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Archive for September 2011

Runs before he walks

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Just six days after Karoo Lus festival-goers appeared to have wrecked the wicket at the Botanical Ground, cricket was played on it. Walking past each evening after work I’d monitored intensive therapy to the hallowed turf and on my way back into town on Friday a day/night Twenty20 match was in progress. So naturally I added a lap of the boundary to what had already been quite a long walk (for an evening) including an off-road climb up the ‘kloof’, along the edge of the karroid* plateau and back down. Three wickets fell during one medium-paced circuit making me wonder how much extra help the bowlers were obtaining post-repair. Incidentally for a small town club the Botanical Ground has floodlights that Eastbourne Borough would die for.  A Stadium Tour Guide would find plenty to say about them.

* adjective derived from The Karoo, the desert on our doorstep

On Saturday I was back for an entire Mossel Bay innings in reply to Graaff-Reinet’s 136. The very fact that this fixture exists impresses upon me the size of South Africa – they thought nothing of a 375 km, five-hour drive for a Twenty20 and a friendly match (M Bay camped overnight beyond the edge of the boundary). I’ll never grumble about getting Chris to an away match at Tunbridge Wells Borderers again. Speaking of Chris and appropriately on the equinox, as South African pre-season was under way, he was at the Eastbourne Cricket Club Annual Dinner, his end of English season black tie knees up. Southern and northern hemispheres moving in opposite directions as equinox passes.

Back on the Botanical Ground boundary, four byes off the first ball and ten from the opening over prefaced a straightforward Mossel Bay win. Although all catches were held and five wickets went down – including fortuitously my best ever sporting shot (below) – the wicket seemed to play true and 136 was simply never going to be enough. Enjoyable cricket banter on the boundary and, having completed the Mail & Guardian cryptic crossword save for one clue a week ago, this week I managed a paltry three answers between balls.

Sunday was dominated by the 14 km Eerstefontein Day Walk in the Camdeboo National Park. Setting off at 07:30 I had high hopes of seeing a variety of wildlife and was encouraged by an early sighting of a soaring black eagle. Fantastic, peaceful walk through the Valley of Desolation – it was quite a scramble in parts including ascents and descents so I was glad for my Zamberlans, walking boots whose usefulness I’d debated as I lugged cases through three airports. Plenty of insect buzz and bird song; regular lizards sunning themselves on warm rocks and a glimpse of two large brown backsides as kudu scarpered, startled, into the bush but little else to report. It put me in mind of the Gary Larson cartoon below (blog continues):

It seemed as if there was a conspiracy amongst the local fauna… and then there (s)he was, ambling down the Eerstefontein Walk towards me: the elusive leopard tortoise. Weirdly I said “hello” as if I were Johnny Morris – without, I hasten to reassure you, doing a ‘tortoise voice’ back to myself. It was my first ‘conversation’ since breakfast. Having set off in cool morning the car thermometer read 32 degrees when I finished just over six hours later.

A national park day pass allows multiple entries so the bonus this evening was a drive around the Game Viewing Area for an hour and a half as the sun sank and the sky over the mountains turned orange. Ostrich galore, springbok city; eland, wildebeest, Cape buffalo & mountain zebra and for the birders: an eagle owl and a pretty pair of blue cranes.

 

Cricket gorgeously located In Graaff-Reinet                    Jonesy captures bails flying

 

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September 25, 2011 at 6:17 pm

Planting seeds

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When you plant a seed, it decays a little before it sprouts

(Jonas Gwangwa, jazz trombonist (associate of Hugh Masekela & Miriam Makeba) in last weekend’s SA Sunday Times)

I’ve spent the week gaining a strong sense why this is a three-month assignment. Maryna and I have been busy planting seeds in our clinics and are keeping our focus on the end of November – and beyond. In the process we’ve been perishing: the clinics are unheated and the temperature driving to work 7 degrees centigrade – that’s before the windows are thrown open to disperse TB. The jumper that I threw into my suitcase as a last-minute afterthought has proved necessary indeed.

As we promised the staff – did they interpret this as a threat or a promise, I wonder? –  we have spent three days in the Graaff-Reinet primary care clinics. We’ve committed a regular day a week to each with the goal of getting every NIM-ART-trained sister into mentoring in order to have initiated antiretroviral therapy by 30th November.

