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Tugela Ferry is already beginning to feel like a dream and I haven’t even left South Africa. This last day in Durban has been like what astronauts must experience when they hang out on this side of the atmosphere trying to acclimate to re-entry from space. Within the world they exist but not quite amongst it. We are in a city where water and electricity flow and the internet connection is fast and shops and restaurants line the streets. It could be San Francisco or Los Angeles or Philly or any other place we might call home. But we are still in Africa, moving closer to home mentally until we start our physical journey back. The scenery is familiar, even if the town is not.
This Is Not Malibu by Meghan Ramsey
It is hard to believe that I may be experiencing culture shock, but I think that is what I felt on my walk about town today. The vervet monkeys in the park seemed less surprising to me than the shopping mall where Shant and I ended up, buying bottled water and a cookie at the espresso stand. Even he was not sure of what to do with the choices of dessert displayed before him, having gotten used to a carefully doled out supply of gummy vitamins that I had brought with me and used as “treats” to facilitate or reward desirable behavior. We are back in a world of plenty. A world of manicured beauty. A world where illness is neatly contained in tall white buildings set apart from the rest of the scenery.
I feel afraid that with coming back, I may forget the patients who have made me weep and triumph over the last five weeks. I fear being preoccupied with things that I easily lived without, taking on a monstrous importance and replacing the raw human experiences that I was free enough to feel. I am not sure how to hold on to that right now, seeing how even today I felt swept up in the buzz of the city. It concerns me, and makes me slightly uneasy here. I am longing for belonging to somewhere just perfectly, but it seems further out of reach than when I arrived.
Two sunrises remain until I figure it out which I suspect in all their promise and clarity, will not be enough. In some ways the end of this journey marks my new beginning.
This clinic week passed faster than I thought it would given how anxious I felt to be done. I mostly enjoyed my last interactions there, and seemed to forge an even stronger connection with my interpreters and returning patients, whom I now can recognize. By yesterday afternoon, I finally felt comfortable as a clinic doctor, and somewhat satisfied with my brief weeks of service. I exited clinic on the last day like it was any other, not wanting to draw out goodbyes. Although I know I will be back to South Africa, I am not sure in what capacity or where, as this experience has upturned many of my beliefs about myself in the realm of global medicine. There are parts of it that suit my personality and lifestyle inclinations to an ideal, and others that leave me terribly frustrated and unhappy. I will have to attempt some reconciliatory reflection if I ever return as a clinical doctor here or in any other resource-poor setting so far away from most of those I love. It is humbling to consider that I just do not have what it takes, or to admit that my priorities will forever be elsewhere.
The final few days in Tugela Ferry went in a whir of last minute social gatherings, hospital visits, and goodbyes filled with promises. Sara successfully mastered the impossible feat of getting her photographs printed and distributed to the traveling nurses to deliver to patients who had sat for her portrait series. They were received like gifts of silk and gold, frozen moments that captured their beauty and defiance in the face of AIDS and TB. Meghan and I finally braved the COSH men’s soccer team practice, challenging the much touted cultural belief that women do not belong on the pitch. We ambled up to the rocky field set at the base of the mountains and faced ten South African men with part bravery, part ignorance of such ludicrous notions. The friendly reception and coaching we had during our match defied every sexist superstition we had heard about soccer in this part of the world. Leaving the field, I regretted not having joined the welcome crowd sooner.
