In general, the civil war had degraded the quality and availability of health care since independence. Logistical problems with supply and distribution of equipment as well as the lack of physical security impeded the provision of health care throughout the country, and public health services existed only in areas under government control. The rest of the country depended on international and private relief organizations, although UNITA provided a fairly extensive health care system of its own in rebel- controlled areas. Poor even by African standards, health conditions in Angola were made even worse by the failure of government health programs to reach much of the population and by the movement of a significant part of the population out of war-ravaged regions. The country remained heavily dependent on foreign medical assistance because instruction in Angolan medical schools had progressed slowly.

Prior to independence, only urban inhabitants, many of whom were Portuguese, had access to health facilities. One of the MPLA's priorities when it came into power was to provide health care to the entire population through a network of health facilities overseen by the National Health Service, an organization subordinate to the Ministry of Health. In theory, basic health workers determined the level of care required by each patient. In rural areas, village dispensaries and health stations were staffed by a nurse, and district health centers provided outpatient services, a pharmacy, and up to twenty beds. District health centers referred patients to provincial hospitals when necessary. In reality, health care was limited and often unavailable in rural areas because of the lack of resources and the absence of government control throughout much of the country. The government claimed, however, to run 700 health posts and 140 health centers in rural areas in the late 1980s. UNITA, as part of its general goal of disrupting government services, impeded and often prevented the movement of health care personnel and medical equipment in many areas of the country, including regions outside its immediate control. Reports from various sources, mostly appearing in the Portuguese press, alleged that UNITA forces had attacked and destroyed rural medical facilities.

The OMA, the National Union of Angolan Workers (União Nacional dos Trabalhadores Angolanos--UNTA), and the Angolan Red Cross were also involved in promoting health care through the provision of health education, vaccination campaigns, and surveillance of health conditions. Particularly prominent was a primary health care program provided by the Angolan Red Cross in urban shantytowns. Most health-related programs, however, were administered by foreign and international organizations with the cooperation of the Angolan government. Most of these programs, primarily the International Committee of the Red Cross (ICRC) and various UN agencies, provided emergency relief aid to those affected by the UNITA insurgency. The ICRC operated mostly in the provinces of Huambo, Bié, and Benguela, administering projects for improving nutrition, sanitation, and public health, with a total staff of some 70 people, assisted by about 40 physicians, nurses, technicians, and administrators from foreign Red Cross societies and an estimated 800 Angolan relief workers.

Infectious and parasitic diseases were prevalent among most of the population. These diseases flourished in conditions of inadequate to nonexistent environmental sanitation, poor personal hygiene habits, substandard living conditions, and inadequate to nonexistent disease control programs. These conditions caused a cholera epidemic in 1987 and 1988 that killed almost 2,000 people in twelve provinces.

Conditions worsened in the 1980s, primarily because the UNITA insurgency had resulted in the creation of a massive internal refugee population living in tent camps or urban shantytowns. The most frequent causes of death included gastrointestinal diseases, malaria, respiratory infections, and sexually transmitted diseases, all of which were aggravated by endemic malnutrition. The most prevalent diseases included acute diarrhea, cholera, hepatitis, hymenolepiasis, influenza, leprosy, meningitis, onchocerciasis, schistosomiasis, tuberculosis, typhoid, typhus, yaws, and yellow fever. In addition, in 1989 approximately 1.5 million Angolans were at risk of starvation because of the insurgency and economic mismanagement. The United Nations Children's Fund (UNICEF) estimated that Angola had the world's fourth highest mortality rate for children under the age of five, despite a program launched in 1987 by UNICEF to vaccinate children against diphtheria, measles, polio, tetanus, tuberculosis, and whooping cough. UNICEF claimed to have vaccinated 75 percent of all Angolan children under the age of one.

If statistics provided by the chief of the Department of Hygiene and Epidemiology in Angola's Ministry of Health were accurate, the incidence of acquired immune deficiency syndrome (AIDS) in Angola was fairly low by African standards--0.4 percent of blood donors in Luanda and 2 percent to 4 percent of adults in Cabinda tested positive for the AIDS virus. The highest percentage of cases was in the northeast region bordering Zaire. There were indications, however, that the actual number of AIDS cases was significantly higher; the United States-based AIDS Policy Research Center claimed a high incidence of the disease among Cuban troops based in Angola and Angola-based African National Congress members. The biggest problems in determining the extent of the epidemic were inadequate communications systems and the lack of modern blood testing or computers to tabulate the death toll in rural areas. In cities controlled by the government, the World Health Organization helped initiate an information and testing campaign in 1988 that included the distribution of condoms.

