Healthcare in South Africa

Heart Transplant Museum

After working in the United States, healthcare in South Africa is vastly different to that in the US. In South Africa there are two sectors of hospitals, the private and the public sectors. The private hospitals are typically for those who have insurance, and are entirely dependent on your ability to pay for the services required. These hospitals, which have many more resources, only tend to approximately twenty percent of the country’s population. Public hospitals are run by the government, and provide everyone with access to healthcare, regardless of their ability to pay. These hospitals are divided into primary day clinics, secondary hospitals, and tertiary referral hospitals. Day clinics provide obstetrics units for normal deliveries, regular doctor visits, and follow-up visits. I am working at Eersteriver Hospital, a secondary hospital. The hospital has five departments, internal medicine, pediatrics, casualty, surgery, and psychiatry as well as an eye clinic; while many patients are completely taken care of at this level, and then eventually discharged, those that need more specialized care will be sent to a tertiary hospital. Despite the fact that everyone has the ability to be seen at the hospital, there are significant challenges that both patients and physicians alike face.

Due to the large amount of people that they serve, the government hospitals are always overcrowded, leading to a constant shortage of beds. Some of the patients who came to Eersteriver during my time there waited as long as three days in casualty before they were able to attain a bed and be admitted to the hospital. To further the problem, there are also scarce financial resources, which leads to a lack of equipment, including an onsite laboratory. Specimens must therefore be sent to an off site facility, significantly lengthening the time frame for test results to be received. It is also common to have to refer patients to tertiary facilities for tests, including CT scans, which increases the time it takes to diagnose the patient. This also restricts the care that can be offered to patients. For example, it is difficult for people to get on the list for dialysis, and there are a limited number of available ventilators in the tertiary hospitals intensive care units. Last this financial challenge leaves the hospitals significantly understaffed, which leaves the physicians very overworked and underpaid. This overcrowding of the wards, lack of equipment, and understaffing of the wards significantly limits the interactions that the physicians have with the patients and lowers the quality of care that hospitals like Eersteriver are able to offer.

Another problem that some of the individuals of lower socioeconomic class face is the lack of proper sanitation and hygiene in some of the townships. This increases the spread of diseases between individuals due to close quarters, lack of proper plumbing, and poor ventilation in the housing situations, which heightens exposure to diseases, especially over long periods of time.

This situation is exacerbated by a lack of education in these areas, regarding hygiene, proper diet, proper body care, and proper disease management. Even with access to healthcare, life expectancy in the country remains lower. Many people do not end up in the hospital until they have incredibly severe health issues, including heart failure, COPD, kidney failure, uncontrolled diabetes, and serious infections that often require the need for amputations. Furthermore, those who do receive it early enough to encourage preventative measures do not seem to understand the severity of their illnesses. People go home and do not remain on their ARVs, Tuberculosis medication, or insulin, leading to serious complications from uncontrolled HIV, Tuberculosis, and diabetes.

Cultural beliefs and practices also pose a sizable issue when it comes to changing these habits and situations to decrease the spread of diseases. For example, the Xhosa circumcision ritual, which is performed on boys during their transition from boyhood to manhood, leads to cases of dehydration, hypothermia, infection, and deaths every year. Although it is inappropriate to discuss the intricate details of this ritual out of respect for the Xhosa culture, some of the issues come from the lack of sterilization of tools and proper wound care for the circumcision, as well as the harsh living conditions that the boys face during their seclusion. Despite the risks, the Xhosa people are very hesitant to alter their cultural traditions because of the rich history that underlies them.

All of these things affect and are affected by the current healthcare system in South Africa, which is a direct result of the changes that have occurred in their government over the past century. The quality of care that hospitals are able to offer patients is relative to the state of the country’s healthcare system. As a result, our expectations for quality care should be based on the resources that are available to the hospitals. Rather than finding someone or something to blame for the challenges that the healthcare systems face in both the United States and South Africa, it is crucial that physicians, nurses, and staff work to offer patients the highest quality of care that can be achieved within the current situation. We simply cannot expect that the quality of care in the United States should be the same as that in South Africa; as the state of the healthcare systems are entirely different, the care available, especially in the public sector is different. Nevertheless, by recognizing the problems and the merits in both systems we can learn from each other and continue to work to offer patients the best quality of care available.






