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. Bushs 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 Nkosis Haven

Nkosi
Johnson
4 February 1989 1 June 2001

Posthumously received the International Childrens 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?

Thats Ayoba!

Ngiyabonga!
(Thank you)