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Interview with Gauteng MEC for Health, Dr Bandile Masuku

Updated: Jun 27

On 31 May, a day before South Africa moved to Level 3 of our national lockdown, SWOP's director, Dr Prishani Naidoo, got to speak with Dr Bandile Masuku, MEC for Health in the province of Gauteng. She and Dr Masuku got to know each other as comrades and friends when they were both student activists – in the South African Students’ Congress (SASCO) and when they served together on the National Executive Committee of the South African University Students’ Representative Council (SAU-SRC) between 1995 and 1998. Almost 18 years had passed before this conversation, hopefully the first in a series of conversations with him about the current pandemic.

We apologise for the poor sound quality in this recording. The conversation happened over Zoom and poor connectivity meant that transmission was lost a few times during the session. It was also not always possible to edit out background noise. We have, however, tried to make sure that the original conversation is audible without too much distraction. 


Good morning Bandile. Thank you so much for making time to speak to me at what I know is a very busy and difficult time for you. I thought we could use this time together to reflect on some of the questions that this pandemic has thrown up for all of us but to do this in a way that also stretches back in time. We go back quite a long time in terms of our own history in the student movement and you know, at the start of the pandemic I was watching the first Gauteng press conference with you, David Makura and Panyaza Lesufi and it took me right back to that time many many many years ago and I think right now we're all thinking and acting in relation to the very immediate in crisis mode. But if we look more closely at the responses, your work, the work being done by government - a lot of it could also be understood in relation to past choices in this history: training received in the student movement at that time, how different contestations play themselves out over time and how decisions and experiences of the present moment relate to choices that are made over time. So I'd like you to start by reflecting a bit on this and then also on some of the broader philosophical issues that are playing out in this moment. With the pandemic we've heard a lot about science. With covid-19 there's the fact of the virus and we've heard claims that science has to be put first, but we've also seen as the spread of the virus has progressed, a lot of contestation emerge in even the scientific community. So I'd like to ask you to share some of your views about these contestations and what you understand as science and on what we could call the relationship between science and politics, or an idea of science and these broader contestations and how choices have been made. Thanks for leaving me on the conversation. I think it's worthwhile just to go through what we didn't think that it's training, you know, over in the student movement, but I I guess that whatever we went through in terms of our experience, individual experiences, at least they've given us some form of an edge you know to be able just to understand what could have been a better approach in terms of our response. I agree with you that the science has taken up the higher part of the public discussion. I think the better part of the response has been met solely by technical and so much scientific way of how we understand the pandemic. But I think the issue about the science is also tring to give us some certainties that we need to have, you know, something to work towards because if we don't work towards a particular... creating a particular certainty it might make our response quite meek and quite weak so yes science, has taken up a whole lot of our discussion in the earlier part of our response and I think our response has only been there for three month now since March. And we also think learning from what the HIV debate you know from the HIV response, you know, you will find that early nineties there was a whole lot of philosophical and political ideological debate, just about HIV and AIDS, you know, which at some point led to us not being able to respond effectively and quickly, you know. Now, because of that lesson that we had from HIV and AIDS response, at the current moment hence it made science to be the most pronounced and most profound basis of our response. And of course it was inevitable that the politics will come into place, the philosophical issues will come into place, you know, because ultimately we also have to talk about it. My own thing is that there might be some, to a greater extent we can't defy what natural or nature would be, what we call natural selection, and I don't think that's the goal of the health care system to defy you know or to oppose natural selection, but healthcare system is meant to manage, you know, somehow, you know, the natural selection on things that we can be able to decide on: that this one, we can be able to manage, others we might not be able to, like if somebody gets cancer you know whatever we try to put up it's just to manage the disease process but not to really take out the cancer from the individual. So there are a number of philosophical aspects that come up sharply on this response, you know, but one of them that comes clearly is the issue of of natural selection, you know, the weaker species might not survive and it becomes a difficult conversation if somebody listens to me in a public platform saying that no but the weak will definitely perish but I think because it's a matter that we have to deal with ultimately is the issue of death, you know, which is something that most people all of us I think we have different subjective understanding about it. So yes indeed I think now we are discussing the politics and discussing the philosophy and you can see within our country, essentially in other parts of the world like the United States you see there's a greater amount of politics that creeps in which also stumps you know, really stumps an effective response to the science itself. It's a big balancing act that we need to do but I'm quite pleased that we started off mainly focusing on the technical aspect or the science of the virus so that our response becomes quite effective and it's