“Malawi Health Service Ailing from Brain Drain”

By Alison Duncan

“Brain drain” is a phrase which has come into common use in recent years, as it refers to an issue which is of increasing importance throughout the developing world, particularly on the African continent. The issue interests me because it has a huge impact on the functionality of many countries’ economic, educational, and health care systems. The case study represented here, by Malawi, is paralleled in countries all over the world. I found it particularly interesting to compare its situation in Malawi to that of South Africa, a much wealthier nation in the same region. Without ever explicitly stating so, the article challenges our society to find a solution to this growing problem which is often overlooked when considering health care challenges and crises.


This article was printed in the South African newspaper The News and Guardian and addresses the brain drain crisis in Malawi, though the issues brought up are by no means exclusive to that country. It starts out by giving a personal story of a Malawian nurse who has decided to leave her home country in order to make more money in Britain. Cases like hers are becoming increasingly common in Malawi, according to the article, where an estimated 120 registered nurses have migrated to Britain and the United states every year for the past ten years. The article implies that this brain drain is due to salary, stating that the “Health Ministry is unable to even begin to match the wages on offer abroad.” Malawi’s crisis is particularly acute because there is such a need for health professionals given the HIV/AIDS epidemic in that region, which makes it all the more upsetting when those who are able to provide services choose to leave.


The article notes that “14% of the country’s population is infected with HIV,” and that it has only “56.4 nurses and 2 doctors for every 100,000 potential patients.” This is well below the World Health Organization’s recommended minimum of 100 nurses and 20 doctors per 100,000 people, and that recommendation does not take into account the added strains of such a large population infected with HIV. By comparison, South Africa has 393 nurses and 74.3 doctors per 100,000, which is more than adequate. In the rural areas the crisis is at its worst, with a vacancy rate for nurses at 60% according to a survey by the Ministry of Health.


Interestingly, Malawi’s government recognized the problem three years ago and “launched an emergency plan… which saw health workers receive an average 52% pay rise… and aimed to strengthen training capacity, repatriate professionals and fund recruitment of foreigners.” The Malawian Health Minister Marjorie Ngaunje noted that “there are serious problems…Malawi needs to train 1000 nurses annually if we want to arrest the situation.” She pointed to the necessity of increasing intake at nursing colleges as a primary solution. Doctors without Borders is concerned that the Malawian government’s plans to provide free anti-Aids drugs are going to be compromised given the healthcare worker shortage. They are quoted as saying that “it is evident that the rapid scaling-up of ARV therapy… will be limited by non-availability of adequately trained nurses, clinic officers and doctors.” In all, the article convincingly illustrates the severity of the problem and the urgency with which it must be dealt.


I always associate the issue of the brain drain with the healthcare worker shortage because the two are directly and inextricably linked, as the Malawi case clearly demonstrates. The cyclical nature of the brain drain is underscored all the more by Malawi because of the exacerbating effects of the AIDS epidemic there. Essentially, healthcare workers leave to get higher pay, which shortens the staff in over-crowded hospitals and clinics, which then causes healthcare workers to leave in order to recognize a pay increase and escape the pressures of being short-staffed, which makes healthcare workers want to leave, and so on. To my mind, the key to solving this problem is not to get bogged down in the cyclical parts of being short-staffed and over-worked, but to tackle the primary cause. This article suggests that a desire for an increase in wages is the main causal reason that nurses and doctors leave their countries. If this is true, then it seems obvious that the salary discrepancy between countries must be eliminated and benefits drastically increased. I was also struck by the idea that healthcare professionals in these countries are seemingly no longer satisfied with their jobs intrinsically, because they are seeking extrinsic benefits overseas as opposed to within their own countries where they could be of greatest help. In my opinion this is a very big problem, as it indicates a decrease in healthcare workers’ genuine interest in administering aid to needy patients. As far as dealing with that issue, I am not sure what the solution is, or even where to begin. If our healthcare providers are no longer interested – at their core, regardless of pay – in providing healthcare, then we are indeed in trouble: not just Malawi or other developing countries suffering from the “brain drain,” but the world as a whole.

