“That Sucks”: Practicing the Language of Compassion

About a year ago, I was complaining to my boyfriend on gchat about a series of unfortunate events I’d experienced.  After unloading, perhaps melodramatically, he replied to me with two words – “that sucks.”  Suddenly, gone was all the self-pity I’d been wallowing in, evaporated by the blood that was now boiling in my veins. Attempting to convey my frustration, I sent back: “That is the least possible empathetic response.”

Since then, I’ve caught myself more than once, about to give the same automatic response back to others. Each time, I’ve tried to sort out exactly what it is about the phrase that irks me so much.  Part of it is the lack of thought, the way the phrase it almost too easy a response, suggesting that the responder is at best uncreative and at worst not even listening.  Part of it is the crude etiology, pointed out by a high school teacher years ago.  And part of it is the way it closes the conversation, leaving both parties unsure of what to say next.

Today, during an elective course on group facilitation, I finally put together why “that sucks” is the worst possible reply to another person’s suffering.  We were discussing empathy in the context of motivational interviewing, and we watched this funny little video about empathy vs. sympathy.  It’s comical, but also strikingly accurate. To be empathetic, you must meet someone where they are, not immediately offering salves but first acknowledging whatever level of suffering they’re experiencing.  Responding to pain with “that sucks” or “at least…” is easy, not empathetic.  Such phrases protect us from the possibility of experiencing the pain of others by maintaining distance from the problem, rather then stepping down into whatever dark hole a patient, friend, or stranger may have fallen into.

Arguments for empathy aside, the fact is it’s difficult to muster up during times of necessity if it’s not practiced.  Empathy is conveyed during language, and too often I fail to choose empathetic words, resorting instead to easy phrases devoid of thought or meaning.  So today, I begin an effort to practice the language of compassion, to choose words carefully rather than toss out the first ones that come to mind.  It’s difficult, but I want to show genuine empathy to patients, and that will only come from practice.

Camden Classroom: Confronting Hunger

Going to school in Camden means often being confronted with people and things that make you uncomfortable.  Our building is settled on a corner of a fairly busy street, and there’s pedestrian traffic throughout the day.  Issues of homelessness, addiction, poverty, and mental illness are on full display nearly every day and therefore impossible to ignore.  Having worked in Camden for the last year, I am generally accustomed to seeing the people who are struggling with these issues.  I’ve also spent a fair amount of time learning about the resources available in the city and while funding is generally meager, I’ve felt hopeful about continuing progress.  Perhaps that’s why I was so unprepared for what happened today.

When I left school around 6pm, riding the high of a compliment received in a practice patient encounter, I walked past a man who had been rummaging in the trash can looking for food.  When he spotted me, he stopped and began to say something I couldn’t quite make out.  I gave my usual response of “I’m sorry, I don’t have anything to give you.”  While I wish I could carry around enough granola bars to hand out to anyone who asked for food or money, I often forget.  I’ve also come to terms with the impossibility of solving hunger on my own, and have resolved to accept that I do what I can.  But caught up in my own excuse, delivered with a practiced expression of grim apology, I hadn’t even heard what the man was saying.  In fact, he wasn’t asking for anything.  He was apologizing.

The apology jolted me out of my protective empathy armor.  This man, who was so hungry and desperate for food that he was willing to eat from a trash can, was apologizing to me, because he believed I might have been upset when I saw what he was doing.  This was a thousand times sadder than asking for help, and I deeply wished at that moment that I hadn’t eaten my afternoon snack so I could have given it to him instead.  Instead, at a loss for what to do, I offered a general reassurance that “It’s okay” and moved on, at least physically if not entirely in my thoughts.

Of course, there are places that offer free meals in Camden, and many require nothing from patrons except that they respect others both running and receiving the services.  I’ve wondered if I should have informed the man about where he could go, but it was getting late, later than dinner is served at any of those places.  I also know there are lots of reasons someone might not use services like free meals, even when they are available.