quicker and at least where we are now we have a better basis that you we have a certain outcome that we are expecting to happen. I think basically that's what I would say and I had a conversation last week with Eusebius. He wrote a very good article about fear, you know, just about fear. A lot of what we are trying to do, the variable that is so important and that we cannot deal with it on science, is the one on fear, you know, because people just hearing that somebody's covid positive, it just creates a whole lot of fear, anxiety. Even yourself you know, like even I don't know how I would respond if you say I'm positive, you know. So those are the few elements that are coming up now sharply in the whole conversation about the response on covid-19. If we can just spend a little more time reflecting on this question of science. If we think back to the start of the pandemic, there was a lot of support for lockdown as a strategy based on scientific observations and predictions but over a short period of time we've seen some questioning of this choice within the medical community. What do you make of the outcome of the strategy now and do you have the same outcomes in mind for it now that you had when the strategy was adopted. The lockdown is a very blunt tool. I think first it was a good choice to make and of course there were certain things that we we were totally blind spotted from and that we didn't consider...and how our backlog on cancer patients and cancer treatment would be, access to reproductive services, you know, like the termination of pregnancy, your contraception, you know, access to TB, HIV treatment; I think from the word go, there were things that we took for granted which I think we need to accept that; we were totally blind spotted on it and also there is a sociology you know aspect of the lockdown which we also didn't take into account, how the lockdown will impact in an informal settlement, in the township, over and above where poor people are staying in urban areas, you know, like your cities or your suburbs. You would say to you know, like at some point you had to now try to think about how do I expect a family that stays in two-room shack in Alexandra to be on a lockdown, 24 hours, and they are 10 and these are families that usually they don't have groceries so every day these are people that go to the shop to get something to eat to come and prepare, something to eat, so when you say there's a lockdown in that area there wouldn't be any lockdown unless you wanted them to help by other... but I think it becomes unfair for anyone to then say we needed to have considered those things because we didn't know, you know, That why I'm saying it's a blind spot. These are things that came up with the execution of the lockdown and I think one thing that made it easier for us, for which it makes it better for us, is that we then were able to respond to it as it goes and become dynamic and make sure that we use a variety of strategies to deal with it. So for me the lockdown, particularly from the point of view of Gauteng, it reduced movement basically, you know, the most important movement it reduced was the inter provincial movement so our borders you know as you'd say, and also the international travel which was also the major source of the pandemic. So it helped in that regard but then it also exposed us, like I said, this sociological aspect of it, that somebody who say that I can't isolate, I can't self isolate, I stay with 10 people in my house; everyday we have to go out and look for something to eat because we stay in this house, we bath in the same tub, we sleep there, we eat there, so it's going to be highly impossible. If you look at it from that point of view and experiences in other countries which chose, and remember they also had a benefit of hindsight to say ok, it didn't work in other parts. Like if you look at India, for example, other parts of India struggled with lockdown and the state of Kerala took a different turn, you know, on how they're going to apply the lockdown, how they're going to do things. So we had to now change a bit and try to combine all the strategies. So for me the lockdown helped us, it slowed down the transmission tremendously. If we didn't have the lockdown it would be close to almost I think... We'd be expected now to be on a peak, you know, over a day over a thousand new infections a day, so it helped a lot but there are sociological aspects that we we're not... I think it's not for a lack of leadership; it's just how the situation panned out. That's what I would say on the thing but even the doctors had raised the issue; we are supposed to be the ones that had planned it in a short space of time, how we are going to deal with chronic medication, people to get three months medication for their treatment that they are getting. We also had to make them or create a space for other operations to continue, like there are other pressures that'd continue, though with a very big backlog oncology continued, your cancer operations continued though in a very small scale, which now increased the general backlog but I think there are other individuals or academics who just stretched and exaggerated the impact as if the lockdown itself on its own is the one that can create this backlog because we have been dealing with the backlog ever since... The compliance on HIV treatment, it's not because of the lockdown only - it's something that we have been struggling to try get 100% for people to comply to stay on treatment, to get followed up, so yeah I think those are the other aspects that we now know that we need to do something different going forward. I'd like to come back to this question of the peak but if we could just spend a little more time thinking about what you've called the sociological issues that were not considered in the strategic choice. So if we think back to some of the ideas that seem to have been lost in policy choices made post 1996 in particular, there was an idea at some point that health could be central to the transformation of society if we adopted a primary healthcare approach that would bring scientific questions together with the sociological, the economic, the political. So questions of access to water, adequate housing, food and so on, were seen as part of a health approach, and I'm wondering now, there was a lot given up you know with