Life of a doctor in the Transkei, South Africa

Whatever happened to......

2010-07-07T06:02:00.001-07:00

During my time at Madwaleni there seemed to be a constant stream of new initiatives to be set up and followed- many of which I covered in this blog. Now it is time to move on I would like to report on some of the successes and failures.

Microfinance group was my favourite initiative and thankfully kept going throughout the 3 years. In numerical terms the bank's capital is around R12000 (made up of kind donations), we have lent approximately R24000 and have around R11000 currently loaned out, ie total repayments of around R23000 over 3 years.

But microfinance became much less about numbers as time went on. The initial aim was to make lives happier by empowering a world of self determined income generation, but on many occasions I offered to shut down the scheme on the grounds that it just didn't seem to be making people happier. Nor did the figures suggest that huge amounts of money were being made. Despite all my best efforts there was a repeating cycle of borrowing money, making money, spending ALL the money and then paying back the loan from their very low stipends earned by working as 'volunteers' at the hospital. Despite this I never had any positive responses to my idea of shutting the whole thing down.

There may be several reasons for this. One is the meat and chocolate I sometimes provided at meetings, another is the thought that as long as people kept paying back they would be eligible for further loans (this is the experience of the Grameen bank). However, I wonder how much people just enjoyed being part of a club. Our monthly meetings were always jovial with a hat being passed around to collect money and people would routinely attended even if they had no money to repay. I probably should have just asked them but I think the team atmosphere was a draw.

So what happens next? I offered to find another outsider to take over running the group but instead they have opted to run it themselves from now on. My great friend Nomanono Maphosela has taken the lead. We have converted the Excel spreadsheet from my laptop to a paperbased system and they are on their own. I very much look forward to attending another 'meeting with meat' (the name for quarterly meetings where I supply the meat!) and seeing how they are getting on. I wouldn't be surprised if things have gone from strength to strength sine the meddling mlungu left town.

Wrapping things up

2010-05-23T10:12:00.000-07:00

My time at Madwaleni is rapidly drawing to a close but before I wrap up this blog for good I'd like to feed back on some of the previous stories.

November 3rd 2007 I wrote about a man with HIV I had been looking after who was refusing to take his drugs even though his was likely to die soon and add another orphan to the pile in the Transkei. He put his faith in God to save him and nothing I could say made any difference. Then on February 14th 2009 I updated the story to say that the day had finally arrived when he was admitted to hospital with an extremely serious condition that he was unlikely to survive. It was cryptococcal meningitis which is a fungal infection of the brain which in my experience less than half of people survive.

Perhaps I wouldn't have written this follow-up otherwise but I am surprised and happy to say that he is currently alive and well. We treated the meningitis and he agreed to go back on to anti-viral drugs. He has now been stable on them for more than a year and is even working in our clinic as a volunteer. The chances are good that he will live a long and healthy life from this point on and most likely see his grandchildren grow up.

Whilst I wouldn't say that he is completely converted to idea of anti-virals (he is already complaining about the side-effects) he is doing well and has taken the tablets well. I did ask him if I could at this stage reveal his identity on my blog and even post a picture but things have not moved on that far yet. Maybe he'll give permission if I come back in a couple of years

I used to be a doctor

2010-04-06T20:50:00.000-07:00

Two months ago the most senior doctor in the hospital (the clinical manager) left and I was asked to fill his role. This didn’t seem like such a problem as I had watched the job being done for a while and was keen on the extra autonomy so I could make changes to the hospital that I’d had in my mind. What I hadn’t quite factored in however was that in the last year the hospital manager and the manager in administration have also both left and are yet to be replaced. That’s 3 of the top 4 management jobs in the hospital currently vacant.

Filling those gaps are a senior nursing manager who is acting as hospital manager and me who acting as clinical manager. Both of us have been trying to fill in for our old posts, our new posts and somehow the other unfilled ones.

Whilst I previously spent 80% of my time seeing patients and 20% on administrative matters but the numbers are now reversed and this has been a rude awakening to the world of management and administration.

It means that when the water supply to the hospital has not been running for a few days (not an uncommon experience) we are the people the hospital staff turns to. No running water in a hospital is an emergency situation in my opinion and therefore requires pretty much undivided attention until the problem is solve. As a result I can spend a whole day driving around different sites in the antiquated water system, turning on pumps, turning off valves, hitting things with hammers and the like to try to get things going again. A trickle of water might be the result and then 2 days later we have to go through the whole process again.

Learning to be a plumber has been a breeze however compared to being a human resources manager. Something as seemingly simple as getting a staff member added to the national government payment computer can seem like trying to solve the Middle East conflict at times. There are endless phone calls, documents to be signed, faxed, and delivered by hand and when all that is done people are commonly paid at the wrong rate or 2 months late. I’ve already had 2 staff members threaten to leave as a result.

