"How sick are the world's healthcare systems" is deserving of a journalism award.
In the best of health? Photograph: Getty/Guardian
China - long lines; access to care is bureaucratic. A soaring demand for quality medical care by Jonathan Kaiman
In Lewis Carroll’s Through the Looking Glass, Alice finds herself facing a difficult conundrum. She’s running towards a distant hill; yet no matter how quickly she runs, her surroundings move with her, effectively stranding her. She meets the enigmatic Red Queen. “Now, here, you see, it takes all the running you can do, to keep in the same place,” the Queen explains. “If you want to get somewhere else, you must run at least twice as fast as that!”
China’s healthcare system suffers from the same problem – despite running at full speed over the past few decades, it can’t possibly move fast enough to keep up with the country’s social and economic changes. China’s per capita GDP grew more than 25-fold from 1980 to 2011; its life expectancy rose by nine years; its infant mortality rate quartered. Yet as Chinese citizens grow older and wealthier, they are also burdened by a rise in pollution, smoking, obesity and other public-health hazards, creating a soaring demand for quality medical care.
During the Mao era, in the 1940s through to the mid-70s, the country’s healthcare system was rudimentary but egalitarian, entirely supported by the state. Yet in the 80s, reformer Deng Xiaoping dismantled the system, leaving hospitals suddenly responsible for their own economic wellbeing. The result has been rampant profit-seeking: overprescription of medications, excessive testing and shocking efforts to cut corners. Many Chinese hospitals don’t keep soap in their public bathrooms. Physicians are so underpaid that they often must supplement their salaries with kickbacks from drug companies and patient bribes.
The system is also deeply stratified. A typical villager, upon falling ill, will first visit a local clinic – usually a concrete-floored, one- to two-room facility, equipped with little more than intravenous drips and a small pharmacy. If his malady requires further attention, he will be forced to ascend through a hierarchy of institutions – to a county hospital, then a provincial hospital, then a specialised clinic in a metropolis such as Beijing or Shanghai. Major institutions, inundated with patients from afar, suffer from chronic overcrowding. It is common to see families sleeping overnight on hospital lawns to avoid early-morning queues.
With the stakes so high, tempers run hot when treatments fail. Patient-on-doctor violence has become startlingly common – stabbings and mob-style attacks have risen 23% a year on average since 2002, according to the China Hospital Management Association. A typical hospital suffers one such incident every two weeks.
The Chinese government has poured billions of pounds into healthcare reform in recent years, and the system has improved accordingly. At present, 99% of the rural population gets some kind of insurance, up from 21% a decade ago; the country plans to roll out universal coverage by 2020. Yet the price of basic medical services has also risen, and many insured patients are paying as much as they once were. As of last year, the government gives each rural resident 280 yuan (£28.34) in annual healthcare subsidies. Yet elaborate procedures can cost many times that, and patients must pay the difference out of pocket. China has one of the highest savings rates in the world – about 50% – largely because families fear catastrophic healthcare costs.
Chinese authorities have been embracing other, more innovative ideas to improve the system: new technologies, private investment, new training regimens for doctors – in short, redoubling their speed just to keep up the pace.
South Africa: ‘Labouring under a two-tier system’ With the world’s biggest HIV caseload by David Smith
HIV with rampant tuberculosis (TB) and rising obesity, South Africa's healthcare is under strain.
The government spent more than 8.5% of GDP on healthcare in 2012, higher than the 5% recommended by the World Health Organisation (WHO) for a country of its socioeconomic status, yet performed worse than comparable nations.
The historical legacy of colonialism and apartheid is still manifest in one of the most unequal societies in the world. Health care is not exempt from this culture, so South Africa continues to labour under a two-tier system.
The private sector consumes 60% of total health spending yet caters to only about 15% of the population. The facilities are world class and less expensive than in Britain, the US or Australia – fertility treatment, for example, attracts foreigners at a fraction of the cost – but are beyond the financial means of most South Africans.
Public healthcare struggles to meet the needs of the other 85%, with often overcrowded facilities, poor equipment and shortages of drugs. Less than 30% of doctors, dentists, pharmacists, physiotherapists and psychologists, and just 40% of professional nurses, work in the public sector.
