Industry without art is brutality
Ruskin’s quotation is blutacked to the computer in Eastbourne Sexual Health Clinic’s room 11 , the HIV clinical room, a weak play on ‘ART’ (antiretroviral therapy) and a reminder that there is an art in effective healthcare.
Week two raced past with visits to eleven primary health clinics and to Kalafong Hospital’s Immunology (HIV) Clinic in Tshwane (Pretoria). I wrote about the numbers last blog – they are similarly immense wherever I go. Now I’m swimming in numbers too: an alphabet soup of data entry with three dozen semi-structured interviews and a focus group already conducted.
Sister Jostina outside Kameeldrift Clinic, FPD mobile HIV testing outside Nelmapius Clinic, Tshwane and allotment garden & gardeners outside Eersteruste Clinic – a common feature of South African primary health clinics – the produce is distributed to the community.
On Saturday David drove the short distance from Pretoria to Johannesburg, through the gleaming skyscrapers of South Africa’s financial hub to the Apartheid Museum. Like the Holocaust Museum in Washington DC it’s a testing visit. The tour begins with an arbitrary separation: me through the entrance for ‘BLANKES / WHITES’ David through ‘NIE-BLANKES / NON-WHITES’. We walked through separate corridors of pedantically absurd yet sinister former-public signs that once separated people in every daily activity imaginable, along lines of race. SA’s sign industry was brutal. The tour articulately documents long-established pre-apartheid racism and maltreatment of black and other non-white people before walking visitors through the apartheid years, allowing its rulers’ and administrators’ extraordinary prejudice to speak for itself.
Witnessing the bravery and sacrifice of those who opposed the regime made my eighties ‘activism’ in the UK seem token: buying Free Nelson Mandela, angrily boycotting (Paul Simon’s) Graceland and marching in protest outside South Africa House pale beside the suffering of those who stood up to apartheid and the shocking exhibition of cruelty and violence they suffered that are commemorated here. I was fascinated to see familiar images from recent history and relieved to exit with a feeling of optimism provoked by the final displays, which led to the dismantling of apartheid and free elections. As we drove back through the central business district and Sandton on the N1 David provoked a difficult reflection: what would I do in the face of extremity..? I wonder, how brave would I be?
The exit from the Apartheid Museum and outside Emalahleni (isiXhosa for ‘a place of coal’) Clinic
On Sunday I picked up a white Ford Figo for my first drive, 100km east to Witbank. The Protea Hotel Highveld’s lobby is orange and brown with explosions of white heat in Dan Myburg’s atmospheric art photographs of local heavy industry. Driving around the area, there are deep black gouges of open cast mines blasted into the landscape, mountains of slag, cooling towers and chimneys discharging steam and smoke from power stations, pot holes the size of the Great Rift Valley caused by the ceaseless round trips of heavy, articulated transporters that clog the roads as they lumberingly move the coal from mine to furnace. I’ve yet to see the vervet monkeys or meerkats that ran in abundance across the wilder roads of Eastern Cape. There’s industry but – unless you’re Myburg – little art here.
After a productive day in the clinics of Witbank, its surrounding townships and nearby small towns, today was spent in Middelburg ‘Home of Stainless Steel’ and the Steve Tshwete / Emakhazeni sub-district. In fact the landscape was far more agricultural. The challenges for people living with HIV include miners negotiating time to collect antiretrovirals and remote farmworkers even reaching clinics. After seeing a patient who’s HIV is stable and well-controlled after three years’ successful treatment being issued only thirty days’ pills I discussed issuing longer prescriptions with today’s roving team: if one hundred patients like him attend clinic every month, they’ll need 1200 appointments a-year; shifting to six-monthly follow-up would release 1000 of those seemingly needless appointments, relieve some of the burden on clinic sisters by reducing clinic queues and solve some of the patients’ barriers to attendance and retention in HIV care. If mineworkers cannot collect their ART there’ll be no industry.
There may be no sign of wild mammals but as we drove past Mpumalanga fields the cows were followed by gleaming white ‘tick birds’ (cattle egrets) and I’ve seen guinea fowl & two long-tailed widowbirds barely more airborne than the Wright brothers’ Flyer at Kitty Hawk thanks to the weight of their extended tail feathers.
