26 October 2007
The last 2 days have been very interesting. Yesterday I went to morning report as usual and then did ward rounds before going to the clinic. There was one colposcopy scheduled. I had understood that they had done colposcopy here in clinic previously but found they weren’t sure what to have set up for colposcopy. Once we had everything we needed, we got started. Although we had one patient scheduled, three showed up. No one knows how that happened but I was glad that we could do several since it would be the only chance we would have. Everything went very well. I was able to do all 3 colposcopies and show the residents and students quite a bit since the system they have has a video set up so they could all watch on the video screen. The colposcope has the video screen but not a direct view eyepiece so that took some adjustment on my part. Overall it was a great experience and it felt like the most effective thing I had done since I got here. Following that, I had lunch with Dr Mdaka and we discussed the colposcopies we had done and then how they might structure an ongoing colposcopy clinic. Then we discussed how to start doing laparoscopic surgery at NMAH. This would be such a benefit for the patients but also hopefully use significantly less hospital resources and open a severely clogged system allowing more patients to be treated.

Last week I had asked the interns about foods that were part of the local traditional diet and that I wanted to find a place that served these foods. They were going to think about where to send me but had concluded that there wasn’t anywhere that served good local cuisine so they were going to cook for me. They decided to have a braai which they described as an African barbecue. It was held at one of the intern’s homes and there must have been 30 people from the department there. They asked me to invite the other volunteers as well so 5 of us went. The meal is largely centered around meats. They have a large grill outside and cook massive amounts of sausage, pork and chicken. They served it with chakalaka, a dish called pap which is a stiff porridge made of maize and spinach cooked in a sauce. The chakalaka is cooked tomatoes, peppers and cabbage and can be quite spicy. It was all very good. I made chocolate chip cookies to bring as my American contribution. We had a chance for conversations outside of medicine. I heard some of their stories about coming to South Africa and the political unrest they experienced before leaving their home countries. We spoke about the fall of apartheid. Dr Mdaka was at the university during apartheid. He spoke about being involved in demonstrations. There were several banned political groups and the students formed new ones to replace them but much of it was done in secrecy. They got a copy of Roots and smuggled it in because it was banned. They had to watch it secretly and it had a profound effect on many students that motivated them to fight apartheid. It was quite a dangerous time for them. He was arrested once with a large group of student protesters. They were jailed for several days and eventually convicted en masse but then released since it wasn’t practical to keep them all locked up. In spite of the risks, his family was supportive. It was a risk to be in the movement to fight apartheid but it was also a risk for a university student in the Transkei not to join. After dinner they turned up the music and danced in the living room. It was a very nice evening. I was so pleased that they included all of us and how willing they all were to share themselves and their culture with me. It felt like a very successful day.

I have a new appreciation for the term African although I am not sure exactly what it meant to me before. The term is used on forms that ask for race but they use it in conversation as an identity of heritage and at the same time to identify where they live. The country of origin is also an identifier as is their native language. South Africa has been an attractive destination for refugees of other African countries affected by political and ethnic violence or by suppressive regimes, even before apartheid, but much more so since. After living here for years they will still refer to themselves as Ugandan or Nigerian etc. but also as African. I am having difficulty describing it but it’s very different than saying I am white. Black is used only as an adjective for skin coloring. There is a sense of identity in being African and there isn’t a similar term for me. Being American seems more like a political than even a geographic term. To me it is a statement of collective commitment to freedom and democracy rather than nationality. African is a description of origin and of culture at least as diverse as American but doesn’t seem associated with a philosophical identity. There is a definite pride in their tribal heritage and histories. They recognize their different backgrounds but the African concept brings them together.

Friday morning starts with the usual morning report but also is the time set aside for educational presentations. I gave an update on contraception today. They have a somewhat vigorous style of discussion following a presentation. For some reason it seems like the difference in style of debate that I have observed between US congress and British parliament…..perhaps not quite as loud as the British. In any case, I had not thought of this topic as being controversial but they found points to discuss. Some of them were things I had thought about but didn’t put into the presentation such as the lack of availability of some of the options because of economics. I didn’t see the abortion issue coming but it did. One of the doctors expressed his objection to offering contraception to teenagers because it would encourage them all to be promiscuous and get HIV. I obviously disagreed with him and was pleased to see that several others strongly voiced their disagreement as well. What I thought would be a 20 minute presentation took most of an hour with all the discussion. Everyone seemed pleased with the discussion. I was also thankful that the power didn’t go off until the time for discussion so I was able to use the power point with my video of the Essure procedure. We finished our ward rounds. I gave a photo to a couple of the patients who had requested one when I was taking pictures earlier this week.

