Government’s ideological framework is neoliberalism and its brief is being the best it can in service to South Africa’s super-rich – those behemoths who have rand-earning assets in South Africa but who transcribe these into profits via the dollar-euro circuits of global financial markets. This means high-interest rates and bond yields for the rich and the banks while ignoring the need to fix the healthcare system on whom the poor rely.

Covid-19 was a difficult moment for the government. Alongside so many countries in the West, they dithered while the news came out of China and the WTO that a new coronavirus was on the way. Our 2020 budget still had as its centrepiece cuts in the health budget, despite the fact that the virus was on its way. 

But to its credit government did respond in March with a lockdown and social distancing response. Lockdown meant that the government was going to harm huge swathes of business alongside the millions of ordinary South Africans who would lose livelihoods and be further impoverished. There was a huge risk of popular non-compliance and dissatisfaction but the lockdown was a response that was simply politically impossible not to proceed with. 

As part of managing the lockdowns the public was encouraged to go along with the measures by regular health warnings, mass programmes of education as to the nature and dangers of the virus. The government introduced the MAC – an advisory group of health scientists who were given space on TV to talk the public through the strategy. 

Over the last five years, the government has unveiled its commitment to universal healthcare via the NHI, set up systems of evaluating public hospitals, passed an NHI Bill in 2019 and appointed a special Competition Commission enquiry into high costs in the private health care system. Successive budgets even spoke explicitly that the government might have to take unpopular measures – like increasing VAT – to fund the NHI.

This put health scientists in a unique position –a position normally reserved for economists – that government would be “following the science”. Of course, this was not unique to South Africa but was the strategy all over the world.  The strategy was about prevention – hygiene, handwashing and masks, social distancing – and mitigation. And what was made abundantly clear was that the lockdown was to flatten the infection rate curve so that the healthcare system could be prepared and therefore not swamped when the infection rates peak.

Prior to the Covid-19 pandemic there had been a consensus amongst both the health science community and government that South Africa’s healthcare system was not fit for purpose. It was a dual system whereby 80% of the people rely on the public sector while the 20%, the wealthy, the middle classes and those in full employment – who have one or other medical aid – relied on the private sector. This skewing is replicated across all spheres in the healthcare sector – from health specialists, to ICU beds and staff.   

This system has become so pernicious that South Africa’s private hospital monopolies – Netcare, Mediclinic, Life Healthcare and the like are now major players in private healthcare in Britain, Switzerland and the UAE, while the poor risked their lives in the overburdened and underfunded public system. And the biggest Medical Aids business, Discovery, moved on to launch its own bank.   

Over the last five years, the government has unveiled its commitment to universal healthcare via the NHI, set up systems of evaluating public hospitals, passed an NHI Bill in 2019 and appointed a special Competition Commission enquiry into high costs in the private health care system. Successive budgets even spoke explicitly that the government might have to take unpopular measures – like increasing VAT – to fund the NHI.

The health scientists have been researching the state of the public health system for years as they sought to provide the government with the most up to date information as to what would be needed to fix the healthcare system.                              

In the meantime, the SAMRC warned that South Africa faced four epidemics in which its profile is amongst the worst in the world – HIV/AIDs and TB, Infant and Maternal Mortality, Non-communicable diseases such as diabetes and strokes, and Violence – all of which require both behavioural changes and better healthcare ….

And then came Covid-19, and then came the lockdowns and the health scientists took centre stage … 

And, then surprise, surprise, government’s commitment to the necessary healthcare reforms to make universal healthcare possible, simply dissipated. And when the government implemented the lockdown and it was clear that starvation loomed for the poor majority in South Africa? The government announced a package of budget adjustments and underwriting private bank loans – with much uncritical media fanfare as if it were a R500-billion stimulus package … and then it all quietly died down as people read the small print. 

Reality was stood on its head …  

The NHI? Gone the way of the dodo… The test site reports on the readiness of hospitals? On the back burner…. Filling the some 40% staff shortages in public hospitals? Treasury long-ago vetoed this…. Implementing the Competition Commission’s recommendations on pricing in the private sector? Filed in some bottom drawer…

Then, unlike in Ireland and Spain where governments temporarily took over the private healthcare resources, the SA government announced a deal to procure ICU beds in the private sector. This after the public had been told that the fiscus has no resources.

