Healthcare Challenges in Cape Town, South Africa

June 6th – July 4th 2015

Nanis Elkaramany

Minnesota State University- Mankato

Biol 497 (Internship)

Introduction This summer, I participated in a global health education program with the non-profit

organization Children Family Health International. This program offers a comprehensive clinical and cultural immersion experience in a developing country with healthcare professionals working under difficult and vastly different circumstances compared to Western countries. I chose to participate in this program because I am interested in public health problems and potential ways to bring my education and exposure in the United States healthcare system to developing countries that lack the resources that we have. I applied for the program 6 months prior to the program date after researching several global brigades programs that involved medicine and healthcare. The application process included completing the application form, writing a paper about my objectives in participating in the program, and providing a copy of my transcript. I chose CFHI compared to other programs because I believed it would apply all of my undergraduate studies into real-life situations. This postulation was undoubtedly correct. During my one-month internship, I was required to recall information I had learned not only in my biomedical sciences courses— such as genetics, microbiology, chronic aging, and even evolution— but also general courses such as mass media, art, and music. My ultimate objective for participating in the Healthcare Challenges program in South Africa was to determine which educational or career path I should pursue as my undergraduate studies come to an end.

I completed approximately 140 hours of clinical rotations in the tertiary hospital Red Cross War Memorial Children’s Hospital in Cape Town, South Africa. I had the opportunity to rotate between the Trauma Unit and the Theatre Ward (known as operating rooms in the U.S.). I also had the unexpected opportunity to work on a research study with Dr. Albertyn on “burn kids,” social and emotional issues they might face after being released, and how to implement ways to prevent burn incidents. Finally, the program staff took the students on a weekend trip called the Garden Route, which is an ecologically diverse stretch of the south-eastern coast of South Africa that extends from Western Cape to the Eastern Cape. This report will include my clinical experiences working in the Trauma Ward and Theatre Ward in Red Cross Children’s Hospital, my research findings with Dr. Albertyn, problems in the healthcare system in South Africa pre- and post-apartheid, as well as in comparison to the American healthcare system, ecological and wild-life observations during the Garden Route, and finally, my reflection on this experience and whether my objective was fulfilled as I turn a major cornerstone in life as an MNSU graduate.

Figure 1. Hospital badge/ student ID during internship.

Red Cross Children’s Hospital - Trauma Unit and Theatre Ward Red Cross War Memorial Children’s Hospital is the largest children’s hospital in Cape

Town. It serves as a regional referral base for many specialties and its primary task is to provide care to the low-income children of Cape Town. Its trauma unit has 2 operating theatres and an outpatient clinic. During orientation, I learned that this hospital is also a tertiary hospital, meaning that it is a teaching hospital and medical students from the University of Cape Town come here for their rounds and also for some lectures. I would later learn that these medical students would provide me with invaluable information and one-on-one teaching experiences that I would not have otherwise received. There were a total of 12 other students in my program—10 physician assistant students from Pace University in New York participating in this program as one of their required electives, 1 pre-med student from the University of Notre Dame looking to gain some clinical experience before he applies for medical schools, and 1 nursing student from Texas. We received our schedules on the first day, which was packed with ward rounds, meetings, lectures surgeries, and consultations. Our day started from 6AM when our driver picked us up from our host families’ houses. We arrived at the hospital at approximately 7AM when ward rounds started, and throughout the day we attended the scheduled events. Our work day ended at 4PM where we would be picked up in front of the hospital.

Figure 2. Visiting Student Timetable (scanned images). These schedules were given to us on the first day and were kept with us at all times during our internship. We were welcomed to join any event, even if specified only for doctors.

Figure 3. Example of a Lodox (low-dose x-ray machine) being used to scan a pediatric patient’s thoracic region in the trauma ward.