the adoption of GEAR and a more neoliberal approach generally in the country, and I think we could argue that that had an impact on the kind of health system that we're sitting with today: do you think that the crisis today has reopened those questions in a manner that could see some shifts in terms of how we're approaching health policy? Do you think those historical choices are playing themselves out now in a really critical manner? If you look at all the discussions about South African development that we've been having, you know, it has always been about how health becomes an essential component of social transformation, and now we are faced with those choices that we need to create a sustainable way on how we can be able to mainstream; like now with a discussion about mainstreaming the SDG goals to make sure that we then deal with all the other aspects that are health determinants, or social determinants of health, and there've been now before the pandemic, in fact the whole universe or the whole world was dealing with the issue of universal health coverage. In our situation we were discussing the NHI bill and everything and all these aspects that you are raising came up very sharply. There was a good intention. I think the RDP document for me could have helped us a lot to just to create a broader base for primary healthcare to happen, but like we said you did make some choices which created two levels or two systems in one country where there is a very clear, stronger private sector, which is also not preventative, which is almost hospital centric, like everything else that we have to do in the country, when you're sick you must come to the clinic, when you're homeless you must come here, so there was no role that we were playing in terms of prevention on the ground, so we've been flirting.... So what I normally say is that we've been flirting with the ideas, knowing very well, we know that these are the ideas, this is what we're supposed to do but we still didn't put effort into making sure that we get to that particular discussion. The first discussion we had on NHI strongly from the side of the ruling party was around 2008, you know, and you can count now - it's 12 years on, you know, we're still having a discussion, we are still having a discussion but the basis for us to have a very strong universal health coverage is to have a very strong primary healthcare system which will then deal with all this other aspects and I want to bring it closer to what the pandemic has also showed us now. It has demonstrated fully well that health is an essential part of everything. While we were dealing with the pandemic, the food security issue came up very sharply, poverty level, things that I think we undermined, you know, we underscored, we undermined and... of sanitation and and all the other aspects came up now sharply, you know, the cleanliness of our government, all these things are things that became now sharp and we have to now deal with it in one point of view, in one aspect, and as as I'm chairing the you know, the command center, leading the response, it makes so much sense to have everybody in one room, you know, to have social development here, to have education here, to have everybody. We also now realized actually that the public health has been stripped of its role essentially. Even those that are there which are in the Constitution, whch are in the act, have been stripped away you know, the environmental health aspect is no longer the role of the Health Department. It's another Department, you know the issue of water and sanitation, we know it has in the broader scheme of things, it has a health... the public health aspect, but it sits with another department. You know, there are many things that we have realized which clearly it means, going forward, we should be doing things differently. I just think that if we have not learned anything now and if we are going to go back to where we were before the pandemic, then I think we... I normally say, and I think most people feel a bit uncomfortable with what I say, that if we go back to where we are then we don't deserve you know to be in a leadership or to be a surviving species, you know, actually to be blunt because it means we should have learnt and we should have realized our shortcomings and we should now start to do things differently. I can tell you now the delivery of water in, one example, you know it very well, that in the space of two months we were able to try and uncover the better part of the country but essentially we knew that no, that place doesn't have water but we were just blasé about it so there are things that we have learnt which bring it forward sharply the issue of our mainstreaming the Sustainable Development Goals and making sure that some of this health... social determinants of health are actually met and we need to have one center to manage it. You know currently I'm in the cabinet I'm the... they call it the champion of mainstreaming SDG goals, so I was in the process of engaging with all the departments, creating one program which will be a program that we will report on as a province on SDG goals. So we met with transport, we created some aspects, we met with sports; there's one program that we call an SDG program that we are pursuing as the Gauteng government I think the pandemic is making us realize that there are things that we should have done better, you know, but we cannot go back. I think we cannot go back to where we are. We need to be doing things differently going forward and some of the institutional arrangements must be changed, you know, and we must capacitate ourselves in that way to do things in an integrated way which we have not been doing. So even housing, you know, the problem of housing is a big problem. We dealt with it as a policy matter, not as a program. Yeah that's interesting. and this might be a little bit of an unfair question but do you think this might mean going forward that we see a shift in some of the approaches to, for example the provision of water and other resources? Is there space do you think for a move away from policy positions like payment for water and electricity and so on? The shift has actually happened, should be there. It's how sustainable... the shift has definitely happened that government has taken it upon ourselves to make sure we provide water in areas where