Breakthroughs, Bungalows and Bureaucrats

I've had a pretty good week so far. I 've had three personal breakthroughs and one logistical nightmare partially solved:

Breakthroughs

1. One of the women at the clinic who wouldn't look at me during my first week actually said my name this week. And she wasn't yelling at me when she did it. I think it may have been partially due to the fact I bought Ntombikayise (our technician) a stuffed dog for her son's first birthday (May 21st). She was showing it around to everyone, so I must have made some points. Interestingly, first birthdays are a big thing here like in the U.S. There was no party, no cake, not big presents. I don't think it's about money, I think it's just that they don't celebrate kids like Americans do.

2. On Monday Tami (our pharmacist) was about three hours late coming to work. So, I had to be the pharmacist for the morning. I gave out medications to about 20 people. I didn't get their names exactly right, which was a cause for laughter with Ntombikayise. The patients were friendly and I only had one get a little frustrated when I couldn't understand her question. Ntombikayise came to my rescue and everything was fine.

3. While packing the monthly food parcels yesterday a couple women in the HIV support group started a conversation with me. They were actually telling me what to do like I was just a regular guy and part of the group. That made me feel very good, because I don't want to be seen as anything other than a friend.

Last week I was told by an American working in Botswana that it takes a couple months before people open up and trust you. I guess he was right. It will be fun to see what the next two months brings.

Bungalow update

Well, the third try really is the charm. Yvonne managed to get a third group of men with hopes of getting the bungalow moved. And, wouldn't you know, it's working. She asked one of the cleaners at the Centre to round up some guys. This woman found a guy who found three others. They took the bungalow down on Tuesday in only 90 minutes. Yvonne's waiting for another guy she knows to bring his truck around so the panels can be moved, at which point the four new guys will reassemble it. I'm not holding my breath but it's possible it will all be sorted out by this weekend. And just in time, too. Nomasomi's daughter has been beaten up twice in the past month because other kids know she has money to travel back and forth to school. She needs to get settled and in a school closer to home. Stay tuned.

The President Comes to Zwane! (Sort of)

We got word late yesterday that the Deputy President, Phumzile Mlambo-Ngcuka, was coming to the Centre today as part of a day-long tour around Cape Town. She's currently the Acting President because the real President, Thabo Mbeki, is out of the country and the constitution calls for the Deputy to take over when the President is away. Ms. Mlambo-Ngcuka has spent a lot of time in Guguletu in her lifetime, and she is very well liked and well respected there. Many people would like to see her become the next president when elections are held in 2009. Because of the way the political process works here, she is considered the front-runner right now because she is the second-in-charge in the ruling party.

As you can imagine, it was a beehive of activity this morning. Rev. Spiwo is gone for a few days in the Eastern Cape, so it fell to Edwin and Zethu (Rev. Spiwo's wife, the head person at Brown's Farm clinic (my boss) and head of the Zwane HIV support group) to make sure everything was in order. (I think Spiwo called Zethu about 5 times this morning to make sure everything was okay, so he really was in charge.) She stayed at the Centre for about 45 minutes. Edwin did a great job of explaining what we do and how every program is designed to meet a community need. Because the Deputy President has a special interest in HIV/AIDS, Edwin and Zethu spent more time on the AIDS hospice programme, even bringing some of the patients and caregivers to the meeting. Siyaya, JL Zwane's music and drama group, did two songs that were well received. After a few words of encouragement and congratulations, she left in her bullet-proof BMW.

Because it was “Take Your Girl-child to Work Day” Ms. Mlambo-Ngcuka had five girls shadowing her for her visit. Each was in her mid-teens and came from a different high school in Cape Town. She took the girls to Parliament for cabinet meeting to let them see the political process at work before coming to Zwane. I was impressed that she really engaged the girls, even making one of them speak at the Centre to show that impromptu speaking skills are important.

It was interesting to watch the process and compare it to U.S Presidential visits. They didn't block off any roads, although the police made sure no cars were hanging around. There were only 6 or 8 “secret service” officers, basically one for every door. People were walking around freely, with no restricted areas. Indeed, people were coming in off the street and sitting down to watch the show. The motorcade was 6 cars, with only one SUV and including a VW Golf. I cannot imagine a U.S. Presidential motorcade with a VW of any kind, let alone a little Golf. The laid-back atmosphere added to the personal sincerity that the Deputy President seemed to exude.

Here's a picture of me shaking her hand just to prove I was there. I didn't realize how pale I am, even after being out of the Minnesota winter for two months. I really need to get outside more. Here's also a picture of Edwin, Yvonne, and Zethu with the Deputy President, with the hospice director (Ed) and manager (Esther) standing behind them. The other guy is security.

More to come.

Two news articles published this week point to some of the incredible social problems that South Africa is dealing with.

