Week 2: Universitas

5/19
Universitas was a bit more demanding than I anticipated, but the atmosphere has forced me to move rapidly and think rapidly. The hospital is very large, and holds a lot of patients that were referred from various other hospitals to receive specialist care. It has ten floors and a couple elevators that are always ridiculously full, so most of the doctors, surgeons, dietitians, etc. take the stairs (the nurses and patients opt for the elevator). I thought Sunday was leg day, but apparently every day is leg day. There are 5 dietitians, each in charge of a different ward. There are so many wards and units on each of the ten floors that I struggle to remember where anything is at all. Yesterday began with Marli making her rounds in the cardiovascular ward with a group of other doctors huddling into each room to review each patient's status. It was excruciatingly long and was likely very awkward for the patients. I also saw a lot of diabetic patients with calcified toes, black and stone-like. In fact, there were very few diabetic patients at the hospital who did not have calcified or amputated toes. I then followed Monica around the ear, nose, and throat ward as well as the pancreatic and gallbladder diseases section. She informed me about Whipple's procedure, a surgery designed for those with cancer to remove the head of the pancreas, the duodenum, the gallbadder, and the end of the common bile duct (because they are all so tightly integrated) and then reconnect the intestine, bile duct, and remaining pancreas. We sat through a brief presentation from a Fresenius Kabi (supplement company) rep speaking about the importance of including glutamine in the feedings for critically ill trauma patients in order to consistently maintain blood glucose levels. I then followed Will around what I guess was either a geriatric unit or a surgical unit, but he sat down with me and introduced me to the application of estimated energy and protein calculations to nasogastric tube feeds and which feeds he typically prescribes for diabetics, cardiovascular patients, those with decreased renal function, malnourished patients, patients recovering from surgery, etc. He also noted that it is important to note the amount of fluid a patient is getting through the drip in order to prevent oedema. Mariechen briefly showed me some dermatology patients, some with Stephen-Johnson syndrome, a severe skin rash caused by an adverse reaction to medication. In this hospital, it is usually found in patients with HIV or TB due to a bad reaction to an ARV or antibiotic. It is a really nasty disease that causes a lot of painful, bleeding, blistered rashes that can even spread to a person's GI tract, making eating incredibly painful. Mariechen said she treats these patients much like burn victims due to the increased protein needs to repair the skin, not forgetting to include glutamine supplementation (an essential amino acid). She also checked in on a few babies who were suffering from malignant brain tumors and were severely malnourished. When I first saw the babies, I thought that maybe I was looking at conjoined twins, because the tumor was about the size of the infant's head, and the skull had formed to accommodate such. She said that she struggles with charting the infants' growth due to the weight of the tumors, and that she hopes to collaborate with a hospital near Cape Town soon. One of the infants was 2 years old, yet only weighed 17 lbs, much of which accounted for the tumor weight.

A couple of years ago I could not have handled this kind of constant exposure to gruesome deformities, but I think that I have reached a point where I am no longer appalled by the abnormal, but compelled to improve the patient's condition in any way I can, even it it just means smiling and talking sweetly to the babies that don't receive enough social stimulation.

We also visited some patients on nutropenic diets, immuno-compromised patients who must reduce bacterial exposure, so bacterial culture in foods such as yogurt and unprocessed fruits and vegetables must be avoided. We also noted that patients treated with steroids have greater appetites, so they are often fed according to diabetic guidelines (low fat, low added sugar). Tuberculosis patients are typically placed in the sunniest rooms of the hospital in rooms that also have blue lights, as light kills a lot of harmful bacteria and somehow contributes to recovery. Heidi showed me around the dialysis center, which is definitely one of the most interesting but most depressing units in the hospital. If I was ever diagnosed with end stage renal failure, I think I would just eat whatever I wanted and die quickly. In the end stage, there is no hope for ever regaining renal function or qualifying for a transplant. Even the patients with higher renal functionality who qualify for a transplant may have to wait a while remaining on the chronic program. End stage renal failure patients do not qualify for the chronic program, so if a patient wants to continue dialysis, he or she must pay out of pocket. I know the wait list for a kidney transplant in the US is at least 7 years. In the public sector of SA, there are so few donors that Heidi couldn't give me an estimate. Certainly longer than 10 years. On hearing that, I was introduced to an end stage renal failure patient that also suffered from diabetes.

After that depressing prognosis, Will brought me to the kitchen to meet the foodservice manager, Thelma, and to retrieve the nasogastric feed that he had prescribed earlier. At this hospital, there is some form of a computerized system. The dietitians input general diet orders for patients receiving something other than the house diet. Listed options were endless and included diets order such as "Diabetic 7000 kJ" or "Low fat low sodium cardiac diet 8000 kJ." If the dietitian really wanted to, they could fill out diet cards with specific menus for every meal and snack that a patient receives and submit to the cafeteria, but that would be insanely time consuming. He fills out a diet card every now and then for a patient with mild renal failure. All of the items prepared come from Cook-Freeze, a foodservice company right by the university that prepares foods six months in advance and freezes it with nitrogen before distributing. Hannelise has actually been stationed there for the past couple of weeks. Will also explained the "Kangaroo Mothers" initiative for breastfeeding. Mothers are encouraged to hold their babies skin-to-skin for at least 2 hours following the birth, along with all the other breastfeeding guidelines that I've talked about previously. All of the hospital's nurses are required to be trained in breastfeeding and bottle feeding is heavily discouraged. When a baby is given a bottle or a pacifier, the sucking reflex is encouraged, rather than the suckling reflex needed for breastfeeding. Once the baby learns to suck, the ability to use the whole mouth and tongue to suckle is reduced, and the baby may refuse the breast. If the baby cannot be breastfed, cups are used in feeding, because cups still require the infant to lap up the milk using the tongue. Apparently in many grocery stores, you must request infant formula from behind the counter, because it cannot be found directly on the shelves.

