Poverty and Disease Burden: Reflection on the Rural Community Health Services of the ‘Natives’ in the Former Northern Transvaal of South Africa, 1930s–1980s

Abstract

The twentieth-century period in South Africa was characterised by social-, political- and economic disparity between blacks and whites. Poor socio-economic conditions of blacks resulted in subjection to tuberculosis and other poverty-related diseases. This study explores rural exposure to diseases due to segregationist and subsequent state of racial disparity in all spheres of live. Focus is particularly thrown at incidents of malaria and tuberculosis in the rural communities of the Transvaal. This study also considers efforts forged by government in an attempt to abate and arrest the spread of these and other epidemics through rudimentary health services. The study relies on the use of published sources, archival materials and data collected through interviews. It is the position of this study that the escalated incidence of these diseases had immense impact on the lives of the rural than urban population. Other related pandemics, such as HIV-AIDS and COVID-19 will be explored. Lastly, the study will argue that evidence of ill health and death caused associated with these diseases irrespective of invented vaccines and other related medications.

1. Introduction

The chronic prevalence of pandemics has been a toxic threat to the lives of South Africans and the world in general. Over many decades after the establishment of the union government, the killer diseases such as malaria, tuberculosis, HIV-AIDS and lately COVID–19 had been a ‘headache’ to the Department of Health and the World Health Organisation, respectively. It was upon these challenges that blacks found themselves vulnerable due to their state of poverty and other socio-economic defects. The Northern Transvaal, which included the so-called ‘native areas or reserved and later the 1960s ethnic-based homelands of Lebowa, Venda and Gazankulu, became victims of disease diffusions. At times these conditions compelled many young and adult to migrate to the white farms and mining towns where poor living conditions, marginalisation, poor wages and ultimate disease infections were common. The deterioration of health of the blacks compelled the state to come up with measures to deal with the diseases through the establishment of native health, which was followed by popularisation of the concepts such as preventative, progressive and community-based primary health care. The killer diseases such as HIV-AIDS and COVID-19, which erupted in the early 1980s and early 2020s, respectively also continued to inflict ill health and death among the blacks in the country.

2. Malaria in the transvaal and its impact on health care provision

Malaria has been a life-threatening disease that affected Africa and other world countries. As a seasonal disease, in South Africa, it starts to appear in October and reaching its peak in January and February. The disease is usually transmitted through a bite by a female mosquito that carries this disease. It targets mostly the humid high-temperature regions of the world. The Lowveld areas of the former northern and eastern Transvaal, with extreme high annual temperature and rainfall, are popularly known to have favourable breeding ground for malaria-carrying mosquitoes. It has generally been noticed that the intensity of this disease decreases from east to west as reflected in Figure 1 of the map. One can, therefore, also realise that there is a positive correlation between the rate of malaria, temperature and rainfall, with serious risk areas followed by moderate and light risk areas.

Figure 1.

Malaria risk areas in South Africa, 1938 [1].

The effect of malaria was witnessed during the Voortrekker movement to Mozambique when Louis Trichardt, as a leader of the movement, his wife and 20 members were killed between 1837 and 1838 [2]. As a precautionary measure, farmers in the entire area of Transvaal Lowveld considered choosing the high-lying slopes and dry areas for settlement as they were deemed free from malaria-carrying mosquitoes [3].

It was in the midst of the growing malaria challenges that the state saw it fit to come up with workable measures to control and prevent the disease. Gambiae and Funestus were the mosquitoes typologies that were causing malaria in the area. The Department of Public Health was assigned to carry out this duty through the efforts of N.H Swellengrabel. Meanwhile, malaria continued to worsen in the Lowveld area of the Transvaal, Swellengrabel recommended the establishment of a malaria station in Tzaneen. His influence led to building of the station in 1932 by the South African Institute of Medical Research (SAIMR) under the leadership of De Meillon and Annecke, to carry out research and control of the disease. This effort encouraged the establishment of another station in Eshowe, Natal, in 1934 [2]. Annecke recommended the spraying of indoors and roof surfaces using Quinine Hydrochloride to the Tzaneen Malaria Station in 1939 to control the disease [4, 5, 6]. Traditional leaders were visited and supplied with quinine for distribution to Thabina and the entire Lowveld region [3]. The utilisation of native commissioners through effective depot system was considered critical through constant supervision in the affected areas (Figure 2) [8].

Figure 2.

The two malaria transmitter mosquitoes in southern Africa [7].

Meanwhile, malaria showed an upward trend in the 1940s and 1960s, and the state continued to resort to other additional measures. Educating the communities through the engagement of Tzaneen malaria station staff was crucial as lecturing was presented to black school teachers in the districts of Waterberg, Potgietersrus and Groblersdal [9]. This effort was supplemented by the recommendations of the Tzaneen magistrate, who saw the need for the control malaria depots in Tzaneen and the surrounding countryside [8]. Other areas included Mphahlele’s location in the Pietersburg district, municipalities of Potgietersrus, Naboomspruit, Nylstroom and Warmbaths [10]. Towards the end of the Second World War, Annecke endorsed the use of dichlorodiphenyltrichloroethane (DDT), which was recommended internationally as effective in the control and prevention of malaria. The reported cases were also dealt with at Giyani area of the Letaba District, the Shingwedzi area of the Letaba District and the Shingwedzi area of the Sibasa District [8].

