Observing Dr. Jack Biko at Femina Clinic in Pretoria, South Africa, made me feel like I was back in the United States. Femina clinic is a private women and children’s hospital in the capital of South Africa, Pretoria. Dr. Biko received his bachelors of medicine from the University of Witwatersrand and his masters in medicine from the University of Pretoria (where I am studying) and specialized in both OB/Gyn and Infertility. Until my time with Dr. Biko, I had only experienced the public health sector at the Chris Hani Baragwanath Hospital, which is the largest public hospital in the southern hemisphere and at the PHRU, which is a non-governmental organization that provides VCT and ARVs for free. The public sector is still in the category of developing and far behind the Westernized world in terms of technology, infrastructure, and resources. The private hospital, on the other hand, is very developed and reminds me of a hospital in the States before its most recent renovation. It was definitely as nice if not nicer in all aspects as a small town hospital in Oklahoma. The demographic population of patients at Bara is nearly 100% black with a few colored patients as well. The majority of patients at Femina are also black, but there are a large number of white, colored, and Indian patients.
Dr. Biko’s office was modern and cozy, as is typical of OB/Gyn offices but he even had a sofa in this consulting room which was actually his office. It reminded me more of a psychologist’s office. Actually he does have a psychologist on hand to counsel his couples and patients dealing with stressful infertility issues. Dr. Biko does have EMR (electronic medical records unlike at Bara where they have the patients keep their charts on them since they don’t have a set doctor nor make appointments. Dr. Biko even has snapshots of his patients in their EMRs to eliminate any risk of incorrect identification. Dr. Biko takes his own vitals, preps the exam room for each patient himself, and conducts his own sonograms and ultrasounds which I found rather impressive. It is not only a convenience for his patients to be able to have a sonogram or ultrasound right then and there, but it also strengthens his relationship and trust with his patients, which is crucial to a successful practice. Plus, getting to see the baby is the best part of the job ;) Dr. Biko’s full-scale, one stop shop care allows him to be fully informed and in contact with his patients.
Before shadowing Dr. Biko I had no experience with reproductive endocrinology despite my interest in it as a sub-specialty (however I am no longer considering it significantly since being to Africa and developing many more, stronger interests. As I mentioned previously, Dr. Biko has a psychologist in his office for patients struggling with infertility problems. I realized how hard it can be counseling couple who cannot conceive on their own. One of the couples who came to see Dr. Biko couldn’t conceive, obviously. The woman was 43 and her husband was in his late forties. Dr. Biko ran fertility tests and had to tell them that if they use her eggs for invitro that they stood a 5% chance to conceive with a 70% chance of miscarriage and on top of that slim possibility, the baby would be at high risk of having down-syndrome or another chromosomal disorder. I about cried for them. And also got rather angry when the husband said, “Doctor, I came in with her today to see if it was a problem on her side or on mine.” Fortunately Dr. Biko took the words out of my mouth when he replied, “When it comes it infertility it is a couple’s issue, not one partner. You contribute to the baby just as much as she does.” I am glad that I got to experience a couple of sessions of infertility counseling.
The second day with Dr. Biko was in the surgery theater. I got to observe two surgeries, one in utero polyp removal and a laparoscopy for endometriosis. We had to switch hospitals for the second because his patient’s medical aid wasn’t accepted at Femina. Femina’s surgical ward was not as modern as the rest of hospital surprisingly. One of the newest pieces of equipment in the room was the cd player which played Beyonce’s I Am Sasha Fierce cd during surgery…. TIA. The second hospital was very modern. I could tell Dr. Biko was a bit jealous that he didn’t get to do more surgeries here. During this surgery we listened to Boyz to Men. Hahaha : )
Tomorrow I will be observing at the maternity ward at Baragwanath, where they deliver an average of 50 babies and conduct 20 c-sections per day, for 24 hours. Oh ya and they don’t have epidurals…. Yikes! I’m just about every emotion you can image right now. It’s going to be one for the books. I’ll blog about it soon!
Friday, May 21, 2010
Sunday, May 2, 2010
Afrika Burns
Afrika Burns is an annual, creative arts festival with complete freedom of expression. I have selected this as my ritual because I have spent the past week in the Karoo desert observing and participating in the most intense, inspiring gathering of people, events and ideas that I have ever experienced. The main objective of Afrika Burns is simply to create an atmosphere for participants to project any creative endeavor that they desire and to project aspects of themselves in an environment with no outside judgment or pressures. It is an exercise in total self-reliance; participants camp for five days and provide entirely for themselves, including all their water, shelter and food needs. All money was prohibited; gifting was the only form of exchange. Free love was the underlying theme of the ritual. Love for oneself demonstrated through the lack of make-up, mirrors, razors and clean and stylish clothing, all of which allow a person to reflect on oneself from his or her core. Love for others through gifting, interacting with others without the daily distraction of life and responsibilities, meeting people from all over the world, and seeing beyond their exterior. Finally, love for nature by truly getting to the basics with no running water, electricity, plumbing or littering. All are welcome in this ritual. The only stipulation for attending is that you must participate in whatever way you can: donating something to the community, creating a piece of art, or offering a service. An offering can be large-scale interactive art, music, and performance installations, or small interpersonal offerings between fellow participants such as offering wet-wipes to all those exiting toilets or offering a cooling spray from a water filled spray bottle on a hot day. It was an incredibly liberating week of my life.
