In planning out my study for this summer, I defined my project in part by the questions I wasn't asking. Things like pain managment training and cultural issues ("We're poor/Xhosa/coloured. People like us suffer. Rich people get medications.") will need a different sort of investigation, and this was anticipated to one degree or another. But yesterday it was brought to my attention that a new question arose last week.
"The Michael Jackson thing is going to set us back. People are going to be afraid of opioids again," said a pain specialist. Now, there's a lot that can and has been said about MJ's death, but this was the first time I had thought of how it might impact medical care. Christian Sinclair, who writes about palliative medicine in the new media, had a post or two about it as well.
What a tragic legacy it would be if his death erected yet another barrier to pain management for people who need it.
Tuesday, June 30, 2009
Friday, June 26, 2009
Go Pens
Yesterday was the best day I've had since getting here. I feel like I'm hitting my stride with the interviews, and having a car to explore has been a real treat.
I spent the morning in Fish Hoek, interviewing the interdisciplinary care teams (doctor, nurses, social worker, chaplains--hello Mariska and MB!) about their experiences with pain control. They were really helpful and I learned a lot about some of the system barriers that are preventing optimal pain relief. And while I'm not actually sure where my medical career will take me, I do know that I have huge amounts of respect for the team model that I've seen in palliative care.
I took the combination of a productive morning and some good weather as a sign that I should spend the afternoon exploring, which I did. How much do I love summer research?
I ate here:
And then went down to Boulders Beach and saw the penguins:
If my commute home looked like this every day, I'd be pretty happy:
I ended the day with a fantastic sushi dinner with E. and her daughter. We availed ourselves of all the seafood Cape Town has to offer. Oh, and I had springbok sushi. It was pretty amazing.
Next up: hiking Table Mountain in the morning with officemates. The weather has promised to cooperate this time.
I spent the morning in Fish Hoek, interviewing the interdisciplinary care teams (doctor, nurses, social worker, chaplains--hello Mariska and MB!) about their experiences with pain control. They were really helpful and I learned a lot about some of the system barriers that are preventing optimal pain relief. And while I'm not actually sure where my medical career will take me, I do know that I have huge amounts of respect for the team model that I've seen in palliative care.
I took the combination of a productive morning and some good weather as a sign that I should spend the afternoon exploring, which I did. How much do I love summer research?
I ate here:
And then went down to Boulders Beach and saw the penguins:
If my commute home looked like this every day, I'd be pretty happy:
I ended the day with a fantastic sushi dinner with E. and her daughter. We availed ourselves of all the seafood Cape Town has to offer. Oh, and I had springbok sushi. It was pretty amazing.
Next up: hiking Table Mountain in the morning with officemates. The weather has promised to cooperate this time.
Wednesday, June 24, 2009
Dozen
For some time now, and with increasing frequency since coming to Cape Town, I am asked how I came to be interested in palliative medicine. I usually answer by talking about my time working in social medicine; it is true, it is accurate, but it is wildly incomplete.
The full truth is this: half a lifetime ago I sat on my father’s hospital bed while his surgeon told us that they would both do everything they could, but that their primary goal was to keep him comfortable. It’s the last time I remember my father being fully cognizant, although he lived for another year and a half. In that time he underwent surgeries, radiation, chemotherapy, and was on a cocktail of drugs to prevent seizures and reduce the swelling in his brain.
Hospice became involved at some point, although it was for longer than the insurer-prescribed six months. We learned how to guide him as he lost his sight; and tricks for delivering medication. I remember having coffee with a chaplain and not knowing what to say, how to make sense of what had happened to my life. And I remember our community coming together as an informal care unit, keeping our freezer filled with dinners and providing rides to school and to doctors’ appointments. And I remember my father’s physicians, how attentive they were to us, how they bore witness to our pain and confusion throughout the process.