I thought after about 18 months at the hospital that I had learnt almost everything I was going to learn but once again I was wrong; the last 2 months have probably taught me as much about running a hospital as the first 2 months taught me about TB and HIV. In another 2 months time I will be leaving Madwaleni and these problems will be handed on. From a personal perspective I must say I’m relieved, I’m looking forward to being a doctor again.

Madwaleni can do it....

2010-02-21T00:49:00.000-08:00

The Transkei can be a frustratingly dirty place at times; I bought a 'coke' for a senior member of staff the other day and he had no qualms whatsoever about winding down the car window and throwing the empty can into the ungergrowth. I slammed on the brakes, reversed the car and asked him retrieve the can as if he were my child rather than my boss. Luckily he took it in good spirit and was actually embarassed by his actions but many other people see no problem whatsoever with this kind of behaviour.

The concepts of re-use and repair are part of Xhosa lifestyle but care for the beauty of the environment is not and recycling is a largely novel concept. You see re-use all the time, be it plastic shopping bags or bricks from broken down houses. There is also a culture of repair with many items of clothing being constantly mended until there seems to be more patching than original material. The cars on the roads and particularly their tyres are technically well beyound their usable time but people seem to keep them going. But at the same time people are very happy to discard anything which seems to have no further use or monetary value even if it causes a dreadful eyesore.

This is where the corney title of 'Madwaleni can do it' comes in. Drinking from cans has been faily unusual up to now but is on the increase and at the moment cans go the same ways as everything else with no percieved value- into a rubbish bin if you are lucky or to the side of the road if you are not. Cans in South Africa are mostly made of steel rather than aluminium and have a recycling value of approximately 2.5 cents per can (that's South African cents not US cents). It's not much and transport costs would essentially reduce the value below zero. However, staff frequently make trips to Durban in large and fairly empty cars which means transport at close to zero cost is feasible.

The trick now is to collect the cans efficiently. This is easier said than done when the value to the individual is so small and only a community effort will be worthwhile. My plan is to collect around 40,000 cans which would be worth R1,000 and be enough to buy something useful for the community like a small childrens playgound. So far my efforts have been lame and commical. Whenever I am near the rubbish bins outside the shops I sift through for the cans and show people the large empty water container that we have set aside for collection. Needless to say the site of the doctor going through the bins only makes people think we are even more crazy than they already thought. My next plan is to build some kind of 'tree' with magnets hanging from chains and somehow try to pursuade people that the thing you do with cans is not put them in the rubbish bins or discard them but acutually they need to be hung from the tree on a magnet. We can then collect them daily for safe storage. Wish me luck with that one but whatever happens we will have fun trying and we might even end up with a new swing and a see-saw for the kids in the end.

Comparison with Ethiopia

2010-01-20T10:53:00.000-08:00

I recently visited rural Ethiopia when attending a friend's wedding and realised that it was the first time I had travelled to socioeconomically deprived area since living in the Transkei. Prior to my time in South Africa I had been to various developing countries as a backpacker but I now see things in a different light having actually lived in similar areas.

The comparisons were obvious, lots of children running around with no shoes on and toddlers wearing nothing but a loose fitting T-shirt. Curiosity from most at the sight of white people carrying backpacks in the mountains with expensive looking sunglasses and cameras. There was great hospitality at the mountain camps and nothing seemed too much trouble for anyone.

However, it was the differences between rural Ethiopia and the Transkei that were eye opening. The most obvious difference was that during the day just about everyone seemed to be working. Most were farming the land or tending to animals, others were carrying huge loads in or out of the mountains and many of the children were 'looking after' their younger siblings. The other striking thing was the communal nature of the work. The fields of barley were far too big for a single family to work alone and often had numerous workers dotted around. It was clearly harvest time and we were told that families grouped together so that on a single day everyone would help a single family with a harvest and the next day they would all move on to help another family from within the group.

There are some very hard workers in the Transkei of course, mostly these are women who carry huge loads of wood to heat their home and cook and clean for large families. What you don't see though is the constant industry on the land, there are animals and some small maize fields but this is always kept within a family and is very small scale in comparison. There are often groups on men hanging around who seem to have little to occupy themselves and have very little interest in farming.

There must be many historical and cultural reasons for this of which I am not aware but I can't help thinking of two potentially destructive factors. Firstly the only prospect of work for most men in Transkei is to migrate to the mines in the north. This is really tough physical work and not for the faint hearted so I suspect that many of the hardworking men from the Transkei are actually absent and therefore the ones left behind tend to be the less committed workers.

