Meaning...

The Power of Meaning.

I had the opportunity to meet with three Songomas, or traditional healers, last week. All were within a “city block” of Marion hill Clinic where I’m working this week. That’s more market share than Starbucks! Vusi, the clinics HIV workshop and support group coordinator, brought me to the healers’ homes. However, he was not able to come in with me as he is in a

wheelchair. You can imagine the extent of “handicap accessible” homes in this area. He was left paralyzed from the waist down from Pott’s disease (or Tuberculosis of the spine). The TB infiltrated his spinal cord, stopping the electrical instructions to his legs. This is a very difficult disease to treat, it requires 4 drugs, taken continously for 18 months, with little room for lapses in medication...Pushing the wheelchair was an awesome workout, given the wicked hills and gravel roads… of course, it was well worth it.

Prior to these visits my only connection with Songomas was through their patients. Who all too often suffer from kidney and liver failure secondary to traditional medicines. One of the most important questions to ask patients here is, “When was the last time you took “traditional or Zulu medicine?” Having seen some of the negative aspects of traditional medicine, I was somewhat skeptical of their work. However, my preconceived expectations about South Africa are often wrong, and it’s in the best interest of our patients to partner with traditional healers, rather than burning bridges with a major source of “healing” in the area.

The first Songoma I met came from Malawi, and moved to South Africa more than 20 years ago. His house and clinic are directly across the street from Marion Hill clinic. When I first entered the house the smell of the traditional medicine and smoke were readily apparent, although a completely new olfactory experience. The room was filled with old water and vodka bottles containing orange, red, and yellow substances of an unknown origin… Roots, clay, herbs, and what appeared to be rodent bones were all combined in something that looked like a frying pan. I later found out he uses this for fortune telling.

At first the Songoma didn’t appear interested in talking. Almost every question I asked was replied with an audible sigh, hands on his face and 1 or 2 word answers. I didn’t take it personally, and assumed it was either because he was tired or because I wasn’t paying for any healing, I just came to listen and discuss what he does. Perhaps he felt I was questioning his ability to heal his patients…After all, I came in with my stethoscope around my neck, looking very western “doctor like.” Which, to him may silently screams disbelief or at least inferiority of any benefit from his medicines and practices.

At this point I could tell he wanted me to go soon. But, then he offered what I think is the primary reason Songomas continue to be utilized in great numbers. Put simply, MEANING. They deploy medical information in a relevant way that has meaning to their patients. They relate the meaning of an illness in way that is harmonious with traditional beliefs, something western medicine can’t do. Western medical practice in South Africa, especially within language barriers, relies heavily on the pattern of very specific complaints and objective exam and lab findings. It is difficult to fully understand how the patient’s beliefs, background, culture and ethnicity affect their interpretation of their illness. Songoma’s give patients information via a story. For example, This songoma offers all of his patients a “fortune telling” (i.e. diagnosis based how bones land in the pan). He tells his patients why they got sick, what they can expect and how he is going to treat them. These stories or fortunes have meaning to the patient, while a clinical diagnosis may not. The patient’s understanding of their disease in terms of lab tests and exam findings fails to convey a “meaning” of that illness. Meaning is

important to all of us… we want to know why we are sick, how to get better and how to prevent it from happening again. More importantly, meaning can help patients heal. He can explain and treat illness in a way that “means” something to his patients. Helping patients understand why their disease is happening and how he is going to treat it is a very powerful way helping patients start the healing process. He also has authority entrusted by his ancestors, a blessing I lack.

