Tuesday, 29 January 2008

Last chance to see


James eyes the huts of mud and wood that line the landscape through which we are driving.

“I hadn’t realised that it would be so great – this difference between rich and poor.”

I glance at the village and then at him, guility. It is not that I do not notice poverty anymore but it no longer seems strange. And, shamefully, it no longer bothers me that South Africa’s great tourist destinations are almost without exception positioned in rural areas of equally great deprivation. The first time I came here to the mountains I could not understand how it was possible to go on a hiking holiday in a park in which the chalets had satellite television but the people just outside walked daily to the communal pump for their water. Now however I feel self-righteous indignation because the camp is experiencing a 1 hour power cut – and I want tea now.

James is however just off the plane. He is seeing South Africa for the first time – an Africa “virgin”. And he is my younger brother. I am giving him a high speed tour of KwaZulu-Natal’s greatest hits: a night in the berg, 3 nights in the game park, a night on the beach before returning to his gracious (and supernaturally patient) wife and two children.

After our visit to the game park I take him to the hospital – it is just 20 minutes from the park gate. It has been just over 2 weeks since I left. My 20 minute quick tour proves hopelessly optimistic. At each place I take him people demand to know where I have been, when I am coming back and then take James’ hand, shake it vigorously and ask why he is taking me away.

“We don’t want him,” James replies with a grin, “you can have him.”

And they turn to me and look accusingly: “Why then are you leaving?”

We go down to the ARV clinic. Sister Sithole is brought into the room to scold me.

“Why are you just leaving? We would do juice and cake if we had known.”

“I do not like long departures,” I reply, “I prefer to slip quietly away.”

“But,” says Sister Hlabisa, “it is our culture to send you off.”

Sister Sithole turns to my brother. “You must give our regards to your mother. And you must tell her to scold him. She must scold him for leaving!” She studies James more closely. “Hauw! How are you brothers? He is thin and you are fat!”

“He must be married!” pipes in Sister Hlabisa.

“I am.”

“There! I told you. We tried to find Dr Moran a wife but…” Sister Hlabisa shakes her head sorrowfully.

On the way out we bump into Matron for maternity. She launches into a speech about how much they will miss me. “… and when we call Dr Moran in the night, even if he is not on call he will come. The others they say ‘Why are you calling me? I am not on call’ but Dr Moran doesn’t.” I grin amiably, absolutely certain that I have never arisen when not on call. Or maybe there was once but I complained bitterly for hours – and shouted at at least one nurse.

I do not disabuse James. He turns to me as walk away. “So what did you pay her?”

Finally we come to high care. Sister Nene is waiting. She has called down Sister Perumal. They present me with a pair of sandals and hug me as I leave. As we walk away back to the car one of the OPD nurses, the one with the powerful singing voices shouts my name. I head back. “Sister Khumalo wants you. You heard my voice? My powerful voice?!” I once told her she had the most impressive volume of any nurse I had ever met.

“Yes I did.” She grins in satisfaction.

Sister Khumalo is standing outside OPD. I have a soft spot for Sister Khumalo.

“I have something for you.” She produces a small bead and wood necklace which she fastens around neck. “It has muthi. Muthi to make people like you. We will miss you. May God bless you where you go next.”

I thank her. And walk away from Hlabisa for the last time.

Wednesday, 23 January 2008

CIty Life


I stick my head out of my consulting room into the corridor. Chair line the walls and they are occupied by Desmond Tutu’s rainbow people: Indian, Zulu, Chinese, White – all are represented.

“Who’s next?”

A little old lady who look, for all the world, like my granny totters to her feet and, stick in hand, creaks slowly into my room. I show her to a chair and pick up her notes. I flick through them pretending to read – but the reality is I am stunned.

