Apartheid is Not Yet Over: Legacies of Apartheid on the HIV epidemic in South Africa



Over 6 million people in South Africa are currently living with HIV – more than any other countries in the world. As a middle-income country, South Africa is in fact doing a lot worse than many other poorer African countries that suffer from greater shortage of money and health expertise: the HIV adult (aged 15-49) prevalence in SA is approximately 17.8% whereas Uganda has an estimate of 5.4% and Nigeria has 3.6%. Meanwhile, although South Africa’s HIV epidemic has grown so large that it affects people from all walks of life, some populations are significantly more at risk than others. Studies show that HIV infection in South Africa is distinctly divided along racial lines: 13.6% of black South Africans are HIV-positive while only 0.3% of whites have the disease. The epidemic is largely concentrated in black townships and young black women bear the highest burden of disease. There must be certain reason why some people are necessarily able to live healthier lives than others. It seems to me that historical political decisions, notably apartheid, are one of the major contributors to the current situation.

The entrance to the Apartheid Museum in Johannesburg

Racial segregation in every aspect of human life

      The apartheid legislation in 1949 did not give rise to the beginning of a new system that creates social inequality, but rather the conclusion of a long historical development of racial segregation. During the apartheid era, the society was stratified along racial lines in almost every aspect of human life, including workplace, schools, residential environments, civic activity, healthcare, and social intercourse. Although the HIV epidemic, which emerged in South Africa around 1982, wasn’t widely addressed until a decade later, the apartheid policies consolidated a variety of distinctive features of South African history that would account for the prevalence of HIV/AIDS, including racial and gender discrimination, income inequalities, migrant labor, the destruction of family life, and extreme violence. Since apartheid was eventually ended at the negotiation table in early 1990s rather than by revolution, no fundamental restructuring of the socio-economic system occurred, and many of the inequalities remain and continue to shape the contemporary landscape of public health in South Africa.

        Starting in 1948, millions of black people were forcibly removed to Bantustans, areas of land centered on the rural labor reserves, which comprised of merely 13% of total size of land yet were home to over 80% of the population. In those areas, health services were largely compromised by abuse and maltreatment due to poor funding and regulation by the national government. In 1978, for example, only 0.23% of the South African GNP was allocated to health systems in Bantustans whereas as 2.3% was given to urban health centers. Also, in early 1970s, doctor to population ratio was estimated at 1:15 000 compared with 1:1700 in the rest of the country. As a result, residents of these under-resourced townships have become extremely vulnerable to infectious diseases like HIV/AIDS, with little access to quality care.

Distribution of black homelands in South Africa during apartheid

      The apartheid government also adopted a policy of deliberate undereducation of black people, leading to vast income inequalities in the society, a quarter of the population unemployed, and overall low educational levels of blacks. These factors in turn result in greater health inequities, and undermine both the physical and financial capabilities of blacks in the face of HIV epidemic.

Several children in a household sharing a bowl of porridge.

      In addition, family life was extensively destroyed under the migrant labor system, as between 60-80% of the economically active adult men in Bantustans were away from home to seek jobs while women were dedicated to domestic work. Children were then increasingly raised by the extended family at home and suffered from high levels of sexual, physical and emotional abuse and neglect. As a consequence, both the adults and children are more likely to engage in unsafe & inconsistent sexual behavior, and become victims of STDs like HIV. Moreover, persisting gender-based violence, particularly rape and violence against women in urban areas, further increased the vulnerability of women to HIV/AIDS.

      Furthermore, the apartheid era witnessed the beginning of serious fragmentation of health services, including the separation between public and private sectors, and the inequitable distribution of resources between geographical areas and different levels of care. At the time, the government allocated more than half of financial and human resources to the private healthcare system, which had emerged during the 1980s and were only accessible to 15% of the population dominated by the urban middle class. Meanwhile within the public sector, more than 80% of the resources went to hospitals. These situations made it even more difficult for black South Africans in rural areas to access high quality health care, and to beat HIV.

      In conclusion, the apartheid era has a significant & lasting political, economic and social impact on the current HIV epidemic in South Africa, with those still-existing apartheid ideologies and legacies in the healthcare system. In this sense, apartheid is not yet over.

By Yutong Zhou, 19 July 2013