Feeling Safe in the Middle East

School holidays are a traveler's nightmare in South Africa:  everything is booked up months, if not a full year, in advance, and neighboring African countries are not immune to the frenzy.  For Brandon's Easter vacation, we came up with a neat, heretical solution-- travel to a predominately Muslim country.  After exploring  options to Morocco, Thailand and other countries in Africa we decided on Jordan. The fact that my good friend Yvonne’s daughter, Stesha, is working in Jordan as a Peace Corp volunteer clinched the decision.

We had a great time spending our first full day and second night in the desert at Wadi Rum (where Lawrence of Arabia was filmed) and were happy to have Stesha join us.  Our Bedouin host, recommended to Stesha by other Peace Corp workers, was very welcoming, and clearly an enterprising man, as he managed several different groups of visitors all with different time frames.  He was quite surprised by my iPhone: what was I doing, he wanted to know, with an outdated 3G?  He was very happy with his iPhone 4 and urged me to upgrade!

We rode a canopied truck out into the desert with an Australian couple, currently living in Dubai, and made several stops for sightseeing and hiking.

After a long, eventful day we arrived in our camp for the night.  The complex was quite impressive, given the remote location, with electricity from a generator, and a bathroom featuring a shower and flush toilets (not always a given in Jordan).  There were a dozen other people staying with us, and we all enjoyed the evening meal of grilled meat, vegetables, and delicious salads.
To top it off, the night we stayed there was a full moon illuminating the desert in a soft, silvery light.



The next morning we rode back to town, caravan-style.  It was great fun, except for the fact that the saddle on my camel was incorrectly positioned.  In protest, the camel unexpectedly sat down in the middle of our journey, unceremoniously dumping me in the sand (which, fortunately, was extremely soft).  The camel ride was definitely a highlight.

We followed up our time in Wadi Rum with an all-day excursion to Petra.  We were amazed by its size and beauty.  I could have easily spent another couple of days exploring the place.  Mike and I walked up several hundred stone-steps to view the impressive monastery, while Brandon not-surprisingly opted for donkey transport.  At a cafe opposite the monastery, we conversed with another American family, currently living in Moscow -- turns out the husband recently was appointed as U.S.  ambassador to Russia.

After one last night with Stesha we headed north to Jerash.  The city features some of the Middle East's best preserved Roman ruins.  Brandon was very excited to see structures he studied in history class at St. Bens, including the Hippodrome and the temple of Artemis and Zeus.

Umm Qais, in the far North, was our next destination.  It, too, has Roman ruins, though not as spectacular as those in Jeresh.  We had a memorable meal at a nice restaurant amidst the ruins, overlooking the Golan Heights and the Sea of Galilee -- very beautiful.  It was hard to fathom all the ongoing unrest and violence in Syria, a few minutes away, so tranquil was the setting.


Our time in the capital, Amman, was very limited, but again I was struck by how safe I felt to walk around the city, day or night.  Unfortunately we did not budget enough time for getting lost on the way to the airport and ended up missing our flight, though we were able fly out that evening.  As a result our time in Dubai was limited to getting to the hotel and passing out.  Will have to explore next time.


Overall our eight days in the Hashemite Kingdom were marked by wonderful adventure and crazy driving -- in a setting and society dramatically different from what we have become accustomed to in South Africa.  It was great to travel with Stesha for the first couple of days and receive a rudimentary education in Jordanian history and culture.  For me, the most striking contrast was how safe it felt, particularly for women.  While men both in Jordan and South Africa are allowed to have multiple wives, and the de facto status of women is subjugated to that of men in both societies, violence towards women and children is an entirely different matter.  In Jordan, as Stesha explained to us, women are expected to maintain their family's honor in their dress, decorum, and interactions with men.  Violence is uncommon except in the rare case of infidelity (I'm not saying infidelity is rare, but honor killings are).  I was pleasantly surprised to see that most men where likewise conservative in their dress code and behavior.

What struck me, as we walked around the cities of Aqaba and Amman at night, was how safe we all felt.  Shops were open late, people were milling in the street conversing, and everyone we encountered was extremely helpful and gracious.  I had become accustomed to South African life, where everyone retires early behind locked gates with high tech security systems.  I realized how much I miss the freedom of being out at night.  That, in itself, is reason enough to return home and not continue working and living in South Africa indefinitely despite the great beauty of the place and the amazing work experience.