The second Songoma I visited with was a wonderful, 97 year old (although she looked 75 at most) Gogo. This was an absolute wonderful visit. I started on the right foot by greeting and thanking her in Zulu, at which she gave me a curious grin. After which she said Ngyathanda, meaning, I love you… which I replied back with Nami Ngyakuthanda…which, I think means “I love you too.” First she showed me her treatment for Shingles, a painful blistering rash affecting one dermatome (the sensory distribution of one nerve) from a latent chicken pox infection most people my age had when they were children. The traditional cure involved three rubs of different root mixtures. The “active ingredient” was in the “Holy Root” which you also drank in addition to rubbing it on the affected area. One is supposed to leave the rub on for three days and then wash it off. She understood that we also have a treatment for Shingles and said she always told patients to go to the doctor if it doesn’t get better.

I asked her how she helps patients with HIV and AIDS. I had heard some traditional healers were claiming they could cure HIV, which concerned as it can undermine patient adherence to lifesaving medication. She encourages them to eat healthy, drink water, be faithful, wear condoms, and to always…. ALWAYS take their pills. Also, to see their doctor, if they are getting sick or weak. This was a great for me to hear! When patients get consistent messages from two sources it increase the likelihood those patients will go on to do well. The number one reason individuals “fail” treatment for HIV is not taking their medications. When medications are taken every day, without lapses, almost all patients can expect their viral load (a measure of infection, transmissibility, and treatment efficacy) to be undetectable within 6 months and can expect to live in good health. Patients stop taking their medication because of drug side effects, misunderstanding of the chronic character of the disease, or lack of transport to clinic or money. To start on Anti-retroviral medications one must complete 3 modules that explain the disease, its treatment, and common questions. As a side-note, in South Africa all HIV medications are free off cost as of last year.

I also asked her what advice she had for me. She said listen and understand your patients, and to “be tough” on them if they are not following your treatment plan… she laughs and states that if patients don’t do what she says the first time she tells them to “go away!” I told her I give my patients a few more chances, which she returned a nice grin and laugh ;).

The third, Songoma actually hosted a school for training Songomas. Songomas will train from 7 to 12 months depending on their ancestors. As some ancestors “prepare” Songomas for understanding traditional medicine faster. She charges a small fee for the training. This Songoma also tells her HIV patients similar advice and encourages her patients to see both traditional healers and doctors.

The clinic is located in Marion Hill Township and is run by the IMA (Islamic Medical Association), an NGO that runs several clinics in the townships and one-mobile clinic. The clinic’s spectrum of care is limited and similar to a “minute clinic.” Complicated and very sick patients are sent to the hospital, via public transport. Antibiotics, vitamins and cough suppressant are handed out like candy… which in a setting without a labs, X-rays, a high prevalence of HIV and TB and limited transport may be more appropriate than I first thought. The clinic is run by 1 to 2 that sees around 100 patients between 8 and 4! This is with a tea break 10 am and an hour lunch and prayer break at noon. Patients are run through very quickly, i.e. sometimes less than 2 minutes for a patient which is understandable given it is important to see all the patients and she wants to get home before 10pm.

Visiting the Songomas has given me a new perspective on understanding the patient and the importance of meaning.

Hospice

This is my Zulu Family, From Top left Carrie (Yale), Mantombi (mama), Tayna (Yale) Me

Bottom left oluhle (4) Anele (17), She'(19) Akona (12), Ansiwa (13), Amy (Harvard)... cool folks.... now onto the blog

“Don’t feel sorry for me, I don’t want anyone to feel sorry for me. I’m here and I’m alive. Cancer didn’t beat me, I beat this cancer, if people feel for sorry for me they are concentrating on my cancer, and not on our friendship, love, or the conversation.” These are amazing words of wisdom spoken by a women with bladder cancer. This week I’m working at Chatsworth Hospice in greater Durban. For the last two days I’ve been going on home visits with two of the sisters at the hospice.

