Ethembeni: clinic life

Ethembeni clinic: Yesterday, 7.25.07, we visited one of the 13 satellite clinics operated by Department of Public Health nurses. The waiting room was packed with women, men & children awaiting a visit with the nurse. Some to get ARVs, some for antenatal care, and many for other various ailments. The beauty of this place- is that it is operated by nurses- all 13 of the clinics in fact. The nurse I observed operated like a Nurse Practitioner. It was such a great thing to see, because as far as we have been able to tell- NP is not a role held in South Africa. These lead nurses in the clinics however, may not be called by this title, but they seem to act as such.

The nurse I observed did assessments, diagnosed & dispensed medications. I watched her do a routine antenatal (or prenatal) visit. She measured the fundal height, listened for fetal heart tone (not with a doppler, but a plastic device you put your ear up to- I am sure I should know the name of it), and she palpated for the position of the fetus. It was such a pleasure to see her in action, and was role in which I could totally see myself- especially if I could speak Zulu... Yebo.

As a former manager of a community health family planing clinic in Cali, I could not help but note the details of the procedure for seeing patients. There were no appointments. The patients came in on a first come, first serve basis, and waited as long as it took to be seen. There were 2 "clinicians"- the lead nurses seeing patients and at least one nurse taking blood pressure, weight & blood & urine type measurements. There were several lay counselors that were doing VCT: voluntary counseling & testing, for HIV testing, as well as counseling on medication adherence, & PMTCT: prevention of mother-to-child transmission, of HIV- for pregnant patients. There were front desk staff and the chairs for waiting patients spilled out onto the covered front porch. I read every detail on the wall when I was in the room with the nurse. There were antenatal care visit guidelines, STI treatment guidelines, diabetes medication guidelines, and an injectable contraceptive calendar- all hanging on the wall. Oh how it reminded me of my life at PP. I just love clinic life, and it was great to feel it in my blood again- even in the other side of the world. I wanted to start working there right away, if only I was already a NP...

Amazing to me how similar rural Msinga can feel like urban Richmond, California at times like this. Instead of me struggling with my Spanish I struggle with comprehending the musical language of Zulu. Practicing my humorous linguistic "clicks," oh so natural to the people here. My Sewanee anthropology professor & advisor, Dr. O'Connor would be so proud.

This one's for T.

The road home to Tugela Ferry from Pietermaritzburg:

7.20.07

The Pediatric Ward

I believe that you can understand the health of a community by looking at its children. I have visited the pediatric ward several times now, but today more than ever, I am distraught. I am saddened & I am holding back tears from the disparity that exists so plainly before me. Before coming to South Africa I completed my pediatric clinical rotation in New Haven at Yale New Haven Hospital. It is with that hospital fresh in my mind, that I cannot help but compare. I think that I am upset today because the reality of the situation of the community is not only increasingly more complete at this point in my experience, but I am also now more attached to its well-being as a whole.

Many of the children run to us & surround us as we enter the ward. It is actually a very difficult thing to experience. The children appear, so many of them, so very in need of touch- so very in need of so many things in fact. Immediately my instinct is that I want to bathe them all. They have nasal drainage dripping from their noses & many faces are encrusted with what appears to be yesterday's nasal drainage as well. Some are coughing, some are limping, many are bandaged, some are burned, and these are the ones that can walk over to us with enthusiasm. Many others are confined to their beds, either because of age or condition. The beds are metal, somewhat rusted, and seemingly 30-year old versions of the ones they have in the pediatric wards at Yale. The patient charts are placed in abandoned boxes of what I think once held X-ray film. These "Agfa" boxes are strung up to the foot of the beds. There are children in the beds with meningitis- very common in this high HIV setting. Other common diagnoses include failure to thrive, & TB. Some children await a diagnosis of HIV, as they are being treated for vomiting, diarrhea & fever.

Today one child is presumably waiting to die, because her liver has failed. The doctor informs me of her poor prognosis, explaining that the only hospital capable of a liver transplant is on the other side of the country, in Cape Town. She looks around 6 years old, but may be younger. Because of poor nutrition, malnutrition, & chronic debilitating conditions such as HIV & TB, I find that many children look much younger than they are. This girl exerted so much effort to breathe, that you could hear her grunting with each inspiration from halfway across the room. It hurt me just to watch her breathe, & left me wanting to do something more. Her family arrived at some point while I was there. I assume it was her family, but no one spoke to them and they did not ask any questions. They just stood with saddened eyes next to her bed. When next I looked they were gone.

One child had cerebral palsy & was experiencing uncontrolled seizures. His mother was with him constantly, & seemed to be working so hard to take care of him. My heart broke three times just observing her love. Another mother cared for her 9 month old daughter, who I would have guessed was 4 months old had she not been sitting, unsupported on her bed. Her body & most notably her head, were so small. Her beautiful, bright eyes appeared to bulge slightly, perhaps from their size in comparison. There were some mothers scattered throughout the ward, some children on the floor reclining, some on foot, & many in beds. I could see all of this with one watchful glance, because there are no private rooms & no curtains to draw- everything is exposed. The children at our knees & in our arms do not wear underwear. I saw no diapers, just the gowns, white & blue.

