Stories From the Field:

SOUTH AFRICA

Whoonga: An epidemic emerges

Dr. David J. Grelotti, a Research Fellow at Harvard School of Public Health, was granted a Center for Global Health Travel Award to conduct pilot research on whoonga use in Durban, South Africa.

Thin-framed, quiet, and polite, it was hard to believe that Sipho* was involved in drugs at all. Only 20 years old, his problems with whoonga addiction had become so severe that smoking whoonga was all he did or thought about. He found himself continuing to use it in part for the high, but also to keep from experiencing its dreaded, painful withdrawal.

Despite the seemingly overwhelming poverty and unemployment of his township, Sipho’s greatest obstacle to achieving his ambition of finishing his degree and finding a job was whoonga. Finding no addiction treatment services in the township, Sipho described how grateful he was that his family found services in one of nearby Durban’s only substance abuse treatment centers – the SANCA Lulama Treatment Centre.

Addicted to whoonga at age 16, Sipho started using this drug cocktail not long after it emerged in Durban. In the time since its introduction, we still don’t know a lot about whoonga.

It was once – and may be still by some – believed to be a myth. That is certainly not the case. Sipho is one of many whoonga users. Driven out of one of Durban’s public parks into a grassy area surrounded by major roads entering and leaving Durban’s central business district, my collaborators at Maternal and Child Health Research in Durban showed me how whoonga users now congregate in this space to get their fix, under the watchful eye of city workers charged with public safety.

Sadly, Sipho did not know what whoonga is. Indeed, many years after its emergence in South Africa no one really does. It is presumed to be a mixture of many things.  Low-grade heroin is likely at its core. However, it is rumored to be mixed with other substances as well, such as rat poison, household cleaning products, and antiretroviral medication used in the treatment of HIV.

With HIV prevalence in and around Durban among the highest in the world, any misuse of these life-saving medications poses a tremendous risk to the global efforts to combat HIV. Diversion of medications for recreational use takes them away from their intended purpose. My collaborators and I have also hypothesized how exposure to antiretroviral medications from recreational use might cause resistance to these medications among whoonga users with HIV who do not know they are infected or who have not yet started treatment. Either scenario would likely increase the cost of providing care as well as result in significant HIV-related morbidity and mortality.

Even if whoonga does not contain antiretrovirals, it still has exacted a heavy toll on the communities in and around Durban. Almost everyone living in Sipho’s neighborhood with whom I spoke knew of one or more people addicted to whoonga, some living in their own homes. After selling all their worldly possessions to feed their whoonga addiction, many users resort to crime.

Crime is taking many forms. Residents of Sipho’s township lament how loved ones addicted to whoonga “empty their homes” of their belongings to pay for whoonga. News articles have also reported how young men addicted to whoonga trade sex for money to buy drugs. “Whoonga gangs” have also reportedly engaged in violent crime to steal money or goods. Indeed, it is presumed that a substantial portion of Durban’s urban crime is related to whoonga.

What was once a hidden epidemic is beginning to be recognized as a significant public health concern. The emerging whoonga epidemic highlights the incredible burden of disease imposed on individuals and families by substance use disorders, as well as the considerable treatment gap for those suffering from addiction. Whoonga’s effect on Durban and its communities also demonstrates the complex relationship between drug use, HIV, and the health and safety of communities. It underscores the need for the provision of comprehensive clinical services that include mental health and substance abuse treatment in every corner of the globe.

*To preserve confidentiality, we did not use the patient’s real name.

Acknowledgments: This trip was supported by a travel award from the MGH Center for Global Health. I am grateful to the Center for Global Health for their support and to Sipho, who graciously agreed to the telling of his story. I would also like to thank the SANCA Lulama Treatment Centre and Maternal and Child Health Research (“MatCH” - part of the Wits Health Consortium of the University of the Witwatersrand). I look forward to our continued collaboration as we endeavor to investigate the whoonga epidemic.