Afrika Burns was a festival like no other I have seen. It felt like a retrospective circus. Tents of every imaginable color, red, white, purple, orange, green, and neon pink, were arranged in a wide circle leaving a center to be filled with art installations and dancing, congregation people. The tents were decorated with hearts, lanterns, balloons, flags, and banners. They were constructed with thick canvas stretched taut over long bamboo sticks. The tents varied in size, and my group’s tent was approximately 6 meters by 12 meters of canvas shielding us from the harsh desert sun. Participants also had small camping tents scattered around and some were even mounted on top of their vehicles. One of the most fascinating additions that truly created the circus, festival atmosphere were the vehicles that people travel in. For instance, there was a mini cooper covered in orange carpet with a white, sixty-nine pool ball adorning either side that a clown could have popped out of at any moment. There was also a trailed that had been transformed into a massive battle ship with red sails, which hauled around tens of people at a time blaring much as it went. Best of all was the bukkie covered with hot pink feathers, streamers, and air horns pulling a living room complete with a television, a matching love seat and couch set, mounted deer antlers, a family portrait, 1980’s lampshades and wood paneling. On the front of the bukkie were two horns that sent out burst of flames into the dark night while half naked people danced and sang along to an eclectic mix of oldies and contemporary music.
The people at Afrika Burns were as unique and ostentatious as the tents and vehicles they brought. One of the first people I saw was a cross dresser wearing a hot pink, sequin dress with white platform heels and a pink afro. He was one of the most extreme examples of freedom of expression that I encountered. There was a lot of makeshift clothing and hand sown dresses. Girls wore scarves tied around their heads to hide the unwashed, matted hair. Scarves also comprised the wardrobe for many girls as dresses or skirts. Guys were often shirtless with jeans or khaki shorts. We had to dress accordingly with the weather, which required changing clothes three times per day: dressing warmly in jeans and sweaters in the morning, changing into shorts or dresses in midday; and returning to the warm clothing with an additional scarf or layer in the evening. Given the artiness of most participants, many added very ostentatious accessories to their outfits from buttons to feathers to lights. Many also had their bodies and faces painted with bright designs. The best thing about the apparel for this ritual is that everyone could wear absolutely whatever he or she wanted, or lack thereof for the very free souls, without any judgment or worry of not fitting in.
Gender and age were of little concern in the dynamics of the ritual. Everyone was in the same environment with the same access to water, food and supplies. All people, men, women, young and old, participated in some artistic and loving fashion. The majority of participants were in their twenties and thirties, but there were people from every age group represented. Afrika Burns is one of the few instances where I felt completely equal and not discriminated against in anyway. Also in this event there was no sense or concern with time. During the five days the only instance that time was mentioned was in reference to when meals would be prepared. This was again a very liberating change from my normal, daily life.
The aspect of Afrika Burns that encompasses the ritualistic qualities most strongly was the burnings. The ritualistic burnings occurred at night. Day one nothing was burned. The second night two wooden figures of a man and a woman connected by a rod between their chests were sacrificed. Ironically, the man had a penis where his heart should have been despite the theme of love. On the third night, a ship with tattered sails went up in flames. This burning was accompanied with the first display of nudity of the event. A thin, white male in his mid-twenties was the initiator. No one expressed any opposition to his expression of freedom, but many of us were mildly startled initially. Following this, nudity accompanied each burning thereafter.
Day four was the focal night of Afrika Burns. It began with the sacrificing of the Burning Men. This event drew the largest gather of participants, both clothed and unclothed. The red ship and living room trucks were adding their oldies and techno-music to the ambiance; the smell of cigarettes, alcohol, and paraffin filled the crisp, cool air; and flaming men illuminated the dark, starry sky. The simplicity of such an experience that is able to stun and captivate hundreds of people from all over the world who have undoubtedly seem many of the world’s wonders is remarkable. It brings humanity back to a primal state of being. The fourth night continued well into the dawn. After the Burning Men was the lighting of the Pendulum. Again, all of us starred at the ball of fire swinging in between two massive pillars in fascination. We were all standing on our tip toes in anticipation for the ball to reach the very top of the circular pay and flip. You could hear the chant of “go, go, go” and “ah, so close” with each swing. Finally, the crowd roared with celebration when the circle was complete. We all continued watching the Pendulum in amazement until it was finally stopped by the igniter. For an hour, we were all brought back to childhood. The next object to burn was what we termed the Birth Canal. There were many names thrown around for this piece, the Whale and the Echo, and the beauty of Afrika Burns is that everyone was free to interpret things as he or she wished. There were no boundaries or expectations. The Birth Canal was a series of red wooden panels arched into a half moon shape. The wood went up in flames very quickly and the entire structure was down to ashes within ten minutes. This night, like every other, carried on with plenty of drinking and dancing.
On the fifth and final night, the Letgo Man was sacrificed. He was a four meter tall replica of the Lego man surrounding with blue, white, yellow and red blocks with “letgo” carved out on the top of them. The Letgo Man had been the center of congregation for the group throughout the duration of Afrika Burns so it was a bitter sweet burning. The loudest cheer came when the Letgo Man’s head crashed to the ground and rolled to the edge of the circle of on-lookers. Being the final night, all pieces around the camp had to be burned. Therefore, into the flames of the Letgo Man’s remains went a heard of sheep, a collection of frames, and support poles. This was the first time that participants were allowed to come into contact with the fire. Again, we were all as giddy as children searching for any wooden objects that would give us access to the inner circle.
After the Letgo Man fired simmered, the group migrated to the three meter by three meter Rubrics Cube. The Rubrics Cube was first constructed in its unsolved form with a mixture of green, yellow, red and blue squares decorating each side, but on the night of the burning it was now solved. Apparently it had been repainted during the previous night. As it when up in flames the structure of the Cube remained; the multi-squared pattern was carried into the sky by the rising smoke. All of the on-lookers were in awe. It went down quickly in comparison to the other objects due to its smaller size. The final burning of Afrika Burns was the Sleepy Head. It was layered wood carved into the shape of a profile of face sleeping on a pillow. The burning was accompanied by a parade of nude people dancing around its smoldering ashes to electro-music. It created a very tribal and primitive feel. Later, as I was laying my head on my pillow, I could still feel the vibration of the music.