Then, there is even more reality. Many of these children have no family, no parents, & have no one visiting them. Some are actually on the ward partially because they have no where else to go. Perhaps this is the case, we wonder after leaving, for 2 of the children that were acting out towards the other children. Perhaps they have no one available to give them love. This is part of the troubling state of the greater Msinga community, and much of South Africa. Where a generation of mothers & fathers with households of pediatric age children are lost to, or dying from AIDS. The number of children in this ward alone, infected with HIV is undoubtedly staggering in comparison to a ward in the United States. Theses children, the future fathers & mothers of the country, already affected by such physical hardship at such a young age- a lifetime of ARV treatment, managing side effects, & dealing with stigma.

I am in no position whatsoever to assert any hardened facts about this crisis, only to say that it is one. The people of the hospital here, work wonders in the community, and I by no means wish to criticize the incredible work that they do. There are true freedom fighters here in this community of health care, working everyday on the fight against the injustices of health disparity, wealth disparity and racial disparity. People here have devoted their lives to this, and make great changes in the lives of many each day. I am grateful and honored to be amongst so many of them. I only wish that I could move mountains & do more.

My Mind Raced: a home visit

Today I visited a family of six that lives far out in the hills of the community. The road to their home was rocky & could almost not be travelled by a 4-wheel drive bakkie (AKA: truck). The view on the drive was spectacular. Their home was in traditional Zulu style- a rondavel (a round hut with conical thatch roof) and it was about the size of a large bedroom. There was a dirt floor & the walls encircling us were a mixture of mud & cement. A man, the patient we were there to visit, was covered in a blanket on a mat on the floor. Beneath the blanket the outline of his body was difficult to trace. He was so thin that the lines were blurred in deciphering where his body began & where a slight lump in the blanket ended. A woman, his wife, held a child. The child had on only a shirt, I noticed as she sat him on the floor. I learned he was 8 months old. Another child, age 3, toddled inside the rondavel. He was fully dressed, but from behind I noticed his shorts were torn in several places revealing his buttocks. A third child hovered outside, shy, with several neighbor children. I was informed that the family's oldest child was at school.

The father, our patient, had recently been diagnosed with tuberculosis. Mary, taking on perhaps her most enduring role, as home-based caregiver, knelt & sat next to him on the floor. Another home-based caregiver escorted his wife outside. I was explained that this was to secure privacy for the man in case he was HIV infected, and had not disclosed. The patient explained that he had been to the out-patient clinic at the hospital where he was diagnosed with TB. He had been on medications now for 1 week. In South Africa, and particularly in this area, when one has TB the next question asked is regarding the possibility of also having HIV. The patient was of course asked this, and he said he had not been tested. I was explained that he later mentioned being tested & that his results were negative. A South African medical student also visiting Tugela Ferry, and with me at this time, mentioned that it was not uncommon for people to say that they have been tested and are uninfected even when they have not actually ever been tested. With these statistics, who can blame someone for being afraid.

I have several times on this trip been in a position where I know that I will never fully be able to describe the circumstances of the situation, and this was one of those times. The poverty was palpable, & the reality of it was all consuming. There was very little in the home, a single size bed, cot-like with wooden legs tied together at the corners, a small table which held 2 cardboard boxes, the contents of which seemed to encompass the few kitchen supplies they had. Several tomatoes sat nearby as well as a large, dusty jug of water-resting on the floor. I was told that they had no food. I was left to wonder: was this the literal translation from Zulu? No food? Or did they perhaps say: "little food"? It was hard to know in that instant if I was prepared to meet a family of 6 with no food. Immediately my mind raced: How many Rand might it cost to feed them right now, then tomorrow, and next week?...

The home-based caregiver assited the mother in the administration of her husband's TB medications- one, two, three, four, five pills I counted as she scooped each of them individually on to a spoon and then slipped them into his mouth. He appeared just strong enough to momentarily prop himself up on his elbows, in order to swallow the pills. I was explained that the home-based caregiver asked them about their water source. The woman replied that she normally fetches the water from a local spicket, but since it has been broken she has gotten it from the river. I was told that they normally grow food, but cannot now because there is no water. Again, I wondered: No water? or perhaps they meant, "little water"? My mind suddenly flashes to a movie theatre in the Unites States, with giant 8 dollar jugs of soda and long lines at the snack counter to purchase them. The American cinema in this moment to me, was nothing more than a seemingly unlimited & extravagant buffet of food & drink. I could no more imagine this family in line at the theatre than I could imagine a Monday with no food and no water.

