Urban Hospital, Cultural Clash

Today I started working at Rob Ferriera hospital, an urban public hospital in Nelspruit. It is quite a contrast to last week. Moreso than I have felt yet while I have been here, I sense my “otherness.”

In the ACTS clinic last week, the patient population was totally foreign to me. A people whose lifestyle I understood poorly, and a language I didn’t speak. And although I think the doctors there have done an excellent job learning the language and the cultural practices so that they can be effective physicians, they are still very Westernized, and it was very comfortable for me to work with them. In addition, they wanted us to come, asked for us to come, and were eager for us to be there and teach.

Yesterday we arrived at the hospital, and the minister of health of this province had not sent a letter or given advanced notice that we would be there or that we had permission to be there. So yesterday we could not work, and subsequently, our position and role has been ill-defined. Today the minister of health appeared in person to give her permissions. Although all the staff have been quite kind, I can imagine it is not a great way to start your week to find people who you perceive as “auditors” to be spending the week with you.

This week, I am working with all South African physicians, which is wonderful, but I definitely feel like more of an outsider, and am feeling the cultural rub. When they shake your hand here, when you greet, it is a bit of an involved handshake, releasing, repositioning, and then releasing and going back to normal handshake position. It felt like a secret handshake to me the first day, I know I still can’t do it quite right, and I am practicing in my room out of their vision. The patients all speak another language as well, but mostly Swazi, not the SwiZulu that was spoken last week. I have picked up that “Dokotela” means doctor.

Not knowing the culture, I speak and act with more cautiousness this week, wanting to not overstep boundaries or do or say something culturally unacceptable.

In addition, today I was paired with an older male, a general practicioner (many of the physicians here, especially in the public sector do not specialize), who does most of the peds work. Upon being introduced to me, I could tell he was uncomfortable hearing that he was going to be taking advice from someone who appeared to be about 20, was a woman, and was white. While we were waiting for the first patient, he was talking about why he hadn’t specialized, why he had never been to America, etc. Almost felt like he was defending himself. I felt awful. I didn’t want him to feel emasculated or threatened by me or made to feel inferior by me. It was a challenge all morning, when I saw things being done incorrectly, to make suggestions without feeling like I was bossing him or criticizing. At one point, he left the room to see a screaming patient…I suspect he took longer than he needed to, because he told the nurse to keep sending me patients and I could see them and dismiss them without him being in the room…Maybe I am overanalyzing that. It is hard, when my main job is to teach out of what is not working and what is missing, to not FEEL like an auditor.

I have to keep encouraging myself that I can just do the best I can. I can just be as gentle as I can, as understanding as I can, to have as much wisdom as I can in the settings I am in. I hope and pray, that my heart is open, my eyes are open, and I am seeing and hearing without putting too much of my own cultural superiority on things. And that in the meanwhile, in the midst of the chaos, in the midst of trying to speak and understand a totally different cultural language, I am seeing and understanding the beauty of what is around me.

I continue to be struck by the numbers of orphans here. I think half of the pediatric patients I saw this morning were AIDS orphans. In the Mpumalanga province, approx 28% of the population is infected with HIV. That sounds like an enormous number, one that you can’t quite get your head around, but when you start to see all the orphans, a generation of children abandoned, your head starts to get around it.

I was also made aware today of how much denial and stigma exists around the disease, even a disease that is now getting political attention, that is getting national festivals around curing and preventing, that is infecting almost a THIRD of the population. Stigma and denial still exist. We saw a woman today who was 36 weeks pregnant. She is an educated woman (which is not true of the entire population). During her prenatal care for her last child in 2006, she was diagnosed with HIV. She has not since seen a dr about HIV. She did not come to the dr during this pregnancy until today, almost at her due date, knowing that medicines were necessary throughout her first pregnancy to help prevent mother to child transmission. In addition, her CD4 count is now 22, which is SEVERE immune suppression. It could have been prevented from getting that low had she presented to care at some point between 2006 and today. The only way I can explain this is denial. Denial that this disease was in her, that she was part of the stigma…Because otherwise, there is no logical explanation for why she would not come.