South Africa thoughts

Cape Town:
This has to be among the most beautiful cities in the world – Table Mountain towers over the city, the Atlantic Ocean surrounds it, Cape of Good Hope is just down the road, plus the gorgeous ladies of mixed ethnicities. I visited Robben Island last Friday. It’s the prison island near Cape Town where the Apartheid government kept Nelson Mandela and other political prisoners. My tour guide was one of the prisoners there. A couple of sobering thoughts: Why did so many South Africans (especially the church) keep so quiet for so many years at the incredible injustice that Apartheid represented? Am I guilty of such inaction regarding other things that I know are happening in this world?

Johannesburg:
This is perhaps the most dangerous city in the world. Since the end of Apartheid, violent crimes such as car-jackings, kidnappings, and armed robberies have skyrocketed. Supposedly, most offenders are from the townships, whose inhabitants during Apartheid had limited access to white districts. I wonder how much more violence is necessary before the rich and middle class will finally get around to advocating for changes to the social welfare of the townships. Does this violence indirectly represent a long-suppressed cry for help? Some are saying that they need more policing (to add to the metal bars, barbwire, and guards that make their homes look more like prisons) – though I wonder if the solution instead lies in improvements in education, employment, and social services for the townships. Albeit, I've only been here for 5 days, so take it for what it's worth.

Observations

As I finish my time here in Angola, some interesting observations over the past 5 weeks:

The Fashion: if you just look at the T-shirts worn in this city, you’d think you’re in Canada – lots of T-shirt with emblems of Canadian corporations, a “French Canadian club” shirt, a Calgary Flames shirt, race shirts from every fun run in the country – the reason being that Canadian charities and thrift shops ship their used clothing over here to distribute to local merchants to sell. Most women wear pannus, colorful cloths wrapped around the waist. While men usually wear jeans or pants, in some rural areas you can see men in traditional tribal dresses. Shorts are reserved for the kids, or to go swimming. Dressing nice is very important to most Angolans.

The Weather: due to the altitude of the city, the temperature here is very nice at this time. It is summer here, and also the middle of the rainy season. Nights are 15-20 degrees Celsius, and days are 20-30 degrees. It has rained almost every day I’ve been here, though only for a few hours at a time. When it rains, it usually pours. During the winters, sub-zero temperatures are not uncommon at night, but they don’t see snow, since winter means dry season.

The Language: The Portuguese spoken in Angola is very similar to that spoken in Portugal, and very different than that spoken in Brazil. A Brazilian speaking to an Angolan would be akin to a Aussie speaking to an American with a Southern Drawl. However, Portuguese is the second language for most Angolans, and some of the elderly and those living in rural areas don’t speak a word of it. There are many different tribes in Angola, and Lubango features a convergence of tribes, being the biggest city in Southern Angola. The Umbundu is the largest tribe, representing over 50% of Angolans, and is the language I would learn if I stayed here longer.

The Goods: You can buy almost anything here that you can buy in Canada, except that all imported goods are double the price back home. This is mostly due to shipping costs, plus the horrible roads from the Namibia border which taxes the trucks greatly. The praças are places where there are hundreds of booths in which merchants set up shop to sell anything from underwear to charcoal to carrots to electric cables. Most foods that are grown locally are cheap, including various meats, vegetables, grains, and fruits. For those who prefer to get their shopping done a little quicker, there are supermarkets where both imported and local stuff are sold.

The Transport: Most people get around by foot. Walking several kilometers are day is part of daily life. For those not wanting or able to walk, “taxis” are available and ubiquitous – blue and white Toyota vans that are supposed to seat 7, but I’ve seen more than 15 crammed in. They stop at various locations depending on what route they are on (you don’t know the route until you ask, and the driver sets the route depending on demand). They cost the equivalent of $0.70 USD per trip. The most popular private cars are SUV’s, and in this city they are needed, as potholes line the city. There is not a single functioning traffic light in this city of over 300,000, so oftentimes the biggest car goes first.

Return Itinerary

Yesterday was my last day in Angola. I will write a wrap-up blog sometime soon. My return adventure:

Feb 3: Lubango – Windhoek – Cape Town (stay 4 days)
Feb 7: Cape Town – Johannesburg (stay 2 days)
Feb 9-10: Johannesburg – London – Vancouver
February 12: Vancouver – Seattle – Philadelphia – Charlotte – Winston Salem

Sacrifice

One of the precious gems of my time here has been getting to know the Europeans and North Americans who are doing NGO work here, mostly affiliated Christian missions. The community is diverse – we have Canadians, Americans, British, French, Dutch, Swiss, Germans, Finnish, Brazilians, Portuguese and South Africans. They also serve in diverse ways – agriculture, medical work, teaching at the seminary, teaching at the international school, flying relief flights.

