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PubMed2002

In the high court of South Africa, case no. 4138/98: the global politics of access to low-cost AIDS drugs in poor countries.

In 1998, 39 pharmaceutical manufacturers sued the government of South Africa to prevent the implementation of a law designed to facilitate access to AIDS drugs at low cost. The companies accused South Africa, the country with the largest population of individuals living with HIV/AIDS in the world, of circumventing patent protections guaranteed by the intellectual property rules that were included in the latest round of world trade agreements. The pharmaceutical companies dropped their lawsuit in the spring of 2001 after an avalanche of negative publicity. Yet, despite the government's victory, AIDS drugs remain very expensive in South Africa, and the government still refuses to provide antiretroviral therapy to adults. These events have shone a spotlight, not only on the possibilities for coordinated political activism in the era of instant global communications, but also on the tangled social, economic, and political dimensions of AIDS treatment in poor countries.

Acquired Immunodeficiency Syndrome↗

PubMed2003

Secondary data analyses of dietary surveys undertaken in South Africa to determine usual food consumption of the population.

OBJECTIVE: The primary objective of this study was to generate a reference table of food items and average amounts of these items consumed by South Africans, for the Department of Health. The reference table was required to be representative of foods and beverages eaten frequently by children and adults from all age and ethnic groups in order for the Department of Health to test for contaminants in these foods. DESIGN: The National Food Consumption Survey (NFCS) served as a framework for compiling data on children since this was a national representative survey of 1-9-year-old children undertaken in South Africa in 1999. However, there has never been a national dietary survey on adults in South Africa. Consequently the data had to be extrapolated from existing isolated surveys on adults. Secondary data analysis was conducted on existing dietary databases (raw data) obtained from surveys undertaken on adults in South Africa between 1983 and 2000. Available datasets were regional and independent, and were not individually representative of the South African diet. It was therefore necessary to use different statistical methods, including factor analyses, weighting and correlations, to generate ethnic and geographic representative data for adults. Two methods were used: Method 1, which corresponded with results of the NFCS (over-sampled for low socio-economic status), and Method 2, which was based on ethnic proportions of the population. RESULTS: The secondary data analyses generated food items most commonly consumed by the South African adult population (Method 1) in descending frequency of usage and average (mean) amount per day: maize porridge (78%/848 g), white sugar (77%/27 g), tea (68%/456 g), brown bread (55%/165 g), white bread (28%/163 g), non-dairy creamer (25%/6 g), brick margarine (21%/19 g), chicken meat (19%/111 g), full-cream milk (19%/204 g) and green leaves (17%/182 g). In 6-9-year-olds, maize porridge (72%/426 g), sugar (76%/23 g), tea (51%/258 g), full-cream milk (35%/171 g) and white bread (33%/119 g) were eaten most frequently. Similarly, in 1-5-year-olds, the foods consumed most frequently were maize porridge (80%/426 g), sugar (76%/21 g), tea (44%/224 g), full-cream milk (39%/186 g) and white bread (24%/83 g). In order to evaluate the validity of the adult data generated, kilojoule values of the individual food items (per capita) were compared with food balance sheets (FBSs). The comparison was favourable except that the FBSs had a higher overall energy intake per capita of between 22 and 28%. CONCLUSION: Reference tables of commonly consumed foods and beverages were generated at minimal cost based on secondary data analyses of past dietary surveys in different South African populations.

Adolescent↗

PubMed2005

Addressing the paediatric HIV epidemic: a perspective from the Western Cape Region of South Africa.

In the Western Cape province of South Africa, a prevention of mother-to-child-transmission (PMTCT) intervention programme, based on short-course nevirapine, achieved universal coverage in 2003. Despite this programme, an estimated 1,400-1,650 HIV-infected children were born in the province in that year. These crude estimates suggest that there are many children in the province who need medical care. Several strategies could collectively reduce the size of the paediatric epidemic and improve the outcome of HIV-infected children in the region, including intensification of the existing PMTCT programme and provision of antiretroviral therapy (ART) for children with moderate or severe disease. Progress towards implementing these interventions is discussed. Future challenges include understanding the factors that favour long-term survival of children on highly active antiretroviral therapy in resource-limited settings, identifying appropriate treatment for the metabolic complications of ART, and the provision of adolescent services for long-term survivors. Developments over the next few years will determine whether these challenges can be met.

