Monday, August 30, 2010

Some thoughts on Cape Town and how it fits into my impressions of south africa

A few posts ago, I talked about how South Africa was super segregated, was a culture of the conquerors and the conquered. And I still stand by a lot of those views, but my visit to cape town definitely gave me a different perspective on South African race relations.

In Cape Town, you see biracial couples and children everywhere. Moreso than in the US. I was confused to see that in comparison to what I had seen on the other side of the country. They even have a name for people who are half black and half white: “coloured” (and it is not a derogatory term there). As I went to a few museums and learned more about the history of cape town, I was even more fascinated.
It seems that in cape town, back before apartheid came to play in the 50s or 60s, that white and black people lived together in relative harmony (not to overpaint it as all peachy keen, and I am sure people stuck to their own, more or less, but people interacted and lived in each other’s neighborhoods). Then, when the government passed the district acts, the whole city was torn up into districts which were labeled as “black” or “white” or “coloured.” In one famous district, district 6 (where there is now a museum), black people were forcibly removed from their homes, and the homes were bulldozed, because it was zoned as a “white” district. And the forcible separation of people definitely created more tension between them. As I was in the district 6 museum, looking at pictures of pre-apartheid era in district 6, I was shocked to see sports teams, social clubs, etc, with a mix of black and white people.

As I took all this in, I was thinking, “can I be interpreting this correctly? That people of different races and cultures were living in harmony, socializing together, intermarrying, until the government came and messed it up?” So foreign to me, as I felt like our experience in race relations is so different/opposite in the US. As I walked around and read more, it seemed that that was more or less the case (without sounding too extreme or making it that simple). I know that now in cape town, people mix, but there is still racial tension and inequality, and I am sure there was some pre-apartheid as well.

That said, I was trying to take in why it was so foreign to me that different races would so easily. IN the US, so much violent crime and hate has focused around racism. The government has had to intervene to DE-segregate. But here, African-Americans arrived as slaves, arrived captured, so from the start, there presence was brought with it a sense of inferiority and power balance. In Cape Town, whites invaded into black territory, I am sure there were years of turmoil and tension and power struggle, but somehow they worked it out…What makes that difference? What makes people learn to get along? Is it breeding? Cultural training? Or do we all secretly want peace around us, and as the historical conflicts and power struggles of government and society fade away, we are allowed the freedom to see that as a possibility? Big questions I really can’t answer… And I don’t think anywhere in the world has completely abolished racism. Sometimes, in the US, I wonder how much racism has changed. We are in an increasingly mixed society (and mixed world for that matter), but do we just push racism below the surface so we can be “PC” and appear “civilized?”

It is also interesting to me that the race issues and segregation seem so different in South Africa based on your province (as previously described my experiences in Gauteng and Mpumpalanga provinces). Maybe it isn’t that different than here? That race issues might be different if you lived in Alabama or California or Michigan? And I just wonder if no matter how you got to where you are, no matter how the government has been involved or not, is the end product the same?

If anyone has any answers, let me know (just kidding).

Wednesday, August 25, 2010

Back in the states...

I have been back one week now, and jumped right back into things.
An emergency last minute site review the day I got back, then starting on wards, 63 hours in 5 days, barely time to think or sleep.

I am not sure how I feel. Rushed back in so fast I didn’t have time to feel. Today was my day off, and I think I feel a little displaced. I have enjoyed reconnecting with friends, taking care of patients more directly, but definitely something in me feels different. I feel like Africa changed my subconscious if nothing else. I went to target today to get some necessities. Normally I like to wander in target, spend a lot of time, and normally spend too much money. Today, no desire. It’s weird, I am not directly thinking about Africa, thinking about the things I have seen, but somehow my subconscious is different.

I have been having dreams about people in Africa. In my dreams, I am crying for them, my heart is breaking for them. I wonder if in sleep, when I am allowed to let go of the day, I am connecting more meaningfully with my emotions. Am I mourning for Africa?

I spoke with my dad today on the phone, for the first time since I have been back. As I talked about Africa and the things I had experienced, and my perspective, I realized something else that struck me about the whole thing…The country is losing it’s young. The young are fatally ill. This is so strange to see, I don’t think I was able to put words to it before. It’s this disease that starts so insidiously, so slowly, that nobody knows it is happening, it is ignored, until Boom, you are in the hospital, critically ill. Too often it is not caught in the early stages because people aren’t testing. The highest group that is getting infected is those who are in their teens and 20s. Normal development at that time states you are invincible, you take risks, you experiment. And the consequences of experimentation are ignored, because still, you believe it can’t happen to you.

