A Serendipitous Journey:
On Doctoring in the Developing World
Dawn D. Johnson, MD
Assistant Professor, Pediatrics
September 3, 2014
Outline
1. Facts about South Africa
2. Brief history of HIV in South Africa
3. Harriet Shezi Clinic, Baragwanath
Hospital, Soweto
4. HIV, AIDs, TB, MAC, PCJ, LIP:oh my!!
5. Culture
6. Privilege and service
7. What is Global Health?
• Mainly colonized by the Dutch
(1652) and the English (1815)
• Enforced apartheid 1960: strict
discriminatory laws
• 1st heart transplant done in
RSA in 1967
• 1st democratic elections 1994
(Nelsen Mandela elected)
• Key industries currently:
mining, tourism, wine
• 11 national languages, most
people are multi-lingual
• 52 million people, 25% have
high school education
History of HIV in South Africa
In 2001 President George W. Bush’s PEPFAR
program began funding clincs that provided
treatment for HIV/AIDs in South
Africa and other resource limited settings.
• 1982: 2 white homosexual
men diagnosed with HIV
• 1987: 1st black SA dx HIV
• 1990s-conspiracy theories,
witchcraft,
• HIV prevalence in 1990
was 0.7%
• ARVs ‘rolled out’ officially
in RSA in 2005 – HIV
prevalence nearly 20%*
• Today RSA has the highest
number of people living
with HIV in the world: 6.2
million (1:3 women)
70% of the global
health burden of HIV is
in SS Africa
History of HIV in RSA
• Nelsen Mandela said
that one of the things
he regrets most is not
doing more about
HIV/AIDs in RSA.
• His son died of AIDS in
2005 and he spoke
publicly about it
Nkosi Johnson
• Born with HIV, orphaned
• ARVs were banned in the
public health system by
Mbeki and the MoH
• Refused admission to
primary school
• Keynote speaker at the XIII
International AIDS
Conference, 2000 (Durban)
• Pres. Mbeki walked out
during his speech
• Founded Nkosi’s Haven
Nkosi
Johnson
4 February 1989 – 1 June 2001
Posthumously received the International Children’s Peace Prize in 2005
Global TB Burden
Burden of TB in South Africa
Rate of TB cases:
Globally: 139/100K
High burden countries:
177/100K
Africa: 363/100K
South Africa: 940/100K
TB rages onward (although here, not so much…)
• The most common OI
• Leading cause of death in
people with HIV
• Will kill ~3million people this year
• Infects someone every 1 second
• Infects 1/3 of the human
population
• Kills someone every 10 seconds
(360 people this hour)
• Is preventable and treatable
Constitution of the WHO:
“The enjoyment of the highest attainable standard of health is
one of the fundamental rights of every human being.”
Unjani Dokotela?
Working in RSA
• 2.5 years – Worked in an HIV specialist clinic at
Baragwanath Hospital, Soweto (PEPFAR)
• Helped to set up an Adolescent Clinic day at Shezi
• Volunteered: several orphanages, a hospice,
participated in a few child abuse cases pro-Deo,
homeless clinic and outreach projects, soccer boots,
cash for gogos (grannies)
• Pediatric Technical Team at WRHI and adjunct faculty at
Witwatersrand University – oversight of HIV/AIDs and
TB programs in multiple provinces, teaching, research,
DOH, participated in writing updates to the HIV
guidelines 2013 (PEPFAR), ran a complex care clinic at
Natalspruit Hospital
Herpes Zoster/shingles
WHO Stage II
Scrofula
HSV keratitis leading to blindness
TB LAD
Parotid enlargement
BCG adenitis
Flat Warts
Neonatal syphilis
Measles
Epidemic of Orphans in RSA
*15.1 million orphans live in sS Africa
*RSA – 3.7 million orphans, estimated 5.5
million by 2015
Happiness!!
Things I Learned Along the Way
• Respect cultural differences (greet, respect,
sangoma, indirect communication)
• Listen first, have an opinion later
• Take a history from people who are culturally very
different from myself. (mom?)
• Practice medicine all by myself – no/few
subspecialists.
• Do a really good physical examination, draw blood
• Improvise
• Smell TB, eyelashes in TB, X-ray tricks
• Cope with so many of my patients dying/suffering
What is Global Health?
Health is Global
What is global health?
• “There is a global crisis
of severe shortages and
marked maldistribution
of health professionals
….think globally about
the education and role
of health professionals.”
Nigel et. Al, NEJM 2014;370:950-7.
Workforce and Burden of Disease According to WHO Region.
Crisp N, Chen L. N Engl J Med 2014;370:950-957.
Ethical Considerations
• Should students be allowed to do in other
countries what they are not allowed to do in
the USA?
• Should research be conducted on patients
who will likely not receive the benefit of that
research?
• Should America recruit physicians from
nations with significant health care worker
shortages?
• Is health equity a basic human right?
• What difference does it make?
That’s Ayoba!
Ngiyabonga!
(Thank you)