On the sixth day, everyone was packing up and moving out. There was a solemn ambiance on this day as we were all reluctant to leave is open, care-free, loving celebration to head back to our real lives again. Yes, people were ready for the luxuries of a bed and shower, but with that came the responsibilities and constraints of the real world; time to grow up and be an adult again.
Afrika Burns is a ritual that celebrates freedom of expression and love for all of humanity. It is growing by the hundred each year and will continue to grow in the future no doubt. As my own experience and my interviews reflect, Afrika Burns is a liberating experience that will undoubtedly enhance the lives of all who participate.
Afrika Burns was a festival like no other I have seen. It felt like a retrospective circus. Tents of every imaginable color, red, white, purple, orange, green, and neon pink, were arranged in a wide circle leaving a center to be filled with art installations and dancing, congregation people. The tents were decorated with hearts, lanterns, balloons, flags, and banners. They were constructed with thick canvas stretched taut over long bamboo sticks. The tents varied in size, and my group’s tent was approximately 6 meters by 12 meters of canvas shielding us from the harsh desert sun. Participants also had small camping tents scattered around and some were even mounted on top of their vehicles. One of the most fascinating additions that truly created the circus, festival atmosphere were the vehicles that people travel in. For instance, there was a mini cooper covered in orange carpet with a white, sixty-nine pool ball adorning either side that a clown could have popped out of at any moment. There was also a trailed that had been transformed into a massive battle ship with red sails, which hauled around tens of people at a time blaring much as it went. Best of all was the bukkie covered with hot pink feathers, streamers, and air horns pulling a living room complete with a television, a matching love seat and couch set, mounted deer antlers, a family portrait, 1980’s lampshades and wood paneling. On the front of the bukkie were two horns that sent out burst of flames into the dark night while half naked people danced and sang along to an eclectic mix of oldies and contemporary music.
The people at Afrika Burns were as unique and ostentatious as the tents and vehicles they brought. One of the first people I saw was a cross dresser wearing a hot pink, sequin dress with white platform heels and a pink afro. He was one of the most extreme examples of freedom of expression that I encountered. There was a lot of makeshift clothing and hand sown dresses. Girls wore scarves tied around their heads to hide the unwashed, matted hair. Scarves also comprised the wardrobe for many girls as dresses or skirts. Guys were often shirtless with jeans or khaki shorts. We had to dress accordingly with the weather, which required changing clothes three times per day: dressing warmly in jeans and sweaters in the morning, changing into shorts or dresses in midday; and returning to the warm clothing with an additional scarf or layer in the evening. Given the artiness of most participants, many added very ostentatious accessories to their outfits from buttons to feathers to lights. Many also had their bodies and faces painted with bright designs. The best thing about the apparel for this ritual is that everyone could wear absolutely whatever he or she wanted, or lack thereof for the very free souls, without any judgment or worry of not fitting in.
Gender and age were of little concern in the dynamics of the ritual. Everyone was in the same environment with the same access to water, food and supplies. All people, men, women, young and old, participated in some artistic and loving fashion. The majority of participants were in their twenties and thirties, but there were people from every age group represented. Afrika Burns is one of the few instances where I felt completely equal and not discriminated against in anyway. Also in this event there was no sense or concern with time. During the five days the only instance that time was mentioned was in reference to when meals would be prepared. This was again a very liberating change from my normal, daily life.
The aspect of Afrika Burns that encompasses the ritualistic qualities most strongly was the burnings. The ritualistic burnings occurred at night. Day one nothing was burned. The second night two wooden figures of a man and a woman connected by a rod between their chests were sacrificed. Ironically, the man had a penis where his heart should have been despite the theme of love. On the third night, a ship with tattered sails went up in flames. This burning was accompanied with the first display of nudity of the event. A thin, white male in his mid-twenties was the initiator. No one expressed any opposition to his expression of freedom, but many of us were mildly startled initially. Following this, nudity accompanied each burning thereafter.
Day four was the focal night of Afrika Burns. It began with the sacrificing of the Burning Men. This event drew the largest gather of participants, both clothed and unclothed. The red ship and living room trucks were adding their oldies and techno-music to the ambiance; the smell of cigarettes, alcohol, and paraffin filled the crisp, cool air; and flaming men illuminated the dark, starry sky. The simplicity of such an experience that is able to stun and captivate hundreds of people from all over the world who have undoubtedly seem many of the world’s wonders is remarkable. It brings humanity back to a primal state of being. The fourth night continued well into the dawn. After the Burning Men was the lighting of the Pendulum. Again, all of us starred at the ball of fire swinging in between two massive pillars in fascination. We were all standing on our tip toes in anticipation for the ball to reach the very top of the circular pay and flip. You could hear the chant of “go, go, go” and “ah, so close” with each swing. Finally, the crowd roared with celebration when the circle was complete. We all continued watching the Pendulum in amazement until it was finally stopped by the igniter. For an hour, we were all brought back to childhood. The next object to burn was what we termed the Birth Canal. There were many names thrown around for this piece, the Whale and the Echo, and the beauty of Afrika Burns is that everyone was free to interpret things as he or she wished. There were no boundaries or expectations. The Birth Canal was a series of red wooden panels arched into a half moon shape. The wood went up in flames very quickly and the entire structure was down to ashes within ten minutes. This night, like every other, carried on with plenty of drinking and dancing.
