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.



Monday, 20 August 2007

Betrothal

I can feel my eyelids beginning to droop. I was up almost all night in theatre doing the anaesthetic for Caesarians. One of the children born was very unwell and needed fairly intensive resuscitation, much to the shock of one of our American pre-medical students. It is now 2pm and I am in our anti-retroviral medication clinic seeing problem patients for the nurses. I turn to the counsellor I am working with.

“Thulani, do you reckon I could have a cup of tea? I am fading!”

Thulani, who can’t be more than 19, grins. “Let us go ask!” he says. We nip out into the hall and stick our heads round the admin door. I summon my best Zulu.

“Wait for it,” deep breath, “Ngicela itiye!” They all burst out laughing and one of the counsellors jumps up.

“I will get you tea.” We get back to work. 5 minutes later the counsellor, Nomusa, stick her head round the door and hands in a cup of - to be honest - fairly grim tea.

“Ahh! Siyabonga! [Thanks!]”, I cry. “Ngiyamthanda!” I am rather proud of myself. I worked out the sentence myself from my textbook – “I love you!” Nomusa looks startled and then bursts into peals of laughter. Thulani shrieks with laughter as well and claps me on the shoulder.

“Hey doctor! I enjoy working with you! It is always entertaining!” I hear Nomusa go into the next room and presumably relate what I have just said to the other counsellors. Through the wall I hear a muttering and then shrieks of hysterical laughter from everyone inside. I begin to worry slightly.

An hour later I am leaving. Nomusa is leaning against the wall of the cabin. “So doctor. When will you pay the lobola [dowry]?”

“How many cows?” I ask.

“For me? 11.”

“Is that enough?”

“13!”

As I pass through outpatients I relate the incident to Nomfundo, one of the docs. She arches an eyebrow. “What did you think you were saying?”

“Well, ‘I love you.’”

“Yes – but it does not mean quite the same thing in Zulu as it does in English. It means much more. I would be careful how much you say it or you will find your life very complicated!”

I walk back to the flat rather soberly, imagining a future in which I am hunted by the father’s of the countless Zulu girls to which I have unwittingly pledged my undying love.

Tuesday, 14 August 2007

Empowering

I wander onto labour ward. There is a loud voice shouting. Not unusual in itself. But it is doing so with an American accent. “Push. Push! You can do it! Push!”

“Who is that?” I ask Matron.

“It is one of the students.” I look around the curtains. Sure enough it is Stephanie. She is an American pre-medical student who has been with us for a few days and has decided to learn how to deliver a baby whilst she is with us. It is 11pm – you have to admire her dedication.

“Excellent! Way to go! You’re nearly there!” she shrieks. There is a yell from the mother and a second later a baby starts crying.

I leave Stephanie to it and slip off to bed.

The following morning in the morning meeting someone nips in. “Has anyone seen Stephanie?”

Nicky gives a small grin. “I saw her a second ago. She said she was nipping off to empower the social worker.”

Sunday, 12 August 2007

The first time was a chicken

“Come. Now.” The nurse grabs my hand a physically drags me to a cubicle. Inside, three nurses are gathered around a tiny baby. It is emaciated and dehydrated and has clearly a victim of gastroenteritis. And probably HIV.

One of the nurses looks up. “We cannot get an IV line doctor. You must try.” My heart sinks. If these guys cannot get a line into a 6 month old my chances are nil. I have an embarrassingly poor success rate of achieving IV access in babies. In fact, I don’t think I have ever successfully achieved it where the nurses failed.

The child clearly needs fluids urgently. Without any expectation I look at the baby’s hands and scalp. I cannot see anything remotely resembling a vein. “We will have to do an intra-osseous line,” I say. In children the bone marrow is fairly vascular and pushing a needle into it allows fluids to be given in an emergency situation. I rifle through the drawer looking for a suitable a needle and in the end settle on the tiny orange needle used for local anaesthetics.

“Have you done this before?” asks a nurse.

“Yes. Of course.” I do not mention that I have done it once. 10 years ago. In Liverpool. On a chicken thigh. From Sainsbury’s.

I palpate the baby’s leg and feel the tibia through the skin. Taking my needle I twist and push it through the skin. I cannot help myself wincing slightly as I do so. There is a grinding noise as it passes through the bone. Then a sudden give as it enters the marrow. I nervously feel the other side of the bone, suddenly terrified I might have pushed it right the way through the tiny tibia. Nothing there. I let go of the needle and it sticks there solidly, wedged in the bone. I connect a syringe and squeeze fluid through. It goes through. I feel the leg – it seems to have entered the bone rather than the leg. I push more fluid through.

