Movivng On

I haven't done any blogging since I returned from South Africa.  It isn't for lack of thinking about it; rather I think that the merging of my reflections on my time in Africa, with my anxious planning for this fall, is creating an overload of thoughts and emotions that are better left in my head than on paper (err, cyberspace).  At least for now.  Nonetheless, I will say a few quick things about the aforementioned life events:

First, "Reflections on South Africa." Upon settling in back home, Shanley and I promptly and laboriously compiled our pictures and memorabilia from ZA into albums.  If you're interested in seeing the final product, complete with page-by-page commentary from yours truly, just let me know - I'm more than willing and enthusiastic about sharing my experience from abroad.

Second, "Anxious Planning for this Fall."  The word is out... I'm going back to school, and couldn't be more excited!  Before Shanley and I left for South Africa, we both submitted our applications for graduate schools.  As we prepared to leave Cape Town, Shanley received her acceptance to Oregon Health Sciences University School of Medicine. Then, while in Jo'Burg literally days before flying back to the States, I received my acceptance into Portland State University for a Masters in Public Health as part of the Oregon MPH Program.  We were elated then, and even now, for the academic adventures that begin this Fall, and for the fact that we will both be in Portland, OR!

So on that note, let me direct you to my new blog: www.pdxmoll.blogspot.com, where you can keep track of my progress over the next few years, in school and in life.  This blog will remain as it is: an experience that stands alone.  To that end, I hope you'll continue to enjoy the stories/pictures posted here, AND stick around to see what's next!

Across the Universe...

30+ hours of flying definitely feels like I traveled that far, but alas it was only a mere ten thousand miles or so: Jo'Burg to Cape Town to Amsterdam to Wash. DC to Denver to Seattle...

HOME AT LAST!

My time in South Africa was formative in so many ways personally and professionally. In particular, I have grown a deep respect for the country and its people; who have demonstrated courage in post-Apartheid years, learning to forgive and to never underestimate the power of one person in making a difference.  The poem Invictus (by William Ernest) was an inspiration to Nelson Mandela, and I have been impressed by the selection of words as I continually try to comprehend his legacy:

 Out of the night that covers me,

Black as the pit from pole to pole,

I thank whatever gods may be

For my inconquerable soul.

In the fell clutch of circumstance

I have not winced nor cried aloud.

Under the bludgeonings of chance

My head is bloody, but unbowed.

Beyond this place of wrath and tears

Looms but the Horror of the shade,

And yet the menace of the years

Finds and shall find me unafraid.

It matters not how strait the gate,

How charged with punishments the scroll

I am the master of my fate:

I am the captain of my soul.

Powerful words - powerful leader - and the power of one! 
[Note: "The Power of One" is also a great movie about South Africa during Apartheid years]

Hakuna Matata

Yes, I'm quoting the Lion King: "Hakuna Matata! What a wonderful phrase, Hakuna Matata! Ain't no passing craze. It means no worries for the rest of your days, It's our problem-free philosophy...Hakuna Matata!"

In any case, that's how Shanley and I spent our last days in South Africa... problem-free on safari. From Jo'Burg we flew into Hoedspruit, which boarders Kruger National Park. We booked the safari with a group called Africa on Foot, which interested us because it offered bush walks as well as game drives. Our four day experience was incredible: the serenity of the bush, awe-inspiring animals, African sunsets, and clear night skies exposing a galaxy of stars (and the Milky Way)!

Our daily schedule was something like this:
05h30 - wake up
06h00 - coffee/tea and rusks (biscuts)
06h30 - bush walk for 2 to 3 hours
10h00 - breakfast
LEISURE TIME
14h30 - lunch
15h00 - game drive for 3+ hours
19h00 - dinner
CAMPFIRE
22h00 - lights out (literally... the camp utilized a generator for only a couple hours each evening).

The bush walks were guided by Rangers from our camp, who were equipt with vast knowledge about African wildlife (AND rifles). The bush walks are intended mostly to explore smaller wildlife and to be able to do animal tracking on foot. On the flip side, the game drives are conducted in an open top Land Rover and are scheduled for the time of day where the afternoon progresses to dusk and then to night, whereby allowing us to experience the nocturnal life of the bush. The Land Rover also allowed us to do some off roading, trail blazing through the bush in careful pursuit of game animals.