We Are All Sisters Here
Even Match
Game Changer
Match Point
Shant has not quite been himself these past few days which has been difficult for him and the household. This afternoon he finally succumbed to the febrile illness hopping its way through the doctors’s children on the hospital campus, just in time for a tearful goodbye to Peter and Salomie and our car ride to Durban. Forty minutes into the three-hour trek, he went pale green and subsequently vomited all over himself, sending his gag-happy seatmate Sara into dry heaves. As if Meghan and Sara haven’t already unwittingly taken on a disproportionately intimate and involved role in parenting, they claimed the prize at the gas station where we cleaned up the mess my feverish son had released over upholstery and baggage alike. With our suitcases, along with a change of clothes and the children’s Tylenol in another car heading to Durban, we had little to work with to clean up Shant and the vehicle well enough to make the remainder of the trip tolerable. While I gave him a puddle bath in the gas station toilet, Meghan and Sara dutifully removed everything from the backseat and proceeded to mop it up with a dwindling supply of baby wipes. Sara, looking peaked herself at this point, occasionally came up for air as she scrubbed the wipes to tatters. A clown-car rotation followed midway through our departure from the gas station when it dawned on everyone that Shant’s illness was getting to the degree of concern that required a parent by his side. I relinquished the driver’s seat, and Sara her comfortable place as backseat concierge, and Meghan took the wheel. Without medicine or much else, I had only my hand to offer my burning listless son, and the occasional swipe of his forehead with the only cool thing in the car, the all-purpose baby wipe.
We have finally arrived in Durban, our last stop before flying out Monday evening towards home. Shant grudgingly took some Advil after accepting my chocolaty bribes. He willingly stood under the shower until the smell of bile came out of his hair and has settled into an evening of spiking temperatures intermixed with fitful catnaps. He keeps mumbling to me that he wants to go to San Francisco and no longer wants to fall asleep in Africa. I have worked out a deal so that he agrees to three more nights, and it seems to have set me back a hefty amount of chocolate Smarties. For now he is a quiet damp lump sharing my queen bed in this eclectic guest house called the D’Urban Elephant. It’s a modern-day caravansary, and we the weary nomads.
From high on the hill overlooking this coastal cityscape, a strong breeze is pulling clouds past a yellow moon. It reminds me of the one that greeted us far up in the Tugela Ferry sky what seems like a much longer time than a month ago. Time passing here has had a different meaning for us, having experienced every moment in painstaking stillness. I understand how Shant feels at this moment. After any long trip away from home, right before the journey back, the days start to stretch to eternity. This is the moment where it seems most important to be where you are, and feel it. There is more than patience to be gained in this long goodbye.
Still Moon City by Meghan Ramsey
I just want a different taste, Dzov. Please.
I have taken to heart Sara’s earnest plea from weeks back in considering my nightly meal preparation. In a place where work days are so hot and harsh and coming home inspires a yearning for comforts not quite as readily available, mealtime represents more than just fueling one’s body. It is re-feeding time for the soul. With our staple ingredients being a brief rotation of starches and an even more limited supply of the local fresh produce, it has become more challenging every week to remain creative, and to offer a different and satisfying taste to our hungered spirits and stomachs.
Our evenings have sunk into a predictable routine of communal child-rearing and tending to hearth that makes me seriously wonder why more cultures don’t favor having multiple wives. The honest truth is, I have not been alone in caring for Shant, as the labors of that love are divided amongst the three women who live here with him. Meghan and I have come accustomed to staggering our lunch breaks from the clinic in order to be around Shant at midday when the hours away from mama start to accumulate. In the evenings, Sara usually gets home before we do and relieves the nanny, joining him outside to kick balls and trample ants like he is used to. She calls me at clinic and reassures me that he is well and to not rush trying to get home. This rise to action by my two generous roommates has been from their own volition. I have never asked either of them to tow a heavy line in the care of my son but they are both sincerely invested in his wellbeing, and it seems in mine.
Mama's Socks-Dressed by Aunt Sara
Shant has been testing my limits in logarithmic frequency in our final weeks here. I am crawling to the finish line of this parallel marathon, preoccupied by his happiness and safety and well-being while trying to offer him an otherworldly experience. I wish I could say it was Angelina-effortless. I wish I didn’t feel as raw and impatient and ugly as I sometimes do. I wish he never had to see me exasperated, or as exhausted, or on the edges of melting down alongside him, not certain of what I am saddened by. But my reality is that I am spent, and occasionally I run out of reserves. On evenings like this one, Meghan and Sara carry a disproportionate load, and they don’t get the recuperation they deserve from their arduous days. We pool our resources and become mothers of Shant and guardians of one another, and no one gets to exhale until the boy sleeps peacefully.
