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The initial classic Fontan utilising a direct right atrial appendage to pulmonary artery anastomosis led to numerous complications. Adults with such complications may benefit from conversion to a total cavo-pulmonary connection, the current standard palliation for children with univentricular hearts.
A single institution, retrospective chart review was conducted for all Fontan conversion procedures performed from July, 1999 through January, 2017. Variables analysed included age, sex, reason for Fontan conversion, age at Fontan conversion, and early mortality or heart transplant within 1 year after Fontan conversion.
A total of 41 Fontan conversion patients were identified. Average age at Fontan conversion was 24.5 ± 9.2 years. Dominant left ventricular physiology was present in 37/41 (90.2%) patients. Right-sided heart failure occurred in 39/41 (95.1%) patients and right atrial dilation was present in 33/41 (80.5%) patients. The most common causes for Fontan conversion included atrial arrhythmia in 37/41 (90.2%), NYHA class II HF or greater in 31/41 (75.6%), ventricular dysfunction in 23/41 (56.1%), and cirrhosis or fibrosis in 7/41 (17.1%) patients. Median post-surgical follow-up was 6.2 ± 4.9 years. Survival rates at 30 days, 1 year, and greater than 1-year post-Fontan conversion were 95.1, 92.7, and 87.8%, respectively. Two patients underwent heart transplant: the first within 1 year of Fontan conversion for heart failure and the second at 5.3 years for liver failure.
Fontan conversion should be considered early when atrial arrhythmias become common rather than waiting for severe heart failure to ensue, and Fontan conversion can be accomplished with an acceptable risk profile.
Economic policy has never been simply a technical, neutral exercise devised by impartial bureaucrats, and, in the modern world, the relationship between politics and economics has become ever more apparent and explicit. The nature of economic policy is determined by political variables and economic interests influence state priorities as much as the availability of material resources. Thus the adoption and legitimation of economic policies represents the advancement of political as well as economic interests, and the implications of economic policy are as much political as they are socio-economic. It can therefore be argued that the art of generating and implementing a particular set of economic policies is, at one level, merely ‘the continuation of politics by other means’.
This ‘continuation of politics’ acquires added significance in societies that are in transition to a new political order. Political transitions enable different social groups to enter the political arena in new ways, and this creates possibilities for significant changes in economic policy. South Africa's democratic transition is a typical example. The debate around future economic policies became one of the central contests between contending social groups and political organisations. The contest revolved around three key issues: growth, poverty alleviation and inequality. The goals of growth and poverty alleviation are widely shared across the political spectrum but political actors have very different views on how to achieve these goals. Some believe in unhindered markets, whereas others argue for market regulation and the containment of excesses, but almost all recognise the moral and strategic responsibility of tackling these problems.
Inequality is another matter. Many political actors, some explicitly and others implicitly, believe that inequality is part of the modern economic condition, and a necessary price to pay for economic growth and poverty alleviation. Chaudhuri and Ravallion (2006), for example, cite the examples of the United States, and more recently China and India, to sustain their argument. Others, such as Stiglitz (2012) draw on western Europe's social democracies and developing states in South East Asia, to argue that that inequality can be reduced with appropriate policies and interventions if it is twinned with poverty alleviation and sustainable economic growth.
South Africa's Suspended Revolution engages with the country's transition into democracy and its prospects for inclusive development. It is an antidote to many descriptive and voluntarist explanations in which leaders and other actors are treated as unfettered agents whose choices and behaviour are merely the result of their own abilities or follies. In contrast, Adam Habib explains the story of how South Africa arrived at this point by locating these actors in context. He tries to understand the institutional constraints within which they operated, why they made the choices they did, and what the consequences are. The book also explores what other policy options and behavioural choices may have been available, and why these were forsaken for the ones that were eventually adopted. In essence, the book is about how South Africa got to its present state of affairs, what the country's current challenges are, and how these could be transcended. It is deeply historical in the sense of understanding what possibilities may have existed in one moment, but not another. The narrative recognises that societies evolve and as a result the potential for political and socioeconomic advances themselves change. This then is a story of the dynamic interplay between actors and context, how the latter can constrain and condition the former, but also how individuals and institutions can, with imagination, act against the grain of their location and historical moment, thereby transforming the possibilities and, through them, society itself.