you know that people won't be able to pay for that service. So we needed to provide water in a sustainable way in making sure that everybody gets you know access, including energy. I think the whole reliance on home based energy means that we must be doing things in a different way; we must be talking I think more solar, we need to talk more about other alternatives that you know which are coming now at the moment, you know. For electricity, a number of new developments in suburbs, you know, don't rely on the fleet for electricity for lighting and other basic things, so it means the shift is there, you know. So the only thing if you go back to where we were then clearly it means we have not learned anything, but it's also not something that will happen naturally. It means those of us who are there who are aware, we need to be pushing, advocating for the sustainability of the shift because it is not going to happen without us putting an effort. Okay, so we've seen changes; I mean even with the economic interventions, the extension of a social grant system and so on, but I guess what I'm thinking about are the longer-term possibilities. You know we've seen these immediate shifts in terms of being in crisis mode, responding to crisis, but I mean longer-term, are these possibilities real in terms of those kinds of changes? How do you reverse it? How do you reverse the covid grant? How do you then take the decision as government to say, no this grant is not important, you know, and whilst we introduced the grant because we realized the depth of poverty, you know, the unsustainable way of delivering food parcels, you know, how it reduces and takes away the dignity, taking away their choice - they don't want to have mielie meal but will provide mielie meal anyway. And so those are things that going back, let's say post the pandemic, and other things, if we go back to where we were before, I'll keep coming back on it that it means that we we have not learned anything and we don't deserve anything going forward. It's one of those things that the other political parties, if I was them, I was going to enter in that space because it's the space that talks about what would happen post the pandemic, not to talk about what is currently happening, advocate for some of the things now during the pandemic would be better. From our point of view in health, there's now general support that we need to build more facilities, capacity within our own health system. There is general support that we need to employ more healthcare workers. Also just the understanding that we cannot afford to have an unemployed healthcare worker, and yes businesses who went thinking that they will cash in on the pandemic; they bought a lot of stock but it won't make sense that the stock is in their warehouse, not where it's supposed to be, so it means even procuring outside everything we need to make sure that those small businesses, those who are trying to make ends meet wherever, there are a number of things that we need to be doing now which are becoming urgent and ordinarily we needed to convince a lot of people to employ, you know, health care workers, get stock from other people, so now there's general support for us to be able to improve the healthcare system which is something that we cannot go back to the old one. For now, I don't advocate for field hospitals. You know, everybody wants field hospitals because they saw it somewhere but I'm saying let's build this capacity in our facilities. If we have to put up a five hundred extra beds, let's put them up at Bara, let's put them up in other hospitals so that after the pandemic it's a capacity that we have, you know, it's not like it's something that you spend one billion building and then after the pandemic we place it down. Then it's not very much sustainable. So yes, there are things that we need to be doing, which I think going forward they need to be maintained like that and we need to be urgent. And the universal health coverage discussion makes it more urgent for us. You know, when we were going around with the bill, I made a point about what are the common causes of death in Gauteng: all of them are preventable and all of them are related to how we live our lives. So it's about alcohol, about smoking, it's about alcohol underlying all the trauma cases we get in hospitals, whether people stabbed each other, shot each other, car accident, underlying that every time there will be some influence of alcohol. Cancers: if we do preventative programs they are vaccines now against some of the cancers, so all these are things that are preventable and with the pandemic now talking about more preventative discussion, it makes it easier. So we just have to see how we maintain the momentum going forward and for the better, not to regress. I'm going to come back to this issue of alcohol and cigarettes and so on but I'd like us to spend a little more time on the role of community health workers. You know for me at least, in those first few weeks of the response, the recognition, the acknowledgment, the bringing into the center of community health workers,for me was a shift, a very significant shift in terms of how this group started to be spoken about and seen by government. You know there's been a critique from even before the pandemic that community health workers are one of the most vulnerable groups of workers and yet they take on such huge responsibilities in meeting the needs of communities. So how are you seeing their role going forward? I think it didn't come easy, the recognition. I am one of those who is a advocate for their inclusion as a formal cadre in the healthcare system. In actual fact, we have a drawn-out process which includes them because I also feel that, you know, there are some NGOs, some unions who want to talk and advocate for their inclusion but they are not in essence talking to them. It's not community healthcare workers who are determining what will happen, so we have a group now that we are using as an advisory committee of community health workers which has to deal with issues of, firstly, the principle of them being included. We are not debating - we have passed that debate; it's supposed to be a formal cohort. Remove the uncertainty or what you call the temporal nature of it, it must be a permanent group which has got grading in terms of experience; they must