Zithulele currently has about 3,000 outpatients who are being treated for HIV infection. With this number it would not be practicable to have all of them come for their management and follow up to the already crowded and furiously busy outpatient clinic. There is a specialised antiretroviral clinic at the hospital (HIV is a retrovirus hence ‘antiretroviral’ drugs). This is sited away from the other clinic areas and has two consulting rooms, a waiting area and a separate hall-like building where patients are registered and their paperwork prepared. Even having this dedicated unit it would still be virtually impossible to handle the whole HIV infected cohort, each one of whom needs a clinical assessment somewhere between one and three monthly.
For HIV infected patients on treatment, adherence to taking their medication is utterly critical for its success (even though we tell patients what we think they should do and also, in no uncertain terms, what will happen if they don’t, we can’t use the term ‘compliance’ in the UK any more as it is their choice, thus – adherence). For many medical conditions studies suggest that compliance with taking medicines is between 50 and 70%. Despite this most treatments work surprisingly well. For HIV however we know that it has to be 90%+ to be successful otherwise the virus develops resistance to the drugs and this is bad from every possible point of view (of which more later).
Continuity of drug supplies to the patients is thus vital. The road to Zithulele from the N2 major trunk road is, by and large, pretty good for a rural road (of which much more later) but the terrain away from the road where most people live consists of soaring, mainly trackless hills, and rivers that are prone to flood, rendering the few paths and dirt roads impassable. Even with a much larger clinic at the main hospital many patients could not get to there sufficiently frequently or reliably to make it a realistic option. Many also cannot afford on a regular basis the few rands it costs for transport by taxi from their nearest point on the road all the way to the main hospital.
If the patient can’t get to the drugs, the drugs have to get to the patients, so, in response to all of these logistical issues, the hospital has developed a devolved clinic system. Eight peripheral clinics operate weekly, some now have a doctor in attendance every week but most are medically supported on alternate weeks; the intervening week is supervised by the clinic nurses. Patients actively ask for their care to be ‘down-referred;’ to these clinics because of their convenience and their relative closeness to their homes. Everyone whose clinical management is in a reasonably stable state is accommodated.
I am to go to my first clinic visit today. The sun, which has been threatening for the last two days to prove it really is Spring, has vanished. I was woken in the night by the sound of pounding rain. By morning the cloud has partially lifted and there is now merely a light drizzle. It is generally grey and damp, with large puddles everywhere. The brown mud along the roadside outside the hospital is becoming evenly spread in thin coats over everything, stationary or moving, as the taxis go by creating spray. The stray dogs are brown from the feet up to the belly, the chickens are brownish and the goats too. Even my favourite rooster is looking a bit bedraggled but he gives me a defiant crow as I pass. I begin to believe that, like cats, they take most notice of those who are not their greatest admirers, and that they are fundamentally sadists.
After the morning clinical meeting we start to get the van ready to go to the clinic. The sooner we can get off the better as the clinic will already be open by now as it is 9.15. The van itself is a midsize vehicle slightly larger than a Ford Transit with MOBILE CLINIC stamped on the side and a rising sun logo proclaiming that it was a gift from Japan. It has a vague military look about it and looks much older than it probably is; the term ‘war surplus’ crosses my mind.
In the back go the boxes of anti HIV drugs. These have all been assembled into separate packs, one for each of the patients that we are booked to see. Each prescribed drug combination is in its own carefully labelled plastic bag with a patient clinic number and bar code on. This task of preparing a complex collection of prepacked personalised drug regimens is performed by a charity employee assisted by two remarkable and invaluable medical volunteers. Currently they are two UK students both on their gap year. These two indefatigable and conscientious individuals are a complete and heart-warming counterblast to the stereotypical ‘Gap Yah’ image. All three are at it flat out every day to get these medical supplies ready and their work is faultless. The hours of medical time saved, and the reassurance of knowing that what you are handing to the patient is exactly what you prescribed, is beyond price.
We stack four long plastic containers and five cardboard boxes of tablets and paperwork into the back of the truck. Karl is the driver and we jump into the cab. We wedge between us in the front a fortunately not very large medical student from the Walter Sisulu Medical School outside Mthatha. Eight of them arrived early on Monday just beating the request from their Medical School that Zithulele take them on for a four week attachment. However they are bright, keen, only a year from qualification and – bilingual – I have my interpreter!
Everything is ready to go and we pull up at the hospital gates at 9.45 to sign the truck out on the inevitable clipboard held in the security guard’s brick hut. As Karl is filling out the various boxes on the form the guard points out that the back tyre is flat, although not completely. It is probably a slow puncture. Most of the route to the clinic is mud road of varying severities of incline and we decide that it would be best to start out in as good a shape as possible.
Karl has an electric pump in his car so we get that and hook it up to the cigarette lighter in the truck (it must be post 1945 after all). There is a deafening silence. Of all the things that might be defunct from overuse in a hospital owned truck this seems to me to be an unlikely one. I speculate that, as part of the campaign to make Zithulele a smoke free hospital, one of the mechanics has disabled it to scotch any chance of a miscreant hiding in the cab for a quiet fag.