On the fifth and final night, the Letgo Man was sacrificed. He was a four meter tall replica of the Lego man surrounding with blue, white, yellow and red blocks with “letgo” carved out on the top of them. The Letgo Man had been the center of congregation for the group throughout the duration of Afrika Burns so it was a bitter sweet burning. The loudest cheer came when the Letgo Man’s head crashed to the ground and rolled to the edge of the circle of on-lookers. Being the final night, all pieces around the camp had to be burned. Therefore, into the flames of the Letgo Man’s remains went a heard of sheep, a collection of frames, and support poles. This was the first time that participants were allowed to come into contact with the fire. Again, we were all as giddy as children searching for any wooden objects that would give us access to the inner circle.
After the Letgo Man fired simmered, the group migrated to the three meter by three meter Rubrics Cube. The Rubrics Cube was first constructed in its unsolved form with a mixture of green, yellow, red and blue squares decorating each side, but on the night of the burning it was now solved. Apparently it had been repainted during the previous night. As it when up in flames the structure of the Cube remained; the multi-squared pattern was carried into the sky by the rising smoke. All of the on-lookers were in awe. It went down quickly in comparison to the other objects due to its smaller size. The final burning of Afrika Burns was the Sleepy Head. It was layered wood carved into the shape of a profile of face sleeping on a pillow. The burning was accompanied by a parade of nude people dancing around its smoldering ashes to electro-music. It created a very tribal and primitive feel. Later, as I was laying my head on my pillow, I could still feel the vibration of the music.
On the sixth day, everyone was packing up and moving out. There was a solemn ambiance on this day as we were all reluctant to leave is open, care-free, loving celebration to head back to our real lives again. Yes, people were ready for the luxuries of a bed and shower, but with that came the responsibilities and constraints of the real world; time to grow up and be an adult again.
Afrika Burns is a ritual that celebrates freedom of expression and love for all of humanity. It is growing by the hundred each year and will continue to grow in the future no doubt. As my own experience and my interviews reflect, Afrika Burns is a liberating experience that will undoubtedly enhance the lives of all who participate.
Sunday, March 21, 2010
Soweto Tour
March 3 2010
Drive around Soweto:
Vali, a PHRU driver, took me around with him on his visits to the patients of the clinic to deliver letters. This was my first full tour of Soweto. The only word to describe Soweto is diverse. The living conditions range from areas like Mulswatle with shacks, dirt floors, tin roofs and no roads to areas like Rocktown and White Town with two story homes with beautiful architecture located across the street from the friendly, well maintained Thokoza Park.
It is very disheartening to actually see the children living in the shacks playing on the roads and wearing dingy, holey clothing. No one should live in these conditions. The government is building RDP houses in between the shacks in certain communities such as Freedom Park. These houses have a living area and one bedroom plus a bathroom. Each family is allocated one house regardless of the size of the family. The shacks are not destroyed, so new families then move into the abandon shacks.
Another occurrence is that the family that has received an RDP house rents out the RDP house and continues to live in the shack. Building RDP houses is a right step toward eradicating the squatter camps but there needs to be some improvements to the system to actually manifest the change.
The poorest, must run down and dirty area of Soweto is Kliptown. The residents of Kliptown actually live with pigs and use the same river water to clean themselves and wash clothes as the pigs. In this area, there is not even room between the shacks for the government to build RDP houses, nor are the residents of Kliptown shacks being moved into the newly built RDP houses in other communities. The PHRU driver said he doesn’t believe the government is doing ANYthing in or for Kiptown (like its just a lost cause). This is so frustrating and disappointing that I get sick when I think about it. And what’s more is that just across the main road from Kliptown is Eldorado Park with nice, fenced in houses and street lights and sidewalks. The disparity is unimaginable until you actually see it with your own eyes.
On the other side of Soweto, is a first world development. It begins with the brand new rail station that has been built for the World Cup traffic. Across the railroad tracks you will find a very modern, enclosed, shopping mall, a beautiful park, and houses that would go for millions of dollars in certain areas of the US.
On a side note: There is a lot of drama between the new buses and rail system that the government is implementing and the older minibus taxi services which are losing business to the new buses. The minibus taxis have been going on strike in attempts to get the government put a stop to the new bus services, which in my opinion would be horrible because SA is in need of serious public transport improvement and this one of the first large movements by government toward that end.
During the drive, I got to see the Morris Iaasikson High School where the infamous student riots began on June 16, 1976. On that day, black students organized together in protest to the Afrikan’s infiltration of schools and burned down any building or structure that was Afrikans and also burned and stones many Afrikans people. This riot was the spark to the flame that ignited the rest of South Africans to demand equality or at least better treatment from the Apartheid.
The visit around Soweto was eye-opening to say the least. Previously, I was obviously aware of the disparity surrounding South Africa but it took seeing the conditions in person to really grasp how stark of a disparity actually exists.
Drive around Soweto:
Vali, a PHRU driver, took me around with him on his visits to the patients of the clinic to deliver letters. This was my first full tour of Soweto. The only word to describe Soweto is diverse. The living conditions range from areas like Mulswatle with shacks, dirt floors, tin roofs and no roads to areas like Rocktown and White Town with two story homes with beautiful architecture located across the street from the friendly, well maintained Thokoza Park.
It is very disheartening to actually see the children living in the shacks playing on the roads and wearing dingy, holey clothing. No one should live in these conditions. The government is building RDP houses in between the shacks in certain communities such as Freedom Park. These houses have a living area and one bedroom plus a bathroom. Each family is allocated one house regardless of the size of the family. The shacks are not destroyed, so new families then move into the abandon shacks.
Another occurrence is that the family that has received an RDP house rents out the RDP house and continues to live in the shack. Building RDP houses is a right step toward eradicating the squatter camps but there needs to be some improvements to the system to actually manifest the change.
