Rachel’s Blog

Home Sweet Home

Sorry to disappoint you all with my poor bloggy follow up!  I really highly recommend anyone who is remotely interested, however, look more into the Millennium Development Goals.  There’s a lot to know, and a lot to do.

I encourage anyone who’s hunting for pictures to check out my facebook over the course of the next week (I’m very friendly :D).

I had to do a couple of essay questions for INMED since I’ve been back, and I thought that some of you might be interested in reading a couple of the ones that were most reflective and interesting to me.  So here you go.

What do you believe are the greatest threats to world health today? You can focus on particular diseases, behaviors, or policies. Select one of these threats and describe what actions a health care facility like where you served could take to combat this threat.

I believe the greatest problem in world health care is access to timely, quality care.  The main barrier to this—present in different ways but equal amounts in America as in South Africa—is the idea that health care is a privilege that must be earned.  I believe the solution to this is to integrate whatever work I do in government efforts to provide health care.  A well-functioning system will be integrated and communicate well within itself, and I believe in most settings the national government is in the best position to make that system happen.  On a more personal level, I believe that treating patients with respect and equality regardless of their social or financial status will make a difference in their attitudes towards healthcare as well.

Many healthcare professionals are enamored with the possibility of international service. Yet relatively few ultimately make this a part of their career. What steps can you recommend to help turn this dream into a reality?
I think that continued involvement is an important aspect of turning this dream into reality.  It’s interesting because I have been involved in international health efforts continually from before I came to medical school to now just before I graduate, and I have seen my roles and attitudes evolve over the years.  In some ways “growing up” this way has been slightly de-motivating, because I felt I actually contributed more in non-clinical ways to communities I’ve visited in the past.  However, I also view my contributions with a much more critical lens, with an eye to sustainability.  By way of example, I felt much less prepared for this trip than I did when I traveled to Cameroonafter my first summer of medical school, but going in I knew so much more both clinically and from a public health standpoint.
In terms of specifics, I think a database of global health resources (books, organizations to travel with, scholarships, etc.) that is kept up to date is particularly helpful.  I also feel that offering more detail in terms of academic material could be inspiring (i.e. HIV Care for the Advanced Provider, or More Detail about Clean Water).  I’m sure there’s a lot more to learn.  Also having links to stories (blogs) from providers in the field on a full-time basis are also encouraging and challenging.  On a personal sort of level, I find it helpful to dream specifically—i.e. where I once was going to just be a doctor who works in another country, I am now pursuing being a family doctor who works in academic medicine and helps to implement family medicine residencies in developing countries, and I have the challenging of figuring out where and how to make that specifically happen.

Now onto match day, graduation, and the rest of life!!