I am continually amazed at the “life lessons” and new perspective these patients have taught me. One is the healing power of Denial. It’s strange to think of Denial as helpful, but it allows us to take in information slowly, at a pace we can control. For this patient it is “denying the disease’s ability to control my life” and focuses one’s attention on things they can control. Control is a big word when your faced with a diagnosis and prognosis that is completely out of your control. One patient stated, “I don’t concentrate on the cancer, I concentrate on me. If I concentrate on the cancer I can’t stay positive and I miss out on what’s important, my friends and family because I am focused inward. What I need right now is my friends and family, my tea, and my garden. It’s a different attitude on life than I had before. When I get a pain here (pointing at back pain secondary to metastasis to her lumbar vertebrae), I say to it, damn pain! Get out…. It helps, its mind over matter.”

According to the sisters, many of the patients go through a transition of inward perspective to an outward perspective. At first many are overwhelmed by their prognosis and the concurrent change in life plans, goals, and hopes. Patients become detached from the world and sometimes isolate themselves from their support. The family also doesn’t know how to react, and will pull away from their loved one. Does any of us really know HOW to react to a poor prognosis? Of course, we just do whatever comes out of us, and that is exactly what we need to do at that time, and exactly what is right for us to do. Our job as compassionate witnesses for our dying friends or family is to be there for them with our ears and some actions and recognize what is healthy grief and what is not healthy grief.

Here are some normal and abnormal reactions:

Adaptive: Humor, Denial, Abstract anger, Anger against the disease, Crying, Fear, Realistic Hope, Sexual Drive, Bargaining

Non-Adaptive: Guilt, Pathological denial, Prolonged Rage, Anger against helpers, The “Impossible Quest,” Unrealistic Hope, Seduction, Manipulation

Adaptive behavior moves the inward perspective to and outward perspective. Outward perspective examples include finding meaning through reflection activities, pursuing relationships with family and friends, and on growing personal interests. I just wish that these patients and myself could incorporate this into our lives without having to experience a terrible diagnosis

As a doctor in training, I am use to focusing on the disease. Is it not a physician’s traditional purpose? That is, figure out what the etiology of the illness is and treat it. There is however a growing appreciation for holistic medicine, medicine that focuses on the whole persons health, including not only their physical health but also emotional, spiritual and social health. This may be why I am so attracted to hospice and palliative medicine. The focus is not on the disease, it’s on the person and helping them on the journey we all must go on… dying. But, its not about dying, its about living, putting life in perspective, controlling pain, maintaining dignity in our most vulnerable state, and supporting the family.

Coping

Coping…

Those who know me, know that this is an interest of mine. Yes I admit it is a strange interest, but death, dying, grief and bereavement are as important aspects of the human experience as birth, love, pleasure, aspirations and companionship. Our grief is a physical and emotional representation of the depth of human interaction and experience that is difficult to describe in words. Any loss, whether a death or not, represents a departure from one path to another. Whether the loss is expected or not it forces us down a road of reflection of meaning. In way grieving is just a way of us finding what the loss means and what our life will be like without.

Loss and Death happen a lot in Mseleni. It is hard to appreciate the enormity of all the death without being here. Babies die of severe malnutrition or an acute meningitis, pneumonia, or severe gastro. Children and young adults are plagued with HIV and all it’s associated illness, Many pregnant women have little prenatal care given lack of transport and far proximity from regular care. The physicians who have been here longer seem to handle it an almost disassociated way. Admitingly it’s easier to do, because we could never truly understand Zulu culture or their bereavement fully. To protect our own psychi’s some find it easiest to check out. This short denial is not necessarily a bad thing, we just all cope with it in our time and way, some run, some write, some cook… we are all coping . I have difficulty putting “the facts of life (and death)” here in perspective. Usually people die when they’re old… not when they are young. The discrepancy fails to “make sense” in my mind and thus, the “normal” way I cope with death gets screwed up.

When I child dies in Mseleni, the child’s caretaker (often the gogo (Grandma) will wail over the child’s body, sometimes for hours. This is not in there own personal hospital room, its in a ward with 20 other kids and mothers surrounding them, The cries hit one’s heart directly to the core and serve as a reminder of how often death occurs. For me this is actually somewhat helpful, as a time and place to grieve the loss. Yes, I don’t know this child and most of the time, my interaction with him or her is limited by language and cultural barriers… but obviously he or she is still an important part the world, and all have unsurpassable worth. Ignoring the multiple losses indefinitely would not be sustainable.