Much more discussion & education took place in the home that was not translated. They wanted pictures taken I was told. I showed the father a picture of his youngest son on my digital camera. He laughed & smiled. Still strong enough to smile, I thought. How will he get his medications when he runs out? I wondered. It was such a long & difficult drive- an even longer & more difficult walk. He'll be stronger by then, I hoped. The mother & children accompanied us back up the road to our vehicle. I see their plot of land, drying brown in the Sub-Saharan, winter sun. Mary pulls out toys to give the children: used ones, presumably donated from America, the hand-me-downs of many children who now have bigger & better toys. One is a McDonald's happy meal prize, another a tiny troll doll with striking blue hair, a picture book, a paper clock with moveable arms, & a catching game with a ball and 2 torch-like plastic mitts. I have seen it before, played by children at the beach.

Mary hands one of the children a loaf of bread and begins packing up large quantities of raisins from a box, into a plastic pitcher & tin bowl brought from the family's home. Kun & I give all the children heaping handfulls of raisins, as the bowl & pitcher are filled beyond their limits. My mind races: Are my hands clean enough to handle their raisins? How long will these raisins even last? Is this all they will eat today? How can I give them more? How far will a loaf of bread go in a family of 6?
I continued to hand out raisins. The mother thanked us, shyly. We thanked her. What had we done really? There was so much to be done. We said our goodbyes. As I wished I had so much more to give, I imagined the asiles at Target & things the family might get there: diapers, baby wipes, big family size boxes of cereal, & shorts with tags that read things like, "size T3." & "wash with like colors." We parted ways, my mind raced, and my hands were sticky from raisins.

One thing leads to another

Question: How do you set up systems to care for this disease: HIV/AIDS in a community with so many risk factors?


When the risk factors are so plentiful: poverty, lack of education, inadequate access and knowledge regarding health care, cultural/traditional beliefs & barriers. I have learned from this experience many things, one being that you cannot talk about health and prevention of HIV/AIDS without discussing these matters.

Last week we drove to one of the farthest village areas of the community known as Msinga Top. The drive is at least an hour up a mountain. Most people who live there do not have cars. We knew we reached our destination when we arrived at a tree surrounded by at least 20 women sitting beneath it, awaiting our arrival. There were about 5-7 men scattered close enough to listen to the conversation that ensued. We visited Msinga Top with Mary, the home-based caregiver leader. She frequently goes on home visits herself to visit patients out in the community & tirelessly visits communities to speak to members to educate them on their health & safety.


On this day we were visiting to give a talk on prevention of HIV/AIDS. Susan was speaking & Mary translated her words into Zulu. The discussion went well- it was spectacular to witness community education on a mountaintop, under a tree, & out in the winter sun. The women of the community listened carefully but did not ask any questions. The men however spoke up with many thoughts, concerns & jokes. It was eyeopening to watch the conversation move from HIV prevention & testing to the pressing issues of poverty, unemployment, & lack of resources & transportation. One man asked how he could make money from the crops growing in the nearby community field. Another man asked what he was to do for money, with no job, in order to pay for transportation to the clinic or hospital. "How do I even afford to go the clinic to have a test." Another man questioned how he was to stop having sex with women other than his wife. This was a significant concern for the men. They expressed that the prevention tactic of remaining faithful to their partners was unrealistic. "Are we to get rid of our concubines?" An older man asked, seemingly a little angry. He actually stomped away a little later. One man mentioned how it is hard with his wife because she is always so tired when she comes back from gathering water & firewood. He said that because she is tired she ends up yelling at him. Susan asked if perhaps he could help his wife with her work so she would be less tired. All the men laughed, as well as the women. What a peek we had into the men's perspectives, at least, on this area of their lives. The answers are not easy. At the end of the discussion the men strolled away casually & the, until then silent women, thanked us warmly. There is much to think about here, everyday. The problems before us in the community are many & complex. There are people dying from AIDS everyday here in Tugela Ferry. Nearly everyone is affected in some way by the disease.

community health in action & song

Yesterday, 7.18.07, we helped out at a 1-day conference for the volunteer home-based caregivers. It was part information session and part appreciation day, since these 300 some odd women work tirelessly for no financial compensation. It was a wild experience of community health in action. It was seemingly a bit disorganized but at the same time, a very large affair. The building used was the actual church at the Mission. The Rock of Life Church, AKA "The Mission," here is very intertwined with many of the community health activities. It runs the Orphan Care project for instance as well as Philanjalo- the hospice for AIDS patients. Similarly, Philanjalo runs the volunteer community based caregivers work in the community. They are also associated with the public health clinics out in the community, which are government run.

The day yesterday began with the preacher speaking for quite awhile in Zulu, and when I say speaking I mean yelling. It was intense to not know what was being said- but it was religious in nature. There was beautiful Zulu songs throughout the day. Each speaker in fact, except Dr. Tony Moll, began their talk with singing: some call & response type songs, there was clapping and arm motions to accompany songs. This was beautiful & lively. It kept the women's energy up as they listened to information regarding their care delivery system. At a point during the day many of the caregivers came to the front of the room & sang a song in Zulu which was completely moving. They danced with the words, swaying & motioning their arms at certain points in unison. I learned during it, that the song was listing the anti-retroviral medications. It gave me goosebumps. This was health education & Zulu tradition in action, a beautiful merging of culture. At the end of the day there was food for the women to eat, for many it might be their only meal of the day. I helped with administrative tasks that were many & challenging in such a large group. I was asked to take photographs, mug shots if you will, of the new home-based caregivers so that they could get issued photo IDs to wear when out in the community. Above is one of my favorites- sorry it is sideways...

