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).

Chasm Between the Rich & Poor

Do not wear yourself out to get rich; have the wisdom to show restraint. 

Cast but a glance at riches, and they are gone,

For they will surely sprout wings and fly off to the sky like an eagle.

                                    -Proverbs 23:4-5

Smiling When Life is Tough

“Next!” wails my nurse, an elderly Zulu woman who is pre-disposed to napping during patient encounters.

To my surprise, enters a stout, Amazon-sized, Afrikaner woman pushing a stroller with a happy Zulu boy sitting in it.  The baby is small for his age, but healthy-looking. 

“Hmmmm, this is clearly not the boy’s mother,” I think to myself, “maybe he’s adopted.”

The large Afrikaner woman sits down across from my desk, takes the baby out of the stroller and places him on her lap facing me.  The baby has short tight curls and smooth, milk chocolate skin.  He looks younger than his age of 4 months, but his cheeks and arms and legs are filled in.  He looks at me wide-eyed, and smiles.  No one can resist a smiling baby.  Immediately, my nurse and I fall in love with this cute boy.

“So why are you here today?” I ask.

The large Afrikaaner women replies, “Jacob has had a cough for 3 days.  He has HIV, but he’s on ARVS (anti-retrovirals).”

“Has he had any fever or weight loss?” I ask.

“No, he has actually been eating well and gaining weight,” she responds.

We continue back and forth with questions and answers until I have mentally listed the most likely diagnoses for the baby.

Curiously I ask, “Is he an orphan?”

“Yes.  It’s a long story how he came to be under my care.  In my home I care for several children that have been orphaned, but this is the first HIV positive baby that I have cared for, and he’s been doing quite well.”

“What happened?”

“Well, Jacob was born early at 28 weeks old.  His mom didn’t want him so she took something to abort him.  After he was born his father tried to strangle him with a cord.  Then his parents put him in a black bag on the ground and left the house.  While they were gone, thieves broke into the house.  One of the thieves accidentally kicked the bag and it began to cry; when the thief looked inside, it was a baby.  So he took the baby to the police station.”

“What happened to the thief?”

“People always ask me if he was charged, but I don’t know.”

“Well, Jacob’s lucky to have been saved; he’s been through a lot.”

“His first 2 months of life were hard.  After he was found, he had severe pneumonia and stayed in the hospital for over 1 month.  He was started on AZT at the time, but it was already too late and he became HIV positive.  The good thing is he won’t remember the first 2 months of his life.”

“It’s a very good thing,” I agreed.

How can such horrible things happen to a person who has been alive for only 4 short months?  He entered this world innocently, not of his own free will, and has had to battle to survive from the time he was a fetus.  And yet, he has overcome.  Now he sits smiling before me, all of the trauma of his past forgotten, and unaware of the tragedies that occur around him everyday.  I think, this child is resilient – he was meant to live. 

While my nurse and I play with him and speak to him in baby talk, I feel saddened that the beginning of his life was a nightmare, and that he has to live with HIV for the rest of his life.  At the same time, I’m glad that he is now in a safe, loving home, and getting medical attention.  Although his life is nowhere near perfect, I know that there is hope for him and I know that someone cares.  I see orphans, both HIV positive and negative, on a regular basis, and these stories are not unique.  These kids are tough.  God is looking out for them; for what purpose I do not know, but in them I see hope in what sometimes seems a hopeless situation.  From this baby and many others like him, I am reminded that life can get tough, but if he can struggle through and come out smiling, so can I.



Main street in town in Durban.



Issues Many Wealthy South Africans May Not Realize About Their Country (Part 1)

We frequently hear that “South Africa is not like the other African countries; we’re not so poor.  You can’t tell you’re living in Africa when you’re in South Africa.”  Many upper middle-class/wealthy people compare SA to other first-world countries.  However, most have not been to other first-world countries, other African countries, or even poor or rural areas in their own country; their assessments are far from objective, and far from reality. 

