Sunday, 30 December 2007

Lament

The nurse and I study the baby hopelessly. Just 5 months old she was admitted last week with severe diarrhoea and breathlessness and has been going steadily down hill. She is almost certainly HIV positive and probably has a severe pneumonia related to that. Over the last couple days we have been adding various drugs for the purpose of treating various conditions she probably doesn’t have but there is nothing to lose.

“I don’t think there is anything else we can do,” I say to the nurse. The child is semi-conscious with a heart rate of over 200 and a respiratory rate of 70. She will soon exhaust herself. I could put in a breathing tube but there are no paediatric ITU beds available at our referral hospital.

I sit by the phone and work through the Durban hospitals. “Any paediatric ITU beds?” and it is the same story. None. Sometimes because they are full, sometimes because the beds are closed due to lack of staff. They suggest things I could try (but I have done them already), and if “she doesn’t improve phone me later we might be able to take her then.” But they and I know by that time she will not even survive the journey.

The nurse and I pull up a bench to talk to the tearful mother. She knows what we are going to say. She has been here 24 hours a day for a week and has watched her daughter’s decline. She lets out a loud wail of lament and falls to the floor on her hands and knees sobbing and screaming.

This is what I find the most difficult here: the knowledge that if we were in a city, even perhaps a city within South Africa, these children might make it. Not definitely make it, but might make it. Our referral hospitals want to help – but they do not have enough beds and those they do have tend to be given to the more salvageable surgical problems. Not children like these. These HIV ravaged skeletons of children.

Tuesday, 25 December 2007

Merry Christmas!


The Hlabisa Docs Christmas dinner

Merry Christmas!

Hope you had a wonderful day. We had the weirdest (for a northern hemisphere junkie) Christmas: 35 degrees, in the game park. Saw elephant, cheetah, rhino and buffalo - and all before breakfast. Not a single carol.


Thanks for dropping by and reading over the last 10 months. Only 6 weeks to go. Do you have the stamina to make it to the end? Do I? Stay tuned.

Monday, 24 December 2007

Photos I had no excuse to show

A couple of photos for those who like to just look at the pictures:

Anna with the mobile clinic crew on their way to some tree too far from the usual clinic buildings. Marlene, the nurse driving arrived at Hlabisa in her 20's when it was still a mission hospital and has lived here ever since.



The Game Park wilderness burning towards the end of the dry winter. The ominous crackling could be heard from the road and the smoke spread for miles.

Sunday, 23 December 2007

The Hlabisa Family

The sun is low in the sky by the time I turn off the highway and join the road to Hlabisa. All around me the hills are basking in rich yellow light, in front of me the road drops in and out of sight as it follows their undulations to the horizon. Along the grass verge people are slowly making their way home, stray dogs bark lethargically at each other and minibus taxis hurtle past me, defying death for at least one more day. It is rather like one might imagine the closing scene of Mr Benn, had it been made in Africa.

It is dark as I pass out of the game park and into Hlabisa itself. A hot wind blows the occasional coke can skittering across the town’s wide, and only, street. There is a curious multi-coloured glow up ahead and as I pass the shops it resolves into a small illuminated sign strung across the road: “Happy Christmas!” And behind it another, “Welcome to Hlabis” – the “a” is broken. I grin – there are also illuminations on the lamp-posts – a multicoloured candle, Father Christmas, and most incongruously – a snowman – in this town that I cannot imagine has ever seen snow.

I turn into the hospital. The hospital has also been infected with festivity: Father Christmas and his Snowmen are strapped to the gate. The guard greets me. “Where you coming from?”

“I have been in England for my sister’s wedding.”

“Ahh! And now you are back.” He takes the obligatory and cursory look into my car boot “Happy Christmas!”

I drive on to the residences. I am an emotional smoothie: the high emotion of a family wedding, the poignancy of Dad’s absence, returning to South Africa for my final two months, the sinking feeling of being on call the weekend before Christmas. All blended together. I heave myself out of the car somewhat reluctantly and drag the suitcase (overladen with Fox’s Biscuits – like the French, South Africa has not discovered the art of biscuit making). There is the murmur of voices from Magnus’s flat. Wednesday is always our “Braai Night”. I had been intending to unpack and sleep but I will just say hello. I slip open the door and stick my head in and am greeted by cries of welcome. A plate of food is thrust into my hand, hugs and kisses are exchanged (with blokes and girls respectively. Obviously), news exchanged.

Bed later. This is my Hlabisa family and it will not last much longer.

Wednesday, 19 December 2007

Return encounters

The queue is moving slowly and I look out of the gangway window at the ground crew as they scurry around the plane. I spot my bag being loaded into the hold – a cause of some reassurance. Finally I enter the plane and flash my pass to the stewardess.

I am back in South Africa and have been killing a few hours at Jo'burg airport before now, at last, catching the short flight to Durban. My heart sinks as I approach my place – the seat next to me is occupied by a classic African Mama – not much of my seat remains. I greet her with a cheery hello. She grins and we strike up a conversation.

"What are you doing here?" she asks when she finds out I am British.

"I live in Hlabisa – a small village in KZN – I work there."

"At a hospital?"

"Yes."

"Ah! Thank you. Thank you. Thank you for leaving your pound for our Rand! The Lord will bless you for that."

I smile at her. "Well, it isn't that bad. It is a bit of an adventure."

"Yes – but you are making sacrifices to come here and God will honour that. He sees everything! Are you married?"

"No – that is something the Lord has not yet provided!"

"Ah – but he will! He will! And he will give you many children as well I am sure!"

She is called Agnes (not her real name - see disclaimer above) and I discover that she is on her way to join her son on holiday in Margate, the improbably named KZN South coast beach resort that is considerably nicer than its name might imply. The steward comes round checking our seat belts. Agnes delves down to each side of her chair and manages to retrieve each half of her belt but there is no chance that they will meet – they cannot even glimpse each other over her ample girth. "I think this seat is not designed for the African woman!" she mutters, and calls the steward over. He returns with an extension – Agnes can't quite reach the far side, and I join her to delve down and pluck the belt socket from under her bottom. Finally, she is legal.

"Do you have family?" I ask once airborne.

"I have four children and the Lord has been good – they all have good jobs and they take care of me. My son paid for this ticket. He phoned me last night and said, 'Mama – don't miss that plane. Don't miss it – you will forfeit the ticket and we will have to buy another', so I set my alarm for 5 in the morning to make sure. I was packed 2 days ago!" It is now 2pm so her preparedness is commendable.

The conversation moves to politics. The ANC is choosing its new leader and there has been considerable friction between the current state president, Thabo Mbheki and the ex-deputy (sacked for alleged corruption and famed for sleeping with the daughter of a friend, known to be HIV positive and then announcing he was not worried about infection because he "had taken a shower after sex"). Zuma is extremely popular and is highly likely to win.

"Why is Zuma so popular when he has done all these things?" I ask her.

"Ahh. I think that when a man does the things of darkness it makes him attractive to the people. And anyway – these people who are voting for him, they are not the people of the country, the normal people, they are the people of the party. They don't represent us."

"I guess there isn't really a proper opposition in South Africa – the Democratic Alliance is too small."

She snorts. "The DA? They are the old Nationalists in disguise. They would bring back apartheid. They want the white man to rule again." She looks at me, and looks a little taken aback at herself. "Sorry – you are white, but you know what I mean." I nod. "No – I think the country should be run by women. Because we, we are all mothers. And when the men argue we can say to them, 'Stop! You cannot argue like this,' and they will stop because people listen to their mothers."

"Perhaps you should form a party?" I suggest.

"Hauw! No. I like my time. I like my personal space. You cannot have these in politics." She looks out of the window. "Are those clouds?" We are out our cruising altitude and the cotton wool meadow of clouds stretches out in all directions.

"Yes – amazing isn't it?"

The speakers give their static laiden announcement of our descent.

"Already!" she exclaims. "This has been the quickest journey."

10 minutes later we are on the ground. She heaves herself up and as I lift her bag from the overhead locker she says, "It has been wonderful to meet you. Enjoy your work – and thank you." And, at a speed that belies her size, she is gone.

Tuesday, 18 December 2007

Back on the Grid

I am back in SA. Apologies for speaking to so few people - it was a hectic few days. In response to feedback I will attempt to increase the photographic content - apparently many people just look at the pictures. And to think of the time I spent carefully crafting the words.

