To paraphrase Renton in the opening monologue of Trainspotting "... the thing people forget (about taking heroin) is the pleasure of it, otherwise we wouldn't do it. After all we're not stupid, at least we're not that stupid".
Of course, I wouldn't equate the down-side of working here to the downside of taking heroin but I didn't realise quite how much fun some of it would be. I'm not talking about the windswept beaches and the rolling green hills this time but the work itself.
One factor is that if something needs doing then you have to do it yourself because usually there is no-one else who is going to help. This mean that if you honestly believe it is in the best interests of the patient for you to perform a procedure compared to it not being done at all then you should do it. This means attempting things that a physician like myself would usually have to pass on to a specialist. It's a bit like doing other peoples' homework, it is so much more fun than doing you own. I had forgotten how satisfying it can be to drain a really painful swollen abscess or relocate a dislocated joint. You have to be careful not to get too gung-ho but if you stick to the rules it can be really good fun.
Another factor is the huge variety of things to see. One day I'm going to make a list of all the things I see on a random weekend on-call. Chances are it will include being involved in delivering a baby or two, seeing a road accident victim, admitting a sick child, suturing a few stab wounds, draining an abscess and setting a fracture.
Perhaps I will write about the frustrations of working here another time because there are many. But for now I would just like to focus on one or two of the pleasures.
Monday 19 November 2007
Saturday 3 November 2007
Cross cultural medicine
You can't expect to move from a first world to a third world setting without crossing a cultural divide. Here are a couple of recent cases where I have had to be at my most understanging. (In the interest of confidentiality some details are changed)
I'm looking after a young man who is single handedly raising an 8 year old boy. He has HIV which is at an advanced stage. He helps out at the clinics and has had some formal training in HIV so he knows, or should know, that without the appropriate drugs he does not have long to live and that if he waits until he becomes sick it might be too late; even so he refuses to take the drugs. His reasoning is otherwise sound, at the moment he feels fine and looks quite well. He tried the drugs about a year ago when he was sick and also had TB. He had some side-effects and I think the time he decided to stop the drugs co-incided with him getting on top of his TB so all in all he felt a lot better off the medication than on it. While I can see his reasoning I also know that he will be dead soon leaving an orphan if he does not at least give it another go. I have sat with him and discussed all the options including stopping the drugs a second time if we can't get him through the side-effects but he is adamant that his strong faith will see him through. When it comes down to it I am not in the business of trying to force people to do anything they don't want to but I really can't help feeling dreadful for the son.
Slightly less sombre is a new phenomenon we have encountered. We test for HIV using a simple and cheap finger prick test that gives results in minutes, although very good these tests are not perfect. Although we feel that the benefits of this strategy outweigh the costs it is inevitable that occasionally people test as positive for HIV when they are actually negative. The problem is picked up a little further down stream when they have more conventional blood testing and it sometimes falls to me to tell people that after all they are in fact negative. You might expect that this is like telling someone who thought they had cancer that there was a mix up with the test results and they are all clear but the reaction of the patients so far has been far from what you might think. By this time the patients have joined an HIV support group with many members who talk openly about their status and help each other through. Although it can be difficult to get people to join the groups, once they are settled in they often really enjoy it. So these people who are in fact HIV negative don't want anyone else to know and are generally keen to keep attending support group without revealing their status. Maybe one day we will have a support group for people who thought they were positive but are in fact negative but don't want anyone to know!
I'm looking after a young man who is single handedly raising an 8 year old boy. He has HIV which is at an advanced stage. He helps out at the clinics and has had some formal training in HIV so he knows, or should know, that without the appropriate drugs he does not have long to live and that if he waits until he becomes sick it might be too late; even so he refuses to take the drugs. His reasoning is otherwise sound, at the moment he feels fine and looks quite well. He tried the drugs about a year ago when he was sick and also had TB. He had some side-effects and I think the time he decided to stop the drugs co-incided with him getting on top of his TB so all in all he felt a lot better off the medication than on it. While I can see his reasoning I also know that he will be dead soon leaving an orphan if he does not at least give it another go. I have sat with him and discussed all the options including stopping the drugs a second time if we can't get him through the side-effects but he is adamant that his strong faith will see him through. When it comes down to it I am not in the business of trying to force people to do anything they don't want to but I really can't help feeling dreadful for the son.
Slightly less sombre is a new phenomenon we have encountered. We test for HIV using a simple and cheap finger prick test that gives results in minutes, although very good these tests are not perfect. Although we feel that the benefits of this strategy outweigh the costs it is inevitable that occasionally people test as positive for HIV when they are actually negative. The problem is picked up a little further down stream when they have more conventional blood testing and it sometimes falls to me to tell people that after all they are in fact negative. You might expect that this is like telling someone who thought they had cancer that there was a mix up with the test results and they are all clear but the reaction of the patients so far has been far from what you might think. By this time the patients have joined an HIV support group with many members who talk openly about their status and help each other through. Although it can be difficult to get people to join the groups, once they are settled in they often really enjoy it. So these people who are in fact HIV negative don't want anyone else to know and are generally keen to keep attending support group without revealing their status. Maybe one day we will have a support group for people who thought they were positive but are in fact negative but don't want anyone to know!
