Over the last couple of months I have been struggling mightily with my dissertation project. As I switched from the field to the archive, from the oral to the written, I switched from collecting information that I think is important to sifting through information that other people thought was important (to investigate, write down, and preserve). This has its benefits; things that I never would have thought to ask about suddenly appear – sites of cattle dipping tanks, government subsidized maize schemes, the first beetroot plant. And I can experiment methodologically with tangential data collection without tiring out interviewees.
The archives have also helped to remind me that this small, remote, rural area is a part of a much larger network and country. Indeed, the archive at the University of Witwatersrand contains information from the National Health Services Commission, which used Pholela as a model for the rest of the country. And the archive of the Rockefeller Foundation in Tarrytown, New York houses an Annual Report from Pholela and letters from its founders, showcasing Pholela’s global reach. This larger footprint is indeed exciting; however, it also leads to problems – defining the context of this project.
No single dissertation can do everything. Or at least that’s what our advisors tell us when we begin this process. Sitting in my office on the fifth floor of Science Hall in Madison I was convinced they were wrong; my dissertation could and would do everything. I would trace the global impact of Pholela while understanding the intricacies of the labor migration patterns as related to industrial capitalism while also understanding how topography, crops, and nutrition all interact in the bodies of HIV+ young women.
Sound ridiculous? It was.
Therefore, after ten and a half months of research, I have been convinced, once again, that my advisors are correct. No single dissertation can do everything. And it is this realization that brings us to the subject of this post: how does one define context and gain focus (in the middle of the project)?
I spent the first six months of my research wandering through the rural areas of Pholela, volunteering, conducting a household survey, and interviewing various people from sangomas (traditional healers) to old housewives. While attempting to keep some focus on health and nature broadly, I spent these first months doing what one of my advisors referred to as “getting lost.” I collected lots of information, much of which I still do not know what to do with. But while I collected this information I asked questions. There were, of course, unexpected answers, but my question guided the conversation.
I then spent much of the month of September working in the archives during the day and compiling my field notes at night in an effort to figure out what exactly my dissertation is about. My notes covered topics as disparate as stories of monster snakes, 1940s plowing techniques, and how much money a household earns from government grants. Once I compiled all of this information I spent hours trying to figure out how it all fit together and then how it related to the things I was finding in the archives. And guess what I discovered: it doesn’t all fit, at least not into a single, cohesive, and well-argued dissertation.
This epiphany was not an end in itself, rather it was and is the beginning…of a lot of work. I have spent the past two months working to retool my focus; to find a core that is manageable. This has resulted in two new central questions: why has small-scale agriculture in the Pholela region of South African changed from 1936 to the present? And how have changes in human health and ideas about health evolved with changes in agriculture? These questions are specific and focused, yet broad enough to show something interesting.
But what does this mean for actually conducting research?
First it means that I must define the context, or the extent, of my project. And I can do this by asking more specific questions. For instance, does WHO policy on global health affect the Pholela Community Health Centre? Perhaps. But is it directly relevant to changing agricultural patterns in the area? Probably not. Does the mineral content of the soil affect agricultural practices in this area? Probably. But is it relevant to understanding how ideas of health, even nutrition-related ideas of health, are related to agriculture? Probably not. Do labor migration patterns from the late nineteenth century affect agricultural patterns in the mid-twentieth century? Certainly. Would in depth, primary research of the late nineteenth century seriously enhance a story that starts in the middle of the twentieth century? Probably not. Or do scientific ideas and experiments about nutrition have a bearing on the health of people in the Pholela area? Undoubtedly. But to what extent should one do primary research on scientific debates in distant cities like Johannesburg and Pretoria? Probably not to a large extent.
Defining context is about setting limits, necessary limits, on what you will research. These limits can be geographical – I am focusing on three small rural communities that are within 40km of each other. They can be temporal – though I recognize that history does not begin in 1936, my story starts then because it was the moment the government took an interest in the environmental health of the area. There can be methodological and research time limits – I would love to know about soil, but I neither have the knowledge to take soil samples nor do I have the time to take and analyze them properly. Defining context is also about knowing your focus and setting limits on how much primary research you conduct on areas peripheral to your core interests. For example, while historical scientific debates on nutrition are fascinating, the results of those debates – the lessons that health assistants brought in to the homes of Pholela’s residents – are far more important for my project than the various papers published on nutrition.
Defining one’s context is especially important in working in the archives. But as I return to the communities to continue my oral history collection and ethnographic observation I find myself faced with the flip side of the context question: what is the core focus of this research? As one moves and interacts in these communities it is clear that there is a larger geographic, temporal, and ideological context to agriculture and human health. However, following this larger context would likely take away from more specific understandings, from the focus of the research. I need to know my focus in order to direct conversations and observation. For example, following from the key questions, detailing and understanding agricultural change is at the core of my project; helping in fields and with livestock must be primary objectives. However, agriculture is only a part of the livelihood system in this area. As a result, going with people to collect their monthly pensions and to shop for food (to supplement agricultural yields) will also be important. But there are limits. Remittance income from family members working in urban areas supplements household livelihoods. However, I do not have unlimited time and so I likely will not go to cities to interview those family members about their income and what it is spent on. If agriculture is my focus, time would be better spent on interviewing people from the Department of Agriculture, rather than following remittance flows, even though both likely affect agricultural decisions.
What I have discovered over the last couple of months working through field notes and finding archival documents is that focus and context are intimately related. Without knowing your focus, you cannot set the limits of your context. And without knowing the contextual limits of things like geography, time, and subject one cannot understand what is most important to focus on.
As I switch gears from extensive to intensive collecting mode I know that I will continue to find new and interesting ideas, which will challenge my focus and my context. I will adapt to some of these, as they help to strengthen my project, and others I will note in a place designated for future projects. I have come to realize that without these limits this project would fail to say anything meaningful, and this would do great injustice to the very people who are giving so much to help me understand their agriculture and their health.
Tuesday, December 23, 2008
Wednesday, September 3, 2008
A Tragic Lesson
In planning this long overdue blog post, I had been thinking a lot about the process of conducting a large academic project like a dissertation – about setting the parameters of research and forming an academically suitable argument. This was going to be a very academic post. Therefore, as I was driving to the University of Witwatersrand’s Historical Papers Archive on Monday morning I was thinking about what the limits and extent of “context” are; I was constructing the post in my mind.
And then the phone rang.
Against my better judgment (I was driving through Johannesburg in rush hour), I answered the phone. It was one of my dear friends from Bulwer, Esther. As I answered, she said, “Hello dear. Have you heard any news from Bulwer?”