For starters allow me to inflict just two wedding photos upon you.


Mother, Sister bridesmaid and Sister Bride



Aidan and Sally

Monday, 10 December 2007

From 31 to 3 degrees in 10 hours 50 minutes.

I am in the UK for my sis's wedding for a week. From 31 to 3 degrees
in 10 hrs 50 mins.

Sala kahle.

Saturday, 8 December 2007

Why the policeman is always right.

The phone in outpatients has been ringing stridently for several minutes. Everyone walks past, oblivious, but I finally crack.

“Hello?”

“Hi? Who is that?” says a unexpectedly Englishly accented voice.

“It’s Ed.”

“Hi – it’s Steve.” Steve is one of our elective students. “We’ve run into a bit of a problem.”

“What?”

“Well, I went with Emma to clinic and we were sort of stopped by the police. And I think we have been arrested.”

“What?!”

“And Emma is quite upset. I was wondering whether you could send someone down to get us?”

“Where are you?”

“Mtubatuba police station.”

Hours later we hear the whole story from Emma herself.

“We were driving to the next clinic when the police pull me over. And they looked at the Hospital Transport Itinerary document and see that Steve is not on it. ‘Who is he?’ they asked.

‘One of our students.’

‘Why is he not on the itinerary?’

‘I didn’t know he had to be. I can put him on now.’

‘No you can’t – that is illegal. You are using this car illegally. You cannot use state property for giving lifts to an unauthorised person.’

‘But he is a student.’

‘He is unauthorised. I could confiscate this car.’

And that is where I probably over-reacted. I started ranting a bit: ‘It’s no surprise no one wants to work in these rural places. We come here, we try to look after people and then people like you stop us. This student – he will never come back now. I have 30 people to see at the next clinic and you are stopping me from looking after them. You say you can confiscate the car. Well go then! It’s not my car. I don’t care. Confiscate it!’”

“And what happened?” we asked Emma breathlessly.

She shrugs. “He confiscated it. I had to follow him to the police station. I cried all the way. Steve just kept saying ‘Oh God, oh God.’”

“And when do we get the car back?”

“Apparently I have to write a letter of apology,” she says with a grin.

I suspect it was a somewhat equivocally phrased letter of apology. The car was returned just recently. 3 months later.

Friday, 7 December 2007

I want the baby to die

“That girl is in again, Doctor Moran,” says the nurse. There is resignation in her voice. I look to where she is pointing and recognise the patient immediately. She has been in four times over the last 4 weeks.

“What is it this time?”

“Cough.”

Barely out of her teens she is 6 months pregnant and like nearly 50% of such patients, HIV positive. She started anti-retroviral drugs 6 weeks ago but has been failing to take them. And she keeps coming back to hospital: diarrhoea, breathlessness, cough – an array of trivial complaints which we have never actually seen first hand and improve within 48 hours of admission.

“Why do you not take your drugs?” I asked on that first admission. She looked at the floor. “If you do not take them there is a good chance your baby will get HIV and become very sick and die.”

She muttered something and the nurse gave an exasperated sigh before turning to me and saying, “She says she does not care – she wants the baby to die.”

So I have to admit to some relief when I find that she is on the side of the ward Emma is covering today. I see Emma moving to the girl next. A few minutes later they pull the curtains around the bed. I carry on the my round.

45 minutes later and Emma has not emerged. I am intrigued. Emma is not a soft touch and is ruthlessly intolerant of time wasters.

Just as I am finishing the curtains are pulled back and they emerge. As we walk to coffee I ask Emma what was going on.

“Poor girl. At first I thought she was just a foolish waster. I asked her why she wanted the baby to die. She started crying. It turns out her parents are dead, her sister is dead and she has to look after her sister’s four children. She never finished school because her sister died before matriculation. She has no job and no husband. When I asked her about the baby she just burst into tears. She doesn’t know how she can cope. Who will look after the children when she has the baby? Who will help her care for the other four? Who will pay when she has no money. That is why she hopes the baby will die.”

I am devastated. At one time I prided myself on communication. Looking behind the presenting problem to the real issue that lay beneath. But I have let the culture and language barrier inhibit me from hunting out those issues in the way one might at home. It is too easy to make the mistake of thinking that just because you cannot ask how someone might be struggling, or because they are disinclined to say, that they are indeed not struggling. You are protected by the insulation of the translator. Today I am reminded that fear, responsibility, loneliness, isolation and desperation are the companions of many rural Zulu teenagers and mothers – whether or not they choose to tell me.

Thursday, 6 December 2007

10 Rules

A recent batch of students watched us for a week and then created these 10 rules governing our behaviour, based upon their observations.

10) Bring your own TB mask.

9) Even doctors can’t read doctor’s hand writing.

8) Almost anything can be diagnosed by ultrasound.

7) Rubber boots are not just useful on rainy days.

6) Triage is an unappreciated art form.

5) Gloves are required when handling clinic cards.

4) It’s probably TB – and if it’s not, treat them for it anyway.

3) Abbreviations are not an international language – especially the one you just made up.

2) A good translator is as hard to find as a sharps container.

1) Tea time is at 11am – unless you just managed to obtain an outside line to Durban.

Sunday, 2 December 2007

Abscess

The phone rings. I am lying on the sofa in the dark squinting at the laptop screen: someone has lent me series 1 of Spooks. I struggle up and bump across the room to the phone.

“Hello?”

“Moran!?”

“Yebo.”

“How are you?”

“I am fine.”

“I am fine too.” And then those four dreaded words. “Please hold for maternity.”

The line goes dead for a second and then a midwife comes on the line.

“Moran?”

“Yes.”

“How are you?”

“I am fine.

“I am fine too. I have a 22 year old primip. She is in labour but I cannot do a PV. She has a Bartholin’s abscess.”

I ask a few intelligent questions and then, pausing only check what exactly a Bartholin’s abscess is (an abscess of the Bartholin’s gland apparently) I head for maternity. On arriving I am taken to the woman concerned and, yes, sure enough there is a large abscess in the position that I imagine a Bartholin’s gland might sit if I knew exactly what it was.

“I cannot do a PV to check the cervix because it is too painful.” The abscess blocks the way.

“Right.” I try to look like I know what I am doing.

I prod the abscess a few times.

The woman winces.

I stick a needle in it – some black fluid comes out.

“Could you pass me a blade and some local anaesthetic please?”

I infiltrate a little local anaesthetic.

The woman winces at me – a little more purposefully than before – just in case I hadn’t noticed.

I try to make a small cut in the abscess.

Nothing happens.

I try to make a deeper cut.

A little blood.

I put some welly into it and am rewarded by a pressurised jet of black pus. It hoses over my shirt, up my arm and I just manage to duck away to avoid it in the face. And it keeps going. And going.

“There we go!” I say, trying to look nonchalant as I wipe down my arm and chest.

The woman gives me a grin. And two thumbs up.

Monday, 26 November 2007

No really.

"Did you see that patient?!" asks Debbie.

"No, which patient?"

"The one with the eyeball hanging out?"

"No!"

"Yes! He was gored by a goat. The horn went into his eye and pulled it out. It was hanging on his cheek still attached to the optic nerve. Poor man. It was really gross."

"Could he still see?"

"Not very well. I should of asked. Do you think he could see the floor when looking straight ahead?"

Another doctor who saw him joins us. "I phoned the specialist and do you know what he said? He said why don't I just cut the eye off! Cut the eye off! He said he would be able to do anything about it and we might as well cut it off! I said no way I'm not doing that and sent him in an ambulance to the specialist himself. If he wants to cut the eye off he can do it himself."

Couldn't agree more.

I stand corrected.

The phone rings.

It is Durban.

"How many patients do you have?"

"3."

"Oh my God - I thought it was 2." There is a muttering in the background. "Can we see them on Monday?" More muttering.

"Ok Doctor. We will see them Monday - you will need to keep them in hospital for a few weeks after they start treatment."

"No problem." I find a nurse and we phone the patients to tell them to travel to Hlabisa to catch the 2am patient transport bus to Durban.

It is only 2 weeks since I called. The fastest time yet. I stand corrected.

Friday, 23 November 2007

MDR

I am flicking through the pile of TB culture results back from Durban. All the sputum from patients with TB requiring culture are sent to the massive hospital there to be cultured. As always there are a few which have been identified as multi-drug resistant (MDR-TB).

