Hospital Visit and Research Topics

I visited St. Mary’s private-public hospital outside of Durban today; it was wonderful! St. Mary’s was founded in 1927 and allegedly (although not likely) serves a population of 1 million people with 200 hospital beds. The hospital is relatively comprehensive with casualty units, obstetrics, surgery/theatre, medical, and outpatient and tuberculosis units. I found the politics of the hospital and the tuberculosis unit the most interesting.

As a private-public hospital, St. Mary’s has funding form the South African government and private funders. The private funding was previously dominated by PEPFAR (the Presidents Emergency Plan for AIDS  Relief)– the African HIV/AIDS funding provided by the US government during the Bush administration). However, PEPFAR was not supposed to last forever and has been steadily decreasing in funding. As a Catholic hospital, St. Mary’s does not want to become a fully public hospital and solely exist on government funds because it would have to give up on some of its Catholic values, namely abortion and family planning. This was interesting to me because apparently the hospital could receive much more funding from the government if it became fully private, however because of religious affiliation, they are reluctant to do so.

The PEPFAR funding also provides a really interesting discussion. PEPFAR is considered one of the most successful aspects of the Bush administration, however it has been critiqued for it’s earmarked funding (funding that can only be used for certain purposes). Before Obama came to office, 2/3 of PEPFAR funding could only be used for pro-abstinence programs; none of the PEPFAR funding could promote safe sexual practices or contraceptives to prevent HIV transmission. Obama overturned this, but it does provide an interesting example of the complexities surrounding foreign aid. If this is interesting to you, check out Dead Aid by Dambisa Moyo; she provides a fascinating synopsis of the complexity surrounding foreign aid and provides a critical analysis of its effectiveness.

The topic of my consolidation paper is Tuberculosis in South Africa, focusing on the DOTS programme. Our consolidation has to be on a health promotion policy in South Africa and I chose Tuberculosis as the heath problem because it is a truly interesting disease: Tuberculosis is truly a disease of the poor. As I have previously discussed, HIV is a disease that effects approximately 30% of South African youth. HIV itself does not usually cause mortality; it weakens the immune system, making the person susceptible to opportunistic infections such has Tuberculosis. Tuberculosis is an airborne disease and is most commonly transmitted through sneezing. It is most commonly found in areas of high density, inadequate housing (dark and damp areas) and in people with poor diets. Therefore, poverty exacerbates tuberculosis while tuberculosis exacerbates poverty- talk about the pervasive cycle of poverty and disease!

To matters more complicated, despite being curable, TB requires a rather extensive treatment plan that involves a six-month antibiotic course. The BCG vaccination against Tuberculosis is effectively useless, especially in adults. There are four epidemiologic patters of TB: 1) in persons with HIV in developing countries 2) in immigrants in developed countries (the Southern US has high TB rates) 3) in areas with economic decline, poor TB control and substandard health 4) Globally, Sub-Saharan Africa is disproportionately effected by TB. TB used to be a disease of young men, however with the HIV co-infection (women are more susceptible to HIV), TB in sub-Saharan Africa is now becoming a disease of women. This is even more interesting because it is attributed to societal/gender norms, namely intergenerational sex. Women are typically seven years younger than men and men typically have multiple and irregular sexual partners and often engage in high-risk sexual behaviour. You can really see how HIV and TB go hand-in-hand. A quote from our visiting professor exemplifies this: “Nothing in the history of the world predisposes people to TB like HIV”.

