PLEASURE AND PAIN IN SOUTH AFRICA



PLEASURE AND PAIN IN SOUTH AFRICA

INTRODUCTION

After our 2 month journey through South Africa, I found much to say about medicine, politics, security and life as a local or a tourist in this beautiful country -- so there is plenty to see and read in the pages to follow. We hope you enjoy the stories and pictures…

SERIOUS STUFF (SAFETY, POLITICS, ECONOMY...)

TOURISTS IN CAPE TOWN

ROAD TRIP

SAFARI

Eager to broaden our minds, Diana and I sought a foreign elective during our residency training. Her internal medicine program offers an exchange with Uganda, but radiology training there would not be very useful. With the help of Dr. Ken Magnus and his counterparts abroad, Drs. Steve Beningfield, Bongani Mayosi and Dick Pitcher, and about a year of red tape, we arranged a joint elective in Cape Town, South Africa. A month of radiology in Groote Schuur hospital for me, and a month of internal medicine for Diana at nearby New Somerset Hospital. We were lucky to get the same 4-week block in the same city, and 4 weeks holiday each afterward, especially at the perfect time to travel in South Africa, February-April, when Christmas crowds have dwindled, the sun is a little cooler and the rains have not yet come. Not a bad couple of months to get out of Edmonton's winter cold and snow into a place nearly everyone told us is the most beautiful city in the world.

Leaving Edm

Frankfurt

Diana's supervisor was Dr. Roal van zyl Smit, Chief of Internal Medicine at the New Somerset Hospital. This was an imposing name and set of qualifications, but any fears of formality disappeared when Roal turned up at the airport Sunday 7 AM to greet us. After a 28 hour journey with 10 hour time change, arriving exhausted in a city we heard to be quite dangerous, it was a huge relief to be greeted so warmly. He and his wife Jean were the finest hosts imaginable, treating us to warm hospitality, a picnic basket for our room, support to enter a huge bike race which was a highlight of our visit (LINK), two cell phones, many happy nights of conversation and laughter over delicious dinners, and even a chance to spend the weekend with them at their Bettys Bay retreat (LINK).

Warm welcome

DANGER AND VIOLENCE

There is plenty of danger in Cape Town. Various expatriate physicians have explained to us that they left South Africa because they "lived like prisoners" behind elaborate security fences and gates, always at risk of being robbed, mugged and/or shot. On the flight from Frankfurt we saw an independent South African movie showing township kids with a gun casually robbing several white people at gunpoint, increasing their social standing with each crime. The local newspapers give alarming examples (many of the items are not big enough news for the main journals): (1) the cyclist training for a race who was pushed off his bike and stabbed, developing a pneumothorax, for 60 rand ($10) and a cell phone, (2) the mugger who stole a laptop from the window of a car stopped in traffic on the N2 highway, then died when hit by a car coming the other way as he fled; (3) the three robbers who emptied the till and left the store, then returned to shoot and kill the 30 year old female shop clerk who had probably recognized one of them; (4) the the three armed robberies on Long Street on Monday and Tuesday, all done between 9 AM and noon, which we read about in a restaurant on Long Street at about 11 AM on Wednesday; (5) the hospitalized 25 year old school security guard who was shot twice by three guys who then stole his gun, in full view of the students he was supposed to be protecting. And even closer than newspapers: one of the guests at a dinner we went to, aged fifty or so, had been "hijacked" just two nights before -- after entering her suburban compound and closing the security gate, two guys who had snuck in while it was open stole her car and purse at gunpoint. She took it in stride. At our residence, the fortyish man with a limp and a transplant kidney, whose father was shot and killed five years ago by armed robbers. At the hospital, the trouble Roal had finding interns to cover the ward while one went to Natal province for the week-long funeral for his brother, shot and killed in unclear circumstances. There are stories like this in Canada too, but in South Africa it seems like nearly everyone has had a close brush with violence. Statistically, consider: Cape Town had about 1,900 murders last year (625 per million people, or 6 per day), while Johannesburg had nearly 3,000 (near 1,000 per million, 9 a day). Compare this to Edmonton, at 1 million people one of Canada's most violent cities, where there were ~35 murders last year (3 a month). From this you are 20 times more likely to be murdered in Cape Town than Edmonton. This statistic hides a stark and obvious fact, that most of the violence in South African cities is in the very poor, almost entirely black townships -- but it's still risky to be a wealthy person in South Africa and, arguably, getting riskier. Apparently it used to be much safer for the white people under apartheid, since the police would ruthlessly crush any menace from the townships. Now, like in post communist Russia, post-apartheid South Africa has more crime and violence.

Security

But safety in South Africa is still comparable, on a day to day basis, to a lot of other spots in the world -- if you limit yourself to your gated compound at night (with "Armed Response" to an alarm), drive to shopping malls and restaurants with security guards patrolling the parking lots and corridors, and work in heavily guarded office towers or public buildings. This is a similar lifestyle to that adopted by the wealthy in Brazil or even in the USA, and in fact security is tighter in Washington, DC than at any building we saw in Cape Town. Perhaps the truth is that Canada and some European countries are abnormally safe, while the rest of the world takes the need for armed guards and heavy security for granted. Fortunately, the threat of political violence is low since apartheid ended. This is not the case in neighboring Zimbabwe, where a corrupt dictator is clinging to power despite the bankrupt economy with its 1800% inflation rate, savagely beating dissidents and disregarding the international community's feeble pressures. People are fleeing "Zim" in hordes and we met several ex-Zim people during our visit.

ECONOMY

South Africa is lucky to have the rule of law, a stable currency, excellent infrastructure such as highways, strong property laws, abundant natural resources especially diamonds and minerals, plentiful cheap (though mostly unskilled) labor, and a popular democratic government that has made life better for most people since apartheid ended just 12 years ago. For example, nearly 50% of the township population now has electricity, and a basic minimum amount per month is supplied free (almost as a human right). Of course this means 50% of South Africans still lack electricity -- but progress must be expected to be slow. The national expression of post-apartheid hope and excitement is the planning for World Cup soccer in 2010, including what we think are quite impractical plans to tear down the hospital Diana was working at and build a 60,000 person stadium in just 2.5 years, not even started yet. This is supposed to happen in a country where even building a few hundred homes for low-income people becomes a years-long mess riddled with incompetent bureaucrats and shoddy workmanship. We hope they can overcome these obstacles and show off to the world what they can do.

White professionals are still leaving South Africa. The ANC government is trying to rectify the evils of apartheid by affirmative action, which means that white medical or law students have a very hard time getting a job. It's a bit odd to see a nearly all-white medical faculty teaching nearly all-black medical students; in a sense, it's a changing of the guard and the black people want their country back.

Medical school

The job hunt is probably even worse if you are a white construction worker -- it was the poor whites that the apartheid regime was trying the hardest to protect. Currently the highest-paid professionals are chartered accountants (a bit of a switch from back home), and a public-sector family physician might make $50,000 a year, a nurse $15,000. Given that these people are trained to a caliber at least as fine as any Western country, is it any surprise that they head abroad. Meanwhile, business confidence is high and businessmen and the world's wealthy are flocking to South Africa, where the economy is booming. The real estate market is truly insane, with the best coastal properties priced right out of even wealthy locals' reach. Our accommodation was in Green Point, a large and extremely wealthy gay white community, and the suburb of Clifton a few minutes down the Atlantic coast is an enclave of movie stars and ultra-rich. This is just as beautiful and temperate a place as advertised, and plenty of people are willing to brave the security risks to enjoy it.