1. Education and Pregnancy

Last week's Sunday Times (a national newspaper) reported statistics about pregnancy rates in schools. In the Eastern Cape, from which many people migrate to Cape Town and the surrounding area, there were 5,015 pregnancy schoolgirls in 2006, up from 3,264 in 2005. According to the provincial statistics, 55 of these girls were in Grade 5 (that's age 10 or 11); 129 in grade 6; 346 in Grade 7; 648 in Grade 8; 913 in Grade 9; 1,131 in Grade 10; 1,003 in Grade 11; and 790 in Grade 12.

One school, Mqikela, had 144 pregnancy students out of a school size of 1,500.

Authorities list many reasons for the rise in pregnancies. These include:

• Girls lack negotiating power regarding the use of condoms, both with younger and older men. Even though condom education and usage is up (because of the anti-HIV programmes) it's possible they are not used correctly, and other birth control methods are being ignored.

• Because the government provides child care grants (R190 per month per child), some authorities believe girls are having babies to get financial assistance. Many of the girls mentioned in the article are orphans or living on their own. One principal was quoted as saying “These kids are competing over the number of children each has and how much money they earn from this. They are poor so they want more kids.” It's creating a cycle of poverty that will be extremely difficult to break free of.

• Sexual abuse, coercive sex and survival sex (trading sex for money, but not as prostitution) are ever-present in both urban and rural areas.

• Poor school attendance, poor discipline, gangsterism, and drug abuse were also cited as reasons. Class sizes can run as high as 100 students, making learning very difficult. Many students skip school and hang out on the street. Gangs are very common and have little fear of authority (they loiter outside JL Zwane from time to time and harass the after-school students).

I've seen some of the schools and the conditions under which children are expected to learn. I'll write more on that in a later posting.

2. South Africa: Hub in the Drugs Wheel

The Wall Street Journal had a Page 1 story on Monday (21 May) about the role South Africa plays in global distribution of methamphetamine, known locally as tik (pronounced took). Major gangs in the country are trafficking in both raw ingredients and finished products to and from countries like China, Mexico, and Australia. They are even using non-monetary items as payment, including abalone poached from the Indian Ocean.

Tik usage is getting more and more press here and I get the sense it is a major and growing problem. There is a concern about the impact it will have on the HIV rate here, since methamphetamine usage can contribute to higher rates of unsafe sex and HIV infection.

The writer spent a lot of time with the leader of a local gang called the Americans. Their motto is
"In God we Trust and die we must.” The gang leader claims to be a legitimate businessman and makes sure his own kids do not use drugs. It could be a Sopranos storyline.

(I have been warned here before about calling myself an American, that some people may think I'm with the gang. Instead, I'm supposed to say I'm from the U.S. Crazy.)

If you want to read the article, try this link (you'll have to paste it into your browser): http://www.emailthis.clickability.com/et/emailThis?clickMap=viewThis&etMailToID=1744036003. If this link doesn't work for you, let me know and I'll send you a PDF of the article.

More to come.

Cold, Coworkers, and Casino

It has been cold and rainy the past three days. Highs have struggled to get above the mid-50s, and it's rained hard off and on since Friday evening. I heard on the news today that about 60 homes in the shack areas of Guguletu, Philippi and Mitchell's Plain have been lost due to fire or floods and well over 100 people are homeless because of the weather. It's supposed to be in the 50s all week, with a couple sunny days coming up and then more rain.

Fires are a problem because people will start fires in their shacks to keep warm. Paraffin heaters, just like kerosene heaters, are also used. There's a tendency for these heaters to tip over or be knocked over by kids, and it's not uncommon to hear of kids getting badly burned in shack fires. As you can imagine, a shack fire can quickly spread because of the extremely cramped conditions in the informal settlements (i.e., shack areas) and the materials used to build the shacks.

Floods are a problem because there's nowhere for the water to go during a heavy rain. Nearly all ground is covered by structures, and people build shacks right up to the edge of swamps and marshes. A walk through the informal settlements during a rainstorm is like walking along dirt roads near farms: There are puddles everywhere and sandy muds get all over everything. One man I talked to said that during the rainy times he will have to place milk crates all over the floor of his shack and walk, sit and sleep on them to stay out of the water. It takes about 2 days for his shack to dry out after the rain stops.

Just having a watertight house is a big problem. Roofs are attached to shacks with bolts or nails. They are rarely hole-free, and most that I've seen have big gaps where the wood or zinc doesn't quite butt up right. Noloyiso, the girl who takes care of her brother on her own, has a roof that leaks so bad they wear damp clothes for days until the rain ends. A luxury is a big piece of plastic or a tarp to cover the roof, and then you just have to worry about it blowing off in the 35 mile-per-hour wind gusts.

For those of you that fight with your coworkers about thermostats and temperatures, imagine working in an office without heat. Both the clinic and JL Zwane are unheated. I think the temperature in the pharmacy was about 60 today, if that. At JL Zwane everyone wears their jackets all day. I'm lucky because I have Minnesota blood in me, but I can tell it's not going to be too long before I start wearing a sweater all day. It is good sleeping weather, though...