I have had warmer receptions to what I thought was a vaguely amusing comment, but perhaps no one heard.
The fuse for the cigarette lighter might have gone suggests Karl so we drive the limping vehicle over to his house and he gets some pliers and starts swapping the fuses around. The student is sitting in the front seat intent on her mobile phone. Much as I dislike using pictures to emphasise or describe where words can suffice, I prise her away from Facebook (yes it was, inevitably) and get her to take a photo of me standing by the truck next to the words MOBILE CLINIC with the flat tyre easily visible just below.
I am probably just imagining a slight air of frostiness in my immediate vicinity.
Fuses swapped and we plug in and switch on – to a further silence. Perhaps the pump has broken. One of the other staff has a pump so Karl wonders about getting this and meanwhile, sensing that I might be able to do something useful, I take the pump over to my car and try it in my cigarette lighter – success! The pump is fine after all. I drive my car to the truck and park close to the errant tyre. We plug in again and the pump pumps furiously away. It is my first experience of these devices. I am used to garage air supply pumps or even bike pumps where in a few seconds you can feel or see the flaccid rubber being restored to full turgid functionality. At first – actually for quite a long time – I can see nothing happening; the tyre still looks flat. I note the time is 10.15. I observe that the audio component definitely makes it more exciting than watching paint dry. Karl goes off to make a phone call. By about 10.25 I start to be convinced that a few millimeters of tyre is now visible that wasn’t before. But maybe my head position has slumped with the excitement. Karl returns and notes with enthusiasm that it is really much more inflated than when he left. I have the same sensation of those times that relatives, having not seen my children for a few months, expostulate about their amazing rate of growth, of which I have been completely oblivious. But this time I admit that by now even I can see a vague roundness on the tyre. I joke that it would be amusing if they used these pumps in Formula 1 at the pit stops. In the generally lightened atmosphere it provokes a slight smile.
By 10.30 we are all set to go. The rain has stopped and we take off down the ‘tar’ road and then swing off down a dirt track that first descends in long steep curves and then ascends in shorter steeper ones up to the clinic. We arrive about 11 at a smart brick building surrounded by the inevitable barbed wire fence and are let in through the padlocked gate. We get out and unload the vital supplies. In the distance through the fog there is a school where I can make out diminutive figures with satchels and backpacks. Our road didn’t pass anywhere near the school gate so presumably they just walk across country to get there.
As we enter the clinic reception we are confronted by an array of six benches stretching across the width of the clinic and more along the corridor leading to the clinic rooms. There is not a square millimetre of seating room left and in fact someone has pinched the chair from my room to sit on. The assembled crowd is listening with rapt attention to one of the staff giving a rousing talk on HIV. I am impressed at the energy and commitment. My high horse at losing my chair is rapidly stabled as I realise that we are two hours late and for these people, many of whom have walked for hours to get there, some starting at first light, there was an expectation that things should really be in full swing by now.
Although the organisation is all paper based it is very streamlined and we rattle through consultations and hand each patient their personalised prescriptions, order the odd blood test and do the occasional examination. We can’t spend a long time with every patient and I have to tell one sad lady that this isn’t a clinic in which I can investigate her year long absence of periods (pregnancy test negative) but that I sympathise with her desperate wish for a fourth child. My sympathies are coloured a little as my excellent student interpreter explains that the motivation isn’t entirely maternal. She is angling for amenorrhoea as a qualification for a disability grant – because she can’t have another baby and get the additional child allowance which is what she really wants. By contrast it would have felt better to have given some more time to the young girl with the hunted look in her eyes who, the notes reveal, acquired HIV after being raped.
The clientele is mostly female. Other than adolescent boys and older men, most of the working age males are away at Rustenburg in the mines. This in itself is a major feature at Zithulele as the birth rate rockets in September each year following the Christmas break when the miners return home.
The clinic slows from frantic to civilised and then to a mopping up of the stragglers and by 3pm, without a break, we are finished. We pack up the van with the empty boxes. Remarkably the tyre is still inflated. The drizzle has returned and it is frankly cold. We set off with a couple of the clinic nurses in the back. Karl sets a fine pace down and then up the bumpy track which by this stage has some very slippery patches of mud and puddles of unknown depth strewn across it. The old Japanese war horse pulls us through and we arrive back at the hospital. A slightly battered pair of ladies emerge from the back of the van. Tomorrow I am told the clinic is at the end of a really wild drive. I have other commitments though and that pleasure will have to wait.
For the staff this was just one more routine clinic visit. I muse on a day in which from this little underfunded hospital, in a quiet (well not quiet), but in a competent, energetic, ‘can do’ way, drugs which have changed the outlook of HIV infection from a 100% death sentence to – in the most perfect circumstances – something near a normal lifespan, have been delivered to another 50 or so of some of the poorest folk in Africa. And people still hunt for heroes