In South Africa

10 years on

2011-06-01T16:43:00.003+02:00

The door flies open. Lele peers in.

"You must come out here and see. They are doing a play!"

I finish up my case file annotation and come to the doorway. The waiting area is in chaos. A gang of school children are manhandling a couple of marimba's to the space in front of the consulting rooms, a team of nurses and counsellors are creating a stage area. Patients look on mutely. Some with interest, others - presumably feeling proportionately less well - without.

"What is going on?" I ask.

"It is 10 years since the clinic started. 10 years since MSF first started the HIV treatment programme and proved that it could be done in Africa. So the staff are celebrating. They are doing a show or something."

The sister in charge of the clinic has moved to the front of the crowd of patients. She calls for silence and then gives a short introduction. Lele translates for me.

"She is saying that this is a very important day. 10 years ago people were dying. And 10 years ago right here is where people began getting treatment..."

Lele is silent for a while as Sister talks further.

"... she apologising for the delay in seeing the doctor," she mutters.

I become aware of a insistent pulling at my trouser leg. I look down and see a 5 year old boy. He tugs and points at my stethoscope. I place it in his ears and whisper "Molo" (Hello) into the other end. He grins.

"Molo!" he shouts.

Sister introduces another lady. She is dressed in a colourful cape and immediately starts shouting and singing loudly in Xhosa, all the time swirling and running up and down the waiting benches. She is a Praise Singer.

"She is praising Ubuntu Clinic and God," Lele explains. There follows a rapid stream of Xhosa - I catch "35kg" and "85kg". "When she first came here 6 years ago she was very sick and weighed just 35kg. Now she has been on ARVs for 6 years and she is 85kg." Everyone cheers and applauds.

The play begins. Sister introduces the cast in English. Thabo Mbheki - played by a counsellor - nods solemnly. Manto - a previous health minister who resisted ARV treatment for so long extolling instead the virtues of vegetables - scowls at the audience as she booed loudly. Dr Rath - a quack who marketed his own vitamin pill as a substitute to

ARVs - is played by the best known doctor in the clinic in a colourful clowns wig to great hilarity. Scripts are read, large crowds of nurses and counsellors play the parts of patients and pressure groups. There is dancing, chanting, singing. The school boys play their Marimbas with impressive skill and enthusiasm at appropriate points.

And I am moved by the story. By the suffering and ignorance and denial people experienced. By the commitment of those - many of them here - who fought and campaigned for treatment. And by the enthusiasm and zeal they continue to demonstrate for those suffering in their communities. And for the joy in what they have achieved. It is only the tip of the iceberg but there are thousand of people on treatment in the city now - healthy, working, raising their families. And it is because of what started here.

2011-05-17T16:38:00.002+02:00

The next patient is in her mid-20s. She sits gracefully on the edge of the chair and looks at me.

"How can I help you today?" I ask.

"It is this," she says, hands clasping her belly, "I look like I am 4 months pregnant!"

"And are you? Have you checked?"

"Oooh! Yes. MANY times - and always negative. I have been talking to my friends and they say it could be the HIV treatment."

"Yes - that is true. You are on one of the older drugs, the one called Stavudine. That can make fat appear in different places on your body, and sometimes disappear from other places. Some people find that it makes their face thin." I suck my cheeks in briefly. She laughs.

"I used to have a VERY round face, now it is thin!"

"I suggest that we change that drug then. We have more drugs available in the public clinics than we did when you started and the one I will use has less side effects. Is that what you would like?" She nods enthusiastically.

As I do the paperwork I ask, "If you don't mind me asking, how do you feel about having HIV among your friends and family. Do you tell them? Do they know?" She grins broadly and pulls off her jumper. Underneath she has a T-shirt, upon which is printed in 6 inch letters 'HIV POSITIVE'.

"Everyone knows. I am not embarressed. It is important that we are not ashamed, then other people will test and get treatment."

"That is brilliant. I used to work in rural South Africa, up in KwaZulu-Natal and there people were very unwilling to be open. There was a lot of stigma about HIV."

"I used to think like that, but when I got my diagnosis I joined a group for people who were HIV positive and when you discover that they are normal people just like you, and that they have been on treatment for 5 years, or 10 years and are well - it makes you realise it is OK! So I make sure everyone knows!"

Otherwordly isolation

2011-04-07T14:10:00.012+02:00

I lean across the reception desk and catch the attendant’s eye. “Sawubona,” I say, dusting off my rusty Zulu. I see you.

“Sawubona, ninjani?” she replies. I see you, are you well?

“Ngiyapela.” I’m fine. She grins at me.

“You must be a doctor.”

“I am! How did you know?”

“It is only the doctors around here who use Zulu. Even if it is only the greetings.” She arches an eyebrow.

“I used to work here, at Hlabisa hospital up the road. I have a few other Zulu words, you know like ‘Does it hurt?’ and ‘Take a deep breath’.” She laughs. And then launches into an excellent impression of an elderly Zulu lady rattling off a series of complaints, waddling across the reception area clutching her back in mock agony. She gets it exactly right.

I have come up to KwaZulu-Natal for a few days. Tonight I am staying in the Hluhluwhe-iMfolozi game park, 20 minutes or so from where I used to work. Awarded my entry ticket, I drive into the park. The sun is low in the sky, the kills bathed in amber light. I take it easy driving the 30km to the camp. Just a few minutes later I pass a rhino, slumped wearily on his side in a mud puddle. Just beyond him two giraffe lollop languidly along the hill brow.

I arrive at the camp in the dark, headlights on. The stars blaze gloriously overhead in the darkness. It is hot and sticky. My accommodation is a rustic thatched single room rondavel. After the urban sprawl of Cape Town this is other-worldly isolation: the darkness, the stars, and the sounds of life rising from the trees below the camp – cicadas, baboons and barks. I stand there drinking it all in.

And then go to the camp's award winning restaurant where I have an all you can eat dinner buffet.

World T-Shirt day

2011-03-28T09:51:00.005+02:00

"The T-shirts are here!"

I am in the clinic room with a patient but hear the cry go up from next door. The floor of the flimsy prefab building creaks and gives with the sudden influx of nurse and counsellors to the room beyond.

Today is World TB day, and everyone who is anyone has a special T-shirt. Swing a cat in the clinic waiting room and you would hit half a dozen different NGOs: feeding groups, research groups, patient support groups, medical charities. And today each has their special T shirt and we are no different. I sign off my patients paperwork and they wander off. I slip next door and join the throng looking for a shirt. "Here, these are mens. Try medium," says Thandi. I do. It hangs rather loosely below my waist. Sister Manke eyes me critically.

"Ah, Ed. You are but a small man." I glare at her but she does not notice.

T-shirted up, we load into the cars and head off in convoy through Khayelitsha to the soccer stadium for the World TB fayre, hosted by the City of Cape Town. AnyNGO who is anyNGO will be there. The outside has rows of new palm trees and tastefully cobbled walkways - a World Cup face lift. The inside is more in keeping with the environs. We all make our way in. It looks like around 10-20 organisations are represented. The biggest queue is for the Provincial Dept of Health tent where free blood pressure and blood sugar checks are on offer. The queue to the free "sputum testing" is a little shorter.

A drama group are doing a sketch. Lots of running and coughing. The watching crowd laugh and cheer appreciatively. "What is happening?" I ask one of our Xhosa nurses.

"He has TB but hasn't taken his medications for a few weeks and is getting sick again." The charactes engage in animated conversation with each other. I catch "MDR" and "TB" a few times and get the gist.

The compere applauds them as they end. "Weren't they amazing?! Now, who can remember what the sketch was about?" A lady rushes up and gives her answer into the microphone. "Very good - yes, you must take your medication if you have TB or you will get MDR and get very sick!" he affirms. The prize is a... you guessed it... T-shirt. The woman takes it, studies it briefly, and then looks grumpily at the compere. They exchange a few sentences. "What do you mean 'It isn't your size?'", he cries into the mic. "This shirt is like a condom - one size fits all!"

Disclosure

2011-03-21T19:54:00.003+02:00

The waiting area is full. Children are running up and down between the benches, their mothers (and some fathers) watching them as they wait to be called into a consulting room to see a nurse or counsellor. A woman stands in front of them talking loudly in Xhosa. She bangs her palm with the edge of the other hand, as if emphasising her point. She appears to be delivering a lecture. As I get closer I recognise her as the sister in charge of the HIV clinic.

I slip into one of the consulting rooms used by one of the clinic Sisters. “Molo Sister Sibisi”

“Molo Doctor. Ninjani?” She has just given a vaccination to one of the anti-retroviral patients – a flu jab. She applies a dressing, and the man thanks her and slips out.

“Sikhona,” I exhaust my meagre Xhosa. “What is Matron talking about out there Sister?”

“She is giving them a talk on disclosure.”

“Disclosure to their friends?”

“No doctor, to their children. This is parent-child clinic day so the HIV positive parent comes with their positive child and we see both at the same time. The thing is, many of these parents do not tell the child that they are positive.”

“That the parent is positive?”

“No doctor, they do not tell the child that the CHILD is positive for HIV.”

“But how?! The child is on tablets and has been coming to clinic for years.” Most of the children here will have become HIV positive as a result of infection during, or shortly after, birth. Whilst there are treatment regimes that can reduce the rate of infection in pregnancy dramatically the mother needs to know she is positive (and many do not - or do not act on the result) and drugs need to be available at the right time.

She shakes her head sorrowfully. “Yes doctor, but there is a lot of stigma still. And they tell the child that they are taking the tablets for flu. And then one day when the child is 11 or 12 they want to know why do they take the tablets when their friends do not. And then it is very bad, because when the child finds out they often get very cross, and they stop taking their tablets, and then the virus comes back and they can get very sick. So Matron is telling the parents they must tell the children they are positive.”

“But that must difficult as well. A very young child will tell their friends and then might get into problems at school.”

“Yes doctor – both ways have their problems. But we think that the truth is the better way. Nothing good can come from secrets.”

The race

2011-03-15T17:04:00.006+02:00

The city is quiet. The sun, just up, bathes the mountain side warm orange. I pull the bike out of the car and pull on my borrowed cycling shoes. A large 4 wheel drive pulls up behind me. The man leaps out and lifts his racing bike off the back. "Good luck," he grunts at me in Afrikaans accented English as he cycles off.

I climb on the bike and wobble precariously down the street as I try to figure out how to lock the cycling shoes into the pedals - and then promptly over balance as I try to work out how to remove them at the traffic lights. "Guess the whole idea of the race is not to stop," I mutter, embarressed.

Wobbling through town I head towards the Civic centre. I join a stream of professional looking cyclists - all in the full kit, with expensive racing bikes. There will be 44000 bikes on the route today - am I the only idiot on a mountain bike?