How dermoralizing, during the phase of your life when you are “invincible,” to be grounded and incapacitated! And how strange to see the young generation die, while it is being ignored.

One woman comes to mind when I think of this. She was about 22, and was hospitalized for life threatening infections due to AIDS. She was thin, gorgeous, high cheekbones. If I saw her in a different context, I would believe she was a supermodel. She lay in bed, her excrement all over her gown, because she couldn’t control it anymore. Her mind was still all there. My mind struggled to adjust to this picture. A 22 year old, with bright eyes, a beautiful face, and so much potential. Incapacitated, dependent, out of control of her body. Things like that aren’t supposed to happen until you are elderly, and even then I imagine it is quite demoralizing. How can a country see it’s young people, it’s potential, it’s future, it’s work force, die off one by one, and stand idly by? I have heard the phrase “the missing generation” to describe the countries where AIDS has ravaged. Now there is a picture in my mind to give a story to that phrase.

One more person whose story I must document.
Enos was my cab driver coming back from the airport when I returned from the Port Elizabeth conference. He was very friendly, and open about his life. He was from Limpopo, which is the province north of Gauteng province (where Pretoria and Johannesberg are – it is the smallest province, but the most densely populated). His wife and 4 children were still in Limpopo, but he had had to move to Gauteng for work, as there was not enough in Limpopo. I asked where he lived in Pretoria, and then wished I hadn’t. He named one of the townships – acres of land that are essentially squatter camps. Miles and miles of corrugated tin sheds that people set up and live in. No running water, no electricity. He lives there while he works, and his 2 days off a month he goes to Limpopo to see his family. This story is not uncommon here. He spoke of his youngest daughter, how smart she was, how good in school. His eyes lit up with pride when he talked about her. He said that she was sick that day, and his wife had had to take her to the doctor. He said he knew it was probably something minor, but it was hard being away when you knew your child was sick. This story broke my heart. Here he is, a man driving foreigners in this Mercedes to and from their destination, at night he returns to his shed where he is missing the comfort of his family. This story is not uncommon, and I admired this man for his strength of character. For doing what he had to do to support his family, for his love for his family, and his desire to be with them. For the pay-by-the-minute cell phone he had so that he could call them every day.

Now that I am back, I am not worried about forgetting. I am sure I will get more used to the luxuries of my everyday life, stop feeling guilty about them, and getting back into the groove. But I have realized now that there is no way I can stop doing international work. I don’t know what this will look like in the future – if it will continue in Africa, or in Latin America, if it will be long term, or a month at a time. But I can no longer imagine never doing it again, or putting a big part of myself into it.

Saturday, August 14, 2010

A quote from today...

"Strangely, the foreigner lives within us: he is the hidden face of our identity, the Space that wrecks our abode, the time in which understanding and affinity founder. By recognizing him within ourselves, we are spared detesting him in himself. A symptom that precisely turns 'we' into a problem, perhaps makes it impossible. The foreigner comes in when the consciousness of my difference arises and he disappears when we all acknowledge ourselves as foreigners." -Julia Kristeva.

An appropriate quote to think about as I spent the day learning about south african history and seeing it expressed in art.

Friday, August 13, 2010

Last day in Pretoria

Today I leave the “work” part of South Africa. I will spend a few days in Cape Town for my “vacation” time, and then fly back to the states.

As I am packing up the studio, I am feeling a little choked up and teary for sure. And needing to record, for the final time, some of my thoughts about South Africa (I expect that when I get to cape town, it is going to be a very different experience than it is here).

South Africa is a country of great contrasts. It is a country of great diversity, but that diversity seems polarized. Half the country is living in wealth, in areas that you would not be able to tell are NOT in the United States, and half lives in abject poverty. You can drive just a few kilometers and go from seeing gorgeous, mansion-like houses, to viewing the “townships” – basically squatter camps where people live in shacks with corrugated tin roofs, without running water or electricity.