Now, I get nerdy and into my favourite global health figure: Paul Farmer. This is an example from Mountains Beyond Mountains by Tracy Kidder. Globally, the WHO initiated the DOTS programme: Direct Observational Therapy. This policy was tried and tested in a central African country before being recommended by the WHO as a worldwide solution for TB. This programme dealt with people who were not recovering from TB, despite allegedly taking the drugs. However, the study found that due to inherent conflict and displacement in the experimental community, patients were not completely adhering to their drug regimes. They countered this by giving more drugs to the patients and directly observing them to ensure that they took the drugs. When this policy was implemented globally, Partners in Health in Lima, Peru found a problem. Despite adhering to DOTS principles, patients were getting worse and worse as they continually adhered to the programme. Finally, Paul Farmer and his colleagues found that the DOTS programme worked in the Central African context specifically because people were defaulting on their drugs. However, in Peru, people were taking the drugs and were still getting sicker. The problem was that the TB patients in Peru had a different strain of TB. Pumping the patients with more drugs that weren’t really working effectively served to create multi-drug resistant tuberculosis (MDR-TB), which has now evolved into XDR-TB (an even worse version of multi-drug resistant TB that is almost universally fatal).

For my consolidation paper, I am excited to explore the effectiveness of DOTS in South Africa. South Africa provides such a unique perspective for diseases like TB, especially because of their social determinants and vast social inequality following Apartheid.

I figure I should also clue you into my ISP project as of now. I am still planning on exploring the impact of donor funding in HIV non-governmental organizations. As I discussed above with the PEPFAR reference, donor funding can have a profound impact on an organization’s behaviour and successes. The Global Health arena is dominated by six main agencies: The Global Fund to Fight AIDS, Tuberculosis and Malaria, The Bill & Melinda Gates Foundation, PEPFAR, the World Health Organization, the International Monetary Fund and the World Bank. All of these organizations are Western and Northern based and mostly work in the Eastern and Southern hemispheres. I have pasted a passage from my electronic journal that discusses my proposed topic:

HIV/AIDS In KwaZulu Natal

According to the SANAC KwaZulu Natal Provincial AIDS Spending Assessment Brief, the prevalence of HIV/AIDS is the highest in Durban of all the provinces in South Africa, with prevalence at 37.4% in 2011 and a population of 1,576,025 people in KZN living with HIV/AIDS in 2011(SANAC 2013).

As elicited in Reimagining Global Health, biosocial approaches to health dictate that “biologic and clinical processes are inflected by society, political economy, history and culture and are thus best understood as interactions of biological and social processes (Farmer et al, p.735, 2013). Thus, HIV/AIDS is a disease that is social in nature and as such is complex with many factors influencing its prevalence and incidence.

Shifts in Funding

The onset of the HIV epidemic and the establishment of NGOs were relatively synonymous. According to Jeffery Sachs and Amir Attaran (2001) from 1996 – 1998 the donor funding for HIV programs was US$170 million (US$69 million went to Sub-Saharan Africa (SSA). Since 2001, donor funding for HIV programs has drastically increased, with total resources for AIDS rising from US$1.6 billion in 2001 to US$8.9 billion in 2006 (Attaran and Sachs 2001).

The epidemic coincided-with and lead-to further increases in funding for global health programs. It is estimated that “development assistance for health from private and public institutions rose from US$8.65 billion in 1998 to US$21.79 billion in 2007” (Farmer et al, p2518, 2013). The Gates Foundation, a primary donor of global health programs has donated over US$10 billion to global health programmes (Farmer et al, p2567, 2013). In a period of less than ten years, an unparalleled level of massive global health programmes were initiated: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Emergency Plan for AIDS Relief, UNAIDS, and programs by the WHO, IMF, and World Bank. Development funding for health increased from US$5.6 billion in 1990 to US$9.8 billion in 1999 and even more to US$21.8 billion in 2007 (Farmer et al, p. 2567, 2013). This increase was not only unprecedented, but astronomical.

This incredible influx of international funding for global health programs, especially for HIV/AIDS programs lead many African countries into dependency, relying on foreign and seeing their “health budgets dwarfed by foreign aid and health policies determined by donor organizations” (Johnson, p. 496, 2008) South Africa has attempted to avoid dependency and now has the world’s largest public sector antiretroviral treatment (ART) programme, which is 95% funded by South Africa and not by outside donors (Johnson, p.496, 2008). Despite this, as Krista Johnson states, South Africa still has a long history of tension between the government and the donors, namely perpetrated by “western paternalism and South Africa’s determination to avoid dependency” (Johnson, p.496, 2008). The increases in donor funding have been drastic and in some cases even overtake government budgets. “In Uganda and Zambia external donors exceeded public health expenditures by almost 185%” (Johnson, p. 498, 2008). A donor representative told Johnson that the “tepid relationship between the [South African] government and USAID/PEPFAR in part stems from US support for the apartheid regime” (Johnson, p.502, 2008).

