The Advent of Antiretroviral Therapy in South Africa

The history of HIV/AIDS and response to the raging epidemic in South Africa has been a tumultuous one to say the least. The first case of AIDS in South Africa reported in 1982 was of a homosexual man who had contracted the virus while in California. It was over 20 years later in 2004 when the government finally began making antiretroviral treatment publicly available. It's sobering to think that was only 9 years ago. Here's a timeline and description of what happened in that HIV/AIDS landscape during that period.

BMSF started unrolling HIV/AIDS treatment programs in 2001 (with SA government's blessings of course) with specific target populations, like pediatrics, and were moving ahead with general adult populations by 2004. One such treatment centers funded by BMSF was the CDC Clinic at Ladysmith Provincial Hospital, which is also part of in the Impilo Yonke Mental Health and HIV/AIDS project I'm involved with. Here are some images from the hospital.

Tune in to the next post about my time in the CDC clinic.

Breast Cancer in Swaziland

The Kingdom of Swaziland is a landlocked country, roughly the size of the state of New Jersey, situated northeast of South Africa. It's one of the few absolute monarchies still remaining, and as such has two capitals: Lobamba, the royal capital, and Mbabane, the administrative capital. It is here in the Mbabane breast cancer clinic that I've been scoping out a possible project with the Swaziland Breast and Cervical Cancer Network (SBCCN).

Breast cancer is the most common cancer in women in both the developed and developing world. There is a widespread belief that cancer plagues mostly higher-income countries; however, that is not the case. For example, almost 50% of breast cancer cases and 58% of deaths occur in the developing world. Although incidence and survival rates vary greatly worldwide, survival rates are lowest in developing countries, attributable to lack of early detection programs, leading to high proportion of late-stage disease presentation, lack of adequate diagnosis and lack of treatment facilities.

This is the outpatient building of the Mbabane Government Hospital in which the breast clinic runs. Patients occupy every available space in the corridors from early morning waiting to be seen. Babies wailing, children screaming, adults chattering- if I closed my eyes, the sounds would lead me to think I was rather at a busy market. 

There is currently one oncologist in the entire Kingdom of Swaziland...and he's from Cuba. He is a jolly fellow who's been in the country for a little more than a year now. His English is very basic (his conversations are mostly composed of nouns, pronouns, and present tense verbs) and he calls everyone "my friend." I learn that he's 1 of 19 Cuban physicians here. There's a bilateral exchange agreement between the governments of Cuba and Swaziland, in which Swazi doctors go to Cuba to train and Cuban doctors go to Swaziland to provide much needed specialist care. It's mandatory public service; instead of being drafted for military service, you're drafted for medical mission. 

In the course of 4 hours, we saw 39 patients. That's nearly 10 patients per hour! Documentation is a meager process here, as notes are scribbled into the patient's Health Card. This is the equivalent to the medical chart, but instead of staying with the institution, patients carry it with them at all times (and it can get pretty ragged).

Patients come for screening, examination, follow-up, and referrals. The clinic takes place in a very small room containing a desk, chairs, and a room divider that separated the examination table. There were 7-8 people in the room at any given time, with 2-3 different patients, leaving very little patient privacy or confidentiality. This was the epitome of a HIPAA compliance nightmare.

There are not many options for women who are found to have breast cancer here: either surgery or do nothing. There is no availability of radiation, chemotherapy, or targeted therapy. Hormone therapy is available, like tamoxifen, but the tricky part is that testing is not done here to determine whether the tumor is estrogen/progesterone receptor positive and whether therapy is warranted. Patients who can afford it come to South Africa go to seek treatment. The Swaziland government used to have a program to send breast cancer patients to SA, but for unclear reasons, the program no longer functions. Most patients are from rural areas, and they struggle to collect enough money to ride the taxi bus, or kombis, to the clinic (~R5 or $.50). Even when early screening and diagnosis is achieved, it sometimes is fruitless as patients can't afford to come back for follow-up. Until the time Swaziland expands its health care delivery system, most patients who are diagnosed will go untreated. 

