Thursday, 31 May 2012

31-5-12  Time flies...it's the last day of May!!

MUCPP Township


Summary
Today we returned to the Chris Hani Township and did home visits.  We once again saw extremely poor families along with some that were well off.  We provided supplements and referrals here and there and I learned more interesting facts about the black culture and traditions.


Detailed Account
Today was much like the first day of the internship.  We picked up our translator but unfortunately our security guard was unable to join us.  I was shocked to learn that he had to appear in court today as the guardian of his niece.  She had skipped her two previous court dates from being raped so she was arrested yesterday, which is absolutely absurd to be arrested for being raped!  Anyway he managed to meet up with us later in the day.

We spent the day visiting many homes in the Chris Hani Township and completing the nutritional assessments.  Many people throughout the day came up to us and asked if we could give them seeds.  It was wonderful to see how eager they were to plant their own gardens and have a vegetable supply.  We saw one very thin 14 year old girl on the side of the road.  We proceeded to follow her home so we could determine her BMI.  She was extremely thin, so we provided supplements for her to begin immediately and then return to the clinic for more in two weeks.
At a home visit
Fat cakes, a normal part of their diet (very unhealthy)
I learned of a few more interesting facts about the traditions and thoughts of the black communities...
People have so many children in the townships in hopes that they will be looked after when they are elders.  Rarely can anyone afford or wishes to go into a nursing home, instead the children take care of their parents.  Even with these thoughts I find it common that many of the children have children of their own and then leave the grandchildren with their Opas and/or Omas.

I also found it intriguing that sex is seen as a common occurrence in the households.  Because the homes are so small and privacy is so very limited very young children see their parents during intercourse.  Many of the families sleep together in their living rooms and the parents have little shame and will engage with everyone around.  Therefore children follow in their parents footsteps and begin having sex at a young age because it is as common to them as eating breakfast and going to school.  I honestly don't think I have an opinion of this new found knowledge yet, I am just in shock.

What might have made my day when we drove past a day care.  The children were playing outside and we stopped by.  They immediately all ran over to the fence while I said "Dumela!" (hello), they responded so eagerly back.  Goodness they were so innocent and full of life and hope, I can only pray they will safe happy, healthy, and well in the difficult years that they are sure to face.
One of the best moments!!!

Wednesday, 30 May 2012


30-5-12

MUCPP Clinic

Summary
I was at the MUCPP Clinic for the duration of today.  We assessed patients and distributed nutritional supplements to the sick and malnourished.  We were able to help a multitude of patients ranging from a couple months of age to people in their 70s.  They were all living difficult lives but their appreciation for what we were doing was widespread, making the day unforgettable.

Detailed Account
Today we headed straight for the clinic to see patients and help distribute nutritional supplements.  We walked through the busy waiting room and organized ourselves before we started seeing the patients.  We didn’t deal with a line, yet the patient’s orderly figured out whose turn followed with no hassle.  I was given a brief rundown of how things would work today.  If a baby came in we would take the length, weight, and head circumference.  If an adult was the subject we would take the height and weight to determine the BMI.  With these measurements we would then provide nutritional supplements accordingly.
Me taking the head circumference of a little one.
For malnourished babies under 6 months Melegi, a milk supplementation, was prescribed.  This was the milk that all the mothers were previously given when it was considered dangerous to breastfeed.  The weight of the baby dictated the amount of supplements we provided.  In one case we gave 8 tins and told the caretaker to mix 5 scoops with clean water 5 times a day for the period of one month.  After evidence proved breastfeeding was beneficial a mistake occurred and roughly one million rand worth of Melegi was ordered.  Now since this milk is only prescribed in extremely rare circumstances the majority will expire before it can be put to use.  It the already dwindling funds the MUCPP has this is a devastating truth.

Malnourished children between 6 months and 10 years were given varying amounts of PediaSure.  For malnourished children we administered 3 tins, and for severely malnourished children we administered 6 tins.  For children suffering from certain conditions including Cerebral Palsy, Marasmus, Kwashiorkor, TB, and/or HIV varying supplements were given regardless of weight.  People above the age of 10 were usually given between 3-5 tins of Nutren (7 scoops, 2x day).  For severely malnourished patients, with a BMI below 17, 8 tins of ensure was prescribed. 