Thursday 18 October 2007
Orphans and vulnerable children
I just wanted to say a little more about the work that is going on here. The hospital has recently started an Orphans and Vulnerable Children project. The name is fairly self-explanatory but in general it seeks to help children who have lost their parents (often this means losing their mother as many fathers are absent) or who are at risk of losing their parents (often because the mother has HIV). It is also for those children who have become heads of household and those who are not accessing eduction.
The project is backed by The Donald Woods Foundation. Some of you may remember Donald Woods as the white anti-apartheid activist portrayed in the film Cry Freedom. It is not a doctor focused project and in many ways not a medically focused project so I have only been involved in some of the planning stages. It runs on a kind of 'Soup Kitchen' model which means that rather than targeting individuals and visiting their homes there is one day set aside each week at a local clinic and the word is spread that any children who might fit the criteria should come along. They are assisted with transport as much as possible and are given food during the day. School children come along when school has finished.
The day is staffed by the programme co-ordinator along with two nurses, a physiotherapist and an occupational therapist each with an assistant, a social worker and various community health workers. The feedback I have had so far has been really great; the physiotherapy and occupational therapy team have done a great job with them. Thankfully not many of the children have been sick and none so far have tested positive for HIV. Many of the problems have been social, particularly that the carers of these children are not receiving the appropriate funding from the government. This is often because of a lack of documents or other red-tape. It has not been easy to solve these social problems but it is a learning curve for everyone and hopefully things will soon become a little easier.
The project is backed by The Donald Woods Foundation. Some of you may remember Donald Woods as the white anti-apartheid activist portrayed in the film Cry Freedom. It is not a doctor focused project and in many ways not a medically focused project so I have only been involved in some of the planning stages. It runs on a kind of 'Soup Kitchen' model which means that rather than targeting individuals and visiting their homes there is one day set aside each week at a local clinic and the word is spread that any children who might fit the criteria should come along. They are assisted with transport as much as possible and are given food during the day. School children come along when school has finished.
The day is staffed by the programme co-ordinator along with two nurses, a physiotherapist and an occupational therapist each with an assistant, a social worker and various community health workers. The feedback I have had so far has been really great; the physiotherapy and occupational therapy team have done a great job with them. Thankfully not many of the children have been sick and none so far have tested positive for HIV. Many of the problems have been social, particularly that the carers of these children are not receiving the appropriate funding from the government. This is often because of a lack of documents or other red-tape. It has not been easy to solve these social problems but it is a learning curve for everyone and hopefully things will soon become a little easier.
Friday 5 October 2007
About parenting.
I'm in no position to make judgements about parenting but I'd like to share a few observations from my time in the Transkei.
My idea of parenting is to plan a pregnancy, read all the books, go to the scans and the classes then attend the birth. Take the baby home to a freshly painted nursery and basically put a lot of time and effort into the process.
It is no surprise that the reality in the Transkei is quite different but I didn't expect it to be this different. Firstly, girls tend to get pregnant very young and they are getting younger. Fourteen seems to be common and it is unusual not to have a child by twenty. There is some debate about why teenage pregnancy is on the increase, some say that the girls need to prove their fertility before a man will marry them, others that the girls are after the social grant money that comes with having a child and others that girls are just growing up faster and having sex younger. To be honest I wouldn't like to say what the reason is but it is a worrying trend.
These girls are all unmarried and the interesting thing is that because of this the child belongs to her whole family rather than to her. This means that if she has two or three children and then gets married she doesn't take those children into her marriage, in fact she may not even count those children when you later ask her how many children she has had. Instead the children stay with the family which often means the wife of her eldest brother. Therefore if a woman marries a man with several disorganised sisters she might end up having to raise a whole group of children who are not even blood relatives.
I can imagine that most maternity wards in first world settings these days are full of pround men weilding video cameras and mobile phones. I've yet to see a man within 50 yards of our maternity ward (except the doctors and nurses). The area we use to care for the sick newborns is also much quieter that I would have thought. I don't think the women are uncaring for their infants, perhaps they just want to let the medical staff care for them until they are ready to be nursed by the mother but I seldom see them camped out beside the cot.
My idea of parenting is to plan a pregnancy, read all the books, go to the scans and the classes then attend the birth. Take the baby home to a freshly painted nursery and basically put a lot of time and effort into the process.
It is no surprise that the reality in the Transkei is quite different but I didn't expect it to be this different. Firstly, girls tend to get pregnant very young and they are getting younger. Fourteen seems to be common and it is unusual not to have a child by twenty. There is some debate about why teenage pregnancy is on the increase, some say that the girls need to prove their fertility before a man will marry them, others that the girls are after the social grant money that comes with having a child and others that girls are just growing up faster and having sex younger. To be honest I wouldn't like to say what the reason is but it is a worrying trend.
These girls are all unmarried and the interesting thing is that because of this the child belongs to her whole family rather than to her. This means that if she has two or three children and then gets married she doesn't take those children into her marriage, in fact she may not even count those children when you later ask her how many children she has had. Instead the children stay with the family which often means the wife of her eldest brother. Therefore if a woman marries a man with several disorganised sisters she might end up having to raise a whole group of children who are not even blood relatives.
I can imagine that most maternity wards in first world settings these days are full of pround men weilding video cameras and mobile phones. I've yet to see a man within 50 yards of our maternity ward (except the doctors and nurses). The area we use to care for the sick newborns is also much quieter that I would have thought. I don't think the women are uncaring for their infants, perhaps they just want to let the medical staff care for them until they are ready to be nursed by the mother but I seldom see them camped out beside the cot.
