St. Mary's & women's health

LOVED this week! Favorite place so far, but I knew I would love it because it is primarily a women's health clinic, or the part where we are rotating is. We saw mainly cesarean sections and one natural birth here, and they were all so amazing! On my first day we saw 2 c-sections, the first one was twins! I was amazed at how quick and mechanical the procedure actually is. I had always pictured a c-section to be a very complex and risky surgery, but the doctors performing it are not even specialized in OB/GYN or surgery. In fact, they are not even fully-fledged doctors yet, meaning they are doing their "community service" years, which is a requirement here. I guess it is similar to residency in the US. But either way, judging by what I observed it is actually a pretty simple procedure anyway, so maybe you don't need a whole lot of specialization, unless there are complications. The facility was really nice though, and there was a peaceful little church inside since it is Catholic-based.

But anyway, that initial moment when you see the baby, wow...your heart just melts. As cliche as it is, it is exactly as beautiful a moment as you'd expect, if not more. However, the fathers are usually not present. I only saw one father present for the c-section of the twins actually, during the whole time that I was here. The other student who has been here over a month did not see any fathers at all. I was told by a Zulu man that the reason for this is modesty, actually, so that women can preserve their image in their husband's eyes. I suppose it is quite messy, but such a scary thing to have to undergo alone :( The natural birth was so encouraging to me as a woman :) The mother handled it like a champ. The actual birth lasted all of 30 seconds. The baby almost popped out, she made it look so easy, which calmed my anxiety a bit. There was very minimal tearing, and the mother seemed so relaxed anyway. I was very comforted :) While we were waiting then in the hall for another birth, she just walked out like nothing happened, an hour after giving birth! I guess South African women are quite strong!

I'm so glad that this was my last clinic. I absolutely loved it and was happy to end on this note :)

For social time, we did quite a few fun things this week. Dinner for my birthday, which was on 8/22 over the weekend. So we went to the restaurant inside the aquarium, which was really cool! We also went to the Victoria St. Market which is famous for all the wares and crafts. In the same area is the Juma Mosque, the largest in the southern hemisphere, so of course we had to check that out as well. The tour guide was so amazing and excited and truly made it a wonderful experience. We even got little goodie baggies when we left :) On Wednesday we went to a Johnny Clegg concert. He was an iconic singer/composer during the apartheid period and a strong activist as well. He worked with Nelson Mandela and the freedom movement. I absolutely fell in love with his music and was so grateful to have been able to see him live. I even bought his CD to take a little of South Africa home with me :) On Thursday we went to a wine festival and I was able to taste the famous South African wine! Overall an absolutely fantastic week!

Closing thoughts...wow...I don't even know where to begin. This trip has been absolutely incredible in so many ways. I can't believe still the amazing experiences I was able to have here, the things I saw and learned...it is truly once in a lifetime. I met some pretty incredible people as well and made some really good friends, to whom I am so grateful for making my experience here so meaningful. South Africa has truly captured my heart. There is just such a unique, beautiful yet broken energy here. I know I will definitely be back ~ I really could see myself doing HIV care here. I came here a little unsure about whether or not I wanted to pursue medicine, like many of my fellow students in the program. I know that for me at least these 4 weeks have answered that question loud and clear! Though it was a short time, we were exposed to so much with no filters that I felt I was able to really get a real picture of medicine in resource poor settings, and able to therefore make decisions based on these experiences. This program was so helpful and I am so grateful. I think it would be interesting to practice HIV care in South Africa in particular. I was surprised and very intrigued by all the barriers to accessing care, despite all the efforts being made to stop the epidemic and get people on ARV treatment. It would be an amazing and rewarding opportunity to return here as a doctor and be a part of these efforts. Only time will tell...

For now, I am homeward bound! :)

Surgery Week!

Very interesting indeed! The very first day we were in minor ops and the first operation we saw was an adult male circumcision. I never knew I would be one of those people, but I got dizzy and felt sick, and almost passed out. I was fine once I left the room, but seeing the patient in pain and empathizing too much with it is what made me feel sick. This was a very important lesson for me - as a doctor or health care provider you must really learn to create boundaries between yourself and the patient, health boundaries. I also had to keep reminding myself that whatever pain was being caused, it was in the best interest of the patient, and done in order to make for less pain in the future. Once I started thinking like this it became much easier to observe the other surgeries. We saw such a wide range of surgeries from abscess removals to major orthopedic operations.