The Joe Slovo Informal Settlement

By Alyson Zandt

On a recent weekend, the Weekend Argus ran an article entitled ‘Youths at forefront of Joe Slovo protests.’ This article is chronicling the involvement of the youth in last week’s N2 Gateway protests by residents of Joe Slovo, the informal housing settlement named for perhaps the most famous white activist in the Anti-Apartheid movement. The government is currently implementing a plan to advance the economic situation of communities directly alongside the N2 highway. This project has two primary goals: to improve the circumstances of the numerous residents of informal settlements flanking the N2 and to make Cape Town more appealing to tourists and international investment. The N2 is the main thoroughfare between the airport and the city, and as a result it is the first impression of Cape Town that visitors have.


Because the government would prefer investors and tourists to view development rather than abject poverty upon arrival, a plan was developed to move residents of communities out of their shacks so that formal housing could be built in the area. As the article discusses, this means uprooting an entire community and moving them to a less desirable area. When the formal housing is completed, there will not even be enough room for everyone to return. Today I was in an informal settlement in Atlantis. Despite the housing backlog, the informal houses are slowly being replaced by government houses. In this case, the residents remain in their informal homes until the formal housing (just on the other end of the settlement) is completed. This would not work in Joe Slovo because there is no undeveloped land nearby for the government to build on, but it does show that not all removals are so negative for the residents.


The N2 Gateway Project has been in the works for several years now, and it has been in no way secret. Only recently have the protests begun, despite the awareness in Joe Slovo of the planning that was occurring. The reasoning for the recent uproar is unclear, but it could stem from the shift in government priorities. There was a program withtin the Office of Social Development that was tasked with communicating with those that would be affected by the N2 Gateway Project, but it was halted with the change in the local government. Since one of the problems is the residents of Joe Slovo not being informed of the process and another is that the government is unclear of the specific concerns and realities of Joe Slovo residents. Another possible reason is the current national tide of protests which began in Soweto and have spread to other urban centers.


This article was particularly interesting to me because I was inadvertently caught in the middle of the thousands gathering to go to the Cape Town High Court. They choose to march towards the court after gathering around the Phillip J. Sauer Building downtown—which just so happens to be where my office is located. Walking out of your office to be greeted by a mass of thousands of angry (but decidedly composed) protestors is a tad disconcerting. I found myself curious to know more about their reasons for gathering, but as a lone white female (and employee of the City) I thought it best to make my way through the large and intimidating crowd and continue on my way.


The connection to health of this situation is obvious—conditions in informal settlements are unsanitary, hazardous, and conducive to a variety of diseases and health risks. However, mental health is often overlooked by the development field, and the strength of community felt by Joe Slovo residents should not be disrupted without due consideration. Additionally, the proposed move to Delft will carry with it new heath concerns. The residents raise concerns about the cold and transport. Because of the more difficult transportation system in Delft, the youth would not be able to reach school or employment as easily. This means more down time and the loss of their support network, which increases risky lifestyle choices.


This situation has taught me a very important lesson about development—your view of progress as an affluent outsider is not necessarily shared nor is it always correct. While it is important to fight against poverty, traditional methods such as providing formal housing are not automatically the best option. It is essential to make sure that the people involved in orchestrating development (whether it is the government, civil society, or private interests) must emphasize communication and dialogue with the people ‘benefiting’ from the development. Culturally important aspects of peoples’ lives, such as a strong sense of community, should not be undervalued.

Failure of Vaccine Test is Setback in AIDS Fight

By: Jillian Casey
October 4th, 2007


This article came as old news to me as word around the office was already buzzing about the cancellation of Merck’s vaccine trials. The only piece that was new was the aura of an overwhelming loss that I have not perceived here in the HIV-fighting community of South Africa. The Desmond Tutu HIV Foundation was already almost a year into the vaccine trials when the plug was pulled and defeat admitted by Merck and infectious disease experts alike. To my amazement, I have yet to witness any surprise or disappointment from my colleagues at work. There are no gray clouds over anyone’s heads, no gloomy faces, and not even a whisper of acknowledgement of the loss this community has just incurred. It makes me wonder: What faith does the developing world, and concomitantly, the populations most ravaged by HIV/AIDS, instill in vaccine trials as the potential knight in shining armor to slay this human predator? I can’t help but suspect that defeat was actually expected at the DTHF, and for that reason, the news was not received as defeat at all. What I really want to know is why.