MDR-TB is South Africa’s other health crisis. The TB epidemic has exploded, fuelled by the HIV epidemic. The biggest single component of our outpatients work is TB related – people with chronic cough, people with TB related complications, people deteriorating despite TB treatment. And if people do not complete their treatment, or take their drugs erratically there is a risk that the organism will become resistant to standard drugs. They will then fail treatment and stand a good chance of passing their resistant organism on to someone else. When that person develops symptoms they will unwittingly be put on treatment to which the organism is already resistant and continue to deteriorate for weeks or months (coughing all over their family) before the treatment failure is recognised.

Experts say that MDR-TB is evidence of a failed public health system: if everyone got treatment and was compliant, completing the whole course, resistance could not develop and they would be cured.

I hand the results to the coordinator of the TB tracing team. He will track the patients and we will try to arrange follow up for them in Durban. We are not allowed to start people on MDR-TB treatment – it is felt, perhaps not unreasonably, that if just anyone started MDR treatment exactly the same failures that led to the creation of the MDR epidemic will result in an epidemic of even more resistant TB: the dreaded XDR-TB. Last year there was an outbreak of XDR-TB in Tugela Ferry, another KZN town – embarrassingly enough it appears many of the cases were transmitted within hospital. I think of our wards and cannot even try to pretend exactly the same thing could not happen here.

An hour later the coordinator returns with the details of the patients. Two are fairly well and one is sick – they are bringing him to the TB ward. I phone Durban to book them appointments at the MDR clinic.

“What?” barks the doctor at the end of the line.

“I would like an outpatients appointment for three people with MDR.”

“Oh God. I have no appointments. We are in complete crisis! Complete crisis! We have no staff.”

“Well when can you see them?”

“I don’t know. No idea. What is your phone number?” I give it. “I will phone you sometime. How many men and how many women?” I tell him and hang up despondent. Sometimes it can take weeks before appointments come up. And in the meantime well patients infect their families and sick patients get sicker. I go to the ward and cast an eye over the patient admitted there. He looks fairly well at the moment. I hope he is still when Durban calls.

Monday, 19 November 2007

Breast donation

I am taking a new pair of elective students on a tour of the hospital. As always I enter C ward with some trepidation. Sister always enjoys an audience and never ceases to surprise: she sees no reason to be limited by what others regard as boundaries of taste. As we approach the nurse’s station Sister makes a beeline for us.

“Hauw doctor Moran. Who are these new people?” I introduce the students. She eyes them carefully. I can see she is going in for the kill.

“How old are you?” she asks one hapless girl.

“25.”

“25! 25!” Sister grabs one of the junior nurses. “This nurse is 25. Look at her she has breasts! Where are your breasts?! You have no chest!”

The poor student is speechless. And to be honest it is only by Sister’s own prodigious standards that anyone could consider her horizontally challenged. She laughs awkwardly.

“Ah!” cries Sister grasping her own impressive bosom. “If only I could take some of mine and give it to you, I would!”

The student thanks Sister for her generosity and I sweep them out to the much safer environment of the paediatric ward.

Saturday, 17 November 2007

Celebration

There is a soft knock at the door of the consulting room and Nathi sticks his head in. He is one of the senior counsellors on the ARV programme. “Dr, can you give a speech?”

“A speech? What for?”

“It is a celebration of the new Park Homes and we need a representative from the hospital. Matron is not here.”

“Sure – I will only be short. Is that OK?”

“Sharp!” He give a grin and thumbs up and retreats. I am on my fortnightly visit to Macabuzela clinic and return to my patient – a lady the nurses believe is diabetic. She is tired and drinking and peeing a lot. Unfortunately the clinic has run out of urine analysis sticks and their blood glucose meter has not worked for months. I guess a truly committed physician would have tasted her urine - I cannot bring myself to do it and instead send her to the next clinic along the dirt track – about 20km away. I am a monster.

The music starts outside as the celebration gets under way – I have to shout to make myself heard. Sister is unconsciously gyrating her shoulders to the music as she translates for me, and through the window behind her I can see the clinic’s pink-clad domestic workers dancing away in the midday sun.

“Is this the last patient?” I ask. She nods. “So we can go and dance?” She grins and we head out.

The massive increase in work brought about by the ARV programme has not been paralleled by an increase in space and the Park Homes have been set up to provide more consulting rooms. Chairs have been positioned under the awning in front of the new building where patients, staff and local dignitaries are gathering. I must admit at this point that our ARV programme is run "in partnership" (for which read, "they do the vast majority of work") with a local NGO. Our fortnightly management meetings rotate between their headquarters and the hospital. At their headquarters we are served fresh muffins and coffee. At the hospital we are told there is no budget for such extravagance. We prefer the meetings at theirs.



The speeches are underway – each sentence punctuated by shouts and ululation from the small crowd. As each speaker gyrates up to the makeshift stage – a trailer – the spectators cheer them on. The “compere” announces me. I stand up and walk across the baking grass to the trailer. The music starts and I attempt a nervous dance as I walk. The crowd erupts into yells of what I - perhaps naively - decide to consider approval. One of the ARV programme staff holds an umbrella above my head to shield me from the sun and translates.

“Sawubona!”

“Yebo!” comes the reply.

“Ngiphuma kwaHlabisa.” That is the end of my Zulu and I continue in English with translation at the end of each sentence. I thank everyone I can think of and waffle about now we have this space we must fill it with the people who need our help and everyone should encourage their friends to get tested.



We gyrate off the stage and, speeches over, the music kicks off in earnest and the nurses and domestic workers at the clinic form a conga-like line and dance around the trailer to the whoops and cries of the audience as drinks are served. I climb reluctantly back into my (small 2WD) car to head back - the NGO team climb into their (large 4WD) vehicle to head to the next "Partnership celebration" at the next clinic.


Sister getting on down.

Thursday, 15 November 2007

Oystein in Antarctica

Oystein, one time Hlabisa doctor, has - in his quest for every more extreme experiences - exchanged increasing toasty South Africa for icey Antarctica. You can read what he is going through here.

Open

I cautiously open the door and peer in. The consulting room in Philanjalo, our anti-retroviral clinic is full of counsellors.

“Sanibona!”

“Yebo!”

“Where is Sister Sithole?”

“She is outside, she will be back soon,” replies Nomusa, the counsellor to whom I once mistakenly proposed. She eyes me. “Sister tells me that you are unfaithful. She tells me that you have lots of girlfriends. You do not love only me.”

“No!” I cry, “that is not true.”

“She says you hug everyone.” Sister enters at that moment and a rapid discussion follows in Zulu. She turns to me.

“It is true – you have many girlfriends.”

“Ah – but Sister when I hug other nurses it just a pat on the shoulder. Like this..” I demonstrate precipitating shrieks of laughter.

“Ah,” says Nomusa. “It does not matter – I have another boyfriend.”

“Who?”

“Dr Magnus – he too loves me.”

“So you too are unfaithful?” She smiles and winks.

“So Dr, do you have a wife?”

“No.”

“So.. you are a virgin!” There are hoots and cries from all in the room. Suddenly I am aware that these are not just women – these are powerful Zulu women.

Sister Sithole cries, “Hauw Doctor! You must leave quickly or they will open you!”

She hustles me out and their peals of laughter follow me down the hall as I beat my retreat. I do not want to discover exactly what she means by “open”.

Tuesday, 13 November 2007

Starlight

It is approaching 10pm and I nip outside to hang the washing. After the days of rain and cold that have been providing a convinving simulation of a UK autumn, summer has returned. For the first time in two weeks the air is warm on my arms as I step out and a hot dry wind blows past me as I walk to the lines. Above, the sky is completely clear, stars brilliant and bright. Orion - tonight the only recognisable constellatory friend from the North - hangs low in the sky, upside down as far as I am concerned with his sword projecting up. The cicadas have cheered up considerably with the warmth and their chirruping joins the nocturnal frog chorus. I peg my sheets and then stand in the darkness savouring the heat, the stars and the noise for a few moments before reluctantly returning to my flat and bed.

Lion

Dusk is falling fast and Alison and I driving through the park on the way to Zulu lessons in Mtubatuba. As we reach the crest of the hill and curve down the other side we see a car stopped in the road just ahead. Alison slows.