have a common job description and duties, they must have career pathways, you know, for those who've got an appetite of going further with their studies or in different modes. You know, we need to increase them... they must be formal, so that they must also have benefits, so that we don't pay them stipends, you know, we pay them properly, they're part of the persal system with benefits and everything. And so this group ... we were slightly interrupted by the pandemic but we are almost... the work has been done; you know, we're almost at the point where in the next coming few weeks we'll be announcing their inclusion and all the aspects that are there, you know. I'm also looking at them in the model of EMS - you know how EMS is organised? It's organised as a group of individuals who are working there; they've got their own directorate, their own uniform, their protocols; they've got everything, so I want it to be in that way so that they become formal and they must be in charge of... I just see so many letters of complaint on everything from different... but these are people that do a google search and then they put it as if they've spoken to everybody, but when you go to speak to them and understand at the grassroot level what they are doing and what is their main issue, you'll understand that some of the proposals that are made by other unions are not appropriate for them. So the discussion of their inclusion is complete; their role is for me in the healthcare system in Gauteng in the next coming ten years or to the future, they are the greater aspect of what we're doing with the fight against pandemic. It was a difficult conversation we had with some of our colleagues from other provinces just to say we have a base of tracers, we have a base of people that have been doing the work, so they are not going to do something new; you just need to add a new aspect but it means we need to be double going forward to formalise them; it's not a very easy discussion because other people feel they don't have the budget to take them and so on, but now, as we speak, there is no doubt about it - their role is entrenched. Now it is just for us to implement that. As Gauteng I think we'll be the first province to pronounce on it. I know that the minister might not be happy but our challenges in Gauteng might not be the same with the ones in Mpumalanga so I might not wait for Mpumalanga to agree to be at the same level with us when it comes to formalising the healthcare workers. Somebody has to do it and I think we are ready. I've been fought against but it's fine. I want them, I need them, that's the future for our healthcare system, you know, that's where ... system works; these are the people that do the actual work. Our hospitals might remain empty afterwards, or clinics might remain empty, because medicine can be distributed. At their doorstep, people can get their checkups at home, people can get a whole lot of things at home. So, we are in that space of making sure that community healthcare workers are... I don't like the term 'recognized'; I think the issue is that they have to be formalized as a cohort and be included as a cohort in the healthcare system. We say there will be nurses; we must say there are community health workers, then nurses, then, then, then. They must be part of the therapy. been massive so they must also be... Okay so I think it's important to reflect historically on something your response has raised. So you've spoken about certain groups you're consulting; you've also mentioned before political parties, opposition political parties needing to come in and contest the space, but we've also seen civil society groups come together, emerge, and you know groups that have been fighting about some of these issues for some time now, for example the C19 People's Coalition, there's the Working Class Campaign that's emerged from initiatives led by Khanya College, different groups in civil society and at community level that have come out to take up sometimes very on-the-ground, immediate issues, or to mount critiques of positions being taken by government and sometimes to provide alternatives. How do you see relationships between government, in particular local government, and these kinds of initiatives playing themselves out over the next while? Civil society is so important; it's a space that for some reason we completely ignored and I think our civil society for a long period have not been recognized for the role that they've been playing. You know against the fight on HIV and AIDS, they paid a very tremendous role. You know, just to activate what we call RDP way of doing things, so I think the role is so important; they need to come in, like even now we are relying in a great extent in terms of improving the awareness, including the the new things that we need to be embracing, what people call a new normal: the hygiene, the face masks, we need them because those things they, you know, we cannot be using police to enforce some of those things, you know. Imagine police coming up and saying we are not coughing appropriately, you know. or you are not washing your hands; so that's where civil society should come in; they should be able to assist us in our response as a province or as a country. I think it started here in Gauteng, was to create a pillar in our response that means essentially, with social mobilization, you know. We had that initial discussion on the lockdown that pillar under lockdown couldn't find greater expression because then how do you then say we're on lockdown but there are people who are walking the streets, trying to educate, doing door-to-door you know. So now it's an integrated way on how to do things. So civil society, they are an important component of creating a proper, comprehensive primary healthcare in the country, and we meet them more than ever, you know, and we just need to support them more. What I find is that we also use our own discards and our own budgets to even underdevelop that particular sector. You know, we support very few that are pronounced; we don't even support the ones that in a real sense don't even have access to write a better proposal, so we need to be able to create that capacity in them to be able to be part of our work. There's a covid-19 front now which is basically almost like a SANEC(?)