Since I had just spoken with her on Saturday, I replied, “No, nothing new.”
And she said, “Oh, OK. It’s Les.” Les is Dr. Les Pitt, the HIV doctor for the district who has spent a lifetime working with rural Zulu-speaking people.
Esther went on, “There’s been a terrible accident…”
The rest of the ride was a blur. I listened to Esther talk about how deep a loss the passing of Dr. Pitt would be for the communities in the Pholela area and for her personally. But all I could think was, “Not Les. Surely not Les.”
Then, like any good researcher I spent the day at the archives. But, like any normal person, I spent very little time actually working.
The last three days have been a mess of emotion. This tragedy has robbed Pholela of a devoted doctor and a trusted civil servant. In this week alone tens of HIV+ people will go to three different clinics in the district to begin medication or to see the doctor and get his opinion about something related to their health. But there will be no doctor. For them, and for literally thousands of other people in the area, the loss of Dr. Pitt spells immeasurable tragedy.
For me, the loss of Dr. Pitt means the loss of a dear friend and trusted mentor. Much of what I learned in my first six months in South Africa I learned through Dr. Pitt. Obviously he taught me about rural medicine; things like what a tubercular pulmonary effusion looks like on a chest x-ray or why certain people get lactic acidosis, how to recognize it, and why it’s important. Dr. Pitt also taught me more subtle things like how to understand a person’s health as a part of his or her larger life and circumstances and how to treat some of the poorest and sickest people in the world with dignity and respect. We literally spent hours talking about my research and about his experiences and observations over 40 years of practicing medicine in rural South Africa. In many ways, as should be the ideal in academic work, my deepest insights came through conversation with Dr. Pitt.
As a result, on top of mourning this tragic loss for the community, and the loss of a dear, dear friend, I must reconcile a deep loss for my dissertation. And this is where it all gets tricky. I had been (foolishly) thinking that I could keep “my life” here in South Africa different from “my work.” For example, I have a system for taking field notes that is designed to keep parallel notes – one set that is more “objective” and therefore research oriented, and the other, which is more about my experience and impressions. I had thought that by keeping separate notes, I could keep my personal experience out of my research. In fact, even in thinking about how I wanted to portray myself and my research process through this blog, I had decided that I would keep it about my professional experience and not about my personal life.
And then tragedy strikes and I am reminded, rather forcefully, that the separation between the personal and the professional is artificial. Dr. Pitt was an important person to me personally, to my experience and comfort level in rural KZN, and to the ways I think about health and nature. He introduced me to many, many people in the community and he challenged me both subtly and overtly to ensure that my work would matter to the communities in which I conduct my research and not just to the academic world. He was an integral part of both “my life” and “my work.”
Dr. Pitt is an important reminder that life is messy, that the compartments we set out to keep things organized and separate rarely make sense. And indeed, why should they? In order to be good at what we do, we, as academics, must pick topics that we are passionate about, that touch us deeply, that make us more humane; even if that means that some days we can’t keep our focus. If there is anything positive that can come out of a senseless tragedy like this one, it is the reminder that if one truly, deeply cares about their professional pursuits then that line between the personal and the professional must disappear. That if we are to be truly humane scholars and compassionate individuals we must allow ourselves to be, to live, without these boundaries. In many ways it is only fitting that this lesson comes once again from Dr. Pitt.
For both my life and my work he will be sorely missed.
And then the phone rang.
Against my better judgment (I was driving through Johannesburg in rush hour), I answered the phone. It was one of my dear friends from Bulwer, Esther. As I answered, she said, “Hello dear. Have you heard any news from Bulwer?”
Since I had just spoken with her on Saturday, I replied, “No, nothing new.”
And she said, “Oh, OK. It’s Les.” Les is Dr. Les Pitt, the HIV doctor for the district who has spent a lifetime working with rural Zulu-speaking people.
Esther went on, “There’s been a terrible accident…”
The rest of the ride was a blur. I listened to Esther talk about how deep a loss the passing of Dr. Pitt would be for the communities in the Pholela area and for her personally. But all I could think was, “Not Les. Surely not Les.”
Then, like any good researcher I spent the day at the archives. But, like any normal person, I spent very little time actually working.
The last three days have been a mess of emotion. This tragedy has robbed Pholela of a devoted doctor and a trusted civil servant. In this week alone tens of HIV+ people will go to three different clinics in the district to begin medication or to see the doctor and get his opinion about something related to their health. But there will be no doctor. For them, and for literally thousands of other people in the area, the loss of Dr. Pitt spells immeasurable tragedy.
For me, the loss of Dr. Pitt means the loss of a dear friend and trusted mentor. Much of what I learned in my first six months in South Africa I learned through Dr. Pitt. Obviously he taught me about rural medicine; things like what a tubercular pulmonary effusion looks like on a chest x-ray or why certain people get lactic acidosis, how to recognize it, and why it’s important. Dr. Pitt also taught me more subtle things like how to understand a person’s health as a part of his or her larger life and circumstances and how to treat some of the poorest and sickest people in the world with dignity and respect. We literally spent hours talking about my research and about his experiences and observations over 40 years of practicing medicine in rural South Africa. In many ways, as should be the ideal in academic work, my deepest insights came through conversation with Dr. Pitt.
As a result, on top of mourning this tragic loss for the community, and the loss of a dear, dear friend, I must reconcile a deep loss for my dissertation. And this is where it all gets tricky. I had been (foolishly) thinking that I could keep “my life” here in South Africa different from “my work.” For example, I have a system for taking field notes that is designed to keep parallel notes – one set that is more “objective” and therefore research oriented, and the other, which is more about my experience and impressions. I had thought that by keeping separate notes, I could keep my personal experience out of my research. In fact, even in thinking about how I wanted to portray myself and my research process through this blog, I had decided that I would keep it about my professional experience and not about my personal life.
And then tragedy strikes and I am reminded, rather forcefully, that the separation between the personal and the professional is artificial. Dr. Pitt was an important person to me personally, to my experience and comfort level in rural KZN, and to the ways I think about health and nature. He introduced me to many, many people in the community and he challenged me both subtly and overtly to ensure that my work would matter to the communities in which I conduct my research and not just to the academic world. He was an integral part of both “my life” and “my work.”
Dr. Pitt is an important reminder that life is messy, that the compartments we set out to keep things organized and separate rarely make sense. And indeed, why should they? In order to be good at what we do, we, as academics, must pick topics that we are passionate about, that touch us deeply, that make us more humane; even if that means that some days we can’t keep our focus. If there is anything positive that can come out of a senseless tragedy like this one, it is the reminder that if one truly, deeply cares about their professional pursuits then that line between the personal and the professional must disappear. That if we are to be truly humane scholars and compassionate individuals we must allow ourselves to be, to live, without these boundaries. In many ways it is only fitting that this lesson comes once again from Dr. Pitt.
