At 18, Pietermaritzburg-born Hasina Subedar was attacked by a man who tried to kill her, losing two fingers and very nearly her life. Afterwards, a nurse washed the glass and sand from her hair, and she never forgot it. It was what led her to nursing school.
Now, 30 years later, Subedar is South Africa’s foremost expert in rolling out HIV prevention drugs, responsible for getting lenacapavir, or LEN, into 360 clinics across the country, writes Sean Christie for Bhekisisa.
The imminent roll-out of the twice-yearly HIV prevention jab lenacapavir (LEN) has been a spot of bright light. Countrywide, staff in 360 healthcare facilities are trained and ready to receive and administer the drug.
The person responsible is Subedar, the Health Department’s senior technical adviser in HIV prevention. She works from 6am to 11pm daily, and typically takes off only from the Day of Reconciliation each year until 3 January. Last year, however, she worked through.
“I had to sit and finish all the training materials (for clinic staff to be able to administer LEN), while worrying over consignments of drugs that still needed to come into the country,” she says.
For the past nine months she has had meetings with all of the organisations involved in supplying the drug, a process she describes as “immensely complex and at times quite fraught”.
“Relax your grip, and there’s a chance the drugs will simply not make it into the country. I have had to become a very hard taskmaster for people who don’t do the things they’re supposed to be doing.”
Grit, grace and humour
With the drugs now here, the next step is getting LEN to those most likely to benefit from it, a challenge made trickier by the Trump administration’s funding cuts to South Africa, which, according to a report released by Physicians for Human Rights and partners in April, have undermined much of the infrastructure – like community-based testing and field recruitment for HIV prevention services – needed to create demand for LEN.
How will such yawning gaps be bridged?
Subedar focuses on the opportunity inherent in decreased donor funding.
“Previously, with the oral PrEP roll-out, we had donors telling us, ‘This is where you must implement, the populations you must implement for’. It was initially led by them (donors), which often resulted in fragmented service delivery.
“With LEN, I was determined it would be government-led, and not rolled out by partner-funded projects but instead integrated within public primary healthcare from the outset.”
If questions remain about the viability of the plan (one prominent HIV researcher told me that Subedar “is constantly having to make things work in a sea of mediocrity”), her competency is widely acknowledged.
Francois Venter, executive director of Ezintsha at the University of the Witwatersrand, recognised Subedar’s work ethic and “absolute integrity”. Desmond Tutu Foundation CEO Professor Linda-Gail Bekker praised her ability to work well with a spectrum of role-players, “doing so with grit, grace and humour”.
These are not innate abilities. How, I wonder aloud, were they forged?
Lessons in life
Subedar’s parents – Hajira and Goolam Subedar – were both largely self-taught people, “but it was important to them that we should receive the education they were denied”.
“My father, a tailor, always said, ‘The one thing you must always do is educate yourself, because nobody can ever take away your education’, which is so true.”
For junior school, the girls attended the Nizamia School, and later, went to Pietermaritzburg Indian Girls High School.
Subedar says she was “non-conformist” and found the compulsory afternoon sport “quite challenging”.
As the middle child, she was often left to fend for herself, never quite included in the alliances of her two older and two younger sisters. This would prove consequential.
The Subedars were a political family who often shared what little they had with the families of Robben Island detainees like Harry Gwala. Subedar’s father decided one of his daughters should go and live in the home of another detainee, Abdool Kader Hassim, to support his wife Nina and two young sons.
“My older sisters refused, and since my younger sisters were too young, it pointed at me,” says Subedar, admitting that she resented the imposition initially, but came to appreciate the experience.
“Living with Nina and her boys I learned a lot. I became more politicised, which wasn’t unique to me. It was a common experience in the areas and communities in which we lived, but it shaped my thinking. There wasn’t this thing of we are Indian and they are African. We were very integrated in many ways.”
The other force shaping Subedar’s outlook was money, or rather the lack of it.
“My father’s work completely dried up when I was at high school, so I had to work to support myself,” says Subedar, who dropped out of a social work degree after just one year due to a lack of funds.
Her choice to study nursing was born mainly from need – she would be able to study and earn, and help support the family – but there was something else.
“When I was 18 I was attacked by a man who tried to kill me. I was left badly injured: two fingers were completely severed, and a third was left non-functional,” she recalls.
Amid the chaos of that emergency, the nurses who attended to Subedar in hospital provided a refuge of calmness and kindness.
“My hair had lots of glass and sand in it, and one nurse said, ‘Let me wash your hair for you’. And that meant so much to me,” she says, confirming that these experiences of care strongly factored in her decision to study nursing.
She emerged from the experience a more compassionate person, and strongly resolved to move forward “without any self-pity – without ever talking about it, in fact – while finding ways to compensate for the considerable loss of functionality in my left hand”.
Black section and white section
Within a month of applying to train as a nurse, Subedar was on her way to Cape Town, to Groote Schuur Hospital, where “there was a black section and a white section, and you stayed on your side”.
