African Animals

Look at the birds of the air; they do not sow or reap or store away in barns, and your heavenly Father feeds them.  Are you not much more valuable than they?  Who of you by worrying can add a single hour to his life?

- Matthew 6:26-27

Hluhluwe, South Africa

Hluhluwe-Umfolozi is a game reserve in KwaZulu-Natal, where we live.  It is the oldest game park in Africa.  It was established in 1895 to protect the then endangered white rhino.  It now boasts the largest number of white rhinos in the world; unfortunately, poaching continues to be a major problem and over 1400 rhinos have died in South Africa since 2008.  The park is home to Africa’s Big Five—the elephant, rhinoceros, leopard, cape buffalo, and lion.

Rhino baby & mom

Rhino sniffing his own poop.  This is where he marks his territory.

Giraffes eating

Cape buffalos grazing

Elephant

Zebras grazing

Natal Lion Park, South Africa

The Natal Lion Park is a privately run lion enclosure just outside of Durban.  Visitors drive their personal cars through the park with the lions walking right next to the vehicles or lying in the middle of the road.

White lions are a result of a recessive gene.

Male & female lions gazing at each other. 

Female lion resting on her friend's back.

Serengeti & Ngorongoro, Tanzania

Serengeti, which means “endless plain,” extends from north Tanzania to southwest Kenya.  It contains the world’s largest terrestrial migration.  Each year during the Great Migration, zebras, wildebeest, and other game animals travel north from Ngorongoro through Serengeti to Kenya during the wet season.  The Serengeti was used as the inspiration for the movie, The Lion King.

Ngorogngoro, just southeast of the Serengeti, is a conservation area and UNESCO World Heritage site that is also home to the Big Five.  It is a large crater that formed when a volcano exploded and collapsed on itself 2 to 3 million years ago; it forms a natural enclosure for animals, but animals are able to migrate in and out of the area.  It has the densest population of lions, but many are inbred.

Leopard sleeping

Elephant herd walking towards a bath.

Cheetah brothers

Male agama lizard

Hippo pond.  Each year more Africans are killed by hippos than any other animal.



A lion pride guarding a buffalo carcass.

Simba means lion in Swahili, the national language of Tanzania.



Crane

Eland lying in the grass with a baboon passing by.



Thompson's gazelles grazing



Starling

Wildebeest

I hope you enjoyed my photos!  Each one was an exciting experience for us.

South African Fact:

The rhino poaching demand is driven by Asian countries like Vietnam and China.  Some animal parts can be worth as much as gold by weight.  In an effort to control rhino poaching, as of 2012, South Africa will be denying hunting permits to all Vietnamese nationals.

http://blogs.smithsonianmag.com/smartnews/2012/08/in-vietnam-rhino-horn-is-the-drug-of-choice-at-both-parties-and-hospitals/

To Be, or Not to Be

But he said to me, “My grace is sufficient for you, for my power is made perfect in weakness.” Therefore I will boast all the more gladly about my weaknesses, so that Christ’s power may rest on me.

- 2 Corinthians 12:9

Suicide Attempts

The average life expectancy in South Africa is less than 50 years, one of the lowest in the world.  In addition to natural causes like HIV and TB, death by trauma and suicide are also common.  Everyday we see at least one patient who comes to the hospital after attempting suicide.  Most are medication overdoses – on everything from multivitamins to iron tablets to anti-epileptics to diabetes medications.  Oftentimes the patients are young Indian or black women between 14 and 25 years old, who have had an argument with a parent or a boyfriend.  One 16 year old patient tried to overdose on Tylenol because her high school boyfriend, and father of her 2 month old baby, wanted to leave her.  At home, we were taught that depressed people attempt suicide, but most of the ‘parasuicides’ here are not depressed and do not want to die.  Rather they are immature young people who are seeking attention.

Nevertheless, everyday we also see many patients who suffer from serious psychiatric illness.  Many are young but have already experienced a lifetime of trauma and tragedy.  Hangings are common amongst Indian girls, and more likely to be successful than overdoses.  Last month, I admitted a twenty year-old Indian girl with a history of depression, for suicidal thoughts.  She had previously attempted suicide by drinking gasoline the year before, and her mother had a history of depression and suicide attempts as well.  Her parents were going through a divorce, and the week before, her 16 year-old sister – by all appearances a happy, well-adjusted teenager – hung herself.

