Day 5 -- St Mary's distrct hospital

Day 5
Tuesday
4/9/09

Today was the first official day of rotations. We grumpily arose before dawn for our 6:45am pickup which took us to St. Marys, one of Durban’s district (public) hospitals. A brief tour took us through the pediatric department and maternity ward. Both wards consist of large rooms with rows of beds – privacy is not an option. In the pediatric ward a doctor gently assisted a toddler-aged malnutrition patient in taking a few wobbly steps on tiny skin-and-bone legs while he cried empty, tearless, sobs. In the maternity ward we were told that no epidurals are given but the number of cesareans has jumped due to the HIV/AIDS epidemic. A sign on the wall requests “Parents are kindly asked to take care of their babies and do not give them to strangers,” in both Zulu and English. It is not uncommon for newborns to be abandoned.

Nicole and I were sent to Ithemba, the PEPFAR funded ARV clinic. In South Africa the government provides ARVs, but not until the patient’s CD4 count is below 200 – far below the US recommended guideline of 250-350 (with some peaople pushing for treatment inititation at 350-450). Patients come to Ithemba for all of their HIV/AIDS needs including check-ups and prescription allocation, which includes pill counting in order to check for compliance. The man behind the counter tells us it is a very slow day for the clinic. I can’t imagine what a busy day looks like as the line stretches around the corner and the waiting area has patients queued up five rows deep. A few of the patients actually look sick; most of them just look bored or are chatting and laughing.

My first stop is in “Vitals,” the first room all patients pass through. According to the nurse, they see approximately 100-150 patients per day with 60-70% being women. Patients are brought in once per week to start and then progress to once per month dependent on compliance. One of the check in questions is whether or not the patients is on or has completed treatment for TB as the vast majority of patients test positive. Most patients come in for testing once they have a nagging sickness, very few get tested regularly without symptoms.

1st line: d4T+3TC+RVP or NVP
2nd line: AZT + dd + LPVlr

Next stop is the pill count room, where patients bring their remaining pills to be counted. The actual count is compared to what it should be with 100% compliance and, if “not balanced,” the patient receives compliance counseling. As far as I could tell the counseling consists of the patient being scolded and warned not to do it again but, with lines of patients out the door, there’s little time for more. The clerk let me “pill count” a few patients while he watched over my shoulder which, for some reason, rendered me unable to do the most basic addition. I began to get the hang of it after a few patients which gave the clerk enough confidence to get up without warning and leave for five minutes. Not wanting to seem completely helpless, I just kept on counting.

After the requisite tea time, Nicole and I went in search of a doctor to shadow. Since it was a slower day we ended up spending the rest of the afternoon in a conversation with the one physician on duty, a beautiful younger Indian woman with a firecracker personality. We learned all about the upcoming elections, SA’s government corruption, her frustrations with tradition Zulu culture and patient compliance. Everyone here has a strong opinion about the charges against Zuma being dropped, and the doctor was no exception. According to her, the ANC will win no matter what as they are the majority and will have it no other way. She explained that the vast majority of Zuma’s support comes from people, especially the black population, wanting to support the “party that brought SA to freedom” and have no understanding of “stupid, stupid Zuma and the rest of his monkeys.” Zuma’s win will make SA the “next Zimbabwe” and the doctor is already working on obtaining her visa to “get the hell out of here.” Her outrage as a physician is understandable – polygamy is a major cause of HIV transmission in SA and Zuma is notorious for having four wives (he had five before one’s recent suicide). After a young HIV+ woman accused him of rape, Zuma claimed it was consensual and that he is safe from contracting HIV because he took a shower afterwards. The government is taking money away from healthcare and other urgent needs in order to erect the giant stadiums being built for the 2010 World Cup and other superficial post-apartheid fixes such as changing street names to more pre-colonial monikers such as Smith St to Dr. Methumbi Rd. It was fascinating to hear such candidness from someone with such firsthand knowledge of how SAs government corruption is fueling the spread of HIV/AIDS – and very depressing at the same time. The doctor has thrown her hands up and it’s easy to see why.

After another tea break, our conversation turned to girl talk – US and SA comparisons of cost of living, plastic surgery, where to go on holiday, interracial marriage, etc. The doctor had a million questions about our boyfriends and relationships, the cost of everything in the US, and US city vs suburb living. The cost of living is much less here -- one Rand is worth approximately 10 cents with our lunch today costing 12 Rand ($1.20). The doctor couldn’t believe we wouldn’t be constantly going on holiday to places like Egypt and Thailand, where we would be so rich. It’s strange that, even as a respected physician, she hasn’t been able to come to the US for holiday as she would have to “save up for two years for one week.” Oh… and she was very surprised to meet thin Americans since she thought we were all… insert puffer fish gesture here.

Looking forward to tomorrow – we’ll be in surgery observing cesareans, absess draining, and more.