Global Health Travel Blog

UNC Gillings students share their global field experiences around the world.

Category: South Africa

Faculty in South Africa

Blog post by Kurt Ribisl, Professor and Department Chair, Department of Health Behavior

Greetings from South Africa!

I am spending 10 days in South Africa (Johannesburg and Cape Town) and Zambia (Lusaka) to meet our research and practice partners.

My days have been filled with meeting UNC undergraduate students taught by Alex Lightfoot in Cape Town and visiting their internship sites. I gave talks on e-cigarettes and vaping at the University of Witwatersrand and the University of Cape Town. I have also been meeting with researchers doing cutting edge work in HIV and gender-based violence. On Sunday, I fly to Zambia to meet with Dr. Ben Chi (UNC Gillings) and his colleagues at the University of Zambia including the dean of their School of Medicine, Dr. Fastone Goma who leads some exciting CVD and tobacco control work.

Alex Lightfoot and I also met with the leaders of Black Sash, a group started by a white middle-class woman who opposed apartheid in the 1950s. They are still going strong and now advocate for social policies to benefit vulnerable populations in South Africa. We then visited the Red Cross War Memorial Children’s Hospital in Cape Town, which is regarded as South Africa’s leading center for postgraduate specialist pediatric medical and surgical training. We met with a student who shadowed health care providers carrying out trauma surgeries to basic family medicine. She saw 30 burn patients and is the only specialized pediatric burns unit in Africa. Several were burned by hot water and others by cooking oils. She wants to learn more about public health and injury control programs that could prevent these devastating injuries. She saw two very young children were being treated for lipoid pneumonia, a condition brought on from inhaling oils in the home. I immediately thought of the 6 people who have died from vaping over the past 2 weeks, most of whom also had lipoid pneumonia from vaping THC and CBD oils.

Deborah Baron gave me her copy of Trevor Noah’s book, Born a Crime. I can’t recommend this book enough – it provides an insightful look at what it is like to grow up under Apartheid. Alex assigned this to all of her students taking her Apartheid class and we have referred back to it several times.

Just before I left, two events have shaken South Africa. First, there have been numerous xenophobic attacks against foreigners and their businesses. Many people are being forced to flee back to their home countries.

I met with Dr. Mutale from the University of Zambia the day before I left Chapel Hill and he mentioned that they had to repatriate all of their students from South Africa. Refugees filled the Scalabrini Centre on my visit there. Volunteers were creating resumes for them, helping them find jobs and fill out asylum paperwork. I watched a room full of migrants taking online courses at the University of Southern New Hampshire to earn their AA degree. One woman lost her livelihood when looters torched her business. Like others in our group, I bought one of her remaining 15 handmade bags to help her raise funds to start over. We were also saddened to hear of an African migrant whose asylum was rejected by a panel of 3 white male judges ‘because she had not been raped enough times.” Scalabrini workers are doing all they can to advocate for migrants during these tough times.
Finally, Uyinene Mrwetyana, a Univerity of Cape Town student was raped and murdered at a Post Office. Crowds of protestors are speaking out against gender-based violence. You can see images I have seen all over campus and town. I am so proud that many of our faculty also work in addressing gender-based violence. Like most of public health, this trip is exhausting and totally inspiring. I look forward to forging stronger ties with our colleagues and partners here in Southern Africa.

Warm regards,
Kurt

Equity as a Public Health Priority

“Is cervical cancer a big problem in South Africa?” This is a question I get, in some form or another, from many people back home when I tell them about the project I’m working on in Johannesburg.

The short answer? Yes.

Urban hiking in the Melville Koppies

The long answer? Yes, cervical cancer is a major public health issue in South Africa and many other African countries. UNAIDS estimates that women living in Eastern and Southern Africa are 10 times more likely to die of cervical cancer than women living in Europe. Within South Africa, Black women are almost twice as likely to be diagnosed with cervical cancer compared to White women.

Over 90% of cervical cancers are preventable, and the UNC-Wits-Right to Care team is working to increase access to prevention services in South Africa. Routine vaccination against HPV, the cause of most cervical cancers, did not begin in South Africa until 2014. And, although cervical cancer screening is free, only a third of South African women receive screening at the recommended intervals.

Rendani modeling her Right to Care jacket

In our classes, we learn about criteria used by governments, organizations, and funders to determine public health priorities: the number of people affected, the magnitude of a disparity, the evidence in favor of intervention, the cost (in dollars, years of life lost…) of action or inaction. By any measure, cervical cancer is indeed a public health problem, and these statistics are important–they tell the story of a disease that is almost entirely preventable, yet continues to kill hundreds of thousands of women every year.

