Fri May 2, 2014
Reimagining HIV/AIDS And Healthcare In South Africa
HIV/AIDS is commonly considered an individual affliction, however Abigail Neely says that HIV/AIDS needs to be considered within the social, cultural, and economic environment of South Africa.
In South Africa, HIV/AIDS is endemic. Neely says that over 30 percent of the population is infected with HIV, however co-infection with tuberculosis is also prevalent.
“[HIV/AIDS] makes it hard for you to fight off infection meaning that you can get all sorts of illnesses” Neely says. “As a result of that, people are contracting tuberculosis in much higher numbers because their immune systems can't fight it off.”
Although co-infection is widespread throughout South Africa, Neeley says tuberculosis rates in South Africa among the HIV-negative population are also high.
“We normally think of HIV as this terrible disease that deteriorates people's immune systems and makes them susceptible to all sorts of infections beyond tuberculosis,” Neely says. “But there are these infectious diseases that now are much more common even when people are HIV-negative. So trying to think about HIV as having an impact in a much broader way is a lot of what [this] work is trying to think through.”
Neely says that the consideration of cultural, economic, and social factors like poverty, poor hygiene, or traditional beliefs in HIV/AIDS treatment was common practice during South African medical care in the 1940s and 1950s but has since been overlooked.
“The government started… a model of social medicine. So the social medicine model was to pay attention to not only what made people sick but it was to pay attention to why these people got sick in the first place,” Neely says. “So thinking about poverty education, a lack of knowledge about what makes people sick, poor hygiene, those sorts of questions.”
Neely says that a modern day re-contextualizing of South Africa’s HIV/AIDS epidemic in this holistic framework of social medicine could benefit contemporary efforts to treat the disease.
“I think that sort of logic could really recognize HIV as a broader problem and help intervene in positive and productive ways to make people healthier,” Neely says. “There are other ways of understanding health, but when we're talking specifically about HIV/AIDS - its health impacts, its tuberculosis impacts - this model could do wonders for thinking about and treating people.”
Abigail Neely is a historical geographer whose research focuses on the relationship between human health, cultural practices, agricultural practices and the mediating effects of culture and government policy. She conducted her research in a rural area of South Africa called Pholela and is currently an Assistant Professor of Geography at the University of Minnesota, and a Resident Fellow at Yale University, where she’s working on her book Witchcraft and Wellness: Agency and Change in Twentieth-Century South Africa.
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SUZETTE GRILLOT, HOST: Abigail Neely, Welcome to World Views.
ABIGAIL NEELY: Thank you.
GRILLOT: Now we know that there's this connection between health and the environment, but can you tell us in general what are the primary health concerns that are related to the environment and environmental issues that affect health? Just give us the context here.
NEELY: Sure. So I do my research in a rural area of South Africa called Pholela, which is a Zulu speaking area in the mountains. And the reason I'm orienting us there - it's sort of on the southern border of Lesotho - and I'm orienting us there because it's a place that is high in the mountains so it has very cold winters, which means that the relationships between health and environment are different than we often think about in Africa. And so what I mean by that is that there isn't malaria. There are no vector-borne illnesses, no mosquitoes that bear illness. And there are no water-borne illnesses either, so the streams are cold enough and protected so people aren't getting sick in the ways we often think about health and environment in rural spaces. And so the research that I do looks at the middle of the 20th century. So it follows two different strands of relationships between health and environment. The first is through nutrition. I look at agricultural practices and in particular gardening practices - so small, home kitchen gardens - and then the food that people eat and the particular nutrients in that food, so thinking about vitamin A, iron, all these sorts of things and micronutrients are really important in people's health for ensuring that cellular processes function. So macronutrients, protein, carbohydrates, things like that build our selves and the micronutrients make sure that they do the things they're supposed to do and that our immune system, which fights off illness, works as it should. And in this area gardening was particularly important. And gardening was introduced by a community health center in the forties and fifties. They introduced particular techniques - scientific gardening techniques- as well as particularly nutritious foods - things like beet roots and carrots and other nutritious vegetables. And the other one I look at it a local healing or protection ritual in which families would hire an Isangoma (an Isangoma is a healer who heals in consultation with their ancestors) and that healer comes and protects their homes - so the homesteads are kind of demarcated in the landscape. You can see the edges of them. So protects the home and the people who live in it. The crawl - a crawl is a livestock enclosure - so the crawl and the animals that sleep in it - mainly cows- and then fields and the crops that grow in them. And this healer is protecting these spaces and the crops or people or animals that inhabit them from illness or misfortune due to witchcraft and weather. And so you can see here that this is a radically different way to understand health and environment, but health and environment are deeply intertwined in this way as well as through nutrition. And so my work really tries to think through the ways in which people get sick and the environment shapes the ways in which people get sick and the ways in which they get better or protect themselves against ill health. Because in some senses the gardening - and the doctors at the health center even articulated it this way - the gardening project was in many ways a health protection program. So to protect people thinking about nutrition as the baseline of good health, to protect people against ill health that's part of that gardening program similar to what the Isangoma was doing.