The poorest, must run down and dirty area of Soweto is Kliptown. The residents of Kliptown actually live with pigs and use the same river water to clean themselves and wash clothes as the pigs. In this area, there is not even room between the shacks for the government to build RDP houses, nor are the residents of Kliptown shacks being moved into the newly built RDP houses in other communities. The PHRU driver said he doesn’t believe the government is doing ANYthing in or for Kiptown (like its just a lost cause). This is so frustrating and disappointing that I get sick when I think about it. And what’s more is that just across the main road from Kliptown is Eldorado Park with nice, fenced in houses and street lights and sidewalks. The disparity is unimaginable until you actually see it with your own eyes.
On the other side of Soweto, is a first world development. It begins with the brand new rail station that has been built for the World Cup traffic. Across the railroad tracks you will find a very modern, enclosed, shopping mall, a beautiful park, and houses that would go for millions of dollars in certain areas of the US.
On a side note: There is a lot of drama between the new buses and rail system that the government is implementing and the older minibus taxi services which are losing business to the new buses. The minibus taxis have been going on strike in attempts to get the government put a stop to the new bus services, which in my opinion would be horrible because SA is in need of serious public transport improvement and this one of the first large movements by government toward that end.
During the drive, I got to see the Morris Iaasikson High School where the infamous student riots began on June 16, 1976. On that day, black students organized together in protest to the Afrikan’s infiltration of schools and burned down any building or structure that was Afrikans and also burned and stones many Afrikans people. This riot was the spark to the flame that ignited the rest of South Africans to demand equality or at least better treatment from the Apartheid.
The visit around Soweto was eye-opening to say the least. Previously, I was obviously aware of the disparity surrounding South Africa but it took seeing the conditions in person to really grasp how stark of a disparity actually exists.
Wednesday, March 3, 2010
Some facts and experiences with the SA Healthcare system
Training for Midwife nurses:
I set in on the training session for the midwife nurses at Lenasia South Community Health Clinic today. The obstetric ward at Lenasia South CHC is a MOU (Midwifery Obstetric Unit), which means that all babies are delivered by a midwife. In the public (governmental ran) health care systems in South Africa, the majority of labor and delivery attendants are midwives. Women will be delivered by a doctor if she has complications or is high risk initially; very few women fall into this category. Even most HIV + pregnant women will have safe, normal deliveries and be attended to by a midwife.
For this reason, HIV + specific obstetrical training occurs at the MOUs and hospitals on a regular basis. This month’s training is crucial, however, due to the change in SA governmental guidelines for treatment of HIV in pregnant women and in HIV exposed babies.
The 4 major changes being implemented in April 2010 are:
1) All HIV + pregnant women will be initiated on AZT at 14 weeks gestation (as opposed to waiting until 28 weeks)
2) Women who have a CD4 count < 350 cells/ml will begin ART (triple-therapy) (as opposed to just AZT – mono-therapy)
3) Provision of a “tail” to prevent NVP resistance from single-dose NVP. The tail consists of two new ARV tablets.
4) NVP to ALL HIV exposed babies for 6 weeks (instead of AZT)
Another major change that is being discussed is the promotion of exclusive breastfeeding. Currently, the government supplies 6 months of formula to all HIV + mothers. The government is now discussing recommending exclusive breast feeding due to cost of tins of formula. Yes, breast milk carries HIV, but the pathway through the baby does not allow for the virus to enter the baby’s blood… as long as the stomach lining isn’t compromised. Mixed feeding will wear down the lining of the stomach, however, so women MUST practice EXCLUSIVE breast feeding to reduce risk of transmission. This is obviously a controversial issue.
Labor and Delivery in SA:
One common occurrence in SA is that the women who should be delivering at their local MOU (such as Lens. South) are traveling to the larger Baragwaneth hospital when they go into labor, which is causing an overflow of patients and stressing the system at Bara. I will be researching the reasons for this bypassing of local clinics during labor more in depth, but for now the general idea is that women believe that they will be attended to by a doctor at Bara versus a midwife at a local clinic. However, this is false. Yes, there are doctors at Bara, and Bara is more equipped for complicated and high risk deliveries and can perform c-sections, but if the woman has no complications she will still be attended to by a midwife at Bara. Neither hospital setting provides epidurals on a regular basis since there is rarely an anesthesiologist available. Also, women are not allowed to have family present during labor.
Bara is actually beginning to turn women back to their local MOU clinic if they are not in active labor because their resources and staff are so strained. During my 24 hour observations of the Bara and Lenasia South Ob Wards, I will discuss with the women what their opinion of the services and staff is and why they have chosen to deliver at their particular location.
The PRIVATE hospitals and clinics (not governmental) operate in the same manner as hospitals in the US with patients seeing the same gynecologist through the duration of her pregnancy and delivery. I was told that in private hospitals doctors do not recommend that women be tested for HIV because they do not want to offend the women, whereas in the public systems it is part of the guidelines to recommend HIV testing in pregnant women.
Oklahoma Hospitals Vs. South African Hosptial:
So far I have observed in the Chris Hani Baragwaneth Antenatal Clinic and Obstetric Ward and in the Lenasia South Clinic. During my time there I have noted quite a few differences in the infrastructure of the health care systems other than the actual building infrastructure, which is very out of date and ran down compared to those in Oklahoma.
10 Key Differences:
1) Services in the public clinics and hospitals are free of charge.
2) Epidurals are not available in most settings.
3) Families are not allowed in the labor and delivery wards.
4) Governmental hospitals such as Bara and Lens. South are walk-in clinics. No appointments are made. Therefore, patients will wait at the clinic as long as it takes to be seen. There will be two or three doctors at the clinic, and they simply see the next patient in line. The patients line the walls of the hallway at the clinic.
5) Patients do not see the same doctor for each visit so it is not possible to develop a personal relationship.
6) Due to the lack of organized system I have just described, patients carry around a patient card with them that contains their medical history on it. In the ARV clinics, the medical records are kept at the site because it is crucial that the records not be lost or end up in the wrong hands.
7) For the obstetric visits, blood is drawn in the waiting room.