-type which we're working with and I think we need to be maintaining that that particular aspect of work, so yes, I think civil society have a greater role and I think it is an important irritation, you know, sometimes to be reminded as government to say you are not doing things properly. I think the conversation that we're having should be a conversation that is out there, you know, and shouldn't be something that is couched in political language. We should just have our honest reflection of things and maybe as government, as politicians we get to a point where we failed to understand our own role of being facilitators of development, not the actual drivers of development And that's where our problem becomes itself. Okay, so you mentioned the police and we've seen some very heavy-handed actions by the police and army during the lockdown. When we speak about death, it's not just deaths from the virus but also deaths at the hands of the police and army in this time, and related to this, there's been an argument made that certain aspects of lockdown might be seen as infringing on the ability to exercise one's freedom and rights that are protected by the Bill of Rights and the Constitution. And some have argued that the restrictions on alcohol and cigarettes could also be viewed in that light. Can you share a little what has happened in terms of related discussions that have taken place in government, in the party and then also some of your own reflections on some of these incidents which have been very real, as well as the critiques that have been raised? We've been unfair in a way that we wanted for this to... and even the army, to enforce some form of these regulations, because these regulations. you know, some how they're not... police can't actually do that, I think it's something that we made a big error or error of judgment on it and maybe our expectations on that. Hence there was no standard way on how these things can be done. And it also speaks to what type of police force that we wanted to have. So some of the things of the regulations, of the lockdown are things the society, the community themselves must be able to police. And that's how the successful enforcement of regulation won't be done because, just imagine police coming up and say you are not wearing a mask, you know, or soldiers coming that you're on the street, you're not having a mask on. So those are things that we need I think, social health activists on the ground, people who you know, people who will call you by name you know and say, ah Bandile, you can't leave the house without a mask you know, so this is the other pillar that I said to you, we had a dilemma on how to unfold it going forward, you know, with the lockdown but with the new levels of the lockdown coming up we are getting better now that the social mobilization aspect will be more pronounced in terms of the enforcement of regulations. And the other one that we had a discussion on is that maybe the army must be part of the one who go loudhailing, you know, 'stay at home', whose role is educating and raising awareness. So there are things that have caught us in a blind spot which I think all of us as a country we have realized that it. Also the discussion on the rights, the individual rights, how do they supersede the whole society or polity, so it's going to be an interesting discussion on the people that we want to protect, you know, going out to say they want access to alcohol and we know how the effect and the impact of alcohol on the healthcare system and when we opened up alcohol, and people come and say we don't have ICU because ICU would be taken by trauma patients; what would be the balance because that's some of the other conversations that the society you should be having with them that some of the things we cannot give government authority to run it on your behalf, you are responsible for your own health, taking care of your own health. You will see in the next coming two to three weeks, I'm expecting that our trauma units will be full backed up in terms of being full and all that. So I think the role of police it's going to be a continuous discussion even beyond the pandemic on the type of police force we want. Other times we are the ones that say police are very soft on criminals, you know, very soft I think you would know people who have made that no, they demand Bheki Cele come back today to the police force as to create that that thing about the police being there and have authority to fight crime and at some point, in the same breath, we also say but hey, you're much too heavy-handed on other things. During the Fees Must Fall protest, the uprising, it came up also, you know, how police... So it's going to be a continuous discussion how as a democratic society we will have to create a police force that will fight crime or enforce regulations but we need to be able to say how do they do it in a way, in a manner in which it will be acceptable to society and also, during apartheid it was normal because you know for the whites at the time it was normal to see how protests gets. So I think it's just a matter that we need to continuously discuss but I think society civil society organizations have got a greater role to play but particularly just in the soft aspect of policing, the soft aspect of regulation, so that you don't really have to have the army coming out to do that or the police but we take ownership as the community, as society, because universal health won't come as a an act in parliament, you know, a bill that is passed parliament and we then say okay, now we have achieved. It's once more what we put in place as civil society, how are we going to prevent disease spread, how to deal with issues of sanitation, water and all those things so for me, that's what I would think that that's the future and how the police force would be, you know, like CPFs are supposed to be... THERE you know as part of society or community to control these aspects but you still find problems in our schools, you know school patrollers, so maybe a conversation should be how does society police themselves, how society polices themselves in terms of crime, how do they police themselves in terms of maintaining good health and maintaining hygiene, maintaining these things, knowing very well where to get treatment, how does society come in and be the one that say, this is how we want things to be done so it doesn't become a