Although we were only able to sight three of the "Big Five" animals: Elephants, Rhino, and Lions, we had numerous other encounters with wildlife including a unique showing of hippo. Several times I was literally stopped in my tracks, humbled by the magnitude of the African bush and wildlife.

Me & the Land Rover

Our humble abode with Africa on Foot

(Shanley and I shared this little round hut, which did include our own bathroom)

Elephants

(There were about two dozen or more elephants in the herd we encountered)

The BurgS

The original South African itinerary did not include Johannesburg, but because we had Friday free from clinic and had to get there by Sunday to meet our safari transfer, we improvised and here we are… in Jozi!

BazBus is a recommended, affordable method of transport for backpackers and tourists in South Africa; and to that end, they conveniently had a route from Durban to Jo’Burg. We spent ten hours in total on a bus, but the route took us through the Drakensburg, which was a scenic way to go. We also had good sightings of Soweto (the largest township in South Africa) and the Jo’Burg skyline.

Jo’Burg does not have a high record on safety, in fact all of our tour books adamantly advised against going anywhere on foot. So to err on the side of caution and appease worried parents, we stayed near our lodging and only ventured to a flea market (South Africa’s largest, at that), where we bargained for some final souvenirs.

Week Eight

Our final week in Durban started at Malagasi Clinic, which is located in the township, Umlazi. At this clinic we had a new experience: participating in child immunizations and planning visits. All children in South Africa have a “Road to Health” card, which outlines when they need to be seen at a clinic for check-ups and immunizations. When the child is brought in we collected their weight and measurements to plot on the card. Then we would see what visit they were there for and if immunizations were needed, we would prepare and administer the drops/shots. Similarly, women from the township come to the clinic with their “Family Planning” card. Like the “Road to Health” card, this card keeps track of what method of birth control they are using and when they are due for the next injection or set of pills (We also prepared and administered the shots for these women). The card system may seem primitive, but in this setting where patients do not necessarily have a PCP, it is effective in recording the patient’s pertinent history and also a record that the patient keeps to remind them of important health details.

After the immunization and family planning visits, the clinic switched back to regular primary care. The clinic is entirely run by Sisters (nurses) and so they were relieved to have our help for the day. As a result, we were allowed to assist the Sisters and serve a more active role in the visits – often biting our tongue and remembering to be respectful of cultural differences.

Unfortunately, the rest of the week unfolded as a frustrating series of events at our clinic sites – so I’m not even going to blog about it! But in the end, we completed the program on Thursday and enjoyed that evening with our host family, who put together a braai (BBQ) for our last night.

Learners' WeekEND

The red trumpet looking thing is a vuvuzela - it is especially popular with the World Cup just around the corner!

The highlight of this weekend was visiting the primary school where our host mom, Zodwa, is the principal.  The school is located about 40minutes drive from the Durban suburbs, in a more rural area.  It accommodates grades R (kindergarten) to grade 3 and there are over 1100 learners who attend her school!  Oh, “learner” is the term that is used in South Africa for “student.”

On Saturday, Zodwa and some other administrators had organized an optional fun day for the students, including football (soccer-boys) and netball (basketball –girls) against another primary school.  When we arrived at the school before 09h00 (on a Saturday, mind you!) the learners were already waiting for us, in their uniforms and with their vuvuzelas.  There was lots of singing, hooting of the vuvuzelas, and general enthusiasm about the special day.  Not all of the students were able to participate in the sports, but Zodwa explained that one reason they came was for the free meal that is provided; often students will stash some of it to take home to help feed their families.

In general though, the learners demonstrated a spirit of resilience and hope: they played hard, cheered for their teammates and indulged me with hugs & smiles!

Week Seven

Special surgical scrubs again, this time I felt like Kermit the frog... 

"It's not easy being green!"

Another week at King Edward Hospital, and another rotation in theater!  Surgery at King Edward is much different than GF Jooste because it has seven theaters versus only two.  That means that there are a handful of surgical teams that get slated for specific days of the week and there is always a variety of things to see.  Here's the short list of the most memorable things we saw:

Total Abdominal Hysterectomy (Gyn.)

Zygomatic Lift & Debridement (ENT)

Pediatric Cleft Foot Repair & Soft Tissue Release (Ortho)

Genital Warts Cauterization (Gyn.)

