private and the public sector. In 1974/75 (not counting industrial hospitals) approximately 42 per cent of health expenditures were carried by the private sector and the remaining 58 per cent borne by the public sector. ?/ In 1975/76, the State spent R 394.1 million on ?Notes and Documents,No. 11/77. ?J/ Ibid. ?24 Edington et.al.,"Disease vatterns in a South African rural bantu population",- South African Medical Journal, 1972. ?/ McGrath,"Health expenditure in South Africa",(mimeoJ1978.

- 14 - health for black South Africans (including R 64.4 million spent on bantustan health services) and R 224.6 million on white health care.__/ This represents R 18.5 per capita for blacks and R 52.9 per capita for whites of the private sector; white expenditure represented 94 per cent of private health expenditure in 1975.?/ In terms of personal health expenditures, McGrath's study of health expenditure in South Africa shows that whites and Asians spend approximately three per cent of their income on health while Coloureds and Africans spend l5 per cent and 1.2 per cent respectively. If we look at the breakdown by item, the main difference appears to be utilization of physician and dentist services, probably in the use of preventive and minor curative services. The study also shows that Africans spend 49 per cent of their health budget on non-prescription medicines as opposed to 6 per cent for whites. This would seem to indicate that many Africans are treating themselves due to inability to secure professional medical services. The study also finds that ethical drugs represent an insignificant proportion of African health expenditures while they represent 14 per cent of white expenditures. a/ It is difficult to determine how much of each racial groupTs personal health expenditures are out-of-pocket. The South African Instituteo. Race Relations (SAIRR), Survey of. Race Relations, 197 reported that at State-subsidized facilities black outpatient charges were lower than white outpatient charges. For inpatient charges, white charges were calculated on the basis of net income controlled for dependentsbut black charges were calculated without control for dependents. Thus, a white family of five making R 2,400 could obtain a 15 day stay for the admissions fee of only R 1 while a black family in similar circumstances would pay R 37.50 (although maximum charges were stated at R 2.50 for blacks and R 6 for whites). While Africans may receive more subsidized health care, whites have more health insurance. The McGrath study shows a greater percent of white health expenditure going into insurance schemes. There are two major employment related schemes. The first are the medical aid and medical benefit societies where expenses are shared by employee membership dues and erployer subsidies. At the end of 1975, 75, 1 per cent of the white population and 2,5 per cent of the black population were covered under this system. The econd system is the sick paid funds under which all workers are required to be covered. In 1972, 64 per cent 26/ Philip Scheiner,"Sources of finance for health care in South Africa" (mimeo),1978. ?/ McGrath, op. cit. 28/ Ibid.

- 15 - of white woikers and 10 per cent of African workers were covered under these more favourable industrial council agreements. The main reason for this differential is undoubtedly the restrictions on African trade union activity and collective bargaining under the apartheid system. Although the South African Government frequently asserts that Africans are well-off because their health services receive more Government subsidies, reality appears to be very different. The Government provides African health services but not in sufficient quantities. Many Africans cannot be accomodated by these subsidized services and do not have the funds to demand other types of health care. They have less health insurance than whites and they are less able to pay for adequate medical care. Thus, apartheid has produced major financial barriers to access to health care for black South Africa. Discrimination within health Just as there is discrimination in the delivery and financing of health services for black and white South Africans there is also discrimination within the healing professions themselves. This differential begins in opportunities for medical training and later extends into discrimination in salaries and supervisory position. (a) Training. Discrimination in the health professions begins in the medical schools of South Africa. Substantially fewer blacks are enrolled in medical education than whites. In 1977, there were 5,905 whites, 120 Coloureds, 444 Indians, 34 Chinese and 270 Africans in medical schools. 92/ Part of the low black enrolment is due to apartheid in earlier education to the failure of the education system to give black South Africans the premedical training in science and mathematics needed to qualify for admission. Another part, however, is due to the restricted number of places for black South Africans in medical schools. There are five universities open to whites and three which take Coloureds and Indians (Cape Town, Natal and Witwatersrand). Africans are non-restricted to Natal although there are still six African students completing degrees at Witwatersrand. The South African Government is moving towards complete segregation of Africans from other racial groups in medical education. The Medical University of Southern Africa Act No. 78 of 1976 provides for the establishment of a medical university entirely for Africans near Ga Rankuwa. This new Medical University is integral to the policy of separate development, as can be seen from the provision for its governing council, which will include, inter alia, representatives from each of the bantustans. Both the Council and the Medical University Senate will be multiracial. The South African Government has also announced its intention to phase out African enrolment in Natal University, although this decision has met with opposition from Natal faculty and students. ?/ South African Institute of Race Relations, Survey, 1977.

- 16 - As the Medical University incorporates a dental school, it will also lead to the development of segregated dental education. In 1977, there were 1,055 whites,27 Coloured, 56 Indian, 2 Chinese and 7 African enrolled dental students. Nhites were enrolled at Pretoria, Stellenbosch, and Witwatersrand. Indians and Coloureds were enrolled at and Witwatersrand; and Africans were enrolled only at Witwatersrand. Apartheid in medical training means that South Africa cannot meet the need for more African doctors. (b) Remuneration: The low initial enrolment of Africans in medical training combined with the restructive conditions of life and better opportunities for practice outside of South Africa have meant that in 1974 Africans accounted for less than 2 per cent of all registered medical doctors in South Africa. 0/ Those that remain in South Africa are compensated for their services at a significantly lower rate than white medical practitioners. Approximately half of all physicians in South Africa are salaried. The South African Institute of Race Relations (SAIRR) Survey of 1977 reports that salary scales in state and provincial hospitals were as follows (in rand): Rank 1hite Coloured/Indians Africans Professor/Chief Specialist 15,600 13,200 ll,250 Senior Specialist 13,200 11,250 9,540 Specialist 12,600 10,800 9,180 Chief Medical Officer 13,200 11,250 9,540 Principal Medical Officer 12,600 lO,800 9,180 Medical Officer 7740-11100 6300-9900 6300-8460 Intern 5,100 4,050 3,300 Discrimination in remuneration under fee-for-service cannot obviously be determined. However, given the restrictions on black practice on white patients, it can be deduced that black private practioners serve a lover income clientele than their white counterparts and thus receive lower payments for their services. Notes and Documents 24/76.

- 17 - Salary discrimination exists only in dentistry. In 1976, the SAIRR Survey reported that white dentists on the Government payroll were earning R 11,700, Coloureds and Indians were earning R 9,900 and Africans received R 8,460. The SAIRR Survey of 1977 reported nurses salaries as follows (R per annum): White Coloured/Indian Africans Student female nurse Student male nurses Staff nurse Male staff nurse Sister/male nurse Senior sister/charge male Nurse/matron Head matron/senior male nurse 1680-2250 1680-2850 2250-3480 2250-4020 3000-4380 3840-5340 7740-8460 1350-1980 1550-2220 1740-2700 1740-5150 2540-3450 350-4200 5820-6500 840-1350 900-1620 1260-2100 1260-2460 174o-27oo 2340-3450 4740-5100 After entry into the profession, salary discrimination is the first type of discrimination encountered by the African medical professional practising under the apartheid system. Whether she/he is a doctor or dentist or a nurse, and regardless of rank, the African medical person is paid significantly less than a white counterpart in South Africa.