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Cablegate: South Africa Public Health October 29 Issue

This record is a partial extract of the original cable. The full text of the original cable is not available.




E.O. 12958: N/A

1. Summary. Every two weeks, this post publishes a public
health newsletter highlighting South African health issues
based on press reports and studies of South African
researchers. Comments and analysis do not necessarily reflect
the opinion of the U.S. Government. Topics of this week's
newsletter cover: a UNFPA report that projects population in
South Africa to decline by 2050; a new survey on sexual
violence; the increasing but largely ignored South African
orphans; the Global Fund contribution of R430 million to the
Western Cape; a large increase in South African child
mortality; the withdrawal of Thembalami Pharmaceuticals' bid
for government ARV contract; trends in HIV risk behavior in
South African migrant workers; and the implementation of ARV
treatment in all nine provinces. End Summary.

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UNFPA Report Projects SA Population Decline

2. The latest United Nations Population Fund (UNFPA) report
puts South Africa's population growth rate at 0.6 percent,
indicating a concrete decline for the first time. The report
estimates that the country will have five million fewer people
in 2050 with a little more than 40 million people, compared
with previous projections of twice as many. The world's
population is expected to grow by a third (2.5 billion people)
by 2050. Statistics SA, projects a South African population
growth rate of 1.8 percent primarily because of a higher
assumed total fertility rate. The actuarial sciences department
at the University of Cape Town said most population models
based their calculations on an estimated growth of under 1
percent, less than half of the South African official
projections. This is in line with other recent international
reports such as that of the International Monetary Fund and the
UN Development Program (UNDP), which projects a radical decline
in life expectancy for South Africa to as low as 37 years by
the end of the decade. According to the latest UNFPA report,
most of Africa's population is expected to grow by more than 2
percent despite AIDS, with the exception of South Africa,
Botswana (0.9 percent), Zimbabwe (0.5 percent), Namibia (1.4
percent), Swaziland (0.8 percent) and Lesotho (0.1 percent).
Five of these southern African countries were also rated by the
UNDP as among the 10 most unequal societies, while they are
also among those with the highest HIV and AIDS infection rate.
70 percent of people in southern Africa live below the poverty
line on less than $2 (R13) a day and 40 percent on less than $1
a day. The UNFPA report does not discuss the reasons for the
decline in South Africa, but refers to AIDS as a prime cause.
Professor Rob Dorrington, an actuarial scientist at the
University of Cape Town, said that South Africa's fertility
rate had been dropping since the 1980s and, along with AIDS,
would be the main cause for the declining population rate,
which he estimates to be 0.7 percent. Source: Sunday
Independent, October 17.

Survey Released on Sexual Violence

3. A study published by the British Medical Journal found high
incidents of sexual violence and perceptions of sexual violence
in South African pupils. The study, conducted in the last
quarter of 2002 interviewed 269,000 South African students in
1418 schools. It found 8.6 percent were forced to have sex in
the past year. A further 58 percent said forcing sex on
"someone you know" was not sexual violence, 30 percent said
girls had no right to refuse sex with boyfriends and 26 percent
said girls enjoyed rape, with findings similar across race,
religions and class boundaries. The questionnaires were in
nine languages, and used the term forced sexual violence
because not all languages have a direct translation for the
word rape. The study, funded by the Canadian International
Development and Research Center and the United Nations,
highlighted an apparent expectation of sexual coercion among
young people that contributed to a culture of sexual violence.
About 11 percent of boys and 4 percent of girls claimed to have
forced someone to have sex in the past year. A third of the
boys and 71 percent of the girls had themselves been forced to
have sex. Almost 16 percent said they would have unprotected
sex, and a similar number said they would spread HIV
intentionally. These views were expressed most by older (15-19
years) boys from rural areas. Only 60 percent of the pupils
surveyed believed condoms prevented the spread of HIV. A third
said they never spoke to anyone about sex. Source: Business
Day, October 20.

South African Orphans Increasing but Largely Ignored
--------------------------------------------- -------

4. Around a quarter of a million South African children are
orphaned but large numbers are falling through bureaucratic
cracks. By mid-2004, according to the Actuarial Association of
South Africa (ASSA) 2002 model, 250,000 children in South
African had lost both parents but government departments tasked
with the welfare of these vulnerable children are unable to
confirm actual numbers who are being cared for in children's
homes. Department of Social Development statistics indicate
that 2,238 children were adopted in 2000 compared to 2,320 in
2003 with only 369 of these children classified as abandoned.
Figures from 169 affiliates of the SA National Council for
Child Welfare, a non-governmental organization that collects
statistics from many child welfare societies, indicate that
during 2003 there were already 1,803 abandoned children. 6,356
children were added in 2003. This translates into about 8,000
abandoned children reported to the Council. Nationally,
238,610 children access monthly foster grants, amounting to
just over R126 million ($20 million, using 6.2 rands per
dollar). Government statistics reveal that of the 2 320
children adopted last year, 371 were cross-cultural and 224
were by parents outside the country's borders. More than half
of the cases were processed in Gauteng courts alone. Source:
Health-e News, October 20.

