MB the M.D.

Last Days in South Africa

Ironically, I’m writing this post retrospectively. My last day at the clinic (just one week ago!) was incredibly bittersweet, as I bid farewell to the staff and place that I had come to know as my family and home. South Africans truly know how to properly say goodbye, and much to my shock, a surprise party had been arranged on my behalf, complete with speeches, shared memories and moments and lovely gifts and presents. I’ll forever look back on my final day in the clinic with gratitude and fondness for those that I had worked closely with for an unforgettable 9 months. 

Now that I am back at Union College for the month of May to attend classes, lead presentations and talk to others about my time and experiences, I find this quote especially relevant and applicable to my past and present self:

"There is nothing like returning to a place that remains unchanged to find how you yourself have altered."

Southern African HIV Clinicians Society Conference!

Last week I had the good fortunate of presenting at the Southern African HIV Clinicians Society Conference that was held at the Sandton Convention Center here in Jo’burg. Our abstract titled, ‘Breastfeeding practices in the Option B+ Era,’ drew upon a pool of over 3,000 FRESH Start mothers (both HIV positive and HIV negative) and compared the rates of breastfeeding intentions (before delivery) with that of reported post partum breastfeeding between the two groups of women. Since the inception of A FRESH Start in October 2014, our statistical analysis demonstrated that our program has successfully increased the rate of breastfeeding over implementation time of our holistic, comprehensive program that promotes exclusive breastfeeding.

I attended a variety of talks throughout the day that ranged in topics from adherence, to novel advances in basic sciences regarding HIV research, to statistical modeling and pharmokinetic interactions with ARV medications and other prescribed drugs (be it TB-related meds or chronic management meds). 

In honor of International Maternal Health and Rights Day, PEPFAR featured an awesome article from an MD about Prevention of Mother to Child Transmission initiatives! According to the World Health Organization, all pregnant and breastfeeding HIV positive women should be managed on antiretroviral treatment (ART) for life--a policy known as Option B+. The PMTCT program that I am working with specifically, A FRESH Start, has successfully integrated Option B+ into our provided services, thereby reducing risk of HIV transmission from mother to baby. Consequently, our program optimizes health outcomes for our mother-infant pairs, ultimately ensuring the health and well being of both. 

Follow A FRESH Start on Twitter (@GiftofHopeUS) to see more from the Witkoppen Clinic!

As part of our FRESH Start holistic approach to postpartum Prevention of Mother to Child Transmission (PMTCT) health care, mother-baby dyads (pictured above) receive individualized dietary and nutritional advice, along with routine clinician visits and repeat HIV testing. The South African Department of Health advises all HIV positive women to breastfed exclusively for 6 months, and then introduce solid foods at this time. However, if food or porridge (traditionally known in South Africa as ‘pap’) is given to the baby (before this time period) along with breastmilk, the infant’s intestinal lining may be susceptible to HIV infection. Following 6 months time, the intestinal tract and mucous lining is developed and therefore an HIV positive mother can continue breastfeeding while simultaneously adding solids. This type of information is absolutely critical for ensuring that HIV positive mothers do NOT mix feed (breastfeeding and giving other food before 6 mo. time) and therefore do not risk transmission of HIV to their exposed infants. 

Out and about in downtown Joburg’s hip & artsy Maboneng precinct. Think Brooklyn, but with an African vibe/twist. 

http://www.mabonengprecinct.com/about/

Yesterday the Post Natal Clinic received an extremely generous donation of 70 beautiful baby gift boxes for our FRESH Start mothers and newborns, to welcome new moms into motherhood! On behalf of the Brescia House School, an all girls school down the road from the clinic, 4 newborns now have adorable baby clothes, teddy bears, and an assortment of baby soaps and lotions...items that these mothers might not have afforded otherwise. 

I wrote a thank you, and sent along a picture of the mothers and their days’ old babas and nanas (little boy and little girl, respectively). The school then posted my thank you and picture on their blog! 

Check out the smiling new mommas below:

Clinic Happenings:

During a breastfeeding support group (a platform for education, help and support from the clinic and other moms!) patients learn about proper latching and good breastfeeding techniques; 

a happy, healthy 6 month old and her proud momma;

a female condom demonstration in one of the patient waiting areas;

fatherly involvement at the first Post Natal visit;

During a conversation today about the importance of vaccinations and adhering to scheduled visits, one of my coworkers told us of her own personal tactic:

"When I speak with the moms, I like to use comparisons. I tell them, 'White people bring their dogs and cats for every immunization visit and they never once miss these important vaccines. If a white person does this for their pet, then you black South Africans can and should be doing this for your baby!"’

When the mothers express their concerns about losing work/ missing a day of work when their children have scheduled immunizations, my coworker tells our patients: "Well you tell your white boss that your baby has an immunization date at 6 months, 8 months, and 9 months and they'll be so impressed with you for knowing that they can't fire you after that!"

After seeing my partially amused but mostly horrified expression at the racial parallel, she grinned at me and said, “When I tell these stories the patients and I always laugh, but they know what I'm saying is both right and true….and all that really matters is the children receive their immunizations.”

Christmas at Witkoppen!

December marked the start of the festive season at Witkoppen, with the clinic's annual staff party scheduled for the second weekend of the month. The social committee at Witkoppen (yes, there is a dedicated social committee that schedules dedicated meetings devoted to all social matters) decided the theme would be 'All White with a Bit of Gold,' and hilariously enough went so far as to email every staff member a PowerPoint on 'how to dress your best' for the occasion.