doctor Masuku who'll come and say you are not taking your medication when we know, community healthcare workers must be knowing that okay, the grandmother who stays there the last time you went for checkup was three months back. Probably that treatment is finished so we need to have that community health system and I think we have a good opportunity now to do that. Okay that then brings us back to the question about the relationship between science and politics right? if we just reflect on the cigarette issue for one, there's been a lot of questioning of that curtailment and there have been arguments made that by restricting the legal sale of cigarettes and illegal black market has proliferated under lockdown, and other habits like the sharing of cigarettes get worse, so that could be seen as a contestation of the usefulness of that curtailment right. And then I believe there have been some studies done about the effects of tobacco use or nicotine on the possible impact of the virus on an individual. So this for me raises a lot of questions around the relationship between science and politics, science and its contestations, science and the individual's choice and so on. I think on a health aspect of everything we know what nicotine does, what tar which is part of cigarettes does to the lungs. I think there is no debate about it, you know what it does to our body, how it does. There is no debate I think; the real debate is about the issue of regulations is what you're correctly pointing out, is there economic relation on the decision to ban sale or the sale of tobacco over the proliferation of the black market. Two years three years, even now you know that we've been having a big discussion on the what they call it... It's advertising the effects of tobacco on the carton that you buy but it's something that Canada is doing, Australia and parts of New Zealand where when you buy, you know, in South Africa we write just the warning that smoking does this, does this, does this but there's been a big debate internationally about just branding the whole package with people with lung cancer and all that. The debate when you listen to the tobacco industry you know: how would you know that you are buying a counterfeit or buying_. So it's a whole lot of debate about it so the issue is not even how the effects are not going to be much higher. It's just about the economy, the economics of it. Who buys what and what will happen to the market, and all of that. There was even an attempt to use science to say that people who are smoking don't have much effect, they don't get negatively affected by covid, so science can be used I think maybe it's something that we didn't say when we started the conversation that science also can be used to create a particular bias you know because as much as you will say it is the truth it's a fact, you know somebody can say it's not and also provide some level of evidence to say nahah it's not the truth, and you would know that the China versus US story it's also about the science, it's also about the economy, so whilst we say we've got a virus that we are fighting but what was the impact of the whole pandemic internationally? We saw oil prices going down completely so there are a lot of things that we can come across that in a real sense science you can say it's fact but it can be contested fact. During the Cold War the same facts in Russia, facts in the United States were totally different. So yeah science can be manipulated, can be understood as not value-fair because it has its own subjectiveness that comes from how it gets applied and I think it's a yeah it's a big debate. You know we know I know what all of us know what tobacco does but it's not about that, the discussion is not about whether tobacco kills or not, it's just about how it's going to be sold, who's going to benefit from the lockdown. Now the accusation is that those who are running counterfeit industry are actually cashing it in big time hence the pressure to balance off so it's one of the questions going forward. Tomorrow we're moving to level three so I thought I'd end by asking you how you're feeling about this we're also anticipating our peak in a few months and we're living with a lot of uncertainty in spite of science so moving forward are there any certainties we can hold on to and how are you feeling about the next few months? You know the the one thing that we've been debating is the messaging aspect of it which creates a wrong expectation, the messaging that says if we have to say we had a good response plan, we would have stopped the spread because if we say that then it creates an_ it's clear that we won't stop the spread so it cannot be a good outcome. The good outcome of our response plan should be how we managed the spread and when you say managed the spread it means slowing it down, it means treating people who are infected, means creating awareness so it's just managing the spread. It's not about us saying you won't get covid-19 if somebody would say that that is the core of their response plan, then they've already failed so everything else that we do now should be about managing the, you know the spread managing people who are infected managing the effect of the regulations themselves. And what creates my anxiety more is just about when tomorrow they say tonight when they announce 60,000 more infected individuals in Gauteng and they are all in Diepsloot. Does it equate to say that I as a department, we have failed? I don't think so and with moving down with levels now, it might just mean that you need to as the whole society we need to now be moving towards taking some form of ownership knowing very well that if you get the, you know, the infection you should be in a space where you can be able to be treated. If you've got symptoms if you need a hospital bed you are going to be able to get a bed. I think that's what you need to be doing now and my anxiety is just the control and the numbers at a given time. At the current rate, I think we are not even close to the peak but I think the Western Cape situation when you look at it they are already there, you know. What we had a discussion on this morning with the premier was that maybe now it's time that we start talking about what will be the trigger to say we're at the peak, we need to have like the trigger points when we have this situation panning