This evening’s encounter interrupted the concentrated state I’d been in all week, in preparation for our first exam this Friday.  Despite feeling helpless, I’m reminded of why I wanted to go to school here, and of my ultimate goal, to advocate for the health (and the factors that affect health) of my patients and the population they’re a part of.  Tonight I’m approaching my studies with a bit of renewed energy, and sending a little prayer for the man who won’t ever know he was the source.

Medical School: The First Day

I started this blog two years ago with an explanation of why I wasn’t going to medical school. And now here I am, about to tell you about my first day of medical school. But wait, how’d I get here?

That’s kind of what I was thinking yesterday, on my first day of real medical school classes.  After two weeks of blissfully calm orientation to the school and the student run clinic, we dove in to problem-based learning groups, info-packed lectures, and genomics lab.  Somewhere in the middle of that, I thought to myself this is going to be a lot of work. Also, can I do this? And, why am I doing this?

It’s fairly common to hear that the beginning of medical school can be overwhelming; the accepted metaphor is drinking water from a fire hydrant. For me, it wasn’t even the material itself that seemed daunting, but the dawning realization that there was an enormous volume of information to be absorbed in the next two years.  After dreaming about going to medical school and becoming a doctor for a very long time, it was finally happening, and that was a little bit scary. 

Oddly enough, a little girl and a bandaid helped to put things in perspective last night.  I was at my boyfriend’s hockey game and a girl who was probably 7 or 8 was sitting in front of me, watching her dad.  She got a small cut on her hand, and was completely distraught, begging her dad to get off the ice and come to her aid.  I realized I had one, found her crying in the bathroom, and offered to help.  Of course, she would have been fine, and all I did was pat her hand dry and stick the bandage on her – but her face lit up with a smile and she thanked me before wiping her tears and running back to her sister. And that’s when it clicked, and I remembered the joy that seeing your impact on others can bring; that’s the joy that has drawn me to medical school.

Thinking In Systems

This quarter I’m taking a class on Safety in Healthcare, and a (if not THE) prevailing theme throughout the first five weeks has been a the need to focus on systems.

When it comes to medical errors, the old (and unfortunately still existent) way of thinking is to place blame on the individual clinician – whether it be the nurse who gave a patient the wrong medication or the doctor who misdiagnosed a patient and missed the critical opportunity to provide effective treatment. This approach gives into the instinctual need to place blame on someone, and is in line with the litigious nature of society (in turn contributing to the rising cost of medical malpractice, a factor in the extremely high medical costs overall).

What this person-focused approach does not consider, however, are the broken systems that make it far too easy for clinicians to make mistakes. For example, medications that look similar or have similar names can be easily mixed up by a nurse who is busy looking after multiple patients, and a physician who has been up all night on call might not have the cognitive acuity needed to make the right diagnosis. While there were actions that led to these errors, the errors only occurred because of the multiple failures of the system.

Other industries, such as nuclear power and aviation, have embraced the systems approach, and have seen a resulting decline in errors. Healthcare is following suit, albeit slowly. New ways of preventing errors within care delivery systems are being developed, supported by voluntary reporting systems that focus on near-misses and system problems.

Thinking in systems is useful far beyond these industries. The questions asked in a systems view is “Are we doing all that we can?” Whether that be to achieve industry goals such as preventing nuclear disasters, lowering aviation accidents and mortalities, and improving patient safety, or to achieve other social goals. Are we doing all that we can to create a health population of productive citizens?