Staff photos

Here's a few photos of the people I work with at JL Zwane. People are not into posing here, so most of the pictures I have are action shots.

Edwin is Associate Pastor. He is in charge of visitor programmes and helps with some administrative work.

Cacisa (it looks easy but her name is very tough name to pronounce, even the locals have a hard time with it) is the administrative assistant and receptionist. She lives very close to the Centre and is a great source of knowledge about growing up and living in Guguletu.

Yvonne is Director of Ministries. She is in charge of all outreach programmes and is leading the child-headed household project. Yes, this is the best picture I have of her as she doesn't ever stop moving.

Mama Nqo is the head cook. She manages all of the meal programmes, including the HIV support group and the after-school programme. She also makes lunch for the staff everyday, a big reason why I need to keep exercising.

Mama kaToni or Mama Baps is the assistant cook. She has a son named Toni (kaToni means mother of Toni), which can sometimes cause great confusion in the kitchen if people are saying something about me and she thinks its about her son.

I will introduce you to the rest over the next few weeks.

Nightlife

A couple weeks ago my dad asked me what I was doing for nightlife. Sadly, the answer is not much. I am not a big drinker and I get up really early so bars are not a big deal for me. I'm actually somewhat of a homebody. Last Saturday, though, I decided I'd better get out of the apartment so I went to Cape Town's big casino, GrandWest. It's like any Indian casino you've ever seen. It had thousands of slot and video poker machines, with titles just like you'd see in the U.S. They had very few blackjack tables or other card games. Roulette must be big here, though, because they had more than I've ever seen in a casino, Vegas and Atlantic City included. Sadly, no craps tables, though, and no sit-down restaurants that I could find (no buffets!). They did have a big indoor ice rink and it was pretty crowded. The crowd was about half Whites and half Coloureds, with very few Blacks playing games (most of the workers were Black, though). I played roulette for about 30 minutes, won R100, and left. I probably won't go back.

More to come.

Road Trip! And, an emotional evening

Spiwo, Edwin, Xolani May and I went on a trip to Ceres yesterday. Ceres is part of the Witzenberg area, about 90 minutes (beautiful) drive northeast from JL Zwane. The area has about 86,000 residents in 5 towns, with Ceres being the largest. Over 13,000 people in the area, or about 17%, have HIV (keep in mind the US rate is about 0.3%, and Minnesota's is even lower).

Ceres' main industry is juice. The Ceres Food Group is based there - you may have seen their products in your favourite grocery store. They have a 55% market share for juice and juice-related drinks in South Africa. They are part of an even larger food company here, making them a real powerhouse both locally and nationally. CFG employs only 450 people to produce 8,000 pallets of juice per week, as their plants are fully automated and no person touches the product from the time the fruit is dumped into the line until the product is shipped out.

Our objective is to bring Siyaya, the singing/dancing/drama HIV education group from JL Zwane, to Ceres to put on a show for the community. We met with staff from the municipal offices and workers from a local HIV advocacy group. We had a great meeting, and it looks like the show will happen in July after the winter school holiday. We'll be focusing the show on the local youth, but everyone will be invited and encouraged to attend. A local youth dance group will probably be opening for Siyaya, which should help draw the locals in. We're hoping CFG and other local businesses will get involved financially and in marketing the show to employees and residents. I'll keep you informed as we go.

This nice day followed a depressing evening. I went to two homes on Wednesday with Yvonne and Nomokwazi, a woman who works with the Centre. The first was to see a 26-year old woman with advanced AIDS who lives with her mother. She has had HIV since 1996. She now has lymphoma of her central nervous system, for which she recently had a week of chemotherapy. She goes back to the hospital next week to see if it was effective. Whatever the outcome, she is in tough shape. To relieve her mother, who is visibly tired from caring for her daughter non-stop for the past two years, Nomokwazi and I washed the woman's feet and hands, clipped her nails, and rubbed warm Vaseline on them. She talked non-stop the whole time, partly because we were listening and partly because (I think) she's suffering from a mild stage of AIDS-related dementia. After about an hour, we left for house #2.

This house was Sophie's and Sam's. Sam is the 4-year old with HIV who has not been doing well lately. We were at the house as part of a prayer group, made up of men from the Men's Auxiliary from JL Zwane church. We prayed and sang for about an hour as Sam sat on Sophie's lap and she cried. The men, plus Yvonne, all spoke for a few minutes between songs, and quite animatedly at that. It reminded me of a being at a revival meeting except that there were only 9 of us in a small living room in a small house in the middle of Guguletu. Sam had a doctor's appointment yesterday and I'm waiting to hear how things went.

It's going to be cold this coming weekend, with highs of 55 or so and lots of rain. I'll be at the store buying sweaters before long.

More to come.

