She was from South Africa and there was nothing unusual about her arrival in the world. She was born on the side of the road as her mother tried to get to a Roman Catholic clinic in South Africa. When time ran out, the bus she was waiting for was nowhere to be found.

This story was supported by the Pulitzer Center.

Mshengu was pregnant with her own child more than a decade later. The labor story she told was different. She was taken to Greys Hospital in Pietermaritzburg, the capital of the province of KwaZulu-Natal, because she was pregnant. A baby boy was delivered and a 41 kilometer trip paid off.

She said through a translator that she had access. I was taken to experts to give birth. My child didn't have any health issues. Didn't I?

The system of forced racial segregation and institutionalized discrimination that white South Africans created in 1948 came to an end in the early 1990's. Many black men were forced to live in townships beside whites-only cities because they were not able to find jobs in the city. Children's health was harmed by the effects of apartheid on black South Africans.

Sixty of every 1000 babies in South Africa died before they were five years old. The number was 10 in the US at the time. The president of the country immediately made health care free for pregnant women and young children after the African National Congress won the first multiracial election. In the nation of more than 60 million people, 81% are black and 36% are younger than 20 years old.

I was a visiting medical student in South Africa in 1986 when the apartheid regime was still in full effect. At the King Edward VIII Hospital, where black people were required to seek care, I worked on the children's wards. I saw toddlers suffer and die from vaccine-preventable diseases such as measles, aphoid isolation unit that consisted of a crib placed in a corner of an open ward, and babies crammed into a bassinet. White children received high-end care at a beachfront hospital. The experience changed my career path, sending me to journalism and away from clinical medicine, which was outgunned in the face of a brutal political system.

Since the democratic changes of the early 1990s, I have wondered how the health care of children has changed. I returned in July to find out.

The place where my plane lands is not the same as it was when I was there. The beachfront of the Indian Ocean seaport was only open to whites. The city was scarred by riots last year. They were sparked by political divisions and caused by a yawning economic divide between rich and poor. Electricity and water shortages are a result of corruption. There is a high rate of crime. The face of poverty in South Africa is overwhelmingly black despite the fact that democracy has elevated a substantial black middle class. The health care system has high-end private care for those who can afford it and public facilities for those who can't.

Changes to health care went well beyond free services for pregnant women and young children as a result of the collapse ofapartheid. A national immunization program was launched by the government within a few years. There are more than twice as many community health clinics today as there were when it built them. Laws were passed to make clean water and Sanitation Universal. Between 2000 and 2021, the proportion of the population with access to a flush toilet, a ventilated pit latrine, or a composting toilet rose from 27% to 98%.

Overcrowding in the newborn nursery at Durban’s King Edward VIII Hospital in 1986 Ward with signs warning of typhoid
Overcrowding in the newborn nursery at Durban, South Africa’s King Edward VIII Hospital in 1986 (first image). A child with typhoid fever at King Edward in 1986 (second image). The Durban hospital was the only major center for black patients in the province. M. WADMAN/SCIENCE

Huge gains in child health have been made after this. The under-5 mortality rate fell by half by 2020. The figure is 6.3 in the US.

There is a nuanced picture when I visit the medical campus of the University of Kwazulu-Natal. The site of King Edward is 17 hectares. Victoria Mxenge, a nurse, midwife, lawyer, and antiapartheid activist, was killed by agents of the regime in 1985. Moherndran Archary has worked at the hospital and the Nelson R. Mandela School of Medicine for over 30 years and has seen some of the misery alleviated.

I remember seeing a 5-year-old boy in 1986 with a raging case of Measles, which had invaded his lungs. The boy's mother was asked if the child had been vaccinations. He shook his head when he said that she said it was a long wait at the immunization clinic. Most of the 1-year-olds in South Africa received a first dose of the vaccine.

Archary tells me that these children don't show up on the wards often. The number of babies getting a first shot for the disease went up last year. South Africa has been a leader in the introduction of vaccines against diseases that can cause death in children.

Sanitation improvements were made to help children stay healthy. The number of hospital admissions for young kids with gastroenteritis is still high, but the numbers are much lower than they used to be. In the past year, Archary estimates he has seen one child with a water-borne disease that used to be common.

Refiloe Masekela is a specialist in lung disease and head of the medical school's department of pediatrics. She says that vaccine coverage isn't as good as it seems because it falls off in kids more than a few months old. She tells me that most of the kids in the province are not up to date with their immunizations.

There is chronic nutrition. The percentage of children under the age of 5 who were growth-stunted was the same as in 2003 Many schools were closed and parents lost their jobs as a result of the COVID-19 Pandemic. At King Edward and outlying provincial hospitals, pediatricians like her are seeing patients with acute malnutrition for the first time in a long time.

Journals, white paper with red covers
Journals the author kept as a medical student in South Africa in the fall of 1986.E. PETERSEN/SCIENCE

Statistics show that the end of apartheid didn't help black people as they had thought. South Africa has a system of racial disparity that has led to economic disparity. The economic disparity is not different from race.