Today (Tuesday) kicked off with a visit to the plastic surgery ward with Will, a unit usually host to patients with cleft palettes and breast cancer survivors. There was however, one outstanding patient who came in for a sex change, because he had previously visited a sort of village wizard called a "sangoma" who had given him funky tea and and then advised him to cut off all of his genitals. Unsurprisingly, the home operation was unsuccessful and landed him, who is now a her, in the hospital due to infection of the wound. He was referred to the dietitian due to increased protein needs while recovering from surgery. Village sangomas have the potential to be quite problematic for the health of rural communities. In addition to infections caused by primitive surgeries, some pregnant mothers are given strange teas and herbs that may cause fetal deformities. We also visited the CVD ICU unit and the cardiothoracic ward.

Monica and I visited the prem clinic again and checked on some babies who suffered from the blinding effects of congenital rubella. Then Marli took me to the gastrointestinal ward and pop quiz roasted me about paraenteral nutrition, total gastric outlet obstruction, ulcerative colitis, Crohn's disease, refeeding syndrome, Billroth 1 and 2 procedures, and the Roux and Y procedure. I haven't yet taken medical nutrition therapy or nutrition counseling, but I did my best to infer and maintain a minimum level of dignity. One thing I learned that really stuck with me while in that ward was the importance of maintaining a positive attitude and what I like to call 'doctor etiquette.' Doctor etiquette usually means avoiding habits like standing by a patient's bedside and saying to the intern, "Very few people recover from a condition like this," or "Hopefully the nurses don't forget to flush the tube this time." It kind of frightens the patient into thinking that they are not receiving adequate care and that their illness is terminal, which doesn't quite improve the odds of recovery.

5/24 
So I am trying to document all that has happened since Tuesday, and I finally just gave up on trying to describe everything in detail. Let's just sum up the week by saying that Universitas was a difficult place to work. The workload was heavy and individualized patient care was often compromised for the sake of time. Not to mention the poor students Johanrè and Shannon are always stressed, always working on blue books for the patients that the dietitians assign. Wednesday was a bit more relaxed as I visited National hospital, specifically the branch associated with Universitas' oncology patients that were referred here but still classify as Universitas patients. Rianna showed me around the oncology department and I noticed that most of the inpatients had esophageal, mouth, or lung cancer due to excessive alcohol consumption and smoking. A lot of patients smoke sketchy things rolled in newspaper and drink homemade brews, which increases the exposure to toxins and carcinogens even further. I try to be very good about greeting all of the sisters because otherwise they get very offended. But of course, the one time I forgot was on my way to the bathroom. I noticed one sister outside the bathrooms intently reading, so I thought it best to not disturb her, but afterwards when I was trying to exit the bathroom, the door was locked. I voiced to the sister my concern and she said she locked the door because I didn't introduce myself, to which I responded, "Oh sorry! Hi, my name is Jordan. Nice to meet you. Can you please unlock the door?" Her name was Gladys, and I picked on her later in the day when she couldn't remember my name, "...even after all we had been through together." We laughed about it and all was good at the end of the day.

Thursday was an easier half day at Universitas. After going through the ward rounds with Heidi, Monica, and Marli, we went to a guest house for a seminar on polycystic ovarian syndrome and insulin resistance, an interesting combination, though we also sat through a drug representative's presentation for Inositol and a presentation about PEN, a dietetics database of evidence-based research compilations. It was actually quite a relaxing event as there was abundant tea, milktart, salad, and quiche prepared by a catering service that Carlien was stationed at this week. I am beginning to understand why companies like interns so much. Unpaid, obedient employees that desperately seek your approval and positive evaluation are stellar for workplace efficiency. I stayed with her until the place closed up, which wound up being around 5:30 pm. Afterwards, I went to learn some field hockey moves from Hannelise and got some sushi with her and some friends after the hockey game. 

Friday, I went to the department presentations just like last week, but Marli wanted me to come in afterwards. When I arrived, she handed me a thick textbook and a couple pages of questions that I was to look up and define. I did about a page before it occurred to me that I was at the hospital for clinical experience and I was not receiving grades from the distributor of said busy work, so I asked Marli if we were going to do any more clinical work such as ward rounds or counseling sessions. I had not planned on staying past 1:30 pm anyways, because our daily itinerary that I had received at the beginning of the week said that I would stay no longer than 12 pm on Friday. She didn't have any other work for me, so she let me leave, and I was thanking my lucky stars that I did not need her evaluation. She doesn't seem to favor the other two students despite their desperate efforts to appease, so I'm not exactly sure how fond she is of the American who couldn't even remember the difference between a Billroth 1 and a Billroth 2 procedure. I was just proud of myself for knowing what a Billroth procedure was, because we've not yet discussed it in any of my classes.

Weekend 2: Good Company in Bloemfontein

5/15

I was really hoping that today would be the day that Hannelise, Wieda, and I go to the cheetah park, but it looks like that may have to wait. Rather, the morning was mostly occupied by dietetic presentations. Only five of the dietetic students gave presentations on their case studies, but it lasted from 8 am to 12 pm. It was not a bother though, because I had very little concrete plans for today, and I was really enjoying everyone's presentations. Unfortunately, the alcohol presentation was given in Afrikaans, so I only got a few key messages from the talk here and there. It was strangely comforting to hear some biochemical references in the presentations. It was also assuring to know that America is not the only nation to use the IDNT manual and the nutrition care process. I got to meet a couple of the lecturers there, and the ones I met seem very nice. Hannelise said that she really likes her department, and I agreed, because I also really like the nutrition department at Appalachian State. I do wish that our department was a bit smaller so that I could be closer friends with everyone in it, which seems to be the case for the dietetics department at the UFS. It is a rare a wonderful thing when you can say that since entering the department, you've only ever had high quality professors who genuinely care about you and your education. (Subtle shout out to Dr. McAnulty, Dr. Ball, Dr. Gutschall, and Prof. Casey). Maybe it is just a dietetics thing.

After the presentations, I briefly checked my email, spellchecked the blog (my tablet does not have that option apparently), got my UFS student ID card, and finally withdrew a substantial amount of money (praise the Lord!). Hannelise invited me to go with her and her sister to a field hockey game at the high school because I had previously told her how much I hated not having any plans at all for the evening. So we went to the game and talked a good bit, which was very pleasant and beautiful as the African sunset painted the sky bright pink and red. 

