Africa: A Practical Guide for Global Health Workers

7: South Africa

156 south africa x 7 7 michelle scott palav babaria neel r. gandhi South Africa is a country of diversity and contrasts. Not only is its population racially diverse, but it encompasses a wealth of varying cultures, from French villages in the Western Cape,1 to the Minstrel Carnival in Cape Town, and to Zulu homesteads in KwaZulu-Natal. Economic diversity ranges from upper-class wealth comparable to that in the United States or Europe, to abject poverty similar to some of the poorest countries in Africa and the world. South Africa is best known for its modern political history—in particular, the brutal segregation of the apartheid regime, followed by a peaceful democratic transition under the leadership of Nelson Mandela. The legacy of South Africa’s political history continues to influence all aspects of modern-day life. In this chapter we will try to paint a picture of today’s South Africa, along with a historical context in which to understand it. Our vantage point into this fascinating country is from the small rural hamlet of Tugela Ferry, in the province of KwaZulu-Natal. KwaZuluNatal is best known in South Africa for its beautiful beaches on the Indian Ocean, which straddle Durban, the busiest port city in Africa. Unfortunately , KwaZulu-Natal is also home to the country’s worst epidemics of hiv, tuberculosis (tb), and drug-resistant tb. These contrasts, pervasive throughout modern South Africa, can be tangibly experienced in the 180-kilometer (112-mile) journey from Durban to Tugela Ferry. Durban is a beautiful tropical city with a diverse population of whites, Indians, and blacks, and all of the comforts of an American or European city—modern beachside hotels and resorts, shopping malls, and south africa 157 cafes. The drive north of Durban passes through the Natal Midlands—a landscape of scenic rolling hills, dotted with lush sugarcane and timber farms. These estates, once havens for British colonists escaping the humid Durban summers, are now emblematic of South Africa’s continued economic strength (South Africa remains the world’s fifth largest producer of sugar). After passing Greytown, a small town that serves as a commercial crossroad for this agricultural region, there is a bend in the road where Natal turns into KwaZulu, the relocated heartland of the Zulu people. As you cross over a hill, a nearly distinct line separates the green of Natal from the red, rocky, desert land of KwaZulu. This region is home to descendants of the great Zulu tribe who were devastated by wars with white settlers in the nineteenth century, and oppressed by homeland policies of the apartheid regime in the twentieth century. Now the region is among the poorest and least developed districts in South Africa, with unemployment rates as high as 40 percent. Most inhabitants live in traditional homes of packed mud and thatched roofing, the majority lacking running water or electricity. The hiv epidemic has ravaged this region; hiv prevalence rates among pregnant women reach 30 percent, and nearly every family has lost someone to aids. The recent discovery of a drug-resistant tb epidemic in this region only adds to the suffering and the challenges of improving healthcare for this highly underserved population. Just as the journey from Durban to Tugela Ferry that we’ve described embodies South Africa’s sociopolitical history through its changing landscape, the historical, political, and socioeconomic factors we describe in this chapter have shaped the current status of health in South Africa. Our viewpoints are inevitably shaped by our experiences as American clinicians and researchers working at a district hospital in a small rural town. Yet Tugela Ferry epitomizes the post-apartheid challenges that characterize much of South Africa and have played a key role in fueling the hiv/aids and tb epidemics in this country. To understand the challenges, you need to start by understanding the history. A Short History of Early South Africa Indigenous San and Khoikhoi nomadic tribes resided in South Africa for thousands of years. In the fourth century, they were joined by 158 africa : a practical guide Bantu-speaking agrarian tribes that migrated south from Central Africa . These groups remained largely undisturbed until 1497, when the Portuguese explorer Vasco de Gama established the spice route around the Cape of Good Hope. The Portuguese left the area unsettled. However , the Dutch East India Company began to use the coast of southern Africa as a rest stop along its...