This blog relates my experiences of working in a South African rural hospital for a year. Although I am no longer updating it I hope it will transmit something of the passion and excitement of those months. May be even inspire some to go work there themselves.

Posts are in reverse order so to start at the beginning click on Feb 2007.

Ed.

Wherever you go...

I pull the sterile gloves over my gown sleeves and look at the nurse.

“Please could you…?” I ask shrugging my shoulders in the universal “my-sterile-gown-is-about-to-fall-off” gesture. She grins and slips around the bed to fumble for the poppers at the back. I eye her name badge. Startled – I glance at her. “Your name is Ndlovu?”

“Yes.”

“But that is a Zulu name!”

“Yes!” Her face lights up. “You have been to South Africa?”

“I was working there last year.”

“Oh! Where were you working?”

“Hlabisa.” She claps her hands for joy, an enormous grin crossing her face.

“But I live near there. If you take the road from Mtuba to the hospital I live in a village on the right.”

I laugh at the incongruity of it. Here, in the dark at 2am, on a medical ward in an Oxford hospital, working with a Zulu nurse just I did for the last year. We talk animatedly about her home. “Did you train at Hlabisa?”

“No. I trained at Bethesda. Do you know it?”

“Oh yes – I visited a couple of times and worked there when I was a medical student.”

“That is amazing! Why did you go? Why would you want to go?” I talk about the experiences I had there. The terrible problems, the unnecessary suffering and death but also the passion and vibrancy of the life and the motivated dedicated people – both medical and non-medical – who worked so hard to make a creaky, groaning, cumbersome healthcare system deliver.

“Will you go back?” I ask her.

“One day. I do not want to stay here forever. Here they work you so much! Every day! And the money you earn you use up just living! It is so expensive. I will stay a few more years, then I will go home.”

Guiltily I suddenly remember the patient I am caring for. She has fallen asleep. I am putting in a central line. “We better get on with this,” I say. And suddenly I am dragged back from Africa to Oxford – I would not have been attempting this on a ward in Hlabisa: not because I couldn’t but because no one lived as long as this patient in South Africa.

Back in town

I am back in the UK and starting work Monday. Looking forward to catching up with people soon. And come back here for entertaining tales of culture clash as the weeks pass - my first job is ITU which could not be further removed from rural South African medicine.

The recession

I am in the bank to tie up my financial affairs before going home. The girl dealing with me is fascinated about why I might have come to South Africa to work - all her friends are going to the UK.

"One of them came back with a MILLION RAND! And he only worked there for a year."

"What work was he doing?" I ask.

"Working in a bar!"

I would be keen to know which bar pays over £75 000 a year - I might be tempted.

She asks me about HIV and whether people "up there" in the rural areas were very sick. "Was it stressful?" she asks as she takes my passport.

"At times."

She studies my ID photo. Then she studies me.

"Well you've definitely got less hair than before."

Robben Island

We file silently into the building exchanging the harsh bright white mix of sun and limestone for the gloom of the interior. As our weary eyes recover and vision is restored the darkness recedes. A tall black man stands at the end of the hall. He watches us silently as we file in. As the last person enters he booms, “You are late!” There is a ripple of nervous laughter. Is he chastising us or is he joking?

“My name is Thulani,” he continues. “And I was a prisoner here on Robben Island.” Everyone shuts up.

There are about 120 of us – of which just 5 or 6 are South African. The rest: tourists, pilgrims really, from all over the world. And all of us have come to see the place where Nelson Mandela, perhaps the greatest man of the second half of the twentieth century, was imprisoned by South Africa’s apartheid regime.

Thulani tells us how he was imprisoned for his involvement in a bomb placed in the intelligence service building in Pretoria. “It was not in working hours – there were 47 minor injuries. No one was killed,” he emphasises.

He was sent to Robben Island to serve his sentence – joining Nelson Mandela and several others that later became prominent members of the new government.

“I was brought on the same boat that brought you to the island today. I was brought into the room in which you stand now. They then made me take off all my clothes. I stood naked before the prison officers and they examined me and then gave me one set of prison clothes and one thin jumper. If I had been Indian or Coloured I would have got a thick jumper. But because I was Black I got a thin jumper.”

“Did you have visitors?” someone asks.

“You were allowed visitors but they had to apply. One day they called me and said, ‘Thulani – on Friday you have a visitor. Your father is coming.’ I was so excited. Then, the day before the visit, I was called to the chief officer. ‘Your father is not coming. He is intensive care. He was shot yesterday 8 times.’ I went back to my cell and I just sat on the floor. The others – they came and asked what had happened and I told them. Later I found that after my father had applied to visit me the security services went to see him and they beat him up and shot him 8 times. He lived – but he could not walk again.”