The day went on into the evening. There was the challenge of issuing money to leaders so that they could pay for each of the caregivers' transportation to & from the meeting. Many came from very far away. Thanks to Yale School of Nursing we also gave gifts of bread flour, mealie/maize meal & sugar, to each of the women. This in itself was a challenge, in organization- somewhat of a comedy of errors. We ordered the large (300!) quantities of each of these gifts on Monday (not nearly enough time, in out eyes) when we were informed of the conference, in only 2 days notice and instructed that would be the day to administer this gift. When we went with Mary to order the products at the Spar, nothing was written down, no numbers or time tables exchanged. Very un-American in style. Unfortunately the arrangements did not all unfold exactly as planned so we ended up giving vouchers to the women to take to the grocery store for these 3 items. What a day!

Mhlangana Clinic

Today Kun & I had our first session of teaching at one of the 15 government/department of public health community health clinics in the extensive area surrounding the hospital. The session included approximately 30 of the 300 volunteer home based caregivers (HBC). The 300 care givers are each clustered in a group around one of the 15 clinics, the closest clinic to the community in which they live. These HBCs go out into the community and act as liaisons from the community health clinics. They link the community to the nurses, called "sisters" here, that predominantly run the community clinics. The HBCs are in essence an extension of the clinic & nurses, in that they go to visit people in the community that are either too sick to travel the distance to their local clinic, or far enough away that they cannot afford to pay for transport to the clinic. They are not medically trained, but they are trained in the work that they do as home-based caregivers. These women work very hard in this position for free. Mary, who is our liaison here in Tugela Ferry, is responsible for the HBCs, as well as so many other wonderful things. She is full of life, energy & selfless compassion, and she has become over this brief time here, our friend. One of the many things she coordinates, is the training of the HBCs. She drove us this morning the hour long drive to Mhlangana Clinic, where a group of HBCs were awaiting our arrival. She also acted as our interpreter. At the clinic Kun & I gave a talk covering basic information on the following topics: the pathophysiology of HIV/AIDS, ways for the caregivers to protect themselves when working with patients, the significance of the use of gloves, signs of tuberculosis, ways to protect themselves from TB, procedures for disposing of or cleaning linens & supplies that have had contact with bodily fluids, nutrition support for patients with AIDS and TB, including specific foods, the significance of hydration, ways to detect dehydration by brief physical assessment (thanks Linda Pellico!), the importance of assessing for pressure ulcers, caring for them, and the ways to prevent them. It went very well. Kun & I had very little prep time & we pulled if off wonderfully- a very good team. After we finished we asked the women if they wanted to share any of their stresses or concerns. This was one of the best parts. After a slight pause, women began to raise their hands to speak. They discussed fears regarding limited access to TB masks amidst the rise in MDR & XDR (multiple drug resistance & extremely drug resistant) TB in the community. Several women discussed patients' concerns regarding privacy & the stigma of AIDS. They shared that some patients worried that if the caregivers used gloves to care for them, than their neighbors would know they had HIV. They complained that sometimes when they left gloves in the home for the primary caregiver/family member to use when caring for the patient, someone in the family would use them for such things as mixing cement instead. It was an eye-opening & invigorating day. I felt so welcome & grateful to be there with them. The meeting closed with the women singing a beautiful song.

Snapshot 7.16.07

A snapshot of yesterday: On a quick drive to secure a setting for a home based care giver in-service: to discuss with the local Chief availability of a community hall...

Brown mountains surround the horizon, many with plateaus- the hills are speckled with shrubs some brown, some a faded shade of green. The land around me is dusty, for it is winter and there is no rain. It is rocky. Goats wander through the streets and on the surrounding land- in fact everywhere you look there are goats. Roosters & hens meandering, pecking at the ground. Today we saw baby chicks. In South Africa it seems you don't always need a "road," as we are accustomed to, to drive from one place to another. Any land will suffice. You can make your own simply by where you to decide to drive your vehicle.