Having a Ball
Stand-Off
Between denuded knee scabs and over-tired tirades and behavioral impasses with excited playmates, I managed to get dinner on the table and ourselves around it and we ate in soulful meditation. Sara mostly with her eyes closed. Meghan in perfect silence. Me with my head in one hand and the other on Shant’s dinner plate threatening a tumble. We are a sight to behold this forceful tired tribe.
Sometimes the best thing to share is a friend’s fatigue, thereby diluting your own. I am grateful that my days here end with the challenges that my spirited child presents before me even though there are moments I am unsure how I will do right by him. I am equally thankful that precisely then I am flanked by two friends who effortlessly intervene, and change the flavor of my maternal desperation to something less shaming. It leaves me too, with a much welcomed different taste, and the strength to get through another unpredictable day.
We experienced a part of South Africa as yet unfamiliar this past weekend. In our usual Friday afternoon scramble, we made the breathtaking ascent through a mountain pass amongst the Drakensberg peaks followed by a gradual descent into a valley unimaginably more picturesque. The last sixteen kilometers of our drive into the artsy village of Clarens, now characteristically done as a race against the setting sun, were through Golden Gate National Park. I liked the name before we passed the entrance gates. I loved it as we exited. As if golden gate were meant to describe a place you dream of going to, and can’t believe you are there when you arrive. A place of freedom, promise, and lofty dreams, all expressed in the landscape. Imagine the bright orange crumble of the Grand Canyon, turned inside-out and carpeted in green. Hang up an endlessly blue sky with three-dimensional layers of kindhearted clouds in pure white. Suddenly there exist two crimson portals paving way to my heart, on opposite sides of the globe.
Free Sky
We arrived at our cozy rental home at the base of the dramatic Maluti Mountains and celebrated a standing shower with as much joy as the postcard backdrop off our covered patio. For the first time we were able to walk outside after dark, and gleefully strolled the seven minutes into town for an evening meal. I felt an appreciation for the freedom to use my legs for further than the fifty meters to the hospital, and to be able to do it in the sweet night air by the light of a half-moon. We sat near the door of our restaurant sipping a celebratory South African Pinotage in honor of Sara’s newborn niece as Shant ran barefoot on the large field outside, stopping to make friends with curious locals. We poked into a cozy pub on the way home, intrigued by its festive music, and ended up dancing with the locals to the strummings of an energetic fiddle-and-guitar duo. It was a night to remember and revisit years from now when the memory of this difficult journey is encased in bronze moments like that one.
The weekend was atypical for our time in South Africa, without the stresses of our usual inconveniences, food access issues, safety concerns, and commercial shortages. We could have been walking through the coastal art galleries of Carmel-by-the-Sea, or eating our way through the sidewalk cafes of Sonoma in summertime if not for the hint of Afrikaans in the people and flavors around us. Clarens is far east in the province of Free State, formerly known as Orange Free State, to represent the home region of the Dutch-descendant Afrikaaner people. It is a whiter South Africa than we have ever seen, and felt less trying of an existence than KwaZulu Natal, but nonetheless moving . After two days of prying apart Shant and his new friend Zoe, the daughter of a documentary filmmaker friend of Sara’s who joined us from Johannesburg, as well as three sit-down meals a day of a different flavor and global origin, washed down with delectably foamy cappuccinos and a much needed foot massage and pedicure, we were recharged to make the 380-kilometer solar marathon home.
Lord of No Flies by Meghan Ramsey
As if KwaZulu Natal wanted to welcome us back with a reminder of what living in the real South Africa represents, our car hit the umpteenth pothole at just the right speed and angle to divot the rim and pierce our tire on the final stretch to home. I felt the steering wheel lilt to the right and heard the flapping of deflated rubber meeting strips of asphalt connected by large circular absences of it. As luck would have it we were five kilometers from Tugela Ferry, and Theo was kneeling at the flat within minutes of our phone call. We watched him replace it with as much finesse and efficiency as the countless emergency C-sections he does on a monthly basis. Work training for life, and vice versa.