The majority of the people who came to the clinic were so incredibly grateful for their nutritional supplementations.  They were also extremely honest with their progress, most of which was in an upwards direction.  They were happy to see improvements and as much as they appreciated the help of the supplements they strived to not need them.  Once a person was doing well on a growth chart or had an acceptable BMI for 3 consecutive months they were taken off supplements.  On many occasions we gave them their final supplement and asked them to return in two months instead of the normal one.

Although the majority of the people were doing much better and improvements were obvious some were not as lucky.  One child came in with Kwashiorkor, where they had a high energy, low protein diet.  This caused the child to be very lethargic, have swollen extremities, skin lesions, brittle hair, and a protruding stomach.  PediaSure was prescribed and I hope that his family can emphasize the importance of his nutrition.  Another child’s weight was declining over the months and the mother received a lecture about abusing her child, I can only hope this scare worked because the social workers do not have the best reputation here.  I also met some of the frailest people I have ever seen in my life.  Not frail like an elderly person, frail as in a 25 year old male who worked hard, had a good attitude, but whose waist circumference was less than a basketball.  On a brighter note some of the patients were a pure joy to be around (I’ll upload some pictures of the day soon).
Shop Shop ("good")
My favorite patient of the day, boy what a personality!
Once again, today has been incredibly fulfilling and educational in a multitude of ways.

I also must add that when I came back to campus I…
got a gym membership and worked out!
tried pap!
found the climbing wall!!!
went climbing!!!!
met some great local climbers that are psyched to get me out on some real rock and give me info about Rocklands!!!!!

Tuesday, 29 May 2012


29-5-12

MUCPP Clinic

Summary
We began with a lecture in the van covering nutritional supplementation, growth charts, Prevention of Mother to Child Transmission (PMTCT), the referral system, the baby friendly initiative, and controversial issues all with respects to the township population.  We then proceed to MUCPP to tour the facility.  After our day was over I toured UFS’s incredible anatomy museum and anatomy laboratory followed by a guest speaker about egg consumption.

Detailed Account
Today was a bit more of a lecture day than an ‘in your face’ township experience.  We met in front of the nutrition building and jumped in the van.  We drove to a nearby parking lot and began our lecture in the laid back van atmosphere.  The topics we covered were nutritional supplementation, growth charts, Prevention of Mother to Child Transmission (PMTCT), the referral system, the baby friendly initiative, and controversial issues all with respects to the township population.

The Department of Health is in charge of the Nutritional Supplementation Policy (NSP) and determines the entry and exit requirements one must people to obtain supplements.  When residents visit the clinics they bring their growth charts/cards and there growth/BMI is assessed.  Supplements are given if an adult/child is below the 10th percentile.  Once the adult/child passes the 10th percentile and remains above it for three months they are taken off the supplements, but must return monthly to be weighed.

Growth charts are a vital resource for the dieticians, regarding children below the age of five.  Children’s growth progression is plotted on the charts, many are below average but not severe enough to hospitalize.  The growth charts also contain important information about the child’s immunizations, PMTCT and HIV information, vitamin A supplementations and deworming, as well as any notes doctors or nurses may have and health education messages.

The Prevention of Mother to Child Transmission (PMTCT) is a growing program in the poor areas of South Africa.  The main focuses are currently providing medication and education to families.  When a mother is 7 months pregnant she is given a medication that she must take right when contractions begin.  It is important to educate them about this because some will take it instead when they are 7 months pregnant if they are unsure.  This medication helps to protect the baby when blood is shared between the mother and child during birth.  All mothers also receive Antiretroviral (ARV) treatments, which is the primary treatment for HIV.  If a mother is HIV+ the child will also receive ARV treatments.

Prior to this year all the PMTCT provided milk supplementations to all babies and encouraged mothers to supplement rather than breastfeed.   It was found that when mothers used these milk supplementations more babies died from secondary means such as, supplement preparation and the lack of clean water.  The child’s immune system was also compromised resulting in more deaths as well.  Research shows that even in HIV+ situations it is better for the mother to breastfeed for 6 months after the child is born since ARV treatment is available.  It is difficult to convince many of these mothers that this is a safer way to raise their child because they have it ingrained that breastfeeding if they have HIV will be detrimental to the child.  ARV treatment is also much cheaper for the government to provide than milk supplementation.  In rare cases supplementation may be prescribed for example if the mother has a chronic disease or is mentally unstable or if the child is an orphan.