“Look!” she whispers suddenly. “Could that be….?”

Through the half light we can just make out a form lying in the road. We edge closer. As we do so the black outline moves slightly and we see it clearly, the green retinas reflecting back our headlights – a lioness.

As our eyes adjust we make out one, two, three, four others in the grass either side of the road. The first heaves herself up and pads nonchalantly to the middle of the tarmac and flops down again – wallowing in the heat of a days stored sunlight.

We edge forwards a little. I wind my window down.

Directly outside the window in the grass by the road is lion five, no further than your window is from you now. I look at her – she meets my eyes with her luminous yellow pair. I hold her gaze. Her eyes are so big. After about half a minute she curls up the left hand side of her upper lip and the faintest rubble of growl slowly wells up from her belly.

I wind my window up. Alison glances up. “Do you think they might try the sunroof?” That Far Side cartoon in the game park flashes to mind: “George, quick, start the engine! This one’s got a coat hanger!”

We watch for a few more minutes then reluctantly head away. We’ll be late for Zulu. I text to apologise: “Will be little late – stopped by lions”. Seconds later the reply comes “Best excuse ever!”

Saturday, 10 November 2007

Unsung heroes

“So who is speaking from Hlabisa?” says the facilitator.

We all look at each other. Or rather, all the nurses look at me. I heave myself up and go to the front of the room. The tables are arranged in 5 groups around which sit an assortment of doctors, nurses and paramedical staff – each representing one of the 5 hospitals in our district.

We are in a hotel in Hluhluwe. It is the 6 monthly regional anti-retroviral roll-out meeting. Three or so years ago the KZN Dept of Health asked the University’s Centre for Rural Health to support and improve the ARV roll-out in our district. They brought in an American organisation, the “Institute for Health Improvement”.

“What does the Institute for Health Improvement do?” I asked Bud, the very American representative from IHI, at the first meeting I attended.

“We’re into health system improvement,” he drawled. “You’re from the UK, right?” I nodded. He grinned triumphantly. “We were behind many of the recent improvements in your NHS!”

Fortunately the improvements in the Umkhanyakude (our district) ARV programme are open to less debate than would those in the UK NHS. As each hospital has presented its figures we are startled to discover that between the five of us we have over 10,000 people on treatment. Since there are allegedly just over 100,000 people on treatment in the province it is extraordinary that 5 rural hospitals can alone count for 10% of that.

As I talk and describe the work being done at our hospital I find myself terribly moved. Moved by the work and commitment of all the people here and their passion to see their countrymen and women receiving the best care available. Moved by their drive to see things improved when government has not necessarily been behind them, and when there was no leadership to look to. And amazed by what they have achieved. Sure, it is not just about numbers and yes, there are loads of problems with the quality and accessibility of healthcare. But were it not for people such as those in this room it would be so much worse.

I finish my presentation with a statistic gleaned from a local research institute. Their survey of deaths in the community has identified significant drop in deaths among young adults over the last 2 years. Of course, it could be some dramatic improvement in road safety. Or perhaps food hygiene.

But I think it is because of the people in this room.

See here for a review of ARV rollout in SA.

Thursday, 8 November 2007

Status

Emma and I are doing our morning ward round. Sister eyes up Emma in a manner that can only be described as sly.

“So doctor,” she says, “are you married?”

Emma looks startled. “No.”

“Ahh – so you have a boyfriend?”

“No.”

A slow smile spreads across Sister’s face in a manner that can only be described as evil. “Ahh!” she declares triumphantly, “So you are a virgin!”

There is a pause and then Emma smiles in a manner that can only be described as demure. And says nothing.

Monday, 5 November 2007

Prude no more

I have just spent an entertaining hour in the sea at St Lucia on my body board and am heading for the open air showers in the car park. There are 3 people using them already - they appear to be washing their clothes and are chatting animatedly in Zulu. I wait for them to finish. One of the ladies turns and realises I am waiting. I in turn realise that she and her friend are topless and wearing just their nickers - everything else is out for washing.

She drags her friend away and gestures for me to take a go in the shower. I smile, "Ngiyabonga" and take my place. I scrub away whilst the others chat and watch and wait for me. I towel off and they return to their washing. I thank them and head off. "Sala kahle" I say. "Hambe kahle" they reply with a wave and a smile.

Only as I am driving away does it strike me - I showered with 2 topless women and did not even turn red.

I am a prude no more.

Sunday, 4 November 2007

De Nile ain't just a river...

It is my first day back on the TB ward. After several months of relatively high levels of staffing the exodus has begun. The Norwegian doctor left to work in the Antarctic last week. In 6 weeks the 5 community service doctors (the South Africans who have to work for a year after their internship in a hospital lacking doctors if they are to be registered) will begin to leave. So I have moved to TB ward to cover the gap.

I had forgotten what it was like. A few people are well and improving on TB treatment. They are there simply to receive their medication as it is too far for them to get to their local clinic. But most are there because they are too sick to be managed by relatives at home. They are on TB treatment but continue to waste away, either because they have advanced HIV, or because they have resistant TB that we haven’t been able to identify. One man lies in bed near paralysed by TB of his spine. Another lies moribund and semi-conscious with TB meningitis.

We enter the side-room. One man, with the unlikely name of Bruce* enagages the nurse in animated conversation. The nurse replies and an extended debate ensues.

She turns to me apologetically. “I am sorry Dr. I am explaining about his HIV test. He does not believe it.”

“Why not?” She asks him. He explains with great animation, expansive arm gestures and widened eyes. He gestures at times towards his finger tips. Finally the nurse turns back.

“He does not believe that a tiny drop of blood from the finger can tell you he has HIV. He believes the sputum can tell you he has TB because that is from the lung, but how can a spot of blood from the finger tell you he has HIV? What has the finger to do with HIV?”

We start a rather tortuous conversation. HIV is partly a disease of your blood, I explain. That is why it does not matter where the blood comes from. He looks at me doubtfully.

“Sister, how about if I take the blood from a big vein in the arm? We can test that. Will he believe that?” She asks him.

Yes Dr. He would like you to take blood from the big vein. The big vein is from the body – he says he will believe that.” I write the form as the nurse takes the blood - but rather doubt that he will be converted to belief.

*Not his real name but a pseudonym chosen for its broad anaculturistic similarity – a term I have invented to describe something that is out of place culturally aka. anachronism for time. There is probably a proper word for it. Answers on a postcard.

Tuesday, 30 October 2007

The Borrower

We have a new bunch of elective students. From the States. They all look terribly young. They are following close at my heel as I wander onto the ward. They try to follow me into the toilet but halt when I tell them to “stay”.

We start the ward round. Sister is on excellent form. She sizes up the students.

“So – where are you from?” she demands, pulling up her sleeves exposing her formidable forearms as if she was about to punch the answers out of them. They shuffle back involuntarily and admit to being American.

“Ahh – America. I wish to go to America,” she says dreamily. She studies the students. Her gaze settles on one – a girl of about 4 foot tall who is presumably some kind of child genius. Or a long forgotten trans-Atlantic cousin of the Borrowers. Her eyes widen.

“Hauw Dr!” she says to me. She grabs the girl. “Look at this one – you must check her hormones. She has not had puberty. Her endocrine system is defective!” The poor girl colours and tries to look even smaller were it possible.

Monday, 29 October 2007

Back from Holiday

Few pictures from the Drakensberg Mountains.

First night stayed in a cave. Just the three of us - massive electrical storm filled the evening, the flashes lighting the valley below our cave mouth as bright as day. Then brilliant sun as we cooked breakfast in the morning by the river.


After breakfast we got in touch with our never-far-below-the-surface inner children - a played in the river. The water carved the rock into pools connected by natural flumes. Best fun ever. And freezing.




A couple of days later off to Royal Natal National Park - named after Elizabeth's trip there before taking up the family business. It is famous for the 7km long cliff line named the Amphitheatre. Around 1km high from the base.


And having got a taste for mountain streams...

Contrary to appearances I am in more than my birthday suit.

Saturday, 20 October 2007

On holiday

I am away for the next week. Please leave a message after the tone.

Friday, 19 October 2007

Team Hlabisa


Taken by one of our students

Grants

So. I don't think I have told you about Disability Grants have I?

