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Oluwarotimi Okunade '07 is working with Medicine in Need to assess the need for and acceptability of a hand-held inhaler device used for the treatment of Multi-Resistant Tuberculosis in Pretoria, South Africa.

July 4 | July 11 | August 9

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August 9

Work:
About three weeks ago, I made several site visits to a TB specialised hospital in the slumbering town of Witbank in the neighbouring province.  Renowned for its prowess in generating a lot of mining products (iron, coal and such), Witbank was needless to say very foggy, densely aerated with all sorts of particulate matter and not without its pungent fumes.  How people live in that city/town escapes me, but nonetheless, it serves a population of TB patients that come as far as the lands bordering Swaziland and Lesotho.  The hospital was a far cry from my expectations (seemed a bit worse than the city itself): the buildings resembled brick shanties; they were bungalows, notoriously populated by cats, all of which were black or variations on that colour.  Okay so you have the setting in mind.  The people, like most South Africans I have met thus far, were welcoming, however they did not resist from giving me a bit of the run around (they supposedly had to get approval from higher powers, although I was working in association with the Medical Research Council, a governmental body).  That aside, I was finally able to get a translator on my second day there, which enormously facilitated my study administration.  A lot of the patients I have encountered have schooled only up to the high school level, some having never even attended school.  I expected their command of English to be suitable for my purpose, however many insisted on reverting to their native tongue, for my discomfort I initially thought since my English has been said to be a bit garbled and fast for them, but really because their native language induces an atmosphere of comfort and ease for them.  Again, I note the tenacity and pride in conversing in native African languages.

A few observations to be made about Witbank.  Both care providers and patients especially, have been receptive overall towards the concept of the inhaler and what it could mean for TB treatment.  Previously inundated by clinical professionals at the seeming subservience of patients to the opinions of their care providers, I was quite surprised at the level of depth couched in some of the questions I received concerning inhaled therapies and their efficacy. However there has been some scepticism in terms of how this technology can be adopted and at the same time ensure patient adherence to treatment. As always, it is interesting to note the perpetual lag between advances in technology and their translation to clinical care.  A potential roadblock which I really did not anticipate is some amount of resistance from the health care staff; a few of the people I talked to, had very real doubts about the efficacy of the inhaler, not only in delivering the adequate treatment dosage, but also in reducing the burden of care in treating TB.  Some patients, very ironically, also favoured the surety of injections, despite their renowned pain.  As an aside, I continue to be amazed at the insistence or perhaps I should say the pervasiveness of populist technologies.  During my interactions with patients (most of them from rural areas) in Witbank which looks like it is in the middle of nowhere, I startled to hear the very intriguing ring of a patient's cell phone.  Mind you, these people come from low-income backgrounds, with a majority of them currently unemployed.  My project very recently took me to Durban the 2nd biggest city in SA, located on the Eastern coast of South Africa, and the proposed site for the 2010 world cup.  However I will reserve my experiences there for a follow-up email.

More generally, the TB crisis is an alarming one.  A major burden in Africa but an even greater one in Southeast Asia and (of course with co-linkage with HIV), wherever AIDS rears its ugly head?there it is as well.  I am dismayed to say that my growing sense of alarm is only recent.  And another thing to think about, despite the isolationist spirit which America purports, it too is not immune from TB.  There are many cases of TB and MDR-TB in relation not only with the community of AIDS sufferers but also in connection with the US's rather loose borders.  With the ever-growing disparity in wealth and opportunity, and globalisation's far-flung reaches, immigrants as they flood the borders of the Western world, will carry with them the risk of this disease.  And yes, a third of the world's population is currently infected with TB.  However TB is such that it only becomes active in certain cases, especially if one is immunocomprised; clinical active TB is always possible years after initial infection. So you see, despite the very real fears associated with the AIDS pandemic, there is much to worry about and equip oneself for the latter day where TB is concerned.

And despite the current and very real alarm over HIV/AIDS, with HIV there is some modicum of protection: the physical barrier of the body (generally speaking there must be breakdown somewhere for contact with bodily fluids); with TB it traverses all borders and is airborne.  Furthermore with the augmenting HIV pandemic, there has been a rise in acquired drug resistance TB which is even more dangerous; current treatment protocol consists of a five to six drug regimen, which consists of very painful injectables and is of course somewhat pharmacologically toxic.  Ironically, there hasn't been much commitment in the pharmaceutical industry to TB drugs.  TB is special because it was 'eradicated' in first world where it was a serious issue between '60s to late '70s.  The latest line of TB drugs were developed in late 80s, and with most of the burden gone and in light of the global attention to AIDS, there are currently only 3 pharmaceutical companies interested in TB and even so, interest is only in relation to AIDS.  They are not to be blamed of course; drugs take about 15 to 20 years to develop and billions of dollars of support.   MEND is therefore interested not in formulating new drug but rather in optimising drug formulation, or how it is delivered, for better access and availability physiologically for the patient.