October Breast Cancer Awareness Month

The Swaziland Breast and Cervical Cancer Network (SBCCN), a NGO sponsored by BMSF, recently ended a month-long campaign to raise awareness of breast cancer in October. It started with a ceremonial launch that included official remarks from the Swaziland Department of Health, WHO, and BMSF. The most exciting parts were by far the traditional singing and dancing by Swazi women. Here's a taste:

Last weekend, my colleagues at BMSF and I participated in the 10km Brave the Breast Walk (it was really more of a hike) up Sheba's Breasts. Named after the legendary beauty and mysterious Queen of Sheba from Ethiopia, who supposedly seduced King Solomon, these distinctive twin-peaks rise above Ezulwini Valley in Swaziland. The views as we ascended the mountain was absolutely breathtaking. Southern Africa has such a natural beauty, and hiking has by far been one of my favorite activities. Swaziland is no exception.

Before the walk with the Royal Swaziland Sugar Corporation, the main sponsor for the walk.

We finally made it to the top!

We relaxed at Mantenga Waterfalls on our way down. Having dipped our feet into the fresh, cold water, we were so relaxed that we lost track of time and were the last participants to return to the finish line. :)

Women of South Africa

Everywhere I go in the community and every community I go to in this country, I notice a lot of women. In the professional realm, they run the Department of Health clinics in the townships, they reach out to clients as community health workers, and they manage the NGOs. It may be that the healthcare sector is dominated by women here, but there are very few men to be found. It's also common to see women running households, perhaps the men are off working in the mines, and it's even more common to see older women, grandmothers running it.

As I mentioned in the previous post, many children were orphaned when the HIV/AIDS epidemic stole the lives of parents. Many of them sought refuge with their gogos, or grandmothers, who would now take care of their grandchildren since their own children had passed. 

In 2001, Bristol-Myers Squibb Foundation funded a project now known as GAPA, Grandmothers Against Poverty and AIDS. This project was designed to meet the needs articulated by gogos living in Khayelitsha, a low socioeconomic area outside Cape Town, who were now taking care of their grandchildren. GAPA runs workshops for gogo's with the aim to empower them to take charge of their lives and circumstances through education and transfer of practical skills, like parenting, vegetable gardening, and business/income generating skills.  

There is a strong kind of woman in South Africa. Women, especially gogos, hold together the fabric of this society.

Orphans and Vulnerable Children

With the HIV/AIDS epidemic raging at full force during the '90s and 2000s, entire families were destroyed when it took the lives of mothers and fathers alike. Hearing stories from that time, it was commonplace to have dozens of funerals take place each weekend in one community alone. The result was a flood of children left behind as orphans. At some point, extended families cared for orphans, but the vast number of deaths have left children alone, to be cared for by a grandmother or by an older sibling in orphan-headed households. This is one manifestation of how HIV/AIDS has drastically changed the social fabric of South African society.

One response to this crisis and the needs of orphans and vulnerable children (OVC) was the establishment of halfway houses, child care centers where children could drop in during the day. Mpilonhle founded 18 halfway houses in the rural uThukela district surrounding Ladysmith. It is estimated that the HIV/AIDS prevalence rate in this area is about 40%, and there have been over 3,000 OVC identified. Each halfway house cares for more than 50 children.

Vezimpil Project is one of the halfway house I visited with Mpilonhle.

The halfway house programs take place in donated buildings that are hosted by a family or located in community centers. OVC go to the halfway house in the morning before school for a hot breakfast and return again after school for lunch, assistance with homework, grooming, laundry, life skills, art, and recreational activities. As one can imagine, given the circumstances OVC face at very young ages, many of them have great psycho-social needs. There are workshops to help children deal with the trauma and the pervasive death surrounding them. Positive changes, in regards to school attendance and performance and health and wellness, have been observed in OVC who attend these halfway houses.

Vezimpil Project is housed in a long, narrow room. Here, the volunteers, who only receive a small stipend, cook and serve the meals and the children gather.

In the past year, the kids have helped paint and decorate it so as to create a warm and inviting atmosphere. The next project involves getting books for the children and shelving to store them.

Important messages are painted on the walls reminding the children about how to maintain their health and wellness. 

As you can see from this message about the importance of knowing your HIV status, these young kids are aware of very mature concepts.