The other factor is the supply of government grants. Many families are almost completely dependent on government grants, either for young children, for disability or old age pensions. I can't help thinking that before grants became available there must have been much more subsistence level farming going on in this very fertile land and that these days it is far easier to find a grant and buy a sack of maize meal than to grow it yourself. It would be a sad thing if true but it would be interesting to find out just how much farming practice has changed since the mass introduction of the grant system

The season to be merry.....

2009-12-27T09:22:00.000-08:00

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

2009-02-14T22:32:00.000-08:00

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.

Sanctity of marriage

2008-09-28T00:43:00.000-07:00

Yesterday I had the pleasure of delivering a healthy baby girl from a 14 year old mother. She looked completely bewildered as this child was handed to her, almost as if she hadn't realised what had been growing inside her these past 9 months. Teenage pregnancy is not an unusual occurance, in fact it might even be the norm in this area, and one of the reasons is illustrated by another patient of mine. She is a 26 year old who has been left infertile and childless following an ectopic pregnancy. She is absolutely distraught as you might expect any 26 year old to be. However, it is not just her yearning for a child that distresses her but also her yearning for a husband as in Xhosa culture she has little chance of finding a man without first proving her fertility. With such high unemployment her only realistic chances of an income are a husband working in the mines and child support grants which means her future is far from secure. The impact on the HIV epidemic of the need to prove fertility before marriage is plain to see. These young women are clearly having unprotected sex with casual partners with little thought for their own health.

If a woman manages to avoid HIV infection whilst proving her fertility the problem is not over. Choosing to marry brings many advantages but it also comes at a price as she will be entering into a very unequal partnership. Put simply, most Xhosa men are very reluctant to use condoms and women do not have enough bargaining power within their marriage either to insist on their use or to persuade the husband to have an HIV test in the first place. Add to that the very high prevalence of HIV in men who spend most of their time woring away at the mines and this puts married women in a very dangerous position.

If a woman passes the fertility test without being infected with HIV she is actually in a much safer position should she choose to remain unmarried. Not only has she proven her fertility but because she is unmarried she is in a much stronger bargaining position when it comes to condom use. She is much more likely to be able to refuse sex if the man will not use a condom and as such unmarried women are in a better position to protect themselves from HIV than married ones.

Whether many women think of this dilemma when considering marriage I'm not sure but I do see many unmarried women with children who seem to have put aside the idea of marriage as they have become a little older and wiser. For these women the chance to build a future through education and training seems to me to be of the upmost importance and is one of the reasons I'm so keen on the idea of microfinance in this area.

On a lighter note.....

2008-09-07T10:23:00.000-07:00

Way back at the very beginning of my time in the Transkei I landed at the airport and was picked up by a driver from the hospital called Mabena. His English, while better than my Xhosa, was not great but we managed to pass the time during the journey with a conversation based largely on the words Liverpool, Steven Gerrard, FA cup and Premiership. I boasted of my time as a goalkeeper for my college while he told me that he was captain of his team and promised to give me a try out. Ever since then I have been known to Mabena as 'my goalkeeper' and he has been known to me a 'my captain' although despite my constant nagging the try out has yet to happen.

Luckily for me the hospital has recently formed a team and as the tallest guy around and quite frankly the only one who showed any interest I was a shoe-in for the number 1 shirt. Practices have largely consisted of 5-a-side games on a tennis court with no goalkeepers so I was a complete unknown when we had our first game recently.

The day of the game started with few surprises. Firstly, our captain had his first beer will before the scheduled meeting time of 10am. Secondly, the actual meeting time turned out to be about 12 o'clock and after driving half an hour to the pitch I was told that the opposition had not yet set off and were 2 hours away. So no great surprise then that the game kicked off about 4 hours late. What was more surprising was that each team had a full set of clean kit, the goals had nets, there was a ref with a whistle and two linesmen complete with football socks tied around stick for their flags.

The game itself was a scrappy affair on a dusty and uneven surface and as full-time approached with the score was locked at 2-2. The full-time whistle blew and no-one was satisfied so it was decided to play extra-time. By this stage the opposition were passing beer bottles between them as they played so I felt we had a chance. It was deep in the second period when a looping shot came in and with half an eye on bowling it out for one last counter-attack it slipped through my hands and trickled over the line. Gutted wasn't the word. I sheepishly returned the ball to the centre circle but the final whistle blew shortly after. I apologised to my team mates as we sauntered off but within five minutes it seemed to have all been forgotten. The focus turned almost immediately to the pub and how we were going to beat them in the pool competition later anyway. It's comforting to know that whether in Africa or Anfield some things never change.

The difference a decade makes

2008-08-15T12:38:00.000-07:00

The 17th March 1995 was a Friday. In the UK it was ‘Red Nose Day’ and it was the day one of the Kray twins died. These facts are etched in my memory because it was the day I stuck an HIV contaminated needle into my finger. I remember almost everything about that day from the feeling of horror at the first sight of blood on my finger to the look on the face of my girlfriend when I told her later that evening. It was a Wednesday three months later when the consultant told me that the HIV test was negative. The details are a blur but I can still remember the sleepless night beforehand and the feeling of utter relief at the news.

