South Africa

OP-ED

At 50, the SA Medical Research Council is helping redefine democracy

Illustrative image. Photo: Michael Longmire/Unsplash

The SA Medical Research Council, born 50 years ago as an instrument of apartheid and of mining and industrial capital, has transformed into a key institution of South Africa’s democracy. And it has a crucial role to play in the country’s future social and economic development.

The South African Medical Research Council turns 50 in 2019. Understandably, there is an expectation that this is an occasion for celebration – prompted by the SAMRC’s longevity, the contributions it has made to the medical sciences and its importance today.

But to merely speak of celebrating 50 years would be a travesty as one can trace its genesis to the era of segregation, and the SAMRC straddles the years of apartheid and democracy. There are many other institutions in South Africa which straddle these years… But, as colonialism and apartheid were denials of our common humanity and as questions of health are so much intertwined with notions of human well-being and our understanding of humanity, the SAMRC’s journey is no ordinary one. As such it is more important to reflect on the journey of the SAMRC as part of the journey we have undergone as a nation.

One important question which emerges from such a reflection is what this says about our use of institutions which are hangovers from the oppression of the past. Could we just use them by focusing on the “scientific rationality”, supposedly, as in the case of the SAMRC, or was something more radical required?

The development of science, particularly the biological and medical sciences, is one of understanding the building blocks of our species, contributing to the fight against pathogens and epidemics, and advances in healthcare which have lifted humanity out of being merely the victims of our biology and the natural world. But the history of the biological sciences is also a history of social Darwinism to justify slavery, colonialism and racism and the use of race “science” to promote eugenics and apartheid.

With the #RhodesMustFall movement in 2015, there were politicians and commentators who tried to delegitimise the anti-colonial sentiments of that movement by arguing that “colonialism wasn’t all bad” and that “colonialism” (apparently) gave us good infrastructure, the rule of law, governance etc. As if we can merely sift out the good from the evil from systems whose intentions were fundamentally about oppression and privilege and then carry on with the good as if this is merely a matter of finding the best tomatoes in a rotten crate and cooking a beautiful meal.

At heart, it always assumes that the so-called good things were developed in the European heartlands and then “exported” via colonialism. It is important to debunk this myth.

If we take the three European countries that impacted on South Africa – Portugal, Holland and Britain – then we can see the errors of the myth.

Portuguese explorers who reached Southern Africa in the 16th and 17th centuries left a little footprint. And in what later became their colonies – Guinea Bissau, Angola and Mozambique – theirs was a classic seaboard empire, extractive of human and natural resources via the ports, but with little appetite or capacity for development. Far from exporting governance and the rule of law, Portugal in the 1960s and ‘70s – the time national liberation movements in its colonies were fighting for independence – was a fascist dictatorship. With all their later problems, it was the liberation movements which tried to bring forms of development and governance to the former Portuguese colonies.

Similarly, Dutch colonialism in South Africa was initially conducted through the vehicle of a private company (a forerunner of today’s transnational corporations or TNCs), the Dutch East India Company. Development and governance were not on its mercantilist agenda, nor was Holland of the 17th and 18th century a country known for the quality of its governance, let alone having any to “export”. Every quality we associate with Holland today – democracy, tolerance, rule of law etc – was brought about by rebellions of ordinary Dutch people against their own rapacious elites.

And British rule – which formally ended in with the Act of Union in 1910 – may have presided over the development of infrastructure and the bureaucracy of governance. But it was also a development entirely at the behest of and in the interest of the British elite – witnessed not only by the seizures of land but also the conquest of indigenous people during colonial wars. And, when gold was discovered in Boer territory, going to war in the interest of the new mining barons.

Far from a “good” colonial development, South Africa still exhibits the networks of transport and energy infrastructure geared towards mining and extraction. And far from exporting “good governance”, what went for democracy in Britain was the outcome of struggles against the British elite by millions of ordinary British men and women to win the franchise (which women only won in the 1920s) and human rights.

Likewise, democracy and the rule of law (with all its shortcomings and caveats) are an outcome of the liberation struggle in South Africa. Our liberation struggles against apartheid and for democracy at least brought us a written Constitution – which the modern United Kingdom doesn’t have, but still relies on a mixture of legal precedent, landmark treaties and royal decree.

With all our difficulties there is much we can teach our ex-colonial masters about governance and democracy.

Which brings us to the history of the SAMRC, and how there is something to celebrate after 50 years, provided we continue the ongoing transformation of the institution.