The province with the highest HIV burden in the world is located in the hills of rural KwaZulu-Natal. The Centre for the AIDS Programme of Research in South Africa is known as CAPRISA. Some people work as cashiers, drivers of taxi minivans, and domestic workers in this village of 8000, although most are unemployed, because it is located at the UKZN medical campus.

Before we get to the edge of the village, the dirt road is completely rutted. The family has a windowless wooden hut. She doesn't have electricity or running water and her grandmother is looking for firewood on the far side of the valley. Her parents couldn't afford to take her and her brother to the flower farm so they didn't want her to go to school. She would like to become an airline pilot. She wants her family to have a proper three-room house and plans to stay away from boys.

Her determination is in place. By the time young women reach their early 20s, the prevalence of HIV is three times that of young men. By the time they get pregnant, 42% of the girls and women tested positive for the virus. Thirty percent is the figure nationwide. In at least 15 years, it hasn't budged.

For girls like Sandiswa, who are powerless to negotiate the use of condoms, it's crucial to have a means of protection that they themselves control. The study showed the cycle of HIV transmission is maintained by older men infecting younger women.

Sandiswa Zondi in the yard of her family’s hut in Mafakatini, South Africa
Fourteen-year-old Sandiswa Zondi in the yard of her family’s hut in Mafakatini, South Africa. She dreams of becoming an airline pilot.GULSHAN KHAN

South Africa has dealt with the AIDS epidemic and its impact on teen girls for many years. After leaving office, he became outspoken about fighting HIV, despite the fact that his administration ignored the virus in the 90s. There was an AIDS denialist in charge in 1999. The president refused to give the drugs to pregnant women. In the late 1990s and the early 2000s, about one in three infections resulted in a baby with HIV, and the child mortality rate went up. As we were reaping the benefits of democracy, HIV swooped in and robbed us. It was not pharmaceutical companiescharging too much. Your own government was the one you had. The office of the president was taken over by another person in 2008.

Daya Moodley is a research scientist with CAPRISA and UKZN who has spent decades trying to prevent mother to child transmission of HIV. In less than 3% of HIV-positive pregnant women, mother-to-child transmission is rare thanks to an aggressive program that tests and treats them. The World Health Organization recently recommended cabotegravir, a long-acting, injected antiretroviral drug, after it was shown to protect women from infections in a clinical trial. The drugs will have a huge impact if they can be used in at-risk girls and young women. High hurdles remain to distribute the drugs, and in sub-Saharan Africa, "we're always at the end of the stick to receive any effective and cost-effective treatment."

Young children's early days are still dangerous despite the fact that prevention causes of death have declined. Maternal death in the first week of life remains persistently persistent. Statistics South Africa shows that perinatal mortality is the leading cause of under-5 mortality. Infections, trauma, and prematurity are some of the causes.

The epidemic of HIV/AIDS took hold in South Africa after the end of apartheid. Over time, the outlook has improved due to the treatment of pregnant women.

Timeline shows notable points in South Africa's health care history

One of the deaths I witnessed as a medical student was in a small hospital. The baby's feet emerged first, followed by the legs, torso, and arms of the young woman. The doctor was unsuccessful in delivering the baby's head. The little body hung limply as the pulsations in the cord slowed and then stopped.

The doctor stood next to the woman. He told her what needed to be done to save her life without looking at her. He used local anesthesia and cut the pubic bone to widen the birth canal. The baby had an enlarged head due to a build up of fluid on the brain. In spina bifida, the neural tube fails to close in the early stages of development, which leads to hydrocephalus. The baby had that condition as well. The rate of spina bifida began to fall after South Africa began fortifying food with Folic acid.

I wrote in my journal that the mother was upset.

Death in the first 28 days of life has fallen in South Africa. The rate of stillbirths has gone up but the gains have gone down. The country has made strides in the area of fetal care. Almost all of the pregnant women and girls delivered their babies in health facilities last year. In Kwazulu-Natal, too few visits to prenatal clinics are a problem. subpar care during labor and delivery was found to be a factor in the deaths of women in the province.

A charity clinic is located in a squalid settlement of shacks with corrugated iron roofs on the south side of the city. There are a lot of crying toddlers at the Islamic Medical Association's clinic. Weights and temperatures are taken by nurses who give oral rehydration therapy. On the day I visit, the small patients are not in need of hospital admission because their eyes are moist and their skin is elastic.