Although they live in relative comfort compared with the general population here, this is definitely not an easy place to live compared to what they had enjoyed in their home countries. Inconveniences abound – it takes a half day just to go grocery shopping (supermarkets here are far from complete), documents take months to process, most car parts take weeks to arrive, water needs to be filtered, power outages occur almost daily, and roads are horrible. Most who have lived here long enough have had things stolen from them: cash, medical supplies, car radios, clothing (While examining one of his patients, Dr. Bob found the patient wearing his wife’s underwear which had been stolen a few months previous – needless to say he did not ask for it back). Yet, they stay and make these sacrifices because they see the needs and know they are called to be here.

These are people which take the last part of Matthew 25 seriously – serving the hungry, the poor, the sick, as they would have served Jesus. Fortunately, their selflessness and desire to serve others is infectious. I can proudly list off a whole bunch of abilities and accomplishments that I possess; however, in this business, what matters most are a heart of service and an attitude of selfless giving, which I fall far short of, and trust that God will provide for me.

TB

The past two days, I have begun to appreciate the enormity of the task of tuberculosis control in this post-war country. I spent Wednesday with Dr. Karen, a Canadian doctor who works as the medical director at the Rio de Huila clinic. While most cases are seen by nurses, who initiate and monitor DOT (Directly Observed Therapy) for multi-drug treatment of this disease, the more complicated cases are referred to her. We saw cases of extra-pulmonary TB, some HIV positive patients, plus some cases where the patient has not been getting better despite treatment, and a drug resistant strain is suspected. Much patient education is needed, since new patients have to commit to spending the first 2 months in a TB sanitorium, where they undergo an intensive treatment phase and are isolated from their communities to prevent further transmission. Often their families will camp out nearby for the duration of that time. After the initial 2 months, they will then be “sent home” for another 6 months of therapy, and required to come to the clinic at least 3 times a week for direct observation of them swallowing each dose. This is pretty much a world-wide practice, because non-compliance with therapy is the biggest contributor to drug resistance. Understandably, the 6 months of “home” therapy, plus follow-up afterwards, is extremely hard to monitor, and such challenges may only be overcome with improvement of transportation and healthcare infrastructure.

Thursday, I worked with Dr. Rijk, a Dutch “double doctor” (he holds both an MD and a PhD) working with SOLE and TEARfund. He is involved in tuberculosis control for this province, and has spent the past year traveling to various health outposts to help with development of TB treatment and public health education. Many of these outposts are operated by churches, some with funding assistance from foreign NGOs.

Thursday, we drove 130 km to the health post at Quipungo, a village of 20,000 people, to collect statistics on their tuberculosis treatment program. Sr. Jonas, a nurse trained at Kalukembe Hospital, is the medical director there, and operates quite an effective healthcare delivery system on very limited resources. With 3 other nurses on staff, plus laboratory and pharmacy technicians, they serve a very large region (we met a family who walked 30 km). Sr. Jonas has been at the health post for 15 years now, and very much dedicated to improving the health of his community. We hope to help him establish some public health education programs, as it is apparent that most people here have very little knowledge of disease prevention. One example is that bednet use is almost unheard-of, despite convincing evidence that they prevent malaria and other insect-borne diseases. With thousands of children under 5 dying EVERYDAY from malaria, it’d be way cool to see more Africans use them. (I must be tired – I just departed from my documentary-style writing form)

Amazing scenery

As opposed to what you may be led to believe from my previous postings, I do not spend 24/7 doing medical stuff. There have been many opportunities to enjoy the beauty of this country. Since Lubango (elevation 4000 feet) is located in a valley surrounded by 1000-foot cliffs, my morning runs up the hills have provided amazing views to start my days (plus some altitude training in the process). This past weekend, I was able to travel to the coast city of Namibe, where there are amazing beaches, albeit with rather chilly water currents (which originate from Antarctica). Unfortunately, the waves break too close to the shore to get much good surfing in, but I was stoked to at least be able to swim without fear of schistosomiasis. The 4000 foot descent to the coast offered awesome views, and in a matter of minutes we went from chilly mountains to humid and hot plains to a very dry desert. I had a very enjoyable and refreshing time.

