Day 3: SSDOH+: Innovation Labs

Activity 6: The innovation labs

5 hours


To help us to:

  • Reflect on the historical and political context, how these manifest in social determinants and what this means for advancing health equity (enhanced by preparatory reading!)
  • Meet Eastern Cape activists, hear about the communities in which they are working and their activism towards shaping new frontiers 
  • Learn about grounded political economy struggles stories and SSDoH stories, as well as about leadership, from the site visits, with the support of our hosts and Senior Fellows.

Task 1
Group work: Preparation for site visits

1 hour

You will have been assigned to one of the four site visit groups.  Find your name card on the table and join other group members to meet your site anchor, a Life Long Fellow, and prepare together for your site visit.

Overnight reading will have prepared you well for the discussions that begin now and continue through today. For those who arrive ahead of starting time, take the time to go over your site’s overview and the core reading.

Your site anchor will have a brief 15-minute interactive discussion on what the overview and core reading highlights. After this you will have 15 minutes to use your journal, to note down your reflections on the following:

  1. What are the questions that you have for this site visit, based on your reading?
  2. What should this site visit offer you as considerations for your own SCI?
  3. What angles of leadership issues are you keen to explore with your site hosts, based on your reading? 
  4. We will have volunteers within your group share their journal writings on these questions.  After this, we will travel to the different sites, to spend the rest of the day there and returning.

Task 2
Arrival at the site and host presentations

1 hour

Each of our site hosts and anchors have been provided with the background papers from our earlier case studies, as well as the key readings for this session. We will hear from our hosts on the following:

  1. What are the key historical, political, and socioeconomic issues defining the context in which you work?
  2. What do you do?  Why do you do this? 
  3. Please tell us about the key pathways that your work is defining in challenging inequality, and health inequity in particular?
  4. Once you have heard from our site hosts, Senior Fellows present will speak to their work and research with these formations or communities.
  5. You will get an opportunity to ask questions of clarity, remembering that you will be visiting each site shortly, which will provide an opportunity for further engagement.

Task 3
Around the Site and Engagement

2 hours

You will be taken on a walk around the site, while the site host continues sharing their work and experience, with site anchors contributing to this.

An hour into the walk about, we will pause for around 20 minutes, to allow you to:

  • Go back to your journals, reflect on the key questions developed earlier and consider whether you have any additional questions, reflections you will want to ask or share.
  • Refine your thinking about what it is from the site that you want to explore for your own SCI.
  • Refine what it is you hope to take away from the visit to enhance your activist leadership.

When the walk about continues, find ways to raise angles that you have not yet managed to, with your host, your site anchor and Fellows.

Fireside Stories Tonight

After an early dinner, we will have Fireside Stories on the Site Visits as our Activity 7 (see below for the approach we will take). 

The evening session will be shorter, if groups take time on the return journey from the site visits or in the later afternoon after getting back from the visits, to do Task 1 of Activity 7 below.

Site Visit Guidelines & 4 Site Overviews 

The Eastern Cape presents a striking monograph of some of the worst structural and social determinants in our country.  Here we see how low or no incomes, the reliance on social grants, poor education, failing infrastructure, rurality, poor or no housing, unsafe communities, etc. all contribute to poor health outcomes. And we see how acutely these affect poor, black, working class communities and women in particular. 

Our site visits this year take us to four sites, communities or formations that, through their angle of social justice struggles, grapple with key SSDoHs. Understanding these in depth and being able to adapt and apply what we know, will allow us to contribute to possible improvements of individual and population health and to advancing health equity.


The objectives of these site visits are to: 

  1. Develop empirical perspectives on the SSDOH, with a specific focus on land, housing, food systems, farmworkers and their living conditions, and the gendered realities of the public health system 
  2. Learn from activists, social movements and community struggles against socioeconomic precariousness 
  3. Learn about the activism of the site visit communities in the design and implementation of policies to address SSDOH
  4. Deepen the application of the political economy as a tool of analysis of the health system and its social context, building on what we did in Module 2
  5. Begin thinking about how these learnings can empower the work Fellows are doing on their SCI’s, in their communities, and ultimately in identifying levers for intervention in the reduction of health inequities. 