Scapular Open Reduction Internal Fixation (Ortho)

Femoral Open Reduction Internal Fixation (Ortho)

Mastectomy (Gen.Surg.)

Emergency Laporatomy & Thoracotomy (Gen.Surg.)

Because we weren't attached to any particular surgical team, we had the opportunity to interact and learn from them all.  Most of the surgeons and anesthetists were extremely communicative and made sure we understood the procedure; talking through each step and quizzing us along the way. This was our last week at King Edward and it was certainly an exciting way to make our exit!

A Tisket a Tasket, a WeekEND and Some Baskets!

The weekend kicked-off with a Friday night movie at home with our host family.  They wanted us to see Sarafina! which is a musical film adapted from a theater production about student-led resistance to Apartheid.  It was a great movie and even better to have watched it with our Zulu family.

On Saturday we woke to grey skies, and as we were waiting for the bus downtown, the clouds broke and we got poured on with rain!  As it showed no signs of stopping, we resorted to Plan B: exploring "the Pavillion", a giant (indoor) shopping center. I think it's safe to say we covered every corner of the complex, including the movie theater where we caught a showing of the new Robin Hood with Russell Crowe.

Fortunately, Durban weather pattern is predictably tropical; so although it rained all day Saturday, sunshine and hot temperatures resumed the next morning.  We fulfilled our original weekend plan by taking a minibus taxi downtown to Victoria Street Market, and then settling on the beachfront to soak up some sun.  The purpose in going to the market was to bargain for some Zulu baskets, which are both traditional and beautiful. With baskets in tow, we navigated our way back to the suburbs on the minibus taxi.  As our host brother MakaB says, riding the minibus taxis is traveling "African style!"  The taxis are basically 15 seat vans (full to capacity+), and using a series of hand signals and names of stops you can take them downtown and practically everywhere else for a fraction of the cost of other transportation.  Our round trip adventure cost us 12 ZAR per person or about $1.50 USD.   Weekend is over, but mission accomplished!

Our newly acquired collection of Zulu baskets!

Week Six

This week we began new placements at another district hospital, King Edward VIII Hospital.  Shanley & I were both on the pediatric rotation which was a nice change of patients and exposure to a lot of new things medically.  At King Edward there is a Pediatric Outpatient Department (POPD), a Pediatric Resuscitation Unit (critical care, PRU), a Neonatal Unit ("Nursery"), two inpatient wards, and an entire unit of pediatric gastroenteritis.

Monday through Wednesday we stayed pretty close to the PRU, learning from the department chief Dr. Ramji, who spent anywhere from 2 to 3 hours doing rounds with us!  King Edward is a teaching hospital and is linked to the University of Kwazulu-Natal's Nelson Mandela Medical School.  There are 4 interns and 1 resident on his service in the unit and they invited us to go to a lecture on Newborn Assessment/Physical Exams and the weekly M&M (morbidity & mortality) meeting, which was also pretty cool.  For the rest of the week we worked in the outpatient department doing measurements for neonates, as well as experiencing the nursery with its high volume and insufficient resources.

In nursery there is a constant flow of babies needing intensive care and only 3 respirators for the whole department. As such we witnessed some very difficult decisions being made about which babies had the best prognosis and social support to continue receiving care, versus those who didn't and would be taken off ventilation in order to make it available for another child in need.  On the other hand, we saw some pretty unique life-saving procedures like placing a central line through the umbilicus, which provides both venous and arterial access.

When we had some spare time we would go into the inpatient wards and play with/comfort the kids.  The inpatient wards are chaotic, with the kids roaming in hospital gowns doing anything to keep themselves entertained.  What was most difficult about the week was working with the kids that have conditions as a result of being a victim of their environment.  One little girl in particular, aged 10, presented with severe dehydration and headaches.  She has AIDS and had a recent admission of cryptococcal meningitis - which was the readmitting diagnosis this time.  She weighs only 17kgs, which classifies her a marasmus patient and stage IV AIDS.  Despite her physical condition, she kept bright eyes and a diligent smile which made reflect on why I love medicine: work is love made visible.

30 Days 'til Kick Off

.... which means I will be home in less than one month:

enjoying the World Cup with the comforts of home,
leaving the madness right here in South Africa.
You can be sure, however, that I will be returning donned in official FIFA gear.