For both my life and my work he will be sorely missed.
Sunday, June 8, 2008
Conducting a Household Survey
For the past six weeks I've been working with a team of people from a local NGO called the Turn Table Trust to survey 100 households in three communities around Pholela. Two of those communities were a part of the original focus area for the clinic and the third lies some 45km from the health center.
Visiting 100 different households to gather demographic, health, and agricultural information has been an amazing and eye opening experience. Here are a few photos from the process...
Khulekhani and Jack from Turn Table Trust interview a Gogo at her home.
A typical homestead situated on a steep hillside with a vegetable garden and goat kraal.
One Gogo's door sized garden of green leafy vegetables, growing even in the dry and cold southern Drakensberg winter. She was taught how to make a door sized garden by the local Community Health Worker.
Conducting the survey with a group of Gogos from one of the communities.
An 'Mkhulu (Grandpa) takes his turn answering questions at his home.
Visiting 100 different households to gather demographic, health, and agricultural information has been an amazing and eye opening experience. Here are a few photos from the process...
Khulekhani and Jack from Turn Table Trust interview a Gogo at her home.
A typical homestead situated on a steep hillside with a vegetable garden and goat kraal.
One Gogo's door sized garden of green leafy vegetables, growing even in the dry and cold southern Drakensberg winter. She was taught how to make a door sized garden by the local Community Health Worker.
Conducting the survey with a group of Gogos from one of the communities.
An 'Mkhulu (Grandpa) takes his turn answering questions at his home.
Sunday, May 25, 2008
In Search of the "Local"
As most of you are no doubt aware, South Africa is making headlines across the globe these days. This week the world has seen South Africa as a place where xenophobic mobs chase down poor immigrants from other African countries, looting and burning down their houses and shacks, beating and sometimes killing the inhabitants, and leaving thousands displaced (again). On first glance this most recent spate of violence has basically nothing to do with me and my research. I am working in a rural place, two hours from the closest major city, and my research is very local, focused on a state run health center and two South African communities.
In thinking about my next post 10 days ago I was looking forward to writing for the first time about my very own research. At the end of April I finished volunteering at the health center, then spent a week in Durban catching up on some outstanding work, visiting libraries, and generally enjoying the warmer climate. In the second week of May I returned to Pholela ready to begin conducting research. The first part of my field work is to conduct a comprehensive survey in two communities – one that provided the original focus area for the Pholela Community Health Centre and another that is located much farther from the reach of clinics or hospitals. Part of the idea is to bookend the history of Pholela with basically identical household surveys.
In 1942, in their effort to prove that even the poorest members of South African society could receive quality health care, Drs. Sidney and Emily Kark along with the help of trained Zulu Health Assistants conducted a comprehensive survey of 100 households located along the Umkomaas River, across the road from the health centre. The information gathered through these surveys helped to create targeted home-based interventions, which the doctors hoped would help to improve the overall health of entire families and by extension, the community. This baseline data, which was added to every year thereafter until at least the late 1950s, would also help to determine the efficacy of various health interventions.
My plan all along has been to conduct a resurvey of the area trying to find as many of the initial households as possible. The data collected in 2008 would then help to reveal both community and household differences between 1942 and 2008. This data set would then be one of the richest sets of local data available for a rural community in this part of the world. It would allow for a truly in depth understanding of a local context.
However, as I suspect is the case for all dissertation researchers, data collection is never this easy, nor this straightforward. First, there are the rather obvious issues that many people who were alive in 1942 are no longer alive today, especially in a place noted for ill health. And second, those 1942 (and 1944 and 1956, etc.) are no longer in South Africa.
In 1958 working under a government that no longer cared about the health of the African population and facing increasing surveillance, the Karks left South Africa to continue their work in community oriented primary health care. They first traveled to the US, where Sidney started the epidemiology program at UNC and then to Jerusalem where they helped to found the department of community medicine at the Hebrew University. In their decision to leave, and presumably to take much of the Pholela data with them, the Karks took my wonderfully local study and placed it into a global context.
However, when the Karks left South Africa in 1958 it was not the first time that Pholela garnered international attention. Indeed, throughout the late 1940s and 1950s foreign, and in particular American, doctors came to Pholela to gain an understanding of this pioneering model of primary health care and to conduct research with the local populations. They took the lessons they learned back to their home countries, establishing a network of health centers in the United States based on the Pholela model as a part of Lyndon Johnson’s war on poverty, and becoming leaders in global primary health care. Still other young South African doctors who trained at Pholela left South Africa looking for the freedom to pursue careers in social medicine, some of these doctors went on to change the field of epidemiology others became world renowned scientists teaching at some of the world’s best Universities.
In my first two months at the health center none of this history was obvious. Sure, people talk about the Karks and their history, but it is understood in the context of local health improvements and a clinic and government that used to care more for the health of Pholela’s communities.
It was sitting in my little cottage in tiny Bulwer, connecting to the internet via a terribly slow cell phone modem, that I began to piece together this remarkable international history. I was e-mailing anyone I could think of who might have an idea where the 1942 survey results is located, and only one of these people was in South Africa. In that first week that I was back in Pholela, writing the survey, I had academics at Wits, UNC, Harvard, Columbia, CUNY, and the Hebrew University all wracking their brains to think of where those original surveys might be. While I was physically located in Pholela, the “research” I was pursuing was literally all over the world.
I spent my second week back on Pholela working to lay the local foundation for my research. In a rural place like Pholela, one must get the permission and support of the traditional authorities and the local Inkosi (Chief) in order to conduct research. As a result, with the help of colleagues from the health center, I went first to the tribal court for the community that is far from Pholela to ask for permission to conduct research. After some discussion, confusion, and a few questions, the Inkosi and her (the Inkosi for this area is a woman, which is very unusual) headmen gave me permission. The next day, accompanied by a headman who works at the clinic, I went to visit the Inkosi for Pholela to ask for his permission. After some discussion and some very insightful comments, I had permission and a guarantee of protection. Despite my growing network of international contacts, the time spent organizing to meet and then meeting with the local traditional authorities served as an important reminder that mine is a project that in deeply local.
Working with a team of young people from a local NGO and the Community Health Workers from these two communities, we began conducting the survey this past week. Climbing all over the mountains where these communities are located, walking from one homestead to the next, collecting GPS points, and spending an hour plus with each household head to gather basic demographic data and ask questions of health and environment, this research began to feel again like it was extremely local.
