We need to think differently about what ‘health’ means. At this time of our history and in the year of a general election it may well be time to ask: Can we have a battle for public opinion which places health at the centre of both achieving and measuring human well-being.
In May 2019 we face the sixth national and provincial elections of the democratic era. The right to vote, to campaign and be elected as a public representative is at the heart of citizenship and was also at the centre of the liberation struggles against the white minority regimes of apartheid and segregation, which denied citizenship to the black majority.
Of course, we also know that elections, parliament and political parties do not, in and of themselves, fully constitute the much bigger questions of democracy – questions which haunt electoral systems all over the world today. Questions like: how do the people have the power to make decisions over all aspects of their lives? How do people hold representatives accountable? And so on. The lack of answers to these questions is why there is widespread alienation from electoral politics globally.
But, while elections are not sufficient they are an important barometer of public opinion and indeed a much broader forum than what ordinarily goes for public opinion – as expressed by the professional political class. But even so, public opinion is not reducible to elections and the professional commentariat. It would be a sad commentary on the quality of democracy if people’s involvement in the issues of public opinion and political power is confined to elections and is not also the subject of movements, campaigns and organisations.
South Africa is a special case because we have a rich history of social movements fighting for the franchise – when we didn’t have democracy – and now that we do have the franchise and electoral democracy – the question of the relative weight between elections, political parties and social movements will tell us how far we have come.
Meanwhile outside the sphere of political parties we continue to be the protest capital of the world. Daily poor people across the country blockade roads, demonstrate, go on strike and toyi-toyi. Interestingly enough the frequency and spread of protests were unaffected by the periods of good economic data – the first Mandela-presidency boom years, the Mbeki years when we had a fiscal surplus – and the bad years of the Zuma presidency. Whatever the inconveniences to middle class commuters and consumers these are active citizens engaging in their right to protest against the erosion of their well-being and raising their voices in the battle for public opinion.
But what are the issues for which political parties are contesting for our vote and which dominate the battle for public opinion as expressed in the bubble of political pundits and commentators?
We know that, if we use the criterion of voter registration, that the number of voters is likely to be down significantly. There has been a steady decline in the voter percentage turnout since 1994. In 2019 fewer than a third of young people between 18 and 25 are registered to vote.
Specialist pollsters make predictions about the likely outcome of the elections and the fortunes of the various contesting parties. But we know little else about what shapes the choices of people and what really matters to South Africans.
But what is the dominant narrative?
The rot of the Zuma years dominated the narrative – that South Africa stood on the precipice of an abyss – identified in the media with rating agency downgrades, a collapse of the Rand and other economic issues – and the proliferation of state capture and corruption, which was used to explain everything about the state of human well-being in South Africa.
In all this there is an underlying thread linking the diagnoses of what the problem is (economic breakdown), the cause of the problem (state capture/corruption) and the solutions (charge the looters, appoint the right technocrats) – that is the sphere of the economic. So even though elections are primarily about the sphere of the political the current narrative of the commentariat is that we need people who “know their stuff” in place so that the economy can be “fixed”.
Pundits predicting the outcome of the 2019 General Elections place great importance on whether “good news on the economy” will benefit the ruling party or whether the apparent “economic management credentials” of the main opposition will hold sway.
The economic has thus become the alpha and omega of political discourse. In this we are echoing global trends – in which the economic is taken both as the means for, and even the best measurement of, human well-being. GDP growth, positive investment inflows, currency stability, low debt etc are the stuff of good governance because “getting them right” is the path for a better democracy.
This inverts the vision for which we fought – to have a democracy so that the people have the political power to decide all questions, including matters of economics. Now economics defines our political choices. We now are being encouraged to choose the best economists.
This is particularly bad for democracy not the least because the track record of economists is not a particularly good one in explaining and predicting – here one thinks of the 2008 financial crisis (and, further back, the 1929 Wall Street crisis).
So, there is also a measurement story to be told that is not reducible to the language of economists, which looks beyond the categories of economics for understanding human well-being. Political sociologists such as Goran Therborn have even begun to challenge the usefulness of economic categories – such as share of assets and income – in defining and understanding inequality. Authors in the Human Sciences Research Council’s 2018 State of the Nation review have raised the need to employ notions such as respect, affirmation and discrimination as expressions of inequality and to design appropriate measures to do so.
Which brings us to health and health information as more direct expressions of the state of the nation.
What do we mean by health?
For many years, people tended to speak interchangeably about medical science and health. When we think of health we often think of healthcare – of doctors, nurses, clinics and hospitals.
But there have been major shifts internationally to see health in a much broader way – that includes medical science and healthcare but also includes those things that enhance or threaten human well-being. From environmental pollution that can cause asthma and cancer; to how global warming can unleash new pathogens, to the role that good quality drinking water can play in reducing deaths in children, to how exercise and community networks can restore mental health and how reducing rape and violence against women can improve all our lives.
At the World Health Organisation (WHO) many of these social factors became integrated into the notion of health – these are called the social determinants of health. This journey has seen health become the broadest possible measure of human well-being. Health has become both a means and an end. You get a healthier nation by improving the social conditions under which people live, and a healthier nation also reduces the need to spend public resources on healthcare that could have been spent on education and infrastructure whilst having a more productive population.
In South Africa today the top ten killers of our people are non-communicable diseases (such as diabetes); TB and HIV; Maternal and Infant deaths, strokes, upper and lower lung infections, diarrhoea; and violence. Some of these sound like traditional medical, drugs, and hospital-related stuff but most of them are about clean water and air, decent housing and good diets and exercise. All of them are solvable and do not require high-tech solutions but political commitment and public policies which prioritise the majority.
In many ways, language still lags. Even our institutions of government and our Constitution reflect this lag. We have a Ministry of Health and a Department of Health but really, they are only dealing with medical issues and healthcare, whilst water – the single biggest factor in dealing with infant mortality – is a responsibility of local government and thereby the Ministry of Co-operative Governance and Traditional Affairs. Rape and violence against women is under the Police and the Ministry of Justice. There may be ongoing compelling political and practical reasons why this should continue to be so, but we need to start thinking differently when we debate matters of public policy at the time of the elections.
But 2019 is also the 50th anniversary of the South African Medical Research Council (SAMRC) – a statutory body undergoing deep reflection of its role over 50 years – encompassing the transition from apartheid to democracy, from exclusion of citizenship of the black majority to the struggles over the quality of representation today.
The SAMRC is the custodian of the nation’s health statistics. It regularly publishes major studies such as the Burden of Disease Reports and the Demographic and Health Surveys. It also investigates the impact of environmental conditions on people’s health and the scale of rape and violence against women. It undertakes research on the health impact of different kinds of health systems so that we can make progress in achieving universal access to healthcare. It works in ways that can both assist government, at all levels, to make better decisions as well as to provide social movements with information so that they can hold government accountable.
At this time of our history and in the year of a general election it may well be time to ask: Can we have a battle for public opinion which places health at the centre of both achieving and measuring human well-being. Maybe that will help us achieve a better democracy?