Cape Town Map

Green Point

Clifton

APARTHEID

So why did apartheid come to South Africa, and how did it end? A very complicated question, but here is my short capsule history of South Africa (those who know, correct me if I am wrong!). Originally populated by elephants, lions and nomadic black hunters, the first whites to settle in South Africa were in a colony of highly religious and independent-minded Dutchmen at Cape Town in the late 1600's. These went inland and became settlers and farmers, displacing and enslaving the locals using their guns as Europeans typically do. They were soon joined by Huguenot French fleeing political instability at home. The Afrikaners, speaking a dialect of Dutch later evolving into Afrikaans, ultimately developed apartheid. Some joined a shadowy "Brotherhood" of sometimes-militant white separatists reminiscent of Nazis or KKK (for 40 years every South African president was a member of this group). How did such a perverse thing happen? Back in the 1700's the British established their own Cape Town colony, and predictably, given that they had the Royal Navy and the full support of the world's richest nation, the British soon dominated the coasts of South Africa, established cities, and drove the Afrikaners (Boers) inland into dusty inland farm country. Two Boer wars were fought, the first round won by the tenacious Afrikaners and the second won decisively by the British. There has thus been a big divide even among whites in South Africa, between the Afrikaners (often joked about as the less-educated, amusingly religious country peasants) and the wealthier and more cosmopolitan British. Both of these white groups used the local blacks as slaves and imported many others from central Africa, while Indian merchants set up shop in Durban on the Indian Ocean near home. The British did outlaw slavery eventually, but the system of having thousands of black men working the mines far from family for negligible wages was not much better day-to-day than slavery. This segregation of sexes (and associated prostitution, alcohol and drugs amongst the displaced male mine workers) is probably also responsible for some of the other social ills in South Africa today.

As the British empire began to collapse after World War II and other black populations in Africa overthrew their colonial bosses, the South African whites became anxious, afraid to lose the wealth and privilege they had accumulated . Apartheid was born, and voted into law by a majority of white people -- just 60 years ago, in 1948. This was a way to keep the black majority in check -- deny them education, deny them homes except in the Homelands (like Native reservations in Canada, occupying 8% of the land area of South Africa, and not exactly prime real estate either) and townships far from cities (now the source of much traffic congestion as the black people in the townships must commute long distances to work in the white cities). The denial of higher education seems to be what is mostly now crippling South African government -- despite the "scarce skills supplement" to their pay, the few educated whites who know how the water treatment plants or the power grid works are leaving for better paid jobs abroad, and affirmative action is promoting blacks who are part of the "gap" generations lacking proper education, into positions where much damage can be done. Whites can use the resulting examples of black incompetence to justify superiority and smugly say "I told you so", but of course there is nothing innate about this superiority, those "scarce skills" would be a lot more common if the education system had been structured differently. Just wait 30 years... It seems to me that apartheid was born of the fear held by the white minority that they would be trampled by the black majority if unchecked. Basically, the understandable wish for self-preservation, often admired in other contexts, lead the whites of South Africa, and particularly the Afrikaners who eventually cemented national isolation by withdrawing from the Commonwealth, into the perverse policy of apartheid. As someone married to a German I can say that, just as the Nazis were German but individual Germans were generally not Nazis, the same applies to the kind and civilized South African white people we met individually. If a social group is threatened but still holds power, what steps do its leaders take to meet the perceived threat? And before we get too holier-than-thou up north, what would Canadian and American whites have done if the Natives were, instead of a few thousand exhausted and weakened nomadic people, a vast group numbering 10 times the white population and whose labor built the country? Did we really behave much differently anyway? Native "reservations" in Canada, USA, or Australia seem a lot like black "homelands" in South Africa, and the marginalized people in these places experience the same depressingly familiar blend of poverty, HIV, TB, violence and despair. No easy solution to these problems, and no easy way to blame apartheid on "others", for any powerful minority might act the same given the chance.

Townships

How did apartheid end? I haven't read Nelson Mandela's "Long Walk to Freedom" (Diana has), but in brief, it seems that persistent nonviolent and violent resistance by the African National Congress (ANC), supported by the Soviet Union and encouraged by international boycotts, had a lot to do with it. Without Nelson Mandela, though, there might still have been apartheid today, and/or civil war. If you think of it, it is amazing that the whites finally allowed the massive black majority (10% vs 90% of the population) the vote and essentially their country back, without war or even that much bloodshed (hundreds rather than many thousands as in, say, Iraq). Nelson Mandela is like Russell Crowe in Gladiator, the prisoner who would be king -- after being in jail 27 years, shortly after his release he became a Nobel laureate and President. It was his civilized way, generous and without revenge or malice, and his extremely skilled and patient negotiations over decades which finally made white government officials including F W de Klerk see that the way forward was actually better by ending apartheid than continuing it. What a truly amazing man -- Abraham Lincoln of South Africa. Can you believe he is still alive and well and blessing students at graduations, revered as "Mandiba". Visiting Robben Island made Diana and I understand his impact and his greatness. As an example, he actually refused multiple offers of conditional release in the last decade of imprisonment, because he sought true freedom and a better life for his nation. Though let's not forget, unlike Gandhi, he embraced violence almost from the start as a means of resistance. This means George Bush would have called him a "terrorist" from the Axis of Evil, and look where that would have got everyone.

Robben Island

An interesting geopolitical tidbit -- the start of apartheid was closely tied to the fall of the British empire, and its end was closely tied to the fall of the USSR, since the ANC-vs-whites struggle was also something of a proxy war reliant on covert funds and rhetorical support from bigger Cold War players abroad. Thus we get oddities like the South African army withdrawing from Angola to avoid defeat at the hands of Cuban troops and planes! When the grand chess masters of the north tired of their South African gambits, the ANC ran out of money and weapons and the Afrikaners, crippled by worldwide sanctions, seized on this apparent weakness as a time for negotiation. Unintended byproduct of the sanctions and war: South Africans make excellent military equipment including the virtually indestructible Nyala troop transport vehicle that is now being made for Americans in Iraq and Canadians in Afghanistan.

Apartheid, with its massive segregation of blacks into crowded townships/homelands far from family and work, surely is the biggest single contributing factor behind South Africa's current massive social problems, but other factors are also at work. The violence and crime that pervade the society are probably due to the very steep slope separating the extremely wealthy from the desperately poor -- wherever this wealth gradient at its steepest, eg. in Rio de Janiero, Los Angeles or Washington DC, then violence and crime rise up like crashing surf, attempting to flatten the beach by redistributing the sand. And once the population has guns and violence is bred in, like a bear that has learned food in campgrounds is tasty, something turns nasty and you can't go back to quite the civilized peaceful society there might have been once. And of course in South Africa, a country perhaps best thought of as recently post-war, there is the possible additional justification that a common criminal is still rising up against the white oppressor.