On one of the days we were with Dr. Singh as he was lecturing a group of medical students in the GI Unit. He spoke of the growing apathy he is seeing new doctors and tried to encourage the students to remember what got them in the field of medicine in the first place. He said all the new interns now only care about themselves, their time off, their schedules, not extending themselves an inch beyond what is required. He drew a scale with Altruism on one end and Egoism on the other end, and asked where the students were on this scale today, and told them to ask themselves that question every day. I found it to be very good advice. I think the nature of the job, especially as a surgeon, causes you to forget sometimes what made you want to be a doctor in the first place, what with all the stress and demands. You begin to forget the passion. I hope to remember this scale as I progress through the stages toward becoming a doctor.

We did do an overnight shift once, which was interesting. It was a rather slow night, though we did get to see 2 orthopedic surgeries in the middle of the night, nothing trauma-related though really. But I liked seeing the flow of the hospital at that time, how it empties out and becomes all quiet after all the chaos in the day.

In terms of down time, we did do some decent exploring of other beaches in and around Durban. We drove up to a suburb area up north called Umhlanga with a gigantic mall and a bunch of nice restaurants. I tried the famous dish here called Bunny Chow, a type of bread bowl with curry ~ delicious! The beach was also beautiful with a pier made of whale bones.

 

We also went to the Ushaka Marine World Aquarium, which is the largest in the southern hemisphere.

Oh! And I jumped off the largest swing in the world in the Moses Mabhida Stadium. It was pretty scary but actually so much fun!

Cricket and other fun stuff :)

Another great weekend in Durban :) Went to the beach with the group because it was Gabriel's birthday and he had a packed itinerary to check off. It was more like a birthday weekend! First, we drove a little out of the city to a suburb called Phoenix, which is actually where I am from in Arizona :) This is where Gandhi's Phoenix Settlement is, where he spent 20 very formative years of his life in South Africa. I did not know that he lived here for so long. It clearly influenced his world view and perspectives on civil disobedience. Very interesting stop!

Then after that we went to Ushaka Marine World to boogey board and kayak. It was a really nice, sunny day for it too :) I love the beaches here...

In the evening we went to the Roma Revolving Restaurant by the coast, which I guess is one of 31 revolving restaurants in the world, so now I have been to 2 :) Since we are such a big group it always takes a long time to get seated and get food, but well worth it for the company. We had a very nice time.

We also got to see a cricket match, which was so much fun!!! Way more so than rugby. Although I didn't understand anything at all going in, I really got into it toward the end. It is a very strange pseudo baseball kind of game, but much lazier because they don't have to actually run the bases. It's all about how well you can bat. But the pitchers are called "bowlers" because it honestly does look like bowling the way they run up before throwing the ball. Very interesting. And South Africa won this time! :D So of course we were that much more excited! I could definitely watch another cricket game though, for sure.

Pediatrics at King Edward Hospital

Wow, what an interesting week! It has flown by!

So on Monday we had the day off since it was a national holiday, Women's Day, which from what I saw is actually much like Mother's Day, though they celebrate that too. But it seems it is a day to honor women, especially older women, ie. buying them chocolates and serving them tea :) We got our host mother pastries from the bakery. Other than that we did not do too much, just went to the cafe at the local mall and caught up on emails and work.

On Tuesday we had our registration to get our student ID cards for rotations at King Edward Hospital. We are technically rotating as students of the University of Kwa-Zulu Natal, which houses the largest medical school in this region. The process took a couple hours, and the international students department had a spectacular view.

In the evening we were treated to dinner by CFHI now that all of us are here. We went to a beautiful restaurant right on the water at a place called Wilson's Wharf. It would be a perfect date spot! :) We had a great time ~ I really enjoyed myself and I like the dynamic of the group of students I am with. I think it will be a great few weeks.

So then on Wednesday-Friday I had my rotation with the pediatrics clinic at King Edward. The hospital is very old, but there is a lot of construction going on and clear efforts at renovation. The pediatrics facility for example is brand new, state of the art, and I learned that it is due to the grant writing efforts of the director, Dr. Ramjee, who is the one we observed this week.

