Yesterday started with a typical morning
of rounding in an under-served hospital with really sick HIV/AIDS patients. The middle consisted of a shock back into the
reality of modern medicine with a teleconference with Columbia presenting cases
from South Africa. The day ended with the slaughtering of 30 chickens, on a
hill, at midnight...Let me explain.
Since the new interns have started, the chief of medicine
has given small introductory lectures each morning. This morning he discussed how the hospital
came to be such a challenging environment to work in. Its mission was always to the under-served,
and in a place like South Africa, that seems equivalent to under-funded. However when the AIDS/HIV pandemic hit South
Africa in the late 1990s, the hospital was in the thick of the action, the
patient presentations were novel, they were sick, the hospital was unprepared
and not well funded and many died. It
became such a challenging, hard place to work that many doctors and nurses left
thus depleting the hospital even more.
In fact, in the room with us, there was only one internal medicine
physician that was present during the start of this pandemic that is still
working at Edendale today. Never-the-less
outside funding finally came in, new staff were hired and it seems that most of
the energy was directed towards the most dire needs, HIV/TB and complications
from these diseases and not so much to systems improvement and expansion in the
hospital. Hearing the chief of medicine
speaking about the timing of HIV, I finally came to understand how new this
disease truly is.
Rounds started and we were post call. As we walked to the admitting area to see our
patients it was a mess. 200+ people were
in the waiting area (I had to put my N95 mask on early) and it was impossible
to tell who were the patients, the family and the friends. Yet somehow there was some order to the madness
and thanks to the help of some well placed nurses we found our patients. They were on cots, by the wall, waiting to be
told they had a bed so their family member could transport them upstairs. The first patient we came upon was the
sickest. She had defaulted on her ARVs,
had the most profound cyanosis I had ever seen and likely had PCP pneumonia. She had
decompensated quickly since her initial evaluation and by the time we saw her
in the AM, we all knew her prognosis was poor.
While the team moved on (they had to secondary to the sheer number of
patients) I volunteered to get IV access, ensure her meds were given and watch
her status. It became clear by
midmorning she either needed to be intubated or made comfort care. Unfortunately an ICU consult was less than
helpful. They have only 6 vent beds for
the entire 900+ bed hospital. She was not
a candidate for ICU. She was too far
gone and deemed not fixable. She passed by noon that day.
In the early afternoon after rounds had finished it was my
responsibility to present cases from Edendale hospital in a teleconference with
the medicine residents at CUMC along was an ID MD and a pulmonologist. As I presented numerous chest x-rays, cases
on cryptococcal meningitis, TB and aspergillus I was asked about bronch
capabilities (none, they are transferred out), pleural biopsy (yep…but booked
for several months away and I doubt with VATS) and culture data (sparse, there
is no official micro lab with microbiologists).
Hearing these questions, it again dawned on me how much the medical
house staff and consultants are asked to do on a daily basis without the
benefit of ever present specialists, diagnostic tests and rapid lab turnaround
time. How under-served and resource limited
the hospital is and much they are asked to do, with less.
After conference it was time to go to Krista’s (the head of
ITEACH and the person who helps set up my time in Edendale) for dinner. On arrival I was greeted by her and the chief
of medicine at Edendale and was asked a simple question. Would I like to go with them at night to the
middle of a township on top of a large hill to watch 15 traditional Zulu
healers perform a traditional ceremony? Ummm
yes. The two questions I had
were: 1, is it safe? Yes absolutely, no one in the township would
dream of ever harming anybody associated with traditional Zulu healers. And 2, what does this entail? These traditional Zulu healers had been
working with Krista and ITEACH on the acceptance of ARVS into the
community. These Zulu healers were
branching out on their own to start a new ARV integration program where they
would promote amongst other things these ARVS and to help with their acceptance. They were performing a ceremony to ask their
ancestors for help and good luck in this endeavor. Krista (and by proxy us) had been invited because
of her previous relationship with many of the healers. Oh, and by the way, 30 chickens were to be
sacrificed (2 per person). But don’t worry, we weren’t expected to bring our
own chickens. I proceeded to ask if
anybody had ever seen Major League the movie where a practicing voodoo baseball
player on the Cleveland Indians demands he sacrifice a live chicken before a high stakes
game? Instead he is brought a fried chicken
from KFC. There are crickets in the
room, no one thinks it is funny and I can only imagine the look my wife would
be giving me right now.
After dinner we leave for the township. It is dark, misty and visibility is only 10
feet in either direction. As we pile into
Krista’s old, beat up range rover and drive into the township I start to question
this whole safety thing.
We end up picking up two of Krista’s associates;
fortunately one is a spiritual healer in training and has been “chosen.” He is
able to direct us. We head up a long,
steep, rocky hill with drop offs on either side and mist in all directions. The pitch on the range rover is intense and
at times I think we are going to tip over.
Finally we can’t go any further and we head out. There are drums playing in the distance and
on our approach we spot several fires surrounded by 15 people and 30 live
clucking chickens. They were waiting for
us and we are greeted warmly, all of us like friends with huge hugs and warm
smiles. It doesn’t matter that we don’t
speak Zulu and very few speak English.
The ceremony begins with dancing, singing and drums blaring,
the ritual sacrifice of 30 chickens commences and it appears much like a
koshering. While chants are sung the
throats are slit, the blood drained out, the chickens plucked and tossed into a
pin and salted. The gallbladders
however, are removed. The Zulu healers
believe that the souls of their ancestors reside in the gallbladders and these
are to be saved.
Finally around
midnight, after enough dancing, singing and drum playing Krista, myself and the
chief of medicine at Edendale have to leave.
It is late and while the healers will be there all night, we have work
the next day.
As we head down the hill getting intermittently lost in the township and dealing with the same rocks and pitch I start reflecting on what I had just witnessed. This was a very spiritual and old ceremony revolving around something extremely modern and contemporary, ARV compliance. I think about many of the patients in Edendale and those who do or don’t take their meds. How much work has actually happened in Kwazulu-Natal and that the mortality curves for HIV and TB are finally flattening. Krista had explained that the first modern ARV attempts in South Africa weren’t until the very late 1990s into the year 2000. That she was there for major role out in 2004. It has finally occurred to me that this disease is still so new and when it hits resource poor, underdeveloped nations like South Africa, perhaps what is happening here could be much worse. People are actually getting there medications, mass treatments with standardized approaches to medication availability, acceptance and adherence are happening and people are getting better. And I think the take home of working at Edendale hospital is that while it is happening at the population level there is still a lot of work to be done for it to happen at the individual level.
The best quote I have heard so far while here: “Just another day in Africa”
