Community outreach

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

The Queen of the Night

Port St Johns is a beach resort on the Eastern Cape. A colleague’s daughter, Amy, is working at a hospital further up the coast so we plan to combine catching up and exchanging experiences with a trip to what is portrayed as one of the hidden gems of the Wild Coast. It’s a bit logistically complex as she is at a course in East London and driving back this weekend so we decide provisionally to meet for lunch at the resort when she arrives back on Sunday.

Port St Johns is about two hours by car from Mthatha. There is no easy way to get there without going through that particular hell hole. It boasts the Nelson Mandela museum since he was born not far away (actually it was closer to Zithulele). I cannot imagine anyone other than the most uninformed casual visitor with a burning desire to lose all their possessions wanting to stop here to visit it, which is a shame for the Mandela legacy. Mthatha has a reputation for unpleasantness which some say exceeds Jo’burg. I am sitting in my car in a traffic queue at the ‘robot’ – the local name for traffic lights – when someone tries the car door handle and finding it (as always here) locked, runs away.

Outside Mthatha the suburbs straggle away and eventually I am in hilly countryside again. The road follows the river Mzimvubu valley leading to Port St Johns. The scenery is rugged and impressive and by the time the river reaches the town itself it is a huge brown torrent 100m wide. It dominates the beach, hitting it near the North end and cutting diagonally across southwards making two beaches out of a very large stretch of sand.

At high tide the whole beach is underwater. At low tide acres of smooth, stone free sand appear. Even if the weather was better I would have no intention of swimming. My source of all information about sharks told me before I left the UK that Port St Johns has the highest shark attack rate in the world. There have been 6 fatalities in the last 5 years. At that rate, as she pointed out, if I stay here two days I have a 1 in 150 chance of witnessing the seventh. The Zambezi or Bull Shark is the culprit. It haunts estuaries as it can swim upstream into fresh water. By unhappy coincidence it is also the most aggressive of all shark species. As an aside it must have the same remarkable physiology that the salmon and eel have in being able to survive in both salt and fresh water. One was found 50km upriver.

I find my hotel along a dirt road and am shown to my room. Entry is through a Dutch door into the small bedroom (the ceiling fan spans about one third of the width of the room). It is simply furnished with a soft bed, a desk and a narrow cupboard. Opposite the entrance another door leads into the en suite shower room. Something about it suggests it wasn’t always a bedroom. The ceiling looks as though it is made of corrugated iron and it has a utilitarian feel. In fact the corrugations turn out to be the imprint of moulding on the cement as there are two stories of bedrooms above me. Even so, to me it still says ‘shed’. As I start to unpack a large millipede strolls in on glissando legs through the large gap under the door and heads purposefully for the bathroom. I redirect it back out.

After 6 hours on the road what is needed is caffeine and I drive down to the coffee shop on the road leading back into town, just after it becomes tarmac again. I sit watching the street life over a moderate apple cake but a nectar-like coffee. It is early afternoon and the children are coming home from school. Small knots of figures in coloured uniforms walk past, giggling and playing up like school kids everywhere. Three go past slowly. From their close attentions to each other two are a couple I think; they contrast sharply as he is a tall gangling lad and she is about 4 foot 6. The third is another girl about the same height who stands out because of a huge mane of black hair cascading down her back. Also, for someone so petite, she is, how can I say this delicately, rather inappropriately buxom.

I pay my bill and get directions to the dam where I am told there may be good birds to watch. It is up a winding steep hill and much further than I imagined. I come back to the town convinced I have taken the wrong route because I have found nothing. I make friends with a workman using my limited Xhosa (I am now fine at asking if you are vomiting or having night sweats but these are not the best gambits for getting directions). He assures me the dam really is up there. I try the same route yet again and miss the turning; no one had mentioned it was down a dirt road signposted ‘landfill site’. At first I cruise past this up and up and eventually reach the very top of a small mountain. Strangely two taxis come past me in the other direction. The road suddenly becomes hugely wide and very straight and flat. About 400m ahead I can see a plane facing me. I have hit the airstrip which is also the dead end of the road. A swift about turn and eventually the dam is found. It is a series of brick steps a few courses high. The water from the lake beyond cascades over it and also funnels under it through some pipes. From here it streams in multiple rivulets over a broad flat rocky area before disappearing down a steep slope into the valley. It is very picturesque and worth the trip and I am rewarded with a chestnut bellied kingfisher, fairly rare and very pretty. After about an hour which includes a chat with some workmen from the landfill site on their way home in the back of a pickup truck, and a mercifully brief visit by a pack of young boys, the drizzle has become persistent and I leave. It is more than two hours since my coffee and another one seems due. Driving back down the hill I encounter schoolchildren on their way up going home and amongst them, to my surprise, I spot Little and Large and Dolly Parton wending their weary way upwards. They must walk for two or three hours each way, every day, to school and back.

The town is buzzing and posters proclaim that I have had the great good fortune to arrive on the weekend of the Wild Coast music festival. There are large marquees and to add to the sense of a miniature Glastonbury the fields around them are a total mud bath.

After dinner I go to bed. Thankfully my hotel is a distance away from the late night revelry and all is silence. Sleep for me requires four components: – warmth, a comfy bed and peace – meaning both absence of loud noise and a lack of any sense of danger. I am woken at 3 am when the latter two vanish announced by the unmistakable shrill ‘eeeeee’ of a female mosquito hovering near my ear. Although the competition is strong and includes cicadas and frogs, mosquitoes must be serious contenders in the decibels per kilogram stakes. It is not misogyny to accuse my tormentor of being female since males only eat fruit sap; females need a blood meal before they can produce and lay their eggs. The falsetto whine bizarrely triggers thoughts of Der Hölle Rache kocht in meinem Herzen, the exquisite Mozart soprano aria from The Magic Flute with its thrilling tessitura sections*. Is it the sound or perhaps the translation ‘Hell’s rage boils in my heart’, possibly both.