Field hockey looks pretty fun, so I may have a go at it soon with Hannelise's team during a practice. Afterwards we went to her house to chat and eat dinner, which I really valued because I got to know Hannelise a bit better. After a cup of Rooibos tea, she dropped me off at the apartment, in which I found a kitchen full of visitors drinking and chatting about. I heard Veronica (Czech Republic) and Nicole say something earlier today about a party, so apparently that did come to fruition. There were a lot of students from Holland, one from Germany, one from France, and one South African. I talked with the French guy for a bit because he seemed interested in political history and economic development in South Africa, which turned out to be really good

conversation for the 10 minutes that we spoke. I do regret not speaking longer with more of the international students, but I was so tired and found great delight in retiring to my room. Loud parties are really not the best way to get to know someone anyways. I nearly lost my voice trying to ask for everyone's name. Tomorrow morning I will be waking up early again, this time out of choice, to run a 5k at naval hill. It is a community run that occurs every Saturday morning, so if I don't travel anywhere, I will try to make it a habit. Hannelise, her mom, Michelle (the dietitian), and I will be slow jogging starting at 8 am, which should be pretty fun and casual considering we are all a bit out of shape. I am then hoping to visit some local craft markets and the mall with Carlien. I'll just fly where the wind takes me.

-Jordan

5/17

Naval Hill

First time I've ever spotted an antelope on my morning run.

What a fun weekend! Yesterday (Saturday) I practically spent the whole day with Hannelise, which was absolutely lovely. We woke up at 8 am to run at Naval Hill, because there is a community-sponsored park run 5k every Saturday morning that is advertised to the public, which I think is a splendid idea that should happen in more places. It was really wonderful to see all races, genders, and ages out there enjoying the sunlight and the beautiful surroundings. What I didn't realize until we got there was

Nelson Mandela Statue on Naval Hill

that Naval Hill is actually also a game reserve, right on a mountain in the middle of the city! The view from up there was magnificent, as you could see all the city and miles around it. Also, running with Hannelise was really nice, we were both about the same level of fitness, so we took an easy run/walk and chatted the whole way. Her mom came with us too, but was not as interested in running, so she caught up with us at the end. The place was void of any navies or bellybuttons, but we did see some antelope grazing around the second mile. Most of the animals were out of sight as they knew that Saturday mornings were busy around the trails. After the run Hannelise took me to the boere mark, the farmer's market, and I bought a good many things there.

It was a bit of a hybrid of a farmer's market and a festival, because there seemed to be

Hannelise at Naval Hill

far more crafts and fried foods than there was produce. Hannelise bought me coffee and we tried out the milk tart pancakes, which is apparently a very Afrikaans thing to eat. It was much like a crepe with thick sweet custard. What a highly nutritious post-workout breakfast. At the end of the day I wound up with a bag of dried mangoes, some handmade crafts, loads of wooden earrings, and a sugar rush.

Boere Mark

 

Later in the day, Hannelise took me to one of her field hockey games, as she plays for one of the varsity teams just for fun. It did look really fun, and Hannelise said that I may practice with them later this week because her coach is very relaxed. After the game, Carlien and I went shopping because I was looking for maybe a few cheap professional-looking clothing items (because a lot of stuff didn't make the cut into the suitcase), but I didn't find anything that was cheap enough or close enough to what I needed to warrant buying. Regardless, it was nice hanging out with Carlien, not to mention that Carlien loves shopping, and I think she needed to take a homework break. I am very sensitive to the fact that all the dietetics students are very busy because it was only a couple weeks ago that I was in the same struggle boat. I think that makes me appreciate all the more their efforts to hang out with me or take me places. That night there was load shedding, but afterwards the Wi-Fi did not turn back on in the apartment. So Martie (roommate from Holland) and I walked around the block looking for a signal from maybe a different University router. We take Wi-Fi "roaming" quite literally. I found enough to text my mom and Ryan, but when Martie left, I got scared and went back inside as it was a few hours past dark. Rather, I made brownies for Hannelise and her mom and read some C.S. Lewis Out of the Silent Planet for a bit.

Today (Sunday) Shannon, another dietetics student, took me to church with her and her boyfriend, Tyler. He is very sweet and polite, though I think Shannon is self-conscious about introducing him to folks at church because he is colored and she is white. I didn't even think about that factor before she brought it up. I just thought it was neat that he could speak Xhosa, an eastern cape language that I  really enjoy pronouncing (side click)osa. They go to St. James, an evangelical church, which was not quite so different from what I am used to at home. It was contemporary with a live band and full of a lot of young families. The message on discernment was right on, though briefly interrupted by the astonishingly loud outburst of a baby, shall we say, letting his burdens go. I discerned that he and his father were going to have a spirit-filled time in the restroom after the service. But seriously, the service was wonderful in that it helped me acknowledge that America is not the only place where the church is thriving. Afterwards, Tyler, Shannon, and I went to the bridge (school outdoor cafeteria/mall) to get some coffee and chat for a bit. Then I went to Hannelise's house again and played dominoes with her mom and mom's friend for a bit. We then went for a good 2-mile walk and I had to opportunity to talk with her about faith and about nutrition and their relation, which was really lekker. We got back to the house and did some pushups, lunges, sit-ups, blurpees, squats, and step-ups. I am hoping that I will be in decent shape by the time I leave Africa, but that may be inhibited by all the foods that accompany socializing. We ate some leftover braai (grilling foods like steak and sausage and such) and I got to call Ryan for a bit on WhatsApp. Tomorrow I will be working at Universitas, the hospital across the street from where I am staying, and I will be working with Shannon and another student named Johanre, a name that may take some muscle memory development before I can properly pronounce it.

-Jordan

Week 1: Botshabelo

5/11
So today was a really extreme experience. This is my first clinical experience regardless, and I suspect it will be unlike any hospital setting I will encounter in the future. Because the hospital is public, I expected that the facility would be understaffed and primarily occupied by low-income black African patients. After about an hour drive with Carlien, Lara, and Michelle, the dietitian who drove us, we finally made it to Botshabelo.

