South Africa

Thirty Hours in a South Africa Emergency Department

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Taken from an anonymous subreddit post. One often wonders whether such things are fictional. Yet the details of this anonymous post are such that I am very sure it is genuine. Simply by chance those several specific details confirm that I was in South Africa when this student was there. The original is more than 3500 words, so I tried to edit it some. Yet I could not bear to cut more than about 5%. It was too close to the bone. The last 20 years of my own life were spent in a very busy Emergency Department, and I started there as a ‘moonlighter’ in medical school; these scenes, though more intense than those I lived, are familiar. It may be that part of the author’s name appeared once in the post; first or last is unclear. I expect to read more, somewhere, some time. S-He is a writer.</em

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"Having been originally sucker-punched into medicine during high school by reading the romantic and adrenaline-laced tales of war doctors, I wanted to get my own taste of trauma during my elective. I chose to go to [a very large hospital in a developing country].
It was mental. As an overseas student, you essentially function as a doctor because of the huge patient load. During one of my 30 hour shifts, I tried to chronicle events, the patients I saw and helped resuscitate, as best I could.
07:00 – I walk through the front doors. The scent of the Pit hits me – old foot sweat, fetid pus and a special ingredient I still haven’t been able to identify. I walk through the resuscitation bay… past a young child half inside a morgue bag, still warm from dying of burn injuries. The relatives are grieving around him, while arguing with hospital staff about … harvesting the organs.
07:01 – “There you are, get some gloves on and get this guy stitched up.” He has been stabbed in the face with a broken bottle, big deep cuts across his forehead and face. “You sure?” I ask – pretty sure this guy would be sent straight to Plastic Surgery at home. “Yeah it’s fine, just make sure to stay away from his eye when you do the eyelid, and line up his ear and eyebrow properly.” I grab the suture pack and get to it. The scissors don’t cut, the forceps don’t grab. It’s like knitting with a knife and fork.
07:45 – 6 year old boy has been hit by a car on his way to school. His left thigh is swollen to the size of a party balloon – he has broken his thigh bone. He comes in gritting his teeth, not a sound. “What a brave little kid” I think as I help cut off his school uniform, to reveal a worn-out Batman costume he was wearing underneath. It’s only when we have to cut that off too that he starts to cry. Comment: Many details make it certain I was in S A when this student was there. Because uniforms were required to attend ‘free’ schools, and a uniform cost more than many people lived on during half a year, to lose a uniform was tragic.
08:20 – A taxi has gone through the wall of a house, killing the girl sleeping inside. The front passenger died on the scene. The driver is comatose. We rush him to the resuscitation room, put a tube down his throat to let him breath. We put a catheter in – he is urinating blood. The FAST scan of his chest and abdomen shows large amounts of free fluid inside. We take him to theatre, but it’s too much, his liver, spleen and kidneys are in pieces. He dies on the table.
10:00 – I come back to the Pit, and there is a bit of calm….I start to see some non-urgent patients.
10:05 – a chap with headaches after being beaten in the head with an iron pole 3 days before. I ask the important questions, examine him to rule out the serious things, then tell him that a few headaches probably are to be expected, and send him home with pain relief.
10:30 – A man with a wedding ring trapped on his sausage size swollen digit after being cut on the finger 5 days before. I anaesthetize his finger and slice off the ring with the nifty tool.
11:00 – A guy with a swollen left eye and a bleeding eyebrow. I ask what happened. “My girlfriend tried to bite off my eyebrow.”… the same girlfriend bit off his ear in 2009… I tell him that the relationship might not be too healthy.
11:30 – A lady has spilled acid all over her lap, with deep dry burns across her thighs and buttock, maybe 15-20% total body surface area. Nasty, but not life-threatening. Not much we can do for her until the chemicals wear themselves out – they don’t have any neutralizing stuff here. I send her to the ward.
12:15 – A middle aged man who has sliced his palm and fingers with a circular saw. I test all his nerves and tendons – his hand is still working fine, it’s just bleeding and a little mangled. I stitch him up carefully, and it looks nice afterwards. He is happy. “I’m glad I got white doctor” he grins. I tell him for the umpteenth time that no, I’m still a student. He is still glowing.
13:15 – Lunch. A treasured 15 minutes.
13:30 – A man comes in after being dragged behind a car by an angry horde after being caught in the act of a crime – #mobjustice. He has degloving injuries to his thighs & buttocks, and his scrotum has been torn away, leaving his testicles completely exposed.
14:15 – Walking to the radiology room I am stopped by a man. “Hey doctor” he calls. Look friend, I’m busy. And I’m not a doctor, sorry. “Quick boss, quick.” Ok fine, what is it? “I’ll trade you gun for your stethoscope.” [Gestures towards butt of gun sticking from his belt.] I hurry away.
