why there is no doctor: harsh realities in zonkizizwe (part 2) (11)

(photo: Zonke Testing Day banner on the back of a van used to transport people to the clinics)

While working in Zonke, a fact that shocked me was that an HIV-positive person can only access ARV treatment [for free, otherwise it is very expensive] if their CD4 count is below 200. This is official South African government policy and numerous studies have shown that accessing treatment earlier has greater long-term health benefits as ARVs are meant to be taken life-long. A World Health Organization (WHO) study in 2008 outlined four clinical stages of HIV progression. The WHO recommends that when a patient hits stage three with a CD4 count below 350, life-long ARV treatment should be started. Starting patients earlier negates complications later. However, in South Africa once the CD4 count goes above 200 again, treatment is stopped, which allows for greater complications and the need for new strains of ARVs. This year a push to increase the CD4 count threshold for treatment was rejected by the National Health Council on the grounds of affordability (85).

Prof Robin Wood, director of the Desmond Tutu HIV Centre at the University of Cape Town, is among the clinicians who have been calling for the South African government to raise the standard of treatment set out in its guidelines. However, he pointed out that better guidelines would be meaningless without improving the quality of care and access to services (86).

Professor Wood brings everything back to perspective. Anyone can call for greater access and more treatment, but if there is no distribution system for health services and care then what is the point. It would be like having a big supply of pizzas and no delivery drivers. This is the problem in many former “homelands,” townships, and informal settlements. There are inadequate or non-existent delivery systems for health services and treatment and so in areas where the HIV/AIDS crisis is most critical, there is no system to address the problem.

Today was the 2nd half of Prevention in the HIV/AIDS course. The kids are incredibly receptive with questions, comments, and the desire to learn more. We will be covering Treatment and resources this Friday. Celumusa did a great job of translating and really getting the course lessons through to the kids. Later in the evening she talked with us – her passion and drive to get people tested and aware and knowledgeable is amazing and so admirable with all she has been through. She is so excited about a Zonke testing day, the HIV/AIDS class, working with the staff and community to make more people talk and not be afraid to talk. Today she told the kids that she was HIV positive and they all did not believe her at all – they asked her to cross her heart that she was not lying. I could tell from the first class that the kids were learning much more than they had before beyond what HIV and AIDS stands for (87).

Much of the work at the center and the work that needs to happen in Zonke is HIV testing. Once tested you can learn how to take care of yourself, your children, and your community. When I asked Celumusa why people don’t test she said that people don’t know that they can live with HIV. So many people are involved in risky behaviors, she said, they have family members die from HIV/AIDS, but don’t test themselves. She also noted that pregnant mothers are tested and are given tablets, but not told their status. Testing is critical and we began working on this by planning a Zonke Testing Day for July 31st.

As I began organizing for the Testing Day, I came into contact with more of the health services available in Zonke. There are a number of traditional doctors and surgeries in Zonke. I can only imagine that this is because there is such a lack of other health services. Celumusa and others have bad perceptions of traditional medicine: evil, it kills people, and the traditional healers are crazy people. I was still having no luck finding any doctors, until I finally caught a traditional doctor in his office. He ran a clinic that was more Western than others and was supposedly trained by the government in traditional healing, but his office was empty every time I visited – no patients (88). Why are there no doctors?

Across the road from his office was a private clinic run by a group of Indian doctors. I also had a difficult time finding them, as did many Zonke residents. I was able to visit the private clinic only when Celumusa had to schedule an appointment for her baby. The private clinic had become her last option that she was sure to see a doctor. This says a lot for the health care system in Zonke (and other overcrowded settlements and townships left over from apartheid era) that the poor will pay to see a private doctor because the government health services are unreliable. Celumusa said they always give injections at the private clinic. Yet again I wonder about the quality of care. The clinics give painkiller tablets and the private clinics give injections (antibiotics?). If care is inadequate and access to ARV medication is beyond the ability of most, then the extended scenes of cemeteries become less shocking.

In the past 2 weeks, 3 people have passed because of HIV and AIDS that we have been directly informed of because the Buthelezi family has been close to the deceased – a father, an aunt, and a neighbor. Living in an HIV positive community is so different when you can fully understand the impact of just one life (89).

