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Nkangala to Capricorn

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Glossary

Bakkie [noun: pick-up (US) / ute (Aus)]
Challenge [noun: applied universally in South Africa to any problem / deficiency / etc. faced by FPD or health service staff.]
FPD [abbreviation: Foundation for Professional Development, my employer]
Roving mentorship team [noun: a collective comprising doctor, nurse, data capturer and health information mentor (HISM) providing technical support to a sub-district’s primary health clinics.]

Rain from Watervaalboven Clinic FPD Witbank Office (2)

Torrential downpour from Watervaalboven Clinic; outside FPD, Witbank

The Nkangala adventure finished up at the evocatively named Watervaalboven (‘Above the Waterfall’) Clinic. Fortunately Dr Tema drove us in a four-wheel-drive bakkie beyond coalfields, through agricultural megacorporation Alzu’s boundless agricultural fields and up into the hills of Mpumalanga: a two hour journey, the final thirty minutes on gravel roads in sluicing rain that had taken its cue from the Elands Falls at our destination. I know that Britain is flooded so I’m not even beginning to grumble but I was relieved not to be in my little Ford Figo.

In that last paragraph lies one of the challenges facing FPD’s roving mentorship teams. Outside metropolitan areas such as Tshwane, the clinics are far flung. Teams can spend four hours a day on the road, halving the time available for actual mentoring in the primary health clinics that they partner. On top of this there are many clinics in each sub-district, spreading the roving team thinly. In remote South Africa patients are affected too: a local nurse remarked to me that they can spend R100 on the round trip to their ‘local’ clinic 50-70km away.

Our visit to Watervaalboven revealed another recurrent challenge. When we arrived the clinic was in disarray without a person in charge, the professional nurses all absent and a long line of patients waiting for the relief nurse to arrive from Middelburg, more than 100km away where she’d abandoned her plans. Tema could do little other than roll up his sleeves and deliver primary health care, with no NIMART nurses for him to mentor or for me to interview. At one o’clock, according to institutionalised practice our assisting enrolled nurse disappeared for a long lunch leaving patients to wait for sputum pots that we were unable to locate for TB screening, X-ray forms, etc.

Dithabeneng Clinic J Mamabobo Clinic Capricorn (3)

Condoms at Dithabeneng Clinic; plaque at Nobody Clinic taken on the anniversary of Nelson Mandela’s release from Victor Verster Prison 11/02/1990

The other side of the coin for NIMART mentees – the clinic Professional Nurses – is that there are multiple demands on the roving mentorship teams. In the three weeks that I’ve spent in the field I’ve witnessed mentors drawn away from their schedules for In Depth Reviews – several days helping to audit clinics’ performance against national standards – Stocktaking – two days presenting plans for the year – Action Research – a whole day polishing research proposals such as promoting MMC (Medical Male Circumcision), increasing cervical screening in women with HIV, testing babies at age eighteen months, etc. It’s not hard to imagine the frustration of clinic nurses who book their challenging cases to review with their mentors, ask patients to repeat their long, expensive journeys (see above) – there may be loss of pay on top – only to find that the agreed schedule is postponed.

All these counter demands on the mentoring teams are important. Without audit, how will South Africa know whether or not national standards are maintained? Auditing in partnership with the Department of Health demonstrates that service improvement is the goal of both parties and secures joint working. Without agreeing their plans roving teams risk “running around like headless chickens” which was one senior interviewee’s assessment of their early operation. With seventeen initiates dying in the mountains of post-operative complications following traditional circumcisions in Mpumalanga last year, promoting MMC is imperative; and when another interviewee – a clinic sister – expressed amazement that asymptomatic women with HIV had abnormal cervical smear results this is another intervention that will save lives: waiting for symptoms will often be too late for successful treatment.

Beyond my work, South African President Jacob Zuma has announced that the general election will be in early May. Despite widespread disillusion in the comment pages of national newspapers he seems certain to lead the African National Congress into his second term. Rows about corruption, high unemployment, poor public service delivery, may surround them but the ANC know that there is no opponent with a hope of winning.

Anticipation of the Proteas v Australia three-test cricket series that starts on Wednesday is intense. With Valentine’s Day marking the first anniversary of Reeva Steencamp’s death there is OJ Simpson-like attention on the Blade Runner: The Oscar Pistorius Trial: A Carte Blanche Channel will broadcast twenty-four hour coverage of the Olympian’s murder trial.

Thubelihle Clinic and Roving Team Malemati Clinic (5)

Dithabeneng Clinic Pepe Street sign Polokwane (2)

Roving team at ThubeLihle Clinic, Nkangala; view from Malemati Clinic, Limpopo; Pepe outside Dithabeneng Clinic, Limpopo; Cool street name, Polokwane.

I’ve carried out 70-80 interviews, visiting thirty primary health clinics with names that are sometimes bizarre – ‘Nobody Clinic’* – other times prosaic – ‘Extension 6’, ‘Zone 2’, etc. – and often evocatively South African – see the photos. I’m staying in Polokwane’s Rustic Rest Guesthouse, just around the corner from Peter Mokaba Stadium, a World Cup 2010 stadium that I discovered on a six a.m. power walk. Next visit: Saturday afternoon, Polokwane City v Orlando Pirates when the congregations of crowned plover that flock to the surrounding grassy areas in the quiet of first light may not be so evident. It’ll be hot for football in Capricorn, this district is named for the Tropic of that passes right through it – which is something that I did today.

Yours in the Tropics.

* The Operational Manager at Nobody Clinic told me that once, the road simply ended there. Travellers would come to a halt saying “Nobody here”.

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Written by martinjones183

February 12, 2014 at 3:19 pm

Industry without art is brutality

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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.

004   009

012 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?

Apartheid Museum exit (2)   Emalahleni Clinic

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.

Manwick and Martin UB Manwick Banda, The Willows

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:

Mission
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?

http://www.tshwane.gov.za

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.

Written by martinjones183

February 5, 2014 at 3:15 pm

Warming up

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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 lesego motsepe_1

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.

Har-dee dar bird UB (2)

Hadeda ibis

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.

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January 26, 2014 at 7:13 am

NIM-ART Nurse Ready to Return

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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…

SA map       Mpumalanga

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

2011

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.

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January 15, 2014 at 7:50 pm

2013 in review

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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.

Click here to see the complete report.

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December 31, 2013 at 5:40 pm

2012 in review

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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.

Click here to see the complete report.

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March 11, 2013 at 5:33 pm

2011 in review

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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.

Click here to see the complete report.

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January 1, 2012 at 9:55 am