There is silence.

One of the 5 South Africans, a Zulu girl from Durban, asks, “How can you be here? After all this how can you come and work here every day.”

“Some days it is difficult. In the middle of the tour sometimes I feel sad. I make an excuse and slip away and I cry for a minute. And then I wipe my face and I go back. But is difficult. I was beaten. The stripped me naked. They placed electrodes on my private parts and shocked me. I know the man who did this. He now has a rich company and makes money. He went to the Truth and Reconciliation Commission and got amnesty.”

“But don’t you want justice?” someone asks.

“After the Commission they said we could pursue these things in the civil courts. But my family, we sat down and we spoke and we decided we wanted it to be over and let it go. It would not make my father walk again. Desmond Tutu said that without forgiveness there is no future so we decided to leave it to God to judge that man.”

He looks at us.

“Any other questions?”

We are silent. Or rather, we have been silenced.

“Then we will continue the tour.”

As we walk I turn to one of my friends. “That makes it more real,” I mutter. She is weeping.

Thulani shows us Mandela’s cell. “He used to come here and do his own tours for visiting dignitaries,” he tells us. “But the last time he came he said to me that he does not think he will come again now. He does not want to come back.”

As we leave we all shake Thulani’s hand vigorously. He is not famous. He is not glamorous. He is not powerful. But he is a remarkable man.

We walk back to the boat, less chatty than when we arrived. We file on aware this time that this same boat carried Thulani and his fellow inmates. We look at the stunning view of Cape Town and Table Mountain - the same view that would have glittered on the horizon, tantalising and unattainable, as Thulani and his colleagues laboured pointlessly in the lime quarries. And we cannot help but be amazed and thankful for how completely and how bloodlessly the world changed.

Flying Comedaire

Flew to Cape Town with a low cost airline called Kulula. They are famous for their quirky cabin announcements: fun for the tourist. Bloomin’ annoying if you fly regularly with them. For example:

"To operate your seat belt, insert the metal tab into the buckle, and pull tight. It works just like every other seat belt; and, if you don't know how to operate one, you probably shouldn't be out in public unsupervised. In the event of a sudden loss of cabin pressure, masks will descend from the ceiling. Stop screaming, grab the mask, and pull it over your face. This is a no smoking flight and anyone found smoking will be asked to leave the aircraft immediately.”

Others have reported the following (gleaned from Google search):

"Ladies and gentlemen, we've reached cruising altitude and will be turning down the cabin lights. This is for your comfort and to enhance the appearance of your flight attendants."

"There may be 50 ways to leave your lover, but there are only 4 ways out of this airplane."

"Thank you for flying Kulula. We hope you enjoyed giving us the business as much as we enjoyed taking you for a ride."

As the plane landed and was coming to a stop at Durban Airport, a lone voice came over the loudspeaker: "Whoa, big fella. WHOA!"

"Your seats cushions can be used for flotation; and in the event of an emergency water landing, please paddle to shore and take them with our compliments."

"As you exit the plane, make sure to gather all of your belongings. Anything left behind will be distributed evenly among the flight attendants. Please do not leave mother-in-laws.”

Overheard on a Kulula flight into Cape Town, on a particularly windy and bumpy landing: "Ladies and Gentlemen, welcome to The Mother City. Please remain in your seats with your seat belts fastened while Captain Kangaroo bounces us to the terminal."

Once crusing altitude reached the captain announced, "Ladies and gentlemen, this is your captain speaking. Welcome to Flight Number 293, non-stop from Durban to Cape Town, The weather ahead is good and, therefore, we should have a smooth and uneventful flight. Now sit back and relax... OH, SHIT!" Silence followed, and after a few minutes, the captain came back on the intercom and said, "Ladies and Gentlemen, I am so sorry if I scared you earlier. While I was talking to you, the flight attendant accidentally spilled a cup of hot coffee in my lap. You should see the front of my pants!" A passenger then yelled, "That's nothing. You should see the back of mine!"

Time out

I am taking a few days out traveling to round off the year in South Africa. Please leave a message after the tone. Back next week.

Last chance to see

James eyes the huts of mud and wood that line the landscape through which we are driving.

“I hadn’t realised that it would be so great – this difference between rich and poor.”

I glance at the village and then at him, guility. It is not that I do not notice poverty anymore but it no longer seems strange. And, shamefully, it no longer bothers me that South Africa’s great tourist destinations are almost without exception positioned in rural areas of equally great deprivation. The first time I came here to the mountains I could not understand how it was possible to go on a hiking holiday in a park in which the chalets had satellite television but the people just outside walked daily to the communal pump for their water. Now however I feel self-righteous indignation because the camp is experiencing a 1 hour power cut – and I want tea now.