Some essential services are provided free by the state. TB treatment, for example, is not available in private clinics. After diagnosing a patient with TB, private doctors refer the patient to the public sector, where everyone receives TB medicine free of charge.
The most striking success in free provision is the antiretroviral treatment programme for people with HIV, initiated 10 years ago after the government, accused of “Aids denialism”, lost a landmark court case. Today, South Africa has the world’s biggest public-sector HIV programme, with 2.5 million people receiving treatment (!). The country’s life expectancy has consequently increased from 53 in 2002 to 60 in 2013.
But there are practical barriers. Patients’ first point of contact are primary healthcare clinics where, in serious cases, nurses and community health workers can refer them to hospital. These clinics are concentrated in cities and towns, often inaccessible to people in rural areas who cannot afford transport. Some 47% of children live in rural areas where only 12% of doctors and 19% of nurses work. Some villagers rely on an informal network of traditional healers and medicines.
Not everything in public hospitals is free, and only an estimated 17% of South Africans are part of a medical aid scheme to cover the costs. In addition, staff shortages translate into long waiting times. Critics say treatable conditions are not treated on time and preventable diseases are not prevented. The government has admitted the need for a “radical improvement” in the quality of services and “massive investment” in buildings and equipment, as well as fundamental changes in management.
The health minister, Dr Aaron Motsoaledi, has been known to roll up his sleeves and work a night shift at the Chris Hani Baragwanath hospital in Soweto, the biggest hospital in the southern hemisphere. He and his family use public hospitals and in 2011 he told the Mail & Guardian newspaper: “It’s a self-defeating prophecy to keep on saying we don’t have the means. There are good services in countries with fewer facilities and staff than us.” Nevertheless, Motsoaledi has a big plan for healthcare reform: a national health insurance scheme. The aim is to provide essential healthcare for all, irrespective of employment status and ability to pay, as enshrined in the post-apartheid constitution. Anyone earning above a certain income will be required to contribute to the NHI Fund.
The plan has met resistance from the private sector. But the government insists: “It will actually make the sector more sustainable by making it levy reasonable fees. The intention of NHI is rather to make sure that citizens are able to use both the public and private sectors in such a way that they complement each other rather than one undermining the other. At the moment, private healthcare is only for the rich. NHI is trying to blend the two in a more sustainable manner that benefits the population.”
India: ‘Public or private, India’s health care system is largely unregulated’ by Anu Anand
When Ria, 12, an illiterate maid’s daughter, suddenly developed a giant lump in her abdomen, her mother knew better than to trust India’s publicly run hospital system. Mazes of dingy corridors, outdated equipment and filthy wards where linens are absent and rats run freely greet the desperately poor and sick patients seeking care.
India spends just 1.3% of GDP on healthcare, one of the lowest in the world. Every day, patients from around the country, some who have travelled for days, can be seen queueing outside India’s biggest public teaching hospital, the All India Institute of Medical Sciences (AIIMS) in New Delhi. Hundreds jostle to see erratically available specialists. Others push their way to the counters of crowded roadside medical shops to purchase not just bandages and surgical equipment, but even life-saving drugs and the pints of blood patients are often expected to provide. At night, dozens of patients and their relatives sleep under the bright lights of the closest bus shelter, unable to afford accommodation.
The other option, equally inaccessible for poor Indians, lies a few miles away. In the lobby of one of New Delhi’s swanky corporate hospitals, wealthy patients from around the world sip lattes as they wait for doctors in brightly lit waiting rooms, complete with cleaners, attendants and stacks of glossy magazines.
Here, by global standards, the best diagnostic tests and procedures can be had for a fraction of western prices, a fact that fuels medical tourism to the tune of an estimated $78.6bn in India. But public or private, India’s health care system is largely unregulated.
In May, David Berger, a visiting Australian doctor writing in the British Medical Journal of his experiences in a small Indian hospital, blew the lid off the widespread practice of doctors receiving kickbacks for referring patients for medical tests, scans and even surgery. Subsequently, a group of doctors at AIIMS formed the Society for Less Investigative Medicine to counter corruption, which is deemed widespread by many.