Its predecessor – the South African Institute of Medical Research (SAIMR) – was founded in 1912 at the behest of the Chamber of Mines and the Union government. Its preoccupation was the spread of TB and pneumonia among workers in the deep-level mine shafts of South Africa’s gold mines. But it saw disease through a colonial lens as the racial division of labour was one in which white workers were regarded as skilled – doing the blasting and rock-drilling – while black workers were brought in as migrant labour from all over Southern Africa and housed in single-men’s compounds. So, the response to pathogens and the fight against the disease were about providing care to, and keeping records of, the white workers and pre-checking and excluding diseased black workers and sending those who contracted disease back to the Reserves.

The widespread disease of TB flourished among malnourished black mineworkers living in overcrowded conditions in single-sex hostels. Miners who got infected with TB were repatriated and TB was spread to rural areas. By the late 1920s, more than 90% of adults in parts of the rural reserves of Transkei and Ciskei had been infected with TB.

Once set up, the SAIMR did major studies of diseases contracted by white South African soldiers serving as colonial surrogates in German East Africa – where malaria was rife. Needless to say, at this time, SAIMR scientists were entirely white and largely male.

Between 1912 and 1945 the scientific work of the SAIMR can be understood in a twofold way:

On the one hand, it was associated with groundbreaking medical research whose relevance and validity are widely acknowledged globally. But, on the other hand, it was informed by a paradigm shaped and coloured by a very Eurocentric approach to disease. This approach tended to see health in terms of pathogens which threatened “European lives” in Africa – malaria, sleeping sickness and yellow fever. In this it echoed the traditions of other institutes in European countries which had a similar paradigm – one thinks of the London Institute for Tropical Medicine etc – in which health research prioritised colonial objectives.

After World War II, the Smuts Government absorbed the research work of the SAIMR into the much larger Council for Scientific and Industrial Research (CSIR) in 1945 (the SAIMR continued its work on virology and pathology until 2001 when it merged with the National Institute of Virology, the National Centre for Occupational Health as well as university and provincial pathology laboratories to form the National Health Laboratory Services).

The CSIR, as its name suggests, had less of a medical and public health remit and was part of a broader strategy to harness scientific research to enhance industrial development. Medical Research was undertaken now under the auspices of a committee of the CSIR – called the Committee for Research in Medical Sciences (CRMS).

It was the CRMS which championed the need for a separate council for medical research – which was finally realised in the formation of the SA Medical Research Council (SAMRC) in 1969. The MRC (as it was usually known) had two main research programmes – joint research with or research support of universities and medical institutions and research carried out by the MRC’s own in-house scientists. The MRC was responsible for breakthroughs in the identification of the causes of parasitic diseases in humans such as typhoid, trachoma and cholera as well as fungal toxins in food; for developing vaccines and for early treating and treatment of TB. The MRC also began combining medical research with broader health research such as epidemiology and identifying disease patterns in South Africa.

The early heart and other organ transplants in South Africa would not have been possible without the support of the Cape Provincial Administration and the MRC (provision of animals for practising transplant techniques and research on rejection and immuno-suppressants). And the MRC was also associated with groundbreaking scanners which improved medical diagnostics.

But, in the intervening years, the 1948 codification of South Africa’s racial oppression into what became known as apartheid after the victory of the National Party in that year’s whites-only elections, saw apartheid thinking frame the health research paradigm of the 1969-launched SAMRC.

The Cape Town campus of the SAMRC was shared with Stellenbosch University – which was seen as the philosophical home of apartheid’s intellectual arm. The SAMRC also became the port of call for senior apartheid politicians seeking medical interventions.

Alongside the apartheid regime’s ideology of racial identities and its quasi-scientific embrace of genetic racial difference, the SAMRC focused much of its health research on seeking the continuity of “race”, genes and disease. Also, apartheid South Africa’s global alliances framed the MRC’s international research collaborations – notably Israel and Taiwan – while African partners did not exist.

By the late 1980s, it was apparent in apartheid state institutions that change was on the way. But these were also the years when the apartheid government initiated what we today know as the neoliberal policies which dominate globally. These include the privatisation of Iscor and the commercialisation of Eskom and SAR&H. In 1989 the SAMRC was corporatised and a commercial company – Medical Technologies Ltd (MedTech) – formed to house its investable medical research.

MedTech’s failure and subsequent liquidation, however, resulted in the SAMRC having to write off an estimated R2.7-million of its investment in the company in 1993.

But since the 1970s the world outside the SAMRC was changing. At the international level, a range of activists and progressive countries began to challenge the over-medicalisation of health and introduced notions such as public health, the social determinants of health and the need for primary healthcare and universal healthcare access. Many of these were championed by the World Health Organisation (WHO) at its ground-breaking summit at Alma Ata in 1978.

