Home Visits in Soweto

This has been a week of no visits to the Outreach Center; Meisie was in a car accident yesterday morning and, though she's okay, is weakened by aches in her muscles from the impact. She is staying home to recover the rest of this week. I have been doing research on systems of care for vulnerable children in South Africa.

However, I did want to report on events before Meisie's accident. A week ago today, after our usual late start, turned into a full afternoon of home visits to Nomsa’s granny clients around Soweto. Our task was to distribute donated school uniforms to seven grannies for the HIV+ children they care for, entering their homes and chatting with them for a bit. Meisie encouraged me to take photos of each granny and they seemed happy to have photos taken of them and their grandchild/grandchildren. The poverty and cleanliness of each grandmother varied quite a bit. The first granny we visited lives in a one-room tin shack; neat piles of children’s laundry covered a single bed, but the “kitchen” wall was cluttered and the space was dark and rather dismal. Margaret, the grandmother was warm towards us, though she was clearly unwell and almost emaciated. Meisie told me after we left that Margaret was “positive” but has taken no steps to deal with her illness until, maybe, recently. She told Meisie that she’s been tested, but refuses to come to support group. It’s difficult to understand the degree of denial that can squelch concerns about the children’s welfare. Who will look after her grandchildren after she dies of AIDS?

Almost every granny was doing laundry or ironing when we arrived! Nomsa gave each of them a rather hideous knitted ski hat and scarf—all donations. About three grannies were not home, but we were able to leave the uniforms either with the children or a neighbor. The uniforms are for the children who are HIV+. Donations of uniforms may make the difference in whether a child can attend school or not. Some of the kids also got shoes with their uniforms.

One home we visited stood out dramatically from the others because it was bright, well-furnished, decorated with bright patterned curtains and chachkis, such as animal statues, a head of Mandela, pottery, and a beautiful enlarged photo of her eldest daughter in traditional Nbele clothing. The leather couches, while very worn, were shiny-clean, with linen squares of embroidered cloths along the backs. The granny showed me her beautiful, new tin bucket that she uses to get water for cooking or washing, as well as the two tin shacks in her back yard where her sons live. It was all very neat, and one shack had a rustic sculpture near the door made of metal and string. She was very proud of her home; as we left, I noticed and commented on her succulent garden at the front of the house. Her grandson, who seemed about ten years old, was quiet but polite and sweet. His head was covered with lesions, probably karposi’s sarcomas, and he was very thin. But, he was eating a sandwich he made for himself when we ended our visit.

Across the road and over the dusty red-dirt ‘yards’ was another client’s home, tucked behind a brick house. There were two shacks there, as well as an elder couple who seemed to live in one of the buildings. The client was not home, but someone went to fetch the two children, who would receive the uniforms, and the elder neighbor woman would sign for them. The children were delighted with their uniforms, which they took inside their shack (after posing for me). Meisie told me that Cotlands had built the shack for this granny & the children because it had been too crowded for them in the house fronting the road. It was a one-room shack constructed of corrugated tin. Cotlands also makes sure that each client has a small refrigerator (to make sure the ARV’s are kept cold), a stove, and a space heater. None of the homes we visited had running water and used outhouses for toilets. In one home, an entire room was filled with a queen-sized bed covered with stuffed animals for the children.

Home sizes varied from one room to four—I don’t know how many people actually lived in each, although none held fewer than three people. Men were few and far between. In the back of one home, the yard for two shacks and a house, several men were building coal stoves out of scraps of metal or old appliances. Another backyard that we entered held a shack and a shabeen. The client was not at home in her shack, so Nomsa had the shabeen owner accept and sign for the uniform. Four very drunk men sat outside the shabeen with their almost-quart-sized cups, filled with a yeasty brew that has high alcohol content. Alcoholics, the men will spend every cent they should to buy food on drink, much like alcoholics the world over. The little girl client appeared as we were leaving, running up to and embracing Nomsa with a huge grin on her face.

The last home I will describe was, as most of them, at the back of a house fronting the road; four children sat on a wall and got very excited by our appearance (and my camera). Meisie showed me the house garden next to the granny’s shack, which Cotlands had helped her start, and which she had added to. While it was impressive, I am skeptical that it would ever provide a significant amount of food for the family. Meisie’s goal is to have every granny in the program have a home garden to help decrease her poverty. This garden had a primitive wire fence, a box of used plastic bottles at the end, and a pile of trash or some stuff at the other end. There is much to be done with such chronically poor people, even these who are so committed to improving their lives and those of their grandchildren.