Patients and families like this are difficult to treat, but it is at these crucial moments when a doctor needs to stop, listen, and show compassion and empathy.  Doctors – in particular family doctors – have the privilege to care for an entire family and become privy to many family secrets. Our role is even more important in times of crisis.  After I admitted the patient, I continued to visit her in the ward, and her mother came to see me for counseling.  The following week they came by my office to drop off a chocolate bar, expressing gratitude for the time I spent with them.  The hospital here may frown upon doctors spending an hour with a patient and her family instead of seeing 6 patients in that hour, but there are critical, fleeting opportunities, in patients’ lives that doctors must recognize and use before they are gone.

Emergency Room

One 15 year-old girl (whom I will call ‘Lucy’) that I kept on my ward for over a month, had attempted suicide by overdosing.  Her father had left her mother when she was very young and then her mother passed away when she was five years old.  Her grandmother took custody of her, but her grandmother was an alcoholic who also smoked marijuana.  Her grandmother repeatedly told her that everybody hated her, and that no one could ever love her.  When her grandmother was drunk, she would physically abuse the girl—she even stabbed her on multiple occasions.  During this time, she was also raped by her step-grandfather.  When her grandmother died, she moved in with her aunt.  She was ten years old. 

Her aunt’s boyfriend, or “uncle”, had a drug problem he could not afford.  In order to pay for his habit, he would drug her and then invite to the house men to whom he owed money.  To pay back his debts, he would let them gang rape her.  This occurred over and over.  She still has flashbacks, in which she can feel and even smell the men who raped her.  Her uncle was eventually arrested and sent to prison, and she was sent to an orphanage with over 100 children.  To this day, she still receives calls from her aunt, who tries to pressure her to revoke her accusations against the boyfriend so he can be released from prison early.

Lucy has been diagnosed with post traumatic stress disorder, and is now showings signs of a personality disorder.  When I told her that she had been doing well on her anti-depressants and would soon be discharged back to the orphanage, she threw a tantrum, running around the ward screaming that she did not want to take her “ugly” medicine.  Later that same day, she lay in bed pretending she could not move, which alarmed the nurses.  Recognizing it as another plea for attention, I ignored her and soon after she got out of bed and acted normally again. 

Two weeks after she was discharged from the hospital, she attempted suicide again by overdosing on cough syrup and was re-admitted.  The night after her re-admission, she was found in the hospital bathroom, standing on the toilet with a rope dangling over her head, contemplating suicide again.  (I do not know why there was a rope left hanging from the 20 foot ceiling; I reported it to the hospital CEO.)  The next day, I had a long meeting with the psychologists, social workers, and orphanage director in order to come up with a plan for her care and safety.  Lucy and I had a long heartfelt talk and she told me that even though people at the orphanage, school, and hospital tell her that they love her and care about her, she does not believe them because her grandmother always told her that no one could ever love her.  It saddens me that this young girl is so bright and full of life, but at the same time is in so much pain.  She has little self-worth, and her thoughts have been polluted by the trauma of her early childhood.  Without conquering the demons from her past, she will not be able to grow into a healthy productive adult who loves herself.



Patients waiting in the outpatient clinic.

 

This story is not unique.  Another very intelligent 15 year old girl whom I admitted after she slit her wrists twice and drank tile cleaner, wrote me the following poem before I transferred her to the psychiatric hospital:

In my mind

I see scars.

In the sky

I see stars.

In the lie

I see the truth.

In a smile

I see the hurt.

In a cry

I hear the pain.

We’ve been pushed so hard

but still we act normal.

We have been through it all.

Through the pain

there’s no other road.

Pushing brings on a strain,

the clouds only bring cold.

I’ve given up my name

because it feels like stone

to know I can no longer reign

so still I try to prove that

In my mind

I see scars.

In the sky

I see stars.

In the lie

I see the truth.

In a smile

I see the hurt.

In a cry

I hear the pain.

I see no mercy passed.

Nobody sees me for me.