In SA there is basically no employment benefit. In some areas unemployment is over 40% so it is an economic impossibility I suppose. Instead there are Disability Grants. The intention is laudable enough: give those with TB or advanced HIV money to eat, give those with diabetes or chronic illnesses money to get to clinic. But of course in practice the grants are an incentive to be ill. Until very recently we were supposed only to give HIV patients grants if their CD4 count was under 200. So, once on ARVs if their CD4 rose above 200 they would stop taking their medication in order to maintain their eligibility. When diagnosing TB the production of sputum is supposed to be witnessed - there have been black markets in TB-positive sputum, with patients selling their sputum to uninfected people so they can get treatment and therefore money.

So each Wednesday we sit with the social worker and work through 20 people with "disabilities" - ranging from the genuine "my eye is missing" to the perfectly well lady with "total body pain".

Apparently last weekend some local politician came to Hlabisa town. He spoke to a big meeting and told the people all about Disability Grants. He said if you have high blood pressure, if you have diabetes, if you have arthritis, if you have basically anything you can get a grant. So go to your local hospital and get a grant!

When the doctors turned up on Monday there were over 200 people outside the gate demanding their grants - most it has to be said looking intimidatingly undisabled.

Tuesday, 16 October 2007

Cattle rustling South African style



Saw this in a newspaper. A Tazz is similar in size to a Renault Clio. The backseat had been removed from the car, the cows trussed up (3 of them) and piled in. Although shaken up by their ordeal they were, you will be glad to hear, otherwise unharmed as indicated by their willingness to pose for the newspaper photographer following their rescue.

Monday, 15 October 2007

Comic picture of the day


Taken not, as you might suppose, at our hospital but in the St Lucia Wetland Park. If you look very closely you can even see his cry of horror.

Saturday, 13 October 2007

Waiting times

I open the next outpatient card. It is Thursday evening and I am on call in outpatients. My heart sank as I arrived – there were at least 40 people still waiting. Some had been there since 8am. The card I have opened has a piece of paper inserted. It is headed “Waiting time survey” and is all part of the entertaining clash of first world standards and third world communities, resources and managers.

Let me describe a typical patient journey:

Week 1
Monday – goes to clinic with cough for 3 weeks. Clinic gives amoxil and takes sputum.

Friday – patient goes back still coughing. Result lost - clinic repeats sputum.

Week 2
Wednesday – patient goes to clinic. Sputum negative for TB but still coughing so told to go to hospital.

Friday – gets up at 5am having found the money from a friend for the journey. Arrives 5 hours and 2 taxi journeys later. Sits in OPD for 6 hours. Seen briefly by stroppy doctor at 4pm who wants an X-ray. X-ray has just closed. Sleep on the floor overnight with 30 other people using mattress carefully impregnated with urine and lice.

Saturday - get your chest X-ray. Seen at 2pm by stroppy doctor who loudly complains that you are not an urgent patient and “why have you come on a Saturday for a cough that has been going on for weeks?” Started on TB treatment and told to register at the office. Pharmacy has just closed for the weekend. Office closed til Monday.

Making piles always helps. I divide the cards: non-urgent compassionate see (15 patients - e.g. joint pains but been waiting for 12 hours), non-urgent won’t see (4 patients - e.g. chronic cough arrived at 4pm), urgent must sees (15 patients - acute breathlessness, vaginal bleeding etc.).

I could just see the urgent “sick” ones – it is not as if people can go home until the morning anyway – but I have still not been able to shed the “responsibility guilt”. One colleague commented regarding it that I “seemed to spend rather more time feeling guilty than a protestant Christian is supposed to.”

Bastard.

Saturday, 6 October 2007

Pick your battles

I come to the next patient. She was admitted earlier in the week “happily psychotic” (as opposed to “aggressively psychotic” – which will lead to the nurses locking you in the side room and laughing at you through the window). As such she was allowed a bed in the main ward - in which she sat and smiled and giggled.

She looks a lot quieter now. I have been slowly winding down her sedatives trying to get her settled. Sister looks over my shoulder as I re-write the drug chart.

“I think we can reduce the haloperidol now sister. She is looking much quieter now.”

Sister puts her hands on her formidable hips.

“Ah – no doctor. We cannot do that.”

“But I have been halving the dose each day all week – and look at her, she is still quiet and probably over-sedated. We can reduce again now.”

“Ah – but at night doctor she is different. In fact doctor – I have been giving extra haloperidol – same dose as on admission.”

“But you have signed on the chart where I wrote 2.5mg?”

“Yes doctor – but I gave 10mg.”

“Why?”

“Because at night doctor, she gets up. And she sings and does Zulu dances in the middle of the ward. And then she goes to the male ward and does the same."

I think of raising the point with sister that perhaps she should have told me rather than ignore the drug chart entirely – a loss of temper might be justified. But instead just meekly write on the chart as instructed.

I don’t want to end up locked in the side room being laughed at through the window.

Tuesday, 2 October 2007

More money than sense


The man wanders up to me as I pace around the car, eyeing it admiringly. It is a 4.5L 1928 Bentley. It looks brand new.

“Wonderful isn’t it!” he says in a way that isn’t a question.

“It is!” It is one of over 30 Bentleys in the car park of the hotel we have stopped for lunch in. We have stumbled upon the Bentley Owners Club’s South Africa jamboree. A little questioning later and I have found out that it cost £3000 to ship the car here from the UK and there are others from New Zealand, Australia, the USA as well as South Africa. They are spending 6 weeks driving around the country. He hands me the brochure – each car has a photo and an entry by the owner describing the car. It is full of comments like “we have had some wonderful threesomes: me, the car and my wife Margaret I mean.”

“It must be a way of life rather than a hobby,” I comment. The man eyes me.

“It is a pursuit for foolish old men with more money than sense!”

Later in the hotel garden I meet a peroxided lady – one of the wives. She agrees. “This year they aren’t too bad. Quite nice people. Some years they are terrible.” She rolls her eyes and makes out that she hates doing this – but clearly isn’t. “I love Africa – we spent years living around Southern Africa. We loved Zimbabwe. Not any more of course. That Mugabe. I wish I had what he’s got – he’s going on and on. First he was supposed to have syphilis, then AIDS, but look at him! Eternal youth!”

She asks what I do and I tell her.

“You must see a lot of AIDS.”

“Yes – and it’s going to be around for a long time.”

“I suppose people don’t change because they are only 2 year olds educationally and you can’t easily change that.”

My mate quickly excuses himself as I sustain a slightly awkward conversation for 2 more minutes before following him.

Friday, 28 September 2007

Retrospective

Got a few hours on broadband - so let me give you a couple of short videos from the strike in June.

video video

Converting?


Perhaps it is rubbing off on me, or maybe it is the cabin fever – living in a closed community with few distractions – but suddenly birds seem quite interesting. For example, even I stood for hours, well OK, not hours but several minutes.. 5 at least, watching these Weaver birds. Stripping fibre vigorously from the palm leaves they then flew across the garden to the tree in which they were building their nest colony and got weaving. Amazing.



Wednesday, 26 September 2007

Twitching

Olstein and our guide, Amy.

The thing about Olstein is that he is not only a twitcher. He is a Twitcher. His tally of individual bird species seen in his 6 months in South Africa stands at over 250. He can tell you not only what he saw but where exactly in South Africa he saw it. So when he hands me a pair of binoculars as we head out for a guided walk on the Lebombo hills of Northern KwaZulu it is not a casual gesture. It is akin to being handed a Bible by the earnest friend who invites you to church. In fact, I realise, walking with Olstein visits upon me the exact sensation I spent my earnest years visiting upon others whilst in the University Christian Union. It is like visiting church and standing next to a fervent Charismatic when you yourself are “just interested”.

“Look! Over there!” he exclaims.

“Where?” I look in the direction of his pointed finger.

“There – it is a blurdy blurdy blur [substitute some South African bird] !”

“Really?” I lift my binoculars to my eyes and singularly fail to locate with them the distant speck I can see with my naked eye. I wave the bino’s in ever decreasing circles in the hope of stumbling upon the speck.

“Oh – its gone. Did you see it?”

“Yes,” I lie, feeling very much like some cousin that has had to repeat grade 1.

Our guide, Amy, is very impressed with Olstein.

