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.