The Language barrier I spoke of in the “Lost in Translation” blog further complicates the ability to understand what all of these loss fully mean and how this culture is coping. When young adults are dying, family is often not there, likely because of lack of transport or inability to miss work and sacrifice what little income they have. Also there is no palliative or hospice of any kind here. Family care is palliative care, but this often does not involve pain medications or comfortable environment… it means going home to the care of their family. Which is good, but this may also mean that they die in pain, short of breath, physically uncomfortable and in poor hygiene.

I know that their faith is very important. The community support is large as well. Singing, praying and talking are all regular parts of the day… not reserved for a special place or time. It is not unusual to walk by a group of 5 people singing on the hospital grounds at 10 am… and I think this is a key component of how this place copes… the community is the support system. The feeling I get here is “We are in this world together and together we will be okay.”

Ubuntu

“Ubuntu” is a traditional African philosophy that we are all interconnected and that as “brothers” and “sisters” we are not individuals but just part of the “whole.” Put simply, “no man is an island.” The world set in this framework has resounded in my time here in the way people interact with each other. Overwhelming the people I’ve met here have been genuinely interested in who I am and what makes me tick… Its not that I am more interesting than anyone, it is the belief that we are connected, and that connection inherently means that you should understand one another. More importantly it is our very human nature to be connected. In my US-centric life thus far, individualism and self-achievement is held in very high regard. This drives us to push ourselves to “succeed” and do great things, but at the same time it ignores why we got here. I could not have “succeeded” at anything had it not been for the people in my life. My parents gave me the vision of a bigger world and my whole family has helped me understand true compassion, love and caring. My best friend, Tim, is the reason I pushed myself so hard to learn and perfect drumming… making music alone is not nearly as satisfying as what two or more can make together. My mentor Jim Rothenberger gave me the opportunity to pursue medicine and more importantly grow in my understanding of the world in so many ways … as he put in Drugs, Sex and Death… those of you who know him will understand what I mean. I never disregarded my success has been dependant on others, but many back home would say that “my” achievements have been impressive. First, I haven’t done much yet besides school and second, “my” achievements, passions and interests have been totally shaped by those around me. Ubuntu! I am truly not an island.

This realization also is a reoccurring theme in medicine and public health. In fact, I can’t think of a more important practice in public health and medicine than understanding each other. If you don’t understand your patients, and if you patients don’t understand you, seeing the doctor is a waste of time. Luckily, most of the time, we could do anything (or nothing) and our patients will get better. The idea of “success” in public health and medicine is not black and white. It is often a summation of numerous interventions, individuals and a little time and luck. We must be aware of our interconnectedness. We have so much to learn from Africa. Ubuntu reminds of this.

Lost in Translation

Lost in Translation:

Many interactions involved in medicine require well thought out, straight forward and at times compassionate communication. One of the hardest parts of working at Mseleni is the communication barrier. The primary language is Zulu, some speak some broken English, but not at a level capable of communicating a complete medical history without the help of an interpreter. My Zulu is limited to short greeting phrases and limited medical questions, “What brings you here today? Where does it hurt and for how long?” Obviously, just because I know the questions does not mean I can understand their answers. But at least the fact that I am trying helps in making the patient feel more comfortable, and at least some get a good laugh at my attempts. Its not easy, the three different “clicks” and “hl” sound… which to me sounds like a start of a luge (if you don’t know what that is, just google it, or ask my sister, Beth, she was the luge queen;)… Adding to the barriers is the nurses who translate have limited knowledge of pathophysiology (the physiological processes of how things go wrong in our body) and are often unable to translate the message across or gather the important intricacies of an individuals’ symptoms to us in a clear way. Time course is also confused. Many state that the problem started years ago, at which point I always ask, “what is it that brought you in for this problem today…” answers are somewhat comical at times… for example a patient who presented with knee pain, stated that it started 10 days ago, but he came in today because it itched a little 3 years ago, and 5 years ago he vomited once… and that’s where the answer begins??? Leaving me a little reluctant to ask the next question. However, I have learned if you ask “what happened today to your knee, you get a better answer… which makes me wonder what the nurses are asking…