In addition to the divide between rich and poor, there is the divide between modern and traditional. Parts of South Africa have very modernized medicine, yet many patients still mix this with traditional medicine men/women. There is an advanced system of roads and freeways, yet you often find to get to the poorer people you are suddenly on dirt roads. Many of the people in South Africa have cars, but the majority of the people in the lower socioeconomic class still walks to work (or rides in packed vans/backs of trucks). And as you are driving down the freeway, you may, in the same line of vision, see a brand new, luxurious BMW driving, as you see a woman walking, in traditional African dress, balancing her load on her head.

I love that there are still glimpses of the traditional culture here- the way women wrap their heads, the way they carry their babies, the way they carry their loads balanced on their heads, and I hope that these things are not lost if the economic divide begins to shrink (IF it does, I am being a tad optimistic here).

The country is one of the conquerors and the conquered, and you see evidence of that everywhere. First, there were the native blacks. Then the Dutch, who colonized cape point (and somewhat drove out the blacks) when they were looking to create a stopping point for the ship lines of the Dutch India Tea Company. Later, the British colonized this point, and drove the Dutch further inland. Isolated, and second class citizens, their dutch developed into its own dialect, “Afrikaans,” and they developed their own isolated culture. In their own minds (and probably in the structure of society at the time), they were inferior to the british, yet superior towards the blacks. So everyone lived in their own, enclosed communities, with their own rank in mind, and their own structure of society.

Then, in more recent years, with the ending of apartheid, the black culture is being again recognized. Town names are reverting from their Afrikaans names to African names (which honestly, is a bit confusing when you are driving somewhere, and trying to keep your directions straight. They don’t label their freeways north/south/east/west here, it is labeled by which city you are going towards). These constant changes continue to give one the impression that the power structure is constantly shifting – the conquerors and the conquered.

It seems that little has changed in this segregation. The neighborhood in Pretoria where the UCSD studio is located, is largely Afrikaans. Gorgeous homes, yet each is enclosed by automatic gates, topped with an electric fence. Security guards patrol the streets. And in between the locked fortresses, black people roam – going from job to job, selling brooms, etc. And I wonder – how must that feel to be a black person wandering the streets, distanced from homes by electric fences – is the implication that the Afrikaaners are trying to keep them out? Yet they are let in for short periods of time to clean or garden. It is so striking to see, and so disturbing. One of my co-workers said something to the effect of “the racial tension is so dense and near the surface, you feel like it is going to break out at any second.” Although I feel that is a tad dramatic, I know what she means. People are civil to each other, but live in their own isolated bubbles, with visible structures to keep it that way.

I don’t mean to over-generalize and say that there is no mixing between cultures, or that every black is pushed down by the man into a lower socioeconomic status. There are plenty of black African physicians, some of whom work in I-TECH, but even in that, I sense a cultural divide within the company. Not even necessarily a hateful or prejudiced one, but definitely people coming from completely different racial/cultural worlds, and sometimes not knowing how to interact or communicate effectively with each other.

There is also the “coloured” race here- further evidence of mixing. Here, “coloured” is not a derogatory term, as it may be in the United States. It is a description of a “new race” – people who are half white and half black. Almost as the “mestizo” or Mexican people group developed.

But yes, certainly a mix of things, certainly a country of contrasts. Makes you feel a tad schizophrenic while you are here, not being able to reconcile the 2 worlds you are seeing.

Monday, August 9, 2010

A Single Thread...

There is a little boy I can’t get out of my head. I saw him one afternoon at an extremely rural clinic on the paper mill. The nurse there asked me to see him because she was uncomfortable treating children. The boy was 6, HIV + since birth, never on medication. He was being seen in clinic that day because he had been exposed to TB at home, and they were concerned that he may also have TB.

The boy walked into the clinic behind his grandmother. She looked exhausted, worn down, and hopeless, the child looked downcast. From the door, I could see his cheeks puffed out bigger than they should. When he came in, I realized they were his greatly swollen parotid glands (saliva glands at the back of your cheeks). I examined him and found evidence that he has had lung disease for years…Likely not getting enough oxygen for a long time. I evaluated his chest xrays, one from 2008, one from a week before his visit, and confirmed my suspicion that he has had lung disease for some time, likely secondary to his HIV. I also suspect he had TB.