The New York Times article, Failure of Vaccine Test is Setback in AIDS Fight, embodies the disappointment and frustration of the Western World in the war on AIDS. I have to wonder why American journalists, multinational Big Pharma executives, and western medical culture as a whole, are more distraught over the failure of Merck’s drug than are the very people who witness the devastation of HIV/AIDS on a daily basis. Granted, I have not had the opportunity to pay a return visit to the DTHF’s vaccine trial center since the cancellation of the trial, but I would still anticipate a more heartfelt reaction from those in the head office (who are running the show) than I have thus far observed. In fact, upon questioning a few coworkers, I have even discovered that many of them are not aware of the response or the impact this has had on the organization or the HIV community at all.

So how can this be? The best answer that I can come up with is that on the ground in South Africa, where almost a quarter of the population is infected with HIV, there is no time to waste hoping for a successful vaccine. The doctors and medical professionals here cannot wait years for the approval of a vaccine because people are dying by the day. Parallel to the argument that those who live in poverty can only afford to think of today, so too must the doctors who work for the impoverished focus their efforts on the present. To expend energy on vaccine trials, and therefore divert energy away from ARV treatment by impact of opportunity cost, one is jeopardizing the lives of those already infected. In the developing world, where resources are stretched to exhaustion, the dream of an HIV vaccine can only be entertained with promise of outside funding and staff so as not to pinch the pockets of the already under-funded treatment programs in existence.

Even still, when funding is provided by the NHVTN (National HIV Vaccine Trial Network) from the States, and PEPFAR has leant money for the staffing and supervision, how then can the doctors closest to the cause not feel a surge of distress when they learn that another effort has failed? Perhaps it’s because it is the very doctors who are so involved who can understand and appreciate the gap between our understanding of and our ability to eradicate this virus. Doctors know that HIV is a biologically simple virus; they know that it can be prevented and even treated. But they respect that we are a long way from grasping how to vaccinate against it, and so they leave that task to those with the time and money to take on such a challenge. They let those who do not have to listen to the coughs of dying parents and look into the faces of children who are soon to be orphans on a daily basis worry about the long-term struggle.

Perhaps these assumptions are entirely inaccurate. Perhaps I am just struggling with my own romantic hopes of a vaccine versus my practical plans for life-saving today. I can say that being in South Africa, and working for an organization participating in the trials when a promising vaccine is pulled, has not at all produced the response I would have expected. As time goes on, I suspect I will find a greater understanding of why such setbacks are received so differently across cultures. I often feel as if I am just an outsider here, window-shopping through the confusing streets of South Africa’s public health network. But this lens lends me the benefit of seeing things from a more patient eye, one that can project into the future because my today is not so desperate. In talking to the doctors at the DTHV, I see in their eyes that nothing has changed since the cancellation of the trials. Tomorrow, like today, they will again face patients whose CD4 counts are plummeting and whose T cells are being assassinated by opportunistic infections. Either way you like to look at it, they are either not as fortunate, or not as naïve as me and my western counterparts in their investments in an HIV vaccine initiative.

I can only hope that these seemingly separate communities can merge at some point and the vision of tomorrow can be reconciled with the reality of today. Because even though a vaccine would undoubtedly be the most valuable development in the global campaign against AIDS, it is important to remember that treatment and education cannot suffer in the name of a prospective solution.

WHO Expert Addresses Vaccination Achievements and Challenges in Africa

by Deborah Bender, PhD, MPH

Dr. Rose Jallah Macauley, WHO Coordinator of Routine Vaccinations and New Vaccine for the Africa Region, visited Cape Town to share her expertise with UNC Honors Students this past week. Dr. Macauley, an alum of the UNC School of Public Health, received her MD from the University of Liberia and an MPH from the Department of Maternal and Child Health in 1987.