Today was different. Although I start each day at Ithemba HIV clinic I hadn’t previously spent a whole day there. It’s a nurse-led walk-in clinic from 07:30 in the morning so patients arrive in fits and starts. The sure-fire way to keep the waiting room empty though was for South Africa’s third Rugby World Cup match to kick-off in North Shore City Stadium, Auckland at 10:30 local time. It was just like one of those soccer world cup days when Fabio’s under-performers bring England to a stand-still as we all travel home in hope. Staff clustered around the waiting room telly to ensure that the next patient through the door would have immediate attention… somehow none materialised for an hour and a half… So all we could do was watch a Bokkies romp v hapless Namibia.

Returning to work, it’s interesting to compare two public HIV services 10,000 km apart:

Source of equipment Ithemba: USAID, items stickered “from the American people”.

First line therapy if CD4 <200 Ithemba: (with cotrimoxazole & isoniazid prophylaxis (IPT)) adds up to eight tablets; Avenue House (IPT not necessary): two tablets.

Adherence monitoring Ithemba: bi-monthly pill count in returned containers and discarding the unused pills – (look away now Venita (HIV Pharmacist in Eastbourne)) that’s a minimum of 24 days’ therapy per patient per year – Avenue House: viral load monitoring.

Patient pill recognition Ithemba: bi-monthly nurse demonstration of changes to pills’ appearance due to supply fluctuation between different generic manufacturers; Avenue House: consistency.

Frequency of review for stable patients on ART Ithemba: two-monthly with annual blood tests; Avenue House 3-4 times a year.

Integrated care Ithemba & Avenue House: HIV care separate from primary care. The (near) future in Camdeboo sub-district, Eastern Cape: HIV and primary care provided by NIM-ART trained primary care nurses.

As Jonas Gwangwa said of South Africa:

When you plant a seed, it decays a little bit before it grows. [] We achieved so much following the end of apartheid. Now we are going through some rot. It is this that bothers us: how long is it going to stay this way before we sprout?

How long is it going to stay this way before we sprout in Camdeboo? – Our target: three months. But we’re prepared to go through some rot first.

 

The discarded pills bin                                                         Inside the discarded pills bin

 

Free condom dispensers

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September 22, 2011 at 6:58 pm

Morning after the Karoo lus

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As you might guess, the South African media has swung back around to heap praise on the ‘Bokkies’ after they roundly thumped Fiji. I watched with my host, Pierre. The razzamatazz seems a bit too much when the thunderous Fijian Cibi gives way to the blandness of Black Eyed Peas’ ‘I Gotta Feeling’ on the stadium PA. Otherwise my third exposure to the oval-balled game in eight days was pretty enjoyable – not least for Pierre’s fan’s company. NZ seems to be putting on a good show despite a snippy comment in one of the weekend papers about longer traffic queues in Wellington than experienced anywhere during last year’s football World Cup in South Africa.

Sundays seem to be the longest days for me here but a good time to email, blog, Skype, idle over the newspapers… After the match yesterday I walked up to the ‘Karoo Lus’ a local festival on the cricket field – I tell you, the groundsman is going to do his nut when he sees the state of his unprotected wicket tomorrow morning. It’s been tramped and driven over for two days, leaving umpteen grassless, loose-dirt and uneven patches. I was reminded of Headingley’s ‘George Davis is Innocent’ desecration that caused the abandonment of England v Australia in the seventies. I had a tour of the stalls in the morning and took away a very good vegetable curry that I microwaved later for dinner. A nurse I’ve met at Day Hospital was displaying baby animals including amazingly a three-month old rescue zebra that children queued to bottlefeed. I returned to see what was going mid-afternoon and finally spent a mild-temperatured evening experiencing South African musicians live on stage.

