Some medicine

As much fun as it has been learning about a new culture the main reason I came here was for the medicine. So far it has been mostly ups and a few downs- but the obvious place to start is with the HIV programme where I spend most of my time. The background as many people know is that there is an epidemic of HIV/AIDS in Southern Africa. The good news is that there is effective treatment for HIV and there is money available from various sources to pay for it. The challenge therefore is effectively distributing the drugs. The first challenge is for people to test for HIV and part of the programme is a ‘Voluntary Counselling and Testing ’ approach which uses various methods including attending public gatherings to encourage testing.

Once tested people can join the programme but of course this is also voluntary and not everyone joins. Once selected as needing the drugs the main problem is how to get people to take the medicines properly. Basically, people need to take tablets twice a day 12 hours apart every day and more than likely for the rest of their lives. If they take the tablets chaotically the HIV will become resistant to the drugs and will become difficult or impossible to treat and people will go back to square one. Patients with resistant HIV may also pass this to other people who themselves will be difficult to treat from the outset which would be a disaster. If you read the Daily Mail this would be like developing the ‘HIV super-bug’.

It is difficult for most people to finish a course of antibiotics let alone comply with these measures and in particular many of the patients are illiterate and have never used a clock or a calendar before. To address this problem the programme has formed a series of support groups; they are run by local people and involve a gathering, usually once a week, when they talk about and are educated about these issues and also get something to eat and drink. Anyone without a clock is given one, everyone has a treatment partner to help them and they are strongly encouraged to disclose their status to their family because keeping the drugs hidden from people in their tiny houses would only lead to chaotic drug taking.

The programme is exactly 2 year old, so far about 700 people have been put on medication and there are a further 700 who are on the programme but so far don’t need the drugs. There is no waiting list to start drugs and currently we are starting about 10 per week. This is scratching the surface of the problem but it is a good start. As you can gather it is a major undertaking and in some ways is more like a business than a hospital but there are no half measures. People are either taught how to take the drugs correctly and are supported so that they can continue to do so or we are wasting our time. So far the results have been really good, only a handful of people have been lost to follow-up and less than ten have developed resistant virus. The challenge ahead then is to sustain the early success and to allow the programme to grow without compromising on quality.

More Xhosa culture

As much as I want to tell everyone about the medicine here I’m still learning so much about the Xhosa culture that I’d like to share some more.

It is currently the male circumcision season; at this time of year you see groups of young men parading down the streets carrying weapons such as knives and spears. It is all part of the preparation for their coming of age celebrations which involve a big party and a circumcision. After the party the new men burn all their clothes and wrapped in blankets with faces painted they leave to spend 3 weeks living in the bush with an elder. During that time they are taught all the skill needed to be a man in Xhosa culture, this includes hunting and even how to kill another man. At the end of the three weeks they can return to their village and dress in normal clothes and continue their life as a man.

The whole thing is interesting in itself but also has some medical implications. Firstly the tradition says that the same blade should be used on all the boys on a given day. In theory the rules have been tightened up in the HIV era but in practice this still goes on. As well as the risk of HIV transmission there is also a risk of wound infection. Apparently there is a whole ward full of men with circumcision infections at the referral hospital. Apparently they regularly come to our hospital but I’m yet to see one.

The other tradition I’ve learned about is Xhosa marriage; our social worker has just got married, she has had a legal marriage, a Xhosa marriage and is waiting to have a ‘White wedding’. Before the first marriage her fiancé had to negotiate with her family about how much ‘labola’ he was prepared to pay for her. The currency is ‘cows’ but for her one cow was equal to R1,500 (about £100), he eventually agreed to pay 17 cows! The traditional wedding involved her doing a lot of cleaning, making lots of tea for people and cooking a lot of food. She now has to wear a head scarf for a month as a sign of her marriage and most married women wear them lifelong.

If she has a baby it become a bit weird, she will have to bring the child directly to her mother-in-laws house and has to live behind the front door for a month just eating sleeping and feeding the child, her husband is allowed to visit but not to stay.