JENNIFER DOHRN, CNM, is Director of Midwifery Services at the Childbearing Center of Morris Heights, the Bronx, New York, the first birthing center in the United States to serve inner-city women of diverse backgrounds. Jennifer also directs the midwifery education program at Columbia University School of Nursing. She has been working in South Africa to expand health care in pregnancy, birthing and postpartum in the context of an AIDS health care crisis of epidemic proportions. The following are letters chronicling her most recent visit in South Africa in August 2007.
Missive Week 1
August 12, 2007
I am on a veranda with lush jacaranda blooming around me, and a monkey just jumped from a tree over my head. Back in South Africa, and as always, my heart finding an old strangely familiar home.
I arrived on August 4 after a 24-hour trip. It is winter in Durban, which means the temperature varies from 70 to 80 degrees. We stayed at a very old, funky hotel on the beach, so I was awakened to brilliant red sunrises each morning. This was the third workshop of the International Center for AIDS Care and Treatment Programs (ICAP) for a pilot nurse-mentoring program based in the Eastern Cape. The four of us who have led this project have been working together since last September. The first three days this time involved directly teaching/learning with 9 of the mentors. They are experienced nurses who left families and job security to join ICAP to become really skilled in HIV/AIDS care. Each one travels several hours a day to rural clinics to work with the professional nurse at the clinic on how to test and treat people with HIV/AIDS. It has not been an easy journey for each of them, as working conditions are very challenging and the epidemic continues to increase. My focus is always helping in the area of pregnancy, birthing, and this time, the immediate two weeks after delivery when the highest rate of maternal mortality happens. Women go home with their babies and die from postpartum complications and no immune system to rally to fight infections and hemorrhage, due to advanced AIDS; there are no statistics and little focus on this particular time in a woman’s life, and actually the more we reviewed postpartum care and practiced physical examinations on each other, the more excitement there was that interventions could be done.
The fourth and fifth days we were joined by 30 nursing leaders from the department of health and universities and colleges in Eastern Cape. This time we actually managed to have great debate and dialogue about all of the difficulties in getting pregnant women tested and onto antiretroviral medications. Perhaps because there is more trust in the group, perhaps because there is more recognition of how complicated and lacking the current system is — whatever, we actually agreed on areas to take back to sites and begin initiating changes. I wish I had more time to travel to some of the clinics I visited last summer. Tomorrow I am flying to Port Elizabeth in the Eastern Cape to go with 4 of the nurse-mentors to their sites to talk with their clinical supervisors about care for pregnant women. It will be a new area to visit for me.
There is much uproar here as the Deputy Health Minister was fired by President Mbeki after she refused to resign. She is an amazing woman, who stepped in when the Minister of Health, Manto Tshabalala-Msimang (who has promoted beet root juice for AIDS treatment), was sick. Madlala promoted progressive HIV/AIDS policies and did a public HIV blood test, urging all government officials to test. It is a big setback in stopping this epidemic to have her fired. There have been demonstrations and outcries in support of her.
So that is my news for now, as my colleagues are anxious to get on the road. I am trying to be present here, in South Africa, in my work. My family and friends give me amazing support to be here. Thank you.
Missive Week 2
August 19, 2007
Today is my son Amilcar’s 33rd birthday! I called him at 9:01 a.m. this morning, which was one minute after midnight in Los Angeles, to wish him birthday greetings and thank him for his very long and miraculous journey into my life. Hard to comprehend that it has been this amount of time — I guess we are graced with the incomprehensibility of time passing as we mature.