I told the grandmother we were going to have to treat him for TB, and about 2 weeks after that, we were going to have to start him on antiretrovirals. She sighed, and her face fell further, if that was possible. She admitted she was overwhelmed. One of her daughters was dead, one was hospitalized a day before with advanced AIDS complications, and she was left to care for all the grandchildren. As I talked to her further, she noted that she had another 7 month old baby at home who had also been abandoned, and likely exposed to TB. She sighed and said she would walk home and get the baby, so we could check him out as well. It took her about 30 minutes to walk there and back with the baby. In the meanwhile, the 6 year old sat with us. He stared straight forward, face expressionless, nothing we did could make him smile. How many 6 year olds do you know that can sit still without entertainment for half an hour? It broke my heart, and made me fear his young spirit was already broken. His deep, wide, dark eyes seemed that they had already seen much darkness and disappointment, and this had aged him. Finally, Vivian found a mint in her purse, and offered it to the boy. He took it and put it in his mouth, and I thought I saw a tiny smile as he sucked on it. It encouraged me to see a little light back in his eyes. I can only hope that as he receives treatment, he will have somewhat of a new beginning; that as his health improves he will feel life returning to his body and have hope for his future potential. Sadly, I know his health is not the only obstacle he must overcome.

A day later, we visited his mother in the hospital. She had the same wide, dark eyes, sunken with the pain and what she has seen. We updated her on her son, and a bit of worry crossed her expressionless face. Towards the end of our conversation, she suddenly perked up and demanded to be put on antiretrovirals. She had been refusing them in the past, and I think her hospitalization and the sickness of her son made her want to take control of her health. Again, my cautious optimism made me hope that she would follow through so that she could take care of her son, and not become another thing to fail him.

As I mentioned in my previous post, I am struggling a little with knowing in a week I will have to transition back to a completely different world. I thought about this as I took a walk around my neighborhood in Pretoria this afternoon. Although I have never done anything quite like this before, I have definitely had experiences where I have gone out of my comfort zone and had a difficult transition back. And I think I need to remember that every experience is a part of the bigger picture of our lives…And that in the short term, it is sometimes hard to see how a short term experience will fit in to the bigger picture. But it always does. Every experience leaves impressions on us and ultimately becomes seamlessly woven into the whole – as much as we feel so fragmented by our experiences in the short term.

So I hope and pray that as I leave, I will not feel fragmented or disillusioned or disconnected. I pray that I will have faith that this trip has been another thread in the story of my life, and as it continues to be woven together on the loom, this thread will also become woven in, and become a part of the bigger design.

I am deeply grateful for this experience, and humbled by it. I know I am changed, and I hope that I will stay changed, and not forget the lessons I have learned. I hope that this experience will become integrated into the person I am, that it won’t have to be compartmentalized or sequestered or become isolating.

Saturday, August 7, 2010


I have one week left of my time in South Africa.
I spent my first week or 2 here crying, feeling so homesick, aching to come home. Then week 3, there was a transition. Something changed, shifted in my brain, almost as if something had permanently remodeled so that I am no longer able to think the same way. Now I feel I will have a hard time coming back.

I think the thing I struggle with here, is that I am in, and not of. I have worked every day with now 4 different tribes of people, with 4 different languages, and me struggling through understanding their culture and trying to communicate effectively in the things that are not said. I have been so touched by the people here, so humbled by their experiences and stoicism…Despite this, I am definitely still an outsider. So many times I have wanted to take a child into my arms, to hold them in their loneliness…I have wanted to reach across the huge cultural lengths with my adult patients and tell them that deep down, despite our experiences, we are the same…But I am definitely still an outsider. And honestly, I am still much more comfortable in my own cultural setting…It is hard to see so much pain, concurrently so much beauty, to want to reach in, and to still be so distanced.

At the same time, I feel that something in me has shifted and I don’t know that I will still be “of” home when I get back. I now feel removed from my home culture. And I am just anticipating not adjusting well to being home, not fitting back in. And part of that doesn’t make sense to me. There are people at home that I love and miss and why wouldn’t that itself be something to make me fit back in, to feel back at home?

I feel between two worlds, not fitting in either, and it feels lonely.

I struggle with the concept of “home.” There was college and starting to feel at home there, starting to develop a community and friends. And then I moved to Detroit very quickly. Same thing in Detroit, struggled to fit in, find a place of belonging in a really temporary job where you are constantly re-learning, switching things up, and never getting into a groove anywhere…And started to develop community there and feel at home, feel passionate about the location and my integration there, and then felt called to San Diego.

