Leah Gilbert

Treading the path of least resistance: HIV/AIDS and social inequalities a South African case study.

This paper outlines aspects of the HIV/AIDS epidemic scenario and the complexities associated with it. It reveals the socio-epidemiological patterns of the epidemic and in doing so identifies the populations with the greatest and fastest growing rates of infection. From the data presented it is evident that the pattern of HIV/AIDS in developing countries in sub-Saharan Africa in particular is unique. The pattern emerging in South Africa follows closely. The features of this pattern are as follows: the epidemic is mainly a heterosexual epidemic, the rates of infection in the general population are very high and the percentage of HIV-positive women is greater than men. An additional unique feature is the young age of onset of infection for women. These data demonstrate the need to focus our attention on young African women and the factors underpinning their predicament. In order to understand their position we examine the long standing relationship between social inequalities and health in general and further invoke the concepts of vulnerability and social capital to shed light on the position of women in the epidemic. Within the constraints of limited and problematic statistical data, the paper argues that a mixture and complex interaction of material, social, cultural and behavioural factors shape the nature, process and outcome of the epidemic in South Africa. It concludes with recommendations for the way forward.

'My biggest fear was that people would reject me once they knew my status...': stigma as experienced by patients in an HIV/AIDS clinic in Johannesburg, South Africa.

Stigma is not a new concept; however, it remains highly significant in the context of HIV/AIDS in South Africa. There is wide consensus that HIV/AIDS-related stigma compromises the well-being of people living with the disease. This paper is part of a larger study that seeks to understand the social and cultural complexity related to the provision and outcomes of antiretroviral therapy (ART) in South Africa. It explores and analyses how patients on ART perceived and experienced stigma and how it has shaped their behaviour towards, as well as their understanding of the epidemic. The data have been collected by means of in-depth face-to-face interviews, conducted between June and November 2007, with a sample of 44 patients in an HIV/AIDS clinic in a resource-limited setting in Johannesburg, South Africa. The findings reveal that the level of felt and anticipated stigma is intense and affects all dimensions of living with HIV/AIDS, particularly disclosure and treatment. Stigma permeates the experience of HIV-positive people on ART who participated in this study. The intensity of HIV/AIDS-related stigma can threaten to compromise the value of ART, thus impacting on the daily lives of people living with HIV/AIDS (PLWHA). This study suggests that three decades into the epidemic, stigmatisation remains a core feature of the patient experience of HIV/AIDS. In the clinic in which this research was conducted, HIV/AIDS was regarded as a chronic condition increasingly manageable by ongoing access to ART. However, this approach was not shared by many family members, neighbours and employers who held highly stigmatised views.

Older Female Caregivers and HIV/AIDS-Related Secondary Stigma in Rural South Africa

South Africa’s HIV/AIDS epidemic poses a major public health threat with multi-faceted harmful impacts and ‘socially complex’ outcomes. While some outcomes relate to structural issues, others stem from society’s attitudinal milieu. Due to negative attitudes toward People Living with HIV/AIDS, stigmatisation mars their own experience and often extends to those close to them, in particular their caregivers. Many of the caregivers in South Africa are older women; thus, older women are the focus of this paper, which aims to examine HIV/AIDS-related stigma from their perspective. This paper explores secondary stigma as a socio-cultural impact of HIV/AIDS through repeated semistructured interviews with 60 women aged 50–75 in the MRC/Wits Rural Public Health and Health Transitions Unit research site (Agincourt), many of whom had cared for a family member with HIV/AIDS. Respondents’ narratives reveal that many older persons attribute high rates of death in their community to young persons’ lack of respect for societal norms and traditions. The findings illustrate the forms and expressions of HIV/AIDS-related secondary stigma and their impacts on older female caregivers. The types of secondary stigma experienced by the respondents include physical stigma in the form of isolation and separation from family members; social stigma in the form of voyeurism and social isolation; and verbal stigma in the form of being gossiped about, finger-pointing and jeering at them. Despite mixed reports about community responses toward infected and affected people, HIV/AIDS-related stigma remains a cause for concern, as evidenced by the reports of older women in this study.

HIV/AIDS: South African women at risk

A previous version of this paper was presented at the AIDS in Context Conference, University of the Witwatersrand, Johannesburg, 4–7 April 2001 This paper engages some aspects of the HIV/AIDS epidemic and the complexities associated with it. It outlines the socio-epidemiological patterns of the epidemic and in doing so identifies the groups with the greatest and fastest growing rates of infection. The pattern of the epidemic in South Africa is as follows: it is primarily a heterosexual one, the rates of infection in the general population are very high, and the percentage of HIV positive women is greater than men. An additional feature is the young age of onset of infection for women. These data demonstrate the need to focus our attention on young African women and the factors underpinning their predicament. In order to shed light on the position of women in the epidemic and the particular risks they face, we examine the long-standing relationship between gender and racial inequalities and health. Within the constraints of limited and flawed statistical data, the paper argues that a complex interaction of material, social, cultural and behavioural factors shape the nature, process and outcome of the epidemic in South Africa. It concludes with recommendations for the way forward.

Community pharmacy in South Africa: A changing profession in a society in transition

The analysis of community pharmacy as a profession in transition acquires an additional dimension in South Africa, since it is inextricably linked to its social characteristics as well as to the political transformation taking place. Using data collected by means of a documentary search, interviews with key informants and a survey of community pharmacists, the paper presents the relevant societal features and explores some of the complexities associated with the existing as well as the potential future role of community pharmacy in the context of changing health services in a society in transition. It concludes that the changes in community pharmacy and the role it can play in the provision of Primary Health Care to all the people of South Africa are linked to the greater transition in society and its future health care services.

