It seems South Africa’s long-awaited new anti-tobacco legislation is set to go nowhere slowly — again. 

On Wednesday, parliament’s newly appointed portfolio committee on health sat to discuss the Tobacco Bill for the first time since South Africa’s post-election government was formed in June.

The contentious Tobacco Products and Electronic Delivery System Control Bill has been in the making since 2018, when then health minister Aaron Motsoaledi asked people to comment on proposed laws that would ban vaping in public spaces and rule that tobacco products such as cigarettes and vapes must be sold in plain-looking packaging, as will be decided by the minister. 

But because of pushback the Bill got to parliament only in December 2022.

At Wednesday’s meeting, though, some committee members said that they’re worried about the “potential social and economic impacts” of the Bill, like causing people to lose their jobs, illegal sales and the government losing out on taxes. 

Lekan Ayo-Yusuf, public health expert from the University of Pretoria and a member of the World Health Organisation’s (WHO) study group on tobacco regulation, says not only is there no evidence to back up such concerns from impact assessment studies but it could also be taken as calls for the whole public participation process to start from scratch. 

If this were to happen, “it could take years for the Bill to pass”, says Ayo-Yusuf — and something that would play right into the hands of the tobacco industry. 

Swopping smokes  

The reason for South Africa having to get stricter on tobacco use is the country has signed the WHO’s Framework Convention on Tobacco Control, an international contract in which signatories promise that they will put legislation in place to protect future generations from the health problems linked to smoking, such as cancer and lung and heart diseases.

In 2021, more than a quarter of South Africans older than 15 used tobacco — a worrying figure because, already back in 2016, 26 000 people died from smoking-related diseases in the country, costing the government more than R42 billion in healthcare expenses and lost productivity. 

But the profits are as addictive as the tobacco that generates them, which means that the tobacco industry needs to keep on recruiting a new generation of lifetime smokers to fill their pockets. 

Over the past decade, the use of e-cigarettes among teens and young adults exploded. In 2011, about 1.5% of youths in the United States vaped; by 2018 the number was close to 21%. 

Easy flavours, sleek designs and child-friendly packaging are all designed to make these products appeal to children, says a WHO report published in May. 

Moreover, says the report, the tobacco industry promotes their so-called next-generation goods (products that don’t need tobacco to be burnt to give you a kick) as “safer” than old-time cigarettes, even though they still contain nicotine — which makes them no less addictive than cigarettes and can be a gateway to smoking.

Because the Constitution says every South African must have a chance to weigh in on how laws are made, public hearings on the Bill started in August 2023. By February, people from seven of the nine provinces had had a chance to air their views. 

But the meetings then paused ahead of the elections — without people from KwaZulu-Natal and the Northern Cape having had their say. 

“I think we will proceed as we have in the past,” said the committee’s chair, Sibongiseni Dhlomo, on Wednesday, referring to picking up on public hearings where they left off in February.

With Big Tobacco having a long history of trying to interfere with tobacco control policies, the industry watchdog Stopping Tobacco Industries and Products has set out a list to help government and citizens see through their tricks.

Here are three tactics Big Tobacco uses to stall the Bill’s approval. 

Twisting the science

The tobacco industry has been called out for manipulating science before. Even though research started linking smoking to cancer back in the 1950s, tobacco companies denied it. Philip Morris International (PMI), for instance, tried to cause doubt and dissuade the public from quitting in the 1960s, saying “we don’t accept the idea that there are harmful agents in tobacco”. 

And still they won’t quit. 

Punting their so-called next-generation products like vapes and nicotine pouches as safer than cigarettes, they’re using the idea of harm reduction — an evidence-based way to help reduce effects an addiction has on someone’s health — to simply hook new clients, experts say.

One way to do this is to fund other research organisations to spread their message.

In 2017, the Foundation for a Smoke-Free World (FSFW) was set up, a nonprofit and seemingly independent organisation that supported harm reduction research, despite being funded by PMI. 

In 2020, the foundation claimed that findings from a study among teens in the US which showed that fruity, chocolate or mint flavours rank third in the list of reasons for young people enjoying vaping, as evidence that flavours are not what gets people hooked. 

In an analysis of how Big Brand companies skew science to fit their goals, public health policy experts found that attacking research that paints these corporations in a bad light is a typical strategy. For example, a 2020 article in the tobacco-funded Filter magazine called health concerns about e-cigarettes “a fear-driven crusade” of “lies and junk science”. 

Statements like these can influence the public and policymakers’ decisions, when given airtime by seemingly impartial groups, such as the organisation that owns the magazine and who says their “mission is to advocate through journalism for rational and compassionate approaches to drug use, drug policy and human rights”. 

People who participated in the public hearings said that since vapes and cigarettes are different, they shouldn’t be regulated in the same way, and on Wednesday, some of the members of the portfolio committee asked for “comprehensive data” to compare the health problems that could come from vaping with those linked to traditional smoking. 

Skewing public opinion surveys 

In 2019, Japan Tobacco International (JTI) published a report based on “a nationally representative survey” that asked people how they felt about plain packaging of tobacco products. 

Although JTI said that the research was conducted independently, critics from the Research Unit on the Economics of Excisable Products (Reep) at the University of Cape Town said the study was flawed. For starters, the fact that JTI funded the survey made it biased by definition, they said, and with getting views from only 1 014 people it could not be considered representative of the country’s more than 32 million adults at the time. On top of that Reep called them out for using leading questions, which, simply in the way they were phrased, could show an opinion that would fit their narrative. 

Apart from the questionable research method, the report also looked strikingly similar to one JTI had funded on public opinion about plain packaging in the United Kingdom.  

Plain packaging is a touchy subject. With advertising rules having gotten tighter over the years, for example, tobacco advertising not being allowed in films, on TV or in magazines in many countries, Big Tobacco has had to rely on packaging as a marketing tool.

Pictures, colours or even certain words used on cigarette packaging can make the products look attractive or falsely reassure consumers about possible dangers, research says. For example, brands targeted at young people are marketed as less harsh and include descriptions of appealing flavours like “mint” or “strawberry”.

Instead, research shows that plain packaging will create negative expectations about the taste of cigarettes and will cut down on its cool factor.

Causing confusion about illicit trade

One of the main arguments against the new Tobacco Bill is that it could cost South Africa billions in tax revenue. That’s because plain packaging and bans on till displays in shops will encourage smugglers to sell counterfeit products, big names in the tobacco industry say. 

When cigarettes are produced illegally with fake trademarks or sold to customers before taxes are paid on the goods, it is seen as illicit trade.

But research shows that tobacco companies have been exaggerating the size of the illicit market for many years for their own gain. 

Last year, for example, British American Tobacco South Africa (Batsa) claimed that they had to lay off 200 people because of how much the illicit market had grown during the 2020 tobacco ban, which they said made up 70% of the country’s tobacco business. 

The 70% estimate comes from a survey that the tobacco giant paid the market research firm Ipsos to do — except the Ipsos paper doesn’t come to this conclusion. That figure refers only to the proportion of shops that sold illegal cigarettes in one province, while for the country overall, the number of stores that sold illicit cigarettes actually dropped from 47% in 2021 to 34% in 2022. The real share of the tobacco market owned by illicit trade, is likely to be closer to 54%.

There’s probably more to Big Tobacco’s concern than meets the eye, experts told Bhekisisa previously. What looks like a company trying to be a good corporate citizen, they said, is more likely to be a new approach to an old goal: to protect its bottom line. 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

South Africa is one of 14 countries that will be financially supported by the Africa Centres for Disease Control and Prevention (Africa CDC) and World Health Organization (WHO) from this month until February 2025 to draw up and roll out plans, including vaccination strategies, to fight mpox.

The budget for the “mpox continental preparedness and response plan for Africa” is about $600-million of which just over half of the money — 53% — will go towards the mpox responses of 14 of the 55 African Union member states in which cases have escalated, and human-to-human transmission of the monkeypox virus has become relatively common.

In addition to South Africa, the 13 other countries that will be helped to design and roll out plans are: Democratic Republic of Congo (DRC), Burundi, Central African Republic (CAR), Congo, Cameroon, Côte d’Ivoire, Gabon, Liberia, Kenya, Nigeria, Republic of Guinea, Rwanda and Uganda.

Most of the rest of the money — 45% — will be spent on funding the efforts of partners such as Unicef, the International Organisation for Migration and the International Federation of Red Cross, to help countries to set up their plans, become better at testing and contact tracing, managing cases and rolling out vaccines.

The budget for South Africa is $45.5 million (R813 million), of which $10.1 million (R178 667 million) to cover the logistics of rolling out vaccines against mpox. This money can’t be used to buy jabs. The Africa CDC and WHO say vaccines will be funded via in-kind donations and in cases where countries can afford to buy shots, the prices will depend on ongoing negotiations with drugmakers.