The focus of her remarks was on the Global immunization Vision and Strategy (GIVS) developed by WHO and UNICEF for 2006-2015. The GIVS sets a number of goals to be achieved by 2010 and another set by 2015. The immunization coverage goal for 2010 is that all countries will attain 90% DPT3 coverage at national level and 80% in all districts.

For the past 4 years African countries have be implementing the Reaching Every District (RED) approach to improve and maintain high immunization coverage. The 5 operational components of the RED approach (Re-establishing outreach services, Supportive supervision, Linking with the community, Monitoring and use of data for action, and Planning and management of resources) were chosen to re-energize immunization delivery in the Africa region and to provide management infrastructure sufficient to enable local districts to reach their targets.

Dr. Macauley reminded her audience that measles mortality reduction remains very important in Africa. The GIVS Measles Mortality Reduction Goal which challenges countries to reduce mortality attributable to measles by 90% by 2010 as compared with 2000 levels. The strategies being used to attain this goal are: Catch-Up campaign, Follow-Up Campaign and Keep-Up Campaign. The Catch-Up Campaign which targets infants and youth up to 15 years of age is unique in global health strategy because of its extended the age limits.

In addition to the measles mortality reduction, Dr. Macauley also spoke about other accelerated disease control initiative, including polio eradication initiative, yellow fever control and maternal and neonatal tetanus elimination.

The polio eradication initiative has 4 strategic areas: strong routine immunization achieving >90% OPV3; supplemental immunization activities (NIDs, SIDs, Mop ups). WHO and it partners have focused major efforts in Nigeria, the only polio endemic country in Africa, to interrupt the transmission of wide polio virus. While great progress has been make in reducing the number of wide polio virus cases, there still have been isolated reports of the occurrence of vaccine derived polio virus (VDPV) cases reported in Nigeria. Risk factors associated with the VDPV in Nigeria are said to include: Low routine immunization coverage, poor sanitation, over crowding and the tropical condition.

With regards to the introduction of new vaccines, over 80% of African countries have introduced Hepatitis B vaccine while about 50% have introduced Haemophilus influenzae type b vaccine.

Dr. Macauley reminded the audience that childhood immunization is one of the most successful and cost-effective health interventions ever. During the 1980s, under John Grant’s leadership at UNICEF, vaccination rates reached new high levels. However, during the 90s, during the years when the global funding shifted priorities (e.g. combating of the emerging HIV/AIDS crisis), vaccinating the world’s children took a back seat. Immunization coverage either stagnated or decline in most countries in Africa. Estimates are that 2.5 million children under five years of age die every year as a result of diseases that can be prevented by vaccination using currently available or new vaccines. Dr. Macauley expressed confidence that the innovative integrated approach of the GIVS Strategy will achieve its 2010 and 2015 targeted goals.

We Have a Long Way to Go

By: Deborah Bender, PhD, MPH

I met Mirriam Goa at National Heritage Day. She heard from a mutual friend at the gathering that I was a public health person and, immediately, she introduced herself to me. She told me that she was a public health nurse and that I must come to visit her program, Ilinge Lokuphila, in the Guguletu Township.

Yesterday, I went to visit Mirriam. The Township lies 20 minutes outside of Cape Town, on the N2 highway, just south of the Cape Town International Airport. It is the second oldest township in the Province. I listened, intrigued, as Miriam told me about the home visiting program she and other women in the community have created together. Mirriam worked as a staff nurse in a Home for the Elderly in Cape Town for many years. Though she is retired now, she is not about to slow down! She and the 18 others – all volunteers -- regularly make home visits to elderly residents in the Township. They help out with bathing and feeding and ensuring that each resident is taking medicines according to doctor’s prescription. When necessary, they make referrals to the social worker or to hospital.