At the same time, I have been thinking about how we frame public health problems, and what larger dynamics these measures can obscure. Cervical cancer is a disease of inequities, and confronting the social conditions that give rise to unequal health outcomes (in the words of Link and Phelan, their fundamental cause) must also be part of addressing this problem.

Public health is not immune from reproducing the patterns of inequity that we seek to solve. As a student, I have concentrated on gender and other social inequities as they impact women’s reproductive health. These dynamics are also reflected in gender inequality in the global health workforce and geopolitical inequalities that influence public health priorities. If the goal of global public health is “real partnership, a pooling of experience and knowledge, and a two-way flow between developed and developing countries,” we have a long way to go until this vision becomes a reality.

Recently, leaders at the National Institutes of Health pledged to take steps to end the “manel”– all-male speakers panels–and increase diversity in global health leadership. In his statement, Dr. Collins, Director of the NIH (and UNC School of Medicine grad), writes, “it is not enough to give lip service to equality; leaders must demonstrate their commitment through their actions.”

Shadow Boxing by Marco Cianfanelli in the Joburg CBD

It is an incredible privilege to be in South Africa doing work that I find important, challenging, and fulfilling. I feel very lucky to be completing my practicum with UNC-Wits-Right to Care and learning from a team that truly demonstrates this commitment to promoting equality–from increasing access to Pap smears to building partnerships and creating opportunities in global health.

Krista

Preventing Cervical Cancer in South Africa

My practicum is with the UNC Global Women’s Health Division, specifically the UNC-Wits-Right to Care Partnership for Cervical Cancer Prevention in Johannesburg, South Africa (SA). In SA, cervical cancer is the leading cause of cancer death among women. Although cervical cancer is largely preventable through HPV vaccination, routine screening, and treatment of cervical precancer, there are significant disparities in access to these life-saving prevention strategies within and between countries. Currently, approximately 90% of cervical cancer mortality occurs in low- and middle-income countries. While SA is considered an upper-middle income country, it is also one of the most unequal societies in the world.

Overall, health outcomes in SA remain poor relative to the country’s economic development, and cervical cancer disparities by race and socioeconomic status are stark. According to the recently published SA Demographic and Health Survey, approximately 78% of White women in SA have had at least one Pap smear (to screen for cervical cancer and precancer) compared to just 32% of Black women. Not surprisingly, Black women in SA are also more likely to be diagnosed with cervical cancer. In 2014 the cervical cancer age standardized incidence rate (ASIR) in SA was about 27 per 100,000 Black women compared to 10 per 100,000 Asian women (the group with the lowest ASIR).

Staff at the cervical cancer team meeting
Top row (from left): Kopano Kgopa, Tafadzwa Pasipamire, Dr. Masangu Mulongo, Krista Scheffey, Patricia Mofokeng, Boikie Mohamme
Bottom row (from left): Bawinile Njoko, Sophie Williams, Rendani Nenzhelele, Ntombiyenkosi Rakhombe

The UNC-Wits-Right to Care team is working to reduce disparities in cervical cancer morbidity and mortality by providing free Pap smears and precancer treatment to thousands of women in SA. I’ve joined an amazing team of clinicians and researchers who have been extremely generous with their time and expertise as I get up to speed (and ask a million questions). Over the last few weeks I have been shadowing in clinic to better understand how the program operates and how clinicians educate and counsel patients. My main project this summer will be creating and updating patient communication materials to raise awareness and convey key educational messages about cervical cancer prevention with the goal of improving Pap smear screening coverage in program sites.

Observing Boikie and Bawinile at work on the mobile van in Diepsloot.

In addition to my time in the clinic, I’ve also been exploring Johannesburg and continuing to learn about SA’s history. This country provides a vivid example of the way that social factors, particularly historical and contemporary patterns of oppression, impact population health. While I’ve been doing a lot of reading, the opportunity to live and work in this city is a daily reminder that reality is much more complex than can be captured in journal articles. When I’m feeling guilty about spending time at one of Johannesburg’s downtown markets instead of working on my master’s paper (which I am also planning to write while I am here), I remind myself that closing the data visualizer, leaving the office, and taking time to learn first-hand about the community with which I’m working is also a critical part of public health practice.

Johannesburg from above. The Carlton Centre is the tallest office building on the continent and its observation deck is known as the “Top of Africa.”

I feel very lucky to be a part of a team that is doing such important work here in Johannesburg. Stay tuned for more journal articles, statistics, and photos in my next update. (To tide you over, here’s bonus reading: while cervical cancer is much less common in the United States compared to SA, disparities by race persist.)

Inside the Constitutional Court of South Africa.

– Krista