With Manwick 2011 and 2014
In other incidental news, I bumped into an old friend from 2011, Manwick Banda, a Malawian waiter at The Willows opposite the FPD offices. I’m back in the gym thanks to Protea Highveld’s deal with Planet Fitness. South Africa being a society of extremes, from Jo-burg’s millionaires to the poor in in formal settlements and no matter how industrious my workout, I wonder if I’ll ever join the elite that are inadvertently targeted on Tshwane municipality’s website:
To enhance the quality of life of 911 people in the City of Tshwane by promoting and
Protecting the health and wellbeing of our people through leadership and best practice
In rendering accessible, affordable, sustainable, equitable quality, efficient and effective
Services in a manner that builds partnership.
Population served: year estimates 2007) based on the 2001 census figures.
(My italics) Surely a typo for all that escaped the proof-reader?
To work soon and another day witnessing the enormous strides being taken to provide ART to millions in South Africa. My evaluation may reveal the art behind such industry.
Assignment, reading, weather… everything warmed up during my first week in Tshwane (Pretoria). In the media HIV/AIDS was in the news as former soap star Lesego Motsepe died having stopped treatment in 2012 to exclamatory headlines: ARV SHOCK! HIV+ Lesego opts for beetroot Manto style – a reference to former Health Minister Manto Tshabalala-Msimang who denied South Africans access to antiretroviral therapy, advocating healthy eating.
Firstly, at work. How great it was to see the truly impressive progress made in three short years. Blog followers from my Eastern Cape assignment and anyone who’s looked back at earlier posts may remember that in late 2011 the NIM-ART (Nurse Initiated and Managed Antiretroviral Therapy) programme was just starting.
Maria Rantho Clinic and Lesego Motsepe, former soap star and AIDS activist who died this week
As part of my re-introduction I visited primary care facilities in the township areas of Winterveldt, Ga-Rankuwa and Soshanguve built 35km outside Pretoria at the time of apartheid. And what a long way NIM-ART has come in a short time. I sat with Sisters Rose, Stephi and Ann who competently and confidently managed long queues of booked and walk-in patients from cohorts of four to five thousand people with HIV per clinic.
When I arrived I asked one of the sisters if she knew why I was there. To my chagrin she replied “Because we are the worst performing clinic in the district”. If that was the worst then it was a pleasure to tell her – and her sub-district manager – how truly impressed I was. In a week when the Sports Minister caused a stir using the language of a BBC 5live 606-caller as he lambasted Bafana Bafana – “What I saw was a bunch of losers” – motivating staff by praising their impressive vocation and dedication to NIM-ART might be considered..? In the Mail & Guardian newspaper public HIV testing services were praised by a scientist who spent several fruitless days trying to get a private test and tried the public health service in desperation:
There were quite a lot of people waiting to be tested but the whole process went very quickly. The nurse  was well informed – you could tell all the staff had been well trained for this
Not only were nurses that I saw managing HIV caseloads the size of the very largest UK centres but doing so in primary care. The variety of problems was beyond what many UK-based HIV specialists would see in a very long time. There were complex treatment questions, TB symptoms, defaulters returning to HIV and TB management, orphans brought in by family members and the visibly sick with advanced HIV / TB disease; there were infants and people in their seventies, some were pregnant – and there’s another good news story. Nurses are struggling to complete their NIM-ART portfolios since effective prevention of mother to baby transmission was introduced in 2010 with the consequence that insufficient new-born and very young cases of HIV exist for them to manage.
Let’s not get too rose-tinted: I am here for a reason. At a time when international donors are contemplating the withdrawal of funding significant challenges lie ahead if South Africa’s ambitious HIV programme is to achieve its targets: millions more need testing and life-long therapy, multi’ and extremely drug resistant TB are on the march and the overall number of TB cases has not fallen; significant gaps exist in funding staffing and infrastructure; there are reports of drug stock-outs – though not in the facilities that I visited – and the questionable quality of data means that the true magnitude of loss to follow up is uncertain. The day before I was there, the Minister for Health visited one of the Soshanguve clinics and found a patient who had waited from 07:30 until 12:00. He blasted ministerial hot breath under the poor manager’s collar.
I’ve finished my first South African novel on the new Kindle, Karen Jayes’s shockingly violent For the Mercy of Water set in a near future beset by drought, corruption, brutality and water wars.