Social pacts have become a mantra of South Africa's political transition. Ever since the notion was mooted by Geoff Schreiner (1991; 1994) and Adrienne Bird (Bird and Schreiner, 1992), who were then senior officials in the Congress of South African Trade Unions (COSATU), the idea of a social pact has appealed to leadership figures in business, labour and the state. It is not difficult to imagine why. After all, a social pact promises the possibility of peace between warring social partners, a non-zero-sum outcome where all sides stand to gain at least part of what they desire. For an incumbent political elite, who needed to manage popular and stakeholder expectations and grow the economy, a social pact was a particularly attractive solution. But the romanticised expectations and euphoria surrounding the establishment of the National Economic Development and Labour Council (NEDLAC) in 1996 were soon dashed by the cold reality of everyday economics and politics. Within a year or two, business, labour, and the state were bickering over the Growth, Employment and Redistribution (GEAR) strategy, and almost all other government policies. A climate of political mistrust spread throughout the country during President Thabo Mbeki's terms in office, interrupted by brief attempts by the African National Congress (ANC) and COSATU to broker a kind of truce – usually around election periods.
Yet although hopes for a social pact were dashed, the idea retained its hold on the imaginations of many academics and leaders in business, labour and the state. Every now and then, therefore, the idea resurfaces. It arose for example after the upsurge of labour activism following the ANC's victory in the general elections of April 2009. At that time, driven by the biting effects of the economic recession, the global backlash against corporate executives’ remuneration packages, and the fear that the ANC (including COSATU members deployed in the Cabinet and in government more broadly) was abandoning its roots and being seduced by the trappings of office, unions became more active and robust in their wage negotiations. Over the next few years, this led to a set of rolling public and private sector strikes. In 2010 20 674 737 workdays were lost – the highest yet recorded (Department of Labour, 2011: 26). Caught off guard, business and political leaders initially reacted by berating workers.
South Africa has served two terms as a non-permanent member of the United Nations Security Council. On both occasions its tenure was plagued by controversy. In the first term (2007–2008), human rights activists were demoralised by what they interpreted as the country's defence of ‘rogue powers’, when South Africa refused to support Security Council resolutions condemning and imposing sanctions on Iran, Myanmar, Sudan and Zimbabwe. Similarly, in its second term (2011–2012), activists were horrified by South Africa's stance on the crises in Côte d'Ivoire and Libya.
On Côte d'Ivoire, South Africa's official neutral stance was interpreted as implicitly supporting Laurent Gbagbo. This went against the decisions of both the United Nations and the Economic Community of West African States (ECOWAS) to recognise Allasane Ouattara as president after his victory in the country's national elections. On Libya, South Africa first supported Security Council Resolution 1973, which mandated the imposition of a no-fly zone to protect Libyan civilians against the army, but subsequently criticised the NATO-led bombing as an example of regime change backed by the West. In effect, the human rights community saw these positions as betraying the spirit of South Africa's own democratic transition and the international support that facilitated it (Human Rights Watch, 2012: 4; Neuer, 2007; Taljaard, 2009).
But is this label of betrayal not too simplistic a portrayal of South Africa's decision making? Is the suggestion that South African diplomats were simply appeasing the Russians and Chinese (Democratic Alliance, 2011) too lazy an explanation of South Africa's foreign policy? And is the same true of other explanations (see Bischoff, 2003; Nathan, 2005; Zondi, 2012) that see South Africa's foreign policy as incoherent and inconsistent? None of these views engage sufficiently with South African government officials’ explanations of their own decision making, or the concerns they have expressed about the abuse of multilateral institutions (such as the United Nations, the International Monetary Fund and the World Bank) by the world's largest and most dominant countries, including their lack of even-handedness and their hypocritical posturing. While wishing to avoid being an unwitting agent of these great powers, however, one must be careful not to fall prey to politicians’ rationalisations of their aloofness from the concerns of ordinary citizens or their own undemocratic behaviour, even if such elites are from the developing world.
The title of this chapter, essentially that of Vladimir Lenin's (1902) famous essay, may seem pretentious but it is merely meant to indicate that the analysis of the preceding pages need not discourage leaders and activists from working towards the construction of a better society. This chapter defines the contours of an alternative progressive political agenda that recognises and flows from an understanding of the balance of power, without compromising the goals of democratisation, empowerment and inclusive development. This agenda involves two distinct tasks: (i) conditioning political elites to become more accountable and responsive to the concerns of citizens; and (ii) fulfilling the overall objectives of the Constitution when the provisions of different clauses come into conflict with each other.
The lack of accountability among the political elites towards citizens (or their greater responsiveness to stakeholders who hold more leverage than ordinary voters) has been identified as a problem in several chapters of this book. In Chapter Two, I engaged with the accountability deficit to explain not only the aloofness of the state and its adoption of policies that do not speak to the interests of ordinary citizens, but also the service-delivery problems that continue to plague all tiers of government. Similarly, in Chapter Three, the conservative macro-economic policy of the Mandela and Mbeki eras, and the continued resonance of this perspective in some quarters within the ruling party and the state, was shown to derive from the leverage of domestic and foreign businesses with their command over investment resources. In Chapter Four, I showed that the balance of power in favour of the business community explains the failure of the social pact of the 1990s. Attempts afoot in 2012 and 2013 to establish a similar pact are likely to come to naught unless political elites develop the will to challenge elite aspirations as much as they challenge those of ordinary citizens. And in Chapter Five, I explained that the evolution of civil society in the post-apartheid era can be seen as a response to consequences of the state's adoption of policies that reflect the inequitable balance of power.