In many ways, we are not. Take, for example, one of the millions of young African American males incarcerated for drug offenses.  The prevailing view is that these men are “bad” or “lazy” and have ultimately made a choice that deserves some severe punishment.  This is the individualist view.  The systems view might recognize that a young man who grows up in poverty without a father who wants to care for a disabled or elderly mother might not be able to graduate from his poorly run inner city high school, and therefore won’t qualify for a job that pays more than minimum wage or might not be able to find a job at all, and may feel that they only way to make ends meet and fulfill his duty as a son is to sell drugs for cash, a far more lucrative career than most of those available to those without high school diplomas or college degrees.  This view is more difficult to think about, and makes it harder to place blame, but ultimately shows how many lost opportunities there were to prevent the boy from failing and from feeling coerced into a criminal activity. We can look at social ills in society and think that they are creations of circumstance, or we can think of them as the flaws of individuals; too often we choose the latter.  But until we learn to think in systems, we will continue letting too many failures happen.

Turning the Tables: My Patient Experience

I am not an avid or advanced skier, a fact I proved while attempting to conquer ‘just one more’ icy slope this past weekend.  While I didn’t require assistance from the ski patrol or a ride on  the back of a snowmobile, I did bang up my knee quite a bit, and the swollen size convinced me I might as well get it checked out my a doctor.

Thanks to the recent proliferation of “Urgent Care” Centers, even our local orthopaedic institute has one now, promising quick access to a team of experts no matter your injury. I figured that was the most appropriate option, so I walked in around 11am, filled out a basic history on an iPad, and handed over my insurance card.  The kind woman at the front desk asked me about my injury- briefly- confirming what body part I’d hurt.  Minutes later I was upstairs getting several x-rays, before I’d ever even seen a nurse.

Had anyone asked about the problem with my knee, I would have emphatically explained the issue was a bit of swelling and mild muscle pain – I hadn’t heard any pops, cracks, or snaps, and everything seemed to still be in place.  A quick physical examination would have informed any clinician that it was likely just a pulled ligament (which did happen, only after the x-ray). Instead, I was sent to be scanned, ensuring that the office could cash in on the comprehensive insurance I’d presented.

For obvious reasons, I don’t consider myself an “average” patient; I’ve spent far too much time reading about healthcare and considering the problems of enormous healthcare costs in the US.  But that was precisely what I found so disturbing about the straight-to-x-ray process, as well as the unnecessary brace I was given (which I will not wear, and would have told anyone in the office who’d asked).  Both are guaranteed payments from my insurance company, despite their questionable medical necessity.  I understand some patients may be comforted by an x-ray, or enjoy the extra support of a brace; but I can’t agree that they should be standard.  To be honest, the genuinely excellent care I received when I was finally seen by a PA would have been more than enough to calm my fears.

Generally, the availability of urgent care centers (for a variety of specialties) are a movement I applaud.  They provide an excellent alternative to the ED that is generally more convenient and more appropriate in terms of level of care. But the indiscretion in ordering tests and treatments is a profit-making technique I cannot get behind. Ensuring these urgent care centers help to reduce overall healthcare costs will require some additional oversight and responsibility.

Pray to End Sidewalk Bullying

I live around the corner from a Women’s Center, a euphemism for abortion clinic.  Every day, a crowd of the faithful gather in front of the clinic to protest abortion, and few things infuriate me more.  Several months ago, some brave soul added lawn signs that read “Pray to End Sidewalk Bullying” and “Jesus Didn’t Shame Women”, which I thought were absolutely brilliant, hence the inspiration for the title of this post.

Over the last year or so that I’ve been monitoring the protesters, they’ve changed tactics.  The Catholic church a few doors down leads parades to the clinic, some carry signs, and one man brings rather grotesque posters, opting for the horrify-the-masses approach.  I can’t deny I find the protesting irksome – I’ve often been tempted to pull over and explain that there is a center for women’s health around the corner that offers pregnancy testing and assistance to pregnant women that could probably very much use some volunteers, and that seems like a far better use of time.  But the latest approach has me absolutely stunned – parents are now bringing their small children to stand outside the clinic to protest with them.