The markets of Tugela Ferry are bustling: women selling sweet potatoes, onions, avocados, long net bags of oranges and even long plastic bags filled with "Cheetos." Clothes are laid out on the street for sale. Blankets & towels are draped over fences & aloe plants to be sold for use. These are used creatively here. Women wrap towels in many ways. Some wrap them around the waist as a skirt, or even on top of another skirt, as added layer. Some use towels as a means to attach their babies to the their backs. The process to do this is certainly worth observing. As the process begins, the child appears magically suspended in air, or suctioned to the woman's back. The woman manipulates the towel so that it surrounds the child's back. It is tucked under the child's bottom and then again at the child's shoulders, and finally tied in front, at the woman's chest. It appears unstable & unsafe to our American eyes: will the child fall out the bottom, will his head swing to freely with so little neck support? Yet, this is done enumerable times, everyday, and it works. I notice that some teens & younger women wrap their towel skirts much shorter, letting it hit at the knee. Skin care: many women here rub a kind of soil over their faces to act as a shield from the sun, dare I say sunscreen. It appears as a pale orange color over the skin- like a mud mask of sorts.
The diet of the Zulu people of this area is fairly simple, in that they have & can afford very little. "Mealie meal" is a staple, or maize meal, and it is made into many things depending on the consistency or form it is shaped or stirred into, when it is prepared. One preparation is a putu porridge, resembling the grits of the American south but less creamy. Putu porridge is most often eaten with milk, or meat if this is available. Sugar beans are a common staple, as well as pot bread which is made from cake flour. The pot bread I was told, is a staple to eat especially when there is no other food. It would be eaten with tea-most likely rooibos, which comes from South Africa. Sugar, salt & cooking oil are other items that an individual here would want but might not always have.

Identity in this Context

I have learned that the people of this area of South Africa are defined by where they call home. In the South African context, to lose home is to lose one's definition of self. The people here are very clear about where they come from; difficult for me who has to have a short story to explain where she is from... Arkansas to North Carolina to California to CT, now. S0me people here have physical distinctions to define to others their identity, where they come from, in this context. Some have scars engraved on the sides of their face, & some have an alteration to the lobes of their ears- all to identify self & home. The significance of this, in this culture, is not lost on the orphans left in the wake of the AIDS epidemic here. Here, there are many children burdened in ways I cannot even imagine, by the loss of both parents to the disease. Some have lost parents so prematurely, they do not even have memories of this family from which to draw their history.

A very amazing woman, a warrior in this crisis, named Elzhet (I am surely butchering the spelling of her name) explained to me that to lose a family is one thing, but to be born with no knowledge of where one comes from, is in essence, to be born without a home- and this is to all extents & purposes, to be without an identity. As children are born to ailing mothers and already deceased fathers, families are broken, and as the people that are to rear you and teach you about your past pass, there is an emptiness left behind, that I cannot even begin to understand or explain. There is a loss in the community, and there are children without papers or birth certificates and most importantly with no one to claim them as their own. Don't get me wrong, there are amazing people and neighbors in these communities that pull from what little resources they have, an extra amount of bread & love to shower those feelings & expectations of family on another- making him or her their own. There are also stories of children alone far out in the communities, going days without food or adult supervision, after their mother or grandmother or caregiver has passed away. Young girls left with even younger siblings might resort to selling their own body for money for some food. I was told of a young boy who took off his only shirt for his mother who died, so that she would be taken away with clothes on- he was found, shirtless, in the only corner still standing of his dilapidated home. These are the things to think about when deciphering the next step for the orphans & vulnerable children of the community. It is such a growing problem in fact, that there exists an acronym to shorten this title, OVC- The phrase needs to be spoken so many times, that is must be abbreviated for brevity. That speaks to the magnitude.

I am learning about identity in this context. A child born with no knowledge of his home, suffers in ways I hadn't even considered. A child that sees his caregivers pass away, it is argued, is better left to stay at his home, alone without adults, than to be taken out of his home, his identity, & put in an institution. I have learned that a South African child can survive without parents, without a great deal in fact, but to be without a home, is to be without a piece of one's self.

So, I have come to define my own home more precisely: I am from the southern US originally, & my home is wherever Taylor, my husband, is.

Weekend at Drakensberg Mnts

This weekend we took our first "holiday" from Tugela Ferry to the Drakensberg Mountains. We were invited by Dr. Francois Eksteen to join him and some others for a few nights in the mountains. Dr. Eksteen is a pediatrician extraordinaire at Church of Scottland hospital. Kun observed him doing his amazing & tireless work in the ARV clinic last week. Susan, Kun & I began the adventure on Friday. It began with a drive along a rocky, unpaved road that wove through the beautiful Msinga Hills. As the terrain changed from the dusty hills sprinkled with the prehistoric-looking aloe plants characteristic of the region, the rondavals (traditional round Zulu homes) decreased in number and we entered for a brief time, the Weenen Game Reserve. No stopping, no hunting, no feeding the animals... Driving with our eyes peeled for an animal, perhaps one of the "big 5," we squealed (literally) with delight when we spotted our first giraffe. As we stopped to take pictures we noticed an entire giraffe family grazing the tree-tops. They were beautiful, so regal. We left the game reserve soon after and came upon the bustling, city of Estcourt, where we were to stop for food for the braai (South African BBQ) that we would partake in on Saturday evening. Kun & I practically skipped through the aisles of the grocery store, literally like 2 kids in a candy store, as we chatted with excitement over the fresh bread, candy aisle (cadbury chocolate!!), and warm samosas sold for snacks. It was as if we had been completely without food for the past week in Tugela Ferry. After the grocery, (we love the Estcourt Spar), we were on the now darkened road to our accommodations: Greystone, an outdoor education camp for school children, now deserted because of the recent strikes. The view from outside our room was breathtaking (see below).

