I cannot believe that there is less than a month left of my time in South Africa. I have only begun to understand the complexity and truly appreciate South Africa in the last week or two. On 1 November, I was supposed to move to Chatsworth to stay with a family in an Indian community where one of our programme partners was going to set up several interviews. Unfortunately (well, now I’ll say fortunately), this programme partner is rather flaky and our plans fell through. I ended up saying in the Tekweni Backpackers (a backpackers is the same as a hostel) with two other girls. This backpackers is right on Florida Road, which is a hot spot for restaurants and things to do. It’s a 20-minute walk from the beach and our office- the ideal location! The best thing about this place is the atmosphere, which is fun, relaxing and incredibly chill. It’s run by a bunch of locals and the people who stay here are so interesting! It’s also a local hang out spot so I’ve finally met a lot of locals who are more than excited to talk to us about Durbs, take us surfing and show us around. It’s amazing how incredibly friendly everyone is.

The other two girls who were staying with me were both quite sick. One had a stomach bug and had to return home from the rural home areas and the other had some crazy bacterial infection and ended up in the hospital for a few days. Needless to say, I was on my own for making friends at first. This was intimidating in the beginning; I would just walk up to a group of people and introduce myself. So far, I have met only incredibly friendly people, so it has worked out quite well.

The other day I was thinking about what I love so much about Durbs and I came up with a few conclusions. I love how diverse it is. South Africa truly is a rainbow nation and with the “most inclusive/liberal constitution in the world”, it is truly a country of hope. South Africa has only been a free and democratic country for 20 years and while it still has a long way to go, people (for the most part) are hopeful. They have a strong faith in humanity, I mean, South Africa turned over one of the most oppressive regimes in world history without a civil war. Mandela and Tutu’s Peace and Reconciliation Commission is considered one of the most profoundly successful justice initiatives. For an aspiring development/health person such as myself, Durban has it all. It’s absolutely stunning aesthetically, with lots of cultural events and things going on but it also has a long way to go developmentally. The socio-economic divide is striking. The upper class and predominately white area of Umshlanga is like Newport Rhode Island, with restaurants, shops, beautiful beaches and a posh atmosphere. This is within 10 – 15 minutes of some of the poorest townships where HIV, TB and other diseases are rampant. Then in another section, also next door, is the largest diasporic Indian community in the world (although SSB would disagree with the word diaspora as it is used here – there is no desire to return home to India in these people – for the most part – and they consider themselves South African, not Indian).

It’s so fascinating that twenty years post-apartheid, the effects are astronomical and still ever present. Apartheid is still apparent in a structural sense; the Black townships, Indian communities and White areas were created by this government and even though the government was overthrown, the areas remain the same. The townships were strategically placed with very limited access from highways and main areas; they were often hidden over a hill or in a forest- out of sight out of mind. This has had incredible implications on development. You could presumably live your whole life here and not see the squatter camps (informal settlements) or townships. Apartheid also created the perfect recipe for HIV and TB. The mining industry was established and was staffed by Black South Africans, mostly from the rural areas. They lived in poorly ventilated and overcrowded housing with poor nutrition and were frequently visited by commercial sex workers. This is the ideal situation for both TB and HIV to spread. THEN, to exacerbate this, the men return home to their families in the rural areas, bringing TB and HIV with them. Now we’re faced with these structural limitations of development and these social determinants of healthcare. So far, the most effective TB prevention method has been to reform housing (as seen historically in London late 19^th century), unfortunately South Africa doesn’t have the infrastructure to completely redo all of the housing (not to mention, the government already built all of the houses in the townships).

I have been exposed to the incredibly complexity of health. I really enjoy the slogan of public health, “providing the greatest good to the greatest number”, but it’s really hard. How do you break such a pervasive cycle of poverty and disease? Also, where to the Whites fit in? A lot of White South Africans whom I have met are really struggling to find jobs because of a “Blacks come first” mentality. Then, where do the Coloureds and Indians fit it? They face similar problems as the White populations, but they feel as though the struggle is always labelled as black versus white, when there are far more ethnicities. This isn’t even mentioning the MASSIVE immigrant population from other African nations, which is clashing with South Africans and resulting in Xenophobic violence. It’s really mind-boggling.

On the other hand, the 1994 Constitution is incredibly liberal and is the only constitution in the world that addresses all people, not just the country’s citizens. Legally, every single person has equal rights, gay marriage is legal, everyone has the right to shelter and other things that the U.S. and many other counties consider privileges. The only problem is that none of these rights are upheld because of corruption, capacity limitations, logistical problems, societal norms, or in my opinion, a constitution that is too idealistic in nature. While I agree with most of the rights listed in the constitution (that also has a really difficult task of combining traditional and modern rights/laws), they are unlikely to be implemented because of their extreme idealism.

