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Erica Dwyer
South Africa
See previous Erica Dwyer submission 
July 2004
A Compelling Story
My adventure in South Africa is over. I have said many goodbyes and left good friends, mentors and almost a year of my life behind. I'm on a plane to Philadelphia, anxiously anticipating the next step in my life: med school! Without a doubt, my experiences in Durban will have an immense impact on how I approach medicine and how I think about the content of my studies in the years ahead. Hopefully, the lessons I learned will allow me to be a better health practitioner.
In my last week in South Africa I met with Mitch Besser, an American-born obstetrician in Cape Town who (among other things) has been running an innovative HIV program for HIV-positive mothers-to-be and their children. We spoke about the joys and challenges of working in HIV medicine in South Africa at this time when more people are focusing on AIDS and the
government is beginning to roll out antiretroviral treatment programs. This is a field and place where every day can be exciting and fruitful.
Each step is new and uncharted (never before has a country tried to treat so many HIV positive people) but there is great reward for those who truly try to make a dent in the HIV/AIDS epidemic. Part of what makes HIV work interesting (and sometimes frustrating), however, are
the many challenges that persist. My meeting with Mitch inadvertently became an unofficial debriefing, touching upon some of the key themes I had struggled with during my stay.
1) Many of the barriers to providing good HIV/AIDS care in South Africa are of an organizational rather than technological or financial nature. I met several international medical students who came to Durban to experience medicine in a resource-poor setting, Expecting to be frustrated by a lack of sophisticated equipment and fancy diagnostic tests. Instead, they faced much bigger (and simpler) problems: lab tests that had been sent out but were lost or misplaced; patient charts that were incomplete and difficult to understand; statistics that were not recorded in the same way they needed to be reported. This all made adequate patient follow-up and care more challenging than necessary and provided weeks of work to volunteers like who were trying to retroactively gather some of the information.
2) Doctors, nurses, and HIV counselors must find better ways to work together and complement each other. Doctors and nurses alike do not yet feel confident or adequately trained to administer antiretroviral drugs to HIV patients. Although most new HIV/AIDS treatment programs strive to be less doctor-dependent (i.e. cheaper) and to give more responsibility to nurses and other health workers, most HIV training programs I experienced focused on doctors. Nurses receive less support and recognition for their role in running the health system. At the
same time, communication between doctors and nurses is often poor and heavily burdened by issues of class, status, race and language.
In Durban, some doctors spoke to me about the frustrating lack of initiative and leadership among nurses, while the nurses I worked with were disheartened by the fact that their input was rarely acknowledged and decisions concerning their work were made without their consultation. While I, as an outsider, heard both sides, the two parties did not successfully communicate their concerns to each other.
3) Care is not patient-centered. Patients, as a rule, are given a confusing, tiring, expensive, frustrating, daunting, often terrifying runaround by the health system. They may wait long hours to be seen, not knowing exactly whom they are supposed to see next and how many
more procedures they will have to endure or pay for. Often the doctor and the patient do not speak the same language, and important information concerning the patient's health is not successfully
communicated. As if being HIV positive is not enough, the process of being a patient and seeking care can in and of itself resemble a nightmare.
Telling Mitch about some of the things I had seen helped me sort through the many images and impressions that had been placed in my mind. I still think every day about a particular very sick 7-year old boy I met at the HIV/AIDS clinic. His father brought him early in the morning, right after his night shift at the factory - hoping to get life-extending antiretrovirals for his son, and hoping to get some sleep for himself before his next shift that evening. In the end he did not achieve either goal that day and spent more money (and time) than he could afford on unexpected diagnostic tests. I accompanied father and son on the endless trek from X-ray to ultrasound to the TB nurse, to the pharmacy and onward. I, who was only a bystander, became frustrated and angry when it became apparent that some of the tests were necessary only because the boy had been mismanaged and misdiagnosed during an earlier hospital stay. Both father and son were close to despair by the end of the day - but they would have to come back again for more tests in less than a week.
Mitch pointed out that by starting with that boy and spiraling outwards to those who care for him at home and in the clinic, someone could tell a compelling story providing an analysis of the many facets of HIV, the health system and the social setting within which it must function. Some day soon I hope to write that story - it has the potential to illustrate most of the lessons of my Fulbright year.
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