Comment: healthcare and livelihoods.

Abstract

In preparing a comment on these papers, it is the commonalities I seek though I am struck by some differences. The four research projects have been located in the Agincourt health and demographic surveillance site and are floated, as it were, upon the infrastructure of this site. This highlights benefits of the longitudinal demographic surveillance resource: the ability to select particular study participants (for example those in households where deaths have occurred), and gain entree into a village community that is part of the site. Perhaps the most significant aspect of the DSS infrastructure, though, is the established relationship between ongoing surveil- lance and the community that affords researchers relatively easy access into the lives of others. It also raises the stakes and demands that research is acceptable to the community so that neither the long-term relationship nor the viability of future research endeavours is jeopardized. Managing this is a cost that DSS sites have to bear. The papers share a background of poverty, disease, death, and survival. They share the same location, the same community and are conducted over a similar time period. They are different in that they ask contrasting questions from different theo- retical and disciplinary research traditions and apply differing methodological approaches. The common location and time period makes consideration of findings in combination possible, while the multi- plicity of approaches allows a nuanced and rich insight into some aspects of community life in Agincourt. The paper by Golooba-Mutebi & Tollman tables the issue of individuals' competing underlying beliefs concerning cause and effect and how this influences their actual health-seeking behaviour (1). This is not a new finding but it has an urgent relevance because of the unprecedented impact of the HIV epidemic in Southern Africa. The need to get people into treatment and prevention programmes begs the old question of how to make programmatic interven- tions appropriate and accessible. A cursory review of articles on health-seeking behaviour in the current medical literature suggests they do not incorporate the notion of competing health belief models. The paper highlights the potentially negative impact of competing belief models on people's readiness to access care and life-saving technology in the form of antiretroviral treatment, and how professionals and role models need to take this into account. The paper by Hunter et al. (2) talks to positive aspects of traditional beliefs and knowledge: how knowledge handed down through generations can empower families to survive in situations of dire need. It also speaks to the impact of poverty and disease in eroding not only survival but the knowl- edge base required for that survival. Meeting basic needs - water and fuel - would liberate time, in particular women's time, to engage in other activities that may enrich meals as well as lives. These papers draw attention to the intersection of interventions (social grants, antiretroviral treatment) with the social norms prevailing in communities. Case & Menendez examine social grants and the positive effect they have on household survival and functioning (3). In this instance, the positive out- come of pensions for the elderly may be because the grant is placed in the hands of people who attain status with age. Social grants for the elderly dovetail with the place of gerontocracy in many sub-Saharan societies. Local norms and mores keep individuals and groups within communities in their usual,