Mirriam stops mid-sentence to add – these problems, --the isolation of the elderly -- they are caused by people, by these people’s own children not coming to care for their parents. This is to say, that in African culture not caring for one’s parents is almost unimaginable. But, today, despite Mirriam’s sense of disbelief, this is happening.

When Miriam or one of the volunteers makes a home visit, they sometimes uncover other unexpected problems. Sometimes a daughter has left her children with her elderly mother to go to work. Other times, it is more difficult; the children may live permanently with the elderly relative because have been orphaned by AIDS, which has taken a parent’s or parents’ lives. The hardest for Mirriam to accept is that some of her elderly, themselves, have contracted HIV/AIDS through being unaware of protective precautions necessary when caring for an infected adult daughter or son.

It is hard to talk about AIDS, she tells me, because there is still a lot of stigma associated with the disease. People infected with the disease are often forced to leave their homes and shunned by friends. So, no one talks about the disease, and the disease is left to spread silently through the community.

The home visiting program is vital to the community, but Mirriam wants more. She would like a larger space where community members could meet and share a noon-day meal. She would like to use the same space to create a support group, to help people infected with HIV/AIDS and their families. “Now,” she explained, “If a daughter discloses, she’ll tell her mother first above all. But, often her mother will deny what her daughter has told her. It is just too hard to accept.” Mirriam believes that people need a place where they can learn about the disease, and where they can learn how to talk to one another about AIDS. “The way to take apart the stigma is to talk about it – to talk about it directly, “she added parenthetically.

Mirriam says that TB is also a problem in the community. Again, sometimes people do not take their medicines. But, in this case, Mirriam thinks that it is the doctors who prescribe the medicines who do not understand the community well enough. One of the volunteers made a follow-up visit to the home of a man who did not return to the clinic for his TB meds. The volunteer asked him why he did not come. He answered, simply, “The doctor told me to come back for my medicine after I had eaten. I haven’t eaten. That’s why I didn’t come.”

Mirriam and the other women of Guguletu, the volunteer home visitors, are busy. They work from 9 to 5, and sometimes evenings, too. Still, there are more homes they would like to be able to visit; meeting space to be negotiated with the City of Cape Town; and, additional services to be offered. A garden promotion program would help in providing improved nutrition and needed micronutrients for community members. She also imagines creating a park with swings for the children to play in. A crèche for the very young children right next to it would be ideal. "We have a long way to go," Mirriam concludes as other volunteers in the room nod in agreement.

A New Man: Interviewing Yesterday Star Kenneth Khambula

By: Andrew Daub

Men are complicated creatures. Confronting the many roles of son, brother, lover, and friend, men often struggle to find a sense of masculinity that anchors their existence. It is when this masculinity is threatened and forced to change that angry floodgates of insecurity open. What exactly is released in those floodgates? Just ask Kenneth Khambula, star of Darrell Roodt’s Yesterday, a 2004 South African film that hit the big screen and Oscar-nominated stage thanks in part to HBO Films. By taking on the role of Yesterday’s husband, Khambula unearths a sharp reflection of the changing tides in masculinity that have stunningly swept across South Africa as coattails of the HIV/AIDS epidemic. New York Times wannabe correspondent Andrew Daub reports in an interview tracing a performance that probes at the shifting culture of masculinity and the raw core of the once beaten down, then newly defined South African man:

AD: Yesterday exposes many ugly and beautiful heads of the HIV/AIDS epidemic, especially how it manifests across South Africa. With Bono, Angelina Jolie, Desmond Tutu, and the folks at UNICEF branding HIV/AIDS as the trendy global issue du jour, what made you jump on board with this particular project?