I suppose they believe this to be effective, visually reminding people of what a fetus becomes after birth.  But I really take issue with this tactic – it was bad enough when I passed a girl who definitely should have been in school instead of standing on a sidewalk in the middle of the day, but this afternoon two tiny kids, no older than 5, were standing out in the pouring rain, aides to their (I presume) mother’s protesting.  At what point do you sacrifice your own child’s health to prove a point to women whose circumstances you are completely ignorant of? Also, have you explained to these small children what abortion is? Do they understand the cause they’re being used for?

I don’t have children, so I hesitate to pass judgement on parenting – but something about this just seems off to me.

Race in South Africa

My first week in South Africa I met Tessa, the strong-willed director of the Blue Roof Clinic.  She invited me into her office, and thanks to the other students’ warnings, I was prepared for her quizzing on South Africa, HIV, and healthcare.  What I wasn’t prepared for, however, was the statement she made just five minutes into our conversation: “Apartheid, you know, wasn’t so bad.”

It was all I could do to keep my jaw shut, as I racked my brain for anything good I had ever learned about the oppressive racist system and came up with nothing.

Tessa is colored, and although that term has a derogatory history in the US, it is a completely valid identity classification in South Africa, used to describe the group of people of mixed (white and black) descent¹.  During apartheid, the white minority was given the highest forms of privilege; below them, the colored, followed by the Indian population, and finally the black Africans.  Tessa elaborated on her claim about the racist system, saying “It kept people like each other together, and they lived in the same communities and knew each other and protected each other.”  As she continued, I tried my best to understand where she was coming from.  Through not entirely free by any means under the apartheid government, the coloreds enjoyed more freedom than the blacks and the Indians.  The ingrained racism of the system no doubt led to the colored’s own ingrained interpretations, becoming more suspicious of blacks as it allowed them a certain degree of superiority.  And since the end of apartheid, crime has risen dramatically.  Though there are some very good sociological explanations of this, such as poverty and lack of social mobility opportunities, it is possible to understand how South Africans might just make the simple link between freedom and more crime and feel that one directly caused the other.

It turned out that Tessa wasn’t the only one who felt this way.  Roy, who drove me back and forth to the hospital and clinics everyday, felt similarly.  “Now you get blacks marrying Indians, and coloreds marrying whites, and that’s not the way it’s supposed to be,” he told me.  Roy had a cadre of advice that always centered on race, such the warning that black men, because they were free, might think that they could approach me on the street and “be fresh”.  He actually prided himself on being able to tell people’s countries of origins, a system he developed based on stereotypes that allowed him to further segregate, pushing immigrants from Zimbabwe and Malawi to the very bottom of the social ladder.  As the weeks went by, I came to dread these car rides and the inevitable tide of stories and warnings about people identified only by their race. 

When I met some friendly young Zulu guys working at Moses Mabhida that were interested in discussing politics, I asked them about the apartheid-wasn’t-all-bad-statement. They laughed.  “Who told you that? Some whites? It was bad, man, it was bad.”  It was clear they didn’t share Tessa’s and Roy’s sentiments, but it was also clear that they still found race to be a dividing factor.  I asked the guys about President Zuma, who Tess and Roy had told me was corrupt.  “They don’t like him ‘cause he’s Zulu,” they told me. “Our last two presidents were Xhosa.  But everyone hates the Zulus.”  When I changed the subject to sports, they chattered happily about AmaZulu, Durban’s soccer team, but in reference to the Shark’s, Durban’s rubgy team, they told me “Rugby is mostly for whites.”

Leaving the stadium, I was approached by a haggard young white man who offered me a cross made of palm and asked for a donation to help keep him off the streets.  I obliged and told him the cross was beautiful, a compliment he evidently took as an invitation to friendship.  As he walked with me along the path, he shared a bit of his story, explaining that he was trying to make money to take care of himself and his girlfriend while saving up bus fare to go home, but times were tough.  “You know,” he said, “there aren’t a lot of jobs.  And ever since freedom came here, blacks are taking jobs, and there aren’t enough for the white people.” I simmered, knowing the unemployment rate of black Africans in South Africa was multiple times higher than that of whites, but said nothing² as my companion continued chatting.  “Some people say there might be a war here, and the blacks would win because they outnumber us.  But you know what? I know we’d win, because we’ve got brains.  They can’t beat that.”