The trip to Botshabelo

I was very thankful that Hannelise let me borrow her navy blue sweater and red blouse, because that matched nearly perfectly the uniforms that the other girls were wearing. The dietitian there, Michelle, first instructed us to complete nutrition screenings in the maternal ward in order to assess if the program was adequately addressing all the objectives of the breastfeeding initiatives the hospital was implementing. I spoke with a woman who had just given birth the previous day and interviewed her about breastfeeding, maternal bonding, and the education and care she was given. Because Michelle instructed us to also offer information to the patient, I encouraged her to continue trying to express the milk, continue keeping the child close to her chest in skin-to-skin contact, and continue encouraging the child to suckle in a few different positions so that the baby's suckling will eventually produce the first milk, which I just said was very nutritious and good for the baby. The woman was very receptive to the interview and of course very pleased that she had given birth to a healthy baby even though he was over a month premature. Then we were sent to the main ward, which hosted various types of patients, mostly respiratory diseases and pulmonary tuberculosis patients (PTB). With these patients we were told to screen them by just asking questions and visually assessing nutritional status, such as estimating BMI and taking note of any physical signs and symptoms. If we determined the patient to be of nutritional risk, we were to note any recommendations and report them to Michelle. I was so thankful for the classes that I had taken during the past spring, particularly Nutrition Assessment, Advanced Nutrition, and Health Risk Appraisal, because the information that I absorbed was immensely helpful in assessing patient needs and determining if the patient would benefit from a nutritional supplement. I encountered a COPD patient and a bronchial pneumonia/PTB patient who were both very malnourished and clearly feeling terrible, so I recommended the "peanut butter" supplement called Imunit. Many of the patients barely spoke English and only spoke a little Afrikaans, so the other students had to interview as best they could in Afrikaans. I got used to reading the medical records that sit at the end of each patient's bed, because it was far easier to assess nutritional status through doctor’s notes than by trying to decipher Sotho. Even still, the medical records were very scattered and difficult to interpret. I now truly understand why digital, uniform medical charting is a need in hospitals. It is very easy for a patient to be given the wrong treatment when the medical records are unclear and not in chronological order. I also visited a diabetic woman who only spoke Sotho, but she was not properly managing her diabetes according to the charts and needed further diabetes education. However, none of the dietitians spoke anything other than Afrikaans and English, so we searched through some pamphlets to find one that she could read in order to give her clear information about insulin injection. I may try to learn Spanish when I get back to the states, because I realize that a language barrier in health care truly can mean the difference between life and death.

The hardest place to visit was the neonatal unit. I was not excessively emotional, but my heart did fracture in interviewing a mother and reading the charts of numerous infants diagnosed with PTB or pneumonia and were experiencing severe malnutrition because his or her mother did not breastfeed the child for long enough and had switched to diluted formula and pap (porridge) because they believed it was fine for the child to eat solids at ages younger than 4 months. The infants had likely contracted the diseases from either relatives or crèches, day cares that vary from seriously sketchy to reasonably adequate. I saw malnutrition in magnitudes that are unheard of for the United States, but more than common in South Africa. Today I saw one baby who was 9 months old and weighed only 5.2 kg, less than 12 lbs. Her physical and cognitive development was severely retarded; she was still toothless and basically the size of a 1 month old. Her aunt was there and the dietitian had prescribed F75 and F100, a nutrient-dense milk supplement, because the baby was not yet ready for solid food.

F-75 formula supplement

I saw another baby with PTB and pneumonia who was experiencing some sort of vitamin or mineral deficiency (likely pyridoxine) due to her tuberculosis medication interfering with absorption, and at 1 1/2 years old she weighed about 11.6 kg, or about 25 lbs. Her forehead was flattened in deformity and her eyes and eyebrows tiled downwards so that she constantly looked sad. Despite my best efforts to cheer her, she maintained a blank, emotionless face.

Staff entrance to the hospital in Botshabelo

It was in the neonatal unit that I truly realized the weight of my position as a dietitian. If there is one thing that I would want people to understand about dietitians, it is that they are health care professionals that do not exist for the shallow purpose of making people feel guilty for eating chocolate cake, rather, dietitians exist to save lives because they care about the welfare their patients and their community. When I changed my major from occupational therapy to

View behind the hospital

dietetics, (not at all to discount the crucial importance of physical therapies) I never knew that I was dropping the objective of improving lives in order to pick up the responsibility of saving lives. It's a pretty heavy feeling honestly. Even still, I believe that this is the profession that I am called to pursue, because I know that the weight of life is a bearable burden for Christ, so because Christ is in me, it is a bearable burden for me. I've been on countless missions trips, led youth and small groups, participated in numerous dietetic association committees, volunteered with pretty much any nutrition-related event at Appalachian State, and even given a sermon series at Wesley called "spiritual nourishment," but for the first time in my life, I felt abundantly fulfilled by my actions, like God was approving them by offering me the opportunity to use the knowledge that I have worked so hard for in order to tangibly affect and feel the lives of others. And by "feel," I mean allowing my life to take the shape of the contours of another person's life. That is the only way I think I can define what true service feels like. I know it has only been a day, and it was hard and tiring, but I am positive that this profession is where I am supposed to be. I tried to express how I felt about the day to Nicole, then Wieda and Hannelise, but I really wish that Ryan was here. He is wonderful at really listening with his heart and is probably my favorite person to discuss these sorts of things with.

On a much less contemplative note, the other roommates are back, and I met one of the Italians after Nicole and I screamed at the sight of a mouse in the kitchen. We frightened the poor thing out the front door, but thankfully he came back in time enough to rescue us from the mouse. I don't remember everyone's name yet, but I know there is another girl from Holland across the hall, a girl from the Czech Republic in the room next to mine, and two Italian boys down the hall. You could say that we live in a melting pot. I was hoping I would meet a student that would go to Cape Town with me, but everyone has already travelled quite a bit and Nicole is about the only one that I think I would like to travel across Africa with. The others are a bit eccentric. They really like to party and have told me many stories of their weekend trip and other various trips just jam packed with wild fun. Personally, I find my frontal lobe to be quite useful in hazardous situations, and I try my best not to offend it.

I also got coffee today at Mimosa Mall with Wieda and Hannelise, which was a really fun time. Both of the girls are really sweet and have been incredibly helpful. Wieda gave me her university credentials to log on to the computers, which I will attempt to use tomorrow, and both of the girls are keen on showing me the activities and sights of Bloemfontein. I also had just barely enough Wi-Fi at the coffee shop to send an email to Dr. Jones explaining why she hasn't heard from me for a while (sorry Dr. Jones!). Anyways, tomorrow I will be at one of the crèches, or day care centers, and I was told to bring my flexible measurement tape, so I'll likely be hanging out with Centi. I heard she is nothing special but I'm still excited to meter.