TB AND HIV

Health in South Africa is also in crisis, again due primarily to the inequities of apartheid and daily African life. HIV and TB are cutting the life expectancies of black South Africans to half that of their wealthy white compatriots. Some of those whites whooshing past the townships at 120 km/h in their silky quiet Mercedes are physicians on their way to private hospitals to treat wealthy whites like themselves. Why is the situation so bad, and what can be done about it? One thing to understand is the relation between TB and HIV. Tuberculosis, the "red snapper" under a microscope, is an elusive bacteria that spreads through the air (particularly in the cramped quarters that most poor people in townships live), is very hard to kill and requires a complex immune response to contain. Most people exposed to TB don't get very sick, just a flu-like illness, because the body's T-cells act with other immune cells called macrophages to identify and surround the TB bacteria in "granulomas", isolation wards within the body, often found at the apices of the lungs. If at any time your immune system weakens (stress, diabetes, old age or other illness), the TB bacteria can overwhelm the body's defences and produce severe and lethal illness, the weight loss and gradual death once called "consumption". The HIV virus, spread primarily sexually (via a lack of education, lack of rights for women who have no chance to insist on using condoms, and male promiscuity in a society which has historically separated male workers from their families for extended periods), unfortunately has its main effect on those T-cells which would otherwise be controlling TB. And since HIV takes so long (at least 7 years) to do enough damage to T-cells to cause obvious symptoms, "healthy" young men are out there spreading the disease widely amongst the women of the township. Really disturbing is the belief that if you have sex with a virgin you will be cured of HIV -- which leads directly to distressingly common child rape.

Misinformation about HIV extends to the highest levels of government. The current South African health minister recommends garlic, lemon and beetroot to cure HIV. Perhaps the fates are rewarding her for this bizarre stance -- she is currently severely ill in hospital with an undefined illness that required an urgent liver transplant (people suspect TB/HIV or alcoholism). This stunning lack of understanding of HIV among high government officials is widespread -- deputy president Jacob Zuma, on trial for rape of an HIV-positive girl, said he's unlikely to have caught HIV since he had a shower afterwards!

So, everybody catches HIV, which unleashes their latent TB, which then spreads further through the township, and an entire generation is dying of "consumption", at the doorstep of some of the most beautiful scenery and expensive homes in the world. White people catch TB from their black servants and laborers (in the newspaper: a white construction mechanic caught it from his black carpenter who always wanted to sit in the cab of the truck because he was having chills), and catch HIV from sexual indiscretions too. And because so many people don't finish their TB treatment completely, the bacteria develop resistance, and now there is XDR-TB (Extreme Drug-Resistant), for which the only cure is isolation until death, just like the sanatoria of the pre-antibiotic era. Diana saw plenty of MDR- and XDR-TB, and hopefully didn't catch either of these. This is all very frightening, since Cape Town is also either the 4th or 6th most visited tourist city in the world, meaning disease can and will spread from this city at the speed of an international flight.

TB articles

TRAUMA AND TWO-TIER HEALTH CARE

Like most countries, South Africa has a two-tier health care system. The best example of how this works is in orthopedics, as highlighted to us by an ortho resident over a delicious seafood dinner in Cape Town. Public-health orthopods are extremely busy 24 hours a day patching up trauma victims, related either to assaults or cars. The gunshot/stab/beating wounds are usually in victims domestic violence or other assaults that are part of the crowded and impoverished township lives. Cheap booze (a litre of wine is as little as $1.75 even in tourist areas and a beer costs the same as mineral water at the restaurant) and readily available drugs, including "tik" (methamphetamines apparently prepared by vaporizing across the spark in a broken light-bulb, making a "tik tik tik" sound), encourage the violence. Highway accidents are often due to drunk driving (if arrested for drunk driving apparently you will spend the night in jail sobering up then return to your usual ways). These collisions are particularly awful in South Africa because the roads are so good -- speed limits are 120 km/h, many are driving new or used Mercedes or BMW that can exceed 200 km/h, and because townships are far from places of work, thousands of township residents have to walk along the side of the highway hitchhiking. Thus the perfect storm -- drunk on cheap liquor, a businessman races home after dinner at 150 km/h and mows down an entire family of township dwellers who were crossing the highway and misjudged his speed. Key steps being undertaken by the ANC government are building overpasses, sidewalks and overhead lights along the highways. This won't stop the carnage though, as people don't like climbing stairs to overpasses. The other major source of deaths is collisions between minibus taxis, each holding 15 occupants without seatbelts; these routinely overtake other vehicles around blind corners. On the Easter long weekend alone, there were 181 road deaths in South Africa (47 million) -- adjusted for population, about 10 times as many road deaths as one would see in Canada.

Highways - pedestrians

Pickup truck full of people

The public-sector orthopod, then, is busy patching people up, with such a limited budget that the hospital can't afford for him to use the device that would actually fix the fracture properly. With this penny-wise and pound-foolish approach, a man with a tibial fracture, which if plated properly would heal so he could be back to work in a couple of months, is instead put in a cheap plaster cast. He now has a high risk of non-union with lifelong disability and may never work again (might have to resort to selling drugs or stealing from white people, you never know). The need for cheaper orthopedic devices and better funding is obvious. Meanwhile, the orthopod becomes so burnt out after years of grueling work at high personal risk (trauma surgeries are bloody operations and patient after patient has HIV, hepatitis C and TB) that he wants to go into private practice. After all, the government, far from allowing the surgeon to occasionally pursue specialist surgeries or go to conferences to meet colleagues occasionally, wants to send every orthopod into often remote township hospitals to be "bush doctors," much like going to war. But in private practice, there are far too many orthopods (all fleeing the miserable conditions in the public sector), all chasing too few patients (the aging white wealthy with their hip, knee and shoulder problems that can be fixed with fancy arthroscopic surgeries which are the most fun part of orthopedics in my opinion, or joint replacements, which are highly lucrative). Apparently competition here is so fierce that the private-sector orthopods resort to putting each other down ("oh, his work is rubbish, don't go to him") in a most unprofessional way. So there it is -- 20% of the patients have 80% of the money and are over-served by orthopods, while the penniless 80% of South Africans get barely adequate care from idealistic but burnt-out public-sector orthopods. This little drama replays itself in each medical specialty to some degree.

Triage rooms, bars on door

Physicians in South Africa might go into medicine with idealistic dreams of helping the sick, then train in the public sector where they do have to do a year of community service in a rural place and then enter residency programs where as "registrars" they have the idealism systematically ground out of them by years of struggling with inadequate resources against the overwhelming mass of desperately sick patients that never stop coming through the door. Sounds rough, doesn't it; no wonder many head for private practice or even flee the country for other western nations, where these English-speaking, highly trained and experienced physicians are prized as welcome guests for much higher pay. In fact, medical students from abroad often come to South Africa for the rigorous training and intense experience, particularly in emergency medicine and surgery. As a patient, if you are penniless you get the public system, and if you have any money at all you will buy into one of the literally hundreds of private health care insurers, ranging from extremely low-rent plans which provide effectively no coverage all the way to super deluxe plans for the extremely wealthy. Private health care doesn't necessarily provide better care, as pointed out by Roal -- for at a private hospital you might be one of twenty or thirty patients under the care of one experienced internist, but his attention turns many places and he might only physically be in house once a day, meanwhile at a public teaching hospital there are interns and house officers and students and staff onsite all the time. But the private system certainly offers a deluxe experience, much in the way that the "Postnet" courier service is more pleasant than the post office -- 3x the price but shorter lineups, faster service and a general lack of those pesky black people (a feeling that hopefully fewer and fewer people are allowing themselves these days). In Groote Schuur hospital, the public radiology department on "C" floor has a 1- and 4-slice CT scanner, crowds in the waiting room ands and some quite antique X-ray equipment, while upstairs in the private department (staffed by the same radiologists on different days), there are softly carpeted floors, flat-screen LCD monitors on the computers, and nicer viewboxes. Is the diagnosis any better on the private floor? Not necessarily…although sometimes, particularly in radiology, technology is critical. Radiologists on the private side do sometimes help out the public -- for example a private clinic graciously donated scan time on a 64-slice scanner for an important CT angiogram on a child with Takayasu aortitis, since none of the public-system CT scanners were fast enough to do the scan.