Wednesday 26 September 2007
About dying...
I always knew that coming to a place like this would mean looking after lots of people that ended up dying. It was therefore no surprise to find empty beds on a Monday morning where patients had been on Friday. What took longer to accept was that it was not my fault. It sounds strange perhaps but initially all this death left me wondering whether I should really be here and perhaps I was doing more harm than good. It has taken me a few months to come to terms with the fact that I am doing my best and that, although many people are dying, that is good enough.
From a medical point of view I have noticed a few key markers of likely demise. Getting oxygen on the general wards is a real mission usually involving you personnaly looking around the hospital for a tank with any gas left. Consequently you generally only tend to do that when a patient really needs it, so much so that so far not a single patient who I (or my TB colleagues) have got oxygen for has survived. The patients were the first to notice this and have given a name to the oxygen tank which is 'the big black man that brings the death'.
I use the word death and dying freely here but not with the Xhosa people. I quickly noticed that the word for death was never used and in it's place were euphamisms like 'rested in peace' and 'she has left us'. It's not that people are afraid of death just that the word itself seems to be taboo.
From a medical point of view I have noticed a few key markers of likely demise. Getting oxygen on the general wards is a real mission usually involving you personnaly looking around the hospital for a tank with any gas left. Consequently you generally only tend to do that when a patient really needs it, so much so that so far not a single patient who I (or my TB colleagues) have got oxygen for has survived. The patients were the first to notice this and have given a name to the oxygen tank which is 'the big black man that brings the death'.
I use the word death and dying freely here but not with the Xhosa people. I quickly noticed that the word for death was never used and in it's place were euphamisms like 'rested in peace' and 'she has left us'. It's not that people are afraid of death just that the word itself seems to be taboo.
Sunday 9 September 2007
5 minutes if fame
Madwaleni hospital had a brief moment of fame recently although much of it was more of a farce than than a drama.
It was announced a few weeks prior to the event that a group of VIP's would be arriving. These were to include the health MEC for the province, this is a political appointment by the ANC similar to a provincial health minister. Once the announcement had been made the hospital suddenly went into overdrive to prepare for the occasion.
It is important to point out the context; the hospital suffers from a chronic lack of resources. There is frequently no water and no diesel for the generators when the power fails. Drugs are usually in good supply but it can be very difficult to get oxygen for a patient and there is frequently a lack of consumables and stationary.
So it was amazing to see what could be done when a VIP was expected. Suddenly there were small armies of men putting in flowers everywhere and laying concrete over previously muddy paths. A supply of new beds arrived ( although the old ones were perfectly good). New linen arrived for the beds and a supply of pink dressing gowns arrived for the patients. We were asked to remove the old bits of cloth we were using as make-shift curtains and so the list goes on.
On the big day the VIP's arrived by helicopter or 'e-balloon' as the patients called it. An excited entourage followed the group around and finally they were treated to a lavish lunch in a newly decorated dining room.
The effects of the day continue; all the new linen has had MDL inked into it in big black letter, there are now groups of male patients walking around in bright pink dressing gowns and there is a pile of old beds lying in a ditch outside the hospital.
I don't want to be too critical, after all many people were employed during the preparations and the hospital does look a lot nicer but perhaps next time there is some money available we could have some oxygen cylinders instead...
There are a few PHOTOS of the event here:
http://www.facebook.com/album.php?aid=14263&l=51e76&id=573386765
It was announced a few weeks prior to the event that a group of VIP's would be arriving. These were to include the health MEC for the province, this is a political appointment by the ANC similar to a provincial health minister. Once the announcement had been made the hospital suddenly went into overdrive to prepare for the occasion.
It is important to point out the context; the hospital suffers from a chronic lack of resources. There is frequently no water and no diesel for the generators when the power fails. Drugs are usually in good supply but it can be very difficult to get oxygen for a patient and there is frequently a lack of consumables and stationary.
So it was amazing to see what could be done when a VIP was expected. Suddenly there were small armies of men putting in flowers everywhere and laying concrete over previously muddy paths. A supply of new beds arrived ( although the old ones were perfectly good). New linen arrived for the beds and a supply of pink dressing gowns arrived for the patients. We were asked to remove the old bits of cloth we were using as make-shift curtains and so the list goes on.
On the big day the VIP's arrived by helicopter or 'e-balloon' as the patients called it. An excited entourage followed the group around and finally they were treated to a lavish lunch in a newly decorated dining room.
The effects of the day continue; all the new linen has had MDL inked into it in big black letter, there are now groups of male patients walking around in bright pink dressing gowns and there is a pile of old beds lying in a ditch outside the hospital.
I don't want to be too critical, after all many people were employed during the preparations and the hospital does look a lot nicer but perhaps next time there is some money available we could have some oxygen cylinders instead...
There are a few PHOTOS of the event here:
http://www.facebook.com/album.php?aid=14263&l=51e76&id=573386765
Saturday 25 August 2007
So what is the medicine really like?
Here is a mixed bag of some of the things I’ve seen since being here and there has been quite a range.