No one cares anymore.

Through the stress

I’ve been pressed

to keep pushing, still

In a smile

I see the hurt.

It isn’t over yet coz

in my mind

I see scars.

In the lie

lies the solid truth.

Midlands Meander

South African Fact:

Every year in South Africa, 150, 000 people commit suicide.  In the last 15 years, the rate among children between 10 and 14 years old has more than doubled.  A study from the University of Stellenbosch estimates that each year almost 20 percent of high school students think about fatally harming themselves.  Also, about 25 percent of all general practitioners' patients suffer from psychiatric conditions, not medical.

http://www.hst.org.za/news/mental-illnesses-rise-sa

(For those of you interested in reading more about South Africa’s current plight, please read The Economist from October 20^th-26^th 2012.   The front cover reads "Cry, the beloved country: South Africa's sad decline."  It covers many topics that I have been blogging about this past year.)

Turkey Picture Diary

¹³ Now listen, you who say, “Today or tomorrow we will go to this or that city, spend a year there, carry on business and make money.” ¹⁴ Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes. ¹⁵ Instead, you ought to say, “If it is the Lord’s will, we will live and do this or that.” ¹⁶ As it is, you boast in your arrogant schemes. All such boasting is evil. ¹⁷ If anyone, then, knows the good they ought to do and doesn’t do it, it is sin for them.

-James 4:13-17

Why were you in Turkey?

We went to Istanbul, Turkey for my high school friend's wedding.  It was nice to meet up with old friends and take a break from public hospital life here in South Africa.  The winter has been fairly cold because we have no heating and our cottage is poorly built, so it was pleasant to enjoy a week of smoltering summer in the middle of winter.  Istanbul seemed much more developed and safer than Durban.  It is a beautiful, metropolitan beach city that is always bustling from morning to late hours in the night.  It is a mix of the ancient and the modern.  Turkey is ideally situated between Europe and Asia, making it a bridge between the two continents, and its unique location has richly shaped its history, food, and culture.

Basilica Cistern

View of Istanbul from the Bosphorous

Dolmabahce Palace

Blue Mosque

Topkapi Palace

Characteristic Turkish Blue Tiles

Hagia Sophia

Hagia Sophia

View of the Bosphorous from Galata Tower

How is the food in Turkey?

The food in Turkey was delicious.  It was fresh and light.  The diet was heavy in vegetables which was a nice change from the rich meat diet in Durban.  The food was lightly seasoned but flavorful.  Much of the food is similar to the food in Greece and Bulgaria.  There are a lot of salads, kebabs, feta cheese, and fresh fish.  Since it was summer, there were a lot of fruits too, including a variety of cherries that were so delicious.  We would just buy a bag of cherries and munch on them while we walked down the street. We also visited the Grand Bazaar and Spice Bazaars, which had hundreds of vendors selling Turkish crafts, teas, spices, and more.

Spices

Baklava



Turkish Delight
(Sign on left reads: Turkish Viagra- 5 times in the night.)

South African Fact:

Boerewors, which means "farmer-sausage" in Afrikaans, is a spicy sausage that is usually made with a mixture of mutton, beef and pork.

Survival of the Fittest

In everything I did, I showed you that by this kind of hard work we must help the weak, remembering the words the Lord Jesus himself said: 'It is more blessed to give than to receive.' (NIV)

- Acts 20:35

Whatever you do, work at it with all your heart, as working for the Lord, not for human masters.

- Colossians 3:23

Working in a South African Public Sector Hospital

One of our doctor friends likes to joke that “survival of the fittest” is the rule in SA’s public hospitals: only patients who are strong enough can survive care in the public sector.  (Roughly 90% of South Africans – over 40 million people – receive their medical care through the public sector.)  Many patients are already extremely sick with end stage AIDS and would die even with the best care, but far too many others suffer iatrogenic injury or neglect on a daily basis.  (‘Iatrogenic’ refers to illness or injury caused directly by medical treatment: medication errors, side effects of treatment, incorrect treatments, poorly done procedures, etc.)