The analysis in the preceding chapters also identified policies and political choices as having compromised the substantive fulfilment of the Constitution because of trade-offs made when different constitutional priorities came into conflict with one another. Three such trade-offs were explicitly identified.
It is a common assumption that Africa's democratic and developmental experiences hold very few lessons for the rest of the world. For example, Anthony Butler, in the introduction to the second edition of his book, Contemporary South Africa, suggests that ‘African democratization … generated no fundamental theoretical innovations’. He argues that southern European and Latin American experiences in the 1970s and 1980s, on the other hand, have challenged determinist assumptions of democratisation, ‘emphasizing the role of human agency and historical contingency’, whereas eastern and central European transitions created ‘contagion effects and external precipitation in Moscow, [and] resulted in further productive intellectual reconfiguration’ (Butler, 2009: 156).
Of course, this conclusion is controversial, particularly as it is supported by so little evidence. For instance, while Butler discusses Mahmood Mamdani's (1996) work on bifurcated forms of political rule in the urban and rural, he does not seem to take into consideration the theoretical challenges that the Ugandan scholar's study poses for theories of democratic transition, and especially for notions of governance and conceptions of citizenry. Similarly, Butler does not reference or engage with Bratton and Van de Walle's (1994; 1997) comparative studies on African democratisation, whose notion of neo-patrimonial regimes, even though I am not partial to it, nevertheless forces traditional democratisation theory to grapple with how underlying structures and prior regime types condition the subsequent evolution of democratisation and its outcomes.
Butler's conclusion does an even bigger disservice to South Africa's democratisation process, which was the focus of his study. To take but one example, South Africa's transition was founded on the dual principles of reconciliation and justice. This manifested in the establishment of the Truth and Reconciliation Commission, which itself has generated much scholarship (see, for example, Boraine, 2000; James and Van de Vijver, 2001; Tutu, 1999; Villa- Vicencio and Verwoerd, 2000). In addition, South Africa's broader reconciliation agenda allowed scholars such as Mamdani (2009a) to posit the notion of survivor's justice as an alternative to the type of victor's justice symbolised in the Nuremburg trials that took place after the Second World War.
This book has long been in the making. I have been meaning to write it for over a decade but work pressures, new jobs, alternative research projects, and deferred sabbaticals all conspired against it. So, when the opportunity for a sabbatical emerged at the end of my first term as deputy vice-chancellor at the University of Johannesburg, I had no doubt as to how I should spend the time. For many years, I have been immersed in academic and public discourse about South Africa and its future. The book is, therefore, a culmination of at least two decades of debates, reflections and thoughts about resistance in South Africa, its political and socio-economic evolution, and the conundrums and dilemmas related to the making of this society. In many ways the book is about how we got to where we are, why our present is not what we had hoped it would be, and what we need to do about it.
I see myself as both an academic and an activist. Although some may view these as separate endeavours, I have always seen them as mutually compatible. Indeed, my decision to take political science as a subject in my undergraduate years was motivated by a belief that this would enable me to better address the challenges that my compatriots and I confronted as activists. Of course, this didn't work out in the way I had imagined it might, but the academic grounding provided by my undergraduate and especially my postgraduate studies, were essential in developing my understanding of my country and world.
This book therefore reflects both of these facets of my life – academic and activist. The debates I engage with in the book occur both within the academy and in the broader public sphere. In my view, newspapers and magazines, as well as academic journals, are of intellectual relevance, and I therefore challenge, support and reference political leaders and activists as well as academics in this text. But the book is unashamedly scholarly. Although some suggested that I strip the book of its academic debates and theories, with a view to broadening its readership, it seemed to me that this would undermine one of the central purposes of writing it; namely, to bridge academic and public discourse in order to enrich each with the reflections and debates of the other.
There was little that united South Africans at the dawn of their democratic transition, but if there was anything – other than the desire to avert a civil war – it would have been a yearning for political accountability and service delivery. South Africans may have meant different things by these terms, but there was nevertheless a general desire across racial, class and gender divides for a political elite and a state that would be responsive to the needs of its citizens. Yet, by 2013, public opinion across the breadth of the political spectrum concurred that there was both a lack of accountability and a general shortfall in service delivery in South Africa. How did this come to pass?