Adolescent↗

PubMed2000

The prevalence of different African horsesickness virus serotypes in the Onderstepoort area near Pretoria, during an outbreak of African horsesickness in South Africa in 1995/1996.

During 1995/1996 parts of South Africa experienced exceptionally high rainfall. Large numbers of Culicoides midges were seen and an outbreak of African horsesickness (AHS) followed. In the Onderstepoort area, near Pretoria in Gauteng, a number of horses died of suspected AHS. Virus isolation and typing was done from blood and/or organ samples of 21 suspected cases as well as from five zebra which were kept in the area. Virus was isolated from 14 of the 21 suspected cases but not from the zebra. The neutralizing antibody response of the zebra to the nine different African horsesickness virus (AHSV) serotypes was determined. Results indicated the highest prevalence of serotypes 2 and 4 followed by serotypes 1, 6 and 9. Reverse transcription polymerase chain reaction (RT-PCR) was performed on total RNA extracted from blood samples of the zebra. AHSV RNA was indicated in three of five zebra by agarose gel electrophoresis analysis of amplicons and in four of five zebra after Southern blot hybridization using a 32P-labelled probe. RT-PCR can be used together with serological techniques in studies of AHS to further clarify the epizootiology of the disease.

African Horse Sickness↗

PubMed2004

"We have our own special language." Language, sexuality and HIV/AIDS: a case study of youth in an urban township in South Africa.

BACKGROUND: Despite the fact that most South African youth know about HIV/AIDS and how it can be prevented, there is a high prevalence of HIV/AIDS amongst youth in South Africa. Generally youth do not practice safe sex, and youth sexuality is characterised by multiple sexual partners, not using condoms and transactional sex. OBJECTIVES: To minimize the risk of HIV infection, it is necessary to understand youth sexuality. In this paper I explore youth sexuality with a specific focus on how language influences sexuality. METHODS: I use discourse analysis and qualitative research techniques. Purposive sampling, a form of non-probability sampling was used. I interviewed seventy youth individually or in groups and used in-depth semi-structured interviews. RESULTS: The use of language influences youth sexuality. Youth have developed a specialised language to talk about sex and sexuality and this language has become part of the daily discourse, so that unsafe sexual practices become norms and are justified. CONCLUSIONS: The realm of language can be a creative way for peer and HIV/AIDS educators to work with youth towards creating a healthier sexuality. However, as language always occurs in a material context, it is also necessary to work towards changing the material environment, such as poverty. This environment not only facilitates the development of a particular language but it also encourages unsafe sexual practices such as transactional sex.

Acquired Immunodeficiency Syndrome↗

PubMed2003

Acid mine drainage arising from gold mining activity in Johannesburg, South Africa and environs.

The Witwatersrand region of South Africa is famous for its gold production and a major conurbation, centred on Johannesburg, has developed as a result of mining activity. A study was undertaken of surface and ground water in a drainage system in this area. Soils were also analysed from a site within the mining district. This study revealed that the ground water within the mining district is heavily contaminated and acidified as a result of oxidation of pyrite (FeS2) contained within mine tailings dumps, and has elevated concentrations of heavy metals. Where the water table is close to surface, the upper 20 cm of soil profiles are severely contaminated by heavy metals due to capillary rise and evaporation of the ground water. The polluted ground water is discharging into streams in the area and contributes up to 20% of stream discharge, causing a lowering of pH of the stream water. Much of the metal load is precipitated in the stream: Fe and Mn precipitate as a consequence of oxidation, while other heavy metals are being removed by co-precipitation. The oxidation of iron has created a redox buffer which controls the pH of the stream water. The rate of oxidation and of dilution is slow and the deleterious effect of the addition of contaminated water persists for more than 10 km beyond the source.

Acids↗

PubMed2004

Tuberculosis at Edendale Hospital in Pietermaritzburg, Kwazulu Natal, South Africa.