I am tucked into my lovely home in Durban, where I stay each visit here. I am on the verandah, the monkeys that I talk to Amina about are jumping from tree to tree, unimaginably lush foliage is in bloom, and it is Sunday morning. In contrast to this scene of tranquility and peace, I spent the week at public health centers in the city of Port Elizabeth working with two nurse-mentors on issues of care in pregnancy. The first clinic we were at, the head midwife called a group of pregnant women who were having their first antenatal visit together into a small exam room — gathered on a small metal bed, she talked to them about the importance of testing for HIV. The midwife said to them, “If you have the virus, you must still fight to have your dreams for your life.” Their ages ranged from 19 to 34, some were 24 weeks into the pregnancy, another woman who had just arrived from Zimbabwe was 38 weeks. She had recently crossed the border (as thousands are doing each day), her husband without work and no healthcare had been available. We then worked together with each woman alone, drawing the blood and waiting for the lines to change on the test packets to indicate positive or negative status. Two women had positive tests, and the midwife then very gently and insistently began to comfort the women and encourage them to go forward. One was distraught as her brother had just died of AIDS, and she thought her mother would not be able to bear this news. We then palpated bellies and listened to fetal heart tones and complimented the women on how well their babies were growing and what a great job they were doing. Women bring cloths in their bags, as well as their healthcare charts, as the clinics have no ability to provide sheets to cover the women while we do their exams. What came through so strongly was the absolute conviction of the midwife to make sure that everyone got tested and that they would leave with a sense that they had her compassion and support to work through acceptance of this diagnosis and that there could be a future.
My co-worker spent the week in a tuberculosis hospital, where a large ward was divided into spaces for men, women, and children. One nine-year-old boy, who had a large tuberculosis lymphadenitis on his chest, had been in the hospital for one month. During this time his mother, who would visit at nights, died of AIDS, leaving 3 other children with no one to care for them. So a neighbor brought the siblings, and all 4 children were living in this ward until a distant relative from another province could come to take them. A separate small room housed people with multiple drug resistant TB, since there was no more space at the facility that treats XDR TB (extremely drug resistant) or MDR (multiple drug resistant). This is the daily reality here.
An amazing thing happened during the week. We had spent time in our workshop the week before talking about the criticalness of the first week postpartum visit for women with HIV who had just birthed their babies. One of the nurses that I was working with, Kaya, really caught on fire about doing this and had a strategy of how I could help her during my visit. We started at the local primary health center and won the head nurse to the idea of starting a clinic for this visit, as a way to intervene in the high rate of maternal mortality immediately after birth. Kaya then arranged a meeting with a doctor from the Department of Health who worked in women’s health and presented her plan for opening a clinic at the major hospital where women deliver. This hospital has about 1,000 births A MONTH; the day before we visited, the midwife on the Labour Ward told me they had 13 births between 4:30 and 5:45 p.m. Hard to imagine. When I looked at the log book, in July there were 950 births in June with 156 women being HIV infected, and 149 babies who lived through birth being HIV exposed. We had already toured a space not currently being used, and Kaya described how at this clinic the women and babies could talk as a group, individual postpartum exams could be done, and lunch cooked and served! And the doctor agreed! A big step forward. So a plan was developed on how to draw up an operational plan, get buy-in from hospital and clinic administrators, and hopefully begin early postpartum clinic.
The big message is that there is incredible suffering and hardship, and also steps to find ways forward. The nurses are really heroes.
On Friday when I flew to Durban I went to the University of KwaZulu Natal School of Nursing to meet with the midwife who will be project director for the 5-year project to train advanced midwives in HIV care that has been my dream for so many years. It was great to see her and start building our relationship. Tomorrow we will have a four-day workshop to develop curriculum, so I will meet all of the other people who will be centrally involved. I am very excited about it.
I did get to hear great South African jazz last night at a place on the waterfront in Durban. It was much needed balm for my soul.
I hear it is very hot in New York, and there is a building hurricane in the Caribbean. I love getting news from you, and know you are traveling with me.
Missive Week Three
August 27, 2007
Here I am in Johannesburg, on Monday morning, wrapped in my friend Nomsa’s bathrobe as it is a very cold morning, quite different than Durban and its perpetual tropical climate. Nomsa has left for work, Pumela (her daughter) off to university, and I have a quiet house to myself. I will do a sit, read, pack for my trip to Capetown later today. This has been a very full week and much to share.