15:30 – The pit is busy. I’m trying to help out seeing the non-urgent cases, and notice the homeless man I noticed a little earlier is still here. He has wet gangrene of both his legs, he stinks, and he is drunk. No-one in general surgery wants anything to do with him. The waiting line is long, there are other patients to see. He eventually gets bored, drops his pants, and starts playing with himself vigorously. STILL no-one bats an eyelid, and he is left there vigorously jacking.
16:30 – A young man with the first gunshots of the night. The first grazed his arm, the second went through his thigh. He is stable and not bleeding much, so we x-ray him. The bullet has smashed his thigh bone apart, he will need surgery. We put him into traction.
17:15 – A 16 year old kid trapped in a house fire. Many people living here have rudimentary shacks for homes, and rely on open fires for warmth. This lad had 60% partial-full thickness burns. As we do the immediate resuscitation, I can hear the senior doctor talking angrily with the Burns Unit over the phone. They won’t take him – 60% is their cut-off. She slams the phone down. “Cover up the burns, keep him warm, and then move on” she sighs. He died later in the evening.
18:00 – Old guy with a massive inguinal hernia comes in with burns all over his football-sized scrotum. Another open fire. This time the Burns Unit take him.
18:50 – A man stabbed in the temple region a few hours before. He has a sore neck, severe headaches and has lost consciousness a couple of times…I can’t feel a fracture in the skull… Neck collar him, and order the brain scan.
19:40 – A middle aged guy who got kicked in the nuts a couple of weeks ago now comes in with pain and swelling in his scrotum. I can get above it, it’s not a hernia. He gets an ultrasound scan, which shows the testicle has died and is now festering. I call the surgeons.
20:40 – I’m eating dinner, and watching the news with some other docs. Nelson Mandela is still sick in hospital, and the whole nation waits – everyone is hoping he hangs in there until his 95th birthday.
21:15 – A guy who got knocked over by a car, twisted his ankle and hit his head. Remembers waking up to his concerned mates standing over him. Scan the brain.
22:00 – A car hijacking. The three assailants chucked a rock through his window, and then forced opened the door. Guy comes in with stab wounds to his palms from where he tried to defend himself from their knife. He gets yanked out of the car… manages to start sprinting away, but they catch him. He has his front teeth kicked in, a sore neck, painful ribs and spine. His ankle is badly swollen. His head is fine and pupils are reactive. I just order him xrays wherever he is hurting.
22:40 – A guy comes in who has taken an axe to the face. His parotid gland is hanging out, and is squirting arterial blood. “Put some stitches in there quickly to stop the bleeding, I’ll be there soon.” I put one in. That bleeder stops, but it starts up two more; it’s like a Hydra. I eventually give up and get the registrar, he gives it a shot, but no luck. By now he has lost about a litre of blood, and his whole face has swollen up to the size of a grapefruit. “Ok let’s get him to theatre.” We go quickly to write the forms, and come back. He has gone, just up and left to no-one knows where.
23:30: “STAB CHEST, LETS GO”. A man has been stabbed just above his heart, and he is deteriorating fast. Everyone runs in. Get the airway, intravenous access, ABGs, put in a catheter. He’s still crashing, his oxygen saturation is going down. His neck veins are distended, his heart sounds are distant, and his blood pressure is in his boots. Unwavering, the consultant steps up, grabs the scalpel and slices open the chest; with what looks to be a hammer and chisel he cracks open the ribs. Blood splashes out all over the doctor’s scrubs as the pressure is released, and there it is; the man’s beating heart is laid open to the air. I’m dumbstruck. Purple lung pumping up and down on the other side. They start giving him blood but it’s all leaking out. …I hold the heart between my hands as it beats slower and weaker until he dies.
00:05: “GUNSHOT CHEST”. It’s a young guy covered in blood, brought in by the paramedics. Looks like it has gone straight through front to back and out through his shoulder blade. The bullet has torn through his right lung, deflating it, but aside from that he is ok. He is struggling to breath so they give him morphine to calm him down, and pump him full of oxygen. “Your first chest drain for the night.”
00:30: “GUNSHOT CHEST”. Almost a carbon copy of the previous guy, shot front to back through the right lung. …He does well, too. There is a row of stationary bikes on the ward where the guys with chest drains do their workouts the next few days; they usually go home in a day or two.
01:20 – The drunk people start rolling in. Young lady was in the back seat during a car accident, and is in serious pain. She is making a big fuss as the paramedics pull her from the stretcher to the bed; obviously stressed out and frustrated at the endless stream of intoxicated people they have seen tonight, they are shouting at her to keep calm and cooperate. …I look at her legs – one of them is shorter than the other and rotated inwards. “Stop pulling her hip, I think it’s dislocated!” I urge. They back off, and wait for the xrays. I mentally high-five myself.
01:45 – A guy in his mid teens has been clocked in the face with a brick. His whole side of the face is mashed, and he is struggling to breathe. They are struggling to intubate because there is something in the guy’s mouth. The brick broke the eye socket and the orbit has fallen … into his oropharynx, blocking the doctor’s view of the throat.