Odds and Ends

Here's some odds and ends from the past week:

1. This is Thomsanqo and his son. I visited them at their home last week. Although they're nice people, it's not the reason I'll remember them. I saw something in their house I've never seen in any other South African home I've been in: a mentally handicapped child. He must have been 3 or 4 years old and looked to have Down's Syndrome. It's something you don't think about until you see someone like this, namely where all the handicapped kids are. I've been to a home for abandoned children where half the kids have a handicap, but that's the only other time I've seen them. You don't see challenged kids on the streets, in malls or shops, in church, or in schools. I'll have to keep my eyes open and ask about how they are cared for.

2. Sophie's son, Sam, who I wrote about a while ago, is apparently quite sick. I'm going to see her tomorrow and will update you on that. For those of you into praying, they could definitely use some.

3. The murals for the Treatment Action Campaign have started. Here are the mock-ups for the murals that are being done. They're supposed to be in series: people go to clinic, get educated, and then live more comfortably. The workers started this week and expect to have them done within 10 days. TAC is planning to have a formal unveiling when the murals are completed and I'll post the pictures.

4. This picture is from a somewhat spontaneous street market just up the way from JL Zwane. It happens every month on Pension Day, my name for the day pensioners (the elderly) get their governmental support payments. Informal sellers will set up shop with food, clothes, and any other things they can sell.

5. I met with the pharmacy director for the Provincial Government of the Western Cape (PGWC), Stefan Venter. He's got a tough job, running all of the pharmacies in the government clinics and hospitals, making sure patients get good care within his restrictive budget. I'm going to help where I can as they set up new programmes or expand those currently in place. He said he was hoping I'd agree to come and work in their offices instead of at the clinic but understood that it probably wasn't where I wanted to spend my time. I didn't say anything – I certainly didn't come all this way to have another desk job!

6. JL Zwane has an after-school tutoring program for kids every day. They do this because many kids have parents who are functionally illiterate and cannot help with homework. I made a casual offer to help with English, and before I knew it I was sitting with ten 6-year olds trying to teach them about weather. I think they knew about 20 words between them, so it was just a little challenging. I ended up talking about satellites and drawing the solar system, which they kind of understood (or so I told myself). The next day I worked with sixth graders. We read a story together, each reading a page and then passing the book on. We defined words, worked on punctuation and pronunciation, and how to read to others (when to pause, etc.). I hope to do this at least once a week or so, hopefully with a more formalized teaching plan. If anyone knows of any good home-school resources please pass them on.

7. I bought petrol (gas) last week. It was R7.70 per litre, or about R27.75 a gallon. That's just shy of $4.00 a gallon. It's lower than I thought, probably because of all the oil and gas production here. It's still high for the economy and people are getting worried about the impact on taxi fares and delivery costs. The Rand is very strong right now so that might help lower the price a bit. When I came six weeks ago the exchange rate was R7.25 to $1.00. Today it was R6.89. Good thing I converted my money when I came or I'd be 5% poorer.

8. I attended a lecture on Darfur this evening. The speaker has spent about 14 months there as an observer for the African Union. He said there is no end in sight, that it's really just beginning. According to him there has to be wholesale changes in government before anything will happen, and that's not likely any time soon. I don't know enough to comment, except that the pictures he had spoke loudly that something needs to change.

More to come.

Project Bungalow: The Saga Continues

It was not a good weekend for Project Bungalow. I feel especially bad for Nomasomi, who had her hopes really high and saw them crash.

As I mentioned previously, I paid for the bungalow on May 4th. At the time we spoke with a woman from the JL Zwane congregation who lived just down the street from where the bungalow is sitting. She has a couple guys working on a house for her, and she negotiated with us that four guys would tear down the bungalow, move it, and rebuild it, all for R500. She was also going to arrange for a truck, which would be additional (price to be determined). Yvonne and I were told that they would start at 10:00 on Saturday and have it done in one day.

I should have taken a picture of the place, but here's a quick description: The bungalow is about 12 feet by 16 feet. It's made of corrugated asbestos panels, each one being about 3 feet wide and 8 feet tall. The panels are held together with a wooden 2x8 frame at the top and another at the bottom with 2x10 beams forming a t in the middle of the ceiling. There are no support posts that I can remember. It has single small windows on three sides and a main entrance door. The roof is the same asbestos tile. All in all there are probably 35 tiles, the beams, the door, and hardware to keep it together. I figure 4 guys could easily disassemble the structure in 2-3 hours and re-assemble it in 3-4 hours if they work hard and have the proper tools.

When we got there at 3:30 yesterday, there were two guys working on the roof panels. They had about half of them down. Obviously, there were not four guys working since 10:00. They told us that they could only do the roof and would come back on Sunday to do the rest. The main guy gave me his word that he'd be there at 9:00 with the other workers and they'd have it done on Sunday. They asked for partial payment, as they had other workers to pay (there were allegedly a couple other workers there in the morning.) I paid them R200 of the R500 and made it clear that I expected to see workers at 9:30 Sunday when I passed by on my way to church. He said they would be there.