The oddest experience I think was seeing a man who had a painful bottom- he seemed reluctant to take his clothes off in front of my interpreter. I thought he was shy because she was a woman but it turned out that it was because he didn’t want her to see the pistol he had hidden in his coat. Mental note to self- don’t mess with the taxi drivers around here!
Another that sticks in the mind was a 14 year old girl I saw a few days later who was 8 months pregnant and had just found out she was HIV-positive. She just sat there in her school uniform sucking a lolly-pop as if nothing was the matter.
Unlike what you are told about South Africa there seems to be very little gun crime in the Transkei (the odd taxi driver excepted). Apparently most with a criminal tendency tend to move to the cities as they are not tolerated here. That’s not to say that there isn’t a constant stream of drunken men who have been fighting but they seem to stab each other instead and so far the consequences have not been too bad.
The same can’t be said for the roads which are lethal. Just before I arrived 17 school children were killed in a coach crash. On call a few weekends ago 6 (drunken) men were brought in after overturning their truck. One died at the scene another while we were treating him and another on the way to the referral hospital.
Had a typically African experience this week. We went to a peripheral clinic and there was a young man who needed to have his blood taken. The problem was that he was in the middle of his 4 week circucision school which is where the boys go off into the bush to learn how to become a man. As a result he was not allowed to see any married women at all so I went to take his blood in the security hut at the entrance to the health centre. When I got there I found this man crouching behind the door dressed only in a blanket covering his shoulder and a some leaves tied around the end of his penis. Under the blanket he was covered from head to toe in white clay. It was uneventful from then on but an interesting start to the clinic.
By the way there are plenty of PHOTOS on my facebook page just follow the links below
http://www.facebook.com/album.php?aid=11146&l=cf191&id=573386765
http://www.facebook.com/album.php?aid=5776&l=a3887&id=573386765
The oddest experience I think was seeing a man who had a painful bottom- he seemed reluctant to take his clothes off in front of my interpreter. I thought he was shy because she was a woman but it turned out that it was because he didn’t want her to see the pistol he had hidden in his coat. Mental note to self- don’t mess with the taxi drivers around here!
Another that sticks in the mind was a 14 year old girl I saw a few days later who was 8 months pregnant and had just found out she was HIV-positive. She just sat there in her school uniform sucking a lolly-pop as if nothing was the matter.
Unlike what you are told about South Africa there seems to be very little gun crime in the Transkei (the odd taxi driver excepted). Apparently most with a criminal tendency tend to move to the cities as they are not tolerated here. That’s not to say that there isn’t a constant stream of drunken men who have been fighting but they seem to stab each other instead and so far the consequences have not been too bad.
The same can’t be said for the roads which are lethal. Just before I arrived 17 school children were killed in a coach crash. On call a few weekends ago 6 (drunken) men were brought in after overturning their truck. One died at the scene another while we were treating him and another on the way to the referral hospital.
Had a typically African experience this week. We went to a peripheral clinic and there was a young man who needed to have his blood taken. The problem was that he was in the middle of his 4 week circucision school which is where the boys go off into the bush to learn how to become a man. As a result he was not allowed to see any married women at all so I went to take his blood in the security hut at the entrance to the health centre. When I got there I found this man crouching behind the door dressed only in a blanket covering his shoulder and a some leaves tied around the end of his penis. Under the blanket he was covered from head to toe in white clay. It was uneventful from then on but an interesting start to the clinic.
By the way there are plenty of PHOTOS on my facebook page just follow the links below
http://www.facebook.com/album.php?aid=11146&l=cf191&id=573386765
http://www.facebook.com/album.php?aid=5776&l=a3887&id=573386765
Tuesday 31 July 2007
Some medicine
As much fun as it has been learning about a new culture the main reason I came here was for the medicine. So far it has been mostly ups and a few downs- but the obvious place to start is with the HIV programme where I spend most of my time. The background as many people know is that there is an epidemic of HIV/AIDS in Southern Africa. The good news is that there is effective treatment for HIV and there is money available from various sources to pay for it. The challenge therefore is effectively distributing the drugs. The first challenge is for people to test for HIV and part of the programme is a ‘Voluntary Counselling and Testing ’ approach which uses various methods including attending public gatherings to encourage testing.
Once tested people can join the programme but of course this is also voluntary and not everyone joins. Once selected as needing the drugs the main problem is how to get people to take the medicines properly. Basically, people need to take tablets twice a day 12 hours apart every day and more than likely for the rest of their lives. If they take the tablets chaotically the HIV will become resistant to the drugs and will become difficult or impossible to treat and people will go back to square one. Patients with resistant HIV may also pass this to other people who themselves will be difficult to treat from the outset which would be a disaster. If you read the Daily Mail this would be like developing the ‘HIV super-bug’.
It is difficult for most people to finish a course of antibiotics let alone comply with these measures and in particular many of the patients are illiterate and have never used a clock or a calendar before. To address this problem the programme has formed a series of support groups; they are run by local people and involve a gathering, usually once a week, when they talk about and are educated about these issues and also get something to eat and drink. Anyone without a clock is given one, everyone has a treatment partner to help them and they are strongly encouraged to disclose their status to their family because keeping the drugs hidden from people in their tiny houses would only lead to chaotic drug taking.
