Debating Ideas is a new section that aims to reflect the values and editorial ethos of the African Arguments book series, publishing engaged, often radical, scholarship, original and activist writing from within the African continent and beyond. It will offer debates and engagements, contexts and controversies, and reviews and responses flowing from the African Arguments books.
As an anthropologist I have studied the history of the HIV/AIDS in a village of Bushbuckridge in the South African lowveld, over the past three decades. The results of my fieldwork appear in AIDS in the Shadow of Biomedicine: inside South Africa's epidemic (Niehaus 2018). In the monograph I observe that for the most part, the pandemic is not experienced in the setting of the clinic, but in the village and at home. For this reason, an understanding of social relations, cultural practices, and symbolic meanings that prevail in these settings is vital for understanding and devising appropriate interventions. I explored the connections between beliefs in the pollution of death and AIDS stigma; and between modes of allocating blame such as witchcraft and conspiracy theories about AIDS. I argued that beliefs in the destructive power of certain words might explain the silence about AIDS. At the same time, local models of kinship have informed care for the sick and have facilitated the fostering of AIDS orphans. These examples suggest that a one-size-fits-all response to the pandemic by government and the biomedical fraternity, that ignores the particularities of local situations, might be counter-productive and alienate those they set out to help.
On 14 March this year, whilst teaching at Brunel University London, I developed the symptoms of Covid-19. I experienced high fever, intense fatigue, a continuous dry cough, and difficult breathing. On medical advice, I self-isolated for two-weeks, having colleagues deliver my groceries at the door. Fortunately, my symptoms were relatively mild, and my condition rapidly improved. Only now, after grading numerous scripts online, is it possible to think reflectively about the possible and potential impacts of the Covid-19 virus in South Africa. My emotional and intellectual concerns are interwoven. My parents, who reside in a comfortable retirement village on the outskirts of Cape Town, are most vulnerable to serious sickness. My brothers, a criminal lawyer and civil engineer, who live in suburbs of the same city, are liable to lose a few months' income. But, having access to excellent medical facilities, their situation resembles that of middle-class residents in London. The prospects of my host family and friends in Bushbuckridge are more uncertain.
An obvious difference between the time of AIDS, and that of Covid-19, lies in national political leadership. At the height of the AIDS pandemic, South Africa's presidents, Thabo Mbeki (1999-2008) and Jacob Zuma (2009-18) entertained dubious relations to medical science. Mbeki denied any link between HIV and AIDS and refused to make antiretroviral drugs available through the public health care system. Zuma, during his infamous rape trial, admitted to having had consensual sexual intercourse with his accuser. He knew that she was HIV-positive, but did not use a condom, and he stated that he took a shower afterwards to reduce the risk of infection. By contrast, the policies of South Africa's incumbent President Cyril Ramaphosa during the Covid-19 crisis are thoroughly informed by medical science. Ramaphosa enforced a strict lockdown at the very start of the epidemic - prohibiting people from leaving home, except for essential trips. Moreover, his government organised 67 mobile testing units, and aim to test 30,000 people each day.
Experiences in the United States underline the urgency of these interventions. In the beginning of the pandemic, the most vulnerable were members of the cosmopolitan middle-class. But as the pandemic matured, African Americans became disproportionately affected. They currently comprise around 70% of those who died from Covid-19 related sicknesses in Chicago, Milwaukee, New Orleans and Detroit. This indicates not only unequal access to appropriate health care facilities, but also a higher prevalence of pre-existing conditions such as diabetes, hypertension, obesity and asthma (Evelyn 2020). Similar conditions prevail in South Africa, where low government spending on health has generated critical shortages of medical facilities and personnel (Hull 2017: 86-8). The recommended norm for rural district hospitals is one doctor to ten beds. However, Tintswalo Hospital in Bushbuckridge, a 423-bed facility, has a complement of only 14 full-time medical doctors (Versteeg et al. 2013). Also, South Africa has witnessed a rising tide of diabetes. Current estimates are that 3.5 million citizens (6% of the country's population) suffer from this condition, and another 5 million from pre-diabetes (where insulin resistance causes blood glucose levels to be higher than normal) (Pfeiffer et al. 2018).
At the height of the HIV/AIDS pandemic, the urban-based Treatment Action Campaign (TAC) led opposition to the government's underwhelming response by calling for the distribution of antiretroviral drugs. Resistance to the Ramaphosa government's overwhelming response to Covid-19 seems more likely to be diffuse. Citizens have complained about over-zealous attempts by police and the military to enforce the lockdown and social distancing. Soldiers have beaten some transgressors and forced others to do exercises in the township streets. Police have arrested a man who claimed on video that testing kits are contaminated by the virus, and a bride, groom and their guests who attempted to celebrate a wedding in KwaZulu-Natal. The unfortunate couple spent their honeymoon in jail. Police have also used pump guns to disperse shoppers and have been alleged to have killed at least three wrongdoers. Citizens have also complained about the prohibition on jogging and sales of alcohol and cigarettes. Reports have emerged of regular drinkers robbing and looting liquor stores.