Go Bafana Bafana!

Bunny in My Belly

This is a "bunny" (also called "bunny chow"):

It is a loaf of bread (or in this case, 1/4 loaf), hallowed out and filled with curry.  We read about bunny chow in all of our tour books, and have waited until Durban to indulge because Durban is known for having the best curries.  It was well worth the wait, and a perfect start to our WeekEND!

On Saturday, as is customary with the start of a new program, we were given a tour of the townships. As in Cape Town, the townships are primarily areas of very impoverished living.  However, in Durban the dwellings are less compacted together and there are more modern homes mixed in.  Umlazi is the second largest township in South Africa, and even after driving through it for two hours, we hadn't seen it all.  Still, after all these weeks, the scale and severity of these communities with people struggling to meet basic needs for survival is truly humbling.

The later part of the weekend we spent time with one of our host brothers, MakaB (age 13), at the Durban beach front and uShaka Marine World. The climate here is such that I suspect we may be spending more of our free time at the beach!

Week Five

The beginning of our stay in Durban has been clipping along with something new almost everyday.  On Monday we visited the University of KwaZulu-Natal, where we got registered as international students at the Nelson Mandela Medical School.  Our driver gave us a brief orientation of Durban city center and beach front, before we spent most of the afternoon viewing the new football stadium.  The rest of the week was back to work!

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The New Group: Patricia & Chris from Univ. of Michigan, both undergrads

Tuesday and Wednesday we worked at the Marianhill Clinic, which is a private clinic run by the Islamic Medical Association and is located in a very rural township area.  On any given day, the clinic has one or two Sisters (nurses) who conduct the patient visits and administer treatment, as well as a counselor for HIV testing.  This is the only primary healthcare clinic in proximity to the rural community, so the volume of patients ranges between 140 and 160 people per day!  Because of the huge patient load, the Sisters move through the patients very quickly, taking only a few minutes to assess, diagnose and prescribe treatment.  Medications are dispensed and administered in the same visit, but this is delegated to a nursing assistant so that the Sister take the next patient.  Patients who present with an STI or signs of a viral infection (ie. shingles) are directly referred to the HIV counselor for testing. Although the pace of this sort of healthcare would be unheard of in the States, it is extremely efficient in this setting.   Because the clinic is private and in no way subsidized by the government, every patient that is seen must pay 40ZAR (about 6USD); this includes the visit and any medications that are given; however, HIV testing and counseling is free.

During our days at the clinic, the HIV counselor was kind enough to take us to see a sangoma, who is a traditional healer in the South African culture.  An overwhelming 80% of people in South Africa have sought treatment from a sangoma at one time or another.  The sangoma that we met was a 97 year old woman, who showed us her collection of herbs and mixtures for treating different ailments.  People must pay the sangoma for her services and sometimes this can be several hundred Rand.  Our sangoma was very patient with all of our questions and wide-eyed observations, and even did a good luck burning ritual while we were there.

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The Sangoma with her herbs and mixtures

Thursday and Friday we moved on to Chatsworth Hospice, where we became acquainted with the hospice system in South Africa and went on home visits with the Sisters.  Chatsworth is a dominantly Indian community in Durban, in a suburban-like setting; during Apartheid it was where Indians were allowed to live, and have since stayed.

Hospice in South Africa is a non-governmental organization and is comprised of inpatient and home-based care.  Chatsworth only has ten inpatient beds and so most patients received care at home (which is the majority preference anyway).  The Sisters keep logs of patients who have terminal diagnosis as well as patients who are in remission.  During the home visits they assess the patient’s needs and will either make a referral for them to be admitted to the inpatient facility or they will just provide education and social support to the families.   Hospice Sisters and the few doctors that make rounds on the inpatients, work on a primarily volunteer basis which is truly impressive considering the workload.  Each geographic region/district has a hospice that serves its respective community, but again, it receives no support from the government.  Hospice in South Africa is more widely accepted and carries less of a stigma than in the US; it was a humbling way to end the week, working alongside the dedicated Sisters.