-Jordan

5/13

Yesterday (Tuesday) I took a break from the blogging because I was so exhausted from the day. I don't know why the jet lag is just hitting me now, but waking up at 6:30 am feels very much like 12:30 am to me. It takes about an hour to get to Botshabelo, so we try to leave by 7:30 am every morning. My fogginess made yesterday a very frustrating morning, because as we were interviewing patients my mind was not as sharp or as clever as usual, which made interpreting accents and responding accordingly very difficult. Also, we counseled a couple patients in the morning before heading to the crèche, and I felt generally useless. Lara and Carlien are very good at counseling because they have had loads of clinical experience, and as of right now I have about two day's worth of counseling experience. I am still not familiar with some of the commonly eaten and available foods here, so I fear giving irrelevant advice or sounding insensitive to the patients. I have learned that pap is a very common staple for most of the patients and I am also trying to understand how and where most of the patients obtain their food. So rather than counseling or educating, I sat and watched the other students counsel patients for a couple of hours. It was torture because I wanted to help so badly. I remained patient and tried to remember that I was here to learn, and that I was learning by watching them counsel. The first patient who came in was a mom with an 11 month old baby that nearly exclusively ate formula milk and pap. After the 24-hour recall, Carlien and Lara explained to the mom that the baby is old enough to be eating finger foods and soft fruits and vegetables. The baby was significantly underweight, so they continued the baby's supplementation of Imunut. Another patient who came in for counseling was a 35 y.o. woman who was referred because of her obese classification. The 24-hour recall was really helpful in assessing where changes could be made. She had never received any nutritional education before. She ate 4 cups of pap for breakfast, lunch, and dinner, as well as 2 cups of pap every time she wanted a snack. Sometimes she would combine the pap with chicken or beef, and most always she seasoned it with brown onion soup, a commonly used, high-sodium mix. She maybe ate 1 fruit a day and very rarely ate vegetables. In addition, she drank 4 litres of soda every day. I wasn't as much astounded that she ate some much pap and drank so much soda as I was impressed at her iron stomach. If I ate like that I would definitely hurl. Lara explained to her some easy ways she could alter her diet, such as reducing the amount of soda she drank and increasing the amount of clean, safe water as well as replacing some of the pap she ate as her snack with a fruit or a vegetable. As Lara talked, Carlien drew a myplate for the lady and labeled all the commonly eaten foods in each category. I think hand-drawing the plate and hand writing the recommendations made the information seem a lot more personalized and prescription-like.

Visiting the crèche brightened up my day as I began to feel useful again and the children there were really adorable. We couldn't find an operable scale to weight the children with, so we just focused on mid upper arm circumference (MUAC) and vitamin A supplementation. We were instructed to sort through about 50 "Road to Health" books, government-issued books given to all children born in South Africa that mothers are instructed to keep track of and keep safe. The booklet holds all of the child's immunization records, growth charts, and medical information. We searched each book for children aged 5 and under who had not received a vitamin A supplementation in the past 6 months. Over 2/3 of the children needed their next vitamin A supplement, so all of the children were sent through our dietetics assembly line to have their MUAC taken. Those in stack A were sent to Lara and Carlien to take a dose of the vitamin A. I measured 50 little de-sleeved arms, each dangling out from under a scrunched-up shirt that revealed 50 little bellies, about 1/3 of which were abnormally swollen, a sign of protein deficiency. Some little boys handed me flexed biceps to measure, while a couple little girls were not sure what I was doing, but were positive that it was going to be some form of torture. The only doctors in the hospitals and clinics are white, while all the nurses, the "sisters," are black. Michelle told me that little children only know white people to be associated with needles or pain. Thankfully, most of the children were happy to be cared for and maintained their darling smiles. As we departed, we were bombarded by a fleet of little thumbs, their owners shouting "shap," which means something like 'all good' in Sotho. We returned the "shap" by sticking our thumbs and snapping them against the children's palms. "Dankie, goodbye! Shap!"

When we got back to Bloem I was able to use Wieda's university credentials to log on to the computers, which was like taking a breath of fresh air. I was finally able to check my final grades, and I was pleasantly surprised to find that my semester GPA ended up being a 3.9, all A's and one B+ in Advanced Nutrition. Not bad for a 19 s.h. workload. At the point of discovery, my true nature was revealed to my new South African friends through sudden dancing and cheering. It was mildly embarrassing in retrospect, but let's be real, if they knew what a GPA was and the same happened to them, they would be breaking it down in the computer lab too. That bumped me up to a 3.64, so my day was rapidly re-calibrated to level fabulous. That is, until I went to the international office to check on my internet situation. Without going into detail, I think I must have had a really long, roller-coaster day, because I was not in an emotionally stable state, especially not in the face of sarcasm. It may have had something to do with having seen malnourished babies all day or missing my family. After the Wi-Fi voucher was sorted out, Wieda and I went to the grocery store so I could once again take on the challenge of withdrawing cash. Cash back from shopping with the credit card was unsuccessful, though I gained a lot of bananas in the process. However, after a sophisticated process of troubleshooting I like to call "randomized button input," I was finally able to withdraw 100R from the ATM, which unfortunately turns out to only be about $8. I'm telling you though, $8 goes a long way in South Africa. I think I can recreate the process. To get my student access card, Marleen explained that I needed to pay 65R to the bank while handing in an account number so that they would give me a receipt that I would then bring back to Marleen before 3 pm. Since the bank closes at 3:30 pm and I had no idea when we would be back from the hospital, Wieda said she would do it for me since her station is on campus this week. I don't know how I am ever going to properly thank Wieda for all of her wonderful, sweet-hearted help, but I am brainstorming my hardest.