In August the WHO declared mpox a public health emergency of international concern, and in the same month the Africa CDC announced it a public health emergency of continental security.

This was the first time that the Africa CDC has made such a declaration since its inception in 2017. The World Health Organisation’s declaration is the second in two years with regards to mpox — in 2022, the WHO also declared mpox a public health emergency of international concern, after a multicountry outbreak, but announced the emergency over in May 2023.  

An invitation for vaccine manufacturers to express their interest in listing their anti-mpox shots for emergency use was announced by the WHO on 7 August. 

SA now has 25 confirmed mpox cases 

Meanwhile, South Africa’s health department announced another mpox case on Monday — a 38-year old man who was diagnosed at a private medical facility in Cape Town — on 6 September.

This brings South Africa’s total number of 2024 cases to 25. Twelve cases were diagnosed in Gauteng, 11 in KwaZulu-Natal and two in the Western Cape. Three have died.

South Africa’s first 2024 case was reported on 8 May.

Where and when were South Africa’s mpox cases diagnosed? 

Use our interactive map, created by Bhekisisa’s health reporter, Zano Kunene, to see the details.

None of the country’s cases are the relatively new strain, clade 1b, which seems to be deadlier than other forms of the virus. All of South Africa’s cases were infected with clade 2b, the same type of the virus that caused outbreaks in Western Europe and the United Kingdom in 2022 and 2023, according to health department spokesperson Foster Mohale.

Almost all South Africa’s cases were among gay and bisexual men, most in their twenties or thirties, and many of them were infected with HIV, but untreated.

South Africa’s latest case does not have an international travel history and went to the doctor on 4 September after he noticed typical mpox-like blisters on his face, chest and genitals. He wasn’t hospitalised, but is in a stable condition and isolating at home.

The differences between clade 1 and 2

Mpox is caused by the monkeypox virus and there are two known clades: clade 1 and clade 2. Mpox starts off with a fever, muscle aches and a sore throat, followed by blister-like bumps on the skin on any part of the body. Most people recover spontaneously, but people with weakened immune systems, such as those with untreated HIV, often fall very ill with the disease, and some die.

Clade 1 has been rampant in the Democratic Republic of Congo, where mpox has been recorded for over a decade, but in August cases were also detected in Sweden and Thailand. Moreover, from 2023 onwards, clade 1 cases were found in Kenya, Rwanda, Burundi, the Central African Republic and Uganda; all countries close to the DRC. The cases in Sweden and Thailand had both travelled to African countries where clade 1 cases had been detected.

The WHO says clade 1 cases in the DRC have increased steadily over the past decade, especially in 2023. At over 15 600 cases and 537 deaths, the numbers reported so far in 2024 are more than last year’s total. 

Clades 1 and 2 cause the same type of disease, but infection with the clade 1 virus makes people feel sicker and can lead to more deaths. Although symptoms of a clade 2 infection are milder, virus of this type spreads easier. Clade 2b cases have mainly spread among gay and bisexual men with HIV, but who are not on treatment, or don’t use their treatment correctly. Clade 1 cases, however, can also spread via children and heterosexual adults who live closely together in a household and may share a bed or linen. 

A worldwide vaccine shortage

Last week, the DRC received two shipments from the European Union donation programme of about 100 000 vaccine doses used against mpox each — but it’s not nearly enough. Two such jabs are currently being used globally, both recommended by the WHO’s advisory group on immunisation.

Vaccines specifically against mpox are being developed, but there have not yet been clinical trials that include thousands of people, which is a necessary step in getting any medicine into commercial production.

Although the United States medicines regulator, the Food and Drug Administration, issued an emergency-use licence for a new type of smallpox vaccine to be used against mpox infection in August 2022, in most other places earlier anti-smallpox jabs are used against mpox, because the two diseases are caused by similar-looking viruses.  

In South Africa, people were vaccinated against smallpox until the 1980s, when the pandemic was eradicated; those who were vaccinated have about 85% protection against getting infected with mpox.

LISTEN: Mia Malan speaks to the NICD about the mpox outbreak

The health department has previously announced that it will start to vaccinate four groups of people with a higher chance than the general population to contract the monkeypox virus — men who have sex with men, sex workers, health and lab workers — against the monkeypox virus as soon as jabs arrive in the country. 

But the department has not yet managed to secure donations.

Mohale says the department has tried to source mpox jabs from Western countries, but “it’s difficult to tell when we can expect the vaccines”. “The department is still considering several options, while at the same time looking at the epidemiological surveillance data.” 

With a huge shortage of mpox jabs, the current spread of clade 1 cases is unfolding against the background of vaccine inequity “and yet another looming failure”, experts wrote on 15 August in the British Medical Journal (BMJ). 

“We have seen this before, and it does not end well for anyone,” they said. 

“Vaccine inequity is already evident”, the BMJ authors wrote, “with Africa CDC reporting a need for approximately 10-million vaccine doses to control the outbreak, of which only about 280 000 are available — less than 3% of the estimated need, even as wealthy countries hoard, stockpile, and refuse to share vaccines.”

The WHO and Africa CDC’s continental plan aims to get 10-million people in Africa vaccinated within the next six months.

The BMJ authors, however, concluded: “Having observed COVID-19 and previous epidemics, we have every reason to worry that high-income nations will make the same mistakes again — from vaccine hoarding to unfair travel bans and anti-Black racism.”

Our health reporter, Zano Kunene, put together a timeline of how mpox has unfolded in South Africa and we’ve added the cases to an interactive map. We’ve also uploaded all the health department’s updates in chronological order, so that you’re able to find all important mpox information in one place. 

Mpox in South Africa: 8 May to 9 September 2024

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Health department spokesperson Foster Mohale said in a statement that 12 cases had been reported in Gauteng, 11 in KwaZulu-Natal and now two in the Western Cape.

The latest patient has neither an international travel history nor contact with a suspected or confirmed mpox case.

Mohale said based on the current number of active mpox cases, South Africa has enough treatments to treat mild symptoms of smallpox. Currently, South Africa does not have any vaccines, Mohale said.

Earlier this year, South Africa secured a few batches of Tecovirimat, also known as TPOXX – a treatment donated by the World Health Organisation (WHO) as part of “ongoing support to the country’s response efforts to this preventable and manageable disease”.

Last week, the Africa Centres for Disease Control and Prevention (Africa CDC) said the first shipment of 99 100 doses of the JYNNEOS mpox vaccine had arrived in the Democratic Republic of the Congo (DRC), which has had the biggest outbreak of mpox since September 2023 caused by the spread of the new clade I MPXV variant. 

Since the start of 2024, the DRC has reported more than 4 901 mpox cases, with more than 629 associated deaths, representing a sharp escalation in both infections and fatalities compared with previous years.

In 2023, the DRC reported 14 626 mpox cases and 654 deaths — the highest figures recorded in the country and the highest among countries in the WHO African region.

The DRC’s health minister, Samuel Roger Kamba Mulamba, said the newly received vaccine will be rolled out to adults in the country’s high-risk areas.

“We know which provinces are heavily affected, notably Equateur and South Kivu,” he said. “The idea is to contain the virus as quickly as possible.” 

JYNNEOS, which was first administered in 2022 to curb the global outbreak, is a live virus vaccine scientifically proven to be safe and effective for the prevention of mpox, according to various centres for disease control.  

The clade I variant reported in the DRC’s South Kivu district bordering Uganda and Rwanda carries predominantly APOBEC3-type mutations, indicating an adaptation of the virus as a result of circulation among humans.

It is not known whether this variant is more transmissible or leads to more severe disease than other clade I MPXV strains. 

The clade I strain has also spread to Burundi, which has reported 100 cases. Rwanda has four cases, Uganda 10 and Kenya has five confirmed cases.

According to the WHO, mpox is a viral illness caused by the monkeypox virus. Common symptoms are a skin rash, which can last for up to four weeks, accompanied by fever, headache, muscle aches, back pain, low energy and swollen lymph nodes.

South Africa and Cote d’Ivoire are experiencing the spread of the clade II variation, which is reportedly less lethal. Cameroon and the DRC are the only countries reported to have both variants of mpox.

The virus has also been detected in Pakistan, the Philippines, Sweden and Thailand. So far, no countries have reported travel and trade restrictions because of the mpox outbreak. 

In August, the WHO and the Africa CDC declared mpox a public health emergency of international concern. 

The virus was discovered in 1958 in monkeys kept for research in Denmark. It was first discovered in humans in 1970.

Nine-year-old Mira Baher Khaled Ayash arrived last week for a skin graft after one of her legs was severely injured in an explosion. 

