Human Rights Analysis:
(Adapted from transcript of a speech I gave at the American Friends Service Committee on applying the UN Universal Declaration of Human Rights (UDHR) to current challenges in South Africa)
Good evening everyone and thank you for everything that you have all shared. I am happy that I get to be the last person to step up to talk as what I am going to talk about sort of links in what has been said as a kind of end effect and everything that has been said up until now has given such a powerful context to this.
I was going to talk about service delivery but unfortunately I can’t help myself from talking about healthcare service delivery. I’m going to do a different approach to what has been done. I’m going to apply what’s called the World Health Organisation’s Guide to Good Prescribing – so I’m a full medic today.
In medicine, when you start prescribing the first thing that you have to do is you have to define the problem – in this case its healthcare service delivery.
So I’ll present the case:
Case Scenario: A 31 year old woman from Zimbabwe known living in the community of Imizamo Yethu outside Cape Town presents to Hout Bay Clinic with a 6 weeks history of productive cough, LOW and nightsweats. She reports a previous positive HIV diagnosis and was not initiated on ARV’s. She was placed on TB treatment one year previously while living in Zimbabwe but defaulted on 6 month course. She is initiated on TB treated and work-up for ARV initiation.
Why did I choose this specific issue? I think it sounds like an elaborate story but it’s very real and very common. I don’t think people often recognise how real and commonplace stories like these are.
It is a topic that is intersectional and intersectoral in that it results from a collaboration of different factors: health status, nationality, gender and race of the patient and heath access.
In terms of defining the problem the first human right that I will mention as being violated in this case is the right to life liberty and personal security which is Article 3 (of the UDHR). This is something that is very clearly impacted by a poor health status.
Next is that of Article 2: to be free from discrimination. Most importantly this article says to have access to these rights without distinction. This “distinction” is based on race, sex, language or national origin. In this way it moves beyond simply interpersonal discrimination into factors… of economy, or healthcare access. So when people are treated unequally or when healthcare is inequitable it directly infringes upon this human right.
The point I was to make in this analysis is this: People often speak about disease as this great leveler, great equalizer, “everyone’s equal in disease/illness” – but when you look at the statistics and the reality of health equity in South Africa and around the world you realise that disease is not equal… disease is bigoted. We realise that TB is racist, HIV is sexist and healthcare access is xenophobic.
450 000 People in South Africa are diagnosed with active Tuberculosis per year, which is the third highest incidence in the world next to China and India and obviously their population difference is what accounts for their position. We have an estimated highest prevalence of 88% latent TB in certain informal settlements. I won’t get into the difference between latent and active TB. But in south Africa even the general population has a 70% latent TB infection so most of us are probably infected – but don’t worry it’s not necessarily contagious. This prevalence is found to be highest in the 30-39 year age group living in informal settlements. KZN (KwaZulu-Natal) and the Western Cape have the highest case incidence of 1076 and 1033 per 100 000 respectively which is roughly one percent.. in other words one per hundred people get active TB every year in these areas. The cure rate is about 71% in the Western Cape in 2010 but then if we look at inequity the cure rate is about 45.2% in KZN even though they have similar prevalence.
In terms of sexism – around 6.9 million people are infected with HIV in South Africa, which is the statistics that I used because they were good statistics and at that time approximately 36 million people in the world were infected by HIV – we have nearly a fifth of the world’s entire HIV Positive population. 60% Are co-infected with HIV and TB , and there is an incidence of 350 000 new cases per year (which is fortunately falling). Prevalence increases to a 39.3% in women presenting for their first prenatal checkup in KZN. So if we think of the prevalence in our country, which is already huge at 12.7% increasing to 39.3% in women who are having children we have to factor in the realities that these special groups are facing.
Xenophobia – this comes down more to health access so it’s not just interpersonal discrimination – being rejected from healthcare facilities – it’s also lack of knowledge, language barriers that restrict people’s awareness of the help/health that they can acquire. And also there is a lack of targeted interventions to these populations but I will talk about this later.
The next right is covered in Article 25 Subsection 1 which speaks to the right to a standard of living adequate for well being – when we move back to tuberculosis we can see that while there might be genetic considerations as to why certain populations are more affected than others but there are also social determinants of health. TB is one of those diseases that is considered in its essence environmental.
Issues like overcrowding, proximity, the legacy of the homelands system and mining barracks which brought a large number of men int close proximity with each other in poorly ventilated areas and then they went home are raised. We talk about rapid urbanization and informal settlements – how do you plan healthcare access when you’re dealing with the 80:20 split – it’s a very rough statistic but 80% of the resources and the knowledge and skills in South Africa are aimed at targeting what was 20% of the population and now that we have the rest of the 80% of the population joining us (a legacy of the Apartheid system in SA) – how are they catered for? When you have rapid urbanization, none of the systems have been put in place to anticipate this.
