My Bid Farewell to Nongoma and Hla Tun

Abundant sunshine and intermittent rain has marked the end of my last week in rural Nongoma South Africa and the beginning of summer, turning the mountainous landscape into a green haven. From the Saint Benedictine Hospital soap opera to the cheering children of Ngxongwane Primary School, I accumulated a lifetime of stories in a two month period. I have seen atypical cases like Marfans and diabetes insipidus to the ubiquitous HIV/AIDS and TB. Sometimes the faucet spits out brownish water and sometimes the electricity is stubbornly nonexistent. Yet the people of Nongoma continue to share their kindness and culture with me, treating me like a wifeless and cow-less King. The memories of Nongoma will forever sit in my conscious and seep into my subconscious when I begin practicing medicine. I hope to come back some day.

This is not a farewell. This is the auspicious beginning. This is window into my future and Dr. Hla Tun gently introduced me to the future of unsettling tragedies and brilliance. As a former UN volunteer, he allowed me ask inane questions, observe the ridiculous, and celebrate laughter. Like Benedictine Hospital, I have been fortuitously blessed to cross his generous path in the midst of Nongoma chaos. The staff huddles around him, knowing he will inevitably lessen the disaster with his kindness, diligence, and intelligence.

In my Minnesota life, I have had few Asian role models (other than my parents and Dr. John Song) with similar backgrounds and characteristics. Of course, Dr. Hla Tun is more than just an Asian role model; he is the epitome of a good physician, a guiding light for young physicians wanting to be global citizen. Or more accurately, a good physician is the epitome of Dr. Hla Tun. Even though Dr. Hla Tun likes Felicity and Seventh Heaven, he makes me proud and joyful to become a physician in my sometimes cynical world. He has left me forever changed.

Moreover he has already left Nongoma forever changed. Yet it still sits unknown to the world and to much of South Africa. It is only notorious for violence and turmoil. On the other hand, Nongoma does not have a fix image of violence, HIV/AIDS, or poverty. Good or bad, it is fast forwarding itself into the 21st century. I won’t dare try to encapsulate the nuances of this rural district in a small blog comment. However I do know that I am fortunate to learn ~6 Zulu words (particularly one click sound), laugh at our cultural differences, and eat fried chicken until the rooster cock-a-doodle-doos again.

As a medical, nursing, public health, social work, corporate volunteer, etc, you naturally aide the people with your knowledge and skills, but just as importantly, the experience provides an investment in your own personal growth. Textbooks can fill your brain with factoids and desensitize you about the tragedy of HIV/AIDS, but it can never reach your heart. As a volunteer, the people of Nongoma will reach your heart and then ask for more. Besides, you can’t help but give them more because they are part of our global world. However, like any experience, you must actively participate. You must strive to break your own boundaries and share greasy plastic cups with 80 kids.

You must also be aware to expect challenges, loneliness, and frustrations. People might be late (or they never show up); people might lie and steal; people might not help you; and people might be negligent. But always remember that is the minority of Nongoma; let the majority lift you up and those challenges, loneliness, and frustrations will become stepping stones to success. Otherwise just hang out with Dr. Hla Tun’s five star flat and you’ll succeed too.

So I invite the world to see Nongoma in its madness, sadness, and joyfulness. Take a year off from school, fly into Durban and hop on a short ride with Jabu to Nongoma and you’ll find yourself bathing in relaxation. Just don’t open your eyes because anarchy is usually lurking in the bushes.

Now it’s time to kick it in Joburg and Capetown.

The Lost Generation and the Orphans

Even if an AIDS vaccine or elixir magically appeared in ARV clinics, the frightening scars of HIV/AIDS will last for several generations. HIV/AIDS has stolen the youth away from South Africa. Ambivalent twelve year old daughters with their frail sixty year old grandmother strain to care for their wasting thirty year old parents. Without a viable working adult in the household, grandmother’s 700 rand pension provides for the family. In more unfortunate cases, grandmother also suffers from the grip of HIV/AIDS, leaving the daughter as the head of the household.