It was as if I had seen the walking dead. The prospect of death is so intertwined with life in Zonkizizwe that the author who wrote that South Africans attend more funerals than weddings was supported by my experiences this summer. The hardest hitting example was with the passing of the father of one of the families at the center. Three of the children attended the center. The oldest was 17 years old and was taking care of her frail father as he withered away, making sure her younger brother and sister were going to school, and attending school herself. This small family had already lost their mother to HIV/AIDS. The burden of disease was not met by the health care system or any the government response. The burden of disease rests completely on those who are affected and they do not have the resources to help themselves.

A critical aspect of combating the effects of HIV/AIDS in South Africa is education. As one of my goals over summer I developed an HIV/AIDS curriculum, based off of the Peace Corps Lifeskills curriculum, that the youth could share with the friends and families as peer educators. The spreading of knowledge is a powerful first step in giving people the resources they need to prevent HIV/AIDS. It is especially important when there exists no other means to access this information. The Zonkizizwe schools are under-funded and teachers are under-trained. This translates to the lack of a teacher for the Lifeskills curriculum and therefore the lack of knowledge on sexual health and HIV/AIDS. VVOCF is beginning to fulfill a service where the government is horribly failing.

All of our kids were tested, plus about 20 others. In all over 60 people tested. […] The community and guardian support was incredible. There were a few positives that we expected from already young mothers […] and unexpected bad news surprise […] Many good surprises came out of the day as we learned of many negative cases that were expected to confirm our worst nightmares (90).

Year – Number of HIV Tests (*from clinic 2)
2006 – 128
2007 – 246
2008 – 412

The success of solutions driven by citizens was best evidenced by the culmination of the HIV/AIDS peer education courses, health classes, and the death of a father in an area wide testing day. I had taken the lead in organizing the testing day with the clinics, MSU study abroad volunteers, and various local organizations. Because of the stigma attached and sensitivity of the issue I was a bit nervous when the day came. July 31st 2008, the first Zonke Testing Day was a day of success fueled by the youth at the center. And while the numbers of people testing have made steady increases, the reality remains that the majority of those who need treatment after testing will not have access. Many in the generation just older than these youth mocked or scoffed at the testing day, but our kids were set on it.

We really are building a new generation of freedom fighters – not afraid of stigma, talking about sex, ready to be tested, and not about to turn a blind to HIV/AIDS. These young people stood today with a powerful support base of each other evidenced by yesterday’s action and the larger community is taking notice. The youth continue to give me hope and pride in being allowed to take part in such a community action (91).

The realities of Zonkizizwe paint a vivid picture of the effects of apartheid on health care for the majority of the South African population. The health system operating in Zonke is the ground zero of the failures of post-apartheid government policy to address the far-reaching impact of HIV/AIDS.

85. “South Africa: Funding shortfall threatens treatment programme.” IRIN/PlusNews. 2 April 2009. http://www.irinnews.org/report.aspx?ReportId=83762
86. Ibid.
87. Hill, Alex B. Journal Entry. 30 June 2008.
88. Ibid, 17 July 2008.
89. Ibid, 6 June 2008.
90. Ibid, 31 July 2008.
91. Ibid.

Coming next: Conclusion

the universal currency of being under the weather

Review of Healing and Curing: Issues in the Social History and Anthropology of Medicine in Africa
by: Megan Vaughan

Everyone everywhere gets sick whether it is a common cold, a serious disease, or even a life-threatening virus. Likewise, communities across the world work to heal these illnesses and afflictions. Megan Vaughan reminds us that illness and healing are everywhere; there are unwell bodies everywhere and always attempts to heal those bodies. Illness and healing are regular, even normal, features in our lives. However, as Vaughan notes, illness and healing have different definitions and meanings in different areas of the world and within different cultures. How then can we unite the rhetoric into one common topic for academics to discuss?

One of my first thoughts goes to the international organization, Medecines Sans Frontiers (MSF, Doctors Without Borders), and their work across the globe conducting medical missions. How are they able to work towards comprehensive fighting of illness and healing when there are so varied ideas of illness and healing? Do they have anthropological training? Are they equipped with a cultural guide?

Vaughan notes that in Feierman’s article he cited Gilbert Lewis’ work in Papua New Guinea.