-Rachel

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Week three, finished!  I was in the outpatient department this week, which is sort of like urgent care or family medicine + emergency medicine.  It’s been a bit slower than I expected, which was frustrating at times, but overall I think I’m still learning quite a bit.
Medically, there is lots to be learned about tuberculosis, or TB.  For those who don’t have a medical background, TB is a slow-growing bacteria that most commonly causes lung infection.  A long time ago it used to be called “consumption”, and it’s frequently associated with coughing up blood (although in reality it’s far from the only thing to cause that, and it’s not at all uncommon to have TB but not cough up blood).  It’s pretty rare to get a full-blown TB infection in a patient with a normally functioning immune system, but it’s so contagious that all healthcare workers in the US get tested every year with a PPD (that weird circle with all the prongs) to make sure they aren’t carrying it around.  It’s interesting, because in the US TB is really very very rare, in no small part because is taken really seriously with quarantines and screenings like the PPD.
But here, TB is incredibly common.  Probably more common than any other kind of pneumonia.  And if someone comes in with belly pain, or chronic diarrhea, the most likely thing is probably abdominal tuberculosis, which is virtually unheard of in the US.
So why is it so much more common, you ask?  Well there are a few reasons, some of which we’ve discussed a little previously.
1. The population is more vulnerable. The HIV rate is much higher here than at home, so more people are susceptible at baseline because their immune systems don’t work as well.
2.  It’s common.  I know that sounds a little circular, but basically the more you have, the more it spreads.  And because it’s common, it’s not dealt with as swiftly or seriously– patients aren’t isolated and they can spread the disease to others around them much more easily than could happen at home.
3.   South Africa is a country of both prosperity and poverty, really hard to classify, and TB is a disease of poverty.  The World Health Organization (WHO) recognizes that TB is a disease of poverty– that it’s spread in places where immune systems are compromised and people live close together and hygiene is poorer, where there is limited access to healthcare and money to afford treatment.  It designed some good guidelines for treating it as such, but because South Africa is such a land of diversity, with some very prosperous areas, the health leadership felt that it shouldn’t follow the WHO’s guideline– and as a result TB, and particularly TB that won’t respond to the first line of therapy, is rampant.
So that’s an interesting and incredibly challenging public health problem, to be sure. . .  I feel like this trip is opening my eyes much more to the systems and factors that shape the way healthcare is delivered, which is a valuable thing to see.  It’s a part of what I was expecting to learn, but it’s just so much bigger and all encompassing– I’m just taken aback by the system challenges, much more than the individual disease processes.
Maybe there will be more on that later. . .
And now for promoting gender equality and empowering women, Millennium Development Goal #3 (wow am I inching along!).  Generally, this is viewed through statistics reflecting gender parity in education, non-agricultural employment, political representation, and sexual health/reproductive rights.  According to the Millennium tracker, South Africa is likely to achieve this goal.  That’s pretty awesome when you think about it.  I can say from my experience in the hospital, while there aren’t many attendings/consultants who are female, the intern cohort is pretty fairly balanced, which is laudable.
However, I feel like there’s more to promoting gender equality and empowering women than just sheer numbers and jobs.   I think part of empowerment is how safe you feel when you walk around, or how respected or disrespected you are on a daily basis, which is a bit harder to quantify but still crucially important.  It’s interesting because while for the most part I and my fellow students haven’t felt personally threatened or in danger, you can get a sense of a “culture of violence” at times, of which a significant part is a culture of violence against women.
We’ve been going to movies every week– it’s half price on Tuesday– and the first movie we went to see was “The Girl With The Dragon Tattoo.”  I don’t recommend it.  There is a horrific rape scene, I would have walked out if I could have walked home, and shockingly during this scene so much of the moviegoing audience was laughing.  It blew my mind.
Some people estimate that a woman born in South Africa may stand a greater chance of being raped than learning to read.  One in four South African men admit to raping someone in the past, most before they turned 20, and many showing no remorse.  One in three women report having been raped IN THE LAST YEAR.  So crime, and crime against women, is a big problem in South Africa.  The main explanation seems to be that it’s because of the level of poverty– and not just poverty (because there are many poorer nations with far less crime) but inequality, disparity, racial economic division.  It’s like the anger against the violence of apartheid and racial oppression turned inwards and outwards and every which way against whoever is nearby.

(here are some sources http://www.rape.co.za/index.php?option=com_content&task=view&id=875, http://www.time.com/time/world/article/0,8599,1906000,00.html)

The good news is it used to be worse.  It’s a bit hard to believe, but crime rates are improving.  Rape rates are staying steady according to the sites above.  It seems that one major force in the progress of South Africa is Archbishop Desmond Tutu.

Basically he designed this Truth and Reconciliation Commission, an open forum where both victims of human rights violations and perpetrators of violence could give statements about their experiences.  The goal wasn’t necessarily to send the perpetrators to jail– they were allowed to request amnesty– but to promote healing and forgiveness in the deeply divided and hurt nation.  It’s kind of the opposite idea of the Nuremberg Trials; the term is “restorative justice.”
Anyway, I know I’ve written a lot, and I know I am far from qualified to discuss most of this at any length, but it’s interesting and a lot of food for thought.  And maybe if we all chew on it and process it we can help to come up with some solutions.  Here’s hoping
-Rachel
Oh PS– next time we’ll do MDG #4– reducing childhood mortality and try and discuss maybe immunizations, malnutrition, and integrated management of childhood illness (IMCI)/ community health workers.

