In Sierra Leone

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

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.

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 s

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 p

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 dutiful

“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

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 s ervants – 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 how

“Ed – you must leave immediately!” I look up from the notes in which I am writing – it is Dr Ndlovu, the doctor from Thulasizwe. “But we are going at 3pm.” “No – it’s all changed. BB called me and asked me to come over. They can’t use government vehicles to take you back. Benedictine Hospital in Nongoma has closed and they are afraid that the strikers will block any vehicle with government plates.” “So what’s happening?” “Someone has agreed to take you in a private car – but they want to get back before dark. Go!” I find Hendy and we quickly pack. Our lift is from Adolph once again – but this time in his own Toyota Corolla. “I need the money,” he explains. We chat about the strike as we drive. I ask him about Mbheki. “Hey - he has lost the people. He has forgotten what it is like.” “But you are ANC?” I ask. He nods. “But here you cannot say that. This is the heart of Zululand. All these people,” he gestures to the huts we are passing on the road, “they are IFP [Inkhata Freedom Party].

“So do you think we can?” “I think so. Don’t you?” We have been talking like this for most of the day. Dr Kekana told us about a spa resort near the hospital which she went to last week. “You must go,” she said, “it is so nice!” We mentioned it to the manager’s secretary and she said she would arrange transport. However it kind of goes against the grain – leaving the site when you are supposed to be available. “It’s only 7km away – we can be back in 15 minutes if we need to.” I say. At 5pm a hospital 4WD rocks up outside the house. We climb in and set off. Our driver, Adolph, is a genial fellow who works in the Facilities department. As we chat it turns out he is not Zulu at all but Sotho, from Limpopo . He came to KZN some years ago for work. The spa is only a few minutes drive down the dirt track. We park and find the bar. It is a highly improbable set up – “luxury” accommodation and a restaurant nestled in a valley in this remote part of rural Zululand and full of elderly Afrikaane

“Did your patient make it to Empangeni?” Hendy asks. It is Wednesday morning and we are drinking coffee on the stoep in the morning sun. I was on call last night. Well, I say on call. OPD was empty by 6pm, we watched a DVD and I was not disturbed again. And to think I was reluctant to come here. “I think so,” I reply, “Why?” “Because mine got sent back?” “What?!” “The ambulance got to the hospital and the strikers turned it away.” Last Friday was the start of the first big general strike since South Africa went truly democratic. Government employees are striking over an unsatisfactory pay settlement. Hospitals, ours included, have been displaying big posters reminding people that hospital staff are considered "essential" employees (from nurses to cleaners) and are not permitted to strike. Ha! The cities were affected first and badly so. At the weekend we huddled around TVs watching the news run pictures of people being turned away by picketers outside all of Durban’s biggest

The sun is bright and the air cold as Hendy and I walk to the wards on Tuesday morning. We are, after all, approaching the depth of winter. We enter the central area of the hospital. Ceza is more compact than Hlabisa. It is an old mission hospital, founded in the late 40s. The lab, switchboard, offices and wards all open onto the same covered walkway. Hendy heads off to paeds, I head to the medical wards. Yesterday Dr Ndlovu, a physician at Thulasizwe TB hospital a few km down the road and in possession of the most dangly ear-rings I have ever seen, gave us a quick tour. The wards are only around a third full and it feels something of a ghost hospital – the word has been spread: there is no doctor at Ceza. Patients are going elsewhere. After our tour I dropped into the wards to introduce myself and ask if there were any problems – it had of course been 3 days since they were last seen. “No,” says Sister, “go home and rest. You can come tomorrow.” I walk onto female medical. Sister in-

I am woken with a jolt. The 4-wheel drive has left the tarmac and we are on dirt road. I look ahead into the hills – the road wends its way high up into the distance. “How far?” I ask Amos, our driver. “About 40km.” I settle back and watch as the settlements become less and less pseudo-bungalows and more and more mud rondavels. The road to Ceza It was about a month ago that our medical manager first mentioned that we had been asked to help out at Ceza Hospital – a remote rural hospital about 2 hours away. Its medical staff (only 8 at the best of times) had been steadily departing and only one remained. He was leaving at the end of May and they were desperate. Desperate enough to accept help from us. As I said – a month ago – but it was only last Thursday that I found myself agreeing to go. Two of the others had been that week. I phoned them to ask what it was like. “There are no words to describe it,” said Nomfundo, “speak to Dr Kekana.” Dr Kekana comes on the line and after humming an