Tourism:
The last few weeks have also been an opportunity to venture out into the city and be the tourist I have always longed to be.  A few weeks ago I visited the Voortrekker monument, the monolithic memorial to Afrikaner history and a lasting assertion, it seemed, to their ownership of Suid Afrika.  In visiting such places (and of course having the bias that is my race), it is always interesting to note from which vantage point history is written, or perhaps some will say, revised.  Voortrekker made quite an impression on me: gave me some empathy to the historical plight of the Boers in their struggle to attain SA, against the resistance of the Zulus and other native African tribes. Ironically despite the attempts of the monument, which architecturally was quite beautiful with its fluency of bas reliefs and Hagia Sophia-esque structure (on the inside that is), to create empathy for the Afrikaner side of things or perhaps to simply disseminate knowledge of their past, I walked away with the distinct notion of the non-nativeness of the Afrikaners to South Africa.  Despite their successful rise to power, it is interesting to note that many Afrikaners that I have encountered do make the distinction between themselves and (native, that is black) Africans; but they all call themselves South Africans.  You can imagine my initial confusion!  On the same note, by the famed Union Buildings (the analog of the white house), stands the SA police memorial, a monument this time to all police officers that died in the execution of their duty.  Needless to say I was quite alarmed to read from the monument that the list of officers extended well into or rather began during the apartheid period.  Though we are well into the era of peace and the resurgence of black economic empowerment, I continue to be amazed at how acutely politicised some issues are in relation to race.  Here duty was defined such that it became inclusive of all in the armed forces, even when the execution of such duties inherently violated the inalienable rights of an entire race.

On a more positive and culturally aware note, a co-worker friend of mine took me to Lesedi Cultural village, located in the neighbouring North-West province. Here we were serenaded with dances, dress, décor and architecture of various African tribes.  We even got to try our tongues at some of the languages, with the characteristic clicks of the Xhosa and Zulu languages being a far cry from the throat scratching noises of Afrikaans.  The day ended with an appetising traditional feast; you'll be proud of brave little me as I sampled the meats of all types of 'endangered species' including ostrich, crocodile, impala and the likes.  We were further cajoled into savouring with gusto, a special dish called 'beans that thunder the buttocks'! To treat myself, I walked a couple of weekends ago, to the Pretoria Art museum. It turned out to be quite the delightful escape, well lined with works of different genres.  For those of you who are art aficionados, I note the condensation of various artistic techniques not only in space (physically) but also historically in the span of time.  I saw derivations of cubist art, Fauvist influences, Dali-like techniques and a post-modern collage, which looked Guernica-esque, but was all the same powerful in its treatise of the plight of industrial workers and the convolution of themes such as race, economic disparity and the concomitant population boom in SA.  There was also a private exhibit, with works made entirely of rust.  Very articulate and impressive, it was evocative of township life and explored other salient themes, some of which I am not even sure I am completely aware of.  On a humorous note, I encountered some people at the museum, who couldn't quite comprehend my interest in the art especially since I was not an aspiring student of art.

Self:
As part of my cultural immersion scheme, I went to a rugby game at Loftus here in Pretoria.  The local franchise team, the Vodacom Blue Bulls were playing the Natal Sharks, hailing from Durban.  Though I can truthfully attest to my lack of thorough knowledge of the rules of this game, rugby is definitely more interesting than American football with its sheer physicality and very acrobatic defensive techniques.  Beyond the game however, rugby is enjoyed solely it seems by whites, not all them from the city, i.e. they are more racist.  I was one of the few blacks in the sea of screaming white faces at Loftus.  Unfortunately, the polemic in racial interactions was heightened by the fact that the few blacks present at Loftus, were all food hawkers, serving the screaming and very dismissively rude, if I may add, fans.  Otherwise it was a wonderful experience.

I got to venture back to Sandton, the very posh and exclusive suburb of Johannesburg to attend the Fashion Glam Party, the extravaganza which caps off the annual SA fashion week.  Here I got to hobnob a bit with the beautiful and well-to-do crowd of the young and upcoming.  In the weeks that have passed, I have also encountered a new roommate--a 30 year old, recent divorcee. Quite sad, I know, but she is wonderful, and really nice.  My experiences with people so far have been overwhelmingly positive; I have been made to feel quite welcome. It does make me wonder a bit whether the degree of acceptance I have achieved here by white people has to do with the fact that I have from the States and therefore seen to be cognizant of my rights in relation to society. I have also gotten to display a bit of the Nigerian in me in my journeys to the Hatfield flea market.  The experience of haggling with the sellers has been quite titillating, intoxicatingly so in fact. I do admit however to some feeling of concern as to whether they are making a profit, but then again my conscience regains its comfort when I remind myself of my status as a student scraping by for survival.

The opposite sex:
I have had many firsts here, some of which I am shocked still occurred.  Before your imagination runs away with you, let me explain.  In coming here I have encountered both perspectives (that is black and white) of race relations here.  Despite the progress being made, I have been told that there is a ways to go still.  So you can imagine my shock when one day as I was taking a stroll through a park, an Afrikaner guy approached me, asking to give me a lift and further for my contacts.  In Durban, the same occurred with some Indian guys, and at the MRC where I worked the sexagenarian driver, at his age can you imagine, followed suit.  One thing that I have learned while here is that African men are a race unto themselves; the concept of platonic relationships/friendships does not exist here.  And the stereotype that men are not monogamous as a rule is not a false one, but rather an unbeatable reality; quite amusing for me as an outsider however it does induce real fears on the behalf of those South African women who are victim to this phenomenon. Finally, in making my stay here ever so pleasurable, I have met quite a bit of students and can finally tap into life here as a young adult.  With a little less than three weeks left here in this fabulous country, I have to admit to a very real sense of dread to come back to the States (and especially face dear old Harvard).