These are experiences of illness that work against suffering, but supportive care alone provides little relief in the face of physical discomfort. And so the physicians tended to his body as well his family. To the extent that medicine could provide relief for him, it did. We were lucky in this regard, as my father’s symptoms were mostly cognitive, and he suffered negligible pain. As a family, our suffering was great, but essentially limited to the personal and spiritual realms. Suffering beyond that—from poverty and inequality, for example—is beyond my imagination.
So how did I get here, working to improve access to palliative care drugs in rural South Africa? Experiencing the effects of good palliative care, before I even knew the term—that’s a good starting point. But it’s hardly a straight line from my family’s experience to here; years of education, formal and otherwise, have intervened to shape my goals. I’m here in part because of a genetic sense of social justice, from my conscientious objector grandfather, to my father, who marched against Vietnam in his dress whites, and my mother, who came out in the cold New England winter to knock on doors for Barack Obama.
The full truth is this: half a lifetime ago I sat on my father’s hospital bed while his surgeon told us that they would both do everything they could, but that their primary goal was to keep him comfortable. It’s the last time I remember my father being fully cognizant, although he lived for another year and a half. In that time he underwent surgeries, radiation, chemotherapy, and was on a cocktail of drugs to prevent seizures and reduce the swelling in his brain.
Hospice became involved at some point, although it was for longer than the insurer-prescribed six months. We learned how to guide him as he lost his sight; and tricks for delivering medication. I remember having coffee with a chaplain and not knowing what to say, how to make sense of what had happened to my life. And I remember our community coming together as an informal care unit, keeping our freezer filled with dinners and providing rides to school and to doctors’ appointments. And I remember my father’s physicians, how attentive they were to us, how they bore witness to our pain and confusion throughout the process.
These are experiences of illness that work against suffering, but supportive care alone provides little relief in the face of physical discomfort. And so the physicians tended to his body as well his family. To the extent that medicine could provide relief for him, it did. We were lucky in this regard, as my father’s symptoms were mostly cognitive, and he suffered negligible pain. As a family, our suffering was great, but essentially limited to the personal and spiritual realms. Suffering beyond that—from poverty and inequality, for example—is beyond my imagination.
So how did I get here, working to improve access to palliative care drugs in rural South Africa? Experiencing the effects of good palliative care, before I even knew the term—that’s a good starting point. But it’s hardly a straight line from my family’s experience to here; years of education, formal and otherwise, have intervened to shape my goals. I’m here in part because of a genetic sense of social justice, from my conscientious objector grandfather, to my father, who marched against Vietnam in his dress whites, and my mother, who came out in the cold New England winter to knock on doors for Barack Obama.
***
Today is a dozen years since my father died. I have mixed feelings about it – after all, until 1997, June 24 was nothing but an early summer day. And then it became a marker in my life, a place to orient a before and an after. As each year has passed, I have been able to see more clearly the role my father’s death played in shaping my life. At one year, I was lost; at five years, I was found, and beginning to think about a future of some sort; and at ten years I was writing my application essays for medical school. At twelve years, I’m here, in an office thousands of miles from home, on an ordinary workday. In many ways, I’m worlds from a life with my father, but at other times I can conjure his encouraging voice. I know he would be proud of me—he always was—but sometimes I’d trade anything just to hear him say it one more time.
Monday, June 22, 2009
From the people who brought you the weekend
Today is the first day of a doctors’ strike in South Africa. Having not received a 50% (that’s right, fifty) pay raise from the government, they have taken to the streets in protest in several provinces here.
It blows my mind that doctors can go on strike; who’s taking care of patients?* Of course, it's not unheard-of: when the U.S. government shut down in the 90s, my physician uncle was working part-time at a VA hospital. If I recall correctly, he didn’t go to work at the VA during this time; at the very least, I know that he wasn’t paid during this time. It wasn't the same thing—certainly it came from a very different set of circumstances, but it's the only time I can recall doctors actively not working.