It was not these abhorrent outright statements, however, that bothered me the most. I found myself collectively more flabbergasted by the subtle racist undertones of everyday conversation, and the constant references to color, made by almost everyone I met. “Oh, you’re at King Edward? Lots of blacks there.” In four months, I saw one interracial couple.  They sat on the same side of the table at a rotating restaurant, and it could have been my imagination, but the Indian wait staff seemed somewhat less friendly towards them than they did towards me.   As I traveled through the areas around Durban, I came to realize that each was closely associated with race – Chatsworth was full of Hindu temples and people of Indian descent.  Umhlanga Ridge, the high-class beach town that boasted Land Rover and BMW dealerships, was almost entirely white.  The townships were still reserved almost exclusively for blacks, and a large population of colored people lived in Bluff.  Anywhere I went, the crowd around me was invariably monochrome.

Nelson Mandela called South Africa “the rainbow nation” and unfortunately he couldn’t have picked a more accurate metaphor.  Like a rainbow, the people of South Africa segregate by color, aligning themselves in proximity to each other, but with little to no mixing of races. I imagine Mandela’s vision for South Africa was not this rigid rainbow, but more of a mosaic, a mixing and blending of races to create a stronger nation.  I can’t pretend that my own surroundings and social circles always resemble such a mosaic.  After all, my undergraduate college was largely white, as is the neighborhood I grew up in.  But never before have I found myself in such a stringently divided environment, surrounded by people so pre-occupied with race.  When I went to an area dominated by whites, people gave me little notice.  When I went to an area dominated by Africans, however, I got stares and some even stopped me, wanting to take my picture on their cell phones.

The memory of apartheid is still very fresh in the minds of many South Africans, and I’ve reminded myself of the long transformation the US has taken, from abolition to civil rights to affirmative action, and still we struggle with equality.  And there are, of course, exceptions to the divisions I witnessed in the hospital.  At Nelson Mandela School of Medicine, linked to King Edward Hospital, I saw white students from Germany studying with Zulus and Indians alike, seemingly united in the quest of intellectualism.  Hopefully it will be this youthful generation who begins to break the rainbow, working toward a mosaic nation.

 

1. As a fun aside – A book I read about HIV in South Africa explained the development of the colored race like this; “In the early 1600s white settlers joined the black Africans, and a generation later there were colored people.”

 

2. I don’t usually condone this, and believe it’s good to speak up when you can.  However, I was a woman, alone by myself, being followed by this somewhat desperate man.  For the sake of safety, I kept my mouth shut until I could excuse myself and head into a shop.

Surgery at King Edward

This week I have been in the surgical ward at King Edward.  Monday, I watched surgery.  In the morning I dug through an unorganized pile to find tattered scrubs that sort of fit, I observed the removal of a large tumor from the back of a 65-yr-old man, and an attempt to remove the point of a knife that had gotten stuck in the back of a 24-yr-old male who’d been stabbed.  Despite the surgeon’s efforts, using an x-ray machine in the theater, the knife blade was too deep and they could not remove it.  The most frequent surgery of the day, however, was debridement.  Damaged and dying tissue in patients’ arms, legs, and hands was cut off and removed, the wound left open to drain.

The surgical wards are large open rooms, filled with beds.  Though the nurses can be seen mopping regularly, the oldness makes them seem perpetually dirty.  The first day in S-block, as it’s called, I saw a sign warning about a rat problem, and by the second day I’d seen one myself, scurrying around the patient’s bathroom area.  Some of the surgical wards are so crowded that the patient’s beds are less than an arm length’s apart, and when we did rounds, the entire team does not fit around a single bed.  Though there are curtains on tracks around patient beds, they are rarely pulled closed, even when we examine patients and discuss what might be termed “confidential” information.