KK: Well, Darrell Roodt is a genius, so when the script fell into my lap, I just – well, you saw the film – I just couldn’t resist getting in on the action. It is true that HIV/AIDS is a buzz issue and Africa is the topic of conversation. But that’s the funny thing, you see. We’re talking about those Africans dying of HIV/AIDS. We’re hosting conferences and writing papers and reading books and sending our checks in support. But that’s where the conversation ends. People don’t really know HIV/AIDS. And Africa certainly is not the place to be, if you ask many of the people I hope got around to seeing this film. I suppose this frustrating dichotomy of talking about these issues and actually doing something about them is why I found Darrell’s vision so empowering and, quite honestly, necessary. Darrell just has this way of covering so much ground in the hour-and-a-half film. I mean, audiences basically leave the film with the social nuts and bolts of this epidemic. This movie has a lot to say about a lot of things that need to be said. Take my character, for instance. Everyone who is talking about HIV/AIDS is out there hating on men, rounding up the troops to bring in the sugar daddies and wife beaters. But that’s only the surface of what really is going on in these men’s lives. It’s just the tip of the iceberg.

AD: You are exactly right in that Yesterday’s husband brings many complexities to the table. Considering that your first scene has you abusing Yesterday, how did you manage to still create a sense of sympathy for your character?

KK: Yes, it’s quite an introduction for a character. The audience hears these good things about Yesterday’s husband, and you definitely see how her face lights up when she arrives in Jo’burg. Unfortunately, the physical abuse Yesterday suffers is all too common. As an actor, I saw the need to do my character justice. To show the ugliness of his abusive tendencies and slowly work in, you know, hone down on his more redeeming qualities. As a man and simply as a human, I wanted to convey the darkness and light we all carry as individuals. Much of why Yesterday’s husband is so violent lives in that darkness. There is ignorance, fear, intimidation, even guilt before the guilty act. There is his burden of infidelity, which I think the movie washes over, but yes – that burden is present, lurking inside of him in those first moments in the abuse scene. But Yesterday’s husband is hardly static. No one really is one-dimensional. Showing the good old days as Yesterday leaves Jo’burg for home allows the audience to see my character as more than just an abuser. And of course, the rest of my time in the movie speaks to the tremendous complexities built up inside of him. When my character comes home toward the middle of the movie – I think it’s then that I am able to stir up sympathy in the audience. He’s a victim, too. His confession of stinking like an animal, shitting everywhere, getting beaten and fired – and doing it all in tears in front of the woman he abused and loved at the same time is really explosive. There is so much pressure involved in disclosure. And I’m not talking just about disclosure of HIV status. There is a broader disclosure of guilt and recognition of fear that are just as if not more important. It takes guts, because that kind of disclosure forces you to recognize both the loss of so much good and the inheritance of some really debilitating pain.

AD: You bring up a very insightful point about the links between what is lost and gained in the mix of this epidemic. The movie largely pits the joys of the past against the misfortunes of the present. As a whole, the film taps into the idea of cherishing good memories in hopes of offsetting the losses of today. Do you think men like Yesterday’s husband are similarly trying to hold onto whatever good is left?

KK: Oh, absolutely. Look, men are a big part of this epidemic. They are, I think, the missing link in our fight. There is a need to educate men, to inform them about healthy communication and relationships. To eliminate the violence and shift our focus on developing strong partnerships and more open-minded, tolerant, and especially honest lifestyles. And that’s just not where the money is going. And that’s not really what we’re talking about either. When we are bringing men into the discussion, we only focus on how men are the bad boys of HIV/AIDS – which is hardly helping out matters at all. Men like Yesterday’s husband are everywhere – confused, scared, struggling to live. We need to help these men get over their guilt and pain. How else are we going to move beyond such violence and anger? I just don’t see how we’re going to win the fight against HIV/AIDS, poverty, really anything without men on the world’s side. I’m not saying that all men are suddenly off the hook. We just need to realize that guys have feelings, too. And right now, many of them are just as beaten down and intimidated and unsure as women. At the root of all of this is the fact that we are – at our very core as human beings – unhappy, plain and simple.

AD: So if happiness is only a part of our personal and global yesterday, then what keeps us going on? Why put up the fight at all?