To be fair, South Africa is wealthy for a sub-Saharan African nation.  And crime, poverty, and disease do exist in every country to some degree.  However, nearly all statistical indicators show that SA is doing worse than its developing country peers – whether African, Asian, or South American.  Countries like Kenya and Ethiopia continue to improve (in terms of life expectancy, HIV prevalence, economic productivity); SA regresses.  Sometimes I get so irritated when South Africans make comments about the poverty in Ethiopia or the street children in Vietnam that I just want to shout at them, “Open your eyes!  Every city in this country is full of shantytowns that aren’t even fit for dogs.  There are kids begging at stoplights.  You can’t miss them, they’re everywhere – outside that upscale mall where you bought your $100 Puma shoes, across the street from that fancy restaurant where you just had your romantic dinner.  Why is it sadder when it’s somewhere else?  Why are people in other countries more deserving of your compassion than people in your own backyard?”

I know I sound angry and judgmental, but it is difficult, day in and day out, to watch many people suffer and go without basic needs, while at the same time we see the wealthy spend money on designer clothes, iPhones, and BMWs.  They ignore the poor, or judge them as lazy.  I believe that God exists and that He is good, but He gave us free will.  We are responsible for the societies we build, and the poor have fallen victims to our selfishness, our apathy, and the failures and corruption of our political leaders. 

I cannot say that I know what it feels like to be poor.  However, from speaking to poor people in SA and other countries (including the US), many have physical or mental illnesses that prevent them from working.  Some beg or prostitute their bodies because they see no other way to feed or clothe their families.  And some, having grown up in townships or slums filled with poverty, violence, and substance abuse, internalize all the negativity of their surroundings, and come to believe that taking what they need or want by force is acceptable – whether it is sex, money, revenge, or entertainment. 

People have asked, “Why go to SA when there is so much poverty in the US?”  This is a valid question.  At home, we have always made conscious decisions to work in underserved, poverty-stricken communities, and will continue to do so when we return.  We understand that poverty-stricken areas in the US experience shortages of doctors; however, the shortages in countries like South Africa are far more severe.  Likewise, the degree of poverty and social injustice is far more severe in developing countries than it is in the States.  Both of us have always felt motivated to serve where the need is greatest.  Before either of us became doctors, we knew we wanted careers where we could work with those in need in poor countries.  (Naively, we did not consider the fact that we would also have to work with the bureaucracies of these countries.)  However, we are learning the limits one faces when trying to effect change in someone else’s country, and that it is easier (and sometimes more appropriate) to effect change in one’s own country.      

It is true that tourists visiting places like Cape Town will think they are in a modern European country, with nice paved roads and fancy restaurants.  SA wants to make a good impression on its visitors.  The sad truth is that the majority of people in this country live in abject poverty, without running water, electricity or medical care.  Having pride in one’s country is a good thing.  At the same time, by turning a blind eye to obvious problems, a person passively contributes to the decay of his or her society.  Only by honestly and sincerely confronting these issues can people overcome them, and move their country forward.  Otherwise, SA risks becoming another in a long line of failed African states.

Flying over an expansive shantytown just before landing in Cape Town.

South African Fact:

Many South Africans use the phrase “izit!?” to mean “really!?” or “is that so!?”  It is a combination of “is” and “it” placed together.  It is said as an exclamation and a question.  When we first arrived to SA, we were confused when someone would say “izit!?” to a factual statement we just made.  We did not know if they were questioning us or if we were supposed to reply “it is!”

Example:

Mary: “Today we saw over 700 patients in the outpatient department.”

Tom: “Izit!?” You must be tired.

(Note: On an average day, over 600 to 700 patients are cared for by our hospital's outpatient department.  Outpatient includes the chronic outpatient clinic, urgent care, and pharmacy.  The goal, although not always reached, is to have 10-14 doctors seeing patients and a few pharmacists and pharmacy technicians working each day.)

The Story of HIV/AIDS in South Africa

Rich and poor have this in common: The LORD is the Maker of them all.

                                                                  -Proverbs 22:2

How’s work?