When DDT was banned in 1970, followed by its complete replacement in the mid-1980s, the disease once more reflected an upward trend. The banning was influenced by the poisonous impact of this insecticide to the biotic and abiotic environment. Although the public concern was justified, the malaria trends started to increase again, reaching the highest peaks between 1996 and 2015 [11]. Since millions of people throughout the world, including South Africa are currently at risk of contracting this disease, the National Department of Health considered it as a matter of urgency. Its impact as a barrier on social and economic development in the country compelled the state to prioritise meaningful measures to prevent its escalation.

3. Tuberculosis and health services

Tuberculosis (TB), which is caused by a virus called mycobacterium tuberculosis, was unknown to South African blacks until the arrival of whites of European descent in the nineteenth century [12]. People with tuberculosis can be detected by symptoms, such as excessive coughing, physical or body weakness, weight loss, shortness of breath and continuous stress. The discoveries of minerals during the early 1800 in the TVL had a significant impact on the rural-urban migration by the impoverished blacks. As such, blacks became targets of this disease [1]. Researchers such as Shula Marks and Neil Anderson associate poverty and racial discrimination with the high rate of tuberculosis in tuberculosis in the rural areas.

In the industrial towns and cities like in the Witwatersrand, the black migrants found themselves vulnerable to the tuberculosis infections caused by unfavourable living conditions. These migrants could easily spread it to their rural environments where health services were poor and inadequate. The soaring ill health and mortality appealed to those in power as well as the employers in the domestic, mining and industrial environments to remedy the situation. They feared the dwindling of labour force and ultimate negative impact on the country’s economy. One of the measures initiated by the state was the National Health Service Commission during the early 1940s, which recommended the increase of hospital nurses, doctors, beds and health education for the rural black communities [7]. Apart from the state’s request for local authorities to increase hospital beds as a way of overcoming the challenges, immunisation through vaccination was considered the most effective preventative measure. The efforts to combat tuberculosis were made easier when the radiological services were improved with several authorities and mission hospitals and mission hospitals having acquired X-Ray units suitable for other health services [13].

The need to increase a number of beds for tuberculosis patients in hospitals coincided with the acute increase of black population during the 1950s and 1960s. Statistics in Table 1 show the highest incidence of tuberculosis for Bantu (blacks) as compared to whites, coloureds and Asiatics in all six regions in 1964 [14].

Region	Whites	Bantu	Coloureds	Asiatics	Total
Eastern Cape	74	3684	5	18	3781
Western Cape	118	2601	2593	—	5312
Natal	16	5047	76	245	5535
Northern Transvaal	—	2709	—	—	2709
Southern Transvaal	50	5408	—	—	5458
O.f.S	38	1487	12	—	1537
TOTAL	447	20,936	2686	263	24,332

Table 1.

South African tuberculosis infected patients in 1964.

The Northern Transvaal homelands of Lebowa, Transvaaal and Gazankulu continued to experience increasing reported cases of tuberculosis in the 1970S, with the north-eastern Transvaal in the Mhala district of Gazankulu recording the highest trend. Attempts by the state to deal with this challenge led to the testing of tuberculosis in primary schools including those formerly owned by the missionaries, with subsequent immunisation through vaccinations and distribution of tuberculosis tablets [14]. The forced removal of blacks by the state and subsequent inception of homelands or Bantustans, rural-urban migration, overpopulation, unemployment, poverty and ill health mitigated infection rate. The homelands became breeding grounds for TB and other poverty-related diseases. For example, in the Transkei homeland tuberculosis notification growth was at the rate of 489 per 100,000 in 1975 [1].

Alarming notification of tuberculosis encouraged meaningful efforts of educational researches through conferences and symposiums by various institutions of high learning. Attempts at dealing with the challenges of increasing infections in the homelands and developing countries were highlighted during the symposium held at the then University of the North (now the University of Limpopo) on 28–29 October 1976. Pulmonary tuberculosis, which is the tuberculosis of the lungs, was singled out as still by far the most common threatening disease in the homelands [15]. A wide range of recommendations was initiated based on the idea of primary health care approach, with emphasis on preventative and community-oriented care. The reported findings of the health officials from the Pietersburg Regional Directorate of Health Service on the 1978/79 after Lebowa hospitals, such as Knobel, Mogalakwena and Kgapane, were visited revealed increasing notifications. Similar findings were reported from other homelands from the findings by the Medical Research Council during the early 1980s.

Challenges associated with tuberculosis continued to surface in South Africa and worldwide. The disease is currently one of the killer diseases with non-HIV tuberculosis as commonly reported at Waterberg district in 2018. It was here that 1.1 million cases have been estimated [16]. Other districts in Limpopo experienced cases of illnesses and deaths caused by this disease.

