Kruger Park
Herd Medicine
“…physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective health care.” From The American College of Physicians Ethics Manual, 6th edition.
After 10 days on the Cape, at the Southwest corner of South Africa, 10 days driving thousands of klometers overland on the’wrong’ side of the road and 10 days in Kruger Park at the North East extreme of the country, I hated to leave. Similarities and contrasts between our two nations is evident everywhere: the clash of humanity with nature, cultural present with past, progress with preservation, power with weakness, national language with other languages; all were apparent, even in the relatively sheltered and civilized ‘rest camps’ of Kruger Park. Of course I was at Kruger for the wildlife; perhaps there is nowhere in the world where an English speaking stranger can be sheltered at night in ‘rest camps’- luxurious electric fenced two or five acre cages- yet be free roaming by day in a different sort of cage- a car- while being ignored by herds of wild animals a few feet away. At the same time the visitor is relatively sheltered from political and social conflicts.
Yet even the park exists within the margins of history. The newest and largest rest camp is named ‘Skukuza‘- a native term for broom– because the park founder, Kruger, swept the native peoples from this 19,633 square km area, creating 360 x 40 km park bordered by rivers and by a similar park in Swaziland to the East. The current president, Jacob Zuma, in contrast to Nelson Mandela, epitomizes racial and tribal values. He declares that South Africa is for all (black) Africans; therefore the nation’s borders are now open, by virtue of ethnicity. The park is more affected by poaching; rhinos are affected, though there are so many herds of elephants they must be thinned and exported to other preserves. The Zuma position on open borders is herd politics, supported by a clear majority, who find it justified by inequities or oppression. It was democratically imposed by government, leading to turmoil, as has our Affordable Care Act (ACA), sometimes fearfully referred to as Herd Medicine.
The veterinary medical term “Herd medicine”, when applied to human health care, is disturbing to those who see the ACA in terms of Huxley’s Brave New World , while others find our current “system” antiquated, inefficient, and as unfair as the sweat shops of the Industrial Revolution. I suggest both views are flawed; a dual system is required featuring individually focused care and herd focused care, both are complimentary and necessary in a sustainable national health program. Veterinary medical practice offers a model of such a dual care system where “Herd Medicine” is focused on the greatest benefit to the greatest number, and the economics of health care, while “Companion Animal Medicine” is focused on the benefit to individual animals.
The table below provides side-by-side comparisons between what I will call Herd-Vet ( large population medical care) , and Pet-Vet (Companion Animal) medicine.
Herd Vet
|
Pet-Vet |
Focus: •Large populations •Collective well-being
Cost/Benefit: •A major factor •Economic viability/profit critical •Herd owner pays Euthansia: •Justified with societal oversight Animal Rights: •Limited
|
Focus: •Individuals •Individual pet well-being Cost/Benefit: determined by vet and pet owner •Pet owner pays Euthansia: •Limited/constrained by law Animal Rights: •Abuse is severely punished. |
“Pet-vets” practice a type of fee-for-service medical care. The Affordable Care Act (ACA) attempts to retain that kind of care, but requires practicing herd medicine also. These two aspects of national of health care need not be mutually exclusive. Indeed, every nation that has an ongoing viable national health program allows or employs a dual system: one focused on large numbers, outcomes, and economics; and the other focused on outcomes and options for individuals. Both rest on ethical and practical considerations, which address different aspects of national health care.
Where does that leave us in the current medical perfect storm? I confess to optimism. Any objective look at human life on this earth makes clear that over the centuries, people in general have lived progressively longer, healthier, more comfortable lives. I expect our nation will develop a unique U S functional, ethical, and viable system of national health care consistent with both Hippocratic/Oslerian medicine and with the medicine of large numbers, as revealed by the most significant word in the ACA title.
That word is Affordable.
“Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care…The primary function of regulation in health care…is to constrain decentralized individualized decision-making.” From “New Rules” by Troyen A. Brennan and Donald M. Berwick,1995, ISBN-10: 0787901490.
“MDs do not think of…patients as (a) herd (but) future health care decision-makers will.” From “Obama’s Herd Health Program” by Heather McCauley, DVM.
Four Sketches of South Africa
South Africa, Nov Dec 2012; Capetown, Kruger Park, northern KwaZulu-Natal, and Bulembu, Swaziland
I Capetown
A few years ago I met people who ever since have insisted I visit in Capetown. So I finally did on Nov 12, 2012. (36 hours, 24 in the air!) No question: Cape Town is one of the most beautiful, civil and civilized places on earth, home to wealth and privilege, where Table Mountain looks down on the city and white sand beaches and a cold writhing South Atlantic from 3700 ft. (To enlarge photos, tap- click image)
Close by offshore is Robben island where a revered and heroic Nelson Mandela spent 17 years as a prisoner.
