Soweto

Soweto is a township near Johannesburg, famous for its former residents Nelson Mandela and Desmond Tutu, and for being a hotbed of opposition to apartheid. The 1976 student uprising was centered in Soweto, and it has seen many moments of fame, shame, and sadness.

I had seen photos, newsreel, and movies set in Soweto, so I was not surprised to see the living conditions in some of the areas -- tin shacks, on tiny plots of land, no running water, electricity, or paved roads, lots of flies and garbage about. Chickens and cats walked around with no apparent restraints. Near the entrance to the neighborhood we visited (whose name I cannot begin to pronounce or reproduce) was an elementary school. We chatted with the proprietor, who told us that 30 children attend from 8am until 6:30pm every weekday. She gets donations from parents, but no real funding for the school, and we speculated that whatever money she earns comes from the group of men who were drinking inside an adjacent small building. The school itself was one room, and was about 1/2 the space of the room of Henry's classroom (which has half the kids).

There are porta-potties scattered about, as well as occasional fountains where running water can be found. As we walked around (and "we" were two black Africans and two white Americans") we were followed by kids. The kids were periodically shooed away by our guide, who knew that any coins we might give the kids might diminish what he would receive.

Soweto (which actually comes from Southwestern Township, the same way that Tribeca comes from Triangle Below Canal Street) is more diverse than I had known. Immediately adjacent to the neighborhood that we visited there is a modern paved road, with street lights, signs, and the occasional store or gas station. Moving along we saw neighborhoods with houses that are more durable -- brick, wood, or stone. These, I was told, also did not have indoor plumbing. Further on, we visited the Mandela's old house and Winnie Mandela's current house (in Orlando West, or "the Beverly Hills of Soweto"), where both electricity and running water are the norm.

In Orlando West, as with every other moderately wealthy neighborhood that I saw in Johannesburg or Cape Town, the houses were protected by fences and gates. They had driveways and garages, but these were also inside the gates.

We went also to Regina Mundi Catholic church, the scene of some of the terrible violence and most impressive resistance of the apartheid era. In those days, it was illegal for more than two people to "gather" (even to talk on a street corner), but religious gathering were excepted from this policy. So when, inevitably, the churches were used for organizing purposes, the police responded by raiding, and occasionally shooting at the people. They still have bullet holes in parts of the church.

The government is slowly building new housing to replace the shacks, but even this has opposition -- people don't want to move out of their places in order for the building to occur, so the government has to evict each person.

I've seen unemployment estimates in Soweto from 30-70%. The range doesn't surprise me, as the official population is about 1.5 million -- but residents say that 3-4 million people live there.

Observations of South Africa

Here are a few general observations from my first time visiting this country.

Today is Freedom Day, the 12th Anniversary of the official end of apartheid. This is still an incredibly segregated society, and it is segregated in nearly every meaningful way: geographic, economic, education, dress, accent, and language. Of course, segregation is not an official policy, but the inertia from apartheid is very strong.

A white woman in Cape Town (who works at a Pop Council-sponsored clinic) told me she is very concerned over the crime rates here. I looked the statistics, and it is sobering: while murders have been stable over the past decade (even slightly down), assaults, rapes, and robberies have increased significantly. Interestingly, attempted murder is up, even as murder is a bit down. Some people here are skeptical about the quality of the statistical reporting, so this may explain some of this.

While there is strong criticism of the government, including the president and health minister, from many quarters, there is near-universal praise for the finance operation here. The economy is growing, and expanding at a very productive pace (4.5% in 2005). They manage their inflation rate here, which some credit with keeping a fairly stable growth rate. This growth rate is astonishing, in my view, when South Africa has a 50% unemployment rate and over 20% of its population infected with HIV.

My next post: my trip to Soweto.

Which and When?

One of the best talks of the conference was an attempt to synthesize much of the progress of the field. You might ask, "How complicated could this be?" The answer is -- "Pretty darn complicated." Let me give you a flavor.

There are at least six different classes of microbicides. Some of them, like Carraguard (the Council's candidate), are fusion inhibitors, which seek to physically block the virus from attaching to the woman's body. Others include using anti-retroviral therapy drugs (the drugs used to treat HIV at the moment). Still others are CCR5 Antagonists (which are also potential drugs to treat HIV), which basically block the entry of the disease at the cellular level (CCR5 is a co-receptor for the virus). There are several other areas being looked at, like cervical barriers, vaginal rings, and even using live bacteria.

Choosing the "right" microbicide will be like choosing a job from about 20 different offers. It will depend on your criteria, and -- by the way -- all of the offers will not come at the same time. Would you rather have a good job now, or the potential for a great job in two years? Switching jobs can be messy and expensive.

There are 5 microbicides in Phase III clinical trials right now, including Carraguard. But even we have 2nd generation microbicides being developed and tested for safety. If the first round produces three partially effective candidates (and we don't know how effective they will be, but they will likely not be 100% effective used on their own), which one would you choose? And would you invest in the development and production of one of them, or wait a year or two for something that might be more potent?

Surprise Guest Speaker

The unannounced visitor who kicked off this microbicides conference was none other than Archbishop Desmond Tutu. As it happened, one of my colleagues had ushered me to the third row of our 2000 seat auditorium, and so I sat about 8 feet from the great man.