Back to the case:
The last article that I reference is that of Article 28 – the right to social and international order in which rights can be fully realized. If we look at this case of this woman from Zimbabwe, she migrated as an economic migrant, she could also potentially have had other factors that would have caused her to migrate. We have to look at why people choose to move It’s economic factors, political instability, it’s lack of opportunity to access those very public services that we have been talking about in their home countries.
In my view mobility is a factor of stability and as we had one of our speakers talk to us about this week – “African’s vote with their feet”.
The key driving factors of poor healthcare access to mobile groups are at an individual level:
- Not feeling welcome to healthcare. It’s this idea of a defaulter status. So I said this patient didn’t complete her TB treatment – there’s a lot of stigma is South Africa amongst healthcare worker’s against people/patients who don’t complete their TB treatment – you are viewed as somebody who is not caring about your own healthcare, a waste of time. Very often patients are refused treatment and even the terms that we use – “defaulter” somebody who is “non-compliant” – these are the terms that are written down in the patient’s folders so that you know how to engage with them.
At the sociopolitical level:
- There is an economic concern – how do I access healthcare if I am an economic migrant and I have to work during the day? There’s no nearby clinic and there’s lack of services in my area and I have to care for a family of 0 people. There are political concerns as well: fear of movement. At an economic level access is more than just physical proximity. It’s also a factor of stability, if you don’t have job access, how can you afford private care? If you don’t have land, how can issues of overcrowding and making your home into a safe place be of any concern to you?
- I’ve talked about density in the urban population – there is a lack of urban planning with poor decentralized services and we are left with this legacy which is probably the most important point – how do we expand who is considered a citizen?
In terms of setting the Therapeutic Objectives, which is what is the next thing that you do when you prescribe, we have to define what the outcomes we would like to achieve are:
At the individual level:
- An individual solution is to combat healthcare worker discrimination – but how do you do that? It is a tough question but one that involves a systematic rewriting of medical culture. We have to target vulnerable groups specifically – we have to target HIV positive people, women, children and mobile populations which includes migrants, refugees and asylum seekers.
- And then we have to realise that healthcare is more than just the healthcare sector – we have to focus on economic opportunity. As stated in Article 23 Subsection 1
At the sociopolitical level:
- We have to look at decentralizing the system and restructuring it – we have to alter that 80:20 dynamic. Public healthcare is for all… therefore the private sector has to engage.
- When we talk about medical education: – I had a surgeon this year when I was scrubbed in with him ask me jokingly, how do you decolonize surgery, and in the moment I just ignored him, carried on with whatever we were doing, cause he was obviously not willing to engage but I wish I could have said that there are ways to decolonize surgery. In this case it doesn’t necessarily mean drawing on the history books of what has been written about in surgery and ignoring modern advances. It means we have to look at what are the African problems and how do we restructure our medical education system to target those problems. So the one thing that I’ve talked about with some people if I get the chance is this idea that why are doctors the be all and end all of activities – we apply this very hierarchical, Eurocentric model to healthcare and we don’t recognize that people have knowledge of their own health systems and their communities. Community health workers and nurses are the backbone of our healthcare system. There are some areas where we have realized that for example in midwifery, midwifes deliver something like 90% of the babies in our country. But for some reason we are lacking in the other areas.
- The last thing is that of intersectoral collaboration – I have said that healthcare is not just the health sector – we have to look at sanitation, we have to look at transport and very importantly we have to look at housing.
The next step in prescribing to to choose the preferred drug:
In terms of choosing the drug, a number of individuals are important here:
- It’s the patient , it’s community organisations like Article 29 says community duty is important. They are important in contact tracing, in screening, in healthcare education.
- NGO’s serve as the first contact in many health cases – and they have an increasing responsibility in setting the priorities for policy particularly in areas where government has failed to do so. We can look at the powerful impact of organisations like the TAC (Treatment Action Campaign) etc which made a significant impact on ARV access to the most disenfranchised members of our population
- Local government needs to be innovative, national government needs to reallocate funds and focus on education campaigns (upstream).
- The international community needs to take responsibility for the problems of the developing world.
- The private sector needs to engage, whether that is through the national health insurance we can discuss but it is through taking responsibility.
The last task we get down to is actually writing the prescription.
The prescription that I would write for Health Inequity will not be for all of these specific issues raised that we said we’s solve as they require much more nuance than could ever be delved into in one speech, but it is for the Universal Declaration of Human Rights.
Article 25 Subsection B says that there should be special care paid to people in motherhood and childhood and I think that that should be extended. I think that’s too limited, we need to extend rights to all vulnerable groups – women, children, migrants, people with disabilities and actively go out and seek providing them healthcare.
When you give a prescription you have to give a warning at the end of some of the potential side effects – and the side effects of having rights that we are all very aware of and that we flaunt or a constitution that we flaunt is that rights set standards but they don’t initiate actions.
The things that do initiate action are economic factors. And the side effects of having a constitution that you can throw around or a set of rights that you can throw around is that we experience apathy. We insulate ourselves against the facts and the reality and I think that’s why it’s so important for us to take a responsibility in really shocking ourselves with the statistics.
This is my Human Rights prescription.