The children stare into the death of their parents without knowing or understanding the HIV status of their parents. However they know the pain and the fear that stems from HIV/AIDS. They feel the anger, the violence, the discrimination, the stigma and the loneliness that stems from the community. Fortunately some communities come together to care for the children before and after the demise of their parents. Still, millions of orphans surrender to the slow death and aftermath of HIV/AIDS without a support of a role model or love one. Furthermore, the millions of orphans will be compounded exponentially as the 40 million HIV positive South African begin to submit to the virus within the next two decades, dismantling an already fractioned post-apartheid South African family network.

In rural South Africa, extended families, neighbors, and communities not orphanages support the dismantled family or care for the orphans. However the sheer overload of death has destroyed family and community structures and thus eroding the ability for families to find mechanisms to cope with the loss of parents and financial support. The orphans teeter from poverty to destitution and neglect. The right to shelter, food, clothing, health, and education for the orphans becomes impossible. Extended families and foster homes tend to deny the orphans these necessities first during financial difficulties.

The stigma of HIV/AIDS force many children into social isolation or in negligent foster homes. Quite often many assume that the child is also infected with HIV, denying schooling, health care access, and opportunities for any future. In school, educators may not recognize the loss, grief, or mourning from the child. Instead the child may be punished for their unstable emotions, leaving the child increasing vulnerable and isolated.

Organizations like Media in Education Trust and HERO provide the foundation of information, counseling, coping skills acquisition, and contact in order to change attitudes and behaviors. The community-based approach deals beyond the physical plight of the orphans and into the stigma at a collective and individual level. Their strategy to educate community leaders, teachers, and parents reduces the stigma surrounding children affected by AIDS. Consequently these adults learn to build empathy and skills to empower the orphans. Most importantly the adults learn to remember that these head of the household grown-up orphans are still joyous children in need of occasional tuck in the bed and night time story.

Oops I am now forever part of Saint Benedictine

I absentmindedly walked through wet concrete. But hey I think my shoe print is a nice artistic touch to the boring driveway.

Cuong was here!

Broken Bones on My Last Day

At 4:30pm, it looked like OPD was wrapping up another typical day in Nongoma. Then a flood of ~10 patients rolled in from a minibus accident, transforming the OPD into the ER. Skull fractures, vertebrae fractures, hip fractures - everything fractures -, facial lacerations, leg lacerations, back laceration, - everything lacerations – jammed onto wheelchairs and stretchers. Unfortunately our ortho surgeon, who is our only surgeon, was unavailable and thus emergent surgery was not an option. With some blood stains on my rolled-up sleeved white coat, we cleaned the lacerations, threw some sutures, put up fluids, fired up the x-ray machine, and made phone calls to referral hospitals.

By 8pm, the chaos settled into a few moans, marking the end of my topsy-turvy clinical work at Saint Benedictine. What more can I say other than “This is life in Nongoma.”

Bomb Threat

It’s another wild day at Saint Benedictine. Police cars and dogs cruised in the outpatient department (OPD) looking for a BOMB. The patients and staff calmly evacuated the entire OPD building, filling the lawn with curious people. Apparently yesterday, an anonymous to the hospital switchboard threatened to bomb the hospital grounds. This is the second threat within the last year.

No one really took it seriously, but protocol was followed and we got a longer tea break.

HIV and Stigma

Stigma and disease has been intertwined throughout human history - cancer, leprosy, tuberculosis, mental illness, and the long list of STDs. Over the past two decades, HIV/AIDS has supplanted all other disease as the most feared and most stigmatized all over the world.

Other than the obvious physical symptoms, HIV/AIDS induces denial, fear, violence, silence, and isolation in many communities and individuals. These emotional reactions layer the stigma and thus undermine effective treatment from a public health scale. The stigma prevents condom use, HIV testing, and care-seeking. Therefore, reducing stigma through education is the foundation of solid ARV treatment.

