NGO's

I am sorry to post what amounts to a 'rant' but it's been that kind of week. NGO's (Non Governmental Organisations) often get a bad press for reasons ranging from disorganisation to culturally inappropriate interventions that have little long-term impact. However, as a rule I would be quick to congratulate most NGO's for the undoubted good work that they do, in fact I am currently employed by an NGO although I work in a public sector role.

This weeks however I have seen first hand the negative impact that well meaning interventions can have. An NGO has moved into our area in an attempt to improve one of the patient services (I would rather not identify them on the internet so have omitted the exact details). That is a great idea and we are keen to form a partnership with them to improve these vital services. We even presented their job opportunities to our own staff and encouraged them to interview. The NGO is paying triple the wages that we can pay and are working in the same field so there should be no problem. However, the NGO has not been organised enough to actually find any work for the new staff to do. The result is that they are sitting around being bored while earning triple their old salary. Of course they are still friends with our current staff who, not surpisingly, now all want to go and work for an NGO. So at a stroke they have spent a great deal of money, they have reduced the quality of care for the patients by recruiting our staff who now do no work and they have managed to demotivate all of our remaining staff- thanks alot. Even worse if they don't get their act together and produce results soon their own funding will be withdrawn and all their staff will be out of work- great.

My own view is that the world has enough NGO's now. I think that anyone wishing to found a new NGO should think very carefully about their own motives as I'm convinced that a talented motivated individual could have a much bigger impact on the world by re-organising an existing organisations than going to the trouble of setting up a brand new one.

Milestone

At the risk of patting ourselves on the back we are pleased to announce that we put our 1000th patient on ARV's last month. There was some debate, or perhaps arguement, about which exact patient was the thousandth, at least three people were told that it was them. Perhaps it is like being the one billionth person in India or China, it's best just to pick someone at about the right time and go with it. As my personal contribution was small compared to the collective effort I think I can say that it was pretty fantastic to get there. There has never been a waiting list to start so it represents everyone in the area who is tested for HIV, who needs the drugs and most importantly has committed to take them lifelong.

One thing that struck me the other day was the strengh of the link you have with the patient. If as a doctor you spend your life handing out pills for high blood pressure you have to treat quite a few people for quite a long time to prevent one of them having a heart attack. That means that you never actually know which of the patients is still alive as a result. With HIV medication it is different, when I talk to a guy who had 'full blown AIDS' 2 years ago but now leads a normal life I can be as certain as a doctor ever can be that he is alive because of the drugs. Many branches of medicine can say the same of course, any surgeon who removes a malignant cancer at an early stage for example, but it is not something I have experienced that often and it's a good feeling.

About being rich...

Since I started earning a doctor's salary I've never been short of money, but neither have I ever felt truely rich. By that I mean that I have always found it hard to undestand how someone could spent £1,000 on a pair of sunglasses or £2,000 for a night in a hotel. It just seemed like a waste of money; could the expensive sunglasses really be that much better than a pair for £20 from the chemist for example?

South Africa has one of the largest income inequalities in the world. The average income of the richest 20% of South African households is 45 times more than the average income of the poorest 20% of households for example. Thus I find myself being in the former group while living in an area made up mostly of the later group. So while I earn something like 8 times the minimum wage, with the employment rate being under 10% in this area most families survive on far less than that.

I bought 12 bottles of wine today and it cost more than the monthly income for many families and I drove home in a car which for many is as far out of reach as a helicopter is to most people in the UK. I don't see why I should feel more guilty about that than if I had done the same thing in the UK but I do. And it has definatley opened my eyes to why people pay so much for their sunglasses.

Microfinance in the Transkei

The HIV unit could not run without it's 20 or so counsellors. They are all volunteers who do a great job supporting the programme. Their primary role is in educating patients about HIV/AIDS and about the drugs that can be used to tackle the infection.They run support groups and do individual counselling to prepare patients to start their lifelong therapy. They do many other vital things from translating for the doctors to filing and even cleaning the buildings. Although technically volunteers they should not be confused with people who have perhaps retired and have some free time on their hands. As there are very few employment opportunities around here most see it as a full-time job; it is skilled work and they work very hard. The problem is that the government does not recognise their vital role and therefore won't fund their positions, they are therefore paid a stipend through the charitable funding of the programme. It amounts to around 800-1000 Rand per month. To put it in context a loaf of bread costs 5 Rand and a hospital cleaner takes home around 3500 Rand per month. Quite understandably, when a cleaning position becomes available many of the counsellors apply for the post. I think I would consider becoming a hospital cleaning for a 4-fold pay increase!

This is where microfinance comes in. Most of the counsellors want to carry on with their job but really need to supplement their income and they often have an idea for a small business venture. My only knowledge of business it to try to make more money than you spend but I'm trying to help with simple advice and a little start-up capital in the form of an interest free unsecured loan. So far we have six ideas that are at various stages of development. Christina has a camera which she uses to take photos of local people, she makes a 4 hours round trip to Mthatha to print the pictures and then sells them on at a profit. Another idea is to use a sewing machine that was donated to the hospital to make linen and other items, a third is to simply buy basic items like paraffin and sell them on in a small shop in a village. It is early days but so far all the loan repayments have been made on time and although I am expecting to lose some of the money the hope is that as loans are repaid more loans can be given. I'm grateful to members of my family and some friends who have kindly offered to take on the financing of some of the projects.

