Holiday in Hermanus

One of my classmates told me that Cape Town was “just like Pittsburgh!” Now, I love my adopted hometown, but this was not encouraging. I had hoped to travel halfway around the world to find something different for a few months. We do share championship sports teams and lots of hills, as well as an alarming love of mayonnaise and French fries. However, my friend was referring only to the weather. Every day there is a chance of rain, and more days than not there is some precipitation.

Today the forecast was again cool and rainy, but I woke up to a beautiful sunny day. It’s Youth Day, a national holiday commemorating protests by schoolchildren seeking equal education during apartheid. As far as I can tell, it means no one works and big box stores have huge sales. Fortunately, I had other plans.

E., my site mentor took Camilla and me to Hermanus, a coastal village east of Cape Town that promotes itself as the best place in the world to whale watch from land. We saw zero whales but two baboons and several dassies. They look like rabbits but are most closely related to elephants, and they enjoy "sunning themselves," as my Rough Guide informs me.

We ate lunch overlooking the water and walked around for an hour or so afterwards. It was a beautiful day, and a treat to see a different part of the Western Cape. As it turns out, actually, I’ll be doing some exploring for the project as well. E. and I decided that I should travel to the hospices to interview people, instead of using the phone. This is great on so many levels: I won’t be in an office all day on the phone; I’ll be driving around the countryside; and I’ll get to actually see what’s happening “on the ground.” My first interview is scheduled for next week.

More pictures from Hermanus are below.

Weekend II: rain-outs and World Cup construction delays

Yesterday we were greeted with the worst possible weather in which to scale a mountain: rainy, cold, and thunderstorms in the distance. So while we saw the bottom half of Table Mountain from various vantage points, we limited our exploring to the city proper. Camilla (another visiting student) found a tour guide through the NGO we’re working with, and he drove us in and showed us around the remains of District Six and its museum.

District Six was an integrated, working class neighborhood in Cape Town that was declared “whites only” by the apartheid government in 1966. The neighborhood was demolished, and the black and coloured residents were sent to live in the Cape Flats, 40 km away. The townships out in the Flats are filled with shanties and lean-tos, and the area is rife with gangsterism. The museum commemorates the neighborhood with interviews, artifacts, and artworks from the citizens. It was quite a moving experience.

Today the idea was to find the Green Point Market, but it has been displaced by the construction for the World Cup 2010 – starting in less than one year, as I hear several times a day. It took us about an hour of walking to find it, at which point we were too tired to walk around , so we caught a minibus back into the city and had lunch. Our guide picked us up and drove us down to Chapman’s Peak, just south of the city. There's not much to say about it, but the view was lovely:

C. and Leon walking around Chapman's Point. The Sentinel, the peak seen in the distance, is privately owned and up for auction. You can't develop it, and the owners expect to get about R12 500 000 (~$1.5m). Any takers?

And in my spare time . . .

There is another visiting student here for a few weeks, and she and I are planning a day hike up Table Mountain this weekend. Hopefully I will be able to report back with some nice photos.

I've mostly stayed in the Southern suburbs, where I am living and working, but I was able to wander around the city bowl a bit on Sunday -- it was pretty quiet, but provided a good chance for me to get oriented to the area. I'm very excited to explore a bit further.

A visit to St Luke's

Yesterday I went with some med students to a satellite branch St Luke’s Hospice, opened to address the AIDS epidemic. They have inpatient beds, as well as an outpatient program where you can come in, see the doctor, speak to a social worker, have a meal, and attend support groups with other AIDS patients from the community.

We spent the first few hours in lecture and PBL(!), in which we were actually given resources and left alone to solve the case. We then presented our findings as a group in an informal setting. Is it strange that this was the best PBL I had all year?

(Note to non-medical students: PBL, or problem-based learning, is a much-maligned supplement to our lectures. In the first session, we are presented with a case and create relevant assignments. In the second session, we present our assignments—usually in PowerPoint—and hope to get out early. It could really be so much better.)

Then it was off to patient interviews. I was assigned to a cachexic (wasted) twentysomething man who was sitting wrapped in blankets on the patio. He was newly diagnosed with AIDS and TB, although he wasn’t convinced that he had AIDS. Interestingly, he knew his CD4 count, a marker of HIV.

The palliative care physician we heard from earlier in the morning was careful to note that this was not a place of death, but rather a place of life: “the patients here are close to the end of their breathing life, but they are living.” And yet the patient I interviewed was in hospice for another chance at life, specifically to start a course of anti-retroviral therapy (ARV). It is entirely possible that if he is able to receive the support necessary for ARV adherence—government grants (akin to SSI in the States), nutritional counseling, symptom control, family support, housing, and transport to medical care—he will do quite well for the foreseeable future. In a more rural area in 2009, he would indeed be close to the end of his breathing life; a few years ago in Cape Town and over 13 years ago in the States this would also be true.

