Taking Care of the Caretakers and Interview with a sangoma

While my father’s been busy observing and mentoring the doctors, I’ve been working on a project of my own. It’s based on a few heartbreaking anecdotes related to me by Thuso, the volunteer coordinator for Limpopo. He had witnessed a few cases of elderly women who contracted HIV by caring for their HIV-positive grandchildren because their knowledge of the modes of HIV transmission was frighteningly limited. The focus here in South Africa is really on transmission by unprotected sex; thus, elderly women don’t know that they can become infected by bathing the open wounds and sores of their grandchildren.

With the help of Mulalo, one of the social workers at Hanyani, I started interviewing women over the age of 60 about their knowledge of HIV transmission and how they might have become infected. About ½ of the women I interviewed could have contracted HIV sexually; the other half clearly got infected as caretakers for their children and grandchildren. The common thread was that none of them were ever educated about HIV transmission and were completely unaware that they were at risk by caring for HIV-positive family members. When I brought this up to one of the doctors in the clinic, he was surprised. “We just assume that everyone knows these things,” he said. There’s counseling for testing and counseling for drug adherence available at the clinic, but nothing in the way of preventive education.

Recently, the project has gone in a new direction: two of the women I interviewed were sangomas, or traditional healers, who contracted the virus through treatment of HIV positive patients. One aspect of traditional medicine here in South Africa involves blood-letting-- healers make incisions in certain parts of the body to relieve pains, to cure diseases, and to guarantee luck and long life. Sangomas who treat HIV-positive patients are obviously at a huge risk, and the elderly healers don’t know it.

So, the past few interviews have been with traditional healers-- some HIV positive, some not-- about their methods of healing, their knowledge of HIV transmission, and about what kinds of precautions they’re taking to protect themselves and their patients from HIV. Talking to these women has lead to some interesting, intense, and very surreal experiences.

Yesterday I talked with a traditional healer who works very closely with the Tiyani Health Center, which is a rural outreach clinic that feeds into Hanyani. I’ve tried to write about it here; I’m not sure how well I’ve expressed the experience, but have a look.

Interview with a Sangoma-- Mphephu Shihluri

The hospital truck pulled up to an empty compound of four rondavels, all painted sky blue. When Mphephu didn’t respond to our calls, a neighbor strolling past informed us that she’d be back in just a moment-- she was a few compounds down the road performing an infant initiation ceremony.

When she arrived, Mphephu was as playful and colorful as her rondavels. She greeted us with warm, firm handshakes, and joked to Mulalo, “Oh, so you’ve brought me a white to heal this morning?” She ushered us into her clinic, and busied herself with a few preparations as our eyes adjusted to the dim light.

About one quarter of the round cement floor space of the clinic was carpeted in jars of every size and shape, containing herbs and plant remedies collected and ground by Mphephu herself. On the wall hung five framed certificates listing her credentials as a traditional healer; hung beside those were three public health posters from Tiyani Health Center-- one on diagnosing and preventing the spread of TB, and two about HIV/AIDS awareness. Other than these sparse decorations, the round room was bare, and the only light came from the open door.



Mphephu spread out a straw mat and two impala skins across the cement floor while we pulled up plastic chairs. On one skin, she scattered a handful of shells and animal bones; she positioned herself carefully on the second impala skin, tucking her legs beneath her red and black skirt. She pulled her matching shawl a bit closer around her shoulders, adjusted her headscarf, and indicated to us that she was ready to begin.

Mphephu has been a traditional healer since the age of eight-- her mother also practiced traditional medicine, and passed the art on to her young daughter. She’s been practicing ever since.



She begins each treatment session by casting her bones and shells on the ground-- from the pattern in which they fall, she claims she can diagnose any disease, including HIV. Many of her patients are HIV-positive; after diagnosing their illness she treats them with a sweet herbal remedy, and then refers them to Tiyani Health Center for further treatment. She has a solid relationship with the clinic and nursing staff, and encourages all of her HIV-positive patients to seek medical care in addition to her traditional healing; she says that with that combination, they are all now better.