India’s new health minister has also vowed to clean up corruption. And the new prime minister, Narendra Modi, has further spoken of his vision for universal healthcare. Partially inspired by Obamacare, it would potentially be the largest scheme in the world and tackle such daunting silent epidemics as tuberculosis, which claims 300,000 Indian lives annually.
But critics argue that such a private sector-led scheme will further marginalise the state system and leave India’s poorest citizens increasingly vulnerable to exploitation and substandard treatment, especially in rural areas.
Ria successfully had a grapefruit-sized tumour removed from her ovary. Her mother’s employer led the search for credible doctors, interpreting their advice and helping to cover the roughly £600 in diagnostic and surgical costs. Thankfully, her tumour was benign.
Brazil ‘A huge gap between standards of private and public care’ by John Watts
When more than a million protesters took to the Brazil streets last year, the woeful condition of the public healthcare system was high among their list of grievances.
Inequality and vast distances are the main problem. According to the World Bank, the country has 1.8 doctors for every 1,000 people – well below the 3.2 ratio in neighbouring Argentina, and significantly below those of Mexico, the US and the UK.
On paper, however, Brazil has one of the most comprehensive and generous public health networks in the world. The Unified Health System, or SUS as it is widely known, is universal and free for everyone. It has notched up impressive achievements. Since the turn of the century, life expectancy is up from 68.8 to 74.5, infant mortality is estimated to have fallen to 14.4 per 1,000 live births from 17.6, and the government says 95% of children are now fully vaccinated. Brazil’s healthcare spending was 9.3% of GDP in 2012.
But, reflecting this very unequal society, there is a huge gap between standards of private and public care. In state capitals, the one in four of the population who can afford private services benefits from almost double the doctor-patient ratio. For those in the SUS, there are insufficient beds, and waiting times for basic diagnosis and treatment are long.
Regional disparities are even more glaring. Residents Maranhão, the country's poorest state, have barely a quarter of the spend per head as the inhabitants of wealthy Rio de Janeiro.
To address this problem, President Dilma Rousseff last year launched a crash programme to fill the gap with thousands of primarily foreign medics. The “Mais Medicos” (More Doctors) programme offers incentives to those go to medical schools in remote and poor areas, such as the Amazon, so that in the long term they can train a new generation of professionals. So far, 4,199 doctors have been dispatched and the plan is to increase this to 11,500 doctors by the end of 2017.
The vast majority have come from Cuba. This is politically controversial because the Cuban government pockets about a quarter of their salaries. When they arrived, Brazilian doctors booed and chanted “slave” at the newcomers and accused them of lacking the necessary qualification and language skills needed to do a good job.
While it is true that the normal diploma requirement has been waived for the Cubans, the government says this is justified because they are only expected to provide primary care, not surgery. “Mais Medicos is a success because it is serving the public with quality and because it is greatly improving health indicators throughout Brazil,” says health minister Arthur Chioro. “Fifty million people who did not previously have primary care now have exactly what they need most of all.”
Egypt ‘A system that doesn’t know how to manage itself’ by Patrick Kinsley
A few weeks ago, a woman gave birth in a street outside of a public hospital in northern Egypt. Depending on who you believe, the hospital either didn’t have enough medics to tend to her – or they demanded money that she couldn’t pay.
Hers was an extreme example of the problems with Egypt’s public health service, particularly in provincial areas. Thanks to a decree issued earlier this year, all Egyptians should get free access to emergency hospital care for at least 48 hours. But in practice some state facilities, particularly in the countryside, either cannot provide instant healthcare – or have to charge for it. Due to a shortfall in government funding, they have no other way of paying their staff.
And the problem goes beyond A&E. A state-run insurance scheme nominally provides subsidised non-emergency healthcare to children, government workers and the families of those workers – a group that the government says totals 54% of the population. But by the government’s own count, only 8% of those covered by the scheme actually use state facilities. “This in itself denounces the problem,” says Ayman Sabae, a doctor and campaigner for healthcare reform at the Egyptian Initiative for Personal Rights, a prominent watchdog. “Both the service quality and access to the services are so limited that only 8% use them.”
