Stigma

(image source)

This week our president made some of the first positive statements I have heard from the government regarding the AIDS epidemic in our country. Hopefully this will mark the end of the denial phase in the process of grieving for our country's slow death from HIV. I pray that now, as our country must inevitably move through the rest of the stages, that we will come to accept that AIDS is here to stay, and then move forward in developing strategies to fight it's rampant spread. This has been a long time coming.

You may ask what is fuelling this rampage? I have some ideas, and although they are not by any means a comprehensive list of all the factors, I suspect them to be some of the major role players. The stigma surrounding HIV, and denial of it's existence (supported by the government up until now) and the belief that "it will never happen to me" lie at the heart of it.

Why is it that a patient will come to hospital (or even bring their infant or child), and then not want to find out what is wrong with them and refuse treatment? Why seek help in the first place?
The prevailing attitude is: "If I dont test myself for HIV, I dont have it, and I dont have to make any lifestyle adjustments."

I am of the opinion that HIV is no different from other chronic or terminal illnesses. It's survival rate is comparable with that of ischaemic heart disease and diabetes (untreated, you may have HIV for 5 to10 years before developing any symptoms), and is better than most forms of cancer! The difference is that it is infectious, and you have to make adjustments to your lifestyle to avoid giving it to others (ie. stop sleeping around). This is the hard part, giving up the risky behaviour, and the topic for another post.

I am also of the opinion that the stigma is no different from syphilis, or TB. Why is it then that these are notifiable diseases, and HIV is not? I think that this is the first step to de-stigmatising the disease - make it notifiable, and bring it out into the open. Let clinics, employers, insurance companies etc. test people routinely. Changing the existing HIV testing policy (VCT) from an "opt-in" to an "opt-out" type process (as suggested recently by some Western Cape Health Department MP's) would be the first step. With the prevalence then revealed, it would be very difficult to discriminate against those infected with HIV, as I suspect the incidence would be much higher than expected. (The antenatal prevalence is 29% in our country, and I believe this reflects the working population). This is the best way to increase awareness of the seriousness of the disease, and get people to start thinking about the risks they are taking. Infected individuals would, with the knowledge of their status, be able to access treatment earlier, and therefore most likely live longer and healthier. Their partners would be able to take proper precautions too, and reduce their risk of infection.

Everybody wins.

Eavesdropping?

When one of my patients is emerging from an anaesthetic, I often ask them to open their eyes as confirmation that they are awake before moving through to the recovery room. I never really wondered before what their level of awareness might be before this point.

A patient came for a routine incision and drainage of an abscess, and recieved a routine anaesthetic for the procedure. The whole process was completed uneventfully. As the surgeon was about to place the dressing, a nurse pointed out to him that the particular dressing he was using was inappropriate, and suggested another (as she had previously been a rep for a company manufacturing dressings, and knew what she was talking about). The surgeon changed his mind, and used the suggested dressing. When this was done, I closed the gas and woke the patient.

The next day, the nurse sought me out to tell me that the patient had thanked her for suggesting the alternative dressing to the surgeon! The patient had heard, and remembered every word of the conversation! I must say, I was taken aback.. to my eyes the patient had been asleep, there had been no signs of possible awareness, she had not even been breathing on her own at the time (no muscle relaxants were on board) and this implied a deep level of sedation! (In addition to my usual approach wherein I tend to give more of an agent rather than less - this is the first such case that I know of in one of my patients). The nurse re-assured me that the patient had not seen it as a negative experience. I assume therefore that she must thankfully have had an adequate level of analgesia. Unfortunately, I didn't get a chance to talk to the patient myself.

This led me to wonder how often this happens? Maybe more often than we think, and the patients just never say anything? How many and how much of our conversations are they actually evesdropping in on? Thats quite a scary thought...

Maybe I should play them some music, or maybe I should start using the entropy monitor more often...

A Beginning

For some  time now I have been reading and enjoying blogs. I have found them to be informative, entertaining, encouraging, and a number of other similar adjectives. I have on occasion thought 'that happened to me once', and 'thats a good idea', but never thought to start writing myself. Recently, I read about the blogworld expo, where Dr Val would be moderating a panel on the topic 'Blogging for  change: How to influence healthcare through blogging', where a friend of mine would be speaking. Also, recently, I was listening to an interview with the same friend here, when he made an interesting point. He was asked if he knew of any other medbloggers in South Africa, and he said he didn't.. This sparked a thought - how can we effect change in our health care system through blogging if there are so few here! I decided I needed to start writing, so that maybe, on the off chance that someone of any importance stumbled across these pages, they might be enlightened to the plight of a South African doctor and his patients.


First off, a little about me. I am a medical doctor, with experience in the state and private sectors in South Africa, and more recently in the first world. I have spent the majority of my time working since my community service in what felt like a deeply rural hospital (and was staffed like one), although it isn't.. it is a referral hospital, for rather a large area. At this hospital, I spent my time split almost equally between surgery (daytime hours), and anaesthetics (after hours). I am currently looking for a post to begin specialising in surgery. I will let you know what happens in this regard in due course..


Secondly, my intentions for this blog:

1. I believe I have a rather unique viewpoint from inside the operating theatre, in that I have experience from working on both sides of the so-called 'blood-brain barrier', sometimes even at the same time, and that this would make for some entertaining reading.
   
2. It is a way to share interesting experiences, ideas, and case studies, and sometimes even give some advice I myself would have liked to have had.
3. It is a means to de-brief, and even 'rant' if necessary.
4. It is a place to share successes/ failures/ joys and frustrations.
5. My wife has a blog, and I need to show her I can do it too.
6. And lastly, I should be studying, and this is another means of procrastination.

There, thats it.. a beginning..