So today (Wednesday) was a much easier day at Botshabelo. We were instructed give a breastfeeding presentation and then a diabetes presentation, both as introductory courses to the topic. The breastfeeding education was my favorite, because I know that breastfeeding education is the best way to prevent the severe malnutrition that I saw on Monday. In areas such as this, breastfeeding is still strongly promoted even if the mom is HIV positive. We say that as long as the ARVs are properly taken, there is a very low risk of transmission to the baby. Breast is always best. We explained that if the mother had cracked nipples or if the baby has sores in his or her mouth, that the breastmilk should be expressed by hand and heated in a jar over boiling water for 30 minutes, then cooled before given to the baby. We also explained how to express the milk by hand by cupping the breast and rolling the thumb over the glands to release the milk. Instructions for storage were also given: three days in the refrigerator, three months in the freezer. It may be convenient even to put the expressed milk in ice cube trays so that defrosting in a bowl over a simmering pot of water is easier. We also gave advice on how to position the baby, how to detect signs of hunger, and how often/long the baby needs to feed (the answer always being "as long as the baby likes"). 

Patient breastfeeding pledges

At the end of the session, all of the expecting moms were offered an opportunity to take the pledge to exclusively breastfeed for the first 6 months of their baby's life. About half of the 30 women that we talked to decided to take part by leaving a painted handprint on a signed piece of paper. The new handprints accompanied several others that already hung on the wall of the waiting room.

We then headed to another ward of the hospital to offer diabetes education to a group of about 6 diabetic men and women, some of which were newly diagnosed. Lara and Carlien explained with pictures exactly what diabetes is, "when there are not enough keys (insulin) or the key is rusty, sugar cannot get into the cells to feed your body." They also explained what glycemic index is, and the difference between low GI and high GI foods. My part in the demonstration was to play the American that needed help creating a healthy, low GI plate. The folks giggled at my accent and seemed to have a pretty enjoyable time explaining to me why some foods were bad and others were good. I don't normally like classifying foods as black vs. white, good vs. bad, but for the general nutritional education level of Botshabelo, it is very important to ring home a clear message. It was pretty clear that alcohol should be avoided and fruits and vegetables are better snacks than soda and pap.

I was so thankful that I got to talk to my dad and Ryan this evening. It was good to hear familiar, encouraging voices. It was also good to hear that we are selling our beat up old Volvo. If you are reading this and want something to pray about, pray that I find joy in the Lord through all circumstances, and pray that I serve as a beacon of hope to those who have so little. I am praying that my heart remains sensitive to the needs and wants of others, even the people that are difficult to love.

5/14

Michelle outside a clinic in Botshabelo

Today was my last day at Botshabelo, so I was a bit disappointed that I didn't get the opportunity to check in on those babies again. Rather, today we traveled around Botshabelo to various rural clinics to offer general nutrition education to everyone in the waiting rooms. I didn't get to present as much as I would have liked, but I am at peace with that. Lara and Carlien are being graded on their performance, while I am mainly here for the ride. Also, as soon as I open my mouth, everyone in the room realizes that I am American, which led to one woman's post-presentation request that I give her two rands to buy salted peanuts. I dodged the question by telling her that we don't want to eat the salted peanuts, we want "minder sout," less salt to stay healthy. Carlien and Lara though it was hilarious. The presentations were nothing too new, we just went through explaining the myplate visual and had some volunteers build a healthier plate for us using the abundance of laminated food in our education bag.

What was really helpful for me in understanding poor South African foodways was our visit to a massive grocery store called Rite Brand. As we have been driving around Botshabelo this week, I have witnessed the surreal pilgrimage of people from miles around walking through barren grassy fields scattered with garbage and livestock waste just to get to this store. The landscape in this area is quite eerie and fascinating actually, because the land is incredibly brown and flat, except for the occasional mountain.

View from just outside a clinic in Botshabelo

Carlien outside one of the clinics

Mountains are very randomly scattered and equally barren. All of the plants that grow here, aside from the tall grass, look fierce with thorns, spikes, spurs, and rough leaves with jagged edges. The plants honestly look like gladiators who fought for their lives, but remained merciless and scarred after the battle. South Africa is not an easy place to live, and the botany is not the only species that has experienced great strife. The reason Botshabelo experiences such high rates of poverty and unemployment is because there are very few jobs to accommodate such a massive unskilled workforce. If you just take a 360 degree look at the surroundings, it is pretty clear why there are no jobs. Most of the area is barren and undeveloped. There are numerous cattle and goat roaming regions, several small shanty shack villages, maybe a gas station, the hospital in the distance, and a giant grocery store that caters to a vastly unemployed population. Michelle said that most of the population is unemployed and survives off of child grants, which accounts for 330R per child per month. In US dollars that is about $28 per month. For a family with three children that is about $83 per month. Michelle also said that some women may drink heavily during pregnancy in order to get a disability grant, which is a slightly larger sum. Health care is free for those below the poverty line, so nutritional supplements are also free. However, it is not uncommon for mothers to let their child's weight decline so that they can go to the clinic to get free supplements that are designed to be eaten in addition to a nutritious diet, but end up being the child's greatest source of nutrition. It is clear that families are forced to take drastic measures to survive in this climate.

How does a population recover from this? This is where my various interests begin to merge. The only way for a community to experience an improvement in public health is if the local economy is stimulated in practical, strategic, long-withstanding ways. This is one of the many reasons I wanted to volunteer at Bulembu, Swaziland; I want to understand specific pathways by which a community as a whole can break away from cyclical, generational poverty. My goal as a dietitian is to help people maintain a balanced diet and a desirable standard of health if nutritionally applicable. Though difficult, it is possible for a family to roughly adhere to the nutritional guidelines provided to them. Breastfeeding is certainly attainable for infants. Maybe 3 fruits and vegetables rather than 5 per day is attainable. Maybe cooking chicken without the fat and replacing the salt in pap with pepper and herbs is attainable. These are guidelines recommended to prevent nutritionally-related diseases, but it is important to note that constant worry and struggle do not contribute to a high quality of life, and the worry and struggle will often occur regardless of nutritional status. So how do we address the root cause of widespread poor quality of life?

I attempted a causal loop, so bear with me.

All roads seem to lead to poverty, and all roads seem to originate with poverty. I know that unemployment is the primary factor that contributes to poverty, but it is also important to note that unemployment is caused directly by a lack of education, limited access to resources, a lack of a skilled workforce, a lack of economic development, and an increased rate of contagious or psychological/addictive diseases. However, it is indirectly caused by lack of government support for economic development, malnutrition, obesity, tight living quarters, and a high cost of living in comparison to income. The primary factor that can directly contribute to higher employment rates is an increase of economic development that is spurred by an educated, skilled, healthy workforce. In my opinion, public education and accountable educational systems are among the best ways to begin equipping the economy for stimulation in addition to reducing disease rates.