Another prevalent health concern centered on the tens of thousands of people, many of them women and children, crippled by land mines planted by UNITA insurgents and, according to foreign relief organizations, by government forces. Estimates on the number of amputees ranged from 20,000 to 50,000. Foreign relief organizations operated orthopedic centers in both government- controlled and UNITA-occupied areas, providing artificial limbs and physical therapy. The largest facility was the Bomba Alta Orthopedic Center in Huambo, Angola's second largest city, which was operated by the ICRC. Designed essentially to manufacture orthopedic prostheses and braces for paralytics and to provide physical rehabilitation, in 1986 the center treated 822 patients, of whom 725 were adults and 97 were children. In 1987 the center was staffed with twenty-one Angolan and three foreign medical personnel, ten of whom specialized in orthopedic prostheses for the lower limbs. The center provided 1,260 patients with prostheses in 1988.

Most of Angola's estimated forty-five hospitals, all government operated, were located in urban areas. Conditions in the hospitals, however, were often deplorable. Poor sanitation, a lack of basic equipment, and disruptions in water and electrical services were common. Trained medical personnel were in chronic short supply; in the late 1980s, Angola had only 230 native-born doctors, and only 30 percent of the population had access to health services. Most physicians, nurses, technicians, and national health advisers were foreigners--principally Cubans, East and West Europeans, and South Americans. In 1986 there were about 800 physicians in Angola (1 per 10,250 people--a very low ratio even by African standards) and somewhat more than 10,500 nurses. A Western source reported in February 1989 that 323 physicians, or 41 percent of the total number of doctors in government-controlled areas, were Cubans.

The government had placed a high priority on health and medical training programs, requiring that all foreign medical personnel teach classes in medicine, in addition to performing their clinical duties. There were two physician training programs in the country (in Luanda and Huambo) and more than twenty nursing schools, staffed primarily by Angolan, Cuban, and Soviet teachers. Most of the instructors in all medical training programs were foreign (primarily Cuban, Yugoslav, Soviet, and East German), and Angolan students attended medical training programs in Cuba, East Germany, and Poland.

According to a Portuguese source, health care in UNITA- controlled Angola was well organized and effective. The rebels operated a hospital in Jamba, which was staffed by Portuguese- trained medical personnel assisted by several French personnel from the volunteer organization Doctors Without Borders. Jamba's hospital was highly specialized, with the capability to meet most of the needs of the surrounding population; the only unavailable treatments were neurosurgery and cardiothoracic surgery. The hospital was apparently well equipped (probably by South Africa) with both instruments and medicines. Although tropical diseases were prevalent, war casualties were often the reason for hospitalization, with most of the wounded having first been treated at field hospitals established along the military fronts.

Sections of this chapter dealing with preindependence subjects and general discussions of the structure of society are based on parts of larger studies. Such studies include Hermann Pössinger's "Interrelations Between Economic and Social Change in Rural Africa," Lawrence W. Henderson's "Ethnolinguistic Worlds," Douglas L. Wheeler and René Pélissier's Angola, and Joseph C. Miller's Kings and Kinsmen, which includes a discussion of the complex character of Mbundu matrilineages.

Much of the more recent information has been culled from books, studies, and translations of foreign publications provided by the United States Joint Publications Research Service. Keith Somerville's Angola: Politics, Economics, and Society provides an excellent overview of the government's policies on education and religion; Linda M. Heywood's "The Dynamics of Ethnic Nationalism in Angola" contains a detailed analysis of UNITA's aspirations among the Ovimbundu as well as Ovimbundu life in present-day Angola; and Angola's official press agency, Angop, has provided detailed items pertaining to issues of health and education. Also of great value are articles in the Washington Post and New York Times by foreign correspondents such as Blaine Harden and James Brooke dealing with the effects of the UNITA insurgency on the rural and urban populations.

Two valuable sources on the grave conditions in which most Angolans live are the U.S. Committee for Refugees' Uprooted Angolans and the final report of the United States Private Voluntary Agency and the United States Government Assessment Team to Angola.

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Source: U.S. Library of Congress