J&J Scholar reviewing a CT Scan taken at the referral hospital
Clinical Care in Tugela Ferry is focused on the 350-bed Church of Scotland District Hospital (COSH), a rural government district-level 350-bed hospital, typical of many in rural Sub-Saharan Africa, The hospital, combined with the 15 outlying outpatient clinics, and clinical services provided by Philanjalo, the local South African NGO, forms the backbone of care for the 180,000 traditional and impoverished Zulu people who live in the beautiful Msinga area of KwaZulu Natal, 2 and ½ hours from the city of Durban. COSH inpatient services consist of male and female adult medicine and TB wards, pediatric, surgical and psychiatric and OB/GYN wards. Outpatient services consist of a modern HIV/antiretroviral (ARV) clinic and a TB DOTS program.Philanjalo’s step-down inpatient unit, a nearby specialized program and hospital dedicated to treating drug resistant TB, as well as an active community based home care program are all part of the clinical facilities and services the patients rely on. COSH medical staff consists of ~ 8-12 doctors all of whom are generalists and many, superb clinicians, teachers and extraordinary role models.
The doctors who staff the hospital, along with hospital and clinic nurses serve as the primary health care for the people of the area. The COSH ARV clinic was the first site providing antiretroviral therapy in the public sector in KwaZuluNatal province and has initiated treatment for more than 5000 adults and children since 2004.
Johnson and Johnson Scholars from the Yale/Stanford Global Health Program, representing institutions throughout the U.S., work in the adult and pediatric ARV clinic, casualty department, step down inpatient unit and TB and general hospital wards. For those interested in clinical work in Tugela Ferry, it is critical to appreciate that theSouth African medical organizations are very strict and clinicians must obtain a South African temporary license. Registration takes a long time, so submission of licensing forms is required no less than 6 months in advance of visiting and working in Tugela Ferry.
The staff of the clinic, assisted by the efforts of the Johnson & Johnson scholars, actively manage all aspects of HIV care, including opportunistic infections (particularly TB), ARV initiation, and complications of therapy. Started in 2001, the Philanjalo step-down inpatient unit augmented the Philanjalo Home Based Care model in use from 1999. Prior to the national ARV rollout in 2004, the unit’s primary mission was to supply end-of-life care. Since the rollout, it has served as a step-down for patients who are too sick to return home, but not sufficiently ill to require hospital services. Often their patients are in the process of initiating ARV or TB medications and require education or observation prior to being discharged home. The Philanjalo Clinical Manager, rounds on the unit several times per week, often joined by the J&J scholars or other visiting physicians.
TFCARES has also played a key role in supplying technical assistance, enabling the development and implementation of the district decentralized Community Based Multiple Drug Resistant (MDR) TB Treatment Program at nearby Greytown Specialized TB Hospital. This weekly clinic supplies follow-up to the ~200 patients in the district currently at various stages of treatment for MDR TB, most of which is provided at home with daily visiting nurses and other staff. The model is innovative and avoids lengthy hospitalization distant from homesteads and contrasts with other provinces that have often required forced detention for the duration of the patient's 24 months of care. The model emphasizes respect of the patient, and tries to balance their needs and well-being along with public health needs of the community.