An Epidemic of Mass Proportion

This past weekend Shanley and I arrived in Durban, South Africa to begin the second leg of our internship. Durban is on the East Coast of the country and is very lush with scenery; although the climate is much hotter and more humid than Cape Town. The focus of this part of the internship is directed to the HIV/AIDS epidemic in South Africa; it is so widespread in a sense that it can be difficult to imagine for those living elsewhere. To help give perspective, here are some of the hard facts:

-In South Africa, one in five adults are infected with HIV

-Half of all deaths, and 71% of deaths among those aged between 15 and 49, are caused by AIDS

-In 2005, there were 1.2 million children orphaned by AIDS

-The average life expectancy in South Africa is 54 years; without AIDS it is estimated to be 64 years.

-In 1990 the first national antenatal survey to test for HIV found that 0.8% of pregnant women were HIV positive. By 2005 the rate had increased to 30.2%.

You may be reading and asking yourself, "Why did South Africa's AIDS epidemic go unchecked for so long?" From what I've learned so far, it's a problem that can be traced back to leadership, even in the last few years there have been mixed messages from the government on this issue:

-The most rapid increase of HIV prevelance took place between 1993 - 2000, during which time the country underwent major political changes with the disembarkment of Apartheid and so the problem was not given adequate attention.

-In 2000 at the International AIDS Conference in Durban, President Mbeki gave a speech conveying his belif that poverty, not HIV, was the root cause of AIDS.

-In 2006, then deputy president Jacob Zuma was on trial for allegedly raping an HIV positive woman. He attracted further controversy when he stated that he showered after sex in belief that this reduced his chances of becoming infected with HIV.

-In 2006, the health minister of South Africa spoke at the International AIDS Conference and promoted nutrition (specifically beetroot juice) rather than antiretrovirals (ARVs) for the treatment of HIV.

In response to the epidemic there have been mass campaigns throughout the country.  Evidence of this can be seen all over, especially in healthcare environments, with posters and other propaganda pertaining to the HIV/AIDS epidemic.  Here's just a sampling:

Ode to Jooste

From top to bottom: "Stop TB" signs in English, Afrikaans and Xhosa; HIV posters; our favorite snack stand outside the hospital (the only food available, and yes it is made from converted shipping container); ME!

Week Four

Special Surgical Scrubs

 

My final rotation at GF Jooste is in the Surgical Ward and it has, so far, been a great week!  Each morning the surgeons perform ward rounds to review the cases of surgical patients. After rounds we move to theater (the operating rooms).  By far, the two most prevalent surgical issues that patients present with are 1) stab wounds, and 2) diabetes related infections requiring amputation.

In the general Cape Flats community, when you mention GF Jooste people will raise their eyebrows in a wary, disapproving way because they say, "that's where you go if you want to die."  The truth of the matter though, is that the hospital is located in one of the worst neighborhoods in the city and so its volume of aggravated traumas is enormous.  But to set the record straight, of the stab wound victims that present at Jooste, they have over 85% "save" rate.

So back to stab wounds in the ward... attackers go right for the heart.  Most of the stab wounds that I have seen have been left upper abdomen wounds.  In fact the first surgery that I observed was a stab wound of this kind that had penetrated and nicked the stomach as well.

The other recurring theme in the surgical ward is diabetes related sepsis and amputations.  This is a huge problem in the aging population, and because patients without medical aid (insurance) do not present for routine medical care, they often end up in the hospital with wounds that have gone too long without treatment.

On my first day in theater, I actually got to assist with an above the knee amputation (AKA).  I was not expecting that privilege whatsoever, but when the surgeon asked me to scrub in, I couldn't say no!  The level of sterility in the OR is mostly on par with standards back in the States, but the surgeons have to be more resourceful with the tools they have at their disposal.  For example, putting patients under general anesthesia is the exception not the rule.  Spinal blocks are used more frequently because they are less expensive and require less concern for recovery.  So the patient who presented for the AKA was awake the whole time!  Aside from the cauterizing tool (which I got to use a lot), everything else in the surgery was performed by hand, using blades, a saw, and a pitcher of sterile saline water.

Scrubbing in for surgery was an amazing way to spend my last week at Jooste.  The level of medical care provided at this hospital is great due in large part because of the Medical Officers (doctors) who choose to work here.  Given its reputation, there are a lot of other places that these qualified providers could find work (including the private sector), but for many of them (native South Africans at that), they come to Jooste because they care about this community; one where the people fight everyday to stay alive - and so they join the fight to help them survive.

