South Africa's population in general enjoys good health, compared with other African countries in the 1990s. Rural health care compares favorably with delivery systems in Kenya and in Nigeria, for example. The system reflects the biases of apartheid, in that superior care is available to wealthy urban residents, most of whom were white as of 1995, and inferior services are available to the poor, who are black. These differences began to narrow in the early 1990s, as apartheid was being dismantled. Under the government's 1994 blueprint for social and economic development, the Reconstruction and Development Programme (RDP), R14 billion (for value of the rand--see Glossary) was set aside for improvements in health care.

Incidence of Disease

Tuberculosis is the most prevalent disease reported to health officials in the 1990s. European settlers probably introduced this disease into southern Africa in the seventeenth or the eighteenth century, and it was perhaps reintroduced by nineteenth-century gold and diamond miners from Europe or China. Miners of all races lived in unhealthy and unsanitary conditions during the first decades of industrial development, and these conditions contributed to the spread of the disease in the early twentieth century. From the beginning, whites who became ill received better treatment than others. In 1955 tuberculosis reached epidemic proportions among black mineworkers, which prompted the South African Chamber of Mines to improve mineworkers' dwellings and health care services.

About 90 percent of tuberculosis cases reported after 1970 were among blacks. The rate of infection appeared to decline between 1970 and 1985, and the government, citing this decline, ended compulsory tuberculosis vaccinations in 1987. Although tuberculosis among blacks increased after that, health officials believed other causes were important. Overcrowding in urban housing projects increased in the late 1980s, and many tuberculosis patients discontinued treatment after only a few weeks, rather than the prescribed year. The South African National Tuberculosis Association reported that its case load increased from 88,000 cases in 1985 to more than 124,000 in 1990 and continued to increase after that. More than 6,000 people died of tuberculosis and related effects each year in the early 1990s. More than 47,800 new cases of the disease were reported in 1994.

Malaria ranked second among reported diseases, again affecting whites less than other racial groups. This disease reached epidemic levels in the late nineteenth and the early twentieth century, especially in the northern Natal and the lowveld areas of the northern and eastern Transvaal. During the 1960s, there were 2.7 cases of malaria per 100,000 nonwhites, compared with only 1.1 cases per 100,000 whites. As malaria increased during the 1970s and the 1980s, the gap between races widened and these rates rose to 40.5 cases per 100,000 among blacks, Asians, and people of mixed race, compared with six cases per 100,000 whites in the early 1990s. In 1994 health officials reported 4,194 cases of malaria nationwide.

Several factors probably contributed to the changing patterns in malaria incidence. The use of insecticides helped reduce the incidence of malaria temporarily in the 1950s. The 1972 worldwide ban on the insecticide, DDT, though only partially observed in South Africa, was followed by a steady increase in the incidence of malaria. At the same time, mosquitoes and other parasites became more resistant to chemicals and medicines. Residential patterns also changed, and several mosquito-infested areas of the country were permanently settled. For example, the black homelands of Venda, Gazankulu, and Lebowa were established in heavily malaria-infested areas of the northern Transvaal.

Most other diseases decreased between 1970 and 1990. In keeping with world trends, smallpox was virtually eradicated in South Africa by the 1970s. Diphtheria declined to almost negligible levels--fewer than 0.1 cases per 100,000 people--by 1990. Leprosy showed similar trends, diminishing to 0.5 cases per 100,000 in 1990.

Typhoid continues to appear in scattered areas of the country in the 1990s, and most typhoid cases are among blacks. In the early 1990s, between twenty-five and thirty-five cases of typhoid were reported per 100,000 blacks, per year, compared with fewer than eight cases per 100,000 whites, Indians, and coloureds. A total of 581 new cases were reported in 1994. Measles outbreaks remained fairly steady in the early 1990s, with thirty to seventy new cases per 100,000 whites, coloureds, and Indians, and sixty to 150 cases per 100,000 blacks, each year. In 1994 a total of 1,672 cases of measles were reported. Other common ailments, such as gastroenteritis, kill several hundred black South Africans each year, even though these diseases are easily treatable in South African hospitals.

Infectious and parasitic diseases cause roughly 12 percent of all deaths among blacks but only 2 percent of deaths among whites. Health officials attribute the high incidence of infectious diseases in poor areas to the lack of clean water and sewage disposal systems. As a result, these services are high priorities in the government's development plans for the late 1990s.

Heart disease and cancer, which are common in industrialized nations, affect whites more than other racial groups in South Africa. Heart disease accounts for about 38 percent of all deaths among whites in the 1990s, compared with only 13 percent of deaths among blacks. Cancerous tumors are responsible for 18 percent of deaths among whites, but for only 8 percent of deaths among blacks.