The volunteers also maintain a garden that provides food for the house. This is one way to make the house more self-sustaining and less dependent on donor funds. Means to diversify income sources are continually explored to ensure that the houses can continue after grants end. 

Impilo Yonke: Mental Health and HIV/AIDS

Mental health correlates of HIV and AIDS remains a rather unacknowledged and unexplored domain in Sub-Saharan Africa. What we do know from limited research is that people with mental illness are more likely to become infected with HIV as they may be vulnerable to abuse and may engage in risky sexual behavior. Conversely, people living with HIV/AIDS are more likely to develop some form of mental illness. The rates of mental disorder are as much as two to three times higher than the general population. Bottom line: mental health problems are both a precursor to and a consequence of HIV/AIDS. 

The implications for mental health status can be far-reaching and the consequences can significantly impact HIV/AIDS treatment outcomes. For example, a person with poor mental health status is more likely to have poor adherence to medications and antiretrovirals (ARVs). Health services directed towards this vulnerable population is lacking in South Africa, further magnifying the considerable health burdens of this group.

Impilo Yonke, a collaboration between Mpilonhle and Ladysmith Provincial Hospital, is one of the STF projects I've been working on in Ladysmith that aims to provide a coordinated and comprehensive care model by integrating health services for mental health disorders, substance abuse, and HIV/AIDS. The project has 4 components:

1. Promoting and providing HIV counseling and testing (HCT) in persons suffering from a mental health disorder

2. Screening for substance abuse in youth who are being treated for HIV

3. Providing psychosocial support and budgeting skills training to patients who are receiving government disability grants 

4. Training and educating health care workers to tailor care and HCT specifically to patients with mental health disorder  

There are currently no services that specifically address HIV testing in the mentally ill. Substance use run rampant in the community, especially with young people, and patients accessing ARV treatment are not formally screened for drug abuse, thereby jeopardizing their treatment. All patients who have been diagnosed with a serious mental illness or who have a CD4 count <350 are eligible for a governmental disability grant. Often this is the primary source of income for patients and their dependents. Providers have observed that many patients often have difficulty budgeting this money, and they frequently default on their treatment due to not being able to afford food and transport. The government issues disability grants without equipping patients with the necessary knowledge or skill to budget that money. 

My role in this project has really pushed me outside my comfort zone and let me dabble in areas that I previously had limited (really no) experience in. I came on board in the initial stage of the project when it was still trying to set up and gain momentum. I've been working with the Mpilonhle director in managing the project and mentoring her through various processes (e.g. improving communication with all parties involved in project, streamlining implementation procedures, increasing financial transparency of grant money). I had my first exposure to the realm of Monitoring and Evaluation (M&E) and helped the team develop an M&E structure and plan to capture data and outcomes. Putting on a more academic hat, I taught the physicians and nurses about the model for planning and evaluating continuing medical education and helped them develop assessments to capture the impact of the HIV/Mental Health training workshops they were giving. All this said however, I think I've made the greatest impact on the data capturer. I've worked with him very closely and mentored him on things like development of these assessments, analysis of the data, and writing of reports summarizing that data. 

There are many little things that seem quite simple to me and for which I take for granted (e.g. creating agendas to increase efficiency in meetings). But this mentoring and management experience has reminded me that someone at some point had to teach me about these "simple things," and now it's my turn to teach another. 

Solitude in South Africa

re·treat  /riˈtrēt/

Verb     (of an army) Withdraw from enemy forces as a result of their superior power or after a defeat

Noun     An act of moving back or withdrawing

After months of numerous life changes, cross-country/cross-continental moves, and excitement-filled adventures, I needed to step back from the whirlwind. I retreated to Ha phororo, a Sotho name meaning "the place of the waterfall" for the weekend, seeking renewal and refreshment in its waters through reflection and prayer.

This youth retreat community sits near the Magaliesberg mountains, overseeing the Hartbeespoort dam. It is an ecumenical center with a foundation rooted in the Catholic Church. What made this community so unique and beautiful was the obvious influences of various religions, cultures and philosophies. For example, take the Izolwana Garden of Tranquility- a Zen garden, traditionally intended to aid meditation about the true meaning of life.

"In the East, the raking of a sand garden is a way of life. Calming and soothing, a pattern between the rick islands emerges and stress and anxiety flee. So rake a while, and take home a little tranquility from this place."