Culture Shock


Although I have travelled outside the United States in the past, there are several things about South African culture that immediately were vastly different than anywhere else that I have been, and these I learned quickly.


Race Distinctions Number one: Ethnicity is broken down into three categories: white, colored, and black. People do not identify with their ancestors’ roots. Of those three terms for ethnicity, black is considered offensive due to the country’s history, and these individuals prefer to be referred to as just South African, or by the native language that they speak.



Number two: Accents don’t differ based on where people are from. Instead they are determined by ethnicity.



Number three: Butter is basically a food group. Butter seems to go on everything, and with everything. Furthermore, it seems that meat and carbs are pretty standard for meals, while a wide variety of fresh fruits and vegetables, especially leafy greens, are not typically served regularly. Nevertheless, it is important to note that the food my South African mama, Wendy, makes is very yummy.







 Number four: Indian foods and spices, specifically curry and roti, are very common everyday foods in the country.




Number five: The poverty in some areas of the city is very overt and noticeable.



Number six: Tipping in South Africa is not a thing, and will result in a very happy taxi driver providing you with his number and requesting that you call him personally every time you need a ride.




Number seven: Pedestrians do not have the right of way. Whether or not you are walking across the street, the car will continue to drive.



Number eight: In South Africa the driver sits on the right side of the vehicle, and left hand turns are the wide ones. Furthermore, there is no turning on red, right or left. Do not get on the road if you do not know what you are doing.


Number nine: There is something worse than LA traffic. In South Africa, on top of there being a lot of traffic commuting into the city, you also have to deal with pedestrians, who will weave in between cars, crossing the road in the dark in the middle of traffic.



Number ten: Access to Wi-Fi is incredibly low on the priority list, and is thus nearly impossible to find on a daily basis. In fact, the local Internet café at the nearby mall actually closed down.


Although these random tidbits represent my initial thoughts during my first few days in the city, it quickly became apparent that these silly first impressions are incredibly superficial differences; once you place them in comparison to the unique cultural history that surrounds the country it is very apparent that these differences actually represent the history of the country in the same way that the culture in the US represents our history.

First, the ethnic background of Cape Town is much more complicated than I originally understood, dating back to the aboriginal Khoi San people who originally occupied the area, only becoming more complex leading up to its current situation. This includes the arrivals of the Dutch, the English, the slaves, which they brought from Indonesia, Malaysia, Madagascar, Mozambique, and, as well as Indians and Asians. The apartheid led to the development of eighteen categories of ethnicity, based largely on looks and superficial characteristics. Differentiating between white and colored was based on characteristics including whether a pencil stuck in your hair or fell out, the width of the bridge of your nose, the color of your nails, and the color of the areola surrounding a woman’s nipple. The decided ethnicity was designated on identification papers, which everyone was required to carry with them on a daily basis during the apartheid. This forced categorization, and the limitations that surrounded them clearly justifies and rationalizes the desire of people to not identify as a specific ethnic background, because the oppression during the apartheid was solely based on ethnicity and appearances. Nevertheless, the three most commonly heard ethnicities came about. Black Africans comes from the aboriginals, as well as the Xhosa speaking people, Zulu speaking people, and the Bantu speaking people. Because of the racial oppression during the apartheid, many people in this ethnic group do not like to be referred to as black. Coloureds represent those of mixed origin, specifically from white males and slave females, leading to a mix of the white Europeans, East Africans, and the slaves brought from the East Indies. Because of this mixed origin, as well as the constant conflict between the ethnic groups, and the very biased assignment of ethnicity during the apartheid, it is nearly impossible for people to know fully what their ethnic background is, explaining even more the generalized racial groups that are now used to differentiate between South Africans. These mixed racial groups also explain why a variety of foods from different ethnic groups become a very common part of food in South Africa, including curries and roti, which are traditionally Indian dishes, and Koek Sisters, which are traditionally Muslim dish served at parties and weddings.