Pit Stop
I awoke early with a newfound motivation to get through this my last working week in South Africa, for now. This is the final five of a marathon. I am on the other side of The Wall, having hit it and staggered through the last two weeks now thankfully behind me. My day in clinic started late and went without a break until after five, and for the first time all month I could have kept going. It must be because I can see the finish line, and have finally gotten my steps in sync. I bemuse the fact that this comfort and facility has arrived when it has, at the moment I am packing by bags. It reminds me of most other difficult periods, which seem to break up the moment I feel I can finally live with them.
The time to move on is coming near. I am starting to enjoy myself here.
It did not occur to me that KwaZulu Natal knew of St. Valentine. So I was surprised at the giggling of my interpreter today as her phone jangled text after lovey text from her boyfriend far away. Some of our patients were wearing red in the spirit of the occasion, and for once I appreciated the distraction from an otherwise colorless interaction. I might have also been struck by Cupid’s arrow by the infant son of a returning patient who has come to be the face I want to remember from my work here. She is strong, stoic, and healthy. She has buried her husband from the disease she is successfully fighting. Her heavy green dress is her mourning costume for the next three years but does nothing to weigh down her determination for life. And the chubby baby on her lap who I cannot help but snuggle is HIV-free because she did everything right to protect him. She represents the best case scenario in a sea of sad outcomes and she makes me want to remember her above all else when I leave. In a moment of understanding we exchange as mothers, people, and doctor and patient, I share that hers is the face I will take home with me. She reveals a modest understanding smile, which I am able to capture with nothing but my mind’s eye.
With Mother’s Permission by Sister Jabo
There are somethings I obviously cannot take with me when I leave. But the spirit of most everything luckily fits in the luggage of my heart.
Flat Stranded by Dzovag Minassian
Due to major potholes on the information highway running through Tugela Ferry, we regret to inform you that the weekend getaway post will be delayed until we are able to patch together some internet connectivity. We suggest you, too, find a quiet corner.
Siyabonga-
Red Chair Radio, reclining
It was one of those days where my patience and courage were openly challenged from all corners of this little universe. Ongoing new nanny misunderstandings, a queue we could not ‘kill’ in clinic, a toddler who refused to be anything but difficult. To boot, our internet stopped working. Apparently we have used up our allowance for the month and it being after five, there is no one official to help us figure out how to reconnect. As I type, my cell phone SIM card, which a good neighbor helped us install into the router, and for now is miraculously functional, is counting towards zero Rand by Rand.
To connect in one way I have had to unplug in another. This is becoming quite the theme.
It was a pediatric day. One sick child followed the other. I cannot help but want to escape clinic faster to get home to my healthy one. I see him in every little pair of tiny hands I hold. I am unable to unplug in this domain. On evenings after work days like this one, I am conflicted when Shant challenges my ability to stay reasonable. I feel guilty towards all these children if I fail. After tending to those who are not healthy enough to test their parents’ resolve, here I am upset that mine can.
If you want to remember how vulnerable they are, just look somewhere on their body that shows their parts. The tiny veins in their arms or neck, their little ribs, their teeny flickering pulse. It will disarm your maternal rage when you are reminded of their fragility.
A dear friend of mine and mother of three gave me this brilliant piece of advice at a low moment of mine in early motherhood. I use it often to size-down my tiny challenger, and it’s a tender disarmament every time. Here I notice veins and ribs on every child and it has redundantly frayed me.
The little boy from last week who had fallen off his growth chart (see The Plunge) has died in the pediatrics ward. His lab results came back today and my interpreter shared this news in the middle of my exam with another child. I lost my breath. My concentration. And just gazed at her in horror.
We do our best. That is all we can do.
That is little consolation to me now.
I put Shant to bed early after his fifth meltdown of the afternoon. In the dark we lay there, in a battle of exhausting wills- me fighting off sleep, he resisting it. We are nuzzled up close, face to face in the dark, his hands are sandwiching mine.
You tired Mama? My tired too. Let me hold your hand.
I feel his tiny pulse, regular and reassuring.
There is nothing more we mothers need today.
FYI, car stopped in middle of nowhere. I think dead battery but I can’t understand. Sisters working on it. I guess I will find my quiet corner.