An Education

Now for Millenium Development Goal #2–Achieve Universal Primary Education
According to the WHO, South Africa is on track to achieve this goal!  I don’t have a whole lot of experience (or hardly any at all) with the primary school here, but I can tell you what I know about the education system in general.
Primary school lasts seven years and secondary school lasts five years.  From there, students either go to a sort of technical college or a university to continue their studies.
And now for an overview of medical education:
First, the US system for those who are unfamiliar with it.   In the US, you do typically four years of undergrad, four years of medical school, and then you are officially a doctor, but your job options are pretty limited at that point.  You generally match into a specialty (no one does “general practice”) and will complete an intern year and 2+ years of training after that during which you are a resident, and then you graduate and are free to practice on your own in your field of training.  You’re typically known as an “attending physician.”  If you want more advanced training, you may take on a fellowship in your area of interest, and after you graduate you are a specialist.
In South Africa, like in Europe and I think most of the rest of the world (darn you US!) medical students go directly from high school into their medical studies.   Programs here (and in the UK) are typically six years total, but they start directly from high school so practicing doctors are not infrequently younger than you would find doctors in the states.  After you graduate here, you complete an “intern year” which last two years, during which you rotate through surgery, pediatrics, medicine, and OB/Gyn.  All graduating interns are expected to be able to perform c-sections (and I wouldn’t be surprised if they were expected to do appendectomies, too!).  After you complete your internship, you complete a community service year and then become a medical officer (MO).  If you want to pursue more training, you will become a registrar and when you graduate be a consultant.  Interestingly, the word physician here is not used to designate all doctors, but just consultants who have specialized internal medicine.  Nurses are known as sisters.  Anyway it’s an interesting system.
McCord is a semi-private hospital was founded in 1906 to provide care to the underserved Zulu people in the area.  It receives some funding from the government and some from private donors, and patients without insurance (”medical aid” programs as they’re known here) pay set fees for the services provided.  It’s interesting to see where the hospital fits in in the structure of the South African healthcare system. . .  There are government hospitals, which are generally crazy busy, understaffed, and variably supplied, but the services they provide are free for all South Africans.  Then there are the private hospitals, which are quite cushy and probably comparable to fairly nice hospitals in the States.  The clientele here are either people with a good medical aid scheme or just enough money to pay for the services.  And McCord is somewhere in the middle, which is interesting because South Africa doesn’t really have all that much of a middle class.  I’ve seen patients of all different races, from East Asian to Indian to Black and White, but I would say the majority of O&G patients are probably Indian, with Black coming in second.  The hospital was founded by an American missionary doctor, and there are some vestiges of the religious heritage around, but I would say at this point it doesn’t really operate as a mission hospital in the sense of active outreach.  It’s sort of like a Baptist or Methodist hospital back home– there are some chaplains around who would be glad to pray with you and tell you what that means, and some pictures on the wall to that effect, but the employees don’t feel the mission the way that the founder likely did.
So anyway, now I’ve completed my second week and am leaving the Ob/Gyn department.  I was hoping to do two weeks of HIV care at the Sinikithemba clinic, but unfortunately they’re only able to accommodate me for two days due to a high volume of other learners (some students coming in from Harvard this weekend and I think some other students maybe from South Africa).  I’m a bit disappointed about it, but those two days will be good, and I made a connection with another doctor up there who I might be able to spend some more time with, and I will be in the medical outpatient department and see my fair share of HIV (and multi-drug resistant TB!) there.  And then I’ll be taking off the last week to travel with my new friends!
Speaking of which, allow me to overview my fellow apartment mates at the Doctors’ Quarters (hospital housing just a 5 minute walk away from the hospital):
-Lebby: Born in Botswana (a country just a bit north of here), she went to undergrad in the states and graduated last year.  She’s doing this year as a research/volunteering year and will go to work on her masters in the UK (I think?) next fall.  She wants to study medicine after that.  She’s been here 6 months with 3 to go.
-Elaine:  Final year (6th year) medical student from London.  She and Christine had been here for two weeks when I arrived.  Quiet and sweet, best friends with Christine.  One of my travelmates!
-Christine: Final year medical student from London.  Loud and sweet, best friends with Elaine.  My other travelmate!
-Ashley: Final year (4th year) medical student from Chicago.  Totally awesome!  Reminds me of a combination of my two bridesmaids, Ashley and Michelle.
-Godfrey:  A second year South African intern.  He is ridiculous, just over the top and very class clown-y.
-Siya: South African studying to be a psychologist.  He’s really quiet and kind of the foil to Godfrey’s ridiculousness.
And we have I think 3 more arriving this weekend!
Well thanks for bearing with me through that long update. . . This weekend looks fun as well with some trips around Durban– the beach, craft market, and uShaka (like Sea World) hopefully!  Next time: MDG #3–promote gender equality and empower women.
-Rachel