Acquired Immune Deficiency Syndrome (AIDS)

Although the incidence of sexually transmitted diseases had declined from 1966 through the 1980s, the overall rate of infection increased after 1990, and among these diseases, acquired immune deficiency syndrome (AIDS) raised the greatest fears. South Africa's first recorded death from AIDS occurred in 1982, although the risks of AIDS were not widely publicized at the time. In 1985 health officials began testing blood to prevent AIDS transmission through transfusion.

By early 1991, 613 cases of AIDS had been reported nationwide, and 270 people were known to have died from the disease. Officials at the South African Institute of Medical Research estimated at that time that 15,000 people were infected with human immunodeficiency virus (HIV). The World Health Organization (WHO) reported 1,123 cases of AIDS in South Africa in 1992. By March 1996, the number of reported AIDS cases had reached 10,351.

Some health researchers estimated that between 800,000 and 1 million South Africans were HIV-positive in the mid-1990s. More than 500--perhaps as many as 700--people were becoming infected each day, according to these estimates, and the rate of infection was likely to double every thirteen months in the late 1990s. These figures suggested that between 4 million and 8 million people would be HIV-positive by the year 2000. Estimates of the number of likely deaths from AIDS in the early twenty-first century ranged as high as 1 million.

As in most of Africa, AIDS is primarily an urban phenomenon in South Africa, but it has spread rapidly into rural areas and has affected a disproportionate number of people between the ages of fifteen and forty. Recognizing the potential impact on the country's economic output, the South African Chamber of Mines, the nation's largest employer, began an aggressive campaign to educate workers and to curtail the spread of AIDS in the 1980s, after the chamber's health adviser warned that AIDS could be the country's most serious health problem by the late 1990s. The industry already had established treatment and counseling services for workers afflicted with sexually transmitted diseases, so it used this network to promote its campaign against AIDS. The Chamber of Mines found an incidence of only 0.05 percent of HIV infection among more than 30,000 mine workers in a baseline study in 1986. It then initiated random blood testing on 2,000 to 3,000 workers each month and found that the rate of HIV infection had risen to 6 percent by 1992.

The government was able to build on the early efforts of the Chamber of Mines to help stem the spread of HIV and AIDS in the 1990s. Government officials, health specialists from the ANC, and others established the National AIDS Convention of South Africa to coordinate the nationwide campaign emphasizing public education. In 1993 the National AIDS Convention, working with the Chamber of Mines, WHO, and other international experts, received financial assistance from the European Union (EU--see Glossary) for its efforts. In 1994 and 1995, however, the campaign became embroiled in funding disputes and was slowed by partisan political debate.

Although health officials were concerned about the spread of AIDS, some were still more concerned about the incidence of tuberculosis in the mid-1990s. They argued that tuberculosis caused as many as thirty-six deaths each day, on average, compared with less than one death per day from AIDS. Moreover, methods for preventing the spread of tuberculosis were already well known and could help in the fight against AIDS. Health officials had reported that people infected with tuberculosis are more susceptible to HIV infection and more likely to develop AIDS symptoms in a shorter time after being infected, and that these AIDS sufferers are likely to die sooner than those free of tuberculosis.

Health Care Services

Until 1990 apartheid was practiced in most hospitals, to varying degrees. Some admitted patients of one racial group only, and others designated operating rooms and special care facilities for patients of certain racial groups. This practice often led to expensive and redundant services and organizations, and, at times, unnecessary neglect. A few medical personnel, nonetheless, ignored apartheid-related restrictions, especially in emergency rooms and public clinics. By the early 1990s, deliberate racial distinctions were beginning to disappear from hospital care in general. Health care services continued to reflect the status of the communities in which they were found, however; wealthier people had easier access to health care and generally received better care.

South Africa's health care facilities include hospitals, day hospitals, community health care centers, and clinics. In 1995 about 25,600 doctors as well as 24,500 supplementary health professionals, 160,000 nurses and nurses' auxiliaries, and more than 5,100 dentists and dental specialists were registered with the South African Medical and Dental Council (SAMDC) and the South African Nursing Council. In the early 1990s, only about 1,500 doctors, nationwide, were black. Wealthy white areas averaged one doctor per 1,200 people; the poorest black homelands, one doctor for 13,000 people.

Seven universities have medical schools, and six provide dental training. Nurses are trained at several universities, hospitals, and nursing schools. More than 300 hospitals are managed entirely or in part by provincial governments, and 255 hospitals are privately operated. There are an estimated 108,000 hospital beds nationwide, and almost 24,800 beds in psychiatric hospitals.