As I turn the corner the starting area comes into view, the atmosphere electric. The dawn light is grey here, but the buzz of people, the gathering cyclists and the pounding upbeat music quicken my pulse. I find my starting "pen" - along with 2000 others. I fall into conversation with two men waiting with me in the toilet queue.

"So where have you come from?" I ask. They look at me.

"Don't you know us?" says one.

"We're famous," says the other.

"Sorry," I say, a little flustered. "I'm a Brit." They laugh.

"So are we," the South African accent they had previously used has vanished. "We're accountants from Pretoria."

The loudspeaker calls out group to move onto the starting pen. We all cycle on, everyone has fallen silent in anticipation.

"5, 4, 3, 2, 1 - go" shouts the speaker. And we all wobble off.

The route leads out onto the motorway. Everyone is taking it easy at present. There is a low murmur of conversation and gears, and rubber on the road. We pass the University - resplendently neo-classical - and follow the mountain foot south. It is 8am, and people are up and dressed, lining the sides of the road, and hanging over bridges. "Come on!", "You're doing great!". Some people have set up gas braai's and are cooking breakfast for family and friends. We hit the first hill - and the locals have concentrated themselves along it to shout encouragement. I cannot stop myself from grinning, waving and thanking strangers and I drop a gear and pant up the slope.

2 hours later and I am just over a third through. The route winds through the coastal towns and is now hugging the shoreline of the National Park. The sun beats down - down directly overhead. The riders are not talking now - just the whir of gears, the crash of the waves and the the cries of the birds.

Nearly 4 hours in. Over two thirds. I push past the refreshment station - hundreds of cups of coke, and a tent advertising massage. A couple of cyclists have had a puncture - they are pulled off the dirt to the side of the road. Three young children from the Township we have just past have rushed up to help him - one holding the bike, whilst the others look on avidly as the cyclist rapidly changes his inner tube. Up ahead four more young kids are cheering - they are holding out their hands for a "low five" - I reach out and we slap palms.

Four hours, 20 minutes. I have managed Chapmans Peak - the highest point, and the exhilarating run down to the beach resort of Hout Bay, but now I am bored. Every pedal move is an effort. But finally - 4h 50min - it is the end.

I phone a friend and we have beer. But there are certain parts it is definitely not reaching.

Yes Man

2011-03-12T18:50:00.003+02:00

I am at the head of the pack, with three other blokes. We have been running for over an hour now. I feel a warm glow of achievement – I am keeping pace with real trail runners! They are chatting animatedly. One of them turns to me, “So do you run often?”

“No...” I gasp.

“Well...”

“In...”

“Summer...”

“Maybe...”

“Twice...”

“A...”

“Week.”

I think I am about to die. “And is this your first time with CRAG? How did you hear about it?” Crag – Cape Runners Against Gravity – is a trail running group that meets each Wednesday at different parts of the mountain for a 90 minute run.

“My...”

“Old...”

“Boss.”

We are nearing the end now – we can see the car park. My three companions reveal their extra gear and storm ahead. I slow to a stagger.

10 minutes later the entire group has re-gathered and – you have to love this about South Africans – chilled beer is produced from the cars. Conversation turns to other outdoor Cape Town activities. This weekend is the big bike race, the Argus, a 110km circuit around the Cape peninsula – including all its hills and famous Chapman’s Peak. “Are you doing it Ed?” asks someone.

“Oh no – I have only been here 3 weeks so it is too late.”

“It’s not!” a friend from work, also testing CRAG, interjects. “I phoned and international people can sign up right until the day before.”

“Really?”

“Yes – do you want to do it? I will if you will.”

“Nah – I haven’t trained and I have no bike.”

“My housemate has a bike you can use. And I haven’t trained either. Go on.”

“I did it last year with only 10 days training,” says one of the other runners. She looks reassuringly normal. But you cannot tell with these South Africans. “You should do it.”

I open my mouth to refuse because surely to refuse is the sensible thing to do. But then a scene from “Yes Man”, discovered whilst channel hopping late at night last week, comes to mind. The protagonists life is made infinitely more varied by saying “Yes” to every and any opportunity. “What would Jim Carrey do?” I wonder.

“OK” I say. “Why not.”

And so here I am, Saturday night. I have a bike (mountain – infinitely unsuited to a long distance road circuit), padded shorts (in which I look a tit), a variety of energy drinks. None of which can make up for the fact that the longest cycle I have done in the last 6 months was 2 miles. Up the hill to work.

Check out the route here.

My target? To stay out of hospital. And not to face the ignominy of being put on the truck back to Cape Town when they clear roads of stragglers prior to reopening to traffic at 1730.

7 hours or less. Wish me luck.

Single malt

2011-03-06T14:54:00.002+02:00

The coffee has been served and people are making their excuses and heading off. We shuffle around the restaurant table, closing the gaps. I am sitting next to Sister Nene.

"How are you doing? Did you enjoy the food?" I ask.

"Oh yes - and all the better for it was free." The evening has been a work social gathering. A waiter comes up with a glass which he hands her.

"What are you drinking?"

"Whiskey," she replies, a little indistinctly.

"What kind?"

"Normally I like Jamesons. I don't know what this is like. It is something called 'Glenfiddich'."

"That's very good."

"I know. It is a single malt." She reaches for the water jug and eyes me conspiratorially. "I like a little water with it," she whispers and pours half a pint of water into the glass. I watch in horror. "It takes the edge off it and brings out the flavour." As she lifts to drink the light catches the drink - not even a homeopathic amber tinge remains. "Ah - it is excellent."

I'm not in Kansas

2011-03-02T16:31:00.003+02:00

I am driving back along the beach front towards the city centre. It is late and dark but the air is warm, the window down and I hold my arm out relishing the 70km salty breeze that rushes over it. I am returning from dinner with new friends from work. Dinner in a Mexican restaurant on the African coast - or the "Atlantic seaboard" as locals call this area of the city which makes it sound like Florida. And it could be, superficially. The BMWs, the beautiful people jogging along the promenade, the high end restaurants.

The elevated roadway curves around, brushing the city centre. I glide down to a six lane junction. There is a queue. I cannot see quite why - the lights are green. The car in front of me moves slowly forward. Then, illuminated by its headlights I see a withered figure in a crumbling, bent wheelchair. The chair is in the middle of our lane. On either side cars hurtle past to join the Freeway up ahead. Unperturbed the figure reaches up to the window of the car in front. Its occupant passes a few coins. Nearer now I can see that it is a man. His legs are withered useless sticks - heritage of childhood polio. They are folded, contorted rather, in a way no normal limb could across the seat of his chair. The lights turn red. He pushes his chair across the traffic lane to the next car. Its occupant remains cocooned within - there is no response to the silent appeals. He pushes his chair on to the car behind that, the one beside me.

I instinctively look straight ahead - as if I have not seen anyone or anything. Perhaps he will ignore me. In the rear view mirror I see he has moved to the car behind me, pushing his broken chair with his broken body, hands up in a gesture of supplication.

I look at the lights, willing them to change, cursing them for their slowness. Cursing that I cannot blame laziness, drunkeness, or drugs as the root of this man's destitution. Cursing that perhaps the only way to make myself feel better about myself, about him, is to give him something.

The lights change, the abrupt red-to-green flick that is a continual surprise to a British driver more used to the excruciating politeness of a UK traffic light. I pull away, accelerating off to the freeway. In my rear-view mirror, a chair now silhouetted by the headlights of the cars behind, sits folorn and vulnerable in the middle of the highway as the cars hurtle around it.

Something for the weekend?

2011-02-28T16:52:00.004+02:00

First day at the office

2011-02-27T17:41:00.003+02:00

“You will have to sit in the back,” Rachel says as she opens the car. She grins ruefully. “The front door is stuck. I keep telling my husband we need to sort it out but he is Johannesburg a lot at the moment.” I clamber into the back seat. The interior of the car is like a furnace; my shirt clings to my back. It is 7:30am but already hot. Rachel revs the engine and we move out of the parking lot.

“Where are you from Rachel?” I ask as we pass the boom-gate of the medical campus and onto the highway.

“Zambia. I came a few years ago to study at UCT. And then I stayed.”

“Why did you leave?”

“I did my medical school in Zambia but there are not many opportunities for graduate study up there. And my husband had more opportunities down here.”

“Do you think you would ever go back?” She smiles and shrugs.

“I don’t know. Its home but what would I do up there? And the children are in school here. They didn’t like it much at first – it took a while but now they are happy.”

“What made school difficult?”

“Oh – just settling in, you know. It was hard at first because most of the black kids were Xhosa and would speak Xhosa to them but they didn’t understand it. They hung out with just the white kids at first because they spoke English. But now they are settled and have loads of friends.”

We are on the freeway now, heading out towards the airport and beyond that, Khayelitsha. I am being introduced to the clinic – and vice versa. A concrete fence shields the road from the huts behind. I notice one spot where a few posts have been removed creating a gap. A gap just big enough – it would seem – for a cow. For tethered by a rope a few metres from the road two cows stand grazing on what little grass grows on the verge, untroubled it would seem by the vehicles hurtling past at 130 kilometres an hour. We leave the freeway and few minutes later and follow the road into the township. The central reservation is beautifully landscaped with palm trees, rocks and scrub. It leads to a gleaming new building that looms incongruously among the tumbledown shacks. “Visitor Centre”, a sign proclaims, a heritage of the World Cup and the tourist interest in township life. Rachel points out landmarks to help me find the clinic when I come on my own. Turn right after the shipping container that has been turned into a hair salon, go through the next “Stop” sign and then turn right at the BP garage, NOT the Caltex garage. The clinic is after the Shoprite store.

“I would come a few times with someone else before you make the journey alone,” she says to my alarm.

“Why?” I say nervously. “Is it dangerous to come alone?”

“Hmm? Oh. No. But you might get lost.”

2011-02-22T21:43:00.002+02:00

We step out of the air conditioned halls of the airport into a blast of Cape heat. It is nearly 30 degrees and I am wearing jeans and walking boots. I have been met by three friends from Hlabisa days, gathered in Cape Town for a wedding. We are chatting animatedly in the car as we leave the airport complex - developed massively for the 2010 World Cup – and I am struck by how glitzy and new everything looks.

10 minutes later and we are hurtling down the freeway towards the city. Table Mountain looms ahead of us, cloud pouring over its edge like the head on a hastily pulled pint. As the road curves the towers of the city centre buildings bristle at the mountain foot. I turn to look at the road side – I had seen it before but I am still startled: the glass of the airport buildings has given way to the shacks of the Townships and informal settlements that line the freeway. Thrown up with scraps of wood, corrugated iron, and plastic sheeting these are no temporary shanty towns. There are street lights, webs of cabling dangle from central pylons dispersing electricity to each dwelling, and one shack wears a precariously positioned satellite dish. At the edge of the road stand around 30 or 40 huts, each big enough to accept a person standing.