During my time at the trauma unit, I witnessed the various medical techniques used in pediatric trauma, such as radiological imaging, total body digital imaging, emergency ultrasound, abdominal sonography for trauma, laparoscopic surgery, non-operative management of abdominal injuries, and management of brain injuries. I learned about the LODOX machine which I often saw being used on children in the trauma center to diagnose their condition. LODOX, a South African innovation that gained recognition and fame after a feature on a Grey’s Anatomy episode, stands for “Low-Dose X-ray” and provides minimal radiation exposure that provides whole-body scans—a pertinent feature that is critical to any trauma ward, especially to a children’s trauma ward where patients are more susceptible to radiation’s damaging side-effects. I attended a lecture about radiation imagery and its importance in health-care as well as some of the most common radiation techniques’ potential harmful effects. As the only American group in the hospital during that time, we were often pointed out in lectures and meetings and usually mocked for our readiness to over-expose patients to radiation, over-prescribe medications, and were even poked fun at for our vastly abundant resources. During this particular lecture about radiation imagery, I was surprised to find out that a) despite its obvious benefits of extremely low radiation compared to other imagery techniques and being FDA cleared, LODOX machines are extremely rare in the United States, with no alternative or comparative substitute and b) At least 1 in 1,000 children exposed to radiation will develop cancer as a result. Initially, this statistic did not strike me as alarming until I realized that this hospital treats thousands of children daily and performs even more radiation scans, often more than one on a single patient in order to receive an accurate diagnosis.

I did my own research online to validate these claims and came to the conclusion that radiation use in medicine is an unknown public health issue— and that American doctors are indeed, “scan-happy.” Researchers estimate that at least 2% of all future cancers in the U.S.—approximately 29,000 cases and 15,000 deaths per year—will stem from CT scans alone. About one-third of the 80 million scans performed annually in the U.S. serve little, if any, medical purpose. Furthermore, children under the age of 5 who receive a CT scan are 35% more likely to have cancer in adulthood due to their young bodies’ vulnerability to radiation. (Consumer Reports, 2015)

Figure 4. Trauma Unit at Red Cross War Memorial Children’s Hospital and the staircase leading up to it. Paintings found on the walls exemplify South Africa’s resilience, as well as its vibrant culture.

A common reasoning for radiology scans is that the benefits outweigh the risks; however, in my opinion, there are obvious financial and legal obligations that seem to increase these risks more than necessary. The lack of awareness to the extent of potential harmful effects of radiology in United States healthcare is evident by the lack of usage and demand for these full-body low-dose scans which are widely available in South Africa. A possible research that could be conducted is a study of cancer rates in modernized countries with high usage of radiation imaging tests such as the United States, compared to countries that use these techniques sparingly due to limited resources or availability of low-dose radiation scans such as the LODOX.

In South Africa, an operating room is also known as a “theatre,” and ironically, that is exactly how it felt as our group and the medical students took turns poking our masked faces in to look at the organs and tissues being identified by the surgeons. The most interesting surgery I have seen is a skin graft on a burn victim. During surgeries on burn victims, the theatres were required to be extremely hot, up to 30 degrees Celcius (86 degrees Fahrenheit), in order to maintain normotheric conditions, or an environmental temperature that does not cause increased of depressed activity of body cells. (Flint, 2008) This proved to be very physically daunting and physicians and students often stepped outside of the room for water breaks. My level of participation during surgeries was strictly in observer capacity; however, in trauma, I was able to assist physicians in gathering patient history, delivering paperwork, restraining and/or comforting the patient when needed, and even some simple medical procedures such as molding casts. I learned the most from medical students who were also present and explained to me in great detail about their patients’ cases and diagnoses.