Saturday we were off to the Drakensberg Mountains to hike with 4 Zulu young men (that live with Dr. Eksteen), Dr. Eksteen, his nephew, and 2 of Dr. Tony Moll's children. We began at Monk's Cowl and hiked to 2 different waterfalls over the course of the day. The mountains were amazing, rich in texture and colored by various shades of pinks & brown. There was such depth to the scenery: rows of mountains, layered one in front of the other.

After our hike we visited Dr. Tony Moll's home that he is building for holiday in the Drakensberg Mountains. How great to finally meet the famous (in my mind) Dr. Moll. He & his family invited us over for braai: grilled meat, and lots of it. They inquired for the culprit, having heard there was a vegetarian in the group. "It is me," I responded shyly. The lone pescatarian of South Africa, "I eat fish...," I explained. "Poor American," they must have thought. The view from the house was truly impressive (see photo). The house is still in the works, but functioning-with a great firplace. The Molls had such a feast for us, it was like a holiday. Deborah Moll welcomed us and Jessica, their youngest daughter, took several of us on a walk around the property-all of which was spectacular. We ate and talked well into the night and had such a great time.

Today we began our drive home to Tugela Ferry, with one or 2 stops for souvenirs, and a quick stop one last time at our new favorite grocery store to stock up for the week. No giraffes this time, but one of the best parts of driving through the countryside is seeing the people. We are undoubtedly always impressed by the strength of the women, literally. The things a woman here can carry on top of her head is unbelievable at times. Last week we saw a woman carrying a shovel, balanced perfectly, up the street of Tugela Ferry. As we drive we witness the lives of the people that live in the hills, as they carry out their day. Children playing, women gathering water, groups of young adults walking & talking, flat bed trucks packed with people traveling up & down the road, and a person or two resting, faces toward the sun.

7.12.07 On this morning I spent time with the support group for mothers & children waiting to be seen at the ARV clinic. As they wait for follow up check up, monitoring of their medications, getting more meds, they learn about nutrition, and get advice for supporting the health of their children and themselves. The children get to play, get some snacks, and sometimes some donated clothes. The mothers can talk about their fears, concerns, & questions. They are taught such skills as how to make a lotion out of the cheapest aqueous solution & aloe that grows here.

Birth & Children

Today Kun & I saw our first birth in South Africa. We were visiting the maternity ward & it was happening & there we were. The birthing position is without options at this hospital. Supine, flat, no raised beds whatsoever. Feet are tied into stirrups with black straps resembling the fabric of a seat belt. Nevertheless, the experience was beautiful & moving. The woman delivered a baby boy who was initially in respiratory distress but was very soon breathing independently after resucitation. She had an episiotomy, my first to see, which was told after is unusual there since the onset of HIV. Because the infant was in distress, not making a sound, the entire "team" in the room with the woman followed him as he was taken away, somewhere behind the curtain. The woman lay on the table barebreasted, naked with her feet still in the stirrups alone behind the curtain except that she was still with Kun & I. Kun wiped her brow with the crumpled sheet beneath her & I held her hand. The moment I slightly feared, occured next, when the new mother opened her eyes- to see us. There stood an Asian woman & a white woman with blonde hair, comforting her. The universality of childbirth was prevalent through the entire experience but especially when she spoke. Her first words (in Zulu): I am never doing that again. This was only a 30 minute portion of my day.

We visited the pediatric ward to day as well. It was difficult for so many obvious reasons.

Sweet as well, of course. Many children surrounded us and asked to be held...

the pharmacy

Yesterday I spent 2 hours in a ARV pharmacy. Little about the notion I had of pharmacy was relevant to this experience. I sat at a rectangualr table with 3-5 other people all Zulu speaking, public health/hospital employees, plus one younger sister of the "pharmacist." She was helping. There was a plastic covering, ripped and wrinkled over the table top. Piles & piles of multi-colored pills laid scattered across the table. Large yellow "horse pills," small white & red pills without a coating, bright, shiny yellow & white stripd pills, and some pills still in the foil. Most of these pills were piled free on the table with uman fingers picking through them, ungloved & unsanitized. When I entered the room to help package pills no one asked me to wash my hands or glove up, no one even asked me what my position was- why was I helping, was I a pharmacist. No- Hi I am a nursing student. They all giggle at my attempt at Zulu introductions. I sat fairly silent for the next 2 hours listening to a comedian yell & hollar jokes with apparently hilarious punch lines over a speaker in the room- all in Zulu. I packaged pills as I was instructed into tiny pastic bags based on a dosage the HIV or AIDS infected patient would be taking. It was not the fact that I did this with my hands repeatedly, as some stapled individual day's doses onto a claendar- a tedious, never ending task for each of the so, so many patients to make it easier to administer. It was the gold-like quality, the significance of the medication, so needed by the people of the community, to fight their disease, the commodity, all around me, with my american-fingertips. Iworried about dropping one on the floor...