Despite the less-than-ideal relationships between the South African government and the United States (USA) and other donors, the USA provided US$584 million through PEPFAR to South Africa. Furthermore, the Global Fund had provided over US$88 million for AIDS and TB (Johnson, p.506, 2008). Johnson also found that significant amounts of donor funds are being refunded to the donors because they are earmarked for specific objectives or programs (507, 2008). A key point in Johnson’s article is:

“According to Ndlovu, ‘Although earmarked funding is beneficial in ensuring that new and critical projects are funded, donor funds may hinder or clash with national government priorities, leading to decreased flexibility for implementers when spending on vital local priorities.’ In addition, spending donor funds is hindered by weak provincial health systems and insufficient capacity of government to commit the money to augmenting key programmes. In recognition of this, several donors, the European Union and the United Nations in particular, have targeted capacity building within the public sector”

(Johnson, p.507, 2008).

There are several key points to be made. As shown above, a lack of sustainability, balance and even distribution of HIV/AIDS funding threaten its success and lasting influence. As Johnson states, a vast civil society influence is necessary but will not happen without funding. Given the unpredictability of funding, it is difficult to adequately plan and implement programs (498).

I will need to undertake further research on how these funds are spent and within the private sector, where they come from and which programs they fund. I also hope to look at Global Fund and Gates Foundation presence in South African HIV/AIDS programs and how much influence they have over which programs run. However, I am slightly concerned that I will hit a ‘dead-end’, as South Africa has clearly gone to extreme lengths to avoid the dependency trap that many other African nations have fallen into with foreign aid.

Donor Influence: Significance

Donor funding is important to address because it has many underlying implications. When donor funding exceeds government budgets or is substantial enough to compete with government budgets, macroeconomic stability and fiscal management are threatened and even potentially undermined (Johnson, p.498, 2008). Donor funding can also undermine the public sector simply by bypassing it; if the government does not have the stability or resources to properly utilize the donor funds or direct them, the funds can subvert institutional capacity and exacerbate government problems (Johnson, p.498, 2008).

PEPFAR provided over US$584 million in 2008 for HIV/AIDS programmes in South Africa and worked with over 300 NGOs. None of the money went to the South African government, but the United States Agency for International Development (USAID) does work with national and provincial departments in South Africa. This is significant because PEPFAR is the largest donor that does not give funds to the South African government; other large donor organizations such as the European Union and the Global Fund provide funds to the South African government. At a 2006 PEPFAR conference in Durban, the South African Health Minister stated that “PEPFAR in South Africa ‘started off on the wrong foot. We were not consulted’” (Johnson, p.507-508, 2008)

This touches upon the significance of donor influence. As stated by Johnson, undermining the government and directly funding NGOs and local programmes “creates a coordination problem” (p.508, 2008).

As seen in Haiti and described by Dr. Paul Farmer: “It wasn’t a good idea to funnel foreign assistance exclusively through NGOs and private contractors. Without real and sustained commitments to strengthening the public sector-including its capacity to monitor and coordinate services offered by NGOs- who would make sure development funds were used effectively?” (Farmer, p.1097, 2011).

Donor influence in health organizations is an important area to study, especially as the world is increasingly dominated by a few select organizations. As discussed above, the main organizations dominating global HIV program funding are the Bill & Melinda Gates Foundation, PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank, the IMF and the World Health Organization (Farmer et al, p2567, 2013). It will be important to explore and begin to understand whether these organizations are funnelling their funding through the South African government or directly to NGOs and programs.

On the other hand, Johnson identifies further potential implications of donor influence. U.S. Secretary of State Condoleezza Rice implemented a plan for “transformational diplomacy” where the aid will go to governments and not to NGOs. This not only divides up funding for disease specific programs (ie by overriding the Global Fund), but also increases the likelihood for aid to reflect U.S. strategic interests in a more overt manner (Johnson, p508-509, 2008).