8) The sheets on the bed are not changed between each patient.
9) As explained above, most deliveries are attended to by midwife nurses not Ob/Gyns
10) Lining the walls of the clinics are posters explaining the importance of vaccines for Polio and Measles and how to avoid TB and Malaria and HIV transmission… all disease that at not prevalent in the US or other developed countries.
I set in on the training session for the midwife nurses at Lenasia South Community Health Clinic today. The obstetric ward at Lenasia South CHC is a MOU (Midwifery Obstetric Unit), which means that all babies are delivered by a midwife. In the public (governmental ran) health care systems in South Africa, the majority of labor and delivery attendants are midwives. Women will be delivered by a doctor if she has complications or is high risk initially; very few women fall into this category. Even most HIV + pregnant women will have safe, normal deliveries and be attended to by a midwife.
For this reason, HIV + specific obstetrical training occurs at the MOUs and hospitals on a regular basis. This month’s training is crucial, however, due to the change in SA governmental guidelines for treatment of HIV in pregnant women and in HIV exposed babies.
The 4 major changes being implemented in April 2010 are:
1) All HIV + pregnant women will be initiated on AZT at 14 weeks gestation (as opposed to waiting until 28 weeks)
2) Women who have a CD4 count < 350 cells/ml will begin ART (triple-therapy) (as opposed to just AZT – mono-therapy)
3) Provision of a “tail” to prevent NVP resistance from single-dose NVP. The tail consists of two new ARV tablets.
4) NVP to ALL HIV exposed babies for 6 weeks (instead of AZT)
Another major change that is being discussed is the promotion of exclusive breastfeeding. Currently, the government supplies 6 months of formula to all HIV + mothers. The government is now discussing recommending exclusive breast feeding due to cost of tins of formula. Yes, breast milk carries HIV, but the pathway through the baby does not allow for the virus to enter the baby’s blood… as long as the stomach lining isn’t compromised. Mixed feeding will wear down the lining of the stomach, however, so women MUST practice EXCLUSIVE breast feeding to reduce risk of transmission. This is obviously a controversial issue.
Labor and Delivery in SA:
One common occurrence in SA is that the women who should be delivering at their local MOU (such as Lens. South) are traveling to the larger Baragwaneth hospital when they go into labor, which is causing an overflow of patients and stressing the system at Bara. I will be researching the reasons for this bypassing of local clinics during labor more in depth, but for now the general idea is that women believe that they will be attended to by a doctor at Bara versus a midwife at a local clinic. However, this is false. Yes, there are doctors at Bara, and Bara is more equipped for complicated and high risk deliveries and can perform c-sections, but if the woman has no complications she will still be attended to by a midwife at Bara. Neither hospital setting provides epidurals on a regular basis since there is rarely an anesthesiologist available. Also, women are not allowed to have family present during labor.
Bara is actually beginning to turn women back to their local MOU clinic if they are not in active labor because their resources and staff are so strained. During my 24 hour observations of the Bara and Lenasia South Ob Wards, I will discuss with the women what their opinion of the services and staff is and why they have chosen to deliver at their particular location.
The PRIVATE hospitals and clinics (not governmental) operate in the same manner as hospitals in the US with patients seeing the same gynecologist through the duration of her pregnancy and delivery. I was told that in private hospitals doctors do not recommend that women be tested for HIV because they do not want to offend the women, whereas in the public systems it is part of the guidelines to recommend HIV testing in pregnant women.
Oklahoma Hospitals Vs. South African Hosptial:
So far I have observed in the Chris Hani Baragwaneth Antenatal Clinic and Obstetric Ward and in the Lenasia South Clinic. During my time there I have noted quite a few differences in the infrastructure of the health care systems other than the actual building infrastructure, which is very out of date and ran down compared to those in Oklahoma.
10 Key Differences:
1) Services in the public clinics and hospitals are free of charge.
2) Epidurals are not available in most settings.
3) Families are not allowed in the labor and delivery wards.
4) Governmental hospitals such as Bara and Lens. South are walk-in clinics. No appointments are made. Therefore, patients will wait at the clinic as long as it takes to be seen. There will be two or three doctors at the clinic, and they simply see the next patient in line. The patients line the walls of the hallway at the clinic.
5) Patients do not see the same doctor for each visit so it is not possible to develop a personal relationship.
6) Due to the lack of organized system I have just described, patients carry around a patient card with them that contains their medical history on it. In the ARV clinics, the medical records are kept at the site because it is crucial that the records not be lost or end up in the wrong hands.
7) For the obstetric visits, blood is drawn in the waiting room.
8) The sheets on the bed are not changed between each patient.
9) As explained above, most deliveries are attended to by midwife nurses not Ob/Gyns
10) Lining the walls of the clinics are posters explaining the importance of vaccines for Polio and Measles and how to avoid TB and Malaria and HIV transmission… all disease that at not prevalent in the US or other developed countries.
Friday, February 26, 2010
Clarens, SA: My Happy Place :D
Clarens: Most peaceful place I have traveled to...
Last weekend the residents of Tuksdorp spent the weekend in Clarens, South Africa. Clarens is a quaint, quiet mountain town. The town is nestled in the middle of the mountains, so towering around the city are massive, beautiful mountains of rolling green grass. It is breathtaking. It is about a four hour drive from Pretoria, and a trip I will be taking again.
On Friday night we had dinner at the “mom” of Tuksdorp’s house. She lives in both Pretoria and Clarens. .. so jealous. Brad Pitt also owns a house in Clarens, which is proof that it is one of the most beautiful places in SA because he could buy a house anywhere, right?! We had a lovely dinner and a beautiful night. The second day we woke up and left for the Bokpoort Ranch where we went for a trail ride on horses. It was a “textbook” ranch. It had been in the family for three generations, and they offered all kinds of guided activities, my favorite being horse riding of course!