The second patient is 17-year-old Lina Zyiad Hasan Abu Ea’mar, who suffered a severe femoral fracture in an explosion on 5 December and was later diagnosed with avascular necrosis, which requires surgical intervention and specialised care.

Representatives from the groups said they began the process earlier this year of bringing children with complicated medical conditions to South Africa to receive medical care after being evacuated from Gaza to Egypt. 

“The initiative was launched as part of the hospital [and MealSA’s] ‘Gift of Mobility Programme’ to facilitate the treatment of children that have been physically affected by the war in Palestine and this is only the beginning of the treatment programme,” one of the hospital’s directors, Dr Ismail Mitha, told a media briefing on Thursday. 

The hospital’s chief executive, Dr Iftikhar Ebrahim, said more patients from Gaza are expected to arrive in coming weeks. 

“We have started the process of documentation with the PCRF to bring other children from Gaza who have sustained life-threatening injuries,” Ebrahim told the Mail & Guardian. 

He added that Raslouw Private Hospital and MealSA have asked other hospitals in South Africa to provide medical treatment for injured Palestinian children. 

Since January, the Palestine Children’s Relief Fund has coordinated the evacuation of more than 120 Palestinian children from Gaza. South Africa joins Turkey, Spain, Egypt, Qatar, the United States and the United Arab Emirates in offering medical attention to Gaza’s wounded children. 

The Palestine Children’s Relief Fund explained that an injured child is placed on a list for countries to offer medical assistance, after which the fund then facilitates the patient’s documentation and evacuation approvals through Egypt. 

“We are very happy that South Africa has opened the doors for our children and we will be waiting for others to also come and receive medical treatment,” said PCRF representative Ghada Al-Gharably, who accompanied the children from Egypt to South Africa. 

The Palestine Children’s Relief Fund said the initiative would not be possible without assistance from the department of international relations and cooperation. 

It is not yet clear what will happen to the patients once their treatment is complete. But Al-Gharably said that based on previous cases, the patients might be sent back to Egypt once their rehabilitation is over. 

Since the war in Gaza began on 7 October 2023, more than 17 000 children have been killed while 20 000 are missing and 10 000 more have been displaced or trapped under the rubble. Many still remain unidentified and more than 25 000 children have been left with no surviving family. 

The World Health Organisation says about 5 000 people have been evacuated for medical treatment outside of Gaza, with another 10 000 still awaiting evacuation.

This comes after a joint press briefing by the health department and the Special Investigating Unit (SIU) on Saturday on the findings from the unit’s ongoing inquiry into 10 679 legal claims against the state’s health departments from 2015 to 2020, amounting to a total of R107 billion. 

This amount is close to half of what the health department’s budget was in that five-year period — about R215-billion — which should best be used for hiring health workers, buying medicine and running hospitals.

The SIU’s work has, so far, saved the health department R3 billion. But if dealing with a dispute between doctors and their patients after treatment didn’t always have to end up in court, it might not have been so easy for dodgy lawyers to exploit the system in the first place.  

An “explosion” in legal cases brought against doctors and hospitals (so-called medicolegal claims) occurred since 2015, the health department said previously, which led to President Cyril Ramaphosa ordering the SIU to look into possible fraudulent claims two years ago. 

So far, the investigators have found cases of unscrupulous lawyers getting patient records illegally, claims having been made on behalf of patients without their knowledge or patients being “tricked” into suing the state.

Turning to the court to decide on a medical negligence claim is not necessarily in patients’ best interest, said Motsoaledi.  

“Because in court, it depends [on] who has fired more bullets or who has fired the first shot that hit. So we want to change that method.”

The silicosis class action

Something that could yield a better outcome is to opt for mediation — and “we have seen it work”. This was a reference to the out-of-court settlement reached between mineworkers and mining companies in a class action on behalf of workers who had developed silicosis as a result of their labour.

Silicosis is an incurable lung disease caused by breathing in large amounts of dust from grinding or drilling into rocks, like during mining. 

Mediation is a process in which two opposing sides negotiate a settlement with the help of a qualified independent adviser so that they come to an acceptable agreement together instead of having to go to court. 

For example, in the silicosis class action, the miners’ representatives and the different mining companies decided to talk to each other rather than present their case to a judge. After three years, a settlement was reached that let the miners who developed lung disease as a result of their work get compensation payouts to cover their and their families’ costs from a trust fund set up as part of the settlement. 

Negotiating the deal meant the case didn’t need to go through the court process, which may not necessarily have ruled in the miners’ favour, and could have meant their losing out on compensation.

But mediation is not common in medical disputes — despite a 2020 rule (called R41A) that is meant to guide legal proceedings in civil matters. The rule says that negotiation must be considered as a way to resolve a dispute first, before the case is taken to court. 

If a case does end up having to go to trial, the lawyers need to show that their clients had considered mediation but that there were valid reasons why it couldn’t work and the case therefore has to be argued before a judge. 

Settling disputes faster

With R41A, the idea is that fewer cases will end up unnecessarily clogging up the courts, likely bringing down the high costs that come with lawsuits, and get disputes resolved faster.

An analysis of 19 medical lawsuits by the South African Law Reform Commission (SALRC) found that it took anything from one year and six months to as long as 16 years and one month to get to a judgment. In fact, three-quarters of the cases took longer than five years to draw to a close. 

Lengthy lawsuits make costs pile up, as applicants need to pay for the services of an attorney, travelling to court, submitting documents and hiring expert witnesses (when needed). In most cases, lawyers charge an hourly rate for their work, so the more often they have to go to court or the longer a case drags on, the more expensive a case becomes. Sometimes, depending on the outcome of the case, a court can make one party cover the legal costs of the other.  

But the Contingency Fee Act gives lawyers’ clients the option of not having to pay anything upfront or for many billable hours; instead, if the ruling is in their favour, the lawyer is entitled to up to 25% of the payout. 

Because medical malpractice cases often involve large awards as compensation for a patient’s suffering or loss in quality of life, this is an attractive option for unscrupulous lawyers.   

And, said Motsoaledi, while the cap of 25% exists in theory, “in practice we know that many take more”.

The SIU’s investigation found instances of law firms keeping most of the money that the state paid out. For example, for one case in the Eastern Cape the department paid R373 million to a single firm for 22 different claims — but “[the firm] pocketed all the money for themselves”. 

‘Creative potential to find solutions’

Mediation can save time and costs, says Shamal Ramesar, a medical doctor and qualified mediator who heads a nonprofit called Mediation in Motion Mediators (MiMM).

Advisers can charge only up to R6 000 a day as opposed to the up to R6 000 an hour a highly experienced attorney could charge.  

But the outcome of mediation doesn’t always have to be a financial reward, says Jacques Joubert, advocate of the high court and who also works as a mediator. The idea is to settle the dispute in a way that is the best for both parties, which means “there’s a creative potential to find solutions, such as, for example, the hospital or doctor offering further treatment”. 

To encourage people to choose negotiating a deal outside court as a way to settle medical disputes, the MiMM has partnered with the South African Medical Association (Sama) to offer doctors and their patients a free meeting should a conflict arise after treatment.

The MiMM drew up a clause for a pre-mediation meeting that doctors can add to their patient consent forms. If the option for such a meeting is taken up, an appointed mediator will listen to both sides to hear what the conflict is about and then advise on whether it can be solved with mediation rather than going to court. In this both parties can make an informed decision about their course of action.

A study by the United Kingdom government shows that attending a pre-mediation meeting helped people dealing with family disputes to try negotiation rather than a lawsuit.

Participants were interviewed before and after attending a session with a mediator, who gave them information on the process and also assessed whether it would be a good option for their case. Most of the participants decided to negotiate with their opponents, with clients who knew little about the idea of mediation getting the most benefit from the pre-meeting.

Although a part of rule 41A says that if one of the parties in a dispute refuses mediation and rather opts to take the case to court, they may have to foot the bill for the court application, the stipulation is rarely enforced and there are even talks about removing it in special cases. 

That’s where a pre-mediation meeting clause, like the one doctors have an opportunity for through the mediation pilot project, could come into play. 

In fact, a discussion paper by the SALRC recommends including this type of clause in patient admission forms to help people consider mediation instead of going straight to court, especially in the public sector, where negligence claims are high.

Says Ramesar: “You’ve got nothing to lose in this meeting. And as it’s free and voluntary, and able to be stopped at any stage, why not give it a try?”

 This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Mays Chemist is a bright, bustling pharmacy on Main Road in Melville, Johannesburg. Since July last year, a small revolution has been taking place there — and one that could make a real difference to HIV prevention in South Africa.  