The staff party was held at a venue off-site and immediately upon arrival, the dancing began. And it did not stop, until the last person left the make-shift dance floor 6 hours later. The rhythm and style of dance was unbelievable, with flawless, smooth movements from one song to the next. I had several people approach me throughout the day and ask how their South African party compared to the ones from back home, and I answered gushing about the dancing and the sheer amount of fun that I was having at the time. Earlier in the year, an acquaintance had said "If dancing were a sport, South Africa would win every single time," and I couldn’t agree more with such a statement!

The next day was the Witkoppen Kids Christmas Party, which was arranged by Social Services and part of the Research Department. Over 500 children showed up at the clinic that morning, with taxi after taxi unloading mass amounts of children eager to celebrate Christmas. For some perspective of how different life is for a child in the township, one of our Post Natal mothers was celebrating her baby girl's 1st birthday. The mom later broke down in the dietician's office saying not only did her daughter not have a single birthday present or a special gift, but that she couldn't even afford sugar to make cookies, or worse yet, give a spoonful of sugar to celebrate her birthday….much different than my extravagant childhood birthday parties. If that's how a birthday was, you can imagine then, what Christmas must feel like to these children. Of course, that's not to say this is the scenario for every family, but it is the sad and heartbreaking reality for some.

At the clinic, we had arranged for breakfast, snacks, lunch and various stalls of food scattered throughout the clinic for both the kids and their caregivers. A massive bounce house, a live DJ, and various activities were held all throughout the day as well. In the midst of all this chaos, one of my coworkers and myself operated a face painting booth all day long. The kids absolutely loved it, and so did we! The best part of the day was when Father Christmas made an unannounced appearance and every single kid at the clinic was given a properly wrapped Christmas present, filled with unexpected surprises and treats. Our mantra for planning the organization of the party had been to let the kids be kids, and to have the entire event focused on their fun and enjoyment. From the smiles and laughter to the full bellies and painted faces, they truly enjoyed themselves and had a well-deserved Christmas party.

"Can I ask a personal question…how many of you are unemployed right now?"

About half the room raises their hands.

"For those of you who are employed, are you working your dream job? Are you happy where you currently are?"

The response is a resounding no amongst the mothers.

"And why is that? Why are you unhappy where you are?"

"Because we are not educated," mutters one mom. "There was never opportunity for us," says another.

"Then lets teach our children to be better than us. As mothers, lets give them a better opportunity than us. How do we do this, how do we give them this opportunity? You may not have been educated in your childhood home, but think: What can YOU do, what can YOU do as parents, as mothers, in your home to educate your child?”

And so began the powerful introduction of an educational tool known as BrainBoosters. With contact previously established by former Minerva Fellow Rahul Pattagunta (thanks Rahul!),  I arranged a demonstration with a representative from the non-profit company to engage with our mothers about the importance of education. Our patients in the Post Natal Clinic, along with the staff and myself, were immediately interested in the potential and possibility offered by this tool. BrainBoosters is based on the premise that neural connections develop in infants long before they are able to talk and communicate, therefore encouraging parents to speak with and educate their children from birth. This tool is especially relevant for our patient population, as the quality of the primary education system in South Africa is subpar, resulting in below-average student performance (UNICEF). Thus, BrainBoosters originated with the hopes and vision to improve a reportedly incompetent system.

The program that I represent at Witkoppen, known as A FRESH Start, or A Future Realized through Education, Support and Healthcare, is a holistic, comprehensive program for mothers and children from birth through 18 months of life. The education component is covered in the clinic by our fantastic health educator, who speaks with the women in individual and group sessions on various topics that range from exclusive breastfeeding to the importance of HIV testing and knowing your status, to paternal involvement and parenting skills.

As an additional way in promoting education by encouraging communication between mother and child, BrainBoosters demonstrated this idea to our mothers through 'educational packs.' Each 'theme' in the program is structured based on one concept and subsequently builds upon the other. During our demonstrations that day, we stimulated mother-baby interaction by having a mother present a colored card to her baby and read off the appropriate color. For more of a challenge catering to older children, they were able to match the colored cards and their names to respective colors on a chart (shown in the pictures above!). Following this first block or theme of colors, the packs gradually advance to include numbers, shapes, and animals. After engaging with as many moms and babies as possible, the feedback we received was highly positive.

Besides the obvious educational connection, how does BrainBoosters relate to the overall FRESH Start program? As an 18 month comprehensive program, our mothers are scheduled for 7 visits to the clinic in total. However, there are many reasons or obstacles that present when attending these visits. For our patients, sometimes R10 (less than 1 US dollar), for transport is too expensive, rendering them unable to attend their visit for that day. For others, it may be work obligations (many are domestic workers, hence the collective response when the representative asked if they were working their dream jobs) or additional family responsibilities that may cause a barrier to accessing care. Lastly, the clinic sees many foreign patients from Zimbabwe, Malawi, Lesotho, and Mozambique, and as a result, we deal with a fairly mobile population, one that is difficult to reach in either person or via the phone, as physical addresses and cell numbers change frequently. With all of these obstacles in mind, A FRESH Start offers practical incentives for milestone visits (the 6 month visit being especially important), to retain as many mothers in care as possible. Because the educational packs are relatively inexpensive, A FRESH Start can utilize the various themes as incentives for subsequent visits, further promoting education and mother-baby communication--the core of our holistic approach. Needless to say, our patients and staff are excited about our partnership with BrainBoosters and we are grateful to be involved in the critical area of childhood cognitive development. Not only is A FRESH Start helping to raise a generation of children born free of HIV, but we are also providing them with an educational opportunity that they may not have had otherwise.

Education = powerful, and as the BrainBoosters representative told the mothers, "Learn to communicate with your child. Communication is power."

December 1st marks World AIDS Day.

From the World Health Organization:

1) Fast-track now to end AIDS within a generation 

2) Targets have been set to speed up the HIV response