Thursday 9 January 2014



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”

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