I just saw an intern (first-year doctor) interviewed on the news, and he explained how the current system made it difficult to do his job: "the conditions are terrible . . . patients are dying all around you. Last week there was no oxygen in the hospital . . . there was no water for two days." He also revealed his salary: 8,000 rand/month, or $12,000 a year. Pay increases as you progress through training, but not by much: a senior general surgeon with 15 years experience quotes his salary as $28,500.
There are two systems for health care in South Africa, one public and one private. The private system is similar in many respects to the U.S. system, with insurers (called, hilariously, “schemes”) paying for a portion of medical care. Most patients are in the public sector, however, which is notorious for overcrowding and poor conditions. Public physicians make far less than their private counterparts, and they work well beyond the 80-hour workweek that has been imposed on U.S. medical trainees.
Usually I stand with the workers—but these are doctors.
And usually I think doctors who complain about money are jerks—but that’s in America.
I know it’s more complicated than this, but South Africa would be wise to give the doctors what they’re looking for. It means standing with the patient, the 80% of South Africans whose already-precarious healthcare is at risk.
You can read more here, here, and here.
*Nurses, as always. They’re also bringing in private sector doctors for relief.
It blows my mind that doctors can go on strike; who’s taking care of patients?* Of course, it's not unheard-of: when the U.S. government shut down in the 90s, my physician uncle was working part-time at a VA hospital. If I recall correctly, he didn’t go to work at the VA during this time; at the very least, I know that he wasn’t paid during this time. It wasn't the same thing—certainly it came from a very different set of circumstances, but it's the only time I can recall doctors actively not working.
I just saw an intern (first-year doctor) interviewed on the news, and he explained how the current system made it difficult to do his job: "the conditions are terrible . . . patients are dying all around you. Last week there was no oxygen in the hospital . . . there was no water for two days." He also revealed his salary: 8,000 rand/month, or $12,000 a year. Pay increases as you progress through training, but not by much: a senior general surgeon with 15 years experience quotes his salary as $28,500.
There are two systems for health care in South Africa, one public and one private. The private system is similar in many respects to the U.S. system, with insurers (called, hilariously, “schemes”) paying for a portion of medical care. Most patients are in the public sector, however, which is notorious for overcrowding and poor conditions. Public physicians make far less than their private counterparts, and they work well beyond the 80-hour workweek that has been imposed on U.S. medical trainees.
Usually I stand with the workers—but these are doctors.
And usually I think doctors who complain about money are jerks—but that’s in America.
I know it’s more complicated than this, but South Africa would be wise to give the doctors what they’re looking for. It means standing with the patient, the 80% of South Africans whose already-precarious healthcare is at risk.
You can read more here, here, and here.
*Nurses, as always. They’re also bringing in private sector doctors for relief.
To the left, to the left
Not much to update on today -- just preparing for interviews, which start tomorrow.
I am renting a car to get myself from hospices to hospitals to Department of Health offices, and I am uncharacteristically nervous about driving. I have been adequately warned about the maniacal South African drivers, and to stay to the left; however, the fact that I thought my friend was taking me the wrong way down the street does not bode well. Wish me luck!
On an entirely unrelated note, I wanted to share this, courtesy of a fellow palliative medicine person. I feel that I'm minimizing its impact by telling you that it's Roger Ebert (he of the famous thumb) reflecting on his own mortality. It is well worth reading.
I am renting a car to get myself from hospices to hospitals to Department of Health offices, and I am uncharacteristically nervous about driving. I have been adequately warned about the maniacal South African drivers, and to stay to the left; however, the fact that I thought my friend was taking me the wrong way down the street does not bode well. Wish me luck!
On an entirely unrelated note, I wanted to share this, courtesy of a fellow palliative medicine person. I feel that I'm minimizing its impact by telling you that it's Roger Ebert (he of the famous thumb) reflecting on his own mortality. It is well worth reading.
Wednesday, June 17, 2009
Exactly
Today I called the hospices in Cape Town to make appointments for interviews. Here is an excerpt from one call:
me: blah blah blah to look at the availability and usage of opioids in HIV-positive patients receiving palliative care.
her: I don't think you would get much from coming here. We haven't had opioids in three years. Our nursing sisters wouldn't know about it.