James is however just off the plane. He is seeing South Africa for the first time – an Africa “virgin”. And he is my younger brother. I am giving him a high speed tour of KwaZulu-Natal’s greatest hits: a night in the berg, 3 nights in the game park, a night on the beach before returning to his gracious (and supernaturally patient) wife and two children.

After our visit to the game park I take him to the hospital – it is just 20 minutes from the park gate. It has been just over 2 weeks since I left. My 20 minute quick tour proves hopelessly optimistic. At each place I take him people demand to know where I have been, when I am coming back and then take James’ hand, shake it vigorously and ask why he is taking me away.

“We don’t want him,” James replies with a grin, “you can have him.”

And they turn to me and look accusingly: “Why then are you leaving?”

We go down to the ARV clinic. Sister Sithole is brought into the room to scold me.

“Why are you just leaving? We would do juice and cake if we had known.”

“I do not like long departures,” I reply, “I prefer to slip quietly away.”

“But,” says Sister Hlabisa, “it is our culture to send you off.”

Sister Sithole turns to my brother. “You must give our regards to your mother. And you must tell her to scold him. She must scold him for leaving!” She studies James more closely. “Hauw! How are you brothers? He is thin and you are fat!”

“He must be married!” pipes in Sister Hlabisa.

“I am.”

“There! I told you. We tried to find Dr Moran a wife but…” Sister Hlabisa shakes her head sorrowfully.

On the way out we bump into Matron for maternity. She launches into a speech about how much they will miss me. “… and when we call Dr Moran in the night, even if he is not on call he will come. The others they say ‘Why are you calling me? I am not on call’ but Dr Moran doesn’t.” I grin amiably, absolutely certain that I have never arisen when not on call. Or maybe there was once but I complained bitterly for hours – and shouted at at least one nurse.

I do not disabuse James. He turns to me as walk away. “So what did you pay her?”

Finally we come to high care. Sister Nene is waiting. She has called down Sister Perumal. They present me with a pair of sandals and hug me as I leave. As we walk away back to the car one of the OPD nurses, the one with the powerful singing voices shouts my name. I head back. “Sister Khumalo wants you. You heard my voice? My powerful voice?!” I once told her she had the most impressive volume of any nurse I had ever met.

“Yes I did.” She grins in satisfaction.

Sister Khumalo is standing outside OPD. I have a soft spot for Sister Khumalo.

“I have something for you.” She produces a small bead and wood necklace which she fastens around neck. “It has muthi. Muthi to make people like you. We will miss you. May God bless you where you go next.”

I thank her. And walk away from Hlabisa for the last time.

CIty Life

I stick my head out of my consulting room into the corridor. Chair line the walls and they are occupied by Desmond Tutu’s rainbow people: Indian, Zulu, Chinese, White – all are represented.

“Who’s next?”

A little old lady who look, for all the world, like my granny totters to her feet and, stick in hand, creaks slowly into my room. I show her to a chair and pick up her notes. I flick through them pretending to read – but the reality is I am stunned.

My year working in South Africa has so far been a year of rural Africa. The catchment area of our hospital included a town with a small white community but we never saw them. Almost without exception they would have had private health cover and I suspect many would have chosen death over Hlabisa Hospital if it came down to it. Pietermartizburg is however a small city and in the apartheid era had three hospitals: a black hospital (in the township of Edendale) and white hospital (Grey’s) and one for all the rest (Northdale). Grey’s was opened in 1985 and even now its wide corridors, pristine halls, large wards and quiet emergency department contrast starkly with Edendale’s overflowing halls, grimy floors, long queues, and privacy-less wards.

The little old lady and I chat amiably. She has mild heart failure and I cannot entirely work out why she is here – this is the Medical Outpatient Clinic and serves as a referral service for the difficult or complicated patients the district and rural hospitals cannot manage.

Greys from the air - taken on the way back from outreach visit

“Well, Mrs Smith,” I conclude, “you are doing very well and your medication is just right. I don’t think we need to see you here again. I will write a letter to your local clinic and they can continue to give you your medication.”

Her face suddenly tightens.

“Do I have to? Really? Can’t I get my medication from here at Grey’s?”

“I’m afraid that this clinic is for complicated patients and once we get you better then we refer you back. If there are any problems we can see you again here.”

Her eyes fill with tears.

“Don’t make me go to the clinic doctor. You have to wait so long and I am so weak. I hate it at the clinic. Can’t you let me get my tablets here.” Her knuckles have whitened as she grips her walking stick anxiously.

“Is the clinic so bad?”

“It is terrible doctor. And my husband is so ill. We came from Zimbabwe 15 years ago and we lost everything. Our pension, our house and everything. We have no insurance, nothing. Don’t make me.”

