I recently, completely by chance, came across a paper published in 2019 in a peer-reviewed journal, Focaal – Journal of Global and Historical Anthropology, authored by a United States based, South African academic, Theodore (Ted) Powers entitled, “Echoes of Austerity”.
(https://www.berghahnjournals.com/view/journals/focaal/2019/83/fcl830102.xml?rskey=kneG81&result=1)
It was disconcerting to find that I featured as a less than flattering central point of this anthropological discourse on, “Policy, temporality and public health in South Africa”. Further investigation revealed that Powers is an Associate Professor at the University of Iowa having previously been affiliated to the University of Pretoria. In the abstract of the paper he indicates that his intention was “to explore how policy principles associated with austerity travel across time, space and the levels of the state of South Africa, eventually manifesting in a public health policy that produced cuts to public health services”. In itself this was a worthy intention. With my background in clinical medicine and my exposure to scientific journals related to my field, I was nevertheless surprised by some of the language in opening paragraphs of the paper. I would encourage readers to read the article for themselves although it is not the easiest read for those outside the field of anthropology. For those with the fortitude to do so, I would welcome your comments.
Powers discusses and analyses the socio-economic transformation over two decades into South Africa’s democratic transition and states that in his opinion it has yet to materialise. He refers to the impact of the World Bank introducing, as he puts it, leading ANC members to the tenets of neoliberalism which in his view limited spending on eduction, health and other social services to lower government debt levels while privatising government functions such as electricity and water provision. This sounds plausible but is in my view factually incorrect particularly with regard to the provision electricity and water which remain firmly in the hands of government entities. The lamentable history of South Africa and AIDS during the Mbeki years is similarly laid to an extent at the foot of Neo-liberal policies. Finally his argument is that the “limited post-apartheid social transformation due in part to austerity and its socio-economic effects has entailed a continuation of rampant poverty that resulted from colonisation, segregation and apartheid”. Powers does acknowledge, grudgingly its seems, that the ANC has “attempted to create a redistribution state within the limits of Neo-liberal macroeconomic norms”. He states that “multiple epidemics and long-standing illnesses of poverty have grown out of sustained resource deprivation for South Africa’s predominantly black poor”. Although with a somewhat different focus and emphasis I would agree much that Powers advocates in this part of his paper.
So what was my involvement?
Well as those who know my background, I for the period 2002 until 2015 headed the Western Cape Department of Health, a provincial department in South Africa, and it was during this time that the events in the paper occurred. I am not a social anthropologist and thus I would not venture into the theoretical discourse of Powers related to the impacts of the limitation of resources on the lives of the poor which in my view are self evident. However, Powers then ventures into an area where I have more expertise and personal experience since 1995 – that is his intention to “show how policy actors on South Africa’s Western Cape mobilised the principles of austerity to develop policies that limited access to public health.”
Suddenly five pages into the paper, Dr Craig Househam is introduced. Once appointed as the Head of the Free Sate Department of Health (in 1995) I, according to Powers, “undertook an aggressive restructuring of provincial health spending within the limitations associated with austerity, earning himself the nickname of “the butcher” due to decreased worker compensation he oversaw on various fronts.” Factually incorrect, the justification for this statement is a reference to a news report written by a reporter shortly after my retirement in 2015! Through the juxtaposition of unrelated facts, it is lamentable that an academic, such as Powers, seeks to define my character and ethics but it is useful to the thesis of his paper.
With this background Powers then describes my move to head the Western Cape Department of Health in 2002 and suggest that I “emulated my Free State work by bringing public health expenditure in line with stringent national resource allocations amid austerity” He then takes it to himself to determine that the driving force behind my efforts to limit public health spending were debates on the national resource allocation for specialised medical interventions. An assumption which is erroneous as rather than this reason, as an accounting officer in terms of the Public Finance Management Act (PFMA) I had no choice legally but to remain within the budget allocated to health as approved annually in the Western Cape Provincial Legislature. Powers however seeks to personalise this fact and relate it to an aspect of my personal ethics, or lack thereof, which I reject.
