The Coronavirus crisis and the struggle for health
The COVID-19 crisis in South Africa has resulted in welcome signs that our government, at last, is becoming serious about actually governing the country. It acted early and effectively by declaring a state of disaster, developed new legislation, and implemented a range of important measures, across government sectors, to flatten the curve of the epidemic. As the numbers of proven infections escalated, it acted decisively and appropriately to halt further spread by imposing a lockdown. It has done so openly and with an unusually high degree of transparency. Political parties seem to have dropped tit-for-tat politics in favour of a focused non-sectarian approach.
At this stage of the crisis it is crucial to save lives and to prevent the crisis from overwhelming our health system. As the crisis eventually winds down, we must ensure that we come through it with a unitary, equitable national health service that delivers universal health coverage. There must also be a programme that involves all state sectors collaboratively to ensure that everyone has equitable access to the causes of good health. This article looks at the background to the crisis and its implications for the struggle for people’s health.
This is a crisis on top of a crisis – our long-standing, “normal” health crisis. Even before COVID-19 began to spread, our health outcomes were far worse than those of all other middle income countries at the same level of GDP, as well as those of many poorer countries. This long-standing underlying crisis is rooted in 1996 when the state adopted neoliberalism with its Growth, Employment and Redistribution (GEAR) macro-economic policy. GEAR entrenched and deepened the overall inequality inherited from apartheid. On top of this came corruption at all levels of the state and the private sector.
Against that background, our health crisis arose from 2 key failures of the state:
- Failure to address inequalities in access to the goods and services we need to be healthy. These are generally known as the social determinants of health (SDH).
- Failure to unite our health services into a single, equitable national health service around a common goal of achieving health for all and building social solidarity.
- The SDH include an adequate income as well as socio-economic rights in our constitution: social security; education, adequate housing, safe environments, adequate food, water and sanitation, good nutrition, freedom of movement , and safety and security.
A fragmented health system
Failure to unite our well-resourced but fragmented and inequitable health system has led us to normalise the existence of a large and powerful private sector that uses as much money as the public sector to provide services to a small, elite minority, the healthiest 15% of the population. This an extremely inefficient use of resources. In contrast, the public sector provides health care to the remaining 85% of the population – which also bears the overwhelming share of the disease burden – with the same amount of money. Those who need the most health care have the least access. This inequity is unacceptable in a constitutional democracy based on human rights and values, social justice and equality. It is incompatible with any attempt to correct the wrongs of our apartheid past.
COVID-19: some key issues
How the corona crisis evolves from now on depends fundamentally on a range of key issues:
- The extent to which we “flatten the curve” of the epidemic by minimising spread of the virus through the country.
- Whether the health services combine their human and other resources urgently and unite as one, without an impact on the fiscus.
- How we use the experience of this crisis to build a united, equitable and effective single national health service that provides good quality essential health services to all.
- Whether we prevent social disruption and build social solidarity. The virus reminds us that we’re all in this together. Solidarity is rooted in the principle of “from each according to ability, to each according to need”. It is relevant not only in providing health services, but also in caring for others, including people we don’t know, and acting to relieve their plight.
- Whether we come out of this crisis with a total commitment to address the social determinants of health by mobilising resources and people across sectors.
Why flattening the curve, though difficult, is essential
Flattening the curve is a challenge in crowded working class peri-urban slums, and rural areas. That is where people carry the overwhelming share of the burden of disease and lack access to the SDH. Unemployment is high, the level of trust in the government and the economic system is low, crime is rampant, and many people are disillusioned. People rely on crowded taxis for personal transport. It is difficult to avoid contact with others who carry the corona virus and who feel well. It is practically impossible for many to practice frequent hand-washing with soap and water, and physical distancing.
The challenge of flattening the curve also applies to affluent middle-class environments where many people are not taking the crisis seriously and go on with life as usual. Maybe this is out of sheer ignorance or maybe it is because they believe themselves to be somehow above it and think it doesn’t really apply to them.
The lockdown announced by President Ramaphosa on 23 March is a critical step. It aims to stop the spread of the virus. It is drastic and will impact heavily on many people, once again most heavily on those most vulnerable. But the consequences for all of us of allowing corona to spread will be catastrophic for everyone—there is no option.
Response from the health sector
How the health sector responds now is critical. The public sector will have to care for the vast majority of people who get sick from the virus. If it has to do this on its own it will be overwhelmed. After decades of having to cope with austerity budgets under GEAR, it is demoralised, understaffed, under equipped and its facilities are crumbling. The Office of Health Standards Compliance’s Annual Inspection Report for 2016/17 found that of the 696 facilities it inspected, only five were fully compliant with National Core Standards, and 412 were unconditionally or critically non-compliant.