By visiting these sites and in learning from these communities, we once again break down and simplify what could potentially be complex. Each of the sites highlight a set of political economy and SSDoH issues that are being struggled over. We have chosen these sites because they bring to the fore, issues of:

  • Economic stability: This is about the link between financial resources, your class status and your health – including poverty, food security and general wellbeing. These are structural, personal and affect the mental and physical health of people in profound ways.
  • Healthcare access and quality:  This is about the connection between and across and an understanding of health issues, one’s own health, the health of others and health services. In South Africa, like everywhere, this takes a gendered dimension.
  • Social and community context: This involves the connection between the contexts in which people live, learn, work and their health and wellbeing, including workplace conditions and general societal participation. One’s quality of workplace, work itself and conditions of work, can help improve health, social interaction and personal development. We grapple with what this means in a context of high levels of unemployment and high levels of informal, unrecognised and precarious work? 

The site visits are a critical component in our story and journey of learning about the structural and social determinants of health. The visits will expose Fellows to experiences of precariousness, health inequity, thwarted transformation and resistance. 

The sites 

Fellows will visit one of four sites dealing with a key social determinant of health. Unfortunately, not everyone gets to visit every site. You will be divided into 4 groups and will be supported by senior fellows who will serve as site anchors, as well as site hosts.

These sites were chosen because they offer important empirical knowledge about the connections between key social phenomenon and health inequity and also provide important community activism learnings that we hope will enhance your leadership and provide critical lessons for the work on your SCIs.

Site 1: Housing

Lungiswa Majamani is a rural based activist. Her work has included support for small scale farmers, women, youth, community leaders and children. She served the Rural People’s Movement for close to a decade where they fought for the rights of Ngqushwa villagers. In addition to this she also worked with the Rural Women’s Assembly and the Masifunde Education and Development Trust. She is located in Peddie in the Glenmore location.

Supported by Ivana Merckel

Site 2: Access to food

Siyabulela Mama is a food sovereignty activist with the Assembly of the Unemployed and part of the Gqeberha Amandla Collective. He works in eight communities around Gqeberha providing an understanding the food system and the climate crisis, including the practice in creating food sovereignty through community gardening. 

Supported by Lebohang Molete

Site 3 Anchor: Women’s access to health

Mzikazi Mkata is a forensic pathologist.  She works in the public health service, is a member of the National Union of Public Service and Allied Workers (NUPSAW) in the Eastern Cape and is a local activist.  Her work has brought her into closely understanding the systemic impacts on women’s health and the issues confronting women health workers, community health workers in particular.

Supported by Judiac Ranape

Site 4 Anchor: Farmworkers rights and conditions

Simphiwe Dada is a farmworker rights activist . He coordinates the Khanyisa Education and Development Trust, which advocates for the socioeconomic and political rights of impoverished communities around Gqeberha.  Their work with farmworkers has highlighted the labour rights violations linked to the lack of access to drinking water, acute pesticide poisoning, and harassment of union representatives 

Supported by Hlanga Mqushulu

Code of conduct for site visits 

Be respectful and conscious of time at each site – the actual time we will spend at each site will only be a few hours, so value it carefully.

Apply critical reflection and thinking skills to observe, learn about, discuss and reflect – this means a critical eye, a keen ear, listening to understand and learn, and asking genuine questions to understand what may not be clear.

Combine critical enquiry with respect, fairness, and being reasonable in engaging with our site anchors and the communities they work in at each site.

Be fair and just in giving each other opportunities to observe, learn and engage. 

Psycho-social pain and trauma  

As with the site visits in Module 2, by their nature, the complex realities witnessed in various sites are often painful and traumatic to engage with, especially when we realise that there are millions of people who are still living, enduring and suffering from the deep realities on injustice and inequity. This time we won’t come into direct contact with communities, but we do recognise that the video visualisation of these realities and the viewings (where these happen), will affect our feelings and emotions. We ask Fellows to embrace these feelings and emotions as part of the story and journey of the reality arising from the political economy of our health and health systems. 

We ask that Fellows provide mutual care and support to each other. While we know this may be difficult in the learning space, we encourage an openness to share and learn as we all process the emotions and issues these visits may surface.