GSH radiology technical

CAPE TOWN HOSPITALS

Groote Schuur hospital (GSH) is one of the largest teaching hospitals in Cape Town, rebuilt to a capacity of ~2000 beds in the 1980's at about the same time as the University Hospital in Edmonton was built, with a similar layout including a mechanical floor between each "real" floor which means walking a lot of stairs. In the 1960's, GSH was the site of the first heart transplant in the world, and it is still a big transplant centre. But also in the 1960's, GSH had separate entrances and separate wards for black and white patients. The location is fantastic, backing onto Table Mountain with a panoramic view of Cape Town, close to wealthy suburbs and far from the townships. Parking is tightly controlled and if you can't get a pass for the parkade, it's not just inconvenient, it's unsafe -- you have to walk a few blocks outside the hospital at uncertain hours in not the best neighborhood, and incidents happen. I was told that one cause for these parking-lot muggings is that patients, once discharged, have no way to get back to their homes in the townships and get cash any way they can. Urban legend? Anyway, the hospital itself is spacious and comfortable, with lecture theatres and a snack shop, several eating areas and air conditioning. As a tertiary hospital, patients can't get here without referral from a secondary hospital, so the problems are highly filtered and patients very complex.

GSH separate entrances

GSH entry

Medical school

Diana's hospital, New Somerset Hospital (NSH), is next to the Waterfront, a vast tourist development of expensive restaurants, tony shops and an Imax theatre at the harbor surrounded by $400+/night hotels. The original yellow building is not in much use, and in fact a recent sweep was done to kick out the many vagrants who had started living in its corners and attics. The newer concrete monolith that is the actual hospital serves a mix of poor white and black people, with a triage area resembling a large jail cell -- gates bar the way into the E.R., manned by security guards aiming to prevent gangs from finishing off the job on wounded assault victims. Nearly everyone at NSH has tuberculosis -- Diana's medicine team admitted ~12 patients per night and 10-11 of these would have TB, most also with HIV. Most people deny that they are HIV positive, or say they "don't know", because of the social stigma associated with it. The polite euphemism for the medical charts is "RVD+" (RetroViral Disease). So overwhelming is the burden of TB that there is essentially no isolation -- a patient with multi-drug-resistant TB (MDR-TB), who in Canada would be isolated in a room with negative pressure ventilation drawing air carefully through a safe path and examined by a team wearing special masks, gowns and gloves, in South Africa is probably in a common ward room with 6 other patients and the medical staff don't even bother with masks. But relax, almost everyone else in the room has TB already. A sample of the fluid building up beside the lungs is drawn from a large needle placed with virtually no precautions, just an alcohol swab on the skin.

NSH

- fortress, TB, chest tube

NSH is an urban secondary hospital, whose sickest patients (those without garden-variety HIV and TB) would be sent to GSH. The largest secondary hospital in the townships is GF Jooste, which is totally overrun with patients. In a typical night on internal medicine in the main Edmonton tertiary hospital, a resident would admit 5-10 patients; at Jooste, it's 30 patients a night, many with a complex mix of HIV, TB, and side-effects from the multiple drugs being given for those diseases. Plus a wide selection of trauma. Luckily, Jooste is benefiting from government priorities, which are to "bring health care to the people" by putting resources into primary and secondary hospitals. This means Jooste, and rural hospitals like Vredenberg, 50 km from Cape Town, are getting new equipment and facilities, while the tertiary hospitals (which still serve mostly black people but which might mistakenly be thought to be serving whites since they are in white areas) are left with budget cuts despite strenuous opposition.

Jooste

Vredenberg

The South African government is trying to force health care delivery by a model quite different than in Canada. In Canada we have been centralizing care -- instead of having multiple peripheral hospitals, we'd rather have a very good ambulance system bringing people to central tertiary-hospital beds, where the best specialists rapidly deliver critical care and the patient, his problems "sorted out", then is sent to a step-down hospital for continuing care during convalescence. Here, the opposite is happening: the ambulance system and tertiary hospitals are both being gutted, with funding increases for the smaller regional hospitals. The rationale, quite honorably, is that everyone deserves a minimum standard of medical care and many South Africans currently have no access at all. But, the South African way seems to be being done without consulting the doctors and nurses -- it's just not practical. No one really wants to work in an isolated setting without proper backup and resources, and it is virtually impossible to fill most staff positions with anyone other than the most junior and least skilled at any of these regional hospitals. An example: Jooste has the nicest CT scanner in the public system in Cape Town, with 6 slices, but it only has staff to run it from 8 AM to noon on weekdays. If this scanner had been installed at GSH, it would be running 24 hours a day for the complex problems it is designed for, with the radiologists to interpret the images and the surgeons to act on the pathology. At Jooste, the only radiologist seeing the scans is a resident like me, 4 hours a day, and the cases with anything interesting get referred on to GSH anyway, after some delay. So it is a strange way to allocate resources -- almost as bizarre as the donation of a portable MRI unit to Jooste. The MRI sits in a locked room because no one knows how to use it, and anyway even if they could figure it out, it can only be used to assess knees and other joints for which no surgeons have time to fix out there anyway. One doesn't know whether to laugh or cry...

Jooste CT scanner

- politics - budget cuts

The Red Cross Children's Hospital is the main tertiary hospital not only for Cape Town but arguably for nearly the entire continent of Africa. Any child sick south of Cairo would ultimately end up here if sick enough. It's a beautiful place, not far from GSH. Between devoted staff, wealthy donors and the general sense that one ought to help sick children, they have been able to sidestep the latest round of budget cuts and the financial situation overall seems a bit healthier than at GSH. The hospital really has a great work atmosphere and it's a pleasure to go there.

Red Cross

RADIOLOGY ROTATION

My one-month radiology rotation was an absolute pleasure, as the residents and staff welcomed me warmly right from the start. Doing an elective abroad as a senior resident, one year away from writing the final exams, is in my opinion a much better choice than traveling as a medical student. One knows a lot more and can actually contribute (I dictated numerous X-rays, especially in the pediatric hospital, and did a CT arthrogram of the shoulder since that afternoon I was the person in the department with the most experience). Seeing a different patient group and pathology at this stage is a great way to "shake up" one's medical knowledge -- for example I now have a much better sense of when to include TB in the differential diagnosis, and also of how important it is to think of TB or HIV. Even trauma is different in South Africa -- the people here have figured out that stabbing someone in the eye is very effective at crippling them, and while I have never seen this done in Edmonton I saw two in the same morning in Cape Town!

As Qonita and I observed, it is also a pleasure to see how much we think alike as residents/registrars, despite training on the opposite sides of the world. In a sense we shone mirrors on each other's programs, and could see the strengths and weaknesses of each. For example, the Edmonton program is strong in musculoskeletal and chest radiology and nuclear medicine, while GSH is particularly strong in hepatobiliary, vascular/interventional and neuro-imaging. The GSH group is currently struggling with the loss of several specialist consultants but coping remarkably well, and (for the moment) the training remains as good as what I have seen in Canada. The residents (registrars) at GSH have a great deal of clinical experience, as they have a more demanding call roster than we do and I think a higher volume of cases, particularly X-rays. They are good at taking responsibility, since they don't review all cases with their consultants but only the ones they find difficult or uncertain. This is intimidating at first -- if you miss something on an X-ray and are confident it is normal, no one else will ever look at it. Back in Canada, a staff radiologist also looks at the cases that are done, so it's more relaxing for the resident -- you feel that at least if you miss it, someone else will catch it. But I think a senior resident benefits from this (after all, if I pass my exams in a year I will be the only one looking at almost all the cases). It forces one to think about what abnormalities are likely to be important and those which are not.