In order to be a patient at MUCPP you must first have and identification card.  If a person is sick they must visit the clinic closest to their home (there are roughly 26 small clinics in the area).  Only nurses work at these primary health care clinics and they are allowed to issue drugs of the essential drug list (EDL).  The EDL is composed of about 15 drugs that treat the common diseases.  If the patient is still not improving they will be referred to the secondary clinic (there are 5 in the Free State), like MUCPP.  This is a bigger clinic, containing a pharmacy, three doctors, and about 16 nurses.  If a patient is still unresponsive they are sent to a district hospital followed by an academic hospital.  If they visit a hospital and have a referral everything is free but if they do not want to wait at clinics then they must pay the bill of their hospital visits.

The Baby Friendly Initiative partners with Kangaroo Care and is promoted within the hospital.  It is focused on lowering the stress levels of new-born children by close contact with mothers.  They emphasize skin to skin contact.  Incubators are not used due to increased sounds and separation from the mother.  If a baby is not breastfeeding well it will be cup fed and lap up milk much like an animal would.  It is found that a pacifier or bottle teaches the child to suck which is different from suckling the nipple and therefore not promoted.
Many traditions and beliefs make providing the best care extremely difficult for patients, especially concerning children.  Women have been told how dangerous breastfeeding can be if the mother is HIV+ but now it is known that is untrue.  Convincing these women is difficult and it is usually more difficult to convince the elder women of the family to let her daughter breastfeed.  Also traditions state that women should not eat eggs during pregnancy but we know they contain important amounts of protein, lutein, choline, folate, and other vitamins and minerals vital for healthy babies.  These traditions make the dieticians role increasingly challenging as they try and educate the current generation.

Once the lecture was complete and I received hand-outs to read this evening we headed to MUCPP to tour the clinic.  MUCPP was established in 1991 after the Kellogg Foundation of the US invited all universities in South Africa (ZA) to propose partnership-concepts in the community.  The proposal from the University of the Free State won the competition and the MUCPP Clinic was built in partnership with the University of the Free State (UFS).  Departments from all areas of the UFS use MUCPP including medical, nursing, nutrition, economics, agriculture, construction, education, sport, recreation, youth, culture, administration, and theology.  Out of all the departments the nutrition is the only one that actually walks through the streets of the township and is engrossed in their living conditions.  Unfortunately a few years ago the funding for the MUCPP program was pulled and they have been struggling ever since.

The clinic was much bigger than I imagined but it was heart wrenching is some aspects.  We walked through desolate isles that could not be used because of insufficient funds.  We would then come to waiting rooms that could seat 500 and all chairs would be filled with people waiting.  Some hallways were packed of parents and children; every now and then I would hasten my walk and hold my breath through some overly occupied areas.

We stopped by the maternity ward and visited two mothers who had healthy babies earlier that day.  Our lecturer chatted with the nurses about the growth charts and we quizzed the mothers on how long they would breast feed for.  A great deal of the nutrition program is to educate the people on healthier lifestyles and the majority of the time they were eager to learn more.  We learned that the hospital had been out of growth charts for over two months and they had been copying them to give them to the mothers, which was illegal but the best they could do.

At the end of the day many people are turned away after waiting all day to be seen.  They arrive early in the mornings but are not guaranteed treatment or medication.  The TB and HIV area and supplementation pick up areas are always overflowing with patients.  Although the patients must go through a great deal of hassle to come to the clinic and are not always treated fondly they still continue to come, and I am so thankful for that.  I am extremely excited to work there tomorrow and I’m sure I’ll have lots of stories to report!