The text from Sara this morning summarizes the experience and sentiments of many of our moments throughout the day. In stark contrast to the American way, where information is abundant and time is sacredly parsed to pieces, the Zulu way is to suspend both. Information is shared on a critically need-to-know basis, and time seems to be a mere suggestion of itself divided into morning, afternoon and night- not hours or minutes.
Sara sat for many of both on the side of the road while the TB injection Sisters tried to tinker with a dead engine. At some point they alerted her to their obvious car troubles when they needed help pushing it for a rolling start. After several failed attempts, a single Sister walked off into the nothingness without any indication of where she was going. At that moment my phone call found Sara.
I am channeling my Inner Zulu, Dzov. I don’t know what the hell is going on, but I am going with it.
If channeling one’s Inner Zulu were a sport, this household would be Olympian, and the ARV clinic the Coliseum. Meghan and I arrive every morning with the predictable intention to see the throngs of patients piled up outside. Every morning we perform a decathlon of events to find an interpreter. Getting the head Sister’s attention, often interrupting her tea-time. Following the string of Zulu commands that she splatters to the crowd of staff around her. Scanning each face for a sign of recognition of who are the designated interpreters of the day. Following those around in turn until they acknowledge our desperate presence. Corralling one into a consultant room and cornering him to take a seat. Requesting that she call the first patient. Initiating the interview when they are good and ready. We break a sweat before we ever begin the main event.
Twenty minutes of Zulu conversation between my interpreter and patient this morning before I got to say hello.
How is she feeling?
She is fine. No complaints.
I am pretty sure this patient was itemizing her somatic ails from the tip of her hair to her toes, at least if I understand some sign language. That all just got distilled down to ‘she is fine.’
Come in, Inner Zulu. Do you copy?
Towards the end of the morning, the waiting room was surprisingly empty. No more clients for the day, we are told, confirmed by Sister after Sister. And Head Sister. I wonder out loud who all the people in the bigger waiting area are. I am told they are here for treatment only, no medical visit required. I know by now not to get excited at the idea of a half day, which sounds incredibly appealing given my developing carpal tunnel, my scabbing nose bridge from the TB mask, and my second job awaiting me at home, hopefully still taking a nap. But I have been down this rabbit hole before. So I sit still in my chair, and take my time with the last patient.
The waiting room is the soaking sand on a shoreline, and these patients are the waves. They tumble in predictably, with a lulling rhythm. As soon as I finished my last patient, another one walked past my door holding her charts. And after her another one. And after him another. They rolled in and out until my interpreter decided it was time for lunch, and sent me home for the same.
Meghan returned to the clinic well before I did. I called over to see if there was enough business for me to go back.
There’s three more out here. Doesn’t make sense for you to come. I will call you if it gets busy.
My lunch hour went by. I hung my laundry. Started packing some of my suitcases. I kept checking my phone to see if I had missed a call, reflexively twisting my left wrist to look at the watch I no longer wear. The trace elements of American in me felt an urge to rush back uninvited, just in case. The Zulu in me stayed still. At the end of the day Meghan pushed open the door, flush with sweat and frustration. The impression of her mask bore a fresh brand on her tired face.
They just kept coming. One by one. At any moment I would have called you there may have been no one to see. But there was always another one for me. I can’t believe they said there were no more patients hours ago. There are always more patients.
An ocean is not an ocean without its waves.
Sara finally got tired of her quiet corner and took her Inner Impatience meandering into the nearest village in search of portraits. In the middle of photographing a woman sitting in the kitchen, her subject paused the shoot to give her an update.
Your car is allright now.
In the distance the puttering of an engine finally turning over could be heard.
In the more advanced stages of one’s Inner Zulu, the stillness delivers everything you must know, when you need it. You just need to find a quiet corner, and wait.
Some days more than others it feels like we are in battle. Against the heat, Zulu logistics, the mosquitoes, and these diseases. Nothing comes easily, from dawn till sundown. At the end of the day this mobile home feels more like a barracks, with exhausted foot soldiers slumped around, sharing war wounds from a fresh fight.