With the support of pharmacists and an in-house nurse, 210 people have started getting PrEP (short for pre-exposure prophylaxis) here, which is medication that can protect someone from contracting HIV. PrEP has been available in South Africa since 2016 and over a million people have already started taking it to help protect them against HIV infection. 

So, why are the new clients getting their medication from Mays so important? 

Because they’re taking part in a project that’s looking at whether letting people get HIV prevention medicines from healthcare facilities that are part of their everyday routines, such as pharmacies that are near to where they work, study or shop, can work. At the moment, people have to go to a government clinic or hospital to get PrEP.  

So far, the project has proven popular — over 1 200 people across 10 pharmacies have started PreP. 

The medicine is a Schedule 4 drug under the Medicines and Related Substances Act and so a private pharmacy can only give it to someone who has a prescription from a doctor or a specially licensed nurse who works at a state clinic or hospital.  

We think that also allowing pharmacists and nurses working at private facilities to prescribe PrEP and other anti-HIV drugs, which are also Schedule 4 medicines, is more than an urgent medical need — it is a human right. 

Take your pick — then tell your pharmacist

Around 90 000 women and 50 000 men were infected with HIV in South Africa last year — on top of the 7.8 million who already have HIV. We have to prevent new infections with every tool we have and to do this we have to make it as easy as possible for people to get anti-HIV drugs.  

But more than that, we have to give people a choice about how they want to take their medication. 

Until now, PrEP has been available only as a daily pill. It contains the two antiretrovirals emtricitabine and tenofovir (drugs that stop the virus from multiplying in your body). It works so well that it lowers your chance of getting HIV through sex to almost zero — but for that level of protection you have to take it diligently every day.

In December, though, an injectable form of the drug cabotegravir, called CAB-LA for short, was approved as PrEP in South Africa. The first two injections are given four weeks apart and then one every two months, which makes it convenient to use because you don’t have to remember to take a pill every day. 

Studies have shown that taking the injection virtually wipes out someone’s chance of getting HIV through sex. 

CAB-LA will be available from some state health facilities before the end of the year, with the health department also looking to buy more — if the price is right, Bhekisisa reported as part of their coverage of the International Aids Conference in July.

Our project also offers CAB-LA as a PrEP option in a substudy called Axis, which is run at some facilities in Gauteng, under the umbrella of our bigger PrEP project. 

We want to see whether people prefer to take the daily tablet or the two-monthly injection and also want to know what people think of the injection and how practical a PrEP option it would be in real life for people in South Africa. 

Since we started the Axis study in March, 143 out of the 200 people enrolled chose CAB-LA over the daily PrEP pill and 108 came back for their first follow-up shot a month later. 

In in-depth interviews, people told us they prefer the long-acting injectable form of PrEP over the daily pill because it’s convenient, easy to take, more attractive than having to swallow a big pill and they know that they’re protected against infection. 

But the prevention pill is still useful to people who are scared of needles and those who are used to taking tablets every day. 

Why the focus on private pharmacies?  

Participants told us they like private pharmacies because they’re conveniently located at malls and near busy taxi ranks, are open on weekends and the service is fast and efficient. Moreover, people said, they trust the professionalism of the staff and the confidentiality of their relationship and that they faced less scrutiny from other customers.  

In our project, people who want to start PrEP speak to a pharmacist, who refers them to an in-house nurse for advice on things like contraception and lowering their HIV risk and to do tests for HIV and other sexually transmitted infections, hepatitis B and kidney function, as set out in the health department’s guidelines. 

Once all that is done, people have a phone conversation with a doctor, who then writes the prescription.

If pharmacists and in-house nurses could issue the prescriptions themselves, the process could be cheaper and faster. Although this is a change from the current way things are done, it’s not a radical one. 

In South Africa, pharmacists are already part of the process to get people started on treatment for a health condition, give advice on using medicines, check how well someone sticks with their therapy and follow up with clients to make sure that they know what to do in case of a missed dose or how to deal with possible side effects. They also dispense emergency contraceptives without prescriptions.  

The South African Pharmacy Council, the regulatory body to which pharmacists belong and which audits practitioners’ service level, backs the Pharmacy Initiated Management of Antiretroviral Therapy (Pimart) course. This programme, which has been part of pharmacy practice since August 2021, trains pharmacists and in-house nurses to prescribe ARVs, HIV prevention medicines (whether taken before or after sex) and tuberculosis treatment.  

But Pimart is on hold for now after the Independent Practitioner Association Foundation, a network of general practitioners and dentists, took the pharmacy council to court to stop the programme from running. Even though the Pretoria high court ruled in favour of the council in August last year, the network of doctors and dentists was allowed to appeal and a new court date for that is yet to be set.  

Dara Vucevic, a pharmacist at Mays, completed the Pimart training, but because the programme has been stalled, she’s not received a certificate and isn’t allowed to add the tasks to her day-to-day work.  

But, she says, with her four-year pharmacy degree, 28 years’ experience and this extra course under her belt, she understands what clients need and that she could put that knowledge and skills to good use when prescribing HIV prevention medicine. 

And because she’s able to build up a relationship with clients, she can guide them through starting a new treatment. They can pop in and ask questions, which is often not possible in busy clinics, and she knows immediately if they don’t arrive to pick up a refill.

Excluding the close to 3 600 private pharmacies in South Africa from delivering HIV prevention services will be a wasted chance to halt new infections in the country. 

Angela Tembo is a social scientist with extensive experience in implementation research at Ezintsha, a research and policy unit based at the faculty of health sciences at Wits University.

Tsitsi Nyamuzihwa is a pharmacist with experience in clinical trials at Ezintsha.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Last year, Danish pharmaceutical company Novo Nordisk announced a deal with local drug manufacturer Aspen to produce human insulin in vials on their behalf for Africa.

But, says human rights lawyer and founder of the Health Justice Initiative Fatima Hassan, “they’re trying to frame this licence as progressive, but Novo Nordisk’s restrictions are taking us to the dark ages”. 

Insulin is a hormone produced by the pancreas and controls blood sugar levels by helping cells absorb glucose for energy. If someone’s pancreas doesn’t make enough insulin they have a condition called diabetes and may have to inject themselves with a lab-made hormone called human insulin to mimic the body’s natural sugar control system.

Novo Nordisk says it aims to make enough insulin for just over one million people in Africa (about 16 million vials) by 2026 at roughly R45 ($3) a pop. 

About 24 million people in Africa have diabetes, set to at least double in the next 20 years — but only about 1% of what the world pays towards diabetes care is spent in Africa. 

The snag, though, is that the medicine will be made available in vials — not injection pens. These pens, which are plastic tubes prefilled with insulin, have a disposable needle on one end and a dial on the other end. Turning the dial makes a clicking sound as it passes numbers in the dosing window, which helps a user set the exact amount of medicine for injection. This makes it especially convenient for users who may have arthritis in their hands or people who can’t see well.

But, since May, these pens have been running low in South African public hospitals and clinics after Novo Nordisk decided to stop supplying the health department because of “capacity limitations”.

This means many of the people with diabetes have no choice but to switch to syringes and vials, which take many steps to prepare for injection, because public hospitals ration the remaining pen supply to people who can’t safely make the switch from pens to vials. 

Putting patients in this position is “unconscionable, unconstitutional and a clear abuse of intellectual property rights”, says Hassan.

What is SA going to do about it?

Aspen’s contract with Novo Nordisk is to complete the fill-and-finish stage of insulin production, which means that the local pharmacy company will fill the vials with medicine and finish packaging it.  

Aspen will get the insulin in powder form from Novo Nordisk’s Denmark facilities, dissolve it in a watery solution that has a chemical make-up that’s similar to that of your blood, pour it into vials, do quality checks, and finally label and pack the bottles in boxes. Novo Nordisk will then collect the boxes and distribute them, says Aspen chief executive Stavros Nicolaou.

Following the announcement of the deal, the department of trade, industry and competition said it was an “excellent first step” to manufacturing refills for reusable insulin pens, which are in short supply in the public sector. For South African manufacturers to do that they may need permission from the company that holds the patent to make and supply them, called a voluntary licence.

In response to Bhekisisa’s questions about the further licensing for insulin pens, Nicolaou says he can’t predict whether Aspen will be able to make pens in the future. The vice-president and general manager of Novo Nordisk South Africa, Sara Norcross, says the focus of their new partnership with Aspen is to increase the supply of affordable insulin in Africa.

Novo Nordisk has a strong stance on intellectual property rights, according to the company website. It says that because making new drugs is expensive, recouping the investment is important so that they can continue to make more lifesaving medication. For this reason, and because they already “sell human insulin at low prices through large government tenders” in many low-income countries, the company is against voluntary licensing.

