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.