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.

The Dark Side of South Africa

Why South Africa is like 1950s US

1. Racism is blatantly and shamelessly expressed. 

South Africans often pride themselves on living in the ‘Rainbow Nation’ because SA is more diverse than many other African nations.  However, ‘rainbow’ gives a false impression that everyone has been living happily and peacefully after apartheid; in reality, there is still significant fear and ignorance about people of other races or religions.  Even in the post-apartheid era, some people feel justified in their racism and express it freely.  Sometimes they will preface their comments as “I’m not being racist or judgmental,” which is invariably followed by a racist or judgmental statement.  In Durban, people still self-segregate so interracial relationships—marriages, dating relationships, even platonic same-sex friendships – are extremely rare.  People of mixed black and white descent (‘coloured’) are at the bottom of the totem pole in Durban.  They are considered the people who commit crimes and abuse drugs and alcohol.  Since Akbar is well-liked and respected here, when Indians are being racist, I bring up that Akbar is actually biracial to challenge their preconceptions about how much one’s race actually reflects one’s character.

Alien, a single South African mother, raising a multi-racial family.

2. Across all races, gender roles are male-centered and male-dominated. 

During apartheid, women were traditionally held as inferior to men; these ideas stemmed from traditional African beliefs as well as misreading of the Bible.  A recent church bulletin (in a mostly Indian church) stated, “Feminism is dead wrong!”  Even though many women in SA work full-time and more are getting university educations, it is still commonly women’s responsibility to do all of the domestic work.  If both spouses work, the women still act as primary caretakers of the children, and do all of the cooking and cleaning while husbands sit at the table and wait to be served.  People are shocked when we tell them that our fathers can cook for themselves, and well.  They are even more shocked to learn that Akbar’s father lives on his own and does not need a ‘helper’ (i.e. maid), to cook and clean for him.  ‘How can a man ever survive without a woman?’ is their unspoken question.

(http://en.wikipedia.org/wiki/Women_in_South_Africa)

Tai Long, 1 month old, growing up on the rough streets.

 3. Homophobia is rampant and often leads to violent crimes. 

Desmond Tutu, the former Anglican Archbishop of Cape Town and Nobel Peace Price winner, has said that homophobia is "every bit [as] unjust" as apartheid.  Since SA’s post-apartheid constitution outlawed discrimination on the basis of sexual orientation and legalized same sex marriage, the only African country to do so, SA has advertised itself to homosexual tourists as a “gay-friendly” nation.  Nevertheless, hate crimes are common and human rights organizations have criticized how the SA police and government handle these crimes.  Gay women in particular are frequently victims of beatings, rape, and murder.  In some cases, male perpetrators claim that rape will “cure” the woman of her sexual orientation.  In a country where most people come from a faith background, they somehow have forgotten that God loves everyone and calls us to love our neighbors as ourselves.

(http://www.afrol.com/articles/13584 & http://en.wikipedia.org/wiki/LGBT_rights_in_South_Africa

 4. The ‘meat and potatoes’ diet is alive and well. 

Despite decades of research proving that a high fat, high carbohydrate diet and large portions lead to heart disease, diabetes, and premature death, people of all races here continue to indulge in generous portions of white bread, potatoes, sodas, red meat, and sugary desserts.  To justify their ‘carpe diem’ attitude, they blame poor genes as the cause of their central obesity, clogged arteries, and early-onset diabetes.  As an American, I did not think I could be impressed by another country’s obesity or ridiculous eating habits; South Africa has proved me wrong.  South Africans die of heart disease and uncontrolled diabetes as early as their 30’s – especially those of Indian descent.  It is actually quite unique and sad for a country to be plagued by both developing world illnesses, such as malnutrition, HIV and TB, and developed world illnesses, such as diabetes, heart attacks and strokes.

Pumpkin, 1 month old, hiding from the smoke and pollution.