KK: Because that is what we do. We live. We fight for the people we love, we fight for our passions, we fight for ourselves. Above all, that is what the film is addressing. Life has no alternative. Yesterday sums up that idea perfectly when she asks the doctor if she is to just stop living. No. Unequivocally, absolutely no. Yesterday comes to understand that life is more than the fight. More than accepting what is gone. That Yesterday finds forgiveness for her husband and survives to see Beauty’s first day of school show that not all is lost. That happiness is still possible keeps us going. When you cut away all of the filth of this epidemic – and really, the grime of all of our world’s problems – you find not just joy. You discover the joy of joy. The joy that gets us through each day, overcoming the bad and ugly of our world in order to deliver us some much needed good.

AD: So if this movie really does put out the good, the bad, and the ugly, what can we take away from your character? With all of his demons, is there a new man flourishing inside? Who is he and how is he fitting into the big pictures of HIV/AIDS, South Africa, and the world?

KK: There is a new man out there. A man of strength and humility. Today’s men aren’t just breadwinners or abusers. Not all of them are off having affairs or ignoring their children. Perhaps, these men of a new breed are hard to find. But I wholeheartedly believe that they are out there. In fact, I would go so far as to say that all men are capable of broadening our concepts of masculinity. The change in my character speaks to how even the most guilty can grow. Yesterday drives home complexity above all else. And if we’re dealing with issues and countries as multifaceted as HIV/AIDS and South Africa, then we need to understand that the people living those experiences embody just as many complexities. And if the new man really is out there – and I think he is – then the big picture is brightening up. Hey, this new man is no cure. But he is a role model, a step in the right direction. And how can you say no to that?

AD: I don’t think you can. For a low-budget film, Yesterday bites off a considerable amount of serious issues and certainly does offer some much needed momentum. For all of its overwhelming weight, the film seems to have found a distinct place on the DVD shelf. People all around the world know this film. Is Yesterday the little movie that could and did attract unexpected audiences, or does HBO Films’ support imply that a film about HIV/AIDS set in Africa needed some extra help to reach so many people?

KK: Well, I would certainly hope that our movie stands on its own merits. HBO Films definitely deserves major kudos for helping us financially and getting our film out to multiple time zones. I think the low budget and family-like production gave Yesterday an intimacy that catered to audiences. So in a sense, I do think we are the little movie that could. Independent and smaller scale productions usually are holes in the walls of our film world. Of course, it’s unfortunate that some of the bigger kids on the Hollywood block aren’t getting their hands wet with all of the real life issues found here in South Africa and elsewhere. But we all know money makes the world go round, and we little guys have to make do with what we have at our disposal. Even if we aren’t creating box office hits, we make films because they count. Because they speak for the silenced and marginalized. Because they poke at the things many people want to ignore. So yes, it would be so empowering to see more films like Yesterday get made and shipped out beyond the film festivals, artsy theaters, and cable television packages. I do hope that the real Africa – and not the Bono-driven continent seen on headlines – gets more and more time on the big screen.

AD: So what about the prospects for a Tomorrow hitting that big screen?

KK: There is such rich material here in South Africa that I do think something like a Tomorrow will be made. A sequel would be great, although I’d obviously be out of the picture. If nothing else, I hope that we keep making movies and people keep watching them. After all, there is no business like show business.

Kenneth Khambula also starred in I Dreamed of Africa. He is presently unattached to any film project. Andrew Daub is currently juggling a 20-25 page research paper, a personal blog, and the beginnings of his take on the next great American novel.

Staffing in South Africa's Health Care System

by: Deborah Bender, PhD, MPH

Cape Town, South Africa is indeed one of the most beautiful topographical settings I have ever visited. Behind me, just out of the kitchen window sits Table Mountain. The mountain, the coast, the gardens – they are each just a bit more striking than I had anticipated.

A second expectation I had on arriving in Cape Town was that health conversations would be all about HIV/AIDS and how best to contain the epidemic through distribution of anti-retroviral and advocacy for behavior change.

On September 1, just a week after my arrival the Weekend Argus Newspaper of Cape Town published an article titled, “Health staffing crisis ‘wrecking the Aids [sic] battle.’”
The article focuses on a recent meeting to discuss the crisis of human resources held recently in Johannesburg. “The government needs to hire an extra 1,000 doctors, 3,000 professional nurses and 700 pharmacists by next year to successfully deliver anti-retroviral medicines to millions of HIV-positive South Africans using public health care.”