Mphephu is well-educated about HIV transmission; when asked how much she knew, she quickly rattled off a textbook list. And she knows to take careful precautions when treating HIV-positive patients-- Tiyani Health Center supplies her with gloves and alcohol-based disinfectant, as well as surgical masks. She assured us that she’s very careful about spreading HIV/AIDS, and that she knows it’s a big problem. We got a big thumbs up when we expressed admiration for her knowledge and willingness to work with the clinic.

She was less positive, however, when we asked about other traditional healers, and whether she had imparted any of her knowledge to them. Her face darkened as she told us that most other healers in this area are very resistant to working with the local clinics and hospitals-- that they believe medical institutions take away their clients and don’t respect their beliefs and practices. She said they don’t want to hear about how HIV is transmitted or what part they can play in preventing its spread. We suggested organizing a conference of traditional healers to discuss the important role they play in identifying and treating HIV patients, and Mphephu seemed to think this was a good idea. She even expressed interest in giving a presentation on HIV transmission and prevention-- we got a second thumbs-up at this.



As our conversation came to a close, Mphephu was summoned for a second infant initiation, so she invited us to come along. We walked with her down the dirt road while Mulalo explained to me the purpose of the ceremony we were about to witness: sangomas perform infant initiation rituals to ensure a long life for the baby.

We entered the family compound and were welcomed into a second dimly lit rondavel. Mulalo and I took seats on the edge of a big double bed, while Mphephu sat cross-legged on a blanket on the floor, cradling a one-month old infant in her arms. The child’s mother sat on the opposite side of the bed, her face hidden in the shadows, while the infant’s older sister crouched next to the healer, looking on with wide eyes. Mphephu bounced the baby on her knee as she laughed and chatted with the mother and pinched the chubby cheeks of the sister. Then in one quick motion, she produced a razor blade and made four small incisions on the child’s head-- one above each ear, one in the center of her forehead, and one at the top of her neck. The child begin to wail as the blood trickled down her face; Mphephu smiled at me and shushed the infant’s cries. She wrapped a small plastic bag around her finger, holding it up to me as a demonstration of the serious precautions she takes against the spread of HIV, and rubbed a small amount of ground black seeds onto her fingertip. Then she rubbed the seed into each of the incisions, dragging the mixed blood and seed upward from the cut to the top of the now-screaming infant’s skull. The baby’s sister looked almost as horrified as I felt, but the mother looked happy with the progress; as the infant wriggled to break free from her grip, Mphephu made four more quick incisions-- one on each ankle, and one on each wrist. The moment she dropped the razor blade, the infant stopped crying, and there was a moment of complete silence in the rondavel.

Mphephu bounced the baby up and down a few more times, grinning at her handiwork. She turned to me and smiled, “Would you like me to do this for your child?” I managed a weak laugh, but was too overwhelmed for genuineness. I thanked her again for talking to us as we walked out, and returned her third and final thumbs-up.

Hanyani Clinic at Elim Hospital

We’ve been at Hanyani Clinic for four weeks now, working closely with the doctors and nurses to improve clinic flow and patient care. It’s been a challenge, to say the least.

Each day, we arrive around 8:30 AM to a waiting room swarming with very sick patients-- there are never enough chairs, so some of the healthier patients lean against the walls or the windowsills. On nice days, there’s a sheltered area just outside the door of the clinic, and some patients opt to wait there in the grass rather than dealing with the chaotic mass of ailing, coughing bodies inside.

The clerks rush to get everyone registered, while the nurses hastily take weights and write down a cursory summary of the patients’ complaints (usually the chart reads something really specific and helpful, like “C/O aches,” or “C/O sores.”)

Then the patients wait. And wait. And wait.

The doctors saunter in around 10 AM, take a coffee break, hit on the pharmacists, and generally begin seeing patients by 11.

And I mean “seeing” patients in the most literal sense. The patient enters the examining room, and takes a seat across the desk from the doctor, who reads the nurse’s note and glances briefly at the patient. Then he’ll flip through the chart, see that the lab results ordered 4 months ago have not yet come in, and jot down a prescription vaguely based on the complaint described by the nurse before handing the chart back to the patient. The patient opens the door to shuffle out; the next patient has already squeezed herself into the room before the doctor can call out, “Next!”

The doctors get through most of the patients before lunch at 2 PM; they’re usually done for the day by 3:30.