SETTING: Edendale Hospital, Pietermaritzburg, KwaZulu Natal, South Africa, a 1275-bed hospital that serves a mainly ethnic African population of 1.6 million. OBJECTIVE: To describe the demographic and clinical characteristics of hospitalised active tuberculosis (TB) cases, and correlates of their in-hospital survival. METHODS: A retrospective cohort study of adult TB cases admitted to the medical wards, 16 November to 13 December 2001. RESULTS: Of 760 (28%) admissions, 215 had active TB, of whom 26.5% died in hospital. Patients were mostly young, first diagnosed on admission, and had pulmonary TB. Human immunodeficiency virus (HIV) co-infection was common and predicted by lower absolute lymphocyte count (OR 1.2, 95% CI 1.05-1.38). Extra-pulmonary TB, including pleural and pericardial, was significantly associated with not having HIV infection. In-hospital death was predicted by TB diagnosed prior to admission (OR 3.18, 95% CI 1.67-6.07), acquired immune-deficiency syndrome (AIDS) associated disease, and higher total leukocyte count--by higher leukocytes only in patients without AIDS (OR 8.52, 95% CI 2.67-27.13). CONCLUSION: Active TB was common in in-patients at an acute care hospital. TB patients presented late in disease and had high in-hospital mortality. Early detection and effective treatment of active TB in the community is likely to reduce hospitalisation and improve survival.

Adult↗

PubMed2006

Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa.

A third of adolescent girls in South Africa become pregnant before the age of 20, despite contraception being free and mostly accessible. This qualitative study was undertaken in Limpopo Province in 1997 on the barriers to adolescent girls accessing clinic services for contraception. Thirty-five in-depth interviews and five group discussions were conducted with girls aged 14-20, and interviews with nursing staff at 14 clinics. Many of the girls described pressure from male partners and family members to have a baby or prove their fertility. Other barriers to sustained contraceptive use included medically inaccurate notions about how conception occurs and fears about the effects of contraception on fertility and menstruation, which were not taken seriously by nurses. Nurses' attempts to stigmatise teenage sexuality, their scolding and harsh treatment of adolescent girls, and their unwillingness to acknowledge adolescents' experiences as contraceptive users, undermined the effective use of contraception by girls. Youth need better information on reproductive physiology and sexual health, and detailed information on contraception. Tools to enhance the accuracy and availability of knowledge in the clinic setting have a role, but need to be introduced along with initiatives to ensure that services are adolescent-friendly and do not stigmatise adolescent sexual activity.

Adolescent↗

PubMed2001

Changes in public health in South Africa from 1876.

The present population in South Africa, roughly 43 million inhabitants, is made up of Africans (77.2%), whites (10.5%), Coloureds (mixed race) (8.8%) and Indians (2.5%). In 1900 the infant mortality rate (IMR) among Africans was 330 per 1,000 live births; this has now fallen to 50-60. In Soweto, a primarily African city, IMR averages 20-25. Life expectancy in the past was only 25-30 years; by 1995, this reached 63 years. However, this could fall again due to the rapidly spreading HIV/AIDS epidemic. Life expectancy could fall to 40-45 years by 2010 with the AIDS epidemic being the cause of half of all deaths--a disastrous change from the previous relatively commendable public health situation. Formerly, the most common causes of deaths in young people were infections, diseases associated with malnutrition and gastroenteritis. Adults died almost solely from infections, including typhoid, dysentery, malaria and tuberculosis (TB). Even though diseases associated with malnutrition are less common today, many infections still remain a major problem, particularly TB, which is increasing. As late as 1970, Africans who reached 50 years had longer life expectancy than whites due to the low prevalences of the chronic diseases of lifestyle. This is no longer so, due to the recent rises in non-communicable disorders/diseases, principally obesity in women, hypertension, diabetes, stroke and the cancers of prosperity. In the not so distant future, the level of control of HIV/AIDS related diseases will be the major health/disease regulating factor among Africans. Among white, Coloured and Indian populations, there have been falls in the mortality rates of the young and, despite rises in lifestyle diseases, increases in life expectancy are continuing. For all populations other important public health regulatory factors include water supply, sanitation, clinic/hospital services and personal environmental factors, employment, dietary pattern and intake, smoking practices and alcohol consumption and physical activity, particularly in urban dwellers. Unfortunately, public health expenditure, also a highly regulating factor, has fallen from 8.2% of the gross domestic product in 1994 to 4.1% in 2000.

Health Status Indicators↗

PubMed2002

"Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa.