“What are those?” I ask, puzzled.

“Toilets” our resident Capetonian replies. “The shacks don’t have their own plumbing.”

As we approach the city the Township becomes more developed. Shacks give way to one room bungalows with water and waste plumbing. A large billboard by the highway shows a smiling black family and the tagline “From shacks to civilisation”.

My friends drop me off at my home for the next few months, a flat in a Cape Town suburb belonging to a family friend in the UK. I wave them off and lug my bags into the building. I walk into a reception area. “You must be Ed? We were wondering where you had go to!” says the smiling woman behind the desk in heavily Afrikaans accented English. The reception area is decorated with pictures of times past and several high backed chairs placed around a table are occupied by a group of white haired pensioners. A little old lady heaves herself slowly across the hall on a Zimmer frame, followed closely by a nurse. A poster on the wall declares “Are you having trouble getting to the shops?” I am momentarily puzzled, and then realise: this is a retirement complex.

A man comes down the stairs on a stick. “Look at you, young man!” the receptionist shouts at him cheerfully, “using the stairs at your age!”. My apartment is on the 4th floor. I take the lift.

The return

2011-02-11T12:00:00.007+02:00

After 3 years back in the UK I am returning to South Africa. This time to help with a research project in Cape Town. Kick off next week.

2008-07-11T12:54:00.002+02:00

This blog relates my experiences of working in a South African rural hospital for a year. Although I am no longer updating it I hope it will transmit something of the passion and excitement of those months. May be even inspire some to go work there themselves.

Posts are in reverse order so to start at the beginning click on Feb 2007.

Ed.

Wherever you go...

2008-03-31T19:53:00.001+02:00

I pull the sterile gloves over my gown sleeves and look at the nurse.

“Please could you…?” I ask shrugging my shoulders in the universal “my-sterile-gown-is-about-to-fall-off” gesture. She grins and slips around the bed to fumble for the poppers at the back. I eye her name badge. Startled – I glance at her. “Your name is Ndlovu?”

“Yes.”

“But that is a Zulu name!”

“Yes!” Her face lights up. “You have been to South Africa?”

“I was working there last year.”

“Oh! Where were you working?”

“Hlabisa.” She claps her hands for joy, an enormous grin crossing her face.

“But I live near there. If you take the road from Mtuba to the hospital I live in a village on the right.”

I laugh at the incongruity of it. Here, in the dark at 2am, on a medical ward in an Oxford hospital, working with a Zulu nurse just I did for the last year. We talk animatedly about her home. “Did you train at Hlabisa?”

“No. I trained at Bethesda. Do you know it?”

“Oh yes – I visited a couple of times and worked there when I was a medical student.”

“That is amazing! Why did you go? Why would you want to go?” I talk about the experiences I had there. The terrible problems, the unnecessary suffering and death but also the passion and vibrancy of the life and the motivated dedicated people – both medical and non-medical – who worked so hard to make a creaky, groaning, cumbersome healthcare system deliver.

“Will you go back?” I ask her.

“One day. I do not want to stay here forever. Here they work you so much! Every day! And the money you earn you use up just living! It is so expensive. I will stay a few more years, then I will go home.”

Guiltily I suddenly remember the patient I am caring for. She has fallen asleep. I am putting in a central line. “We better get on with this,” I say. And suddenly I am dragged back from Africa to Oxford – I would not have been attempting this on a ward in Hlabisa: not because I couldn’t but because no one lived as long as this patient in South Africa.

Back in town

2008-02-16T12:54:00.002+02:00

I am back in the UK and starting work Monday. Looking forward to catching up with people soon. And come back here for entertaining tales of culture clash as the weeks pass - my first job is ITU which could not be further removed from rural South African medicine.

The recession

2008-02-11T19:06:00.001+02:00

I am in the bank to tie up my financial affairs before going home. The girl dealing with me is fascinated about why I might have come to South Africa to work - all her friends are going to the UK.

"One of them came back with a MILLION RAND! And he only worked there for a year."

"What work was he doing?" I ask.

"Working in a bar!"

I would be keen to know which bar pays over £75 000 a year - I might be tempted.

She asks me about HIV and whether people "up there" in the rural areas were very sick. "Was it stressful?" she asks as she takes my passport.

"At times."

She studies my ID photo. Then she studies me.

"Well you've definitely got less hair than before."

Robben Island

2008-02-09T00:20:00.000+02:00

We file silently into the building exchanging the harsh bright white mix of sun and limestone for the gloom of the interior. As our weary eyes recover and vision is restored the darkness recedes. A tall black man stands at the end of the hall. He watches us silently as we file in. As the last person enters he booms, “You are late!” There is a ripple of nervous laughter. Is he chastising us or is he joking?

“My name is Thulani,” he continues. “And I was a prisoner here on Robben Island.” Everyone shuts up.

There are about 120 of us – of which just 5 or 6 are South African. The rest: tourists, pilgrims really, from all over the world. And all of us have come to see the place where Nelson Mandela, perhaps the greatest man of the second half of the twentieth century, was imprisoned by South Africa’s apartheid regime.

Thulani tells us how he was imprisoned for his involvement in a bomb placed in the intelligence service building in Pretoria. “It was not in working hours – there were 47 minor injuries. No one was killed,” he emphasises.

He was sent to Robben Island to serve his sentence – joining Nelson Mandela and several others that later became prominent members of the new government.

“I was brought on the same boat that brought you to the island today. I was brought into the room in which you stand now. They then made me take off all my clothes. I stood naked before the prison officers and they examined me and then gave me one set of prison clothes and one thin jumper. If I had been Indian or Coloured I would have got a thick jumper. But because I was Black I got a thin jumper.”

“Did you have visitors?” someone asks.

“You were allowed visitors but they had to apply. One day they called me and said, ‘Thulani – on Friday you have a visitor. Your father is coming.’ I was so excited. Then, the day before the visit, I was called to the chief officer. ‘Your father is not coming. He is intensive care. He was shot yesterday 8 times.’ I went back to my cell and I just sat on the floor. The others – they came and asked what had happened and I told them. Later I found that after my father had applied to visit me the security services went to see him and they beat him up and shot him 8 times. He lived – but he could not walk again.”

There is silence.

One of the 5 South Africans, a Zulu girl from Durban, asks, “How can you be here? After all this how can you come and work here every day.”

“Some days it is difficult. In the middle of the tour sometimes I feel sad. I make an excuse and slip away and I cry for a minute. And then I wipe my face and I go back. But is difficult. I was beaten. The stripped me naked. They placed electrodes on my private parts and shocked me. I know the man who did this. He now has a rich company and makes money. He went to the Truth and Reconciliation Commission and got amnesty.”

“But don’t you want justice?” someone asks.

“After the Commission they said we could pursue these things in the civil courts. But my family, we sat down and we spoke and we decided we wanted it to be over and let it go. It would not make my father walk again. Desmond Tutu said that without forgiveness there is no future so we decided to leave it to God to judge that man.”

He looks at us.

“Any other questions?”

We are silent. Or rather, we have been silenced.

“Then we will continue the tour.”

As we walk I turn to one of my friends. “That makes it more real,” I mutter. She is weeping.

Thulani shows us Mandela’s cell. “He used to come here and do his own tours for visiting dignitaries,” he tells us. “But the last time he came he said to me that he does not think he will come again now. He does not want to come back.”

As we leave we all shake Thulani’s hand vigorously. He is not famous. He is not glamorous. He is not powerful. But he is a remarkable man.

We walk back to the boat, less chatty than when we arrived. We file on aware this time that this same boat carried Thulani and his fellow inmates. We look at the stunning view of Cape Town and Table Mountain - the same view that would have glittered on the horizon, tantalising and unattainable, as Thulani and his colleagues laboured pointlessly in the lime quarries. And we cannot help but be amazed and thankful for how completely and how bloodlessly the world changed.

Flying Comedaire

2008-02-08T15:00:00.000+02:00

Flew to Cape Town with a low cost airline called Kulula. They are famous for their quirky cabin announcements: fun for the tourist. Bloomin’ annoying if you fly regularly with them. For example:

"To operate your seat belt, insert the metal tab into the buckle, and pull tight. It works just like every other seat belt; and, if you don't know how to operate one, you probably shouldn't be out in public unsupervised. In the event of a sudden loss of cabin pressure, masks will descend from the ceiling. Stop screaming, grab the mask, and pull it over your face. This is a no smoking flight and anyone found smoking will be asked to leave the aircraft immediately.”

Others have reported the following (gleaned from Google search):

"Ladies and gentlemen, we've reached cruising altitude and will be turning down the cabin lights. This is for your comfort and to enhance the appearance of your flight attendants."

"There may be 50 ways to leave your lover, but there are only 4 ways out of this airplane."

"Thank you for flying Kulula. We hope you enjoyed giving us the business as much as we enjoyed taking you for a ride."

As the plane landed and was coming to a stop at Durban Airport, a lone voice came over the loudspeaker: "Whoa, big fella. WHOA!"

"Your seats cushions can be used for flotation; and in the event of an emergency water landing, please paddle to shore and take them with our compliments."

"As you exit the plane, make sure to gather all of your belongings. Anything left behind will be distributed evenly among the flight attendants. Please do not leave mother-in-laws.”

Overheard on a Kulula flight into Cape Town, on a particularly windy and bumpy landing: "Ladies and Gentlemen, welcome to The Mother City. Please remain in your seats with your seat belts fastened while Captain Kangaroo bounces us to the terminal."

Once crusing altitude reached the captain announced, "Ladies and gentlemen, this is your captain speaking. Welcome to Flight Number 293, non-stop from Durban to Cape Town, The weather ahead is good and, therefore, we should have a smooth and uneventful flight. Now sit back and relax... OH, SHIT!" Silence followed, and after a few minutes, the captain came back on the intercom and said, "Ladies and Gentlemen, I am so sorry if I scared you earlier. While I was talking to you, the flight attendant accidentally spilled a cup of hot coffee in my lap. You should see the front of my pants!" A passenger then yelled, "That's nothing. You should see the back of mine!"

Time out

2008-02-02T23:00:00.000+02:00

I am taking a few days out traveling to round off the year in South Africa. Please leave a message after the tone. Back next week.

Last chance to see

2008-01-29T23:11:00.000+02:00

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.

CIty Life

2008-01-23T23:06:00.000+02:00

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?

Outreach

2008-01-21T07:21:00.000+02:00

“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.

Departure

2008-01-19T18:47:00.000+02:00

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.

Time's up

2008-01-16T22:11:00.000+02:00

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.

Not entirely New South Africa

2008-01-13T12:32:00.000+02:00

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.