During all of this drama, poor Nomasomi was sitting at the bungalow watching nothing happening. She was in an absolute panic, because she was kicked out of where she was staying and had nowhere else to go. Yvonne talked to her and calmed her down, and we left the place on Saturday with a renewed sense of hope but a growing cynicism that the result would be a good one.

This morning (Sunday) I did drive by the bungalow on my way to church and, as I feared, no men were there. Yvonne and I drove back after church (1:00) and still no men. Nomasomi was sitting outside the bungalow with her heart in her hand. We didn't stop because we had other people in the car, so I can only guess at what Nomasomi was feeling (fear, anger and disappointment for sure).

As a back-up plan, Yvonne spoke with two men from the Men's Auxiliary about the situation. They agreed that the group would take on this project and make it happen. We drove by the site this afternoon with one of the men to help him understand what is happening. Hopefully, we will have Plan B in place this week and Nomasomi will be in her new home very soon.

Besides the problems with the bungalow, I also found out this week that we will probably have problems in the near future with Nomasomi's situation, even after the bungalow is finished. Yvonne never told me that Nomasomi will have to pay rent for the plot where the bungalow will sit. It never crossed my mind, partly because no one ever talked about it. She will also have electricity costs, assuming she gets a box and a hook-up. Because of the size of the shack, the rent will probably be about R250-300 per month. Electricity will probably run another R30-50. Nomasomi is not working and has no prospects. She is not skilled, so her chances of finding well-paying work are poor to none. I am very afraid that she will soon end up homeless again because she can't afford to have a home. I don't know what I would do then.

I can't tell you how frustrated and disappointed I feel right now. I promised a woman that she would have a new home, and I have not been able to carry through on that promise. I feel robbed by the men who promised to do the work and then didn't even show up. I'm upset that no one stopped to explain the whole scenario so we could put together a proper plan. But mostly I'm angry with myself for not asking more and tougher questions assuming that what I already knew was sufficient. I broke one of my own rules about not promising something I can't deliver. I have certainly learned many lessons from this and will not move so quickly on anything again until I truly know and understand the financial, social, cultural, and humanistic consequences of my actions.

Yvonne thinks everything will be fine now that the other men are involved. I'm reserving judgment. I'll keep you all informed as things proceed.

On a happier note, the HIV support group took over for most of today's service. They did a play about people's acceptance of those living with HIV. They had five scenarios, including an employer/employee, student/teacher, mother/daughter, lesbian couple, and two school friends. First each pair did disclosure and rejection, and then each came back and did acceptance. Part of the acceptance message was about JL Zwane being a church that welcomes and supports people living with HIV, unlike other churches in Guguletu. It wasn't exactly a happy play, but it had a strong message at the end and the congregation loved it. The support group also gave gifts to Rev. Spiwo and his wife Zethu (she's a nurse and a leader in the support group), the two cooks who make the daily support group meal, the doctor who attends the group, and the social worker who is in charge of the group. It was very nice.

More to come. Please think happy thoughts for Project Bungalow.

Another Funeral Day

It's been a long day, filled with emotions and panic, to use Yvonne's favorite word of late. I have a lot of topics to cover but no energy to do it, so I'm only going to write about one today. I'll update you tomorrow on Nomasomi's bungalow situation (that's the panic part) and the rest in a couple days.

I spent most of today with Zindzi's mother's funeral. I was there from beginning to end so I have a much clearer idea of the goings-on. I was about 6 hours in total, partly due to some timing problems, but those point out some of the infrastructure problems people here deal with every day.

(I almost wrote “put up with every day” which sounds a little too apathetic. In some regards, people do just put up with it because it's the way things have always been. Service levels here are poor, at best. The peristatal companies, Eskom (electricity) and Telkom (telephone), and government agencies are typically the worst, but just about everyplace is bad. Clerks are rude, time has no relevance, and your priority is not any else's. Most people here do just put up with it because that's how it's always been. It even trickles down to interpersonal relationships, where someone just won't show up for a meeting or to do a job. A lot of people are hoping that the planning and program installation for the 2010 soccer World Cup tournament will help, getting people to understand what's going to be needed to convince the world that South Africa is a first-world player. I hope so too, but I'm not holding my breath.)

The day started at 9:00 with a gathering at Zindzi's house. It is customary to gather for prayers and worship, kind of like the deceased person's “last day at home,” as Zindzi told me. It was a beautiful day for it, sunny and cool. Of course, my bald, pink pate didn't take to the sun too well but I'll live. The house owner will attach a tent, more like an awning, to their house to create a theater of sorts. This is also where lunch is served after the graveside service (more on that below).