Violence against women is pervasive in South Africa where, as in many other countries, cultural values and norms serve to condone and reinforce abusive practices against women. Primary health care nurses, who are widely distributed throughout the rural areas, may appear to be an ideal network for addressing this issue in resource-poor settings. However, based on a qualitative and quantitative study of a class of 38 PHC nurses, this paper emphasises that the nurses are women and men first--and as such, experience the same cultural values, and indeed, similar or higher levels of violence, as the clients they are expected to counsel and treat. Current models for encouraging nurses and other health care workers to detect and address gender-based violence have evolved largely in the context of developed countries, and have focused primarily on acquiring the knowledge, skills and attitudes necessary to engage this issue in the health care setting. Yet, as this paper suggests, there is an urgent need to understand and address the lived experiences of the nurses, and the duality of their roles as professionals and as community members, before promoting the training of nurses as an effective strategy for dealing with gender-based violence. One such training model was piloted and assessed in this study. The intervention used partnership with a domestic violence NGO to initially focus on dealing with the attitudes and experiences of the nurses as individuals, and to begin a process of self-awareness and sensitisation. Only then did the intervention turn to their roles as professional nurses. Clearly, there is a need for further research to explore these issues in more depth and to inform the development of appropriate training strategies for health care workers, particularly in developing countries. Moreover, such research may well have implications for the design and implementation of training interventions aimed at raising awareness and capacity within other sectors such as the welfare, police and judicial systems.

Adult↗

PubMed2001

Relationship dynamics and teenage pregnancy in South Africa.

Teenage pregnancy is extremely common in South Africa. Whilst its 'problematic' nature is a subject of debate, it reflects a pattern of sexual activity which puts teenagers at risk of HIV. Currently one in five pregnant teenagers is infected with the virus. This creates a new imperative to understand teenage pregnancy and the pattern of high risk sexual activity of which it is one consequence. This was an exploratory study undertaken to investigate factors associated with teenage pregnancy amongst sexually active adolescents in an urban and peri-urban context. The study used a matched case control design, with 191 cases and 353 school or neighbourhood, age-matched controls. Subjects were under 19 years and recruited from township areas of Cape Town. A structured questionnaire was used to obtain information on socio-economic factors, contraceptive knowledge and use, and sexual behaviour. Conditional logistic regression was used to analyse the relationship between teenage pregnancy and the factors investigated. The results presented focus on relationship dynamics and their association with the risk of pregnancy. Both groups of teenagers had been dating for a mean of two and a half years and about half were still with their first sexual partner. The partners of the pregnant teenagers were significantly older, less likely to be in school and less likely to have other girlfriends. The pregnant teenagers were significantly more likely to have experienced forced sexual initiation and were beaten more often. They were much less likely to have confronted their boyfriend when they discovered he had other girlfriends. Multiple modelling shows that both forced sexual initiation and unwillingness to confront an unfaithful partner are strongly associated with pregnancy and also related to each other. We argue that the associations are mediated through unequal power relations within the relationship which are reinforced by violence. We further discuss indicators of greater intimacy within relationships of the pregnant teenagers which may suggest that more of the pregnancies were wanted than was suggested. Both of these conclusions pose critical challenges for health promoters.

Adolescent↗

PubMed1988

Private medicine and the privatisation of health care in South Africa.

Health services in the Republic of South Africa (RSA) are provided by a mixture of public and private providers and institutions. Estimates of total health-related expenditure for 1985 range between 5.3% and 5.9% of gross national product (GNP), divided on approximately a 55:45 basis between public and private sectors. Basic preventive and curative services are provided by a hospital- and clinic-based public system. The public system does not adequately serve the rural areas and African tribal bantustans, and racial discrimination and/or segregation are obvious in its organisation and funding. The public sector's strength is the provision of state-subsidised care to many citizens who are unable to afford private medicine. The vast majority of hospitals are operated on a non-profit basis by government, industries, and voluntary agencies. Excluding hospitals that receive state subsidies, private investor-owned hospitals control about 10% of all hospital beds in the RSA. One-third of these investor-owned beds are held by state-dependent contractors providing long-term care. Two-thirds are wholly independent. Growth has been rapid in the independent hospital sector, and major corporations have entered the market. In 1985, over 85% of the white population was privately insured by a variety of prepayment programmes, including those organised through parastatal corporations and government departments. Despite major enrollment growth in the preceding decade, only 8% of blacks held private insurance by 1985; their coverage also tended to be less comprehensive. Faced with deficit financing, a sluggish economy, complaints from its white constituency about taxation levels, and pressure from private sector interest groups, the Nationalist government has endorsed the concept of privatisation of health care. Exponents of privatisation claim that it will permit differentiation by income to supplant discrimination by race. However, the direct links between disposable income and race, the rapidly rising costs of private insurance, and the still-limited extent of private coverage among the black majority, indicate that privatisation is likely to co-opt a comparatively small proportion of the total black population. It may exacerbate the urban-rural imbalance in health status and health services, promote growth of hospital-intensive curative services rather than needed expansion of community-centred preventive and primary care, and create financial barriers to access for low-income patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Health Services Administration↗

PubMed1998

The 1996 outbreak of African horse sickness in South Africa--the entomological perspective.