Down the cape is a bit of Huguenot France subsumed in a wine country as fine as any in the world; it is there thanks to those who fled from the religious Inquisition in France.
Capetown was once the apex of South Africa’s history; yet the political and economic center of the nation is now far away in Pretoria and Johannesburg. The Cape is a relatively white enclave in a democracy of 50 million where 80% are black or ‘colored’.)
The country is arguably even more diverse than the USA, and we share many resulting opportunities and challenges. It is predominantly and nominally Christian; but the culture is religiously, racially, economically, and culturally divided. The official languages are English and Afrikaans, though after beginning high school students only use English.
A large sector of the people remain illiterate, and a polyglot of tribal languages are a basic right, and vital cultural and ethnic nutrients for many South Africans who maintain lifetime connection to their tribe. Young men working in larger cities often return to their tribal homes for the rites of manhood , including circumcision, and return to their jobs with a new sense of identity and place in African life not otherwise present in cities. Hundreds of loyal Zulu families send their 14 year -old daughters to the Zulu king’s annual birthday party where he will choose one as his next wife. Current president Zuma has seven legal wives.
These photos were taken on a Saturday in a -beach-side restaurant east of town toward the Cape. The food is rich, varied, and colorful. Biltong, the famous South African jerky was a bit tough, but irresistible because it is prepared from the full range of African animals. I tried some canned pâté, reportedly from impala, but it tasted like-any other pâté.
In Capetown as elsewhere, almost all food is prepared and served by blacks and ‘coloreds’, who do virtually all the hands-on work everywhere. I couldn’t help thinking of Kipling’s poem , The Sons of Martha; and of California, where beds are made, yards kept, and even the houses built by Martha’s Children.
South African historic abuse and oppression of blacks has been changed by representative government only during the past 19 years; so racial/economic inequality are greater than ours in the US, despite aggressive efforts to correct the imbalance. The ANC (African National Congress), which demographics suggest cannot be defeated for the foreseeable future, inherited and instituted Nelson Mandela’s practical egalitarian idealism. It led to the building of roads, schools, health centers, imposed broad and effective affirmative action, and proudly hosted the last world football /soccer competition.
Nonetheless, during the past five years the ANC has become the personal property of current president, Jacob Zuma, who abandons the country in favor of his own tribe, family, cousins, and cronies. He has fed corruption and starved education, health, infrastructure, and economic freedom. Recently, despite fervent, often eloquent public debate, Zuma was re-elected easily for a second term while frankly and clearly projecting the following stance: I am one of Us, not one of Them! We are the majority. We share color, tribal values, and a history of oppression. This is our time. Sound familiar? Listen to the voices heard in the world today, including the Mid East, the Asian subcontinent, and yes, the USA .
Driving in South Africa:
My daughter Lili arrived on the 20th.On the 24th we left the privileged Capetown community and our generous friends, and flew to Durban, on the Indian Ocean (Much warmer than the frigid South Atlantic). There we rented an SUV and made the long drive to Kruger Park; it’s a big country. I had heard the yearly incidence of traffic deaths is high in S Africa; however, it appears that they are predominately those of pedestrians, at night, many not attuned to the dangers of traffic , or affected by alcohol. Our experience was very good; we usually drove only in daytime on major roads (‘N’ -or national-roads).
We had to adjust to driving on the ‘wrong’-left- side of the road, and to wrong sided controls; but the roads were in fine condition, by contrast to California! There was little traffic except in scattered populated areas; most drivers were considerate and capable. The land rises fairly quickly to an extensive plateau bearing great expanses of sugar cane, forest plantations, fruit orchards, and livestock. By driving, one can speak with people, assess aspects of land, industry, agriculture, and take the pulse of the country. All are difficult from 10,000 meters in the air. Note: an e.savvy youth who can mysteriously operate an irritable GPS or use a dongle for email/browser connection, makes possible comfortable ‘wired’ driving across foreign lands.
Leaving the Atlantic coast, the land rises to a plateau, rolling, verdant, and productive. Inland towns become scarce, the highway unrolls itself ahead through sugar cane and tobacco plantings, orchards, some surprising, like papaya. Livestock country appears, then the hundreds of thousands of hectares of tree farms..some eucalyptus, mostly pine. Messy sugar cane spewing semis are replaced by tight wrapped logging trucks.