Spinach garden outside a Botshabelo clinic

In any case, we surveyed the prices of common food items such as maize mill (pap) and various vegetables and fruits to get a better idea of how far 330R per child can stretch. Not very far, I'm afraid, though food is significantly cheaper here than in the US. I am going to continue mulling over the connection between economic development and nutrition. Bulembu is going to be exceptionally exciting in a few weeks as their mission is to restore community health, education, and economic development.

Some additionally important things to remember about Botshabelo:

1. Always greet the head nurse and the other sisters before you do anything else.

2. Use visuals whenever possible. Ask the patient(s) questions to make sure the message was understood.

3. If you ask a patient if they know about (insert here), and they say yes, ask them what they know. It is highly likely that they need a refresher course.

4. Research all of the medications that a patient is taking to make sure that you know what it is, and that it isn't something that interferes with appetite, absorption, or some other dietary-physiological factor.

5. Afrikaans is fun to speak initially, but after a few days the "g" noise is a serious throat hazard.

-Jordan

Weekend 1: Settling in Bloemfontein

So I haven't had internet access for the past three days, but I finally got a guest verification code. I have been writing my posts on the tablet daily in anticipation for this day. You get serious friend and family points if you read all of this, but I promise that I tried to keep it entertaining.

 5/9

First sight of South African terrain

Looks can be deceiving

As I am writing, I am sitting in the airport of Johannesburg waiting on my flight reflecting on the marvelous discoveries I have made about international travel as a small, white woman in South Africa. Unfortunately, this means that every escort in the place has scouted me out trying to direct me somewhere, which at first was sketchy, at second was helpful, and at third was bothersome because they wanted a $20 tip. For anyone else who would like warned, when anyone asks to help you in a SA airport, even if they clearly work there and have a shiny badge and a uniform, say you can do it yourself and would not like any help, thank you. Also, though JFK was significantly harder to navigate, I am struggling to find any useful shops here, I cannot even find an ATM for currency exchange, nor can I find any medicinal shops. Just food and safari hats. The flight here was okay, it was 20 hrs long and I landed a window seat partnered with a very large fellow that smelled kind of funky, but at least he was nice. The flight attendant for our isle was especially entertaining, as he looked and sounded like Alfred Pennyworth's apprentice. The bowl cut and the plucked-to-an-arch eyebrows may have also contributed to the impression. In a sort of Indian-Dutch accent he delivered our plastic coated cuisine with a classic "Be my guest sir," or "I hope you found breakfast to be satisfactory, Madame." He asked where I was from and after I replied "North Carolina," he remarked "I would expect no less than a Carolina girl. Your people are very beautiful." Yeah, I think I like Ishmael, the butler flight attendant.

Connector flight: Johannesburg to Bloemfontein

I'm not usually accustomed to selfies, but traveling alone warrants trying new things.

So I tried to sleep from 5pm to 1pm to accommodate myself to South African time, but I can't say I slept incredibly well, though the neck pillow was definitely a good call. A couple other dietetics students emailed me yesterday to inform me that I should pack for the diabetes camp this evening at 5pm, which will be a bit of a rush considering I will land in Bloemfontein at 3pm and I have no idea where I will be residing for the next month. Apparently the diabetes camp is overnight, which was also new information gathered yesterday. Unfortunately, all of the well-advertised free Wi-Fi in this airport is inaccessible to me for some reason, and I have no other avenue by which I can check my email to confirm that I will be picked up in the Bloem airport, so I am praying that dear Mr. Olckers (whom I've never met) checked his email yesterday or this morning. I also really need to find a bank or an ATM and some store that sells Ibuprofen. However, this is still vastly less stressful than exam week, so I am doing just fine. I am thankful that there are people back home praying for me.


Now that I am so close to the destination that I have been obsessively planning and researching since January, I am realizing just how long two months is, and am beginning to wonder why I thought this was a good idea. "Hey self, what do you think of traveling halfway across the world alone for two months? Oh yeah, that sounds fun, let's do that." I am already missing my family and friends, but I am hoping that feeling will be overshadowed soon by the addition of new friends. I guess Ishmael was a start.

I'll keep you updated as to what goes down at diabetes camp. Hopefully not insulin levels.

-Jordan.

5/10

Bloemfontein Airport

So thankfully Marleen Olckers did remember to pick me up, though he seemed very much in a hurry to drop me off and leave. Thankfully I remembered to ask for a Wi-Fi password to communicate with my family, because they hadn't heard from me since I left JFK airport. He gave me his university internet credentials, but the internet is so weak that the only use I have for it is to send text messages through WhatsApp. Thanks SO MUCH to Rebecca Barker (a teaching friend who just returned from the UFS last week) for telling me to download the app. So I relied on texting Ryan to call my parents to tell them I made it.

New residency at JBM Annex!

Nicole is one of my apartment-mates who apparently was unaware of my arrival until I walked in. However, Nicole was very friendly and polite after he left. She showed me around the apartment and we chatted for a bit. She is from Holland and has been here since January taking classes in the public administration department as an exchange student. About an hour after my arrival, Carlien (a 4^th year dietetics student) came to pick me up to take me to the diabetes camp. If you are wondering what happens at an overnight diabetes camp, so was I. It was actually really rewarding experience aside from the visual impairment induced by jetlag that made everything seem like a hallucination, though I totally did see a meerkat run across the airport landing in Bloem.

Carlien brought me to the camp and introduced me to the rest of the dietetics students as they were preparing dinner. The overnight camp was surprisingly held at a really nice facility. I guess was expecting an elementary school gymnasium or something, but the estate was called Sandstone Sleeper which was kind of a wedding-hosting resort, but I guess they may have given the nutrition department a discount or donated price. Many of the kids there had been there in years previous so many of them already knew each other. It was neat to see how the program was run in order to teach kids how to properly manage their diabetes. Though you might think that the kids already know how to manage their diabetes from private counseling, many of the children had been diagnosed at a public hospital so they did not receive appropriate diabetes education either because the nurse was a volunteer community member and did not properly understand the diagnosis (type 1 vs type 2 diabetes), or because the hospital was understaffed and could not spare the time for thorough education. Most of the girls are Afrikaans (white African) and speak both Afrikaans and English; they frequently switch back between the two languages. Afrikaans is very similar to Dutch, so there a lot of words that were easy to pick up on, such as "dankie" for 'thank you,' "pleseer" for 'my pleasure,' "hallo" for 'hello,' and "lekker" to describe something likable. All of the girls were very pleasant and friendly and I foresee making some good friends!