Then there’s terrifically warm hospitality of David and Ann Cameron which has made my first week in South Africa so positive. David and I take a brisk forty-minute walk at 05:30 before the mercury rises to the low-to-mid thirties each afternoon. They’ve taken me to visit the Voertrekker Monument last Sunday and Sammy Marks’s House, allowing local history to seep under my skin. Add to that the pleasures of flora and fauna – I’ve been welcomed back to Pretoria by a cacophony of bird-calls and returns including onomatopoeic hadeda ibis, bright yellow weavers, egrets and a delightful pair of grey loerie on the Camerons’ balcony.
Next week I go out in the field with NIM-ART mentors and mentees carrying out interviews, (hopefully) focus groups and issuing questionnaires – gathering evidence from the coal-face of the successes and challenges of NIM-ART that lie behind the numbers. Hot stuff.
With the distractions of Christmas and New Year behind me, suddenly it’s only a matter of days until I fly again to Oliver Tambo International, Johannesburg. Second time in South Africa I’ll be met by (the good) David Cameron who has kindly offered to put me up in Pretoria for my first two weeks on assignment.
In 2011 my objective was to help to get NIM-ART (Nurse Initiated and Managed Anti-Retroviral Therapy) off the ground in the primary care clinics of Graaff-Reinet and surrounding district through clinical mentoring. Three years later I’ll be helping to evaluate the impact of NIM-ART and NIM-ART mentoring in four districts in Gauteng, Mpumalanga and Limpopo (two) provinces. Linda Murray has made the interesting suggestion that I use some of the flight time to list my expectations so that I can reflect upon them at the end of my assignment…
Janet Hearn has advised me on antimalarials as it’ll be hot and humid with Anopheles mosquitoes keen to bite my parts in parts. Janet gets posted by Médecins Sans Frontières to more challenging locations than primary care clinics in north-eastern South Africa: Darfur, Turkish/Syrian border, etc. She describes her pre-assignment feelings as “terror coupled with excitement”. I’m happy to say that I am not experiencing terror. However South Africa’s violent crime statistics are widely reported – in the words of one of my South African patients, “there are so many car-jackings” – so in order not to end up as another crime statistic I’ll be sensible. I’m looking forward to it; a little daunted but in the sort of good way that’ll put me on my mettle.
What’s changed? Most obviously, on 5th December 2013 Nelson Mandela died. On a cold Sunday afternoon on the Sussex coast I watched Mandela: Long Walk to Freedom. Scenes of his birthplace in lush, sun-drenched Transkei heightened my desire to get back there and I thought that the movie was as good a representation of his autobiography’s 784 pages as is possible in 152 minutes with strong actors convincing as Nelson and Winnie Mandela.
In other changes, South African HIV treatment guidelines have embraced new antiretrovirals in new classes – welcome a second protease inhibitor, atazanavir and an integrase inhibitor, raltegravir – opening up the possibility of effective third-line therapy. A recent study has reported “astounding” results from the South African HIV treatment programme:
The roll-out of antiretroviral therapy (ART) in South Africa has achieved “astounding” results, a mathematical model published in the online edition of the Journal of Infectious Diseases shows. Each person who started HIV therapy between 2004 and 2011 had an individual gain in life expectancy of 11 to 13 years. The estimated population lifetime survival benefit for all people initiating ART in this period was 21.7 million life-years. Increasing the number of people linked to care and expanded access to second-line therapies could increase the gain to 36 million life-years.
In 2011 I left my caseload in the capable hands of Caron Osborne; on Friday I’ll leave it in the capable hands of Heather Renton. At home, Steve and Chris are at universities, leaving Angela in a quieter house. Without Angela’s blessing and her being prepared for some quiet times at home – plus the support, interest and good wishes of so many others – it would be harder to go. Thankyou all.
South Africa 2011 vs 2014
Cacadu district (Graaff-Reinet)
Tshwane District (Pretoria)
Nkangala District (Witbank area)
Capricorn District (Polokwane / Pietersburg)
Vhembe District (Zimbabwean border)
1.4 million South Africans on antiretroviral therapy
2.4 million South Africans on antiretroviral therapy
First and second line therapy
First, second and third line therapy
Global Medic Force (New York)
Foundation for Professional Development (Pretoria)
Clinical mentoring – implementation
Roving mentoring – evaluation
Oscar Pistorius preparing for London 2012
Oscar Pistorius preparing for Pretoria court March
Long Walk to Freedom – book
Long Walk to Freedom – movie
Rough Guide to South Africa – book
Rough Guide to South Africa – Kindle
Rugby World Cup Quarter Final: Australia 11 v South Africa 9
Cricket: three test series v Australia. Feb-March
Reference: Michael Carter, http://www.aidsmap.com/page/2810573/?utm_source=NAM-Email-Promotion&utm_medium=aidsmap-news&utm_campaign=aidsmap-news with a link to the original article.