Most road signs are standard, road conventions too, except speed bumps and roundabouts; many highways have three lanes: but the third is split into two half-lanes to the right and left. Drivers move into their half lane when it is clear ahead, to allow passing. At first the open area to pass through seems cramped but it works very well. Signs in at least three languages are at the least, often entertaining.
Kruger Park
The park is bigger than some countries; one can drive alone all through it, over many hundreds of kilometers of good paved or dirt roads, taking daily short personal safaris, lodging at night in electric-fenced park ‘rest camps’-enclaves where people are kept in cages- while the animals are free.
A wide range of lodging is available; we stayed in rondavels– round thatch roofed huts; but with air conditioning, kitchen, private bath- and a nearby decent restaurant and store.
The elevation of Kruger is a surprising 4-500 meters, so the December climate was temperate, equivalent to July in Auburn, CA.
Despite our USPH advice to use malaria prophylaxis there, I saw only a few tiny squalid mosquitoes. (I confess to never using malaria prophylaxis – suppression, never ever – in South or Central America, South Asia, or Filipinas , preferring to know and treat if I get the parasite. I never have.)
The parks were so uncrowded, we could find lodging easily. Two reasons: 1) the best time to see wild life is said to be dry season since most animals,- including the ‘big five’- must drink at water holes, and can best be seen there at dawn and dusk. When there is plenty of water, and foliage, the animals are harder to see. Our experience was that the animals don’t go away when it rains, and we saw them easily though the feed and vegetation were lush. 2) summer vacation doesn’t begin until about the first week of December. After that the park is much busier. Suggestions: the animals, and there are plenty of them don’t leave; go whenever the park is un-crowded, and stay for a week or more.
From about 6 AM to 6 PM, one can roam the roads confined to a car-cage, except for brief indefensible infractions of the rule. We did on a guided veld (bush) walk- with armed guards-but it was disappointing;larger animals are exceptionally wary of people on foot, so we could only see them from 100 yards or more. On the other hand, wildlife generally seems to find vehicles are only smelly harmless asexual beasts; a car can often approach within a few yards. Similarly, night drives we tried using spotlights to see animals were a waste of time. Relax instead!
Unlike leopards, crocodiles, or monitor lizards, most animals are social.
Baboons; the alpha sat off to the side stoically monitoring those in the road.
Wart hogs and bird companion.
In a flat open bush area this lion materialized within a few feet of our car. The pride of lions below were sleeping beside a main paved road.
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I wasn’t aware zebra can be three colored; why do they wear such striking markings. ?They are the most perfectly coiffed animals in the park, even in their striped pajamas
Impala- I assume the local name was ‘mpala- were plentiful this year. Beautiful animals, the females have a genetic birth control: they abort their pregnancies when food is scarce
Elephants have a distinct odor. One can detect them from a few yards away even if they are not seen.
.The hippo was probably just stretching, and yawning, getting ready to leave the water and go foraging. But I didn’t ask.
Hippos are generally aquatic animals during the daytime; they don’t tolerate sun well, and may secrete a pink goo to protect them from sunburn when they can’t stay in water. In the late afternoon they begin to move onto shore, and can range many miles at night, feeding on vegetation.
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Enlarge this; Seven or more giraffes can be seen.
A baobab tree;
Most of the hyenas were very leery of people. These, however didn’t even stir from their place in the middle of the road.
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A solitary Cape Buffalo and a spider colony, found in the area with separate entrances for each spider.
A steenbok
and Vervet Monkeys
All the big animals ignored us excepting the leopard with her food. Maybe she thought we would tattle about her kill to the Gen lions or hyenas.Generally the larger animals are said to be most active in early morning and evening especially in hot weather. It is also said that they are not easily seen when vegetation is lush, as it was when we were in the park; yet we were able to see, and often approach closely by car, when animals were on the open road. Typically they were found in a traffic jam, as people in cars wanted to take photos, and were unwilling to risk irritating rhinos or elephants by nosing through
The park is home to many birds; so many that to include them would overwhelm this post. But the culture of digital photography is worth mentioning. In general, the digitally devoted could be categorized into ‘birders’, identifiable by 18 inch telephoto lenses and sturdy tripods: and ‘beasters’, carrying an astounding assortment of cameras. Birders tend to be solitary and secretive, found in ones or twos, often spending hours whispering together about their prey. Beasters are herd animals, gathering together closely around big animals or herds, calling to one another by iPhone or the like.
Most rest camps offer some rondavels with grand views; in November, which is usually a time of lush vegetation, occasional rain, or warmth, there are fewer visitors, so that these were often available within a few days of arrival. The low plateau where Kruger is situated, provides stunning sunsets so often they seemed scripted. In this photo, a the roof of a rondavel is visible low on the right.