Another area of complication of PEPFAR funding is pharmaceuticals. PEPFAR funding for ARVs can only be used for US Food and Drug Administration (FDA) approved ARVs- AKA brand-name drugs that are extremely expensive as opposed to generic brands that are exactly the same, just cheaper (Johnson, p.509, 2008). This is yet another example of U.S. big business interests trumping cost-effective alternatives to pharmaceuticals.

As you can probably see and as Dr. Paul Farmer states in Haiti After the Earthquake, “Doing good is never simple”. I hope to address some of the complexity surrounding global health and development programmes through my independent study project.

I am enjoying my time in South Africa and am relatively busy with schoolwork. I haven’t found much of the work to be challenging, just lengthy, which is a bit frustrating. I am still enjoying the group, despite the lack of adventure-ness. I am certainly having a socially – relaxing semester compared to my Franklin semesters. It makes me recognize how unique Franklin students are and makes me miss always having someone to call upon for an “adventure”. At Franklin and travelling with Frankliners, we almost universally consider going out a vital part of visiting a new place and consider our travels unsuccessful if we don’t meet locals. It’s interesting being around so many Americans who actually enjoy being considered Americans; this is totally new territory for me.

Pictures from Rural Home-stays in Impendle and UMtwalume

Chatsworth

I spent the past weekend in Chatsworth, the largest Indian community outside of India! It was a really wonderful weekend and a very welcome break from the intensity of work. We had a lecture from the Cassimjees, a Muslim husband a wife who are the definition of a power couple. They are both working for their PhDs, run the “Chatsworth Community Forum” (an multi-faceted development and HIV organization), give lectures, are very politically prominent and have three children! I don’t know how they sleep or have time for themselves! We spent this weekend with Ismail (the husband)’s mother at her house and with their three kids (ages 8, 12 and 13). It was wonderful being surrounded by caring and genuine people who can hold fascinating conversations about anything! We talked about everything from Hinduism to gas prices in Saudi Arabia to the distinct smell of African soil when it rains. It was great. Ismail is truly an incredible man. He is fluent in six languages, has travelled extensively and is so intelligent in so many different areas. Rabia, his wife, is likewise one of the kindest and most genuine women I have ever met. They are an amazing pair.

On Saturday, we went to the Bangladeshi Market. This was a bustling place where you could buy anything from bagged gold fish to fruits to toothpaste to car tires. The main thing that has stuck out to me in Chatsworth is how incredibly friendly everyone is. In the market, we were at a stand that sells homemade pickled items such as sweet and sour mango and others. A man who was also buying some items overheard us saying that we are students from America. He handed the tore owner 20 rand and said “buy these girls whatever they want; they came here from so far away!” People here are SO friendly.

On Sunday we went to a Hindu Temple and sat in on a translation of the Book of the Future. The people were again incredibly friendly and welcoming! We were given a tour of their Temple and one of the directors talked to me for a while about Hinduism. One great aspect of this religion is that they don’t dislike or disagree with other religions; they believe in “all rivers lead to the sea” and that everyone and every religion reaches God in their own way.

After the Temple visit, we went to a Mosque but unfortunately it was closed. It then began raining and got very cold, so we went back home and watched two movies: a Hindi romantic comedy and Lord of the Rings! It was wonderful and relaxing: just what I needed!

The Indian food we ate was great too! We had mutton curry, vegetarian curry, samosas, and many other Indian delicacies! On Sunday, unfortunately (but sweetly) our Grandmother wanted to make us comfortable and tried to make “American” food. We ended up with hot dogs and spaghetti, which was rather disappointing following the amazing curries we had. Oh well, it was very sweet of her!

I’m going to try to return to Chatsworth for my ISP!

The "Rural" Excursions

This blog post is so long overdue that I am a bit apprehensive about covering everything while writing it. If you want any further elaboration on anything, please message me or email me!