I happened to visit her local clinic the other day. It isn’t great. Queues are long and organisation chaotic. But I suspect what really troubles her is that it located in a previously coloured area. The changes the country has seen in the last 14 years have probably been faster than a 88 year old lady can handle.

She looks at me plaintively.

I am a coward. I am only here for a week. This isn’t my battle.

“Well we need to see you in 3 months for a blood test anyway so you can get your medication here til then but after that you must prepare yourself for using your clinic.”

“Oh – thank you doctor.”

I scribble her prescription and she totters out drying her eyes.

I sit in the empty room guiltily for a few minutes.

What would I have done had she been Zulu?

Did I treat her differently because she looked like my granny? Or to put it baldly – because she was white?

Outreach

“Why don’t you sit in the cockpit?” asks Dr Dawood. I look at her sharply.

“Can I?”

“Sure. Do you want to?”

“Do I ever!” I respond, sounding ever so slightly like an American teenager.

“Excuse me. Stefan,” she shouts at the pilot, “can he come up front with you?”

Stefan nods his agreement and I clamber over the seats to the co-pilot chair. Stefan is doing his checks, meticulously noting things down in a book as he points at instruments and switches with his pen, his lips moving silently in his pre-flight safety mantra.

I look out at the tarmac of Pietermaritzburg airstrip. The haze and mist that covered us when we arrived early this morning has lifted and it is safe to fly. Our destination is Dundee. That is Dundee, KwaZulu-Natal – a small farming and tourist town. I am joining Dr Dawood, the infectious disease consultant at Grey’s Hospital in Maritzburg for her “outreach visit” – a trip she makes monthly to support and teach at two rural hospitals. I met her at a conference and she agreed to let me come work for her for a couple of weeks.

Stefan fires up the engine of the small 8-seater aircraft. I look back at the main cabin. The seats are removable, allowing the cabin to become a temporary intensive care unit for retrieving crticial patients. Hooks are placed in the ceiling for attaching intravenous giving sets and other patient equipment.

We trundle to the end of the runway and then Stefan racks up the throttle before releasing us down the runway. In what seems an impossibly short distance we are in the air. And I am grinning like an idiot. He circles over the city and then sets the GPS and autopilot for Dundee. Within a few minutes the city has disappeared. I look below through the cloud and haze – we could be anywhere in Africa. A thin silver line marks the passage of a river through rolling wooded hills. The sun is baking – a thermometer confirms what I feel – it is bloody hot in the cabin. Stefan’s lips move as he mutters into his microphone to some air traffic controller – the engine noise drowns out whatever he might be saying.


Just 45 minutes later we start descending. Stefan gestures in front. A small town is materialising in front of us. I can see what must be the hospital and about half a mile from it a strip of tarmac beckons to us. We come lower, lower and with scarcely a bump Stefan touches down. He taxis to the end of the runway, parking next to a hideously deformed light aircraft that is presumably used for crop dusting. There is nothing else around, the airfield is deserted save for the yellow Department of Health vehicle awaiting us.

We are visiting two hospitals today. Dundee itself and that of another small town, Nqutu, in the heart of the Battlefield territory. The driver takes us at break neck speed the 60km to Nqutu first. We jabber all the way. He tells me about Nqutu’s famous Inyanga (traditional healer) – a man who got so wealthy he built himself an airstrip and bought a plane.

“Did you ever visit him?” I ask.

“Yes,” he grins, but does not elaborate.

The hospital at Nqutu has been rebuilt – its beautiful outpatient department has at least twice as many patients as Hlabisa. And half as many doctors. As we wander around it becomes clear that beautiful buildings help but are not everything. And however bad we thought things were Hlabisa they could have been worse – a lot worse.

Next back to Dundee Hospital. Dundee was built as the “white hospital” in the apartheid era and as such has wide corridors, a beautiful outpatients area, a dedicated casualty. All are deserted – Dundee is a small town. One of the doctors tells us it is the easiest job he has ever had. It is now of course multi-racial. The medical manger leads us through the building and out into the open. The main wards are in a separate wing. As we enter it is all very familiar – these wards feel identical to Hlabisa. The manger explains that these were originally built as the “black” wards. Low budget, low aesthetics, and strategically positioned far from the main entrance so no white people would have to see an unnecessary black person. In this post-apartheid era the old “white” wards now house paediatrics and surgery. But, as so often is the case, adult medicine has been pushed to the periphery.

As the round draws to a close we hear the throb of the plane overhead as it returns to collect us. We bid our goodbyes. By the time the transport gets us to the field the pilot has landed and is sitting at the bottom of the aircraft steps waiting.

I clamber into the co-pilot’s chair again.

And once again prepare to grin like an idiot.