My first week has been splendid!  Drs. Anton and Tania Stoltz are wonderful hosts.  Tania is a splendid cook and I doubt I will lose any weight while here these six weeks.  They have a three and a half year old son named Armand who goes with his mother and her dog to her office each day!  The Guest House is set on a steep hill overlooking Pretoria.  Rose, the maid comes in every day and gives me clean, fresh sheets and towels.  She does the laundry and irons my clothes too!  The guesthouse is well appointed and could be mistaken for a fine hotel.  I have my second car, just got it today, a Nissan with manual transmission…a step up from the Opal I had for the first 4 1/2 days.  The trip to Hammanskraal takes me approximately 45 minutes going at speed limit which is 120 k/h.  Hammanskraal is one of the homelands where thousands of people live in tiny houses stacked on each other.  There are such houses stretching as far as the eye can see in all directions.  After adjusting to jet lag, today is the first day that I can truly say I feel recovered.

The first day at Hammanskraal’s Jubilee Hospital we saw approximately 170 patients in the HIV Wellness Clinic.  Jubilee serves a very large area, not just Hammanskraal, but the entire Gauteng Province and is a secondary referral hospital from the rural clinics.  I had two doctors in the wellness clinic, Dr. Michael Thomas Rambau (Tom), and Dr. Vusimuzi Baloy (Vusi).  Tom is 67 years old and is quite the talker.  Vusi is much younger, only 33 years old.  Both of these gentlemen seem quite eager to learn.  I was quite impressed with their competence and willingness to see the huge number of people that flooded the clinic.  There really was not enough time for the physicians to do proper examinations and history review.  This will definitely lead to the practice of poor medicine.  I am empathetic and understand the need for brevity because of the numbers of people they must see.  Nevertheless, this is not HIV medicine at its best.

The other doctor, Dr.Raymond Mabuse, the liaison between hospital ward physicians and the wellness clinic, I only met briefly on the first full day, Tuesday 07/07/09.  I only saw him again briefly on Wednesday and not at all on Thursday or today, Friday.  I do not know the details of why I haven’t seen him. I made hospital ward rounds with Dr. Fritz Kinkel from FPD and the ward doctors: Dr. Morekane Ramasod (lady) and Dr. Stanley Matlala in Ward 2, the female HIV ward.  Both of these doctors are doing their four month public service stints. Dr. Boikhutso (lady) and Dr. Isila in Ward 3, the male ward.  Dr. Boikhutso is also doing her four month public service.  Dr Isila is a government doctor who is chief of the HIV medicine wards.

Several problem patients were identified: One was a female patient admitted the night before with fulminant PCP pneumonia.  The ward doctors had started her on appropriatly on an antibiotic but we suggested that she also was started on high dose steroids.  She was alert and talking to us albeit short of breath.  When I arrived this morning to make rounds, her bed was empty…she had expired during the night.  I asked if thesteroids had been given.  The answer was a nonchalant “I don’t know”!

The other patient was a man I saw on Thursday who was very confused and close to being obtunded.  He had been there several days and basically had not been cared for.  Nobody knew where he had come from, there were no relatives to be called.  The poor man was curled up in his bed, mouth-breathing had formed thick scum on his teeth…nobody bothered to give mouth care.  The ward doctors had ordered HIV testing which was positive and CD4 count was only 1 (one)!!!  He responded to me calling his name but he could hardly do more than that.  I instructed the staff to start HAART immediately or the man would surely die.  Since only the HIV Wellness Clinic physicians can prescribe HAART medications, the chart was taken to the outpatient clinic.  Dr. Tom Rambau looked at the chart but did not bother to go see the patient.  He merely wrote in the chart that the patient must have counseling  and have liver function tests first before HAART would be prescribed!  Today I went  to make rounds in the wards and found that HAART had still not been started.  Needless to say, in short order the man had HAART!  Dr. Tom’s argument was that the SA Guidelines had to be followed.  Counseling! To a basically unresponsive patient?!  Liver function tests!  The man was going to die without the medications, it is his only hope.

Today, Friday July 10,2009, started well.  I had been asked to make a lecture presentation every Friday to the entire hospital physician staff since HIV affects every aspect of medicine here in South Africa.  So all the department heads and most of the HIV doctors gathered in the main Boardroom at 8:45.  My lecture was on Basic HIV Virology made simple.  It went very well with questions being asked.  In the end they gave me a round of applause.  One physician said he had always been confused what “Reverse Transcriptase”, “Integrase”, “DNAase” meant.  After my lecture he told me it all crystallized for him and now he understood.  Quite gratifying.

That was my first week in South Africa!  I call it a great start.