It was only a week ago but already I’ve forgotten the date. Sixty patients had finished collecting a month’s supply of anti-retrovirals at the isolated rural clinic when a staff member saw her chance to grab a quiet word. She said she knew deep down that she had HIV and neither of us was surprised when the point of care test result was positive. It was at that moment that the needle slipped in my hand and stuck into my finger. As I had done more than a decade before I squeezed blood from my finger but my reaction couldn’t have been more different. With no occupational health service within 100 miles and a recent negative HIV test under my belt I simply put into action the plan I had rehearsed for this moment. I walked calmly to the pharmacy assistant and asked for a dose of anti-retrovirals. I then just returned to the newly diagnosed woman to offer her post-test counselling. I had no worries for the remainder of the day except the wave of medication-induced nausea that swept over me later that evening.

The important difference between the two events of course is the availability of anti-retrovirals. In 1995 I had yet to enter medical school and to many people, including myself, HIV infection meant an automatic death sentence. The knowledge that the chance of infection was only around 1 in 300 did nothing to alleviate the terror I felt. The image of Tom Hanks wasting away in the film Philadelphia was only too real to me as I was working as the phlebotomist on a ward where I regularly witnessed people in the last stages of AIDS. I had no idea, I’m not even sure if the experts new, what was on the horizon.

The figures are debatable but my chances of being infected this time are probably less than my yearly risk of dying in a car crash in South Africa. I also feel comfortable that should the worst happen I could still at least look forward to watching my own grandchildren grow up at the end of a productive life. With the rollout of anti-retrovirals gathering pace, at last many South Africans with HIV can expect the same. The hope is that should I be writing a similar post in a decade’s time the big news will be of the huge increase in the numbers accessing treatment rather than the fact that effective treatment exists at all.

Staffing issues

2008-07-30T12:38:00.000-07:00

Before coming to Afica I was troubled by this point. If I was prepared to donate 6 months of my time to the cause then how should it best be spent when looked at from the point of view of the patients. In short, should I go to Africa and do the work there or alternatively should I stay in the UK, live in a tent in field whilst working extra hours in a UK hospital but sending all the money to someone I trusted in Africa. The thinking was that although the former would be something I would prefer to do for myself perhaps the potential receipients of my 6 months labour would prefer the latter and maybe that was what I should actually do.

While it hasn't taken me all year to work this out I now realise that without a shaddow of doubt the right thing to do is to come and do the work here. As I have eluded to before in these posts it is the shortage of human rather than financial resources that is the biggest problem most of the time.

I'm therefore left wondering if there shouldn't be a shift in thinking regarding the financial needs of hospitals like ours. I will stick to the doctor situation for now although the same could be applied to most other groups. There are 8 doctors working here of whom 5 are foreign, 1 is here as a part of compulsary service and only 2 are South Africans who are here by clear choice. There are 140,000 patients under our care and we are in the middle of an HIV/TB pandemic so the ratios are in no-ones favour. The bottom line is that rural African hospitals can't rely on do-gooder foreign doctors like me in the long-term . I'm personnally very happy with the terms and conditions here (except the lack of hot water!) but I'm not talking about me. For sure a limited amount could be done by tightening compulsary service rules for South African doctors but the reality is that large numbers of staff will only want to come here if the living conditions are excellent and to put it bluntly the salaries are very high.

Significant funds have indeed been chanelled towards improving staff living standards but I can imagine that it would be extremely controversial to direct extra resources towards higher salaries. What I would say is 'look at it from the patients' perpective'- would they rather have a bunch of extra doctors and nurses and rehab. staff etc. or more expensive pieces of equipment that no-one knows how to use or get fixed when they are broken? I think the answer is clear but I suspect the change is very unlikely to happen. Perhaps I should go back to the UK and live in my tent and use the money to fund extra salaries after all!

Cleaner hospitals

2008-07-19T06:41:00.000-07:00

Before I left the UK I remember that 'Cleaner Hospitals' had become a new political catch phrase, along with 'tougher on crime' and 'small class sizes' etc. I also remember when the previous government privatised hospital cleaning in the UK. As I recall they basically sacked all the cleaners on Friday and by Monday same people were hired by the new cleaning companies but were paid less money, it was one of those great advertisements for the motivational attributes of the open market.