5. Smoking is common and accepted. 

Many people smoke on a daily basis as if the link between smoking and cancer has not yet been discovered.  We frequently find ourselves sitting and chatting in a group, even with doctors, where we are the only non-smokers.  Unlike the US, there is no shame in smoking around non-smokers, whether they are babies, patients, or pregnant women.  (Or sometimes the pregnant woman is also the smoker.)  Although smoking is not permitted in restaurants or hospitals, the rule is not enforced.  Nevertheless, restrictions on smoking areas and advertising, have decreased overall smoking.  In 2000, 43.8% of men in SA smoked, down from 51.4% in 1993.  Progress is further evident in the 40% decline in cigarette consumption between 1990 and 1999.  SA has made smoking its 2^nd health priority after HIV.  One man we met always complains that his wife and children are such horrible asthmatics, needing to carry their inhalers all the time, yet he smokes over a pack a day and refuses to recognize that he may be exacerbating their symptoms.  Another man who was recently diagnosed with TB, for the 2^nd time, reports that smoking helps his chest feel less tight.  I often wonder what health consequences we may have after a year of regularly inhaling second hand smoke (and the sulfurous gases from the oil refinery half a mile down the road).

(http://archive.idrc.ca/ritc/sarelease3.pdf & http://www.cansa.org)


Obviously, these problems exist in other countries as well as SA.  However, they are pervasive here to a degree that, despite its relative wealth and political stability, the country’s development is adversely affected by them.  On paper, SA’s goals are that of a progressive, forward thinking 21^st century nation that has far outpaced its African neighbors.  The attitudes of average citizens, the daily lives of those struggling in poverty, and the health outcomes and social indicators data tell a different story.

Samson, a fatherless South African child found on our doorstep.

South African Fact:  There is a national campaign to circumcise males between 15 to 49 years old in an effort to decrease the transmission rate of HIV.  Our hospital has an entire ward dedicated to adult circumcision and, surprisingly, men line up there daily, waiting to be circumcised.  The new interns are expected to perform 100 circumcisions each before the end of their 2 year internship. (I suggested that we give vasectomies at the same time; far too many fatherless children are raised in poverty by their grandmothers, or are abandoned to the streets.)

Circumcision campaign poster in hospital hallway.

Experiencing South Africa

Fraud, Part of Everyday Life

Most people know that crime, like theft, muggings, murder, and rape, is a part of daily life in SA.  What we did not know was that fraud is also very prevalent here. A SA newspaper claims that 15-18% of professionals here have fraudulent certifications.

In December, a doctor from the Congo was discovered to be falsely registered to work as a neurosurgeon in SA.  He had worked at 2 private hospitals and opened a private practice before his credentials were finally questioned due to incompetence.   He was already banned from practicing in Botswana and Zimbabwe.  This man did not have any residency training and he was pretending to be a brain surgeon!  Last year 6 Nigerians were found to be fraudulently practicing as physicians as well.  The same Health Professionals Council of SA (HPCSA) that has allowed all these fraudulent people from developing countries to work as doctors is the same organization that has given us so much trouble and not registered us when we are fully trained doctors from a 1^st world country.

Most recently, the HPCSA has questioned the authenticity of our documents, including our passport.  It is a huge blow to your ego when someone questions everything from your identity to your education that has taken your entire life to accrue.  We have had to explain every document to them because they are obsessed with minutia - everything from the type of hospital stamp to the way our documents are notarized.  For example: our initial hospital documents had an embossed stamp, which was inadequate.  Then we had the documents re-couriered over with an ink stamp and gold seal, which apparently is still unacceptable. Nevertheless, they have agreed to register us to work if we get our documents notarized the South African way.  We hope and pray that this is all they need.  We appreciate all those who have been emailing, praying, and being supportive from afar. 

Zulus

Durban is located in the province of KwaZulu-Natal (KZN), which is home to the Zulus, one of the ethnic groups in SA.  Although the Zulu monarch does not have any official political power, he lives in KZN and receives a stipend from the government, similar to the royal family in the UK.

