The Story of HIV/AIDS in South Africa

Rich and poor have this in common: The LORD is the Maker of them all.

                                                                  -Proverbs 22:2

How’s work?

Well, that is a loaded question.  It is a question that evokes a multitude of responses, emotions and stories.  On one hand, it is good to be working.  On the other hand, work comes with many frustrations.  I am currently working in the urgent care clinic so I see patients with all types of illnesses, from chronic diseases like diabetes and high blood pressure, to acute fractures, drug withdrawals, new cancer diagnoses, and babies in severe respiratory distress. A typical patient scenario: a 6 year old orphaned African girl comes to me with a full body rash (insert any type you like – chicken pox, fungus, herpes, etc) that an outside doctor has treated unsuccessfully.  I do an HIV test, and sadly it comes back positive.  (I have not yet had a negative result in this scenario.)  Another typical scenario: a young, emaciated man comes in for cough, weight loss, and night sweats for 1 month.  I order a CXR and TB work-up, and (over 90% of the time) he has TB – and is concurrently diagnosed with HIV.  Many of the patients I see have HIV and its sequellae, the most frequent of which is TB.

Akbar is currently working in the emergency department, so he sees all types of patients too, from babies with severe dehydration, to teenaged victims of stabbings and gunshots, to patients of all ages with AIDS/TB, to middle-aged people with heart attacks/strokes.  He deals with critically ill patients every day, and struggles to balance the needs of individual patients, against the resources of a system that is dysfunctional and overburdened.  Each day he faces ethical dilemmas, and is learning to deal with them ‘efficiently’ but in a way that allows him to sleep at night.  In the US we are taught to ‘go all out’ for patients and use every test and treatment possible, regardless of severity of disease or age (or cost).  In SA, patients in the public sector with chronic illnesses like HIV or diabetes, or even being over 50 years old, can be refused an expensive test or treatment (like a CT scan or ICU admission) on the grounds that resources are limited, and should be saved for patients with better prognoses.  It has been difficult to see patients with severe illnesses get minimal or no care because it is considered a waste of resources, or to see them be used for practice by inexperienced physicians because they are poor. 

We are learning that in SA’s public hospitals, the ‘right way’ to practice medicine is not always clear.  As a person who thinks primarily in black and white, it is difficult for me to see situations in shades of gray.  In The Crack-Up, F. Scott Fitzgerald writes, “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”  The test for us will be balancing the needs and best interests of the patient in front of us, with needs of a resource-constrained system to provide for the rest of the population.

List of hospital services.

How Did So Many People Get HIV/AIDS here?

There are a number of factors that could explain why SA has the highest number of HIV patients in the world, and why our province, KZN, has the highest rate of HIV in SA (UNAIDS in 2009).  HIV crosses all racial, educational and socioeconomic boundaries in this country.  Even Nelson Mandela, South Africa’s national hero, winner of the Nobel Peace Prize, former president, and a Xhosa prince, had an adult son who died of the disease.  It is a disease that affects people of all ages, but especially young women and children.  Nearly 40% of women in their late 20s have HIV/AIDS, and 57% of childhood deaths under 5 years are HIV related (WHO 2000-2003).  It has been estimated that by 2015, 32% of South African children will have lost at least one parent to HIV/AIDS (http://www.irinnews.org/report.aspx?reportid=87144). 

HIV is a disease that carries tremendous stigma here.  Many people lack basic education, and have minimal medical understanding.  There is a strong fear of being shunned by one’s religious community.  People think that AIDS is a disease of the immoral or dirty or poor.  As a result, people will often deny their illness, refuse testing, suffer from multiple infections and eventually die.  Meanwhile they spread the disease to their families and partners.  We have heard stories of nurses at our hospital who have died from AIDS, simply because they were in denial and refused testing or treatment.  It can even be difficult to transfer HIV positive patients to a higher level of care because some doctors think that it is a waste of their limited beds and resources.  Some doctors have suggested that it is prudent to leave out a patient’s HIV status when trying to transfer a patient.   (Studies show that limiting hospital resources based on HIV status, is a phenomenon that even exists in the US.)