GRILLOT: Well this is truly very fascinating and different, as you mentioned, than the way we typically think about health and the environment coming together, but it sounds like your bringing together some very different disciplines here - medical anthropology and geography. I mean you're a geographer, right? But bringing in this kind of medical, anthropological, cultural connection between that and place, and kind of what the geographical place is providing and how that connects to the culture? Is that kind of the approach you're taking here?
NEELY: Yeah. Absolutely. I think in either of these frames of understanding, place is essential. So the home garden is a place where you can see nutrition growing, right? And then places as protected in particular ways by healers. Both of these ways are essential. I would say in addition absolutely the work touches in medical anthropology or in Africanist anthropology, geography, but it also sort of touches in Africanist history. And then even borrowing a lot of ideas from biomedical science. I take a lot of inspiration and also borrow a lot of ideas about the ways in which vitamin A literally helps you see better if you have enough of it, or the ways in which tuberculosis, for instance, affects the bacteria's affect on your immune system cells. So it borrows from these different places to try to make sense of the world, because I, in many ways, think that the world is complicated so we need lots of disciplines to understand what's happening.
GRILLOT: Well complicated is certainly the right word for it. In this picture I can certainly see the complications here. But let's talk about tuberculosis since you mentioned it. Some of the work that you've been doing has been studying the connection between HIV/AIDs and tuberculosis. How are these things connected and how can we understand one... can we understand one in the absence of the other in the places that you've studied in Africa?
NEELY: So if we move, if we fast-forward now to roughly the present moment, a lot of people who think about tuberculosis or AIDS in sub-Saharan Africa recognize that TB-HIV co-infection is one of the biggest health challenges. So the reason that people think about this is that HIV, which is a virus, what it does is it affects, it's a retrovirus that enters people's cells and basically breaks down the immune system. The immune system is what we use to fight off infection. And so what it does is it makes it hard for you to fight off infection meaning that you can get all sorts of illnesses. Tuberculosis has for a long time been fairly common in South Africa, and as a result of that people are contracting tuberculosis in much higher numbers because their immune systems can't fight it off, there's lots of people with tuberculosis around them, and so they're getting it. This is important in South Africa for another reason, because it's the largest killer right now. Tuberculosis, with usually in combination with HIV is the largest killer in the country right now. So that's the way it's often constructed or explained, articulated. That's a really important way to understand the relationship between HIV and TB. The work that I’ve been doing tries to question that tight coupling of the relationship between tuberculosis and HIV. And so the way that I do that is to think about the ways in which tuberculosis passes. Let's say it's biology - the ways it affects people's immune systems, the ways HIV works, what HIV looks like in immune systems, the other ways in which people achieve immune compromise or have immune compromise and try to think about what it would be like if we understood TB and HIV to be uncoupled. So if we started to try to think about people who have tuberculosis in South Africa but don't have HIV. So the way that I think about this is HIV is absolutely - the place where I do research the rates for HIV are over 30%. So that's a huge amount of the population. With that amount of the population, that's a bunch of people who have immuno-compromise, so they can't fight off infection. Many of them have tuberculosis. Huge numbers of them have tuberculosis, which means that tuberculosis is all over. People pass tuberculosis by coughing or talking or singing or sneezing, and tuberculosis, which is a bacteria, lodges in your saliva, let's say, and you sort of cough and it comes out and somebody near you can breathe it in. And then they can contract tuberculosis. There are three things that happen. Sometimes their immune system fights it off. Sometimes it lodges in their body but they don't become actively sick. And then sometimes it'll lodge in their body and they become actively sick, so they cough, they have night sweats, all the sorts of things of tuberculosis. So the fact that there are so many HIV positive people who also have TB means that there is TB all over