At the viewbox; TB X-rays; people

The GSH radiologists, like the South African radiologists I have met in Canada, have sharp clinical judgment. This is formed partly by the daily routine of a clinical meeting, where complex patients are discussed by the radiologists, surgeons and other specialists in a certain area -- e.g., hepatobiliary, pulmonary, vascular. I sat in on many of these meetings and watched some very good medicine happen, with radiologists often a close and valued part of the team making decisions. This role as respected and useful consultants is part of daily life and easily taken for granted until lost, as it often is in private or North American practice when the radiologist does the test and issues a report "in a vacuum". Without the constant feedback of the clinical meetings, the radiologist doesn't know what the referring physician wants to hear about in the report, and eventually that person loses respect for the radiologist, doesn't read the reports anymore, and maybe even tries to interpret their own imaging -- and then what is the point of being a radiologist at all? The meetings weren't always the idyllic mutually respectful sessions I am describing, with one in particular degenerating into a "test-the-radiologist" session. For this, the surgeons put up a series of films with little clinical history, which the entire surgical department had been discussing amongst themselves for days, and asked the radiologist to render a snap judgement -- then criticized the results and confirmed their stereotype that the radiologist is useless. The best clinical meeting I saw was the pediatric pulmonary meeting run by Dr. Pitcher, where everyone learned something from each other, patient care was the priority, and respect for everyone was in the air. That kind of working environment is worth a lot...

Clinical meetings

Unfortunately, other aspects of being a radiologist in the public system in Cape Town are not so rewarding -- chief among these being budget restrictions and the previously mentioned bizarre purchasing priorities which result in a woeful lack of proper CT scanners in particular. The MRI unit is almost the same one as we have at home, a modern 1.5 T Siemens unit, but there is only one. And while the pediatric ultrasound department is justifiably proud of an ultra-modern machine as good as any back home, the ultrasound used in mammography looks like it was built in World War II. Again, this sharpens your skills as a clinician and radiologist -- when it's hard to get a scan done, you really think about whether it needs to be done, and when the equipment is old and slow you have to be more careful about your technique. The registrars are also more adept at hands-on things, since they have to do all their own ultrasound scanning and start all their own IV's for CT scan contrast dye injections. The hands-on work can be hazardous -- two radiologists have caught TB recently, one case perhaps related to long and close contact in small rooms doing ultrasound procedures. The other case is almost certainly from doing "CT FNAB's" (Fine Needle Aspiration Biopsies). In these procedures, a long thin needle is placed under CT guidance into a mass within the lung, to extract a few cells for assessment under the microscope. If the mass is not a tumor it is usually a TB granuloma, and when this is punctured you can imagine the thousands of bacteria spraying into the air. No surprise, then, that the person doing a dozen CT FNAB's in a day, every week, would catch TB.

Equipment

INTERNAL MEDICINE ROTATION

Diana's experience in internal medicine was dominated by HIV and TB, in a very busy clinical environment. Dr. van zyl Smit (Roal) organized visits to Jooste and Vredenberg hospitals (the latter was a fine day trip which I also went on and which culminated in a delicious dockside lunch in Saldanha!) and some wondrous pathology was on offer. If you are proud and penniless and haven't got a car, it's amazing how sick you will let yourself get before finally seeking help -- often much too late for anyone to do anything. Fortunately, the government has recognized that antiretroviral drugs do prevent HIV, reversing an earlier stance that could be summarized as "let them die" -- and even life insurance companies have just agreed not to deny claims based on HIV status, as long as people show that they have sought treatment. Patients are very, very sick and the cases are often very sad; Diana often had weighty tales to tell at night and I was thankful again for my choice of radiology as a field. Roal and the incredibly talented Dr. Ntusi, a resident who should have been a Rhodes scholar in Diana's opinion, held the fort together and it was an intense and mind-broadening experience for Diana.

Saldanha

I.M.

- Diana's experience: TB, sterile technique, isolation, busy service, ER triage

ACCOMMODATION - WITH ATTEMPTED ROBBERY

Thanks to Roal's connections and efforts on our behalf, were were lucky enough to stay in the nurses residence at the New Somerset Hospital during our elective. This place cost one-third as much as the cheapest hostels and was at a fantastic location at the Waterfront, 1 minute by bicycle from the gorgeous coastal promenade of Green Point. Don't plan on staying there on your next visit though, because the whole hospital and residence are to be torn down shortly to build a massive soccer stadium for the 2010 World Cup. (This is a hot political topic -- they will spend billions on the facilities for the World Cup that many feel would be much better spent within the health care system or other infrastructure for the townships).

Residence

The fact that it is about to be torn down did lead to a few interesting problems during our stay. The place is half empty, with the medical students and nurses who usually stay there being evicted gradually, and security is lax. Because someone was repeatedly climbing through windows to steal laptops and phones, we kept our windows closed despite the heat. One afternoon Diana was off work early and was using the laptop in our room when the seagulls outside started making a crazy racket. Diana got up to look through the tinted window and was suddenly face to face with an agile black teenage boy who was clinging to the wall, trying to push open her window. She shouted at him and both he and she ran away from each other. And unfortunately this scary face to face encounter with a possibly armed thief was on an afternoon when I was at work until nearly 7 PM, so Diana sat for over 3 hours alone in the little room reliving the incident. I wished very much I could have been home earlier -- being together is much better than being alone at a time like that.

Robbery

We changed rooms to one that only a Ninja could climb into, but this led to further trouble as I managed to lose the only key to the new room. This was the same afternoon I dropped my camera breaking the lens filter (luckily not the lens!) and got a speeding violation via photo radar. We discovered that I had lost the key only at 10:30 PM on our return from the fitness centre. The night staff had no key, so we had to cram into a single bed in an on-call room on the top floor, without toothbrushes, awaiting the morning staff who hopefully would have a key. This was a stressful night as I was supposed to be at morning rounds at 7 AM and Diana was giving a Powerpoint talk, which was on our laptop in the room, at 9 AM -- so we had to get in right away. But, Fayza the morning person also had no key. Imagine a hotel where no one has a key to the room, no master key, nothing. So I had to pay a locksmith $80 (I talked him down from nearly $100) to open the thing. Basically he took a power drill and blasted right through the lock. I could have bought a drill for $30 and done the same thing myself! At least he came promptly, so Diana got to her talk just in time. People at work seemed skeptical of my explanation of why I was 2 ½ hours late...

The other issue at the residence was electricity. Only one power outlet worked, and we had cell phones, palm pilots, the laptop, two digital cameras and electric toothbrushes -- all of which needed recharging. We did what we had to do...

Electricity

AFTER WORK: TOURISTS IN CAPE TOWN

Wherever we went, we enjoyed the South African accent and expressions. Leonardo di Caprio drifts in and out of the correct accent in the movie Blood Diamond. Typical conversation:

- "Howzit?" (standard greeting)

- "My bakkie ran out of petrol." (bakkie = pickup truck. Seats 12.)