Unlike the US, where HIV testing is becoming routine, testing in SA is less accepted and less easily accessible.  People can undergo HIV testing only after having received standardized, formal counseling about HIV and medication adherence, and consenting to the test.  Though education and counseling component are important, they often become barriers to testing.  Doctors cannot simply add an HIV test to a lab work-up; they must write ‘HIV counseling & testing,’ which the patient can refuse.  Doctors cannot even cite AIDS as the cause of death on a hospital chart or death certificate, if there is any question of the patient’s disclosure status.  (Instead they write that a patient died of pneumonia or meningitis.)  In the chart, physicians often document ‘retroviral disease’ (RVD) status, a euphemism for HIV.  Vague documentation coupled with large numbers of undiagnosed HIV-infected people, means that many friends and family members of patients are exposed to the disease without ever knowing.

Road to our cottage.

Political, Social, and Cultural Influences on HIV/AIDS Transmission

SA’s high HIV infection rate is not an accident.  It is the result of neglect, mis-education, and mismanagement.  Since the epidemic began, South Africans have been misinformed by many of their leaders.  Dr. Manto Tshabalala-Msimang, an ob/gyn physician and politician who served as Minister of Health from 1999 to 2008 under President Thabo Mbeki, was infamously known as ‘Dr. Beetroot,’ since she advocated the treatment of HIV with traditional herbal medicine instead of anti-retrovirals.  (President Mbeki himself publicly doubted that HIV caused AIDS.)  She feared that the financial costs of treating HIV would infringe upon broader public health goals.  At the International AIDS Conference in 2006, SA was publicly criticized for its HIV policies.  A group of 65 of the world’s leading HIV researchers wrote a letter to President Mbeki calling for the dismissal of Dr. Tshabalala-Msimang; he refused (http://en.wikipedia.org/wiki/Manto_Tshabalala-Msimang).  According to one story, the minister had thousands of condoms stapled to pamphlets on safe sex and HIV, puncturing them in the process.  When asked about the thousands of useless condoms, she said it was meant to show people what not to do.

In addition to the political system, social factors have exacerbated the spread of the disease.  Among black Africans, mistrust of the medical system has led to delayed testing and treatment.  In one study, 25% of the interviewees believed that HIV was created to infect blacks and decrease their population.  Given the country’s history, such a view is not surprising.  During apartheid, blacks received inferior medical care to whites.   Another study in 2002 in KZN showed that 70% of patients consult traditional healers before doctors for health concerns, and some try herbal treatments rather than anti-retroviral therapy for HIV (http://www.irinnews.org/report.aspx?reportid=87144).  High rates of violent sex crimes also play a significant role in the transmission of HIV to South African women and children. 

Zulu and Xhosa cultures have further contributed significantly to the spread of HIV, especially in KZN.  In both groups, multiple sexual partners and polygamy are traditionally accepted.  Where we live, it is a tradition for the Zulu king to pick a new wife annually from a group of dancing virgins.  (Incidentally, everyone in KZN pays taxes to the king to support his family and royal lifestyle – including mansions, luxury cars, and expensive clothes.)  Polygamy is not restricted only to royalty.  One of our construction workers has multiple girlfriends; two have borne him children.  Another worker is married with 3 children, but has a girlfriend on the side, and his wife has a boyfriend too.  Both cultures have a high degree of gender inequality, and call on women to tolerate sexual behaviors that put them at high risk for HIV.     

Summer flowers in bloom by our cottage.

South African Fact:

If you live in Pakistan or China, you are 99.45% less likely of becoming HIV positive than if you live in South Africa.  However, if you live in the US, it is only 96.69% less likely.

(http://www.ifitweremyhome.com/    Based on statistics from the CIA World Factbook)

Cape Town Diaries

¹ The heavens declare the glory of God;
the skies proclaim the work of his hands.
² Day after day they pour forth speech;
night after night they reveal knowledge.
³ They have no speech, they use no words;
no sound is heard from them.
⁴ Yet their voice^[b] goes out into all the earth,
their words to the ends of the world.
                           -Psalm 19:1-4a

South Africa the Beautiful

We are frequently told that “South Africa is a beautiful country, but not the best country because it has too much crime.”  After living here for several months and visiting Cape Town in the Western Cape in January, I can agree with that statement.  We have experienced both petty crime and now amazing natural beauty.  The Western Cape was a pleasant break from Durban; it is very similar to California in weather and geography.  There are beautiful beaches, mountains, and vineyards.