Another complexity that I have come across in my research (and you’ll hear more about this if you read my ISP when it’s complete) is that funding for HIV/AIDS and health related NGOs from foreign governments is drastically decreasing. These donors believe that other African countries are more desperate for aid in areas that the South African government has the funds and capacity to fulfil. Now the funding is drying up and the SA government is overflowing with corruption and a lack of effective local capacity building systems. It’s also nearly impossible for grassroots organizations to even apply for funding.

Anyways, I’ll stop ranting about the complexity of South Africa. I honestly barely started this discussion; the complexity runs SO deep. I’m not sure how this country is going to be in the future, but I certainly hold a great amount of hope for it. They have an election next year and there is a strong opposition to the ANC. A common perception is that the ANC is very corrupt and the elections are not really democratic because there hasn’t been competition against the ANC. We’ll see what happens!

As Paul Farmer says in Haiti After the Earthquake (a great read about the complexity of disasters), “Doing good is never simple”. And, as Nelson Mandela says in A Long Walk to Freedom (another must-read. The Boston Globe said that it is “a manual for human beings…should be read by every person alive”), “it is a long walk to freedom”.  From the time in the backpackers, I’m really learning to chill out and enjoy life, something I sometimes forget to do- stop and smell the roses, if you will (hehe). I’m learning about incredible resilience, similar to what I saw in Kenya, but with even more structural enforcement of oppression. In the beginning of the programme I was feeling disappointed because I didn’t feel challenged. I still haven’t been challenged like I was in Kenya, but right now, what I feel like I have learned is how remarkably similar humans are across the globe. In the Zulu township, the Zulu rural areas, the Indian community of Chatsworth, the fancy Umshlanga Rocks, and my wonderful little backpackers, everyone loves, laughs and cries the same. I feel much more connected to people whom I had never met and see myself looking at people as individuals, not just strangers. Perhaps it is a strange thing to take away from the programme, but I’m enjoying it for now and am going to be so sad when I leave.

Hospital Visit and Research Topics

I visited St. Mary’s private-public hospital outside of Durban today; it was wonderful! St. Mary’s was founded in 1927 and allegedly (although not likely) serves a population of 1 million people with 200 hospital beds. The hospital is relatively comprehensive with casualty units, obstetrics, surgery/theatre, medical, and outpatient and tuberculosis units. I found the politics of the hospital and the tuberculosis unit the most interesting.

As a private-public hospital, St. Mary’s has funding form the South African government and private funders. The private funding was previously dominated by PEPFAR (the Presidents Emergency Plan for AIDS  Relief)– the African HIV/AIDS funding provided by the US government during the Bush administration). However, PEPFAR was not supposed to last forever and has been steadily decreasing in funding. As a Catholic hospital, St. Mary’s does not want to become a fully public hospital and solely exist on government funds because it would have to give up on some of its Catholic values, namely abortion and family planning. This was interesting to me because apparently the hospital could receive much more funding from the government if it became fully private, however because of religious affiliation, they are reluctant to do so.

The PEPFAR funding also provides a really interesting discussion. PEPFAR is considered one of the most successful aspects of the Bush administration, however it has been critiqued for it’s earmarked funding (funding that can only be used for certain purposes). Before Obama came to office, 2/3 of PEPFAR funding could only be used for pro-abstinence programs; none of the PEPFAR funding could promote safe sexual practices or contraceptives to prevent HIV transmission. Obama overturned this, but it does provide an interesting example of the complexities surrounding foreign aid. If this is interesting to you, check out Dead Aid by Dambisa Moyo; she provides a fascinating synopsis of the complexity surrounding foreign aid and provides a critical analysis of its effectiveness.

The topic of my consolidation paper is Tuberculosis in South Africa, focusing on the DOTS programme. Our consolidation has to be on a health promotion policy in South Africa and I chose Tuberculosis as the heath problem because it is a truly interesting disease: Tuberculosis is truly a disease of the poor. As I have previously discussed, HIV is a disease that effects approximately 30% of South African youth. HIV itself does not usually cause mortality; it weakens the immune system, making the person susceptible to opportunistic infections such has Tuberculosis. Tuberculosis is an airborne disease and is most commonly transmitted through sneezing. It is most commonly found in areas of high density, inadequate housing (dark and damp areas) and in people with poor diets. Therefore, poverty exacerbates tuberculosis while tuberculosis exacerbates poverty- talk about the pervasive cycle of poverty and disease!

