In Sierra Leone

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.

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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 ...

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...