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ABOUT
CHRONIC COUNTRYSIDE
Literature on the global rise of NCD’s has been replete with references to urbanisation and its consequences for health. City dwellers are described as more sedentary, more susceptible to stress, more exposed to air pollution, and more likely to consume processed foods, tobacco and alcohol – all of which are major NCD risk factors.
But there is something unexpected happening in South Africa’s Karoo. Despite being a semi-arid, rural part of the country; it has among the nation’s highest rates of hypertension and diabetes, which can in turn give rise to other chronic conditions.
In some parts of the Karoo, we might explain this away because the population is aging or generally unrepresentative of the wider South Africa. But in the strip of Eastern Cape Karoo I am interested in, rates of hypertension and diabetes are unusually high despite a race and age demographic that's very close to the national picture.
I want to know why. What have we missed about the nature of rural life? What does everyday life look like in a place where NCDs have set in so deeply? As NCDs start to outpace HIV and TB as the country’s leading causes of death, what might we learn about the social condition of our country and our bodies?
Tekkies'Story
In our attempts to understand NCDs, we have focused particularly on urban areas. But, in doing so, we might be negating the powerful forces at work in the lives and bodies of rural residents. Urbanisation is not only felt in big cities: it produces effects elsewhere, with real consequences for health. More so, much of what has defined city living is in fact a feature of industrial capitalism, which has expanded far beyond cities.
Over the past six decades, Karoo farms have been shedding labour. Those displaced from farms have often landed in small towns, contributing to regional urbanisation. In the late 1970s, economic decline in the Karoo reached a crisis point, fuelled by overgrazing, deepening drought, and shifts in market prices.[1] Some workers voluntarily moved to town in search of better prospects, while others were forcibly evicted. In the lead-up to the democratic transition, some farm owners sold their farms and/or evicted labourers in anticipation of new land and labour laws.[2] With the institution of minimum wage, those who kept their farm jobs had almost all food rations withdrawn – replaced by purely cash-based wages.
Among those farm labourers who moved to town in the early years of democracy was Tekkies [pseudonym], and it was not of his own volition. Tekkies is a sheep shearer, who now lives Jansenville — the hub of the mohair industry. On the day I first met Tekkies, he told me he’d be waiting outside the USave – a low-cost supermarket owned by Shoprite, which had become a social hub. Today, Tekkies is living with high blood pressure and diabetes. He was diagnosed at the clinic, some years after moving to town, and takes five pills every day.
Tekkies grew up on a farm near Steytlerville, until his family was evicted in 1991. ‘ We were given payment, or maybe half of that payment as food’, Tekkies remembers. ‘Meat and lots of different vegetables. We never ate bread before, just mielie pap.’ But the farm was now being converted into a game lodge, which meant all the workers would need to be removed. Tekkies became one of the 1.7 million people who, for a variety of reasons, have been evicted from South African farms between 1984 and 2004.[3] Game farm conversions are part of this story, demanding not only less labour, but labour of a different type. Instead of sheep shearers, for example; one needs hospitality hands.
When Tekkies and his family were evicted from the farm, it was the only home they ever knew – the home of their ancestors. When they first arrived in Jansenville, the whole family stayed in one house. ‘It was very difficult. You can’t easily get a job without knowing anyone’, he said. But eventually, Tekkies was referred for a shearing contract, and became a contract shearer.
‘On the farm, we didn’t use any money. Here in town, you are forced to work for money’, Tekkies says. There is limited land to plant vegetables or keep livestock, and municipal water rates are expensive. When arriving in town, some described wanting to ‘eat like town people’, who were often seen as more modern, educated, wealthy and free than those on farms. But since farm dwellers now get the bulk of their food in towns, these diets are increasingly merging.
[1] Nel, E., Hill, T. and Atkinson, D. 2007. ‘South Africa’s Karoo: a study of economic marginalization and demographic change in South Africa’s semi-arid interior’, Centre for Development Support. University of the Free State.
[2] Mkhize, N. 2012. Private game farms and the tenure security of farm workers and dwellers in Cradock – implications for tenure reform in South Africa. Doctoral thesis. Faculty of Humanities. University of Cape Town.
[3] Wegerif, M., Russell, B. & Grundling, I. 2005. Still Searching for Security: The Reality of
Farm Dweller Evictions in South Africa. Johannesburg: Nkuzi Development
Association and Social Surveys.