The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.
Here’s an excerpt:
A San Francisco cable car holds 60 people. This blog was viewed about 780 times in 2013. If it were a cable car, it would take about 13 trips to carry that many people.
The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.
Here’s an excerpt:
600 people reached the top of Mt. Everest in 2012. This blog got about 2,000 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 3 years to get that many views.
The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.
Here’s an excerpt:
A New York City subway train holds 1,200 people. This blog was viewed about 3,800 times in 2011. If it were a NYC subway train, it would take about 3 trips to carry that many people.
Before playing at the opening concert of the 2010 FIFA World Cup in Orlando, I watched as people from all different ethnic groups poured out of the station together. Man that felt good. The apartheid government split us into groups, but if we are going to reconcile, we must first get out of denial and learn one another’s cultures, speak each other’s language. Until then we can’t pretend we’re a rainbow nation.
Hugh Masekela, ‘What I’ve learnt’ South African Sunday Times 30th October 2011
My final post from the rainbow nation and in the wake of Basil d’Oliveira’s recent death has me reflecting: the patients that I saw in clinics were universally black or coloured; I worked in teams of black, coloured and white colleagues; I socialised exclusively with white people… I socialise with more black people in Eastbourne. It’s uncomfortable to write that but it was so. So much has been good here but I guess that it’s going to take more time to erode the racial hangovers from apartheid and the inequality that is its legacy. Race is a constant topic in the media and in conversation.
Sitting beside Elizabeth Race in Pretoria again, I’m waiting to talk to sixty delegates tomorrow on my flatteringly given topic, ‘Mentoring colleagues to achieve excellent results’ (David Cameron, the good) my thoughts have turned to home. Angela asked what I wanted to do once she has collected me at Heathrow: she thought that I was joking when I suggested going a little further around the M25 to watch Eastbourne Borough away at Bromley… Just as I looked forward to this South African assignment with excitement, I now find myself excitedly anticipating the return to the UK. I haven’t ever wanted the three months to go faster nor to pass more slowly – they were a fact, so is going home. And I’m going to enjoy that every bit as much as I’ve enjoyed being here.
To round things off in the style of the Guardian: South Africa in numbers, work then play:
1 case XDR (extremely drug resistant) TB encountered
2 occasions in 3 months on which I encountered a doctor in a primary care clinic
4 pills a-day (compared to 1 in the UK) for first line antiretroviral therapy
7 primary care clinics mentored
10.5% estimated prevalence of HIV
850 HIV-related deaths per day
1000 new HIV infections per day
8,400 expected number of people living with HIV in Graaff-Reinet (estimated population 80,000)
5000 HIV treatment centres compared to 400 in 2009
19 tons unused medicines including antiretrovirals destroyed in Eastern Cape, November 2011
69 percentage of patients at Ithemba HIV clinic who are female
107 km to Klipplaat clinic
189 km to Steytlerville clinic
222 people with HIV reached by 2 lay counsellors in six weeks
86 recalled patients attended clinics during those six weeks
86 recalled patients screened for TB
31 started TB preventive therapy
20 started antiretroviral therapy
1 motorbike ride, to Nieu Bethesda and back
2 weeks a gecko shared my room
3 nicknames for Port Elizabeth: ‘Windy City’, ‘Friendly City, ‘Sunshine Coast’
4 farewell gatherings
5 nights at The Willows Country Lodge, Pretoria
6 blue crane, my favourite birds, seen together beside the R75 at Wolwefontein as I turned right to Steytlerville
11 rugby world cup matches watched
12 novels read
24 blog posts
47 Australian second innings total in the Cape Town test match
85 nights at Aa’Qtansisi Guesthouse, Graaff-Reinet
90 hours brisk walking
109 blog comments, not counting emails
3621 blog visits
6196 km in the chevy
9531 km Eastbourne from Graaff-Reinet
Biking to Nieu Bethesda with Brian Jones; Nieu Bethesda brewery; blue crane; leaving Aa’Qtansisi Guesthouse, Graaff-Reinet (Shaun is beside me)