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Week One, Done

Well, I am one week down at McCord Hospital, lots seen and lots done.  Highlights include:

-Delivery (previously mentioned)

-First assisting (what it sounds like, the second in command to the surgeon) on 2 c-sections with tubal ligations, including one with twins (honorable mention: one mom’s water broke on my shoe)

-helping induce labor

-Introduction to obstetric forceps (http://upload.wikimedia.org/wikipedia/commons/thumb/3/3a/Smellie_forceps.jpg/300px-Smellie_forceps.jpg)–I’ve heard of these but never seen them used before

-trip to Oribi Gorge and Leopard Rock
-and today, shark dissection, and a trip to the biggest shopping center in the southern hemisphere

So in this week I’ve learned. . . It’s the little things that make you realize how spoiled American medicine is. . . I was really disoriented on my first day in the OR (or ‘operating theatre’ here).   When you are getting ready to do surgery at home, you go into the OR, you pick out your disposable gloves and your gown from the cabinet, and you open them up and give them to the scrub nurse.  Then when the surgeon gets there, you go out and wash your hands really thoroughly and you walk into the room and stand there waving your hands to dry them until the scrub nurse comes over to you with a sterile towel to dry your hands, and then she holds your gown for you to put on.  Here the gowns are reusable, and someone who knows what they’re doing opens the sterile pack and everyone just takes the towels and the gowns from the table and gets themselves ready.  I was pretty embarrassed at my silver spoon showing when I didn’t know how to dry my hands their way. :-p  I guess it didn’t show too much, because later on the attending asked me “Is it true the way they show it in all the films, that they hold up your gowns for you when you’re getting ready to operate?”  I told him it was, and he remarked “Someone to put on your gown but pump your own petrol.”

The other thing I’ve learned is that this experience is, like many many things in life, what you make it.  In the beginning of the week I was mildly frustrated because I felt sort of lost and not sure what was expected of me or where to spend my time.  I guess I’m used to being told “report here from 6-3″ and the style here from what I’ve seen is, “learn what you want, and be helpful if you can.”  So towards the end of the week I started asserting myself a little bit more and I ended up in the OR on multiple days, in the HIV clinic, and with the attending, learning more about ultrasounds.

In the spirit of getting what you want out of experiences, I think I may be reorganizing my weeks a little bit.  The two things I feel like this site really uniquely offers are 1) more hands on opportunities for procedures/deliveries (because less learners to share with) 2) a comprehensive response to a community with a very high prevalence of HIV infection.  So my hope, if it works for the hospital, is to change out my 2 weeks of surgery and 1 week of peds (both fairly slow services) for 1 week of medicine (hopefully to get my hand at procedures) or maybe another week of O&G and 2 weeks checking out Sinikithemba, the HIV clinic.

More on Sinikithemba later, but briefly the name means “Give Us Hope” (not entirely sure what language, but I would guess Zulu), and the clinic strives to do that by providing integrated services including nutrition, counseling, education, medication, and support for patients diagnosed with HIV.

I was going to say something about MDG #2–achieve universal primary education, and maybe talk a bit about the South African educational structure/medical hierarchy, but I feel like this is long enough. . . so maybe later this week?

Thanks for reading!

-Rachel

Well I’ve made it! Coming to you live from McCord Hospital, Durban, KwaZulu-Natal, South Africa. You can see the ocean from the top of the hill between the Doctor’s Quarters and the hospital (which reminds me, I ought to take that picture). It’s a short walk, but pretty steep and it reminds me of how I haven’t been to the gym very much recently.