This is where the Patents Act may come in.

If companies abuse their patent rights by not meeting the country’s demand for a specific product, for example insulin pens, or refusing to grant a licence on reasonable grounds, the commissioner of patents can issue a compulsory licence to other manufacturers through a court process, which allows them to make the product without the inventor’s permission.

These laws are based on an international contract called the World Trade Organisation’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TripsAgreement), which gives governments tools to tackle intellectual property issues.

Hassan says South Africa needs to use them.

“This deal is insufficient to meet South African needs [for insulin pens]. Both Aspen and Novo Nordisk are remiss in their obligations to the people of this country. The real question now is: what’s the government going to do about it?”

A recipe for success

Compulsory licences, however, aren’t a silver bullet, says  Andy Gray, a senior lecturer of pharmacology at the University of KwaZulu-Natal. These licences have never been issued in South Africa, though, partly because it’s a long, complex court process and the high cost that comes with it blocks people from filing applications for them. 

But even with such forced permissions, local manufacturers would still need a supplier for the insulin.

In 2019, more than 90% of South Africa’s insulin supply came from three multinational companies, Novo Nordisk, Eli Lilly and Sanofi, none of which have manufacturing sites in Southern Africa. “There is no production facility for insulin in South Africa, so we mostly import the product,” Gray says.  

Insulin used as medicine is a biologic drug, which is different from a chemical one because it’s made by a living cell rather than through a series of chemical reactions. The sugar-control drug is produced by putting the gene for insulin into a ring of bacterial DNA, inserting the altered DNA into a specific type of microbe (such as bacteria) and then using them as tiny insulin-producing machines. This gives rise to a product called recombinant insulin, which is difficult to copy because of the way it’s put together.

But with the 2021 launch of the mRNA Vaccine Technology Hub in Cape Town, which makes biologic vaccines by using short lab-made gene sequences to instruct your body to make proteins to fight a particular virus, Gray says insulin production could someday be on the cards for South Africa. 

But big pharma companies that make insulin keep their recipes for the process secret.

The general method for making insulin — in other words, the hormone itself — is well known, but it is tricky to mix it into a final drug form that can be used as medication. That means any small changes in the steps or materials used in this process can affect how well the medicine will work in someone’s body.

The method followed in this process belongs to the original pharmaceutical company and is protected by trade secret laws, which, unlike patents, never expire, Gray says. A trade secret is confidential information like a lipstick formula or a manufacturing process that gives a company a competitive edge — and they can’t be forced to share it. It also means that their process can’t be copied by another manufacturer unless those researchers figure out the steps on their own.  

For example, during the Covid-19 pandemic, the pharmaceutical company Moderna made all the information about the building blocks of their vaccine public, but local scientists still had to use their expertise to figure out how to put it all together to make a copy of the vaccine. To save them the trouble, a technology transfer process, where the original developer shares its trade secrets and expertise, would’ve helped. 

Producing insulin in injection pen format adds another layer of complexity, as many international drug companies, like insulin pen producer Sanofi have patents on the injection device itself, meaning that local drug makers must either design their own injection pen or get a licence to make it.

Don’t bite the hand

Some countries have used compulsory licensing not only to side-step the excessive pricing of lifesaving drugs, but also to negotiate voluntary licences for a reasonable fee. 

In 2007, for instance, Brazil prepared two compulsory licences so that generic manufacturers could make antiretrovirals (ARVs) to treat HIV and sell the drugs to the government for cheap in order for them to be given for free to people through a national HIV treatment programme. One of these licences resulted in generic versions of efavirenz being made available at about R1 200 ($170) to treat one person for a year instead of the R5 400 ($760) deal offered by the pharmaceutical company Merck. 

But the Brazilian government decided to hold off on issuing a compulsory licence for the other ARV, lopinavir. The threat of a compulsory licence alone was enough to get the manufacturer, Abbott Laboratories, to offer a 57% discount on the price — down from about R23 300 ($3 241) per person a year to just under R10 000 ($1 380).

It may be difficult for other countries to get the same results, though, because Brazil is a fairly rich middle-income country with bargaining power thanks to their pharmaceutical manufacturing facilities and knowledge about reverse engineering drugs and so produce copies of them.

Some countries may also shy away from compulsory licensing from pharmaceutical companies because it could lead to backlash from rich countries.

“Pharmaceutical companies have a lot of power in terms of wealth and influence,” says Phumudzo Munyai, head of the mercantile law department at the University of Pretoria.

“A patent is a form of property and if a government is going to force companies in the Global North to give up their property without asking their permission, it could cause damage to our trade relationships and the economy in general.”

For example, in 1997 South Africa passed new laws that would allow the government to use compulsory licences and import more affordable generics of ARVs from other countries to fight the Aids epidemic. 

This led to an application by the Pharmaceutical Manufacturers Association and 41 drug companies at the Pretoria high court in 1998 to oppose these new measures, arguing that it violated the constitutional right to not be deprived of property.

The United States Trade Representative, an American government agency responsible for trade policy, then placed South Africa on a “watch list” for countries that needed to change their intellectual property rules that could result in their trade relationship ending.

Eventually public pressure from international media and civil society, most notably the South African health advocacy group, Treatment Action Campaign, forced the US and the pharmaceutical companies to back off. 

By August 2001, the price of original branded products, which at the time cost more than R80 000 ($10 439) for one year’s treatment per person, dropped to about R6 000 ($712) after competitors were allowed to make low-cost versions.

“The threat of compulsory licensing marked the beginning of reasonably priced ARVs. It was basically a gun to their head,” explains Alex van den Heever, an adjunct professor of the Wits School of Governance.

Says Van den Heever: “This is what the department of health should be doing to provide access to insulin pens. In times like these, the government can’t afford to just sit on its hands.” 

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The department of health however urged the public to be vigilant, saying it was waiting for a further announcement from the World Health Organisation on Wednesday before formulating its response. 

Africa CDC director general Dr Jean Kaseya declared mpox a public health emergency of continental security on Tuesday, saying there was an urgent need for swift and decisive action by the global community to eliminate the threat of the disease. At least 13 African countries have reported outbreaks this year.

“This declaration is not merely a formality; it is a clarion call to action. It is a recognition that we can no longer afford to be reactive. We must be proactive and aggressive in our efforts to contain and eliminate this threat,” Kaseya said.

The declaration is the first such by the agency since its inception in 2017. Kaseya said it followed discussions with experts, including the Africa CDC emergency consultative group chaired by Professor Salim Abdool Karim.

South Africa’s health department would finalise its response after an expected update from the World Health Organisation, spokesperson Foster Mohale told the Mail & Guardian.

“We are still meeting with our expert, then they will be able to guide us on what is it that we need to do differently from how we have been doing things. We are [also] going to wait for another announcement by the World Health Organisation. The World Health Organisation decision supersedes the decision of other continental bodies,” he said.

He said South Africa had adequate doses of treatment for the disease, based on the current number of cases in the country, but added: “Prevention is better than cure, so people must not focus on the treatment but must focus on the prevention by exercising caution and practising good hygiene.”

The health department said it had received another batch of Tecovirimat, also known as TPOXX, donated by the World Health Organisation, as part of “ongoing support to the country’s response efforts to this preventable and manageable disease”.

“The department urges all the identified contacts to cooperate with health officials during contact tracing for screening and possible diagnosis to prevent further transmission of this preventable and treatable disease,” it said in a statement.

As of 4 August, South Africa had confirmed 24 cases of Mpox — 12 of which were reported in Gauteng, 11 in KwaZulu-Natal and one in the Western Cape. The number of deaths linked to the disease remains at three.

According to the department, of the 22 cases recorded between 8 May and 6 July, 19 patients fully recovered from the disease. 

The most recent case is a 20-year-old man from Gauteng who presented with typical mpox lesions at a private health facility on 2 August. The patient had visited Peru, but the health department said it was unclear whether he was exposed to the disease there, or on home soil.

A World Health Organisation multi-country mpox outbreak report listed the South American country as having high numbers of positive cases.

In Tuesday’s briefing, Karim said, based on limited surveillance and evidence, Africa CDC believed the situation on the continent could be more severe than understood.

“Our concern is that we may be seeing more fatalities in Africa due to the association with HIV,” he said. 

According to Africa CDC, at least 13 African countries, including previously unaffected nations like Burundi, Kenya, Rwanda, and Uganda, have reported mpox outbreaks. 

“So far in 2024, these countries have confirmed 2 863 cases and 517 deaths, primarily in the Democratic Republic of the Congo. Suspected cases across the continent have surged past 17 000, a significant increase from 7 146 cases in 2022 and 14 957 cases in 2023. 