We were at the house for about two hours, which is an hour longer than usual. We were delayed from moving to the JL Zwane church because some other church had taken over Zwane's hall for another funeral. No one seemed to know how that happened – when I left the office yesterday Zindzi's mother was the only funeral on the schedule. Zindzi also had trouble with the buses not showing up on time. People rent buses to bring participants to the church and the cemetery because very few people have their own transport. It was a lot of pressure on Zindzi, who is still trying to deal with death and responsibility of running the house. She was doing quite well, though. (When I first met Zindzi I was very impressed by her maturity and demeanor. She acts and talks much older than 19. When I saw her earlier this week she looked like a little girl who had lost her mother. She was shy and withdrawn, like she didn't know exactly what to do. It was a sad and striking comparison. Today, she was back to her old self, having accepted her mother's death and moved on.)

From the house we went to the church. The service was the typical 2+ hours, with about 20 songs and several speakers. (I still can't figure out how they know when to start a song – it seems like someone just starts singing in the middle of someone's speech and everyone joins right in. Sometimes everyone stands and sometimes only half the group stands. I'm sure there's logic in there somewhere but I haven't found it yet.) One nice addition to this funeral was that the ladies auxiliary kept 6 women around the casket all the time, like they were guarding from evil. They'd rotate women every 10-15 minutes so no one got tired. This auxiliary group had fancy cheetah-patterned hats, while the men's auxiliary had matching cheetah waistcoats. It was a nice change from the typical black or white.

After church was the graveside service. This lasted about 30 minutes. I described that a couple weeks ago, it's similar to any Christian burial I've been to in the US. The only difference is that they fill the grave while the people are still there.

Kevin Winge described the cemetery as being like one you'd see in a wild west movie. It is much like that, with the exception of seeing marble markers on some graves. See what you think. It's certainly not like any US cemetery I've been to.

Then came lunch at Zindzi's home. It's custom to wash your hands in special tubs of water outside the house. I learned today that if you wash before the family has arrived and washed their hands you are inviting a curse upon yourself. I made sure to stand way back. When Zindzi's grandmother washed her hands there was a mad rush to the tubs in order to get a good seat under the awning. Lunch was beef neck bones, rice, spinich, and a small potato. I was starving (relatively) and it tasted very good. I sat at the clergy table, again, and talked about religion in America with a Church of Christ minister and a Methodist member. I only wish I knew more about religion in America.

(Lately I'm having a hard time dealing with hunger. My own, not others. Those of you who know me well know that I eat about 5-6 times a day. It's mostly due to the fact that I exercise in the early morning and I can't usually last from breakfast to lunch without a mid-morning meal. I also try to eat something in the afternoon so I don't eat a big dinner. Well, I've been feeling guilty lately when I have my morning sandwich while working in the pharmacy because I've noticed that the tech there doesn't eat anything all day. I don't know if it's her choice or a necessity (I'm guessing the latter). I eat in the storeroom just so she doesn't have to watch me. I also feel bad when I think about being really hungry, like today, knowing that many people here feel like that all the time. Is it bad to eat because I can? Should I feel guilty about eating when others don't or can't?)

We left lunch just after 3:00 and headed back to JL Zwane. From there it was dealing with Nomasomi, which I'll write about tomorrow. Hopefully everything will be resolved by then. Suffice to say things are not proceeding as planned and I'm very worried. I've also learned all about the law of unintended consequences, which I'll fill you in on.

More to come.

Random Updates

Here's a few different things that I did this week:

1. I had a computer melt-down this week and spent two days getting everything back to working order. Kids, downloading software off the Internet can be a bum trip. Stick to legit sources and don't run anything from strangers.

2. I found out that my license has been approved by the Pharmacy Council. So, I'm now legal to be a pharmacist here. I don't think it will change anything, but the clinic is under less pressure to get a locum tenens (temp pharmacist) if Tami is away.

3. The planning for the HIV clinic at Brown's Farm is on track for July 1. While we'll start small, 10 patients per month, there's a possibility of having over 100 patients by the end of September. It depends on how many people being treated at other clinics decide to come to Brown's Farm. There's a general feeling that most of the people who live in the area will come back quickly because of transportation hassles when they need care.

4. I realized that I did not mention HIV/AIDS treatment in my last posting. South Africa only uses six medications to treat HIV, using two different three-drug combinations. The preferred initial therapy is efavirenz/lamivudine/ddi. If the patient is a womanof child-bearing age, nevirapine is used in place of efavirenz. Second-line treatment is didanosine/zidovudine/Kaletra. There are no other options after that. Abacavir is available but not used. Tenofivir was just approved and will be launched in May. There's been no indication of where it will be used – my guess is it will be at least second-line.

Since a large percentage of people with HIV also have tuberculosis, treatment can be difficult. This is especially true here as an increasing number of TB cases are MDR (multi-drug resistant) or, even more scary, XDR (extremely drug resistant). MDR means that the bacteria are resistant to at least two of the five drugs initially used to treat TB. XDR means that at least four of the medications will not work. The XDR problem is worse in the Eastern Cape, but since so many people move to the Western Cape from the Eastern Cape it's a major concern in Cape Town and the settlements. It is entirely possible that in a few years there will be no effective medications for TB in southern Africa. That will be bad.