To matters more complicated, despite being curable, TB requires a rather extensive treatment plan that involves a six-month antibiotic course. The BCG vaccination against Tuberculosis is effectively useless, especially in adults. There are four epidemiologic patters of TB: 1) in persons with HIV in developing countries 2) in immigrants in developed countries (the Southern US has high TB rates) 3) in areas with economic decline, poor TB control and substandard health 4) Globally, Sub-Saharan Africa is disproportionately effected by TB. TB used to be a disease of young men, however with the HIV co-infection (women are more susceptible to HIV), TB in sub-Saharan Africa is now becoming a disease of women. This is even more interesting because it is attributed to societal/gender norms, namely intergenerational sex. Women are typically seven years younger than men and men typically have multiple and irregular sexual partners and often engage in high-risk sexual behaviour. You can really see how HIV and TB go hand-in-hand. A quote from our visiting professor exemplifies this: “Nothing in the history of the world predisposes people to TB like HIV”.

Now, I get nerdy and into my favourite global health figure: Paul Farmer. This is an example from Mountains Beyond Mountains by Tracy Kidder. Globally, the WHO initiated the DOTS programme: Direct Observational Therapy. This policy was tried and tested in a central African country before being recommended by the WHO as a worldwide solution for TB. This programme dealt with people who were not recovering from TB, despite allegedly taking the drugs. However, the study found that due to inherent conflict and displacement in the experimental community, patients were not completely adhering to their drug regimes. They countered this by giving more drugs to the patients and directly observing them to ensure that they took the drugs. When this policy was implemented globally, Partners in Health in Lima, Peru found a problem. Despite adhering to DOTS principles, patients were getting worse and worse as they continually adhered to the programme. Finally, Paul Farmer and his colleagues found that the DOTS programme worked in the Central African context specifically because people were defaulting on their drugs. However, in Peru, people were taking the drugs and were still getting sicker. The problem was that the TB patients in Peru had a different strain of TB. Pumping the patients with more drugs that weren’t really working effectively served to create multi-drug resistant tuberculosis (MDR-TB), which has now evolved into XDR-TB (an even worse version of multi-drug resistant TB that is almost universally fatal).

For my consolidation paper, I am excited to explore the effectiveness of DOTS in South Africa. South Africa provides such a unique perspective for diseases like TB, especially because of their social determinants and vast social inequality following Apartheid.

I figure I should also clue you into my ISP project as of now. I am still planning on exploring the impact of donor funding in HIV non-governmental organizations. As I discussed above with the PEPFAR reference, donor funding can have a profound impact on an organization’s behaviour and successes. The Global Health arena is dominated by six main agencies: The Global Fund to Fight AIDS, Tuberculosis and Malaria, The Bill & Melinda Gates Foundation, PEPFAR, the World Health Organization, the International Monetary Fund and the World Bank. All of these organizations are Western and Northern based and mostly work in the Eastern and Southern hemispheres. I have pasted a passage from my electronic journal that discusses my proposed topic:

HIV/AIDS In KwaZulu Natal

According to the SANAC KwaZulu Natal Provincial AIDS Spending Assessment Brief, the prevalence of HIV/AIDS is the highest in Durban of all the provinces in South Africa, with prevalence at 37.4% in 2011 and a population of 1,576,025 people in KZN living with HIV/AIDS in 2011(SANAC 2013).

As elicited in Reimagining Global Health, biosocial approaches to health dictate that “biologic and clinical processes are inflected by society, political economy, history and culture and are thus best understood as interactions of biological and social processes (Farmer et al, p.735, 2013). Thus, HIV/AIDS is a disease that is social in nature and as such is complex with many factors influencing its prevalence and incidence.

Shifts in Funding

The onset of the HIV epidemic and the establishment of NGOs were relatively synonymous. According to Jeffery Sachs and Amir Attaran (2001) from 1996 – 1998 the donor funding for HIV programs was US$170 million (US$69 million went to Sub-Saharan Africa (SSA). Since 2001, donor funding for HIV programs has drastically increased, with total resources for AIDS rising from US$1.6 billion in 2001 to US$8.9 billion in 2006 (Attaran and Sachs 2001).