SCENES FROM
WASTELAND
In 1966, Mary Douglas famously defined pollution as ‘matter out of place.' The now-ubiquitous presence of waste in South Africa’s Karoo Heartland is one such incongruity.
Traditionally, The Karoo has conjured images of desolate, pristine landscapes. Over the centuries, it has served as a retreat from the pressures and pathogens of city life.
Yet, the question of waste, and its containment, is now central to the everyday politics of many Karoo towns. Residents use it to bemoan ineffectual municipalities: a few organise drives, clearing litter along the river banks or the national highways. On windy days, plastic is flung against farm fences and cans shoot through the air like bullets. At the dump, slices of plastic, and discarded animal fat are set alight by desert heat. For waste-pickers, litter is livelihood. Some are employed by government’s Community Work Project, patrolling plastic in bright orange overalls. Others are trash-heap hustlers, setting up shack-lands on the outskirts of dumps and gathering recyclables in exchange for cash.
In the desert where I do my research,
animal carcasses rot in dry dams.
There is no water in the taps.
But Coke is sold on every corner,
and if you type Amen and share three times, 2020 will favour you.
In October 2019, I collaborated with Yageshree Moodley (and actuary at Percept) on a presentation entitled Social and Structural Conditions Driving NCDs. The presentation drew on my field research in the Karoo, as well as wider NCD data, and was presented at the Actuarial Society of South Africa's annual convention.
The increase in non-communicable diseases (NCDs) demands a revolution in healthcare. This epidemiological shift is fuelled by social and structural conditions such as food systems, habitats and social engagement practices. Let’s probe this epidemiological shift from both a quantitative and qualitative angle. We offer the perspective of the medical anthropologist, considering qualitative research methods to understand people’s experience of NCDs. We then take the perspective of an actuary, considering the cost and risk of the changing disease burden and how these present in both the public and private healthcare sector.
SALT &
SOOTHiNG
In the small Karoo town where I’ve set up base, every day is a confrontation with the mountain. This is not a mountain gently calling your eyes to the horizon, with valleys waiting to cradle you. Instead, it looks you in the eye, commanding your attention and your reverence. The mountain is always at your chest, or your back, hovering over your head, or swimming in your throat. On one of the mountain’s lower peaks stands a tall crucifix, growing larger as you draw closer to the edges of town. During my first few weeks here, congregations gathered at the foot of the cross to pray for rain. On nearby farms, I had seen wastelands where dams once were. All around the region, farmers dug deeper boreholes, and deeper debt.
When the local pharmacist talks about the weight of chronic illness here, she says, ‘people must return to the mountain.’ With nearly every prescription she dispenses, she recommends tea made from mphepho (helichrysum), harvested from the mountain’s slopes and 'returned to the people'. The pills flowing over her counter are for bloed-druk (high blood pressure), suiker (diabetes), respiratory conditions and chronic pain.
While they may not be technically ‘communicable’, the escalated awareness and diagnoses of NCDs has often felt like a similar ‘contagion’. Many people here are taking three or four chronic medications at once, with the town’s health staff desperately trying to support adherence, manage drug interactions, and cope with stock-outs. In the town’s public clinics, I quickly learn the names of Tramadol (for pain relief) and Tripoline (an anti-depressant), adding to the assortment of pills swallowed daily.
When you ask people about sickness here, some will say it’s the water. Others say it’s the food. There is talk of the dust in the air and the cold in the mountain, the slow nights of fast drinking and the families shook by traumas. Labourers work 12-hour shifts sharing bread and Coke at lunchtime. Financial stress and crippling debt rattle black, white and ‘coloured’ households alike. Businesses offering cash loans or funeral services outnumber grocers. Here, descendants of the KhoiSan, the Trekboers, the 1920 British Settlers and Coba’s amaXhosa live together in embattled, but deeply intimate relationship.
This is a place of great dis-ease, but it is also one of care: Where nurses deliver soup in clinic queues. Where Oom Gert sits patiently every week for the Alcoholics Anonymous meeting, even if no-one else shows. Where recipes for afval (tripe) with apricots are slow-cooked and shared on weekends. Where congregations gather to pray for the sick and the elderly. Where clinicians are also mystics. Where town gossip lays bare each one’s physical, emotional and historical wounds — ready for salt and soothing.
