In Sierra Leone

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

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.

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 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 Christ

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." &quo

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

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.

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 u

“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 w

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.

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.

"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.

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.

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

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 an

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 gy

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.

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.. y

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.

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 h

“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 th

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.

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.

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

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 p

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.

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

Taken by one of our students

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 &qu

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.

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.

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 o

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 1

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 wiv

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

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.

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 sin

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.

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, l

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 ad

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 t

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 s

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 w

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.

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

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

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 fut

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 pro

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

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 CD4

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 rath