For a small town’s local festival there were some impressively big names. Even if they’re not big enough to have previously registered on my radar I am reliably informed of their bigness. After an execrable Queen karaoke act, Afrikaans singer and self-styled wild boy Robbie Wessels was up. His band played a driving Proclaimers-like strumming, rock’n’roll while Robbie was a classical strutting frontman his spat out ‘c’s and ‘k’s as harsh as a death rattle in the Valley of Desolation, his grrrowled ‘r’s reverberating seismically over the cricket ground’s outfield. There were apparently some big hits – one song that caught my ear involved the phrase ‘Speedos and Crocs’ at the end of each verse, taken up repeatedly in the chorus (I just Googled: it’s on YouTube). The charmingly named Snotkop sang contemporary pop/dance to a backing track and to enthusiastic bopping in front of the stage (it wasn’t too hard to keep the Jonesy shuffle under wraps); South African Idol winner Elvis Blue followed but I turned in for the night after his first three numbers. It was a curious experience – echoes of sitting in clinics where many of the patients speak Afrikaans but no English. I felt at a distance, not understanding the lyrics but I’m keen to join in with anything that I’m invited to do – and I bumped into and chatted with several people I’ve met at work, making me feel that I’m starting to be a part of this community.

At the Karoo Lus evening I enjoyed my first beer for three weeks, a single Castle lager, its tin proclaiming support for the Springboks:

UNITING OUR HEROES – UNITING OUR FANS – IT ALL COMES TOGETHER WITH A CASTLE

No hyperbole there then. I haven’t exactly planned to be abstinent during my trip but am enjoying an alcohol-free / alcohol-low period – and my per diem won’t allow for it.

This morning, although apparently England had a World Cup game, I helped Pierre, Ria and Shaun (who works here) to clear up their marquee. This took four bakkie-loads, a ‘bakkie’ being South African for a pickup truck (UK)/ station wagon (US)/ ute (Aus & NZ) – you know this has an international readership.

Postscript on yesterday’s walking blog: this being Sunday and Sunday River running between Graaff-Reinet and the Mountain Drive I emptied my pockets, took 750ml of ‘Bonaqua pump’ (water) and had a relaxing if hot stroll to its furthest extremity and back. I was rewarded with a great white egret and a drive-past by the police.

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September 18, 2011 at 6:41 pm

What I think about when I’m walking

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I have two regular walks, both accessible on foot from my guesthouse in Somerset Street. The Mountain Drive runs for 4 km west of Sunday River defining the very edge of town. It’s where I met the leopard tortoise and a couple of octogenarian walkers – separately. It’s not ‘One Foot In The Grave’. There are sometimes other exercisers but none I have to immodestly inform you that demonstrate the power of Jones calves and thighs. I’ve seen vervet monkey, suricate (a small meerkat-like mammal), cape wagtail and other SBSAJs (small brown South African jobs) plus birds that I struggle to identify via Google images.

Since I step out straight after work the sun is already starting to hide behind the dolomite crags, koppies and kops. Trivia spot for those who didn’t know: Boer soldiers fought off the English from these koppies and kops in what is now known as the African War. When English football grounds, most famously at Liverpool, responded to burgeoning crowds by building mounds behind the goals to improve spectators’ views these were nicknamed ‘kops’ by veterans of the war formerly known as Boer.

Entrance boards at either end of the Mountain Drive absolve the authorities of liability for the usual list of risks including death. A few hundred metres from the northern entrance is a memorial to Erika, a police cadet murdered three years ago in an isolated attack that shocked Graaff-Reinet. I have checked: the perpetrator is serving a life sentence. But it’s hard not to get it out of my head despite assurances that it’s a safe route by day. Some of the women at work have raised eyebrows at my going alone while others are reassuring… So I carry no valuables and feel slightly relieved when I complete the walk. It’s totally unlit so I wouldn’t go there after sunset.

The alternative is along the R63, a quiet main road out of town towards small, isolated settlements in the Karoo. The view opens up beside the Nqweba (‘Meeting Place’) Dam and its reservoir. There are more walkers, it’s significantly less secluded and here I’ve seen rock hyrax (guinea pig-like mammal), yellow weaver birds, reed cormorant (I think) yet more unidentified birds and crickets the size of your thumb that sizzle past as I disturb their peace. I can turn around at the Gideon Scheepers memorial, erected in memory of a sickeningly young Boer hero executed by the British when he was finally prised from Spandau Kop above the town – or go further by climbing up the ridge, into the bush along a marked off-road path and back round to the dam.

It’s a tough call. I love the peacefulness of the un-metalled Mountain Drive and don’t want to be imprisoned by fear of unlikely assault: I tell myself, this isn’t Jo’burg or Durban. Walking on the Murraysburg road (R63) is like being on a lightly used A27: less natural, less fauna-filled and commensurately less relaxing. Except for that nagging looking over my shoulder when I’m emptying my mind on the Mountain Drive…

Pierre just came by to reassure me that walking alone is perfectly safe. Good old Pierre. He’s chipper since he and I watched Springboks knock aside a vigorous Fijian challenge straight after breakfast.