KAROO WRITERS' FESTIVAL
A VIRTUAL READING
Excerpts from the draft manuscript of 'We Were Already Sick' [working title], which tells the recent social history of the Eastern Cape Karoo through stories of health and healing. The presentation forms part of the 2020 Karoo Writers festival.
STATE OF DIS-EASE
It’s 2019 and South Africa’s Citizen newspaper carries a front-page article, declaring it the sickest nation on the planet. Twenty-five years into democracy, the country had come dead last in a global health survey. How could this be?
Thanks to what is now the world's biggest HIV-treatment programme, our AIDS-deaths have plummeted. Life expectancy is in fact higher now than it was in 1994. There is broad consensus that living standards have generally improved, with wider access to clean water, sanitation, housing and electricity. And yet, South Africans find themselves deeply unwell.
Within this story of sickness, I think, is another deeper story about unmet expectations: expectations held about the pace and nature of change. Despite the gains that have been made, most South Africans had much higher hopes for what democracy, and inclusion into global modernity, would mean for their lives. The story of sickness in South Africa is, in many ways, about how the cumulative effects of our past, and the profound uncertainties of our future, land themselves on the body.
The global health survey in which we had faired so poorly calculated ‘wellness’ using ten indices, including blood pressure and blood sugar levels, rates of exercise, alcohol consumption, tobacco-use, depression, obesity, and overall life expectancy. One might say it measured threats to a country’s health – threats that are particularly associated with ‘non-communicable diseases’ (NCDs). Anyone diagnosed with this group of non-infectious conditions will have to manage them for the rest of their lives and they are often degenerative.
Diabetes, heart diseases, lung conditions and cancers are among the globe’s biggest NCD killers. Because their causes are located in how we eat, move, settle and play; our prior sicknesses and our genetic inheritances; NCDs are also a powerful example of how social history encodes in the body.
The story of the NCD epidemic is about conditions of ill-health in which there is no single pathogen or mode of transmission. And yet if we fail to intervene at the right times and in the right ways, the consequences are dire for individuals, households, and the country more broadly. It means early deaths from strokes, heart attacks, and cancers. It means many days off work because of clinic visits or chronic pain. It means diabetics losing their sight or their limbs. It means millions of people with HIV more likely to die because they have developed another chronic ailment. It means immense strain on caregivers and on household finances. And, for a health system that is widely considered to be ‘in crisis’, it means more patients to treat and monitor for the rest of their lives.
KAROO
SANATORIUMS
In the early years of the 20th century, the Karoo had become a popular site for sanatoriums, owing to its climate and ‘fresh air’. Victorians suffering from ‘consumption’ (tuberculosis) travelled to sanatoriums in places like Beaufort West, Cradock and Burgersdorp. It is reported that mentally ill patients sometimes opted for sanatoriums to avoid the stigma of asylums. But the sanatoriums also offered a more general retreat, to rejuvenate mind and body. Today, city dwellers continue to look to the Karoo for this purpose. The Zuurberg Hotel and Sanatorium (Now the Zuurberg Inn) is located off the old main road between Port Elizabeth, Cradock and Somerset East.
About Chronic Countryside
More people today die of long-term, non-infectious illness than contagious epidemics, violence or famine. Non-communicable diseases (NCDs), including cancers, diabetes, cardiovascular and respiratory illness, account for 70% of premature deaths worldwide.[1] It has become increasingly popular for international development agencies to describe the world as undergoing an ‘epidemiological transition’: a progression from an era of infectious pandemics to one of long-term degenerative illnesses — including diabetes, cardiovascular and respiratory conditions, and cancers. In technical terms, these called ‘non-communicable diseases’ (NCDs). Among the public, many still know them as ‘lifestyle diseases.’
In South Africa (and elsewhere on the continent) the experience is much less one of ‘transition’ than collision, as people experience multiple, often long-term illnesses at once: both ‘infectious’ and ‘non-infectious’. NCDs compound, and are complicated by the largest HIV and TB epidemics in the world. And while they may not be technically ‘communicable’, the escalated awareness and diagnoses of NCDs, has in many places ‘spread’ with similar veracity.
Where chronic illness is widespread, fewer people go to the clinic because they are sick and in urgent need of treatment. Instead, the bulk of patients in South Africa’s health facilities are routine visitors, and will be for the rest of their lives. This means fundamental shifts in how we define health and healing, where both sickness and treatment are long-term. Never in human history have we been more dependent on lifelong medicine and monitoring. Nor has medical technology — whether in the form of pills, insulin, blood pressure or blood sugar monitors — ever permeated so deeply into our everyday lives.