We spent all of last week in “rural” homestays in Impendle and UMtwalume. We divided our group of 16 into two groups of 8 to avoid having an overbearing influence (which we still were). We stayed in homestays in groups of two and stayed three nights in each home. My group went to Impendle first, which is a community nestled up in the mountains, a 40-minute drive to the nearest “town”. This place was picturesque, albeit not what I was expecting. For me, preparing for “rural” homestays involved preparing for an excursion into what I had been exposed to as “rural” in Kenya. I brought outdoor bath wipes, my ‘all-terrain’ pants, my sturdy shoes and so on. This place was not really rural. While the inhabitants of Impendle mostly have pit latrines (ventilated pits or long drops) and do not have indoor running water, they all HAD pit latrines, running water at a tap and had indoor electricity to watch the favourite South African soaps (especially this show called Generations). In Impendle, we stayed with “Stylish Mama”; I am still unsure of her real name, but is a few years older than me and takes care of her family, plus seven of her orphaned cousins. There were eleven people total in her family. They had three different houses in the homestead, including the round ancestor home that is not lived in (besides the ancestors). Every traditional Zulu home has this ancestor room and their religion surrounds their ancestors. There was one large square house with several rooms, and another circular room that we stayed in and shared with 2 – 6 people per night. It was interesting sharing a room with strangers, but they were all so kind that it was not difficult or that uncomfortable.

Our first day in Impendle involved an excursion to the town. Our trip was focused around exploring the assets of the community. Instead of coming into a region and immediately seeing what is lacking or wrong with the place, our program wants us to see what is working and then explore what could be improved upon. It’s just a slightly different way of exploring a new place, which I enjoyed. Downtown Impendle was far more developed than downtown Kimana (in Kenya). There was a library, a police station, a home affairs office, a grocery store, several food vendors, a butchery, etc. We had several discussions and friendly debates surrounding development. Here is a quick excerpt from our paper that I wrote about it:

“In Impendle, development was a constant feature of discussion in our group and in my mind. The focus on promoting development in the area was quite clear, given the vast investments in roadwork and infrastructural development. In Impendle and in  Nzinga, there were always people working on the roads, with machinery and materials aplenty. The other key development initiative was the new Impendle Library, a recently built facility with computers, lots of books, health promotion posters and a quiet place to learn. These two different initiatives led me to a conflicted notion of development, the purposes behind it and its effectiveness.

I was surprised when we first pulled into Impendle and I saw all of the road infrastructural development because I had been expecting (and found) a relatively rural area with few residents owning cars. Also, the mini-buses and taxis rarely frequented the area. Who were these roads for? They didn’t seem to be for the community members because they didn’t drive. Likewise, they didn’t seem to be for the taxi companies because the route was not a busy one.

We spoke to a man at a grocery store in downtown Impendle about this and gathered his opinions on the development. He thought the road developments were a waste of time and money. His main opinion was “why invest in roads that no one will be driving on”. He believed that the money would be far better spent on education or healthcare, so that people can be healthy and prosperous enough to afford cars to drive on a road. Then the road could be repaired. I realize that only speaking to one man severely limits my sample size, however I felt his input was valid and provided an interesting perspective. His input also suggests that the community was not consulted before the development project began.

On the other hand of the discussion, investing in infrastructure provides jobs to people who otherwise have no options for employment. Providing them with temporary jobs might boost their experience, provide them with some income and enable them to foster their own development on their own.

As for the library, the facilities were very high quality, with internet, clean and quiet reading areas, all kinds of books, and so on, but for some reason the library was very empty(our guides said it was more full during the school days). They also had health promotion posters, mostly for HIV awareness and promoting safe practices. As I stood there, I questioned the relevance of it. Who are these posters for? Who is reading them? Who are these books for? The answer I would speculate is: everyone. However, only four people were utilizing the library and all four of them seemed very studious and involved in their reading. They were clearly educated. Is this message really reaching everyone it could? Is this library really the best use of the space, if most people don’t use it? Our tour guides all said that they would never come here, and laughed at the prospect of it.