 The garden set against the Magaliesberg Mountains, which are among the oldest mountains in the world. It's almost 100 times older than Everest.

A wooden chair with carved images of elephants and game animals. Beautiful interwoven elements of African and Japanese culture.

Labyrinths are an ancient form of body prayer and can be found on all continents and in all religions. There are three labyrinths here, a Native American, a cosmic walk, and another similar to the most famous labyrinth set into the stone floors in the nave of Chartres Cathedral in France.

It was my first time meditating in this form, and I found it surprisingly calming. There are three things I'm supposed to keep in mind while walking- release, receive and integrate. I found myself letting go of my preoccupations and really stopped thinking. Meditation has always been a challenge in that respect for me, as I have found it hard to just clear my mind of all thoughts. But the rhythm of walking around in circles and hearing the rocks crunch beneath my feet did the trick. As I continued walking, I tried to be aware of the present moment and enjoy the beauty of my surroundings. 

 I finally reached the center, where I reflected on a text. 

Friday evening began with a Jewish ceremony of prayer and blessing over wine to celebrate the opening of Sabbath. Taking part in Kiddush for the first time was very special and helped me better understand what Jesus was probably doing on a Friday evening. We closed the Sabbath on Saturday evening and proceeded on a light meditation through the darkness to the bush chapel. On Sunday, it was amazing to take part in Taize prayer-African style. Taize is a religious community founded in France during the WWII, borne out of the desire to show that members of various churches, nations, and races can live together harmoniously. Taize has spread all over the world through its meditative music, in which shorts songs of a few verses are repeated again and again in prayer. 

We closed the weekend with a truly awesome Mass, where all God's creatures were welcomed (the dogs were very well behaved), and chants and song were in English, French, Zulu, Sotho, Hebrew, and Latin. It was a beautiful way to end the weekend. Ha phororo is definitely one of my favorite places so far in SA.

Part II: Umama noSana Uthukela Community Project

 

The second aim of this project as mentioned in the previous post is to revive clinic committee (CC) programs to ensure community participation and service provider accountability. You might be wondering, what are clinic committees?

CCs are a part of SA's governance structure intended to give expression to community participation at a local and district level. They are composed of various community members and can include elders, traditional healers, community care givers (CCGs), and Sisters (the local term for nurses, who are most often female...I've asked about how to respectfully address a male nurse to which I have not gotten a definitive answer, but it has been confirmed that we don't call them Brothers :). The CCs are intended to act as a link between communities and health services, relaying the health needs and aspirations of the community to to different levels of government. They are crucial entities to improving health status of a community, and especially as related to Umama noSana, crucial to improving demand for maternal and child health services through community mobilization. 

There are four CCs we're targeting at four different sites around the Uthukela district. Our first task was to meet with the CCs and assess how functional they are, learn about their work, and find out what challenges we could help them with. The first CC meeting at Driefontain was very productive, and we met an engaged group of people. (Every clinic is identified with medical symbol and the first letters of the area.)

Working with the community is easy-peasy I thought. How naive of me to take ease of communication for granted. My perception was rather premature as things quickly went downhill after that. We arrived to a scheduled meeting with the second CC at which there were zero people in attendance. Apparently the Sister with whom we had talked to and planned the meeting with decided not to tell any CC members about it. I was flabbergasted to hear and see her blatantly deny that we had come to speak to her the week before to set it up. The story turns out that this particular Sister has been having some issues with the Sister in charge at the clinic, and she seemed to be sabotaging clinic work from the inside. Next, we had the third CC meeting to which only two members came because the remaining six to eight of them recently were employed and would not be available during the weekdays to meet. There are telephones at these clinics, but it apparently didn't occur to the CC to let us know and reschedule another time. Then there was the fourth CC that we unsuccessfully scheduled a meeting with, the failure related to the local politics of the community. There was infighting for control of the CC between the former CC chairperson and the tribal chief. We trekked all the way to the tribal court in an attempt to make some headway, but was only met with the chief's mother who told us to come back in 6 weeks to request a meeting with the chief himself when he's back in the area. We could merely only make a request in 6 weeks, not even have a meeting with the CC itself! 