My year working in South Africa has so far been a year of rural Africa. The catchment area of our hospital included a town with a small white community but we never saw them. Almost without exception they would have had private health cover and I suspect many would have chosen death over Hlabisa Hospital if it came down to it. Pietermartizburg is however a small city and in the apartheid era had three hospitals: a black hospital (in the township of Edendale) and white hospital (Grey’s) and one for all the rest (Northdale). Grey’s was opened in 1985 and even now its wide corridors, pristine halls, large wards and quiet emergency department contrast starkly with Edendale’s overflowing halls, grimy floors, long queues, and privacy-less wards.

The little old lady and I chat amiably. She has mild heart failure and I cannot entirely work out why she is here – this is the Medical Outpatient Clinic and serves as a referral service for the difficult or complicated patients the district and rural hospitals cannot manage.


Greys from the air - taken on the way back from outreach visit



“Well, Mrs Smith,” I conclude, “you are doing very well and your medication is just right. I don’t think we need to see you here again. I will write a letter to your local clinic and they can continue to give you your medication.”

Her face suddenly tightens.

“Do I have to? Really? Can’t I get my medication from here at Grey’s?”

“I’m afraid that this clinic is for complicated patients and once we get you better then we refer you back. If there are any problems we can see you again here.”

Her eyes fill with tears.

“Don’t make me go to the clinic doctor. You have to wait so long and I am so weak. I hate it at the clinic. Can’t you let me get my tablets here.” Her knuckles have whitened as she grips her walking stick anxiously.

“Is the clinic so bad?”

“It is terrible doctor. And my husband is so ill. We came from Zimbabwe 15 years ago and we lost everything. Our pension, our house and everything. We have no insurance, nothing. Don’t make me.”

I happened to visit her local clinic the other day. It isn’t great. Queues are long and organisation chaotic. But I suspect what really troubles her is that it located in a previously coloured area. The changes the country has seen in the last 14 years have probably been faster than a 88 year old lady can handle.

She looks at me plaintively.

I am a coward. I am only here for a week. This isn’t my battle.

“Well we need to see you in 3 months for a blood test anyway so you can get your medication here til then but after that you must prepare yourself for using your clinic.”

“Oh – thank you doctor.”

I scribble her prescription and she totters out drying her eyes.

I sit in the empty room guiltily for a few minutes.

What would I have done had she been Zulu?

Did I treat her differently because she looked like my granny? Or to put it baldly – because she was white?

Monday, 21 January 2008

Outreach

“Why don’t you sit in the cockpit?” asks Dr Dawood. I look at her sharply.

“Can I?”

“Sure. Do you want to?”

“Do I ever!” I respond, sounding ever so slightly like an American teenager.

“Excuse me. Stefan,” she shouts at the pilot, “can he come up front with you?”

Stefan nods his agreement and I clamber over the seats to the co-pilot chair. Stefan is doing his checks, meticulously noting things down in a book as he points at instruments and switches with his pen, his lips moving silently in his pre-flight safety mantra.


I look out at the tarmac of Pietermaritzburg airstrip. The haze and mist that covered us when we arrived early this morning has lifted and it is safe to fly. Our destination is Dundee. That is Dundee, KwaZulu-Natal – a small farming and tourist town. I am joining Dr Dawood, the infectious disease consultant at Grey’s Hospital in Maritzburg for her “outreach visit” – a trip she makes monthly to support and teach at two rural hospitals. I met her at a conference and she agreed to let me come work for her for a couple of weeks.

Stefan fires up the engine of the small 8-seater aircraft. I look back at the main cabin. The seats are removable, allowing the cabin to become a temporary intensive care unit for retrieving crticial patients. Hooks are placed in the ceiling for attaching intravenous giving sets and other patient equipment.

We trundle to the end of the runway and then Stefan racks up the throttle before releasing us down the runway. In what seems an impossibly short distance we are in the air. And I am grinning like an idiot. He circles over the city and then sets the GPS and autopilot for Dundee. Within a few minutes the city has disappeared. I look below through the cloud and haze – we could be anywhere in Africa. A thin silver line marks the passage of a river through rolling wooded hills. The sun is baking – a thermometer confirms what I feel – it is bloody hot in the cabin. Stefan’s lips move as he mutters into his microphone to some air traffic controller – the engine noise drowns out whatever he might be saying.