Procedures Needed for South African Adoption

5. Generally, a child is available for adoption once the
mother has been counseled by a social worker in an adoption
agency or an accredited adoption social worker in private
practice. Once the mother has decided, the social worker
identifies approved adopters. When a child is abandoned, the
procedures are more complex. First the police will take the
child to a place of safety pending a decision by the children's
court. This may be a state Place of Safety, an NGO-run
children's home, a foster family or a temporary "safe house"
(basically an emergency foster home). If the child is left at
a hospital, the matter will immediately be referred to the
Department of Social Development, a Child and Family Welfare
agency or sometimes directly to a children's home. In some
regions abandoned children will remain in institutions because
the local commissioner of child welfare insists on a two-year
"police search" before the child is declared abandoned and
released for adoption. There is no legal basis for this
requirement. Some agencies will place abandoned children with
foster families (if they are available) until the children's
situation is clarified but many babies will wait out this phase
in institutional care. Another scenario arises if a child has
been abused or neglected and is placed by the court in foster
care or a children's home. Accepted practice is for intensive
services to be rendered immediately to the family in question,
with a view to restoring the child to their care if at all
possible, or to finding an alternative permanent family if
there is no prospect of reunification. Because of extremely
poor pay and stressful working conditions the Department of
Social Development and many family welfare agencies are unable
to hold onto experienced staff. The children are served by a
constant procession of new recruits who often take months to
catch up with their caseloads. Once they do, the numbers and
the rapid inflow of new cases make it impossible for them to
give more than token attention to children who do, at least,
have roofs over their heads and are not known to be suffering
active abuse. If the system worked properly, intensive
services would be delivered to these families from the outset,
assessments would be made at short and regular intervals as to
whether or not they were responding, and in the absence of
progress, prospective adoptive parents could apply to adopt the
child. Where appropriate, such adopters could be foster
parents who are already caring for the child. The court would
then decide whether or not to use its power to dispense with
the consent of the parents. There is at present no compulsory
training for commissioners of child welfare, and provisions
which had been made by the SA Law Commission in its draft
Children's Bill for specialized training of children's court
personnel have since been removed, a decision currently
contested by non-government organizations. Source: Health-e
News, October 20.

Western Cape Receives R430 Million from Global Fund
--------------------------------------------- ------

6. The Global Fund's R430 million ($69 million, using 6.2
rands per dollar) grant to the Western Cape will accelerate
AIDS programs and ensure that everyone who needs anti-
retrovirals will get them by the end of next year. Two-thirds
of the grant - the biggest to any department in the province's
history - will go to treatment. Currently, in the Western Cape
approximately five thousand people are receiving anti-
retroviral treatment. New funding meant that all of the
estimated 12,000 people who need the ARV drugs could be treated
by the end of next year. In addition, the funding will support
(1) increased peer education programs; (2) additional hospices;
and (3) more community-based and non-governmental
organizations' initiatives. The R430 million will be spread
over the next five years, with R100 million for the first two
years. The money also comes directly to the province, the
first time that has happened in South Africa. Twenty-eight
implementing partners will be involved in the program including
Nazareth House, Medecins Sans Frontieres, Lovelife and the
Desmond Tutu HIV Foundation. Source: Cape Argus, October 21;
Cape Times, October 22.

Large Increase in South African Child Mortality Rate
--------------------------------------------- -------