Yet, when it comes to national health outcomes, the public sector can reach levels of efficiency that can never be achieved by the private sector. For example, in the face of the HIV/AIDS pandemic, the public health sector implemented the roll-out of the largest anti-retroviral programme in the world, resulting in a 10 year improvement in life expectancy, a key health indicator, within a decade.
Our private sector is the largest in the world in terms of the proportion of national health spending it consumes. It has an enormous capacity to assist. Though powerful, it faces a crisis of its own. It is fragmented between multiple byzantine and increasingly complex and unaffordable medical schemes, hospitals and competing corporate stakeholders. In its current form it is unsustainable. It has, up to now, managed to immunise itself against our broader health crisis. But it is now critical for both sectors to unite and work together as one to provide care for all who need it — unity is strength.
In his recent speech to the nation the president Ramaphosa mentioned the possibility of “partnering with the private sector” but referred only to the development of “a tracing, tracking and monitoring system for all those affected by coronavirus”. What about sharing of resources for care? and even so, is it enough should there be a wide-scale outbreak?
The epidemic will almost certainly overwhelm the public sector. Many people, rich and poor, with and without medical scheme membership, will become critically ill. There will not be enough high care and ICU beds for everyone who needs them. It will be essential to involve the private sector fully, bringing both sectors together as one through transparent negotiations to set agreed terms of reference. To address the crisis more effectively, both Spain and Ireland have effectively nationalised their private hospitals, bringing them into the public sector. Why not here? Will the private sector open up its beds and make them available to people who need them, irrespective of social or economic status? Will private and public health professionals work together in solidarity?
It is possible that, even combining private and public sector beds, some people will not find an ICU space. This raises some important ethical questions. Will some people have easier access than others? How will we decide who gets an available bed when more than one patient needs it?
When this crisis winds down and passes, there will be a period of reflection, of healing, of looking into the future and working out a way forward.
All of us must recognise our enormous debt to those who took risks and acted on the frontline, including health workers at all levels, cleaners, and all the working class people who, because of spatial and structural inequities imposed on them by history, carried an unfair share of the burden.
We must be well prepared for the next pandemic. Given our human-induced ecologic crisis it is merely a matter of time before another one strikes. Futhermore, regional and local weather-related catastrophes will occur more often than in the past. We must also address our underlying health crisis. Unless we tackle inequality and the SDH with the same vigour with which we are now addressing COVID-19 crisis we will repeat history over and over again. We must now renew the struggle towards Health for All.
This commits us to 3 interlinked terrains of struggle.
The struggle for a National Health Service
This crisis will show starkly how essential it is to pool all available health care resources into a single national health service that follows the Primary Health Care approach (PHC ) to build social solidarity and deliver good quality essential health services to all though Universal Health Coverage (UHC). The current fragmentation of health care resources into two inequitable systems is unacceptable.
Community participation is a key principle of primary health care. We must take up the struggle for such a NHS through the campaign for a People’s NHI, using a combination of bottom-up and top-down approaches. We can expect that vested interests in the corporate private sector will seek to re-establish a version of the highly profitable status quo by exploiting the corona crisis to perpetuate profiting from disease.
In her important book The Shock Doctrine: The Rise of Disaster Capitalism, Naomi Klein shows how neoliberal capitalism thrives on crises and shocks. Crises such as wars, coups, natural disasters and economic downturns become prime opportunities to impose an agenda of privatisation, deregulation, and cuts to social services. The coronavirus crisis is perfect for disaster capitalism to thrive. We have already seen small-scale “price gouging” as people hoard toilet paper and sanitiser to sell at inflated prices. But the bigger danger is from politicians and large corporate bodies who exploit the crisis for personal gain. President Ramaphosa’s commitment to prosecute corrupt individuals who profiteer from the crisis through corruption seems to address only small-scale profiteering. We must ensure that our struggle for a National Health Service through the NHI prevents disaster capitalism from capturing the health system.
The many struggles for equitable access to the social determinants of health
Access to the SDH encompasses virtually all state sectors working collaboratively to deliver the goods and services essential for health. The corona lockdown shows how important it is for a broad range of government sectors to work together towards a common goal, in this instance coordinated through the Coronavirus Command Council.
Again, full community participation through organised civil society is essential, and we must ensure that civil society and labour are represented there. Meanwhile, a whole range of civil society organisations are involved in campaigns around the SDH, though some might not see the links between their struggles and health clearly. They involve education, housing, transport, water and sanitation, access to information and data, and so on.
The struggle against the global ecologic crisis
The ecologic crisis of global heating is the biggest, most complex, and most difficult threat to health to combat. We must give critical support to progressive struggles to restore our relationships with each other and the earth.