Compare and Contrast

Since the last posting, many frequent flier miles have been accrued, ceasars  performed, and households swapped.  After a stint in Seattle (extended for Mike, abbreviated for Brandon), Mike and Brandon returned to South Africa in early January to a new home in Mtunizini and a new routine.  Comparing our current housing to our previous hospital provided lodgings in Eshowe is not really fair or productive, considering that even in its dilapidated state, our previous house was far superior to that of the typical resident of KZN.  Suffice it to say that our new home is very comfortable, with amenities we take for granted but sorely lacked in Eshowe, including functioning wifi we installed, which is a luxury here.  Additionally, the estate we are living on is very beautiful, with great hiking/biking trails along the Zini river, a resident herd of zebras, interesting birds, and a nice swimming pool to cool off in during the heat of the afternoon.

The town of Mtinzini is very sleepy, with a small super-market, 4 or 5 restaurants, a couple of primary schools, a small library and post office, and the obligatory correctional faciltiy.  From our house it is about a two minute drive to a park that encompasses the Zini River estuary,  a great beach  (with hellacious undertow), and some nice hiking and biking trails through forest.  It is definitley much hotter and more humid here than Eshowe, but fortunately we have a great breeze most of the time, and the house does have aircon and ceiling fans which help make it comfortable.

Monkeys seem to be every where in this town in the early morning and late afternoon.

Our friends Connie & Charlie at Mtunzini Beach

The picture below is from the local dive bar/back packers hostel featuring 'tame' zebras.  Shortly after this photo was taken, the zebra turned and kicked Mike in the ass (literally) with both its rear legs.  And soon after that the bar's resident snake handler displayed a few of the extremely poisonous local snakes he had captured for our enterainment.  The large forest cobra was very unwieldly and nearly bit his captor a couple of times, temporarily escaping his control after one such attempt.  All very amusing.....

Brandon has just completed his first month of High School (grades 8-12 in S.A.) at Felixton College.  The contrast with his previous school in Eshowe is striking:  at Felixton, the kids wear real uniforms, instead of the gas attendant like jump suits required by the Convent school, the class rooms are air conditioned, the facilities far superior (including a very nice computer lab, sport fields, etc), the academics, it seems,  more challenging, and the overt Chrisitan trappings far more muted.  So far, Brandon seems to be enjoying Felixton, and making friends among his classmates, though it is still 'early days', so time will tell if this sentiment persists.

Mike may help out occassinally at Felixton with IT system admin stuff,  in addition to consulting on some data admin work at Eshowe HS and teaching a computer class for 3rd graders at a primary school in Eshowe.  In rural South Africa, IT, much like medicine, is the domain of the generalist, rather than the specialist.  All aspects of technology -- from fixing desktops, managing users, deploying servers, maintianing networks, digging trenches and laying cable, supporting applications, managing licenses, and even development -- typically default to a single, harried individual who often has to perform another function, such as teaching a class.  Breadth, rather than depth of experience, is what counts most.  Compare this to a large organization in the U.S., where several people may be dedicated full time to managing a single application.

However, it is in the area of basic educational attainment that the contrast between here and home is most salient and disheartening.  It didn't dawn on me until recently when I was filling out the death certificate of a young woman, and I had to circle none for education, not even first grade.  The patient worked as someone's housekeeper her entire, abbreviated life. Her sister, the next of kin, unable to sign her name,  left a thumbprint instead.  Later,  I asked my student nurse to translate a conversation explaining to a patient about her "uterus" but I first had to explain to her what a uterus was. The secretary in the human resources office types slowly with one finger. And the pass rate for high school is 30% for an individual subject, 40% cumulative. I just realized how non-existent education was for the black South African until the end of apartheid and the large chasm in education that still exists here between black and white citizens. Not just a lack of healthcare workers and resources, but a lack of basic understanding about one's healthcare in general; the basics we take for granted -- Why there is never any soap in the bathroom or facilities to wash one's hands on the wards between seeing patients. Why the same antibiotic that has no benefit continues to be prescribed by nurses and doctors. It seems insurmountable at times.