Zulu Drummers

Languages with Clicks

Most South Africans are multilingual. There are 11 official languages here and several of them have clicks.  Although English is the language of politics, economy, and the media, it only ranks 5^th out of languages spoken at home (only 8.2% of people).

The accent of the Indian South Africans has been the easiest for us to understand because English is the primary and only language spoken by most Indians.  We have probably had the most difficulty understanding the white Afrikaners’ accent.  Afrikaans has its roots in 17^th century Dutch.

In 2001, isiZulu was spoken by 23.8% of the population, making it the most common language spoken in the country; in the province where we live, KZN,  80.9% of the people speak it.  It is followed by isiXhosa at 17.6% and Afrikaans at 13.3%.

Zulu Dancers

The clicks come from the Khoi-San people who live predominantly in southern Africa.  Most people know them as ‘Bushmen,’ popularized by the 1980s movie, ‘The Gods Must Be Crazy.’ 15% of words in isiZulu and isiXhosa contain clicks.  The types of clicks are numerous and subtle.  Like tonal languages (such as Mandarin or Vietnamese), the differences are difficult for a non-native speaker to appreciate.  In Zulu, they are variously described as ‘a dental click’ (written as a ‘c,’ pronounced as a ‘tsk, tsk’ with the teeth), a ‘palatal click’ (written as a ‘q,’ pronounced like ‘a cork popping from a wine bottle’), a ‘lateral click’ (written as an ‘x,’ pronounced as ‘the clopping of horse hooves), etc.  IsiXhosa has even more variations.  Even the name of the people and their language, ‘Xhosa,’ starts with a click (try saying that out loud). 

As you can imagine, we have great difficulty making these sounds - without being laughed at or feeling like we are going to choke.  One of our construction workers goes by ‘Patrick’ in the city, but his Xhosa name is ‘Xatiana’; despite numerous attempts, we could not pronounce it correctly. Though these clicks are often ridiculed in the US, they are taken for granted by non-black South Africans; some Indians and whites can even manage them quite well.

Zulu Dancers

Zulu Basics
 

Sawubona                    Hello (one person).

Sanibonani                    Hello (many people).

Yebo                            Yes

Cha                              No

(Information from http://www.southafrica.info/about/people/language.htm, http://en.wikipedia.org/wiki/Zulu_language.)

Story about Words

I was asking one our friends what South Africans called these small, green chiles I had.  She quickly said “joll-i-peen-nos.” I did not catch it initially because it was a multi-syllabic new word.  I asked again, and she said “joll-i-peen-no.” Then I saw Akbar smile and I realized it was her way of saying the Spanish word “jalapeño.”  There are no Spanish influences here, so of course the pronunciation would be different.

South African English Word                              American English Word

Robot                                                               Traffic Light

Boom                                                               Gate

Brinjal                                                              Eggplant

Boot                                                                 Car trunk

Bakkie (pronounced ‘buckey’)                         Pick-up truck

Theatre                                                            Operating room

Gynee                                                              Gynecologist

Packet                                                              Plastic grocery bag                              

Braai                                                                BBQ                                                   

Dagga                                                              Marijuana

SMS                                                                Text message

Serviette                                                           Napkin

South African Fact:

During apartheid, each race was assigned to a different neighborhood and beach.  Only the beaches for the whites had shark nets. 

Data from the University of Florida shows that there were 31 shark attacks from 1905 to 1990 between Cape Town and Port St Johns.  Although attacks have risen to 94 incidences from 1991 to 2010 due to human factors, SA still has fewer attacks than the US. 

 

A Happy New Year

A Happy New Year

We spent New Year’s Eve having dinner with church friends and then attending a church service.  Going to church on New Year’s Eve was a first for both of us.  Apparently evening service on New Year’s Eve is common here and the church was packed full of families dressed in their Sunday best. We did not get to bed till 2 am, and then we were back again at 9 am for the regular Sunday morning service.  Not a bad way to start the New Year.