It is also important to note that the apartheid led to the development of the townships, which housed the black and coloured South Africans that were evicted from their homes during the apartheid. These areas are segregated based on ethnicity. Individuals living in these townships do not have easy access to electricity, sewage, or clean water. This leads to individuals stealing electricity from power lines, which causes deadly fires. Furthermore, bathrooms are on the edges of the community, forcing some people to walk very long distances to go to the bathroom. As you travel from one township to the next, ethnic differences are incredibly apparent, ranging from the forms of housing available, including formal and informal housing, and the availability of resources to these communities. Although the apartheid is no longer in effect today, these townships serve as a living proof of where the country came from, and they persist as a reminder of the long road ahead, proving that twenty years of democracy cannot immediately undo the tensions and circumstances brought about during the apartheid. While this certainly does not change the fact that these individuals are living in terrible conditions and circumstances, it allows you to understand and identify with how this situation developed over the years, which can significantly change how you view the individuals who continue to reside in these impoverished areas. Furthermore, with poverty and jobs being a significant issue, it is not surprising that people will jump at any opportunity to make any extra money, including that from American tourists who tip because it is customary for them to, even if it may only be an extra twenty rand, which is about two dollars.


Transportation in Cape Town is sometimes difficult. Public taxis follow their own rules, driving unsafely, and piling more people into the small cars than capacity. There is a lot of competition between these companies, and this leads to aggressive and outlandish tactics to maintain business in this market. This is very problematic, because many of the people living in the townships rely on these taxis for transportation to and from work. This unsafe environment may explain why so many people are walking the streets and dodging traffic while crossing the roads in the morning in a hurry to work instead of using public transportation if possible. Also, the strong European cultural influence easily explains the unusual road rules, and driving directions.


Although these things may be vastly different than the society that we are used to, it certainly does not make them inferior, or worse than what we currently experience. Instead they serve as a reminder that until you are fully aware of the history and the background surrounding a subject that is specific or foreign, you really do not have the resources or the authority to develop an educated opinion on the subject. The more that I learn about the city, the more that I realize that living in South Africa really would not be that different than living in the states. Just because their history differs so significantly from ours, and they are considered a third world country, it does not justify developing a sense of superiority towards them, and it pains me to see people act in this way. Just like us, their current situation is very deeply rooted in the rich history that the country has. While their levels of poverty are much higher than we see in the states, and they may face hardships due to lack of resources and lack of education in these areas, we have areas of immense poverty in our backyards. Just as rate of diseases are higher in these areas, in the US we also see increased incidence of disease in areas of lower socioeconomic class, because of lower access to resources, and to affordable healthcare. Furthermore, life in a middle class home in both, where both adults in the family work to make a living; they have access to some luxuries, however they have deep ties into the history, and they understand what it is like to work for what they have. While this is clear now, it is not what is typically thought of when people hear third-world country. Some of the students were asked if they would be staying in shacks while they were here. While some of these comments do exist and arise out of ignorance, part of the problem is just a lack of knowledge about the cultural background, as well as the economic and political condition of the country. Bridging this gap is just the first step to understanding, accepting, and relating to individuals who come from this background.