I went home and packed and we set off for Coffee Bay. It is very quiet little town on the Indian Ocean. We are hoping for a nice sunny weekend.

27 October 2007
It has been a relaxing day on the coast. It is a very different environment from Mthatha although not that far away. Some of it is simply being away from the city.

Shortly after breakfast, Megan noticed a group of Africans on the beach having some sort of ceremony. There was a group of twenty or so. They had drums and did chanting and eventually some were taken into the ocean and appeared to be dunked reminiscent of a baptism. There were some chickens being held and a goat tied up nearby but I never saw them being harmed or really involved. So the event was interesting to watch but no one seemed to know what it was about.

Some of our group decided to rent ATVs to make a 15km trip to a site called hole in the wall. It’s really the only thing to ‘see’ here. It’s a massive rock formation just off the coast that has an area in the middle that literally came out leaving the ‘hole in the wall’. This wall creates a protected area of ocean that provides a fabulous place to swim and we took advantage of it. The rest of the coastline has much rougher seas and other nearby beaches aren’t as nice for swimming. The wild coast, as it is called, seems very aptly named. The ATVs had some technical problems but the man who owned them rode along and was very nice and knowledgeable and got everyone back safely after a variety of problems en route. I had no interest in riding an ATV but we were told we could hike out to the ocean after parking the ATVs so 3 of us followed in the car since there were only 3 ATVs available for hire. The weather was gorgeous as were the views. The ocean behind the wall was a different place and wonderful for swimming. The hike was unfortunately short so we spent much of the day in the car especially since the ATV problems really slowed the trip down. This is a tourist area and unfortunately the local children have developed the culture of asking the tourists for money. Some come right up to you when on foot or in the car and ask for money or “sweets”. They also may have necklaces made of shells they wish to sell. This has become a real problem in the area from the standpoint of numbers of children and also how aggressive they have become. Tourism is important to the economy and being constantly barraged made it so unpleasant that I preferred not to leave the hotel grounds. I had been warned by many people that this is a problem in this area. If you give them any money you will be swarmed by more children. It is a terrible situation and honestly the children do not appear to be starving. The children in Mthatha seem much worse off to me.

The rest of the day has been spent relaxing. Perhaps I’ll get to hike tomorrow, depending on the weather.

28 October 2007
We have returned to Mthatha. This morning Megan and I hiked up a large hill that looked over the ocean and surrounding area. It was a very easy hike but we had great views. She spotted a group of dolphins playing off the coast and we watched them for a while. The ocean was not as wild today and we enjoyed walking the beach as well. There are a lot of tide pools with interesting sea life, many seashells, and very interesting rock formations. Surfers appeared today and it looked like they were doing well. We returned to pack up and have lunch before leaving mid afternoon. The drive back was uneventful other than it seemed there were even more children along the side of the road begging. They knew where the potholes were bad so that we would slow down and they were very aggressive. This stopped once we got close to Mthatha.

This is our last week here. It does seem like a blur. I am starting to pack some things. On Tuesday we are going to try to organize a more detailed plan about what is needed to start doing laparoscopy. I still have reservations about that because of the unreliable electricity. The first step is to see what is here to work with and start planning. If we can get equipment we’ll start working on training. The laparoscopy equipment here is used primarily by the general surgeons and the suggestion has been made that there may be some difficulty in sharing equipment. I still would like to build on what they have if possible because it would make it so much simpler for the staff to be comfortable with the equipment

We are sending one orthopedic resident home on Tuesday and the next one arrives tomorrow. Harringtons and I leave at the end of the week. There is a constant turnover of volunteers. Some like Jesse will be here for a year. Megan will be here for 5 months. I know there will be many difficult things about leaving but the most difficult will be leaving Megan here. We have become very good friends in a short time. She is an amazing young woman and I have truly enjoyed living with her. It seems to have been a perfect match. She has friends here and the other volunteer, Jesse, lives just up the road so she will have company but I still feel badly leaving her here. I think she is down to her last 6 weeks before she returns to Manchester.

After we leave we go to Johannesburg and then on to Kruger National Park to see some of Africa’s wild animals known as the big five: lions, elephants, buffalo, rhino and leopards. We spend 5 days there and then after making the connections back to Johannesburg, we start the 2 day trip home.