4. The relation of disease patterns since 1980

The changing patterns of malaria and tuberculosis continued in the country and elsewhere in the African countries in the 1980s until recent times. The government found itself challenged by these fluctuating incidents of mortality resulting from these diseases. At times the emergence of the new pandemics, such as HIV-AIDS in the early 1980S and COVID–19 in the late 2019 became repeatedly linked to tuberculosis. The Limpopo Province, which embraced previous homelands of Lebowa, Venda and Gazankulu, is largely rural, with high rate of poverty and unemployment.

The first cases of HIV/AIDS were reported in South Africa during the early 1980s and evoked mixed perceptions as many people believed that it only affected European and American homosexuals. As a result, the public did not take enough precautions in the earlier stages. Similarly, the government believed that it was easy to control the homosexuals as they were handful and easy to contain. As for the HIV/AIDS in the black townships and rural communities, lack of sufficient interest by the state was motivated by the racial policy of apartheid. As a result, intervention through preventative measures during the first 5 years after the incidence of the disease was reported was deliberately ignored [17].

The rapid spread of HIV/AIDS can certainly be linked to the migrant labour system and poverty. The long-entrenched labour system had a huge impact on the spread of HIV/AIDS in most rural areas of the former Northern Transvaal, most particularly in the former homeland areas of Lebowa, Venda and Gazankulu and other rural homelands in the country during the 1980s. The tendency of having multiple sexual partners among the blacks, which was deemed culturally acceptable, accelerated the spread of the disease. Most of these migrants established second families in urban areas [18]. This practice also escalated the spread of infections to the entire rural and township black communities, both within South Africa and other neighboring states.

Although the AIDS awareness campaigns were launched for years since the early 1980s, the post-1994 elections in South Africa strengthened the need for the full implementation of community-oriented primary healthcare system. The production of numerous drugs in recent years did not help much to cure the disease completely but contained it as chronic through utilisation of antiretroviral tablets. The scientific discoveries revealed that the disease aggravates in patients with tuberculosis and the two became co-morbidity that continued to inflict ill health and death. When COVID-19 emerged towards the end of 2019, focus was shifted, and the disease once more escalated.

The advent of COVID-19 created fear and panic in the country, leading to ultimate closure of all public, recreational, private and state institutions, forcing people to stay at home through the ‘lock-down’ regulations [19]. The challenge with the disease was its rapid rate of infection and death due to the absence of medicine to cure it. The changing structural pattern of this disease made it difficult for health scientists to deal effectively with it as they continued to wrestle to find appropriate vaccine. In Limpopo and other provinces of South Africa, the government initiatives were at times hampered by reluctance of most of the rural populations to comply with precautionary preventative measures and the general attitude of distrust against vaccines during the lockdown alert levels. The controversies surrounding the taking of vaccines and some evidences of government officials’ breaking of the lockdown regulations in their gatherings and stealing of personal protective equipment also hampered the government’s efforts of effectively dealing with the disease.

Violet Chewe, a Sub-district COVID-19 Coordinator in Mankweng located east of Polokwane and surrounding rural areas, noted that most of the patients diagnosed positive with excessive sickness were found to have other diseases, such as sugar diabetes, tuberculosis, HIV-AIDS, excessive flu and other related communicative diseases. She further stressed that common challenges were experienced during the tracing of people with this disease as most of rural people were in denial as well as being afraid of victimisation and hatred from other members of the communities. She indicated that these conditions were common to other districts of Limpopo Province and countrywide [20].

As for the role played by the traditional healers in the treatment of this disease, Nani Ramalepe, who is one of the well-known traditional healers in the rural area of Tickyline outside Tzaneen confessed that she successfully treated many patients who had similar symptoms of COVID-19 by using plant-based traditional medicines [21]. It is indeed clear that apart from the current reliance on vaccines, which at times raised controversial issues, more scientific research to improve the available vaccines and effective involvement of traditional healers should be encouraged.

5. Conclusion

Malaria as a communicable disease and non-communicable diseases such as tuberculosis, HIV-AIDS and COVID-19 continued to cause pose a severe challenge to the country and internationally. Specific dates have been identified and officially endorsed for awareness campaigns to be held on yearly basis where curative and to a large extent preventative community health measures are emphasised. However, the whole efforts were hampered by poor administrations, insufficient medicines, corruption, theft and general laxity and incompetence by some government agents and exponential increase of black population and excessive influx of illegal migrants from other African and world countries, which inflicts a severe strain on the available health resources in the country. The rural blacks continued to suffer as most of them could not easily access the quality and expensive health services offered by private health institutions. It is despite the intervention measures from the department of health that health challenges continued to threaten the lives of the South Africans, most particularly poverty-stricken black population in the rural areas as it happened with its recent aftermath of COVID-19 pandemic. Although the recent level of infections showed remarkable decline, forcing the government to lift the National State of Disaster on 05 April 2022, COVID-19 has joined malaria, tuberculosis and HIV-Aids as a killer diseases. These diseases continue to be a cause for concern for the Department of Health and the World Health Organisation because of their instabilities.