I checked the number on the sheet to make sure I was calling the right place--I was.
Then I double-checked by looking at the map--it's about 6 km / 4 miles away from the university. To get there, I'll pass the President's Residence, turn at a Mercedes dealership and "keep an eye out for the sign on the left."
me: blah blah blah to look at the availability and usage of opioids in HIV-positive patients receiving palliative care.
her: I don't think you would get much from coming here. We haven't had opioids in three years. Our nursing sisters wouldn't know about it.
I checked the number on the sheet to make sure I was calling the right place--I was.
Then I double-checked by looking at the map--it's about 6 km / 4 miles away from the university. To get there, I'll pass the President's Residence, turn at a Mercedes dealership and "keep an eye out for the sign on the left."
How to stay safe in Cape Town
Classic and frequently repeated advice from guide books and Capetonians alike, found at a bus stop on my block:
It's part of a larger display, explained here:
It's part of a larger display, explained here:
Tuesday, June 16, 2009
Holiday in Hermanus
One of my classmates told me that Cape Town was “just like Pittsburgh!” Now, I love my adopted hometown, but this was not encouraging. I had hoped to travel halfway around the world to find something different for a few months. We do share championship sports teams and lots of hills, as well as an alarming love of mayonnaise and French fries. However, my friend was referring only to the weather. Every day there is a chance of rain, and more days than not there is some precipitation.
Today the forecast was again cool and rainy, but I woke up to a beautiful sunny day. It’s Youth Day, a national holiday commemorating protests by schoolchildren seeking equal education during apartheid. As far as I can tell, it means no one works and big box stores have huge sales. Fortunately, I had other plans.
E., my site mentor took Camilla and me to Hermanus, a coastal village east of Cape Town that promotes itself as the best place in the world to whale watch from land. We saw zero whales but two baboons and several dassies. They look like rabbits but are most closely related to elephants, and they enjoy "sunning themselves," as my Rough Guide informs me.
We ate lunch overlooking the water and walked around for an hour or so afterwards. It was a beautiful day, and a treat to see a different part of the Western Cape. As it turns out, actually, I’ll be doing some exploring for the project as well. E. and I decided that I should travel to the hospices to interview people, instead of using the phone. This is great on so many levels: I won’t be in an office all day on the phone; I’ll be driving around the countryside; and I’ll get to actually see what’s happening “on the ground.” My first interview is scheduled for next week.
More pictures from Hermanus are below.
Sunday, June 14, 2009
Weekend II: rain-outs and World Cup construction delays
Yesterday we were greeted with the worst possible weather in which to scale a mountain: rainy, cold, and thunderstorms in the distance. So while we saw the bottom half of Table Mountain from various vantage points, we limited our exploring to the city proper. Camilla (another visiting student) found a tour guide through the NGO we’re working with, and he drove us in and showed us around the remains of District Six and its museum.
District Six was an integrated, working class neighborhood in Cape Town that was declared “whites only” by the apartheid government in 1966. The neighborhood was demolished, and the black and coloured residents were sent to live in the Cape Flats, 40 km away. The townships out in the Flats are filled with shanties and lean-tos, and the area is rife with gangsterism. The museum commemorates the neighborhood with interviews, artifacts, and artworks from the citizens. It was quite a moving experience.
Today the idea was to find the Green Point Market, but it has been displaced by the construction for the World Cup 2010 – starting in less than one year, as I hear several times a day. It took us about an hour of walking to find it, at which point we were too tired to walk around , so we caught a minibus back into the city and had lunch. Our guide picked us up and drove us down to Chapman’s Peak, just south of the city. There's not much to say about it, but the view was lovely:
C. and Leon walking around Chapman's Point. The Sentinel, the peak seen in the distance, is privately owned and up for auction. You can't develop it, and the owners expect to get about R12 500 000 (~$1.5m). Any takers?
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