Amy is something of an eccentric. We discovered her through the hotel when we said we wanted to go walking. She has lived in the African hamlet of Ubombo for 2 years and grows bonsai trees, collects fossils, writes (“I’m not yet published”) and paints. The only other white people in the village are the owner of the hotel we are using (with an improbably posh house complete with swimming pool and satellite dish – looking decidedly out of place next to the shacks just meters away) and some local land-owners (“I’m allowed in their house when I pay the rent”). She leads us along the animal tracks of the hills, through small settlements and undergrowth. Children wave, smile, and ask for money. We wave, smile, and tell them no way.


She does not seem entirely sure of the way. At one point our route leads to the entrance of a kraal (the collection of huts that comprise a dwelling – with several family members living together). “I’m not sure we can go through here,” she says, not entirely necessarily given the fencing and barbed wire. She leads us back the way we came.

Afterwards we go back to her house for tea and she shows us fossils. Here at least, I can trump Olstein on nature. I ask whether something is an “ammonite” before he does. It is the only fossil I have heard off. Luckily, it is.

Last year's Protea

Thursday, 20 September 2007

Radical measures

Sister turns to me.

“Doctor. I have an idea. A way to stop HIV-AIDS.”

“Really?”

“Yes. The problem is the men. It is the men that give us the HIV.”

“Yes?”

“So what the government must do is kill all the men. Kill all the men!” She slices her arm vigorously through the air in a chopping kind of gesture. “The less men, the less the HIV.”

“It is a good idea,” I reply. “You should write to the Provincial Government.”

“Of course, after a while when the country had no children there would be problem. But we women could have a few good years before that. I will write to the President!”

She storms off muttering to herself.

Monday, 17 September 2007

Chicken dinner

As I finish my ward round on High Care one of the nurses pulls me to one side.

“Doctor, can I see you?”

“Certainly.” She drags me into the small nurses office and begins describing her symptoms. I try to listen earnestly but find it difficult to concentrate. In the background there is what can only be described as the sound of gentle gobbling. I look around. It seems to be coming from behind the nurse. I try to look over her shoulder. She moves to block my view and carries on describing her symptoms. I nod seriously a couple of times and edge to one side. She moves again, but not before I succeed in localising the sound to a plastic carrier bag on the floor.

I bend down to look and tweak the bag open. There, looking up at me, is a small white chicken. Unlike most chickens I have encountered in carrier bags it is not skinned, cling film wrapped and indeed, dismembered. It clucks at me, as if to emphasise the fact and then shits industriously.

The nurse glances at me, looking highly embarrassed. More at the fact of the presence of the chicken than its tendency to defaecate in public I decide.

“It is for my sister,” she says.

“For what?”

“For dinner.”

Thursday, 13 September 2007

Dead Man's Beds

We are struggling on the ward. We have discharged 3 patients so far but as fast as the beds are vacated new occupants take up residence. They have spent the night on the floor in OPD, and OPD wants them out. I glance at the benches lining the wall of the ward – another 4 people sit there clutching the yellow admission papers, awaiting a bed. There are already another four people using mattresses on the floor.

Sister is getting stressed, and my colleague and I are also getting a little twitchy. We turn to the next patient. He is virtually moribund: unresponsive, eyes rolled up into his head, breathes slow and gasping. “Ah!” says Emma, “Brilliant - we will soon have another bed!” She slaps her hand over her mouth, looking shocked at her own words. Sister hoots with laughter and points to another patient across the ward.

“Yebo! And there is another over there!” We follow her finger and turn just in time to hear the death rattle of the other imminent corpse. This week at least admission to this hospital is a matter of “Dead Man’s Beds”.

Tuesday, 11 September 2007

Shot

As I cut through his skin the young man turns to look at me. He is lying on one of the couches in Resus, panting and groaning in pain, his face obscured from my view by his oxygen mask. He reaches out his hand to touch me and then rests his arm across my shoulders in a clumsy embrace. Just one hour ago he watched as his girlfriend was killed by the same gunman who shot him through the chest.

I work rapidly. The bullet entered just right of his sternum and exited in the right loin – ripping through the lung and liver on its way. From my quick assessment when I was called it is clear his chest cavity is filling with blood impairing both his breathing, and as the heart is compressed by the pressure, his circulation. As I enter the chest cavity there is a gush of blood over my hand. I insert the tube and connect it to the drain bottle. The blood pours out – 200mL, 300, 500. A litre.

“Someone run to the lab and get all the blood they have,” I bark. “Someone else, get some fluid running in that line.” One nurses squeezes a bag of fluid into the line in his arm and I get the biggest IV cannula I can find and stick it into the femoral vein. A nurse stands and squeezes a second bag into that.

The blood arrives – we set up a third line and soon there are three nurses squeezing various fluid. His blood pressure begins to pick up. I check the drain bottle – 1.5L of blood.

I go to the phone and start making the calls to get him transferred to the surgeons. The surgeon accepts him no questions asked. The ambulance service is more problematic – the phones are answered by clerks with no medical knowledge at all. I answer all her routine questions. “So what is the problem doctor?”

“He has been shot in the chest.”

“And when is this transfer for? Tomorrrow?”

“Now! Urgent!”

“Now?”

“Yes! Now now!”

The whole thing takes 30 minutes. I return to the man. “How is he doing?”

“Not so well doctor. The blood pressure is dropping and he is not responsive.”

“Shit.” In my absence he has filled another drain bottle completely – 4 litres of blood. The nurses are squeezing in the 4th unit of our stock. We have only 2 left in the entire hospital. I call one of the other doctors to come help me as I stick in a neck line.

The phone rings as I finish the line and the nurses holds it to my ear as I stitch – it is the helicopter coordinator in Pietermaritzburg. She sounds jarringly cheery. “Hello! How are you?”

“Fine.” I mutter.

“Good. I’m fine too. We were just called about your patient with the gunshot.”

“Just called? But I phoned the emergency service an hour ago!”

“Really? Well they only just called the helicopter service. How is your patient?”

“Not good.”

“Would you still like the helicopter?”

“Yes! As soon as.” She asks a few more questions and assures me it is leaving its base and will be there in 30 minutes.

The man is stirring a little now – his blood pressure is better, but he is increasingly unstable. I call for one of the sisters from high care – she arrives with the anaesthetic drugs. She explains to him what I am about to do. He nods, closes his eyes and I sedate, paralyse, intubate him and stick him on our portable ventilator. I offer silent thanks to ITU Southmead in Bristol where they taught me how to do this stuff. I look up – the resus room has filled with silent nurses in 2 rows watching. Standing at the back are some people who appear to be on a tour of the hospital. One pulls out a camera and takes a photo. I want to shout at them. But don’t.

We have used up all the blood. He is well into draining the 8th litre from his chest and it looks not so much like blood as rose wine – the majority of it being the saline we are pouring in. One of the doctors gets on the phone to an old boss to find out whether we can safely re-infuse what is coming out of his chest: auto-transfusion. But even as she does so the helicopter team arrives.

They take their time transferring him onto their equipment. I am getting agitated: don’t they understand he needs blood and surgery! Sod this! But they methodically continue. As we move him he gives a cough. A great flow of blood erupts from the chest wound – we stick on extra dressing and press hard. His blood pressure is falling and I give him a shot of adrenaline.

At last the helicopter team are satisfied. They wheel him out and load him on, finally leaving 3 hours after my call. As I watch I wonder whether he will even survive the transfer.

I suddenly remember I am supposed to be at a meeting at a nearby research centre – it started 2 hours ago. I phone to apologise. The organiser (a German – not that it is of significance) says I shouldn’t worry. No one else has arrived yet. I burst out laughing. That is so South Africa. “I am glad you find it funny because I do not,” he grumbles.

The rest of the day is a blur. At the end I phone the surgeon who took the man. He went to theatre – they removed the damaged lung and packed the liver. He is on ITU and stable.

I walk home and decide that I will have a (very brief) weep. Of relief.

So I do.

Saturday, 8 September 2007

Stillbirth

The phone rings and I open my eyes blearily, attempting to focus on the clock: 3am. I stagger over and answer. It is Andrew – there is a Caesarian. I pull on my shorts and step out of the flat into the cold night air. The sky is clear and the stars are burning bright and splendid, the Southern Cross hanging directly over the hospital.

I walk down the dark road to theatre, the wind blowing cool and dry across me, whistling slightly in the palm leaves above. The patient has just arrived. “She had grade 3 meconium in the liquor,” Andrew explains. That is a sign of significant foetal distress and in our setting an indication for Caesarian in most cases.