Connie and Charlie recently left for Seattle, via Berlin, after a very enjoyable stay with us.  Brandon missed several days of school to share their safari adventure at Zulu Nyala Game Lodge (about 2 hours from our house).  It is a very nice, low-key lodge.  New animal sighting highlights include a family of cheetahs, and a tiny chamelon.  Very cool.

We look forward to sharing our house with many more guests while we are here, so keep an eye on flights to Durban and give us a shout if you plan on coming.

The Big Adventure to Kruger and updates

After 3 months of work and school we are taking a week long driving vacation to Kruger National Park. As usual everywhere we go, I fall in love with the location and consider making it my next employment destination.

The part of Kruger where we are headed is about a 10 hour drive from our home in Eshowe. We decided to take the slow scenic route to the park with overnight stops along the way. The first 2 nights we stayed near Piet Retief, a small town surrounded by vast stretches of farm land.  Our accomadation was a very nice working farm/ B&B, Dust to Dawn, that received a great review in a recent edition of the Sunday paper travel section. We saw lots of different farm animals and heard the uniform squeal of 7,500 pigs at 5am calling out for breakfast, but didn't get to see them.  For health reasons the pigs are not allowed visitors. The 5th generation German couple who own the farm are very hospitable. In particular we loved the home made German Bread and delicious home cooked meals as well as the elegantly decorated and comfortable rooms.

On Sunday we took a very long drive into Swaziland looking for a hike which we never found.  Although, we did enjoy driving thru the tiny villages and did take a short meander thru the fields despite the scary looking cows!  Swaziland has a very different feel from South Africa, there is no great disparity in wealth, where we drove it looked like everyone was equally impoverished.  We stopped at the Swaziland Candle and Craft Market to find busloads of Europeans and a few gifts for our friends at home. 

After a full day's drive north, we settled into our penultimate destination at Idle & Wild lodge in Hazeyview.  The climate here is definitely more tropical than what we are accostumed to.  For the first time in several weeks (months?) we enjoyed a day of heat and sunshine.  Fortunately, much of the day was spent on or in water: beginning, first with an early morning raft ride down the scenic Sabie river.  Beware of hippos and crocs!  After the big buildup, we only saw a solitary crocodile resting along the bank.    We then drove 40 Km, past the town of Sabie, for a short walk in the midday heat at Mac Mac pools, as highlighted in the Lonely Planet guide.    During the walk, we spotted some suggestive animal tracks that are presented here for possible identification.  The payoff for enduring such a vicious (albeit brief) walk was a plunge in the Mac Mac pool.  Shockingly not everyone participated, even though Lyn assured us there was no Schistosomiasis/ Bilharazia in the water.

After another long drive thru small towns and down dirt roads we arrived at Elephant Plains, an all inclusive luxurious game lodge overlooking a watering hole in Sabie Sands Private game reserve.   It was amazing and wonderful to be so close to these magnificent animals!  We went on 2  three hour game drives per day, at 5:30 am and 4pm and saw 4 of the big 5, all except the cheetah.  During the day we lounged by the pool watching and hearing animals and birds all around. 

The animals are accustomed to the Safari Jeep and allowed us to approach very near to them, almost within touching distance!  The young elephant in the photo had to come check us out, but backed away after a warning from the mother elephant.  It is rather scary to be in an open vehicle sitting next to a pride of lions.  One could have easily had us for a snack.    

Housing Update
We have moved out of the rundown dilapidated Hospital housing, would not recommend to anyone.  Brandon and I will be staying in the Eshowe Louries B&B run by our recently acquired friend Elsa.  She has several rooms in her house that she rents to short and long term guests.  There are many benifits to staying with Elsa, primarily she will be home at night to look after Brandon when I am on call in the hospital.  All meals and cleaning are included so I will be free in the evening to hang out with Brandon.  He is excited that the other boarder, Carl has a huge flat screen TV and an XBOX 360.   Mike will be home in the states planning our next great adventure in the Fall (or Spring), depending on where you live in the world!

Report From the Wards

It has been a long time since we posted our first blog from South Africa and much has happened since then. 