Well, that is a loaded question.  It is a question that evokes a multitude of responses, emotions and stories.  On one hand, it is good to be working.  On the other hand, work comes with many frustrations.  I am currently working in the urgent care clinic so I see patients with all types of illnesses, from chronic diseases like diabetes and high blood pressure, to acute fractures, drug withdrawals, new cancer diagnoses, and babies in severe respiratory distress. A typical patient scenario: a 6 year old orphaned African girl comes to me with a full body rash (insert any type you like – chicken pox, fungus, herpes, etc) that an outside doctor has treated unsuccessfully.  I do an HIV test, and sadly it comes back positive.  (I have not yet had a negative result in this scenario.)  Another typical scenario: a young, emaciated man comes in for cough, weight loss, and night sweats for 1 month.  I order a CXR and TB work-up, and (over 90% of the time) he has TB – and is concurrently diagnosed with HIV.  Many of the patients I see have HIV and its sequellae, the most frequent of which is TB.

Akbar is currently working in the emergency department, so he sees all types of patients too, from babies with severe dehydration, to teenaged victims of stabbings and gunshots, to patients of all ages with AIDS/TB, to middle-aged people with heart attacks/strokes.  He deals with critically ill patients every day, and struggles to balance the needs of individual patients, against the resources of a system that is dysfunctional and overburdened.  Each day he faces ethical dilemmas, and is learning to deal with them ‘efficiently’ but in a way that allows him to sleep at night.  In the US we are taught to ‘go all out’ for patients and use every test and treatment possible, regardless of severity of disease or age (or cost).  In SA, patients in the public sector with chronic illnesses like HIV or diabetes, or even being over 50 years old, can be refused an expensive test or treatment (like a CT scan or ICU admission) on the grounds that resources are limited, and should be saved for patients with better prognoses.  It has been difficult to see patients with severe illnesses get minimal or no care because it is considered a waste of resources, or to see them be used for practice by inexperienced physicians because they are poor. 

We are learning that in SA’s public hospitals, the ‘right way’ to practice medicine is not always clear.  As a person who thinks primarily in black and white, it is difficult for me to see situations in shades of gray.  In The Crack-Up, F. Scott Fitzgerald writes, “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”  The test for us will be balancing the needs and best interests of the patient in front of us, with needs of a resource-constrained system to provide for the rest of the population.

List of hospital services.

How Did So Many People Get HIV/AIDS here?

There are a number of factors that could explain why SA has the highest number of HIV patients in the world, and why our province, KZN, has the highest rate of HIV in SA (UNAIDS in 2009).  HIV crosses all racial, educational and socioeconomic boundaries in this country.  Even Nelson Mandela, South Africa’s national hero, winner of the Nobel Peace Prize, former president, and a Xhosa prince, had an adult son who died of the disease.  It is a disease that affects people of all ages, but especially young women and children.  Nearly 40% of women in their late 20s have HIV/AIDS, and 57% of childhood deaths under 5 years are HIV related (WHO 2000-2003).  It has been estimated that by 2015, 32% of South African children will have lost at least one parent to HIV/AIDS (http://www.irinnews.org/report.aspx?reportid=87144). 

HIV is a disease that carries tremendous stigma here.  Many people lack basic education, and have minimal medical understanding.  There is a strong fear of being shunned by one’s religious community.  People think that AIDS is a disease of the immoral or dirty or poor.  As a result, people will often deny their illness, refuse testing, suffer from multiple infections and eventually die.  Meanwhile they spread the disease to their families and partners.  We have heard stories of nurses at our hospital who have died from AIDS, simply because they were in denial and refused testing or treatment.  It can even be difficult to transfer HIV positive patients to a higher level of care because some doctors think that it is a waste of their limited beds and resources.  Some doctors have suggested that it is prudent to leave out a patient’s HIV status when trying to transfer a patient.   (Studies show that limiting hospital resources based on HIV status, is a phenomenon that even exists in the US.)

