November 14, 2004

The long delay in writing is due in part to the excitement building up to and the depression following the US presidential election.  But I won’t further cheapen this already low budget journal with my personal politics.

Summer’s approaching, sun is coming up before 6, heat is lingering longer in the evening.  I’m now appreciating the eastward exposure of this house.  The pool is warm enough to enjoy it anytime.

Just like resettling anywhere, but particularly in a foreign county, finding stuff is hard.  Finding used stuff is unexpectedly hard.  Where are all the garage sales here?   Furnishing a house with the idea of selling the stuff at the end is hard.  On the other side, I like a relatively empty house without someone else’s furnishings to worry about.

Groceries here are easy to find.  Woolworths (“Woolies”) paradoxically is the upscale grocery chain here.  They also serve as sort of The Bon Marche for clothing and household stuff.  Organic fruits and vegetables are available, as are good meats, cheese and bread.  The cost of food overall is less than at home, though not hugely less.  The Safeway of South Africa is Pick and Pay, an organization that has pushed the shopping center concept here, referred to by most as “Pick and Pay Centers”.  There are also things called “Pick and Pay Hypercenters” and I think you get the idea of these monstrosities:  groceries and hardware and whatever else, similar to K-mart or Fred Meyer.

Glitzy malls are located in the more affluent areas, the larger being Cavendish Square and Canal Walk, places that have the homogenous wares you would find at a US mall.  I do my best to avoid all of them.  There is no Gap or Banana Republic or Crate and Barrel, but the stuff is basically the same.  Kids hang out to see movies and to be seen, but the demographic is different than the city as a whole.  You don’t see lots of Black South Africans from the townships, though you see lots of white and colored people.  “Colored”, by the way, is not the derogatory term it is in the US.  This refers to people of mixed race, without obvious Black African features, including facial and hair.  Colored people here speak mainly Afrikaans.

People in the townships and people with lower income shop for their groceries at another set of stores.  Shoprite and Checkers are generally cheaper and offer much less, especially less “healthy” foods.  Muslim people buy meat from Halaal butchers.  Many take advantage of fruit and vegetable warehouse centers.

Like Seattle, there is a coffee culture in Cape Town, much to my unexpected pleasure.  You don’t find Starbucks here—yet.  You do find some fashionable cafes with beautiful views and beautiful people.  Our closest shopping center even has a café called “Seattle Coffee Company”, with explanations of how “coffee” is spoken in Seattle.  How disorienting to order a tall nonfat latte to go and have a Black South African with a slight Xhosa accent translate that to a “tall skinny latte with wings”.  So far, without exception, every steamed milk-containing coffee I’ve ordered has been scorching, I’m-gonna-sue-ya-if-I-spill-this, hot.  I think when the baristas read the manual, the steamed milk temperature wasn’t converted from Fahrenheit to centigrade. 

Meat is big here.  South Africans have taken the backyard barbeque, known here as “braai” (pr. “bry”), to amazing heights.   More than anything, a braai is a good excuse to have a meal with friends and assure that it stays casual and impromptu.  Gas grilling is not a real braai.  Here a braai is preferably fueled by wood, though charcoal is acceptable.  It takes a while to get it going, allowing time to sip a beer or glass of wine and socialize.  One doesn’t simply grill one type of meat either.  Lamb, chicken, and a sausage known as boerwors are typically grilled all together.  Many marinate the meat beforehand.  I’ve not been around a vegetarian at a braai.  The other night we brought salmon to a braai and may have offended the cultural norm.

Wine is a major commodity in the Cape region.  I’ve never been a wine connoisseur, simply a consumer.  Wine is cheap and really good, though I suspect is not part of township culture.  Constantia, our ‘burb of residence, is still dotted with vineyards.

Quite surprisingly (or not, given the above discussion of food), the prevalence of obesity in this country, where 10% or so of the population are HIV+ and many more live below what we in the US would consider the poverty line, is close to that of the US.  Clearly we need to broaden our concept of “malnutrition”.