There were 20 of us who went for the ride; the majority of which had never ridden before. This slowed us up a bit, but it was nice to go slow and take in the whole scenery. Occasionally those of us who are more experienced would gallop off for a bit. Galloping up the mountains brought me back to my childhood days of trailriding in Colorado.
I really don’t think I have ever been as light-hearted and content as I was in Clarens. Above is the picture of my “happy spot” where I set by myself following the riding to just take it all in. I can’t wait to be back in that exact spot and to feel the same contentment and peacefulness I did at that moment. It is a precious feeling.
I also can’t wait to share this place with my friends and family. I know my mom and grandma will fall in love with it as much as I did.
That evening all of the students went to the pub for drinks except for four of us. The four of us who stayed back just wanted a chill night of peace and quiet. We went for tea and talked for a bit. I took the opportunity to lie out on a picnic table and look at the stars. In the quiet night with all of the lights off the stars were as bright as day; I even saw a few shooting stars. It was the perfect ending to the perfect day!!!!
Wednesday, February 3, 2010
My First Day with Patients :D
3 Feb 2010
Today, I was able to follow Dr. Fatima around the PHRU clinic working with HIV infected patients. I have been dying to get exposed to patient practice here. There are challenges that are specific to the 3rd world and to the HIV population that I was aware of and prepared to handle but when I was actually face to face with the patients who are dealing with these obstacles it was much harder than I imagined. For instance, out of the seven patients I saw this morning, three had to be counseled on medication adherence. It is fairly common for patients and study participants to undervalue the importance of adhering to their ARV regimens. The two most significant reasons for the need of proper adherence are 1) to prevent development of resistance to ARV drugs – this is an issue worldwide but extremely crucial in SA because of the lack of access to alternative medications if resistance does develop to one that the patient is currently on.
Currently there are 2 regimens used in SA –
A: includes the following 3 drugs
*D4T-> metabolic side effects include lipodystrophy (the shifting of body fat to the abdominal area and thinning of limbs), lactic acidosis (the buildup of lactic acid due to mitochondrial dysfunction), and peripheral neuropathy (irritating nervous sensitization in the feet primarily)
*3TC/lamivudine
*Efavirenz or Nevirapine
B: if the patient’s VL does not suppress on regimen A or if patient develop a severe case of lactic acidosis, the patient will be switched to the following regime.
*AZT/zidovudine
*DDi/didanosine
*Lopinavir/RTV/ Aluvia—a PI
If patients do not adhere to these regimens or are unresponsive for some reason, their final option is death.
These two regimens are the only two options available in SA due to the cost of medications. Fortunately, for the patients and study participants at the PHRU, the medications and doctors consults are free of charge. The PHRU is funded by USAID. Go America!
The second reason it is crucial for patients to adhere to their medication when participating in studies is because the study investigator has no choice but to remove them from the study and discontinue ARV medication because they will no longer fit into the criteria of the study and would invalidate the study if included in the results AND the PHRU cannot continue to provide the drugs because they will no longer be paid for by the sponsors since they cannot be in the study any longer.
People who refuse to adhere (after exhaustive counseling) to their medication regimen will no longer receive free ARVs and will die within months or at most a few years.
Today Dr. Fatima had to explain this to a man who has not adhered for many months and told him it was his last chance. The severity of the statement hit me hard, and I had to restrain the overwhelming distress that I’m sure was all over my face.
In addition to lack of alternative regimens, South Africans are also restricted by the availability of medications to treat opportunistic infections and diseases that would not be as inhibitory in developed nations. For instance, a woman had very high cholesterol and Dr. Fatima had to tell her that there was nothing she could give her because the cholesterol medication that Bara could provide (had free access to) has life threatening side effects if taken with her ARVs and the other wouldn’t be effective for her situation. There is a 3rd medication ideal for her but she would have to pay out of pocket (which is typically not an option for most SA). Fortunately, this particular patient seemed as though she may be able to afford the medication.
Also, all infections, sicknesses, and diseases not related to HIV are exaggerated in HIV + people due to their repressed immune system. Today, I saw a ringworm the size of my fist due to this exaggerated effect.
I conducted the HIV dementia test on 2 patients today to analyze the effect of HIV on their brain level activity. HIV is drawn to the brain and can cause severe dementia. Nevirapine is the best ARV available in SA to prevent dementia because it penetrates the CNS very effectively to combat the virus. The first woman I conducted the test on scored the highest possible score; the second man I tested scored very, very low reflecting inadequate brain activity. Knowing a patient’s level of dementia allows a doctor to counsel the patient in the correct and most effective manner.
Today, I was definitely overwhelmed with emotions, knowledge and concern during my short time with Dr. Fatima, but still… I can’t wait to become more knowledgeable and more exposed to this population.
Side note:I have submitted CV (resume) to Dr. Coceka to be included in packet for study approval by Ethics Committee Board so that I can be included in the study team for the premature delivery study.
Today, I was able to follow Dr. Fatima around the PHRU clinic working with HIV infected patients. I have been dying to get exposed to patient practice here. There are challenges that are specific to the 3rd world and to the HIV population that I was aware of and prepared to handle but when I was actually face to face with the patients who are dealing with these obstacles it was much harder than I imagined. For instance, out of the seven patients I saw this morning, three had to be counseled on medication adherence. It is fairly common for patients and study participants to undervalue the importance of adhering to their ARV regimens. The two most significant reasons for the need of proper adherence are 1) to prevent development of resistance to ARV drugs – this is an issue worldwide but extremely crucial in SA because of the lack of access to alternative medications if resistance does develop to one that the patient is currently on.