A government clinic that Sabae visited in rural Qena province last month exemplifies the problem. Like about half of Egypt’s 4,000 state clinics, this one is well-equipped, and newly refurbished. But according to Sabae, there has not been a doctor here for the past four years. Clinicians assigned here might only earn around 1,200 Egyptian pounds a month – about £100, or little more than Egypt’s average monthly wage – whereas they can earn around five times as much in the private sector. So they opt for the latter.
“There’s a couple of finance employees, maybe a nurse,” says Sabae of the clinic. “But no doctors. And that’s very typical – you have a system that doesn’t know how to manage itself. You have the money to renovate the clinic, but not the human resources to manage it.”
As a result, the half of the population who are eligible for free healthcare are often no better off than the half who aren’t. Most end up paying for their care themselves – in fact, 71.8% of healthcare spending in Egypt comes from people’s pockets. NGOs, charities and religious groups pick up some of the slack (the now-banned Muslim Brotherhood part-built their influence on their network of clinics).
Those who aren’t covered by the state healthcare plan can apply for another of state-paid treatment – the Program for Treatment at the Expense of the State. But this is only for those with life-threatening diseases who can show they are incapable of paying through other means.
As a last resort, any patient can get free treatment at university training clinics and hospitals. On the plus side, the doctors here are often the best in the country. On the downside, students observe every operation, the facilities are often unhygienic, and the cost of basic supplies is frequently covered by the patients or the doctors themselves.
“When I worked there as a doctor, I was paid 200 Egyptian pounds [about £20] a month, and I would spend more per month from my own pocket to buy blood from other hospitals,” says Sally Toma, another doctor who campaigns for healthcare reform. “Otherwise, I was told, I would have to choose who should get blood, and who should not.”
Italy ‘A persistent complaint is unfairness’ by John Hooper
Italians by and large regard health as a priority. And it shows up in one of the highest life expectancies in the world. In 2012, according to the World Bank, the average newborn Italian could expect to live to the age of 83 – the same as in Switzerland or Japan.
But, like many things in a country of contrasts and disparities, the provision of health services varies widely from one part of Italy to another. Last year, a report was published by the parliamentary committee that scrutinises what Italians callmalasanita (literally “bad health”): cases of extreme negligence on the part of doctors or hospital staff. Out of 400 deaths attributable to malasanita between April 2009 and December 2012, more than 40% occurred in just two of Italy’s 20 regions, Calabria and Sicily.
Italy’s Servizio Sanitario Nazionale was founded in 1978 and modelled in large part on the NHS. But right from the outset it was only to a limited extent national.
The central government fixes the overall budget, determines minimum levels of care and, for example, negotiates drug prices with the big pharmaceutical companies. But it is the regional governments that administer the system, and there are huge discrepancies between them in levels of efficiency and integrity.
In parts of northern Italy, patients receive attention as good as anywhere in Europe. “Customer satisfaction”, however, falls off rapidly in the southern half of the country. And the drop goes hand in hand with a fall in measures of efficiency.
In Sicily, for example, there are roughly 10 hospital doctors for every hospital bed. In the north-eastern region of Friuli-Venezia Giulia, the ratio is half that.
Discernible in the statistics are variations in the degree of corruption and the use of public services to distribute jobs and patronage. Last year’s parliamentary commission report noted that in Campania, the region around Naples, 383 health officials had been taken on to the payroll without having to go through the bother of a selection process.
A persistent complaint among patients is of unfairness. In the southern half of Italy especially, they often move up waiting lists, not according to the date on which their names were first entered, nor by virtue of the seriousness of their condition, but according to whether they can secure a raccomandazione(reference) from someone with influence over the relevant surgeon.
By and large, the state has been open-handed in allocating resources to health. In 2012, Italy spent 7.2% of its gross domestic product on the public health system. That was less than was spent by the UK, Germany or France. But then Italy’s economy has scarcely grown since the turn of the century and is under growing pressure from European institutions to trim its spending.
Cuts have been made in recent years. But the overall budget for this year, of almost €111bn (£88bn), was still almost 4% higher than it had been in 2011.
