Social epidemiology in South Africa.

In this paper, we review the history, present state, and future of social epidemiology in South Africa. In “developing” nations such as South Africa, social epidemiology is cast in a new light owing to these countries’ distinctive political, economic, and social histories. South Africa is still grappling with the public health legacy of the colonial and apartheid eras while contending with new public health threats that are linked to a changing global economy, as well as the devastating human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) epidemic. Furthermore, the possibilities for research in social epidemiology have been limited by the scarcity of resources and political constraints. While such factors are common to many developing countries, they are thrown into sharp relief in the case of South Africa. We begin by tracing a brief history of social epidemiology in South Africa, noting its remarkable early growth. Then we review intriguing, if sparse, evidence on the current interplay between society and health in South Africa. We suggest that the structural conditions of the past, most notably the racial discrimination and labor migration policies systematized by apartheid-era governments, underlie much of the current variation in population health in South Africa. However, we also point to evidence of a “bipolar” epidemiologic transition superimposed upon this legacy and interacting with it. Looking to the future, we propose that social epidemiology can and must play an essential role in meeting the public health challenge of the HIV/AIDS epidemic. South Africa is a middle-income country of 45 million people with dramatic disparities in wealth, despite a gross domestic product per capita of US $8,900 (placing it alongside countries like Brazil and Mexico in terms of 1999 purchasing power) (1). In addition, racial terminology has a complex history in South Africa, having being used as a means of social division and control (2, 3). For the descriptive purposes of this review, we use the “population group” racial nomenclature formalized under apartheid, since most socioeconomic and health data have been collected and reported in this way for decades. The four categories are African (alternatively Black), comprising 79 percent of the 2001 population; Coloured, a widely heterogeneous group sometimes referred to as persons of mixed ancestry (9 percent of the population); Asian (alternatively Indian) (2 percent); and White (alternatively European) (10 percent). In some contexts, the first three groups have been referred to as Black (4).