1324
Apartheid and health: is reform merely cosmetic? The wave of violence now gripping South Africa has again focused world attention on the troubles of that region. If political conflicts are rife, what of apartheid? Is it still restricting access of the black population to health care as was so convincingly proven in the 1970s and 1980s? To answer this question, Physicians for Human Rights* and its Dutch sister organisation, the Johannes Wier Foundation, sent two doctors on a two-week investigation to identify blocks to reform and areas requiring support from health workers and aid agencies overseas. The mission was specifically linked to the Minister of Health’s announcement of May, 1990, that hospitals would be opened to all races. Their report has now been published.1 The investigation also covered the question of access to primary health care by the black population. Is improvement on the agenda? Information was mainly collected by interview and observation, since data on admission rates are limited and there are confounders such as the growth of private practice, which is reducing the number of white patients admitted to state hospitals. The mission met government officials, members of the medical establishment, hospital doctors and nurses, and members of the progressive sector in five geographical areas-Johannesburg, Northern Transvaal/Lebowa, Cape Town, Durban, and East London/Ciskei. The findings were that improvements in the health sector are very patchy and insufficiently supported by government; that many hospitals remain segregated; that access to primary and secondary care is still very poor for the black population; and that politically motivated violence is severely restricting the coverage of health care in many periurban areas. Health workers and the Human Rights Commission voiced their concern to the mission about complicity of parts of the security forces and the lack of commitment of the government to curb violence. The chief impediments to reform were identified as the apartheid system and the fragmented health service; entrenched conservatism of hospital superintendents; lack of representative local government; and government-encouraged mushrooming of private
practice. Examples of these blocks were numerous. At Grey Hospital in King Williams Town (which is outside Ciskei, a homeland) patients from neighbouring Ciskei are referred to hospitals 30 miles away because a separate administrative system enforces this rule. At
Pietersburg, patients remain segregated in two separate hospitals which sit side by side; the children’s *Physicians for Human Rights is based at the University Department of Forensic Medicine, Dundee Royal Infirmary, Dundee DD 1 9ND, UK, and Johannes Wier Foundation is at PO Box 1551, 3800 BN Ammersfoort, Netherlands. A full report of the mission can be obtained from either organisation.
ward in one housed 75 black children with malnutrition and infectious disease, while in the other hospital 2 of 3 white children were about to be discharged. At Duncan Village near East London, the unpopular and unrepresentative city council cut its staff when there was a rent boycott. The first service to go was the care of the communal toilets which, when inspected by the mission, were completely blocked and offensive as well as being unhygienically sited next to shops and water points. At Khayelitsha in Cape Town, basic health services are scanty for the half million population and follow-up arrangements for patients with chronic disorders and disabilities are virtually non-existent. Preventive and curative
services
are
administered
separately.
Despite these gloomy features, there are signs of hope. Attitudes to change are generally positive, and the non-governmental health sector is rising to the challenge by organising training and support for primary health care. Some progressive organisations have also developed proposals for an insurance-based national health service. The mission was met with the utmost courtesy throughout the country. What of outside help? First, pressure on the South African government is still needed, linked to specific targets such as unification of the fragmented health system and desegregation of hospitals. Second, visiting health workers (academic or otherwise) should be appraised of the inequities present in the system and should attempt to make links with rural settings and primary health care as well as with the tertiary level. Third, assistance to the progressive health sector is needed in monitoring changes in the present system, in health economics and planning, and in public health/epidemiology. 1.
Johannes Wier Foundation (Netherlands) and Physicians for Human Rights (UK). South Africa 1991: apartheid and health care in transition-a report on progress, impediments and means of support. Ammesfoort: Johannes Wier Foundation, 1992.
