Carletonville: Working together for health
A small town on the West Rand,
Carletonville is dominated by the gold mines. It is home to 70,000
miners and 250,000 people who live in the township of Khutsong and the
informal settlements that surround the mines. The choice of this site
for the Epidemiology Research Unit’s three-year project, which is
concentrating on reducing sexually transmitted disease (including HIV),
was strongly influenced by the presence of a grassroots pressure group,
the Carletonville Aids Action group. Made up of nurses, social workers,
trade unionists, local politicians, local health-service providers,
traditional healers and religious leaders, the group had been trying
for three years to get an Aids project off the ground.
The action group joined the committee overseeing the ERU project,
along with representatives of three mining houses, national and
provincial health departments, the miners’ union and the South African
Institute of Medical Research. Each group had its own problems that had
to be addressed and resolved at the outset. The mining houses were
sensitive about being blamed for all the problems of the country and
were initially very defensive. The union was suspicious of management
and needed reassurance about the way the project would be conducted and
who would have access to the results. The health-service providers were
worried that once the project was over they would have to sustain it,
and they were afraid of raising expectations that could not be
fulfilled. The community leaders were desperate for the project to
start, but wanted assurances that they would be actively involved and
fully informed at all stages.
It took nearly a year of meetings and discussions to resolve all the
issues. Finally, a detailed plan of action was agreed on and approved
by the ethics committee of the University of the Witwatersrand. The
British government, through the Department for International
Development, agreed to provide R5 million to fund it for three years,
and further financial support was promised by the provincial department
of health and support in kind by the other major stakeholders.
The project started in January and is concerned both with the
development of effective interventions and with evaluation of their
impact. The intervention side has two arms — management of sexually
transmitted disease, and community-based education and condom
distribution. Medical staff are taught to treat patients with suspected
STDs immediately on the basis of their symptoms alone, rather than
sending off swabs for laboratory testing and hoping the patient will
return a week later for results and treatment. Local doctors, including
GPs, staff in the mining clinics and traditional healers, are given a
week’s training course in the use of a specially developed STD symptom
chart that indicates the most likely diagnosis. If it seems highly
likely that a patient has gonorrhoea and possibly chlamydia as well, he
or she will be treated for both. The drugs are safe, so there is no
risk of over-treatment.
The other arm of intervention is education. Both miners and commercial
sex workers living in the informal settlements around the mines are
being trained to educate their communities about the symptoms of STDs,
the threat of HIV and the need for safe sex. They act out brief,
role-playing exercises in bars and other gathering places, start
discussions and distribute condoms. They are paid a small honorarium
for their work, and the women, in particular, have set about their task
with a proselytising zeal.
The job of the ERU is to evaluate the impact of this work. We have
just completed a baseline survey of 2,000 people from both the mines
and the general community. Using a question-naire translated into five
languages, we elicited information about sexual networking, numbers of
sexual partners and their ages, use of condoms, as well as more general
socio-economic questions. At the same time, a nurse took a blood sample
from each respondent. This was then tested for syphilis, gonorrhoea and
chlamydia. If a person had any of these diseases, he or she was
informed and referred for treatment to either the mine or provincial
health services. The blood was also tested for HIV, but respondents
were told at the outset that the result of this test would not be given
to them. If they wanted to know their HIV status the people running the
intervention would refer them to other clinics where they could be
counselled.
The survey will be repeated next year and the year after. The data
will be supplemented with information from in-depth interviews and
focus group discussions. Interviews with doctors, nurses and
traditional healers, exit interviews with patients and partner
notification slips will be used to assess the STD treatment services.
The management of the project will also be monitored, paying particular
attention to the contribution of the stakeholders — including mine
management, the trade unions, national and provincial departments of
health and grassroots community organisations.
We have learned many lessons in the course of launching the project:
the importance of social and biomedical scientists working closely
together on practical intervention and the need for careful evaluation
if we are to use our experience in Carletonville to design and
implement similar projects elsewhere. Furthermore, while the active
participation of the local community is essential, they could not do it
on their own. For three years they had been trying to put together a
programme but lacked the scientific support and necessary contacts with
experts in the field.
We also learned the importance of ensuring that all stakeholders are
fully committed to the project. Although this probably delayed its
start by up to a year, it would almost certainly have foundered if we
had not taken the time to address all their concerns. The name of the
project is Mothusimpilo — working together for health. We hope it will
become a model for other projects throughout South Africa, so that the
tide of the HIV epidemic may finally turn.