Moreover, community-based programs need to lessen the following myths:
1. Fear of contracting HIV/AIDS through contact
2. HIV/AIDS is a death sentence
3. People with HIV/AIDS contracted through unacceptable behaviors, ie. promiscuity, IV drug use, homosexuality

The reason that many choose not to do HIV testing is that “not knowing is better than knowing”. This was particularly more evident when the South African government did not offer free ARV treatment, which meant knowing ones HIV status became a death sentence. Now instead, people wait until their bodies have nearly succumbed to AIDS. Why wait? Unfortunately, ARV treatment is only effective when the patient has fallen under a CD4 count of 200 which is parallel to full blown AIDS. Thus Nongoma patients prefer to delay knowing their status or in other words delaying the stigma until the body cannot withstand the virus any longer.

Unfortunately, Benedictine staff also faces the stigma of HIV/AIDS. At this point there are no mechanisms to provide confidentiality to staff. Many are afraid to get tested or receive treatment knowing that the entire hospital would soon find out their status. So even the educated succumb themselves to community discrimination with the willingness to die with dignity rather than with AIDS.

Hair in South Africa

I grew up with the stereotypical bowl haircut which had little maintenance. Apparently black African hair requires much more attention and detail than my bowl haircut. I am oblivious of the nuances of black African hair. I asked the educators from Ngxongwane why most of their children, including the girls, have a shaved head. The answer: economics. Many rural families can’t afford to cut and maintain their children’s hair.

Also many middle age women like to GQ themselves with conspicuous wigs. Once again it’s more affordable and less time consuming to don a nylon wig rather than groom their own full head of hair, making hair a socioeconomic status symbol.

As for me, my head is too lumpy to shave.

Ngxongwane Goes to Durban: Day 3

Shoo be doo, shoo be doo, shoo be doo continued to echo throughout the night sky when I realized that it wasn’t gospel music; it was a cappella music – South African style. A cappella groups loudly barricaded us inside the hotel. Apparently we slept on top of all night, all day a cappella competition. It started the night before and continued throughout morning nonstop. At 5am I got up with actually a decent night sleep. In the lobby a group of ~8 men centered surround the leader practicing their harmonizing. Across the street, another group practiced their subtle dance moves in the darkness. It was all a very odd scene in the midst of the excitable school children and my dirty underwear.

Like many others, I refused to shower, ate my breakfast, and anticipated going home soon. We made one quick stop at an Umhlanga Mall to let the kids hoard up on sweets.

By 1pm, the cheers on the bus returned. Re-energized, the kids waived their byes to my last snap shots. Although this was probably the most memorable and fun that I’ve had in South Africa, I was so happy to be home in Nongoma. Moments later, I scrubbed myself silly.

Ngxongwane Goes to Durban: Day 2

The educators and I woke up at 4:30am to beat the crowd of children to the shower. The nonfunctional shower in the boy’s bathroom forced us into the girl’s bathroom. I donned my “way way way to thin” sandals and followed the stench to the shower with another male educator. I held my breath and threw off my clothes onto an one inch nail jetting over a neighboring doorway. Two inches of 95% bar soap water and likely 5% urine covered one half of the room due to the slant of the floor but the soap could not cover the stink of urine and the slant sloped towards the doorway. Since my name isn’t Carl Lewis (Olympic gold sprinter and long jumper), I had to gingerly walk through the sewage. My feet tingled while I stood in the puddle. The cold water splattered out of the shower head, causing rebounding water from the puddle and onto my thighs. Only half of my body could withstand the cold. I felt clean in a dirty way by the end of the shower. My first afterthought was I needed to bleach my entire body, scrub my feet with steel wool, and insert an IV line full of a broad spectrum antibiotic.