However, in the pursuit of the original local data, it became clear that Pholela and the health and nature of the people who live here is not simply local. Rather, this small, out-of-the-way, rural place, is connected to the rest of the world in profound ways. As a result, conducting research in a place like Pholela requires the ability to be in contact with some of the world’s most respected medical thinkers as well as many of its poor inhabitants. What these couple of weeks have shown me, what I have only begun to realize, (and unfortunately what the violence in Jo’burg, Cape Town, and Durban reminds us) is that combining the global and the local is a far more difficult task than it seems. Indeed, the scholarship on this area seems to focus either on the far reaching experiment in social medicine that began in Pholela and spread throughout the world, or on something like hypertension in this population of Zulu speaking people. Combining Pholela community history and ideas with Pholela Community Health Centre history and ideas remains a difficult pursuit.
As I open the Sunday papers I am reminded that Pholela and its surprising history and international links are not unique in South Africa. Indeed, in places far more connected to global capital and human flows, like Johannesburg, the impact of South Africa’s place in the larger continental and global context is being violently felt.
In thinking about my next post 10 days ago I was looking forward to writing for the first time about my very own research. At the end of April I finished volunteering at the health center, then spent a week in Durban catching up on some outstanding work, visiting libraries, and generally enjoying the warmer climate. In the second week of May I returned to Pholela ready to begin conducting research. The first part of my field work is to conduct a comprehensive survey in two communities – one that provided the original focus area for the Pholela Community Health Centre and another that is located much farther from the reach of clinics or hospitals. Part of the idea is to bookend the history of Pholela with basically identical household surveys.
In 1942, in their effort to prove that even the poorest members of South African society could receive quality health care, Drs. Sidney and Emily Kark along with the help of trained Zulu Health Assistants conducted a comprehensive survey of 100 households located along the Umkomaas River, across the road from the health centre. The information gathered through these surveys helped to create targeted home-based interventions, which the doctors hoped would help to improve the overall health of entire families and by extension, the community. This baseline data, which was added to every year thereafter until at least the late 1950s, would also help to determine the efficacy of various health interventions.
My plan all along has been to conduct a resurvey of the area trying to find as many of the initial households as possible. The data collected in 2008 would then help to reveal both community and household differences between 1942 and 2008. This data set would then be one of the richest sets of local data available for a rural community in this part of the world. It would allow for a truly in depth understanding of a local context.
However, as I suspect is the case for all dissertation researchers, data collection is never this easy, nor this straightforward. First, there are the rather obvious issues that many people who were alive in 1942 are no longer alive today, especially in a place noted for ill health. And second, those 1942 (and 1944 and 1956, etc.) are no longer in South Africa.
In 1958 working under a government that no longer cared about the health of the African population and facing increasing surveillance, the Karks left South Africa to continue their work in community oriented primary health care. They first traveled to the US, where Sidney started the epidemiology program at UNC and then to Jerusalem where they helped to found the department of community medicine at the Hebrew University. In their decision to leave, and presumably to take much of the Pholela data with them, the Karks took my wonderfully local study and placed it into a global context.
However, when the Karks left South Africa in 1958 it was not the first time that Pholela garnered international attention. Indeed, throughout the late 1940s and 1950s foreign, and in particular American, doctors came to Pholela to gain an understanding of this pioneering model of primary health care and to conduct research with the local populations. They took the lessons they learned back to their home countries, establishing a network of health centers in the United States based on the Pholela model as a part of Lyndon Johnson’s war on poverty, and becoming leaders in global primary health care. Still other young South African doctors who trained at Pholela left South Africa looking for the freedom to pursue careers in social medicine, some of these doctors went on to change the field of epidemiology others became world renowned scientists teaching at some of the world’s best Universities.
In my first two months at the health center none of this history was obvious. Sure, people talk about the Karks and their history, but it is understood in the context of local health improvements and a clinic and government that used to care more for the health of Pholela’s communities.
It was sitting in my little cottage in tiny Bulwer, connecting to the internet via a terribly slow cell phone modem, that I began to piece together this remarkable international history. I was e-mailing anyone I could think of who might have an idea where the 1942 survey results is located, and only one of these people was in South Africa. In that first week that I was back in Pholela, writing the survey, I had academics at Wits, UNC, Harvard, Columbia, CUNY, and the Hebrew University all wracking their brains to think of where those original surveys might be. While I was physically located in Pholela, the “research” I was pursuing was literally all over the world.
I spent my second week back on Pholela working to lay the local foundation for my research. In a rural place like Pholela, one must get the permission and support of the traditional authorities and the local Inkosi (Chief) in order to conduct research. As a result, with the help of colleagues from the health center, I went first to the tribal court for the community that is far from Pholela to ask for permission to conduct research. After some discussion, confusion, and a few questions, the Inkosi and her (the Inkosi for this area is a woman, which is very unusual) headmen gave me permission. The next day, accompanied by a headman who works at the clinic, I went to visit the Inkosi for Pholela to ask for his permission. After some discussion and some very insightful comments, I had permission and a guarantee of protection. Despite my growing network of international contacts, the time spent organizing to meet and then meeting with the local traditional authorities served as an important reminder that mine is a project that in deeply local.
Working with a team of young people from a local NGO and the Community Health Workers from these two communities, we began conducting the survey this past week. Climbing all over the mountains where these communities are located, walking from one homestead to the next, collecting GPS points, and spending an hour plus with each household head to gather basic demographic data and ask questions of health and environment, this research began to feel again like it was extremely local.
However, in the pursuit of the original local data, it became clear that Pholela and the health and nature of the people who live here is not simply local. Rather, this small, out-of-the-way, rural place, is connected to the rest of the world in profound ways. As a result, conducting research in a place like Pholela requires the ability to be in contact with some of the world’s most respected medical thinkers as well as many of its poor inhabitants. What these couple of weeks have shown me, what I have only begun to realize, (and unfortunately what the violence in Jo’burg, Cape Town, and Durban reminds us) is that combining the global and the local is a far more difficult task than it seems. Indeed, the scholarship on this area seems to focus either on the far reaching experiment in social medicine that began in Pholela and spread throughout the world, or on something like hypertension in this population of Zulu speaking people. Combining Pholela community history and ideas with Pholela Community Health Centre history and ideas remains a difficult pursuit.
As I open the Sunday papers I am reminded that Pholela and its surprising history and international links are not unique in South Africa. Indeed, in places far more connected to global capital and human flows, like Johannesburg, the impact of South Africa’s place in the larger continental and global context is being violently felt.