Our New Babies

Our cat Alien rang in the New Year by giving birth on January 2, 2012.  Mom and her 2 babies are healthy and doing well.   She has decided to solely breast feed because it is better for the physical and mental health of her babies.  I had prayed that she would have less than 3 kittens because life here is difficult for animals (and people), and it would be challenging for us to care for and find homes for a litter of 4 or 5 kittens.  God definitely answered my prayers; I didn’t know that cats could even have 2 kittens. 

1. Ginger & White Kitty

2. Black & White Kitty

What do we have in common with the Dalai Lama?

We are both victims of South African bureaucracy.  The local paper, The Mercury, ran a story on December 28^th announcing that the Dalai Lama would be receiving the Mahatma Gandhi International Award for Peace and Reconciliation on January 6^th in India – because he was not allowed in to South Africa (SA).  Originally the award ceremony was planned for October in SA.  (The Dalai Lama was also supposed to attend Desmond Tutu’s 80^th birthday that same visit.)  However, he could not enter the country because the government never processed his visa application.  After reading that article, I could not help but laugh.   It is both comical and tragic.  It highlights the inefficiency and lack of transparency of SA’s bureaucracy.  If the Dalai Lama, an internationally recognized political/religious figure whom SA invited to attend events in the country could not get his visa application approved, it is not surprising that 2 unknown doctors from the States are struggling to get their medical registration processed.  (You will all be happy to know, though, that the government has assembled a commission to investigate ‘the Dalai Lama incident’ – probably full of the same people who were responsible!)

How have you been spending your time?

Since we do not have a television, car, or reliable internet, the Americans out there probably think we are bored out of our minds or are going stir-crazy.  In actuality, we have been quite busy and entertained, in part because our friends regularly take us out and in part because we have chosen to take advantage of this “down” time.  Akbar and I were looking back and neither of us has had this much free time since we were 5 years old.  That is not to say that this waiting game is not stressful (it is—especially for 2 control freak physicians), but we are trying to be patient and make the most of this God-given time.

Alien and her babies (Day 2 of life)

We spend most of our days reading, caring for the local cat population, cleaning, and cooking. Fortunately, although we are around each other most of our waking hours, we are still enjoying our time together and having fun.  It may be delirium setting in from being “trapped” in a dangerous foreign country with no car, but we laugh together daily.  On Tuesday nights we accompany our friends to Bible study; on Sunday, church evolves into an all day event: first services, then lunch at our friends’ house followed by tea time, then a leisurely afternoon drive to the beach for Indian snacks or a shopping trip.  Another friend of ours from the hospital visits us almost daily on his lunch breaks, and hangs out with us on his post-call days; we’ve enjoyed numerous outings with him and his fiancée to the movies, the mall, and numerous restaurants around Durban.

Accomplishments the last 2 months: completing several books (medical, fictional, spiritual, and otherwise), deepening our relationship (with the help of a pre-marital counseling book and its probing questions), and watching all 3 Godfather movies for the first time (something we have wanted to do for years).  One book in particular stands out, in that we both enjoyed it immensely: Cutting for Stone by Abraham Verghese.  We both read all 600+ pages in just a few days.   It is a story about family, friends, Ethiopian political upheaval, and immigration, set in a medical back-drop.  We highly recommend it.  (When all else fails, we also try to keep up our medical education: journal-reading, books about South African medicine, HIV/TB, and hospital medicine.) 

Watching the ‘Godfather’ trilogy here was an interesting experience.  In a country where the crime seems random, violent, and haphazard, the glamour Hollywood casts over organized crime in America provides a stark contrast.  People tell us though, that there is organized crime here, with involvement in the international drug trade, car-jacking rings, and high profile thefts (once, an entire ATM machine was pulled out of the wall with a tow truck and driven away).  A favorite scapegoat here is ‘the Nigerian mafia.’ 

South African Fact:

SA’s population is 49 million as of July 2011.  Although SA is a relatively wealthy and resource-filled 2^nd world country, many of its national indicators are even worse than 3^rd world countries.  According to WHO statistics in 2006, life expectancy in SA is 48 years, worse than countries like Somalia (50 years) and Ethiopia (56.2 years).  Other 2^nd world countries like China and Brazil have life expectancies > 70 years old (CIA World Factbook). 