My day in the ARV clinic

Kun & I in our house: 7.10.07: Today was a wonderful day. I spent the day observing a doctor see patients in the HIV/AIDS ARV (antiretroviral) clinic. It is an outpatient clinic & patients line up outside beginning early, but with the longest lines forming in the early afternoon. Many patients travel far to be seen at the clinic. The patients are either starting ARV therapy or are already on it and are being seen for follow-up & for other concerns. It is hectic: employees open the door in the middle of the doctor's visit with the patient to ask questions, there are anywhere from 1-3 employees around to translate Zulu for the doctor, there are no sharps containers, doors have to be open when a patient has multidrug resistant TB, no biohazzard bags in sealed metallic bins, and patients waiting outside, all in all it was invigorating. The doctor worked straight through until he had to break for lunch at 3pm and I was right there with him enjoying learning all that I could from his interactions with the patients. There is a system in place so that before a patient starts ARV therapy, aside from the medical attention they get such as baseline liver functions, CD4, & viral load counts, the patients also spend time in adherence classes & counselling to help them really undertand what medicines they will be on, the extent of the side effects and the importance of the careful administration of the meds. True attention to these details helps the patients understand more about what their treatment is and the significance of continuing the treatment to the improvement of their health. The doctors & nurse assistants took this very seriously, making sure the patient was ready to begin what will be a life long treatment endeavour. There are so many complicated factors that are difficult to wrap one's mind around: patient's are not eligible for free ARVs, so starting therapy at all b/c no one has the money, unless their CD4 counts are below 200. The lower the count the more sick the patient. This is difficult for patients with higher counts to understand because it can be perceived as a punishment for being well. The doctor said that he has heard of some patients trying to get sick so that they can start the medications. This is different of course than someone in the States with health insurance, b/c they would start the medications for treating HIV while still healthy (with CD4 much higher than 200). The patient's on ARVs do get all these expensive medications for free, as well as any medications they need for the numerous opportunistic infections accompanying AIDS. The beauty is that this clinic has seen many patients near death get well from the drugs. I loved being there, working in this context & interacting with the patients despite my severe language deficits. Did I mention it was a great day...

education: On the road to Tuegla Ferry...

Me: behind my south africa home:

7.8.09

COSH: church of scottland hospital-

the entrance: 7.9.07

Day 2 in Tugela Ferry

This is Tugela Ferry, where I live.

7.9.07

Today I had an orientation to my clinical experience in Tugela Ferry. Mary, the amazing woman running the home based care program here, showed us around the hospital grounds and introduced us to the administrative staff. We met the manager of all hospital nurses known as a matron, Matron Dube. We discussed with Mary and the matron of the nurses at the hospice what our role would be here as students as well as regarding ways in which we can contribute. The plan, which is extremely exciting, is that we will put on a conference for the nurses of the hospital, the AIDS hospice nurses, & for the community clinic based nurses. The conference will be to provide training on HIV/AIDS related topics and we will organize it and bring in some guests to speak on special topics. The idea is only in the works now, but topics will likely include pathophysiology of HIV, information about medications/ARV therapy & antiretroviral side effects, nutrition considerations, adherence to medications, infection control practices, and such topics. We are thinking it will be a 2 day conference. Here the nurses never-to-rarely get such an opportunity. This will take place on our last week here and the week prior to this our plan is to conduct trainings for the (300!!) volunteer home based care givers, as I think I mentioned yesterday. We will go to various locations out in the community to conduct these trainings, b/c the volunteers are throughout the Msinga district, as are the patients they serve. We are so excited by the prospects.

Today Mary discussed various needs throughout the day as we determined what we would be doing. One of the many things she mentioned that stuck with me was when she discussed the women that make up the volunteer home-based HIV/AIDS care givers. These women do this with no pay & no recognition. They do this very trying work, travelling to people's homes, many, very remote, and they oftentimes find themselves in very difficult situations, with someone dying, or a home extremely disheveled, perhaps they find children at home alone with no food in the house. These volunteers offer care & support to them and bring them supplies such as food. The fact is that many of the caregivers have little to nothing to eat themselves. They hand over supplies of materials that they do not have for themselves at home. They do this selflessly. It is truly impressive, and I cannot wait to meet them and venture out with them in their work.

