South Africa was under apartheid less than 20 years ago.  While 20 years may seem like ancient history to Dartmouth students, it means almost every adult in the country has some memory of that era.  Considering the state of urban segregation in the USA almost 150 years after our Civil War, the implications of South Africa’s very recent political reforms are clear.  For a month last spring, I lived in the town of Plettenberg Bay on the Western Cape of South Africa.  If you never left the town center, Plettenberg Bay would appear similar to many other beautiful beach towns, equipped with fancy restaurants, surf shops, hotels, and million-dollar vacation homes.  But just a 5-minute jog from the city center, I reached thousands and thousands of hand built, wood and tin shacks with no running water.  These two communities inhabited different economic worlds, and they were almost entirely segregated by race as well; blacks and coloreds lived in the “townships,” while foreigners and white South Africans lived in the urban center and along the coast

Now consider HIV and AIDS.  In 2008, the World Health Organization estimated that between 15.4% and 20.9% of the population of South Africa had HIV.  Almost a fifth of the population had a disease with no cure and no vaccine, and the government only started national antiretroviral drug distribution six years ago.  Consequently, much of the population still does not get the treatment they need.

HIV/AIDS is an extremely socially situated disease; stigma, misunderstanding, poverty, and other diseases exacerbate it. I worked for a month with an organization called Plett Aid, which provides home-based care to the townships in the region and helps coordinate the government’s HIV/AIDS response.  I would go out in the mornings with one of the home-based care workers, Margaret, and visit patients around the community.  One of the most powerful aspects of home-based care is that it trains people to care for other people. Margaret was an effective caregiver in Kwanokuthula, the township she lived in, because she spoke the languages necessary (English, Xhosa, and Afrikaans) and cared deeply about her community. We would make sure patients were taking their antiretroviral drugs, check blood pressure, check glucose levels, change bandages, and make sure everyone knew how to take his or her medications. Margaret also was a friend to many of her patients.  Before Margaret measured blood and glucose levels, patients usually invited her in, offered her a drink, and chatted with her.  While HIV/AIDS was a focus, caretakers were responsible for taking care of any other mental or physical problems the patient was experiencing.

The stigma surrounding HIV is enormous. Many patients never tell their families or friends, so their care worker may be the only person who knows their “positive” status.  Since Plett Aid provides chronic healthcare to everyone (even old ladies who get bitten by dogs), neighbors who see care workers walking into a home don’t necessarily think, “he or she must have AIDS.”   These patients were not easy to classify due to a lot of overlap among different conditions. One woman we visited was getting treatment for tuberculosis, and as we were leaving, Margaret told me she probably was suffering from AIDS as well, but had not been tested.

For a moment, it is worth considering what care looks like in the region around Plettenberg Bay without home-based care.  There is a clinic in each of the townships, each of which is generally open to everyone, but all of which are crowded.  More importantly though, the clinic in a township like Kwanokuthula may be up to a mile away from patients toward the edges of town.  The people who need to walk that mile are the sick or the hurt ones: patients with AIDS, TB, or who are severely injured.  I saw very few cars parked outside houses, and the ambulance (which you have to pay for) will take you only to the nearest hospital about 30 minutes away.  All of these factors add up and create a serious barrier to care for a large portion of the population, whether in terms of cost, distance, or time.  By comparison, home-based care is a service that bridges these barriers.  A 2009 study in Uganda compared clinic-based care with home-based care.  It found that home-based care significantly lowered the access cost for users and slightly reduced operating costs.  Operating costs are relatively unaffected because the cost of drugs stays large and stays the same between the two delivery systems.  So on an economic level, as well as a personal level, home-based care is a powerful healthcare delivery system.

However, home-based care service was not the standard health care system in Plettenberg Bay.  Plettenberg Bay is located in Western Cape province, one of the first and best provinces for antiretroviral treatment. Yet even within the Western Cape province, the poorer communities (such as the townships surrounding Plettenberg Bay), still depend on state-funded public health solutions like clinics and home-based care. The provincial or national government funds much of the home-based care, although Plett Aid supplements that funding with grants and fundraising efforts.  In contrast, the residents of wealthier communities stick with private medical care and are less affected by changes in public health care.  Overall, I found home-based care to be a compassionate and effective way to provide quality public health care in resource-limited settings, especially to patients infected with HIV or suffering from AIDS.