A Summer Christmas

Christmas

I have never had a white Christmas before, but now Akbar and I have had our first Christmas in the summer.  It was also notable for a few other ‘firsts’: our first Christmas spent together, our first Christmas where we did not attend church, and our first Christmas spent with Hindus.  In SA, the Christmas season kicks off summer vacation – kids are out of school for 5-6 weeks - and everyone goes to the beaches or shopping malls. 



Ballito Beach the weekend before Christmas



Despite the carols sung in church and long lines in the malls, we never did get the Christmas season vibe here.  I am not quite sure if it was because the weather was warm and humid, we were not around family, we had not been working, very few homes had Christmas decorations, or Santa Claus was just too thin and young in South African malls.  Nevertheless, we did have a lovely Christmas with a few friends. (We actually got 3 separate invitations for the day.)  We had a rich spread of food for our Christmas lunch, or rather all day eating event.  We started off with seasoned prawns and langostines and a Greek-style salad. Then we had lamb roast stuffed with green chile peppers and garlic, cinnamon and sugar carrots, and spicy potato salad with green chile peppers.  (Basically all foods in Durban have a lot of chile pepper or powder added to it, whether it is Italian seafood linguine, Chinese chicken chow mein, or Indian mutton biryani.)  Our friend tried to bring a little of America to SA and even ordered us a turkey with stuffing so we would not feel homesick during the holidays. We ended the meal with trifle for dessert, which consisted of 3 layers—sponge cake, fruit jello, and custard, generously topped with sweet heavy cream.  Although we are far away from our families and friends, we have started to make close friends here.

How’s church?

We have been going to the same church for the last 1.5 month.  It is a “full gospel” church, which seems to mean “pentecostal.”  It is like no other church that we have attended in the States—around 90% of the church members are ethnically Indian.  The other 10% of the church members are coloured, white, or black.  Of course there is no one like the two of us in church.  At home it is rare to meet a Christian Indian, but here many of the Indian families have been Christian for many generations.  Like churches in the States, church is very much cultural as it is Christian.  A Chinese American or Mexican American church service has a different atmosphere and style of worship than a White American one.  At this church people may wear saris or shalwar kameez to attend service.  For Christmas supper at church, everyone ate with their hands and we had mutton curry, chicken curry, rice and semolina pudding (a South Indian dessert). While far away from home, it has been comforting to know that all around the world, Christians of every race and ethnicity worship and pray to the same God, study the same Bible, and may even sing the same songs. 

Home Invasion                                            Luckily, we did not have a home invasion by people; it was by another species—monkeys.  I was in the living room taking a nap and I thought Akbar was rummaging for food in the kitchen because I heard cardboard boxes opening and plastic wrap crinkling.  I thought, “I don’t know why he’s so hungry, we just ate…he really snacks too much.”  Little did I know, Akbar was in his room and he thought I was in the kitchen, so he came out to see what I was doing.  Much to his surprise, he did not find me there, but 3 little monkeys!  He swore and gave the monkeys a cold stare and they quickly ran out of our kitchen window with food in hand.  Since it had rained earlier that day, we had little, muddy monkey hand and foot prints smeared all over our window sill, new white cabinets, counter and tile floor.  All of the fruits from our counter were gone; they took about 3 oranges, 2 tomatoes, and 6 bananas.They only left one white onion with a small bite in it; I guess raw onions are not a favorite amongst monkeys.  They also spilled cinnamon powder, tea, and juice from the fruits all over the floor.  When we looked outside, there were pieces of banana peels on our grass and planter.  The evil-doers sat looking innocent on our front lawn, while a group of their friends sat on the roof of the building next door, waiting for our reaction.  Some of them were eating pieces of oranges and others bananas.  Akbar started yelling and flailing his arms and initially they just stared at him, but then they realized that he was really mad so they ran across the street. I have come to think that monkeys are like young children.  They know the difference between right and wrong, but oftentimes they will do the wrong thing to test boundaries and see what reaction it evokes.  These monkeys had a feast in our kitchen, which was off limits, and they ran away because they understood that they were in big trouble.