We met so many great people today, who dedicate their lives to working here and providing health care to people in the surrounding community. Kun & I also had a brief adventure into the bustling center of town, which is just down the roa. All of the "town" is off one main road. There is a shopping center, rural south african style. We passed women selling platic baggies full of cheetos, women selling bags of oranges & banannas, women in traditional Zulu dress with babies attached to their backs like an appendage, & men hanging out around cars and talking with other men, some grilling meat on makeshift grills. The grocery store we entered was packed and dusty. We did a quick run through & headed back to our nice, temporary new home. I attempted my Zulu along the way, Saubona: hello to 1 person; Sanibona: hello to more than 2 people; Ngiyabonga: thank you; kakhulu: very much; wema: amazing...

some of Tugela Ferry

The drive to Tugela Ferry:
7.8.07





Almost to Tugela Ferry...
7.8.07

On the road from Jo'burg

to KwaZulu-Natal:

7.7.07

(Christina's golden bday!)

Pictures I hope...

Traditional Zulu home:

near Greytown:

7.7.07

Hi! I think I finally got it to work. I am here in Tugela Ferry! We made it early this afternoon after a long journey. We arrive to SA 2 days ago on the evening and had a great night's stay in a hotel. Nothing like my arrival to the Delhi airport. A man was standing there after we passed customs with a sign with my last name on it. Our ride to the hotel... Day 2 included getting our rental car, a VW, and beginning the drive on the opposot side of the road, out of Jo'burg and into Africa. The ride was longer than we'd expected, and it was beautiful. SA looks different than anything I have ever really seen before. At some moments it looks like the western US, like the Badlands maybe, and other times it looks much more majestic. We stopped our drive last night in the closest town-like place before getting to our destination b/c it was getting dark. All rule-books say no driving at night, so we stayed at a B&B owned by an Albanian man, which was lovely. This am we had our first experience in a south african grocery, stocking up before we headed the hour long drive to our new home for the next month. Tugela Ferry is in the Msinga District of KwaZulu Natal. The people are primarily Zulu. On the drive we began seeing the traditional Zulu homes which are round with thatched roof. (i hope to include a picture but we shall see if it works). These houses were everywhere as we drove up into the mountains and crossed the Tugela River and eventually as we entered the town, although I don't think you'd really call T. Ferry a town. Our housing is nice. I am sharing a room with Kun, the other nursing student here with me, and we are living in a home with our preceptor, Susan, and a missionary nurse, Jody, who has devoted her later adult life to South Africa and the Zulu people. She lives here indefinitely and is lovely. We toured the hospice center run by Philanjalo, a non-profit, that we will be working with, that provides palliative care to AIDS pateints in the lates stage of the disease. They do so many other things, all of which we will be a part of to some degree. They provide ARVs, antiretroviral meds, to these patients, have a care center for children with HIV, do home visits out to the Zulu people of the Msinga district. This is run by an amazing woman named Mary, who we met this afternoon. Mary is not Zulu, I forget is she is Xhosa, or another, I'll get back to that, but she has been running the home based services for 8 years. It is amazing the care they can provide by having volunteer "caregivers" of the community go out on foot and car, mostly on foot, to help people who are very far from the 13 healthcare centers or the hospital, all run by the Church of Scotland Hospital, which is the other organization we will be affiliated with-Yale has been doing AIDS & TB work with them for years, as well as with Philanjalo. We will be involved in the homebased care, these volunteers, non medical, but trained, help with medication adherence (crucial to HIV & TB treatment), nutrition, assessing if individuals need to make the trip into the hospital, help with children, etc., I think you name it and they do it, selflessly it seems. We will spend our 2nd week here doing many trainings for the caregivers to help them be more medically astute, no more about ARV (AIDS meds) therapy side effects, etc. We will do one at each of the 13 clinical sites, which are out posts run by nurses to make primary care more accessible. On the third week we will do training for these nurses that act a bit like nurse practitioners, b/c they are more trained and one their own out in the community, which is far reaching I have been told- and will soon see. This week we will be orienting and observing the different aspects of community health provided in Tugeal Ferry mainly, I think observing the pediatrician, in the maternity ward, one home visit, and in the orphan care project. It is a bit unreal to be here. All the things you think you might know or notions you have about what Africa might be like flood your thoughts when you actually see it and are here. This processing is all still happening in my mind and feels difficult to wirte about at this point. Much more to come I imagine. There is poverty all around me... I love you all and hope this doesn't all blob together too terribly. I am jet lagged a bit and probably other things...

My blog won't let me write except for the title, I am here in Tugela Ferry.

I am here in South Africa! Stayed over night in Jo'burg. Flight & arrival all went smoothly.
Today we are renting a car & driving to Tugela Ferry!!
Love you!

Playing catch up from the last year...

New Haven: Orange Street

North Carolina 2007

NC 2007

Skip '07

NC
Spring break
2007

On Laura's wedding day.
6.2.07 in Salt Lake City

Me & B, 6.07:Standers movin' to New Orleans...

Finished classes for GEPN year,
only Community Health clinical to go! 6.28.07

Hilary's Bday 07: Sushi!!

Family in New Haven





Eden & Tess Last day GEPN!
Room 118...

DDR spring break NC 2007

Blainey @ Violet's 1st Bday

6.24.07

Taylor&me
camping in Adirondacks
July 2007