Keeping with the times

2008-01-09T18:28:00.000+02:00

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.

The end of the party

2008-01-05T18:42:00.000+02:00

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.

Training on the job

2008-01-01T20:52:00.001+02:00

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!

2008-01-01T08:34:00.000+02:00

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!

Lament

2007-12-30T09:04:00.000+02:00

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.

Merry Christmas!

2007-12-25T22:02:00.001+02:00

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.

Photos I had no excuse to show

2007-12-24T09:15:00.000+02:00

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.

The Hlabisa Family

2007-12-23T14:21:00.000+02:00

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.

Return encounters

2007-12-19T22:34:00.001+02:00

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.

Back on the Grid

2007-12-18T12:52:00.000+02:00

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

From 31 to 3 degrees in 10 hours 50 minutes.

2007-12-10T10:28:00.001+02:00

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.

Why the policeman is always right.

2007-12-08T07:16:00.000+02:00

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.

I want the baby to die

2007-12-07T07:03:00.000+02:00

“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.

10 Rules

2007-12-06T07:53:00.000+02:00

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.

Abscess

2007-12-02T22:50:00.000+02:00

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.

No really.

2007-11-26T19:18:00.000+02:00

"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.

2007-11-26T19:12:00.001+02:00

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.

MDR

2007-11-23T12:29:00.000+02:00

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.

Breast donation

2007-11-19T18:37:00.001+02:00

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.

Celebration

2007-11-17T23:32:00.000+02:00

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.

Oystein in Antarctica

2007-11-15T16:59:00.000+02:00

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

2007-11-15T16:27:00.000+02:00

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”.

Starlight

2007-11-13T22:15:00.000+02:00

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

2007-11-13T19:35:00.000+02:00

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!”

Unsung heroes

2007-11-10T17:41:00.000+02:00

“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.

Status

2007-11-08T18:35:00.000+02:00

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.

Prude no more

2007-11-05T06:18:00.000+02:00

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.

De Nile ain't just a river...

2007-11-04T10:21:00.000+02:00

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.

The Borrower

2007-10-30T18:35:00.000+02:00

We have a new bunch of elective students. From the States. They all look terribly young. They are following close at my heel as I wander onto the ward. They try to follow me into the toilet but halt when I tell them to “stay”.

We start the ward round. Sister is on excellent form. She sizes up the students.

“So – where are you from?” she demands, pulling up her sleeves exposing her formidable forearms as if she was about to punch the answers out of them. They shuffle back involuntarily and admit to being American.

“Ahh – America. I wish to go to America,” she says dreamily. She studies the students. Her gaze settles on one – a girl of about 4 foot tall who is presumably some kind of child genius. Or a long forgotten trans-Atlantic cousin of the Borrowers. Her eyes widen.

“Hauw Dr!” she says to me. She grabs the girl. “Look at this one – you must check her hormones. She has not had puberty. Her endocrine system is defective!” The poor girl colours and tries to look even smaller were it possible.

Back from Holiday

2007-10-29T18:41:00.000+02:00

Few pictures from the Drakensberg Mountains.

First night stayed in a cave. Just the three of us - massive electrical storm filled the evening, the flashes lighting the valley below our cave mouth as bright as day. Then brilliant sun as we cooked breakfast in the morning by the river.

After breakfast we got in touch with our never-far-below-the-surface inner children - a played in the river. The water carved the rock into pools connected by natural flumes. Best fun ever. And freezing.

A couple of days later off to Royal Natal National Park - named after Elizabeth's trip there before taking up the family business. It is famous for the 7km long cliff line named the Amphitheatre. Around 1km high from the base.

And having got a taste for mountain streams...

Contrary to appearances I am in more than my birthday suit.

On holiday

2007-10-20T09:01:00.000+02:00

I am away for the next week. Please leave a message after the tone.

Team Hlabisa

2007-10-19T14:34:00.000+02:00

Taken by one of our students

Grants

2007-10-19T14:11:00.000+02:00

So. I don't think I have told you about Disability Grants have I?

In SA there is basically no employment benefit. In some areas unemployment is over 40% so it is an economic impossibility I suppose. Instead there are Disability Grants. The intention is laudable enough: give those with TB or advanced HIV money to eat, give those with diabetes or chronic illnesses money to get to clinic. But of course in practice the grants are an incentive to be ill. Until very recently we were supposed only to give HIV patients grants if their CD4 count was under 200. So, once on ARVs if their CD4 rose above 200 they would stop taking their medication in order to maintain their eligibility. When diagnosing TB the production of sputum is supposed to be witnessed - there have been black markets in TB-positive sputum, with patients selling their sputum to uninfected people so they can get treatment and therefore money.

So each Wednesday we sit with the social worker and work through 20 people with "disabilities" - ranging from the genuine "my eye is missing" to the perfectly well lady with "total body pain".

Apparently last weekend some local politician came to Hlabisa town. He spoke to a big meeting and told the people all about Disability Grants. He said if you have high blood pressure, if you have diabetes, if you have arthritis, if you have basically anything you can get a grant. So go to your local hospital and get a grant!

When the doctors turned up on Monday there were over 200 people outside the gate demanding their grants - most it has to be said looking intimidatingly undisabled.

Cattle rustling South African style

2007-10-16T10:46:00.000+02:00

Saw this in a newspaper. A Tazz is similar in size to a Renault Clio. The backseat had been removed from the car, the cows trussed up (3 of them) and piled in. Although shaken up by their ordeal they were, you will be glad to hear, otherwise unharmed as indicated by their willingness to pose for the newspaper photographer following their rescue.

Comic picture of the day

2007-10-15T16:10:00.000+02:00

Taken not, as you might suppose, at our hospital but in the St Lucia Wetland Park. If you look very closely you can even see his cry of horror.

Waiting times

2007-10-13T10:25:00.000+02:00

I open the next outpatient card. It is Thursday evening and I am on call in outpatients. My heart sank as I arrived – there were at least 40 people still waiting. Some had been there since 8am. The card I have opened has a piece of paper inserted. It is headed “Waiting time survey” and is all part of the entertaining clash of first world standards and third world communities, resources and managers.

Let me describe a typical patient journey:

Week 1
Monday – goes to clinic with cough for 3 weeks. Clinic gives amoxil and takes sputum.

Friday – patient goes back still coughing. Result lost - clinic repeats sputum.

Week 2
Wednesday – patient goes to clinic. Sputum negative for TB but still coughing so told to go to hospital.

Friday – gets up at 5am having found the money from a friend for the journey. Arrives 5 hours and 2 taxi journeys later. Sits in OPD for 6 hours. Seen briefly by stroppy doctor at 4pm who wants an X-ray. X-ray has just closed. Sleep on the floor overnight with 30 other people using mattress carefully impregnated with urine and lice.

Saturday - get your chest X-ray. Seen at 2pm by stroppy doctor who loudly complains that you are not an urgent patient and “why have you come on a Saturday for a cough that has been going on for weeks?” Started on TB treatment and told to register at the office. Pharmacy has just closed for the weekend. Office closed til Monday.

Making piles always helps. I divide the cards: non-urgent compassionate see (15 patients - e.g. joint pains but been waiting for 12 hours), non-urgent won’t see (4 patients - e.g. chronic cough arrived at 4pm), urgent must sees (15 patients - acute breathlessness, vaginal bleeding etc.).

I could just see the urgent “sick” ones – it is not as if people can go home until the morning anyway – but I have still not been able to shed the “responsibility guilt”. One colleague commented regarding it that I “seemed to spend rather more time feeling guilty than a protestant Christian is supposed to.”

Bastard.

Pick your battles

2007-10-06T19:37:00.000+02:00

I come to the next patient. She was admitted earlier in the week “happily psychotic” (as opposed to “aggressively psychotic” – which will lead to the nurses locking you in the side room and laughing at you through the window). As such she was allowed a bed in the main ward - in which she sat and smiled and giggled.

She looks a lot quieter now. I have been slowly winding down her sedatives trying to get her settled. Sister looks over my shoulder as I re-write the drug chart.

“I think we can reduce the haloperidol now sister. She is looking much quieter now.”

Sister puts her hands on her formidable hips.

“Ah – no doctor. We cannot do that.”

“But I have been halving the dose each day all week – and look at her, she is still quiet and probably over-sedated. We can reduce again now.”

“Ah – but at night doctor she is different. In fact doctor – I have been giving extra haloperidol – same dose as on admission.”

“But you have signed on the chart where I wrote 2.5mg?”

“Yes doctor – but I gave 10mg.”

“Why?”

“Because at night doctor, she gets up. And she sings and does Zulu dances in the middle of the ward. And then she goes to the male ward and does the same."

I think of raising the point with sister that perhaps she should have told me rather than ignore the drug chart entirely – a loss of temper might be justified. But instead just meekly write on the chart as instructed.

I don’t want to end up locked in the side room being laughed at through the window.

More money than sense

2007-10-02T22:23:00.000+02:00

The man wanders up to me as I pace around the car, eyeing it admiringly. It is a 4.5L 1928 Bentley. It looks brand new.

“Wonderful isn’t it!” he says in a way that isn’t a question.

“It is!” It is one of over 30 Bentleys in the car park of the hotel we have stopped for lunch in. We have stumbled upon the Bentley Owners Club’s South Africa jamboree. A little questioning later and I have found out that it cost £3000 to ship the car here from the UK and there are others from New Zealand, Australia, the USA as well as South Africa. They are spending 6 weeks driving around the country. He hands me the brochure – each car has a photo and an entry by the owner describing the car. It is full of comments like “we have had some wonderful threesomes: me, the car and my wife Margaret I mean.”

“It must be a way of life rather than a hobby,” I comment. The man eyes me.

“It is a pursuit for foolish old men with more money than sense!”

Later in the hotel garden I meet a peroxided lady – one of the wives. She agrees. “This year they aren’t too bad. Quite nice people. Some years they are terrible.” She rolls her eyes and makes out that she hates doing this – but clearly isn’t. “I love Africa – we spent years living around Southern Africa. We loved Zimbabwe. Not any more of course. That Mugabe. I wish I had what he’s got – he’s going on and on. First he was supposed to have syphilis, then AIDS, but look at him! Eternal youth!”

She asks what I do and I tell her.

“You must see a lot of AIDS.”

“Yes – and it’s going to be around for a long time.”

“I suppose people don’t change because they are only 2 year olds educationally and you can’t easily change that.”

My mate quickly excuses himself as I sustain a slightly awkward conversation for 2 more minutes before following him.

Retrospective

2007-09-28T21:45:00.000+02:00

Got a few hours on broadband - so let me give you a couple of short videos from the strike in June.

Converting?