Iatrogenic injury can result from poor training, poor judgment or carelessness.  We often get frustrated that so much of our time is spent treating or reversing iatrogenic problems.  Medical training here has minimal supervision, and doctors do not have to go through residency training to practice medicine (they only have to graduate medical school).  Interns (who are either 1 or 2 years out of medical school) can see patients on their own, prescribe treatment and send patients home — all without any direct supervision from a more senior doctor.  One of our colleagues, a trauma surgeon originally from Bulgaria, told us about an incident that occurred while he was working at another hospital (the three of us are the only residency trained physicians in our hospital of 220 beds, an emergency department, a labor ward, a nursery, and multiple outpatient clinics that see hundreds of patients each day).  One day he was seeing his patients on the wards, when a nurse asked him to see a patient who had had colon surgery the previous day.  He replied, “I’m the only surgeon at this hospital.  I didn’t operate yesterday.”  She answered, “One of the interns did.”  The intern had never seen the operation, or been trained to perform it.  Another intern who had seen the operation the previous week, had given his classmate verbal instructions for the procedure.  Not surprisingly, the patient died later that day.   

The cottage we stayed at with my family in Northern Drakensberg.

Outrageous as this story sounds, it is not uncommon.  Professional standards are not enforced, teaching is unstructured at best, self-directed learning is not emphasized, and human life is cheap.  We work with interns daily, and sadly many do not take their work seriously.  Doctors at all levels of training or seniority come late and leave early, miss work for frivolous reasons, and treat patients disrespectfully.  At our hospital interns rarely have formal lectures, and are often asked to see entire wards full of patients on their own when the senior doctor is sick or on vacation. When I asked one of the interns what consequences there were for interns who behaved unprofessionally or acted negligently, she told me that interns rarely fail rotations because training programs simply want to move bad doctors along as quickly as possible.  This is a major problem, because internship is the only formal training required for South African doctors after medical school.  It has recently been increased from 1 to 2 years, ostensibly to provide interns with more training, but the truth is that the public sector needs more interns to staff its hospitals.  Every day we see the results of unsupervised intern care: iatrogenic injury, prolonged hospitalization, and premature death. 

It is not surprising that a poor foundation in medical school or internship can lead to poor medical judgment, incorrect treatment, and bad outcomes for patients.  Nevertheless, poor training is not an excuse for poor care: doctors should be life-long learners who never stop honing their skills.  Many doctors here do not read textbooks or journals regularly (or at all), and continue giving incorrect or even harmful care.  We see sick, elderly patients on 10 to 15 medications, many with dangerous side effects.  Some patients have been on the same medications for years, with no blood testing and no dosage adjustments.  These medication errors can result in hospitalization, disability, or even death.

The view of the Ampitheatre from our cottage.

Last month a patient was brought to the ER unconscious, breathing heavily and slowly.  While I was examining her, she stopped breathing.  I immediately began CPR and called for help.  We put in a breathing tube and placed the patient on a ventilator (breathing machine), one of two in the hospital.  Within hours, the patient was found to be brain dead – likely the result of a major brain bleed.  When I reviewed the chart, I found that  one of the interns (actually a relatively good one) had seen the patient 3 days earlier.  Even though her blood test showed that her blood was already dangerously thin, the doctor kept her on the same dose of blood-thinning medication instead of reducing it.  The intern had been seeing patients completely unsupervised.  She thought she knew how to use a dangerous medication, but she made a mistake.  Likely as a result, the patient died.  I took the intern aside to explain what had happened, so that she could learn. However, she is not solely responsible.  The entire medical system is at fault.

Even when doctors order appropriate treatment, care often is not delivered.  During night shift, only half the nurses work at a time; the other half go to sleep, and wake to relieve their fellows halfway through the shift.  The half that are on duty, are often unable to deal with the volume of patients in the unit, so they leave important tasks – medications, blood draws, monitoring of vital signs – to the nurses coming on duty after them. (And sometimes nurses simply refuse to work: they sit, they chat, they read magazines – anything but patient care.)  One night I admitted a very ill HIV patient from the emergency department to our ‘high-care’ unit.  I ordered for the patient’s blood sugar to be checked every 4 hours since she could not eat.  When I went to check on her a few days later, her sugar had not been checked since admission.  (‘High-care’ is supposed to provide critically ill patients a higher level of care: 2 nurses and a senior doctor for 4 patients, compared to the general wards where 2 nurses and a junior doctor care for 20-25 patients.)