Globalisation and local power: influences on health matters in South Africa

This paper reviews some of the multiple influences on health issues in South Africa, placing them in the context of globalisation. By examining the complexity of factors, both domestic and global, which impact on these issues, it questions the extent to which global patterns in areas such as health policy, HIV/AIDS, health care pluralism, and neo-liberal macroeconomic policy have played out in South Africa. The identification of some of the multiple and complex forces in each case reveals a relatively consistent story of global pressures interacting with domestic realities, with some recognizably local results. There is no doubt that a full and nuanced understanding of health in South Africa requires an appreciation of developments in the global political economy, international organizations such as the WHO and World Bank, and forces which operate outside of institutions. In each case, however, the specific opportunities available to actors within the country, as well as the relative power of those actors, should be given their due consideration in analysing their potential impact on health matters.

Sociology and the ‘New Public Health’ in South Africa

Abstract The paper explores the dimensions of the ‘New Public Health’ in general and in the South African context in particular. Adopting a historical perspective, Sociology’s role in public health research and training is examined. It starts with an examination of changes that have occurred in society, health, and medicine linked to the need for a sociological understanding for health professionals. In this framework, the ‘socio-environmental model’ of health and disease, which is the outcome of the new understanding, is presented. The development of ‘public health’ and ‘primary health care’ with its links to sociology are discussed subsequently, drawing on international examples as well as focusing on its history in South Africa. Finally, the paper deals with the ‘New Public Health’ in South Africa and the potential role Sociology can play in its research, training, and practice.

“My Legs Affect Me a Lot. … I Can No Longer Walk to the Forest to Fetch Firewood”: Challenges Related to Health and the Performance of Daily Tasks for Older Women in a High HIV Context

Compromised health negatively impacts older persons’ ability to participate in expected social roles. Researchers have published little empirical work, however, to explore these issues in HIV endemic African settings. Qualitative interviews with 30 women, aged 60-plus, in rural South Africa, provide insight into the relationship between health and daily activities, with attention to the fulfillment of social roles. In this poor HIV endemic context, older women make connections between their compromised health and their (lack of) capacity to perform the daily tasks that they view as expected of them. By expanding the conceptualization of health to include the capacity to achieve the expectations and perform the tasks expected of one, we better understand how and why health and performance of daily activities are so intricately linked in the minds of respondents. This also provides a starting point for thinking about the social and structural support needed by older persons in these settings, especially as HIV erodes familial supports.

“Your health is our duty, our commitment, our life's work”: Pharmacists in South Africa claim new ground

Abstract Against a background of transformation of health care services and a shift towards Primary Health Care, this article aims to present, discuss and analyse the changes that have taken place in Community Pharmacy (CP) in South Africa. Particular emphasis is placed on the concurrent shifts from the dominant focus on disease and illness to that of health, and from the exclusive reliance on Allopathic Medicine (AM) to an incorporation of Complementary and Alternative Medicine (CAM) and in some cases traditional/indigenous medicine. The analysis is based on official documentation, two surveys of community pharmacies in Johannesburg, as well as interviews with key informants. The main argument is that in its efforts to change its own role definition, CP is responding to demands from the public as well as to economic and professional opportunities presented. In the process, it is becoming a place for health rather than disease, incorporating lay and complementary healing systems by working with other marginal health professions such as nurses and CAM healers, with a view to generating economic rewards within a holistic framework. The article highlights the main changes and demonstrates how they converge with similar factors to those of the growth of CAM and the rise of the new public health. Concepts such as ‘the healthism movement’, ‘culture of fitness’, ‘consumerism’, ‘medical dominance’ and ‘professional boundaries and jurisdictions’ are invoked in the course of the discussion in order to explain the current developments as well as to point the direction in which community pharmacy in South Africa is likely to develop.

‘Re-Engineering the Workforce to Meet Service Needs’: Exploring ‘Task-Shifting’ in South Africa in the Context of Hiv/Aids and Antiretroviral Therapy

ABSTRACT This article explores the major trends in the South African health workforce in the context of HIV/AIDS and analyses their potential impact on the professional work and status of nurses and doctors. The Human Resources for Health Strategy for the Health Sector 2012/13-2016/17 document, in addition to a wide range of secondary material, is used to depict the shifts that have taken place in the SA health workforce as a response to the unmet health needs and demands emanating from HIV/AIDS. Such a response is particularly challenging in the context of limited-resource settings and inadequate public healthcare services. Therefore, there has been a need to come up with inventive ideas to mobilise all available resources to curtail the spread of the epidemic as well as to cope with the provision of ART to large numbers of people as quickly as possible. Adopting a critical-analytical approach, this article draws attention to three such ideas: task-shifting, the training of new mid-level workers, and the use of members from the community in a variety of roles as ‘community health workers’. Although these ideas are not new, they acquire acute poignancy in the context of HIV/AIDS in South Africa today. They also provide an interesting case study through which to interrogate arguments advanced in the sociology of the professions about ‘medical dominance’, ‘occupational monopoly’, ‘laymanisation’ and the potential challenge to medical authority and power that may have occurred alongside shifts in professional boundaries.