 

Mountain Drive looking west                                              Spandau Kop

Weaver bird nests

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September 17, 2011 at 4:18 pm

Settling into a routine

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The South African working day seems to be more or less in step with its twelve hours of daily daylight. I therefore breakfast before seven and am at clinic by 07:30… just as I would be in Avenue House. Any dietitans or nutritionists reading this might swoon over my twelve-fruit, yoghurt and muesli start (photo below). Five-a-day? Pah! After work I’ve been brisk walking on the edge of town for an hour before reliably early sunset, showering then eating out. Polka restaurant has a good vegetarian choice – I’ve mentined it in an earlier blog – and I know the names of Hannes & Carol-Ann (its owners – to his amusement I punningly named him the ‘sandwich’ in Jo’burg), Andre, Elida and Karl who all work there, an indication of its warmth and friendliness.

Between breakfast and dinner, Maryna and I have spent the week re-visiting the local clinics on their days of preference, attempting to solve a mystery. There appear to be surprisingly few HIV cases presenting for follow up in the primary care clinics. We were reviewing the HIV patient records in all three Graaff-Reinet clinics today. The clinics are surprisingly freezing: un-heated, with windows thrown open in accordance with the stickers on them:

Open this window!

Fresh air fights TB

It was baby clinic wherever we went with waiting rooms heaving – children learn to queue from an early age here – and, as always the nurses were working flat-out. A picture is emerging and we’ve got a data analyst colleague pursuing what appears to be a significant number of patients not seen in clinic for (sometimes well-)over six months, the requisite interval for monitoring here. And then there’s the incorporation of routine HIV testing in primary care where the lay counsellors will be able to help. We reckon that there will be some ‘quick wins’ and that once people with HIV are attending their local clinics and with Maryna’s mentoring and on-going support then the professional nurses will step up to the NIM-ART (nurse initiation and monitoring of antiretroviral therapy) plate. We’ve identified some great work to build upon and certainly feel very welcome. I’m already beginning to feel like a familiar face.

Enjoyed a pleasantly mad evening in Aa’qtansisi Guesthouse on Tuesday. Ria and Pierre (proprietors) are heavily involved in the weekend’s ‘Karoo Lus’, a celebration of local culture on the botanical field that’s expected to draw 10,000 visitors to the small town. Where will they all fit? It’ll be like a primary healthcare clinic waiting room. Or the guesthouse kitchen where ten of us crammed in for a jolly session of bag-stuffing. Unlike my previous experience which has  involved condoms, lube and safer sex pamphlets, this was with dozens of leaflets & cards for local businesses / attractions / etc. With a whole bunch of friendly women who dropped Afrikaans for English in my company and got steadily sozzled it wasn’t unlike being with a group of Terrence Higgins Trust volunteers in the Hart or a bunch of sexual health nurses anywhere: the conversation was  similarly unconstrained and laced with innuendo. A hoot of an evening during which I felt comfortably ‘at home’. I’ve even ended up with the offer of a motorbike ride up to Nieu Bethesda with Brian, an extremely experienced biker and leader of biking tours.

Watch this blog…

  

Breakfast                                                                                Horseshoe Clinic, Graaff-Reinet

 

Kroonvale Clinic Graaff-Reinet                                         Umasizakhe Clinic Graaff-Reinet

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September 15, 2011 at 7:22 pm

Tortoises and T cells

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Having gone thirty-odd years without watching a rugby match I’ve now watched two in twenty-four hours. Even I could tell that the Welsh Dragons were unlucky to lose against my current home nation, South Africa’s Springboks. With Argentina labelled ‘Pumas’ do any of you rugby followers know if England has a cuddly animal name? Watching with Pierre was great fun as he knowledgeably decried Springboks whilst praising Wales and he leapt from his seat like Bolt from the blocks when Hougaard flew over to score the decisive try.

