The Causes of the Causes

One of my South African professors used to say something like, “We need to address the causes of the causes.”

Now, what does that mean? In the context of that class, we were talking about South African community health care workers (CHCWs).  CHCWs are usually black women, who provide basic health care or even health education to members of their community.  They are called community health care workers because their space of work is within their community.  They make house calls to their neighbors.  They travel to and from places.  Simultaneously, the place they work is also the place they call home.

Community health care workers have tough lives; I wrote a whole essay about it.  They are considered outside the health care system, so they have a hard time receiving care themselves.  They are job insecure and financially insecure.  They face the “quadruple burden of disease”.  The quadruple burden of disease are diseases and health concerns related to:

  1. Poverty and Underdevelopment.
    Eg. lack of proper santitation and adequate facilities
    Eg. potholes in the ground could cause her to spain her ankle
  2. Non-communicable diseases (ie. lifestyle diseases)
    Eg. Respiratory disease due to poor quality of air
  3. Injuries and violence (even rape)
    As these incidences are more prevalent in the neighborhoods they live and work in
  4. HIV/AIDS and Tuberculosis
    Highly prevalent in poor neighborhoods as well.

So, CHCWs are faced with this quadruple burden of disease, while dealing with patients who can also negatively affect her health, while being a black woman in South Africa (where there is still major racial and gender inequality).

But, why is this the case for CHCWs?

We have to look back to the causes of the causes.  People can point out to the inadequate formal health care system.  For many South Africans, private health care is better in quality, but is unaffordable.  Therefore, they must turn to the public health care system, which has many problems on its own.

The public health system currently serves about 43.8 million people per year, compared to the 8.5 million people of the private sector (Vavi 2014). [However, roughly about the same amount of money goes towards both the sectors.]  This means that resources in the public health care system is often stretched thin and are incapable of meeting the needs of the population. There are many inequities and barriers to health care provision in South Africa. These barriers include “vast distances and high travel costs, especially in rural areas; high out-of-pocket (OOP) payments for care, long queues, and disempowered patients”, and they disproportionately affect the poor (Harris et al. 2011). The formal health care system is often expensive, inadequate and unequal, unable to meet the health needs of the population.*

Therefore, we have this very crucial need that is not being met by the formal health care system.  This is where community health care workers come in.  They are the supply to meet the demand for health care.  They are tasked with the overwhelming burden of meeting a basic fundamental need when their government and other forms of care cannot.

If we define the problem as a poor health care system, what is the solution?  Health care reform?  What happens to CHCWs in the meantime?  What happens to CHCWs when the health care system is reformed?  How should the health care system look like?

Meanwhile, others can point to poor compensation and conditions of CHCWs as a cause of their hardships.  If they were paid more, it would be easier for them.  If they received proper training and earned certificates to recognize their care, they would be more efficient and respected in the field.

So, how can we address the problem if it is a problem of providing better benefits to these health providers?  Should we encourage CHCWs to leave the profession and seek employment elsewhere?

This question reminds me of the metaphor of crabs trying to pull themselves out of the bucket.  When one crab is just about close enough to pull itself out, the other crabs pull it back down.  I’m not saying that CHCWs pull each other down.  I am sure that CHCWs wouldn’t wish their fellow colleagues to continue living this kind of life.  However, if a few CHCWs are able to successfully leave their communities and do something else, doesn’t that increase the burden on the rest of the CHCWs?  To save oneself, they are simply leaving the work for everyone else.

So what else can they do?  Should they go on strike?

But, if health care workers go on strike, especially CHCWs, that raises another ethical dilemma.  How could they possibly not go to work, essentially abandoning their patients, who need them?  As I have established before, CHCWs are there because they are the only ones left who can provide the much needed care.  If they are gone, who is going to care?  So, is it morally right that CHCWs protest for better working conditions and compensation?

Additionally, even if CHCWs did resolve to unite and protest the government, it is a difficult bureaucratic process to even go on strike legally.  There are other hoops that they must navigate through.  Therefore in the end, nothing gets resolved for them.  CHCWs just live through this constant cycle that they must provide care because they the only ones that can provide care in their communities.  They are placed on the frontlines.  Often their care, because they lack the adequate resources or training or because the disease is too severe, they can only treat the symptoms and not the actual disease.  They know this, and so they also grow frustrated that the problems that they are treating will continue to persist and they are helpless.

The lesson here is about looking at the problem and thinking about how to deal with the causes of the causes.  It is obvious to say, if I have done well in explanation the current situation, there are many factors and pieces that cause disease but also disease to persist.  There are many reasons why CHCWs must live the lives that they do.  They are needed but unappreciated.

But, why?

I’ve already named some.

But, why have those reasons come into fruition?  Why is the formal health care system inadequate?  Why are there poor neighborhoods that essentially are sites of poor health?  Why is it so hard for workers to go on strike?

If you take it back enough, you’ll get to the causes of the causes.  Do you know that the ultimate cause was?

Someone had to decide it was so.

Someone had to have thought of an idea to have these types of ramifications.  It’s not exactly explicit, but we, as human beings, are creators of the systematic world, the society, the communities in which they live in.  We did it.  We created the game.  We wrote the rules.  We made the conscious decision.  It was our choice. And this choice became systemic, embedding into many aspects of life and perpetuated over time.

These conditions don’t come from nowhere.  In the context of South Africa, it must have come from apartheid and how black townships were neglected from federal funding and resources for nearly 50 years.  It must have come from gender and racial discrimination, even way before apartheid existed.  It must come from the belief in the superiority of Western thought and wanting to civilize other populations.  It must have come from the misallocation of funds by the government.  This list goes on.  There are many reasons, and we could take it even further back.  But, it all comes down to the decisions that people have made in the past.

We created this game, which means that we are the ones that are able to fix it.  We are the ones that are able to reverse the rules to favor the poor, the hardworking, women, the disadvantaged.  But, we must use an interdisciplinary approach and not think that the process to the solution is linear.  We must involve all the people that matter and make sure that we meet their concerns and needs.

If we have the power to make bad things happen, it is of absolute certainty that we can make good things happen too.

Over and out.


PS. For the purposes of this post, I haven’t done enough justice to tell the story of the South African community health care worker.  Their stories and the lives they lead are much more complex than I have described here.  If you would like to know more about them, please let me know and I would be happy to share what I know (which is probably still very limited).

PPS. I would like to apply this form of thinking to fixing the American economy and politics.  The government shouldn’t be dominated by money, but by the people.

* This is a section of my essay that I wrote for class.


Harris et al., 2011, “Inequalities in access to health care in South Africa,” Journal of Public Health Policy, 32(1), 102-123.

Vavi, Z., 2014, Healthcare Inequality South Africa’s New Apartheid, SA Breaking News,

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