We’ve been planning it for weeks: The iMfolozi Primitive trail; a guided walked through the Game Park, sleeping in the open, cooking over an open fire, taking turns to watch over the camp through the night in case of predators. I was so excited at the prospect I did not think to ask the price. I ask Olstein in the car on the way and nearly run off the road. I had no idea that this level of primitivity came at such a premium. Setting out We start rather late and our guides keep up a fierce pace. One of them, Samora, tells us he has 8 bullets – one for each of us if we cause any trouble. We look at him doubtfully. “Just joking,” he says. “Are you married?” someone asks him. “Oh no! I am 24 – I do not want to get married. I will get married when I am 30.” “That’s what I said when I was 24,” I mutter. The light begins to fail, they call a halt and declare the rock we are standing on by the river side the campsite. “Now, “ says Sinodi, the leader, “you must divide

The euphoria passes. Matron looks at me. "Hauw! Doctor! I did this at nursing school but not for years now! It is coming back to me but slowly!" And there is the problem: I have a paralysed, intubated teenager (see Brown Trouser jobs ). But our hospital has no ITU, no reliable ventilator and it is midnight – it will be several hours before a transfer is possible. As the girl begins to stir and cough on the tube unceremoniously thrust through her larynx I am also aware we have no intravenous infusion pump and I need to keep her unconscious somehow. I give her another injection of sedative – it will last 15 minutes. I pick up the phone and call our referral hospital. I finally find the doctor in charge of ITU. They have only 1 bed and do not want to take our patient. Try Durban . I try one of the big teaching hospitals. I speak to the ITU registrar. He asks a lot of questions and demands tests which we cannot perform here. I get a little angry and tell him not to b

“Doctor! Come quickly! This girl is having difficulty breathing.” I am in OPD and it is coming up to midnight. I have just been seeing a group of three babies with gastroenteritis. I keep getting them mixed up – they all look the same (despite what their mothers would claim), all have basically the same symptoms, and the nurses have put them all in the same cubicle. I follow the nurse’s voice. They are supporting a teenage girl who has an immensely swollen face and dragging her to the resus room. I had spotted her in the waiting area half an hour before and she looked fine then. They lie her on a trolley. “What happened?” The nurses translate for the mother. Apparently she was well earlier today but during dinner her face began to swell, her lips, and then her eyelids. I ask whether there were any new foods, or insect bites, or stings? No. None at all. Has this happened before? Yes, a couple of times a year ever since she was 6 years old. Can they think of anything that sets it off. No

“Do you have a girlfriend?” I ask. Sibu and Adolph have been not backward in suggesting individuals at the hospital that they believe would be suitable for me, a lippiness at odds with their insistence on calling me “Doctor” all the time. I therefore feel I have carte blanche to ask similarly invasive questions. They both look rueful. “The thing is, doctor, that the girls at university, they want a man with money.” “What do you mean?” “They want someone who can take them out to dinner. And not just once on the first date. They want someone who will take them out all the time. Someone who will buy them fancy things.” “But surely someone who really likes you does not worry about that kind of thing?” “You would think so – but they all compete for what their boyfriends get them.” “So no girlfriends this year?” “Not until the first pay cheque.”

"So what will you do with your first pay cheque when you start work?" Sibu, the final year med student, and I are walking through the car park at the doctors residences. I am eyeing the brand new BMW's, Mercedes and 4WD's. It seems that the first thing you do when you get a well paid job in South Africa is buy an enormous car on credit. Sibu sighs. The first thing I will do is build my parents a better house." "Where do they live?" "In a township outside Pietermaritzburg. It is a very small house. Four small rooms – they built it themselves." "Does your father have a job." "Sometimes – but they are very poor. I nearly had to leave medical school in the third year because they had no money. I did not get a bursary." This surprises me – he is bright fellow and on pushing admits he got 84% overall in his first year. "Why not?" "I do not know but I think it is because they give the bursaries to people from the ru