Doctors and other health workers, unlike the scientists, who work at the increasingly over-burdened coalface have had to deal with moral choices as to who should be allowed to live and who can die.  

In some ways, this response of government could have been predicted by its commitment to austerity and satisfying the markets. Recently a group of heterodox economists penned their critique in Business Day and took up the challenge. It’s the challenge to neoliberal fundamentalism that social justice activists have been waging for some 30 years.

But, in the glare of the public eye, and with this immovable object of government’s prioritising neoliberal orthodoxy over all else…. where were the health scientists to go?  

What we have seen is that the health science community sets its bar lower and takes government intransigence as simply an immovable rock in a river, a fact of nature.  For decades the science community has complained that the government does not take the scientific research seriously. Now, what does it do? It also goes quiet about the state of public healthcare, about the social determinants of health, about the need for universal healthcare, about the NHI.

Doctors and other health workers, unlike the scientists, who work at the increasingly over-burdened coalface have had to deal with moral choices as to who should be allowed to live and who can die.  

In the meantime, a strange irony is developing. As Covid-19 cases surge-swamping public hospitals the private hospitals are, in the words of Wits School of Governance’s Prof Alex van Heerden experiencing (and the wording is priceless) a “drop in demand”. The public hospitals are getting swamped but the private hospitals are experiencing a “drop in demand”.  Middle-class people on medical aid fear hospitals as a source of infection while other surgical processes have been postponed during Covid-19. 

Critics then said that this policy of austerity amounted to making the public pay for the risks taken by the rich. Then in 2020, after some delay, Covid-19 suddenly opened the door to massive state spending and new rounds of QE and showed that austerity was a political choice, not an economic law.         

This is creating an income problem for doctors and senior specialists in the private sector. Many rent space in private hospitals or are only paid by Medical Aids when they actually provide medical services. With a drop in “demand” and with no sympathy from the big private hospital monopolies or the medical aid industry, these people are in trouble.

So a lobby group of doctors calling itself the Progressive Health Forum is lobbying for a “public-private-partnership” in healthcare.                          

But when the clamour from business and other lobbying groups called for an immediate opening up of “the economy” where were the science voices either calling for the lockdown to be maintained or for conditionalities, long propagated, to be implemented by government? – more testing, quicker testing results, fixing the healthcare system, solving the food distribution system and the grant relief etc. etc. It has been left for defensive voices amongst the poor – community organisations and trade unions – to raise the battle for testing and PPE. With the coming surge in Covid-19 cases imminent in the South African winter it is time for some self-reflection amongst the health scientists.

The editor of the Lancet, Richard Horton, has published a long piece attacking the British government for its mishandling of the Covid-19 crisis. He calls it the biggest public health disaster and holds the Johnston government responsible for some 10,000 avoidable deaths, with its tardiness in implementing a lockdown and social distancing, in testing, its lack of resources and staff for Britain’s NHS. 

But he also aims his sights on the health scientists. Blaming them for their complicity and uses the expression that they stood too close to the “economic orthodoxy” and so compromised their watchdog role for public health. Health scientists were guilty of second-guessing politicians and economists.

The economic orthodoxy in South Africa – against which Horton rails against in Britain – is that South Africa is broke. It doesn’t have the resources in the fiscus to do anything that requires major spending – whether on education, on social services or health care. In the major industrialised countries of the North, this was known as austerity and was seen as the price to be paid for excessive state expenditure to save these economies from the 2010 financial crisis. Then governments spent trillions of dollars – via QE, bail-outs and even partial nationalisation – to save major banks and investment houses deemed to be “too big to fall”.    

Critics then said that this policy of austerity amounted to making the public pay for the risks taken by the rich. Then in 2020, after some delay, Covid-19 suddenly opened the door to massive state spending and new rounds of QE and showed that austerity was a political choice, not an economic law.         

Now, no one expects scientists to be politicians or economists. But we do expect them to be uncompromising in their defence of their passion for public health, for the body of scientific work over many years, globally, and to use the weapons of rationality, consistency and evidence.

And to choose sides when it comes to the public good. DM

Leonard Gentle has been an activist since the 1970s, a trade union organiser in the 1990s and is the retired director of the International Research and Information Group (ILRIG). He has also advised the SAMedical Research Council on Research Translation.