The United States ‘More than 13% of Americans still have no health insurance’ by Nicki Woolf
When he announced the news that a doctor returning from Guinea to Harlem, in New York, had been diagnosed with Ebola in October, mayor Bill de Blasio said that New York’s had the “world’s strongest healthcare system”.
But the fact that he referred to the city’s system, rather than the nation’s, is telling. In fact, while the US can boast some of the best doctors and most advanced medical technology in the world, it doesn’t really have a coherent healthcare system at all. Healthcare in the US is private insurance-based and decentralised, with most care providers owned locally by private companies, and local and state governments controlling access to federal programs.
The private and public systems that overlap in some areas, and leave gaps in others, make the US the country that spends the most per capita and as a percentage of GDP of any country in the world, but paradoxically consistently last among comparable nations in measures of quality of coverage such as infant mortality.
Because their cost is decided by private companies, individual procedures can be extraordinarily expensive. A single MRI scan in some parts of the country can cost as much as $2,871 (£1,780); an appendectomy as much as $29,426 (£18,000), and a caesarean-section delivery as much as $26,305 (£16,000), according to a report by the International Federation of Health Plans. Some procedures can be as much as eight times the price of the equivalent operation in the UK, and a 2013 study by NerdWallet Health showed that medical bills are the biggest cause of bankruptcy in the US.
Some of the gaps are filled by government operations. One of these is Medicare, which guarantees health insurance for the elderly. Another is Medicaid, a low-income program which the Obama administration has recently expanded – but state governments, especially those controlled by rightwing Republican governors, have consistently rejected the expansion, leaving many poor residents without healthcare. Yet another is the Veterans Health Administration, which was hit by scandal in April 2014 when it was revealed that at least 40 US military veterans had died while waiting for medical care.
Perhaps the core struggle of Barack Obama’s presidency has been to pass his Affordable Care Act (ACA), which would aim to use state online insurance exchanges to reduce the number of people without coverage. But the bill has become a political football for the far-right Tea Party, who see any attempt to close the gaping holes in coverage as unacceptable government overreach.
The result has been that as of the beginning of 2014, more than 13% of Americans still have no health insurance coverage at all.
Germany ‘It gives patients a lot of choice’ by Philip Oltermann
Germany’s healthcare system is best understood as a middle option between the British state-run and the American market-led model. In principle, healthcare cover is universal, as in Britain: treatment of the unemployed is covered by the state, and ordinary patients rarely get presented with a bill after seeing a doctor.
Unlike in Britain, however, this universal care is not funded by a centrally collected tax, but by so-called Krankenkassen or sickness funds – a system that goes back all the way to Otto von Bismarck’s health insurance bill of 1883. Signing up with a sickness fund is compulsory for every German citizen. Once you have joined, you pay a premium calculated according to your income: half of it is paid by you, the other half by your employer. If you make less money, you pay less.
If you are lucky enough to have a career that makes you a lot of money – and this is where Germany veers towards the US model – you can choose to ignore one of the 131 public, non-profit sickness funds, and go with a private insurer instead. One advantage in comparison with the British system is that you don’t end up having to pay double – say, for Bupa and the NHS. In Germany, about 89% of the population is covered by public sickness funds, the remaining 11% are private.
One of the big plus points of the German system is that it gives patients a lot of choice: you are not restricted to the nearest general practitioner in your postcode but can sign up with any GP you like. GPs also have less of a gatekeeper function: if you know you have a back problem, you can go straight to see an osteopath.
Because the system is less centralised, doctors and nurses don’t have to stick to behavioural guidelines: for foreigners, some German doctors can come across as shockingly informal. “Practitioners enjoy a lot of freedom in Germany,” says Stefan Etgeton, a senior expert of the Bertelsmann Foundation. “But therein can also lie a problem: forcing through new medical standards can be arduous, because some doctors are convinced that their way of doing things is still best.”
In Germany, the healthcare system does not attract the same unholy combination of vitriol and affection that the NHS does – it just about works so that both the left and the free-marketeers can see in the system what they want. But that’s not to say that there aren’t problems eating away at the system.