Just 45 minutes later we start descending. Stefan gestures in front. A small town is materialising in front of us. I can see what must be the hospital and about half a mile from it a strip of tarmac beckons to us. We come lower, lower and with scarcely a bump Stefan touches down. He taxis to the end of the runway, parking next to a hideously deformed light aircraft that is presumably used for crop dusting. There is nothing else around, the airfield is deserted save for the yellow Department of Health vehicle awaiting us.

We are visiting two hospitals today. Dundee itself and that of another small town, Nqutu, in the heart of the Battlefield territory. The driver takes us at break neck speed the 60km to Nqutu first. We jabber all the way. He tells me about Nqutu’s famous Inyanga (traditional healer) – a man who got so wealthy he built himself an airstrip and bought a plane.

“Did you ever visit him?” I ask.

“Yes,” he grins, but does not elaborate.

The hospital at Nqutu has been rebuilt – its beautiful outpatient department has at least twice as many patients as Hlabisa. And half as many doctors. As we wander around it becomes clear that beautiful buildings help but are not everything. And however bad we thought things were Hlabisa they could have been worse – a lot worse.

Next back to Dundee Hospital. Dundee was built as the “white hospital” in the apartheid era and as such has wide corridors, a beautiful outpatients area, a dedicated casualty. All are deserted – Dundee is a small town. One of the doctors tells us it is the easiest job he has ever had. It is now of course multi-racial. The medical manger leads us through the building and out into the open. The main wards are in a separate wing. As we enter it is all very familiar – these wards feel identical to Hlabisa. The manger explains that these were originally built as the “black” wards. Low budget, low aesthetics, and strategically positioned far from the main entrance so no white people would have to see an unnecessary black person. In this post-apartheid era the old “white” wards now house paediatrics and surgery. But, as so often is the case, adult medicine has been pushed to the periphery.

As the round draws to a close we hear the throb of the plane overhead as it returns to collect us. We bid our goodbyes. By the time the transport gets us to the field the pilot has landed and is sitting at the bottom of the aircraft steps waiting.

I clamber into the co-pilot’s chair again.

And once again prepare to grin like an idiot.

Saturday, 19 January 2008

Departure

I stand in the middle of the room and look.

This place has been my home for the last year and in 4 hours I have stripped it of me, and packed myself into a suitcase and 3 cardboard boxes.

A last minute check in the bathroom – site of many untaken baths (for much of this month turning the tap produces a blast of air, silence and a stony absence of water. The borehole has run dry). Nothing.

The cupboards – oops. My Drakensberg mountain maps and compass.

The bedroom – site of many sleepless disturbed nights (“Doctor please hold for maternity”) – empty and ready for the next doctor.

I walk slowly out of the flat, locking the door behind me. I drop the key with Magnus next door. His new adopted daughter, abandoned on the paediatric ward 8 months ago is clinging to his neck. We embrace, awkwardly as blokes do, particularly given the mechanics of avoiding a small child.





I was not very effective at work today – my heart was not in it. Feeling a little wistful, little sad. My ward rounds mostly consisted of prolonged good-byes with the nurses and long explanations of why I had to leave. We all said nice things about each other and I kept saying, yes I might come back to work in South Africa one day but no, in all honesty it probably wouldn’t be Hlabisa.

“But what if we found you a wife doctor?”

“Well Sister, you have had all year but sadly you couldn’t find one.”

“Hauw doctor. I know, I am sorry.”


Londeka and Nomfundo in Outpatients

I head to my overloaded car and with a last glance at the residences head to the gate. I open the back of the car for the guard. He studies the piles of boxes, shoes and cases. Could their be a firearm in there? Could I have hidden an ultrasound machine?