These incidences of breakdown in communication were frustrating, especially since there was quite a bit of preparation for each meeting. Traveling is not a walk in the park either. These clinics are located in remote rural areas, anywhere from 30 minutes to one hour away from Ladysmith. Many of the roads to the destination are paved, but many others are still dirt. These are some of the scenes I saw out of the car window.

So what we found out was that only one of the four CCs is really functional. This may not be surprising as it reflects a national trend. In 2008, there was study assessing the status of the CCs in all of SA. It found that while 57% of facilities reported having a CC, there was a wide range of factors that impacted how functional they are. Yes, national legislation had created a political climate receptive to community participation, but the lack of provincial guidelines, inadequate resource allocation, and the limited capacity of committees constrain their abilities to actively fulfill their intended roles and responsibilities. 

We have a lot of work to do on this part of the Umama noSana, and it's been a humbling exercise of patience so far.  

Part I: Umama noSana Uthukela Community Project

Although I'm based in Johannesburg, I have been spending most of my time in the town of Ladysmith in the KwaZulu-Natal province and working closely with the Mpilonhle Santuary Organisation. Mpilonhle, which means holistic health in Zulu, is one of the original community-based NGOs that was sponsored by BMSF-STF program in the early days. 

Umama noSana Uthukela Community Project, meaning Mother and Child Community Project is one program I'm working on with Mpilonhle and the Nelson Mandela School of Medicine at the Univeristy of KwaZulu-Natal in Durban. The project aims to 1) mobilize the community to improve demand for maternal and child health services and 2) revive clinic committee programs to ensure community participation and service provider accountability.

Many women in parts of the world, including South Africa (SA), have a high risk of dying while giving life. According to figures released by in 2010, there were 625 maternal deaths per 100,000 live births in SA. Compare that to U.S. figure in 2007, the latest year for which data is available, the maternal mortality rate was 12.7 deaths per 100,000 live births. The SA Millennium Development Goal has set a target of 38 deaths per 100,000 live births for 2015. That means there's a lot of work still to be done!

Two-thirds of these largely preventable deaths are a result of non-pregnancy related infections, obstetric hemorrhage, and complications of hypertension during pregnancy. A myriad of factors have been identified as contributing to maternal mortality, including minimal antenatal care attendance, delay in accessing medical assistance, poor diagnosis, and sub-standard care by health workers. As for disease burden for children, the most common causes of death for kids under five are: AIDS-related death including TB (40%), deaths during neonatal period (18%), low birth weight (12%), diarrheal disease (11%), pneumonia (6%), severe malnutrition (5%), infections (3%) and birth asphyxia (3%). A healthy child starts with a healthy mom.

So in order to mobilize the community, we are developing and conducting household surveys to assess the challenges and gaps that exist as related to maternal and child health issues. This will serve as the basis of the IEC (Information, Education, and Communication) materials that we will subsequently develop to improve demand of these health services in the community. We drove out to clinics in four rural areas in the Uthukela District to introduce the project and hopefully get some buy-in from the community.

Mama Zwane, the director of Mpilonhle, is showcasing the project to community stakeholders at Watersmeet Clinic.

 

There were nearly 40 people in the audience at Watersmeet crammed into a rather small room, including community care givers (CCGs), nurses, traditional healers, and community leaders. 

Here we're relating the UN Millennium Development Goals to why we need health mothers in our community at the Driefontain Clinic. 

After a lively discussion with the group, they expressed significant interest and value in Umama noSana. I'm excited that the project is starting to roll out.

Some of us are mothers already, and many of us will be mothers one day. But all of us have mothers. Mothers risk their lives bringing us into this world, and that risk is often greater or less depending on her postal code, if she even has one. There's a disparity here, and we're going to help close it.

Cảm ơn mẹ...thank you mom.