Well, the Eastern Cape government can now claim to be ahead of the UK government on both counts. Until recently the hospital was cleaned by a group of generally older women who mopped the floors with various degrees of enthusiasm and kept it reasonably clean. However, someone somewhere decided to contract out the hospital cleaning to a private firm. So one day a whole new army of cleaning staff clad in heavy grey uniforms weilding yellow signs with flashing lights on top started patrolling the corridors. There are so many of them that it can be an obstacle course getting from one ward to another but the place is looking pretty spick and span. I don't think people have to worry too much about hospital super-bugs around here anymore- so one up for the Eastern Cape.

The killer move however is that instead of sacking the old ladies or making them carry yellow signs with flashing lights they just continued to employ them. They have been farmed out to some of the peripheral wards in droves, they now seem to have even more time for gossip and seem to be loving it. This means that since privatisation we effectively now have two complete teams of hospital cleaners working on the same hospital at the same time and no-one has been sacked or had their pay cut. Now why didn't the UK government think of that?

Learned helplessness

2008-06-29T09:13:00.000-07:00

If you seperate a predatory fish from some prey fish with some clear perspex the fish will initially keep knocking into the perspex to try to get to the food, after a while it will give up trying and just swim around and ignore them. The interesting part is that if you remove the perspex the predatory fish will continue to ignore the prey and will not make further attempts to catch them, this effect is so extreme that the predatory fish will actually die of starvation before it tries again to catch the prey again- hence the fish has learned helplessness.

Life in the Transkei can sometimes feel like the life of the predatory fish. For example I've developed learned helplessness towards accessing various tests for my patients. I have tried hard to access CT scans through the government hospital but have had virtually no success and had essentially given up.

What I've learned is that just as in the fish story it is a dangerous mindset to slip into because you just never know when the perspex has been lifted. It often takes the fresh approach of a new member of staff to spur you into action and in my experience you can get some great results when this happens. For example, I've recently learned by chance of a new approach to the CT scan problem that may well work and it has spurred me on to revisit some other obstacles that I had previously abandoned.

Bumblebees

2008-06-17T10:53:00.000-07:00

I remember learning that while most animals behave to get as much done for a given amount of energy expenditure (maximise benefit/energy cost) this isn't true of bumblebees. They behave in such a way as to get the most done per unit time (maximise benefit/time cost). This is because after a determined length of time they essentially 'wear-out' and die. I've noticed something similar in human resource poor medicine which I wanted to share.

In high human resource settings doctors are generally encouraged to make decisions based on health cost vs benefits. Prescribe a certain drug to enough patients and the adverse side-effects will be out-weighed by the improved quality and quantity of life (health benefits > health costs). When human resources become limited the doctor is often faced with a different question. Is it worth me spending a certain amount of time on an intervention for a given benefit to the patients (maximise health benefit / unit of doctor time). There are a whole bunch of initiatives I would like to start including aspects of preventative medicine and intensive care of the critically ill. The question is not whether there is a cost vs benefit advantage to the patients but given that time is very limited, which of these interventions should I choose to do at the expense of the others. Basically you need to have a much greater understanding of how much something works and not just that it works at all. Financial resources must be considered in both settings but where I'm working financial cost comes into it less than you might think.

I have something else in common with the bumblebee because the only other thing I remember learning about bumblebees is that according to the laws of aerodynamics it is impossible for them to fly!

The similarities

2008-06-03T11:41:00.000-07:00

It is easy to get caught up in all the differences and oddities you are likely to encounter when you move to a new culture. What I hadn't given a thought to were all the similarities that I would find. Steven Pinker talks about the fact that in all cultures people tell stories, recite peotry, sing, dance, decorate surfaces and perform rituals but isn't it the differences in the stories and the rituals that people generally find interesting in other cultures?

What I'm talking about are the things that appear to be all but identical. I'm not surprised that young men love football and drink as much beer as they can afford but it's easy to forget, when people appear engrossed in a daily struggle to survive and bring up children, that there is always time for gossip for example. The old women standing beside the road may have no shoes and smoke long wooden pipes but if you eavesdropped I'm absolutely sure you would hear the same conversation that could be heard the world over about who doesn't keep their house clean and who's husband has run off with a younger model.

The way women look after their children also seems so similar to me. The absolute amount of money floating around might be different but children still nag for a few cents for sweets and mothers still seem to resist for a while but eventually give way for 'a bit of peace and quiet'. Flirting is another thing. A bit of harmless flirting with slightly older nurses seems to get you just as far on the wards here as it does in the UK.

It's the little differences

2008-05-03T00:10:00.000-07:00

When you move to a place like the Transkei it is pretty obvious that you are going to encounter areas where your own culture is at odds with the local culture. After all it’s one of the reasons for visiting a different culture in the first place. What is interesting then is not that you find differences at all but exactly which things are different and also which things are surprisingly similar.

