Notes from Cape Town, Republic of South Africa
By Cassandra M. Klyman, M.D.
Right on the corner of Long and Market street is the tall, brick, turquoise-trimmed hospital named after the renowned heart surgeon, Christiaan Bernard. Cassandra M. Klyman, M.D. was invited to talk to the primary pain managers in this general hospital, which also serves as the tertiary care center for neonatal cardiac cases from all over the South African continent. The audience was mostly women nurses, physical therapists and social workers. Psychiatrists here function as consultation-liaison specialists. Patients unable to be contained in the general wards are transferred to freestanding psychiatric hospitals where “biological” psychiatry is practiced with minimal follow-up outpatient psychotherapy. The few psychoanalysts belong to the Jungian Association and interface little with medical practice.
Dr. Klyman’s visit came in late October and the academic year was winding down for exams and the long holiday break. It was Spring there and like our May-time. The sun shone brightly and, except for a few days, the winds interfered with tennis plans and taking the gondola up to the top of Table Mountain—so-called because it is so flat on its top and because cirrus white clouds settle down on it as if a lacy cloth were being set for a grand banquet. The peninsula is surrounded by the Atlantic Ocean around towards its meeting with the Indian Ocean, which comes in about 10 degrees warmer and permits swimming and surfing. From CapePoint one can look down and see whales. Driving out to beaches, one sees penguins and seals. A little inland, ostrich farms can be visited—up close they grin and dance and mate with a graceful abandon, the male swinging his long neck from side to side. In every flea market and high-end boutiques in very busy modern malls, ostrich eggs are sold--etched, painted or lacquered. Small baboons wave alongside the winding mountain roads. You are prohibited from feeding them lest they follow you home and go directly to your refrigerator for more human food.
Oh yes! The presentation. Dr. Klyman used the Workshop format from her “Psychoanalysis in Medicine” Committee, which has been formatted for outreach to the general medical community. Last year the Committee and/or its members (Drs. Austad, Browne, Evangeline and Curt Spindler) presented at Providence Hospital, the Alzheimer’s Association, the State Rehabilitation Agency, St. Mary’s in Livonia and, in years past, at the Annual Scientific Meeting of the Michigan State Medical Society.
Through the mnemonic of “GUT REACTION,” a medical case--followed over several office visits--is discussed. Participants are encouraged to experience their emotional reactions to difficult patients and to consider that those reactions are likely to be the patient’s feelings as well. When we feel disgust, embarrassment, guilt, impatience, hopelessness, we are not feeling it in isolation. “Whose pain is it?“ captures the idea. Then, counter-transference begins to have a taste and a smell that makes the concept both real and usable, optimizing the experience for the doctor and patient. Our laminated pocket reminders are eagerly taken and feedback affirms that they are being used.
It is an aspect of significant consilience that the Psychoanalytic Neuroscience Study Group is also learning that neuro-imaging demonstrates that empathy has a neural network basis and that the patient’s and attuned listener’s brain both light up similarly. That ability to have a similar but not identical reaction leads to a secure attachment in the child/parent and patient/doctor relationship.
A remarkable part of the Capetown experience was a boat ride out to Robben Island-- the “Alcatraz” in which Nelson Mandela spent 17 years. Freed prisoners conduct tours of this historical site. Our guide was quite assertive in telling us we were hearing “straight from the horse’s mouth, but I’m no horse!” Indeed, it was inspiring to hear that the political prisoners had such strong purpose and discipline that after 8 hours in the lime-pits they would return to their 3 meter by 3 meter concrete empty cells and self-impose a rule of silence so that they could study by the available daylight and finish degrees or obtain advanced degrees. Perhaps that is why, when released, they could be relatively prepared to take on civic and political responsibility and embark upon “truth and reconciliation “ in earnest. Reasons for bitterness were abundant because the mental cruelty was more extreme than the physical deprivation. The former consisted of such indignities as no toileting privacy and intercepted and falsified letters from family that spoke of abandonment, divorce and shame. Even upon release there was semi-isolation because people were afraid to talk to you for fear they would be interrogated.
The ex-prisoners continue to see themselves as having been Freedom Fighters and not terrorists because, they believe, they needed to bring the world’s attention to their plight and because they planned bombings only at night in empty government and corporate buildings. Still, our guide indicated, there is a need for outside help because the unemployment rate is so high that, even with his education, the only job available to him at the moment was being our guide at his old prison. He was proud to be a witness but resentful that he had little choice.
For the last ten years the Republic has struggled with its economy and the scourge of AIDS. Every guide, minister and healthcare worker was concerned. Unemployment, results of decades of only 5% of the education budget going to “blacks and coloreds,” and the idea that you won’t get HIV if you have sex with a virgin has led to a high incidence of early adolescent pregnancy and HIV infected babies. It’s a vicious circle. Some politicians have been stalling on buying and/or subsidizing anti-viral treatment. Their critics cry that they are ignorant or corrupt. While I was there, the newspapers reported that the Deputy Health Minister advised that lemon, olive oil and garlic was the recommended treatment for HIV. Their supporters say that they are negotiating behind the scenes to get a reasonable price from the pharmaceutical firms because they understand that this epidemic will be persisting and that control not cure will be an ever-increasing and enduring burden that they have to ensure will be economically feasible over the long run. Meanwhile, I am informed that Ford Motor Company hands out condoms in bathrooms and at factory doors, trying to slow the rate of as many as 6 skilled employees dying per month.
Dr. Klyman and her husband, Gabe Zawideh, visited the home of Dr. Rosalind Griffin in a beautiful gated community in the Capetown suburbs just next to the new American Embassy. Dr. Griffin bought a home there because of her interest and sponsorship of a center for the Deaf and the need there as here for services for that population. She travels there 3 months/year, and we worked together in networking with the local psychiatrists. It was wonderful conversing with her neighbors and church members, eating at a great variety of local and 5-star winery restaurants.
Leaving Capetown, I was left with the memory of several landmarks. The first was the several-acre field of high grass just as you enter the heart of the city. This little plain, the remains of District 6, is where apartheid began as an integrated lower middle-class neighborhood was evicted into outlying Townships of shanty-towns where all non-whites were relocated from dusk to dawn. An award-winning, cameo-quality Museum that chronicles the event was definitely worth a visit. Then, there is the half-mile long gap between two parts of highway that took so long to be funded that now to complete and bridge the two ends would mean condemning a major hotel and some office buildings. Third, and most important, was the friendliness and optimism of such a young republic and the amazing progress that they have made in just a decade of freedom. With their race relations they seem as far along as we are in everyday life. There is stratification in that while politicians are black, corporate heads are predominantly white and the hospitality and retail business is mixed. Domestic workers crowd into private mini-vans at 4p.m. to get into gridlock rush hour traffic to get to their township homes. The government is offering very favorable loans and mortgages to upscale their communities. Education, everyone agrees, is the “key” and it is now compulsory for everyone. Perhaps we will all progress together.