Richard Pithouse talks to Yogesh Jain, a public health physician in Chhattisgarh, India, about his recent visit to South Africa and the state of healthcare and social movements there. Jain is committed to Rudolph Virchow’s axiom that “Physicians are the natural attorneys of the poor… politics is nothing but medicine on large scale”.
Richard Pithouse: You recently consulted with a number of frontline activists in South Africa. What were your impressions of the health issues that they are confronting?
Yogesh Jain: Yes, I had an opportunity to do clinical consultations with several activists in Johannesburg and Durban. This included South African trade unionists and grassroots militants as well representatives of various socialist movements in Zambia, Lesotho, Swaziland, Tanzania and Ghana.
In general, the people that I consulted with presented a wide spectrum of human illnesses. I was struck by some patterns that were often repeated and illuminated the very poor state of health care services for the marginalized in South Africa. But the problems faced by the leaders in these movements were different, and big, and made me worried about them and the state of movements they lead.
Residents of shack settlements told me of several examples of denial of essential health care at primary level. In my first hour of clinical consultations in a makeshift clinic in a land occupation in Thembisa, I met three middle aged women who had vision problems. This turned out to be due to presbyopia, a normal situation in everyone over the age of 40, when we need reading glasses to help our weakening eye muscles. But these women were not able to access free glasses for themselves from the public system in spite of trying several times. They were rebuffed and told to go to the private system, something that, of course, is impossible for an impoverished person.
I also learnt of user fees for public hospitals. This is alarming. Even the World Bank has declared that user fees are inimical to health care for all. I met many people who had not sought health care even when they wanted it due to worries about the expenses they would incur.
Many of the people that I spoke to in the shacklands of Johannesburg and Durban said something that resonated with what I hear from the poor in Indian villages. When I asked why they didn’t go to the public hospital next door and instead chose to go to a private clinic, they would say they don’t feel respected in the public hospital and do not get dignified attention. This is exactly what I hear from the poor in India, who would often take loans they can’t easily repay to be able to visit a private clinic when they could have received the same drugs from a doctor in a public hospital. The questions of respect and dignity are often overlooked but they are fundamental. Struggling for this crucial aspect of quality of healthcare in our public facilities is a key challenge for health rights activists.
Perhaps the most common physical problem that I saw was related to poor diet. Many young people were obese or overweight. Over time I saw that most meals have an excess of refined starch meals and a load of sugary drinks. I recall walking into an otherwise well organized children’s creche where the mid-day snack was four large slices of white bread and some processed meat and margarine to be washed down by a 350 ml cup of sugary soda.
Given this, it is no wonder that I saw muscle, joints and back issues in large numbers, as well as diabetes in large numbers. Many people also complained of personal image issues, of struggles with self-confidence.
Leaders under stress
I was also very worried by the state of health in which I found almost all the activist leaders. They all live under intense and chronic stress. 80% of those who consulted me complained of poor sleep. Many people ate poorly and erratically, usually eating unhealthy food in a rush. Many had put on excess weight. Almost none of the leaders that I met did any regular physical activity. They often told me that they just didn’t have the time. One of the senior leaders had not found time to get a one-minute blood test done for possible diabetes even though he had been suffering with symptoms suggestive of diabetes for five years. Unsurprisingly, some have found refuge in alcohol to handle stress.
Many activists had not kept their appointments with their doctors, and some were leading miserable lives living on grants from the state and just able to get enough food, often unhealthy food, to survive. Organizations don’t have the resources to materially support their impoverished members.
Considering the state of health of the activists in South Africa I met with, I cannot but be worried about the health of the movements these activists lead. Stress prone activists are always at risk of burnout, which makes them move away from the cause they fight for, but can also harm the ethos of the movement. Movements led by people who are generally deprived of sound health and are chronically sleep deprived, and sometimes self-medicating with alcohol, run real risks.
But there were some encouraging signs. I gathered positive impressions of the awareness of these problems among the leadership of Abahlali baseMjondolo (AbM) and the National Union of Metal Workers of South Africa (NUMSA). Without exception, they realized the importance of seeking healthcare when they fell sick, but also instituting preventive strategies to ensure the good health of the activists by organizing work well, ensuring adequate physical activity, healthy eating, and introducing sleep hygiene.
RP: South Africans generally eat an unhealthy diet with, as you observed, lots of refined starch and sugary drinks. But there are some interesting, although scattered, experiments underway that link land, autonomy and food. More and more grassroots projects in which people produce their own food – mostly vegetables but also chickens – are being developed. Do you see this as something that could be connected to building a politics around health?
YJ: Yes, growing part of the food one eats is an important step forward, but on its own it is not enough. There is also a systemic aspect to the food question.
There is an intimate relation between agriculture, food, nutrition and health, which is best understood if most of us get involved in all four areas. Usually the first one, agriculture, is neglected at a societal level as we move away from land when society ‘develops’.
Capitalist food economics and market forces affect all four of these areas of human life. We have diminishing control over the seeds we use, the fertilizers and agricultural practices we use, how food is processed, which foods are advertised, marketed and made available, and who gets adequate food. Addressing this requires systemic change.
