Download International elective report – Claudia Denkinger Mabatlane, South

International elective report – Claudia Denkinger
Mabatlane, South Africa, 2nd of July 2007 – 6th of August 2007
Location
Mabatlane is a small town in the Limpopo providence (former Northern Providence) of South Africa
about 300km North of Johannesburg. The town and its surrounding have about 32 000 inhabitants, out
of which about 30 000 are black. The largest proportion of the black population lives in the township
Leseding. The township consists of numerous small brick houses and shacks, few with running water and
electricity. Each shack usually houses a whole family consisting of 2-10 people. The rate of HIV amongst
the population of Leseding officially is estimated to be about 30-35%. Unofficial estimates are more in
the range of 50%.
Goals for elective
I decided to do this elective in preparation for a longer stay in South Africa after my residency. My main
goal for this elective and my HIV-fellowship next year is to learn more about HIV and the socioeconomic
implications in a developing country. I decided to pursue this goal in the context of a non-governmental
project, which is aimed towards making HIV medication available to a large number of patients in a
resource poor setting, as this is the characteristic setup for anti-retroviral role-out in Africa where the
health infrastructure is generally underdeveloped and a lot of the healthcare relies on nongovernmental organizations. My goal specifically for the elective was to get to know the organization
and develop a clinically relevant question that could be answered in a small project during my
fellowship.
The organization
The Waterberg Welfare Society (WWS) is a non-governmental organization that was founded by Dr.
Peter Farrant with the goal to improve the health and social support for the black African community in
the town of Mabatlane. With support of the Wilson Foundation and other non-governmental funding
the organization grew over the last few years to provide HIV care to about 200 patients of the nearby
township, Leseding. In addition, support groups were built for HIV-positive patients and their family
members, which provide social support, counseling and teaching on health issues and simple income
creating activities. The organization also provides after school activities, social and psychological support
for over 300 orphaned and vulnerable children as well as sexual education and HIV awareness teaching
at the local schools.
The medical site of WWS
The medical site of the WWS consists of the small day respite with a total of 9 beds where patients in
need can come during the day and get care. The care includes help with daily hygiene, provision of food
and help with medication compliance. Most of the care is provided by unskilled “carers” from the
community, most of them HIV-positive themselves. Three nurses and the doctor do the supervision. In
addition to this day respite program, the WWS has an outpatient clinic where nurses and doctors can
provide care to the large HIV-positive population in the community. The diagnostic possibilities are
limited to a basic laboratory evaluation and microbiological cultures. The treatment possibilities are also
limited largely to six HIV medications (AZT, D4T, DDI, 3TC, Efavirenz and Nevirapine), two antibiotics
(Amoxicillin and Doxycycline), pain medications and anti-nausea medications. For any other medications
or diagnostic tests the patients need to be referred to the governmental clinic or the hospital.
Aside from the WWS there is only a governmental clinic in Mabatlane that is staffed with nurses 24
hours a week, but only has one physician for one half day a week. The next hospital, a level 3 hospital
(lowest level), is about 40 minutes by car in Modimolle. One ambulance is available for patient transport
to the hospital from Mabatlane. Transport to the hospital is provided by the WWS on a weekly basis.
My medical experience
I was working at the WWS under supervision of Dr. Farrant, the founder of WWS and a well-known
pediatrician. I was sharing responsibilities with another visiting physician, Dr. Khalifah, who was working
at the WWS as part of the HIV-fellowship that is sponsored by the University of Texas. Our
responsibilities consisted of the care of the HIV-positive patients both in the day respite and in the
outpatient setting. We managed the patients’ HIV medications, and assessed them for medication side
effect, opportunistic infections and other medical problems. While the WWS is not able to provide
medications for many opportunistic infections or most other medical problems, we were able to provide
the first differential diagnosis to refer patients to the appropriate next care provider. For further
diagnosis and management we had to send patients to the governmental clinic or the hospital. One
afternoon a week we also helped out at the government clinic. One day a week we went to the hospital
to attend a weekly conference and rounds on the pediatric and adult wards. In the hospital we helped
out in the emergency department or the outpatient clinic. Twice weekly a nurse and a doctor went out
to the township to assess homebound patients.
During my time in Mabatlane I started several patients on anti-retroviral therapy and managed both
adults and children, in scheduled follow-up visits or with various HIV- and non-HIV-related problems. I
saw a wide range of diseases and medication induced side effect. In particular, I saw many
manifestations of tuberculosis. I had great autonomy in my decision-making but at the same time had
the back up of an experienced physician who was always available for questions. I also appreciated the
presence of another young physician, Dr. Khalifah from UTSW, with whom I had a lot of interesting
discussions on medical and social topics.
I initiated a training curriculum for the staff at WWS to assure continuing medical education for the
nurses and basic medical education for the carers. I prepared lectures and handouts on HIV and HIVrelated topics.
The context of my medical experience
Aside from the experience on the medical site I was able to gain some insight in the structure of the
WWS and the difficulties it encounters in the community.
HIV affects primarily the black South African population, which despite the 13 years since the end of the
Apartheid is still underprivileged and extremely poor. The black African community also has a great
mistrust towards western medicine in general and large parts of the community still perceive HIV as a
matter of witchcraft that needs to be addresses by a traditional healer. Often time patients only seek
medical care once they have been to a traditional healer several times and once their disease has
progressed. HIV also is associated with a tremendous social stigma that prevents people from revealing
their status to other family members and leads to lack of support and therefore constitutes a problem in
regards to adherence. Aside from that, promiscuity, rape and certain sexual practices make it difficult to
stop further transmission. Alcohol abuse and financial dependency also contribute to the problem. The
efforts of the WWS to overcome these issues in the care for HIV patients include support groups,
teaching at schools, home-base care, and extensive adherence counseling and training.
Achievement of my goals
I was able to learn a lot about the care of HIV-positive patients, both in regards to the medical
management of HIV and the diagnosis and treatment of opportunistic infections. I was able to learn
about the socioeconomic context of the HIV-epidemic in South Africa and the limitations of care.
In regards to my goal to come up with a small clinical, epidemiological project for my fellowship time, I
will need to do a bit more literature research into certain areas. I might be largely limited by the
relatively small number of patients treated at the WWS, the limited documentation and the time
restraints I have during my fellowship. However, the last few weeks stimulated my interest in HIV and
especially the interface between HIV and tuberculosis tremendously and I have many ideas in terms of
clinically relevant questions to study. I am sure that the elective and HIV-fellowship time in South Africa
will influence my future career path.
Possibilities for residents in the future
The HIV fellowship is a program run by the University of Texas Southwestern in Dallas (UTSW) under the
leadership of Dr. Hardy. It is intended for physicians after residency (medicine or pediatrics) or after an
infectious disease fellowship. The duration of the HIV fellowship can be 3-12 months. A stipend is
provided by the UTSW with support of the Wilson foundation.
Residents are only accepted for electives if there is a commitment for a fellowship following residency.
Applications for the HIV fellowship should go to Dr.Hardy. Dr. Farrant is the contact person in South
Africa.
Contact addresses:
Dr. Peter Farrant
Dr. Douglas Hardy
Culmpine Estates
Dept. of Infectious Diseases
Vaalwater, Waterberg
University of Texas Southwestern
Limpopo Province, 0530
Dallas
[email protected]
[email protected]
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Claudia Denkinger, Boston, 6th of August 2007