Starting Out


I know that this is a bit late, but Internet access is scarce, so it may take me a while to get these posted. Nevertheless, after close to forty-eight hours of travel, two flights and an overnight layover in the Dubai airport, I finally arrived in Cape Town, exhausted and very jet-lagged. Upon my arrival, I was greeted by our lovely program directors, Marion and Avril. As we waited for the rest of the students to arrive in the airport, Marion asked me a question, a question I should have been able to give her an answer to. She asked what my expectations were about the program. My initial response was that I didn’t have any expectations, although this is clearly not true. So I got to thinking…what the heck am I doing in South Africa? As I attempted to answer this question for myself, aspects of my journey came to mind. I thought about the people I came into contact with during my many of travel across three continents. Although I could not recollect any of their names, I remembered their faces, and, most importantly, I remembered their stories. First there was the lady I met in the airport at Los Angeles International; I watched her carry-on for her as she took a trip to the restroom before the flight; she in turn watched my pizza. She was an older lady, probably in her mid-sixties, returning home to Nigeria after visiting her children, and ten month old grandchild, in the states. She told me about her home country, why she prefers Nigeria to the US, and why Emirates is her favorite airline to travel. Then there was the lady dressed in all coral with a black headscarf and a navy blue neck pillow constantly around her neck, who sat in front of me on the plane, and misheard my name, continually calling me Leslie throughout the sixteen hour flight. She turned around a few hours into the flight to visit, asked if I was Arab, and then about what I was doing and where I was going. She told me about Dubai, where she lives and works, and about her son, who lives and attends college in Toronto. Then there was the couple I met in line for the bathroom on the plane. Originally from Mexico, and they were travelling back home to Saudi Arabia, where they had been working at a local university for the past few years. Next there was the girl I met in line to go through security at the Dubai airport; she was headed back home to Jordan after completing her summer session at UCI. Then there was the girl at the Emirates information booth; she was in her late twenties, had grown up and attended college in Michigan, and now was working in Los Angeles. She was headed to Johannesburg to meet up with her church group who had arrived a week earlier and was volunteering there. We wandered the airport for a couple hours together, until she fell asleep, and I wandered off to find a way to entertain myself for my eight-hour airport stay. Then, and probably the one who I connected with the most, was the girl I met waiting at gate B30 for my flight to South Africa. She was in her mid-twenties, about my height, with blonde hair, blue eyes and a thick German accent. Born, raised, and now working as an occupational therapist in Hamburg, Germany, she was travelling to visit her boyfriend, who is South African. They met two years ago, during her nine month volunteer trip in Cape Town, and were now planning to get married and move to Germany. We talked about her time in South Africa, and gave me travel tips. She also told me about the different signs for sharks in the water, and we laughed at her surf instructor’s ridiculous advice regarding sharks, who told her if the sign says that a shark was spotted in the next town over, its ok to stay in the water, because it’s the next town over and sharks don’t move that fast. Then I thought about all of the people I did not talk to. There was the middle-aged Indian couple that sat next to me for sixteen long hours on the first flight from LAX to Dubai, watching children’s movies on the entertainment system and waking me up every three hours to go to the bathroom. The only English that they spoke the entire flight was when ordering food from the stewardess. There was the middle-aged African American man who sat at the next table over at Costa Coffee in the Dubai airport. He was next to me for two hours and we never spoke a word to each other. Then there was the Muslim woman who sat next to me for two hours waiting for the flight to Cape Town, and then one seat away from me during the ten-hour flight. Dressed in all black, and fully covered except for her face, the two of us seemed to not have very much in common. Although we exchanged a few glances, and a few nods, we never spoke a word to each other during those thirteen hours. As I began to try to decipher what led to these conversations, and what didn’t, it was clear that the people who I had developed a relationship with all had something in common with me. Sometimes it was clear, a similar situation, in the case of the girls who were around my age and travelling alone, a common ethnicity, or seemingly shared one, as was the case with the woman in front of me on the plane. With the couple, we seemed to connect over the mutual connection to Mexico, as my family has a home there and I had spent a significant amount of time in the country. Others it wasn’t as clear, as with the older woman from the airport. Perhaps it I reminded her of her children, or perhaps it was just a friendly face, someone who seemed trustworthy enough. Nevertheless, after just a few minutes of time spent together, she trusted me enough to leave her luggage under my supervision. Even more apparent was the people who I didn’t connect with didn’t seem to have this; they seemed to view us as entirely separate, lacking any common ground, including ethnicity, culture, and language. Nevertheless, on the flight I noticed something about the woman dressed in all black. On the plane she watched the same movie that I had watched on the previous flight, smiled at the things I had smiled at, and laughed at the same things that I had laughed at. This in combination with something that Avril said to me while I was waiting made me realize that I do know what I am expecting on this trip. While I was waiting for the rest of the students, Avril, who has worked with CFHI since 2004, told me about how students are always coming to South Africa and are being expected to learn and respect the culture of its residents, but how the people they meet in South Africa do not understand anything about where the students, most of whom are American, are coming from. Furthermore, she said that until she and Marion travelled to the US for the first time in 2009, she did not understand many things about the students. Yet less than twenty-four hours into her trip to the US, so many things finally made sense to her. This, in a nutshell, is why I am spending the last month of my summer working at a hospital in the middle of winter in South Africa rather than relaxing on a beach in the hot California sun. Although I may not see or understand things completely, every experience that I have provides me with one more way of connecting with other people, one more culture that I will be able to better relate to, appreciate, and respect. These are my expectations for this summer.