I stick in the spinal anaesthetic – I am having a good run at the moment, it takes only one stab. I turned one poor lady two weeks ago into a veritable pin cushion – I could not feel any of her spinal bones through her ample skin. This lady is significantly thinner.

“Do you want to cut?” asks Andrew.

I have done four Caesars under close supervision. I feel a bit pathetic but at 3am, given the choice between Andrew and a 45 minute operation, and me and a 2 hour operation, I choose Andrew every time. At the start of my last effort I told the nurses that they should feel free to nip off for tea at the start of the third hour. They laughed, but at the end one of the sisters came to me and said with a grin, “Dr Moran, we thought you were joking. But you were not.”

I scrub in to assist. Andrew dissects down to the uterus and reveals the baby’s head. He delivers the head and quickly suctions the mouth before delivering the rest of the baby. There is no cry. The midwife plucks the child from him and takes it to the resuscitation area.

I eye what is going on, even as I hold the retractor. It is instantly clear things are not going well. I leave the operating table, pull off my bloodied outer gloves and join the midwife with the baby. There is no pulse and no respiration. The midwife begins chest compressions as I suction the airway and use the bag and mask to ventilate. I am getting good chest movements but there is no sign of the child getting pink. We give adrenaline and I grab the laryngoscope. I get a good view of the vocal cords and ask impatiently for the endotracheal tube. I pass it down throat through the small gap between the cords. Pulling the mask off the bag I connect it to the tube and ventilate the baby.

20 minutes, 1 naloxone and 2 adrenalines later and there has been no change. The baby never stirred, and never took a breath of its own accord. I ask the Sister in charge to explain this to the mother before we finish. Sister goes to the mother and with great compassion in her face and manner explains what is going on. I watch the tragic conversation, the mother listening even as, behind the green sheet the obscures her view, the surgeon continues to close her abdomen. Sister comes back. “She understands. And she would like to cancel her tubal ligation.” The surgeon nods silently.

The midwife and I stop resuscitation. She takes the baby and wraps it up. I go to the mother. She looks at me and whispers, “Siyabonga.”

The spinal anaesthetic is wearing a little thin now. She winces and give small gasps of pain. I give her a shot of sedative to ease the discomfort for the last 5 minutes of the operation. I time it badly: the midwife comes to show her the dead baby, carefully wrapped in a sheet. She is too spaced out to really notice.

Wednesday, 5 September 2007

Consulting God

The man walks onto the ward and makes a beeline for me. He talking loudly and expressively in Zulu, his arms waving dramatically to emphasise whatever point he is making. He is a little unkempt but not obviously drunk or high. He sees I do not understand and switches to Afrikaans.

“I don’t speak Afrikaans. Try English.”

He obliges instantly. “Doctor, I am here for my medication. I need my medication. Can you write me for my medication? I have run out and I need more.”

“You must go to outpatients sir. They will help you with you tablets.”

“I need haloperidol, chlorpromazine and epilim. You can write me up for them can’t you?” They are antiepileptic and anti-psychotic medications.

“Go to outpatients sir. They will sort you out.”

“Ah yes. Thank you doctor.” He pauses and watches me. I turn back to the patient I am seeing. He begins talking loudly to the nurse.

“Could you keep your voice down sir? It is hard to hear the patients!”

“Of course! Of course! It is very irritating isn’t doctor when people show no consideration?” There is a hint of irony. He is nodding enthusiastically and looking at me seriously. As I continue on my round he wanders off. 20 minutes later he is back with one of the OPD nurses Bongani in tow to make sure he doesn’t get up to any mischief.

“Ah! There you are doctor. You must help me. These people do not realise that I am God. You must tell them who I am. You know who I am don’t you?” A spray of spittle gets me in the eye. “And there is another thing. Can you help my vision?”

“What is wrong with your vision?”

“It goes dim. But only when I read the New Testament.”

“It is OK when you read anything else?”

“Yes – there is no problem with anything else.”

“OK – let me see if I can help you.” And God and I nip over to outpatients to sort out His anti-psychotics.


Outpatients

Monday, 3 September 2007

Spring

I wind down the window and stretch my bare arm out into the onrushing wind. The heat and humidity are testament to the arrival of Spring and I open my hand to catch the breeze as it hurtles by at 120 kilometres per hour. I reach the crest of the hill – the highest point of the highway as it traverses the game park – and the landscape rolls away into the haze on all sides. Vervet monkeys leap out of the way as I head down again. I turn up my (you might say cheesey) African themed music.

As I round the corner the car in front slams on his brakes, as I do in turn. An elephant is crossing the road. We both watch from our vehicles. As I pass the driver he turns to me and gives a broad smile and gestures animatedly to the elephant beside him. I smile and wave back and then pull away.

You gotta love this country.

When Jesus calls

Sister on C ward

I am half way through my round on C ward, the female medical ward. Out of the corner of my eye I become aware of two well dressed women standing a couple of metres away and radiating that powerful aura that so effectively says “I am waiting for you” to your subconscious. I have never learnt how to ignore it and within a few seconds find myself completely incapable of concentrating on the task in hand.

I turn to them. “Can I help you?” They step forward, clutching the familiar bulk of the death certification papers.

“Yes please doctor. Could you sign these?” says the first in perfect English. I take the papers. There are several of these most days – my record is 7 deaths (20% of the ward but that was over a weekend and shouldn't be counted). They must be signed by a doctor to confirm the cause of death before the body leaves for the undertaker. Half the cases we have no idea what actually killed the patient and write “Pneumonia, ?HIV”. A GP in a town 50km away did a week long course on how to do post-mortems apparently – we send the suspicious cases to him – but there is no system for confirming causes of death in those cases where the diagnosis is unknown as there is in the UK.

I flick through the papers and look up at them in dismay. “But this lady was doing fine yesterday!”

“Yes doctor. We came yesterday and she was well. She told us she was being discharged.”

“Yes – but she was young and she was nearly completely better. I am so sorry. I don’t know what happened.”

“Oh doctor. Do not worry.”

“But she was better. She was walking around and complaining that she was bored.”

“Doctor. There was nothing you could have done.”

“Thank you but I am so sorry.”

“Doctor. If Jesus calls someone then there is nothing even you could do about it.”

I sign the papers, again having to make something up as I have no idea what killed the poor woman. Do you know what the a South African’s life expectancy is these days?

48. Much lower if you take out the wealthy city people.

It seems to me that if the lady’s logic were true Jesus seems to want an awful lot of young Zulus.

Saturday, 1 September 2007

Ghost Mountain Inn

It is dusk as we pull in through the gates of the Ghost Mountain Inn in Mkhuze. It nestles at the foot of the Lebombo Hills in KZN and is one of our more luxury getaways – we are using it as a stop over on the way back from the conference. My mind turns to our first visit here a couple of months ago.

We were in the bar in the evening and got chatting to a pleasant Scandinavian couple. He was Swedish, she was Norwegian I think – both incredibly snappy dressers. Since we had a Swede and Norwegian in our gang conversation flowed fast and multi-lingually.

“What are you doing here?” I asked them.

“I am setting up a football academy,” he replied.

“Here?!” Mkhuze is not exactly the centre of the world. It is a small town in the middle of a large rural area with few services and little employment. He was, I imagined, some kind of social-conscience development type, using his football skills as a means of community development and empowerment.

“Yes, but we live in Durban.”.

The girlfriend broke in, “I am house-hunting in Umhlanga.” Umhlanga is one of the most upmarket beach areas in the Durban suburbs. Housing there is not cheap. My vision of a social-conscience development type did not fit well with buying a house on the Umhlanga beach front.

“So where are you living now?”

“Here,” she replied.

“In Mkhuze?”

“No, in the hotel.” I was vaguely aware that some of these European development organisations can have rather excessively generoues expense allowances but there are cheaper ways to live than R540 per night per person.

“Wow! Nice!”

“Well its OK, but of course no hotels will let me have my dog and it is really a problem when you are living in hotels for a while.”

“You got the dog here?”

“No, we brought her from home. She had to spend 6 weeks in quarantine poor thing. It was so expensive but she is out now.”

“So do you have the dog in this hotel?”

