5 October 2007
Friday is generally a short day in all the hospitals. After we finished for the day, I had lunch with Dr Mdaka who is the head of Firm A. The OBGYN service is divided into 3 teams they call firms. The cases are assigned somewhat evenly between the firms. Our main clinic day is Monday which is a very busy day from my one day of experience. Our main operating day is Tuesday. The other days are a mixture of teaching in a variety of formats and patient care. Dr Mdaka is a very patient and dedicated man. He grew up about 80km from here and moved back here after his training to be near family. He seems to enjoy the challenging cases and the teaching. He answered a lot of questions about the South African medical care system and society in general. After medical school, the students have 2 years of general internship followed by a year of public service which usually means working in a remote underserved area to repay some of the subsidized medical education. These are often referred to as peripheral areas or clinics. A few stay in a city to do this. They get paid a small amount and are still supervised. I think there must be an exam and then they are considered “qualified” which sounds like licensed. Then they can go into practice and seem to be called general practitioners, a term which the students tell me is used interchangeably with family practitioner here. Alternatively they can apply to become specialists. They are called medical officers during what we would call residency. After the specialty training they are called consultants. I am a visiting consultant. The department heads are referred to as Prof (not professor) and this is a highly regarded title. As I learn more, I may have clarifications to this. It is hard for them to explain since I want to compare it to familiar terms and they don’t know exactly what those terms mean.

There are still many social changes occurring here. He explained how the “old government” seemed to divide the people into whites, coloreds, Indians and Africans. This was also the order of their status in society although there was a bigger gap between white and colored than between each of the other groups. Colored were those that didn’t fit clearly into one of the others, usually a mixed background of some combination. There was significant Indian immigration years ago, especially to the East Cape area, which is where we are. Now some of the South Africans are not happy with the amount of immigration from some of the poorer countries in Africa. When I mentioned our Somalian immigrants he told me that many here don’t like the Somalians and they have been the target of some violence. Apparently there is resentment from the competition for jobs, even the low paying positions and that the Somalians and other African immigrants work for less and don’t join unions. They are supposed to get visas but many don’t. (Heard any of this somewhere before?) This problem is somewhat ignored because many of those now in power in the government, lived in these countries while they fought the old apartheid government. They feel an allegiance to those that helped them in those difficult times. I hope to hear more about this. The medical students here are mostly from this area and a smaller percentage is from these immigrant groups. Many of them have come from disadvantaged backgrounds and have overcome a lot to get this far.

I took over a “tutorial” today while he attended to a problem elsewhere in the hospital. The subject was postpartum hemorrhage. They were better prepared than I expected and made the same mistakes we would at that stage. Their enthusiasm is noticeable….especially for students in their last 3 months of school. They graduate in December and become interns in January. They find out where they will go in about 2 weeks.

I think they have just started doing some colposcopy. When he found out I do colposcopy, he wants me to get the colposcope out and help teach them how to use it since it has been many years since any of the consultants were trained. Apparently they just got a colposcope. It seems like they would have it going full time with the amount of abnormal PAPs they see. They just don’t have the time and staff to do all that needs to be done.

The housing we live in has been built by donations. The furnishings are a mixture of donated items and things that volunteers leave behind for the next volunteer. We found an old notebook computer in one of the cupboards. It is a Dell Inspiron 3800 and I suspect it is from 1999. They thought it didn’t work but after I charged it up and fiddled with it a little, it is working fine…..with limitations. One of the other volunteers would like to use it simply to write word documents and transfer them to the internet or other computers via a jump drive. It has Windows 98 and didn’t recognize her jump drive (it does have a USB port!). On the internet, I found the company (Kingston) that made her jump drive and downloaded the corresponding driver onto a disc at the internet café. Unfortunately, after I installed it into the computer it still doesn’t recognize the jump drive. I tried copying a small word document onto a CD so she could transfer it that way but still no luck. It said the CD was unavailable. I will get a new CD to try and check the internet again to make sure I found the right driver. If any of you techies out there have another idea, I’d like to be able to have this computer running for her before I am done here. Until then of course, she can use this one, but I’d like to leave her with some computer access since she is here until December.

Tonight, when we got back we saw a large insect that looks like a grasshopper sitting on our fence and Megan called it a locust. It was dark out so difficult to see well. I actually was able to photograph this creature. I will try to add some photos to the blog after this weekend.

Scooby sends his greetings!

6 October 2007
Today we went to the Nelson Mandela Museum. It is in a building next to the downtown area. The first floor has a large room with photographs and information and some historical artifacts. There are 2 large wings with many of the gifts that he has received over the years from countries and cities all over the world. The 2nd floor is not finished. The whole area around it is planned out to eventually be part of a large park.

Following that we walked through the downtown. There are many small shops with mostly the same thing from one to the next. There will be some clothing but mostly household goods and some appliances. The sidewalks in front of the stores are lined with small vendors. They have scarves, clothing, food etc. There are quite a few who have hair extensions for sale and will have several chairs going where women are having them put in and/or having their hair braided. There are some little tents set up for men to have haircuts but those are not done out in the open. Scattered around are tables, usually covered with an umbrella, and a phone or two available to make calls.