Bulembu and Carl Shirk, MD:
Thousands of digital photos later we left Kruger (5 Dec) and drove through the small kingdom of Swaziland , taking a shortcut back to the north Kwa-ZuluNatal area of S Africa. On entering Swazi the road ran beside a rusting old tramway system, once used for hauling ore out and supplies in to a mine.
As we crested a hill, down below we saw what could only be an abandoned mine and town. I had grown up in many such remote places. Mines are like people: we are conceived; with luck, we are born; we live and get old and die, leaving behind the residue of all we struggle to build and to become.
A person may leave behind only a few words, dust, a child, and more rarely, a fortune, or an honored memory that can grow with time. Mines leave physical evidence of the huge investment of money, sweat, blood and tears required to find, develop and dig metals or minerals from the earth’s crust. It is a decaying monument in the form of abandoned homes, adjunct buildings, hoists, shafts, open pits, mills, tailing-ponds, and rooms full of meaningless administrative trash. I have never seen a mine prettied up when it has died. There’s no undertaker or funeral for a mine.
And yet a big mine also leaves behind valuable and formidable infrastructure: potable water, power plant, a sewage system, silent empty houses, a hospital, a school, a bowling alley, a soccer field, and roads. In some cases a person continues to grow and evolve after death for one reason or another: like Jane Austin, Abraham Lincoln, Evita, Luther King. Likewise so do some mines: like Aspen, Telluride, Taos, Eureka, Baguio, the list is long.
The particular mine spread out before us was Bulembu in northwest Hhohho, Swazi high veld. The nearest hospital is in Pigg’sPeak, 10 km away but more than two hours by very difficult dirt road. Bulembu means spider web, named after the dark unseen mine tunnel like passages of local communal spider webs.
It was a town of 10,000 when abandoned in 2001, retaining only about 50 people when purchased by Bulembu Development Corp, which sold the 1700 hectare property in 2006 to a Bulembu Ministries of Swaziland. At the time there was an HIV related orphan crisis. AIDS there has been greatly reduced- largely due to the US/Bush HIV project- perhaps the largest international health project in history. Nonetheless, abandoned infants and children abound.
A few years ago Dr Carl Shirk and his wife Lesley crossed the border between South Africa and Swaziland at Bulembu. They were still there. She teaches English as a second language to ‘aunties’, and Carl works in the clinic. I discovered Shirk is a colleague from California, an 80 yr old farm boy, a horseman and musician, a UCB and USF grad who was drafted into in the US Navy (Korea), returned to teach and practice FP/EM . We have mutual acquaintances here. We spoke of friends, and how small the medical world is; of his work; of the political and economic storms that affect Bulembu, the Shirks, and the world rolling around and around the sun.
The Shirks live in a refurbished house on the hill above the clinic.
Carl was free to show us around because patients were being attended by two volunteer internal medicine residents from Britain, and a local nurse who may be the future Owen Meany of Bulembu. The doctor was only supervising, in preparation for being away during Jan-Feb 2013, to attend to a medical problem of his own.
Shirk is an 80 yr old farm boy, a horseman and musician from California, a UCB and USF grad who was drafted into in the US Navy (Korea), returned to teach and practice FP/EM in Northern CA. We have mutual acquaintances here. We spoke of friends, and how small the medical world is; of his work; of the political and economic storms, of the significant results of the Bush/Gates HIV projects: far fewer infected children, C Sections for HIV positive mothers, and medication for HIV patients.
Bulembu children live in about 100 reconditioned miner’s houses where a live-in paid ‘auntie’, cares for two children at night, while sometimes working part-time in the daytime when the children are in school or the orphanage. Aunties often come and go, as a way to help support their home families.
We visited a rebuilt administrator’s home serving as an orphanage for about 20 healthy looking active 5 yr old boys.
We pondered a world where orphanages clearly and effectively fill a need in Bulembu under the government of a despotic king, while in a wealthy and democratic USA orphanages are politically indefensible in favor of foster homes that are far more expensive and difficult to oversee than an orphanage. I thought of the many highly successful people who grew up in depression era orphanages, and found it ironic that we idealize a fictitious orphan Owen Meany while subjecting orphans to serial foster home placements. Why? Maybe for the same reason we remove clearly mentally incompetent people from institutions and without pity confine them to cruel and costly jails. Clearly much harm can be done in the name of blind idealism or idealized blindness.
The Shirks plan attend to health problems in California during early 2013. In the meanwhile health care in Bulembu will be provided by a nurse, staff, and volunteer physicians.