We drove a new TB patient to her home today. I rode in the back of the car with her. She is pregnant and had come for pre-natal care and left with TB. Every time she coughed I held my breath.
I saw my first pregnant patient in clinic today. Just when I was getting a handle on seeing kids. She walked in with her belly and I thought ‘O God.’ As if I weren’t unqualified enough.
I started a pregnant woman on ARV’s today. She was seven months along. Her belly was like mine is now. I couldn’t even tell. I don’t even know which medications are okay to give her. I hope I was right.
Sara has been feeling particularly worn after weeks of life on the front line in the war against TB and HIV. The efforts of heart and body and faith and conviction that it has taken her to enter strange wards and homes to document these stories are beginning to show on her face. As a physician this frightening environment is my professional home and to some extent I am used to seeing illness and frailty. Although never quite comfortable, it no longer shakes me the way it did in early medical school. For Sara, this has been a new world of subjects, physical bodies and faces wearing every detail of the diseases that ravage them. It must be hard to study from behind a lens, capture, and revisit at day’s end time and again. Sometimes she does not even know just what gravity she is staring at.
There are nights Sara does not share her photographs, as she cannot pay her subjects another visit. And others she spends in pensive company with those who have carefully given her permission to unmask them.
Unarmed Forces
The war is on outside our flimsy metal door. It does not sleep, if we do.
I have not been governed by time since arrival to South Africa, so I was not at all surprised to learn from my mother that I had forgotten my father’s birthday. He would have been 78 years-old and a grandfather of five today. Instead he remains a revered husband and father of four young college-aged girls. Except that they are rapidly accumulating the thick white locks for which he was known, college being a long time ago for even the youngest of the sisters now.
Vartan Levon Minassian
Hayro never loved birthdays. Not his nor anyone else’s. He deliberately sabotaged our efforts to mark his occasion by changing the date of his to two days ago or two days from now, this time every year. To this day I am confused if his birthday is actually the fifth of February or the seventh. As it does not matter what day it is here, ever, I will choose approximately this one to celebrate my father’s life, and I will be right on time when I do.
Every day here there is a crowd of patients waiting to be seen outside the ARV clinic. The day of the week, date or time are all irrelevant. Each patient comes when they are out of medication or when they have a problem and waits until they are seen. If I show up late to clinic, they do not go away. If I show up early to get a head-start, more of them appear in the afternoon. Meghan and I have stopped looking out into the waiting room to count the remaining people in chairs. As soon as it empties out, it repopulates. Appointments here are with fate alone.
My father was a patient man with everyone but himself. He demanded a level of precision and perfection in everything he did, and knowingly transmitted that exigency to his children. For years I refused to believe that his pushing me was anything but believing that I could do better and having a great faith in my infinite capabilities. In my more recent reflections, I have learned with some reluctance that his overbearing confidence in me came at the cost of not teaching me patience or compassion with my own shortcomings.
Do your best and leave the rest.
I can do the former in my sleep. The latter I never learned how to properly accomplish.
Here, I am learning to let go. Of the idea that I am somehow able to tackle any obstacle or make life so much better for each individual patient. I am learning to accept that there are plagues and pains that I am not going to remove, and that most days my best efforts will get me a faint smile from a patient who won’t look at me in the eye, and will not feel appreciably better because of me. It is no longer making me as sad as it used to.
The only time I showed my father any grief about his terminal diagnosis a week before he died, he put his arm around me and encouraged me to cry.
There will be plenty of time to keep a stiff upper lip.
His death was over a decade ago, and even though the hole he left behind will never be filled, the sadness I feel is no longer the same. I have gotten used to a world without him, and embraced the light and life that has come my way since he left. I am learning a new forgiveness of myself when I meet the edges of my intellect, physical strength, or emotional fortitude. Shant, with his grandfather’s name along with his characteristic dimple and laughing eyes, gives me every reason to make peace with the passing of time, and of my father. And with who I am entirely.
He reminds me that the only moment we ever really have is the one we are in, whatever day it may be.
Filling the Hole- Shant Vartan Dorsey by His Mama
Happy Birthday Medzbaba.