My Neighborhood in Turffontein

I am staying on the 2nd floor of Cotlands House, which serves as housing for volunteers (some of whom stay for a full year between high school and university) and for 10 children who, thanks to ARVT, have survived into the ripe old ages of 10-13. I have to unlock two iron gates to climb the stairs to the apartment I share with a Scottish volunteer, Louise, who is heading for home in 4 days after being here a year. I was not provided with a key to the outer gate, and so had to ask one of the kind women who look after the kids downstairs to let me in and out.

This neighborhood at one time was relatively affluent, or at least middle class, but the only evidence of better times is the size and structural qualities of the houses, and the fine old trees that line the streets. Turffontein is now the 2nd most dangerous neighborhood in Johannesburg and few people can be seen on the streets after dark. A few times a week, I walk to the market (SPAR) for supplies like bottled water, bread, and small meal supplies.

The walk to the SPAR begins on our street, Ferreira (named after a gold speculator who discovered gold on the Turrfontein farm back in the 1870s) to the large street at the end of the block. I have wanted to photograph this area, but have been afraid of being robbed. I did snatch a few pictures slyly the other day. The one below is taken from our entry gate, and shows some men working on a car on the left.At the corner, there’s an abandoned building on the right, which often has shattered glass scattered on the ground and sidewalk. There is a wide stretch of what would be grass between the spotty sidewalk and the street; it’s got some patches of ‘grass’, and consists of the red-orange dirt that is everywhere. Across the street, there is a covered area, like a craft fair booth, where one or two men sell haircuts and shaves. I think this was here last year, without the cover. There’s an open doorway nearby the barber that leads into a small room packed with fruit and vegetables; one of the little Spazas that can be found on almost every block (There’s also one along the walk to Cotlands from my apartment, but it’s bigger and in the evenings sells things through an iron grating. An even larger market is further down the road, situated on a classy corner spot). As I walk to the SPAR, I pass many other pedestrians and am unsure whether to smile or to avoid eye contact; I do a little of both. The pharmacy is in the block before the main intersection and the street that holds the SPAR. All over-the-counter and prescription medications are sold at pharmacies, even vitamins.

The main street is divided by a cement path, and is always bustling with both pedestrians and cars. Next to SPAR is an internet place that also sells some technology and a liquor store, where one can buy wine, beer & liquors. SPAR sells wine, but it’s very sweet. Across the street from SPAR is a vegetable market, a clothing store and others; a constant brei is in process in front of the shops, which sends smoke and the scents of burning meat around the neighborhood. Cars move very quickly on the wide sidewalk to access precious parking spaces, so we need to stay alert and be prepared to jump out of the way. Sometimes a couple white bums drunkenly call out to us as we walk by. Sunday night, one of the parking guards gave me a friendly nod of his head—a movement unusual for me—moving his head upwards and to the side after making eye contact.

Below is a photograph of the street that runs two blocks from ours to Stanton Street (too far away to see here), where Cotlands is just around the corner to the right.

HIV/AIDS & African Children

Only a very few countries have as devastating HIV infection rate as South Africa. According to AVERT, an international AIDS charity, 1000 people in South Africa die daily of AIDS-related illnesses. The South African government, with all its potential for democratic leadership, has taken on a counter-intuitive, regressive approach to the HIV/AIDS pandemic. President Thabo Mbeki and his Minister of Health, Manto Tshabalala-Msimang, have questioned the science of HIV and inimated that western nations promotion of antiretroviral treatment reflects western, white hegemony and ongoing oppression of black Africans. In spite of international and national outcries, they instead have encouraged citizens to focus on nutrition, herbal treatments, and even traditional healers (Sangomas). The activist group, Treatment Action Campaign (TAC), begun in 1998 to protest government inaction, brought homocide charges against Manto Tshabalala-Msimang in 2003, attiributing the infection rate of 600 a day to her neglect. The TAC was founded by nobel prize nominee, Zackie Achmat, who protested the government's neglect by stopping taking his ARV medication because only the affluent could afford to get adequate treatment in South Africa. In 2003, the ANC government soften towards antiretrovirals: "The government’s change in attitude towards ARVs was partly a result of a court battle in which GlaxoSmithKline and other pharmaceutical companies agreed to allow low-cost generic versions of their drugs to be produced in South Africa. This made South Africa one of the first African countries to produce its own AIDS drugs" (AVERT).