Doing other peoples' homework

To paraphrase Renton in the opening monologue of Trainspotting "... the thing people forget (about taking heroin) is the pleasure of it, otherwise we wouldn't do it. After all we're not stupid, at least we're not that stupid".

Of course, I wouldn't equate the down-side of working here to the downside of taking heroin but I didn't realise quite how much fun some of it would be. I'm not talking about the windswept beaches and the rolling green hills this time but the work itself.

One factor is that if something needs doing then you have to do it yourself because usually there is no-one else who is going to help. This mean that if you honestly believe it is in the best interests of the patient for you to perform a procedure compared to it not being done at all then you should do it. This means attempting things that a physician like myself would usually have to pass on to a specialist. It's a bit like doing other peoples' homework, it is so much more fun than doing you own. I had forgotten how satisfying it can be to drain a really painful swollen abscess or relocate a dislocated joint. You have to be careful not to get too gung-ho but if you stick to the rules it can be really good fun.

Another factor is the huge variety of things to see. One day I'm going to make a list of all the things I see on a random weekend on-call. Chances are it will include being involved in delivering a baby or two, seeing a road accident victim, admitting a sick child, suturing a few stab wounds, draining an abscess and setting a fracture.

Perhaps I will write about the frustrations of working here another time because there are many. But for now I would just like to focus on one or two of the pleasures.

Cross cultural medicine

You can't expect to move from a first world to a third world setting without crossing a cultural divide. Here are a couple of recent cases where I have had to be at my most understanging. (In the interest of confidentiality some details are changed)

I'm looking after a young man who is single handedly raising an 8 year old boy. He has HIV which is at an advanced stage. He helps out at the clinics and has had some formal training in HIV so he knows, or should know, that without the appropriate drugs he does not have long to live and that if he waits until he becomes sick it might be too late; even so he refuses to take the drugs. His reasoning is otherwise sound, at the moment he feels fine and looks quite well. He tried the drugs about a year ago when he was sick and also had TB. He had some side-effects and I think the time he decided to stop the drugs co-incided with him getting on top of his TB so all in all he felt a lot better off the medication than on it. While I can see his reasoning I also know that he will be dead soon leaving an orphan if he does not at least give it another go. I have sat with him and discussed all the options including stopping the drugs a second time if we can't get him through the side-effects but he is adamant that his strong faith will see him through. When it comes down to it I am not in the business of trying to force people to do anything they don't want to but I really can't help feeling dreadful for the son.

Slightly less sombre is a new phenomenon we have encountered. We test for HIV using a simple and cheap finger prick test that gives results in minutes, although very good these tests are not perfect. Although we feel that the benefits of this strategy outweigh the costs it is inevitable that occasionally people test as positive for HIV when they are actually negative. The problem is picked up a little further down stream when they have more conventional blood testing and it sometimes falls to me to tell people that after all they are in fact negative. You might expect that this is like telling someone who thought they had cancer that there was a mix up with the test results and they are all clear but the reaction of the patients so far has been far from what you might think. By this time the patients have joined an HIV support group with many members who talk openly about their status and help each other through. Although it can be difficult to get people to join the groups, once they are settled in they often really enjoy it. So these people who are in fact HIV negative don't want anyone else to know and are generally keen to keep attending support group without revealing their status. Maybe one day we will have a support group for people who thought they were positive but are in fact negative but don't want anyone to know!

Orphans and vulnerable children

I just wanted to say a little more about the work that is going on here. The hospital has recently started an Orphans and Vulnerable Children project. The name is fairly self-explanatory but in general it seeks to help children who have lost their parents (often this means losing their mother as many fathers are absent) or who are at risk of losing their parents (often because the mother has HIV). It is also for those children who have become heads of household and those who are not accessing eduction.

The project is backed by The Donald Woods Foundation. Some of you may remember Donald Woods as the white anti-apartheid activist portrayed in the film Cry Freedom. It is not a doctor focused project and in many ways not a medically focused project so I have only been involved in some of the planning stages. It runs on a kind of 'Soup Kitchen' model which means that rather than targeting individuals and visiting their homes there is one day set aside each week at a local clinic and the word is spread that any children who might fit the criteria should come along. They are assisted with transport as much as possible and are given food during the day. School children come along when school has finished.

The day is staffed by the programme co-ordinator along with two nurses, a physiotherapist and an occupational therapist each with an assistant, a social worker and various community health workers. The feedback I have had so far has been really great; the physiotherapy and occupational therapy team have done a great job with them. Thankfully not many of the children have been sick and none so far have tested positive for HIV. Many of the problems have been social, particularly that the carers of these children are not receiving the appropriate funding from the government. This is often because of a lack of documents or other red-tape. It has not been easy to solve these social problems but it is a learning curve for everyone and hopefully things will soon become a little easier.