Unlike the US, where HIV testing is becoming routine, testing in SA is less accepted and less easily accessible.  People can undergo HIV testing only after having received standardized, formal counseling about HIV and medication adherence, and consenting to the test.  Though education and counseling component are important, they often become barriers to testing.  Doctors cannot simply add an HIV test to a lab work-up; they must write ‘HIV counseling & testing,’ which the patient can refuse.  Doctors cannot even cite AIDS as the cause of death on a hospital chart or death certificate, if there is any question of the patient’s disclosure status.  (Instead they write that a patient died of pneumonia or meningitis.)  In the chart, physicians often document ‘retroviral disease’ (RVD) status, a euphemism for HIV.  Vague documentation coupled with large numbers of undiagnosed HIV-infected people, means that many friends and family members of patients are exposed to the disease without ever knowing.

Road to our cottage.

Political, Social, and Cultural Influences on HIV/AIDS Transmission

SA’s high HIV infection rate is not an accident.  It is the result of neglect, mis-education, and mismanagement.  Since the epidemic began, South Africans have been misinformed by many of their leaders.  Dr. Manto Tshabalala-Msimang, an ob/gyn physician and politician who served as Minister of Health from 1999 to 2008 under President Thabo Mbeki, was infamously known as ‘Dr. Beetroot,’ since she advocated the treatment of HIV with traditional herbal medicine instead of anti-retrovirals.  (President Mbeki himself publicly doubted that HIV caused AIDS.)  She feared that the financial costs of treating HIV would infringe upon broader public health goals.  At the International AIDS Conference in 2006, SA was publicly criticized for its HIV policies.  A group of 65 of the world’s leading HIV researchers wrote a letter to President Mbeki calling for the dismissal of Dr. Tshabalala-Msimang; he refused (http://en.wikipedia.org/wiki/Manto_Tshabalala-Msimang).  According to one story, the minister had thousands of condoms stapled to pamphlets on safe sex and HIV, puncturing them in the process.  When asked about the thousands of useless condoms, she said it was meant to show people what not to do.

In addition to the political system, social factors have exacerbated the spread of the disease.  Among black Africans, mistrust of the medical system has led to delayed testing and treatment.  In one study, 25% of the interviewees believed that HIV was created to infect blacks and decrease their population.  Given the country’s history, such a view is not surprising.  During apartheid, blacks received inferior medical care to whites.   Another study in 2002 in KZN showed that 70% of patients consult traditional healers before doctors for health concerns, and some try herbal treatments rather than anti-retroviral therapy for HIV (http://www.irinnews.org/report.aspx?reportid=87144).  High rates of violent sex crimes also play a significant role in the transmission of HIV to South African women and children. 

Zulu and Xhosa cultures have further contributed significantly to the spread of HIV, especially in KZN.  In both groups, multiple sexual partners and polygamy are traditionally accepted.  Where we live, it is a tradition for the Zulu king to pick a new wife annually from a group of dancing virgins.  (Incidentally, everyone in KZN pays taxes to the king to support his family and royal lifestyle – including mansions, luxury cars, and expensive clothes.)  Polygamy is not restricted only to royalty.  One of our construction workers has multiple girlfriends; two have borne him children.  Another worker is married with 3 children, but has a girlfriend on the side, and his wife has a boyfriend too.  Both cultures have a high degree of gender inequality, and call on women to tolerate sexual behaviors that put them at high risk for HIV.     

Summer flowers in bloom by our cottage.

South African Fact:

If you live in Pakistan or China, you are 99.45% less likely of becoming HIV positive than if you live in South Africa.  However, if you live in the US, it is only 96.69% less likely.

(http://www.ifitweremyhome.com/    Based on statistics from the CIA World Factbook)

Cape Town Diaries

¹ The heavens declare the glory of God;
the skies proclaim the work of his hands.
² Day after day they pour forth speech;
night after night they reveal knowledge.
³ They have no speech, they use no words;
no sound is heard from them.
⁴ Yet their voice^[b] goes out into all the earth,
their words to the ends of the world.
                           -Psalm 19:1-4a

South Africa the Beautiful

We are frequently told that “South Africa is a beautiful country, but not the best country because it has too much crime.”  After living here for several months and visiting Cape Town in the Western Cape in January, I can agree with that statement.  We have experienced both petty crime and now amazing natural beauty.  The Western Cape was a pleasant break from Durban; it is very similar to California in weather and geography.  There are beautiful beaches, mountains, and vineyards.