He shrugs. “You are leaving, doctor?”

“Yes.”

“Do you want to sell your car?”

I laugh. He is the 14th person to have asked. “I have a buyer.” I climb back in. “Sala kahle.”

“Hambe kahle!”

And I pull out of the gate.

Wednesday, 16 January 2008

Time's up

I am leaning over a patient listening to their chest when I become aware of a presence. I straighten up. Sister Nene is standing behind me. She is looking even more serious than normal.

“Doctor. I saw the rota for the high care doctor for next month today.”

“Mmm?” I reply in as casual manner as possible.

“And I looked up, and I looked down but I did not see you name.”

“No.”

“And then I looked at the other wards and I did not see your name anywhere.”

“No.” I look at my feet guiltily.

“Where are you going?”

I cannot look her in the eye. “I am leaving Sister Nene.”

She says nothing but shakes her head sorrowfully. I feel like I have disappointed some aunt. A severe aunt of whom I live in fear but nurture a secret craving for her approval. She studies me silently.

“I was allowed out of my job in the UK for 1 year but I must return.”

She says nothing.

“I might come back one day.”

Sister Perumal joins her. “Ahh – they all say that. Don’t they Sister Nene?”

Sister Nene nods.

“But they don’t come back, do they Sister?” Sister Perumal continues.

Sister Nene shakes her head and looks severe.

I slink out of the ward.

Sunday, 13 January 2008

Not entirely New South Africa

The normally sleepy tourist town of St. Lucia has been transformed. We drive in, cautiously avoiding the scores of intoxicated, denim clad, beer bellied, grey haired, helmet-clutching Afrikaaners. A sign strung across the street proclaims the annual Harley Davidson gathering. We brake for a string of low slung bikes, each emitting unnecessarily throaty roars.

On the way back from the beach we stop for a drink in a hotel bar. The bar itself is serving as a prop for a number of bikers. I order my coke precipitating howls of disapproval – I am not sure whether it is my uncompromisingly posh accent, or the coke. I smile sheepishly – “I’m driving” I say foolishly. They look at me blankly – too late I realise my words would be something of a non-sequitur to this gang. My mate orders a beer and stays under the radar.

Standing next to me is a 50 something lady with long grey hair. Her denim jacket is covered with fabric badges from around the world. “Where are you from?” she asks. I tell her. “Oh! I am from Blackpool. Well I was. I have lived here since I was 16 years old. Married an Afrikaaner and never went home.” She gestures to the leather clad man next to her. He smiles and raises his glass to us. “What are you doing here?”

“We work at the hospital in Hlabisa.”

“Wow! That must be pretty far out. You must see terrible things here with that HIV. Those poor people with their HIV.”

“What do you do?”

“Oh, I am a reporter. I work for a local radio station down the coast.”

“Is that interesting?”

“Oh – yes. I sort of stumbled into it. Never done anything like it before.”

“Do you get to see a lot of the area?”

“Oh yes. I have just been paired up with this gorgeous little black man. He is so cute. You should see him with his frizzy hair. He looks just like a gollywog!”

In the act of swallowing a mouthful of coke, I choke, spluttering it everywhere. She looks at me startled.

“Are you alright?”

“Yes,” I gasp. I catch my mates glance. He shrugs.

“Anyway – so he took me to the township the other day for a rally. I wouldn’t dare go there on my own! And we had just finished the meeting and taking a few photos and we were heading back to the car when he said, ‘I’ll just be a minute’ and I thought he wanted to take a photo and so I stopped walking. And before I knew it he turned away and was peeing! Just by me! I didn’t know where to look. But it is their culture.”

I cannot think of much to say in the response to this. Perhaps “I know countless Frenchman who would do the same?” or “Why did you stop to watch?” Instead we comment loudly on the time and make our excuses.

Wednesday, 9 January 2008

Keeping with the times

I wheel the trolley to the next patient and look up. She is giving me a hard stare. Paddington bear-like. In fact, scrub that. She is not looking at me. She is glowering. Glowering balefully.