I am not saying that the nurses are bad, actually quite the contrary. The large majority do a great job and are an irreplaceable part of the medical team.

My inability to communicate is most apparent when it is most important. Those times, when a death has occurred or when patients are going through a very difficult situation or don’t clearly understand their treatment. For instance, a vibrant, 22-year women had a miscarriage today. I felt completely unable to make her feel heard, and to make sure all her questions were answered. I was also unable to ease this undoubtedly painful, scary, and confusing time for her.

Another woman with underlying mental illness was abused by her family because she had HIV. (This is NOT the norm; please do not generalize this family’s dysfunction toward South Africa). She was obviously in a terrible situation, and I was lost at how to make her feel heard as well. She looked physically and mentally broken. And now she had to re-tell this awful situation through an interpreter. I wanted to let her know that she was safe here and that she could tell me whatever she felt comfortable with at this, but this doesn’t translate well. I have used translators in the U.S., but for reasons that aren’t fully clear to me, it is slightly easier.

In addition, I will never fully appreciate what South Africa’s apartheid era was like. Where white people represent oppression, abuse and discrimination. Does this play into our interaction? Yes, but I don’t know how.

Long story short, I have never been so aware of how important communication is in the patient-doctor relationship. Things that come easy in my own culture… the right body language, intonation, empathy… I am not very good at here. But I am working on it.

Acclimatization

Acclimatization of Mseleni Culture:

The pace of the world seems to move slower in Mseleni. This may not seem like a profound statement, as many know, in the most general of terms, about the slower pace of life in Africa. I think its partly because the focus is on the present or on the persons in your presence. This is in stark contrast to the pace of my life in Minnesota where my focus is on the future, racing towards the next goal, the next deadline, leaving little room for family and friends. Sadly, at times I focus on the past, the things I wished I’d accomplished, the paths I’ve chosen, or mistakes I’ve made. However in South Africa, and particularly in Durban, many are fully existing in the present. Conversations take hours and usually start late. As far as I can calculate, one needs to add 1-2 hours to a start time and 2-3 hours to the set “ending” time, (that is if there is one).

So many people I’ve met here have made the effort to become friends without the requirement of having met before. By living in the moment, conversations are seldom superficial. One feels heard and gives time to listen. I may be biased, given I am also trying to meet friends, perhaps back home I am complacent with the friends I have. But my new friends here have happily included me in the circle. The two commercial phrases of the 2010 FIFA world cup are “Can you feel it, it is here” and “Make the circle bigger.” Which I think both sum up life here… Live in the present, feel the present, make now important… and the latter, make friends… because we are all here in this circle of earth together.

This same aspect of “African” culture has led me to be frustrated at times. In the clinical setting patients in critical condition receive the same amount of attention and perceived effort as those who are not any acute danger. Nurses (“sisters”) move at their own pace and march to their own drum. Arranging medications, IV fluids, and bloods when they have time. Seeming not to predict the next logical step… why? Possibly because living in the present is so engrained into life that rushing, moving fast, looking to the future is very difficult. It is short sighted of me to expect a certain type of behavior, from a culture that is not my own and is as far from Minnesota as possible. And given the limited resources and the very isolated and rural setting within this hospital’s catchment area, the hospital does amazing things, and is truly a God send to those who live here. The challenges and frustration are more my own acclimatization to life here. Of course, there are things that can and should be improved. However, patients have access to a wide spectrum of care that is provided for free, which is so important given many live on less than $2 dollars a day. I have a lot to learn from this seemingly inefficient way of life, even though at times it is very frustrating.