The staff at the clinic consists of two doctors, six nurses, two clerks, two social workers, and four “data capturers.” This last position I find the most intriguing, as I’m yet to figure out what they actually do. Every time I’ve visited their office in the back of the clinic, I find them napping in front of their computers.

So we’ve had our work cut out for us. My father began by encouraging the two doctors to actually examine patients… and on a few occasions, I think they were pretty surprised by what they found. For instance, one woman came in with the unambiguous nurse’s note, “C/O rash.” The doctor started to write a script for cortisone cream, when my father paused him to ask, “Well, where is the rash?”

The doctor turned and repeated the question to the patient, who gestured to her groin.

“Why don’t we take a look at it?” Dr. Ray boldly proposed.

It turned out that the patient had genital herpes. For those of you who aren’t well versed in the treatment options for genital herpes, cortisone cream is not one of them. Furthermore, having chronic herpes would automatically place this woman at clinical stage IV HIV infection according to the WHO guidelines.

The second major project we undertook was to begin organizing the medical records. Patients’ charts consist of dozens of loose sheets of paper and some lab results shoved into a brown paper folder. Sifting through old progress notes and looking for old CD4 counts and viral loads takes up about ½ the time the patient is in the examining room. So my father found a box of patient history forms that had been hidden away in a dusty corner of the data capturers’ office, and audaciously called for their widespread use. This was, predictably, met with some resistance from the staff, as it required a tiny bit more work on the part of everyone. The head nurse, who is actually wonderful and genuinely cares about the patients and has expressed concern for the substandard medical care the clinic is doling out by the bucketful, has been incredibly helpful in convincing her colleagues to complete the forms for most patients. The doctors, meanwhile, have been pleasantly surprised to find that having a patient history in front of them and a chronological flow sheet of lab results has been useful and time-saving. In a few cases, actual physical exams have been performed without my father’s insistence, and a few actual diagnoses have been made and written in the charts to accompany the list of medications prescribed. Progress is being made, even if it’s at the pace of a giant African land snail.

It's been a while, but...

So life's been busy, and I haven't updated here in a long while. I'm sorry for that, my dear readers, but here's an abbreviated version of my first few weeks in South Africa.

Since I was still recovering from my Indian illness, my father took it easy on me the first few days-- instead of hiking the 3000 foot rise Table Mountain in Capetown, we took the cable car, and only spent about 2 hours out in the blistering sun hiking around the top. Here's a view of the "city bowl" from there:



The next day, the itinerary called for a combination hiking/biking/adventure tour to the Cape of Good Hope, which despite extreme abdominal pain for most of the morning I managed to get through. We were with a really interesting group of people; the scenery was unbelievable, and we saw lots of wildlife: seals, penguins, baboons, ostriches, rock dassies and I even had a close encounter with a Cape cobra!

A few days of driving at a fairly relaxed pace followed that strenuous activity and allowed me some sleep/recovery time while my father did the driving. We toured the South African wine country, spent a day in Oudtshoorn (the ostrich capital of the world) where I actually RODE an ostrich, and ended up in Addo Elephant Park just outside of Port Elizabeth. I can't even list all the amazing animals we saw there, but here are a few of the best pictures:







Then we flew back to Johannesburg, had a whirlwind orientation for our placement, and met Minh, an infectious disease doctor from Chicago who's also working for ICEHA (International Committee for Equal Healthcare Access) in a hospital near us. We spent the next day driving 7 hours on highways and backroads to Thohoyandou, (home-sweet-home for 6 weeks) and Minh learned to drive stickshift, which made the drive that much more exciting. The guide book describes the city of Thohoyandou as a "pile of broken concrete," which is more or less accurate. But the surrounding area is so beautiful that it doesn't matter-- it's wonderfully green, lush, mountainous, and best of all, quiet. Everything I missed so desperately in Chennai...

We're working a Elim Hospital, which is about a 45 minute commute every morning through the rolling hills of Limpopo-- it's a lot of time in the car, but the drive is so lovely that we don't mind.

There's an enormous amount to write about the HIV clinic, the doctors and staff, and what I've been learning about HIV/AIDS and tuberculosis. I'm going to save that for another entry, though, just to keep you all anticipating the exciting things to come.