Figure 5. Red Cross War Memorial Children’s Hospital

One particular case that I found memorable was a young boy whose mother brought him in after a soccer game with his friends. The boy was playing with his friends when he suddenly lost all motor abilities in his legs. Panicked, the mother carried him in to the trauma unit and explained that he had no prior conditions, no trauma or accidents, and was otherwise a “perfectly normal, healthy boy.” The patient’s health records seemed to agree with the mother. After studying the boy’s signs and symptoms—including weakness on both sides of the body, rapid on-set of symptoms, lost knee-jerk reflexes, and an NCV (nerve conduction velocity) test— doctors were led to a differential diagnosis of the rare autoimmune disease, Guillain-Barré Syndome. Guillain-Barré Syndrome presents rapid-onset muscle weakness as a result of the body’s immune system mistakenly attacking the peripheral nerves and damaging their myelin insulation. In patients with severe weakness, such as the little boy in our case, efficient treatment with intravenous immunoglobulins or plasmapheresis, together with supportive care, will usually lead to a good prognosis. (National Institute of Neurological Disorders and Stroke, 2011) Healthcare in South Africa

Avril, the CFHI medical director in Cape Town, summarized that the public health care under District Health System had substructures in eight metropolises divided by district and geographic boundaries. Each served up to half a million residents. Provisions for primary care, and most often the initial point of contact in the suburbs, were through eight-hour day hospitals. Twenty-four hour secondary hospitals for trauma and obstetric/gynecology emergencies included Victoria and G.F. Jooste. Tertiary hospitals provided specialists via referrals. Children under the age of thirteen were sent to the only dedicated tertiary pediatric hospital in South Africa, Red Cross War Memorial Children’s Hospital. Adults were referred to Tygerberg Hospital or Groote Shuur Hospital. Anyone who claimed to be Capetonian would gladly point out that Groote Shuur was famous for the first successful human heart transplant, and Victoria Hospital was home of the first successful penile implant.

The District Health System was established to address the discriminatory practices of health care delivery under apartheid. Sharing the piece of the pie brought about new financial and operational challenges, especially in face of the HIV/TB pandemic. Working in the hospitals, providers and administrative staff shed light on these concerns and some offered suggestions to resolve them. There is a need for centralization and conversion of paper to computer based medical records, including lab and imaging studies. This would offer better assessment of patients’ prognosis given an accurate and legible history. Centralized records prevent wasteful duplications of diagnostic tests. Intra or Internet capabilities would improve communication and data exchange between departments and other hospitals. Digital records would also free up hospital rooms allocated for data repositories. Some of the limitations to reform were due to the economic burden of treating HIV/TB. In the internal medicine wards, a large percentage of beds and isolation rooms were dedicated to HIV/TB. There are organizations like UNAID and reputable journals that can describe in detail the widespread impact of AIDS/HIV in South Africa, where roughly 11% of the population or about 6 million are infected. (UNAIDS, 2014)

Visiting impoverished communities, I met people infected with HIV who readily disclosed their concerns. The government offers antiretroviral drugs and monetary assistance or grants depending on their CD4 counts. The loss of income from these grants as their CD4 count improved put them in a quandary: choosing between long-term healthcare, or keeping food on the table and a roof over their heads. “Burn Kids” Research Study

Red Cross War Memorial Children’s Hospital is a leader in South Africa in promoting child safety in order to prevent injuries. “Burn kids” is a term affectionately used by doctors in the hospital to refer to children who suffer from serious burn injuries. I met Dr. Albertyn in the doctor’s lounge during one of my breaks at Red Cross Memorial Hospital. She came over to our table to meet the American students and introduced the research she was working on involving “burn kids,” and burn prevention and education in impoverished families living in townships communities and informal settlements. In South Africa, townships are urban living areas that, from the late 19th century until the end of apartheid, were reserved for non-whites. Townships were usually built on the periphery of towns and cities and are usually accompanied by informal settlements. Informal settlements consist of houses made up of plywood, corrugated metal, sheets of plastic or cardboard boxes, and often lack proper sanitation, safe water supply, electricity, hygienic requirements, or other basic human necessities. These townships and

informal settlements are also extremely prone to fire hazards, as their residents often use paraffin, gasoline, and other inflammable liquids in order to cook and produce heat in the winters. My internship was during South Africa’s winter season, which explained why the number of burn accidents seemed drastic as we were seeing at least 20 to 30 burn patients a day in the emergency room alone, while the theatre ward was usually booked for skin grafts and burn operations.