Half an hour later the baby is looking distinctly improved. Hendy our paediatrician pops in. He offers to do a line. I am ashamed that there is a sense of relieved satisfaction when he give up on one hand and moves to the other. If a paediatrician couldn’t do it…

Monday, 6 August 2007

Student assessments

It is the end of the morning meeting. Our current pair of medical students from the University of KZN are leaving today and we need to write their assessments. Nomfundo grabs the report sheets from them and peruses the areas we must grade them on.

“I am a very harsh marker,” she declares. “I never give more than 60%.” The students protest loudly.

“But we were there. We worked. You saw us.”

“Yes,” she grins, “but if I grade you well you will be complacent and not work in the future.” The students grumble.

“You are as bad as the Indians in Durban.”

“What do you mean?” I ask. They explain that the medical school in Durban has a largely Indian teaching staff, a heritage of the apartheid era when it was a non-white medical school and there were few black doctors.

“And they are racist when they mark. Like our last assessment. I saw a Zulu patient and got 60% and the Indian student saw the same patient and got 90% and he couldn’t even speak Zulu!”

“And the examiner was Indian?”

“Yes!” One of the CommServ doctors joins our discussion. He studied at UKZN.

“It is true,” he confirms. “Ach – it is terrible.”

“But there must be more black specialists now?” I ask.

“You would think so, but there are not many.”

Later I am speaking with one of the medical consultants at our referral hospital in Ngwelazane who happens to be Zulu. “I do not know where all the black doctors go,” she says. “They are all at medical school and then they disappear. There are very few in specialist training. I think they all go into private practice straight out of their community service. No one wants to train to be a specialist when you can make money as a GP.”

Saturday, 4 August 2007

Now you see them...

I walk onto C ward for the morning round. Something is different. At first I cannot put my finger on it. Then I realise. “Sister,” I ask, “what has happened to the floor beds?” Over the last few weeks the ward beds have been full and the nurses have been laying spare mattresses on the floor wherever a gap can be found. There have been 5 or 6 most days – yesterday there were at least that. Neither is the requisite demented elderly lady crawling along the floor. Everything looks so clean.

“Ah. Today is the Department of Health inspection. Matron came round and told us we had to remove them.” I cannot see where the patients might have got to – although come to think of it there were a few people sat outside on the grass as I walked in today. Sure enough later in the morning a troupe of 5 uniformed people stride in escorted by matron and make important looking ticks on important looking forms.

The next day I look in on the ward – the floor beds are back. As is the demented lady. It is almost a relief.

Thursday, 2 August 2007

Hunchback

The next patient climbs up the step into the porta-cabin that serves as my consulting room at the clinic. He looks pretty well – the last patient required the help of four relatives to lift her into the room, following which she gradually slid to the floor. You develop a talent for spotting the ones that need hospital after a while.

The man sits down and I ask the problem. There is a brief conversation with the translator.

“He has a lump on his back.” He takes of his shirt and sure enough there is an enormous hump over his left scapula. I palpate it. It is, for want of a better word, squidgey.

“How long has he had it?”

“5 weeks.”

“And what started it.”

“He first had a chest infection. Then the lump appeared.” I scratch my head trying to think of classic medical associations or syndromes that link a chest infection and large squidey lumps. None spring to mind. Perhaps I could invent one.

“I will see what is inside the lump. Tell him I am going to stick a needle in and see what comes out.” She explains as I take a syringe and large needle. I insert it under the skin into the centre and pull back on the plunger and am rewarded by a trickle of thick gloopy brown-green pus. I fill one syringe. And another. And another. Then I take some saline and inject it into the lump. I squish it around in an attempt to loosen up some more. And I fill another syringe. And another. By now we are all a bit breathless.

I scratch my head.

“Is their really nothing he can think of which started this?” The nurse asks. There is a long silence and then he begins talking again. A slow smile crosses the nurse’s face.

“He got the chest infection…”

“Yes?”

“Then he went to the sangoma [traditional healer]…”

“Yes?”

“And the sangoma stuck porcupine quills into his back and then the lump appeared!”

The man looks embarrassed as I write him out a course of broad-spectrum antibiotics – I have no idea what might live on porcupine quills but I imagine they will hit it.