Lewis had defined the universe of misfortune by determining who was and who was not ill according to scientific criteria, and then observed how illness was diagnosed and treated within the community. As Feierman pointed out, this was a radically different anthropological approach to that taken by Victor Turner in The Drums of Afflication, a study in which illness appeared to have little independent biological reality, but was described as an important stage in a social drama. (284-5)

Lewis’ work was both innovative and radical in that he worked to apply his Western scientific knowledge well at the same time watching and learning how local communities treated illnesses.
I’d have to say this idea is no longer so radical and more likely than not has become the norm for those working in organizations like MSF.

Among ordinary people in cases of illness caused by sorcery, or in other words by one person’s aggression against another, the course of treatment developed into a contest of power between the medicine men working for and against the sick person. The patient could not recover unless his supporting healer proved fully dominant, and therefore capable of ending the contest of strength. (286)

An issue often arises between separating metaphor and symbol from biological reality in discussions of illness and healing. This is an especially important context in Africa where illness and sickness can refer to actual disease as well as spiritual imbalances or curses. Recognizing the overlaps of science and culture within medical practice is key to effective healing. If culture is ignored in scientific medical realities there can be terrible consequences. But, where is the boundary of biological science in medicine?

More often we have to choose between approaches, since we simply do not have the textured evidence which might allow us to trade both the extent of biologically defined illness and the cultural experiences and constructions of that illness. I would like to argue, then, that we might want to learn something from the new well-documented pluralism of African healing systems. (287)

Something that I have studied and seen is this pluralism of African healing systems. Most notably in Ghana the traditional healers and birth attendants are integrated into the formal health care system. They are provided training and certification and often work alongside those practicing Western orthodox medicine.

[…] we neither have to be totally biologically ‘blinkered,’ focusing exclusively on the disease vector, nor do we have to go so far down the road of social constructionism as to render ‘biology’ totally passive. (287)

Beyond various relative understandings of illness and healing it is important to break into the realm of colonial medicine in order to understand certain inadequacies in response to illness and failures of healing. Vaughan notes that the study of colonial medicine has been one of the areas that has illuminated most clearly the limits of colonial power (288). In Africa, she writes how, “colonial medics were simply too thin on the ground and their instruments too blunt to be viewed either as agents of oppression or as liberators from disease, and studies of African demography confirm this view.” (288)

Although colonial medicine may have been more an inadequate colonial department, it is important to look further and apply the past to the present. The impacts of Western diseases brought by colonial powers ravaged Africa. Because of perceptions of Africans and lacking colonial medical systems, these new diseases were not addressed. A history of disease patterns doesn’t reflect on colonial medicine, but the responses to disease patterns in Africa does. Colonial responses to illness reflected problematic representations of Africa and Africans and so the historical medical accounts are filled with issue.

[…] of course there are many important differences between theories and practices of twentieth century biomedicine, and those of African healers, but in order for us to understand these differences the practice of scientific medicine in its various forms needs to be specified with the same attention to detail as are those of its African counterparts. (291)

To conclude, I applaud Vaughan’s call for medical practice to reflect the pluralism found in Africa health care systems. She writes a compelling piece and hopefully her ideas are heeded at least in medical work conducted in Africa.

a mixture of black, white, red

14 June 2007
Our third visit to the Volta Region.
We visited the Akosombo Dam, creator of the largest man-made lake in all the world. This dam was constructed in a brief three years by Italian engineers. The Lake is formed from the Black, White, and Red Volta Rivers coming from Togo, Benin, and Cote d’Ivoire. Volta in the local language means ‘rapids,’ now there is just a giant dam. The dam was built to be used for electricity and to create a source for fishing. The dam was huge and presented a great mark on the landscape of Ghana’s lush forests near the Volta Region. The dam provides all the power for Ghana, but currently there is an energy crisis. We have experienced this crisis with frequent black outs and power outages al across Ghana. We discovered why this is happening by viewing the extremely low water levels for the operation of the dam. Our guide told us that they are waiting for the rainy season to get into full swing to fill the Lake Volta and increase the power.
No pictures were allowed of the operational side of the dam, but here they are. After learning all about the dealings and history of the dam and how it works we walked back across the bridgeway and I noticed that there were less power lines heading to the north of Ghana and a great number headed to the Accra city center and southern Ghana. This seemed to be an all too common theme and yet again more evidence of the disparitites between North and South in Ghana. Kyle noted correctly that this was a great scar of development. The dam stopped up the rivers that now create the Lake Volta which covers one fourth of the country. It harnesses the water for electricity and development. It sits high and heavy on the once beautiful landscape on Ghana and screams of a continued practice of harmful ‘development.’