The South African Red Cross renders emergency, health, and community services, and operates ambulance services, senior citizens' homes, and air rescue services across the nation, but primarily in urban areas. Some areas also have twenty-four-hour-a-day poison control centers, child-assistance phone services, rape crisis centers, and suicide prevention programs.

One of the interim government's highest priorities in the mid-1990s is the prevention of childhood death and disease through nationwide immunization programs. The incidence of tetanus, measles, malaria, and other communicable diseases is high, especially in the former African homelands. For this reason, one of President Nelson Mandela's first actions after assuming office in May 1994 was to implement a program of free health care for children under the age of six. By early 1996, officials estimated that at least 75 percent of all infants had been immunized against polio and measles.

Malnutrition and starvation also occur in a few, especially rural, areas. These problems are being addressed through other elements of the government's RDP of the 1990s (see Postapartheid Reconstruction, ch. 3). Minister of Health Nkosazana Zuma noted in December 1994 that only 20 percent of South Africans have any form of health insurance. The government plans to institute a program of free universal primary health care, but health officials estimated in early 1996 that it might take ten years to implement the plan fully.

Social Welfare

Disabilities and the Aged

Social welfare services in the 1990s include care for the disabled and the aged, alcohol and drug-rehabilitation programs, previous offenders' programs, and child care services. At least 1,742 private welfare organizations and numerous government agencies administer these programs.

The National Welfare Act (No. 100) of 1978 established a coordinating council, the South African Welfare Council, to help manage these diverse programs. Amendments to the act in 1987 signaled the government's growing awareness of the need to narrow differences in social welfare among racial groups. In the early 1990s, the government spent about R1 billion per year on welfare programs, excluding old-age pensions. About one-half of that amount was spent on whites. Government spending under the RDP in the mid-1990s was geared toward improving social services for other racial groups.

About 3.5 million South Africans are physically disabled in the mid-1990s. The government's approach is to encourage independent, although sometimes assisted, living for them. Assistance is sometimes available through outpatient rehabilitation centers, counseling services, workshops, and sheltered employment centers. Families and church groups are still important in assisting the handicapped, especially the mentally and psychologically impaired, although government-funded services are available for the blind and the deaf. Substance abuse programs, especially for alcohol abuse or marijuana dependence, are also available in some communities.

The government administers about 1.8 million old-age (nonmilitary) pensions in the 1990s that represent a total of about R4 billion. The government began narrowing the gap in pensions for different racial groups in 1992 and pledged to eliminate such disparities. But elderly black and other citizens continued to claim that they were disadvantaged because of their racial identity in the mid-1990s. Government welfare agencies also provide veterans' benefits, adoption and foster care services, services for alcoholics and drug addicts, and services for abused and neglected children.

Refugees

Most refugees in South Africa in the 1980s and 1990s were from Mozambique, fleeing that country's civil war. Estimates of their number varied widely, in part because many other Mozambican migrant workers were in South Africa during that time. The number of refugees was particularly difficult to estimate because until 1993, South African officials sometimes denied access to refugee camps for international observers trying to monitor the refugees' living conditions.

In early 1994, officials estimated that perhaps 1 million Mozambicans were working in South Africa, legally or illegally, and that perhaps as many as 500,000 were refugees. Although only a few took advantage of a repatriation program implemented by the United Nations High Commissioner for Refugees (UNHCR) in April 1994, in early 1995 relief workers estimated the number of refugees at about 200,000. This number was reduced by half during 1995, although several thousand Mozambicans were entering South Africa each month in early 1995--some for the second or third time.

Internally displaced South Africans were believed to number at least 500,000 in 1995, according to the United States Committee on Refugees (USCR). Most of these had been uprooted by official apartheid-related policies in the past decade, and perhaps 10,000 or more were displaced by political violence in KwaZulu-Natal in the early 1990s. The new government established a Land Claims Court and planned to adjudicate several thousand of such claims by the late 1990s. By mid-1996 a few cases had been resolved by restoring lost land, and a small number of displaced South Africans had received compensation for their losses.

Narcotics

After South Africa's international isolation ended and border trade increased in the early 1990s, problems associated with narcotics trafficking and drug use increased dramatically, according to the South African Police Service (SAPS). In 1994 South African authorities confiscated more than 2.4 million ounces of cocaine; nearly 25,000 grams of heroin; more than 16,000 units of LSD; 27,000 ounces of hashish, and 7 million kilograms of cannabis (marijuana), according to police records, and most of these figures were expected to increase in 1995 and 1996. At the same time, officials at the National Council on Alcoholism and Drug Dependence reported an increase in problems related to substance abuse and addiction, and police officials reported that narcotics dealers often were involved in other forms of crime, such as arms smuggling, burglaries, or car hijackings.

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Source: U.S. Library of Congress