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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.98 n.11 Pretoria Nov. 2008




New health ministers - so little time, so much to do




President Thabo Mbeki's dramatic ousting and a subsequent front page news picture of two struggle friends, their fists raised in solidarity and triumph, one the incoming health minister and the other an arch opponent of her predecessor, summed it all up.

The age of political AIDS denialism was over, at least until South Africa's next election in 6 months' time, but hopefully well beyond.

Barbara Hogan, the seasoned administrator and economics and finance specialist appointed by President Kgalema Motlanthe to replace Dr Manto Tshabalala-Msimang, astutely declined early comment on whether she would like to stay on beyond April next year. Declaring herself up to the daunting challenge and with clinician and former North West Province Health MEC, Dr Molefi Sefularo, filling the vacuum as her deputy, the tumultuous events of mid-September were a powerful reminder to her that a week is a long time in politics. Like her political boss, her tenure will depend on the results of the April elections, the outcomes of the paradoxical Zuma/ Mbeki National Prosecuting Authority legal appeals and, ultimately, the internal machinations of the ANC.

That is, if she doesn't pick up on her now-deferred plans to retire from Parliament and 'reclaim her personal life'. Close to tears, she said that in spite of the personal heartache at the sudden appointment, she saw it as a gift and was compelled to accept because of the 'honour and a privilege of helping those suffering, especially with HIV/AIDS'.

'I think we underestimate the heroism of the people who live with this kind of burden,' she said.

Hogan showed an early talent for tempering expectations while firmly promising change without alienating her comrade and predecessor or buying into the universally triumphant denunciation of Tshabalala-Msimang's dismal and haunting legacy. 'I'm energetic about the challenges ahead. The public is expecting to see real change and we need to see our health system back on track. There has been some astonishing work done in the AIDS programme and in the ARV rollout and I'm sure we will be making changes from our predecessor's (AIDS programme),' she said.

Unpacking the word 'astonishing' could point to South Africa's achievements having come in spite of Tshabalala-Msimang's gladiatorial attempts to counter Treatment Action Campaign-led court actions that forced, to cite but two seminal events, a feasible early ARV rollout and the provision of nevirapine for PMTCT, sparing thousands of lives.

No more witch hunts

Morale among hard-pressed health care workers plummeted as she and her provincial acolytes repeatedly and often viciously targeted anyone who put patient loyalty and solid science above the dictates of political policy, sacking several high-calibre professionals.

She and some of her provincial health MECs unapologetically courted snake oil salesmen and AIDS alternative cure protagonists in the form of vitamin entrepreneur, Matthias Rath, and ubhejane herbal concoction dreamer, Zeblon Gwala, persistently punting traditional remedies and vitamins as viable alternatives to evidence-based medicine.

Press briefings, particularly at AIDS conferences locally and internationally, when held on time, turned into circuses as Tshabalala-Msimang defended her latest outrageous claim or petulance that had scientists and delegates shaking their heads. Arguably her most memorable defiance came in the form of woven telephone wire baskets filled with lemons, garlic, beetroot and African potato on South Africa's stand at the XVIth International AIDS Conference in Toronto in August 2006. Alongside the iconic items stood a bottle of multivitamins, a bag of samp and other nutritional mixtures. With not an antiretroviral drug box in sight, a huge panel boasted pictures of President Mbeki, his deputy and the health minister, proclaiming South Africa to have the most comprehensive HIV/AIDS plan in the world.

Particularly amusing at press conferences were the verbal contortions of her acolytes, be they politically appointed scientist sycophants or provincial health ministers, hell-bent on trying to lend some credibility to their chief's latest confusing broadside.

The human resource crisis worsened under Tshabalala-Msimang as she relied on country-to-country staff recruitment agreements and medical conscripts to prop up the crumbling health care system. Small private staff recruitment outfits, like The Placement Project, routinely saved rural public hospitals and clinics from near collapse, through aggressive recreational lifestyle marketing to overseas doctors and nurses. The health department relied on its website and the odd overseas foray by Tshabalala-Msimang to try to lure back locally trained practitioners. Its under-resourced Foreign Workforce Management Program crawled along under a cash-for-jobs cloud involving its pivotal hands-on deputy director, an apartheid-era civil servant.

Mr Stephen Lewis, special advisor to the UN Secretary-General, called South Africa's overall response to AIDS 'obtuse, dilatory and negligent', while 81 of the world's top scientists, including South Africa's, signed a petition calling for Tshabalala-Msimang to be sacked and 'an end to the (country's) disastrous, pseudo-scientific policies'.

Tshabalala-Msimang and her cohorts also alienated the private sector by repeatedly and often unilaterally ramming through controversial (though sometimes necessary) social reforms that arrogate huge regulatory powers to the health ministry.

More public private partnerships?

Now, in a stark contrast that saw jubilant TAC members serenading Hogan outside her Gardens flat in Cape Town on the night of her appointment, Hogan and Sefularo's pragmatism and complementary skills are set to improve delivery and repair relations.

Hogan, an independent thinker who spoke out against AIDS denialism during the Mbeki era, is a highly competent and respected former chair of the Parliamentary Finance Portfolio Committee and the Standing Committee on the Auditor General. She will bring desperately needed organisational, management and financial skills to the department. Sefularo contributes sound medical knowledge (plus diplomas in tropical medicine, public health and health service management). A former deputy medical superintendent at the Thusong Hospital in the former Boputhatswana in the early 1980s and an Azapo detainee, Sefularo was part of the task team that drafted the new government strategic plan on HIV/ AIDS 2007 - 2011. As Health MEC he strongly backed the ARV rollout and PMTCT implementation in his (NW) province.

Struggle background

Hogan, the life-partner of Rivonia trialist Ahmed Kathrada, joined the ANC after the 1976 uprisings when the organisation was declared illegal and moved its activities underground. Her responsibilities were to mobilise the white political left, lead public political campaigns and supply the ANC underground in Botswana with information about trade union and community activity in South Africa. She was detained in 1982 for 'furthering the aims of a banned organisation', and after interrogation, ill-treatment and solitary confinement for over a year, found guilty of treason and jailed for 10 years.

She was released with other political prisoners in 1990 when former President FW de Klerk unbanned outlawed organisations. Hogan played a pivotal role in restructuring the ANC in her capacity as secretary of the PWV (now Gauteng) regional office.

Tshabalala-Msimang, who shed tears at Mbeki's valedictory cabinet briefing, has been re-deployed as head of communications in the President's office. Her courageously outspoken and short-lived former deputy, Nozizwe Madlala-Routledge, sacked for standing up to Mbeki/Tshabalala-Msimang ideology, has catapulted past her to be elected Deputy Speaker of the National Assembly.

Hogan told journalists that she would focus on 'just a couple of achievables' during her potentially short tenure, concentrating on HIV/AIDS 'and all the strains it places on the health system' and accelerating the ARV rollout by 'mobilising every sector of society'.

Other priorities were enhancing the capacity of provinces, boosting morale by improving working conditions for health care professionals and applying her financial and economic background to issues like overall health care funding. The private health care industry immediately expressed enthusiasm at the prospect of working with her as she in turn labelled this an area she was 'very interested in'. The captains of this industry might do well to look to their laurels in future negotiations. Hogan is unlikely to deviate much from current policy, given the vast inequities in access to health care.

Of the faltering public health care sector Hogan neatly summed up her approach thus: 'I want to help create a system that is functional to people who are using it'.

If ever a health minister had a public blank cheque to write on, it is Hogan, thanks in no small measure to her predecessor - and a public hungry for basic health care delivery.

Chris Bateman

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