Site 1: Housing, Water and Sanitation

“Housing, health and wellbeing are intrinsically linked. Housing is an important social determinant of health, recognising the range of ways in which a lack of housing, or poor quality housing, can negatively affect health and wellbeing …”

The SDOH, the site and our hosts

There is no denying that poor quality housing places residents at risk for health problems, nor that insecure and inadequate housing undermines health-related interventions to address preventable health conditions. Poor housing quality and instability have been associated with numerous physical health conditions, including respiratory conditions, cognitive delays in child development, accidents and injuries as a result of structural deficiencies, as well as adverse impacts on mental health. Further, housing ‘instability’ disrupts work, school, and care arrangements, as well as social cohesion. 

If you are poor, black, a woman and/or a member of the LGBTIQA+ community the likelihood of living in poor quality housing is greater, with greater health impacts. Being homeless or in a cold home may raise blood pressure or lead to a heart attack, those in overcrowded homes may be at risk for poor mental health, food insecurity, and infectious diseases.  

Countless research illustrates, amongst others that:

  • Poor or inadequate housing structures can directly impact on health. For example, exposed electric cables and limited space for cooking can contribute to burns and injuries.
  • Informal housing settlements come with poor water and sanitation, with the absence of basic services and the lack of maintenance leading to low to no water supplies, broken and clogged toilets, and inadequate refuse and waste management to name a few.
  • Insecure, inadequate and overcrowded housing has been linked to physical illnesses, including infectious diseases such as tuberculosis and respiratory infections.
  • Insecure, inadequate and overcrowded housing is a contributing factor for psychological distress, where levels of crime and violence (including gender-based violence), increase risks of injury, death and levels of stress, anxiety and other metal health disorders.
  • Insecure, inadequate and overcrowded housing is directly linked to poverty and the availability of fewer resources to improve health, like parks, sport and recreation centres/facilities and community activities.
  • Children who live in crowded housing may have poorer cognitive and psychomotor development or be more anxious, socially withdrawn, stressed or aggressive.
  • The excessive financial burden of unaffordable housing among lower income families can prevent families from meeting other basic needs including nutrition and health care. 

We explore housing as a SDOH, through the work and commitment of a community in the Eastern Cape and their relentless activism. They demonstrate that safe, affordable housing should be a priority to address health equity.

About the site

Under apartheid forced removals turned people and communities into rubbish to be dumped in faraway places. For this site we look back, by visiting an informal settlement located 47 kilometres outside Makhanda (formerly Grahamstown) that was established in 1979, Glenmore.  Its residents were forcibly removed from all over the Eastern Cape. Of these, three thousand people from Coega were dumped there. They lost their work, their cattle and their homes. During 1981 a tornado swept through Glenmore, tearing the fragile makeshift housing from the ground.  140 people lost their lives, mainly children and the elderly. There were no funeral parlours and they couldn’t afford coffins, so the dead were just wrapped in blankets and buried on the banks of the Fish River.  I

For former Coega resident and local activist, Ben Mafani:

“Glenmore is a civic prison. It is suitable for cows that stay thin and graze but that neither he nor any of the other people that were dumped there are cows and it is a terrible place for human beings. There has been huge development in Coega. More than a billion rand has been spent on development there. There is a new port and factories. Mr Mafani insists that the people forcibly removed from Coega in 1979 have a right to return to Coega, to live there and to work there.”

Through this site we go back into Apartheid legislation and one of its key tenets, forced removals.  We remember the grave injustices of the past and deepen our understanding of South Africa as a deeply unequal society.  We see how issues of housing, through the example of one Eastern Cape community, has grave consequences on the health and wellbeing of communities and we learn about how activism and advocacy has served this community for nearly half a century!

This site helps us to see the countless links between housing, land and health and helps us think through housing as a social determinant. We see the undeniable correlation between having decent, adequate, affordable, secure and stable housing and improved health outcomes.  We see how housing security is necessary for the success of jobs, early learning and child development, education outcomes, the elimination of sexual and gender-based violence and overall community development.   This understanding of how housing impacts the health of communities is vital in fighting to end health inequity.