5. For those of you in health care, here's a chance to feel good about how much you make. According to today's newspaper, a Principal Pharmacist (Pharmacist-in-Charge) at a government-run Community Health Clinic gets paid R147,000 plus a 15% scarce worker incentive. That makes it about R170,000 total, or $24,300. I made more than that when I got out of school 22 years ago. Compare it to today's starting salaries in the US public sector of $85-90,000 and up. Nurses are paid about R70,000 or $10,000 per year, at least a third of what registered nurses are paid in the U.S. Principal Medical Officers (doctors) of various specialties start at about R335,000, equal to $47,500. It's no wonder why health care workers are leaving in droves for the U.S. and Europe.

Many doctors in the government clinics here are from outside the country (Cuba, India, Pakistan, etc.) or are South Africans fulfilling their required post-graduate community service requirement. Pharmacists are required to work two years in a government facility after graduation. None of them are too happy about it but it's the only way the government has been able to stem the outflow of workers from its clinics.

6. At today's church service the sermon was given by a Presbyterian minister from Pretoria. He based it around a Ugandan saying: “People of God gather the pumpkins.” He said this relates to using one's life to serve God, that when you think you're done you still have to gather pumpkins. He also, though, made a tie to pumpkins as being good for eyesight and removing the blindness to God's love. Me, being the agnostic scientist, thought he must be talking about beta carotene (vitamin A) in orange vegetables. Sure enough, when I talked to him after the service he said his mother always told him to eat his pumpkin, that it would turn his brown eyes white and let him see better. I thought it was a different metaphor for nutrition as religious enlightenment, different than the ones you usually hear (“bread of life,” etc.).

7. Nomasomi update: I bought the “bungalow” on Friday. (It's amazing how they try to make depressing situations here a little more palatable by calling a tin shack a bungalow. I think "bungalow" and I think beach-front cabin in Florida. I need to work on my American biases.) We're supposed to be dissembling, moving, and re-assembling next weekend. So far, the work crew is one person (me) but I have no doubt that things will come together at the last minute as they always seem to. More on that as it happens. I met Nomasomi's daughter last week, and she is a very personable girl, eager to live with her mother. Hopefully, very soon.

8. Lastly, I went to the Green Point market today. It's a fairly large crafts market about a 15-minute walk from my apartment. Most of the items are commercially made, even if you're supposed to think they're not, but they do have some nice hand-crafted items of good quality. Prices are pretty reasonable and haggling is allowed (and encouraged, at least by shoppers). I bought a messenger bag for R70 ($10) that I'm sure would have been at least $20 in America. So, I feel pretty good today.

More to come.

Working in the Pharmacy

Inzame Zubantu, otherwise known as Brown's Farm clinic, is one of two clinics in the Phillipi area south of Guguletu. Together, these clinics serve 80,000 people in an area roughly 2-3 square miles. The clinic started about 15 years ago by Rev. Spiwo using 12 donated shipping containers. The clinic operated in this way until last September, when a brand-new building was opened on the same site. (The clinic had to operate in a converted community hall for one month as the containers were removed and the new building was completed.) The two pictures above show the clinic's main entrance and its main hallway. The pharmacy would be immediately on your right, with the waiting area just down the hall. There are five consulting rooms, a "lab" room, a treatment room (for bandaging and other wound care), a staff kitchen and two offices further down the hallway.

The clinic sees an average of 200 patients per day, all in about 5-6 hours. People start arriving at about 6:00. By 7:00 the outside waiting area is full. Although clinic staff are trying to tell people to come throughout the day, everyone has been arriving at dawn for years and are unwilling to change (they're partly afraid they won't be seen, as is the case in many rural areas where health care is poorly available). Clinic opens at 8:00 and by 2:00 most days everyone has been seen and sent home with prescriptions.

Inzame Zubantu translates loosely as the People's Initiative. I've had a couple people tell me it's difficult to translate, in that Inzame doesn't have a direct meaning in English. It's meant to portray a positive try or attempt, almost like a challenge but not quite as daunting. I get the sense that Initiative is close but needs to be more action-oriented.

The pharmacy is small, about 16'x16' with an additional 10'x12' room for storage. It's normally staffed by Tami (pronounced Tommy), the pharmacist (sitting on the chair) and Ntombikayise, the helper (what we'd call a technician). (I learned yesterday that Ntombikayise's name means "daughter of Kayise" or "Daddy's girl." Her words, not mine.)

The pharmacy stocks about 300 different drugs. This includes about 200 oral tablets/capsules (probably 175 unique drugs, some with multiple strengths), 30 oral liquids, and 30 topicals, with the rest being injections or other dosage forms. The drugs that are stocked are on the South Africa Drug Formulary, which appears to be derived from the World Health Organization's Essential Drugs List. All treatments are dictated by a government-approved set of guidelines and link to the Formulary. More on that in a second.