The programme is exactly 2 year old, so far about 700 people have been put on medication and there are a further 700 who are on the programme but so far don’t need the drugs. There is no waiting list to start drugs and currently we are starting about 10 per week. This is scratching the surface of the problem but it is a good start. As you can gather it is a major undertaking and in some ways is more like a business than a hospital but there are no half measures. People are either taught how to take the drugs correctly and are supported so that they can continue to do so or we are wasting our time. So far the results have been really good, only a handful of people have been lost to follow-up and less than ten have developed resistant virus. The challenge ahead then is to sustain the early success and to allow the programme to grow without compromising on quality.
Once tested people can join the programme but of course this is also voluntary and not everyone joins. Once selected as needing the drugs the main problem is how to get people to take the medicines properly. Basically, people need to take tablets twice a day 12 hours apart every day and more than likely for the rest of their lives. If they take the tablets chaotically the HIV will become resistant to the drugs and will become difficult or impossible to treat and people will go back to square one. Patients with resistant HIV may also pass this to other people who themselves will be difficult to treat from the outset which would be a disaster. If you read the Daily Mail this would be like developing the ‘HIV super-bug’.
It is difficult for most people to finish a course of antibiotics let alone comply with these measures and in particular many of the patients are illiterate and have never used a clock or a calendar before. To address this problem the programme has formed a series of support groups; they are run by local people and involve a gathering, usually once a week, when they talk about and are educated about these issues and also get something to eat and drink. Anyone without a clock is given one, everyone has a treatment partner to help them and they are strongly encouraged to disclose their status to their family because keeping the drugs hidden from people in their tiny houses would only lead to chaotic drug taking.
The programme is exactly 2 year old, so far about 700 people have been put on medication and there are a further 700 who are on the programme but so far don’t need the drugs. There is no waiting list to start drugs and currently we are starting about 10 per week. This is scratching the surface of the problem but it is a good start. As you can gather it is a major undertaking and in some ways is more like a business than a hospital but there are no half measures. People are either taught how to take the drugs correctly and are supported so that they can continue to do so or we are wasting our time. So far the results have been really good, only a handful of people have been lost to follow-up and less than ten have developed resistant virus. The challenge ahead then is to sustain the early success and to allow the programme to grow without compromising on quality.
Wednesday 18 July 2007
More Xhosa culture
As much as I want to tell everyone about the medicine here I’m still learning so much about the Xhosa culture that I’d like to share some more.
It is currently the male circumcision season; at this time of year you see groups of young men parading down the streets carrying weapons such as knives and spears. It is all part of the preparation for their coming of age celebrations which involve a big party and a circumcision. After the party the new men burn all their clothes and wrapped in blankets with faces painted they leave to spend 3 weeks living in the bush with an elder. During that time they are taught all the skill needed to be a man in Xhosa culture, this includes hunting and even how to kill another man. At the end of the three weeks they can return to their village and dress in normal clothes and continue their life as a man.
The whole thing is interesting in itself but also has some medical implications. Firstly the tradition says that the same blade should be used on all the boys on a given day. In theory the rules have been tightened up in the HIV era but in practice this still goes on. As well as the risk of HIV transmission there is also a risk of wound infection. Apparently there is a whole ward full of men with circumcision infections at the referral hospital. Apparently they regularly come to our hospital but I’m yet to see one.
The other tradition I’ve learned about is Xhosa marriage; our social worker has just got married, she has had a legal marriage, a Xhosa marriage and is waiting to have a ‘White wedding’. Before the first marriage her fiancé had to negotiate with her family about how much ‘labola’ he was prepared to pay for her. The currency is ‘cows’ but for her one cow was equal to R1,500 (about £100), he eventually agreed to pay 17 cows! The traditional wedding involved her doing a lot of cleaning, making lots of tea for people and cooking a lot of food. She now has to wear a head scarf for a month as a sign of her marriage and most married women wear them lifelong.
If she has a baby it become a bit weird, she will have to bring the child directly to her mother-in-laws house and has to live behind the front door for a month just eating sleeping and feeding the child, her husband is allowed to visit but not to stay.
It is currently the male circumcision season; at this time of year you see groups of young men parading down the streets carrying weapons such as knives and spears. It is all part of the preparation for their coming of age celebrations which involve a big party and a circumcision. After the party the new men burn all their clothes and wrapped in blankets with faces painted they leave to spend 3 weeks living in the bush with an elder. During that time they are taught all the skill needed to be a man in Xhosa culture, this includes hunting and even how to kill another man. At the end of the three weeks they can return to their village and dress in normal clothes and continue their life as a man.
The whole thing is interesting in itself but also has some medical implications. Firstly the tradition says that the same blade should be used on all the boys on a given day. In theory the rules have been tightened up in the HIV era but in practice this still goes on. As well as the risk of HIV transmission there is also a risk of wound infection. Apparently there is a whole ward full of men with circumcision infections at the referral hospital. Apparently they regularly come to our hospital but I’m yet to see one.
The other tradition I’ve learned about is Xhosa marriage; our social worker has just got married, she has had a legal marriage, a Xhosa marriage and is waiting to have a ‘White wedding’. Before the first marriage her fiancé had to negotiate with her family about how much ‘labola’ he was prepared to pay for her. The currency is ‘cows’ but for her one cow was equal to R1,500 (about £100), he eventually agreed to pay 17 cows! The traditional wedding involved her doing a lot of cleaning, making lots of tea for people and cooking a lot of food. She now has to wear a head scarf for a month as a sign of her marriage and most married women wear them lifelong.
