The Waste Land

“You cannot say, or guess, for you know only
A heap of broken images, where the sun beats,
And the dead tree gives no shelter, the cricket no relief,
And the dry stone no sound of water.”

 

This will be my last post on this blog. It’s going to be filled with real talk, and will probably be less logical (and more personal) than I want it to be. It’s a rough draft of bigger ideas and burning memories. You’ve been warned.

Throughout this summer I’ve been able to go on some amazing weekend trips all over KwaZulu Natal. It’s been a luxury and I’ve had some adventures I’ll never forget. Last weekend, I was barricaded in Tugela Ferry. The community went on strike.

Water and power shortages have plagued the area for a few weeks, and many of the outlying villages have reached their wit’s end. Combine no water with a lot of very sick people, and you get a recipe for death—even above the usual “death is around every corner” or “life is crazy” threshold I’ve gotten used to. There’s a one lane bridge over the Tugela River. Strikers put boulders, bricks, tree branches, anything they can find on the only roads in and out of the town. They marched down the streets and closed down the local stores.

Monday morning came and nothing changed. There’s still no water; the roads were cleared. Life goes on. Life always goes on. I went to the store and bought a half gallon of milk and that night I had a hot shower behind the barbed wire fence that protects the hospital. As I showered I almost forgot that this water might be better used for a dying person. Should I feel guilty? I don’t know. I didn’t stop showering.

Things are rough here, but not that rough. South Africa is a middle-income country, and there are enough roads, hot water, cell phones, and Coca Cola signs even in Tugela Ferry for me to have lived quite comfortably. After getting internet and power back I read up on Gaza and Israel, plane crashes left and right, and Ebola doctors dying. Hey, at least here people are organized and civilized enough to go on a strike; it’s not a war zone. At least here, there’s a hospital, not the burnt up remnants of bombed medical facilities. Living here has made me appreciate New Haven, and hearing about Congolese refugee camps has made me appreciate Tugela Ferry. It’s all relative. I’m struggling to balance gratitude and discomfort; I have no idea how to contextualize my experiences.

I suppose that means it’s time for one last attempt to paint a picture with words.

At the bottom of South Africa there is a place called Cape Agulhas where the Indian and Atlantic Oceans meet. It’s a line in the water at which two worlds collide. This summer, I’ve walked that line every day.

Tugela Ferry is the Wild West, untamed and unruly and unpredictable. Driving down the road, and you hit a child? Talk to the police. Driving down the road and you kill a cow? Run (or drive) for your life; the vigilante “livestock police” will be out for vengeance if they ever get wind of your doing. Cows are money generators; children money drains.

Tugela Ferry is also modernizing, quick—and not always in the best way. Taverns are extremely popular, as is drinking. To excess. Any evening. Then driving drunk, getting in fights, and ending up on the street. French fries are served everywhere, and Coca Cola has planted its feet firmly into the rural landscape. The intricate Zulu beadwork is being replaced with mass produced plastic; authentic “Zulu cuisine,” as someone told me, is “eating whatever you can get.” That, and fermented milk (don’t try the fermented milk).

Everything clashes. The area is developing, yet poor, losing tradition, yet gaining very little of the positives of “modernization.”

It’s easy to point out the problems, easy to throw out buzzwords. Look at me go. Easy to say that the double burden of disease is so high due to the vicious cycle of poverty and food deserts. The infrastructure needs overhauling. Financial incentives to receive proper medical care aren’t overcoming the stigma of HIV. If only we had a few more startups, a few more NGOs, a lot more money, and perhaps dialysis for the god-forsaken patients that come in with kidney failure…

Is this too bleak? Maybe. I think I’ve realized bleakness inspires me. Because while things may not be efficient, while there may be too many problems to count, while everything seems like it’s on the brink of collapse, it is better than it was before. It takes time, so much time—the smallest of baby steps and the refusal to look back. Bringing about change is the process of water wearing down a rock or two oceans mixing. It’s about dedicating your life to a cause or a person or a reason and then realizing you may never reach that finish line, or tick the checkbox, or cross off the to-do list fully. No matter. Reflect, try harder, keep going. The contributions still count None of us individually does enough, but all of us combined make up the grinding gears of progress.

Almost done here. I’ll miss it and I won’t miss it at all. I’ll move forward and I won’t look back.

“What have we given?
My friend, blood shaking my heart
The awful daring of a moment’s surrender
Which an age of prudence can never retract
By this, and this only, we have existed
Which is not to be found in our obituaries.”