Doctor examines baby in Islamic charity clinic in Durban Nokwanda Mkhize with daughter and niece at an Islamic charity clinic in Durban
A nurse at the Islamic Medical Association clinic in Malukazi, a squatter settlement on the edge of Durban, South Africa, examines the 8-month-old daughter of Nokwanda Mkhize (first image). Mkhize (center, second image) with her daughter and niece, prefers the Islamic charity clinic to the government one, where medications often run out. GULSHAN KHAN

Sister Honey Allee, IMA's nursing director, has a mischievous smile, a white hijab, and a white suit. After nearly 30 years, the democratic government has failed to provide basic infrastructure for the inhabitants of Malukazi. She is certain that this will ensure that small children in South Africa don't die from scurvy. The nurses at the clinic see an endless stream of children with infections from playing in the garbage and having their bottoms fished out of refuse piles.

Allee says that nothing has changed for the poor in South Africa. The square root of all is provided by the government, according to me. She says that we don't have a place that's right for human habitation. In the shantytown, which lacks reliable running water, her charity has installed water taps.

Several of the women who brought their charges here today have no faith in the system. Instead of using a free government health clinic closer to home, Nokwanda Mkhize took a 45 minute trip with his two sick children. She says that she is charged a fee at IMA. They have medication to help the baby.

Samkelisiwe has borrowed taxi fare from a relative in order to bring her daughter to the clinic from the four room house that she shares with 11 people. The baby girl is covered in a rash that makes her scream. She was told to buy her own medicine when she went to the government clinic yesterday.

I have been waiting for days to cross the threshold of the hospital that changed my life. When I think of the place, I think of peeling paint, rats, and a toddler who died under her oxygen tent. She had a chart that said respiratory distress. Artificial Ventilation is needed. There are no beds in intensive care.

The hospital now has a gleaming children's center, an intensive care unit, and a children's emergency department. Permission to see how conditions have changed isn't granted. I stand outside in the middle of the morning to listen to patients tell their stories.

Anele Macanhe looks frustrated. She forgot her appointment card that allowed her to enter the hospital's gated grounds. She wants her partner to text her a picture of the card.

Macanhe's 4-year-old daughter, Sbahle Thunzi, who is standing by with her pink backpack, has eczema, which has turned her knees several shades darker than the rest of her skin, and also afflicts her elbow, hands, fingers, and face Sbahle is seen by a doctor at the hospital at no cost.

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Sister Honey Allee, nursing director of the Islamic Medical Association’s Durban, South Africa–area clinics, says the conditions in Malukazi are making kids sick. “We don’t have a place that’s really fit for human habitation.”GULSHAN KHAN

This Macanhe is appreciated. She works at a call center and cuts hair on the side. She has a baby boy to support. She will have to pay $2.86 for a bus fare and a day's wages when she goes to the hospital today.

She says that they help if you don't have money. Our government is watching over us. Many patients at King Edward don't pay anything because they are charged on a sliding scale.

Macanhe concedes that she would take Sbahle to a private hospital if she were able to. The waiting times are long and the medications are out of stock. She says the doctor gives 10 things and you get five.

The hospital is both inside and outside. Government and press accounts say that the hospital has broken equipment and sewage running in the gutter. Patients were being carried up to the fifth floor of the surgical ward when an elevator broke during a government visit to King Edward. The food isn't good. The cleaning isn't good. Allee, who sometimes accompanies patients there, says the service is not good.

There is more to King Edward than meets the eye. Three other public hospitals in the area were visited by the government team and they all had the same problems. In the spring of this year, a physician at a children's hospital in South Africa wrote an open letter to administrators, telling them to come to the unit and see doctors try to intubate children and administer cardiopulmonary resuscitation by their mobile phone's torch.

The health care services are not good. The era when white managers barked orders at black staff was when he worked. The model of management was a thing of the past thanks to the end of apartheid. He believes that it has been replaced by a system with its own problems. Ineffectiveness in management has aided in the growth of corruption. Quality of care and the provision of services have been compromised.

Sbahle Thunzi waits to enter the King Edward VIII Hospital,
Four-year-old Sbahle Thunzi waits to enter the King Edward VIII Hospital, where she gets regular treatment for eczema free of charge. “Our government is looking out for us,” says her mother, Anele Macanhe.GULSHAN KHAN

The head of the province's health department did not respond to requests to visit the hospital or email questions. Mayise wrote in an email that his team was doing the best they could.

Children with serious ailments can be treated in the public system. There are only 23 intensive care beds for children in the province.

Macanhe and her daughter left King Edward at noon and went to a neighbor's house. She had a plastic bag on her lap that was filled with 10 out of 10 medications.

My heart was heavy as my plane lifted off. I think of Mshengu and her risky roadside birth, as well as her son's safer entry into the world years later. The numbers show that black children are doing better than they were in the 80s and 90s. Hunger, disease, and death are still present.

Masekela said that the primary problem was a socio-economic issue. It cannot be fixed by the health system when you don't have access to clean water or electricity, and you have no food. Children like would-be airline pilot Sandiswa are waiting for a better day.

*Science capitalizes Black to acknowledge the ethnic and cultural identity of Black Americans. Many South Africans use “black people” to refer to people of African descent, a style we follow here.