Much of the debate about these issues has focused on institutional design and the quality of the country's human resources. Thus, since 1994, state officials have regularly redesigned state institutions and the relations between them, with a view to enhancing their effectiveness (Presidential Review Commission, 1998; Swilling et al., 2008). Poorly trained officials have been blamed for the inefficiencies and training and development programmes have thus been introduced (Fraser-Moleketi, 2002). Critics of government have condemned the ruling party's policies of cadre deployment and affirmative action for leading to the appointment of inappropriately skilled personnel and bloated administrative systems (Democratic Alliance, 2012b; The Economist, 3 June 2010). The ruling party's allies have commented on these issues too – see, for example, the call by Zwelinzima Vavi, the general secretary of the Congress of South African Trade Unions (COSATU), for the scrapping of the country's provinces (Business Day, 21 December 2011; Paton, 2012).
But, while institutional design is important, it alone cannot account for the malaise affecting South Africa's governance and political landscape. After all, societies with similar institutional and governance frameworks have fundamentally different service delivery and accountability outcomes. Federal Germany, for example, is far more accountable and efficient than federal Nigeria. Similarly, unitary Britain is more accountable and efficient than federal Nigeria. Clearly, therefore, it is necessary to look beyond institutional design to understand the variety of governance and political outcomes in different societies. Comparisons can be useful, but they cannot replace an understanding of a particular social context and an investigation of how this affects the performance of institutions, individuals and state officials.
Two very different visions permeate public discourse on state– civil society relations in South Africa. The first is well illustrated by the words of Zola Skweyiya who, when he was minister of social development, responded to a question about government's expectation of NGOs as follows:
The basic twin expectations of government are that NGOs will firstly, continue to act as monitors of the public good and safeguard the interests of the disadvantaged sections of society. This performance of this social watch role requires both transparency and accountability on the part of NGOs. The government's second expectation is that NGOs will assist in expanding access to social and economic services that create jobs and eradicate poverty among the poorest of the poor. This requires cost effective and sustainable service delivery. (Zola Skweyiya quoted in Barnard and Terreblanche, 2001: 17)
The second vision is succinctly captured in the words of Ashwin Desai, an academic at the University of Johannesburg and one of the more prominent public intellectuals within the new social movements that have emerged in the post-apartheid era.
For many of the activists … working in different spaces and having different strategies and tactics, there was a binding thread. There was unmitigated opposition to the economic policies adopted by the ANC … Activists spoke of how the right-wing economic policies lead to widespread and escalating unemployment, with concomitant water and electricity cut-offs, and evictions even from the ‘toilets in the veld’ provided by the government in the place of houses. More importantly, there was general agreement that this was not just a question of short-term pain for long-term gain. The ANC had become a party of neo-liberalism. The strategy to win the ANC to a left project was a dead end. The ANC had to be challenged and a movement built to render its policies unworkable. It seems increasingly unlikely that open confrontation with the repressive power of the post-apartheid state can be avoided. (Desai, 2002: 147)
Both statements draw attention to some of the key problems in post-apartheid South Africa and express a wish to enhance the empowerment and living conditions of the poor. Both statements also reflect the institutional locations – in government and in civil society – of those who articulated them. But the absolute and categoric nature of what they envisage makes both statements unhelpful in conceptualising and understanding contemporary state–civil society relations.
South Africa is in the midst of a high-stakes leadership drama that has been underway for some years. The stage is the South African state, including its national departments and ministries, provincial governments and local municipalities. It is a drama that has pitted comrade against comrade, and the ensuing battle has led to friends becoming enemies, and erstwhile enemies becoming friends. The ultimate prize is the presidency and the political power and spoils of patronage that go with it.
The drama's multiple acts have so far each been marked by a symbolic high point. The opening act was the firing of then deputy president, Jacob Zuma, by then president, Thabo Mbeki, in 2005. This was followed by the fightback by Zuma and his allies, which culminated in December 2007, when Zuma was elected president of the African National Congress (ANC) at the party's national electoral conference in Polokwane. Nine months later, in September 2008, Mbeki was unceremoniously ejected from his position as president of South Africa, and after a short caretaker presidency by then deputy president, Kgalema Motlanthe, Zuma ascended to the presidential throne in April 2009. Significant sections of the senior hierarchy in the political establishment and state bureaucracy were soon replaced as cadre deployment within the ruling party morphed into factional deployment.
Soon after this, however, the battle lines were redrawn and a new act in the drama began. This time Zuma, as presidential incumbent, was the focus of the attempted ejection. His nemeses were his onetime allies, Julius Malema, Fikile Mbalula, Mathews Phosa, Tokyo Sexwale, and even Kgalema Motlanthe. Malema was effectively fired as president of the Youth League through the mechanism of the ANC's disciplinary committee. In December 2012, Motlanthe, who was deputy president of both the ruling party and the country at the time, stood against Zuma for the presidency of the ANC at the party's national conference in Mangaung. He lost, and having withdrawn from the candidature for the party's deputy-presidency in favour of Tokyo Sexwale and Mathews Phosa, Motlanthe was effectively cast into the political wilderness. His role in the ANC has been confined to heading up political education within the party.