Friday, April 18, 2008
The Things that are not Asked
This morning I arrived at the health centre and joined the staff for the biweekly prayer session. Once the preacher had finished, everyone brought their chairs into a smaller circle, and one of the older nursing sisters announced that a staff member, Baba’mkhulu (Grandpa), had died the previous day.
Just two days before, as I was visiting one of the satellite clinics, the same nursing sister told me that I must go and speak to this baba to learn about the history of the clinic. The old man had spent many years living and working in Pholela and he had seen many of its changes. Indeed, yesterday I went to look for baba, but he had not come to work.
For my research I am interested in placing today’s health and environment in a larger historical context that begins in 1940 with the opening of the original Pholela Community Health Centre. While as far as history is concerned, sixty-eight years may not be much, as far as living memory is concerned, sixty-eight (or fifty, or even thirty) years of experience is disappearing. I will never be able to ask Baba’mkhulu about his life and his time at the clinic. The questions I have for him will remain unasked and his answers will remain unspoken.
When I first thought about writing a post about the things that are not asked, Baba’mkhulu was still working at the help desk, and I was looking forward to the end of the month when I will finish at the clinic and begin my own, self-directed research. I had been thinking about all of the time I have been spending in the ARV clinic, with the mobile clinic, and at various home visits where I wonder about the life of this or that patient. I had begun to think more and more about the things that are not asked.
For example, in “lifestyle” diseases like Type II Diabetes which are common in Pholela, patients are rarely asked where their food comes from. True, patients are given education about limiting starch intake, boiling food, and eating more vegetables. But they are not asked what food comes from the garden and what food comes from a shop; who controls to purchase of food, or who controls its preparation. While talking to a gogo about what she should eat to control her diabetes is good in theory, if she does not decide what she eats, or if she has no control over how it is prepared, then she has no control over the very “lifestyle” that causes her disease. In the end this gogo will get pills that (may) control her diabetes, whether or not she has the means to or the knowledge to change her eating habits.
Perhaps this is the reason that so much is left unasked, and so much is left unsaid. Or perhaps it is because there are forty more patients waiting to talk to the nursing sister that afternoon and the mobile clinic only comes once a month.
Then there are the questions that are asked, but that people either don’t want to or don’t know how to answer. One sister noticed that a woman had bruising all over her face and asked what had happened. A smile, no answer. Then she asked how things were at home. Again, a smile and no answer.
Perhaps things aren’t asked because no one wants to answer them or because the answers are too long and too complicated and there is a line of people still waiting for their diabetes medication.
The nursing sisters are not the only people who leave questions unasked. A woman of child bearing age arrives at the mobile clinic complaining of flu. The sister takes the opportunity not only to treat the woman for flu, but also to encourage her to go onto “the injection” (a contraceptive administered intravenously by the sisters once every three months). The sister asks if the woman agrees. She says yes. And family planning is achieved. But this woman does not ask if there are other options; if she could take birth control pills rather than the injection or if there are condoms available. She doesn’t ask how it will affect her menstruation cycle, what happens if she happens to be away the day the mobile clinic comes to her area in three months, or how long it will take for her to become pregnant once she stops. And no one asks about the implication of a public health service encouraging its poorest and most disempowered citizens to use birth control.
AIDS is different, or so they say.
In order to be tested one has to go to pre and post-test counseling. If a person is negative he is counseled about how to stay negative. If a person is positive, she learns about how to prevent the spread of HIV and how to begin the process of “getting onto treatment.” This HIV+ person will be advised to have her CD4 count checked and if it is at or below 200 she enters a series of three counseling or education sessions about HIV, the progression of the disease, the treatment regimen, potential side effects, and how to find support. In some ways this system works and both the medical professionals and the patients have the space and the time to ask question.
When the patients come to the ARV clinic the nursing sisters and the doctor ask them about contraception, pregnancy, intimate relationships, TB history and other serious illnesses, if she has ever taken treatment for HIV before, and if she has declared her status to her family. And patients answer these questions (though how representative the answers are of reality is, of course, open to interpretation). Further, within this structure built around AIDS patients are empowered to both see the doctor and to question their treatment. One man today asked the doctor if he should be taking one regimen because in his classes he learned that people who work the night shift should be put on a different regimen. He had the knowledge and the power to ask about his own treatment. Another woman came in to ask to for medication to control her epilepsy. She explained that from 2004 until she started ARVs she had been taking a traditional medicine to control her epileptic fits. She was at the clinic today because she had learned in her classes not to mix traditional medicines with ARVs; since she had stopped taking the traditional medicine her fits had returned. Like the man before her, she was empowered to ask questions.
And yet, there are things that are not asked. What was the traditional medicine that had controlled her epilepsy? Would it really interfere with ARVs? There are more general questions as well. What treatments are patients seeking outside of the clinic system? Why have they decided to test? How supportive is their family? How as this changed? How did they get to the clinic? How much did the transport cost? What do they eat everyday? Where does their food come from?
While the medical system has come to understand HIV/AIDS as a social disease, it is only a particular kind of social. It is about sexual relationships and changing family structures. It is not about different healing systems, transportation networks, or the combination of climate, ecology, knowledge, and political-economy that determines what people eat, where it comes from, and when they go hungry.
But there are many patients waiting, the sisters and the doctor are busy, and people want to finish early so they have enough time walk home before dark or so they can catch the erratic transportation available in this rural area. And so there are things that will remain unasked.
As I leave the health centre and venture out on my own I am eager to begin asking about some of these things that are not asked. I will ask questions about transportation, food, understandings, and history. These questions will lead to different ideas and to more questions. And while I know that there will continue to be things that go unasked and others that go unanswered, I am still eager to begin. For as Baba’mkhulu reminds us, if we don’t ask about things today we may never get to hear the answers.
Just two days before, as I was visiting one of the satellite clinics, the same nursing sister told me that I must go and speak to this baba to learn about the history of the clinic. The old man had spent many years living and working in Pholela and he had seen many of its changes. Indeed, yesterday I went to look for baba, but he had not come to work.
For my research I am interested in placing today’s health and environment in a larger historical context that begins in 1940 with the opening of the original Pholela Community Health Centre. While as far as history is concerned, sixty-eight years may not be much, as far as living memory is concerned, sixty-eight (or fifty, or even thirty) years of experience is disappearing. I will never be able to ask Baba’mkhulu about his life and his time at the clinic. The questions I have for him will remain unasked and his answers will remain unspoken.
When I first thought about writing a post about the things that are not asked, Baba’mkhulu was still working at the help desk, and I was looking forward to the end of the month when I will finish at the clinic and begin my own, self-directed research. I had been thinking about all of the time I have been spending in the ARV clinic, with the mobile clinic, and at various home visits where I wonder about the life of this or that patient. I had begun to think more and more about the things that are not asked.