If she has a baby it become a bit weird, she will have to bring the child directly to her mother-in-laws house and has to live behind the front door for a month just eating sleeping and feeding the child, her husband is allowed to visit but not to stay.
Saturday 30 June 2007
Xhosa culture
I’ve been here a month now; I’m in my new house and have taken over my new ward. It has been a fascinating month and there is a lot to tell. I’d like to start with a word about Xhosa culture.
The most striking feature is the sense of community and willingness to share that the Xhosa show. It doesn’t seem to matter what their place is within a family, any money that someone has is always shared amongst the family. It is normal for a large family to be supported by a grandmother’s pension or someone else’s disability grant or a child support grant. It’s not as if the grants amount to much, maybe as little as £15 a month seems to be enough to keep quite a few people going.
The Xhosa seem to enjoy a party. We had a leaving do for one of the doctors this week and loads of people turned up and danced like no-one was watching, everyone seems to have rhythm (which makes the Brits stand out even more). Interestingly the party started at around 5pm and by 7:30 everyone had packed up and gone home. Also most of the men were drinking alcohol, but only the older women drink alcohol. I’m not sure why but I think it is not the done thing for young women to drink (which makes the Brits stand out even more).
Their society is clearly much closer to death than Western society and it isn’t perhaps surprising that people are more fatalistic about death. It is common for children to die at home without anyone making an effort to bring them to hospital and also fairly common for adults (often with advanced HIV) to refuse to come to hospital and die at home. That’s not to say that there is no mourning. When a married man dies his wife wears all blue or all black for a set period, it seems to vary for how long but can be a year. I haven’t seen any men dressed in black for a year though. The funeral is also a big deal and people save considerable sums to make sure that their family is able to provide a suitable feast when they die.
The strike is now officially over- I've no idea how many people died as a result but even one is too many. Hopefully we can move on now.....
The most striking feature is the sense of community and willingness to share that the Xhosa show. It doesn’t seem to matter what their place is within a family, any money that someone has is always shared amongst the family. It is normal for a large family to be supported by a grandmother’s pension or someone else’s disability grant or a child support grant. It’s not as if the grants amount to much, maybe as little as £15 a month seems to be enough to keep quite a few people going.
The Xhosa seem to enjoy a party. We had a leaving do for one of the doctors this week and loads of people turned up and danced like no-one was watching, everyone seems to have rhythm (which makes the Brits stand out even more). Interestingly the party started at around 5pm and by 7:30 everyone had packed up and gone home. Also most of the men were drinking alcohol, but only the older women drink alcohol. I’m not sure why but I think it is not the done thing for young women to drink (which makes the Brits stand out even more).
Their society is clearly much closer to death than Western society and it isn’t perhaps surprising that people are more fatalistic about death. It is common for children to die at home without anyone making an effort to bring them to hospital and also fairly common for adults (often with advanced HIV) to refuse to come to hospital and die at home. That’s not to say that there is no mourning. When a married man dies his wife wears all blue or all black for a set period, it seems to vary for how long but can be a year. I haven’t seen any men dressed in black for a year though. The funeral is also a big deal and people save considerable sums to make sure that their family is able to provide a suitable feast when they die.
The strike is now officially over- I've no idea how many people died as a result but even one is too many. Hopefully we can move on now.....
Friday 22 June 2007
On living here
Quite a few people have asked me what the living
conditions here are like. Basically they are pretty
comfortable and the social culture shock I was
anticipating has not really materialised. I've been in
temporary accommodation but am moving to my new home
next week. It's called a 'Park home' but in the UK we
would call it a 'Portacabin' or if it was by the sea
even a 'static caravan'. It has a hot shower and
toilet, a separate double bedroom, a fridge-freezer
cooker etc. You don't need central heating here.
There is not much around the hospital but there is a
shop for very basic things and a beer shop (called a
shabeen). The nearest place with a collection of shops
is 30km along a dirt road and it is a further 60km to
anything resembling a supermarket. If you plan well
however you can eat and drink very well.
Week nights are often spent socialising with the other
people living in the hospital compound, mainly
doctors, pharmacists etc. Some people have satellite
T.V. (not me) so it is possible to watch some of the
major sporting events as well. Weekends start at 1pm
on Friday so there is time to get away to the beach or
to a city whenever you are not on call.
Just an update on the strike- it seems to be getting
worse, everyone is spooked today because of a report
that a nurse was shot on her way to work quite near
here (no-one knows if it was related to the strike but
the rumours haven't helped). We are trying desparately
to get medication out to our HIV patients and those in
hospital are at least being fed and getting most
medications. Everything else is on hold though (a
woman gave birth unattended in a corridor yesterday
for example), the big hospitals we would refer on to
are not accepting any patiens at all. The end is not
even in sight at the moment and morale is generally
pretty low, again lets hope there is a resolution soon.
___________
conditions here are like. Basically they are pretty
comfortable and the social culture shock I was
anticipating has not really materialised. I've been in
temporary accommodation but am moving to my new home
next week. It's called a 'Park home' but in the UK we
would call it a 'Portacabin' or if it was by the sea
even a 'static caravan'. It has a hot shower and
toilet, a separate double bedroom, a fridge-freezer
cooker etc. You don't need central heating here.