“Sawubona,” I say nervously. “Kunjani?” Her only answer is to turn away and sniff at me. “What is wrong?” I ask the nurse.

“She wants to go home. Why don’t you let her go home?”

This lady has a condition called lactic acidosis, I explain. She has been on anti-retroviral drugs for a year. One of these drugs in particular has the potential to cause a few unpleasant side effects, one of which is the build up of the acid lactate the blood. She was admitted 2 weeks ago with severe vomiting, abdominal pain and breathlessness all of which were due to the acidity of her blood as a result of the high levels of lactate. Her levels were in fact dangerously high and we had to stop her anti-retroviral medication.

“But she is better now doctor. Why can she not go home?”

“Well I know she feels better. We have given her fluids to rehydrate her. But her lactate is still very high – people can die from this condition and we need to wait for the lactate to reduce to lower levels before we can discharge her safely.” Last year someone discharged herself home feeling well only to return 2 days later extremely sick. She later died so we are very cautious with these patients now.

The nurse explains this to the patient who scowls and shakes her fist at me. The next lady is also here with lactic acidosis. She is a little more chilled and, the fraction of a millimetre of curtain that separates beds not providing terribly effective sound proofing, had been following our discussion. She grins and nods as I apologetically tell her she needs to stay.

I have nearly got to the end of the round when Sister-in-charge of the ward storms in.

“Hauw doctor. Why do you not discharge all the ladies? They are getting angry. I tell you doctor this morning they were all toyi-toyi-ing [kind of Zulu protest/war dance] in the middle of the ward!” she cries gesturing to the 5 people with lactic acidosis. I launch into my speech again. “Ahh,” she interrupts. “But doctor – in our culture we like to go home to die. We do not want to die in hospital.” I look at her nonplussed.

“Is that what you think? That I am keeping these people in here to die?” She detects a slightly taut note in my voice and says nothing. “Have you been telling them that they are here to die?”

“No doctor!” she cries, perhaps not entirely convincingly.

“I am not keeping these people here to die!” I cry, I fear stamping my foot slightly. “I am keeping them here so that they will not die! They feel better but they can still get sick and I want to make sure they stay better. If you have been telling them I am just keeping them here and we can do nothing then no wonder they are all so cross with me!”

Sister is back-pedalling fast now. I am all ready to continue my tirade when suddenly I am struck. These nurses left nursing school perhaps 5 to 10 years ago. This country has only been using ARVs for 4 years. They were taught nothing about them at training. All they learnt about HIV was that it was incurable and eventually fatal. Nurses that qualified before the ARV roll-out have received next to no training on them unless they chose to specialise in HIV treatment. The whole playing field has changed completely and most nursing staff have no idea. So I take a breath. I take a pencil. And I gather the nurses round and draw them a diagram.

Saturday, 5 January 2008

The end of the party

Me on the medical ward round

There is a curious atmosphere at work – a sense that the party is nearly over. The 2007 intake of doctors has begun its exodus and I am back on the medical ward this week. Sister looks at me in surprise as I walk on.

“Where is Dr Riddick?”

“She has left.”

“Hauw – why?”

“She was only here for 1 year and the year has ended. She has gone to her next job.”

“And Dr Janssen, and Dr Mkhwanazi?”

“They have left also.”

She shakes her head sorrowfully. “It is terrible. All our doctors are leaving us. What will happen? Just as we get to know each other, you leave. Are there new doctors coming?”

“A few.”

I don’t expand my answer for her. For 2008 will be a more difficult year than even normal for South Africa’s rural hospitals. For several years now a good fraction of doctors working in places like Hlabisa were “community service” doctors. After qualifying doctors did a 1 year internship and were then required to work for a further year in a understaffed institution before being “signed off” for other employment within South Africa. It was not a popular idea at the time, but most “comm-serves” would now say they benefited from the experience. This year however there are no comm-serves. The internship has been extended to 2 years, so for 2008 hospitals like Hlabisa will have to do without. We are losing 5 doctors (just over a third of the staff) and gaining just 1 South African. The short fall will most likely be made up from overseas graduates like myself.