My impression in Bushbuckridge is that frictions are unlikely to arise from a clash between biomedical and popular understandings of sickness. In Bushbuckridge there are well-established non-biomedical notions of infection. Corpses, bereaved families, widows, pregnant women, and women who had recently aborted were deemed to be in a state of polluting heat (fisa). It was essential for those contaminated by heat to be isolated, abstain from sexual intercourse, cease working in the fields, and refrain from touching young children. Contact and intimacy with them could generate different afflictions - marked by convulsions, severe chest pains, a shortness of breath, profuse coughing and internal bleeding (Niehaus 2018: 16-17). These beliefs are commensurate with the biomedical aetiologies of Covid-19, and to a lesser extent also of HIV/AIDS. However, in the case of Covid-19, death is not perceived as an inevitable outcome of infection, as had been the case in the early stages of the HIV/AIDS pandemic. This lessens the possibility of stigma that stems from the portrayal of those infected as 'dead before dying', and people's reluctance to undergo testing (Niehaus 2018: 27-46, 66-86).
Conventional modes of sociability might well constitute a more formidable obstacle to compliance with the lockdown and social distancing. In Bushbuckridge - as indeed in Italy where infections grew rapidly (Dowd et al. 2020) - multi-generational household are normative. People generally have their own bedrooms, but share bathing and toilet facilities, and watch television communally. Many adults participate in childminding. It is imperative to leave the home several times each day. Broader kinship networks stretch across different households in the same residential area, and there are constant flows of people and resources. Likewise, people are compelled to fetch water, collect social welfare payments and to shop. In the absence of on-site taps, women fill 25 litre water containers, which they load on wheelbarrows, at communal taps. Households have little savings, and usually live from salary/welfare cheque, to salary/welfare cheque. This means that the grocery shopping is done at month-ends, when large crowds congregate at supermarkets. Sociality centres on attending church, participating in rituals, and drinking with friends in taverns. From telephone conversations, I learned that the local police still allow funerals, but prohibit more than a hundred people from attending, and urge mourners to remain at least one metre apart. These measures seem almost impossible to enforce. Social media use is widespread but is no alternative to social intimacy. Younger people generally use their smartphones and send WhatsApp messages to arrange face to face encounters. Whilst drinking taverns that sell bottled beer have closed and remain closed, I am told that sales of home-brewed beer have escalated.
But financial concerns represent the most formidable challenge to an effective Covid-19 lockdown. In 2020, the country is under far greater financial strain than it was during the start of the HIV/AIDS pandemic. The South African economy is currently in the grips of a recession - with spiralling debt, low business confidence, a weak currency, and high levels of joblessness. In 2019, Statistics South Africa calculated a national unemployment rate of 29% (and 36% among people between the ages of 29 and 34). The South African Reserve Bank estimates that as a result of the lockdown the economy might shrink by another 2-4%, 1,600 businesses may go insolvent, and another 370,000 jobs may be lost. Closed businesses and temporarily laid off employees can apply to the Unemployment Insurance Fund (UIF) to pay part of their salary. Under these conditions, the government may well face an unenviable choice, in deciding to extend the lockdown.
To date, my host family in Bushbuckridge have abided by all restrictions of the lockdown. But they have incurred great cost: their only wage earner has temporarily been laid off, and they are unable to operate their informal tiling and roofing business. But they fear that exposure to Covid-19 might be even more devastating. Previously, the victims of AIDS were members of the wage-earning generation. Now, those most vulnerable to death from Covid-19 are the aged. In this era of de-industrialisation, the family's most reliable income is the old-aged pension of their mother and grandmother. As a widow, she is also their most dependable childminder, who cares for four young grandchildren each day. Fortunately, the impact of Covid-19 has not approached that of the HIV/AIDS pandemic. Nationally, the South African rate of infections has drastically declined, and to date there has not been a single known Covid-19 infection in Bushbuckridge.
Dowd, J., Rotondi, V., Andriano, L., Brazel, D., Block, P., Ding, X. Liu, Y. and Mills, M., 2020, 'Demographic science aids in understanding the spread and fatality rates of COVID-19', Demographic Science COVID-19, 15 March, available at: https://osf.io/se6wy/, accessed 10 April 2020.
Hull, E., 2017, Contingent Citizens: Professional Aspirations in a South African Hospital, London: Bloomsbury.
Niehaus, I., 2018, AIDS in the Shadow of Biomedicine: Inside the South Africa's Epidemic, London: Zed Books.
Pheiffer, C., Pillay-van Wyk, V., Joubert,J., Levitt, N., Nglazi, M. and Bradshaw, D., 2018, 'The prevalence of type 2 diabetes in South Africa: a systematic review protocol', BJM Open 8 (8): 14.
Versteeg, M. et al., 2013, 'No improvement in Tintswalo hospital prompts open letter to Mpumalanga Department of Health', SANGONet, 29 August.
Isak Niehaus is a senior lecturer in anthropology at Brunel University London, where he currently co-ordinates the MSC programme in Medical Anthropology. He has previously held teaching positions at the Universities of the Witwatersrand and Pretoria in South Africa, and lectured at several other universities in Europe and the United States. His books include AIDS in the Shadow of Biomedicine: inside South Africa’s epidemic (2018), Witchcraft and a Life in the New South Africa (2012) and Witchcraft, Power and Politics (co-authored with Eliazaar Mohlala and Kally Shokaneo, 2001).