 

For the first couple days we shadowed rounds with Dr. Ramjee and also got to know other medical students in their clinical years also doing rotations. The medical school system is very different from the states and students go immediately into a 6 year program from high school. This means that students in their early 20's already graduate as doctors, and it seems that has a major impact on the production of health care workers now. The doctors seem to be very frustrated with the system and the growing issues of incompetence and apathy in the younger doctors. I cannot imagine being charged with all that responsibility in my early 20's. But I guess they have more demand than we do and have to meet it one way or another.

In terms of what we saw, there were a lot of burns and motor vehicle accidents, which reflects the public health issues I've seen so far. A lot of unattended fires and crazy drivers...people seem to love fire here. We will be driving at night and you can see at least 2-3 areas just glowing orange along the highway, with nobody around to watch it. And of course with the lack of trash organization a lot of people burn their trash, which leads to more safety hazards. As for drivers, there are these crazy mini bus taxis that drive like they own the road. It is not safe to drive on the far right lane of the highway (which would be our far left) because they randomly come to complete stops, and the same in the regular roads. There are just way too many road incidents...and children seem to suffer the most.

Apart from this, there were a lot of premature babies in the nursery, mostly due to HIV-related reasons. I was shocked at how tiny they were, little more than 1 kilo, or 2-3lbs. It was a tough thing to see, little weak bodies engulfed by diapers because they aren't even big enough to fill them yet. However, the facilities seemed very well managed, so I felt confident and hopeful. During rounds in the nursery, one of the mothers there with her newborn had a red eye where she'd clearly been hit. When the doctor inquired about it and insisted the woman see the nurse, she replied that she'd been assaulted. I've heard a lot of assault since I've been here, both from the doctors and personally from my host family and people I've met. Though I have traveled quite a bit and met many people and seen many places around the world, I've never been in a place where the crime and violence felt so real. It's unfortunate.

On Friday we were taken to the pediatric HIV clinic, which I found particularly interesting. I had never thought about the situation of children born with HIV and the implications for youth disclosure counseling and for later on when they become teenagers and sexually active. Due to the height of the epidemic several years ago, there is actually quite a large population of these youth. I witnessed several difficult counseling sessions in which the doctor had to navigate complex situations, talking to youth about using protection for sex, but of course they do not want to talk about it and it makes it worse when parents are present for the appointment. Disclosure about sexual activity then becomes almost impossible, but it is so important to talk about it to promote safe sex and stop transmission. One patient unfortunately suddenly became resistant to first line therapy after 14+ years, and it is likely due to exposure to another strain of HIV. And second line therapy is pretty brutal with all manner of side effects including nausea and vomiting, not to mention the 9 pills/day. We were also invited to a meeting in the afternoon to which all the health care workers came to discuss difficult cases in an interdisciplinary approach. The team included the social workers, nurses, doctors and even the pharmacists. I really thought this was a great approach, because HIV is not a purely medical issue. In fact, it is probably mostly social and has everything to do with the family, friends, relationships, dealing with social stigma, etc. so it makes sense that the social worker be involved in coming up with a strategy for difficult patients. Even the pharmacists contributed by discussing different regimens for patients with trouble adhering to medication. Overall this was my favorite part of this week's rotation :)

Weekendz in Durban

Quite simply...amazing! Had a great time getting to know the other students, who are all here now. We had staggered arrival dates, so it was nice to spend time all together and explore Durban. We went to a rugby game on Saturday, South Africa vs. Argentina. It was my first rugby game, and I never even really watched it on TV either so I had no idea what was going on, but it was fun anyway because the fans were so spirited. We managed to get seats right in the 3rd row, which was pretty amazing! Although South Africa lost we still had a blast, so it was a win for me :)

Afterward we explored the town and grabbed dinner on Florida Rd, which appears to be the lively place to be for Durban nightlife. It is curiously actually Florida themed, with many restaurants named after cities in Florida like Miami, or Cuban culture like La Cubaña. In a weird way it seems South Africa really is the America of Africa, at least there is a clear effort to emulate the US in so many ways.

On Sunday, one of the host families was having a goat sacrifice, so we were all invited to attend. Two goats were being sacrificed to sort of apologize to the family of a girl who got pregnant out of wedlock. In this case, the man's family must go to the girl's family to negotiate what must the price be to apologize to the ancestors for the child being born out of wedlock. In this case, the price was 2 goats. So the goats were brought and tied in the back. For it being a seemingly important tradition, it was very unceremonial. No words were spoken or anything when the goats were killed. I must admit, it was rather difficult to watch...but I tried not to think with a Western mind...cultural differences. From a medical perspective it was actually very interesting to see all of the organs and physiology. In the end, I was surprised by how little actual meat there was, though they use a lot of the organs anyway to eat, so nothing is wasted.