Seeing Lake Volta for the first time reminded me of an article that our professor showed to us about child labour in the fishing industry on lake Volta. The article was from the New York Times and followed the stories of families that could not eat and sold their children into labour for money with the promise of seeing their child once a year and being sent more money. Those promises rarely hold up and often the children are beaten, overworked, and never return home. The article covered the story of a young boy who worked on Lake Volta, fishing in the potentially dangerous waters with little sleep or rest, and a lot of work. Child labour is not beyond the ‘most developed’ country in Africa. It happens here, in the very eyes of development.

We headed over to the Volta Lake Hotel to have lunch. The hotel was a great Western hub catering to Obrunis (this is the correct spelling) and providing one of the most delicious meals yet. I forgot to take a picture before the meal, but here is the after picture of my ravaged plate. I was quite hungry by this time and the fillet of perch with a cocktail fruit drink and fresh fruit hit the spot.
Our bus driver was very tired this day since the day before the bus needed repair and there was trouble finding the part, he had been up since 5 am that day. He took a little nap.

Index of blog post series on Ghana.

she’s taking on more water; the zimbabwean titanic

As a ship with a hole takes on water, so too does a state or government sink with a corrupt and ineffective government. Zimbabwe is sinking, many have noted this before, but presently its plunge to the depths seems to be even more imminent. President Mugabe of Zimbabwe is losing control of his country and is losing support from his allies. Zambian President Mwanawasa has called the Zimbabwean state to be like a <a href="http://news.bbc.co.uk/2/hi/africa/6475851.stm
“>titanic and the BBC notes that, “he said the country’s economic difficulties were forcing its citizens to leave like passengers jumping from the sinking ship to save their lives.” Zambia had previously been a proponent of quiet diplomacy. However, now even South Africa’s criticism is increasing, but has not voiced outright criticism of the Zimbabwean government. The United Kingdom has stated that the solution to the issue of Zimbabwe will be found within Africa. This statment may be gaining strength as the economic crises continue and the devaluation of the Zimbabwean currency continues and fuel costs soar. The final paragraph of this BBC article states, “More than 80% of Zimbabweans are living in poverty, with chronic unemployment and inflation running at more than 1,700% – the highest in the world.”

Yesterday President Mugabe attended <a href="http://news.bbc.co.uk/2/hi/africa/6499059.stm
“>’crunch talks’ in Tanzania as the southern African leaders seek to find a solution to Zimbabwe. Many African leaders see Mugabe as a hero for standing against colonial rule, however I am not so sure that a defiance of colonial rule includes not serving your people and allowing them to suffer. As these talks occurred, the headquarters of the leading opposition to Zimbabwe’s government was raided by police. This has become a common theme. The Zimbabwean government has continually attacked any opposition, demonstration, or dissent. Mugabe arrived at the Tanzanian summit and as he did it appeared as though the police had begun a new crackdown on the opposition. The Movement for Democratic Change’s leader, Morgan Tsvangirai, was among 20 people detained in a police raid yesterday. Some of those arrested were accused of fire-bombing, but Tsvangirai was not among them. The opposition is seen by the Zimbabwean administration as a Western puppet to overthrow Mugabe. The Information Minister told the BBC, “You [the West] are too much concerned with your Tsvangirai because he is your puppet and you make him an international hero.”

Mugabe, who has ruled Zimbabwe since 1980, now says that he favors elections next year. Mugabe had previously said that he would like to postpone elections until 2010 to extend his term, yet his own party, the Zanu-PF party, has stated that they were, “”anxious to get another candidate”. Gone in a year? Possibly, losing support of his own party, his people, and now his own resolve seems to be failing. When dissent is not allowed, opposition is forceable put down, and people are not permitted to voice concern with their government then how can you expect your boat to float?

However I am just a Westerner writing about what I have seen and what I have read. Don’t take it from me. Check out this blog entry from the This is Zimbabwe blog. The entry linked to is a clip from the South African news about the issue of Zimbabwe.