Raison d'etre...ici

"Why are you in Africa again?" a friend asks me. Good question. Here's a bit of context to what I'm doing here. I'm currently the resident in a post-PharmD training Public Health Residency sponsored by Rutgers, The State University of New Jersey and Bristol-Myers Squibb Foundation (BMSF). This program is designed to focus on two different public-private partnerships during each half of the year:

Secure the Future (STF), a program that develops and replicates innovative and sustainable solutions for vulnerable populations, including women and children, infected and affected by HIV/AIDS in sub-Saharan Africa

Together on Diabetes, a program that improves health outcomes of people living with type 2 diabetes in the United States, especially adult populations disproportionately affected by the disease

STF entered its third phase as a Technical Assistance and skills transfer program (TAP) in 2008, and there's an expert pool of TAP faculty members who shares their experience, knowledge and expertise to the organizations receiving grants from STF. While I'm here, I'm providing technical assistance to non-governmental organizations and community-based organizations.

The residency is based on projects rather than rotations, and there has been a diversity of projects I'm engaged in (more to come in future posts). There has also been a fair amount of freedom to pursue projects that I have identified as needs in the community (e.g. diabetes health education in township clinics).

That's why I'm currently in Africa.

The "Farm," Zulu Idol, and Thorn Tree Trek

                                    

Over the weekend, I thought I was going to spend a quiet time at a farm, but instead found myself amongst traditional Zulu dancers. What I believed to be a "farm" turned out to be an epicenter of Zulu culture, more specifically the Kwahlangabeza Cultural Hub. Kwahlangabeza is a lodge designed like a village of traditional Zulu huts that buzzes with traditional and modern Zulu life. It was pretty cool to stay inside a hut, look up in bed and see a thatched-grass roof, and have amenities of running water, toilet, and satellite TV.

                                   

There was a very lively birthday party that attracted what seemed like the whole surrounding community. The party even included a local competition for Zulu singing and dancing. There were more or less a dozen groups who performed. Many of them were choirs of men singing in the isicathamiya style. Isicathamiya- derived from the Zulu verb -cathama, meaning tread carefully- is a Zulu style a cappella singing that focuses on harmonious blending of voices and incorporates tightly-choreographed dance that keep singers on their toes, literally on their toes. Isicathamiya was popularized in the West by Ladysmith Black Mambazo, who lent their voices to some of Paul Simon's tracks in the '80s. (Yes, Ladysmith Black Mambazo is from the town of Ladysmith where I'm spending most of my time working.) These singing groups were amazing. Although I couldn't understand the meaning of the songs, I was moved by their powerful voices and dances, which were exploding with energy and emotion. This was my favorite group.

                                   

Then there were the traditional Zulu dancers. My favorite was Sweet Seven, a group of boys from secondary school who were jumping, tumbling, doing high kicks, and added a modern touch- a guitar.

                                    

The competition was followed by a night of dancing, and the party lasted into the wee hours of the morning. There's no party quite like an African party.

The next day provided some time for hiking and solitude in nature on the beautiful farm grounds. We hopped on rocks across a small river, rested on a bed of black slate facing an imposing mountain, and walked through forests of indigenous thorn trees. Despite their gnarled branches and thorns that are as long as one's thumb and as thick as a crochet needle, they create a graceful and striking form. All in all, it was a magical experience to be at the heart of KwaZulu-Natal.

                                    

Let's talk diabetes...in isiZulu

I taught my first health education class this week in a rural clinic in the township of Steadville, which is right outside of Ladysmith in the province of KwaZulu-Natal (KZN).  I set up the presentation I created (mind you, not powerpoint format but rather using cut out drawings, stick glue, markers and flipchart- hark the days of old!) in the waiting room at the clinic. There was anywhere between 35 to 50 people, including babies, the elderly, and everyone in between, in my audience. Check out the photo gallery.

The topic of the day was "Eating Well with Diabetes." I touched on the basics of what diabetes is and how nutrition affects blood glucose. We discussed glucose, insulin, and the different ways through which we can manage diabetes. As I learned from my diabetes mentor at St. Jo Hospital last year, there are essentially 4 ways to control diabetes: Meals, Movement, Monitoring, and Medications. However, I only presented three. Monitoring is not provided by the state with the resource limitation in this clinic, which is part of the public, government-run health system. A vial of test strips here cost on average R280 (~$28), not to mention yet the costs of needles, lancets, and meter, which does not seem to be as freely distributed as I remember it to be in the U.S. Considering that about half of the population in KZN lives below the poverty line, which means making do with only R500 a month, monitoring is not an out-of-pocket option for patients either. Patients at this clinic receive all of their medications free of charge from the clinic dispensary. Apparently the only medications that are used for patients with diabetes here are oral agents: metformin, glyburide, and glipizide. So I focused on "Meals" and we discussed different food groups, the "my plate" proportions, and the foods specific to the South African palate (e.g. phutu and samp- the staple starch made from milie pap). Especially since I was speaking to a general audience and not one who specifically had diabetes, I also wanted to make the information relevant to making healthy nutritional choices regardless of one's disease state.