In the evening we decided to go bowling together at The Galleria, which is yet another large mall here. It was a lot of fun! The other group of students who had been in Cape Town doing rotations there for 5 weeks arrived in Durban for the second part of their trip. In total we are now 10, so they came as well. One of the students' host brothers came along too, so we were one big happy bunch :) I didn't bowl all that well, but no matter, it was cool to do it in another country and it was actually very much the same. Fun times!

Malagazi & Umlazi

Unfortunately I only had one day at the Malagazi clinic, but I made the most of it and learned a great deal. It is a primary level clinic funded by the Islamic Medical Association and is in the heart of Durban’s largest township, Umlazi. I was told by a driver here that Umlazi is home to about 1 million people, which means it is about a quarter of Durban’s entire population of 4 million. It’s huge! I sat with an older nurse for the morning and she saw about 15-20 patients, about half of them young children. Almost everyone had the same flu-like symptoms because it is winter here and that seems to be going around now. They seem to treat each symptom rather than the sickness as a whole, ie. multivitamin syrup for the lack of appetite, paradol for headache/pain, cough syrup for coughing/sore throat, and then antibiotics for the actual bug. This makes me think about the issues with pill burden in HIV care. I can see how the pills all with their different regimens can quickly add up and be confusing, leading to patients defaulting on their medication. Patients on second line HIV therapy take about 9 pills/day. If that is complicated for example by TB infection, and a flu...that adds up quickly. A patient I saw in Kenya was at one time taking 27 pills/day! Thinking about how difficult it is for me to remember just taking my once/day malaria prophylaxis, I can't imagine having to even think about 27 pills...this symptomatic approach cannot be good for HIV adherence. But I was really glad to see this clinic to compare the different sites. I will be at King Edward Hospital next week, a tertiary level facility and the oldest in South Africa. I'm sure seeing the process of patient referral from the bottom up will be very informative. Overall, great experience!

We also had a township tour of Umlazi on Saturday with a driver who grew up there. It was very interesting! Although South Africa has one of the highest rates of crime in the world, and rampant with rape as well, I felt completely safe in this township. You could feel the sense of community and support. The driver also told us about the culture of "community justice," which is the community's attempt to fill in the power/structure vacuum left after the abolition of apartheid. He told us a story about a man who stole someone's cell phone and was forced to eat it, for example. They basically punish those who commit crimes and protect each other. I can see how that could get out of hand, but I also rather admire the strong sense of community and looking out for one another in the face of a failing government and beautifully broken city. We then visited an orphanage started and managed completely by the community, who all pitch in to donate food and clothing to care for about 38 kids.

Last stop was a place called "How Long" park, which is a little oasis in the middle of the urban jungle where a man without any sort of education made his dream a reality during apartheid. Despite the fact that he had no education and could not read or write, nor could he garden, he wanted to create some beauty and inspiration in the township, and so began How Long Park, which is his ongoing project. How Long, meaning How long must they suffer...this was during apartheid. We happened to be there during the 21 year old virgin ceremony of a young girl. Apparently, if a girl reaches the age of 21 still a virgin (or without having kids in this modern day and age), they throw her a party. All the young girls get together and choreograph a dance, and the whole community comes to watch, and gives the girl money. It's interesting how a society that looks so highly on fertility and the bearing of children also has this tradition that incentivizes women to wait...how ironic. The ceremony was very interesting, and the girls were so overjoyed that this group of Americans came to participate :) The donation of money is also a process, because they dance up to you and you stick the bills to the hat the girl is wearing. So much fun!

Then on the way home, one of the students was thirsty and mentioned it to the driver to see if he could stop for water. Instead he took us to the home of one of his neighbors, who were very hospitable and instead served us all cold juice. The house was full of children! We thought there was a family event or birthday or something, but the man said they were all his, and there were 16! We were confused at first, but then remembered the issue about family dynamics here, and indeed they were not all his biological children, but he took care of all of them and they all lived there. It's still amazing to me how much the HIV epidemic has shaped the country. Very interesting stop :)