WeekEND Wrap Up

This weekend was our last weekend in Cape Town and our last hoorah as a group. We took a half day at the hospital on Friday and drove out to the winelands because neither Jay nor Ryan had been there yet. Our local coordinator emailed us directions on four locations to visit, but her directions were kak (crap in Afrikaans) and so we ended up driving in circles for over two hours! We did make it to Fairview Wine Estate where there was both wine and cheese production; so while my three groupies tasted wine I indulged on very fresh varietals of cheese… yum!

We also made it back to Spier Wine Estate (the place with the Cheetahs) where we ate dinner at the very highly reputed restaurant, Moyo. The food is served all buffet style, and though it was good food the atmosphere of the restaurant was the most stunning element. If you notice on the picture, we all have white face paintings, which is a Zulu tradition for special occasions.

For Saturday we planned a full day trip to drive around Cape Point. We rented a car and left very early in the morning heading due East and then South: traveling through Muizenburg, Fishhoek, Simonstown and Boulders Beach. All of these coastal towns were charming and situated with exquisite ocean views. Boulders Beach is unique in that it is home to the African Jackass penguin population, which we were thoroughly entertained by!

My friend Bridgett met us at Boulders Beach and joined us as we continued South to Cape Point, the southern most tip of the continent. Having worked in the National Parks, Bridgett was a wonderful guide as to the wildlife and scenery… including very sociable baboons.

It's a scary thought that the only thing beyond the horizon is Antarctica...burrrrr.

With no where else to go but North, we drove back along the Western coastline through Hout Bay and Chapmans Peak, where we witnessed a spectacular sunset.

Sunday was pretty unremarkable as Shanley and I took advantage of some R&R (and Vitamin D) on the beach while the boys were off on a shark diving adventure. Of note, however, is the fact that I got to drive the rental car, which was my first experience driving on the left side of the road and shifting the gears with my left hand. It really does require adjusting your spatial orientation, so I was extremely grateful for Shanley’s support as my copilot; I am happy to report though, that we had safe travels.

Week Three

WARNING!
FOR MATURE READERS ONLY

I feel that it is important for me to blog about my week, however, due to the sensitive nature of the clinic I've been in this week, I feel it is also important to alert my readers.  To preface this entry, I have left out all personal and political perspectives because the root of the experience has been about medicine and treating patients.  So without further introduction, this week my clinical rotation was in the T.O.P clinic... or in other words, Termination Of Preganacy.

In South Africa it is legal to perform abortions up to 20 weeks of gestation.  There are only three doctors in all of Cape Town who perform the abortions (they are all female doctors), and they rotate through both the public and private hospitals.  As with other medical services, GF Jooste is popular location for TOPs and accepts referrals from other community hospitals.  In summary, here is break down of the week:

Monday & Tuesday: up to 35 patients are accepted into the TOP clinic for screening and counseling.  The patients must present a referral letter from their community clinic or general practitioner - this letter alone can cost the patient 200ZAR (about 30USD) which is a steep fee, especially when the cost of all other visits is free.  The patients are accepted first come first serve, so they arrive between 06h00 and 07h00 even though the clinic hours do not officially commence until 09h00.

Everyone is poked and tested for HIV (I helped perform the testing), then brought back one by one for the results and counseling based on their status.  Then all of the patients file into the "theater" room ("theater" is the South African term for operating room/OR) where there is one table separated by a thin curtain.  The patients get onto the table for a quick ultrasound to determine the size of the fetus.  The doctor spends only two to three minutes per patient before they are rushed off the table and back to the waiting area.  I actually got to perform a couple of the ultrasounds, which was a good learning experience.

The group is then divided by weeks of gestation: 6-12 weeks (first trimesters) are given an appointment on Wednesday or Friday for the TOP.  When they return to the clinic they will take Cytotec to help open the cervix for the procedure.  13-20 weeks (second trimesters) are counseled seperately, and are given Cytotec tablets to take at 03h00, 05h00, and 07h00 the morning of the procedure.  Everyone is instructed to bring their own towel and feminine pads - nothing is provided for the patient.