She lowered her voice to a whisper. “Yes. But when we check in a have to dress her up as a baby in a blanket and carry her in my arms as if she was a asleep!” She sat back in her chair with a triumphant look on her face. I could feel a slightly hysterical smile creeping irrepressibly over my face and tried to think of something sad.

After a couple more drinks they made their excuses and left. Olstein sat back with a conspiratorial look on his face. “You know who that was don’t you?”

“Who?” I asked.

“Swedish. Into football. Setting up a football academy.”

I struggled and failed to make the connection.

He paused dramatically - I could almost hear the drum roll. “It was..."

"Yes?"

"Sven Goran Erikson’s son!”

“What?! How do you know?!”

“I met one of his work colleagues earlier in the afternoon and he told me.”

“Are they are hear doing social development projects?”

Olstein laughed heartily. “It is not a social project. They are talent spotting and then exporting trained players overseas for loads of money.”

It suddenly all makes a bit more sense.


Then, with the outside company gone we regressed to childhood and spent the remainder of the evening challenging each other to snog the various wooden animal statues that decorate the bar without the foyer guard seeing.

Wednesday, 29 August 2007

Full circle

We are all eating lunch in the large marquee that serves as the conference dining room.

“Have you met Jono?” asks Tracey, gesturing to the man next to me. I automatically launch into announcing that I haven’t and then stop. He looks vaguely familiar. I eyeball his badge – the surname rings a bell and from the dark recesses of the long term storage of my mind I remember. He was the medical superintendent of the hospital at which I did my elective as a student in my final year of university more than 10 years ago. He is now working in Swaziland as an eye surgeon. Perhaps Swazi’s only eye surgeon. Not all tough though - he appears to live in an excessively idyllic setup.

“The amazing thing is that on my last day you firmly told me that I would be back, or words to that effect. I said that just this morning in Tracey’s meeting!”

I determine to work similar psychological manipulations on our medical students on my return. As a long term investment in South Africa's medical staffing future.

Tuesday, 28 August 2007

Governement - a Faith Based Organisation

The speaker has been much hyped and I am not disappointed. Francois Venter, a well known and highly political HIV physician from Johannesburg is speaking on the state of the rollout of anti-retroviral drugs (ARVs) across South Africa.

If you are serious about impacting HIV in South Africa it is impossible not to be political. A few months ago he was in the news for calling for compulsory HIV testing (in a country where in some areas prevalence can exceed 40%, less than 2% have been tested). Today he speaks of the problems and the dismal state of programmes that are supposed to be preventing the babies of HIV positive mothers getting infected. “If these programmes worked as they should, and as they have proven to work in other parts of Africa, we would not need to significantly expand our programmes of treatment for HIV infected children beyond what they are now.” The issue is not money, he declares. Much more money is being spent in South Africa than elsewhere on the continent. The problem is management and the terrible lack of competent personnel.

“However, addressing all these problems is like rearranging the furniture when there is, in fact, an elephant in the room.” Then, with a dramatic pause, he puts up his final slide: a picture of the controversial national health minister. A lady infamous for pushing beetroot over anti-retroviral drugs and who has featured prominently in the South Africa news of late. She was off sick for a while and great secrecy surrounded the reasons. One of the braver newspapers recently claimed she received a liver transplant for alcohol-induced liver disease – and yet continues drinking. Further allegations over how she runs her dysfunctional department have been overshadowing the major health problems that plague the country. In a further twist to the tail her widely respected deputy, who in the course of her boss’s sick leave oversaw the development of the country’s new and widely praised plan to confront TB and HIV, has been ousted following an “unauthorised trip” to Spain to present at an HIV conference.

Someone sticks up a hand to ask a question about the government’s TB/HIV plan. Venter grins. “I like to say the government is a Faith Based Organisation.” He goes on to point out that setting new targets but no new ways to meet them will not increase the number of babies in the HIV transmission prevention programme. Continuing to do just what we are doing now will achieve nothing new. “But the government seems to have faith that it will!”

The meeting ends and I slip into the next room on the hunt for another session. There is a 20 foot bleeding penis on the screen. Someone is describing how to do a circumcision. Lovely.

For information on South Africa's new AIDS plan see this article.
Go here for details about Venter's call for compulsory HIV testing.
For further info on the controversy surrounding the health minister and her deputy see the Sunday Times of South Africa.

Sunday, 26 August 2007

"And what do you do?"

Dr Adam, my boss, is drawing to a close. It will soon be my turn to speak. I feel a little self-conscious – as far as I can tell the room is full of grisly seasoned medical managers and rural doctors with decades of experience. I’ve been here for 6 months. We are at the annual RuDASA conference – the Rural Doctors Association of South Africa. My boss and I have been asked to say a few words about “being recruited” by Tracey, the dynamic recruiter of the Rural Health Initiative.

I am suddenly aware that a photographer is aiming his lens at me for a profile shot. In my day-dreaming I fear I may have lost the look of rapt attention that an employee should always display when listening to his employer. My face rallies quickly – but not I fear, in time for the shutter.

I rabbit on for a few minutes about my “experience of being recruited.” How I was sitting at my desk in March 2006 attempting to write my PhD thesis and wondering at what point I wandered off the track of “what I wanted to do” to “what I ought to do” and how to get back. How stumbling onto the Rudasa website led me to the Rural Health Initiative site. How 4 minutes after I hit “send” the phone rang and the energetic and unmistakeably South African voice of Tracey Hudson demanded exactly when I was planning to come. How the same voice cajoled me through my sluggish efforts at filling in the necessary forms and bulldozed through my intermittent second thoughts.

I decide on balance not to tell them how, on meeting Tracey’s husband, I – Prince Philip like – asked, “What do you do?” He politely told me he was “in finance.” Only later did I discover that Andrew Hudson is a famous South African cricket legend. But hell, I would have asked the same thing of the entire English cricket team.

"Every night I pray..."

As I bump along the dirt track I see two women up ahead, one carrying a child on back wrapped up in a blanket. I pull over and open the door.

“Do you want a lift? Are you going to the clinic?

“Yebo!” they say and they climb into the car.

“Siyabonga dokotela,” says the lady in the front seat. I almost ask how they know, but then what other white person would be driving down this road today?


At the clinic things are a little chaotic. As I walk in a nurse cries, "Excellent! Come!", thrusts a syringe and needle in my hand and pushes me in the direction of a screaming child – he is HIV positive and needs a CD4 count taken. I’m not great at taking blood from kids but with a little probing I get the vein, the screams peak at decibels approaching those of a 747 and it is quickly over. The kid stops his yells and eyes me balefully from over his mother’s arm. The nurse sighs her thanks. “Ach, doctor. It is so busy. We have all the normal patients, and all the HIV patients for their CD4s and viral loads, and all the TB patients.”


The clinic sister insists on working with me rather than sending one of her juniors, “because then I can ask you all the questions I have.” We start work. The first patient is a high blood pressure. “When should I use enalapril?” asks sister. We talk a little about that. The next is a lady who came to the clinic in the night with severe breathlessness. “I though she might have heart failure but her ankles were not swollen. Why is that?” We both huddle over a scrap of paper as I attempt to explain with the aid of a messy diagram.


After an hour she tries to stifle a big yawn. “Oh! I am sorry. I am sooo tired!”

“Why?”

“Well, I am the only senior sister at this clinic, and the only one who can do deliveries. So I work all day. But then if anyone comes in the night who needs a baby or with a difficult problem they call me! So last night I was cooking dinner for my children and then I hear bang, bang, bang, and they are calling ‘Sister! Sister! Where are you? Come and look after us!’ So I stop cooking and have to go and help them. My children have only had bread and jam for 2 nights!”

“And you have to do this every night?”

“Yes. And each night I climb into my bed and pray to my God that this will be the night I sleep. And if I wake and it is morning I say ‘Thank you God for looking after me!’”


“But that is terrible – when do you have days off?”

“I get two nights off a week.”

“And for how long must you do this?”


“Until the other Sister comes from maternity leave.”

“But can’t the hospital find someone else to come and work with you?”


“Ha! They say there is no one – and if I don’t like it I must move to another clinic where you don’t live on the site. But I have been here since it opened. How can I leave? These people know me.”


We see the rest of the patients, and I leave the sister yawning, but smiling. I feel a knot of guilt at my whining over my 1 in 6 weekend calls.


Getting home takes a little longer than expected – slow moving giraffe on the road.