Most of the oral medications come pre-packaged in 28-day supplies from the government supply house. Since every patient is scheduled to return every 4 weeks it's very convenient. Those that don't come pre-packaged either have to be counted when dispensing (slow) or prepared in the pharmacy. Part of what I do when I get in each morning is help pre-pack items so that we don't run out during a busy time. We also pre-pack products that came in as donations, things like multivitamins. Donations allow the clinic to spend more money on prescription items and not over-the-counter products. I prepared about 50 bags of chewable vitamins on Monday, tablets that came from some Americans visiting the Zwane centre a while ago. It's a little strange to be using Target vitamins in Phillipi, but whatever works...

As I mentioned, all treatments are dictated by a standard set of guidelines. This means nearly all patients with the same disease or condition get the same medications. (My apologies to the non-clinicians for the next few paragraphs.) For high blood pressure, people start out with hydrochlorothiazide 12.5mg daily. Step 2 adds enalapril, usually starting at 5mg twice daily. Most patients end up on 10mg twice daily (the ratio is about 10:1 , 10mg vs. 5mg). Step 3 would add amlodipine 5mg daily. Step 4 adds atenolol 50mg daily. And that's about it. No one gets anything else (we don't stock any other drugs in these classes, except carvedilol) and doses cannot be increased above the standards without getting a cardiologist consult, which rarely happens. I've only seen one patient on max'd doses of these items, and one on spironolactone.

For diabetes, all of which is Type-2, it starts with metformin 500mg twice daily, working up to 850mg twice daily. Only a couple people have been on 850 mg tid. Step 2 adds either glibenclamide 5mg twice daily or gliclazide 80mg twice daily. About 10% of patients get gliclazide 160mg bid. If those two drugs don't work, then it's on to insulin. That happens in about 10% of cases, with nearly everyone getting 70/30 and two injections a day.

Asthma is a big problem here because of poor ventilation in the shacks and the use of paraffin (kerosene) heaters and wood fires to cook and keep warm. Everyone starts with a salbutamol (albeterol) inhaler as needed. Step 2 adds a budesonide inhaler, 2 puffs twice daily. Step 3, which usually occurs concurrently with the steroid, adds theophylline. We're supposed to dispense a sustained-release product, but we don't have that. So, everyone gets plain theophylline 200mg twice daily. On a rare occasion we may give out an ipratropium inhaler but we haven't had any in stock for a month. (Note: It could be because for the first couple days I was there we ran out of salbutamol inhalers and substituted ipratropium. I had a hard time doing that but it's what we had. When we ran out of those we gave people salbutamol tablets twice daily. No one's come back complaining of problems yet.)

Antibiotics are also limited. We have doxycycline, penicillin VK, amoxycillin, erythromycin, and flucloxacillin. We have ciprofloxain, but it's limited to 500mg stat doses for STDs and PID. We have metronidazole, both 2gm stat doses and 400mg tid. If it's not a stat dose it's either 5 or 7 days, usually 5. There's no cephalosporins, no alternative macrolides, no quinolones (except stat cipro). For antifungals we have amphoteracin B lozanges and nystatin suspension for thrush. Wehave fluconazole but it's locked up and rarely used because of the cost (it is not available under government contract so it's very expensive). We have only clotrimazole one-dose tablets for yeast infections.

For topicals we have hydrocortisone, betamethasone, clotrimazole, and a couple other antibiotics. We have some compounded items, including coal tar ointment and methyl salicylate ointment (which they call Rub Rub - go figure). Eye drops include a couple for allergies and some artificial tears.

The rest of the products we stock are a mix of some antihistamines (mostly promethazine), psychiatric meds (I haven't yet seen anyone being treated for depression), antiepileptics (phenytoin, valproic acid, and carbamazepine), hormones (I've only seen one person get birth control), vitamins, antiworm drugs, and various one-off meds. The only sleep aid we dispense is amitriptyline 25mg.

Everyone who comes to the pharmacy gets paracetamol (acetaminophen), and about half will also get ibuprofen. Most people also get a multivitamin, and about one-third get supplemental thiamine and/or vitamin C.

I haven't spent much time looking at prices, but those I have seen are on par with Medicaid's generic prices. Inventory levels are kept at a bare minimum, and it's not uncommon to run out of something (or many things) before the next order arrives. Since none of the prescriptions or patients are computerized, there's no good way to track usage and predict order patterns. The clinic is supposed to be computerized later this year which will be a big help but also a major time drag. The only reason we can dispense 400-600 prescription in 5 hours with 2-3 workers is because we don't have to enter anything into a computer (all labels are hand written with check boxes for dosages) or submit insurance claims. We'll see what happens.

Medication compliance is very bad. No one's measuring it but based on my discussions it's less than 50%. Some people sell their medications, but most just don't use them because they either don't want to or don't understand the need to. I'm not sure how to change this (yet).

As always, if you have specific questions about some aspect of the clinical care, drop me a line or leave a comment to this posting.

More to come.