 First off, internet is very different, not readily available and expensive.  Wi - fi and Broadband are extremely limited/ unavailable even in bigger cities.   Internet access is obtained by connecting our laptop via a USB modem purchased from the cell phone company.  We buy a set amount of GB and when it runs out we no longer have internet access.  The first modem we purchased was a 75 MB and it ran out in about 45 minutes.  We have since purchased a 2GB modem and have avoided sites that use a lot of band width such as travel sights and face book.   My most prized possession is my iPhone.

 Hospital Stuff

As you know when I first arrived in South Africa I did a crash course in Obstetrics at a big Maternity Hospital in Empangeni, about 45 minutes North of Eshowe.  I primarily did c- sections and ward rounds as orientation to the hospital system.  I started work at Eshowe Hospital in July and worked less than 2 week before I was informed that my registration was incomplete and I should not work.  Days later the South African Health Counsel (HPCSA) went on strike and I waited for 3 weeks until the strike was over to finalize my paperwork.  By that time my shaky confidence in surgical obstetrics had waned.   I have now been back to work for an eventful 2 weeks and have had no terrible mishaps.  Will need to spend a lot more time working to really feel  comfortable in my “new profession”. 

I am in the Obstetrics and Gynecology department with three other doctors; two are community service doctors who have completed 1 year of internship, the other is a Congolese doctor who is a medical officer which means he’s had no specialty training.  I spend most days in clinic where I see patients for prenatal care and all problems female.  The only medical records are kept by the patients and they are very good about bringing them for their appointments.     We all take turns rounding on the wards (antenatal, postnatal and labor) and being on call for labor ward, emergencies and elective c-sections.

The concept of – See one, Do one, Teach one is definitely in effect here!!  Last week I examined a 40 yo HIV positive woman who presented in labor.  On exam  I found the baby was breech ( the head is up instead of down in the pelvis) and had a cord presentation (the umbilical cord was at the opening of the uterus which can then come out first and the baby will no longer have a blood supply).  I took her to the operating room for a c-section and both mom and baby are well.  Hypertension in pregnancy, pre-eclampsia, and eclampsia are very common in South Africa and often require c-section.  I also do D&C for pregnancy loss.  This week, I had a patient who came in 4 days after delivering a dead baby at home with sepsis and endometritis.  She is also doing well after D&C and antibiotics.

Vaginal deliveries are done by mid-wives; the doctor is only called if there is a problem.   Women are given no pain medications, all first time moms get a lateral episiotomy which is sutured with not very much local anesthetic.  I’ve seen nurses smack patients when they don’t follow instructions and push down on the abdomen if the mom is having a hard time pushing the baby out.   I can’t refrain from telling the nurses to stop!   

Fortunately for me, Eshowe hospital has had NO maternal deaths this year and the c-section rate is hovering around 20%.  GREAT statistics for this country.  The Maternity hospital in Empangeni, which gets all the very high risk patients,  has 2-3 maternal deaths a week, primarily from non pregnancy related medical causes and a c-section rate of about 50-60%.  HIV is the leading cause of death in this country!! 

I think it is odd and certainly not the US model of medicine that patients are cared for by doctors with so little experience in the specialty.  If a patient  doesn’t follow the usual course of a pregnancy or an illness there are few doctors or hospital facilities in this country up for the challenge and the outcome is often bad.  I’ve learned that the model of medicine in South Africa is that all doctors learn the basics of the core specialties – Medicine, Surgery, Obstetrics, Pediatrics and Anesthesia.  They are able to care for the majority of patients that present and some patients (a much higher proportion than in the US) die of preventable illness due to the country wide lack of a higher level of care.  The US has the opposite problem -- many specialists and super specialists and not enough primary care providers.  This is how I get to do Obstetrics without formal specialty training, as a c-section is considered a basic skill that interns master along with pediatrics, spinal and general anesthesia and basic surgery.  After working with an Ob in Seattle, I’ve done more vaginal deliveries and scrubbed into more c-sections than the community service doctor who is doing obstetrics with me.  I on the other hand don’t even have the basics of anesthesia, peds or surgery.   There is much to learn if I am going to fit in with the African model of medicine.   

 

Housing

Short synopsis is our housing situation is not good and we will be much happier when we find another place to live.  Not so easy in a small town with very few rentals and no furnished housing.  Rentals do not even come with a stove or a refrigerator.  We may move to Mtzuni, a small town nearby with more options and a beautiful beach and nature reserve.  It will be a much nice place to host guests. Will keep you posted.

