In Search of the "Local"

As most of you are no doubt aware, South Africa is making headlines across the globe these days. This week the world has seen South Africa as a place where xenophobic mobs chase down poor immigrants from other African countries, looting and burning down their houses and shacks, beating and sometimes killing the inhabitants, and leaving thousands displaced (again). On first glance this most recent spate of violence has basically nothing to do with me and my research. I am working in a rural place, two hours from the closest major city, and my research is very local, focused on a state run health center and two South African communities.

In thinking about my next post 10 days ago I was looking forward to writing for the first time about my very own research. At the end of April I finished volunteering at the health center, then spent a week in Durban catching up on some outstanding work, visiting libraries, and generally enjoying the warmer climate. In the second week of May I returned to Pholela ready to begin conducting research. The first part of my field work is to conduct a comprehensive survey in two communities – one that provided the original focus area for the Pholela Community Health Centre and another that is located much farther from the reach of clinics or hospitals. Part of the idea is to bookend the history of Pholela with basically identical household surveys.

In 1942, in their effort to prove that even the poorest members of South African society could receive quality health care, Drs. Sidney and Emily Kark along with the help of trained Zulu Health Assistants conducted a comprehensive survey of 100 households located along the Umkomaas River, across the road from the health centre. The information gathered through these surveys helped to create targeted home-based interventions, which the doctors hoped would help to improve the overall health of entire families and by extension, the community. This baseline data, which was added to every year thereafter until at least the late 1950s, would also help to determine the efficacy of various health interventions.

My plan all along has been to conduct a resurvey of the area trying to find as many of the initial households as possible. The data collected in 2008 would then help to reveal both community and household differences between 1942 and 2008. This data set would then be one of the richest sets of local data available for a rural community in this part of the world. It would allow for a truly in depth understanding of a local context.

However, as I suspect is the case for all dissertation researchers, data collection is never this easy, nor this straightforward. First, there are the rather obvious issues that many people who were alive in 1942 are no longer alive today, especially in a place noted for ill health. And second, those 1942 (and 1944 and 1956, etc.) are no longer in South Africa.

In 1958 working under a government that no longer cared about the health of the African population and facing increasing surveillance, the Karks left South Africa to continue their work in community oriented primary health care. They first traveled to the US, where Sidney started the epidemiology program at UNC and then to Jerusalem where they helped to found the department of community medicine at the Hebrew University. In their decision to leave, and presumably to take much of the Pholela data with them, the Karks took my wonderfully local study and placed it into a global context.

However, when the Karks left South Africa in 1958 it was not the first time that Pholela garnered international attention. Indeed, throughout the late 1940s and 1950s foreign, and in particular American, doctors came to Pholela to gain an understanding of this pioneering model of primary health care and to conduct research with the local populations. They took the lessons they learned back to their home countries, establishing a network of health centers in the United States based on the Pholela model as a part of Lyndon Johnson’s war on poverty, and becoming leaders in global primary health care. Still other young South African doctors who trained at Pholela left South Africa looking for the freedom to pursue careers in social medicine, some of these doctors went on to change the field of epidemiology others became world renowned scientists teaching at some of the world’s best Universities.

In my first two months at the health center none of this history was obvious. Sure, people talk about the Karks and their history, but it is understood in the context of local health improvements and a clinic and government that used to care more for the health of Pholela’s communities.

It was sitting in my little cottage in tiny Bulwer, connecting to the internet via a terribly slow cell phone modem, that I began to piece together this remarkable international history. I was e-mailing anyone I could think of who might have an idea where the 1942 survey results is located, and only one of these people was in South Africa. In that first week that I was back in Pholela, writing the survey, I had academics at Wits, UNC, Harvard, Columbia, CUNY, and the Hebrew University all wracking their brains to think of where those original surveys might be. While I was physically located in Pholela, the “research” I was pursuing was literally all over the world.

I spent my second week back on Pholela working to lay the local foundation for my research. In a rural place like Pholela, one must get the permission and support of the traditional authorities and the local Inkosi (Chief) in order to conduct research. As a result, with the help of colleagues from the health center, I went first to the tribal court for the community that is far from Pholela to ask for permission to conduct research. After some discussion, confusion, and a few questions, the Inkosi and her (the Inkosi for this area is a woman, which is very unusual) headmen gave me permission. The next day, accompanied by a headman who works at the clinic, I went to visit the Inkosi for Pholela to ask for his permission. After some discussion and some very insightful comments, I had permission and a guarantee of protection. Despite my growing network of international contacts, the time spent organizing to meet and then meeting with the local traditional authorities served as an important reminder that mine is a project that in deeply local.

Working with a team of young people from a local NGO and the Community Health Workers from these two communities, we began conducting the survey this past week. Climbing all over the mountains where these communities are located, walking from one homestead to the next, collecting GPS points, and spending an hour plus with each household head to gather basic demographic data and ask questions of health and environment, this research began to feel again like it was extremely local.

However, in the pursuit of the original local data, it became clear that Pholela and the health and nature of the people who live here is not simply local. Rather, this small, out-of-the-way, rural place, is connected to the rest of the world in profound ways. As a result, conducting research in a place like Pholela requires the ability to be in contact with some of the world’s most respected medical thinkers as well as many of its poor inhabitants. What these couple of weeks have shown me, what I have only begun to realize, (and unfortunately what the violence in Jo’burg, Cape Town, and Durban reminds us) is that combining the global and the local is a far more difficult task than it seems. Indeed, the scholarship on this area seems to focus either on the far reaching experiment in social medicine that began in Pholela and spread throughout the world, or on something like hypertension in this population of Zulu speaking people. Combining Pholela community history and ideas with Pholela Community Health Centre history and ideas remains a difficult pursuit.

As I open the Sunday papers I am reminded that Pholela and its surprising history and international links are not unique in South Africa. Indeed, in places far more connected to global capital and human flows, like Johannesburg, the impact of South Africa’s place in the larger continental and global context is being violently felt.