“We have a good system,” the surgeon told me. “If you need surgery, you get surgery, even if you can’t pay for it.  The problem is we don’t have enough people, and we don’t have enough of the right people.”  He was referring to the twofold problem of South African healthcare.  There is a severe doctor shortage, and many hospitals and clinics are managed very poorly.  As he explained, “Managers don’t have the same priorities as doctors.”

Other problems became clear during ward rounds.  When the doc asked an intern whether the psychiatric consult had been called for a man who had attempted suicide, the intern explained that the psychiatrist wanted the doctors to rule out any medical causes first.  I balked – I couldn’t think of any more obvious need for a psychiatric evaluation than a patient who’d attempted suicide.  “Everybody wants to avoid doing work,” the doctor said.  “You don’t see that in the private hospitals, because they can just come and bill for what they do.”  His sentiments mirrored things I’d been told before and that, while trying to holdback judgment I’d noticed myself, about the lack of work ethic in South Africa and a tendency toward laziness.  During the four days I was on S-block, the psychiatrist did not come.

Like pediatrics, there were some cases that presented differences in treatment from the U.S. and other industrialized healthcare systems.  Most often these differences were surgeries deemed too risky and patients left for palliative care, such as those with pancreatic cancer.  When it spreads to the portal vein, this is still considered operable in the US.  In South Africa, this short distance spread is considered too far, and the patient deemed inoperable.

A large part of why so many patients are resigned to palliative care, I learned, is that they wait so long to come to the doctor.  During my team’s shift at the surgical clinic, I sat with the registrar.  In just under 5 hours, we saw some 100+ patients.  While some were standard follow-ups and other were actually in the wrong place, many had waited so long to come to the doctor that their problems had gotten extremely severe.  One woman complained of a blocked vessel in her leg – when the doctor examined her, it was clear that something more than a blocked vessel was causing her pain.  One leg was swollen to three times the size of the other, and the color was distorted.  She was admitted right away and sent upstairs to the ward.

Patients wait to see the doctor for several reasons.  Some prefer traditional healers and only resort to physicians when their situation becomes dire.  Others are afraid of missing work and receiving a consequently smaller paycheck, and some are worried about the nominal fees (which are generally waived if patients can’t pay).  But another reason became clear when I accompanied the doctor to do a colonoscopy.  “Is this just a routine screening?” I asked.  He laughed. “We don’t do routine screenings.  We think he has cancer.”  I was shocked, and I spent a good deal of time discussing this lack of screenings with the doc.  Though South Africa is stable, with a relatively effective healthcare system, pap smears, mammograms, and colonoscopies – prescribed at measured intervals in the US – are primarily diagnostic in South Africa, utilized only when it’s believed there is a problem.

Though I gained invaluable insight into the reality of the public hospitals this week, I faced a personal struggle as I found myself, most days, to be rather useless.  Without a medical degree (or even any medical training), I couldn’t assist with these riskier patients.  A small highlight came when, during grand rounds, I answered one of the doctor’s questions posed to his interns and medical students, suggested that a patient who had slit his neck may have memory loss due to a head injury or substance abuse withdrawal – and turned out to be correct.  But for the most part, I resigned myself to listening and watching.  In a small attempt to be purposeful, I made it my mission to smile at every patient during rounds each day (something none of the doctors or other student did – many of them did not even greet or make eye contact with the patients).  This elicited some smiles in return, although I also got some unwanted advances and leers from the younger patients, and some glares from the angrier ones.  The best moment came on Thursday.  The man who’d been in for a colonoscopy was small, elderly, and rather confused.  During rounds, he’d often follow us around the ward, hanging on other patients’ beds.  After his colonoscopy, I tried to talk to him, but he seemed to hardly understand.  On Thursday, however, the doctor told him he was discharged, and could go home (cancer-free, at that).  When I gave him a smile as the team moved away, he grinned and gave me two thumbs up. I grinned back.