2007-09-28T21:29:00.000+02:00

Perhaps it is rubbing off on me, or maybe it is the cabin fever – living in a closed community with few distractions – but suddenly birds seem quite interesting. For example, even I stood for hours, well OK, not hours but several minutes.. 5 at least, watching these Weaver birds. Stripping fibre vigorously from the palm leaves they then flew across the garden to the tree in which they were building their nest colony and got weaving. Amazing.

Twitching

2007-09-26T18:25:00.000+02:00

Olstein and our guide, Amy.

The thing about Olstein is that he is not only a twitcher. He is a Twitcher. His tally of individual bird species seen in his 6 months in South Africa stands at over 250. He can tell you not only what he saw but where exactly in South Africa he saw it. So when he hands me a pair of binoculars as we head out for a guided walk on the Lebombo hills of Northern KwaZulu it is not a casual gesture. It is akin to being handed a Bible by the earnest friend who invites you to church. In fact, I realise, walking with Olstein visits upon me the exact sensation I spent my earnest years visiting upon others whilst in the University Christian Union. It is like visiting church and standing next to a fervent Charismatic when you yourself are “just interested”.

“Look! Over there!” he exclaims.

“Where?” I look in the direction of his pointed finger.

“There – it is a blurdy blurdy blur [substitute some South African bird] !”

“Really?” I lift my binoculars to my eyes and singularly fail to locate with them the distant speck I can see with my naked eye. I wave the bino’s in ever decreasing circles in the hope of stumbling upon the speck.

“Oh – its gone. Did you see it?”

“Yes,” I lie, feeling very much like some cousin that has had to repeat grade 1.

Our guide, Amy, is very impressed with Olstein.

Amy is something of an eccentric. We discovered her through the hotel when we said we wanted to go walking. She has lived in the African hamlet of Ubombo for 2 years and grows bonsai trees, collects fossils, writes (“I’m not yet published”) and paints. The only other white people in the village are the owner of the hotel we are using (with an improbably posh house complete with swimming pool and satellite dish – looking decidedly out of place next to the shacks just meters away) and some local land-owners (“I’m allowed in their house when I pay the rent”). She leads us along the animal tracks of the hills, through small settlements and undergrowth. Children wave, smile, and ask for money. We wave, smile, and tell them no way.

She does not seem entirely sure of the way. At one point our route leads to the entrance of a kraal (the collection of huts that comprise a dwelling – with several family members living together). “I’m not sure we can go through here,” she says, not entirely necessarily given the fencing and barbed wire. She leads us back the way we came.

Afterwards we go back to her house for tea and she shows us fossils. Here at least, I can trump Olstein on nature. I ask whether something is an “ammonite” before he does. It is the only fossil I have heard off. Luckily, it is.

Last year's Protea

Radical measures

2007-09-20T17:45:00.000+02:00

Sister turns to me.

“Doctor. I have an idea. A way to stop HIV-AIDS.”

“Really?”

“Yes. The problem is the men. It is the men that give us the HIV.”

“Yes?”

“So what the government must do is kill all the men. Kill all the men!” She slices her arm vigorously through the air in a chopping kind of gesture. “The less men, the less the HIV.”

“It is a good idea,” I reply. “You should write to the Provincial Government.”

“Of course, after a while when the country had no children there would be problem. But we women could have a few good years before that. I will write to the President!”

She storms off muttering to herself.

Chicken dinner

2007-09-17T18:46:00.000+02:00

As I finish my ward round on High Care one of the nurses pulls me to one side.

“Doctor, can I see you?”

“Certainly.” She drags me into the small nurses office and begins describing her symptoms. I try to listen earnestly but find it difficult to concentrate. In the background there is what can only be described as the sound of gentle gobbling. I look around. It seems to be coming from behind the nurse. I try to look over her shoulder. She moves to block my view and carries on describing her symptoms. I nod seriously a couple of times and edge to one side. She moves again, but not before I succeed in localising the sound to a plastic carrier bag on the floor.

I bend down to look and tweak the bag open. There, looking up at me, is a small white chicken. Unlike most chickens I have encountered in carrier bags it is not skinned, cling film wrapped and indeed, dismembered. It clucks at me, as if to emphasise the fact and then shits industriously.

The nurse glances at me, looking highly embarrassed. More at the fact of the presence of the chicken than its tendency to defaecate in public I decide.

“It is for my sister,” she says.

“For what?”

“For dinner.”

Dead Man's Beds

2007-09-13T20:41:00.000+02:00

We are struggling on the ward. We have discharged 3 patients so far but as fast as the beds are vacated new occupants take up residence. They have spent the night on the floor in OPD, and OPD wants them out. I glance at the benches lining the wall of the ward – another 4 people sit there clutching the yellow admission papers, awaiting a bed. There are already another four people using mattresses on the floor.

Sister is getting stressed, and my colleague and I are also getting a little twitchy. We turn to the next patient. He is virtually moribund: unresponsive, eyes rolled up into his head, breathes slow and gasping. “Ah!” says Emma, “Brilliant - we will soon have another bed!” She slaps her hand over her mouth, looking shocked at her own words. Sister hoots with laughter and points to another patient across the ward.

“Yebo! And there is another over there!” We follow her finger and turn just in time to hear the death rattle of the other imminent corpse. This week at least admission to this hospital is a matter of “Dead Man’s Beds”.

Shot

2007-09-11T19:11:00.000+02:00

As I cut through his skin the young man turns to look at me. He is lying on one of the couches in Resus, panting and groaning in pain, his face obscured from my view by his oxygen mask. He reaches out his hand to touch me and then rests his arm across my shoulders in a clumsy embrace. Just one hour ago he watched as his girlfriend was killed by the same gunman who shot him through the chest.

I work rapidly. The bullet entered just right of his sternum and exited in the right loin – ripping through the lung and liver on its way. From my quick assessment when I was called it is clear his chest cavity is filling with blood impairing both his breathing, and as the heart is compressed by the pressure, his circulation. As I enter the chest cavity there is a gush of blood over my hand. I insert the tube and connect it to the drain bottle. The blood pours out – 200mL, 300, 500. A litre.

“Someone run to the lab and get all the blood they have,” I bark. “Someone else, get some fluid running in that line.” One nurses squeezes a bag of fluid into the line in his arm and I get the biggest IV cannula I can find and stick it into the femoral vein. A nurse stands and squeezes a second bag into that.

The blood arrives – we set up a third line and soon there are three nurses squeezing various fluid. His blood pressure begins to pick up. I check the drain bottle – 1.5L of blood.

I go to the phone and start making the calls to get him transferred to the surgeons. The surgeon accepts him no questions asked. The ambulance service is more problematic – the phones are answered by clerks with no medical knowledge at all. I answer all her routine questions. “So what is the problem doctor?”

“He has been shot in the chest.”

“And when is this transfer for? Tomorrrow?”

“Now! Urgent!”

“Now?”

“Yes! Now now!”

The whole thing takes 30 minutes. I return to the man. “How is he doing?”

“Not so well doctor. The blood pressure is dropping and he is not responsive.”

“Shit.” In my absence he has filled another drain bottle completely – 4 litres of blood. The nurses are squeezing in the 4th unit of our stock. We have only 2 left in the entire hospital. I call one of the other doctors to come help me as I stick in a neck line.

The phone rings as I finish the line and the nurses holds it to my ear as I stitch – it is the helicopter coordinator in Pietermaritzburg. She sounds jarringly cheery. “Hello! How are you?”

“Fine.” I mutter.

“Good. I’m fine too. We were just called about your patient with the gunshot.”

“Just called? But I phoned the emergency service an hour ago!”

“Really? Well they only just called the helicopter service. How is your patient?”

“Not good.”

“Would you still like the helicopter?”

“Yes! As soon as.” She asks a few more questions and assures me it is leaving its base and will be there in 30 minutes.

The man is stirring a little now – his blood pressure is better, but he is increasingly unstable. I call for one of the sisters from high care – she arrives with the anaesthetic drugs. She explains to him what I am about to do. He nods, closes his eyes and I sedate, paralyse, intubate him and stick him on our portable ventilator. I offer silent thanks to ITU Southmead in Bristol where they taught me how to do this stuff. I look up – the resus room has filled with silent nurses in 2 rows watching. Standing at the back are some people who appear to be on a tour of the hospital. One pulls out a camera and takes a photo. I want to shout at them. But don’t.

We have used up all the blood. He is well into draining the 8th litre from his chest and it looks not so much like blood as rose wine – the majority of it being the saline we are pouring in. One of the doctors gets on the phone to an old boss to find out whether we can safely re-infuse what is coming out of his chest: auto-transfusion. But even as she does so the helicopter team arrives.

They take their time transferring him onto their equipment. I am getting agitated: don’t they understand he needs blood and surgery! Sod this! But they methodically continue. As we move him he gives a cough. A great flow of blood erupts from the chest wound – we stick on extra dressing and press hard. His blood pressure is falling and I give him a shot of adrenaline.

At last the helicopter team are satisfied. They wheel him out and load him on, finally leaving 3 hours after my call. As I watch I wonder whether he will even survive the transfer.

I suddenly remember I am supposed to be at a meeting at a nearby research centre – it started 2 hours ago. I phone to apologise. The organiser (a German – not that it is of significance) says I shouldn’t worry. No one else has arrived yet. I burst out laughing. That is so South Africa. “I am glad you find it funny because I do not,” he grumbles.

The rest of the day is a blur. At the end I phone the surgeon who took the man. He went to theatre – they removed the damaged lung and packed the liver. He is on ITU and stable.

I walk home and decide that I will have a (very brief) weep. Of relief.

So I do.

Stillbirth

2007-09-08T17:22:00.000+02:00

The phone rings and I open my eyes blearily, attempting to focus on the clock: 3am. I stagger over and answer. It is Andrew – there is a Caesarian. I pull on my shorts and step out of the flat into the cold night air. The sky is clear and the stars are burning bright and splendid, the Southern Cross hanging directly over the hospital.

I walk down the dark road to theatre, the wind blowing cool and dry across me, whistling slightly in the palm leaves above. The patient has just arrived. “She had grade 3 meconium in the liquor,” Andrew explains. That is a sign of significant foetal distress and in our setting an indication for Caesarian in most cases.

I stick in the spinal anaesthetic – I am having a good run at the moment, it takes only one stab. I turned one poor lady two weeks ago into a veritable pin cushion – I could not feel any of her spinal bones through her ample skin. This lady is significantly thinner.

“Do you want to cut?” asks Andrew.

I have done four Caesars under close supervision. I feel a bit pathetic but at 3am, given the choice between Andrew and a 45 minute operation, and me and a 2 hour operation, I choose Andrew every time. At the start of my last effort I told the nurses that they should feel free to nip off for tea at the start of the third hour. They laughed, but at the end one of the sisters came to me and said with a grin, “Dr Moran, we thought you were joking. But you were not.”