Monday was my first day, and as usual for medical student first days, it was sort of confusing. I think one of the toughest things about being a student is figuring out expectations and roles expected of you. . . every place and person you encounter has different ideas, and frequently they’re not volunteered or described well even when you ask. It seems I will be rounding with the OB/Gyn (known here and I believe in the UK as O&G) team at 8:00 AM, although I am not seeing any of my own patients but basically shadowing. Rounds run for an hour maybe and then clinic starts. There’s a little more opportunity for hands-on work there; today I worked with an intern seeing first-time prenatal visit patients. There’s a lunch break, and then I wandered back up to the labor ward to try and catch back up with the interns. No interns to be found, but one of the nurses (known here as sisters) remembered I wanted to get deliveries, so she told me they had a patient at 8 cm (out of 10) and before I knew it I was there in the action, having my memory politely refreshed by the nurse, delivering the baby! I ended up leaving shortly after that to take care of some business with trying to get some kind of voice communication going (so far not so good), but that was a pretty exciting moment in the day

And now, as promised, a bit about South Africa and the millennium development goals. . . maybe we’ll take it one goal at a time and insert other information as we go along too.

Goal #1– Eradicate poverty.
This is an interesting goal in relation to South Africa, as the country is just so diverse. It’s sometimes called the Rainbow Nation– there are 11 officially recognized languages and I believe at least as many more unofficially recognized ones. About 80% of the population is black, but this population comes from a wide variety of tribal backgrounds. The remainder of the population is split between people of Indian ancestry (Durban has the largest Indian population outside of India), Asian ancestry, and European/White ancestry. It has been said that there are two South Africas– one which is quite luxurious, and one which is a developing country. This was formalized under the apartheid system, and since the dismantling of that policy the lines between economic class and race have become somewhat blurrier. Regardless, however, it seems that two South Africas still exist in terms of class. For example, the GDP per capita is about $12,000, but 11% of the population lives on less than $1 per day. Unemployment is as high as 1/4 of the population. The country’s political leadership seems committed to eradicating poverty, in part building on the enthusiasm and momentum of desegregating the country to build a new South Africa. Vision 2014 is the objective to halve poverty and unemployment by 2014, and various initiatives have been undertaken as part of this. Time will tell about how successful these efforts will be.

Alright well that’s it for now! Catch you later (need to work on my Zulu language skills too :D)

-Rachel

addendum: I was writing this without internet, and upon finding it today and looking at the MDGs again, I realized I misquoted the goal.  It’s actually to eradicate extreme poverty and hunger, extreme poverty being defined as living on less than either 1 or 2 USD/day (I’ve seen both figures quoted).  In this regard, South Africa is doing somewhat better. . . not that there isn’t a poverty problem, but the MDG Monitor gives the country a “very likely to be achieved” on this goal (http://www.mdgmonitor.org/country_progress.cfm?c=ZAF&cd=710)

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Oh, we’re halfway there, OH! living on a prayer

Ok, not quite halfway there, but first leg done.  Chilling in Amsterdam, next up: 12 hour flight to Johannesburg.  I will say KLM has the best airplane food (or thank goodness any airplane food!) I’ve had in a good while.

Crazy to think that in like 48 hours I will be actually working in a hospital setting again. . . hope OB comes back quickly!

-Rachel

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Hello, world!

So many things to do!  I leave this Friday for South Africa from D.C., and I just barely got back into my own time zone. . . Right now the laundry and dishes are running, I’ve just finished up my course work to prepare me for the trip, and I am making a list of all the errands that have to get done before I leave.  Geez louise.

But hectic or not, it will all get done, or it won’t, but what needs to get done will anyway, and soon enough I will be on a plane headed east (to Amsterdam), and then south (to Johannesburg, then Durban), and then I will quickly settle in and get to work.

I am rotating with an organization called INMED, or the Institute for International Medicine, which helps network medical students and professionals with global aspirations to training sites in resource-limited areas so the learners have the opportunity to deal with diseases of poverty and public health issues in person.  McCord Hospital is just one of those sites, and I encourage you to follow the links around this site to learn more.

I will be gone for about 5 weeks.  My first two weeks will be spent rotating in obstetrics and gynecology, the next two will be surgery, and my final week will be pediatrics.  I thought since I won’t be doing any rotations in these subjects during my fourth year otherwise, this would be a good chance to really see some variety.

I appreciate all your thoughts and prayers, for me, for the community where I’ll be working, and for the husband who’ll be back in pseudo-bachelorhood for a little while!

Next up (assuming I get a chance to read some on the plane): what I know about health and development in South Africa going in, through the lens of the Millenium Development Goals (read more here if you’re curious)

-Rachel

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