“This is just the tip of the iceberg when we consider the many weaknesses in surveillance, laboratory testing and contact tracing,” the agency said.

Mpox is a viral illness caused by the monkeypox virus. Common symptoms include a skin rash, fever, headache, muscle aches, back pain, low energy and swollen lymph nodes. 

The virus can be transmitted through physical contact with an infectious person, contaminated materials or infected animals.

The World Health Organisation previously declared mpox a public health emergency of international concern from May 2022 to July 2023.

There is an obscure significance to Mzulungile Nodikida’s appointment as CEO of the South African Medical Association (Sama) in January this year and it derives from Nodikida being a product of the South African government’s Cuban Medical Training Programme, sometimes called the Nelson Mandela-Fidel Castro collaboration.

Since its establishment in 1996, the programme has been knocked for being impractical, too expensive and for producing inferior doctors. In a 2013 South African Medical Journal article, Sama’s then vice chairperson, Mark Sonderup, is quoted as saying, “[E]verybody agrees we need more doctors, but is this the best we can do?”

Nodikida now leads Sama and he isn’t the only Cuba graduate who has accessed power and influence in South Africa’s healthcare sector.

“There are a few of us, mostly early graduates, which isn’t surprising because we’ve had time to accumulate experience. In a few years our juniors will eclipse us,” says Nodikida, although he concedes that things were a bit different in those earlier years, when the rough edges of the programme were still being smoothed.

“Perhaps those who made it through were hardened and enriched by that, I don’t know,” he muses.

Sanele Madela, a former classmate of Nodikida who is the the health department’s attaché to South Africa’s Havana mission, says that any special quality the earlier cohorts possessed “is probably related to fewer spaces having been allocated in those days, so they were really sending the cream of the crop”. 

He searches his memory for the numbers to illustrate his point.

“There were, I think, only 11 students from KwaZulu-Natal in my 2002 group, whereas in later years the province sent 100 to 200 students.”

Madela says he, Nodikida and some others in their cohort used jokingly to each other CEOs.

“We still laugh about that because today we are, or have been, CEOs [of medical facilities and organisations].” 

A survey of Cuba- and South Africa-trained graduates published in 2019 found that those from the Cuba programme reported “stronger motivation for creativity and initiative in their career, to work in rural areas, to improve health of the country and to become a community leader”.

This would have made gratifying reading for the programme’s architects, who aimed to address a dearth of doctors in South Africa’s rural areas, particularly, by sourcing students from those areas in the hope that they would be more likely to want to return to work in their own communities.

Context and the underdog factor

“I’m not going to sit here and pretend that it wasn’t a political programme,” says Madela, who is today responsible for monitoring the programme that trained him.

“When Nelson Mandela became South Africa’s first democratically elected president, he was all too aware that apartheid had left the country with a deeply unequal health system, in which facilities and doctors are concentrated in the cities. So he appealed to Cuba’s then president Fidel Castro to supply doctors who could be deployed where they were needed. And he sent them [doctors] but told Mandela that South Africa would also have to train its own doctors in due course,” he continues.

Since the health department in South Africa doesn’t have the capacity to train doctors — it relies on universities, which are highly independent of government strategy, to do this — a deal was struck to send black students from mainly rural parts of the country to study medicine in Cuba. 

“This was 1996 and there were nine of them — five from Mpumalanga and four from KZN. There were more, in fact, but a few dropped out due to culture shock. Cuba is a completely different country from South Africa, so I think it scared the hell out of them,” says Madela — yet several later asked to be sent back, “once they saw the others were making it”.

Bongile Mabilane, who has led two prominent research ethics committees in South Africa for the Council for Scientific and Industrial Research and the Human Sciences Research Council, was the only female student in her 2002 Cuba cohort. She recalls sitting in the induction room and noticing “that the guy next to me was wearing the same clothes he’d had on when we boarded the plane — he was one of those that had come with just one suitcase”.

Mabilane feels there was a difference between the others and her.

“These kids came from hard circumstances in the rural parts of South Africa and they were serious about making Cuba work for themselves. They carried the South African flag so high and that pushed me to really start focusing on my books,” she says.

Nhlakanipho Gumede, a senior manager at Greys Hospital in Pietermaritzburg and former CEO of the iconic Pholela Health Centre, was one of those “one suitcase” students. He grew up in a village called Mbazwana in Umkhanyakude District in the northern parts of KwaZulu-Natal, completing his schooling in Ndumo, at the school where his mother taught.

He was only 16 when he went to Cuba but almost missed the flight because he didn’t have an ID or a passport.

“It took a lot of people to get me onto that Iberia Airlines plane. If my mother hadn’t run around on my behalf, I would have been stuck in South Africa doing I don’t know what,” he says.

Gumede, like all of the others interviewed for this article, had been studying something else before he was accepted into the Cuba programme — a business administration diploma at the Community and Individual Development Association in Johannesburg. 

Nodikida had started a bachelor of science information systems, Mabilane was studying hotel management at Vaal University, and although Madela had started a medical degree at Medunsa (now Sefako Makgatho Health Sciences University), he dropped out in the second year for financial reasons and signed up for financial mathematics at the University of Pretoria — not because he felt called to actuarial science but because a portion of the tuition fee was discounted.

Says Madela: “Were it not for the [Cuba] programme, a lot of good people would have otherwise been lost to medicine in South Africa. I think this is part of the story.” 

Black sheep

Mabilane, unlike most of her peers, was a city girl, “born and bred in Nelspruit, the last of six children”. Her parents were both “very religious”, and somewhat despaired of their youngest child, who was “quite the rebel”. 

Speaking with the easygoing openness of someone who has found their anchorage in life, Mabilane recalls how she used to tell people she was going to “marry a rich guy” and that her sole reason for enrolling for a hotel management diploma “was to learn how to behave in hotels and restaurants, because you need to know that if you’re going to be rich”.

Her parents had other plans for her, though, and staged an intervention.

“They arrived on campus out of the blue, packed up all my stuff, and said, ‘We’ve stopped paying for this. You’re coming home.’ And they took me home to Nelspruit, half drunk.”

Mabilane’s mother was convinced God had spoken to her, telling her that her daughter was going to be a doctor.

“My mother said, ‘Let’s make a deal. If you fail, we will tell the church that this is the path that you have chosen, and we will cut our ties with you.’ I was over the moon, because the last thing I wanted on earth was to be stuck in the township, doing church.”

Back home, Mabilane’s sisters, now pastors themselves, called a three-day fast.

“Five or six women came, and on the second day an angel appeared and told them that they should not worry about me, that my future is secure, and that I will be known as a smart person. 

“My sister dropped on the floor and had a vision of a plane, with me in it, and the aeroplane had legions of angels around it, and it was clear that the plane was heading overseas.”

Mabilane’s mother found out about the government’s medical training programme and applied on her daughter’s behalf — without telling her. 

Mabilane chuckles at the memory. “She couldn’t have known that it was for Cuba, because when we learned that my application had been successful, she freaked and said, ‘My daughter doesn’t even want God and now she’s going to a communist country where they don’t even believe in God.’” 

But Mabilane thrived in Cuba.

“In the first two years you do basic medicine, and because I was quite a high performer, I was selected to be in the ayudantia (“student support”) programme, where you’re paired with a specialist in training, what the South African system calls a registrar. 

“I was allocated to this brilliant Cuban in the second year of his internal medicine residency, and literally became his shadow, following him on all of his rounds,” says Mabilane, who witnessed what she calls “the back-end of medicine” — the manner in which senior doctors relate to each other and go about their work.

“It’s a bit like being the child of parents who are successful in business, where you get to know the culture of business long before entering business yourself. It’s a very real headstart,” says Mabilane, who was able, in her fifth year, to tell her parents: “Relax, medicine is the thing. I’m killing it.”

Lost in translation

Many have spoken about the culture shock experienced by South African students arriving in Cuba for the first time but Gumede’s account is particularly memorable.

“When you’re a poor kid from a rural area and you’re catching a flight for the first time, you’re thinking to yourself, the further I go, the nicer the place is going to be. We transited through Madrid, and I‘m thinking, if this is Spain, where I am going is going to be quite something. And of course, when we got to Cuba it was, like, hang on, this is no different from downtown Durban, except that everyone speaks Spanish.”

Godisamang Kegakilwe, who is acting as the director for district hospitals and the coordinator for National Health Insurance for North West province, was part of the second cohort of students to arrive in Cuba, in 1998. The group wasn’t even aware that they’d be expected to study medicine in Spanish.

“That communication failure led to a 50% failure rate in the first year,” says Kegakilwe, who would painstakingly re-listen to recordings of his classes each afternoon.