- "Shame! Sure I just filled it." (shame = pronounced "shayme" -- all-purpose exclamation, especially when you see something cute. For example, "my little one is 4 months old." "Shame!" Sure = pronounced "shore", also all-purpose)

- "Is it? Look, fill it again" ("Is it" = pronounced "izt", equivalent to "oh?" Many sentences start with "Look,...")

- "Pleasure!" (pleh-zhah; we wish people in Canada said this more as it sounds so good)

"Thanks."

- "Go well." (aka "Goodbye" -- a blessing which sounds conspiratorial and generous).

We worked out at Richard Branson's "Virgin Active" gym, actually a sort of social club for the wealthy gay white male population; the men's locker room has a spa and public shower area and let's just say that many men in there are flaunting what is usually discreetly hidden. The women at that gym may or may not be pleased with how little attention they get! The main benefit of our month-long membership was the chance to meet Greg Lemond, who came for the big bike race at an exclusive and not-well-publicized autograph session just for Virgin Active members. Diana and I had a nice, long, relaxed talk with him, and both came away much impressed. He's a very friendly, down to earth and charming guy, handsome and fun, and just a pleasure to talk with. If only everyone famous was like that!

Virgin Active

Greg Lemond

Dinners were at the waterfront tourist area, a tourist trap but definitely worth a visit anyway. Some tasty restaurants including the pancake place (Afrikaans = Dutch = lots of pancakes) where I had three entrees and a dessert one hungry evening, to Diana's embarrassment, and a nice relaxed safe feeling, as well as the usual spectacular views. It seems like many cities are developing these waterfront or harbor areas as central gathering places in the past decade or so, a type of urban renewal which I love because it makes places like downtown Baltimore, previously a threatening and dangerous place, into a tourist dining and entertainment destination that becomes the face of the city to visitors. Back home, Calgary (Eau Claire) and Winnipeg (The Forks) have this while Edmonton does not -- yet.

Waterfront

If we took a left turn from the hospital gate rather than rightward to the waterfront, we could cycle along the Green Point to Camps Bay promenade, with gorgeous west-facing sunset views of the Atlantic Ocean from the twisty Cliffside road. We cycled and walked here, I jogged, and we swam at a really lovely pool frequented by models doing photo shoots and costing just 10 rand ($1.70) per entry. At or after sunset we often enjoyed dinners at oceanside restaurants. For our one year anniversary I treated Diana to sushi dinner at a Green Point restaurant with a spectacular sea view, and it was lucky we did this then because a week later the restaurant burned down, probably due to arson.

Green Point, Clifton

Green Point Swim

South from the hospital, just a 20 minute drive down an expressway during weekends or off-peak hours took us to Muizenberg, the perfect little town to surf at. Unfortunately this was not something we could do weekdays, because with the very heavy rush-hour traffic the same drive can be 1-1.5 hours. Diana caught some waves and we particularly enjoyed the day that our favorite radiologist Jackie Kieck took us there. She also showed us Cape Point, often claimed to be the furthest southerly point on the continent, but in fact Cape Agulhas, the true furthest-south point is 300 km east of Cape Town. Watch out for the baboons here -- we heard a (secondhand) tale of a South African woman who actually had her bag stolen by one at Cape Point.

Muizenberg

Cape Point

Close to Groote Schuur Hospital, the Cecil Rhodes Memorial is a monument to imperialism, for better or worse; the view is spectacular, from the wealthy white suburbs to the seemingly endless flatlands. Unlike Rio de Janiero, where the slums are on the steep hills, Cape Town is like most other cities where the hills are for the rich. Throughout South Africa, each city on the map is surrounded by massive unmarked slumlands, which obviously contain many thousands of people and are full of activity, but without storefronts or many vehicles. I was particularly startled at Jeffrey's Bay, a small white surfing and holiday community, to discover the much larger black township just to the south, awkwardly adjacent to an exclusive gated waterfront resort development. This is the sad legacy of apartheid. The laws may have changed but the geographic and economic segregation continue. This pattern is familiar to Americans, for instance in Washington, DC where only the bravest white suburbanite would dare to tread in the poor black southeast neighborhoods. I have heard several white South Africans explain that "in many places it is the fact, only here they made it the law.'

Rhodes memorial (for views)

Townships

Cape Town has beautiful roads, originally built for the white minority and still fast off-peak, but now hopelessly clogged at rush hour like every other major city. Public transit is very poor in South Africa and if we had not rented a car we would have been very restricted. Locals often ride in "bakkies" (pickup trucks), 10 to the bed -- which could mean 10 dead in even a relatively minor highway collision. And the minibus taxis drive quite aggressively, creating lanes where none were meant. As more people become prosperous enough to get cars, roads are going to get much, much more congested -- a Los Angeles style traffic nightmare is on its way to Cape Town and apparently already affects Johannesburg.

Roads

The grandest thing in Cape Town is Table Mountain, the huge flat plateau looming over the city. This is over 1000 m high, so that the top of the mountain is at the elevation of Calgary or Banff and has similarly dramatic weather. We went up at sunset one particularly scenic day for some of my favorite photos of Cape Town.

Table Mountain

In a warm climate, a shopping mall can be much more interesting for the architect than in the freezing cold as in Canada. Canal Walk, a large suburban mall, is a gaudy and $overdone place with its own canal/moat (probably not just for decoration -- this would be helpful for security as most poor South Africans can't swim), bridges and terraces, with quite good restaurants. Long Street in downtown Cape Town is the funkier and more truly alive place to visit and shop, though dangerous at night particularly on its southern tip.

Canal Walk

Long Street

We found it easy to make friends and spent many nights over delicious dinners or at a "braii" (BBQ), enjoying good company in South Africa.

Dinner photos

Braiis

2. ROAD TRIP

The first phase of our road trip was, in a sense, aboard bicycles. Roal, Jean and their son Richard outfitted us with all the gear to do the Cape Argus Cycle Tour, the world's largest timed bicycle race, with 40,000 participants. Start times for the 109 km loop around the Cape of Good Hope were staggered by skill level, as measured in previous timed races, with the fastest going first (and some, just to show off, repeating the loop with the slower people who start 3 hours later). As international entrants we were placed near the middle. The gorgeous route includes the road to Muizenberg almost to Cape Point, then turns past Misty Cliffs (our favorite) and up along the Chapman's Peak road -- the longest and steepest hill, carved into the mountain and recently rebuilt from major collapse in rockslides a few years ago. The worst hill is Suikerbossie, only moderately long and steep but coming late in the race when it is hot and you are tired from Chapman's Peak. My mountain bike was slow in the downhills even with slicks and Diana wished she had a third chainring on her road bike for the uphills, but we were proud of ourselves for our 4 h 19 minute finish. This was ~16,000th place! If we lived in Cape Town we would do the race annually -- in a place where there is really only one season, endless summer, the Argus is a way of marking the years. Maybe in 10 or 20 years there will be many black participants -- this race was almost entirely white, and at times there was a bit of an awkward feeling as we realized we were part of a parade of white people riding on expensive bicycles past black spectators in a race where the entrance fee (400 rand or $65) is 15 days pay for many blacks working at minimum wage. Plenty of police were watching the race, not just out of curiosity...

Argus map

Argus start, cycling

During our elective we had a short road trip when Roal and Jean very kindly invited us to their "Jabulani" (celebration) vacation home at Betty's Bay, a 2 hour drive along a twisty cliffside road on the way to Hermanus. Their modest home is extremely well designed for more guests than you might think, and they own the adjacent property so no one can spoil their view. Plus you can walk along the beach to see the penguins!