We finished up early today so the other nutrition student and I stopped by her father’s office, who is a doctor and lecturer on campus.  He allowed us to visit the anatomy museum before he took us to lunch and the anatomy lab following.  The museum was incredible, there were more organs and body parts than I have ever seen.  There was usually a normal organ followed by an organ affected by almost every disease I could imagine.  It was incredible to see the effects of everything from a malignant kidney tumor to a brain haemorrhage to atherosclerosis of the coronary arteries and all in actual humans.  Lunch was lovely and getting to know her father was a real treat.  We then visited the lab and it was the most educational place I’ve been to.  I dreamed of having a place like that to study while I was taking anatomy.  They had cross sections of real bodies you could touch and put together, along with every organ imaginable.  They had cadaver to dissect and plastic models of the full body you could take apart and put back together.  It was by far the most impressive anatomy laboratory I have ever seen.
A Kidney!! and one of the only appropriate pictures I could add from an Anatomy Museum and Lab
At 2 o’clock we met for a lecture about egg consumption.  A researcher from Las Vegas educated us all on the importance of eggs for all people and in all stages of life.  The majority of countries and organizations have always stated that people should eat no more than 3 eggs per week.  There has never been any research to prove this and research since proves that eggs are extremely beneficial to the body.  The World Health Organization, Australian and New Zealand Food Organizations, as well as the UK, Irish, and American Organizations have all removed the egg stipulations and now encourage everyone to eat roughly 6-7 eggs per week.  It was an intriguing talk and made me understand the value and importance of this easy to make, single serving food.



Monday, 28 May 2012


28-5-12

MUCPP Township

Summary
I attended the MUCPP and surround township today to observe and help educate the poorest of the poor in South Africa.  We went to people’s homes and filled out a nutritional survey on the household.  We assessed as a group (the lecturer, translator, South African student, and myself) on the plan of action and what was important to educate the person/family on.  All families were taught about how to prepare and provide healthier meals with the income they had.  To others we explained specifically what was going on in their bodies if they had diabetes, hypertension, TB, etc.  If necessary we referred people to different areas/doctors of the MUCPP Clinic for further treatment and assessments.

Detailed Account
We were warmly welcomed to the University of the Free State’s campus yesterday and moved into our dorms.  Kalie and I are roommates, while Brittany and Aubrey are living together.  We eagerly looked over our schedules to obtain information about what and when we would be doing different activities.  As we scanned over them, questions arose left and right, we were still quite confused about what lay ahead.  I tried to stay optimistic and decided to trust the system.  No matter what I would make the best of each situation and if I really didn’t like what we did, I knew it would change within a week.

That evening we were taken to a lovely dinner with the other 4th year nutrition majors (the students we would be working with), some of the nutrition lecturers, and a few of the international affair staff and students.  During this time we asked lots of questions and got clarification for a great amount of our burning questions.  After dinner I was more than excited about attending Mangaung University Community Partner Program (MUCPP) the following day, as well as each of the different weeks of the internship.  This excitement continued throughout the evening resulting in a restless sleep, although I was still able to jump out of bed.

Let the internship begin!  The nutrition student I would be working with this week met me at Emily Hobhouse, my hostel (dorm), quarter till 8.  We walked to the nutrition department where we were picked up in a vibrant red VW van decorated with kids, healthy snacks, and the phrase “Good choices for better health!  Kgetha hantle, o phele hantle!”  I am surprised at how welcome I have felt in my short time in Bloem.  I entered the van and met the lecturer who addressed me by name before having to introduce myself.  Without hesitation we were on our way to the MUCPP Clinic and surrounding Chris Hani township.  During the thirty or so minute drive we caught up about ourselves and they answered all the questions I could think of, while explaining a little of what I should expect.
The van/our classroom and our wonderful security guard!
When we arrived to the clinic we said hello to the dietitians insides and had a mini lecture in the car describing what we would be doing today.  We then drove to pick up our translator (also a dietitian) and security guard before today’s location in the township.  The knowledge I learned today was so vast in so many ways.  I learned about the development of townships, the traditions of blacks and coloreds, the health and nutrition of people living in townships, the list goes on and on.