7. A study released in 2003 by the Burden of Disease Research
Unit of the Medical Research Council (MRC), has shown that the
below-five mortality rate in 2000 was estimated at 95 per 1,000
children. Infant mortality has risen to 60 per 1,000 live
births, compared to the 1998 figure of 45 per 1,000. HIV/AIDS
is the largest cause of fatalities in children younger than
five, accounting for 40 percent of deaths. Lower respiratory
infections, diarrhea, low birth weight and protein energy
malnutrition, all associated with poor socio-economic
conditions, were responsible for 30 percent of childhood
deaths. The study indicated that HIV and AIDS resulted in the
deaths of 42,749 children under the age of five in 2000, with
32,636 fatalities recorded for the above four causes. As
children get older, the leading causes of death shift away from
HIV/AIDS, with road traffic accidents accounting for about 50
percent of deaths in the five to nine-year-old age group. Girls
in this age group are still vulnerable to HIV and AIDS, which
accounts for 33 percent of fatalities. For 10-14 year olds,
traffic accidents and homicide are responsible for 33 and 15
percent of deaths respectively. MRC researcher Nadine Nannan
points out that although the data between 1992-2002 shows an
increase in child mortality; there is no comparative data yet
available for post 2002. Leading causes of death in South
African children under five in 2000: (1) HIV/AIDS (40
percent), (2) Low birth weight (11 percent), (3) Diarrhea
diseases (10 percent), (4) Lower respiratory infections (5.8
percent), and (5) Protein-energy malnutrition (4.3 percent).
Source: Pretoria News, October 26.

Thembalami Pharmaceuticals Withdraws Bid

8. Thembalami Pharmaceuticals has withdrawn its bid for a
slice of government's multimillion-rand AIDS drug tender, due
to problems with the drugs made by its Indian partner, Ranbaxy
Laboratories. Thembalami is a joint venture between Adcock
Ingram and Ranbaxy and was specifically established to supply
generic AIDS medicines to the South African market. Ranbaxy SA
has voluntarily recalled its entire portfolio of AIDS drugs
marketed in South Africa, citing problems with the research
company, which conducted studies to determine whether the drugs
offered the same therapeutic benefits as the originals. As a
result, only seven companies, two of which can provide
generics, remain on government's short list for the tender to
supply antiretroviral medicines needed to treat South Africa's
millions of HIV sufferers. The remaining bidders on the short
list are Abbot, Bohringer Ingelheim, Bristol Meyers Squibb,
GlaxoSmithKline, Merck Sharpe Dohme's South African subsidiary
MSD, and generic manufacturers Aspen Pharmacare and Cipla-
Medpro. A report to the World Health Organization highlighted
problems with the bioequivalence studies for Avocomb tablets,
and subsequent investigations by Ranbaxy Laboratories
identified similar problems with Lamaid, Nevran, and Zidaid.
Ranbaxy SA CEO Desmond Brothers said the recall was confined to
South Africa, in consultation with the Medicines Control
Council. Source: Business Day, October 26.

Trends in HIV Risk Behavior in South African Migrant Workers
--------------------------------------------- ---------------

9. A study presented at the 11th Reproductive Health Research
Priorities Conference October 5-8 found an increase in the
number of South African migrant workers who report multiple
partners (3-20) in the last six months. Migrant workers from
rural KZN province were interviewed over a three-year period
(2000-2003). Over the three years, the proportion who reported
having two sexual partners remained constant at 39 percent; the
proportion reported having three to 20 sexual partners within
the past six months increased from 8 to 12 percent. 80 percent
of the respondents thought they had little risk of contracting
HIV, unchanged over three years. The proportion of migrants
reporting drug use increased significantly between 2000 (5
percent) and 2003 (13 percent) as did the proportion who
reported being intoxicated between five and 30 times during the
past month (5 to 34 percent respectively from 2000 to 2003).
Between 2000-2003, increased accessibility and availability of
condoms were reported; the proportion that used condoms
increased from 48 to 59 percent. The proportion of migrants
who reported trying to prevent pregnancy in partners increased
significantly from 2000 (69 percent) to 2003 (81 percent),
however the respondents who reported using a method for
pregnancy prevention remained constant at 20 percent. Source:
Abstract from Trends in HIV/STD Related Risk Behavior Among
South African Male Migrant Workers, Authors: Nzwaki Mosery,
Arthi Ramkissoon, Anne Moys, and Mags Beksinska, Reproductive
Health Research Unit, University of Witwatersrand.

All Nine Provinces are Implementing ARV Treatment
--------------------------------------------- ----

10. The Health Department reports that all nine provinces have
begun implementing the HIV/AIDS treatment plan using
antiretroviral drugs, although the number of people on
treatment is lower than planned. 11,253 people received ARV
treatment by the end of September falling short of target of
53,000 patients by March 2005. All but one of the country's 53
health districts have at least one ARV service point which
provides a comprehensive service to people living with
HIV/AIDS. The Department also reports that there is improved
infrastructure, improved training and retention of staff,
certification of 250 laboratories and the establishment of a 24-
hour helpline in place. Source: Business Day, October 21; The
Star, October 22.


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