Bettys Bay, penguins

When our month in Cape Town ended we hit the road in a 1.4 L Ford Fiesta for a 5000 km journey across South Africa. This started in the spectacular wine country just 1 hour east of Cape Town, and we lunched at Franzhoek before settling in for two nights at a very relaxing spot in Swellendam, a small town at the foot of a dramatic mountain range on the western tip of the "Garden Route" scenic drive. Lovely hiking and delicious bobotie (savory mincemeat with toppings including tomato, onion, banana and sweet chutney), and some of my favorite peaceful times on the trip. Although as a married couple we now generally book double rooms with ensuite bathrooms, we are still budget travelers, as we were reminded each time we visited the moldy bathroom at this little place, with its defective toilet and plugged shower. Otherwise, paradise!

Franzhoek

Swellendam

The Garden Route is some of South Africa's lushest terrain, with trees and grass just as green as in the BC coast. Lots of overdeveloped tourist traps, like Knysna, but also some beautiful little resorts like Plettenberg Bay where we stayed 3 nights for surfing, views and delicious dinners. Very prosperous, clean and safe-feeling.

Plettenberg Bay

This coastline has dramatic cliffs and gorges, where you can camp and hike.

Tsitsikamma

The surfing paradise of Jeffrey's Bay is not nearly as beautiful as "Plett" and has become a bit overdeveloped, with discount surf-clothing outlet shopping and so many seaside homes that one part of the beach should be named "Poop Beach", with mountains of fused excrement washing up on shore as if someone's septic tank exploded. But other parts of the beach are clean and many beautiful shells can be found. Our hostel was in a particularly gorgeous location "on the point."

JBay

Further east, the vast "Transkei" area, previously a large black "homeland", is a different place entirely. Hills are covered with small black-owned farms, and for hundreds of kilometers the road is filled with pedestrians and stray animals, the worst being the completely unpredictable goats. You would think it would make economic sense for even the poorest farmer to put up simple fences to keep his stock from becoming roadkill or moving to other people's farms. It would certainly be safer for drivers! The terrain is rugged, with the N2 highway climbing and descending multiple dramatic mountain passes. Packed minibus taxis passing overloaded trucks uphill on blind corners adds to the excitement. This was like visiting another country, more like Thailand, India or Vietnam than the rest of South Africa in terms of wealth and development. Just as rapeseed oil was cleverly renamed canola oil to improve sales, this area has been re-branded as the "Wild Coast" for tourism and you won't find the dreaded "Transkei" name on any modern map. Even the hostels are more rustic and wild out here -- at Cintsa we stayed in a gorgeous spot called Buccaneer's Backpackers, which has been in operation since 1983, ie., during apartheid. Great place except the state of hygiene is among the worst of anywhere we ever stayed, ants filling the sugarbowls (it's not the ants that bother me, it's the thought of scooping their feces into my tea) and 4-5 mm beetle-like insects roaming the beds, giving Diana the worst case of 'bedbugs' we can remember. The beachside horseback riding, including expert training in how to trot and canter, was fantastic though, and our stay was relaxing despite the itches.

Cintsa

Transkei

Our favorite spot on the coast was south of Durban, with warm water and a gorgeous little cabin in the town of Umtentweni just off the beach, perfect for long romantic walks and, if you are competition-ready, surfing in the powerful swell. The waves and beach were particularly dramatic since heavy tides two weeks ago destroyed most oceanside ports, shark nets and docks all the way along the Durban coast -- part of unusual weather throughout South Africa including strange Cape Town heat waves and torrential late March rains in the usually dry northeast. Global warming at work?

Port Shepstone

Due to dawdling along the coast we had to rush to our safari, driving 1000 km in one day north from the Durban coast to Kruger National Park in the northeast. The fact that this was possible in 11 hours driving shows how modern the roads in South Africa are (outside the Transkei). It was a beautiful journey across desert, plains and, surprisingly at the end, high mountain forests. The town of Sabie resembles Revelstoke, BC -- at 1100 m elevation, a lumber town with damp climate and cool nights.

Longest Day

Sabie

Then we began our four-day safari at two bush lodges, which put heavy demands on my two cameras as we (mostly Diana) took up to 400 photos daily. Also a pleasant time with mid-day siestas, plenty of time outdoors on the back of comfortable Land Rovers, delicious food, and total absence of cellphones and email. We would love to do another safari -- but we will need to save up, as these are expensive trips!

Home

3. SAFARI

The unique joy of a trip to Africa is a big-game safari. Once for the adventurous who would go into the wilderness for months tracking big game to shoot, a modern safari is as sedentary and easy to do as an ocean cruise. And very costly. At South Africa's national parks, the elephants, lions etc. roam free. You are able to drive around in the vast parks on paved or gravel roads, looking for animals, for just $30 per person per day, with chalets running about $100 a night. If you do it this way, as we did in Addo Elephant Park, you will definitely see wildlife -- deer, elephants, giraffes. But you would have to be very lucky to see a carnivore this way, and you will surely destroy your rental car if the roads are gravel. Still, at least this gets you into the park at a reasonable cost. If you can splurge, costs are from $225 per person per night at the cheapest private lodge (with electricity, ensuite bathroom with hot shower, 3 meals a day and two 3-hour drives near sunrise and sunset). For better food and deluxe lodgings, the price can easily quadruple before you even blink. Still, after nearly two months of being cheap, we "splashed out" and had a 4 night safari.

Both safari lodges we stayed at were in Timbavati private game park, which is a huge tract of land just west of the Kruger National Park with no internal fences, so the game roam freely. Within Timbavati there are at least a dozen private lodges such as Akeru or Gomo Gomo, each owning a portion (Akeru = ~2000 ha, G.G. = ~12000 ha). The guests at each lodge go for game drives on 10-passenger open Land Rovers, with a ranger with a rifle and a radio, and often a local bush tracker in front, to see animals. Unlike in the national parks, the rangers know where the animals tend to go, the trackers can find them in the bush with amazing skill, and the rangers are allowed to go off-road, using the heavily fortified front end of the Land Rover to bushwhack, knocking over trees up to 10-12 feet high in pursuit of big game. This sounds terrible but the effect of the Land Rover is probably comparable to two rhinos or three elephants walking the same path -- those beasts are very destructive.

Land Rover

Game drives

Bushwhacking

There is a lot of "bush politics" as when, say, a lion is spotted on someone's property, all the rangers from each lodge try to negotiate to be allowed to enter that property to show their guests the sighting. The lodges in the south part of Timbavati are very coooperative and share nicely, but the northern lodge Gomo Gomo is quite stingy -- which they can afford to be since they have the best land, with much of the water (where the animals go to drink). So, for example, we were sitting about 5 m from a rhino in Gomo Gomo land when someone came on the radio and asked, has anyone seen the rhino that was around this morning -- our ranger did not reply, which seemed selfish to me. All the guests and all the reserves benefit if everyone sees the most animals they can.

Two rovers facing each other

The first lodge we stayed at, Akeru, is beautiful inside and the food was amazing; we lounged in the "honeymoon suite" overlooking the watering hole and watched the warthogs wander by. After two days in which we probably gained two pounds each per day, and what delicious pounds those were, we went to Gomo Gomo, which has far inferior accommodation (plugged shower drain, two single beds instead of the luxurious king size four poster one, etc.) but was $150 per night cheaper and actually has a better location, on a beautiful river which is alive with wildlife all day long. Bottom line: if you are going to Timbavati for romance, a place like Akeru is excellent -- if you are going mostly to see the animals, Gomo Gomo is your best value in the park. Kerri the super-ranger at Akeru went to heroic lengths to take us to the best sightings throughout the park, and we are grateful for that, but it is just easier if you are in the right spot to start with. We were always amazed at how the rangers & trackers could figure out how to get back to the lodge, on twisty little bush roads that always look the same.

