A Serendipitous Journey: On Doctoring in the Developing World

Dawn D. Johnson, MD Assistant Professor, Pediatrics

September 3, 2014

Outline 1. Facts about South Africa 2. Brief history of HIV in South Africa 3. Harriet Shezi Clinic, Baragwanath

Hospital, Soweto 4. HIV, AIDs, TB, MAC, PCJ, LIP:oh my!! 5. Culture 6. Privilege and service 7. What is Global Health?

• Mainly colonized by the Dutch (1652) and the English (1815)

• Enforced apartheid 1960: strict discriminatory laws

• 1st heart transplant done in RSA in 1967

• 1st democratic elections 1994 (Nelsen Mandela elected)

• Key industries currently: mining, tourism, wine

• 11 national languages, most people are multi-lingual

• 52 million people, 25% have high school education

• 1982: 2 white homosexual men diagnosed with HIV

• 1987: 1st black SA dx HIV • 1990s-conspiracy theories,

witchcraft, • HIV prevalence in 1990

was 0.7% • ARVs ‘rolled out’ officially

in RSA in 2005 – HIV prevalence nearly 20%*

• Today RSA has the highest number of people living with HIV in the world: 6.2 million (1:3 women)

History of HIV in South Africa

In 2001 President George W. Bush’s PEPFAR program began funding clincs that provided treatment for HIV/AIDs in South Africa and other resource limited settings.

70% of the global health burden of HIV is

in SS Africa

History of HIV in RSA

• Nelsen Mandela said that one of the things he regrets most is not doing more about HIV/AIDs in RSA.

• His son died of AIDS in 2005 and he spoke publicly about it

Nkosi Johnson

• Born with HIV, orphaned • ARVs were banned in the

public health system by Mbeki and the MoH

• Refused admission to primary school

• Keynote speaker at the XIII International AIDS Conference, 2000 (Durban)

• Pres. Mbeki walked out during his speech

• Founded Nkosi’s Haven

Nkosi Johnson

4 February 1989 – 1 June 2001

Posthumously received the International Children’s Peace Prize in 2005

Global TB Burden

Burden of TB in South Africa

Rate of TB cases: Globally: 139/100K High burden countries: 177/100K Africa: 363/100K South Africa: 940/100K

TB rages onward (although here, not so much…)

• The most common OI • Leading cause of death in people with HIV • Will kill ~3million people this year • Infects someone every 1 second • Infects 1/3 of the human population • Kills someone every 10 seconds (360 people this hour) • Is preventable and treatable

Constitution of the WHO: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.”

Unjani Dokotela?

Working in RSA • 2.5 years – Worked in an HIV specialist clinic at

Baragwanath Hospital, Soweto (PEPFAR) • Helped to set up an Adolescent Clinic day at Shezi • Volunteered: several orphanages, a hospice,

participated in a few child abuse cases pro-Deo, homeless clinic and outreach projects, soccer boots, cash for gogos (grannies)

• Pediatric Technical Team at WRHI and adjunct faculty at Witwatersrand University – oversight of HIV/AIDs and TB programs in multiple provinces, teaching, research, DOH, participated in writing updates to the HIV guidelines 2013 (PEPFAR), ran a complex care clinic at Natalspruit Hospital

Herpes Zoster/shingles WHO Stage II

Scrofula

HSV keratitis leading to blindness

TB LAD Parotid enlargement

BCG adenitis

Neonatal syphilis

Flat Warts

Measles

Epidemic of Orphans in RSA

*15.1 million orphans live in sS Africa *RSA – 3.7 million orphans, estimated 5.5 million by 2015

Happiness!!

Things I Learned Along the Way • Respect cultural differences (greet, respect,

sangoma, indirect communication)• Listen first, have an opinion later • Take a history from people who are culturally very

different from myself. (mom?) • Practice medicine all by myself – no/few

subspecialists. • Do a really good physical examination, draw blood • Improvise • Smell TB, eyelashes in TB, X-ray tricks • Cope with so many of my patients dying/suffering

What is Global Health?

Health is Global

What is global health?

• “There is a global crisis of severe shortages and marked maldistribution of health professionals ….think globally about the education and role of health professionals.”

Nigel et. Al, NEJM 2014;370:950-7.

Workforce and Burden of Disease According to WHO Region.

Crisp N, Chen L. N Engl J Med 2014;370:950-957.

Ethical Considerations • Should students be allowed to do in other

countries what they are not allowed to do in the USA?

• Should research be conducted on patients who will likely not receive the benefit of that research?

• Should America recruit physicians from nations with significant health care worker shortages?

• Is health equity a basic human right? • What difference does it make?

That’s Ayoba!

Ngiyabonga! (Thank you)