In Pietermaritzburg, Subedar had been well aware of the inequality in the education system. Now, she saw it up close in the health system.
“One of the things I did as a student was go into Langa to train people in first aid. Ambulances weren’t going there at night, and in many instances people died at the police station for want of basic care.”
Subedar qualified as a professional nurse and spent some time working in intensive care units.
When her son was born, she returned to Pietermaritzburg, working as a mental healthcare nurse at psychiatric hospital Fort Napier, and later as part of an outreach team in communities like Chatsworth, Phoenix and Merebank.
“It was a refreshing change, more humane in many respects, because I could spend time with people who were dealing with life in all of its complexity,” she says.
When she was granted long leave in 1989, Subedar used it to further her studies at the University of KwaZulu-Natal, ultimately being offered a post providing clinical training to student nurses in both psychiatry and midwifery.
Having left Cape Town with a diploma in nursing, Subedar managed, by 1993, to complete a basic degree, a qualification in nursing education, an Honours in psychology and a Master’s in mental health nursing, all while working and raising a son as a single parent.
After South Africa’s first democratic elections in 1994, Subedar, who had participated in some of the strategic teams established in advance to look at the transformation of healthcare, moved back to the Western Cape, where, she felt, mental health services were the most in need of transformation.
“One of the reasons I left academia to go back into the [public health] system was to contribute to the realisation of the idea that basic services should be taken out of hospitals and made available in communities.”
She spent three hopeful years – 1997-2000 – working on the establishment of community mental health services in the province, but became frustrated with the see-saw politics.
“We had three Health MECs in that period with different political affiliations,” she says.
In 2000, Subedar was headhunted to work at the South African Nursing Council as its registrar, opening a new chapter in her life.
“I was the first female registrar, the first person of colour to hold that position,” she says, recalling that the discourse on transformation when she entered the council, “was at the level of worrying about what new pictures to put on the walls, and which building names should change, not about the profession and what was needed to transform it”.
“We had this changing health system, which is also needing to respond to new challenges like the HIV/Aids pandemic. For me, a priority was making sure our professionals are able to work in such a system.”
She instigated a review of the scope of practice of nurses, with appropriate adjustment to their education: South Africa’s Nursing Act of 2005 was largely based on the new frameworks she developed, and she believes it “quite clearly defines what nurses should be doing, what the regulations are, and making sure they enable nurses to do what they have to do”.
The next step was to have been the transformation of the nursing education system.
“That’s the part that …” she starts to say, but her voice peters out. She doesn’t need to describe the current crisis in nursing education, which has been well publicised.
Instead of necessary transformation, nursing education has been compressed by the closure of several nursing colleges, and choked by changing qualification requirements, contributing to a situation where nearly half of all nurses registered with the nursing council are over 50.
Subedar’s time at the council ended badly. In 2008, controversially, her contract was not renewed, leading her to take legal action. She was reinstated for a short time but left in 2009.
“I didn’t know what to do then, but an opportunity arose to come back into the department to assist with the healthcare re-engineering process: ‘how to restructure primary healthcare, and make it more functional in the current system’.”
Learning from scratch
So began her time “of sort of developing stuff for the department and delivering for them”.
When she was asked to roll out HPV vaccination in 2012, it was a one-line instruction: “You will roll out the HPV vaccination, it will be in March 2013, and a Treasury allocation will be made available, but only in April 2013,” she laughs.
“There was no pilot, yet we had to reach every public school within 20 days, campaign style. I learned some valuable lessons … You need to know how many people are required for the work, and to understand who will do what. Your people need to be competent, to be supported. Do they understand their role? Do they have job aids (checklists, algorithms, and explanatory posters)?
“Those campaigns were scripted to the T,” she says, adding, “the beauty is that once people have direction and know what they need to do, they get it done, especially at province level.”
Typically, whenever she has taken on a new project for the department, Subedar has started in complete unfamiliarity.
“On the day I was approached about HPV vaccination, I didn’t know what it was. I didn’t know how it needed to be administered. I knew nothing, but this was a strength because I needed to systematically grasp the subject. I learned from scratch on PrEP, too.”
She advocates “seeking out the experts and literature on the clinical trials and studies, having them provide you with all the technical information you require, and then just shaping it so it will work in the real world in which you want to implement”.
This approach has not been without its challenges.
“With oral PrEP, I sat in the very first meeting with these incredibly forceful HIV researchers, and everybody was doing their own study and had their own ideas about what should be done, which population we should focus on: men who have sex with men, adolescent girls, sex workers or transgender people? Disappointment was guaranteed.”
Her personal motto remains “collaboration”.
“I might not agree with you, but I will listen. All stakeholders should have a space to give their view, including civil society. It (collaboration) doesn’t come naturally to the Department of Health, but if anybody tries to create animosity, or start excluding people, I would intervene.”
Bhekisisa article – Somebody call Hasina (Creative Commons Licence)
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