Mseleni Life

Mseleni Life:

Working at Mseleni has opened my eyes to the stark contrast that exists between practicing medicine in the “west and practicing medicine in a developing country. Resources are severely limited at Mseleni. It is not uncommon to run out of very important chronic medications for TB, HIV

and hypertenssion and needles, syringes, towels and gloves are in short supply. The computers that we have for patient regi

stration and more importantly patient tracking, work sporadically, that is if we are lucky enough to have power. We have one ultrasound machine from the early 80, but it works. Labs that take less than an hour back in the states can take days, and the results are somewhat unreliable. Death occurs daily. Those who are dying are not the old gogo’s but young adults and babies. The young adults die from HIV, TB, Meningitis, gunshots, stabbing, and complications with pregnancy. The babies die of malnutrition, perinatal infections and AIDS related illnesses. Death seems strangely more accepted here. Or perhaps the compounded grief of multiple losses has blunted the impact of any particular loss. More likely I am just not able to understand the gravity of their losses because of language and culturally barriers.

When a child dies the caregiver is more often than not the gogo (grandma) will wail for 2 hours. The wailing is as part of the expected grieving process as attending the funeral. When a young adult dies it is often alone. This is most likely because of transportation barriers, as our hospital serves almost 30,000 people in 50 square kilometers and only some have access to the funds for traveling. Transportation for critical cases is also very difficult.

We had a small 3-year-old child present to the emergency room after being hit by a Kumbi (public transport minivan). The child was obtunded, had fractures of her right tibia and left femur and humerus as well as la

rge skull laceration. She appeared to be in stable condition and continued to respond to us. But she urgently needed a CT scan to assess for intracranial hemorrhages and cervical-spine injuries. We stabilized her neck with two, 1-liter Saline bags and Tape…We had to actually convince the ambulance driver to pick her up within the next 3 hours for the 2 hour drive down to Negwazami Hospital for a CT and further assessment. It came in 4 hours… This is likely due to the lack of ambulances, the large area covered, and the state of the roads, many of which need a 4-wheel drive vehicle to transverse.

Despite all of these limitations, Mseleni supplies great care. Considering that in 25 years the hospital has changed from a one room emergency room and small-8 bed ward to a large Emergency room capable of seeing 300 patients a day, 2 fully functioning operating rooms, a 200 bed hospital, 16 bed maternity ward, a HIV/TB clinic and a primary clinic that both see more than 150 patients a day, and 8 tertiary clinics in the surrounding area, with 12 doctors… it is nothing short of a miracle what has happened here.

The beginning of this change started with Victor and RachelFredlund. They arrived here 29 years ago. Victor was the son of 2 missionaries and grew up in Nigeria and Benign. We he and his wife arrived he had just graduated from medical school in England. There was an existing Lutheran Missionary hospital and children’s home here. Both have expanded as I described above. The Children Homes cares for an average of 150 to 200 kids from birth to 18 years old. Many of the children parents have died, some are in jail or have really unstable homes.

The people of this village are extremely friendly. One of my friends Linda (a male zulu name) told me he thought it was funny (which he likely meant as rude) that Americans don’t say hi to strangers… I jog just about everyday here, and it is not uncommon that every person I run by smiles and states Sowabonna, Kunjanee? (hello, how are you?)… I find this quite awesome, and happily reply “Yebo, nGiyaphila!” (yes, I’m good!). As when I came to South Africa before, new friends will ask you over for tea, a brai (BBQ) or to talk, with hardly knowing you. Its just a very friendly, inviting place. Which, is amazing when you think of the hardships and difficulty of daily life here. Puts perspective when I stress about school work… I actually have the opportunity, money, and support to go school!