Wednesday, Thursday, & Friday:  first trimester TOPs are done on Wednesday and Friday, with second trimester TOPs reserved primarily for Thursday.  The patients arrive by 07h00 to take the Cytotec; when I arrived at 08h00 some of the girls/women are already bowled over from cramping side effects. The doctor arrives by 09h30 and no time is wasted to get started.  The girls/women are arranged in rows of chairs just outside the theater, seated from earliest gestation to latest. They are instructed to remove all clothing below the waist, and so they sit wrapped in their towels waiting for their turn.

Several of the patients abort before they even make it to theater, and so there is a constant flow between the chairs and a (very) small toilet in the room.  When this happens a nurse is called from theather and the patient is given a small paper bag (like a barf bag) to put the aborted contents in.  Mostly though, the girls/women move perfunctorily into the theater area for the TOP.  It is a quick, albeit gruesome, procedure; about five to ten minutes for first trimesters (who get no local anesthetic), and about 15 minutes for second trimesters (who get 20mls of lidocaine injected into the cervix).

When the procedure is completed for one patient, she is rushed off the table and wraps in her towel quickly before the nurse yells "Next" for  the next girl/women to enter. And so it continues until all of the girls/women have been treated.  Wednesday I was in theater for five and a half hours straight and Thursday there were 24 TOPs before noon.  When I use the term girls/women it is to encompass the full spectrum of patients seen; the age range this week was 13 to 39 years old, with everything in between. Many of the women are married and a majority of the patients used some type of birth control before becoming pregnant.
In total, it was a very profound and emotionally exhausting week.  As an outsider, I felt that there was a lapse in the birth control education as well as the counseling that occurs before the TOP.  For example, the patients are counseled that even if they are taking the pill that they are not protected from HIV and so they need to use condoms, but then the sisters (nurses) really push for the patients to get the contraceptive injection (which still doesn't protect against HIV)... so the output is a very mixed message.

I learned a great deal from the physicians this week and my heart was heavy for the patients that I worked with.  I've seen things that words cannot even begin to express and I have been racked with how to process everything that I've experienced and felt.  What it comes down to is this: is it any different than a patient who presents with lung cancer after a lifetime of heavy smoking? doesn't that patient deserve to receive medical treatment if they choose it? and shouldn't the medical care be delivered with compassion and without judgement?

WeekEND Away

The weekend started early… really early… 05h00 on Friday morning!  Each month the coordinators of the CFHI Cape Town program orchestrate a three day weekend excursion along the Garden Route .  Our group has dwindled down to four because Erin completed her month in Cape Town and is returning home to graduate medical school and begin her residency.  So the weekend crew consisted of me, Shanley, Ryan, Jay, plus two foreign medical students on rotation at Stellenbosch University: Inge from the Netherlands and Shazia from Germany.  Our fearless leaders Avril and Marion packed us into the blue VW van and we set off on a five hour drive to the Eastern Cape.

 

First stop: the Cango Caves which include some very narrow passages that you actually have to squeeze through.

 

Next stop: an ostrich farm.  I have no doubt that these animals have prehistoric origins – they are down right creepy to look at up close.  That didn’t stop me from getting an ostrich hug, or from taking a ride on the back of one though!

 

Next stop: We zip-lined through parts of the Tsatsikamma Forest as part of a canopy tour; supported only by a harness and metal cables.  It was a real thrill with some of the cables running 65 meters in length and 30 meters above ground.

 

Next stop: Bloukrans Bridge where you can take the plunge on the world’s highest bungee jump 216 meters.  Shanley, Ryan and Jay did the jump, but I hate the feeling of free fall so I declined.  However, I didn’t miss out on all the fun, so I zip lined across the underside of the bridge instead.  (Shanley has lots of pictures on her blog from the jump.)

 

Next stop: Knysnsa Elephant Park where we fed and walked with a dozen elephants, big and small ones.  Elephants are very gentle in nature but their size is still intimidating.

 

Last stop: We concluded our trip Sunday with a leisurely three hour game drive at Botlierskop Reserve.  It has four of the “Big Five”  animals: Elephants, Rhinos, Lions, Buffalo (no Cheetahs).  There are various other animals on the reserve too; in size there are about 300 hectres of land where all of the animals roam at will (except the lions which have a gated enclosure).

 

As you can imagine, it was a busy weekend, but we enjoyed every minute immensely!  It was another five hour drive back to Cape Town and then back to work this Monday morning with a new clinical rotation.