The epidemic coincided-with and lead-to further increases in funding for global health programs. It is estimated that “development assistance for health from private and public institutions rose from US$8.65 billion in 1998 to US$21.79 billion in 2007” (Farmer et al, p2518, 2013). The Gates Foundation, a primary donor of global health programs has donated over US$10 billion to global health programmes (Farmer et al, p2567, 2013). In a period of less than ten years, an unparalleled level of massive global health programmes were initiated: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Emergency Plan for AIDS Relief, UNAIDS, and programs by the WHO, IMF, and World Bank. Development funding for health increased from US$5.6 billion in 1990 to US$9.8 billion in 1999 and even more to US$21.8 billion in 2007 (Farmer et al, p. 2567, 2013). This increase was not only unprecedented, but astronomical.

This incredible influx of international funding for global health programs, especially for HIV/AIDS programs lead many African countries into dependency, relying on foreign and seeing their “health budgets dwarfed by foreign aid and health policies determined by donor organizations” (Johnson, p. 496, 2008) South Africa has attempted to avoid dependency and now has the world’s largest public sector antiretroviral treatment (ART) programme, which is 95% funded by South Africa and not by outside donors (Johnson, p.496, 2008). Despite this, as Krista Johnson states, South Africa still has a long history of tension between the government and the donors, namely perpetrated by “western paternalism and South Africa’s determination to avoid dependency” (Johnson, p.496, 2008). The increases in donor funding have been drastic and in some cases even overtake government budgets. “In Uganda and Zambia external donors exceeded public health expenditures by almost 185%” (Johnson, p. 498, 2008). A donor representative told Johnson that the “tepid relationship between the [South African] government and USAID/PEPFAR in part stems from US support for the apartheid regime” (Johnson, p.502, 2008).

Despite the less-than-ideal relationships between the South African government and the United States (USA) and other donors, the USA provided US$584 million through PEPFAR to South Africa. Furthermore, the Global Fund had provided over US$88 million for AIDS and TB (Johnson, p.506, 2008). Johnson also found that significant amounts of donor funds are being refunded to the donors because they are earmarked for specific objectives or programs (507, 2008). A key point in Johnson’s article is:

“According to Ndlovu, ‘Although earmarked funding is beneficial in ensuring that new and critical projects are funded, donor funds may hinder or clash with national government priorities, leading to decreased flexibility for implementers when spending on vital local priorities.’ In addition, spending donor funds is hindered by weak provincial health systems and insufficient capacity of government to commit the money to augmenting key programmes. In recognition of this, several donors, the European Union and the United Nations in particular, have targeted capacity building within the public sector”

(Johnson, p.507, 2008).

There are several key points to be made. As shown above, a lack of sustainability, balance and even distribution of HIV/AIDS funding threaten its success and lasting influence. As Johnson states, a vast civil society influence is necessary but will not happen without funding. Given the unpredictability of funding, it is difficult to adequately plan and implement programs (498).

I will need to undertake further research on how these funds are spent and within the private sector, where they come from and which programs they fund. I also hope to look at Global Fund and Gates Foundation presence in South African HIV/AIDS programs and how much influence they have over which programs run. However, I am slightly concerned that I will hit a ‘dead-end’, as South Africa has clearly gone to extreme lengths to avoid the dependency trap that many other African nations have fallen into with foreign aid.

Donor Influence: Significance

Donor funding is important to address because it has many underlying implications. When donor funding exceeds government budgets or is substantial enough to compete with government budgets, macroeconomic stability and fiscal management are threatened and even potentially undermined (Johnson, p.498, 2008). Donor funding can also undermine the public sector simply by bypassing it; if the government does not have the stability or resources to properly utilize the donor funds or direct them, the funds can subvert institutional capacity and exacerbate government problems (Johnson, p.498, 2008).

PEPFAR provided over US$584 million in 2008 for HIV/AIDS programmes in South Africa and worked with over 300 NGOs. None of the money went to the South African government, but the United States Agency for International Development (USAID) does work with national and provincial departments in South Africa. This is significant because PEPFAR is the largest donor that does not give funds to the South African government; other large donor organizations such as the European Union and the Global Fund provide funds to the South African government. At a 2006 PEPFAR conference in Durban, the South African Health Minister stated that “PEPFAR in South Africa ‘started off on the wrong foot. We were not consulted’” (Johnson, p.507-508, 2008)

This touches upon the significance of donor influence. As stated by Johnson, undermining the government and directly funding NGOs and local programmes “creates a coordination problem” (p.508, 2008).

As seen in Haiti and described by Dr. Paul Farmer: “It wasn’t a good idea to funnel foreign assistance exclusively through NGOs and private contractors. Without real and sustained commitments to strengthening the public sector-including its capacity to monitor and coordinate services offered by NGOs- who would make sure development funds were used effectively?” (Farmer, p.1097, 2011).

