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.

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 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.

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.