Who will fight the good fight?

On September 27 the Treatment Action Campaign (TAC) Western Cape marched to the provincial Department of Health to raise concerns about the quality of care provided to pregnant women at maternity and obstetrics units. The march was the culmination of the kind of grassroots activism many talk about, but few actually do.

Not knowing where else to go, a few women had approached the TAC office in Khayelitsha with stories of delayed births and potentially preventable infant deaths. In response, TAC Western Cape called a community meeting bringing together women from Khayelitsha and surrounding areas. Testimonies were taken down, common issues identified, and the wheels were set in motion for taking the concerns to the provincial government. At the time of writing the department had initiated an in-depth investigation into the complaints.

The Western Cape is probably not the worst place in the country to give birth, but we know about the problems here because of the strong presence of TAC in the community. Often when there is no TAC or similar organisation, people simply suffer in silence. Long queues, medicines shortages, rude staff, undignified facilities, many users of the public healthcare system simply just accept it as the way things are.

In some cases the state may even rely on the fact that people do not demand to be treated with more dignity and respect. When over 3 500 community healthcare workers in the Free State were dismissed early in 2014, the provincial department of health no doubt expected them to go quietly. They did not. They sought a meeting with MEC for Health Benny Malakoane to discuss their dismissals. When Malakoane refused to meet with them they held a peaceful night vigil at Bophelo House, the head quarters of the Free State Department of Health. They insisted on their rights and on a decent and reasonable process of engagement. Government refused. Thirty-six hours in cells, 7 separate court appearances, and hundreds of thousands of Rands later, the so-called Bophelo House 94 have been convicted of taking part in a prohibited gathering – a legally puzzling conviction we are confident will be overturned on appeal.

It is extremely disturbing that the state responded so disproportionately to a group of mostly aged women praying and singing. As the court made clear, the arrests and convictions were not because of any threat to public safety or any threat to property, it was purely on a legal technicality – and a misunderstanding of that legal technicality at that. But of course cases like these are fundamentally political. It is simple, the Bophelo House 94 are being punished for daring to speak out against MEC Malakoane.

Another worrying thing is that even in provinces where there appears to be more political will from the provincial government, things do not appear to be going any better. How is it, for example, that more than two years after our ‘Death and dying in the Eastern Cape’ report, we see a report as shocking as the South African Human Rights Commission’s report into emergency medical services in the Eastern Cape. The HRC paints a picture of a public service in a complete shambles. Few ambulances are in working order. How is this level of mediocrity still possible in 2015? How is it that we keep failing at such basics as getting medicines from depots to facilities and in ensuring a reliable ambulance service.

In recent years it has become clear that the key struggle we’re facing is no longer the struggle for treatment, but the struggle against a dysfunctional public service.

Responding to this challenge is in some ways much harder than our earlier struggle. Apart from getting the ANC to drop their extremely harmful policy of cadre deployment, there are no easy policy wins anymore. We’re in a struggle that will be hard to win through big battles, but that instead will have to be won by a thousand blows. We have to demand accountability at every single facility in the country, of every district manager, and of every head of department and MEC. We need to educate ourselves and our members about our rights and demand that our rights be met – even if it means we have to follow in the footsteps of the Bophelo House 94.

Of course, TAC and a number of our partner organisations are struggling financially. Contrary to popular belief, the problem is not that there is no money, a minute fraction of the Global Fund or PEPFAR billions flowing into South Africa can keep the most important civil society organisations in the country afloat. The real problem is that many donors, and UN agencies for that matter, are so scared of rocking the boat that they would rather see organisations like TAC go down that be associated with anything vaguely critical of government. In their way, these donors are not all that different from people who just turn away and tacitly accept substandard treatment at health facilities.

It seems very likely that in a few months South Africa will follow the World Health Organisation in recommending treatment for all HIV positive people. In light of the compelling findings from the START trial this change cannot come soon enough. We are wholeheartedly behind it.

But yet, even as the Minister makes the ‘test and treat’ announcement and as the world applauds, there will be many clinics in this country without key medicines. There will be out of order ambulances gathering dust in quiet parking lots. There will be MECs for Health in place who are still facing serious charges of fraud and corruption.

The conviction of the Bophelo House 94 would not yet have been overturned. In the Free State and KwaZulu-Natal patients will be suffering because of the botched transition from the old community healthcare worker model to the new ward outreach model. And in places where there is no TAC or similar organisation people will just accept this bleak state of affairs.

Of this decaying underbelly most of the world will be silent. Even the WHO and UNAIDS, who in the light of Ebola should really know better, will turn a blind eye to the dysfunction in our healthcare system. Instead, the call for 90-90-90 will continue to resound as if it is the magic formula that will solve everything. It won’t. Travelling at 120 km/h may seem like a great idea, but ignoring the fact that your gearbox is about to blow and your wheels are about to fall off is a dangerous form of wilful blindness.

As in the previous issue of NSP Review, we say again that our healthcare system is at code red. For as long as it remains true we will keep saying it for whoever cares to listen. We will point out the elephant in the room. It is up to you whether you want to face it or pretend it is not there.