This article takes the form of an appreciative contextual response to the notion of ‘just health’ that is formulated in Jean-Pierre Wils’ article, ‘Is there a future for medical ethics?’ It approaches the notion of just health in the South African context from a public theological vantage point. The article addresses the issues of justice, care and the future of ‘medical ethics’ by adopting a position that seeks to constructively engage empire, economics and apathy in relation to just health in South Africa.
In his article, ‘Is there a future for medical ethics?’, Jean-Pierre Wils (2016) offers a clear and convincing argument for a shift in focus from just health care (which focuses on the ethics of health care provision) to just health (the more encompassing view of the relationship between justice and health) as an important consideration for the future of medical ethics.
The central points of his argument are deeply challenging within this context, namely that ethicists shall need to move from a mere focus upon the question of what constitutes ‘just health care’ to a further reaching consideration of what constitutes ‘just health’ (Wils 2016:1). He (Wils 2016:2) situates this discussion within the ambit of the political, namely that medical ethicists ‘have the tendency to isolate moral conflicts from their social contexts: And for this reason questions of justice play only a minor role there’.
Second, and in relation to the above, the discussion on the social characteristics of health is of critical importance to understanding the complexity and subtlety of developing a thorough medical ethic. The two questions Wils (2016:6, 10) raises to frame this discussion were very helpful: What is the ‘good of health’ and how is it constituted? and What constitutes ‘just health’ when it is considered within the context of the social causes related to health and disease?
While Wils’ article (2016) was not written for the South African context, it raises a number of critical contextual issues that we face in South Africa. By bringing these issues into conversation with Wils’ discussion of the future of medical ethics, one is able to further develop the discourse around medical ethics in the South African context. Hence, this article takes the form of an appreciative contextual response to some of the central aspects of Wils’ argument in relation to a particularly South African health care challenge, namely the prevalence of HIV and AIDS. Of course notions of just health could touch upon a much wider range of issues than just this one topic. However, this one issue, namely HIV and AIDS will serve as a vivid example of some of the contextual and intersectional complexities of just health in the South African context. Moreover, this discussion will develop some links between this appreciative contextual reflection and the public theological responsibility of Christians and the church in the South African context.
In 2010 a series of essays written on the subject of HIV and AIDS were collected into a book entitled
This book of Forster (
Of course the reality is, as Wils helps us to understand, that complex social, economic, political and gender intersectionality impacts upon both Christian doctrine and Christian ethics.
Wils (2016:2–3) begins his discussion of the notion of ‘just health’ by placing it in relief against the backdrop of social issues, viz. ‘health as a political issue’. The book (Forster
Nosipho is just 13 years old. Tonight she is lying awake next to her 8-year-old brother and 5-year-old sister. Her father named her Nosipho when she was born. She remembers that her name has a very special meaning. Nosipho was born to her proud parents, Mxolisi and Vuyisile, in a remote part of South Africa called Northern KwaZulu-Natal. There was no work for Mxolisi and he went to the city to find work as a labourer on the roads. Mxolisi wanted to live a good life and take care of his family as best as he could. So, he faithfully brought money back to Vuyisile and Nosipho at every opportunity. He and Vuyisile were blessed with a son who they named Andile (meaning ‘the family is growing’). They loved their children very much and had great dreams for their future.
However, with each year that passed it became more difficult for Mxolisi to be alone in the city. The months that Mxolisi and Vuyisile spent living apart took a toll upon their marriage and they would often disagree and argue. Once, when they argued, he told her that ‘he had needs’ ‘like all men do’. So he decided to take a ‘city wife’ as many of his friends had done. Sadly, his city wife was HIV-positive and when Mxolisi returned home one December, himself HIV-positive by this time, he gave Vuyisile another child, Thandi (which means ‘nurturing love’), but he also gave her the killer virus that would take both their lives.
Mxolisi and Vuyisile discovered that they were HIV-positive in the year Nosipho turned 8 years old. Andile was 5 and little Thandi only 2. Thandi had already been infected with the virus her mother was carrying through breastfeeding. Sadly, both Mxolisi and Vuyisile died of AIDS within 3 years of discovering their status. Thandi, however, is still alive and now a little girl of 5 years old.
Nosipho is a clever little girl. However, she has not been to school since her father died when she was 11 years old. By that stage her mother was already very ill and confined to bed, but at least Andile and Thandi could stay with their mother, while Nosipho begged for food and money at a traffic intersection on the edge of the township. She watched the other children going to school dressed in their smart school uniforms, with book bags that had pencils, paper and, no doubt, some lunch to eat. She wished that she could be like them, but that would not happen. Her mother eventually also died.
Tonight, as Nosipho lay in bed, she was no longer a child, but a parent. Overnight she had become a 13 year old head of a household of three. She knew that she had a much greater responsibility than other 13 year old children. Each day she has to get enough money from the cars and commuters that come whizzing by to feed her two siblings and herself. She has a small cardboard sign on which she has written in a child’s handwriting ‘No parents, no food, no work, 3 people to feed. Please help. God bless you’. She also needs to get some extra money every month to help pay for Andile’s school fees. She wants him to stay in school and learn so that he does not have to suffer like his father did. She does not want him to suffer like she is suffering now. Whatever money she has left after she has paid his fees, if any, is given to the ‘aunty’ who looks after her sick sister, Thandi, while Andile is at school and she is begging at the traffic lights. Nosipho does not trust the aunty, because she drinks, and Nosipho is sure that she hits Thandi. She has, however, no option. It is too dangerous for Thandi to be with her at a busy traffic intersection.