What the Developing Do Differently

At King Edward Hospital, I was invited to sit in on the weekly mortality meeting, where the doctors and interns discuss the deaths that occurred over the past week and how they might have been prevented.  There were three cases – one a child with down syndrome and a heart defect, another with TB meningitis, and a third with heart failure who was waiting for a transplant.  The docs discussed what could have been done differently, but the general consensus on each was that what was most needed in each case was palliative care.

It seemed like a fairly standard meeting of case discussions, and most of the interns looked bored as they tried not to be called upon, but I was unprepared for the last question, posed by the head of pediatrics; “What might have been different if we were in a developed country?”  The interns all spoke up then.  The baby with down syndrome, thanks to genetic counseling, would most likely not have been born, and if so, would have had a heart operation soon after birth.  The TB meningitis case simply wouldn’t have occurred.  On the off chance it did, docs in a developed country might not recognize it, but would probably still give an effective course of treatment.  And the child with heart failure would have been given a transplant at least a year before.

This last question stuck with me, and so I brought it up later to the department director, a senior doctor at the hospital.  By superficial measures, the pediatric ward at King Edward seems to offer a high standard of care.  The outpatient and resuscitation/intensive care pediatric units are bright, airy and clean, newly built by a large corporate donor. Although some docs made comments about the corporation’s desire to be seen doing good rather than offering help where it might be most needed, it is pleasant to see this part of the hospital in such good shape.  Despite some obvious differences, like the metal-contraption beds and cribs that I’m certain have been outlawed in the US and very few toys or murals, pediatrics at King Edward doesn’t look all that different from a pediatric department in the US.  What I discussed with the doctor, however, tells a different story.

All three cases show an interplay of cultural barriers, lack of education, and system incompetence.  In the case of the child with down syndrome and a heart defect, for example, it’s possible that the religious beliefs against abortion of the nurse who performed prenatal testing prevented her from telling the parents about the defects.  When the child was born in a small district hospital without the supervision of a doctor, the midwife might not have picked up the signs of heart defect.  By the time the infant was experiencing problems and was referred to King Edward, the heart had become enlarged (as muscle grew in an attempt to compensate for the defect), and there was severe cardiac distress.  The child had been on what is called the “roll-over” list for surgery, meaning almost any other patient could take priority and bump him off the schedule.  With only one cardiothoracic surgeon in the region, and given the child’s low predicted quality of life and unstable social situation, he passed away before he could be given a coveted spot in the schedule.

TB meningitis is a form of TB that only presents itself in immunocompromised children, such as the second patient, who was HIV positive.  A child gets HIV from his/her mother during birth, either because the mother is unaware of her status, or unaware of the available treatments, or unaware of the importance of preventing mother to child transmission.  In any case, after being born with HIV, the child was then susceptible to becoming infected with TB, passed on from relatives who were either careless or unaware of their own infection.  In the final case of the patient who needed a heart transplant, the doc described the lack of infrastructure around organ transplantation, complicated further by an unwillingness among many South Africans to donate, whether it be due to cultural beliefs or lack of education.  In these series of circumstances, it’s easy to see how the docs were left to offer only palliative care, and how a hospital department that might look a lot like one in the US is debilitated by its setting and support.

Weekend Update: Drakensberg, the Sani-Pass, and Lesotho

This past weekend I rented a car and set out on a four-hour trek to “the berg,” determined to see the Sani-Pass and make it into Lesotho.  After a long drive up, passing innumerable hills and valleys, a smattering of villages, and herds of wondering cows and goats, I finally made it to the foothills of the Drakensberg Mountains and settled in at the Sani-Pass Backpacker’s Lodge.

People in Durban had warned me it would be cold, and I thought they had been mistaken until the sun began to set and the cold sank down from the hills.  I quickly made friends around the lodge’s common room fire with two smiling Germans who were camping on the grounds, and who were eager to pass the time practicing their English before they bundled up to go to bed.  As it turned out, they were heading on the same tour from the lodge the next morning, as was almost everyone staying there.  Eleven of us in all, we divided up into two 4×4’s the next morning and headed towards the Sani-Pass.