Baboons are considered a dangerous nuisance here. 

The greatest disappointment is how healthcare workers treat patients—often with complete disrespect and disdain.  Patients are herded through the hospital like livestock, with little attention or kindness from the medical staff.  The most common excuse is that doctors and nurses in the public sector are overworked, followed closely by ‘public sector patients are more difficult.’  (Most patients do not know their medications; when asked why they came to the clinic, most say that it is their appointment date – few can give a symptom or time course for their illness.  In Zulu culture, patients go to sangomas, or spirit healers, who tell them directly about their ailments; when these patients present to a Western doctor, they expect him or her to know what the problem is without saying anything.  A colleague likens it to practicing veterinary medicine.)  Both excuses contain kernels of truth.  It is frustrating to work here—conditions are poor, patients are uneducated or have poor cognitive skills, and resources are lacking.  However, there is no excuse for the poor treatment that patients receive here.  Dogs in the US get far better treatment than human beings here.  One of the doctors acted concerned for me because a nurse told her that I was working too hard and giving each patient individual attention.  I was confused by her comment: how do I treat a patient without giving him individual care?   I tried to explain that patients come to the emergency room very sick and they deserve personal care and time, even if it is busy and I am tired.

Picture taken while horseback riding just before sunset.

At this point, in the midst of all this negativity, I feel obligated to say that we have met doctors, both South African and foreign, who are truly dedicated, well-trained, thoughtful, compassionate, humble professionals.  These doctors see the suffering around them, and it spurs them to work more diligently, learn more, and deliver compassionate, quality care.  In addition to clinical care, many are involved in teaching, policy-making, and research.  Unfortunately, these doctors are few and over-stretched.  They carry a heavy burden, and burn-out is not uncommon.

Initially many doctors and nurses probably thought we were dumb or poorly trained because we are far worse at placing IVs than everyone else – also we do not do anesthesia or perform c-sections independently.  However, we have slowly gained their respect.  They realize we are hard-working, fast-learning and conscientious about delivering good medical care.  We have learned some of their procedures and medications (long discontinued in the US).  However, we are also sharing our training, knowledge, and way of practicing with those around us; it is gratifying to find that now, our senior colleagues sometimes seek our advice on complex patients. 


A picture taken during a hike.

I find this quote from a 19th Century Boston minister, Edward Everett Hale encouraging: "I am only one; but still I am one. I cannot do everything, but still I can do something; I will not refuse to do the something I can do."  For us, we realize that we are only two individuals working in a very flawed system and country and we cannot fix all the problems, but we can give our time, medical expertise and compassion to do what we can to help the poor.

A full rainbow arching over a few Drakensberg homes.

South African Fact:

South Africans commonly say “shame,” an exclamation that denotes sympathy, as in "shame, you poor thing, you must be tired; you worked all night."

Ignorance Is Bliss

A generous man will himself be blessed,

For he shares his food with the poor.

-Proverbs 22:9

He who oppresses the poor to increase his wealth and he who gives gifts to the rich—both come to poverty.

-Proverbs 22:16

What is work like?

Two weeks after we started work, an old friend asked me what it was like to work in South Africa, so I began complaining to him about the work ethic here.  I explained that most doctors come to work late after 8 am, take a long tea break after 10 am, take an even longer lunch break around 1 pm and leave by 3 pm.  Even though a normal, non-call work day ends at 4 pm, the majority of hospital staff leave early (and sleep during work hours), regardless of the huge line of waiting patients.  Many patients come to wait at 3 or 4 am for clinic to start because there are no appointment times, and navigating the dysfunctional hospital system (bloodwork, x-ray, etc) is an all-day process.  If a patient does not get seen in clinic by the end of the day, they must either wait in the emergency room overnight or come back to try their luck as an outpatient again the next day.  After listening to me vent, my friend replied, “So the work ethic is no work.”  Exactly. 