I scrub in to assist. Andrew dissects down to the uterus and reveals the baby’s head. He delivers the head and quickly suctions the mouth before delivering the rest of the baby. There is no cry. The midwife plucks the child from him and takes it to the resuscitation area.

I eye what is going on, even as I hold the retractor. It is instantly clear things are not going well. I leave the operating table, pull off my bloodied outer gloves and join the midwife with the baby. There is no pulse and no respiration. The midwife begins chest compressions as I suction the airway and use the bag and mask to ventilate. I am getting good chest movements but there is no sign of the child getting pink. We give adrenaline and I grab the laryngoscope. I get a good view of the vocal cords and ask impatiently for the endotracheal tube. I pass it down throat through the small gap between the cords. Pulling the mask off the bag I connect it to the tube and ventilate the baby.

20 minutes, 1 naloxone and 2 adrenalines later and there has been no change. The baby never stirred, and never took a breath of its own accord. I ask the Sister in charge to explain this to the mother before we finish. Sister goes to the mother and with great compassion in her face and manner explains what is going on. I watch the tragic conversation, the mother listening even as, behind the green sheet the obscures her view, the surgeon continues to close her abdomen. Sister comes back. “She understands. And she would like to cancel her tubal ligation.” The surgeon nods silently.

The midwife and I stop resuscitation. She takes the baby and wraps it up. I go to the mother. She looks at me and whispers, “Siyabonga.”

The spinal anaesthetic is wearing a little thin now. She winces and give small gasps of pain. I give her a shot of sedative to ease the discomfort for the last 5 minutes of the operation. I time it badly: the midwife comes to show her the dead baby, carefully wrapped in a sheet. She is too spaced out to really notice.

Consulting God

2007-09-05T20:12:00.000+02:00

The man walks onto the ward and makes a beeline for me. He talking loudly and expressively in Zulu, his arms waving dramatically to emphasise whatever point he is making. He is a little unkempt but not obviously drunk or high. He sees I do not understand and switches to Afrikaans.

“I don’t speak Afrikaans. Try English.”

He obliges instantly. “Doctor, I am here for my medication. I need my medication. Can you write me for my medication? I have run out and I need more.”

“You must go to outpatients sir. They will help you with you tablets.”

“I need haloperidol, chlorpromazine and epilim. You can write me up for them can’t you?” They are antiepileptic and anti-psychotic medications.

“Go to outpatients sir. They will sort you out.”

“Ah yes. Thank you doctor.” He pauses and watches me. I turn back to the patient I am seeing. He begins talking loudly to the nurse.

“Could you keep your voice down sir? It is hard to hear the patients!”

“Of course! Of course! It is very irritating isn’t doctor when people show no consideration?” There is a hint of irony. He is nodding enthusiastically and looking at me seriously. As I continue on my round he wanders off. 20 minutes later he is back with one of the OPD nurses Bongani in tow to make sure he doesn’t get up to any mischief.

“Ah! There you are doctor. You must help me. These people do not realise that I am God. You must tell them who I am. You know who I am don’t you?” A spray of spittle gets me in the eye. “And there is another thing. Can you help my vision?”

“What is wrong with your vision?”

“It goes dim. But only when I read the New Testament.”

“It is OK when you read anything else?”

“Yes – there is no problem with anything else.”

“OK – let me see if I can help you.” And God and I nip over to outpatients to sort out His anti-psychotics.

Outpatients

Spring

2007-09-03T18:56:00.000+02:00

I wind down the window and stretch my bare arm out into the onrushing wind. The heat and humidity are testament to the arrival of Spring and I open my hand to catch the breeze as it hurtles by at 120 kilometres per hour. I reach the crest of the hill – the highest point of the highway as it traverses the game park – and the landscape rolls away into the haze on all sides. Vervet monkeys leap out of the way as I head down again. I turn up my (you might say cheesey) African themed music.

As I round the corner the car in front slams on his brakes, as I do in turn. An elephant is crossing the road. We both watch from our vehicles. As I pass the driver he turns to me and gives a broad smile and gestures animatedly to the elephant beside him. I smile and wave back and then pull away.

You gotta love this country.

When Jesus calls

2007-09-03T07:25:00.000+02:00

Sister on C ward

I am half way through my round on C ward, the female medical ward. Out of the corner of my eye I become aware of two well dressed women standing a couple of metres away and radiating that powerful aura that so effectively says “I am waiting for you” to your subconscious. I have never learnt how to ignore it and within a few seconds find myself completely incapable of concentrating on the task in hand.

I turn to them. “Can I help you?” They step forward, clutching the familiar bulk of the death certification papers.

“Yes please doctor. Could you sign these?” says the first in perfect English. I take the papers. There are several of these most days – my record is 7 deaths (20% of the ward but that was over a weekend and shouldn't be counted). They must be signed by a doctor to confirm the cause of death before the body leaves for the undertaker. Half the cases we have no idea what actually killed the patient and write “Pneumonia, ?HIV”. A GP in a town 50km away did a week long course on how to do post-mortems apparently – we send the suspicious cases to him – but there is no system for confirming causes of death in those cases where the diagnosis is unknown as there is in the UK.

I flick through the papers and look up at them in dismay. “But this lady was doing fine yesterday!”

“Yes doctor. We came yesterday and she was well. She told us she was being discharged.”

“Yes – but she was young and she was nearly completely better. I am so sorry. I don’t know what happened.”

“Oh doctor. Do not worry.”

“But she was better. She was walking around and complaining that she was bored.”

“Doctor. There was nothing you could have done.”

“Thank you but I am so sorry.”

“Doctor. If Jesus calls someone then there is nothing even you could do about it.”

I sign the papers, again having to make something up as I have no idea what killed the poor woman. Do you know what the a South African’s life expectancy is these days?

48. Much lower if you take out the wealthy city people.

It seems to me that if the lady’s logic were true Jesus seems to want an awful lot of young Zulus.

Ghost Mountain Inn

2007-09-01T12:24:00.000+02:00

It is dusk as we pull in through the gates of the Ghost Mountain Inn in Mkhuze. It nestles at the foot of the Lebombo Hills in KZN and is one of our more luxury getaways – we are using it as a stop over on the way back from the conference. My mind turns to our first visit here a couple of months ago.

We were in the bar in the evening and got chatting to a pleasant Scandinavian couple. He was Swedish, she was Norwegian I think – both incredibly snappy dressers. Since we had a Swede and Norwegian in our gang conversation flowed fast and multi-lingually.

“What are you doing here?” I asked them.

“I am setting up a football academy,” he replied.

“Here?!” Mkhuze is not exactly the centre of the world. It is a small town in the middle of a large rural area with few services and little employment. He was, I imagined, some kind of social-conscience development type, using his football skills as a means of community development and empowerment.

“Yes, but we live in Durban.”.

The girlfriend broke in, “I am house-hunting in Umhlanga.” Umhlanga is one of the most upmarket beach areas in the Durban suburbs. Housing there is not cheap. My vision of a social-conscience development type did not fit well with buying a house on the Umhlanga beach front.

“So where are you living now?”

“Here,” she replied.

“In Mkhuze?”

“No, in the hotel.” I was vaguely aware that some of these European development organisations can have rather excessively generoues expense allowances but there are cheaper ways to live than R540 per night per person.

“Wow! Nice!”

“Well its OK, but of course no hotels will let me have my dog and it is really a problem when you are living in hotels for a while.”

“You got the dog here?”

“No, we brought her from home. She had to spend 6 weeks in quarantine poor thing. It was so expensive but she is out now.”

“So do you have the dog in this hotel?”

She lowered her voice to a whisper. “Yes. But when we check in a have to dress her up as a baby in a blanket and carry her in my arms as if she was a asleep!” She sat back in her chair with a triumphant look on her face. I could feel a slightly hysterical smile creeping irrepressibly over my face and tried to think of something sad.

After a couple more drinks they made their excuses and left. Olstein sat back with a conspiratorial look on his face. “You know who that was don’t you?”

“Who?” I asked.

“Swedish. Into football. Setting up a football academy.”

I struggled and failed to make the connection.

He paused dramatically - I could almost hear the drum roll. “It was..."

"Yes?"

"Sven Goran Erikson’s son!”

“What?! How do you know?!”

“I met one of his work colleagues earlier in the afternoon and he told me.”

“Are they are hear doing social development projects?”

Olstein laughed heartily. “It is not a social project. They are talent spotting and then exporting trained players overseas for loads of money.”

It suddenly all makes a bit more sense.

Then, with the outside company gone we regressed to childhood and spent the remainder of the evening challenging each other to snog the various wooden animal statues that decorate the bar without the foyer guard seeing.

Full circle

2007-08-29T10:10:00.000+02:00

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.

Governement - a Faith Based Organisation

2007-08-28T21:01:00.000+02:00

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.

"And what do you do?"

2007-08-26T19:24:00.000+02:00

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..."

2007-08-26T12:10:00.000+02:00

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.

Betrothal

2007-08-20T21:43:00.000+02:00

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.

Empowering

2007-08-14T10:34:00.000+02:00

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.”

The first time was a chicken

2007-08-12T10:17:00.000+02:00

“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…

Student assessments

2007-08-06T14:07:00.000+02:00

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.”

Now you see them...

2007-08-04T22:20:00.000+02:00

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.

Hunchback

2007-08-02T18:30:00.000+02:00

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.

Results

2007-07-28T19:00:00.000+02:00

It is 6pm. I am back at Hlabisa after another bumpy journey. I gave the tube of blood Sister handed me as I left clinic to the lab and have nipped back to see what they have found.

The lab tech hands me the blood results. I quickly scan them. Normal white cell count – I had feared she might have leukaemia. Normal haemoglobin. But there at the bottom, the platelets: 4. Should be at least 150. The platelets play an essential part in the body’s blood clotting system. 4 is well below the point at which spontaneous bleeding can occur. There are a few possible causes but Hlabisa Hospital is not the place to investigate them. I get on the phone to a specialist at our referral hospital who offers to accept the patient for investigation. I pull out the scrap of paper on which I wrote the lady’s cell phone number and call her. As it rings I offer yet again a silent prayer of thanks for the cellphone, a device that has transformed the level of contact we can have with our patients, many of whom have no address to speak of. Somewhat bemused she agrees to go to the referral hospital.

As I hang up I realise that I rather enjoyed myself. In the mass of TB and HIV it is easy to forget that all the conditions we see at home can occur anywhere in the world. Just because the Game Park is full of zebra does not mean that I might not also see a horse.

Bleeding gums

2007-07-28T12:52:00.000+02:00

“So how long have you had the headache?” I ask. I am at one of our most remote clinics. Two hours drive from the hospital, the last 30 mins bumping along dirt road.