Most of the audience speaks isiZulu, the language of the Zulu people who live in KZN, and my isiZulu vocabulary is measly at the moment. I was very grateful to have Ma Nomsa, who I'm working with at a partner NGO, translate and interpret. Despite the language barrier between us, the audience was so engaged and participated in the lively session. I had brought a sack of oranges to incentivize the crowd, and I think they really appreciated the flying fruits in exchange for answers and responses.

Much of Sub-Saharan Africa has been plagued with HIV/AIDS epidemic, especially South Africa, and most of the limited health care resources have been funneled into infectious disease campaigns. Chronic non-communicable diseases, like diabetes, have not and are not receiving awareness and management as they require. And it's not because they are not a problem here. In fact, non-communicable diseases (NCDs) constitute the greatest mortality and morbidity in the developing world today: nearly 80% of deaths in low and middle income countries are from NCDs. There's still a lot of work to be done to change this tide, but at least a waiting room full of people now know a bit more about diabetes. How do you eat an elephant? ... in small pieces.

The faux Po-Po

 

I received the following notice from the Consulate General of the United States of America:

Johannesburg, South Africa Security Message for U.S. Citizens – Fake Police Vehicle
July 30, 2013

U.S. citizens residing in Johannesburg are advised that there is a cloned South African Police Services (SAPS) vehicle masquerading as an official SAPS vehicle. Golf 6 GTI Reg Number: BSF 079 B The call sign on the car is RR1117. This call sign belongs to a Soweto Flying Squad Vehicle, which is a Ford Focus ST. A white Golf 2 with a registration plate starting with CX accompanies this vehicle. The occupants of these vehicles are armed with R5 and 9mm weapons. They were involved in a hijacking in Monument Park West on July 25. They were previously linked to an armed robbery in Centurion. Should a U.S. citizen see the vehicle, please contact SAPS at 10111 immediately to report the location. If you encounter this cloned police vehicle, slow down, turn on the emergency lights and proceed to the nearest public space (police or petrol station or other well-populated locale) before stopping and cooperating with the police. _________________________________________________________________________________________ The private security sector is an unbelievably huge industry in SA. One reason for that is the high crime rate. I was taken back by how most homes in Joburg are equipped with security defenses that rival medieval castles: high walls, electrical fencing, thorny metal wiring, infrared technology, and 24 hour surveillance by private security companies with armed guards. Another reason for the strong presence of private security, per common perception and personal anecdotes a handful of locals have recounted, is the unreliable police force and response. I actually heard a caller on a morning radio show a week plus ago who was telling the host about a fake police car driving around his neighborhood. I suppose the U.S. Consulate finally caught wind of this. I've never had to think about whether or not I could trust the public protector. I've been taught from such a young age that if any emergencies happen, I should dial 911. I didn't realize until now how much I've taken for granted the functionality of a public protection services. When I first got here, I asked the locals about the emergency number. They gave me half-hearted responses about dialing the emergency number. (By the way, it's 10111 in SA, which seems a bit cumbersome to me.) I hope that I will have no reasons to dial it or that I will not have a run in with the faux Po-Po.

Happy Mandela Day!

Nelson Mandela turned 95 years old today. A revered figure on the international stage, he is an especially beloved hero to South Africans. As one woman said, he is everything to South Africans. His birthday celebration is particularly poignant this year, as he has been hospitalized for recurring lung infection, which began when he contracted tuberculosis while a political prisoner. On July 18, also known as Mandela Day, South Africans honor him by volunteering in their communities for 67 minutes. Each minute represents the 67 years Mandela gave in serving the public and fighting for human justice against the apartheid system. 

Happy birthday Madiba.