People (doctors, nurses, patients) here think we are crazy because we go to work on time and oftentimes leave late.  We also follow-up on patients’ tests and referrals and explain the plan to the patient.  (In the US, this is considered standard of practice.) Patients are oftentimes surprised that I listen to and examine them.  Many report that no doctor has laid hands on them or changed their medicines for years; they get yelled at if they try to say anything.  After listening to a man’s heart and lungs once, he told me it was rare to see a stethoscope being used.  There is significant morbidity and mortality in this country and although healthcare workers frequently blame patients (for being uneducated, seeking treatment late, or for being non-compliant), doctors and nurses often fail to recognize their role in poor outcomes.

           

Since many healthcare workers sit around (or disappear) during work hours, we feel compelled to work even harder – because if we don’t, patients (many of them seriously ill) will not be seen.  As ridiculous as it sounds, we sometimes feel guilty for eating lunch or taking a bathroom break, when we know patients are waiting. In a recent card, wise doctor friends gave us some good reminders:

1. drink water
2. eat
3. sleep
4. take time to go the bathroom!

And most importantly, “don’t sit when you can lie down, and don’t stand when you can sit.”

Durban Botanic Garden, a free public garden in town where we had a picnic.

Things Many Wealthy South Africans May Not Realize About Their Country (Part 2)

1. One of the highest crime rates in the world.

SA ranks 10^th out of 60 countries in total crime per capita.  Roughly 50 people are murdered each day.  Although its murder rate decreased by 50% from 1994 to 2009, SA still has one of the highest rates of intentional homicide in the world – 32 homicides per 100,000 people.  Even more astounding, it has a higher total number of homicides per year than the US – a country with over 6 times more people. 

SA is also the rape capital of the world.  It had the highest number of rapes per capita between 1998 and 2000.  In 2009, 25% of men questioned in a survey admitted to rape (either alone or as part of a gang rape); many began in their teenage years and raped repeatedly throughout their lives. 

Because of the high rates of violent crime, fraud, and corruption, many wealthy or educated South Africans have immigrated to safer, more developed countries.  This further handicaps SA’s growth and development.  (http://en.wikipedia.org/wiki/Crime_in_South_Africa)

2. Highest number of people living with HIV in the world. 

Sub-saharan African has 12% of the world’s population, but 68% of the world’s HIV cases (22.5 million people).  South Africa has 5.7 million adults between 15 and 49 years old living with HIV, and 350,000 deaths from the disease each year – far higher than any other country.  The overall national HIV infection rate is 10.9%, with rates much higher among black and female South Africans.  In a study of antenatal clinics in 2010, 39.5% of the women in kwaZulu-Natal (our province) tested HIV positive!! 

The HIV rate had been rising rapidly throughout the 1990’s and early 2000’s, but fortunately has stabilized.  At one point, the total loss of life due to HIV/AIDS in KZN was estimated to be two-fifths of the adult population.  (http://findarticles.com/p/articles/mi_6821/is_2_10/ai_n55302483/)

Since many young women are sick with HIV/AIDS or have died, many family units are held together by either grandmothers or elder children.  (CIA World Factbook & http://www.avert.org/worldstatinfo.htm)  While the long-term impact of these changes in family structure on future generations is difficult to foretell, we are already beginning to see the effects: increasing numbers of homeless children, orphans, and drug abuse. 

3. Decreasing life expectancy, while the rest of the world is living longer. 

Last year a WHO study showed that life expectancy in SA has declined since the beginning of the century, while the global average life expectancy has increased.  Since the 1990s, SA’s average life expectancy has declined by over 10 years, to just over 48 years old.  In KZN, life expectancy is 43 years, the lowest in the country.  The leading cause of premature death is HIV/AIDS, but that is closely followed by flu/pneumonia, diarrheal disease, stroke, heart disease, diabetes, TB, violence, hypertension, low birth weight, and motor vehicle accidents.  Even more tragic is that most of these are preventable or treatable, especially considering South Africa’s wealth relative to the rest of the continent. 

(http://www.irinnews.org/report.aspx?reportid=87144 & http://www.worldlifeexpectancy.com/country-health-profile/south-africa)

A classic x-ray of TB, one of many that we see each day.