Unfortunately, our house has been without phone service for the past week, and thus I have been slow on my blogging.

The hidden disease

The officially reported incidence of HIV in this country is 5.5% - the low number attributed to the lack of travel during the war. Most would see this as a gross underestimate. Surrounding countries have rates at least triple this number (Namibia is estimated to be 25% HIV positive), and with the post-war repatriation of up to 4 million from these countries, an increase in the rate is anticipated. No one knows what the real rate is, as no one is doing much epidemiology here. A survey of patients in our peri-urban clinic run by the church revealed that 20% of our tuberculosis (TB) patients are HIV positive. In this region of the country, the patient has to pay for their own blood tests – why would you want to find out you have HIV if it can’t be treated and you have to pay for the test yourself? HIV medicine is extremely expensive and practically non-existent here (the only patient with HIV meds I’ve seen had driven down to Namibia to get them). Unfortunately, it is still very much a hidden disease – not many people know much about what it does, never mind how to prevent getting it – a far cry from the big billboards in Brazil. I fear that this country may be heading towards the rates seen in the surrounding countries. It will likely take a huge collaborative educational effort, such as the government-church-NGO effort in Uganda, to evade a dreadful outcome.

On Friday, we saw a patient who was HIV positive and was suffering from complications of tuberculosis. Evidently, from a medical missionary who worked here since the 1970’s, the rates of TB have dramatically risen, and I wonder if this is a reflection of the HIV problem. She was extremely cachectic – no more than 80 pounds – just skin and bones. Even with good TB treatment, I wonder how much longer she will live beyond her 18 years. I just pray that I will see these patients with the compassion that Jesus (the one from the Bible) had for the sick, because in many ways it’s so much easier to treat her as a case of HIV/TB rather than as a precious human being created in the image of God.

Kalukembe

I have returned from spending 3 days (Monday to Wednesday) at the Kalukembe Hospital, about 200km (~120 miles) north of Lubango.

The journey there was an adventure in itself. Because of the war, the road has not been maintained for over 20 years, and there is a pothole every 5 meters, plus places where mines had exploded. It took us over 6 hours to make this 200km trip, plus lots of bumps and bruises, even in our Ford F350 with raised suspension. There were constant reminders of the war, as we passed wreckages of military vehicles, and the rare “Beware of Mines” signs. Yet, most of the areas have now been cleared of mines and we passed many fields of crops in what is known as the most arable land in Angola. Along with cattle being herded, we passed many trucks heading north, carrying products from South Africa and Namibia to the capital Luanda.

Kalukembe hospital is a hospital built in the 1940’s by Swedish missionaries, and continued by others. It was the only hospital in the region, was staffed mostly by missionary doctors, and has a long history of training Angolan nurses. Unfortunately, during the war, in the mid-1990’s, it was bombed and then looted, losing much of its medical supplies and equipment, including all the books in the medical library amassed over 50 years. Though much of the staff fled, a remnant remained and used (and re-used) the supplies that were not looted to maintain the operations of the hospital. Even now, there are no doctors on staff, and this 200-bed hospital is run by Angolan nurses, who have been trained to do everything from minor surgeries to C-sections to treatment of tropical infections. They have also maintained the nursing school, now with an enrolment of over 90 students. Dr. Foster and his teams come every 2 months from Lubango to performed surgery on the more complicated elective cases.

I made this trip with Dr. Stephen Foster, his dad Dr. Bob Foster (who had worked at the hospital in the 1970’s), and Bartolomeu, a nurse anesthetist. Upon arrival, we rounded on about 100 of the in-patients (many cases of malaria and TB), and saw about 15 out-patients consults. Dr. Foster used this time to teach the nurses as well. Since the staff did not learn that Dr. Foster was coming until the week prior, most surgical patients were told to come back for the planned visit in February. Therefore, over the next day and a half, we only did 23 surgeries, much less than his usual caseload here, with the most major ones being removal of a humongous abdominal cyst (size 30x15x15 cm), and a lower leg amputation.

Even though I did not know many of the patients personally, glancing at their medical and family histories offered a glimpse into their suffering – most women have lost at least one child to disease (I met a women who had lost 5 of her 6 children, each before their second birthday), adults are crippled by cerebral malaria or polio, grandparents who have lost digits to leprosy, and husbands who have buried their wives after childbirth – and that doesn’t even include all those who lost siblings and parents in the war. And I worry about the zit I got yesterday!