There are other girls like Nosipho. In fact most of the child headed households in South Africa are headed by girls under the age of 15. Nosipho knows this, because she meets some of them every Sunday at the tin church near her shack. They assembled in a small group for children like her. They sing songs, listen to stories from the Bible, read to them by some kind ladies, and then they say prayers and get some food to eat. The church has also given her and her brother and sister some clothes and shoes. There is a lady from the government clinic who comes to visit their group once a month. She always asks Nosipho if she is safe and if she and her brother and sister are getting enough to eat. Thandi needs special medicine to keep her healthy, but she can only take her medicine if she eats properly, or else the medicine will make her sick instead of healthy. On days when Nosipho does not get enough money or food to feed all three of them, she lets Thandi eat first so that she can take her medicine. Andile eats next, because he cannot learn when his stomach is empty. Nosipho often lies awake at night hungry, but she knows that she is a ‘gift’ from her parents to Andile and Thandi – that is what her name means. It is the name her father gave her. She does not play anymore – she simply lives to be a gift to her brother and sister. Tonight she prayed to ask God to help her, because a man has said he will give her R20 if she takes off her clothes and sleeps with him. She prayed, because she is afraid. She has been told at church and she has seen the posters and heard the stories that this is how little girls get sick and die, but she needs the money. She wants to be a gift. She does not know what to do. Maybe God will do something to help her tomorrow. Tomorrow is Sunday and she will ask one of the ladies to help her.
This narrative illustrates in a very powerful way just how correct Wils (2016:1, 10) is in reminding us that when we consider the impact of social issues on health, medical ethics that only engages ‘health care’ could never be enough. Indeed, medical ethics must help us to move from a consideration of ‘just health care’ (Wils 2016:10) to considering the far more important issue of a socially embedded notion of ‘just health’ (pp. 10–11).
A pertinent aspect of this discussion, extrapolated from Wils’ article (2016:11), is how the problem of social, economic and gender inequality compounds the injustice of the commodification of health care and privatisation of the ‘public good’ of just health.
Wils’ article was first presented at a conference at Stellenbosch University in August 2015. The social location of that conference was deeply poignant, because Stellenbosch is the most unequal city in the world. It is widely known that South Africa has one of the highest rates of economic inequality in the world (Bowers du Toit & Nkomo
The reality is that South Africa has two very different systems of health care and two very different realities of health (cf. Nattrass & Seekings
However, as Wils (2016:8–10) mentions in his nine points on the
To my mind, these points are critical as diagnostic tools (to use a medical metaphor), but also as aspirations of possibilities for just health if framed in a positive sense. They help us to understand the truth of how unjust and unequal our experience of the health phenomenon (and by extension health care) is in South Africa where persons are separated economically, geographically, educationally and in terms of class. Of course, this also carries over into the issue of an unjust provision of health care, which our context shows we do not regard as a ‘public good’ (Wils 2016:10).
In August 2011 the South African government released a Green Paper that proposed the introduction of National Health Insurance in South Africa that would seek to raise the standard of national health care for all citizens and restrict the capacity of the private health care sector to commercialise and privatise health care. However, because the private health care sector is such a significant contributor to the Gross Domestic Product (GDP), this project faced massive opposition from powerful and wealthy groups (Mashego
The previous discussion showed the intersectional nature of just health and economic considerations. One pertinent example will suffice to highlight this issue. In 2003, at the height of the Mbeki administration’s AIDS denialism when thousands of people were dying each day because the South African government refused to roll out anti-retroviral medication, Mr Trevor Manuel, then Minister of Finance, said the following in parliament (in Gumede … the ‘rhetoric’ about the effectiveness of ARV’s is a lot of voodoo… buying them would be a waste of time and limited resources.
However, the issue was not only a matter of economics. There were two other contributors that compounded the suffering of the sick. These can be labelled as the trio of empire, economics and apathy (Forster
We have already touched briefly on economics as an intersectional component of just health. The next contributor was what Wils (2016:1-2) refers to as the political nature of health and health care. This can be related to the concept of
The project of the empire was to downplay and deny the point that persons would contract HIV through sexual contact, which, if it was left untreated, would develop into AIDS from which persons would eventually die. Rather, they stated that the primary cause of death was economic deprivation and that it had nothing to do with sexually acquired HIV. Wils (2016:2) stated, citing the example of Greece (Stuckler & Basu
A third contributor, among many other possibilities, to unjust health in South Africa during that period was what came to be termed as apathy. Wils’ (2016:2-3) reminded us of the critical ‘virtue of solidarity’ in relation to just health. The Belgian theologian Edward Schillebeeeckx, who was Professor of Theology at Radboud University, notes that without true solidarity the ‘gospel becomes impossible to believe and understand’ (Schillebeeckx
Had the church in South Africa been in solidarity with its own members, indeed with broader society, at an earlier stage in the pandemic, thousands of lives could have been saved, and the suffering of many more could have been limited.
This article has sought to contextualise and appreciate one of the central arguments of Jean-Pierre Wils’ article on the future of medical ethics. It has been argued that the South African contextual reality supports the notion that the future of medical ethics, certainly in this context, will need to engage critically with what it means to understand just health as a public good. It was argued that the Christian church has a public theological responsibility to seek a different
The author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article.
Nieman (
See for example Wils’ discussion (2016:2) of the intersectional complexity of ‘just health’ and just health care related through the case study of the Greek Medical center’s emergency ambulances.
This story was first written as a case study in the book
Refer to the succinct discussion of income inequality within the Stellenbosch municipal area in