The latest difference I have encountered is in the attitude to exercise. My naïve view of Africa, based on the seemingly endless supply of talented distance runners from East Africa, was of children running 10km to and from school every day and perhaps a few talented adults out on the roads training. I couldn’t have been more wrong.

I go running after work often wired up to an iPod and sometimes with a head torch, thankfully no-one can see that I also have a chest strap under my shirt measuring my heart rate. To begin with I quite enjoyed the small trail of children joining me on the roads. However, the only things I notice now are the old women who, when they spot me coming, start jogging in a caricature of accentuated strides, swinging arms and a mocking giggle. Worse are the groups of young women who simply burst into fits of laughter as I go by.

When you think about it for a minute of course it’s a completely crazy pastime. They all know that I have a car and a housekeeper and could quite easily sit on my veranda sipping cool beer after work. Instead I choose change my clothes and then to run off in a seemingly random direction only to turn around at an arbitrary point and run all the way back, sometimes I do all this in the rain and the pitch dark. I don’t actually go anywhere useful, meet anyone or collect anything. I just get tired, hot and sweaty for no obvious reason at all.

Worse than running is cycling, sometimes I take a bike to a peripheral clinic and rather than drive home in a nice comfortable 4x4 I put on a yellow helmet and some strange shoes and huff and puff my way home on a bicycle instead. To someone who would walk 10km because they don't have a few Rand for public transport this clearly seems like a crazy decision.

If they knew that one of the reasons I did all this was actually to lose weight it would be the last straw. In this area you can reliably predict the income of an individual by measuring around their waist and most people spend more than half or their income on food the idea of deliberately losing weight remains completely foreign. I can't wait to tell them about those crazy foreigners who eat as much as they can only to then pay a doctor to suck all the fat out of their belly so they can start eating again.

Frustrations

2008-04-13T00:53:00.000-07:00

Up until now I've tried to resist writing anything too negative so I'll try to get it all out in one go. I think the worst frustration is that although there is often money available it often gets spent in ridiculous ways. There are so many expensive pieces of equipment lying around that either no-one knows how to use or are not working and no-one knows how to fix them but when you want something simple and cheap it is not available. For example, someone recently installed a very expensive state of the art piece of anaesthetic equipment in our operating theatre, it must have cost £10,000, yet we have no trained anaesthetist and no specialist surgeon with little hope of either arriving soon. Just recently the head of maternity services spent her budget on an enormous desk and comfy chair that are sitting in her office (I think the chair gets more use than the desk); this is in a department that often has inadequate resuscitation equipment for sick newborn babies. It feels like living in dictatorship when the despot spends the last of the foreign currency on fighter jets rather than grain.

I thought that because South Africa is a middle income country it might be spared some of the corruption found in other African states. However, even in the medical profession there are many stories of doctors who claim full salaries from the government but spend less than half of their time working in the public hosptials and the rest of it working in private practice.

I must balance these frustrations with some of the freedoms that working in this environment gives you compared to working in a First World setting. Paperwork for doctors is generally kept to the minimum required to deliver effective care rather than the excessive amounts required to stand up in court, and similarly it is not necessary to over investigate healthy people for reasons of avoiding litigation rather than because it is what they really need. The bottom line is that wherever you work there will be frustrations, when you move from the Developed to the Developing World you really just swap one set of frustrations for another.

About altruism

2008-03-26T11:39:00.000-07:00

Some people have suggested to me that it is altruistic to leave the UK and come to work in a remote rural setting but in my view this could not be further from the truth. Altruism is when you behave towards someone in a way that is harmful to yourself while being beneficial to the other person. Being run over by a car in the act of saving a complete strangers life would be an extreme example. Such acts are pretty rare and when it comes to choosing a job or a way of life they are completely unsustainable. If the people who came to work here were true altrusits they wouldn't last more than a few months, the only way to stay for a long time is to enjoy it.

It has occured to me that if I wanted to be altrustic I would move back to the UK, live in a tent, work 120 hours a week probably in some private hospital somewhere and send all the money out her to be spent for the benefit of the community by someone I trust. Maybe I am overerestimating what that money could do or underestimating what I am actually doing here but it is possible that this choice would be of more benefit to the community.

Just because I'm not an altruists doesn't mean that I think this is any old job. Nobody's perfect and I don't mind admitting that I can feel a little pleased with myself when people ask me what I'm up to. I wish it wasn't so but I can't help it. Nor does it mean that I haven't made sacrifices, a clean hot shower would be real luxury at the moment for example, but hasn't everyone had to make sacrifices along the way.

It also doesn't mean that I think this is the most important thing in the world either. I honestly beleive that a group of motivated teachers, businessmen or water engineers could have a huge impact on this community that would probably far outstrip the benefits that can be acheived by improving healthcare. All I'm saying is that when it comes to leaving the world in a better place than you found it it certainly beats marketing cigarettes to children or writing computer viruses for a living.