I stepped downstairs as the female educators were cooking up a flurry of stew and patching together hundreds of baloney sandwiches. The kids and I devoured the stew with loaves of buttered bread. A couple of hours later the bus drove us to the Durban Metro. The educators asked me why I was quiet and I mentioned about my stifling shower experience. They laughed wildly when I showed them the pictures of the toilet, saying that I was naughty. None of the educators enjoyed the process of showering in our so-called hotel since Nongoma is million times cleaner. Oooh back to the train… Amazingly the children sat quietly on the reserved train with unyielding awe.

We sat for 20 minutes enjoying a couple of Durban stops before we headed to the wonderful world of Ushaka Marine World, the fifth largest aquarium captivity in the world. As advertised, the dolphins can flip on a dime. But why do all dolphin trainers have to gleefully speak like an unentertaining robot? I’d rather take a shower in a toxic sewage than listen to the trainer speak, but I got both. Still the dolphins were lovely and wowed the children. Underground aquariums stocked with turtles, sting rays, and weird deep sea creatures, capturing the children’s attention for two hours.

Then we zoomed off to the beach front. As usual the kids rushed out of the bus and lines of vendors miraculously surround the bus. The children have nowhere to escape except into the arms of the slick vendors even with the warnings from the educators to not waste their little money. Coca Cola, cheap radio players with stylish headphones, peculiar spongy thingies, pacifier-shaped lollipops, and batman bathing suits all end up in the hidden pockets of the children. Even I had to take a look into the vendor suitcases. Sometimes the vendors follow us to different locations, knowing that the kids are an easy sell.

The kids went beach bathing for a couple hours while I went to help get some meat for a night of braai (South African grilling) at the Lagoon Beach. Loads of cut beef and sausage packed the back of the bus. But unfortunately no extra plastic cups. We reach the Lagoon Beach with the sun already down. Mostly Indians and some blacks covered the entire front to do some braai. A few other schools shared the same braai experience. The educators allowed the kids set up the entire grill, heat the charcoal, and cook the meat to let them learn from experience. I walked around the parking lot with Jabu and Sbo to check out the vendors and the Indian foods. By the time we returned, flames up to 5 inches high burst out of the grill and smoke covered 30 foot radius. But the kids continued to cook with enthusiasm. Fortunately the adults took over for our own food.

On a side note, a bus load of school children from another school also parked behind us on the road. Like us, the kids are from rural KwaZulu-Natal Province. Unfortunately a speeding vehicle on the extremely busy road hit one of their children and then the driver ran. It’s uncertain whether anyone got the license. One of the educators called me over to see if I can examine the child. I jogged over to the site. On the ground laid the 5 year old covered in a blanket, moving his head and feet. I did not notice any blood on the ground. Since the police surrounded the child, I knew that the ambulance would approach soon. With the child looking stable, I decided to not interfere (and reality I could not do much) and let the officials do their work.

So after finishing the braai, we landed back into our homely hotel. The owner gave the boys a bigger room, which relieved some of the heat and tight space compared to the last night. After one shot of whiskey to entertain one of the male educators, I found a lovely spot on the concrete floor without children near the top of my head and I thought the night would go smoothly. Instead gospel music echoed from the first floor. I plunged ear plugs deep into my ear canals. And the music never ended…

Ngxongwane Goes to Durban: Day 1

Weeks of treating difficult adult patients made me more cynical about the process of medicine. I am conditioned to not believe the patient’s history or memory. As a health provider, I fight the urge to assume that a patient is malingering (i.e. faking sickness for money or other benefits).

On the other hand, the children of Ngxongwane School run with eagerness to discover and share. Children have little use to malinger (unless coaxed by their parents). Instead they laugh hysterically, run energetically, and smile genuinely even in the face of sickness or the loss of their parents to HIV/AIDS. Children fight to enjoy life. Thus, after visiting Ngxongwane Primary School (Grades R-7), I felt refreshed. When the educators invited me to join the children on their annual educational fieldtrip to Durban, I smiled genuinely and packed my bags.