To close this entry, I wanted to write about today. We had a long weekend for Easter, so we've been in Kruger National Park for the past three days, and today had a road trip back from Phalaborwa. Road trips are usually pretty strange experiences, but road trips in South Africa are particularly strange:

We left the bed and breakfast at 8 a.m. in search of breakfast, ironically, because we hadn't requested breakfast the night before. The owner suggested two places: Steer's and Wimpy's... Wimpy's we're pretty familiar with-- a more run down, South African version of Friendly's, I guess. So we opted for Steer's, thinking it sounded like some kind of local little breakfast joint. It turned out to be a fast food place in a gas station. We had eggs and toast and grilled tomatoes while watching attendants pump gas... weird experience number one. The day was off to a good start.

After breakfast, we drove through Gravelotte (which prompted my father to begin singing "In short there's simply not/ A more congenial spot/ For happily-ever-aftering than here/ In Gravelotte!") and were intrigued by signs for a GIANT BAOBOB TREE! Remembering a family vacation in Ireland where a detour to the world's largest dolmen had turned out to be the experience of a lifetime (or something) we decided we'd better not miss this opportunity. Minh good-naturedly didn't try too hard to dissuade us.

The second sign for the Baobob tree pointed left down a dirt road and read "GIANT BAOBOB TREE 3-5 km." Three to five km? Really? I suggested that perhaps the tree was 2 km across, but we decided that probably wasn't very likely.

So we turned down the dirt road, and immediately noticed that the speed limit was 100 km/hr. Really?? Who's going to drive 100 km/hr on a bumpy, potholed, rocky dirt road? So we're creeping along at a good clip of 35 km/hr for 3 to 5 km when we're passed by a speeding bus and two very fast taxis. We had our answer.

We found the tree, miraculously, and it was indeed very giant. And also quite old: 2007 years old, to be exact. We climbed inside it, climbed up it, and generally enjoyed the weirdness that had led us there.

Back on the road, and we drove happily along for a while before Minh piped up from the back seat, "What is THAT beast?"

Turned out to be a sable antelope-- a large black and white animal with elegant 3-foot-long horns that curve gracefully back towards its spine-- grazing by the roadside like it was no big deal at all. So we backed up a bit (on the highway... driving with Dad is always exciting) and got out to take pictures of it.

The driving resumed, and we passed through dozens of orange orchards, which made us all a bit hungry for citrus fruit. So we stopped at a roadside fruit stand to buy some, and we're immediately assaulted through the open window by 4 or 5 fruit sellers dumping oranges, papaya, avocados, and bananas into my lap and demanding to be payed. It took some tough negotiating, but we finally got a reasonable number of oranges for a reasonable price, and a fresh papaya and an avocado. But not every fruit seller was satisfied with our purchases, and stayed in the window for another 2 minutes, pushing bananas at me, asking for a few extra Rands above the agreed upon price, and begging me for the bag of peanuts at my feet to feed the children.

We finally managed to close the window and escape the market, and headed to Giyani, which we'd read was a cultural center with beautiful crafts, woodcarvings, and beadwork. Maybe we're not very cultured, but Giyani looked to us like a series of malls with chain fast food restaurants. Nevertheless, we persevered in our search for culture, and asked a total of 8 people directions to one crafts place on our list. After driving in circles, ending up at several dead ends, and being laughed at by far too many children, I suggested we try calling the number listed in the guidebook. The conversation Minh had with the woman went something like this:

Minh: Hello, is this Mashoka?
Woman: Yes.
Minh: Textiles and beadwork?
Woman: Yes.
Minh: You make cushions and jewelry?
Woman: Yes.
Minh: Are you open today?
Woman: No. (click).

Well, three out of four isn't so bad, right?

We gave up, and continued on our way, thinking that this would be the last of our road trip adventures and misadventures, since we getting pretty close to Thohoyandou. But no...

As we approached home, we saw a crowd of about 600 people gathered maybe 100 m from our front door, with music blasting, chickens roasting, and who knows what else. Huge party.

Turned out to be for the opening of a new funeral home.

Morbid?

South Africa is a strange place. I'm enjoying it quite a lot here.