During the 1996 summer season (January-April) in South Africa an estimated 500 horses died of African horse sickness (AHS); 80% of deaths were due to AHS virus serotypes 2 and 4. Nearly all cases occurred in the northern, north-eastern and central parts of South Africa. This study reports the first attempt to verify the involvement of the biting midge Culicoides imicola in a field outbreak of AHS in southern Africa. In light-trap collections made at 47 sites over 12 weeks, C. imicola comprised 94.2% of 4.78 million Culicoides. Culicoides imicola was the most prevalent of 34 species captured and was the only species whose distribution matched that of the disease. Record catches of C. imicola were made, and reveal that in years of above average rainfall its numbers can show a 200-fold increase over those in dry years. Soil type appeared to determine strongly the distribution of C. imicola. The largest populations of C. imicola were found in areas with clayey, moisture-retentive soils whereas the lowest numbers, or none, occurred in areas where the soils were sandy and quick-draining. The deaths of two horses (confirmed AHS) in a sandy area were perplexing as they occurred in a region known to be free of C. imicola. The probable origin of these infections was established.

African Horse Sickness↗

PubMed2002

Intrapartum-related birth asphyxia in South Africa--lessons from the first national perinatal care survey.

BACKGROUND: The recent amalgamation of data by users of the Perinatal Problem Identification Programme (PPIP) throughout South Africa has culminated in the publication of the Saving Babies report. OBJECTIVES: To determine the absolute rate of death from intrapartum-related birth asphyxia, and the contribution of intrapartum-related asphyxia to total perinatal mortality in South African hospitals, and to identify the primary obstetric causes and avoidable factors for these deaths. METHODS: The amalgamated PPIP data for the year 2000 were obtained from 27 state hospitals (6 metropolitan, 12 town and 9 rural) in South Africa. In PPIP-based audit, all perinatal deaths are assigned primary obstetric causes and avoidable factors, and these elements were obtained for all deaths resulting from intrapartum-related birth asphyxia. RESULTS: There were 123,508 births in the hospitals surveyed, with 4,142 perinatal deaths among infants > or = 1,000 g, giving a perinatal mortality rate of 33.5/1,000 births. The perinatal mortality rate from intrapartum-related birth asphyxia was 4.8/1,000 births. The most frequent avoidable factors were delay by mothers in seeking attention during labour (36.6%), signs of fetal distress interpreted incorrectly (24.9%), inadequate fetal monitoring (18.0%) and no response to poor progress in labour (7.0%). The perinatal mortality rates for metropolitan, town, and rural areas were 30.0, 39.4 and 30.9/1,000 births respectively. The contribution of intrapartum-related birth asphyxia to perinatal mortality in these areas was 10.8%, 16.7% and 26.4% respectively. CONCLUSION: The high rates of perinatal death from intrapartum-related birth asphyxia in South Africa are typical of those in underdeveloped countries, with the most serious deficiencies in rural areas. Most of these deaths are avoidable and the reduction of these rates presents an important challenge to providers of perinatal care in this country. Areas worthy of research and action include provision of mothers' waiting facilities in rural regions, improvements in fetal monitoring, partogram-based labour management, and the establishment of midwifery staffing norms for South African labour units.

Asphyxia Neonatorum↗

PubMed2005

Factors associated with wanting to know HIV results in South Africa.