On an evening with many great speeches, music, dance, storytelling, and videos, Bishop Tutu was the highlight. He talked about a number of firsts that have happened in Cape Town (first open heart surgery, the place where he announced the release of Nelson Mandela, etc.), and how it would be wonderful to have a breakthrough in this dread disease announced here.

He then said something very powerful. He said that when God looks at Iraq, at Darfur, and at the HIV pandemic, he weeps. God must be thinking, Tutu said, that what has he done, putting these people on the world. But then God sees all of the people who are working so diligently to solve this problem, and he clears his tears away and smiles.

Of course the Bishop was talking about the hundreds and thousands of researchers who are working so diligently to find a prevention and cure for HIV, and it was nice to see people whose work is often so anonymous get recognized by such an eminent personage.

Bishop Tutu also, very wisely, had a behavioral message, which was that a good deal of this problem is caused by the unequal economic and social relationship between men and women. More on that tomorrow. It was a wonderful way to start the conference.

Directions from here? Go North.

I went with a number of colleagues to Cape Point yesterday. It is at the point where the Indian and Atlantic Oceans meet, the southern-most point in Africa. The terrain is gorgeous, and the vista, fog aside, is spectacular. Apparently, the combination of the warm Indian Ocean and the cool Atlantic Ocean produces an ecosystem near Cape Point that is separate and distinct to each. Actually, there are two sub-ecosystems, one on each side of "the border," each of which are different than the ecosystems in their respective oceans.

Driving back up from Cape Point was a treat. First, I drove the van of 9 people. (Cass has famously described me as being a very contented and happy van driver -- she thought I would be driving a shuttle van on our wedding weekend -- so I know this will amuse her.) This is not a big deal until one realizes that in South Africa, they drive on the "wrong" side of the road. Plus, it was a stick shift. The terrain I drove on was the west coast of the southern tip of the continent, which is remarkably similar to Route 1 in California, between LA and San Francisco. Therefore, for most of the drive, I was driving on the edge of a cliff, with a 300-400 foot dropoff to the water. Because I was driving north, I was therefore driving on the water side of the road.

Driving on the left means you have to ignore virtually every natural instinct you have while driving. It changes big things, like how intersections are organized, and little things, like the angle of the rear view mirror. I did manage to get us back without a head-on collision, although I shifted into 1st gear several times when I meant to shift into third.

Another fun aspect of the drive home was when we had to stop to allow the baboons to cross the road. When was the last time your drive up the coast was interrupted by a baboon crossing?

Clinic

Yesterday afternoon, I visited one of the three clinics where the Council conducts its Phase III study of Carraguard, our microbicide. The clinic was open only for administrative work on the day that I visited, and was not seeing any clients. This was disappointing, but made it easy for me and my colleagues to walk through the clinic and ask lots of questions.

I was struck by how bare and plain it seemed. There were public health posters on many, but not all, walls, and it seemed like not a particularly cheerful place. But I learned a lot --- when I asked a colleague of mine for her impressions, she said how nice it was relative to most public health clinics in South Africa. "It's clean, it's well-lit, and there's a place for children to play."**

Indeed, the clinic seems to be a small oasis in a fairly rough area. Another colleague told me that on a previous trip, his driver had overshot the driveway for the clinic by about 25 yards. Backing up was awkward, so my colleague moved to walk the distance. The driver wouldn't let him, saying that it was too dangerous to walk that distance, even in the daylight. This is, of course, a depressing commentary on conditions for the poor in this country.

The site has a generator, but I noted that the generator operates only for the benefit of the laboratory (so the samples do not get ruined). Therefore, when the electricity goes out (as it does frequently), this often means that the clients can't be seen, because of the reliance on computers to check clients in, record data, etc. (not to mention see in the dark).

An even more sobering commentary came from a story another colleague told me from her visit to the clinic earlier in the week. She sat in the waiting room, talking and listening to the clients. One client said how much she liked the product -- because she could put the gel in her vagina in the morning, and then she wouldn't worry as much about being raped as she went to work in the afternoon.

A lot of the Council's work focuses on the dynamic between men and women, and in particular empowering women and giving them choices. This is a good example of the connection between gender dynamics and health outcomes.

** After other colleagues read this blog, they told me quite clearly that the clinic we run is on the very high end of public health facilities in Africa. Other facilities are cramped, dirty, and entirely disagreeable places to visit.

Microbicides

Today was an important day, and a great preview for the conference I am attending next week. My whole day has been spent on microbicides, which are compounds that seek to block the transmission of HIV. The Pop Council is in the midst of a Phase III clinical trial (the last phase before approval) to evaluate our microbicide, which is called Carraguard. It's made from Carrageenan, which is a seaweed used in many food and other products. There are several other microbicides being developed, but the Council's is the furthest along.

My role in this is a limited but important one. If our microbicide is proven to work, we will have to find a manufacturer and distributor for it. I will help to negotiate those deals, along with our scientific and legal colleagues.

There are a hundred ethical issues involving microbicides, but here is just one: what if the microbicide works 50% of the time? Would you want to distribute it? If it worked that well, it would have what is called "herd effect," which means that it would cut severely into the epidemic, benefiting huge numbers of people. But the effect for any one person is only 50%, so one must be careful how one markets such a product. You would never, for instance, want to have people who do use condoms stop using them in such a situation, believing that the product protected them well enough.

The next post will be about my visit to one of the three sites that we have in South Africa to test Carraguard.