The language gap would still be an issue for future cohorts, although Mabilane says, “We at least knew to pack our Spanish-English dictionaries.”

In Cienfuegos, where Mabilane was attending Universidad Ciencias Médicas Cienfuegos (South African students are split between several Cuban universities), she took the initiative of “paying the auntie who used to wash our laundry” for extra Spanish lessons at her house every Saturday, drawing from her monthly living allowance of $200 (around R2 200 at the time).

Kegakilwe’s answer was to throw himself into Cuban society.

“Cuban people are fiesta people, they enjoy themselves. So I was there with them in the bars, in the discoteca, and I would also visit Cuban friends on a farm in a rural area, by the riverside,” said Kegakilwe, the impact of his immersion still noticeable in the way he trills his r’s.

Although disorienting at first, the Cuban system was supportive, Kegakilwe recalled.

“At a very early stage the teachers identified students with difficulties and offered tailored support. In South Africa, if you don’t qualify to do medicine, then that’s that. But in Cuba you can come in and do it, and end up being one of the best students, because they consider where you come from, your language proficiency, any deficiencies or weaknesses, and they will assist you with targeted interventions,” he said.

Burning up on re-entry

South Africa’s Cuba students spend five years abroad and return to do the final year of their medical degree at a South African university. For most, the experience is harsh. In the early years, it verged on the intolerable.

Kegakilwe’s early group returned to limited choices of tertiary institutions.

“The very first cohort of students from Mpumalanga and KwaZulu-Natal went to Walter Sisulu [University] and Medunsa, but when my group of 30 returned to South Africa at the end of 2002, the options included the universities of Pretoria, KwaZulu-Natal and the Free State.” 

Manto Tshabalala-Msimang, the health minister at the time, “strongly discouraged us from going to UFS and UP [the universities of the Free State and Pretoria], due to concerns about the level of transformation and the acceptance of the Cuban programme.”

But Kegakilwe would not be dissuaded.

“We had that rebel radicalism that was in the air at the time in South Africa and so eventually the minister said, ‘Okay, but you can’t go alone.’ So I convinced a friend, Thabo Rampai, to join me. We felt that nothing could stop us, given what we had come through in Cuba,” says Kegakilwe, who better understood the minister’s warning during his first rotation at UP.

“The university had just transitioned from being a purely Afrikaans-medium institution and some of the professors were still resisting this and purely speaking Afrikaans. We did not reveal that we had studied in Cuba initially, because we feared judgment. But our inability to understand Afrikaans exposed us and then people were, like, ‘Ohhh, jy’s die kommuniste? [Oh, you’re the communists?]’” 

Kegakilwe received no sympathy from Tshabalala-Msimang when he complained. “She said, ‘I told you not to go, but you went ahead anyway.’ And I knew then that we were on our own.” 

But he prevailed and passed, as did his friend Rampai, who stayed on to specialise in surgery and is today one of the country’s top gastroenterologists. (Rampai now works in the private sector.)

Gumede describes the homecoming experiences as “a real mess”, highlighting what he terms “the language whiplash” of having to switch back from Spanish to English tuition. 

“Most of us are from rural areas of South Africa and we weren’t confident in our English to start with. In Cuba, we had to learn Spanish in order to study, and by year four, our Spanish was better than our English. Yet in year six, back in South Africa, everything needs to happen in English again. It’s a problem,” he says, enunciating the words like an exhausted marathon runner. 

The demands of the transition proved too much for many of the students.

“A lot of the students were repeating twice, three times,” says Mabilane, who attended UP.

“Things like ‘you guys are half-cooked doctors’ were thrown around. We were told we didn’t know anything, that we were dumb, that we were just political pawns,” says Mabilane, who did not let on that she had studied in Cuba.

“My mother always says, ‘You pour the spices behind the kitchen door.’ In other words, you don’t reveal everything to everyone.”

She would go on to get two distinctions and was judged the best presenter in her cohort in internal medicine.

Many of those I interviewed made it very clear that, in the midst of all of the challenges, there were professors who were immensely supportive. Kegakilwe names Steve Reid, Ian Couper and Musa Mabandla. Gumede singles out Lionel Green-Thompson, now dean of the University of Cape Town’s faculty of health sciences, as someone who “helped us a great deal”.

“Every time I see him, I remind him of the valuable contribution he’s made in our lives. He always asks, ‘Where are you now?’ And when I tell him, his joy is so visible and sincere.” 

Prevention, prevention, prevention

Cuban medical training is often described as being focused on prevention, unlike the South African system, which is more invested in the curative aspect.

“The training is pretty similar up until the third year, when an element of public health enters the Cuban curriculum. You’re told that a doctor doesn’t just stay in a facility; a doctor needs to be present in the community, understanding everything that’s going on — like how many people are living in each household, what type of diseases they have, what treatment they’re taking and so on — in order to come up with interventions that will actually be meaningful,” Gumede explains. 

The emphasis on primary healthcare “doesn’t mean it’s a primary healthcare degree — it is a well-rounded medical degree”, he says.

According to one survey, 80% of South African students trained in Cuba return wanting to work in primary healthcare.

“You can understand why — it’s an impressive system,” says Madela, citing the fact that Cuba competes with richer nations in terms of health outcomes but with a fraction of the expenditure.

“Many of our students have had relatives who fell sick with diseases that could have been prevented with a more community-oriented approach, so the experience they have with the Cuban system, which emphasises prevention, is quite personal,” he says.

Kegakilwe recalls a phrase he used to hear in Cuba: Sin nada, hacemos todos.

“It means ‘with nothing, we do everything’. It comes from the time Cubans call el bloqueo, [the time of] the US embargo against Cuba. When I was there, they were sterilising needles and that sort of thing. They had no resources. That was Castro’s message to Mandela: instead of worrying about how to finance healthcare, rather identify the need and come up with a way to attend to it.”

On completing their studies, students of the Cuba programme must practise in South Africa’s public sector for five years — the quid pro quo for six years of free tuition. All of those interviewed attempted to carry the spirit of their Cuban training into their South African jobs. All encountered steep challenges.

“I got a lot of rejection, both soft and hard varieties,” says Mabilane, who landed a job at George Mukhari Hospital, north of Pretoria upon graduating. 

“I had a patient with congestive heart failure on my first call during my cardiothoracic rotation, and when I wrote my notes about the management of the condition, the first page was dedicated to lifestyle modification. 

The nurses said flat out, ‘We don’t write like this. Where do you come from?’ and gave me a prescription written out by another doctor. ‘Do it like this,’ they said. It hurt because the public health was just flowing out of me. I was, like, let’s get to the root of it, and instead I came up against this strictly curative approach,” she says.

Similarly, when Mabilane told a professor of cardiothoracic surgery that she wanted to be a public health doctor, after he asked her to join his fully male-staffed department, he did not conceal his disdain.

“He said, ‘You are such a waste. You could be saving lives but instead you’re going to study drains and sewage systems.’ And when I went to the province’s public health office to ask if I could shadow someone, like I’d done in Cuba, I was told, ‘No, wait for your internship to finish [and] do your community service. Go about things in the normal way.’ 

“I brought this inflexible South African mindset up in the speech I was invited to make at our graduation. The [health] minister at that time was Aaron Motsoaledi and I told him directly, ‘You’re losing a lot of great students by dictating how things should be and not fostering a culture that recognises and encourages initiative.’”

Bringing community healthcare back home

Kegakilwe’s path led back to Ganyesa in North West, the village he grew up in, and where he lives today.

“In Cuba, there were no resources. In South Africa, there are resources, but only in places — and Ganyesa is not one of those places. 

There was no ATM, and the nearest Kentucky [fast-food outlet, Kentucky Fried Chicken] was 80km away. It is a challenging place to live, let alone work,” says Kegakilwe, who found that many of the clinics in his district were short of basics “like glucometers to test the blood glucose of diabetic patients”.

After looking at the community’s disease profile, he knew he wanted to work there, in primary healthcare. But the situation was untenable, he felt, and so he boycotted, staying away from work for a month. 

In the same period, Kegakilwe attended and shared his story at the annual conference of the Rural Doctors Association of Southern Africa (Rudasa) — and duly became the organisation’s representative for North West.

“Being opinionated, you end up getting yourself into trouble,” he chuckles. Kegakilwe would become Rudasa’s longest-serving chairperson, helping to found the Rural Health Advocacy Project, which aimed to place rural issues on the national agenda. 

During his internship year in Peddie in the rural Eastern Cape, Nodikida helped to found the Eastern Cape Cuban-trained Doctors Forum, which, although short-lived, promoted community diagnosis.

“We carried the message that, if you know what is wrong with the community, you’re able to plan accordingly and manage some of these diseases before they need to be cured, at great expense, at a tertiary healthcare centre,” he says.