To learn more about South Africa’s culture, I borrowed a book from the hospital library called Connecting with South

Africa: Cultural Communication and Understanding, by child psychiatrist and psychoanalyst Astrid Berg. In this book, Dr. Berg shares her experiences and scientific discourse on human development and intercultural communication while establishing mobile clinics in South Africa’s townships and informal settlements with the help of a nurse named Nosisana, whom I would later coincidentally work with. In their work with children and infants, Berg and Nosiana had become instrumental in

building connections with and among her fellow South Africans of all ethnicities.

Dr. Albertyn explained that trauma in children has become a major cause of mortality and morbidity, disability and a socio-economic burden in South Africa. It is estimated that over 95% of all deaths due to injury in children occur in low- and middle-income regions and countries. Although the child injury death rate is much lower among children from developed countries, injuries are still a major cause of death, accounting for about 40% of all child deaths. (World Health Organization , 2014). She also informed us that over 80

percent of children with major burns will commit suicide by adulthood due to PTSD, societal issues, and long-term health problems. This shocking statistic motivated Dr. Albertyn and a group of her fellow doctors to create a comic book to help children with severe burns cope with

Figure 6. One of my favorite patients and I before being released (top), a “selfie” of nurse Nosisana, patient, and I reading the educational comic book Medi-Kidetz (bottom). This little girl was involved in a motor vehicle accident while sitting unrestrained in the front passenger seat. She suffered from burn injuries on the right side of her face and was treated and hospitalized for 2 weeks before being released.

their disfigurement and new appearance. This comic book was created with impoverished South Africans in mind and incorporated their culture in the story, pictures, and book title, hence the African-influenced name of the comic book, Medi-Kidetz. I was very interested in her study and later approached her to ask if I could somehow participate. She was very enthusiastic and asked

me to accompany her during her burn ward rounds and note the children’s reactions as she read the comic book to them. As I did so, we quickly learned that there was a major communication issue as most of the children and their parents did not attend school, and therefore did not understand English and only spoke their native language, Xhosa, a language that involves tongue clicks and requires an interpreter to be present in order to communicate with the patients.

Later during my internship, I performed these ward rounds by myself where I met with the patients and read the comic book with them with the help of a nurse. Recognizing the name on the nurse’s badge, I asked if she had heard of the book I was currently reading. Sister Nosisana confirmed my suspicions that she was, indeed, the same nurse that Dr. Astrid Berg had written about and had been a prime component in her book, Connecting with South Africa.

At the end of each session, I would type my evaluations in the hospital’s library and send them to Dr. Albertyn. We came to the conclusion that the comic book would be more effective if it was interpreted in tribal languages such as Xhosa in order to eliminate the language barrier between English and native speakers, and ultimately teach “burn kids” how to cope with society after their burn accidents.

Ecology and Wild-Life There were plenty of things to do in South Africa during our Garden Route weekend trip:

jump off the world’s highest bungee bridge at Blourkran’s Bridge, ride ostriches and pet elephants in nature reserves in Knysna, explore the Cango caves, swing through treetops in Tsitskikama, climb to the top of Lion’s Head mountain, or hike Table Mountain. While hiking Table Mountain, I discovered a very interesting small creature scurrying between tourists’ feet. When I asked what it was, people from South Africa called it a "dassie", but it is more commonly known as the Cape hyrax or rock hyrax. I found out this animal has a very

Figure 7. Book I borrowed from the hospital’s library during my internship, Connecting with South Africa, by Dr. Astrid Berg.