The gaps in the public health system are not lack of medicines or even the high cost of the treatment. The 80% of the population who receive health care through the public health care system must cope with understaffing of public health facilities estimated to be between 30 and 50 %.

Reasons for the staffing shortage include the migration of doctors and nurses to the UK and to Canada, the flat budget of the public health system during the past ten years and the huge increase in care needs due to rapidly increasing rates of HIV/Aids [sic].

A follow-up article appeared on September 5, indicates that staffing shortages are not only affecting the public health system, but also major tertiary hospitals such as Groote Schuur, Tygerberg and the Red Cross Children’s hospital.

The availability of effective and low cost medicines for the treatment of HIV/Aids in South Africa is only the tip of the ice berg. The staffing shortages threaten to affect not only the ability to deliver services, but also the quality of the services the people of South Africa receive.

Born in Different Places By: Robin Fail

I find the article “Living Next Door to a Waste Dump” published in the Cape Argus Newspaper on August 11, 2007 very disturbing for a number of reasons. Upon first glancing at the article, I found myself most disturbed by my response to the first paragraph, in which the Rooidakkies informal settlement is described. The settlement is described as “under-serviced” and “filthy”, however I did not take time with these words on my first reading, rather, I skimmed right along, hastily searching for the meat of the article, the exciting, important parts. For some reason, that first time, I failed to see the importance in the description of Rooidakkies. I am ashamed to say that to my naïve American brain it seemed… routine. Could two weeks of living in Africa honestly have made my brain process filth as routine? I thought that I was supposed to become more attune, more sensitive to these problems! Without even realizing it I had thought, “Obviously it is filthy, obviously it has unacceptable health standards, it is a township, duh!” But as I read on, the truth of the article sank in; the words took on their dreadful meaning.
The woman in the article, Nosithile Sesimani, lives beside a waste dump and she doesn’t even want to leave. Why? Because she only gets R870 per month to live on, which, according to my rough estimates, totals around 120 U.S. dollars, which is far less than I have spent in my mere two weeks in Cape Town. Where would she go, if she left? What other options does she have? If I were Mama Sesimani, I would have no choice but to visit the neighborhood dump in search of salvation. But I am not Mama Sesimani, so when I run low on funds, I will email my mother, who will (hopefully) help me out. How can I live such a different life from someone, despite so many similarities? We are both humans, we are both women, we both live in Cape Town, we could both say hello to each other if we passed in the street. So why the discrepancy?
I can’t answer the question of ‘why’, but I can look at the facts in search of how this situation came to be. The facts are as follows: “the Department of Environmental Affairs had ruled that it would not require stack emission”, the director of City Development Services believes that “‘Rooidakkies is a very small settlement and in the context of the larger picture, the city cannot enter every informal settlement tomorrow’”, and Cape Town does not have the land and does not “’want to advocate a strategy that gives land to people who occupy land that is unsuitable’”. The isolation of the settlement means that pregnant women are forced to give birth in the settlement, amongst the garbage. Apart from the direct health affects associated with life in areas contaminated with poisons, the indirect health affects of such a lifestyle include alcoholism, illiteracy, high mortality rates, and unemployment. And this (even according to the City Development Services director) is only a small settlement. There are thousands upon thousands more who live in these conditions, and that’s a fact.
I read the article again, after that first read sank in. This time I didn’t dare glance over those words at the beginning. Filthy. Isolated. Unacceptable. I took my time, noticed each one, and let those words sink-in. That is my task here, paying attention. These problems are being faced by people so much like me, we just happened to be born into different places. These issues are no longer text book cases, statistics, or news stories of places far, far away. People here, people who I interact with daily, face these battles and I must recognize them and take the time to think about what their struggles mean. I do not want Nosithile Sesimani to become one more example of one more problem to file away in my head. I am here to make this personal and I must not forget this.