CORRESPONDENCE

 

Fix the system

 

 

To the Editor: I share your 'rage and grief', and share your frustration, about the inability of South Africa (SA) to feed its children, as expressed in your editorial titled 'Fix the system'.^[1] Is there anyone who would not?

In reality, we should be doubly frustrated, enraged and grieving, because your editorial does not only relate to the inability to feed our country's children in 2022 - in fact, it reflects the reappearance of the frank and fatal malnutrition that was such a major problem, and was addressed by so many committed health workers and others, prior to 1994.

However, there are parts of your editorial that contradict the title.

First, malnutrition is a symptom and consequence of gross societal inequity. It is a 'whole of government' and a 'whole of society' problem, not just a Department of Health problem.

Second, your call to 'fix the system' implies that SA's health system is modified to 'ensure equitable access to healthcare for all South Africans'. That is exactly what the establishment of National Health Insurance (NHI) intends to achieve, even though you may have your reservations about its shape and implementation - as have many, including myself.

Third, you state that you are 'sure that Dr Crisp is an able man'. This expression is, I trust, the result of your 'rage and grief' and not meant to reflect ignorance about his actual ability, or, worse, an insinuation of the opposite. In fact, the rage and frustration caused by seeing frank malnutrition reappear in SA is entirely justified, and it will undoubtedly also be felt by Dr Crisp. He and I worked together in what is now Limpopo Province in the 1980s, especially on eradicating malnutrition, improving immunisation and addressing many other conditions affecting people forced to live in 'homelands', using the few highly necessary but low-impact measures doctors and health systems can take to prevent frank and fatal malnutrition.^[2-4]

It is not Dr Crisp's commitment or ability, or his spending time in Parliament, that should be your focus. May I suggest that you redirect your rage and grief for more impact? It does no good to 'personalise' the problem. I suggest that you rewrite your editorial to encourage action by the whole of government and the whole of society, pragmatically, and keep at it until solutions begin to emerge. Your contribution to fixing the system is writing; that of Dr Crisp is his expertise and commitment to fix it at national level. Mine is to write this response to your editorial and, possibly, impact very remotely. While I think that Dr Crisp's contributions will have the highest probability of impact, collectively we will achieve even more. Focusing your rage and grief on collective action is likely to lead to more and more rapid results.

Carel IJsselmuiden

Council on Health Research for Development (COHRED), Geneva, Switzerland; School of Applied Human Sciences, University of KwaZulu-Natal, South Africa carel@cohred.org

 

The Editor responds: Many thanks for your response to my editorial. I am delighted to have caught your attention, and I thank you for your pertinent comments regarding the role of government and greater society in the reappearance of severe acute malnutrition in SA.

Of course this is a 'whole of government' and 'whole of society' problem, phrases frequently used in World Health Organization strategies towards universal health coverage. And I in no way sought to insinuate that Dr Crisp is anything other than competent, and apologise if this appeared to be the case. However, there is currently a major focus on the legislative and technical factors associated with eventual implementation of NHI in SA, which I think many of us see as detracting from major problems in the public health system that should arguably be 'fixed' before embarking on such an ambitious new ideal.

Trust in 'whole of government' in SA is probably at its lowest ebb since the dismantling of apartheid in 1994. We are daily confronted by reports of deeply entrenched corruption across every level of government and apparently in every one of our organs of state. This lack of accountability and the resulting disruption, and in some cases near collapse, of infrastructure and public services have led directly to the deaths of these children from malnutrition.

So yes, you are right - this is where I need to focus. I know that we have huge competence in our national health bodies. I am also quite sure that those working in these bodies have major frustrations working within the system. So, while those in the Department of Health are not solely responsible for the state of health in our nation, it is they who must influence national government policy.

I would welcome further editorials, correspondence, and indeed full position papers on all these issues. Let's open up the discussion and look for solutions.

Bridget Farham

Editor

ugqirha@iafrica.com

 

References

1. Farham B. Fix the system. S Afr Med J 2022;112(5):299. https://doi.org/10.7196/SAMJ.2022.v112i5.16571        [ Links ]

2. IJsselmuiden C. Nutritional status of children under the age of 5 years in northern Gazankulu. S Afr Med J 1984;65:346-347.         [ Links ]

3. IJsselmuiden CB. The nutritional status of inhabitants of northern Gazankulu and the response of the health services. Carnegie Conference Paper No. 208. Presented at the Second Carnegie Inquiry into Poverty and Development in Southern Africa, Cape Town, South Africa, 13 - 19 April 1984. https://opensaldru.uct.ac.za/bitstream/handle/11090/292/1984_ijsselmuiden_ccp208.pdf?sequence=1 (accessed 10 May 2022).         [ Links ]

4. Crisp NG, IJsselmuiden CB, de Swardt R, Steyn MM, Gibbs DM, Tshabalala ET. Provision of immunisation - the Gazankulu experience. S Afr Med J 1987;72:345-348.         [ Links ]