For example, in “lifestyle” diseases like Type II Diabetes which are common in Pholela, patients are rarely asked where their food comes from. True, patients are given education about limiting starch intake, boiling food, and eating more vegetables. But they are not asked what food comes from the garden and what food comes from a shop; who controls to purchase of food, or who controls its preparation. While talking to a gogo about what she should eat to control her diabetes is good in theory, if she does not decide what she eats, or if she has no control over how it is prepared, then she has no control over the very “lifestyle” that causes her disease. In the end this gogo will get pills that (may) control her diabetes, whether or not she has the means to or the knowledge to change her eating habits.
Perhaps this is the reason that so much is left unasked, and so much is left unsaid. Or perhaps it is because there are forty more patients waiting to talk to the nursing sister that afternoon and the mobile clinic only comes once a month.
Then there are the questions that are asked, but that people either don’t want to or don’t know how to answer. One sister noticed that a woman had bruising all over her face and asked what had happened. A smile, no answer. Then she asked how things were at home. Again, a smile and no answer.
Perhaps things aren’t asked because no one wants to answer them or because the answers are too long and too complicated and there is a line of people still waiting for their diabetes medication.
The nursing sisters are not the only people who leave questions unasked. A woman of child bearing age arrives at the mobile clinic complaining of flu. The sister takes the opportunity not only to treat the woman for flu, but also to encourage her to go onto “the injection” (a contraceptive administered intravenously by the sisters once every three months). The sister asks if the woman agrees. She says yes. And family planning is achieved. But this woman does not ask if there are other options; if she could take birth control pills rather than the injection or if there are condoms available. She doesn’t ask how it will affect her menstruation cycle, what happens if she happens to be away the day the mobile clinic comes to her area in three months, or how long it will take for her to become pregnant once she stops. And no one asks about the implication of a public health service encouraging its poorest and most disempowered citizens to use birth control.
AIDS is different, or so they say.
In order to be tested one has to go to pre and post-test counseling. If a person is negative he is counseled about how to stay negative. If a person is positive, she learns about how to prevent the spread of HIV and how to begin the process of “getting onto treatment.” This HIV+ person will be advised to have her CD4 count checked and if it is at or below 200 she enters a series of three counseling or education sessions about HIV, the progression of the disease, the treatment regimen, potential side effects, and how to find support. In some ways this system works and both the medical professionals and the patients have the space and the time to ask question.
When the patients come to the ARV clinic the nursing sisters and the doctor ask them about contraception, pregnancy, intimate relationships, TB history and other serious illnesses, if she has ever taken treatment for HIV before, and if she has declared her status to her family. And patients answer these questions (though how representative the answers are of reality is, of course, open to interpretation). Further, within this structure built around AIDS patients are empowered to both see the doctor and to question their treatment. One man today asked the doctor if he should be taking one regimen because in his classes he learned that people who work the night shift should be put on a different regimen. He had the knowledge and the power to ask about his own treatment. Another woman came in to ask to for medication to control her epilepsy. She explained that from 2004 until she started ARVs she had been taking a traditional medicine to control her epileptic fits. She was at the clinic today because she had learned in her classes not to mix traditional medicines with ARVs; since she had stopped taking the traditional medicine her fits had returned. Like the man before her, she was empowered to ask questions.
And yet, there are things that are not asked. What was the traditional medicine that had controlled her epilepsy? Would it really interfere with ARVs? There are more general questions as well. What treatments are patients seeking outside of the clinic system? Why have they decided to test? How supportive is their family? How as this changed? How did they get to the clinic? How much did the transport cost? What do they eat everyday? Where does their food come from?
While the medical system has come to understand HIV/AIDS as a social disease, it is only a particular kind of social. It is about sexual relationships and changing family structures. It is not about different healing systems, transportation networks, or the combination of climate, ecology, knowledge, and political-economy that determines what people eat, where it comes from, and when they go hungry.
But there are many patients waiting, the sisters and the doctor are busy, and people want to finish early so they have enough time walk home before dark or so they can catch the erratic transportation available in this rural area. And so there are things that will remain unasked.
As I leave the health centre and venture out on my own I am eager to begin asking about some of these things that are not asked. I will ask questions about transportation, food, understandings, and history. These questions will lead to different ideas and to more questions. And while I know that there will continue to be things that go unasked and others that go unanswered, I am still eager to begin. For as Baba’mkhulu reminds us, if we don’t ask about things today we may never get to hear the answers.
Thursday, March 27, 2008
The ARV Clinic
I have now spent three Tuesdays at the ARV clinic at the health center. (ARV stands for Anti-Retroviral drugs, which are used to treat HIV.) Until recently the South African government only made ARVs available through hospitals. As one might imagine, this policy limited the reach of ARVs, especially in rural areas. Therefore, as of December ARVs have been rolled out to a couple of clinics in Sisonke District, including the Pholela Community Health Centre. At the PCHC every Tuesday and Friday, a doctor, hired by the Valley Trust (an NGO close to Durban), comes to initiate new patients (Tuesdays) and monitor enrolled patients (Fridays). This same doctor oversees ARV rollouts in two other clinics.
Over the past three weeks I have met and heard the stories of close to twenty HIV+ patients who are being initiated on ARVs. By deciding to take ARVs and therefore waiting outside of the ARV clinic at the Health Centre, these patients declare their status to the community. In a place like South Africa, where HIV is a disease that comes with tremendous stigma, these patients are brave to seek treatment. In doing so they gain continual access to primary health care, have the opportunity to see a doctor every month, and receive free ARVs from the clinic. They extend their lives, and not simply because of the ARVs.
In order to receive ARVs from the government a person has to have a CD4 count (this is a broad measure of immune system power) of less than 200. (A normal adult has a CD4 count of over 1000, and people with health insurance often begin to take ARVs with a CD4 count of 350.) When an HIV+ person has a CD4 count of less than 200 opportunistic infections often begin. Over those three days we saw patients with CD4 counts as low as 4 and with other infections ranging from TB, to mouth sores, to other STDs, to general fatigue. We even saw a patient who had had TB in her stomach. (Non pulmonary tuberculosis was hardly known before AIDS; now it is no longer unusual.)
Through South Africa’s government health service there are two treatment regimens available. One includes nevaripine, which is safe for pregnant women, but tough on the liver. While in most cases the choice is straightforward, in some it is as though the doctor is deciding between liver damage and potential damage to a fetus. Were any of these patients to have access to the various treatments now available to those with health insurance, their choices might not be so limited. Poverty limits choices; what drugs one can take, what food one can eat, or if one can even seek treatment at all. After all, in order to seek treatment you have to get to the clinic, to get to the clinic you need transport, to get transport you need money. (This is, of course, assuming that there are enough people from your area who want and can afford transport to make it profitable in the first place.)