out. Let's say every day we had 10,000 and tomorrow it's exponential it's 30,000 and the other day 60,000 then we must know that we reach the peak. But is it that what the science says about the peak. Other people when they talk about the peak it's when they say your health care system is strained to a point where you can't handle it. That's what we then say ah that's the peak so we need to be very clear on this determinants on when we say it's a peak what do we mean and when we say we're ready for the peak what do we mean? There's no way that we can be able to admit a million people, no way and if that's what the healthcare system should be preparing to do, aaah then you clear that we're not going to be able to do that, there's no way we can admit a million people. So much nurses and doctors to look after those individuals, there's no way, so we need to have that frank discussion as a country to say the success of our response plan shouldn't be about stopping the spread. We shouldn't be telling people and giving people hope that they will come out without being infected and if that's what we are coming across as saying it's clear that it means we need to change our discussion, but I know that politically and other things there will be people say ah, you know I think the president got a lot of passion when he said it's in your hands, you know. So there are people who still want to see us taking people to Robben island to quarantine them there, to say no this is the group that's infected so there's a lot of things that we just need to be clear on and my thing is that I don't want to be assessed on something I don't have control over and it will be unfair if I'm assessed to say no you needed to have kept it at 50% infection not beyond that then it's pretty much unfair. So that's the anxiety, being assessed on something I don't have control over. I think what we need science for now is to try to create some form of certain scenarios that we can be able to deal with. But we cannot, I can tell you, cannot admit a million people; even a hundred thousand people we cannot admit them today, even if you can create 28 field hospitals and some of our colleagues give that impression that we can be able to do that ; that's not possible, you know, that's not possible and you know they the story about ventilators, we didn't talk about it. Everybody makes the point that if we don't procure ventilators we are not ready, if we don't build field hospitals, we are not ready, so the readiness in many aspects for other people is for us to buy 10,000 ventilators which we know that when somebody is getting into a vent, it's almost a poor prognostic fact for them to be on a vent and we know that it's almost sixty to seventy percent mortality of people who get into the vent. And now, we also have to create an ethical dilemma for doctors to say who deserves the vent. So we have to choose now that it cannot be you, it's to be him so also now the philosophical, ethical, political, ideological things coming into place, so everybody is when the business people who want to make money out of this, they are... and they also have media on their side, and the media will always say, but do you have enough ventilators? but I know that our clinicians, our doctors say they don't want ventilators because a person who's on a ventilator is always a poor prognostic thing. The people both who will get into a vent and succeed they are younger and those are the ones that don't really get a severe disease pattern, but the whole success of everything will be about are you having field hospitals? are you having ventilators? 10,000 or 20,000 ventilators, but people still died. Ford changed their thing to produce a lot of ventilators but people still died. There's a serious dilemma that we need to try unfold. So for me that's my anxiety; we'll be insulted that on the basis that we didn't stop the spread and how do you stop it? with a lockdown maybe? but lockdown has it's own issues which we discussed earlier which might not be successful in that regard you know so what do we do? the question should be what will constitute a great response? you know all the articles I think that I've read you know, Mongolia is one country that they said they didn't have a spread but they had an absolute hundred percent shot down. In Kerala they had infections which are almost similar to us but they've done a lot of social mobilization in that respect; Sweden the same, they didn't have a large lockdown and they managed ... figures South Korea was held, before that they had a brilliant thing but now they're having a second wave in a space of five months, so success...When you say you're successful what constitutes the success? So for me that's the anxiety. There are a number of things that we cannot answer ourselves. Opposition... I don't think they understand the implications you know. Listening to them, the other one the white liberal, you hear the sense of the economy and business speaking when they speak. You know the other one you don't really get a real sense what do they want. You know they say you have done well this side but on the other side no. It's almost like a schizophrenic response. That's a bigger problem managing this whole thing you have to create that sense of where do we go from here like tomorrow, what do we do? We are opening schools; I was telling him, the premier, that you know when you know that this is a right decision to do, this is a correct thing to do, let's re-open schools but you also know because of the noise out there. Eh? is it really the right decision, you know, and France opened schools and a week later they closed them down. I think South Korea did the same, they closed them down, so are we really taking the right decision? I don't know.

Thanks for your frankness and your openness and you know we could talk the entire day and I think I've got a whole lot of other questions and I'm sure there's a lot more you want to say but maybe we should just treat this as we go forward as the start of a set of conversations. .... Next week Sunday we might have a different discussion.

Exactly. We might be faced with another situation that we didn't even think about.

Yeah science is trial and error right? Thank you it's been a great conversation. It was really good to speak to you again.

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