Bara

I like my women like I like my hospitals. The largest in the Southern Hemisphere.

On Thursday I visited Chris Hani Baragwanath Hospital. Bara is the main hospital serving Soweto, a black area that abuts the southwest of JoBurg. It was a separate municipality until 2002 but now Soweto is considered part of JoBurg. There are clinics in Soweto, but if you need a hospital for something serious, or you can't pay very much (or at all) you go to Bara. The hospital gets 150 000 inpatients and 500 000 outpatients per year and 160 gunshot wounds a month (1).

Aside from being really really big, Bara is unlike any hospital I have ever seen. I have only seen hospitals in America, where they are usually squareish buildings with a lot of concrete. Bara has lots and lots of one-story buildings as well as two larger buildings and a variety of sizes in between. The largest building is about 11 stories. The wards are mostly 1 story and they are scattered around the middle area of the grounds. There are brick buildings, concrete, tin roofs, and a variety of colors. There are small buildings scattered around between the wards. Some of them are restrooms, some have doctor’s office, some sell halal food.

I was at Bara to learn about the GERMS-SA surveillance and burden of disease. The Group for Enteric, Respiratory and Meningeal Disease Surveillance-South Africa (GERMS-SA) does surveillance for a variety of disease that are associated with HIV positive individuals. HIV is one of the risk factors for invasive pneumocococcal disease generally, as well as for serotype 19A specifically, which I am working on. Bara has about six surveillance officers for adults and 1 for pediatrics, all women. In SA, nurses are called nursing sisters. Sadly, male nurses are not nursing brothers. When diseases under surveillance by GERMS-SA are identified in the hospital laboratory the surveillance officers go to the patient to ask for consent to have that person be a part of the surveillance.

The sisters told us that finding patients and consenting them can be tricky. Older patients may be illiterate. Sometimes it is hard to locate patients in such a large hospital. Patients with cryptococcus are often experiencing cognitive difficulties. People may abscond. We couldn’t locate a patient and the sisters thought he might have absconded. People may be transferred to the step-down hospital before the sisters have time to see them. People may be unclear about what they are consenting to because they want to be treated and so want to approve everything. This happens with HIV testing as well. GERMS-SA wants to identify HIV positive individuals. Sometimes patients “consent” to HIV testing. Then when asked if they want to receive the results, they don’t.

The first patient we saw was a child. The mother was there and so the surveillance officers were collecting information from the chart and from talking to the mother. They want to know things like vaccination record, temperature on the day the CSF isolate was collected, does the child live with siblings under 18, has the child been hospitalized recently, etc. If the patient is a child, surveillance officers will check when family members visit so they can talk to someone.

While walking to the next patient we had a fascinating discussion about HIV treatment. People will often see a traditional healer, either instead of seeking treatment or in conjunction. This occurs especially in HIV positive individuals with Cryptococcus as the mental effects may seem to be a curse from someone else or spirits and also may affect judgement. The doctors try to incorporate the traditional healers into the health plan and people will come with their healer to the doctor. Also, we learned that people sell anti retroviral drugs to drug dealers. ARVs can cause hallucination even if taken correctly so people will grind them up and smoke them for fun (2). About this time we passed a condom lying in the gutter. Oh JoBurg.

Then we looked for a patient in one of the adult wards. He wasn’t where they expected so they did a bit of investigating. They knew where he had been admitted and so they could check the night counts and what the computer system said about transfers. They weren’t sure if he was transferred to a different ward and it wasn’t noted or if he absconded. The wards are segregated by gender. This seemed strange to me because I don’t think of US hospitals as segregating by gender but I guess they do. We do it by room but their wards are one giant hall so it’s the same idea. It just felt different because it isn’t stated in the US, only one gender but room, but I guess that’s the policy. I asked a sister about it and she said privacy is important and “you wouldn’t put a lion in a room with a lamb.”

The next patient we saw was an HIV positive individual with Cryptococcus. The patient (TP) was experiencing cognitive effects so TP had been admitted to the hospital. TP had ARV medication but hadn’t been compliant with the treatment. Both interviews by the surveillance officers were in languages I don’t speak so they would have to explain what was happening. TP wasn’t clear on the importance of taking medication and possibly TP’s counseling when TP was diagnosed with HIV was not adequate. TP wanted to know about buying ARVs but that would be very expensive and they would be free at the hospital. Sometimes people that are HIV postive are in denial or don’t want to talk about their status because of the stigma so the sisters will talk to them about treatment without talking about their status. It was sad to see TP because TP was very nice and the sisters were trying to impress upon TP to take TP’s medicine and TP didn’t seem to be getting it. One of the doctors told us if TP wasn’t complying with his treatment he would be sent to the step-down hospital and then discharged because they need the bed available. One of the people with me on the site visit was an MD from London and she said TP would probably relapse and die from crypto if TP didn’t take the medicine for that.

Then we went to the morgue where the sisters sometimes go to check about paperwork. There was music playing a bit loudly in the morgue. The sisters told us that is to keep the spirits cheerful.