After lunch I walked the nearby Mountain Road, ten minutes on foot from Aa’qtansisi, 8km there and back. At the furthest distance from home I met a tortoise eight times the size of Wendy Foy’s puny pets… and found myself camera-less. Not even a leopard tortoise moves so slowly that I could’ve returned with the Fuji. Straight after work today I power-walked the same route – this could be a handy gym-substitute – camera in back pocket… but the tortoises were hiding.

Also this weekend and for the HIV-interested readership I read this interesting film review in the Mail & Guardian that reflects the context in which I’m working: http://mg.co.za/article/2011-09-09-tshirts-tcells-and-triumphs/

My mentor nurse Maryna texted to say that she was going to be off sick. I went in anyway and was deposited at Horseshoe Clinic in central Graaff-Reinet (below) by Nthabiseng to wait with her patients for Sister Pieterse. What a marvel! She flipped confidently from antenatal booking to chronic disease management to contraception to child health, the latter using the ‘Road to Health Chart’ a hand-held patient record that’s the norm for all patients. All HIV tests were fingerprick rapid antibody tests adeptly performed by Lay Counsellor Elsie. Over half the consultations were conducted in Afrikaans but the staff all spoke English. I asked Sister Pieterse to ask the one HIV positive patient about her HIV care. In common with all local patients she currently attends the Ithemba Day Unit and answered my question about attending Horseshoe with her fears of losing the cloak of confidentiality afforded by the more remote centre and ensuing stigma in her community. This despite collecting other medication from Sister Pieterse today.

Other thoughts: Horseshoe’s NIM-ART nurse (my targets for on-job training) has left the clinic with those remaining awaiting for a place on a course. Sister Pieterse was impressive in her scope and care… but may well need more support around her once NIM-ART is implemented at Horseshoe. Marvel for a minute in what’s offered in a nurse-led clinic on its sign below. The next doctor’s visit will be a week on Tuesday.

 

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September 12, 2011 at 7:03 pm

Game and game

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I mentioned Rugby World Cup fever in an earlier blog and my host, Pierre has it bad. Good job there’s a nurse in the (guest)house.  I think that he’s seen every match. Mind you, as an ex-centre for Kwa Zulu Natal (that’s good, non-rugby followers: provincial standard (like Wales, Sian, ha ha)) he’s bound to be interested. I was delighted to be asked to watch England’s opener v Argentina with him, even if – double entendre acknowledged but not intended for exploitation – I’m more of a round ball man myself. Well, it’s changed since I last watched blokes of all shapes and sizes with pork-chop sideburns mud-wrestling for three points per try. I felt sorry for the Pumas – note how I’ve caught on – as buffalo-sized Englishmen hurtled rib-crackingly into them. And the kicking! I thought that I’d seen poor shooting at Cambridge United and Eastbourne Borough but this was pathetic. Despite the innovation of a tee, replacing the early seventies divot that I remember and Jonny Wilkinson’s peculiar preparation – he seems to be trying to crack a walnut between the cheeks of his buttocks – neither side seemed capable of hitting the proverbial cow’s backside with  banjo. We’ll be settling down for the Springboks’ first match tomorrow morning.

This afternoon I ventured into the neighbouring Camdeboo National Park. It’s as close as the South Downs national park is to Eastbourne but has rather more ostrich. Ostrich! The first pair that I saw I was out of the Chevrolet with binoculars forgetting warnings to stay in the car in order to avoid goring by Cape buffalo or worse. Walked around the permissive Crag Lizard Trail in the Valley of Desolation managing only one lizard for my R60 (circa £5.50) (photo below). Across the road though… a hoopoe (maximum points in ‘I-Spy Birds’ methinks), vervet monkey, blesbok, black wildebeest, bat-eared fox and the four-legged variety of springbok, mod-style with their sharply defined shades of brown – you could imagine Paul Weller wearing a similarly styled cardigan during his Style Council days.

So a good day. After a week reading the Port Elizabeth Herald, the Mail & Guardian (not the UK organs) today was meatier. I’ve eaten at Polka where I’ve learned the names of four staff… and resisted developing my ‘usual table’. B&B is a little busier this weekend with a friendly Dutch couple who are happy to stop and chat plus a couple who regularly visit a local church. A week with barely a drop of alcohol – just a glass of red on the two evenings with Elizabeth in Pretoria.And twelve days since my last gym – I’m getting withdrawal – from missing gym, not booze!

Ready for tomorrow’s game.

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September 10, 2011 at 6:37 pm