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.

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 season to be merry.....

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

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

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

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

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

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

Some updates

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

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

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

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

Sanctity of marriage

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.....

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

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.