Last Monday I started a four-day workshop with colleagues preparing to develop curriculum for the KwaZulu Natal project to train midwives in HIV/AIDS management. The initiative is a three-year one, with the hope of extending the foundation’s grant to five years if we are able to meet our objectives. Initially the project was to train advanced midwives, but it has now been broadened to train enrolled nurses to receive midwifery certification, and midwives to become advanced midwives, to meet the desperate shortage of trained healthcare providers in rural areas. The project is based at UKZN School of Nursing, with a collaboration with the Department of Health’s College of Nursing schools (that train basic midwives) and Columbia University School of Nursing. The week was filled with group work on developing this new curriculum; I think the biggest thing that we accomplished was a concrete commitment to this project and a sense of teamwork. It gave me the opportunity to introduce myself and to start to know the various nursing leaders gathered. The Vice Chancellor of the Health Sciences Campus is the leading force — a woman of great intelligence, enthusiasm, clear vision, and a work ethic that leaves me running to catch up with her (so you know she works hard!). I also developed a comaraderie with the faculty at the School of Nursing, and even got keys to the visiting professor’s office, which they assured me would be awaiting my return. The need in rural areas for nurses capable of giving care in this epidemic is so critical; this is the epicenter of infection, and transport from nurse-run clinics to district hospitals is extremely difficult. The nurses based at these clinics are also the main connection to the communities which ultimately need to be the source for tackling how to destigmatize HIV and organize prevention programs as well as embrace those infected, raise the orphaned children, and give a sense of a future. A very ambitious timeline was presented for our project, with curriculum to be completed in September, facilitators hired, who will be advanced midwives, for each of the four designated districts, and the first training to be done in January 2008. The target is to have 120 midwives trained for each of the three years (360 in total), and 300 advanced midwives (in total). Our work is cut out for us! I will mostly focus on curriculum and training, which allows me to do work in New York as well as some direct work here.
I also was able to add into the week several dinners out, with the South African leadership of the foundation that supports this project, with the Vice Chancellor, and with friends I have made in Durban. I saw a beautiful Buddhist film set in Bhutan at a local yoga center, went to a book opening (a photographic collection of life in Durban) at a cultural center, and had a mendhi tattoo painted on my hand.
On Friday I flew to Joburg to stay with Nomsa and her family. She is a pharmacist from Umtata, Eastern Cape (who at one point in her life studied at the University of Iowa), and we were consultants together last summer. It was a special time to be with her, deepen our friendship, and be introduced to her family and friends. On Saturday we went to the Apartheid Museum, a must for anyone traveling here. It thoughtfully, graphically, and sensorily teaches the history of South Africa and the struggle for freedom. Parts (especially footage) are indescribable. It grounds one in what the larger picture here is, which gave me renewed strength in this struggle against AIDS. I think I will try to go there each time I return, as only pieces can be taken in at one time.
Saturday night we went to Joy of Jazz, a major jazz festival that occurs in Joburg each year. There were probably 800 people attending, and the audience represented how I picture the new South Africa to be. Music was incredible, and I must admit I was one of the first to be up and dancing. Yesterday we spent meeting some of Nomsa’s family who lives in Soweto, on her father’s side. There has been a great deal of development in Soweto with new housing, widening of the streets, and overall improved necessities of daily life. We went to a very modern health center that has state-of-the-art technology. After having seen slices of documentaries from the uprisings in Soweto, this was a stark difference and a tribute to the advances that have been accomplished in the last thirteen years.
Now I look forward to some fun days exploring Capetown. I will travel home this coming Thursday/Friday. Maceo turns two tomorrow (August 28) and shouts with great enthusiasm into the phone when I call. Amina proudly told me her abuelo has signed her up for salsa lessons on Saturdays, and bought her shoes “with high heels” for the classes. It is hard to believe that this is the beginning of my fourth week in South Africa and that I will be back in New York shortly. These are fulfilling days for me.
I look forward to catching up and seeing many of you soon —