4. Deteriorating education system.

Although basic education is supposed to be accessible to all children now that apartheid is over, the overall quality of education is declining – due to inadequate teacher training, lack of educational materials, and neglect of school facilities.  With few exceptions, the standards in South African schools and universities are lower than those of poorer comparator nations.  High school students only need an average of 30% to graduate.  (Only a slightly higher average of 40% is needed to graduate from medical school.)  Nevertheless, the graduation rate from high school is only 9% in some parts of the country. Of those who do graduate, only 17% will find a job within a year, and only one in six will attend a university; one in three university students will drop out by the end of their first year.  And even university graduates are frequently found to be unqualified and unemployable, by potential employers.  Despite the high unemployment rate, there are actually hundreds of thousands of unfilled positions in the private sector due to lack of qualified applicants.

Even SA’s education minister has admitted that 80% of the schools are “dysfunctional.”  Some schools in rural areas do not have running water, tables and chairs, or a building, despite multiple requests to the education department, over a period of years.  One parent in Durban told us that since the schools are so filthy she tells her children never to use the toilets while at school.  We helped a friend from church make sandwiches for 50 children in a local public school, a weekly task for members of the congregation.  Because of lack of funds, individual schools are forced to seek private support (like churches) to feed needy children.  Like doctors, engineers, and other skilled professionals, teachers are leaving the country or retiring early, as working conditions worsen.  South Africans recognize the worsening standards of their public institutions (health, infrastructure, tertiary education), but the government does not seem to understand (or prioritize the fact) that the country will never develop – and these institutions will never improve – if citizens do not receive adequate primary and secondary education. Living here and directly witnessing the results of a failed education system has made us fear for California’s future, given the repeated cuts to our state’s education budget. (http://www.economist.com/node/21543214 & http://www.iol.co.za/news/south-africa/sa-education-standard-is-dismal-1.421445)

5. Increasing poverty and growing income inequality.

Deepening, crippling poverty coupled with widening socioeconomic disparity, is probably the unifying theme of the 4 problems listed above.  Poverty affects all aspects of the society—the economy, crime, medical care, and education.  Currently nearly 40% of the country is unemployed; in 2001, over half the population of SA lived below the poverty income line.  Amazingly though, many wealthy South Africans are blissfully unaware of these facts.  One friend told us that, unlike some cities in India, one really does not see severe poverty in Durban.  The only way a person could not see poverty here, is if she were blind (literally) or never left her house!  There are cardboard shacks and beggars (both adults and children) strewn across the city.  In some municipalities, over 80% of the population lives below the poverty line.  Although there was no significant change in the proportion of people living in poverty between 1996 and 2001, the gap between the rich and poor rose; more recent studies show that this trend has continued, with the poor sinking deeper into poverty even as the country’s economy has grown.  The poor are getting poorer—literally—while the rich get richer.

The World Development Report in 2006 cited SA’s income inequality as one of the highest in the world.  During the post-apartheid era, income inequality has increased across all races, except for whites where it has decreased.  A small percentage of blacks are very wealthy now, but many more blacks have become poorer, further concentrating wealth in the hands of a few.

The poor continue to lack education, skills, and land ownership.  Non-blacks often complain to us that hiring decisions, especially for high-paying leadership or managerial positions, or those requiring special skills, are not merit-based but rather color-based, as a result of a program known as Black Economic Empowerment (BEE).  Non-blacks claim that this is essentially a system of reverse apartheid.  An example we have seen: even though the medical and educational systems are English-based, some of the black nursing students can barely speak English, or write beyond word for word copying. 

If the current patterns of high crime, poor health, skyrocketing unemployment, substandard education, and overall social discontent continue, SA’s economic growth and development will be permanently stunted, making it a non-entity on the global stage. 

(http://www.sarpn.org/documents/d0000990/ & http://sacsis.org.za/site/article/146.1)

For the middle class and wealthy in SA, ignorance is bliss now, but how long will it last?

Umhlanga Rocks, an area with many luxury hotels and apartments on the beach.

South African Fact:
Maternal mortality, oftentimes preventable, is unusually high in SA with 410 deaths per 100,000 people.  For comparison: it is 38 per 100,000 in China, 24 per 100,000 in the US, and 6 per 100,000 in Japan (CIA World Factbook).