The season to be merry.....

I recently received a letter from a complete stranger who had been reading the older post of this blog and it has spurred me on to begin again. My time in the Transkei is drawing to a close so I will continue while I can.

Perhaps I will just start in the present. Christmas is not a pleasant time to be working in the Transkei. Traditionally, all the people who spend the year working away from home return for a month long break during December. The first consequence of this is that people who are supposed to still be working here think it is unfair that everyone else is having so much fun without them so the workers' attendence record which is poor at the best of times gets even worse making normal activity even more frustrating than usual.

But the itinerant workers bring back much more than just work apathy. You can understand that there is alot more sex, couples have been separated for 11 months and the enormous birth rates every September are testament to that (working in maternity in September is only slightly better than working in Emergency at Christmas- it is a blessing that human gestation is not 12 months long!). What has not to my knowledge been measured are the number of new HIV infections that occur at this time of year. It seems highly likely that a number of these married men have been infected with HIV whist working away (about 30% of gold miners are HIV +ve for example) and with the wives in no position to insist on condom use it seems highly probable that there will be quite a number of new infections amongst the women this Christmas and with the amount of casual sex likely to increases in proportion to the amount of alcohol consumed these will not be the only cases.

Easier to measure and only slightly less disturbing is the amount of violence that comes along at Christmas. The statistics are mind boggling to me- between the morning of 25th and lunchtime of 26th alone we saw 42 stabbings, one shooting, a rape and countless other assaults. Almost everyone involved (excluding the rape victim and the women beaten up by their husbands) was so drunk they could barely stand up. With two doctors on-call for 72hrs straight over Christmas we had to engage in some serious task shifting. We gave the nurses instructions to assess every stabbed patient and to call only for those seriously ill. The rest were to be wrapped in bandages until the morning. The next morning the place looked to me like a scene from a WWI field station. There were bodies littering every conceivable space with bloodstained bandages around limbs, heads and torsos, every patient had a drip in place which was usually hanging from a curtain rail or a nail in the wall. The nurses did a great job that night, nobody died and only a couple ended up being admitted to hospital. By lunchtime most of the patients had been sent home an the place made ready for the next night.

There will be many scars to heal but frustrating few other consequences, most will not report the event to police and even if they did the chance of a conviction is very slight. In all honesty it is hard to see these drunken men as victims, many who had wounds had probably inflicted wounds on others. It's almost as if entering a tavern and getting drunk at Christmas is tacit consent to a free-for-all in which one might get stabbed!

Perhaps next year the community leaders can become involved and their own style of community justice may be used to deters this behaviour but we can only hope.

Some updates

I've not written an entry for about 6 months. I think the reason is that I didn't think I had too much more to say, I think people get the point that living here is very different from living in the First World but at the risk of repetition I'd like to continue.

To begin with I'd like to give some feedback on some of my earlier posts. In November 2007 I wrote an entry about cross cultural medicine in which I told the story of a man with advanced HIV who was refusing to take medication because it had made him feel unwell when he had tried it (some details are changed in the interests of confidentiality). I have been following this man every month since then and as the persuasive approach had clearly not worked I tried to be more subtle. I tried just having normal friendly conversations for a couple of months and then perhaps just mention that I was still worried about him and leave it at that. Eventually after much bridge building he agreed to have a blood test to see how advanced the HIV had become. The answer was bad. His CD4 count, a measure of the strength of his immune system was 8, mine is 1000. Despite this and to my surprise he had remained remarkably well, I noticed some minor weight loss but not much more. At this point I felt one last persuasive effort couldn't make the situation any worse than it already was so we talked again about ARV's and even looked at pictures of his son together but he insisted that God would look after him and he didn't need my help.

Last week I was seriously considering writing the above paragraph and then finishing by saying how amazed I was that he was still so healthy after all this time and that I was somehow beginning to doubt myself. Then the day I had been expecting but dreading arrived. I was asked to see a patient who had presented with what sounded like a serious condition and I recognised the name immediately. There he was slumped in a chair unable to speak to me with a worried look on his face. I will omit the details but he is now admitted to hospital with a very serious condition which he is unlikely to survive. You never know what will happen and he might come back from the brink but chances are he will leave another orphaned child in the Transkei.

I'm searching for a lesson from this story but it has been played out so agonisingly slowly and with so much thought that I still won't know what do when it happens again as it surely will. Perhaps I should be comforted that spirituality will see him through to the end but once again I can only really think of the orphaned son.