the place. At the same time that that's happening, there's a whole bunch of people who are poor. And lots of people have shown that poverty causes immune compromise. So poor people literally aren't as well nourished. They don't have as many micro- and macronutrients so they can't fight off infections. So they're sort of immuno-compromised. So when you have this huge pool of people with HIV and TB and they're coughing all over the place and they're coughing in the presence of people who are poor but HIV negative you notice an uptick in the passage of tuberculosis. So part of what I've been working on and trying to think through is what would happen if we imagined that HIV was impacting the health of people who are HIV-negative. Because we normally think of HIV as this terrible disease that deteriorates people's immune systems and makes them susceptible to all sorts of infections beyond tuberculosis. There are cancers, pneumonia, and things like that and that's what kills them. But there are these infectious diseases that now are much more common even when people are HIV-negative. So trying to think about HIV as having an impact in a much broader way is a lot of what that work is trying to think through.
GRILLOT: So your latest project, then, is titled "Witchcraft and Wellness: Agency and Change in 21st century Africa." So now that you've demonstrated this decoupling of HIV AIDs and how HIV actually has an impact on non-infected individuals, does this come back around to this notion of healing and how is it related to that? Or what does your witchcraft and wellness project focus on?
NEELY: So the witchcraft and wellness project finishes - that's a book that I’m finishing - and that finishes in the 1980s. So that's pre-HIV/AIDS epidemic. But one of the ways in which it connects is that in the 1940s and 50s in this area where I do my research the government started a community health center called the Pholela Community Health Center. And it was a model of social medicine. So the social medicine model was to pay attention to not only what made people sick - say tuberculosis, because people had it then, or a lack of protein, or something like that that causes an illness called kwashiorkor- but it was to pay attention to why these people got sick in the first place. So thinking about poverty education, a lack of knowledge about what makes people sick, poor hygiene, those sorts of questions. So this health center started a model where they would go out and they would visit people's homesteads to teach them about nutrition or other health education. They would help them build healthier gardens. They would help protect water sources. They would do all these sorts of things. And they would also work to get people employed. They would work to make particular things available, things that we don’t' necessarily think of as health related - say powdered milk. So powdered milk has a lot of protein. They would work to get local shops to stock them so people could buy it and eat it. And it was all about educating people and helping people understand and work in ways that they could be healthier. So what's interesting about this model is that it looked at people as whole people. It looked at them as people who could get sick and people who could get healthy in multiple different ways. And so in many ways that's a model that the health system today could use. So the health system in South Africa tends to treat because of the way that HIV/AIDS gets funded. Tends to treat it as a sort of separate illness from tuberculosis, from primary care. And this model that was implemented in this place, said "No. That's not the way health works." People's lives are sort of messy, let's say. All these sorts of things are interconnected so we need to treat the whole person and not only the whole person but their family and their community. So the interventions were usually at household and community scales. I think that sort of logic could really recognize HIV as a broader problem and help intervene in positive and productive ways to make people healthier.
GRILLOT: So what you're saying then is you've got this model that you can develop and migrate to other communities and make an impact on health and wellness in general?
NEELY: Absolutely. So it's a model that was sort of abandoned in the 1960s, but it's a model that we could bring back. It's a different vision of health care. The book that looks at Witchcraft says that this isn't a sufficient vision of healthcare. There are other ways of understanding health, but when we're talking specifically about HIV/AIDS - its health impacts, its tuberculosis impacts - absolutely this model could do wonders for thinking about and treating people.
GRILLOT: Well Abby thank you so much for joining us today.
NEELY: Thank you.
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