Some reflection questions
  1. What did you learn about forced removals and the human settlements in the Eastern Cape?  How has poor, inadequate and insecure housing today been shaped by questions of land, apartheid and post-1994 policies? What is the reality of race, class and gender?
  2. How is the burden of illness and disease shaped by housing injustice and inequality?
  3. This story in a reminder of how Frantz Fanon resigned from the mental hospital he worked at in Algeria saying that it was the system, colonialism, and not his patients that were insane, what about Glenmore and Ben Mafani relates to the Fanon experience?
  4. What from this site offers useful lessons for the conceptualisation of your own SCI?


Core reading

Additional reading 

Site 2: Food and Nutrition

“The dominant corporate food regime has negative health, environmental and social impacts. It is a global phenomenon that takes a particularly pernicious and racialised form in South Africa.”

The SDOH, the site and our hosts

We all know that a lifestyle of healthy foods and exercise helps prevent the onset of chronic health conditions.  But how is the consumption of healthy food possible when the vast majority of people have limited access to foods that promote a healthy lifestyle and an inability to afford these foods?  In our context what we eat is also shaped in powerful ways by the local food environment and the global food system.  Big food corporations are fuelling the problem, flooding our local markets with cheap ultra-processed foods – low in nutrients, high in sugar, salt and fat.  All of this is fuelling an unhealthy Mzansi with a rapid rise in obesity and non-communicable diseases like hypertension and diabetes.

A 2018 Mail and Guardian report stated: “Roughly 50% of our population is food insecure or at risk of food insecurity. People are hungry or at risk, skipping meals or going for days without food so they can survive.” 

COVID – 19 has exacerbated this situation.  For this site we explore a community response to the crisis of hunger and food insecurity.  With COVID-19 leaving many working class communities in greater precarity, communities of iBhayi saw the threat posed to food security as food prices rose. They understood the problem of food security as a problem of the environment, access to land and water.  And came together to share their collective experiences as community farmers in various parts of iBhayi.  In their own words:

“…we know fully that land is a burning issue in South Africa and we see the connection with the land question. Whilst we, community farmers, are claiming and regenerating land in schools, clinics and previously neglected open spaces, this land is still very marginal land. And this is made worse because urban land is most often recognised by the state as associated with land tenure for housing and not for integrating local food production. And this contrast with communities that have settled informally on land which is planned for housing. Land must also be aside for several social purposes including urban farming as seen here in Joe Slovo at Silindokhule Pre-primary School, where the Wathint’Abafazi Farmers grow food. Urban planning processes must follow the land allocation and planning processes of communities themselves, resulting in stronger possibilities for urban community farming.”

This community has demonstrated what is required to struggle for an alternative food system through mobilising communities to organise themselves around food, the right to land, water and energy sources and a safe environment. They have shown how these struggles connect to the struggles for a basic income grant, for good local and national government and the broader struggle of meeting the needs of communities.

About the ‘site’ 

South Africa is considered a ‘food-secure’ nation, producing enough calories to adequately feed every one of its 53 million people. However, the reality is that, despite some progress since the birth of democracy in 1994, one in four people currently suffers hunger on a regular basis and more than half of the population live in such precarious circumstances that they are at risk of going hungry. In 2015 13.8 million South Africans lived below the “food poverty line” with. 27.4% of children under five being stunted due to poor nutrition. In the words of one community leaders: “[It is] genocide of the mind … because it affects the mind (fosters negative thoughts), the spirit (state of hopelessness) and the physical being (hunger).” 

It is important to understand the intersecting ways in which systems of power such as capitalism, racism and patriarchy shape our food systems. High levels of unemployment, underemployment and income poverty, resulting from neo-liberal economic policies, as well as landlessness, detrimentally affect nutrition and, thus, the health of social groups at the bottom of the class, racial and gender hierarchies. We see clearly how people’s participation in the food system is shaped by existing class, racial and gender inequalities with poor black women generally bearing the brunt of food insecurities.

The process of neo-liberal land reform has decimated the agricultural workforce, severely undermined livelihoods and food security, especially in rural areas, and sustained the Apartheid corporate power structure of the agro-food system. There is significant evidence to show that the dominance of the food value chain by large-scale industrial agricultural (agri-business) and retail corporations contributes to malnutrition and health inequities in South Africa. David Sanders observed that “high rates of low birth weight, malnutrition, obesity and disease” are major nutrition problems that “occur in an environment where large food corporations have penetrated the market, offering food of questionable nutrition that is cheaper than healthy alternatives”.