Because they stem from how we eat, move, work and play — as well as our genetic inheritance — NCDs are a powerful example of how social history encodes in the body. The global ‘epidemiological transition’ has been associated with a number of relatively-new social phenomena, in which most people not only live longer lives, but live them in cities. Literature on the rising rates of ‘lifestyle diseases’ often explains them as consequences of urban life. Even though moving to the city can improve a person's public health access, city-dwellers are also thought to be more sedentary, more susceptible to stress, more exposed to air pollution, and more likely to consume processed foods, tobacco and alcohol – all of which put them at risk of NCDs.
Yet there is something unexpected happening in South Africa’s Karoo. Despite being a semi-arid, rural part of the country, it has among the nation’s highest rates of hypertension and diabetes (key indicators for a range of NCDs). In some parts of the Karoo, one might explain this away by pointing to an aging population or a broadly unrepresentative demographic; but in the strip of Eastern Cape Karoo I am interested in, rates of NCDs are unusually high despite a race and age demographic that approximates the national picture.
I want to know why. What have we missed about the nature of rural life? What does everyday life look like in a place where NCDs have set in so deeply? As NCDs start to outpace HIV and TB as the country’s leading causes of death, what might we learn about the social condition of our country and our bodies?
Since the publication of Jonny Steinberg’s acclaimed Three Letter Plague, a lot has changed about the nature of health and illness in South Africa: the country now has the largest HIV-treatment programme in the world, and compounding burdens of chronic illness. Statistics have been released and campaigns launched, but we have not had a piece of writing that tells the story of these colliding epidemics through the lives of people grappling with them.
[1] WHO, 21 June 2017, http://www.who.int/en/news-room/fact-sheets/detail/noncommunicable-diseases
Karoo Sanatoriums
Sanatoriums in the Cape Colony, and particularly in the Karoo, were promoted as sites of healing for Victorians suffering from 'consumption'. Europeans with TB were promised refuge and healing in the Cape. In John Noble's 1875 Descriptive Handbook of the Cape Colony, he wrote the following of the healing potential of the Eastern Cape Karoo: 'When the railways are opened, [the invalids can remove] to the coast, or the elevated plateau above Cradock, where chest diseases are scarcely known.' The threat of these imported TB cases, both to colonial settlers, as well as the black, brown and white people already living in South Africa, was not appreciated before 1895. Indeed, the infectiousness of TB had only been discovered in 1884. The story of TB would become definitive in the colonial, racial and industrial history of South Africa.
According to the Arid Areas Research and Development Programme, Nelspoort TB sanatorium gave rise to early questions around health provision and inequality in South Africa. The sanatorium did not attract the numbers of sufferers from Europe it had hoped for. At a 1924 conference on tuberculosis, the then Minister of Health suggested that the sanatorium be made open to provinces beyond the Cape Colony. This was hotly disputed, since taxes in the Cape were significantly higher. A Mr Turpin, from Bedford, called upon small towns to pay half the costs for patients in need of treatment; while others suggested that state subsidy would lead to the sanatorium being overrun by' incurables'.
Today, South Africa is burdened by one of the world's largest and most severe TB epidemics. And its national origins can be located here, in the country's arid interior.
Researching health and illness in South Africa’s Karoo Heartland
In 1966, Mary Douglas famously defined pollution as ‘matter out of place.’ The now ubiquitous presence of waste in South Africa’s Karoo Heartland is one such incongruity. Traditionally, The Karoo has conjured images of desolate, pristine landscapes. Over the
centuries, it has served as a retreat from the pressures and pathogens of city life.
Yet, the question of waste, and its containment, is now central to the everyday politics of many Karoo towns. Residents use it to bemoan ineffectual municipalities: a few organise drives, clearing litter along the river banks or the national highways. On windy days, plastic is flung against farm fences and cans shoot through the air like bullets. At the dump, slices of plastic, and discarded animal fat are set alight by desert heat. For waste-pickers, litter is livelihood. Some are employed by government’s Community Work Project, patrolling plastic in bright orange overalls. Others are trash-heap hustlers, setting up shack-lands on the outskirts of dumps and gathering recyclables in exchange for cash.