So the medical team at Hlabisa has had to tighten its belt. The on calls are more frequent and the days that little bit busier. But Hlabisa has it relatively easy. Some of our neighbouring hospitals are down to 5 or 6 doctors.

Tuesday, 1 January 2008

Training on the job

My mobile rings. It is switchboard. “Could you go to theatre doctor urgently!”

Offering quick apologies to the patient I had been repeatedly stabbing with a spinal needle I drop everything and sprint to theatre. Ok – brisk walk. It is hot. We have had a couple of near misses in theatre recently – “urgent” and “theatre” in the same sentence should be taken seriously.

I bang through the door to the male changing room and pull on the green trousers (much too small), top (voluminous, of the order of Queen Victoria’s nightie) and surgical wellies. I barge through into theatre. Sister instantly sends me out to get a cap – always forget that. I am reassured – it cannot be that urgent.

Inside theatre things are calm. A naked pregnant teenager is sitting on the operating table looking tearful. It turns out that she has become a little hysterical and is refusing to let anyone give a spinal anaesthetic. They have tried light sedation but she is determined and flails around enthusiastically at the slightest suggestion of an approaching needle. They obstetric team (i.e. my friend Marieke) wonder if I would like to try.

After another abortive attempt we have a impromptu team chat. The Caesarian has to be done – the baby is showing signs of distress – but the mother will not cooperate. We decide to give her a general anaesthetic. We have a new anaesthetic machine, a new ventilator, and the anaesthetist – me – has an entire weeks training. What more do you need?

I pull up all the drugs, question all the theatre nurses until I find one who once actually helped at a general anaesthetic before, get the equipment set up, check the machine and we are ready to go. There is something of a knot in my belly as I sedate the girl. But the tracheal tube passes easily and we quickly hook her up to the ventilator. Things go swimmingly. I feel, it has to be said, as pleased as punch. I look around to see if anyone noticed how clever I was. No one did.

The obstetric team (i.e. my friend Marieke) crack on with the Caesarian and I settle down to fiddling importantly with buttons and writing down blood pressures. Pity I didn’t bring a crossword.

Then, just as I am turning a dial particularly skilfully, there is an ominous electrical sounding clunk and all the lights go out. The hospital has been experiencing regular power cuts over the last few days. Maintenance says it is Eskom's fault (the delivery company) - they say it is not. It is, thankfully, midday so viewing is not a problem. The ventilator can run itself for an hour and the operation will be over before that – the baby is about to be delivered. The obstetric team looks up.

“There is no suction!” We need suction to clear the baby’s airway on delivery and remove any blood oozing from the uterus. The nurses leap into action and whip out a foot pump powered suction device. They switch the pipes from the electrical to foot powered device and hand it expectantly to me.

It is not, it turns out, a particularly efficient device. I watch as my energetic foot movements drag a few mLs of blood down the tube inch by inch. I double my efforts. The Lord is good – there is minimal bleeding and the baby cries almost immediately. I do not like to entertain the thoughts of what might have happened in a different scenario. The power comes on once again as the obstetric team (i.e. my friend Marieke) is closing up.

I wander back to once again stab innocent sick people in the back. I wonder if there would be a market for a bicycle powered theatre lights system for use in the event of back-up generator failure. If nothing else it might help reduce the impressive BMI of the nursing staff, and the cardiovascular risk factors of the doctors.

Happy New Year!


Happy New Year! I was working but if you try hard enough even fizzy grape juice can give a significant headache the morning after. The people of Hlabisa went crazy at midnight with terrifying 5 rand Chinese fireworks. Looking forward to those burns tomorrow. Have a wonderful start to the New Year!