Discussions about food and health need to be built into movement work along with questions like land, labor, gender, repression and so on. There are a number of useful questions to begin this work. People can begin by asking whether the food we have is adequate in terms of quantity and quality. The next question that arises is why we all cannot afford to consume the quantity and quality of food that we need, and how the state supports us in attaining our right to sufficient healthy food. Further questions pertain to who grows this food and controls the choice of food crops that are cultivated, and who controls our food markets? Are we as a nation food sovereign? These are all critical political questions. The production, quality and distribution of food are all issues that need to be politicized.
I understood that a large part of the food that is eaten in South Africa is not grown in the country, or even the region. This is strikingly different from many countries where most consumers of food are also producers of their food or proximate to the producers.
Growing some of the foods that we consume makes us have some control over what we eat in terms of quantity and quality. The experiments of which you speak clearly enrich the quality of food as well as give people access to sufficient food. For example, the green leafy vegetables that are grown on occupied land are a good source of water-soluble vitamins as well as antioxidants. Agriculture choices such as not using pesticides or chemical fertilizers not only makes some healthy and safe foods available, but undertaken in a collective, also makes a political statement. Growing food together also makes group processes strong, which is useful for other political actions.
But outside of these important experiments, food is generally a non-political issue in South Africa. Is it because South Africa has not had any significant agrarian movement and most consumers are not cultivators? Recapturing our power over the food that we eat by determining who eats, how much one gets and what one eats are all essential questions to ask as we build our politics around food.
RP: Sugary drinks are ubiquitous in South Africa, including in activist spaces. So too, of course, is diabetes. Is this familiar from your experience elsewhere? Has it been something that has been confronted politically?
YJ: Sugary drinks are almost exclusively processed drinks with soda, and very large amounts of sugar and some other stuff like phosphoric acid. They have a lot of empty calories. A liter of Coca-Cola has about 110g (almost 24 teaspoonful) of sugar and about 600 calories, all coming from carbohydrates with no proteins and fats.
Coupled with other food such as refined maize, which is largely carbohydrates, they pose stress on the pancreas in our body (the organ that produces insulin which controls our glucose levels in blood), increasing the risk of developing diabetes. For those who already have diabetes, a common affliction in South Africa, sugary drinks make control of the disease very difficult. Of course, drinks with almost 24 teaspoons of sugar per liter also escalate the risk of tooth decay.
The ubiquity of these kinds of drinks is common in rapidly industrializing societies, where control over our food systems and habits are being lost. For example, all over Mexico and several other Latin American countries, and in cities of South Asia, there is an equally worrisome trend of consuming these industrial foods, with the same damaging consequences for people’s health.
These sugary drinks are products of multinational corporations that use aggressive advertising to influence people. The name Coke or Coca-Cola is interesting. Earlier versions of this over-100-year-old drink were laced with a small amount of cocaine to increase its attraction and sales. But now, even without any addicting substances, sugary drinks are still psychologically addicting. There is an urgent need for societal control over what snacks and drinks are allowed to be sold in neighborhood markets and shops.
In Finland, in order to prevent many non-communicable diseases such as diabetes, an effective country-wide project used community-led primary prevention strategies as its bedrock. These mandated local self-governments, such as town municipalities, to decide which snacks could be sold and with what labels in their own areas. There is much to learn from this successful project.
RP: Since you left South Africa there has been an escalation in political repression including assault, arson, relentless arrests on bogus charges, and assassinations. Many people are acutely stressed. Sleep is a particular issue, and something that movement leaders often struggle with on an ongoing basis. Do you have any thoughts and recommendations on this question of stress? Any particular thoughts on the question of sleep?
YJ: Repression leads to insecurity and uncertainty about what might happen, and is extremely stressful to both the body and the mind. Stressed people will fall ill more frequently due to common physical illnesses, or their pre-existing illness might worsen. For example, someone who already suffers from diabetes will suffer a worsening of their disease. Coupled with this, repression often makes it very difficult for people to continue with self-caring strategies such as adequate and balanced diet, exercise, sleep and other social roles that individuals have to play.
But the larger effect of stress is on mental health. Anxiety, feelings of helplessness and depression, often with suicidal ideation, are common. Sleep, which is a good barometer of a sound mental state, is one of the first bodily activities to suffer. Problems such as difficulty in initiating sleep, frequent awakening, premature waking up and not feeling refreshed after a night long sleep are common. If poor sleep persists over many days, it affects heart health, control of diabetes and hypertension, and a host of other illnesses.
When repression is ongoing, as it has been for many activists in South Africa, then stress is chronic. This can cause several illnesses and complicates many more. Activists are usually already stressed but when they must confront repression the situation can be dramatically worsened with serious consequences for physical and mental health.
My own assessment about the prevalence of sleep issues among social activists is that it is already rampant, with over 60% of them reporting significant issues. This could have been minimized by group decision making to organize work times, keeping guarded time for leisure and family time as well as for having some regular physical exercises each day. Practicing principles of sleep hygiene would seem to be urgent. These include bedtime rules as one prepares for sleep, dietary and physical arrangements near sleep time, and use of alarms and carefully controlled use of sleep-inducing medicines when needed.
I would go as far as to suggest that absence of sleep issues among the cadres could be kept as a benchmark for good mental health of our communities. Can our leadership take a call on this?