TB, HIV and.....Ducks???

It's been a long time, so I will give you all the excuse that I have been swamped with work as an indication that I am being super studious over here cuz I know it seems like all I ever do is go on extravagant trips! Haha.

TB

Tuberculosis is a disease that underscores how different South Africa's public health strategy is from North America's. They say that as soon as you have taken a ride in a kombi (a mini-bus taxi) here, that you can pretty much guarantee that you have contracted TB (though it remains latent in healthy people). Others argue that you have it in your system the second you step off the plane at the airport! At any rate, TB is all around us in South Africa. The high rate of TB infection is intricately linked to the high rate of HIV prevalence as well, since TB is the number one killer of people who have AIDS here. The more terrifying stats reflect the number of MDR (multi-drug resistant) and XDR (extreme drug resistant) TB strains that are popping up more and more here in South Africa. As their names indicate, these strains of TB cannot be fought by the regularly prescribed TB medications. As well, since TB is so infectious, MDR and XDR can travel very quickly through poor communities in particular, where people are living very close together. In North America, people with TB are quarantined in hospital, however it is impossible to quarantine everyone here who has TB unfortunately because there are just too many people who have it. Even worse, many local people who I have spoken to believe that forced quarantine is a human rights violation and that for example, a woman could not be quarantined if she had small children to care for.

A couple of weeks ago, the local news stations ran a story about a man who had XDR TB and who was released from the hospital back into the poor township where he lived. The hospital did not know that he had XDR when they released him, but the fact that he was allowed to return home to a densely populated township with an extremely drug resistant strain of TB was terrifying nonetheless. It reveals how susceptible South Africa is to an epidemic of resistant TB strains that will undoubtedly kill massive amounts of people.

In the North American newspapers this morning, an article was run about an American man from Atlanta who travelled to Europe and then back to the USA through Montreal who had XDR TB. The response to this has been a federally-enforced quarantine and notification of all those who may have come in contact with him on his flights. Food for thought when you look at the reaction to TB in the Western world and the reality of the situation here in southern Africa.

HIV

I have been spending a lot of time learning about the local response to the HIV epidemic here and it is absolutely fascinating so I thought I would share some of it with you all. First of all, South Africa has a two-tiered health care system - the private system and then the government-funded public system. In terms of HIV and AIDS, a person who goes through the private system can pay to go to AIDS-specialist doctors (there really aren't that many of them who claim to be AIDS-specialists) and they can pay for first, second and often third-line drug regimens. In the public system, the government provides free antiretroviral drugs to those who need it. When a person discovers that they are ill and need to be on antiretrovirals, they must go to a series of workshops to make sure that they have an understanding of their illness and the drugs that they will be taking (in the Medicins Sans Frontiers programme, the people must attend a number of appointments over a certain period of time before they can be given drugs in order to ensure that they are committed to taking the drugs). The government system then provides the patient with an adherence counsellor. The adherence counsellor is responsible for making sure that the patient understands how to take their medication (often, a regimen of antiretrovirals, combined with vitamins and Bactrin to fight off any infections, can mean taking dozens of pills 2 or 3 times a day). Many professionals argue that the adherence counsellor is the most important piece of the puzzle and some also argue that because the adherence counsellor is only made available in the public system, that the public system therefore has better adherence to drugs than the private system. The importance of taking all of those drugs at the same time for everyday of the rest of their lives is not only to ensure the maximal health of the person, but also to ensure that resistant strains of HIV do not develop. HIV is the fastest mutating thing on Earth. If a person doesn't take their drugs properly, then that gives the virus a chance to develop a strain that is then resistant to those drugs. Normally, if a person takes their antiretroviral medication properly, a resistance does not develop for years. At that point they then switch to a second-line treatment (and third and fourth line in North America). Eventually they are resistant to all the drugs that are offered to them and then the disease will run its course in the body. Resistant strains are detrimental not only to the person but also to others who they may further infect. For example, if an HIV positive person passes a resistant strain of HIV onto another person - even if that person already has HIV themself - then that second person could then contract the resistant strain, which would make that medication non-functional within them as well.

I recently attended a training workshop for people who have been selected to be adherence counsellors in the public system. During the workshop, the group got into a discussion about antiretroviral medicationt that is available here versus in the Western world. The group was outraged that they were receiving what they perceived to be "lesser medications" than North Americans when their country was carrying a much greater burden. I had no idea what to say. I felt embarrassed to be North American for a minute. The truth is, they cannot afford the latest drugs. Their government cannot afford the latest drugs. They don't use bad drugs by any means, but they don't have access to the third and fourth-line regimens that North Americans do because the drugs are so expensive. This gets into a whole discussion of the WTO and patent laws that I won't get into at this time, but I wanted to cry for these people because they are carrying the burden of the disease and they must make do with whatever their goverment is willing and able to provide them.

Some people argue that prevention is key and that money should not be "wasted" on treating people with AIDS. Apart from being a human rights violation however, treating people IS prevention. The viral load is decreased within people who are on antiretrovirals, which means that they are less likely to pass the virus on to others. There are various other economic reasons as well, including not losing a huge proportion of the labour force by providing ARVs and keeping employees healthy enough to continue working (afterall, the disease takes the biggest toll on young adults who make up the majority of the labour force), etc.

Ducks!

Some people may be thinking that I have a comment to make on the current Stanley Cup final series between the Ducks and the Sens. For the record, as a die-hard Leafs fan I do not like the Sens at all!!! However, this is not what I wish to discuss under this heading. What I do want to discuss is the fact that I have now been bitten by a third African bird!! If you recall from previous postings, I got too curious with a penguin and I did not use proper technique when feeding an ostrich. The other day, I attempted to call over a duck who was clearly used to people feeding it, so when I put out my hand to beckon him over, he launched at my hand, beak wide open and chomped down on two of my fingers. Fortunately, no skin was broken. I'm not sure why there is this great bird conspiracy against me, but I am just thankful I have not had the same run-ins with sharks or snakes!