Elbow Taps

            This post comes to you from the town of Mtubatuba, in the Hlabisa district (pronounced clu-bisa, in one of those mystifying linguistic puzzles that happen when people try to spell a language that uses clicks) of Kwazulu-Natal.  This is “Zululand” according to my guidebook, and it is a strange mix of “traditional” zulu culture/black rural poverty and white safari and beach tourism.  I ended up here two weeks ago for work, and then stayed on for the wildlife for the weekend.

 I tagged along with some members of the USAID health team, who came out to do some site visits.  PEPFAR funds a research organization out here called the Africa Centre to support the HIV treatment programs in the rural government clinics in this district.  The last time they came out for site visits for another reason, they noticed that the clinics were lacking some very basic amenities that could be solved with relatively minor renovations.  Since Africa Centre was projected to finish the year with extra money (“pipeline” in USAID jargon), USAID came back to inspect each clinic and ask the nurses what some of their key resource issues are and see whether there wasn’t something our money could do to help. 

The background of this is that these are provincial Department of Health (DOH) primary health care clinics, in which PEPFAR (remember, it’s the President’s Emergency Plan for AIDS Relief) funds the HIV treatment programs.  Though HIV testing and treatment should be an integrated part of primary health care in an area with 23%-28% prevalence, the fact that the former South African administration tended to deny HIV as the cause of AIDS meant that the DOH was not funding AIDS treatment.  PEPFAR stepped in and created an Antiretroviral Treatment (ART) system to fill the gap, which was real and extremely devastating to the community.  The problem is that now you are left with two parallel health care systems, one for the whole community, and one just for people living with HIV/AIDS. 

I spent the week immersed in the intricacies of trying to erase the distinction between the two systems, the logistical challenges of truly remote rural healthcare, and the realities of the power that individual personalities have to derail an entire health system.  We went to 17 clinics in four days, that ranged from brand new sparkling clean facilities to a ramshackle house that a farmer donated as a clinic 20 years ago. Some clinics had the newest digital blood pressure machines, some hadn’t had water for two months and in one the nurses had to pool their own money to buy enough electricity for the vaccine fridge.  The most striking part of things was that everyone seemed so resigned to their circumstances.  We came in asking “What is getting in the way of doing your job? Tell us things we might be able to get you that would make your work easier.” But usually it was a painstaking task to tease out the often enormous problems that the clinic was facing.  We found that if we didn’t ask specifically about water supply, the nurses might not even mention that they didn’t have access to running water, they were so used to the problem.

It was also a lesson in the power of personalities within a system.  On the one hand, we’d see and incredible nursing “Sister in Charge,” full of energy and organizing her clinic to maximize efficiency in the space of extreme space shortages and lack of resources.  Her clinic was treating more than 800 HIV positive people with ARVs.  She was doing her very best with what she had to work with, and we could provide some support to make that job easier, but without real government motivation in the department of health, it seemed impossible to truly resolve the problems. 

On the other hand, you had a beautiful, new clinic with so much space that one room was reserved as a boardroom for meetings once a month.  The sister in charge would not allow the ARV program to use that room for counseling and testing for HIV, even though there were currently three counselors and two nurses squeezed into two rooms.  The ARV nurse was so constrained in her ability to do her job by the capricious power plays of the Sister in Charge, that she began crying while describing the problems to us. The space and the facilities are there, but the clinic is only treating 65 patients with ARVs.  Partly this is attributable to the smaller population of the clinic area, in a rural region with faction fighting problems.  But a lot of the issue is attitude based.  In that clinic, all the government provided facilities and resources were not doing the patients any good, simply because of a personality issue. 

All in all, our visit was a crash course in rural HIV care and primary health care challenges for a comparatively wealthy developing country.  The part that worried me most was this: these are clinics which are being supported by a world class research institution with PEPFAR funding to make renovations and leverage resources from the Department of Health.  If they are in such varying degrees of disarray, what is happening in all the other clinics that have no outside assistance, and rely only on the whims of the local DOH?