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.
Wednesday 7 July 2010
Sunday 23 May 2010
Wrapping things up
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
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
Tuesday 6 April 2010
I used to be a doctor
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.
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.
Sunday 21 February 2010
Madwaleni can do it....
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.
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.
Wednesday 20 January 2010
Comparison with Ethiopia
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 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
Sunday 27 December 2009
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.
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.
Saturday 14 February 2009
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.
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.
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