November 23, 2004

Two Saturdays ago, we went with Sipho’s father (whose name is  Boy) on a tour of several townships in the Cape Flats.  Boy is a Scorpion, a member of a special SA police force, and is a registered tour guide.  We passed through Langa, Nyanga, Crossroads, Phillipi, Gugulethu, and Khayelitsha and first-hand witnessed the abject poverty that we all know exists here.  It was important for all of us to see this up close, particularly my children.  Many visitor to Cape Town will overlook these areas on the way to town from the airport and leave with the impression that most people drive Beamers, eat well, and live the high life.  Many of the people employed as gardeners and housecleaners (here called domestics) live in these areas.  The townships, viewed by most Whites as dangerous, have an amazing feeling of community, at least on the Saturday that we were there.  We watched many more people walking and interacting than you see in the City Bowl or the ‘burbs.  Boy assured us, though, that even he would be in danger in some township areas.  People would know that he wasn’t from there simply by the way he walked.  One of the registrars in dermatology moonlights in Khayelitsha Hospital and comes back with harrowing stories that put most US cities’ “Knife and Gun Club” scenes to shame.  He says the surgical trainees come there for their trauma experience, and don’t care to come back for a second shift.

Boy gave us a great overview of the townships, with brushstrokes of history of the townships.  From a distance, we could see young teenage boys going through their coming of age ritual that still get carries out, even in urban areas.  Here, the boys spend a month mostly alone.  The month begins with circumcision, routinely being done without clean instruments and with no idea who is HIV+ and who is not.  In more rural areas, the ritual has a bit more meaning, as the boy who becomes man after the ritual takes on real responsibility in terms of running the household.  I saw some of the huts that these boys are isolated in while driving to Umtata in the Eastern Cape.  In the city, the ritual has less clear meaning as family units are fractured due to poverty and crime, and death from HIV and homocide.

Boy took us to a friend’s house in one of the townships so we would have a chance to see a house from the inside.  Boy’s friend and family seemed to have all their needs covered and seemed happy.  Most houses in the Cape Flat townships are built with scrap wood walls and corrugated metal roofs, without insulation, often without inside plumbing.  Electricity is often pirated from nearby power lines.  Though poor, the family’s activities on a Saturday are not too different than mine—hanging out with kids, visiting with neighbors, watching the local sports team on the tube. 

The tour ended with a stop in Khayelitsha at Vicky’s B & B and the Waterfront pub.  A township seems an unlikely place to host overnight tourists, but Vicky has successfully made a stay at her place into a positive force for both visitors and the neighborhood in Khayelitsha.  As this was Saturday afternoon, the nearby Waterfront pub (not anywhere near a waterfront, of course) was thumping.  Very friendly and very drunk locals greeted us.  (See photo of Jimmy with the guys).  They kept asking me “Who are you for?” and since this was after the election, I didn’t think they were referring to Bush and Kerry.  When I got this question clear, they meant what football (soccer) team did I support.  I was clueless, not being in the swing of local sports yet.  They had a huge drunk laugh on me.

That evening we had Boy, his wife Gertrude, Sipho and his two sisters Thania and Evelyn for dinner.  Gertrude, a bright, articulate woman who has worked for NGO’s here that have worked with HIV+ and other disadvantaged women, has written a manuscript that she aims to publish.  I bet that every Black South African (and many South Africans in general) has a compelling to tale to tell.  Most have witnessed the end of apartheid and the start of a modern democracy that, though still wobbling a bit, appears to be getting its footing on solid ground.  I have been told by more than one person that the flight of professionals out of the country before and shortly after 1994, the year of the first post-apartheid democratic election, is beginning to reverse.  Relative stability, a growing economy and the beauty of this place are making it hard to stay away.

November 30, 2004

We spent Thanksgiving at an Indian restaurant (Bukara) in downtown CT.  Not being a holiday here, there isn’t this starting gun feeling to the Christmas shopping race.  In fact, Christmas, and the wintry feeling (and depression) that usually accompanies it, seems unnecessary when the temperature here is 75-80 F and the days are still lengthening.  We’re planning on keeping the holiday small and doing some traveling.

The kids had Thanksgiving Friday off, so we had a three day weekend and took off to Beaverlac, a rustic accommodation in the mountains near the Groot-Winterhoek Wilderness area, approximately 2-3 hours north from here.  This was our first trip with Mali, who is out of her stumbling puppyhood and now into the leggy, preadolescent, very energetic phase.  So far the havoc she wreaks has been limited, and I think she will be trainable.  She goes running with us quite ably.