But it gets worse! The introduction of the Healthcare 2010 strategy is stated to be “Househam’s vision” whereas it was a policy document approved by the Western Cape Government of the day and far from being a policy seeking to reduce public services, was intended to ensure the maximum benefit for the population served by the Western Cape Department of Health. Powers, and I am lead to assume those that would agree with him, seem to ignore the reality that health care is a resource which will always be limited when measured against the need. Unashamedly, as a bureaucratic I was obliged to adopt a utilitarian approach to advising the provincial government on how the available resources could be utilised to the maximum benefit of as many people as possible. That is what I did and what Healthcare 2010 sought to achieve.
I accept that those in public office including senior bureaucrats, as I was at that time, must be prepared to stand accountable for their actions. But then again this accountability should be fair and what Powers now does in his paper is far from that. He attributes a decision taken during my term as head of department to reduce the number of funded beds at Groote Schuur and Tygerberg Hospitals which at the time exceeded 2000 beds by 90 beds consequent to a commensurate reduction of national grant for highly specialised services to both Healthcare 2010 and its operational plan, the Comprehensive Service Plan (CSP). The fact that the bed reductions and Healthcare 2010 were two separate issues is conveniently ignored but suits the subsequent descriptions of the protests that resulted from the bed closures. I find particularly offensive a statement, conveniently a quotation, that the Healthcare 2010 effectively sentenced poor and working class people in need of specialised care to premature and unnecessary deaths – this statement supported by no factual data is both emotive and false but achieves legitimacy published in a peer-reviewed journal.
It is also blatantly false to state, as Powers does, that Groote Schuur Hospital during the apartheid era had been a private white privileged hospital to which poor working class South Africans did not have access. It is true that the hospital was unacceptably racially segregated during the apartheid era but having worked there as a junior doctor at the time a majority of patients who were admitted to the hospital were people of colour and the poor. While I would not wish to minimise the reaction to the bed closures from, in particular, the clinical staff at Groote Schuur Hospital, I did not shy away from interacting with and confronting those who were aggrieved by the decision. The various groups that formed to oppose the bed closures had ample opportunity to put their case and did so vociferously even alleging that “Househam puts cash before” in a parliamentary committee. They, however, provided little if any alternatives other than the allocation of more resources to the Western Cape health services. Unbeknown to these lobby groups, in this particularly instance, it had been a definite and considered strategy to utilise this reaction to impress on the National Department of Health the need to reverse their policy decision and restore the conditional grant for specialised services to its previous level. This in fact was the case as the bed closures were reversed and as I described in my valedictory lecture delivered in January 2015 just prior to my retirement, without this “assistance” from particularly two senior professors at the university this may not have occurred. Possibly Powers would find a measure of comfort in this fact as it strengthens his argument as to the value of activism but in a manner not visible to him in his academic analysis.
I would vigorously deny the assertions that this decision was the cause of the sub-optimal conditions as described at hospitals in the paper. In fact, the actions taken with regard to the implementation of the CSP improved, rather than worsened, conditions in hospitals and day facilities in the province. During my term three new hospitals were opened, various hospitals, day clinics and ambulance stations were either upgraded or constructed almost exclusively in areas populated by the working classes and the poor. In addition amongst other positive developments, funds allocated for the purchase of medical equipment and medicines were increased. Hardly a picture of total austerity!
The final insult levelled by Powers against me is that I formed part of what he describes as a “small group of state policy actors who condensed around Househam with the Western Cape Department of Health that sought to implement austere public health policies” such as Healthcare 2010. He couples this to a statement that South African experiences of austerity highlight a variant of “slow violence”, where austerity once introduced, continues to percolate with elite government networks which include people – and eventually able – to implement policies based on austerity principles”.
As a doctor and manager I strenuously reject the contention that I formed part of an elite with the intentions expressed by Powers. I, in fact, together with my colleagues, who were dedicated and caring individuals, on the contrary, faced with the realities of the real world far removed from the niceties of academia took decisions in the best interest of the poor and working class based on data, logic and ethics but not emotion that ensured that the public health services improved during my term as Head of Department and have remained generally at a higher standard than elsewhere in South Africa and the African continent. It is indeed sad that Ted Powers saw fit to embroil me in his paper, in which, in my view he could have made the same arguments without tarnishing my reputation and that of others in the manner that he has.
Echoes of austerity remain and should concern all of us. Activists must continue to protest and raise their concerns. Poverty and sickness are an enemy to the future of everyone living in this country but let us focus rather on realistic solutions from those living and working in South Africa that take into account the realities of the real world.