Shoes drying in the sun after being washed; Clothing drying on a clothesline; a rooms of cribs or day beds for napping; a storeroom full of folded bright clothes; a pantry with a hundred colorful plastic dishes; a half dozen plastic tricycles. A kitchen. These are the faces of an orphanage and the faces of these boys that of Bulembu, this old dead mine.
IV Santa Lucia and iSimangaliso Wetland Park
Passing through tiny Swazi after only a few hour drive, we entered kuaZuluNatal South Africa, and found a guest house in Santa Lucia estuary, where typical large African animals are found at seaside. Outside national parks, one can very comfortably stay in a guest house.
There are almost no motels. Guest houses are generally very comfortable, often elegant, with sturdy fences, to discourage human predators. There are many in the small town of Santa Lucia; One can drive into adjacent iSimangaliso Wetland park during the day, and enjoy an upscale posh evening in town.
A curious feature of Santa Lucia is the occasional night-roaming hippo; they are herbivores confined to water in the daytime but able to roam 30 km to feed at night; sometimes prefer tasty city plants. Cute? Perhaps, but they should be avoided because they cause more human deaths than any other animal in Africa.
See post on Vincent, a hippo with one ear chewed off (Van Gogh), who in turn chewed off a man’s leg. See URL: http://www.theawl.com/2013/01/hello-animal
(Hippo vision is weak their while their temper is strong; easily enraged, they can be deadly. The man who lost his leg is, so far, the only known survivor of a hippo attack in Santa Lucia).
Reflections:
I bought a fine African Christmas CD bought in a Kruger store, combining African lyrics, instruments, and voices with traditional Christmas Carols. These are lyrics from a wholly African carol:
“Give me, an African Christmas,
Peace and love throughout the land.
We need and African Christmas,
standing together hand in hand in hand.
Whenever I’m in a ‘foreign’ culture for a time, I’m more impressed by connections and similarities than differences; maybe that is xenophilia – or love of the Other: the other land, culture, language, food, literature, dress, skin, values, beliefs.
Watching the inauguration of President Obama here in January 2013, it struck me we share some things with South Africa:
# Both presidents, Obama and Zuma, have been re-elected for second terms.
# Both have significant political appeal for being black, or partly so.
# Both preside during a time of heated but principled disagreement over emotionally charged issues .
# Both were elected by imperfect democracies , (though no democracy is perfect), during a period of change, and uncertainty.
# Both preside over very diverse populations, with a history of oppression and racism, though progress is being made constantly.
# Both are focused on that sector of society inadequate education, income, and opportunity.
# Both promise hope and change, but are having great trouble delivering on the promises.
Change doesn’t happen without reference to the past; and while, during periods of change, it’s reasonable to focus on the future, history still matters. For example In South Africa two significant changes are : First, that immigration from bordering African countries is now open, unlimited. Why? Partly to unite Kruger with Limpopo parks. But also to make clear that South Africa now belongs to – Africans; not Europeans. Second, the borders these parks, mainly rivers that can often be crossed on foot, are now not rigorously protected, leading to much more poaching; it’s estimated that 400 rhinos were killed last year only for their horns. Though the horn can be harvested and regrow, they are shot and left to die, especially by people on foot, as opposed to the more sophisticated helicopter trade. The relevant historical context is, in general, the loss of land, language, self-determination, power, and tribal independence by indigenous people; specifically relative to the Park, its founder, Paul Kruger, was a Boer who swept the park clean of people to protect and preserve animals. The biggest and best guest camp there is named Skukuza– which means Broom. What matters now is to incorporate the need for change without destroying too much heritage. Will it be enough to simply rename Kruger Park, like towns in Mexico were renamed after the church power was crushed? Can we , and/or South Africa, resolve our ethnic and economic strife without sacrificing our liberty? Can the tribal peoples of the Middle East do so? It’s worth much thought and effort.
Language can be confusing, in part because it is always growing and evolving. So is society. Our N word is their K word (kafir); both are crude and insulting, though 100 years ago neither was. The acceptable South African use of the word ‘colored’ reflects a heirarchic distinction among Africans based on gradations of skin color. While we generally now avoid the word ‘colored’, it quite realistically reflects societal distinctions that still exist everywhere. On the other hand Mr. Zuma is decidedly black . ‘Colored ‘ can be used to refer to that sector of the population which is of mixed race. I believe it is a vital and growing part of society there, and, likely, everywhere. And if that is so, we our future is promising.
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* A way to get started reading about South Africa
- Nadine Gordimer- ‘The House Gun’ and ‘My Son’s Story’
- Zakes Mda ‘The Heart of Redness’
- James Bryce ‘Impressions of South Africa’(from 100 years ago.)
- J M Coetzze ‘Disgace’