Beaverlac was magical!  Pleasantly hot, set in a rocky, low bush area with a cool river running through the area.  The Ratel River forms wonderful pools along its course that you can cool off in after a hot hike.  The water is purer than bottled water, according to the folks who run the joint, and so far, no ill effects.  Clara and Jimmy have made a big jump in endurance, especially Jimmy.  He and I continued up river during our first hike at Beaverlac to find a geocache near a place called Totem Pool (see link; if you’ve never heard of geocaching, be careful.  It could change you.).  We scrambled up some fairly tricky rocks, and at some points I was holding on to Jim to prevent a nasty fall.  He took it on and didn’t really care that we couldn’t find the cache.  On our way back, we found the “Bum Slide”, a naturally slippery slide where the stream flows over flat rocks and only works when sliding on bare bums.  This was one challenge that Jimmy wasn’t up for.  Our “chalet” was a perfectly adequate, cheaply constructed, two-room hut that had all the amenities we needed.  Our evening was spent braai-ing and eating meat with our hands.  Most of the others who stayed at Beaverlac were Afrikaans-speaking, and this, with the dry ruggedness of the landscape, had me confused that I was somewhere in a Dutch or German-speaking Australia.  The only bad part about our trip to Beaverlac was that we had to return and that we forgot to bring the camera.  Sorry, no photos.  We did nap a geocache at Dasklip Pass, the site of hang gliding launch.  The road up to the pass is STEEP, and once you’re up there, you feel like you are the edge of the planet.  No gliders on the day we went.

December 1, 2004  (World AIDS Day)

Life, including working life, on sabbatical is most pleasant.  When else does one have time to focus on only a half-full plate?  I love having the time and mental space to think about what I’m doing. 

I have three telederm sites up and going, and I will travel to Pietersburg/Polokwane in Limpopo Province next week to set up the fourth.  George has been the most active site and the docs there have sent some challenging cases.  I think the opinions we render are helpful.  My time spent at Groote Schuur has given me some experience with what is seen here and what treatments are available.  Needless to say, newer, expensive drugs, such as biologic agents, are not an option.  The antibiotic repertoire is limited, though for the most part sufficient.  Many of the adults in the hospital are on medications for TB or have completed treatment for past TB.  HIV is very prevalent in the hospitalized population since most who are HIV+ are not on antiretrovirals.  At the bedside, HIV is referred to as RVD, to somewhat protect the privacy of the patient in an open ward situation and also to cloak a discussion among the doctors about the impact or possibility of HIV infection if someone’s status is unknown.  Many patients do not want to know.  I don’t think this is usually borne out of denial.  Practicalities rule here:  many will lose social support or employment if it becomes known they are HIV+.  Spouses leave, even though the spouse may have been the source of infection.  Domestic workers get fired over this.  This may not be as callous as it sounds.  A baby hospitalized at GSH, without any evidence of sexual abuse, was found to be HIV+, even though her parents were seronegative.  It turned out her nannie was unknowingly HIV+ and had been nursing the child without the parents' knowledge.  Tragedy abounds.  I went with the registrars to Somerset Hospital, a secondary community hospital on Cape Town’s waterfront, to see two babies with skin conditions.  In presenting the history, the pediatric registrar doesn’t mention that the babies are HIV+:  it is a given on this ward.  Also, severe malnutrition is common enough that kwashiorkor (severe protein malnutrition) is shortened to “kwash” in the registrar’s presentation.  Often these babies are orphans as well.

But some people with HIV are getting treated here.  The antiretroviral (ARV) “roll out” that began within the past year in South Africa is not moving as quickly or efficiently as originally planned.  This is not due to a lack of funds, but to a lack of administrative infrastructure and manpower to physically dispense and follow up these patients.  Treatment of TB, in contrast to HIV, generally feasible since the treatment is for a proscribed time course.  The challenge for HIV treatment is dealing with the chronic treatment needed and the ease with which drug resistance can occur if one isn’t very compliant with taking the ARVs.  This is going to be a huge challenge for South Africa, to say nothing about many other resource- and administratively-poorer nations.