These developments also intersected with a growing health activist movement inside South Africa in the 1980s, which was an integral part of the liberation struggle.

Then, with the victory of democracy in 1994 the first black president of the SAMRC, Malegapuru Makgoba, was appointed. Thus began the new struggle of the SAMRC to smash the apartheid-era racial paradigm and begin the necessary process of transformation. Transformation in every sense – from the content of the research undertaken by the SAMRC and which it supports; to the composition of the in-house staff and scientists; to the growing of a cohort of black and women scientists; to the embrace of health sciences as a broader meaning than only medical science; to becoming the measure of the state of the nation’s health. Today, the SAMRC is headed by a woman scientist and is unrecognisable from its lily-white past.

Today the SAMRC produces the major studies in South Africa on the principal causes of death and disease; undertakes environmental and epidemiological studies which warn us of the major environmental impacts on public health while producing researched reports on healthcare systems and options that can best realise our commitment to universal access to healthcare. The SAMRC is also involved in the research for new medical technologies and new drugs and undertaking their clinical trials while collaborating in the innovations associated with genomic medicine.

This is not about cherry-picking some of the “good” of the past – this is about the SAMRC as it is today.

But today there is much concern that South Africa may be in a situation where a health research body may be a “nice thing to have but not an affordable priority”. Also, there are pressures from those who seek to turn medical innovations into the sole prerogative of commercial enterprises.

So why should we continue to put public resources into a public institution of Health Research?

Today, some would say that current breakthrough research and technological innovations are driven by commercial research and development, of which Craig Venter’s pursuit of the human genome mapping and Silicon Valley are notable instances which are often highlighted in the public domain. But, while this might be the stuff of legend the reality is very different:

Places, such as Silicon Valley (usually sold to us as a result of venture capital and a bunch of individual entrepreneurs), which have benefited from investments by visionary ‘mission-oriented’ public sector organizations that have created and shaped markets not only ‘fixed’ them – before the private sector was willing to enter. Organisations such as Darpa in the Department of Defense, the National Institutes of Health in the Department of Health, ARPA-E n the Department of Energy and others such as the National Science Foundation (NSF), the Small Business Innovation Research programme, Nasa, and even CIA venture-capital funds. And of course not just in the USA, also in many other countries including Tekes and Sitra in Finland; Yozma in Israel; and increasingly also public banks like KfW in Germany or CDB in China.” (Mariana Mazzucato, The Entrepreneurial State: Debunking Myths, 2017)

But, apart from these case studies, it must be remembered that South Africa has only recently come out of apartheid. But, on the basis of all evidence in regard to race, class and gender, still suffers from the structural architecture of apartheid’s legacy. We thus clearly need to ensure transformation. This means changing the make-up and organisational culture and practices of all institutions of public life, including the science community.

This explicitly means the promotion and development of black people, in the broadest sense of the word; women, and people with disabilities in access to scientific knowledge; the composition of the scientific community; the practice of scientific research; and the nature of the health sciences itself. Where the highest possible quality of research and application is necessary, there is no question that significantly more investment and resources will be required if the transformation is to go hand-in-hand with increasing the quality and quantity of science outputs.

A healthier population is capable of greater levels of productivity. A healthier society which reduces environmental threats, pollution, inter-personal and gender-based violence, increases all forms of equality and access to life-chances and reduces drug addiction is more able to improve skill levels, productive output and innovation, all of which can ensure inclusive economic growth and virtuous economic outcomes.

Moreover, a healthier population reduces the costs of medical care, the need to redirect public resources to mitigating epidemics and reducing the labour days lost to illness and poor health.

These are in a sense economic corollaries to an investment in the health sciences.

But there is also a directly economic argument about why investment in health science is crucial if we are to break the shackles of global dependence through the development of an industrial strategy.

Today, it is generally accepted that, with regard to investment flows, countries can be divided into two categories which roughly correspond with the division into “developed” and “developing” countries:

  • Those who have an endogenous capacity to shape the pattern of investment flows (the developed countries) and;

  • Those who seek to receive investment flows (developing countries) by making themselves as attractive as possible to investment in a context where the direction of flows is exogenous to their capacities.

In simple language, some can determine, at least partially, the direction of investment flows (whether inward or outward) and others have this determined for them and can at best hope that they can benefit by flows over which they have little or no control.

In general, countries in the Global South are forced to make themselves as compliant as possible to TNCs, borrow from multilateral lending agencies and then become the victims of burdensome debt conditionalities and competing in the race to the bottom to lower regulations to TNCs. Countries in the Global North are the principal trading centres for the TNCs, they are the centres for research and development. They lend rather than borrow, they determine the conditionalities for investing in the South.