For a start, the per-capita cost of healthcare has been much higher in Germany than in Britain for years. Most recent figures, from 2012, show the country spending 11.3% of its GDP on healthcare – 2% above the OECD average. “As a whole, the German system encourages overspending,” says Edzard Ernst, Exeter University’s German-born professor of complementary medicine. Doctors, who get charged per item, are incentivised to oversubscribe, and patients are incentivised to use the system more than in other countries.
There are also concerns about the long-term effects of the dual private-public system. One of the problems is that it provides an incentive for the best doctors to move to urban areas where there are more high earners who can afford private sickness funds. As a result, rural regions struggle. A public survey in 2012 showed 58% of the population supports scrapping private health insurance altogether.
Here is President Obama's "Mandela Memorial" Speech:
To Graça Machel and the Mandela family; to President Zuma and members of the government; to heads of state and government, past and present; distinguished guests - it is a singular honor to be with you today, to celebrate a life unlike any other. To the people of South Africa - people of every race and walk of life - the world thanks you for sharing Nelson Mandela with us. His struggle was your struggle. His triumph was your triumph. Your dignity and hope found expression in his life, and your freedom, your democracy is his cherished legacy. Read more: http://www.nydailynews.com/news/politics/transcript-remarks-president-barack-obama-nelson-mandela-service-article-1.1542986#ixzz2n7QZYrlS It is hard to eulogize any man - to capture in words not just the facts and the dates that make a life, but the essential truth of a person - their private joys and sorrows; the quiet moments and unique qualities that illuminate someone’s soul. How much harder to do so for a giant of history, who moved a nation toward justice, and in the process moved billions around the world.Born during World War I, far from the corridors of power, a boy raised herding cattle and tutored by elders of his Thembu tribe - Madiba would emerge as the last great liberator of the 20th century. Like Gandhi, he would lead a resistance movement - a movement that at its start held little prospect of success. Like King, he would give potent voice to the claims of the oppressed, and the moral necessity of racial justice. He would endure a brutal imprisonment that began in the time of Kennedy and Khrushchev, and reached the final days of the Cold War. Emerging from prison, without force of arms, he would - like Lincoln - hold his country together when it threatened to break apart. Like America’s founding fathers, he would erect a constitutional order to preserve freedom for future generations - a commitment to democracy and rule of law ratified not only by his election, but by his willingness to step down from power.
Given the sweep of his life, and the adoration that he so rightly earned, it is tempting then to remember Nelson Mandela as an icon, smiling and serene, detached from the tawdry affairs of lesser men. But Madiba himself strongly resisted such a lifeless portrait. Instead, he insisted on sharing with us his doubts and fears; his miscalculations along with his victories. “I’m not a saint,” he said, “unless you think of a saint as a sinner who keeps on trying.”
It was precisely because he could admit to imperfection - because he could be so full of good humor, even mischief, despite the heavy burdens he carried - that we loved him so. He was not a bust made of marble; he was a man of flesh and blood - a son and husband, a father and a friend. That is why we learned so much from him; that is why we can learn from him still. For nothing he achieved was inevitable. In the arc of his life, we see a man who earned his place in history through struggle and shrewdness; persistence and faith. He tells us what’s possible not just in the pages of dusty history books, but in our own lives as well.
Mandela showed us the power of action; of taking risks on behalf of our ideals. Perhaps Madiba was right that he inherited, “a proud rebelliousness, a stubborn sense of fairness” from his father. Certainly he shared with millions of black and colored South Africans the anger born of, “a thousand slights, a thousand indignities, a thousand unremembered moments…a desire to fight the system that imprisoned my people.”
But like other early giants of the ANC - the Sisulus and Tambos - Madiba disciplined his anger; and channeled his desire to fight into organization, and platforms, and strategies for action, so men and women could stand-up for their dignity. Moreover, he accepted the consequences of his actions, knowing that standing up to powerful interests and injustice carries a price. “I have fought against white domination and I have fought against black domination,” he said at his 1964 trial. “I’ve cherished the ideal of a democratic and free society in which all persons live together in harmony and with equal opportunities. It is an ideal which I hope to live for and to achieve. But if needs be, it is an ideal for which I am prepared to die.”
