When the doctors go

William Saunderson-Meyer says the middle class can hang in, despite a failing state, for only so long


Some of our fiercest public debates are not about ideology but about perceptions of what is happening around us. One such issue, which raises ire, denunciations and counter-denunciations, is whether South Africa is now a failed state. 

As I wrote in this column a fortnight ago, a remarkable aspect of the debate is who stands where. Eager to ingratiate, white columnists yak on about everything would come right if we were all just “positive”, while some of the harshest assessments come from black leaders, often within the African National Congress.

Former President Kgalema Motlanthe says South Africa today “is characterised by anarchy … There’s no order, to speak of.” Former Treasury Director-General Dondo Mogajane speaks of “the things that define a failing state beginning to show”.

What exactly is meant by “failed state” is not always clear. There are as many definitions as there are contesting voices, but the concept boils down to a few key ideas.

The country’s government can’t protect its citizens — neither from criminals within nor incursions from across its borders. The institutions constitutionally set in place to structure governance and service delivery have been eroded and corrupted. Ultimately, the state loses its legitimacy in the eyes of its citizens and is increasingly excluded from international institutions and arrangements.

So, by such definitions, there’s a long, long way for any state to go before it fails. And an equally long way to recover, if this happens. ___STEADY_PAYWALL___

Within these parameters, we can argue until we’re blue in the face as to whether the usually cited examples like Yemen, Venezuela, Afghanistan and Haiti, as well as a distressingly large number of African states — Somalia, Sudan, Central African Republic, Democratic Republic of Congo, and at least half a dozen more — are failed, failing, recovering from almost failing, or are a bit of all of the above.

In this topsy-turvy world, South Africa rates in the middling ranks of fragility, according to the indexes. We’re admittedly becoming steadily less stable but are so far from the tipping point that there’s probably not too much to worry about.

The point is that “failed state” is an academic discourse about a supposedly measurable set of political, economic and social factors. But that’s not how we live our personal lives. We live our lives in little worlds that we create with great ingenuity and usually at significant emotional or financial costs.

Our neighbour, Zimbabwe, is listed on several Fragile State Indexes as one of the worst dozen failing countries. Yet while many of its impoverished professionals and workers are taking refuge in South Africa, there is simultaneously a small but significant counter-flow of wealthy entrepreneurs who see great opportunities and a fantastic lifestyle there.

Similarly, South Africans take their most critical decisions — stay or go, fight or flight — largely based on a personal trajectory. That personal trajectory can be quite different from that of the state, at least divergent for a long enough time for it to be worth taking the risk.

Discovery CEO Adrian Gore recently berated South Africans for not comprehending that the “narrative around the country is much worse than the reality”, and that we should shake off a “pessimistic, declinist mindset” that is “very detrimental” to South Africa’s long-term prospects. Of course, Gore is absolutely right, in his own world.

At a corporate level, he founded and heads one of the country’s biggest companies, which has thrived exactly because of his contra-instinctual business acumen. Given its now global footprint and its chumminess with the government over the proposed National Health Insurance, Discovery will thrive even as South Africa potentially declines.

Gore is also fireproof on a personal level. In South Africa, only wealth can shield against the serrated edges of a violent, unpoliced society in which the most basic elements of state infrastructure to sustain daily existence — water, sewage, roads, rail, electricity, education and healthcare — are collapsing.

Gore lives at the apex of a parallel state — a nation where the state’s failures don’t matter because everything can be acquired, bigger and better, from the private sector — that contains, based on financial industry estimates, probably fewer than 100,000 families. Knight Frank reports that last year South Africa had 31,852 US$ millionaires and 561 ultra-wealthy with assets above US$30m. Much of that wealth will increasingly be held offshore.

The flight from South Africa over fears of a failed state is not generally by the rich, who can afford to stay. Nor by the poor, who have no option but to stay. It’s by the squeezed middle.

Take the growing flight of medical professionals. This is the group whose erosion will most swiftly puncture the “positivity” bubble and spur the exit of other groups who would otherwise hang in.

It's an existential issue. When you need a doctor, you want him or her located as close as possible. It’s only the corporate creme-de-la-creme who can have their surgery done in London. Or ANC leaders fearing witchcraft, like Jacob Zuma, who can have the muti spells of their jealous rivals negated in Moscow.

According to statistics recently released in Parliament by Health Minister Dr Joe Phaahla, our doctor-patient ratios, already among the worst in the world, have worsened substantially in the past two years. In 2019, South Africa, then with a population of 58.6m, had a doctor-to-patient ratio of 1:1,266. Currently, with a population of 60.1m, that ratio is 1:3,198).

That translates to a drop from approximately 46,294 doctors in practice in 2019, to only 19,772 in 2022. If Phaahla’s statistics are correct, that’s a terrifying drop in practitioner numbers in just three years.

Further evidence of this trend comes from a survey last year of clients of the Professional Provident Society (PPS).  A quarter of the 2,500 PPS clients who stopped using the company’s services cited emigration as the reason for doing so. 

PPS’s 2021 Graduate Professional Index, released last week, also shows a sharp increase in medical professionals contemplating emigration. While financial services sector professionals had 80% confidence in the future, the dental and medical professionals were considerably more gloomy, with 58% and 56% confidence levels respectively.

Earlier this year, in a presentation to Parliament, PPS said that 73% of its 30,000 members who are medical professionals felt that emigration would be the outcome if NHI is not implemented responsibly.

As PPS said this week, “Emigration is always a realistic option for the qualified. Each healthcare worker not only represents a skilled worker, but many are also self-employed and pay taxes as individuals, as well as in their business capacity.”

The debate about whether South Africa can be accurately defined as a failed state doesn’t much matter. Increasing numbers of ordinary people are deciding that for them, it just isn’t working any longer.

Follow WSM on Twitter @TheJaundicedEye