Pilanesberg Safari

Six days in Africa, and I got to go on my first ever safari. We drove about two and a half hours from Johannesburg into the North West Province and arrived at Pilanesberg National Park. This Game Reserve is nestled in the crater of a long extinct volcano and is one of the largest parks in South Africa, spanning 55 hectares. (For all my fellow metric-illiterates, that is about 136 acres.) Even in the Winter when the grass is brown and gives the land a dull, earthy tint, the landscape is stunning. Magnificent mountains oversee open grasslands, valleys are speckled with trees and vegetation, and the still blue waters of the lakes reflect back the rocky, red-soiled mountain ranges. It is an absolutely breathtaking panoramic view that only a National Geographic photographer could possibly attempt to capture. This beautiful stage is the playground of countless birds and mammals, including the Big Five. The Big Five is a term first coined by big-game hunters, referring to the five most difficult animals in Africa to hunt on foot. South Africa is one of the few countries that has all Five and in which you can easily see all Five. I had some up-close-and personal encounters with three of the five- elephants, black rhinos, and Cape buffalos- and also some giraffes. (Check out the photos in the gallery.) I barely spotted a female lion lazing around midday in the grasslands, but the bush was a bit too thick and tall to clearly see her. So really the lion and the leopard are the two remaining Big Five that have eluded me. Countless zebras, warthogs, kudus, hippos, elands, wildebeests, impalas, sprinboks, and crocodiles made themselves visible during our outing. One of the most impressive sights though was a little black bird. This particular bird seemed no more unique than any other, that is until he spread his wings to fly away. As the sun reflects off his body...poof! His shiny black feathers are transformed into a brilliant aqua blue. It was like magic. I've been told that no safari is ever like another. It just depends on the luck of the day as to what I'll see. Considering this was my first safari and I was able to see so many animals, missing only two of the Big Five, I would say that was a pretty good day.

Hello Joburg!

 

After a 15+ hour trans-Atlantic flight from JFK, I finally arrived in O.R. Tambo International Airport in Johannesburg early Monday morning. Otherwise known as Joburg by the locals, this metropolitan city is the provincial capital of the province of Guateng, which is the wealthiest province in South Africa. This area also has the largest economy of any region in Sub-Saharan Africa, and its wealth is reflected in my first impression upon leaving the airport: I don't feel like my new surroundings are much different from the surroundings I supposedly left behind in the U.S. Of course the airport was very snazzy (each parking spot in the garage has a light indicator above it hanging from the ceiling, brightening up in either red or green, to denote its availability to prospective parkers- wow... there have been more than a few pre-Christmas shopping trips during which I wish there was such a saving grace), but the world outside the airport was quite similar to the world outside Houston's airport: well developed road infrastructure, the highways were lined with many corporate company buildings, and there were a lot of cars zooming past us. The most awkward thing was when I got into the left side of the car to ride as a passenger and when we turned at intersections, because I kept getting hit by an instinctive reaction that we were about to have a head-on collision with oncoming traffic. All this aside, I remind myself that first impressions rarely tell the whole story and not to be fooled. There is much for me to yet uncover about this country.

Half an hour later, I arrived in the Woodmead office and attended my first pharmacovigilance training session on adverse events. By that time, it was about 18 hours since I boarded my plane in NY, and all I thought about was how glad I was that I opted for an outfit which was both comfortable for a long flight and office appropriate. Talk about first impressions... I had a few introductions to other members of the office before heading off to visit the flat in Melrose that I had arranged for my stay in Joburg. I'm renting one bedroom in a two bedroom flat, and it's the perfect place for my needs- a decent-sized room with a separate bathroom located in a very secure complex with private security. The best part of the flat though, is my expat roommmate. She's a naturalized Canadianne originally from Burkina Faso, who relocated to Joburg two years ago after having lived in Montreal for many years. What are the odds to have such a North American connection in the southern tip of the African continent?! It's so wonderful to be living with a Francophone, to have the radio and TV station tuned into French programming, and dust the cobwebs off my French, which has been stored far back in the recesses of my language cabinet. Even though I'm far from the comforts of familiarity, our common connection brings that familiarity here for me. It's curious where, how, and why we meet the people we do in our lives. I'm excited to have finally arrived in Joburg, and I'm excited about the other curiosities that life may bring in the coming months.