It’s also worth noting that palliative care in South Africa is ideally begun at diagnosis, aiming to manage symptoms, improve adherence, and care for the family. It’s actually the first model of palliative care that I was exposed to (more on that later), but is fairly unusual in the States, where palliative medicine takes over at the end of disease-modifying therapies. There is a movement afoot, however, to integrate the two—it should be interesting to see if and how our super-specialized medical system accommodates this.

Oh yeah, and in a hospice where everyone was dealing with TB: negative pressure rooms? No. N-95 masks? No.

Thoughts at the end of week one

Tuesday: Greeted by a marching band

The first thing I saw when I made it through customs (and sadly gave up my Emirates Airlines cheddar cheese) was a throng of paparazzi and a marching band. A local rugby team had just won the World Cup and was on my flight. I’m on the lookout for a celebratory parade in the next few days.

And I got one additional piece of advice: no walking alone after dark, not even to the store down the block. Clearly I'm not in Squirrel Hill anymore . . .

Wednesday-Friday: Working & a little bit more about what I do

Things are off to a good start here. I met the professor yesterday, and I think we will work well together. She was glad to hear that my apartment was across the way, because she had set up a 7:30 a.m. teleconference for me on Monday. She will be out of town, so I will be introducing the study to our nine(!) research assistants, one in each province. The purpose will be to give them instruction on how to administer the survey and to set goals for each area. It’s kind of intimidating, the idea that I will be taking the lead on this and supervising nine people around the country.

So far, work has mostly consisted of a literature review – a largely disheartening look at how difficult it is for AIDS patients in developing nations to access essential medicines. One study noted that 4% of AIDS patients in urban South Africa received anti-retrovirals (what we think of as standard AIDS care in the States), with perhaps 30% receiving adequate relief for their most common and debilitating symptom: pain.

There are a few bright spots in the literature, though, mostly borne of activism on the part of health care providers. Uganda, for example, passed a law in 2004 allowing certified palliative care nurses to prescribe morphine, bringing pain relief to rural areas in particular. This came about in part because of the serious physician shortage there: 1 doctor for every 50,000 Ugandans. For comparison, there is 1 doctor for every 400 Americans.

There are many components to increasing access to palliative care here, but the Ugandan system provides a good starting point.

In other news, Tuesday I will go with the fourth-year medical students* on their hospice rotation to St Luke’s. I’m not sure what this entails exactly, but I know that I am not cleared to do anything clinically—nor should I be! I am certain that it will be a valuable experience, and it will be nice to spend the day with some peers.

*Theirs is a six-year program, so we are at nearly equivalent points in our education.

BOS-JFK-LHR-DXB-CPT

In an attempt to stay within budget while also getting in a vacation with friends in the UK, I ended up taking a series of four flights to get to Cape Town. I don’t mind flying as much as I used to, which is to say that I no longer panic at the idea. Still, four flights over two days is no one’s definition of pleasant.

Here are the suggestions I got to make my travel easier, all worth heeding:

1. Don’t try to stay up all night to exhaust yourself into a new time zone. I would have appreciated (but likely not heeded) this advice at 15.

2. Better choice = Benadryl + eye mask + foam ear plugs.

3. Leave Heathrow if your layover is even close to long – mine was 11 hours, and I got to go into London and see a college friend with whom Facebook had reunited me. We had a lovely picnic lunch near the National Gallery, and I got to roam around Central London for a few hours. (Tip: wifi is not abundant in London the way it is in American cities. Pret A Manger is your best bet, and they’re ubiquitous.)

4. If you must connect, the Dubai airport is a pretty nice place to do so. It was like being in the States, more specifically Houston, to which it has multiple nonstop flights. I found this rather amusing. On my way back I will be in Dubai for 8 hours, but am not convinced that it’s worth it to go through customs and see the sights.

5. You probably don’t need to pack as much stuff as you think you do. You certainly need less than you want to haul around a major airport. When I went to Vietnam in 2005, my friends convinced me to bring clothes I wasn’t attached to, and leave them behind as a donation. Out of no altruism whatsoever, I am hoping to significantly lighten my load for the trip back to the States.

Other suggestions, which I will report back on:

6. Go to church, and not the white ones. If I could do this in Central PA, I think I will be able to do it in Cape Town.

7. Go to ____ National Park. As I decided against brining malaria prophylaxis, I will bypass Kruger and go somewhere without malaria.

8. Take a weekend trip to Harare.

9. Hike Table Mountain.

10. Find a braai – I think once my friend moves here I will be all set with this, as it was her advice.

Feel free to chime in with your experiences of Cape Town, South Africa, or travel in general.