Some reflection questions
  1. What did you learn about the food system in the Eastern Cape?  What are its main features, social dynamics and the impact on communities?
  2. How has the food system been shaped by questions of land, the history of apartheid and post-1994 policies? What is the reality of race, class and gender?
  3. How is the burden of illness and disease shaped by food insecurity?  Who is contributing to this insecurity and how?
  4. What from this site offers useful lessons for the conceptualisation of your own SCI?


Core reading 

Additional reading 

Site 3: Women’s Health

“Being a man or a woman has a significant impact on health.”

The SDOH, the site and our hosts

Millions of women die every year due to preventable disease. While poverty and inequality are a critical barrier to positive health outcomes for both men and women, the burden on women and girls’ health due to the system of capitalism and its manifestations are far greater.  The effects on women’s health is seen in capitalisms need to maintain sexist societies, in its exploitation of women’s unpaid labour at home and underpaid labour in the workforce, in its perpetuation of gender-based violence and in its objectifying and commodifying of women’s bodies.   These discriminations place women at increased risk and vulnerability, and hence prevent, obscure or plain deny women the benefit of quality health services and attaining the best possible level of health.

To ensure that women have equal access to the necessary opportunities to achieve their full health potential and health equity, it is important to start by recognising that being a man or a woman has a significant impact on health.  Because of social (gender) and biological (sex) differences, women and men experience different health risks, health-seeking behaviour, health outcomes and responses from health systems.

In this ‘site’ we travel with Passionate Unlimited Peers in Action (PUPA), a movement of young people who identify urgent issues that affect them & address these through Advocacy. Their work has largely focused on adolescent girls and young women (AGYW).  In this instance we explore the work PUPA has been doing with women (young and old) in the Alfred Nzo district in the Eastern Cape.  We see and learn from PUPA, exploring the possibilities for extending this work beyond the Eastern Cape.

About the site 

Women are vulnerable by virtue of where they live and who they are. They carry the risk of increased maternal morbidity, which escalates further to a poor quality of life, aggravated by poor social circumstances and a heavy socioeconomic burden. The Eastern Cape and the Alfred Nzo district in particular illustrates this acutely by showing up several interrelated crises in women’s health in South Africa – maternal deaths, including HIV which is still the leading cause of maternal mortality; high rates of intimate partner violence and sexual assault; high rates of alcohol and other drug use; poor to no access to effective contraceptive services in a private, non-judgemental setting; barriers to obstetric care, cardiovascular disease, cervical cancer, among others. We see that while access to healthcare is constitutionally enshrined – considerable inequities remain, including access barriers such as vast distances, no public transport, and high travel costs.

Women’s work, and by extension their health, is the foundation upon which both production and social reproduction rely.  We see these manifest in health disparities among women, including through:

  • Unequal power relationships between men and women
  • Inequities in norms and policies that disadvantage women
  • The private, nuclear family household structure
  • Single women parent households 
  • Higher rates of unpaid, precarious and informal work
  • Potential or actual experience of physical, sexual and emotional violence.
  • Exclusive focus on women’s reproductive roles

These factors combine to increase vulnerabilities, reduce access to needed and effective health services and contribute significantly to women’s ill health. These multifaceted and intersecting inequities over the span of women’s live results in declining mental health and confidence, depression, post-traumatic stress disorder (prevalent in women who have experience sexual and domestic violence), sexually transmitted infections, negative stereotyping and sexualisation.  These can affect educational achievements, economic potential, as well as the outcomes of her children.  

Some reflection questions
  1. What did you learn about the health system in the Eastern Cape, its impacts and outcomes?  How is it impacting men and women differently?
  2. How is the burden of illness and disease of the Eastern Cape patient population shaped by being a woman? 
  3. Can we speak about the politics of women’s health divorced from public contestations for control of the state, policy making, or budgetary allocations? How have these been shaped by both apartheid and post-1994 policies?
  4. How do race, class, and gender interact to create stark health disparities among groups of women?
  5. What from this site offers useful lessons for the conceptualisation of your own SCI?