The Sani Pass, winding up the mountain into Lesotho

We had only barely made it past the South African border when the light blue Condor I was in broke an axel, and our driver declared that “Something is simply not right.”  He waved down the other 4×4, a sturdier Land Rover, whose driver confirmed the problem.  I felt a sinking disappointment, thinking we’d be left to hike back down to the lodge and abandon our trip to Lesotho, until the drivers proposed a uniquely African solution – we’d all just get in the remaining functioning 4×4.

Squeezed in to the middle row, I felt much like the young construction workers that pack into the back of pickup trucks and are a frequent site in Durban.  It took nearly two hours to complete the trek up the Sani-Pass into Lesotho, over a dirt road strewn with rocks that offers some 50-odd hairpin curves.  When we finally made it, we passed round shepherd’s huts made of dry rock, mostly abandoned for the winter as the shepherds sought warmer weather in the lowlands.  To my chagrin, we didn’t stop, but drove another hour in our sardine-like conditions to the top of a mountain, where we had a picnic lunch in near-freezing winds and snow.  Lesotho is called “The Kingdom in the Sky” because it is the country with the highest elevation, and the highest lowest point (figure that one out, eh?).  As I huffed and puffed in the decreased atmosphere during a short hike to the peak, I understood the meaning of its motto. The highlight of the stop, aside from the view of mountain peaks as far as the eye can see, was undoubtedly the shepherds we met on the mountain.  Our driver and guide explained that it’s customary to send teenage boys up to the mountains to live on their own, herding sheep, for three or four or sometimes many more years.  They wrap themselves in traditional Basotho blankets to keep warm, but they didn’t seem to truly be doing the trick.

Basotho Shepherd

On our way back down, we stopped at a small village of five or six rondavel huts, where a Basotho woman showed us her crafts and offered delicious hearth-made bread and slightly less delicious homemade beer.  We spoke with her for awhile, listened to an eclectic band of shepherd-musicians, and headed back down the Sani-Pass.  Of course, not leaving Lesotho until after a pit stop at the highest pub in Africa, where we tried Maluti, the beer made and only available in Lesotho.

Shepherd’s Village

While I laughed and joked with my fellow travelers on the way back to the lodge and around the fire again that night, I couldn’t help thinking about the poverty of Lesotho, quite different from the urban poor I’ve witnessed in Durban.  The people we met on the mountaintop in Lesotho have essentially no money at all.  They live off the land, eating wild cabbage and their livestock, trading wool for milk and other necessities, making homes from rocks and trees and grass.  The sheep they herd are highly prized for their high-quality wool, but our guide explained that money means very little to the Basotho people – what they earn, they spend, and the little they save is spent on educating children during the early years of their life.  They deal instead in sparse cattle and herds of sheep, which they view, I suppose, as their currency.  In the mountains where we were and where the small shepherding villages lie, there is no electricity, no running water, no phone lines.  The landscapes are largely unspoiled, and at night it must be darker than any other place.

The next morning I made the drive back down from the berg, passing all the now-familiar sites in a journey that was no doubt easier on my rented engine.  I stopped at a waterfall and a lion park, and ended up at Moses Mabhida Stadium, built specifically for the 2010 World Cup.  It seems to be one of the few places in South Africa that was built with a very intentional plan – knowing that such stadiums often deteriorate as city fund sinkholes, there are a number of attractions that offer the opportunity to take advantage of the stadium’s structure.  I opted for the 500-step climb up the Y-shaped arch.  When I made it to the top, all of Durban and the surrounding townships sprawled below.  Although the city view made a stark contrast to the mountains I’d looked out over just 24 hours before, it would seem I spent the weekend in the sky.

At the top of Moses Mabhida Stadium