I jumped out of bed from a sleepless night to meet a busload of 80 children and 11 educators at 6am. The bus thumped from Zulu techno beats and the singing children. I greeted them with a shock wave of photos which brought more excitement to the bus. Even the educators stood in the narrow walkway of the bus to freely sing and dance. Each new passenger shook the bus with enthusiasm. For many of the children, they have never been to Durban before or even outside the district of Nongoma. By far, this trip marked the biggest trip of their life. I was elated to partake in their awesome joy of discovery.

Then it rained food for three days, particularly deep fried chicken and loaves, loaves, and loaves of bread. The educators must have been spent hours frying chicken because it took hours to eat all the fried chicken. After chowing on chicken legs and breast cuts, my neighboring passenger took his swig of juice from a plastic cup and then passed me the cup refilled with juice. With a small budget, the plastic cups were religiously conserved. Sometimes the cups became sticky and greasy from our hands that did not encounter any utensils for three days. Still, the plastic cup brought me thirst quenching heaven because by then I usually would have devoured four to six slices of bread. At ~2 rands (~30 US cents) per loaf, bread is the staple food for breakfast, lunch, and dinner. Plus bread is cheaper than rice and without any preparation time.

With the raining food came the raining gospel songs. Usually one person would lead the song and others would follow the a cappella seamlessly. The infectious music made me clap my hands and tip tap my feet uncontrollably. The bus became entertainment on wheels.

The Gateway Mall became the first real stop for the wheel of entertainment. The children swiftly walked into the arcade center of the mall, facing the bright lights of McDonalds. The educators split the children into two tour groups and we began to walk the halls of the mall. Not allowed to purchase anything, the store windows stood like aquarium windows for the children. Escalators rode like roller coasters; elevators lifted like rocket ships; and water fountains danced like a circus act. As the crowd of children moved like an amoeba through the mall, people glanced with smiling curiosity. For me, the best moment in the mall came when two little white sisters shared laughter with the mass of black children. For the children, the sense of discovery between the two cultures overwhelmed stereotypes.

A long the way we visited the stuffed animals at the Natural Science Museum and the stories of Apartheid at the Muhle History Museum. Each stop increased the enthusiasm of the students while decreased the energy of the educators. As a running joke, I offered the panacea injection (Voltaren, Nonsteroidal Anti-inflammatory Drug) to the educators which brought wild laughter each time. To put this into perspective, nearly all Benedictine patients that come in with ambiguous pain or aches want an injection, believing it would take all the pains away.

The highlight for some of the teachers was visiting the South African Broadcasting (SABC) radio station where one of their students now DJs. The teachers were proud and the students were inspired to see one of their own break the Nongoma stereotype of rural uneducated thugs.

After sharing cups and eating with my bare hands, I thought I was gritting the South African life. But the grit was only beginning. The educators had booked a hotel three months in advance. Unfortunately when we arrived the hotel did not have the appropriate accommodation or size to house ~90 people for the school’s budget. The educators had to choose between sleeping in the bus and finding another option at 10pm at night for ~90 people.

They picked the latter option and we drove to a random building in the city centre of Durban. For two nights, the bill only totaled 1400 rand (~$220). The price matched the accommodations. The males and females were separated into two large auditoriums. Bundles of one inch crusty foam mats blanketed the crusty floor. After a meal of fried chicken, tuna sandwiches, and shot of whiskey, I went to the boys’ room and shared the floor next to the two other male educators. Only by 1am did the boys finally loss their energy and slept the night away. As usual the whiskey knocked me out until the kid next to me began to steal my sacred sleeping space. His head nudged into my bubble, forcing me to wrap myself into the fetal position. Concurrently by 3am my bladder wanted my personal attention, but my brain was unwilling to let my body to trample across the little children covered floor to reach the foulest bathroom in this hemisphere.

Toilet seats and stall doors don’t exist in this restroom. The urine soaked stench filled the room and down the halls, sticking to your nose hairs. The concrete floor bubbled up creepy wetness. Rust lined the walls and faucets.

So I decided to hold that bladder till the morning wake up call at 4:30am.