“Just today,” she replies. The patient is a teacher in her thirties with excellent English.

“Any other problems?” She shakes her head, and then stops, looking thoughtful.

“I did cough up a little blood this morning.” She opens her mouth wide, and sure enough there is a little fresh blood on her tongue. There is no torch so I angle her head towards the window through which the still hot winter sunlight is streaming in. I pull up her lip and see a small area of the gum is bleeding. And there, on her palate at the back of her mouth are numerous small red spots, petechiae. The rest of her examination is completely normal.

Guiltily I move from “coasting” to “thinking” mode. It is a terrible thing to confess but we see so many people with non-specific “aches and pains” that it is all to easy to adopt the “take paracetamol and come back in 2 weeks if it doesn’t get better” approach. What we as hospital physicians, safely insulated from the public frontline. used to self-righteously joke about as the “GP-way”.

“Have you any rashes on your skin?” She shakes her head. “Any bruising? Fever?” No. “And you have been completely well over the last few months?” Yes. “Have you ever had an HIV test?” Last year and it was negative. I scratch my head. If I had seen this lady at the hospital I would have been able to do various tests there and then. Out here I am a bit stuck.

“Do you have a cellphone?” Yes, she does. I turn to Sister. “Could you take a blood count?” She nods. “Ok – so take the blood count, and I will take it to the hospital tonight. Then I will phone you to let you know the result and what we must do.”

There are a few classic causes of a rash like that in an individual who otherwise looks well – and none of them are great news.

Confession

2007-07-22T13:48:00.000+02:00

I can only plead temporary insanity. I had been back in South Africa a few days and was feeling a little home sick. So when I was Spar in Mtubatuba and saw not only an English language newspaper but, of all things a UK international edition I could not help myself. In the same situation you would have done the same - you would have bought the Daily Express.

I see it now, on the bottom of a pile of papers, like a dirty magazine I forgot to hide and hope no one will notice. Even looking at it brings the flush of shame to my cheeks. And the worse thing of all was that I enjoyed it. I enjoyed the fact that the man who built himself a shed in the shape of a Roman temple deserves a story occupying two-thirds of page 3, I enjoyed the sad little picture that appeared to show Prince Charles groping a female soldier, I laughed with excitement and glee when I got to page 7 and found that Kylie will be in the Doctor Who Christmas Special and worst of all, I read all of Ann Widdecombes column. And it didn't make me angry.

So, spare a thought for those of us cut off from British culture and in danger of latching thoughtlessly and desperately onto the nearest thing resembling it - no matter how deceptive. And thank God for my only hope of cultural salvation: the BBC and the internet and the GPRS enabled mobile telephone.

Chewing the cane.

2007-07-22T13:15:00.000+02:00

Jabu and I are talking as we walk back to the accommodation after work, discussing some piece of hospital political trivia, when his eye is caught by a gang across the carport. They are standing in a group talking and eating something.

“Hey, Ed, let’s go eat sugar cane.” We walk over and join the circle. Sugar cane eating generally seems to be the equivalent to “Afternoon tea” – an excuse to gather and make small talk.

“How do you eat it?” I ask.

“First you must peel of the outside with your teeth,” says one, Thulani. He demonstrates, rapidly stripping off the bark-like exterior of the cane and spitting it onto the pile that has collected at the centre of the group. I try. “Not like that, use your canines.” I try again with more success.

“Then bite off the inside.” I bite off a chunk of the white moist fibrous interior and chew. It is, as you would expect sweet and tastes a little of tree. I swallow.

“Don’t swallow,” says another member of the party, and she laughs as it sticks in my throat and I gag. I bite off another chunk and then pass the stick on.

“You don’t like it?” Jabu asks.

“Perhaps it is like coffee – I will learn to like it.” I say, and then, being a product of the neurotic fluoride age, nip back to brush my teeth.

Absent father

2007-07-20T08:00:00.000+02:00

I am walking down to do my session at Philanjalo, our anti-retroviral medication clinic where the 450 odd HIV+ patients in the area around the hospital eligible for anti-retroviral treatment are managed. Over 2500 people in our district are on treatment at the moment – an impressive number nationally speaking but still a fraction of those requiring it. I am still chuckling over the wording of a referral note from a local clinic, “Patient suffering from virginal sores – has nasty sores on the virgin.”

I walk into clinic. Sister sees me and shouts.

“Hauw, doctor! Where have you been?”

“I have been in England.”

“But you did not tell me – you just left!”

“I told one of your staff and I arranged Dr Magnus to cover me,” I say somewhat defensively.

“I did not know – you did tell me!”

“I am sorry, I could not find you.”

“But you are our Baba! What kind of father abandons his children like you abandon us!”

“I apologise. I am a bad father.”

“A Baba cannot leave his children. He cannot go away without telling them!”

“I am sorry. I failed you.”

“You did. You are an absent father!” She is smiling.

“I can change,” I tell her, “I can do better if you will let me try!”

“You must! You cannot leave us again.”

“I won’t.”

“OK – now, come this way.” She leads me to my room and I get to work.

Cow head

2007-07-19T20:20:00.001+02:00

There is a bang on the door. It is 7:30am. I hop to the door, pulling on my trousers. It is Zanele. She accosted me in my first week here and offered her cleaning services for R80 a week. She cleans for several of the doctors here.

"Hi Zanele, come in!"

"Hello, doctor."

"How are you?"

"Ah – I am well. You are back!"

"Yes – I visited my family. Are you well?"

"Yes doctor." She pauses. "Doctor, may I have two weeks money this time?"

"Sure."

"I have to buy meat to sell."

She goes on to explain that each week she buys a cows head from the butcher and cooks it. She then chops it up and picks a spot near the petrol station in Hlabisa village centre to sell cuts of the meat to passers-by on Friday and Saturday – the days she does not clean. Zanele has six children. Three are her own and three belong to her late sister who died last year of an illness almost certainly related to HIV. Zanele must now earn enough money to pay for the education,
clothing and food for all six.

I tell her no problem, she can have two weeks money. She is very grateful – it will enable her to buy extra meat.

"And thank you doctor for the extra money," – whilst I was away I left her R100 a week rather than R80 as I did not have change – "I was able to buy extra bread for the children."

The doctor is in.

2007-07-15T21:16:00.000+02:00

I am back in South Africa. Give me some time to re-acclimatise and then tune in for more hilarious goings on at Hlabisa Hospital.

It's not all work, work, work.

2007-06-28T15:55:00.000+02:00

I am away in the UK for a couple of weeks. Flicking back through these entries (and boy, some of them are long-winded - did you really read them or did you "skip to the end"?) I fear I may have misled you. My life in South Africa is not, as the balance of my writing might imply, one of entirely selfless dedication to others. This country is after all, one of the most beautiful and varied in the world. If you were sitting with me in the lounge I would whip out my laptop and inflict upon you the 25,000 photos I appear to have taken on my weekend jaunts. Instead (and I no doubt hear you cry "mercifully") I give you half a dozen highlights. Until a fortnight. Sala kahle.

Approaching the Drakensberg.

In the Drakensberg mountains with Dr Tom (centre) and Dan, an elective student (right).

Hippos in the St Lucia Wetlands National Park.

The Umngeni Valley Nature Reserve - looking down from the crags to the river. Excuse the knees - photographic composition dogma required a foreground.

Crossing the swing bridges in the Mkuze Game Park Fig Forest.

A herd of antelopey things - impala I think but I don't know and you don't care. Mkuze Game Reserve.

Ostriches having sex at the Umfolozi River Lodge. Not beautiful but certainly varied. The accomodation for humans was apparently better than this.

Incommunicado continued

2007-06-24T18:16:00.001+02:00

So, as I was saying, we were cut-off.

I turn to the midwife. “Do you have MTN?” I have found on a few occasions that when Vodacom and Telkom fail, South Africa’s other major phone network inexplicably seems to survive. We check all the midwives phones and one has MTN. She only has a few minutes credit but graciously lets me make a call. I phone Nicky, a colleague at Hlabisa.

“Nicky, can you call me back straight away?” She does and I explain the situation. She gets on the case, phoning all our nearby hospitals. The midwives and I chat whilst we wait, the groans from the woman next door getting louder and louder. It seems an eternity before Nicky calls.

“Bad news I am afraid Ed. Nongoma only have one doctor and all the other hospitals said no.”

“What?” I reply, righteous indignation rising like bile in my throat.

“I tried to explain things but they all said that you should send the patient somewhere different.”

I swear again, this time not under my breath. “I will have to send them to you at Hlabisa then.” Nicky gets on the phone again to speak to the Hlabisa on calls and minutes later our medical manager phones back on the nurses phone – he is on call mercifully. I explain the situation and then he rings off promising to sort something out. Two hours have passed since I arrived in maternity.

I nip back to the accommodation and grab a coffee with Olstein. “How will you transfer her?” he asks. We are at least an hour from the nearest ambulance base and they will not come to pick up until we can confirm where she is going. Her transfer is going to get dangerously delayed. As we walk back to maternity an ambulance passes us on the exit road from the hospital having just dropped a patient in OPD.

“Run!” shouts Olstein. We both peg it down the hill to the hospital gate after the ambulance.

“Stop! Stop!” The guard is opening the gate.

“Don’t let that ambulance go!” I shout. The guard is waving it through.

“Stop!” The guard looks up and can only be startled to see two crazy visiting doctors with shaved heads hurtling down the hill, limbs flailing and yelling. He bangs on the ambulance as it drives through. It halts. Breathlessly we both catch up with it. The driver looks at us somewhat quizzically. We explain the situation and, unlike our medical colleagues in other hospitals, he quickly grasps the problem. He radios the headquarters. They give him permission to do the transfer and we all head back to maternity. Dr Adam phones. Nongoma’s medical manager is going in to help their one doctor so they section can be done there.

We load the woman into the ambulance and watch it drive out of the gate.

“I’m definitely changing mobile network,” I say to Olstein as we head back to the house to put our feet up and finish watching "The Lion, the Witch and the Wardrobe."

Incommunicado

2007-06-23T18:46:00.000+02:00

As I palpate the woman’s lower abdomen she winces and gives a soft cry of pain. “How long has she been in this discomfort?” I ask the midwife.

“For an hour, doctor.”

“And she has had a previous Caesarian section?”

“Yes – doctor, 5 years ago. She has been 2cm dilated for the last four hours.”

I am back at Ceza Hospital for a second round. Glutton. Only this week has not been the mellow experience of my last visit. Word has got out – there are doctors at Ceza. Where 2 weeks ago we were seeing just 20 to 30 outpatients a day now there are over 50. Oystein and myself have been working til 7pm. No chance of nipping down the road to the hot springs. And now, just as we were huddling down for an evening of DVD viewing on a 12 inch laptop screen maternity has called.