We are brought to the resounding question in global/public health and development discussions: how to provide the greatest good to the greatest number. I am not sure whether either of these initiatives reaches the greatest number, but they are certainly bringing a great-‘er’ good (improvements). Perhaps these improvements will prompt further change, development and prosperity. Perhaps they won’t. It brings us to another question surrounding the development and global health paradigm: how to break the cycle of poverty and disease. Will it be through investing in infrastructure and top-down initiatives or through grass-roots education, health promotion and empowerment? What comes first, the chicken or the egg? I do not know the answer, but I am more than intrigued to find out. “

I find this development discussion fascinating. A common theme and discussion on our trip has focused on the concept of “it” (overly inclusive term, meaning relatively everything in life) not being “either-or” but rather, “both-and”. In other words, I think that both infrastructural and social/educational development notions are important and useful, but neither should be on its own.

One aspect of the round ancestor houses that I forgot to mention is the massive amount of smoke I inhaled and am now exuding from my pores. They have a raging fire in the centre of the room and cook and burn anything (including clearly toxic plastic bottles) into this room with absolutely no ventilation. I think I may have taken a few years off my life from that.

The next day, we set out to visit several Sangomas (traditional healers) and the village chief. We did not forsee this being a huge endeavour, but boy were we wrong. We ended up walking for over an hour to the first Sangoma, to find her too busy to speak with us. Luckily, we found a wonderful Sangoma a few minutes away who was willing to talk with us and share her story. A Sangoma is a traditional healer who consults with the ancestors about the health problems of a patient. They believe that many health problems are a result of the ancestors not being pleased with you and seek to provide a link between the ancestors and the patient. Interestingly, a Sangoma does not choose his or her career path, they are chosen by the ancestors to be a Sangoma. If a person is unwell and western/clinical medicine does not appear to work, they will go to a Sangoma and this Sangoma will tell the person that they have “a calling”. The Sangoma we spoke to was fascinating because she was a rarity in that she did not like being a Sangoma. She told us that if she had the option for another life, she would take it in a heartbeat; she does not like being a Sangoma. One girl on our program is doing a really interesting independent study on the intersections of clinical and traditional medicine. Many people go to both traditional healers and clinics, taking both medicines at once. This can be very risky, as the ingredients in traditional medicine, known as muti, are not known and the medicines are unlabelled. They also don’t have an established dosage and are untested. Common problems include side effects when taking both medicines, non-compliance of both medicines, leading to drug resistance and counter-productive habits. For example, Sangomas often prescribe a muti that makes a person vomit to rid their body of toxins. However, if an HIV positive patient is given this, it severely weakens them and is detrimental to their health. Also, cold baths in the morning are often recommended, yet for a TB patient this can also be very risky. This Sangoma was so fascinating; she goes to the local clinic for diabetes medicine and high blood pressure medication.

I suppose this next topic warrants a whole paragraph: nutrition. I was astonished at the prevalence of diabetes in South Africa. I don’t know the exact figures off the top of my head, but numerous people have told me they have diabetes. This was not surprising to me once I saw people’s diets here. It is astonishing how they eat: carbs on carbs on MORE carbs. The starches are endless. It makes sense because they are the cheapest, but carbs and sugars consist of much of people’s diets. They also put endless amounts of mayonnaise and butter on everything. It is quite bizarre. Fruits, veggies and cheeses are a foreign delicacy to us now. Luckily, we students are on our own for lunch and have been living off of vegetarian meals!

The next day we left for UMtwalume, and again I was very surprised about the lack of “rural-ness”. We stayed in a two story house with a shower, our own bed room, a huge flat screen tv, etc. It was really bizarre. In UMtwalume, we walked around the community and explored the surrounding area, seeing the schools and the paths the students would walk on to school. The next day we went to a house with six or seven sangomas. We were able to ask them questions and they danced for us! It was very entertaining.

After returning from the rural homestays, we have had an extreme amount of work (over 50 pages have been turned in the last week). This is why I haven’t been able to update my blog in a timely manner!