03:20 – The guy with the twisted ankle comes back, 6 hours later. He has finally had his head scanned, and has been sitting there for hours waiting for someone to check the result. He’s fine. They splint the ankle and leave him for the bone doctors.
03:30 – Man comes in with scalp lacerations. He is extremely confused and abusive, but is it because of the alcohol or because of a brain injury? We aren’t sure so scan him.
03:40 – Same story. Scan him.
03:45 – Same fucking story. A woman this time.
04:20 – I walk out into the pit; “Dooooctor” a man lying in the stretcher moans. I tell him I’m not a doctor. “Man, the pain is too much”. I look to see if he has been given any pain relief. I get a tiny splinter of glass through my finger from the broken windshield he went through. My finger is bleeding. I squeeze the glass out and pour alcohol disinfectant over the wound. I ask the senior if it’s ok, is it an HIV risk, and she reassures me its not. I double check; he is HIV negative.
04:50 – The drunks have filled the pit. They all need a special mix of what they call “Rocket Fuel”, and so everyone is working together to get the drips up. My guy is shouting abuse at me as I talk to him. He pisses his pants and laughs at me. I try and get the needle in, but he thrashes around and starts hitting me. I back off, breathe, and come back in for another go. This time he to bite a chunk out of my cheek; o I explode. JUST FUCK OFF I yell, and slam him to the bed angrily. The other doctors see I’ve lost it and jump in to help. With two on the legs, two on the arms and one on the chest and head, they eventually get the line in. After it’s all over one of them comes over to me, pats me on the shoulder. “Don’t worry about it man. It happens.” I’m gutted.
05:00 – 07:00 –… I remember at one stage standing out in the freezing cold, trying to unclog the blood from my zipper so I could zip up my hoodie. I remember a guy who had been pistol whipped, and the end of his nose was hanging off. They told me to sew it back on, but I was saved by the plastic surgeon who thought it was a bit beyond me. I remember trying to sneak a nap in the bereavement room – the place where they tell bad news to the family. They have the nicest couches in there. I got interrupted by a bereaving family. “I’m sorry” I mumble as I stumble out.
07:00 – End of the night. I’m falling asleep on my feet, but I still need to go and help on the wards. In a daze, listen to chests, take blood and fill out forms, check blood results.
08:30 – One of the interns gets called away so I do my best; thank god for nurses and charts.
11:30 – A little boy of 10 is on the ward. He is deaf-mute with no family; a passerby brought him because he had seizures on the street. No one has any idea what is wrong; Trauma takes his care. He gets put through the medical wringer with every investigation they can do, many of them painful and invasive. He sits there in the corner of the ward, drooling, staring as you walk past with nothing behind his eyes. It’s heartbreaking and unsettling. Today it’s a lumbar puncture. We give him some panadol and ketamine, then one of the interns hold him while I put the needle in.
13:00 – I finally walk out the front doors, blinking in the crisp sunlight. Somehow I make it to the hospital shuttle bus, and 30 minutes later I am shaken awake by the driver. “You are home now, you sleep at home, not here” he smiles.

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Herd Medicine

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 “…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.

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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.

Quotes:

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

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South Africa, Nov Dec 2012;  Capetown, Kruger Park,  northern KwaZulu-Natal, and Bulembu, Swaziland

I Capetown

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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.IMG_3790

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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.

IMG_3979 IMG_3935 IMG_3989 IMG_3947Capetown 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.


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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. IMG_5603 IMG_4123 IMG_4034

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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.

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The elevation of  Kruger  is a surprising 4-500 meters, so  the December climate was temperate, equivalent to July in Auburn, CA.

IMG_5244  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!

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Unlike leopards, crocodiles, or monitor lizards, most animals are social.

 

Baboons; the alpha sat off to the side stoically monitoring those in the road.

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 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

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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.


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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.

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A baobab tree;    

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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

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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.

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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.

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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.

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 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.

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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.

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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.

IMG_5668,,IMG_5634 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.

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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.

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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.

IMG_6034See 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’