I've heard several people now claim that Johannesburg is the Capital City of Africa. This is the first time I've been here, and Jozi as it is affectionately known is a pretty mind-blowing place. It is a new city – only just over 100 years old, established after the discovery of gold, and it's huge, that's for sure. Freeways carve the city into divisions of extremes – astonishing wealth, and terrible poverty; streets and gardens filled with lush foliage, and land scarred and poisoned by gold mining.
Soweto is half an hour's drive from the centre of the city. This is the township where resistance to the Apartheid regime was focused in the 1960s and 70s. In 1976 schoolchildren in Soweto were massacred during a peaceful protest. Soweto came into being as the Apartheid Government wanted Black workers to live away from the White parts of Johannesburg, but within travelling distance of the mines and city centre. It has been a community of poverty since then. Just over a million people live in Soweto: about one-fifth of the entire population of Joburg.
Chris Hani Baragwanath Hospital is at the heart of Soweto. It is the biggest hospital in the world, with over 2000 patient admissions every day. The Accident and Emergency Dept or E.R. is also the busiest in the world, with a shockingly high number of gunshot and knife wounds requiring treatment. This huge, sprawling hospital has only 11 dietitians. Compare that with 40 at Guy's and St. Thomas' in London, a hospital of less than half the size.
I spent time with the dietetic team. Carey Harman is a Paediatric HIV dietitian working at the Harriet Shezi clinic. This clinic is the largest in the world providing care to children living with HIV – almost 3000 children, of whom two-thirds receive ARVs.
Carey's post is partially funded by PEPFAR to provide education and training, and partially research based. She is currently recruiting to a fascinating project looking at body composition in infants recently initiated on ARVs. They have observed that children between 1 and 2 years old commencing HIV treatment often experience unusual increases in weight, and they intend to investigate whether this weight gain is mostly fat, or a mixture of fat and muscle tissue. Carey also told me that rates of malnutrition in infants and children are fairly low in Soweto. Certainly there seems to be an upwardly mobile section of the Sowetan community. Indeed the day after I visited Africa's biggest shopping mall opened in the heart of the township.
One of the most difficult issues in terms of paediatric HIV is whether to advise Mums to breast or bottle feed. HIV is present in breast milk, and breastfeeding can lead to a baby acquiring HIV from its mother. In Europe all positive Mums are advised to bottle feed to avoid HIV transmission this way, and indeed this was the initial aim in Africa too. However, bottled formula feed can be dangerous if not prepared properly. It must be sterile, and so in deprived areas where water may be heavily infected with bacteria, careful heat treatment is vital. But many homes may not have electricity or even no fuel for a fire and so heat sterilisation is not possible. In these circumstances evidence suggests that more infants will die from diarrhoea than HIV, and so reluctantly Mums are encouraged to breast feed. In Soweto, most areas seem to have access to electricity and water these days, and so the general push is for positive Mums to breast feed. Carey told me however that there a parts of the township which remain terribly deprived, and where the bottle feeding message has resulted in unacceptable rates of infant death as a result of infectious diarrhoea. Carey is working with colleagues to reverse this situation. I hope to discuss the issue of breast vs bottle feeding in HIV in future posts.
Lizwe Malindi works with Carey as a nutrition assistant, and is hoping to start a dietetics degree soon. He very kindly took me on a tour of Soweto, where he grew up and continues to live and work. We visited Nelson Mandela's home, the Regina Mundi church where schoolchildren were fired upon by the Apartheid defence force, and the Hector Pietersen Museum. Many of you will know Sam Mzima's famous picture of Hector Pieterson's body being carried by a fellow student, fleeing the defence force's attack. This image shocked the world into realising the true horror of Apartheid.
(Extracted with permission from http://hivnutrition.org.uk/) More to follow