Core reading 

Additional readings

‘Site’ 4, Workers (Farmworkers)

“A decent job makes it easier for workers to live in healthier neighbourhoods, provide quality education for their children, secure childcare services, and buy more nutritious food (amongst others)—all of which affect health.”

The SDOH, the site and our hosts

Employment precariousness is a social determinant that affects the health of workers, families, and communities.  A safe, reliable, steady and decently paid job is more than just a pay cheque, having decent work can also provide the benefits and stability critical to maintaining good and proper health. On the flip side, job loss and unemployment are associated with a variety of negative health effects.

Decent work and its pillar of full and productive employment, rights at work, social protection and the promotion of social dialogue, provide good benefits, leads to higher earnings and therefore translates to a longer and healthier lifespan.  By contrast, unemployment, underemployment and precarious work without the requisite rights and social protection can lead to numerous health challenges beyond income determinants. 

For the past 12 years Khanyisa Education and Development Trust (Khanyisa), a land rights non-profit organisation that is based in Gqeberha, primarily operating in peri-urban areas and on commercial farms in Sarah Bartmaan District Municipality in the Eastern Cape, works to 

facilitate the building of change agency through establishment and strengthening of popular rural associations in order to deepen South Africa’s transformation agenda. For this site we visit the work of Khanyisa and learn about what they have been doing with small scale farmers in fighting for their rights in the Eastern Cape.

About the ‘site’ 

An important starting point is the realisation that capitalism as a system of accumulation couldn’t exist in its current form without African labour.  The very imperative of capitalism requires the ready availability of a cheap black labour force to ensure the successful operation of a capitalist economic system, especially in the mining and the agricultural industries.  Concretely, farmworkers play a vital role in producing cash crops for export.

Little wonder that South Africa, farmworkers constitute one of the most exploited and neglected categories of the working poor. They are amongst the most vulnerable and marginalised groups with predominantly low income, low skills, and low educational levels; the roots of which lay in colonialism, slavery, apartheid and the so-called “dop system”.  Their conditions see overcrowding, illiteracy and high school dropout rates, go hand in hand with alcohol abuse and domestic violence, teen pregnancy, unprotected sex leading to STDs and HIV/AIDS, a high incidence of TB and foetal alcohol syndrome. All of which have a profound effect on the quality of life and especially on the life of the children born into these communities.

Poverty, born of socioeconomic inequality, is especially prevalent among women farmworkers and women living in rural South Africa. African rural women experience poverty differently and more intensely than that of men.  Aside from lack of access to resources and basic services, unequal rights, they are also burdened with multiple roles concerning productive and reproductive responsibilities, while being subjected to discrimination, subjugation and violence both in and out of their homes.

Highlighting the issue of work (and in this instance agricultural work) and how it is embedded in wider capitalist economies can help us move from treating the symptoms rather than the causes of dispossession, poverty and inequality.  Work as a social determinant of health is critical in in understanding improved health and well-being of workers and their families, especially the most vulnerable and marginalised, in low-income households, and less advantaged due to other social determinants of health.  In doing so work must be considered as a multifaceted construct in which structural issues of racism and sexism, occupational status/prestige/power, income, healthcare benefits, paid sick leave, parental leave, duration of maternity leave, breastfeeding initiation and duration, working conditions (including hazardous occupational exposures), work-related benefits, flexibility in work hours, social support networks, etc. are all linked to ill health and the perpetuation of health inequities. 

Some reflection questions
  1. What did you learn about the lives and conditions of farmworkers in the Eastern Cape, what is the connection between low wages, poor living and working conditions, and illness and disease? 
  2. What are the contemporary ramifications of capitalist accumulation in South Africa labour? And the particular ramifications relevant to health inequity?  How are these shaped by race, class and gender?
  3. How is the burden of illness and disease amongst the Eastern Cape patient population shaped by precarious work? What is the particular impact on women workers?
  4. What from this site offers useful lessons for the conceptualisation of your own SCI?

Core reading 

Additional readings 

Remember…  Fireside Stories Tonight

After an early dinner, we will have Fireside Stories on the Site Visits as our Activity 7 (see below for the approach we will take). 

The evening session will be shorter, if groups take time on the return journey from the site visits or in the later afternoon after getting back from the visits, to do Task 1 of Activity 7 below.