Figure 9. A collage of my experiences during the Garden Route. Bamboos are commonly seen in parking lots (top left), bungee jumping (top middle), the tip of Africa (top right), a “dassie” (bottom left), Cango Caves (bottom middle), and Boulder Beach penguins (bottom right)

interesting evolutionary background, the most interesting being that its the closest living relative is the elephant. Tiny tusks in the form of inscisors can be observed inside their mouths. I also learned that these little animals have an unusually long gestation period of 7-8 months and are very social and intelligent animals, similar to their relatives, the elephants.

We had the opportunity to spend a weekend at Boulder’s Beach alongside the African Penguins, where colonies are notably less nervous than other African Penguins, and are unusually tame and accustomed to people. However, we learned that being a mainland site, these penguins are exposed to threats that are not an issue at island colonies—such as predation by terrestrial predators, and exposure to disease via mosquitoes and terrestrial disease-carrying birds.

Finally, we visited the tip of South Africa, Cape Point, where the Indian and the Atlantic oceans meet. The Cape Point Nature reserve also features some of the world’s highest diversity, density, and endemism of indigenous flora and over a thousand plant species, several of which occur nowhere else on Earth.

Reflection South Africa functions within a very bureaucratic society, which at times, was frustrating.

There is no such thing as HIPPA, or SOP, and often times, I felt as if schedules were too flexible and many things were handled very loosely or could be made more efficient. In order to get things accomplished in South Africa, I had to forget the “American” way of doing things and learn how to adjust and work within this bureaucratic process. I did not attempt to bend South Africa to my Western expectations; but instead, I allowed South Africa to change my mind-set. It is this mindset that literally opened doors for me to learn in the hospital and build relationships throughout the diverse communities of Cape Town. The following is an excerpt from Connecting with South Africa:

” It is a modern nation, yet many of its inhabitants follow ancient traditions. It is a nation with a colonial past marked by periods of violence, yet it has managed to make a largely peaceful transition to majority rule. It is a nation with eleven official languages embracing a great diversity of cultures and customs, and yet it is also a land where public debate is vigorous, free, and ongoing. In short, South Africa is a place where connections are being built and maintained—both those among people with long kinship and common culture, and those that reach across historical, racial, and class divides. The western world is undeniably more advanced in certain areas of science and economic development, but in other areas it seems to lag behind and could learn from places like South Africa.” (Berg, 2012, p. 2)

I wish I could say I fulfilled my objective and I am now decided on my future career goals, but the truth is, South Africa made it harder to choose between public health and medical school. Consequently, I am currently studying for the MCAT while researching public health schools. I have even found medical schools that also offer public health master’s degrees. South Africa taught me that there doesn’t have to be a strict order of doing things. Learning comes from trying and failing, and success comes from following your instincts and working hard. I learned from South Africa how to adapt and conform, and how to use common sense, but most of all; I learned how to welcome new thoughts and ideas with an open mind, and above all, an open heart.

Figure 10. Nature reserve in Knysna, South Africa. “The Western world is undeniably more advanced in certain areas of science and economic development, but in other areas, it seems to lag behind and could learn from places like South Africa.” –Astrid Berg

Works Cited Berg, A. (2012). Connecting with South Africa: Cultural Communication and Understanding. In A. Berg, Connecting with South Africa: Cultural Communication and Understanding (p. 2). Texas A&M University Press.

Consumer Reports. (2015, March). The Surprising Dangers of CT Scans and X-rays. Consumer Reports .

Flint, L. M. (2008). Trauma: Contemporary Principles and Therapy. Lippincott Williams & Wilkins .

National Institute of Neurological Disorders and Stroke. (2011, July). Guillain-Barré Syndrome Fact Sheet. Retrieved from National Institute of Health: http://www.ninds.nih.gov/disorders/gbs/detail_gbs.htm

UNAIDS. (2014). HIV and AIDS Estimates. Retrieved from UNAIDS: http://www.unaids.org/en/regionscountries/countries/southafrica

World Health Organization . (2014). Retrieved from http://www.who.int/mediacentre/factsheets/fs365/en/