Glue ear guidelines: time to act on the evidence Utitis media with ettusion
(OME, glue ear)
is the
for surgery in young children but a systematic review of management in Britain in the bulletin Effective Health Care raises some disturbing questions about variations in clinical practice and the effectiveness and appropriateness of surgery.1 Thus, the annual rate of surgical treatment for OME carried out in the National Health Service in England and Wales is about 5 per 1000 children under 15 years of age and there are substantial differences in rates by region and district.1,2 This variation and uncertainty in clinical decision making3 is an international phenomenon--eg, the US Agency for Health Care Policy and Research (AHCPR) has commissioned clinical guidelines for the management of OME. Episodes of OME vary in duration and the most common reason
Apartheid and health: is reform merely cosmetic? The wave of violence now gripping South Africa has again focused world attention on the troubles of that region. If political conflicts are rife, what of apartheid? Is it still restricting access of the black population to health care as was so convincingly proven in the 1970s and 1980s? To answer this question, Physicians for Human Rights* and its Dutch sister organisation, the Johannes Wier Foundation, sent two doctors on a two-week investigation to identify blocks to reform and areas requiring support from health workers and aid agencies overseas. The mission was specifically linked to the Minister of Health’s announcement of May, 1990, that hospitals would be opened to all races. Their report has now been published.1 The investigation also covered the question of access to primary health care by the black population. Is improvement on the agenda? Information was mainly collected by interview and observation, since data on admission rates are limited and there are confounders such as the growth of private practice, which is reducing the number of white patients admitted to state hospitals. The mission met government officials, members of the medical establishment, hospital doctors and nurses, and members of the progressive sector in five geographical areas-Johannesburg, Northern Transvaal/Lebowa, Cape Town, Durban, and East London/Ciskei. The findings were that improvements in the health sector are very patchy and insufficiently supported by government; that many hospitals remain segregated; that access to primary and secondary care is still very poor for the black population; and that politically motivated violence is severely restricting the coverage of health care in many periurban areas. Health workers and the Human Rights Commission voiced their concern to the mission about complicity of parts of the security forces and the lack of commitment of the government to curb violence. The chief impediments to reform were identified as the apartheid system and the fragmented health service; entrenched conservatism of hospital superintendents; lack of representative local government; and government-encouraged mushrooming of private
practice. Examples of these blocks were numerous. At Grey Hospital in King Williams Town (which is outside Ciskei, a homeland) patients from neighbouring Ciskei are referred to hospitals 30 miles away because a separate administrative system enforces this rule. At
Pietersburg, patients remain segregated in two separate hospitals which sit side by side; the children’s *Physicians for Human Rights is based at the University Department of Forensic Medicine, Dundee Royal Infirmary, Dundee DD 1 9ND, UK, and Johannes Wier Foundation is at PO Box 1551, 3800 BN Ammersfoort, Netherlands. A full report of the mission can be obtained from either organisation.
ward in one housed 75 black children with malnutrition and infectious disease, while in the other hospital 2 of 3 white children were about to be discharged. At Duncan Village near East London, the unpopular and unrepresentative city council cut its staff when there was a rent boycott. The first service to go was the care of the communal toilets which, when inspected by the mission, were completely blocked and offensive as well as being unhygienically sited next to shops and water points. At Khayelitsha in Cape Town, basic health services are scanty for the half million population and follow-up arrangements for patients with chronic disorders and disabilities are virtually non-existent. Preventive and curative
services
are
administered
separately.
Despite these gloomy features, there are signs of hope. Attitudes to change are generally positive, and the non-governmental health sector is rising to the challenge by organising training and support for primary health care. Some progressive organisations have also developed proposals for an insurance-based national health service. The mission was met with the utmost courtesy throughout the country. What of outside help? First, pressure on the South African government is still needed, linked to specific targets such as unification of the fragmented health system and desegregation of hospitals. Second, visiting health workers (academic or otherwise) should be appraised of the inequities present in the system and should attempt to make links with rural settings and primary health care as well as with the tertiary level. Third, assistance to the progressive health sector is needed in monitoring changes in the present system, in health economics and planning, and in public health/epidemiology. 1.
Johannes Wier Foundation (Netherlands) and Physicians for Human Rights (UK). South Africa 1991: apartheid and health care in transition-a report on progress, impediments and means of support. Ammesfoort: Johannes Wier Foundation, 1992.
Glue ear guidelines: time to act on the evidence Utitis media with ettusion
(OME, glue ear)
is the
for surgery in young children but a systematic review of management in Britain in the bulletin Effective Health Care raises some disturbing questions about variations in clinical practice and the effectiveness and appropriateness of surgery.1 Thus, the annual rate of surgical treatment for OME carried out in the National Health Service in England and Wales is about 5 per 1000 children under 15 years of age and there are substantial differences in rates by region and district.1,2 This variation and uncertainty in clinical decision making3 is an international phenomenon--eg, the US Agency for Health Care Policy and Research (AHCPR) has commissioned clinical guidelines for the management of OME. Episodes of OME vary in duration and the most common reason