Meanwhile, UN World Investment reports continue to show that the bulk of investment flows are between the USA, the EU and China, with Japan a distant third.

So, what about South Africa?

South Africa is a country of contradictions in terms of the above classification. It is an African country but is also the biggest source of “foreign” investment into the rest of the continent. Its biggest trading partner is the EU and not another African country. It is in the Global South but has some of the largest TNCs in the world. It is the most unequal country in the world.

South Africa is one of the most resource-rich countries in the world, but it merely exports and hardly beneficiates. It had a low level of foreign debt as a percentage of GDP at the dawn of democracy, but since has borrowed increasingly-more to offset its negative trade balance. It is further challenged by the fact that its key companies have moved offshore between 1990 and 1998 and it now has to send domestically-generated revenue offshore, further undermining its capacity to improve the lives of its people.

It is for these reasons that a range of economic policy advocates – both within government and within progressive civil society – have argued that South Africa needs to develop the tools to ensure endogenous development capacity, particularly to develop an industrial strategy.

Whereas this is much recognised in the case of the beneficiation of our mineral resources, it could also true in the case of the medical sciences as a branch of the health sciences.

South Africa has been at the cutting edge of the development and/or application of medical science innovation in recent years – eg diagnostic scans, new HIV drugs – but it lacks the manufacturing and beneficiation capacity to produce these on a scale to get economies of scale.

Investment in science can contribute directly to the possibilities of a healthy nation. Medical science, as a branch of science and one which draws on a range of other sciences, can benefit and in so doing improve medical care and clinic practice. Recent innovations such as the human genome mapping project, research into the human microbiome and forms of medical nanotechnology and genomic medicine offer the possibilities of pre-empting diseases and pathologies and designing new treatments and drugs which move beyond the framework of cure and mitigation.

The medical sciences associated with virology and epidemiology offer the possibilities of avoiding or offsetting systemic crises, while public health and new forms of primary health care open the way to healthier public practises and forms of more accessible and democratic healthcare practices.

The resources for investment in medical science differ across the globe, roughly in correspondence with the economic power held by countries. In a world in which the technological innovations – which are the products of the scientific capacity of countries – get patented by wealthy corporations in the rich countries, this means that access to these medical innovations comes at a price and perpetuates the exclusion of the majority from the benefits of those medical innovations.

South Africans are already aware of the highly unequal access to the current forms of technology – scans and diagnostic machines, designer drugs etc – from rich foreign countries to private hospitals in South Africa to the public healthcare system, to the least-resourced in rural areas.

South Africa has the highest per capita prevalence of both TB and HIV in the world, and the SAMRC has shown that these two – both associated with the poor majority – are the greatest causes of death. Investment in new TB diagnostics, vaccines and treatment will immediately lead to a healthier population.

Unless there is a massive expenditure in Health Science, in Medical Science and in nurturing medical innovations – while keeping them as public goods – then unequal access will be perpetuated.

2019 is also the year of our sixth democratic elections. As is valid for democracy, political parties vie for votes by contesting the narrative as to what the state of South Africa is today and what their electoral manifestoes may offer to the voting public. Many parties – those that can afford these studies – rely on “experts” who predict what the concerns of the public may be and then promise solutions accordingly. Some parties convene membership fora to produce their manifestos, while others call public gatherings to hear what people want.

Outside elections, the cut and thrust of public opinion is often shaped by specialist commentators and those who have control over and access to various media platforms. So, the commentariat may speak every day about the “economy”, corruption threats of rating agency downgrades etc. Social media can reflect the opinions of networks of like-minded groups, but we may not have a sense of what is the lived experience of ordinary people and what makes people choose political representatives. Elections can, however, be special in that they draw in millions of people who may not otherwise read or listen to political media.

The SAMRC publishes mega-reports that tell us a story about what the state of the public health is today. The most recent of these is the Demographics and Health survey of 2016. This is done in partnership with Stats SA and involves teams of researchers interviewing some 8,514 women aged 15 to 49, and 3,618 men aged 15 to 59. These are people across the country. On the basis of these interviews, we are able to extrapolate trends for South Africa as a whole.

And on the basis of these, South Africans, therefore, have the information to make informed choices about what kind of public policies we want and how public resources should be used.

This is nothing less than redefining what it means to be a democracy.

This is the kind of SAMRC that exists today after 50 years when we rightly celebrate the journey of the SAMRC from the darkness and into the light. DM

Glenda Gray is the President of the SAMRC and Leonard Gentle is an adviser on Research Translation.

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