There is not much around the hospital but there is a
shop for very basic things and a beer shop (called a
shabeen). The nearest place with a collection of shops
is 30km along a dirt road and it is a further 60km to
anything resembling a supermarket. If you plan well
however you can eat and drink very well.
Week nights are often spent socialising with the other
people living in the hospital compound, mainly
doctors, pharmacists etc. Some people have satellite
T.V. (not me) so it is possible to watch some of the
major sporting events as well. Weekends start at 1pm
on Friday so there is time to get away to the beach or
to a city whenever you are not on call.
Just an update on the strike- it seems to be getting
worse, everyone is spooked today because of a report
that a nurse was shot on her way to work quite near
here (no-one knows if it was related to the strike but
the rumours haven't helped). We are trying desparately
to get medication out to our HIV patients and those in
hospital are at least being fed and getting most
medications. Everything else is on hold though (a
woman gave birth unattended in a corridor yesterday
for example), the big hospitals we would refer on to
are not accepting any patiens at all. The end is not
even in sight at the moment and morale is generally
pretty low, again lets hope there is a resolution soon.
___________
Thursday 14 June 2007
More on the strike
I didn't want this blog to read like a diary but the general strike in South Africa is dominating everything at the moment. Mostly it has been a saddening experience but in some ways also quite interesting.
It is sad because of the impact it is having on peoples lives. Patients are afraid to come to hospital and nurses are afraid to go to work. One simple example is a woman who badly broke and dislocated her elbow five days ago. She tried twice to come to hospital but was chased away by militant strikers and finally she made it in yesterday. Normally she would be sent on to a larger hospital but that is completely out of action so she has to wait even longer. Basically somewhere in the country some people have died who would have survived if it were not for the strike.
It is little better for the staff, yesterday the nurses at one of our local clinics were beaten by strikers until they left their posts. It's not to say that many people don't support the strike because they do, they are asking for a 12% pay increase and they deserve it, but hopefully it will be resolved soon.
As for the interesting side, one of the South African doctors pointed out that militant strikes are actually a spill over from the Aparteid era. At that time the unions were one of the few places that black people had power. People didn't want to strike because if they did they were often fired and replaced with other people who needed the work. For that reason the unions used to use force to make sure people came out on strike.
It is sad because of the impact it is having on peoples lives. Patients are afraid to come to hospital and nurses are afraid to go to work. One simple example is a woman who badly broke and dislocated her elbow five days ago. She tried twice to come to hospital but was chased away by militant strikers and finally she made it in yesterday. Normally she would be sent on to a larger hospital but that is completely out of action so she has to wait even longer. Basically somewhere in the country some people have died who would have survived if it were not for the strike.
It is little better for the staff, yesterday the nurses at one of our local clinics were beaten by strikers until they left their posts. It's not to say that many people don't support the strike because they do, they are asking for a 12% pay increase and they deserve it, but hopefully it will be resolved soon.
As for the interesting side, one of the South African doctors pointed out that militant strikes are actually a spill over from the Aparteid era. At that time the unions were one of the few places that black people had power. People didn't want to strike because if they did they were often fired and replaced with other people who needed the work. For that reason the unions used to use force to make sure people came out on strike.
Tuesday 12 June 2007
The Xhosa language
I though you might like to know about the local language. The local tribe are called the Xhosa, it is a very big tribe with many millions people, similar in stature to the Zulus. Nelson Mandela is a Xhosa and was actually born and brought up close to here. If you were wondering how to pronounce Xhosa it's harder than you might think, the Xh is actually a click, a bit like the noise people make when they want a horse to go faster. To make things harder there are 3 different clicks to get your tongue around, ‘c’ is a bit like making a ‘tut’ and and ‘q’ is like the sound of a cork popping. The Guiness Book of Records even lists a Xhosa phrase as the most difficult tongue twister in the world, it includes the work for windpipe which is 'uquoquoquo'. As you can imagine I’m having all sorts of fun and games trying to incorporate this into my daily speech but at least people seem to appreciate it if you just give it a try. Not surprisingly I have to work with an interpreter all the time at the moment and probably will have to for the whole year. If you are accepted by people here they like to give you a Xhosa name, I’m hoping mine will have a click in it that I can show off when I get home.
Just a note on the strike, it is supposed to get worse tomorrow with the unions calling for a complete shut-down of the country. We have been promised a skeleton of staff for the hospital which I hope we will get. Understandably the nurses have been quite scared as working nurses in larger central hospitals have been physically abused but other strikers. Fingers crossed then…
Just a note on the strike, it is supposed to get worse tomorrow with the unions calling for a complete shut-down of the country. We have been promised a skeleton of staff for the hospital which I hope we will get. Understandably the nurses have been quite scared as working nurses in larger central hospitals have been physically abused but other strikers. Fingers crossed then…
Friday 8 June 2007
The toi-toi!
Toi-toi means picket in Xhosa and there is one on today. Basically the unions have called a strike and all the hospital staff are obliged to take part whether they want to or not. In fact the nurses are reluctant but they face a real threat of physical violence if they work. Flying pickets have been dispatched from nearby towns to enforce this and the police have been on site to prevent any trouble. There is a toi-toi which involves lots of singing and dancing happening outside the gates and this should be enough to satisfy any flying pickets.