The meme pool

2008-03-08T02:32:00.000-08:00

Something that has struck me about the HIV/AIDS epidemic in the Transkei is the effect it must be having on the meme pool. A meme is a unit of cultural information such as an idea of practice that is transmitted from one generation to the next either verbally of by repeated action. An example might be a child noticing that her father always unplugs the television before he goes to bed, she copies this behaviour when she gets older, not because her father's genes have influenced her or because she has learnt that unplugging the television is important but because she is copying her father. This is a form of non-genetic inheritance which has some important differences to genetic inheritance. Firstly memes can be passed between individuals or group that are not genetically related such as between groups of friends and unlike genes, memes do not necessarily have to be beneficially to the individual to be propagated, like computer viruses they just need to be good at replicating.

In the Transkei approximately 20% of adults are infected with HIV and without treatment the majority will have died in 10 years. Assuming they are infected around age 20 and become sick some time before they die that means that many of the years that they could potentially spend propagating their memes will be lost. Remember that you don't have to be in your reproductive years to propagate a meme, you just have to be someone that people copy.

With our current level of knowledge about HIV there is only one way to avoid this once you are infected. You must possess the memes 'willing to accept HIV status', 'willing to join an HIV support group' and 'diligent pill taker for the rest of my life'. Although I wouldn't exclude genetic influences on these behaviours they might well be described as memes.

At the moment it seems clear that these memes are more likely to be present in the female popultion who often thrive on the support group environment and seem much more organised about taking medicines than men. Although this is of course a generlisation it seems likely to me that unless there are radical changes to the way we treat and prevent HIV, the popultion meme pool will shift towards acceptance of HIV status and disciplined pill taking as anyone not possessing these meme will die and have less opportunity to pass on their own memes to people around them.

Similar arguements could be made about the way people are infected with HIV in the first place. The meme 'only have unprotected sex with someone who you know (or are very confident) is HIV negative' would spread very successfully if it was readily copied by the group. The meme 'always use condoms when having sex' would also pass to the next generation, interestingly this would be at the expense of the genes as anyone who always used a condom would not be passing their own genes to the next generation.

There are of course many generalisations and simplifications to my arguement, including the interaction of memes with genes, although I would expect the gene pool to be altered in a similar way to the meme pool. Also as I said earlier these memes won't propagate simply because they are beneficial to the individual but given that not possessing them results in your early, death deleterious memes would have little time to propagate. Presumably there are experts in memetics out there studying these effects but if not I think it would make a fascinating study of non-genetic natural selection at work.

NGO's

2008-02-15T07:16:00.000-08:00

I am sorry to post what amounts to a 'rant' but it's been that kind of week. NGO's (Non Governmental Organisations) often get a bad press for reasons ranging from disorganisation to culturally inappropriate interventions that have little long-term impact. However, as a rule I would be quick to congratulate most NGO's for the undoubted good work that they do, in fact I am currently employed by an NGO although I work in a public sector role.

This weeks however I have seen first hand the negative impact that well meaning interventions can have. An NGO has moved into our area in an attempt to improve one of the patient services (I would rather not identify them on the internet so have omitted the exact details). That is a great idea and we are keen to form a partnership with them to improve these vital services. We even presented their job opportunities to our own staff and encouraged them to interview. The NGO is paying triple the wages that we can pay and are working in the same field so there should be no problem. However, the NGO has not been organised enough to actually find any work for the new staff to do. The result is that they are sitting around being bored while earning triple their old salary. Of course they are still friends with our current staff who, not surpisingly, now all want to go and work for an NGO. So at a stroke they have spent a great deal of money, they have reduced the quality of care for the patients by recruiting our staff who now do no work and they have managed to demotivate all of our remaining staff- thanks alot. Even worse if they don't get their act together and produce results soon their own funding will be withdrawn and all their staff will be out of work- great.

My own view is that the world has enough NGO's now. I think that anyone wishing to found a new NGO should think very carefully about their own motives as I'm convinced that a talented motivated individual could have a much bigger impact on the world by re-organising an existing organisations than going to the trouble of setting up a brand new one.

Milestone

2008-02-06T10:02:00.000-08:00

At the risk of patting ourselves on the back we are pleased to announce that we put our 1000th patient on ARV's last month. There was some debate, or perhaps arguement, about which exact patient was the thousandth, at least three people were told that it was them. Perhaps it is like being the one billionth person in India or China, it's best just to pick someone at about the right time and go with it. As my personal contribution was small compared to the collective effort I think I can say that it was pretty fantastic to get there. There has never been a waiting list to start so it represents everyone in the area who is tested for HIV, who needs the drugs and most importantly has committed to take them lifelong.