Donor influence in health organizations is an important area to study, especially as the world is increasingly dominated by a few select organizations. As discussed above, the main organizations dominating global HIV program funding are the Bill & Melinda Gates Foundation, PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, the IMF and the World Health Organization (Farmer et al, p2567, 2013). It will be important to explore and begin to understand whether these organizations are funnelling their funding through the South African government or directly to NGOs and programs.

On the other hand, Johnson identifies further potential implications of donor influence. U.S. Secretary of State Condoleezza Rice implemented a plan for “transformational diplomacy” where the aid will go to governments and not to NGOs. This not only divides up funding for disease specific programs (ie by overriding the Global Fund), but also increases the likelihood for aid to reflect U.S. strategic interests in a more overt manner (Johnson, p508-509, 2008).

Another area of complication of PEPFAR funding is pharmaceuticals. PEPFAR funding for ARVs can only be used for US Food and Drug Administration (FDA) approved ARVs- AKA brand-name drugs that are extremely expensive as opposed to generic brands that are exactly the same, just cheaper (Johnson, p.509, 2008). This is yet another example of U.S. big business interests trumping cost-effective alternatives to pharmaceuticals.

As you can probably see and as Dr. Paul Farmer states in Haiti After the Earthquake, “Doing good is never simple”. I hope to address some of the complexity surrounding global health and development programmes through my independent study project.

I am enjoying my time in South Africa and am relatively busy with schoolwork. I haven’t found much of the work to be challenging, just lengthy, which is a bit frustrating. I am still enjoying the group, despite the lack of adventure-ness. I am certainly having a socially – relaxing semester compared to my Franklin semesters. It makes me recognize how unique Franklin students are and makes me miss always having someone to call upon for an “adventure”. At Franklin and travelling with Frankliners, we almost universally consider going out a vital part of visiting a new place and consider our travels unsuccessful if we don’t meet locals. It’s interesting being around so many Americans who actually enjoy being considered Americans; this is totally new territory for me.

Pictures from Rural Home-stays in Impendle and UMtwalume

Chatsworth

I spent the past weekend in Chatsworth, the largest Indian community outside of India! It was a really wonderful weekend and a very welcome break from the intensity of work. We had a lecture from the Cassimjees, a Muslim husband a wife who are the definition of a power couple. They are both working for their PhDs, run the “Chatsworth Community Forum” (an multi-faceted development and HIV organization), give lectures, are very politically prominent and have three children! I don’t know how they sleep or have time for themselves! We spent this weekend with Ismail (the husband)’s mother at her house and with their three kids (ages 8, 12 and 13). It was wonderful being surrounded by caring and genuine people who can hold fascinating conversations about anything! We talked about everything from Hinduism to gas prices in Saudi Arabia to the distinct smell of African soil when it rains. It was great. Ismail is truly an incredible man. He is fluent in six languages, has travelled extensively and is so intelligent in so many different areas. Rabia, his wife, is likewise one of the kindest and most genuine women I have ever met. They are an amazing pair.

On Saturday, we went to the Bangladeshi Market. This was a bustling place where you could buy anything from bagged gold fish to fruits to toothpaste to car tires. The main thing that has stuck out to me in Chatsworth is how incredibly friendly everyone is. In the market, we were at a stand that sells homemade pickled items such as sweet and sour mango and others. A man who was also buying some items overheard us saying that we are students from America. He handed the tore owner 20 rand and said “buy these girls whatever they want; they came here from so far away!” People here are SO friendly.

On Sunday we went to a Hindu Temple and sat in on a translation of the Book of the Future. The people were again incredibly friendly and welcoming! We were given a tour of their Temple and one of the directors talked to me for a while about Hinduism. One great aspect of this religion is that they don’t dislike or disagree with other religions; they believe in “all rivers lead to the sea” and that everyone and every religion reaches God in their own way.

After the Temple visit, we went to a Mosque but unfortunately it was closed. It then began raining and got very cold, so we went back home and watched two movies: a Hindi romantic comedy and Lord of the Rings! It was wonderful and relaxing: just what I needed!

The Indian food we ate was great too! We had mutton curry, vegetarian curry, samosas, and many other Indian delicacies! On Sunday, unfortunately (but sweetly) our Grandmother wanted to make us comfortable and tried to make “American” food. We ended up with hot dogs and spaghetti, which was rather disappointing following the amazing curries we had. Oh well, it was very sweet of her!

I’m going to try to return to Chatsworth for my ISP!