The results of the South African Department of Health Study (2007) of pregnant women who visited antenatal clinic estimated that 29.1% of pregnant women were HIV+ in 2006. The estimated prevalence in Johannesburg's province of Gauteng was 30.1%. There is some evidence to suggest that the infection rate is flattening out at this level. An earlier household survey in 2005 suggested that 10.8% of South Africans were HIV+ and for those between ages 15-49, the prevalence rate was estimated at 16.2%. However, these estimates are based on adjusted results on the 55% of the people surveyed; the remainder refused to be tested. The AIDS epidemic has had its worst impact on South Africa's poor (black) population (13.3%) and barely affected its white citizens (0.6%). The death rate between 1997-2005 increased 87% overall, but those who suffered the worst increases were adults 29-49 (169%) and children 0-9 (91%). The average estimated life expectancy of South Africans is 54 years.

Women in sub-Saharan Africa are particularly vulnerable to both the virus and discrimination in African patriarchal culture. In spite of major preventative education efforts by the government and NGOs, condom use is widely rejected by men, such that sex workers have two rates: one for unprotected and the other protected sex. The unprotected sex option is more expensive, but also opted for more often by the men who use their services. While female sex workers are often blamed for the spread of the virus, it is their customers who demand unprotected sex, and then infect their wives when they are home. Wives who take the risk to get tested and are found to be positive, are typically severly beaten by their husbands (blamed for getting sick, when it was their spouse who infected them), expelled from their homes, and ostracized from their communities. With the risks to women surrounding the discovery of infection, denial has been the coping method of choice, so that women may have one or more children before one of them becomes sick; not even in acute sickness do the women (and men) get tested, until they end up admitted to a hospital or visit a local clinic for help. This was the case for the mother with TB and HIV whom I visited early in my stay; she was not tested until she got very sick and went to the hospital and had by then infected her two youngest children.


At least 25% of children born to an untreated HIV+ mother will contract the virus, either in utero, during delivery, or through breast milk. This is called 'vertical transmission' in the pediatric AIDS literature. The benefit of proactive HIV testing for sexually active or pregnant women is that their children's chances of contracting the virus drop to about 8%. All the HIV+ children served by Cotlands (both the orphanage and the outreach program) contracted the virus through vertical transmission. The Home-based care tries to address the problem of denial and further vertical transmission by requiring that mothers be tested for HIV before their children can be admited to the program. Breaking through denial is the first step of treatment. Therefore, all the mothers of Home-based care clients are HIV+ themselves, and can qualify for ARVs along with their children. Apparently, there are a number of mothers and grandmothers who still consult traditional healers in addition to using ARVs. This can lead to complications, such as when a child with diarrhea is given enimas. The photo above is of two HIV+ children under a year old in the care of their grandmother.

One of the many tragic consequences of the AIDS pandemic in developing countries, like South Africa, is the impact the disease has on the country's economic development. "Between 1990 and 2003 – a period during which HIV prevalence in South Africa increased dramatically – the country fell by 35 places in the Human Development Index, a global directory that ranks countries by how developed they are" (AVERT). When the greatest infection rates are in the employable age group, a family can become destitute when the visus strikes. More and more households are headed by the pre-and-post-employable, that is by children and grandmothers. The photo is of a grandmother who cares for two grandchildren; the laundry is piled neatly on the bed in her one-room shack. She is also sick from undiagnosed AIDS.

A recent study, Exporing the Role of Family Caregivers and Home-based Care Programs in Meeting the Needs of People Living with AIDS, researched two Home-based Care (HBC) programs from four of South Africa's provinces and found that "most of the study's households do not have a working member" and that the bulk of their income was from pensions and/or social grants. One of the mothers I have met through Cotlands HBC married a man from Nigeria about four years ago for money, and they have stayed married although he is not involved in the care of their son, who is HIV+ and paralyzed from the waist down. Because she is married the mother and son do not qualify for grant support from the government, even though she has effectivelybeen a single mother. On the other hand, her older child does qualify because she has a different father. The mother is too ill now to work.