Currently there are 2 regimens used in SA –
A: includes the following 3 drugs
*D4T-> metabolic side effects include lipodystrophy (the shifting of body fat to the abdominal area and thinning of limbs), lactic acidosis (the buildup of lactic acid due to mitochondrial dysfunction), and peripheral neuropathy (irritating nervous sensitization in the feet primarily)
*3TC/lamivudine
*Efavirenz or Nevirapine
B: if the patient’s VL does not suppress on regimen A or if patient develop a severe case of lactic acidosis, the patient will be switched to the following regime.
*AZT/zidovudine
*DDi/didanosine
*Lopinavir/RTV/ Aluvia—a PI
If patients do not adhere to these regimens or are unresponsive for some reason, their final option is death.
These two regimens are the only two options available in SA due to the cost of medications. Fortunately, for the patients and study participants at the PHRU, the medications and doctors consults are free of charge. The PHRU is funded by USAID. Go America!
The second reason it is crucial for patients to adhere to their medication when participating in studies is because the study investigator has no choice but to remove them from the study and discontinue ARV medication because they will no longer fit into the criteria of the study and would invalidate the study if included in the results AND the PHRU cannot continue to provide the drugs because they will no longer be paid for by the sponsors since they cannot be in the study any longer.
People who refuse to adhere (after exhaustive counseling) to their medication regimen will no longer receive free ARVs and will die within months or at most a few years.
Today Dr. Fatima had to explain this to a man who has not adhered for many months and told him it was his last chance. The severity of the statement hit me hard, and I had to restrain the overwhelming distress that I’m sure was all over my face.
In addition to lack of alternative regimens, South Africans are also restricted by the availability of medications to treat opportunistic infections and diseases that would not be as inhibitory in developed nations. For instance, a woman had very high cholesterol and Dr. Fatima had to tell her that there was nothing she could give her because the cholesterol medication that Bara could provide (had free access to) has life threatening side effects if taken with her ARVs and the other wouldn’t be effective for her situation. There is a 3rd medication ideal for her but she would have to pay out of pocket (which is typically not an option for most SA). Fortunately, this particular patient seemed as though she may be able to afford the medication.
Also, all infections, sicknesses, and diseases not related to HIV are exaggerated in HIV + people due to their repressed immune system. Today, I saw a ringworm the size of my fist due to this exaggerated effect.
I conducted the HIV dementia test on 2 patients today to analyze the effect of HIV on their brain level activity. HIV is drawn to the brain and can cause severe dementia. Nevirapine is the best ARV available in SA to prevent dementia because it penetrates the CNS very effectively to combat the virus. The first woman I conducted the test on scored the highest possible score; the second man I tested scored very, very low reflecting inadequate brain activity. Knowing a patient’s level of dementia allows a doctor to counsel the patient in the correct and most effective manner.
Today, I was definitely overwhelmed with emotions, knowledge and concern during my short time with Dr. Fatima, but still… I can’t wait to become more knowledgeable and more exposed to this population.
Side note:I have submitted CV (resume) to Dr. Coceka to be included in packet for study approval by Ethics Committee Board so that I can be included in the study team for the premature delivery study.
Tuesday, February 2, 2010
Perinatal HIV Research Unit... Finally :)
I spend Tuesday, Wednesday, and Thursday each week in Soweto (a very large township just outside of Jo’berg) interning at the Perinatal HIV Research Unit. I found this internship through my previous internship because we worked with them a bit. I was immediately very intrigued by the work the PHRU undertakes such as conducting many studies regarding the spread of HIV, the social stigma surrounding those infected with HIV, and of particular interest to me… prevention of mother to child transmission of HIV. That is the department I am working in. I am working with Dr. Coceka Mnyani on a handful of research projects for which I am conducting literature reviews, analyzing patients’ charts, and interpreting surveys. So far I have been working on a literature review regarding the risk of premature delivery on antiretroviral therapy and spent 15 hours in a course call Good Clinical Practice and feel completely prepared to conduct , monitor, audit and participate in a study. It was a lot of information to say the least.
I am most excited about traveling to the rural clinics surrounding Soweto with Dr. Mnyani to treat and work with HIV + pregnant women. I should be able to go on my first round later this week :)
The PHRU is a branch of the Chris Hani Baragwanath Hospital, which is the largest public hospital in the southern hemisphere! My first day at the hospital took me by surprise… Bara is definitely not up to the standards of any US hospital I have seen and the electricity is out quite often. Yes, my first day I got to climb 12 flights of stairs 3 times. :O
I was pleasantly surprised to learn that in SA, the government provides free healthcare services and medications to any citizen who attends a public hospital! Of course it is paid for through the tax payers’ money, but everyone enjoys the stability and security it offers them and their family members. For providers it gets a bit overwhelming at times I’m guessing though. Dr. Mnyani said that at Bara there are 60 deliveries and 15 cesarean sections daily! That 10x what I have seen in all my 150 hours of shadowing in just one day! Amazing!
I am most excited about traveling to the rural clinics surrounding Soweto with Dr. Mnyani to treat and work with HIV + pregnant women. I should be able to go on my first round later this week :)
The PHRU is a branch of the Chris Hani Baragwanath Hospital, which is the largest public hospital in the southern hemisphere! My first day at the hospital took me by surprise… Bara is definitely not up to the standards of any US hospital I have seen and the electricity is out quite often. Yes, my first day I got to climb 12 flights of stairs 3 times. :O
I was pleasantly surprised to learn that in SA, the government provides free healthcare services and medications to any citizen who attends a public hospital! Of course it is paid for through the tax payers’ money, but everyone enjoys the stability and security it offers them and their family members. For providers it gets a bit overwhelming at times I’m guessing though. Dr. Mnyani said that at Bara there are 60 deliveries and 15 cesarean sections daily! That 10x what I have seen in all my 150 hours of shadowing in just one day! Amazing!
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