From the doctors point of view we were asked to discharge as many patients as possible this morning and put others on weekend leave. Inevitably there are quite a few patients not well enough for this. I've had a look round the hospital and they are getting food and medicines but not much else. There are six of us (5 doctors and a pharmacist) also on site to try and deal with any emergencies.
It should all blow over by tomorrow when the strike finishes and if there are no dire emergencies the impact will not be too great and I don't think there is a real threat of violence at the moment but it has been a pretty interesting day!
From the doctors point of view we were asked to discharge as many patients as possible this morning and put others on weekend leave. Inevitably there are quite a few patients not well enough for this. I've had a look round the hospital and they are getting food and medicines but not much else. There are six of us (5 doctors and a pharmacist) also on site to try and deal with any emergencies.
It should all blow over by tomorrow when the strike finishes and if there are no dire emergencies the impact will not be too great and I don't think there is a real threat of violence at the moment but it has been a pretty interesting day!
Wednesday 6 June 2007
The people
So what are the patients of Madwaleni like? Well they are certainly very poor, the employment rate is less than 5%, apart from the hospital a few shops and a few schools it is not obvious where job opportunities would come from. There are government handouts to women with children under 14 and those with disabilities (including HIV) but there is not much money floating around. It can cost R20 to make a round trip to the hospital which is a big ask for many people so you have to think carefully about when and how often to follow up patients (although we can offer some financial help to some people for transport).
As there is generally not that much to do for people around here things move slowly! Patients seem fairly happy to be admitted for fairly long periods partly because it is warm and they are well fed when they are here. Food scarcity is definately a problem for some people and children are regularly admitted with malnutrition.
Most of the patients live in huts made from home-made bricks. Very few have electricity or running water so they collect rain water or drink river water. For some reason there is not culture of digging latrines so there are basically no toilets in many of the villages- apparently the dogs and pigs do the clearing up!
That's all for now- but basically I'm having a great time so far and I will post again soon about what I've been getting up to.
Tom
As there is generally not that much to do for people around here things move slowly! Patients seem fairly happy to be admitted for fairly long periods partly because it is warm and they are well fed when they are here. Food scarcity is definately a problem for some people and children are regularly admitted with malnutrition.
Most of the patients live in huts made from home-made bricks. Very few have electricity or running water so they collect rain water or drink river water. For some reason there is not culture of digging latrines so there are basically no toilets in many of the villages- apparently the dogs and pigs do the clearing up!
That's all for now- but basically I'm having a great time so far and I will post again soon about what I've been getting up to.
Tom
Saturday 2 June 2007
First impressions
So I've been here for 5 days now and these are my first impressions. As we drove from the airport to the hospital in the dark I noticed that there were no lights on in the houses beside the road. Then in the distance there was a group of lights which turned out to be the hospital, basically it is one of the few places in the area to have electricity and is also one of the major employers.
A few things happened that didn't surprise me; firstly I got a really warm welcome from everyone at the hospital, from the doctors, the nurses and all concerned. I went straight to clinic on the next morning and saw quite a few really sick people including children and babies. The hospital was very clean, although some of it is brand new and really nice other bits look very old and in need of some TLC. I have a huge amount to learn here- some of the medicine is different but all the processes are going to take a while to get used to. Everyone here seems to work really hard.
Perhaps more interesting are the things that did surprise me; firstly there were empty beds on the wards, quite a few of them, which I have never seen in the NHS. The other was that all the staff and some of the patients rely on mobile phones for communication, even if they have no electricity at home they charge the phones at work or another communal places and make very short phone calls to save money. Another was that the hospital has a tennis court- not in great condition but a tennis court none the less.
A few things happened that didn't surprise me; firstly I got a really warm welcome from everyone at the hospital, from the doctors, the nurses and all concerned. I went straight to clinic on the next morning and saw quite a few really sick people including children and babies. The hospital was very clean, although some of it is brand new and really nice other bits look very old and in need of some TLC. I have a huge amount to learn here- some of the medicine is different but all the processes are going to take a while to get used to. Everyone here seems to work really hard.
Perhaps more interesting are the things that did surprise me; firstly there were empty beds on the wards, quite a few of them, which I have never seen in the NHS. The other was that all the staff and some of the patients rely on mobile phones for communication, even if they have no electricity at home they charge the phones at work or another communal places and make very short phone calls to save money. Another was that the hospital has a tennis court- not in great condition but a tennis court none the less.
Thursday 24 May 2007
What is this all about?
I just wanted to write a simple blog to chronicle my time in South Africa. Mainly for any friends and family who might be interested. The details are that I'm going to a place called Madwaleni which is in the Eastern Cape (formerly the Transkei). I'll be working as a general purpose doctor in a rural hospital with about 200 beds. That means getting involved with paediatrics and obstetrics as well as adult medicine. My interest is HIV medicine and there should be plenty of that there to occupy me. I'm leaving in 3 days and am full of nervous excitement, I'm expecting to work hard under fairly difficult conditions but also to learn a great deal and basically really enjoy the adventure. Other than that I don't really know what to expect but I'll keep you posted....
Tuesday 22 May 2007
T minus 5 days
Due to set off for South Africa in 5 days time. Just saying goodbye to as many people as possible before I go. Getting very excited and also a little daunted by the thought of it. Sounds like it is going to be very hard work but also a beautiful place to live. Will keep you posted when things get started.....
Subscribe to:
Posts (Atom)