The townships are owned by the government and part of a Reconstruction and Development Program.  Most townships arise from a large amount of people squatting in a certain area.  They build shacks from tin and what little resources they can find in large open fields surrounded by great amounts of trash (in respects to what I have seen in Bloem).  When enough people live in these extremely poor and primitive locations the government comes and builds concrete houses, roughly 6-7 square meters) and gives them to the residents, which can range from 2 people to 15 people.  At this time the residents are supposed to tear down there primitive tin houses (Makuko), that usually are in their backyards, although many keep them and rent them for income.  Electricity is then installed in these houses followed by a sewage system.  The majority of the time bathrooms and sinks are located outside of the house unless one is wealthy enough to pay for it inside the house.

The household income is mainly received in two forms; from people working and from government grants.  If a person is a registered citizen some of them may be eligible to receive grants for income, but unfortunately many of these people don’t even have birth certificates or can’t be bothered with getting registered.  If the income is lower than a certain amount people can support themselves with grants.  For every child a mother has, and registers, they are able to get a 250 rand grant per month (roughly $33 USD) until the child is 14 years old.  If a female resident is above the age of 60 or a male resident is above the age of 63 they can receive an old age grant of 1000 rand (~$133 USD) per month.  If someone is unable to work because of disability they may also receive 1000 rand per month.  Lastly, many of the population between 25 and 40 have passed away due to aids, this leaves the grandparents to take care of a great deal of grandchildren.  If a resident is taking care of foster children they can receive 650 rand (~$87 USD) per month for each child.
With lots of new information and a bit of culture shock coming my direction we began our job for today.  We walked through the township looking for open doors or children playing.  When we located a house with someone inside our translator would enter and ask if we could come talk with them about nutrition, etc.  Every time we were welcomed into their homes or outside if they preferred.  Most people spoke Southern Sotho which  the translator would mostly dictate the conversation.  Others spoke Afrikaans where the lecturer and student would jump in.  One well educated lady also spoke English where I was able to help conduct the survey.

When we arrived at each home we completed a MUCPP (Nutrition) Community Survey.  Most of the time the women were at home doing laundry and chores while looking after the children that were under five.  It was good when no one was home, indicating that everyone was at work or in school and therefore caring for themselves.  We would begin by writing the name, sex, and age of each member of the household.  I was told that many households were confusing and nearly impossible to understand.  Lots were composed of a family with their children, along with grandchildren, sometimes a person you didn’t know how they fit in with their children, etc. the possibilities could be endless.

Doing a Nutritional Survey 
If people were present we would take their height and weight to determine their BMI and refer them to the MUCPP Clinic if necessary.  If children under 5 were present we would also weigh them and plot it on their growth chart.  For each child a parent is given a growth chart.  They take the chart with them to the clinic for check ups, where their child’s health is plotted as well as any notes the nurses & doctors have, and their immunization records.  All of the services at the clinics are free of charge so it is imperative that the children are taken there to check their nourishment.  All of the children we encountered today were not needed to be referred to the clinic for supplements but all fell between the 30th  and 50th percentile for their age category.  If a child was noted to be malnourished or abused the children would be referred for supplements and possible the caretakers to social services or the police would be called.

Following the head of the household was established as well as who and how many people provided money for the household (including employment and grants).  Access to fresh water was noted as well as the presence of a vegetable garden.  We tried to promote having their own gardens as a means of constant food and to lower expenses of healthy vegetables.  If they were interested in making a garden we provided them with spinach, beetroot, carrots, and cabbage seeds, as well as a pamphlet on how to have a garden.  Questions regarding going to the clinic for children and for sickness were asked.  If people didn’t go to the clinics we asked why and helped to explain how important it was for them to attend to remain healthy.
We then asked if anyone in the household had any of the following conditions; diabetes, heart disease, hypertension, peptic ulcer, loss of appetite, TB, overweight/obesity, diarrhea, constipation, weight loss, HIV/Aids, other.  To my surprise people were extremely open about their health conditions and most were thankful to have the clinic to obtain regular assessments of their health.  The most common conditions we encountered was diabetes, which they understood as high sugar levels, and hypertension, which they called high blood.  Many of the people who had been diagnosed with these conditions were unaware of what exactly they were doing to their bodies so we used pictures and simplified versions to explain why their body sometimes felt the way it did and gave ways for them to improve their health, while still acknowledging their limited resources and funds.  We gave everyone pamphlets on the three main food groups and how to prepare and eat healthy meals as well as pamphlets for certain diseases that were encountered within each household.