Health for the people

As students, Nodikida, Madela and some others talked about setting up an organisation focused on primary care but it was Madela, who spent his internship and community service years in hospitals in KwaZulu-Natal’s uMzinyathi District, who followed through, founding an NGO called Expectra Health Solutions.

“In my first days on the job, I became alarmed by the complete absence of patient follow-up. In hospitals you treat, write the discharge summary and call for the next patient. Later, you hear the patient has died. Why? And why did that patient get sick in the first place?” says Madela, who started visiting communities on the weekends, checking in on some of the patients he had discharged from the hospital ward. His colleagues told him he was doing work below the station of a doctor.  

“It didn’t bother me because we learned in Cuba that everybody participates, even if you’re a specialist,” he says, insisting that a doctor’s presence in the community helps to “take some of the mystique out of the doctor’s role”.

“In these communities, a doctor is someone you dress up to see. A doctor is someone you are afraid to disappoint, to the extent that some people are not altogether honest — they use tricks to dribble you into thinking that they are taking care of themselves,” he says, giving the example of patients with diabetes, who drink a lot of water on the day of their appointment, “hoping the doctor will mistakenly think that because their glucose levels are lower, they must be managing their condition well”. 

Madela’s NGO attracted the support of powerful organisations, like the US-based Medtronic Foundation, and put tools such as glucometers and blood pressure readers into the hands of community healthcare workers. In 2017, he addressed the US House of Congress about noncommunicable diseases, and attended the World Health Assembly as a guest of the International Diabetes Federation. Madela said there was some irony in this recognition.

“It was like we were bringing this Cuban approach of working in communities to South Africa for the first time and yet the concept of community-oriented primary care started here in South Africa, in the 1940s,” said Madela, referring to the work of Sidney and Emily Kark, South African-born physicians, who in 1940 established a community health centre called Pholela, deep in rural KwaZulu-Natal, and for the next six years, according to one short history, developed “the concepts, methods, and program[me]s of applied social medicine for which they would later become famous”. 

“In 2014, I was working at a district hospital in Creighton called St Apollinaris, and I came to know Pholela, which is in nearby Bulwer. I ended up working there as a medical officer, and as it was leaderless, I did what anyone who likes to see things working would do — I started managing,” says Gumede. He was eventually hired as Pholela’s CEO, “with a mandate to try to get the place back on the map, and beyond this to get the KwaZulu-Natal department of health to re-engineer primary healthcare”. 

By all accounts, Gumede excelled in his duties, although he says the “re-engineering” of primary healthcare in the province remains a work in progress.  

Says Gumede: “The Pholela model of community-oriented primary care has never really come back to the fore. There has been some progress, but the South African health system remains overly centralised and focused on cure rather than prevention.”

Forever Cuba

Almost two decades after graduating, the five profiled physicians are perhaps not as close to the primary healthcare mission as they once were, yet their affection for Cuba and its lessons remains undimmed.

Madela returned to Cuba and splits his time between Havana, Pietermaritzburg and his childhood home in Dundee. 

Kegakilwe named his son Che Guevara and said his home “is a bit of a shrine” to the Marxist icon. “My son sometimes asks me, ‘But papa, why this name?’ and I tell him about my experiences over there, and how, if I could live one other person’s life, it would be Guevara’s.”

Gumede says his life mantra remains a philosophical statement he and his classmates were confronted with in their first year: El hombre piensa como vive, no vive como piensa. It means: “A man thinks as he lives, not lives as he thinks.”

Mabilane treasures a letter from her classmates before she left Cuba. “We all had this passion for public health but we knew we were going to get pushback in our respective countries, so they gave me this letter called ‘Yo maté al Che’, which means ‘I killed Che’, written from the perspective of the man who assassinated Che Guevara. 

“My favourite line is: ‘Y que el hombre que de veras murió en La Higuera no fue el Che, sino yo.’ It means that a moral death is much more painful than a physical death, and the letter goes on to say that the man who really died that day wasn’t Che, but himself, the killer, because even though he killed a body, Che’s ideas are more alive than ever.” 

Mabilane pauses: “I try to remember that whenever I’m faced with a moral choice in life.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Much like the planet’s air temperature, diabetes rates are rising around the world.

Extreme heat, heavy floods, air pollution and infectious diseases will make dealing with diabetes harder and make the condition more common, research shows.

A serious chronic disease, diabetes is the leading cause of death for South African women. 

It is caused by the body’s inability to produce (enough) insulin or use it properly. Insulin is the naturally occurring hormone that allows the body’s cells to take up sugar — also called glucose — from the blood so that its energy can be released to keep the body working. But when enough insulin isn’t made or the body can’t use it well, too much sugar is left in the bloodstream, which can lead to heart disease, vision loss, kidney problems, nerve damage and even amputation.

The world already does a poor job of looking after people with diabetes, especially when public health systems are under pressure. Adding climate change to the mix will make things even more difficult. So what’s the fix?

Types of diabetes

An estimated 15% of South African adults have type 2 diabetes, a form of the disease that develops over time, rather than someone being born with it. In 2011, it was estimated to be around 7%. Family history can contribute to the likelihood of getting the disease but almost 90% of cases are linked to being overweight.

Type 2 diabetes makes up about 96% of diabetes cases worldwide. It is sometimes referred to as a “lifestyle disease” because a healthy diet and exercise can prevent and, in some cases, reverse it. But many people with type 2 diabetes need to take a lab-made form of insulin to keep their blood sugar levels stable.

Doctors aren’t sure how to prevent type 1 diabetes, which is an autoimmune disease. This means that the body attacks itself by mistake. Type 1 diabetes is usually diagnosed in children or young adults and people then need daily insulin injections to control their blood sugar levels and stay healthy.

Hormonal changes during pregnancy can also change how insulin works, sometimes resulting in gestational diabetes. It could up the chance of a child developing obesity or type 2 diabetes. While it usually goes away after the baby is born, it increases the chances of the mother developing type 2 diabetes later in life. 

Diabetes meets climate change

Extreme heat due to climate change affects our health, and research shows that in the US alone, 100 000 new diabetes cases could develop each year with a temperature increase of just 1°C, and heighten the chance of someone who already has diabetes ending up in hospital or the emergency room.

People with diabetes often have trouble keeping their body temperature in check through natural processes like sweating when it’s hot. Overheating can upset the way the body controls blood sugar levels, leading to dehydration or heat stroke which, without treatment, can quickly damage the brain, heart and kidneys.

These complications also influence how full hospitals are as well as the workload of health workers. In Brazil, researchers found that a 5°C increase in daily temperature led to 6% more diabetes-related hospitalisations.

Air pollution is a problem, too. Burning fossil fuels like coal, which is a big part of the reason for climate change, also makes the air dirty. Breathing in tiny bits of solid materials in the air increases the chances of developing diabetes, while the pollution from climate change-induced wildfires can heighten the chance of someone with diabetes needing hospital care.

Infectious diseases such as malaria and cholera will also become more common, with changing weather patterns shifting how far and fast germs spread. Because diabetes can weaken a person’s immune system, they can’t fight off germs as well as healthy people. That means they are more likely to get serious infections, including tuberculosis (TB), one of the main causes of death in South Africa.

Our reporting on the aftermath of the 2021 Durban floods showed more of the knock-on effects of climate-related floods. The closure of clinics, the loss of personal property like ID documents and being forced to move because of the disaster caused people to miss HIV treatment. Other studies have shown that in the face of climate disasters, TB spreads easier too. In the same way, if people with diabetes can’t get their daily insulin, it can quickly turn deadly.

Early warnings and sugar taxes

There are ways we can prepare for the impacts of climate change on diabetes and the healthcare systems that support patients. Early warnings, such as the soon-to-launch pilot programme through MomConnect that will alert pregnant women to coming heat waves, could be expanded.

But getting a handle on diabetes rates is the best place to start.

Clinics and hospitals in South Africa are required to provide treatment for people with diabetes. However, research shows that, in many cases, people aren’t put on the right treatment. A five-year plan released by the health department in 2022 to deal with noncommunicable diseases such as high blood pressure, obesity and diabetes could combat some of that.

Combating obesity, which affects one in four South Africans, will help.

Susan Goldstein, a public health researcher at Priceless SA told Mia Malan in a recent Health Beat episode that barring companies from marketing ultra-processed foods to children and requiring labels on food with too much salt, sugar or fat have been shown to curb sales. The health department’s 2023 draft legislation on the labelling and advertising of foodstuffs is promising.

Research shows that our sugar tax has worked. South Africans bought 28% fewer sugary beverages and manufacturers started cutting back on sugar in their products after it was enacted in 2018. 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.