One thing that struck me the other day was the strengh of the link you have with the patient. If as a doctor you spend your life handing out pills for high blood pressure you have to treat quite a few people for quite a long time to prevent one of them having a heart attack. That means that you never actually know which of the patients is still alive as a result. With HIV medication it is different, when I talk to a guy who had 'full blown AIDS' 2 years ago but now leads a normal life I can be as certain as a doctor ever can be that he is alive because of the drugs. Many branches of medicine can say the same of course, any surgeon who removes a malignant cancer at an early stage for example, but it is not something I have experienced that often and it's a good feeling.

About being rich...

2008-01-20T09:07:00.001-08:00

Since I started earning a doctor's salary I've never been short of money, but neither have I ever felt truely rich. By that I mean that I have always found it hard to undestand how someone could spent £1,000 on a pair of sunglasses or £2,000 for a night in a hotel. It just seemed like a waste of money; could the expensive sunglasses really be that much better than a pair for £20 from the chemist for example?

South Africa has one of the largest income inequalities in the world. The average income of the richest 20% of South African households is 45 times more than the average income of the poorest 20% of households for example. Thus I find myself being in the former group while living in an area made up mostly of the later group. So while I earn something like 8 times the minimum wage, with the employment rate being under 10% in this area most families survive on far less than that.

I bought 12 bottles of wine today and it cost more than the monthly income for many families and I drove home in a car which for many is as far out of reach as a helicopter is to most people in the UK. I don't see why I should feel more guilty about that than if I had done the same thing in the UK but I do. And it has definatley opened my eyes to why people pay so much for their sunglasses.

Microfinance in the Transkei

2008-01-01T02:42:00.000-08:00

The HIV unit could not run without it's 20 or so counsellors. They are all volunteers who do a great job supporting the programme. Their primary role is in educating patients about HIV/AIDS and about the drugs that can be used to tackle the infection.They run support groups and do individual counselling to prepare patients to start their lifelong therapy. They do many other vital things from translating for the doctors to filing and even cleaning the buildings. Although technically volunteers they should not be confused with people who have perhaps retired and have some free time on their hands. As there are very few employment opportunities around here most see it as a full-time job; it is skilled work and they work very hard. The problem is that the government does not recognise their vital role and therefore won't fund their positions, they are therefore paid a stipend through the charitable funding of the programme. It amounts to around 800-1000 Rand per month. To put it in context a loaf of bread costs 5 Rand and a hospital cleaner takes home around 3500 Rand per month. Quite understandably, when a cleaning position becomes available many of the counsellors apply for the post. I think I would consider becoming a hospital cleaning for a 4-fold pay increase!

This is where microfinance comes in. Most of the counsellors want to carry on with their job but really need to supplement their income and they often have an idea for a small business venture. My only knowledge of business it to try to make more money than you spend but I'm trying to help with simple advice and a little start-up capital in the form of an interest free unsecured loan. So far we have six ideas that are at various stages of development. Christina has a camera which she uses to take photos of local people, she makes a 4 hours round trip to Mthatha to print the pictures and then sells them on at a profit. Another idea is to use a sewing machine that was donated to the hospital to make linen and other items, a third is to simply buy basic items like paraffin and sell them on in a small shop in a village. It is early days but so far all the loan repayments have been made on time and although I am expecting to lose some of the money the hope is that as loans are repaid more loans can be given. I'm grateful to members of my family and some friends who have kindly offered to take on the financing of some of the projects.

Doing other peoples' homework

2007-11-19T09:58:00.000-08:00

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.

Cross cultural medicine

2007-11-03T04:40:00.000-07:00

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!

Orphans and vulnerable children

2007-10-18T08:08:00.000-07:00

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.

About parenting.

2007-10-05T09:00:00.000-07:00

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.

About dying...

2007-09-26T11:26:00.000-07:00

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.

5 minutes if fame

2007-09-09T02:40:00.000-07:00

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

So what is the medicine really like?

2007-08-25T03:02:00.000-07:00

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

Some medicine

2007-07-31T10:16:00.000-07:00

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.

More Xhosa culture

2007-07-18T11:08:00.000-07:00

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.

Xhosa culture

2007-06-30T01:18:00.000-07:00

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.....

On living here

2007-06-22T11:01:00.000-07:00

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.

___________

More on the strike

2007-06-14T06:58:00.000-07:00

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.

The Xhosa language

2007-06-12T10:43:00.000-07:00

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…

The toi-toi!

2007-06-08T04:48:00.000-07:00

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!

The people

2007-06-06T09:20:00.000-07:00

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

First impressions

2007-06-02T04:33:00.001-07:00

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.

What is this all about?

2007-05-24T07:11:00.000-07:00

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....

T minus 5 days

2007-05-22T06:41:00.000-07:00

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.....