Victoria & Alfred Waterfront (named after the 19^th century British monarchs) has a busy port as well as many high-end shops and restaurants.

Camps Bay, an up-scale beach town, is bordered by the mountain side called the 12 Apostles.

Table Mountain is the feature of Cape Town that has made the city famous world-wide.

Franschhoek (Afrikaans for “French Corner”) is home to many wineries beginning in the 1600s when the French Huguenots settled there.  Tastings average $2.50 for 6 wines and some come with cheese pairing as well. 

 Scene along the N1/R45 Wine Route.  The vineyard area is very similar in landscape and weather to the Napa Valley.

Cango Caves in Oudtshoorn.  We took the 1.5 hour Adventure Tour and climbed vertically and horizontally through small crevices.  Funny story: in 2007, after repeated requests that she not to crawl through the caves, an obese tourist from Durban was allowed through (after threatening legal action) and became stuck in the cave for over 10 hours, trapping over 20 tourists behind her, including a diabetic who needed insulin and a couple children with asthma.  Emergency services used climbing gear and paraffin wax to extricate her.

Oudtshoorn Wildlife Ranch.  We were able to see big-game animals up close (in enclosures that would never pass American safety inspections), watch crocodile feedings, and play with cheetah cubs.

Scene along the N2/R310 Garden Route.  Ironically, this drive reminded us of the words to America the Beautiful.  Do you see the ‘spacious skies,’ ‘purple mountains,’ and ‘amber waves of grain’? 

Shantytowns.  We have never seen shacks as expansive and dense as those surrounding Cape Town.  They extended for miles, seemingly without end.  Electricity is supplied by makeshift wires criss-crossing over the shacks, connected to utility poles on the side of the road; in the absence of parks, people use the side of the freeway (with traffic streaking past at 80 miles per hour) as their exercise and recreation area – for jogging, soccer games, etc.

Chapman’s Peak Drive, a 9km route, is a picturesque mountain road with multiple switchbacks and scenic vistas along the Atlantic Coast, reminiscent of California’s Pacific Coast Highway.

The Cape Good Hope was previously considered the most southern point of Africa until the Europeans realized they were wrong. (It is now known to be Cape Agulhas, which is 150 kilometers southeast.) It is the legendary home of the Flying Dutchman, a ghost ship that was doomed to sail the seas forever.

Dias Beach was one of our favorite places on the trip.  Secluded between the headlands of Cape Point and the Cape of Good Hope, its only access is by a steep stairway that descends from the trail connecting the two points.

Boulders Penguin Colony.  The colony comprises of 3000 African penguins, the only penguin species to inhabit Africa; it all started with 2 pairs in 1982.  (Fortunately – or unfortunately depending on how you look at it – our parents were not so successful.)

Robben’s Island is where Nelson Mandela was imprisoned for the majority of his 27 year sentence.  We went on a tour guided by a former political prisoner who spent 8 years there.  Although he was a black man, he made special mention of the many women, Asians and whites who opposed apartheid and were also imprisoned.  It has become increasingly common, we have noticed, for people to remember ‘the struggle’ against apartheid as a battle fought and won primarily by black South African men.

Kirstenbosch Botanical Gardens, located at the foot of Table Mountain, features plants unique to the area.  Of the 6 plant kingdoms, the Cape is the only region with its own floristic kingdom.

South African Fact:

From the tour of Robben’s Island, we learned that during the apartheid era, people were not classified as being a certain color until they received their identification papers at the police department when they turned 16 years old.  For people whose race was not obvious, such as certain Asians or ‘coloureds,’ they would do the ‘pencil test’ or the ‘lip test.’  If a pencil could remain stuck in their hair, or their upper lip was above a certain thickness, they could be classified as black.  Maybe I would have been considered black during this time: a pencil can definitely get stuck in my hair and my upper lip is fairly thick.