Academic journal article The Hastings Center Report

Tough Priorities

Academic journal article The Hastings Center Report

Tough Priorities

Article excerpt

Organ Triage and the Legacy of Apartheid

On 3 December 1967 South African surgeon Dr. Christiaan Barnard astounded and delighted the world by performing the first human heart transplant at the Groote Schuur Hospital in Cape Town, South Africa. Dr. Barnard was catapulted to fame as a media star and a public diplomat. South Africa's capability to perform heart transplants placed the country firmly in the ranks of the first world, belying its mixed developed and developing economy that grew out of separatist apartheid policies.

Since the initial worldwide attention that Dr. Barnard's success drew to South Africa, his country has undergone thirty years of arduous metamorphosis. Significant changes have transformed the mineral rich and culturally diverse country from a brutal police state into a oneman, one-vote democracy. But the legacy of apartheid remains.

That legacy is deeply embedded in how South Africans think about expensive medical technologies. In July 1995, I saw an emotional debate on heart transplantation on South African television. The debate featured Dr. Barnard, who was arguing for the continuation of heart transplantation at Groote Schuur Hospital and in other South African hospitals. It struck me as odd that heart transplants were considered a priority when twenty miles from Groote Schuur was a squatter settlement where nearly 500,000 lived in abject poverty.[1] I was then assisting on a project at the settlement that aimed to prevent kwashiorkor in infants and provide contraceptive methods to women Jiving in shacks that had neither running water nor electricity. The relevance of high technology medicine in the "New" South Africa is in question. The progressive, humanistic, and compassionate goals of transplant medicine jar with South Africa's stated goal of striving to reflect, in every sector, the nation's unity and commitment to an equitable distribution of resources.[2]

Understanding the poignancy of the debate requires examining the historical context of the initial operations and probing the political background and health infrastructure of South Africa. Heart transplantation in particular has come under attack for its high costs and elitist bent, and has become a metaphor for the misallocation of resources. While high cost has become an issue in every country of the world in which heart transplants are performed, the South African situation stands out because of the magnitude and severity of poverty and its nearly absolute restriction to the country's nonwhite populations. The price of salvaging a few lives through heart transplantation could easily cover the costs of basic health care for many other people and fund preventive care to detect and ameliorate heart disease at earlier stages. Heart transplantation also suffered attack because of the paucity of well thought out and acceptable policies regarding its appropriate usage.

Yet the availability of heart transplants has also taken on unique symbolic significance as post-apartheid South Africa struggles to define a new place for itself in the world. South Africa is at the forefront of technological scientific training and medical research on the African continent, and heart transplantation is an affirmation of the country as a first world contender among technologically capable developed countries.

As South Africa begins its search for a new unity, heart transplants are one of the few attributes the country is proud of in a forty-year history that has made it shamed and scorned by the rest of the world. Groote Schuur, the public, university-affiliated Cape Town hospital where the first heart transplant took place, and the actual heart transplantation procedure are two sources of great national pride in South Africa. The ardor with which South Africans cling to symbols of national pride (rugby, springboks, braais, national monuments, etc.) as evidence of unity, stability, and worthiness in a chaotic society is very noticeable. …

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