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.