Class divisions in South Africa, particularly the perspectives held by the so-called middle class, have long posed barriers to honest conversations about the struggles of poor and working-class people, an issue evident in discussions linked to the NHI, writes Abongile Nkamisa in the Mail & Guardian.
The middle classes, entrenched in their own experiences and prejudices, often engage in in-group derogation, obstructing meaningful dialogue and understanding of the real challenges faced by marginalised working-class people.
In this opinion, I will attempt to discuss this in-group derogation – the phenomenon where a particular social class adopts a dismissive and often harmful stance towards others within the same broad category, often to distance themselves from the perceived negative traits associated with that group.
For the middle class, this manifests in attitudes that devalue and stigmatise poor working-class communities, creating a chasm that impedes empathetic and constructive discourse.
I argue that the middle class, in its failure to interrogate its positionality and disillusioned privilege, perpetuates a systemic silencing of the true needs and realities of marginalised people.
Moreover, the discussions on corruption and the governance of the NHI often misdirect anger and anxiety, obfuscating larger issues.
When the NHI Bill was first introduced to Parliament in 2019, I was doing an internship with the Rural Health Advocacy Project.
I conducted research on the effect the NHI would have on rural health perspectives, and witnessed the multi-layered and systemic disparities in healthcare access. The inequalities faced by rural communities in accessing quality healthcare contrasted starkly with the relative comfort of urban middle-class experiences.
The disparities were not merely about resource allocation but rooted in historical, socio-economic and racial inequalities.
The middle-class discourse around the NHI often fails to capture these nuances, instead focusing on abstract principles of efficiency and corruption without addressing the realities of those most needing healthcare reform.
Conversations with my peers, even then, often revolved around the inefficiencies and corruption within the healthcare system, a perspective predominantly voiced by the urban middle class. They would argue passionately about the need for systemic reform, citing abstract principles of fairness and efficiency.
These conversations left me grappling with an internal conflict I couldn’t initially articulate. I had been one of those teenage mothers, seeking help at a clinic and being turned away due to resource shortages. I had seen my grandmother, blind from old age, being asked to pay R1 000 for spectacles, which she could not afford.
I had family among the many chronically ill who went through insuperable difficulties, often years of prolonged consultations, to access essential medication.
These were fragments of my life and the NHI, for me, was not just a policy decision, it was a much-needed revolution. Yet, in all of these discussions about healthcare reform, I found it difficult to see myself in the people for whom we were advocating.
I thought there was no room for my experiences – these narrations and discussions about healthcare disparities were being recounted by other people, detached and impersonal.
The dissonance emerged from the clash between my personal reality and the clinical, often detached, narratives of healthcare inequality. Why couldn’t I see myself in the eyes of the poor? Was my intuitive understanding of what the NHI could achieve less valid because I was somehow part of this middle-class lifestyle?
As I spent more time in rural clinics and community health centres, the layers of my cognitive dissonance began to unravel. The systematic disparities in healthcare were, and are still, entrenched in historical, socio-economic and racial inequalities.
The turning point came during a visit to a remote clinic in the Eastern Cape, from where I come. There, I met a young mother who mirrored my younger self – desperately seeking help for her sick child, only to be told the clinic had run out of medication. Her story shattered the last remnants of my detachment.
This confrontation with reality remains both painful and liberating. I began to understand my dissonance stemmed from a reluctance to fully acknowledge the depth of my own trauma within the larger narrative of healthcare inequality.
Maybe this is where the differences among us lie. Perhaps our memories need to be jogged, to remind us of where we come from and how easily we could find ourselves there again. Because, after all, all people of middle-class status today were once, or are descended from, someone of working-class status. Most middle class people know just how fragile and precarious this lifestyle is.
Economic stability can be a fleeting thing, subject to the whims of the market, changes in employment, or unexpected expenses.
In Marxist terms, class is defined objectively by one’s relationship to the means of production. The bourgeoisie owns the means of production, while the proletariat sells their labour. This clear-cut division has blurred in modern society, where a sizeable middle class has emerged, characterised not by ownership through means of production but by marginal access, and social and cultural capital.
This shift complicates class analysis, as middle-class folk often see themselves as separate from both the bourgeoisie and the proletariat, leading to a distorted understanding of their role in systemic inequality. The middle class’s failure to ask the right questions and introspect on its position stems from this lack of clarity.
We do not fully grasp what it means to be “middle class” in a capitalist global order that largely ignores us. Instead, we focus on preserving our precarious status.
This misalignment often perpetuates a discourse that is out of touch with the realities of those most affected by systemic inequalities and healthcare disparities.
The thing about middle-class sensibilities and our struggle to maintain empathy is that it’s often hidden in plain sight. On social media, you can see the depth of our challenges amid the current economic climate. We’ve become a dysfunctional group, resorting to alcohol and drugs to cope.
The soaring cost of living, and healthcare, has made normal functioning nearly impossible. We’re suffocating under the weight of middle-class expectations, yet paradoxically, we perpetuate these norms, to the detriment of ourselves and others.
Our adherence to middle-class ideals of meritocracy and self-reliance creates barriers for poor working-class individuals at every level.
These norms dominate universities and prestigious workplaces, deterring poor working-class people from applying, being selected or staying in such positions.
The disparities in identity, cognition, emotions and political behaviour of the middle class often prevent poor working-class individuals from accessing educational and job opportunities that could enhance their material well-being.
The NHI did not come without political controversy. By the time the Bill was announced as law, it was strategically beneficial for the ANC, which was losing its voter base due to public discontent over allegations of corruption and mismanagement of funds, particularly in the public health sector, which was, and still is, in a state of decline.
This discontent is genuine and must be addressed. I am not saying people should not question why there has been a systemic failure in our government to administer and manage the roll-out of public services.
However, at a point where public services are being rolled out to support and ease the burdens on poor working-class communities, we seem to be shaping a narrative around what corruption is and what it looks like.
If we are sincere in our efforts to seek truth and accountability about corruption, our pursuit of truth and accountability should radicalise us to align with the needs of society, alongside what the majority of society desperately needs.
Abongile Nkamisa is a lawyer at Open Secrets. This is an edited version of the winning essay in the Canon Collins Troubling Power Essay Competition.
M&G article – Class divisions and the struggle for honest conversations about the NHI (Open access)
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