Alien at 1st trimester of pregnancy

Adopted Children

We were only in S. Africa for about 2 weeks before we adopted our first child.  Her name is Alien because she has wide set green eyes, a small head, and round body.  She is a young calico cat (less than 1 year old) that initially just came to our house once a night to ask for food.  Quickly her visits became more consistent and frequent, increasing to morning, lunch, and dinner, and sometimes snacks.  Then we made a bed for on our veranda which she would sleep in every night.  We were planning to neuter and save her from the cruel, African outdoor life, but we were too late and she was already pregnant.  We felt like horrible parents.  We only had her for 1 week and she was already pregnant!  We should have kept a closer watch on her!  Then I realized she must have gotten pregnant prior to meeting us.  Alien realized she needed a dependable food source and made us her patrons.  I started feeling fetal movements last week and I think she will deliver in the beginning of January.  We have moved her bed into our attached storage room so she can deliver and care for her new babies in a private room without feeling endangered by the outdoor environment.

Samson at 4 weeks old

About 2 weeks after we adopted our first child, we adopted a second one…accidentally.  One morning, around 5 AM, we heard a cat mewing outside.  I ignored him and continued sleeping.  The mew was very small, but persistent and I found that it was coming from a small, ginger and white kitten from below Akbar’s room window.  The day was very windy so I figured the little kitty was just distraught by the weather and was waiting impatiently for his mother.  Hours passed but he never stopped crying and his mother never came.  Meanwhile, I saw a circling hawk flying overhead, so I worried about the baby and went out to take a look.  Initially, the baby approached Alien, thinking she was his mother, but Alien hissed at him.  Then the baby approached a post-partum orange tabby cat that we feed; she tried to smack him and hissed at him too.  For some reason he did not remember who his mother was and no one would take him as her own.  After checking on him several times, he eventually started following me around and I was happy to have such a cute kitten follow me.  He even followed me into the house!  I guess he thought I was his mother.  He was about 4 weeks old at the time, so he was still unable to survive in the wild alone.  He still needed milk and there could be dangerous animals outside that may attack and eat him.  Since he had been crying for 5 or 6 hours straight that morning, I knew he must have been tired and hungry.  I took the medicine cabinet from our old bathroom, lined it with a bed sheet, and he immediately started purring, curled up, and fell asleep for hours.  And this is how Samson came to our home.

Samson at 8 weeks old

Unfortunately, Samson was only calm, sweet and cuddly that first day.  After bathing him and removing his fleas, we kept him in my bedroom where it was cleaner and safer.  Like most babies, he required feedings (of special kitten formula) and attention in the middle of the night.  He became so rambunctious that I was not getting much rest at night because he would sleep only 2-3 hours at a time, eat, and then play, which consisted of jumping, biting and clawing at me.  Akbar thought he could fare better than me so we traded rooms, but he quickly realized that sleeping with a young kitten is not an easy task.  As a result, Samson now has taken over my bedroom completely and we have moved my bed to the dining area.  Over the last few weeks I have actually slept better in my “new room” because it is darker and quieter.  Samson did very well at his first veterinarian visit and car ride last week and he will be back next month for his well-kitten vaccines.

South African Fact:

One US dollar equals a little more than 8 South African Rands (R).

60% of all workers in the formal economy earn <2000 R/month (<$250 US)

15% of all workers earn <500 R/month (<$62.50 US)

In 2010, the UN said that 44% of workers in S. Africa lived on <10 R/day. (<$1.25 US)

($1.25 is the most recent international poverty line.  Keep in mind that there is a high unemployment rate, so many people are not even working.)

One gallon of car gas is ~$5.50 US.                 

One avocado, peach, or small pineapple is ~$0.75 US and a liter of milk is $1.25 US.

A Women’s Bible from the bookstore at the Pavilion Mall is ~$40 US.