Akeru lodge

Gomo Gomo lodge

We started small, early in the trip with a visit to the Knysna elephant park, really a "petting zoo" of sorts, where we could feed and touch orphaned elephants who had been rescued from "culling" (lacking predators and now protected from hunting, there is an elephant population explosion in the game parks).

Knysna elephant petting zoo

Then off to Addo Elephant Park, which was great fun -- driving our own rental car through the many square kilometers of bush and meadows, we saw much more than we expected.

* "Will we ever see any animals?" -- 5 minutes into the drive we were rewarded with a sighting of a whole elephant family.

* Our arrival at this water hole in the little Ford scared away the warthogs and even the birds, but this bull elephant stomped in confidently, showing us he didn't care who we were, he was taking a bath!

* We parked for almost an hour watching this elephant family, the twins (rare -- only the third pair the park has had) frolicking in the field, the only sound the wind in the grass, the elephants chewing, and rumbling and trumpeting to each other occasionally. This was beautiful and idyllic.

* At sunset a huge herd of elephants gathered at the big watering hole; young males butting heads, matriarchs keeping everyone in line, a whole society.

* The next morning after a bit of rain, no one was out at all -- we saw only a few monkeys shivering in the dew. I suppose not even the elephants want to stand in the cold rain and hide under trees somewhere.

Akeru

Lions at night

The first night at Akeru, we got to see a pride of lions at sunset, which was exciting and then actually quite scary when they got up to go hunt and walked past us in the Land Rover - so close that Diana could have reached out and touched two of them as they passed by. For a moment I had visions of this being the last picture in the camera when they found our half-digested bodies... But that is overly dramatic. The animals in the game park seem to see the Land Rover as a type of large and noisy animal, too large to hunt but not dangerous to them, and generally ignore it. The only risk is if you stand up or leave the vehicle, because then you are seen separately from it and might be a tasty snack. For this reason the trackers come back from their exposed front seat to sit with the rest of us when we are looking at leopards.

Leopards

The second day was windy and cool, few animals to see, but it was a good night for hunting. That night a mother leopard and her son killed an impala and we visited them at the kill in the morning. Males usually hunt alone after 1-2 years of age but this one is ~3 years old and still with his mother. Not docile like the stay-at-home human male, he was very aggressively protecting his kill, hissing and growling at us and standing up suddenly to approach the vehicle, from a distance of just 5 metres, telling us to back off. This was also quite alarming. The reason for his anger became obvious later in the afternoon when we returned to find Batman the dominant male leopard lounging contentedly after devouring most of the kill. He had forced the mother and son away from "their" kill, because as Big Leopard In Charge he had automatic rights to it in this territory.

This behavior also happens with lions, and the Big Guy with the mane rarely actually hunts himself, just takes over the kills made by the female lions. (You should hear Diana's outrage at this!) That same windy night, a pride of lions had cleverly forced a herd of buffalo over a riverside cliff and made a big kill of 3 buffalo -- enough food for the 5 lions for a long time. The site was easy to find by looking for the buzzards, and once we got there, also easy to smell -- a day is plenty of time for the guts to rot and there was too much food for the lions to finish their plates. They were lolling around lazily like Dad after Thanksgiving dinner and we never did get a good look at the Big Guy's mane.

Lions

At Gomo Gomo, our Land Rover full of happy tourists was racing through the brush in hot pursuit of a fresh rhino sighting, everyone talking animatedly and laughing -- then suddenly as we rounded a sharp corner, we found ourselves against a riverbank, separating a herd of probably 15 elephants from their matriarch. She angrily trumpeted and stamped around in a quite intimidating display, and the rest of the elephants faced us in a solid wall of grey flesh -- quite unnerving and we wondered just what we had gotten ourselves into. Nothing to do but wait for them to calm down, and luckily the matriarch then got a strong urge to itch her flank, nearly knocking over a 20 foot tree in her enthusiastic scratching. Hilariously, a giraffe poked her curious head over the treetops, no doubt wondering what all the trumpeting was about. The elephants eventually wandered off, quite slowly, and we resumed our rhino pursuit. This rhino was also upset (tensions running high in that part of the forest!) and had just charged the last Land Rover to drop by, and apparently charged the next one after we left, but he just ignored us. The animals must want to be left in peace. Life is much better for the animals on a game park than the zoo -- they get to roam hundreds of square kilometers and live life nearly the way they would have done in the wild before, free of hunting and free to roam. The price they pay is putting up with the Land Rovers from 6-9 AM and 3-6 PM, on the days when they are unlucky enough to be spotted or tracked. They can hide and evade the humans too. Our best rhino sighting was actually two of them in an inaccessible field near the park perimeter fence as we roared away at 120 km/h on our way to the airport.

Rhino and elephant herd

Lion at night

Personally I enjoyed the giraffes, so elegant and graceful, and inquisitive and gentle. Even the big old dark male was handsome in his way. They sleep 5-10 minutes at a time, almost always while standing up.

Giraffes

The baboons were always an eerie sight reminiscent of humans. We got to hear them at night, mating with the males making a loud deep cry (apparently the female baboon buttocks become very swollen when she is fertile). Speaking of mating, apparently leopards only mate once every two years, and the act only lasts 15 seconds, but they repeat it every 5 minutes for 3 days!

Baboons

Our rangers were full of tales of questionable authenticity, to say the least -- like the one about the Asian man in Kruger park who had his wife get out of the car and stand next to the lion for photos, "just a little closer, honey", and ended up videotaping his wife being eaten by the lion -- a story the ranger finished by saying "but now the lions are tired of Chinese food..."

We gained much respect for the Land Rover, with its powerful softly grumbling diesel engine which could pull us up steep riverbanks with that surging feeling you also get on horseback, its remarkably smooth and civilized ride, and its surprising ability to be used as a battering ram pushing over bushes and trees when we went off-roading. This seems awfully unfriendly to the environment but the vegetation in the game park already looks pretty rough thanks to the vast elephant herds, and the damage from a Land Rover is comparable to that from 2-3 elephants walking beside each other.

Bushwhacking

The impala (small deer) have an interesting harem system. Some lucky males get to each run with an entire herd of females, any of whom he can impregnate during mating season. The leftover males who couldn't find the females congregate in their own bachelor herd -- a lot of horns in the field!

Deer

We saw plenty of other wildlife. And even if we didn't see anything, it was just nice to be driving around in, essentially, a 4x4 convertible in the wild on sunny African mornings and evenings...

Misc sightings

Sunset

The safari was a magical and often exhilarating experience and we highly recommend it, especially for honeymooners or kids about 7-12 years. The best would be a safari in an area of wide-open plains where you can see the animals from far away. South Africa is an amazing tourist destination -- not only the finest views, beaches, mountains and forests, but excellent roads, delicious and reasonably priced food, friendly and welcoming English-speaking locals. All that and elephants and leopards too! We hope you have enjoyed this lengthy travelogue, describing our unique medical and tourist adventure as nearly newlyweds -- once in a lifetime, we think. As they say, "Go well"...

Jacob and Diana

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