There is a building at Bara for prisoners that require medical treatment. Also you see people with orange jumpsuits and wrist and ankle chains being escorted around the grounds. We went to an HIV clinic next and it was pretty crowded. The waiting room had about 30 people in it including a prisoner. It is an obstacle to testing and treatment that the HIV care is pretty centralized in Soweto. It can be hard for people to get the Bara.

The sisters were very friendly and worked hard. It was great to see where my dataset has come from and what data they have trouble collecting. I asked one how long she has worked at Bara and she had been there 4 years. She said she enjoyed her job and it is interesting but it is hard because so many people have HIV. She said ARV treatment wasn’t helping very much because people get sick before they are started on ARV. I think the CD4 count has to get below a certain number before ARV is started. In the 80’s mortality at Bara was similar to a hospital in the US but now it is much higher. It can make treating patients seem futile. I was a little concerned with some aspects of the data quality after seeing the sisters. For example, they mentioned that they round age up. If I have a date of birth, I use that. If not, I go with the indicated age.

Then I went on pediatric rounds. I have been on rounds once before, at the ICU at SF General. That tine, there were a few people dying, a lot of people with trache tubes that couldn’t talk and seemed pretty miserable, etc. Although yesterday we were seeing sick kids, it was still kind of cheerful, compared to SF. In one room, there was a dad laughing as his kid held a Gatorade bottle for his dad like a bottle. The rooms were painted brightly with lots of images on the walls. There were usually parents with the kids and sometimes there were siblings too. The kids all had infections of some kind and antibiotic resistance is often a problem.

In one of the wards I vaguely noticed something on the ground but it didn’t register because hospitals often have miscellaneous equipment scattered around. The doc mentioned how it is hard to do infection control and pointed. I realized it was a sink on the ground that was ripped out of the wall. Everything was a bit grubby and the doctors talked at times about having trouble getting certain (expensive) medicines, but they seemed very competent and able to treat the kids.

Jeff

1. http://www.chrishanibaragwanathhospital.co.za/bara/article.jsp?id=161

2. http://www.aidshealth.org/news/in-the-media/no-turning-back-teens.html

p.s. I retracted my earlier post about hearing gunfire (in the comments), but I should say it on the front page too. It was just a loud noise. Although a friend of a friend was shot in an attempted carjacking near to where I live. She survived.

Happy 4th of July!

We have upon us what is arguably the best holiday ever -- the 4th of July!

So, what's everyone doing to celebrate this weekend?? Are you celebrating with other Americans, hosting a BBQ, or bringing yard games and fireworks to the locals? Whatever it is, take plenty of pictures and we'll have a story and picture posting blitz on the 5th! Pictures with American flags get extra props!

Happy 4th!

Grananda

First of all, Granada = heaven. It is my favorite place so far in Nicaragua, and I feel slightly guilty saying so because it is very touristy (aka lots of gringos, different foods, streets are clean) but it was really beautiful. It is the oldest Spanish colonial city in Central America and there were great churches and cathedrals. This is us at a lookout over a lagoon that connects to Lake Nicaragua. (Still not sure how a lagoon is different than a lake but enough to look it up). Don't let this picture fool you, we were hotter than ever, it was over 100 and I was sweating sunscreen!




Fabulous market where Allison secured her hammock.



Happy Hour! Two mojitos for $1.25. You know what that means.




Cathedral. For the Jesus lover in all of us.



Time is running out and I am sad! Only a month left. I was going to travel up Central America but those damn Hondurans are having a coup so I think I will instead go down Costa Rica and Panamá. Maybe dabble in Columbia. Mwhahaha.

Tourist in Hanoi (Ron)

I thought I would add some pictures and comments from the tourist sites that I've visited in Hanoi. Most of these I saw a few weeks ago but some were just this past weekend.


This Hoan Kiem Lake, one of the multiple lakes in Hanoi but the most popular being right in the center of downtown.


A refurbished section of Hoa Lo prison. Originally constructed as a prison to hold Vietnamese political prisoners fighting against French occupation it is commonly known as the famous prison where US Soldiers were held during the "American War" as it's known here.


The Temple of Literature is the first "university" of Vietnam established in 1076. It has stone tablets with the names of its doctoral graduates.


I enjoy the Night market better in Hanoi than in other places. It's more of a gathering place for a nice walk than the Ben Thanh market in Ho Chi Minh City (Saigon) where you are treated as a walking wallet.


Speaking of "Uncle Ho" here is his final resting place and Ba Dinh square. The sheer size of this open area is hard to describe. In one of the most crowded cities I have seen, this large open area is just stunning.

My project is coming along fine. Two months just isn't a lot of time to get even basic research done in my mind, but I think what I'll collect will be helpful to ACS and hopefully to the organizations here.

This upcoming weekend I'm going to travel to Sapa which is a nothern mountainous region where many ethnic minorities live. Hiking along the rice paddies from village to village sounds like a great way to spend my weekend in attempt to get away from city life.