We went to back to where we had parked at ‘the mall’. This is new in the last year and there are signs that another mall is coming in another part of town. It is a series of stores linked together with uncovered walkways between them. There are a couple of grocery stores and one that is like a variety/department/hardware store. There are several clothing and shoe stores. The town is growing. I am told it is people from rural areas coming to look for work. There are housing areas sprouting up all over. These houses consist of a small brick/cement building with a few windows. They do not have water or electricity. They each have an outhouse. Some have a large round tank next to the house to collect rainwater. There are a variety of sizes but all are degrees of small. Some have fencing around them. Animals (cattle, goats and dogs) roam or occasionally are fenced. The roadsides are filled with garbage. People are usually walking along the roadside and some are waiting for the unofficial taxis which are usually small white vans. Many people also hitchhike in town, standing on the edge of the road with a sign showing where they want to go. The area is surrounded by rolling hills and from a distance the landscape is quite beautiful.

The mornings are filled with the sounds of very loud birds. They are so loud that it can be hard to sleep through it. The rain seems to come out of nowhere and after a downpour is gone for awhile. I washed clothes in the washer at the rondoval (one of the other volunteer houses) this morning but I have not been able to hang them out to dry because of the rain. They are slowly drying in a variety of locations around the house. Although the metal roofs are practical, they make any amount of rain sound like much more than it is. It is really loud but we are dry so it is not a problem.

7 October 2007
Sunday is a quiet day. Everything shuts down. The Harringtons took me on a tour of the Bedford Hospital. It is a pretty stark contrast to our hospitals and even to the hospital where I work in town. There was a group of people who came to see some of the patients. Their clothes suggested they were part of a church group. The closest comparison I would make is like a group of nuns and priests. They visited patients but then also stopped around the bed of a few that perhaps were from their village or church. They sang in prayer over them and with them in beautiful harmony and with incredible emotion.

In the afternoon, Megan and Jesse and I went on a walk in the hills outside our compound. There is a herd of cattle up there but I don’t know the breed yet. I am told they are a specific type that has particular value in this area. Scooby followed us which was nice until he decided to bark at one of the cows he thought was coming too close. Since he didn’t appear qualified to defend us against this rather large cow, which had impressive horns, I asked him not to do that. We slowly made a wider circle around the cow as it seemed to be considering the amount of trouble it would be to deal with us. It was an uneventful trip back after that. We started out under clear skies and in a matter of half an hour, the clouds came in and we only just made it back before the rain. This is a pattern that seems quite common.

Later this afternoon, 2 new volunteers arrived. Scott is a 4th year resident in orthopedics and Emily is his wife who is an OB nurse at UCSF. They will be here for a month. All the volunteers had dinner together tonight. Megan and I even figured out how to make a small cake out of the ingredients we had. It was quite interesting to do. I had a few recipes on my computer. All the measuring options we have are in metric so we made the conversions, substituted ingredients with what we had and ended up with a cake that was like a pound cake. We had some fresh local oranges and put sections on top. Then we covered it all with custard that we flavored with juice squeezed from the oranges. It was good enough that there was none left, but not exactly what I thought it was going to be when we started! She has a cookbook that she found with African recipes and we are going to try some of those that are simple. One of them is Xhosa pot bread. Xhosa are the people of this area. I have learned a few Xhosa words but it is a difficult language especially because of the clicks in it particularly when combined with another sound. I will be lucky to figure out 10 words before I leave.


8 October 2007
Today has been cold and it has been raining on and off all day. There are a variety of animals around here that seem to have a home but they truly roam at will and go ‘home’ when they feel like it. Cattle and goats and dogs are common but now there is a mare and young filly around. Outside our house tonight, I could hear the mare sounding rather upset. When she persisted, we looked out and I saw her run down the lane with Scooby chasing her half heartedly. She continued to call from the end of the lane and as I was considering going out into the rain to look for the filly, she came tearing down the lane to mama. I think she had taken off earlier and the mare had been looking for her. Mother and child are reunited and I didn’t have to get wet.

Today is clinic day for Firm A. I started out with a woman who is 67 and likely has Stage III ovarian cancer. She had been clinically diagnosed at the end of July and was finally able to get into the surgery schedule this week. Then I saw a primary infertility. There are several secondary infertility patients each day who have hydrosalpinx/tubal obstructions from prior infections. They have no other options available than an attempt at tubal reconstruction so they come here for that. Next was a primary amenorrhea in an 18 year old with very short stature. She had a cough and my differential had to include malnutrition, TB as well chromosomal and some of the other things we might not normally consider. Can’t say those are on my top ten list at home. The last case of the day was a young woman who has a large pelvic mass that we first thought might be an ovarian torsion of a large cyst. It didn’t have the typical US characteristics of torsion and when the intern took us to examine her and we found that her left thigh was significantly enlarged with a 10cm mass anteriorly in the muscle and another just superior to the patellar tendon measuring 4cm. All 3 masses were exquisitely tender. There were no peritoneal signs. She is pale (labs pending) and dehydrated. They will get labs back tonight and anticipate taking her “to theatre” (go to the OR) in the morning. This is a disclaimer for the faint of heart not to read the next part. They had a case of conjoined twins over the weekend with one delivered vaginally and the other requiring a C-section after unfortunately converting to a back down transverse lie. The babies had died long before she came in labor. I’m leaving out the more graphic details.

I am told that October is a quieter month on OB and September is usually the worst. Many men work in Johannesburg and come home in December resulting in an unusually high birth rate the following September. Last month they did 17 C-sections in one day. It is typically 5-7/day this month.

Tomorrow is our day in theatre. Thankfully, I have the scrubs I brought as well as the shoe covers and masks suggested by Dr Barr since I understand they often run out of those. We have a full schedule. We are going to start doing colposcopy later in the week. I have seen the scope but haven’t had the chance to check it out yet.