As a researcher exploring the rise of so-called ‘non-communicable diseases’ in this area, I became interested in waste as a signal of consumption; and indeed how consumption has shifted in this region. Within a relatively short space of time, the Karoo’s food environment has changed dramatically. Big Food — in the form of Super Spars or Shoprite USaves — only arrived in full force in the 90’s. And without Big Food, Big Tobacco and Big Alcohol; much of the waste here would not exist.
The local markets in which farm owners and workers would sell their produce have all but disintegrated, as farmers export to large metros. In an effort to ‘boost township economies’, Coca-Cola has, since the 1990’s, increasingly supported and stocked local ‘spaza shops’ (informal stores), including in the Karoo’s small towns. Meanwhile, the post-1990-period has also brought new players to the Karoo’s food landscape. Somali, Ethiopian, Pakistani and other ‘foreign’ traders have settled in the region, often opening competing spaza shops, selling cheap (even if highly processed) goods.
In his autobiographical short story, Nietverloren, J.M. Coetzee describes shifts in Karoo food and farm culture during the course of his lifetime. On the farm where Coetzee grew up, he discovered a flat circle of earth, on which nothing grew. The story is an account of his trying to make sense of it. It would take years for Coetzee to discover that it was a threshing floor, on which donkeys had threshed
wheat.
The wheat, it turned out (this was the outcome of a long investigation, and even he could not be sure if what he heard was true), was grown right here, on the farm, on what in the old days must have been cultivated land but has no reverted to bare veld. An acre of land had been given over to the growing of wheat, just as there had been an acre of pumpkin and squash and watermelon and sweetcorn and beans. Every day, from a dam that was just a pile of stones now, farmlands used to irrigate the acres; when the kernels turned brown, they reaped the wheat by hand, with sickles, bound it in sheaves, carted it to the threshing floor, threshed it, then ground it to flour (he searched everywhere for the grinding stones, without success). From the bounty of those two acres the table was stocked not only of his grandfather but all the families who worked for him. There were even cows kept, for milk, and pigs to eat the scraps.
So all those years ago this had been a self-sufficient farm, growing all its needs; and all the other farms in the neighbourhood, this vast, sparsely peopled neighbourhood, were self-sufficient too, more or less — farms where nothing grows any more, where no ploughing or sowing or tilling or reaping or threshing takes place, farms which have turned into vast grazing grounds for sheep, where farmers sit huddled over computers in darkened rooms calculating their profit and loss on sheepswool and lambsflesh.
Older Karoo farmworkers speak of a time when labourers received a food ‘ration’ from the farm: lard, sugar, coffee, some vegetables from the farm’s garden, and some meat or livestock. It was a time in which people both lived on, and off, the farm. ‘Farming used to be a lifestyle’, one farmer’s wife in Cradock told me, ‘Now it’s a business’. I do not mean to romanticise the period of food rations: workers were paid very little in actual wages; histories of dispossession and forced labour were brutally proximate; and relationships between farm owners and farm labourers were often deeply feudal (even if deeply intimate). Aspects of this still continue today. But there have been some very significant changes in the food culture of farms, which reflect larger political and economic changes, and have now worked their ways into people’s bodies.
In most places, there is no longer a ration. Workers are paid in cash. This is partly because of the institution of the minimum wage (only R16 p/h for farm workers), and partly because years of below-average rainfall have made it very difficult to grow or farm in the same ways. Many dams are now wastelands of another sort. In 2019, residents gathered to collect tens of thousands of dead fish
from the empty Nqweba dam in Graaff Reinet: fish turned to waste and poured into trash bags
Although a cash-based wage has given workers greater freedom to choose their food, they must buy it. This means travelling (at a cost) to the nearest informal stall or supermarket — often on a monthly basis — and finding tactics to stretch one’s wages. In this context, more and more are swayed towards highly processed, non-perishable food, which of course has significantly more packaging.
Karoo residents are frequently on the road: as fencers, municipal workers, casual labourers, or ambulance drivers. Because of this, roadside rest stops are not only for tourists on road trips. Amidst the empty bottles, polystyrene containers, and chip packets at the rest stop, I find blister packs for diabetes medication.
Uncontained waste is both a signal of what is moving in and out of people’s bodies; and a potential contaminant in itself.
Using waste, and its politics, as a lens to understanding long-term illness helps to locate people’s experiences of sickness in their particular time and place, while also signalling the shared futures of land and bodies.