I was really excited about San Diego, especially as I grew to love it and develop community. And I had more of a constant group of coworkers and work situations (although of course, I pick a dual specialty which causes more switch ups and making it harder to feel at home). That said, I bought a home, it was exciting to develop community, to love the place of San diego, to love the work I am doing, to love to feel integrated into the world around me. Exciting to think I could stay there after residency if I got a job…That I wouldn’t have to necessarily relocate and throw up my whole world again. Finally, was starting to feel at “home.” After years of writing about this concept, trying to understand it, I felt the potential of having it.

And now I am in this strange limbo. Being changed, being different, having seen, having felt, and I wonder how much I will be able to feel “home” anywhere.

Perhaps all this is a bit dramatic, but I am definitely struggling with the tug of being in a weird place emotionally.

What keeps going through my head are the lyrics to one of my favorite songs by Cinematic Orchestra (enough that I am afraid I am going to get tired of the song). "There is a place I call home...There is a place that I'm no longer alone."

Sunday, August 1, 2010

Starting week 4

Today starts week 4 in South Africa!

This past week was pretty awesome. SO BUSY and crazy (I was pretty exhausted), but satisfying. We were working again near Nelspruit, in a small town call Barberton. We were working at a rural hospital there, and also traveled to the outlying community clinics in that area. I respect so much what they do there, they work so hard, and with so few resources...

The rural clinics were really the best part. Before I came here, I had read about the initiative towards decentralizing health care, especially for HIV care. Basically before a few months ago, you could only get HIV drugs in big hospital centers. Which is a problem when 20% of the population is infected, and when many of the patients who need drugs are not within traveling distances of the big medical centers. In addition, there are not enough physicians to staff areas outside of the big medical centers to start people on treatment. So there was this government initiative to fund training for nurses to initiate antiretrovirals (ARV) on less complicated patients, and refer more complicated patients to medical centers.

While I was reading about this initiative, I couldnt help thinking: "wow, that sounds great, but how long is that going to take to make that happen? And will it? Or is it just a lofty pipe dream that sounds great on paper and makes some politicians sound humanistic?" Well, not that it is without it's faults, or is working perfectly, but it is happening!

I think my favorite clinic we visited this week was Glenthorpe. It was about an hour from Barberton, which is already pretty rural, and we had to drive probably 10 miles on a ruddy dirt road to get there. This clinic is inside of a paper mill, which is one of the biggest employers in the area. It is literally in the middle of nowhere, and the workers live in barracks in the paper mill along with their kids and wives.

It seemed pretty bleak as we drove in for the first time. Small tin barracks, a small school with the roof coming off...You know the people are rarely able to get out of this tiny world given the lack of transportation.

Inside the clinic I met "sister" emily (they call nurses "sisters" here). She is overworked, dedicated, and drives up to this remote area every day because she cares about testing people for HIV and starting them on treatment. When we got there, there were some crossed lines of communication (not unusual here), and she thought our purpose was to teach the patients about health, and so she had invited all her mothers to come in for "education." Something we were unprepared for, but decided to roll with it. We moved probably 30 moms and their kids into this tiny room, shoulder to shoulder, kids crawling around all over the floor. So I am trying to give a "talk" to people who are largely illeterate and speak only minimal English. It ended up being really fun, and the women had a lot of good questions (I think my favorite was "You said that we should eat fruits and vegetables. The fruits and vegetables we have here are mostly bananas and avocados. I was told I can't eat bananas and avocados while I am pregnant. What should I eat?"). I wished I could have taken a picture of all these beautiful women and children packed into the room, but in those situations you can't...There is this mistrust when you take people's pictures in a situation like that that you are going to use the photo to advertise they have HIV, which is still very taboo here.

As usual, lots of heartbreaking situations....
The pediatric ward in the hospital had a number of HIV+ children who were abandoned at the hospital. My favorite was "Niki" a little boy who was 22 months old, would wear old man pajamas and a robe, and sit in a chair in the middle of the peds ward, watching everyone with his head in his hand, like he was in charge of the place. After about an hour, I finally got him to smile :) But his expressions and the way he carried himself told how much older he was, and how heavy his heart was.

A week ago, I was counting the days until i could go home. This week, although I miss home, it is harder to imagine going back...