Mandela taught us the power of action, but also ideas; the importance of reason and arguments; the need to study not only those you agree with, but those who you don’t.
(Mandela) understood that ideas cannot be contained by prison walls, or extinguished by a sniper’s bullet. He turned his trial into an indictment of apartheid because of his eloquence and passion, but also his training as an advocate. He used decades in prison to sharpen his arguments, but also to spread his thirst for knowledge to others in the movement. And he learned the language and customs of his oppressor so that one day he might better convey to them how their own freedom depended upon his.
Mandela demonstrated that action and ideas are not enough; no matter how right, they must be chiseled into laws and institutions. He was practical, testing his beliefs against the hard surface of circumstance and history. On core principles he was unyielding, which is why he could rebuff offers of conditional release, reminding the Apartheid regime that, “prisoners cannot enter into contracts.”
But as he showed in painstaking negotiations to transfer power and draft new laws, he was not afraid to compromise for the sake of a larger goal. And because he was not only a leader of a movement, but a skillful politician, the Constitution that emerged was worthy of this multiracial democracy; true to his vision of laws that protect minority as well as majority rights, and the precious freedoms of every South African.
Finally, Mandela understood the ties that bind the human spirit. There is a word in South Africa- Ubuntu - that describes his greatest gift: his recognition that we are all bound together in ways that can be invisible to the eye; that there is a oneness to humanity; that we achieve ourselves by sharing ourselves with others, and caring for those around us. We can never know how much of this was innate in him, or how much of was shaped and burnished in a dark, solitary cell. But we remember the gestures, large and small - introducing his jailers as honored guests at his inauguration; taking the pitch in a Springbok uniform; turning his family’s heartbreak into a call to confront HIV/AIDS - that revealed the depth of his empathy and understanding. He not only embodied Ubuntu; he taught millions to find that truth within themselves. It took a man like Madiba to free not just the prisoner, but the jailor as well; to show that you must trust others so that they may trust you; to teach that reconciliation is not a matter of ignoring a cruel past, but a means of confronting it with inclusion, generosity and truth. He changed laws, but also hearts.
For the people of South Africa, for those he inspired around the globe - Madiba’s passing is rightly a time of mourning, and a time to celebrate his heroic life. But I believe it should also prompt in each of us a time for self-reflection. With honesty, regardless of our station or circumstance, we must ask: how well have I applied his lessons in my own life?
It is a question I ask myself - as a man and as a President. We know that like South Africa, the United States had to overcome centuries of racial subjugation. As was true here, it took the sacrifice of countless people - known and unknown - to see the dawn of a new day. Michelle and I are the beneficiaries of that struggle. But in America and South Africa, and countries around the globe, we cannot allow our progress to cloud the fact that our work is not done. The struggles that follow the victory of formal equality and universal franchise may not be as filled with drama and moral clarity as those that came before, but they are no less important. For around the world today, we still see children suffering from hunger, and disease; run-down schools, and few prospects for the future. Around the world today, men and women are still imprisoned for their political beliefs; and are still persecuted for what they look like, or how they worship, or who they love.
We, too, must act on behalf of justice. We, too, must act on behalf of peace. There are too many of us who happily embrace Madiba’s legacy of racial reconciliation, but passionately resist even modest reforms that would challenge chronic poverty and growing inequality. There are too many leaders who claim solidarity with Madiba’s struggle for freedom, but do not tolerate dissent from their own people. And there are too many of us who stand on the sidelines, comfortable in complacency or cynicism when our voices must be heard.
The questions we face today - how to promote equality and justice; to uphold freedom and human rights; to end conflict and sectarian war - do not have easy answers. But there were no easy answers in front of that child in Qunu. Nelson Mandela reminds us that it always seems impossible until it is done. South Africa shows us that is true. South Africa shows us we can change. We can choose to live in a world defined not by our differences, but by our common hopes. We can choose a world defined not by conflict, but by peace and justice and opportunity.
We will never see the likes of Nelson Mandela again.