Strikes

I have heard about the strikes in South Africa.  Last year the nursing staff went on strike and there was no one left to take care of the patients in the hospitals or clinics.  The HPCSA went on strike last month delaying my registration.  This past week the municipal workers went on strike, vandalized the water pipes so the town including the hospital had NO hot water and very low cold water pressure, enough to drink but not enough to flush the toilet.  They also dumped garbage all over the main street of the town.  Apparently this is strike season.  It seems fairly usual for the government to offer a 6-8% raise when the workers are asking for 18-20% and havoc ensues until the median is reached.    

Getting Sorted in South Africa

We are still in the process of settling into our new home, our new country, but at least a semblance of routine is in sight.  Brandon began 7^th grade, midstream, this week at the Convent school, and so far loves his new school.  Being a foreigner, he is the center of interest to all his classmates.  Furthermore, there is a heavy emphasis on sports, in which the kids get to run around barefoot, which plays to his interest and makes his parents very happy.

After commencing work immediately upon arrival, Lyn has been on sabbatical from Eshowe Hospital the past ten days until her credentialing status is finalized (the irony is that the bureaucratic screw up occurred on the US side of the transaction).  This should be completed any day, but is now being delayed by a strike in South Africa.   Lyn is VERY eager to work.  And maybe get a paycheck.

This unexpected cessation in work has given us the opportunity to tackle other essential activities (opening a bank account, purchasing a car, securing health insurance) which takes a great deal of time, energy, and patience here --won’t bore you with the details, suffice it to say that we have heard the phrase, “Well this is Africa”, used many times in the past two weeks.  It has also provided an opportunity to explore the region.  Eshowe itself is a fairly small town, though it appears loaded with children, based on the number of schools, and funeral parlors.  The hospital, school and markets are all within walking distance (as is just about everything in town) which makes it a nice change from our life in Seattle, where just about every activity necessitated a drive. 

Fortunately, Eshowe is not very far from more interesting places.  We have already taken three trips to Durban, which is a modern city equipped with all the stores, services and conveniences you would find in any large city in the US or Europe.  It also has a fantastic long stretch of beach with great surfing waves.  Both Brandon and Mike are eager to learn how to surf, while Lyn is more focused on the sharks that reside in the water.   While in Durban, we have made many trips to Gateway mall which is billed as the largest mall in the Southern Hemisphere.    It is staggering in size, shops and the number of people walking about and contains a massive rock climbing wall and wave surfing pool, which is a favorite of Brandon’s. 

We have also made a couple of forays to nearby game parks.  Hluhluwe-Umfolozi is about 90 minutes from our house (if you don’t get lost) and is an amazing place to visit.  On Tuesday, while Brandon was at school, we snuck up for a visit and were rewarded with some amazing sights:   a herd of about 20 elephants crossing the road in front of us and disappearing into the bush; an adult and child rhino eating grass and eyeing us with cautious, timid expressions as if we might charge them (JFC, the adult was HUGE!).  We have also seen giraffe, wildebeests, warthogs, zebras, an assortment of deer and Impalas, and monkeys (mostly in town, as well as in our backyard hanging out in the avocado trees).  No lions or cheetahs as yet.

Why the move

I have had my heart set on working in a developing country since well before medical school.  That dream sat on the back burner for many reasons, until about two years ago when I met a wonderful retired couple at Northwest Hospital who were applying for the Peace Corps.  That encounter rekindled my interest in looking for an opportunity to work in a developing country.   Brandon was in middle school and Mike was unhappy with his job.  It was about time to pursue the direction I had intended for myself.   Serendipitously, a nurse I work with directed  me to PATH, a local nonprofit organization.  PATH works to "create sustainable, culturally relevant solutions, enabling communities worldwide to break longstanding cycles of poor health".  Although they did not have a job for me, they introduced me to Therese Hanson who works with Africa Health Placement.  She has been invaluable in helping me find a job in Eshowe, South Africa.  Great web site if you are interested in learning more - http://www.ahp.org.za/. 

Now the day has come!  I have wrapped up my job, my home and my life in Seattle, and am leaving for South Africa June 14, 2011.  Mike and Brandon will join me July 1st.  (Just in time for our 1 year wedding anniversary July 2nd).