The other diseases we were aware of was the amount of people affected with TB and HIV/Aids.  I noticed more people with TB, and most being children.  If someone had TB they were required to take a supplement daily to help with their immune system, although I am unsure if they knew why it was so important that they do it even if it tastes bad.  If one person in the family had TB all children under 5 were tested and put of medication to protect them and be proactive.  People with HIV were also recommended to attend the clinic and receive supplements and treatments, especially when their CD4 count was lower than 200.  Although in each case the personal situation had to be assessed to determine what was necessary.
A question about family planning was always addressed.  It was common that most of the higher educated women understood how important family planning was and they were also the ones with one or two children.  Although most women took advantage of injections (1 every 3 months) some did not and many less educated women had multiple children, many of which they could not care for.  If injections caused unbearable side effects birth control tablets were administered, but rarely due to cost.  Lastly sterilization would become a possibility but almost never happened due to fertility being highly regarded to the African men.

This brought up a great deal of information about traditions in the black culture regarding wives.  Almost all black and colored men still, in some way, pay for their wives before they are allowed to marry.  Men will make an offering to a woman’s family, weather it be cattle or money, etc. in hopes of marrying.  Most of the time the man will make sure the woman is fertile by impregnating her before marrying her, and many times will not marry her at all.  In many instances it will take a man a long amount of time to come up with the sum to pay the family and by that point he will already have multiple children with his future wife, therefore supporting a family and paying for his wife.  This makes many men believe that they own their wives and therefore can have many children with them and highly regards fertility.  Surprisingly the more education a person receives nothing changes with this system except the woman is worth more money to the family.  I found this extremely interesting and surprising in more than one way.

Lastly the family was asked to do a brief recall of the foods the ate for breakfast, lunch, and dinner.  Most of their meals were pup (high in salt and porridge/grits like), milk, chicken (if they could afford it), and a vegetable, but usually only one or two of these at any given meal.  Obviously they were not able to get a well rounded diet eating only these foods so we suggested how to make their meals healthier with foods they could afford.  It was also very interesting to note that families with little money, little education, and many children would often be undernourished yet the parents still acknowledged they spent money on alcohol.  I observed that many mothers were slightly over nourished, children all somewhat under nourished, and men mostly under nourished and relied on alcohol.  It was a culture shock to see where their priorities were and we did our best to convey to them the importance of a healthy diet without being offensive.

If people were in need we would refer them to the clinic on all sorts of accounts.  If their teeth or eyes were bad they were referred to the dentist or optomologist.  This extended to people who needed psychological counselings, dietitians, AIDS treatments, social workers, doctors appointments, etc.

One of the most shocking families we visited was smaller, being just a couple and their one 4 year old child.  Surprisingly the 4 year old was the only one who put money on the table each month.  The mother did not work but kept the house clean.  The father almost lost his hand from a cut and had an operation.  He was on disability but was removed from it so now the family is surviving off 250 rand (~$33 USD) per month.  The child was just above the 30th percentile on his growth chart, the mother slightly overweight, and the father average.  When we addressed what they ate they told us they would eat foods from eggs, to vegetables, to biscuits, to chicken, etc. when they could afford it but nothing was guaranteed each month or day except for alcohol.  It was heartbreaking to see the sweet, well-behaved 4 year old, whose eyes lit up when we gave him a balloon and then realize that his parents don’t understand the importance of his or their own health.
It was nice to know that when we were helping families and telling them how to improve their quality of life they seemed to be so grateful for us.  The children were sometimes a bit startled by us but it could be due to the fact that they might have never seen a person with white colored skin before.  The majority of the people were extremely receptive and seemed to really take their new knowledge seriously.

Although it was a big culture shock and an experience I will never forget I feel like this is a step in the right direction for South Africa.  There are not nearly enough people doing what these nutritionist are doing, it is a start.  We were mearly a drop in the oceans of townships but we educated and helped the best we could.  After today I believe a great majority relys on the education these people receive in order to change their lives and the lives of the next generation.  If we can teach one person in the family and if they can share what they learned with the others, etc. we can begin to improve the system.
Some township homes