-T.S. Eliot, The Waste Land

So It Goes

It’s a wild world out there.

During the clinic meeting, a nurse had an announcement to make.

“There’s a python in my house.”

It had been there for weeks, apparently, seen occasionally by her family members before it disappeared again. She hypothesized that it was living in the walls, and it was making her sick with worry.

Everyone’s reaction was telling. The newest team members could not contain their excitement. The British medical trainees, who had spent nearly a year at the hospital, looked mildly interested but mostly unfazed. And the veteran doctors began to laugh.

“Pythons are the least bothersome,” a doctor said. There were much, much worse things to have in your house: Mozambique spitting cobras and black mambas, for a start. He told us of how once, late at night, he got a call from a home where several nurses lived. They had a cobra in the drainpipes, and were absolutely terrified. No one wanted to approach, for fear of getting the venom in their eyes—this sort of snake was famous for its accuracy. The doctor and another man put on goggles, poured boiling water down the drainpipes, and stoned the snake to death as it emerged.

Another time, on a community visit to a nearby town, a schoolteacher told him a story of a boy dying from a snakebite within four hours. The only snake around capable of killing that quickly is a black mamba, but all the guidebooks say that black mambas do not live anywhere near this area of KwaZulu Natal. He told the teacher she must have made a mistake.

“You’re wrong,” the schoolteacher insisted. “There are black mambas here.”

The next day, when the doctor stepped outside, he nearly stumbled over a crate at his front door. When he opened it up, there lay a dead black mamba at his feet.

I asked him after the meeting if he was ever frightened in any of these scenarios.

“I’m not a fan of snakes, but that’s the way things go,” he replied.

That’s the way things go: it’s a fitting motto for Tugela Ferry. When you’re faced with limited resources, extreme health burdens, and a pressure cooker of poverty and crime, your surroundings can get a little crazy. I’ve found that the only response is to brush things off and keep going.

After being here over a month and experiencing some of my own unbelievable stories, I’m discovering that everything is “no big deal.” Taking cold showers in the dark when your power is shut off for days? No big deal. Watching a goat wander through intensive care, in between bleeding patients waiting for a doctor? No big deal. That crazy man in the wards who is convinced he needs to kill said goat? No big deal. Seeing a snake, mistaking it for a cobra, asking two military men to help kill it only to have them pull out assault rifles and miss from close range? It happened, and it was hilariously no big deal. A gardener stepped on the snake’s head before informing the men it was harmless.

I never thought I’d live in a place crazy enough to make me laugh at a python in some poor woman’s house. But here I am, and that’s the way things go.

A Doctor, a Cat, and a Dose of Reality

So much has happened in the two weeks that I’ve been in South Africa, that it’s hard to know where to start. There are times when simple is best. It’s magic when a few sparse words, doled out Hemingway-style, can get across that feeling that comes with staring into the vast expanse of mountains and sky.  I never get tired of the views.

A picture is worth a thousand words.

However, I’ve found that nothing is that simple here. There is a delicate interplay between the Church of Scotland Hospital (COSH), the community, and the NGOs that conduct research within Tugela Ferry. To get my project going, I’ve had to establish working relationships with members in each organization and navigate past language and cultural barriers to get information. Each day is so surreal, so inspiring, and at times, so full of bleak moments that a simple description just won’t do. Instead, I’ll tell a story.

I live just down the road from COSH, the historic site where extensively drug resistant Tuberculosis (XDR-TB) was discovered, and where hundreds of South Africa’s poorest citizens receive treatment for everything ranging from HIV to workplace injury. It’s an overburdened, constantly buzzing place that’s dotted with adrenaline-fueled med students and visiting doctors, weaving in and out of the endless lines of Zulu patients. Last week, cats were added to the mix.

There are more than enough stray animals to go around in the area—any given night, I’m bound to hear the sounds of goats, roosters, and the occasional donkey. Cats, however, are a (relative) rarity. So when one stray stumbled upon the steps of the trailer right across from mine, it was an unusual sight. The trailer’s residents, two medical students and a hospital doctor, happily took him in. Here begins the impending tragedy: like many suffering in Tugela Ferry, the cat was ill, so very ill.

No one knew where he came from, but he picked the right home to settle. One of the most brilliant medical minds of South Africa lived in that trailer, and he quickly adopted the cat as his own. Soon we were being updated on the cat’s daily care and progress, as the medical students tended to his every need. Oral rehydration solution, antibiotics, a slow re-feeding program, and plenty of rest on a makeshift cat-bed probably as comfortable as my own mattress. Yet it wasn’t enough. The cat grew sicker.