Spending time in these Tuesday initiation sessions is, in a sense, like seeing a microcosm of the AIDS pandemic come through one room. We saw six year old orphaned boy. When the doctor asked his caretaker why she had the boy tested she said that his father had died of AIDS while his mother was pregnant and his mother had died last year, so she thought perhaps he should be tested. She was right.
A young woman came in and when the doctor asked her if she used condoms, she said she tries, but her boyfriend doesn’t always agree. He then asked her if her partner had been tested, and she said yes and he was negative. The doctor asked if she had seen the test. She said no. He asked is she believed her partner. She said no. The doctor asked her to please bring him in for counseling and testing so that he might be able to enroll on ARVs as well. Unfortunately he lives in Pietermaritzburg, a city an hour away. She was scared of him and the truth was that she had no power to force him to change his behavior.
There was a man in his mid-50s who had lost his wife to AIDS and was angry. He said that if he had known about AIDS he never would have gotten it and he was telling all of his children about the disease in order to keep them from contracting the virus. He was unusual, most patients did not want to tell their children, and sometimes even their partners about their status. There are women who still want to have babies, others who have decided abstinence is the best way forward, and even one man whose sister died not from AIDS, but from a side effect of the ARVs. All of these people came through an ARV clinic in remote, rural corner of South Africa in just three days.
These three days at the ARV clinic have helped to give meaning to numbers and put faces and stories together. Perhaps what has been most amazing for me to truly understand about HIV is its variety. In this small sample alone, the man with a CD4 count of 4, who from all appearances seemed much healthier than the man with a CD4 count of 96, reinforced the idea that there is no way to be sure of a person’s status simply by looking at him or her. And their stories are as different as their CD4 counts. Looking out at the patients waiting to enter the ARV clinic makes one realize that there is no single face to HIV/AIDS.
Over the past three weeks I have met and heard the stories of close to twenty HIV+ patients who are being initiated on ARVs. By deciding to take ARVs and therefore waiting outside of the ARV clinic at the Health Centre, these patients declare their status to the community. In a place like South Africa, where HIV is a disease that comes with tremendous stigma, these patients are brave to seek treatment. In doing so they gain continual access to primary health care, have the opportunity to see a doctor every month, and receive free ARVs from the clinic. They extend their lives, and not simply because of the ARVs.
In order to receive ARVs from the government a person has to have a CD4 count (this is a broad measure of immune system power) of less than 200. (A normal adult has a CD4 count of over 1000, and people with health insurance often begin to take ARVs with a CD4 count of 350.) When an HIV+ person has a CD4 count of less than 200 opportunistic infections often begin. Over those three days we saw patients with CD4 counts as low as 4 and with other infections ranging from TB, to mouth sores, to other STDs, to general fatigue. We even saw a patient who had had TB in her stomach. (Non pulmonary tuberculosis was hardly known before AIDS; now it is no longer unusual.)
Through South Africa’s government health service there are two treatment regimens available. One includes nevaripine, which is safe for pregnant women, but tough on the liver. While in most cases the choice is straightforward, in some it is as though the doctor is deciding between liver damage and potential damage to a fetus. Were any of these patients to have access to the various treatments now available to those with health insurance, their choices might not be so limited. Poverty limits choices; what drugs one can take, what food one can eat, or if one can even seek treatment at all. After all, in order to seek treatment you have to get to the clinic, to get to the clinic you need transport, to get transport you need money. (This is, of course, assuming that there are enough people from your area who want and can afford transport to make it profitable in the first place.)
Spending time in these Tuesday initiation sessions is, in a sense, like seeing a microcosm of the AIDS pandemic come through one room. We saw six year old orphaned boy. When the doctor asked his caretaker why she had the boy tested she said that his father had died of AIDS while his mother was pregnant and his mother had died last year, so she thought perhaps he should be tested. She was right.
A young woman came in and when the doctor asked her if she used condoms, she said she tries, but her boyfriend doesn’t always agree. He then asked her if her partner had been tested, and she said yes and he was negative. The doctor asked if she had seen the test. She said no. He asked is she believed her partner. She said no. The doctor asked her to please bring him in for counseling and testing so that he might be able to enroll on ARVs as well. Unfortunately he lives in Pietermaritzburg, a city an hour away. She was scared of him and the truth was that she had no power to force him to change his behavior.
There was a man in his mid-50s who had lost his wife to AIDS and was angry. He said that if he had known about AIDS he never would have gotten it and he was telling all of his children about the disease in order to keep them from contracting the virus. He was unusual, most patients did not want to tell their children, and sometimes even their partners about their status. There are women who still want to have babies, others who have decided abstinence is the best way forward, and even one man whose sister died not from AIDS, but from a side effect of the ARVs. All of these people came through an ARV clinic in remote, rural corner of South Africa in just three days.
These three days at the ARV clinic have helped to give meaning to numbers and put faces and stories together. Perhaps what has been most amazing for me to truly understand about HIV is its variety. In this small sample alone, the man with a CD4 count of 4, who from all appearances seemed much healthier than the man with a CD4 count of 96, reinforced the idea that there is no way to be sure of a person’s status simply by looking at him or her. And their stories are as different as their CD4 counts. Looking out at the patients waiting to enter the ARV clinic makes one realize that there is no single face to HIV/AIDS.
Saturday, March 15, 2008
Vitamin A Campaign
Here are a few photos that give an idea of the area around Pholela and the Vitamin A Campaign.
Gogos with their grandchildren sitting in a primary school and listening to the Sister (professional nurse) talk about the importance of Vitamin A.
A homestead next to one of the primary schools.
Gogos with their grandchildren sitting in a primary school and listening to the Sister (professional nurse) talk about the importance of Vitamin A.
A woman and child arriving at the spot where we are giving Vitamin A boosters.
A nursing auxiliary gives a child one of the boosters out of a Department of Health Vehicle. This stop was along the side of the road.
A homestead next to one of the primary schools.Sunday, March 9, 2008
Arriving in Pholela
I’ve come to realize that in this digital age, when one is 9,000 miles from home, taking advantage of a little technology to keep in touch may actually be a good idea. As a result, despite my past feelings on the matter, I have decided to join the twenty-first century and keep a blog of my fieldwork experience here in South Africa. I can’t promise how regularly I’ll write updates, but I’ll do my best to share some of the experiences I’ll be having over the next 18 months. So here goes…
After three weeks in and around Durban, staying with friends, meeting with academics, and chasing down various leads on places to volunteer and ways to begin my fieldwork in the southern Drakensberg I arrived in Bulwer, KwaZulu-Natal. Bulwer is a village of 36 houses between Pietermaritzburg and Underberg, famous for hang gliding, and nestled in the mountains.