I scratch my head. The lady is at high risk of needing a Caesarian section – not right away but fairly imminently and possibly as an emergency if she is allowed to continue to fail to progress and ruptures her old Caesarian section scar. There is only one problem. Neither Oystein or myself can do Caesars – we are namby pamby European physicians. Not hard core South African generalists. I have assisted at half a dozen sections. In fact, at the last one Jabu let me do the whole thing under his watchful gaze. I proudly stood back after my first solo sewing up the uterine incision awaiting his approval. He studied the oozing bleeding uterus carefully and then, taking a new needle and suture said, “I’ll just tidy this up a bit” - and then repeated the entire thing. So I guess under pressure I could get the baby out. Just couldn’t put things back to together again.

I pick up the phone and dial switchboard. “Could I have Nongoma hospital please?”

“Ah – doctor. I am sorry – all our lines are down.”

“You mean there are no phones at all?”

“No doctor.”

“What about that radio?”

“Radio?”

“The radio in your room for emergencies.”

“Ah – yes. That has not worked since 1990.”

I check my mobile: “No service.” Telkom and Vodacom share the same malady. I swear under my breath. We are in the middle of Zululand. 30km of dirt road separates us from the highway. It would appear we are completely cut off.

Mental stealth act

2007-06-16T09:24:00.000+02:00

I am not sure what to do. The man is standing, shoulders hunched and eyeing me with an expression that can only be described as “baleful” – one of those terms you read in books as a kid and of which you develop a visceral understanding but could never explain in words to someone else. Abruptly he hits out at me – I jump back but not before his fist has closed over the pen with which I was about to write up his anti-psychotic.

When he arrived with his wife a couple of hours ago he was quiet and settled. He was describing three weeks of delusions and hallucinations, particularly severe at night. He was hearing drums and his ancestors were apparently speaking to him. I have come back from theatre to find him aggressive and agitated.

We are now at something of an impasse. 4 security guards stand behind him – but they are not trained for this sort of situation. I am loathe to approach him with my needle until he is restrained. He hits out at me whenever I approach. Nomfundo walks past and eyes it up. “Have you got a death wish?” she says, giggles and walks away. Thanks.

Sipho, one of our younger go-getting OPD nurses walks past. He eyes up the situation. “Need some help?” he says, and without a break in his pace walks into the cubicle, throws his arm around the man’s neck and in a flash has him pinned to the floor. We all stand, momentarily dumbfounded. “Well come on then!” he calls from the ground. I jab my syringe into the guys butt. Sipho stands up and then helps up the man who appears as stunned as we are by his abrupt change in circumstance.

“Boy, I am glad you chose to use your powers for good.” I tell Sipho. He looks rather pleased with himself.

Of strikes and caesars

2007-06-14T21:23:00.000+02:00

I admit it, I am a little nervous about work today. The medical manager spends the morning meeting allocating a named “man” to each ward – women doctors are to keep a low profile, just in case “things get nasty.” I cannot pretend to be a particularly imposing specimen of manhood, in fact none of us can save Jabu. There will probably only be one nurse on each ward, the medical manager explains, and “they will be looking to you for leadership.” Tom (a doctor from London) has come dressed in his jeans today – “so as to blend in,” he explains with a wry grin, looking particularly white and freckly.

After my high care ward round I potter down to my allocated ward. We all spent yesterday discharging patients to get the hospital as empty as possible for today – we had a head start as no one had been coming for admission anyway. To my surprise all the nurses are there, dressed in their civvies. I explain in embarrassed tones that I am their “man” – they look at me doubtfully but dutifully write my cell number on a scrap of paper and promise to call if there are any problems.

In OPD there are more nurses than patients. There are in fact more nurses than there were yesterday on the “non-strike” day. I wander past X-ray. It is open but there is no one around. A sign on the hatch reads, “Gone for tea and picketing. Back in 30 mins.”

I bump into the matron, the medical manager and Dr Kekana as I leave. They are taking the roll call demanded by Head Office. Dr Kekana looks a little embarrassed – “I was asked to,” she mutters. Dr Adam has just come from a teleconference with other hospitals around the province. Ours sounds as if it is one of the more civilised – many are experiencing severe disruption from picketers and poor staff turnout. The nurses and other hospital staff at Hlabisa are as morally behind the strike as anyone else – but from the guy who drives the electro-car that collects the laundry to the ladies who empty the bins to the nurses themselves, every discipline is running if not normally then at least functionally. I am seriously impressed with their dedication – particularly given the intimidation some have experienced from neighbours and some of the union reps.

Nicky tells me later that one of the senior sisters she was working with in OPD looked at her in between patients and said, “Doctor, I am not here. My body might be, but emotionally..” she looked out of the window and gestured to the town hall where the picketers were gathering, “..I am there.”

At lunch time the demonstration reaches the hospital gate. It does not enter the grounds but stops outside. Olstein and I go out and stand on the peripheries to watch. People we recognise wave. One nurses asks, “Are you here to toyi-toyi?” and demonstrates the dance enthusiastically. Another nurses translates the speakers words for us – about the government not listening and how it gets its power from the people and needs to listen to the people. The next speaker accidentally starts his speech in English. He is interrupted by a colleague and there is a brief muttering. “Oh.. sorry..” he says and he starts again in Zulu.

By 2pm there is nothing to do. No more patients have made it in today (the taxis are on strike as well), the demo is running our of steam and the wards are quiet. Olstein and I have a game of squash. Just as I finish showering, Jabu phones. “Want to learn how to do a Caesarian section? I’m going to theatre.”

Well why not? Nothing else to do.

The calm...

2007-06-12T17:17:00.000+02:00

“I am going now doctor,” says the nurse.

She is dressed in her own, actually extremely stylish, clothes. All the nurses came to work in their civvies today. Many of them have been reporting intimidation from neighbours and even friends for continuing to work this week. Some have been getting threatening phone calls. Uniforms have been abandoned in an attempt to blend in.

“Where are you going?” I ask.

“To the strike.”

“Who will be helping in OPD?” She shrugs, smiles, and walks off. I walk around OPD. X-ray is shut, there are no nurses. Thankfully all is calm - only 3 or 4 unseen patients. Our normal number of 80 to 120 a day has dropped in the last few days to just 20 or 30. Those clinics that aren’t shut are operating on a skeleton staff and there have been very few referrals. Many of our outpatients are those with chronic problems that can wait. But many are not – there are a lot of people dying at home this week.

I cannot work so I wander to the front gate. The police are stood on the side of the road watching a crowd of around 100 staff members dancing and chanting. Whenever they begin to spill into the road a man in an ANC T-shirt gestures them back so that vehicles can still pass. The mood is good and they move to let cars and ambulances through the gate. Their chanting is considerably more melodic than their British counterparts.

Strikers dancing with the police looking on in the background

People begin trickling back into work at 3pm and we see those dedicated patients who remained throughout the afternoon.

“What is happening tomorrow?” I ask Mr Zulu, the OPD head. He shakes his head – he doesn’t really know either.

“But Wednesday – that will be a problem.”

A general strike has been called. Cooks, cleaners, telephone operators, patient note filing clerks, nurses, mortuary staff: no one will be going to work.

Apart from the managers.

Oh – and us.

For info on the strike see this Washington Times article and this Reuters online piece. There is amazingly little regarding the extent of the strike in the SA broadcast media, and even the independent newspapers fail to mention the impact on rural health services and make only passing mention of the extent of the morbidity and mortality that is resulting.

Demo

2007-06-11T14:36:00.000+02:00

I am on way to outpatients after lunch when I spot Nkosi and Ziggi. There are both wearing bright yellow trade union T-shirts.

“You on strike?” I ask.

“Ziggi was on strike before the strike!” laughs Nkosi.

They explain they are on their way to a big meeting in town – all the public servants – teachers, nurses, local government employees and so on – are gathering for a march. Durban has been paralysed for the last week – our major referral hospitals are accepting no patients, demonstrators are turning away ambulances, all the ITU patients have been transferred to private hospitals (at what cost cannot be imagined) because no nurses turned up for work. It is claimed that the biggest hospital in Durban had only 10% of its staff turn up.

It has been slow to move up to the rural areas – perhaps because money is more scarce (“no work – no pay” is the government policy) and there is a high chance that you know or are related to the people who will be affected. This week however it has begun to hit. Yesterday the medical manager would not allow Nicky to go to the local clinics – government vehicles were being stopped on the road in some parts – and picketers were turning away ambulances from our local referral hospital in Empangeni and our clinic at KwaMsane.

I ask Ziggi and Nkosi about the strike. It centres over the government pay increase of 6.5% (inflation is 6%). Nurses are extremely badly paid. One (very experienced) nurse tells me she gets R4000 a month before tax (£285). They are asking for 12%. They are thinking of striking they tell me. “Strike away,” I say, “but will you let the red-light ambulances through? I don’t mind about the coughs and blood pressures.” They laugh but do not reply.

In OPD things it is silent. Eerily so. Only Mr Zulu, the head nurse, is there. All the others have gone to the meeting. We see a patient. As I finish I hear singing start up outside. Olstein pops up from the next cubicle: “Want to go watch?”. I grab my camera and we run outside.

50 or 60 staff in yellow T-shirts are standing in a circle singing and chanting. In twos or three people enter the circle and dance to the cheers and whoops of the others. Some are waving banners: “Yes to 12%”, “We cannot live on 6%”. The X-ray man leads a conga of dancing people whilst shouting slogans. The noise is fantastic and exhilarating. There is a party atmosphere. Dr Kekana comes out of OPD and joins the line, gyrating along with the best of them. I would like to join but am too Britishly inhibited – and besides, I can’t do what she can do with my hips. Well not my hips. With “ones” hips. She is doing it with hers, not mine.

I notice the head matron speak to the crowd. I turn to Sister Jele who is standing next to me. “What is she saying?”

“She is reminding them that they had permission to strike for an hour and they must return to work soon.” Astonishingly they seem to listen. Matron herself gyrates and undulates her not insubstantial form across the crowd back to her office. Sister Jele tells me they made sure there were 2 nurses on every ward and all the rest could come out.

The crowd disperses. I walk back in to an almost deserted outpatients. I see Bongani – a newly qualified nurse I have had beer with a couple of times.

“Hey Bongani – why were you not dancing.”

“Ah – Ed. I am a new employee, on probabtion. It would not do for me to be seen doing that! And besides. I cannot dance.”

That evening as I walk back to the accommodation I pass Thandi, one of the black Comm Serv doctors. “Hi Thandi! I didn’t see you dancing with the demonstrators today!”

“No Ed. I was scared!”

“Scared? Why? It felt like a party.”

“I try to keep my head down. It is OK for you. But for me – if they see me working they will say ‘Why are you not striking with us?’ So I keep out of sight.”