Victoria & Alfred Waterfront (named after the 19^th century British monarchs) has a busy port as well as many high-end shops and restaurants.

Camps Bay, an up-scale beach town, is bordered by the mountain side called the 12 Apostles.

Table Mountain is the feature of Cape Town that has made the city famous world-wide.

Franschhoek (Afrikaans for “French Corner”) is home to many wineries beginning in the 1600s when the French Huguenots settled there.  Tastings average $2.50 for 6 wines and some come with cheese pairing as well. 

 Scene along the N1/R45 Wine Route.  The vineyard area is very similar in landscape and weather to the Napa Valley.

Cango Caves in Oudtshoorn.  We took the 1.5 hour Adventure Tour and climbed vertically and horizontally through small crevices.  Funny story: in 2007, after repeated requests that she not to crawl through the caves, an obese tourist from Durban was allowed through (after threatening legal action) and became stuck in the cave for over 10 hours, trapping over 20 tourists behind her, including a diabetic who needed insulin and a couple children with asthma.  Emergency services used climbing gear and paraffin wax to extricate her.

Oudtshoorn Wildlife Ranch.  We were able to see big-game animals up close (in enclosures that would never pass American safety inspections), watch crocodile feedings, and play with cheetah cubs.

Scene along the N2/R310 Garden Route.  Ironically, this drive reminded us of the words to America the Beautiful.  Do you see the ‘spacious skies,’ ‘purple mountains,’ and ‘amber waves of grain’? 

Shantytowns.  We have never seen shacks as expansive and dense as those surrounding Cape Town.  They extended for miles, seemingly without end.  Electricity is supplied by makeshift wires criss-crossing over the shacks, connected to utility poles on the side of the road; in the absence of parks, people use the side of the freeway (with traffic streaking past at 80 miles per hour) as their exercise and recreation area – for jogging, soccer games, etc.

Chapman’s Peak Drive, a 9km route, is a picturesque mountain road with multiple switchbacks and scenic vistas along the Atlantic Coast, reminiscent of California’s Pacific Coast Highway.

The Cape Good Hope was previously considered the most southern point of Africa until the Europeans realized they were wrong. (It is now known to be Cape Agulhas, which is 150 kilometers southeast.) It is the legendary home of the Flying Dutchman, a ghost ship that was doomed to sail the seas forever.

Dias Beach was one of our favorite places on the trip.  Secluded between the headlands of Cape Point and the Cape of Good Hope, its only access is by a steep stairway that descends from the trail connecting the two points.

Boulders Penguin Colony.  The colony comprises of 3000 African penguins, the only penguin species to inhabit Africa; it all started with 2 pairs in 1982.  (Fortunately – or unfortunately depending on how you look at it – our parents were not so successful.)

Robben’s Island is where Nelson Mandela was imprisoned for the majority of his 27 year sentence.  We went on a tour guided by a former political prisoner who spent 8 years there.  Although he was a black man, he made special mention of the many women, Asians and whites who opposed apartheid and were also imprisoned.  It has become increasingly common, we have noticed, for people to remember ‘the struggle’ against apartheid as a battle fought and won primarily by black South African men.

Kirstenbosch Botanical Gardens, located at the foot of Table Mountain, features plants unique to the area.  Of the 6 plant kingdoms, the Cape is the only region with its own floristic kingdom.

South African Fact:

From the tour of Robben’s Island, we learned that during the apartheid era, people were not classified as being a certain color until they received their identification papers at the police department when they turned 16 years old.  For people whose race was not obvious, such as certain Asians or ‘coloureds,’ they would do the ‘pencil test’ or the ‘lip test.’  If a pencil could remain stuck in their hair, or their upper lip was above a certain thickness, they could be classified as black.  Maybe I would have been considered black during this time: a pencil can definitely get stuck in my hair and my upper lip is fairly thick.