After settling into a small cottage I began volunteering at the historic Pholela Community Health Centre, just 15 km down the road in a piece of the former KwaZulu homeland. The PCHC is the reason why I have come to this area – the clinic’s history of holistic and community health care in the 1940s and 1950s provided a model for many parts of the world. Therefore, as you might imagine, the opportunity to begin my fieldwork by volunteering through the clinic is exceptional.
I have been allocated to the health promotions office, which is basically the outreach branch of the clinic. For these two weeks health promotions is sending out teams throughout the “catchment area” (a huge rural expanse) to give children vitamin A boosters. These boosters also come with a brief presentation in an effort to educate the children’s caretakers (generally their grandmothers) about nutritious foods and the importance of vitamin A.
Our team is a senior professional nurse, a nurse’s assistant, a community health worker, and me. Each day we load into the double cab pickup and take off into the mountains over dirt and rock roads. As we approach our destination, we pull out a loudspeaker and announce that we have arrived for the vitamin A campaign. I have trouble understanding exactly what is being said, as it’s all in fast Zulu, but I can tell where we’re headed by the streams of grandmothers walking with children in tow and others strapped to their backs. We then arrive at either a primary school or a mobile clinic stop (which often looks like a simple turn off). We hop out and set up shop, either in a classroom or out of the back of the truck.
The senior, professional nurse gives the short presentation then we begin to give the children boosters (a small capsule squeezed into their mouths). The community health worker along with local community health workers organize all of the grandmothers and children into a line and collect the medical cards. The senior nurse checks and fills out all the cards and the nurse’s assistant gives the kids the boosters. Finally, I, by far the least skilled and only non-native Zulu speaker, keep track of the number of children we manage to give the booster to. (This is by far the easiest job.) These numbers will be compiled and sent to the district office as part of some sort of assessment.
Many different aspects of this, my first experience as a part of a medical operation have fascinated, intrigued, and confused me. One important early realization is how truly remote these people are and how their location and their poverty largely dictate the relationship they can have to biomedical care. In many of the places the mobile clinic arrives once a month, if the roads are passable. These mobile clinics offer basic care, antenatal services (but of course no maternity services), voluntary testing and counseling (but not chance of ARVs), and TB advice. For anything more serious people would have to walk as many as a hundred kilometers to the health centre or would have to get some sort of transportation, which is infrequent, inconsistent, and expensive.
While these mobile clinics go out with two nurses and meet community health workers in the locations they visit, it is these community health workers that then provide the most consistent and direct face of biomedicine. These community health care workers are recruited throughout the Pholela’s catchment and are almost exclusively women. They receive training at the health center and provide an exceptional network through with to pass and receive information from even the most remote corners of the district.
As we travel through vast open pastures and small holdings with tiny garden plots, turning from unsigned dirt road to unsigned dirt road and constantly stopping and starting as we wind our way past the goats and the cows, I find it amazing that the health centre is able to come into contact with any of these people. And I am even more eager to get to know the area, the people, their health, and their nature.
After three weeks in and around Durban, staying with friends, meeting with academics, and chasing down various leads on places to volunteer and ways to begin my fieldwork in the southern Drakensberg I arrived in Bulwer, KwaZulu-Natal. Bulwer is a village of 36 houses between Pietermaritzburg and Underberg, famous for hang gliding, and nestled in the mountains.
After settling into a small cottage I began volunteering at the historic Pholela Community Health Centre, just 15 km down the road in a piece of the former KwaZulu homeland. The PCHC is the reason why I have come to this area – the clinic’s history of holistic and community health care in the 1940s and 1950s provided a model for many parts of the world. Therefore, as you might imagine, the opportunity to begin my fieldwork by volunteering through the clinic is exceptional.
I have been allocated to the health promotions office, which is basically the outreach branch of the clinic. For these two weeks health promotions is sending out teams throughout the “catchment area” (a huge rural expanse) to give children vitamin A boosters. These boosters also come with a brief presentation in an effort to educate the children’s caretakers (generally their grandmothers) about nutritious foods and the importance of vitamin A.
Our team is a senior professional nurse, a nurse’s assistant, a community health worker, and me. Each day we load into the double cab pickup and take off into the mountains over dirt and rock roads. As we approach our destination, we pull out a loudspeaker and announce that we have arrived for the vitamin A campaign. I have trouble understanding exactly what is being said, as it’s all in fast Zulu, but I can tell where we’re headed by the streams of grandmothers walking with children in tow and others strapped to their backs. We then arrive at either a primary school or a mobile clinic stop (which often looks like a simple turn off). We hop out and set up shop, either in a classroom or out of the back of the truck.
The senior, professional nurse gives the short presentation then we begin to give the children boosters (a small capsule squeezed into their mouths). The community health worker along with local community health workers organize all of the grandmothers and children into a line and collect the medical cards. The senior nurse checks and fills out all the cards and the nurse’s assistant gives the kids the boosters. Finally, I, by far the least skilled and only non-native Zulu speaker, keep track of the number of children we manage to give the booster to. (This is by far the easiest job.) These numbers will be compiled and sent to the district office as part of some sort of assessment.
Many different aspects of this, my first experience as a part of a medical operation have fascinated, intrigued, and confused me. One important early realization is how truly remote these people are and how their location and their poverty largely dictate the relationship they can have to biomedical care. In many of the places the mobile clinic arrives once a month, if the roads are passable. These mobile clinics offer basic care, antenatal services (but of course no maternity services), voluntary testing and counseling (but not chance of ARVs), and TB advice. For anything more serious people would have to walk as many as a hundred kilometers to the health centre or would have to get some sort of transportation, which is infrequent, inconsistent, and expensive.
While these mobile clinics go out with two nurses and meet community health workers in the locations they visit, it is these community health workers that then provide the most consistent and direct face of biomedicine. These community health care workers are recruited throughout the Pholela’s catchment and are almost exclusively women. They receive training at the health center and provide an exceptional network through with to pass and receive information from even the most remote corners of the district.
As we travel through vast open pastures and small holdings with tiny garden plots, turning from unsigned dirt road to unsigned dirt road and constantly stopping and starting as we wind our way past the goats and the cows, I find it amazing that the health centre is able to come into contact with any of these people. And I am even more eager to get to know the area, the people, their health, and their nature.
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