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Geographic Area

The sites and the node

The Gauteng Research Triangle proposes a dispersed node comprising two main sites – Hillbrow (50 000 in the selected Small Area Layers – see maps), Atteridgeville (30 000 within selected SALs), and near to Atteridgeville is Melusi (20 000), a slowly formalising informal area. The selected Small Area Layers from Stats SA form a single contiguous space for each site; the three sites together comprise the node.

These three sites taken together offer SAPRIN a remarkable range of urban form and socio-economic status, providing a richer, more nuanced and more accurate representation of urban Gauteng than any single site. All three sites are already working extremely closely with the academic partners in this proposal, and SAPRIN access – dealt with below – can take advantage of decades of work in these three communities.

We guarantee single-point accountability, strong management integrating all three universities in the ‘Gauteng research triangle’, and complete integration of systems and data.

This complementary set of sites which  comprise ‘the node’ meet the population threshold of 100 000, according to GeoTerraImage (GTI) population estimates updating Census 2011 to 2018 for the SALs. Importantly, all sites are very strongly associated with our presence on the ground in health outreach, testing, clinic services and hospital links, extension services, and on-going community research. This is true of all three partners in the ‘Triangle’ and all three sites in the proposed node. Existing relationships and partnerships with the communities in the proposed sites, particularly around health interventions, are strongly evident; so are other community relations and research projects (into urbanism, migration, poverty, sex workers, substance abuse and so on), and we believe our long-standing community relationships, combined with the different urban forms covered by these sites (rather than one single site), will add substantial value to SAPRIN.

In part, this dispersed approach reflects our desire to include a range of different urban forms, rather than locate the HDSS in one, so as to provide a greater richness of analysis and understanding of the relationship between urbanism and health outcomes. The complexities of Gauteng’s urbanisation patterns demand sensitive treatment. At another level, we are also seeking to learn from African urban experience, such as in Nairobi, where the HDSS is moving from two slum sites to multiple smaller sites in many slums, in order to gain greater policy purchase and to limit ‘capture’ by gate-keepers (interview with Dr. Catherine Kyobutungi). We have not tried to propose the 10+ sites Nairobi is planning, but we do believe that the intervention should take account of at least some of the complexity of the urban form in Gauteng.

The Gauteng fieldwork challenge: access

SAPRIN understands that the key challenge for fieldwork in Gauteng is access, and we address it up front. Gauteng is the most densely populated province in South Africa, and most densification is racialised (see attached maps), also ethnicised – and wary. Regular outbreaks of xenophobic violence mean that migrant communities (including internal migrants such as those from Limpopo) are extremely cautious. The consistently high levels of crime have the same effect on the entire population. Our focus is on poorer communities – but the problem of access in Gauteng is ubiquitous.

This will be true for everyone responding to the call for applications. In the recently-completed 2019/20 Census pre-test, Gauteng had the highest refusal to respond rate in South Africa, at 29%. Some of this was ameliorated by self-completed and uploaded census tests (which we return to below), but most remained inaccessible. (Criminal acts against fieldworkers carrying CAPI devices, however, is consistently low, both for state and private sector fieldwork agencies, suggesting that the limitations of CAPI as an item to re-use or sell have been noted.) Sample surveys carried out by every agency in the country have consistently yielded higher refusal rates in Gauteng than anywhere else.

Moreover, 2021 will see both the local government elections (currently set for August 2021) and the national Population Census (set for October 2021). These will both serve to intensify challenges of access, with the Census in particular making respondents anxious about their data being ‘given’ to government.[1]

We believe that for the SAPRIN protocol to succeed, the issue of access should be made explicit because we all need to find ways of dealing with it, rather than by-passing the problem by staying with communities we know we can access, regardless of their socio-economic status, demographic profile or urban form. Our proposal tackles the issue head-on. Hillbrow, for example, is extremely difficult to penetrate – but our partners in the Wits Reproductive Health and HIV Institute (WRHI), with their existing community links and structures and volunteers, clinic services and the like, give us the best possible chance of accessing this particular community – and the rich data it will yield will be worth the effort.

The population living in inner cities across South Africa make major economic and cultural contributions to the country, have complex demographic characteristics and health needs, and yet are often neglected in health and other forms of research in the country. In many ways, the health and well-being of inner city population benchmarks the health and wellbeing of a nation. As in many inner city areas worldwide, these populations in South Africa face amongst the highest levels of crime, road traffic injuries, substance abuse, air pollution exposure and litter in the country.

Moreover, through ‘urban heat island’ effects, the inner city is especially vulnerable to the rising temperatures associated with climate change, and has high rates of mortality and morbidity during heat waves. The photograph below shows the WRHI offices, clinic and associated laboratories in the Hillbrow Health Precinct, where precisely this kind of research is occurring – but often without the ability to return repeatedly to the same respondents (especially when donor-funded, ‘once-off’ projects). Our multidisciplinary approach to this proposal ensures that climate change scientists will form part of the team, helping model the relationship between heat and disease (for example) now and into the future.

Using Hillbrow as perhaps the most extreme example of access challenges, it is worth noting that WRHI outreach activities are all underscored by strong relations with gatekeepers in the community, including at the apartment block owners and ‘managers’. This is necessary because we have a large contact tracing team who make visits to homes of people or to the contacts they have named. This is precisely the kinds of relationships SAPRIN needs to see in situ – interviews or contact tracing within the surveillance node will simply be an extension of existing activities, and done by staff already familiar with these areas and many of its inhabitants. The relationships the field workers have developed with the gatekeepers in apartment blocks, the use of local community members as staff and the appreciation that the community feels due to the services we deliver, provides a degree of security for our staff.

The same is true in the informal area of Melusi and the Atteridgeville SALs we have selected, where the UP Department of Family Medicine and their links with the Steve Biko Academic Hospital will be critical. The development of Community Oriented primary Care (COPC) by UP Family Medicine had a significant impact on the education of students in the Health Sciences and other faculties at UP. Medical students rotate in the community sites from the first to the 6th year in LCAS (Longitudinal Community Attachment for Students) and students from other faculties engage with these communities and services through the UP Community Engagement Programme that involves thousands of students. The same will happen in the SAPRIN node. Built on the existing community engagement of UP COPC Research Unit, community engagement will be an integral part of the SAPRIN node. Community Health Workers are by design recruited from the same community that is served. This means that those working in projects and the service already represent the experiences and views of the community.

Our bid therefore takes on the challenge of access up front, rather than by-passing it, because ‘hard to reach’ places such as Hillbrow or informal settlements are key for SAPRIN to get accurate data on migration and highly dense inner city populations; Atteridgeville, for dense but stratified established township communities; and Melusi for both in-migration and household expansion (from formal to informal) in informal communities. If in future new sites are added in Gauteng – such as the project site in Chiawelo, Soweto, for example, with whom we have good fraternal relations – these will still have to deal with access challenges.

[1] The lead investigator is also chairperson of the South African Statistics Council, and these comments are from Stats SA field teams reporting back on the pre-test.