No matter—these doctors deal with difficult cases all the time. If they can handle drug-resistant HIV/TB coinfections, they can handle anything. I was struck by how dedicated and they were—the loveliest thing about the doctors here is that they will go above and beyond to get things done, even for the tiniest of patients. The cat was given a name: Catiline. With a name (such a noble name!) he became eligible for a medical file. And with a medical file, Catiline became the first feline outpatient at COSH, ready to join the universal struggle for access to healthcare. At a hospital where novel HIV and TB interventions are piloted all the time, it was only fitting that Catiline became a pioneer. Other patients in the area have helped pave the way for policy changes as well, in XDR TB treatment, directly observed therapy (DOTs) programs, and isoniazid preventive therapy for HIV patients.

Just when I was getting used to daily Catiline updates and way too much talk about cat cuteness, he passed away. It might be that the outpouring of care and support stressed Catiline’s (already weak) heart. Perhaps he was yet another victim of the global tendency to overprescribe antibiotics, and succumbed to a viral infection gone unnoticed. Maybe if Catiline had been vaccinated against the measles…(there has to be a lesson in here somewhere).

In memoriam.

It’s been two weeks. Over that time I’ve learned one constant. In Tugela Ferry, despite everyone’s best efforts, death is always around the corner. This really makes all the epidemiological data we encounter, all the policy briefs we read and complain about writing during the school year, all the seminars we attend, seem that much more real. Even if it takes a cat story to describe it.

—

*Some names changed/omitted to protect [cat] patient privacy

**This post is dedicated to the cat lovers who co-author this blog. You know who you are. While I am not very swayed by cute animals, and will forever be on Team Dog, I thought of you all while writing.

The Middle of Nowhere

The view from my window

It is a long way from Johannesburg to Tugela Ferry. Everywhere I stopped, people wanted to know what brought me to South Africa. When I told them where I was going, I was met with the same reaction, the same warnings, time and time again:

“You’re going there? Why?”

“It’s really the middle of nowhere, you know.”

“There’s nothing there for you. Nothing is going to change.”

In a way, they were right.

I’m not going to lie. Arriving in Tugela Ferry was really overwhelming at first. The smell of burnt trash, firewood, and farm animals wafts through the air, when the wind is not gusting too strongly. By day, it is ninety degrees, hot and dry, the sun beating down on the aloe and the tin roofs and the dry soil. By night it is cooler than fifty, the expansive sky dotted with stars, frogs and crickets chirping in the background. After dark the world transforms. You almost forget where you are, until the sun re-emerges and the cycle continues.

Before starting work, I have been getting acquainted with the area, seeing how things are run at the hospital and NGO where I will be working. The first few days have really made me think about why I’m here. It is the middle of nowhere. I could walk the rolling hills for miles without seeing another soul, yet venturing out of my living compound at night is not permitted due to safety concerns. And it is true—I highly doubt anyone in the entire town will change as a result of my being here. I didn’t come to impose any radical departures from protocol, nor will I be able to actually treat any patients medically.

But none of those concerns really matter.

The funny thing about infectious diseases is that they’re not always obvious. Our cornerstone examples in public health—John Snow’s cholera outbreak, cruise ship noroviruses, grotesque pictures of parasitic worms and people dying of hemorrhagic fevers—are important because they generate awareness and excitement. However, oftentimes things aren’t as cut-and-dry. When people hear of epidemics they think about mass casualties, fast and rapid spread, acute panic. They don’t always think of walking down a dirt road with the realization that, statistically, nearly one out of every three people you pass has HIV. That’s Tugela Ferry. That’s what we, as public health practitioners, are up against: the quieter problems, hiding beneath all our new Facebook profile photos and picturesque locales.

But perhaps equally important is the fact that change isn’t always obvious either. Yes, it’s true that by the time I leave Tugela Ferry in mid-August, the streets will probably look the same. The burnt-trash smell will still be there, as will the women who sell stew on the corner by the hospital. However, if I spend my time wisely, I’ll leave behind a dataset that may give insight into why people are abandoning their HIV treatments. That data can be used, expanded upon, or analyzed long after I leave, hopefully adding another piece to the HIV/Tb epidemic puzzle already in place in KwaZulu Natal. That’s the goal, and that’s why I’m here.