I know what to expect intellectually. I have heard about it. I have seen it in photographs. I have read about it. Still, it is a quite different matter, the emotional impact of seeing for yourself: a ward with 30 beds holding 45 people, some on the floor, others sharing mattresses; the nurses stepping over a 30-something year old man, demented as a consequence of HIV, as he crawls on the floor smeared with his own excrement; the wizened, emaciated bodies of those with multi-drug resistant TB; the crowd that masses each day at the outpatient department, some waiting 2 or 3 days before they are seen.
The hospital main entrance - the sign on the right proclaims the hospital "baby friendly".
I am spending my first week shadowing the doctors that are here already. Each morning begins with a 7:30 gathering in the medical director’s office. He is an enthusiastic South African Indian obstetrician. It is impossible not to like him. Each morning he gives a run down of the day’s hurdles: the hospital development is on hold – the 2010 Football World Cup has taken priority, all the boreholes have run dry – the hospital’s water is being bussed it each day so we will only have water at our accommodation for a couple of hours in the morning and evening, a new doctor is coming next month – but the accommodation is full at the moment. Some mornings everyone finds it funny, other mornings all that prevent us from hanging ourselves with our stethoscopes is the lack of readily available hooks. Things are looking good this morning however. I bring the number of doctors to 15, the highest for some years. Last August there were just 5.
I spend the morning with the doc covering T ward – the TB unit. At least 50% of people are infected with HIV in parts of this region and this has fuelled the TB epidemic. Only a handful of people of the TB ward are HIV-negative. Most people start TB therapy in outpatients. The ones that are admitted are those too sick to manage at home either because they come to hospital only when they are extremely weak, or because their treatment has failed (perhaps because they quit taking it, or because they have resistant organisms). Some come with complications of treatment or with other problems entirely, ending up on the ward because they are TB infected. Like an old UK fever ward , it is built right at the back of the hospital – well away from everyone else.
The TB ward
We do the ward round with one of the sisters. She translates for the patients of whom only a handful speak fluent English. This is a rural Zulu area. I learnt the basic Zulu greetings on a previous trip but otherwise I understand nothing. I pick up one phrase that keeps being repeated: “Kubuhlungu”, “I have a pain”. Several people have chest drains – pipes inserted into the chest cavity between the ribs in order to the drain the collections of pus that can form as a consequence of TB. One man drained 2 litres of the stuff after his drain was inserted yesterday. Another has had his drain for weeks. It stinks and the wound oozes continuously. But the drain must stay in – the TB damaged his lung badly and it would rapidly deflate without it. With every breath lightening flashes of pain flicker across his face as the drain rubs on his inner chest wall – we increase his morphine prescription. Three or four patients are fit enough for home now. They are discharged with firm instructions on the importance of adhering to their therapy. The increase in MDR (multi-drug resistant) TB has followed in the wake of poor adherence to standard treatment. Half way through the round a nurse brings the doc two sets of forms to complete – the death certificates from yesterday.
The outpatients department
After the round we go to OPD – the outpatients department. It serves as Casualty and non-urgent outpatients. There is no culture of booked appointments - the means of communicating with people is very limited and many do not have postal addresses. We double up in the cubicles, 2 doctors sharing each space, divided by a curtain and assisted by a nurse to translate and help with any procedure. The place is swarming with people. Each time the door opens for a patient to leave a hundred faces look in your direction and the next person leaps up. My first patient is a baby. There is no “Paediatric clinic” – we all do everything. His mother has brought him because he is not growing. She has brought the growth chart she was given when he was born. He is 9 months old and has not put on any weight since he was 3 months old – and has in fact lost 100g in the last 4 weeks. He is wizened and dehydrated and has not even the strength to cry as I examine him, issuing only a hoarse wheeze. “Why hasn’t the mother brought him sooner?” I ask the nurse. A brief discussion ensues between them. The nurse shakes his head.
“The journey here is too expensive.” A few more questions and it turns out the mother was found to be HIV positive in pregnancy. The baby has not yet been tested but will almost certainly be positive as well. I admit the baby and find the doctor who covers the paeds ward who gives me a brief tutorial on the management of marasmus (the classical name for this kind of malnutrition).
We are supposed to finish at 4:30pm - we started at 7:30 - but there are crowds of patients outside still and no one feels they can leave their on call colleague alone quite yet. We finish at 5:45pm and the doctor on call for the evening begins the task of moving through the queue to identify those patients who need to be seen tonight. That will keep him occupied until 1 or 2am. The others will have to wait until tomorrow.
The residences complete with palm tree feature.
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