HIV-associated stigma is a significant barrier to HIV testing in South Africa. The aim of this study was to determine the proportion of study subjects who wanted to know their HIV status and to describe factors associated with and reasons for wanting to know HIV results. Data were obtained from a cohort study in rural South Africa evaluating the impact of migration on HIV infection. All participants were offered HIV pretest and posttest counseling with the option of receiving their HIV test results. In-depth interviews with 12 randomly selected participants provided qualitative data. Of 628 participants, 80% wanted to know their HIV results. The main reported reason for wanting HIV results was to protect themselves against future infections. In the multivariable model for women, number of dependents (odds ratio [OR] = 1.181; 95% confidence interval [CI] - 1.070, 1.303), partners of migrant men (OR = 0.37; 95% CI - 0.14, 0.95), and those who reported condom use (OR = 0.17; 95% CI - 0.08, 0.39) were associated with wanting their HIV results. No factors were associated with wanting HIV results in men. Our study suggests that participant-oriented counseling produces high rates of participants wanting to know their HIV status. These findings may be useful in providing insight to understand issues associated with stigma in HIV testing.

Adult↗

PubMed2005

Morphological and molecular characterization of Endophyllum species on perennial asteraceous plants in South Africa.

Endophyllum osteospermi is an autoecious, endocyclic rust fungus, which has only been recorded on Chrysanthemoides monilifera ssp. monilifera (Asteraceae, Calendulae), a perennial woody shrub. Both organisms are indigenous to South Africa. Because E. osteospermi is being considered for release in Australia as a biocontrol agent against C. monilifera ssp. monilifera, it was necessary to determine its host range and natural distribution in South Africa. To address this, natural stands of Chrysanthemoides species, as well as other South African asteraceous plants, were monitored for E. osteospermi between 1992 and 2003. A morphological and molecular comparison of specimens referable to Endophyllum was undertaken. Based on these results, E. osteospermi was recorded on C. monilifera sspp. monilifera, pisifera, rotundata, canescens, and subcanescens, C. incana, and an undescribed taxon. E. osteospermi was also recorded on Osteospermum ciliatum, O. pollgaloides, and O. potbergense. Furthermore, a closely related but previously undescribed species, E. dimorphothecae sp. nov. is described on Dimorphotheca cuneata. Aecidium elytropappi is transferred to Endophyllum as E. elytropappi comb. nov., being recorded on Elytropappus rhinocerostis and Stoebe plumosa. This study shows that in South Africa E. osteospermi is restricted to a small group of related plant species in the Calenduleae. This rust is therefore considered suitable as a candidate agent for the biocontrol of C. monilifera ssp. monilifera, and pending the results of host specificity testing, would most likely be safe to introduce into Australia.

Asteraceae↗

PubMedDate not supplied

Virginity testing in South Africa: re-traditioning the postcolony.

Umhlanga is a ceremony celebrating virginity. In South Africa, it is practiced, among others, by the Zulu ethnic group who live mainly in the province of KwaZulu Natal. After falling into relative disuse in the Zulu community, the practice of virginity testing made a comeback some 10 years ago at around the time of the country's first democratic election and coinciding with the period when the HIV pandemic began to take hold. In July 2005 the South African Parliament passed a new Children's Bill which will prohibit virginity testing of children. The Bill has been met with outrage and public protest on the part of Zulu citizens. Traditional circumcision rites are also addressed in the new bill but are not banned. Instead, male children are given the right to refuse to participate in traditional initiation ceremonies which include circumcision. This paper asks why the practice of virginity testing is regarded as so troubling to the new democratic order that the state has chosen to take the heavy-handed route of banning it. The paper further asks why the state's approach to traditional male circumcision has been so different to its approach to virginity testing. Finally, the paper asks what these two challenging cases in the country's new democracy tell us about the nature of liberal democratic citizenship in South Africa 10 years after apartheid's formal demise.

Adolescent↗

PubMed1996

Training to meet the needs of the communicatively impaired population of South Africa: a project of the University of the Witwatersrand.

At a time when South Africa is in the throes of transition, ideologies in the educational, medical, economic and social spheres are being redefined and redirected. The field of speech pathology and audiology is no exception. The Department of Speech Pathology and Audiology, University of the Witwatersrand has acknowledged an urgent need to address the requirements of a multilingual and multicultural South Africa and extend training beyond the white middle-class population. It is the responsibility of the training institutions to redirect the objectives of their curricula in order to meet these needs. This paper describes the changes introduced by the Department. These include teaching of community work principles and primary health care to the speech and hearing therapist, and the training of personnel for an alternative form of service, such as the community speech and hearing worker (CSHW) and the community-based rehabilitation worker (CBRW).

Community Health Services↗