But let me say to the young people of Africa, and young people around the world - you can make his life’s work your own. Over thirty years ago, while still a student, I learned of Mandela and the struggles in this land. It stirred something in me. It woke me up to my responsibilities - to others, and to myself - and set me on an improbable journey that finds me here today. And while I will always fall short of Madiba’s example, he makes me want to be better. He speaks to what is best inside us. After this great liberator is laid to rest; when we have returned to our cities and villages, and rejoined our daily routines, let us search then for his strength - for his largeness of spirit - somewhere inside ourselves. And when the night grows dark, when injustice weighs heavy on our hearts, or our best laid plans seem beyond our reach - think of Madiba, and the words that brought him comfort within the four walls of a cell:
It matters not how strait the gate,
How charged with punishments the scroll,
I am the master of my fate:
I am the captain of my soul.
What a great soul it was. We will miss him deeply. May God bless the memory of Nelson Mandela. May God bless the people of South Africa.
"If they can learn to hate, they can be taught to love."
Sadly, the world is now without the physical presence of Nelson Mandela (1918-2013).
Even more sad than Mandela's death today in South Africa is the void his life creates for those of us left behind.
Hindu leader Mahatma Ghandi died in 1948. He believed in non-violence during India's struggles with independence from Great Britain and he's recognized as the Father if the India. An independent India is his legacy.
Who will carry Mandela's legacy? Obituaries, tributes and memorials like the prison on Robben Island will be challenged to inspire future generations to eradicate inequality driven by racism.
Pope Francis is certainly creating awareness about social inequality. He's addressing greed as being the root cause of injustices, driving economic disparities, that brings harm to the world's poor.
Tibet's Dalai Lama is another leader for peace and understanding and his legacy is continued by his devoted Buddhist followers.
I'm not convinced there's anyone who can fill the populous shoes of Nelson Mandela. Although his activism was certainly muted in his later years, his life represented altruism - an unselfish concern for the welfare of people who want to improve their human condition.
In death, Mandela will be remembered. But, will his legacy have followers? Regrettably, I'm not convinced inspired leadership is forthcoming following Mandela's death.
Yet, the world desperately needs a Mandela vision for world peace and understanding. "No one is born hating," said Mandela. Humanity needs someone who can carry this message into the future.
Mandela spent years in prison because he did not obey the South African Apartheid laws. This system of racial segregation was enforced through legislation by the National Party (NP) governments, who were the ruling party from 1948 to 1994, of South Africa, under which the rights of the majority black inhabitants of South Africa were curtailed and white supremacy and Afrikanerminority rule was maintained. South Africans are fondly holding a wistful vigil for the man who led them away from the harsh discriminatory practices enforced by the Apartheid. While South Africa is in a vigil, Americans are commemorating the concept of freedom, a concept Mandela sacrificed for and believed in, as we celebrate our 276th Independence Day, in 2013. Mr. Mandela undoubtedly appreciates the Americans who are enjoying the traditions began on July 4th, 1777, the first official July 4th celebration. On that first day, firing of guns, cannons, bonfires and fireworks were introduced in Philadelphia, the first city to celebrate July 4th in this manner (which was the capitol of the United States at the time). We Americans celebrate the birth of our young nation and the bravery of our founding fathers with aplomb and noise. A convincing case can be made for Mr. Mandela being the father of South Africa, because it has become a new nation since eliminating Apartheid. Before Mandela's inspired leadership against Apartheid, the people lived under a strict social cast system divided entirely by race. Since his liberating influence, South Africa has become a destination tourist country where people of the world visit so they can touch the place where one man really did make a difference to improve the social order and the human condition.
As Mr. Mandela's family and the nation holds vigil for their Khulu or "great" and beloved patron, Americans can also join his nation in celebrating his longevity, knowing how his accomplishments were acknowledged and praised during his lifetime.
Americans can also dedicate our 237th birthday celebrations to Mr. Mandela's life and passion for freedom, which he shared with all the people of the world.
As Mr. Mandela is lifted into a transcendent universe, the totality of his life will represent transcending from oppression into freedom, an inspiring legacy that will last forever.
In the best of health? Photograph: Getty/Guardian