There are only about 20 people in the department, a good bit smaller than at home, and about 10 of them were at the camp. Carlien said that because the students had been cooking and cleaning for the entire weekend, they didn’t really get a chance to interact with the kids as much as they would have preferred. There were a few practitioner volunteers: a pediatrician, a dietitian, and a couple nurses. One of the nurses was so lovingly called "the fat lady" in whispered tones because she was always complaining that the children were not getting enough food. Carlien made the menus for the entire weekend according to the medical counsel of several physicians, dietitians, and lecturers, which I know must have been a toilsome task, but the woman was insistent that the children were all hypoglycemic because they were not receiving large enough portion sizes, when in actuality, the children were hypoglycemic because they were running around playing soccer more frequently than they usually do during school hours, and so they were injecting too much insulin before meals. I know from advanced nutrition and health risk appraisal that aerobic exercise is incredibly good for diabetics because it bypasses the need for insulin to reach insulin receptors and activates the GLUT4 transporter that transports glucose into the cells. Anyways, the group was frustrated that the woman demanded more snacks, but Carlien went ahead and bought more. The kicker was that shortly afterwards, the lady was found munching on the snacks in the kitchen! Hey, you can't stop  bellyaching when you can't stop the bellyaching.

So anyways, I was excited to talk with the children, but it didn't seem like the children were excited to talk to me. However, they were very excited to play soccer with me, and they told me that I was the first "grown lady" to ever play soccer with them. They had a movie night and we all watched Madagascar 2, which I think was ironic considering the subject matter of American African animals struggling to identify where home is. That was awesome, haha. What was more awesome was that one of the volunteers with the diabetes camp, Jonathan, who had been really interactive with the kids the whole time invited all the kids to sit down for story time before bed. He told some jokes, and my favourite one (warning, this may be offensive to Zimbabweans) was about the president of Zimbabwe, Robert Mugabe, going to China to understand the true meaning of his name. And so Mugabe asked a wise man named Ze Pow Sing to help him understand. The man said that all one has to do is skip a rock across the water and listen to the sound to discover one's true name. So Mugabe did, and when he skipped the rock, the water said "Chee-pan-ze.” Mugabe didn't like that very much so he tried again. "Chee-pan-ze" the water said again. Mugabe was frustrated so he took a big rock and chucked it as hard as he could into the water, and the water said "Ba-bOOn." Oh the kids loved that joke!

Afterwards, while all the kids were leaving for bed, Jonathan and a youth leader named Tabogah talked for a while. They were both black Africans that had grown up dealing with type 1 diabetes, and I was astounded at Jonathan's story. He was a political refugee from the Congo and had escaped the violence of the war by running with a bullet in his leg and cuts all over his body. He made it to South Africa, but not have his insulin, as he had received his insulin from missionaries that came to his church while he was living in the Congo with his parents. He was orphaned by the war and homeless in South Africa at the age of 9. He survived for several weeks without insulin, until one day he woke up in a public hospital and he thought it was heaven. He said, "Yes, the public hospitals are not great, but for me, it was heaven." There he received some diabetes education and was given some insulin pens. He was later enrolled in some sort of foster care program, but sometimes he was physically and emotionally abused because of his status as an immigrant. He was eventually adopted by white Afrikaans that he still calls his parents. He told me that he calls his life miraculous because there were countless situations he had encountered in which he should have died. Not to mention a type 1 without insulin or appropriate dietary intake really shouldn't have lived as long as he did during the refugee periods of his childhood. But he also said that the only thing that gave him the will to live was his faith through Jesus, and he trusted that God would save his life. Now he says that even though managing diabetes was a severe challenge for him, he would never give up the disease, even if he had the opportunity for a cure. He believes that he needs to be a diabetes educator in regions where the diagnosis of diabetes is a death sentence due to the lack of insulin availability. He wants kids to realize that they are not alone in managing the disease and that they can live lives of worth. Jonathan keeps all of his insulin pens, he never throws them away because he feels that they are a symbol of his daily challenge to stay alive. He said diabetes reminds him that he is human and that life is a gift not without challenge.

I went to bed last night believing that God was beginning to answer my prayers, not simply by presenting me with a story that mentioned him in it, but by presenting me with an opportunity to listen and understand people, and not just through the tough stories like Jonathan's, but through all stories privileged or not. I prayed last night that God would open up my heart and eyes and allow me to listen and learn from the people I encounter, and I also prayed that he would allow me to see immigrants in my own nation with a new heart of compassion. It is easy to become dull to oppression when it is ingrained into your own society, and I believe that professing equality as a virtue of a nation is a dangerous profession because there are so many exceptions to the rule. I also prayed that I will make friends and the internet will begin to work. I may not see the latter happen anytime soon, but I am beginning to make friends.

Today I borrowed Wieda's phone to call Cobus, my driver (only for today and yesterday), to take Nicole and me to the Waterfront Mall to buy groceries and use the ATM. She showed me around and kindly bought me a milkshake from Spur, a local burger place she really likes. Though I could use my credit card to buy groceries, I could not withdraw any cash from the ATMs for some reason, which was bothersome. So I've befriended Nicole as well as Carlien, Wieda, Hannelise, and a few other dietetics students.

A very sugary  coffee date with even sweeter people: Hannelise and Wieda

They were so sweet to have given me one of their uniform t-shirts with my name printed on it that says on the back, "Keep calm and ask a dietician," hahaha. Wieda and Hannelise want to take me to a cheetah park soon, so that's also really exciting! Also, they both have WhatsApp, so I can actually communicate a bit with them when I am in my apartment. Tomorrow morning Carlien will pick me up and we are going to start working at Botshabelo, which is a small, rural public hospital.

-Jordan