In Sierra Leone

"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.

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.

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

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 an

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 gy

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.

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.. y

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.

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 h

“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 th

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.

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.

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