I am not good with mosquitoes. What I like to imagine is a usually rational nature evaporates and I can spend a long time trying to eliminate one small insect from my bedroom. Here it is a hopeless task. The room has so many gaps and nooks, and, when I switch on the light, the perfection of the corrugated ceiling with its flecked paint as mosquito camouflage becomes apparent. I smother my face and hands with repellent and try to sleep again. An inspiration is to put my floppy hat over my exposed ear so even if the ravenous monster hovers trying to find a square millimeter of unprotected flesh I won’t hear it. It works and I sleep undisturbed.

Next day the clouds have moved firmly in. The news headlines state ‘Eastern Cape braces itself for more storms. Four drowned in floods’ I call Amy to discuss the weather and logistics. She mentions something about meeting for a meal in Mthatha. I express my doubts along the lines that I can think of better places to discard my money and my life. We decide this weekend is a busted flush and take a rain check on lunch.

I get back to Zithulele after driving through continuous cloud and mist, in some places I can barely pick out the road. Just as in the UK some drivers must be clones of Clark Kent. They roar past using either their x-ray vision or heat vision to bore personal holes in the fog. Back in the flat I look out of the window over the field which I can hardly see. The swallows are perched on the fence, shoulders hunched and with a resigned air about them. Their heads turn to and fro as if in conversation and I imagine an exchange along the lines of ‘What can you do in this visibility’ ‘Yeah nothing flying anyway worth catching’ ‘They say it’s going to be like it for days – call this Spring’.


Apartheid is dead! Long live apartheid!

On our rounds on Friday we were called to the adjacent ward to see a young lady, barely 40 years old. The curtains were pulled round the bed, which was itself unusual, as most consultations and examinations take place without screens. It predicted bad news. On arrival it became clear that we were not going to be able to help as she appeared to be already dead and a swift examination confirmed this. It was not that we had arrived too late to help; she had HIV infection and had been terminally ill with advanced cancer of the cervix. She had a large mass palpable in her abdomen, almost certainly the disseminated cancer.

Cervical cancer is another epidemic that is raging in Southern Africa on the back of AIDS. It is caused by a virus, the human papilloma virus (HPV). Related viruses cause the simple wart. HPV types 16 and 18 are the major culprits causing cancer, but others can do it too. They are sexually transmitted so they can travel with HIV but, more importantly, the immune system plays a major role in controlling and eradicating these viruses. In advancing AIDS, as the power of the immune system wanes, HPV infection can spread unchecked through the cervix. By infecting more cells the chance of a cancer developing increases dramatically. With no immune system to contain it, the cancer grows rapidly and spreads aggressively. In South Africa there are around 7,000 cases each year and almost half of these are fatal.

The tragedy of this case is that, unlike HIV, for which a vaccine is a distant dream (very distant I believe), cervical cancer is now a disease which can be prevented by vaccination. In many countries all young girls are now offered vaccination against HPV 16 and 18. The benefits for the individual are evident and the economics are also obvious since cervical cancer can be expensive to treat, and the loss of otherwise healthy young (taxpaying!) women is bad news. Add to that the unquantifiable damaging effects on children of the loss of their mother, commonly at a very young age, and the case for vaccination is compelling. In a country like this where HIV is rife it is unanswerable. The vaccine has been available here since 2008 but only in the private sector.

The big news story here is the miners’ strikes. At the first of these there was a violent clash between police and striking miners. Confrontations between miners and the police have occurred in the past in the UK, notably during the Thatcher years, but those pale into insignificance compared to this one where 34 miners were shot dead by the police. This provoked predictable and understandable outrage. The most jaw dropping moment however was the authority’s response in which they attempted to bring a charge of murder against the striking miners. The accusation was based on an old apartheid-era law rendering those who initiate such an action responsible for its consequences. The idiocy of this (but possibly not the irony) was eventually perceived and this preposterous legal action was withdrawn.

The strikes have now spread to other mines. They are all ‘wildcat’ which suggests the miners have an equal lack of faith in their employers and their Unions. Sadly they play into the hands of both the employers who then can (and do) dismiss strikers with impunity and, possibly more worryingly, they are fuel for activists like Julius Malema.

Malema was ejected from the ANC for ‘divisiveness’. This firebrand, who hobnobs with the wealthy when not tub-thumping, is now preaching that the deaths of his ‘fellow’ workers are all symptomatic of the underlying problem of South Africa which is white owned wealth. This is a potently seductive rallying cry but might be thought disingenuous from someone sporting a $34,000 Breitling watch.

The wealth of this country depends heavily on mineral exports so that the knock on consequences of the current industrial unrest will be significant and widely felt. Inevitably the folk at the bottom of the tree who are least able to hedge their welfare against adversity and who have no personal reserves will feel it most. One area that will certainly suffer even more is health. The financial resource available for healthcare is already stretched to the limit in South Africa as can be seen every day here in Zithulele, where, if we run out of a basic antibiotic, we don’t know when (if) it will be available again, and where the venerable ultrasound machine, our only radiology, and on which obstetric care is so dependent, sometimes inexplicably decides to stop working for days on end. Currently it is also on a wildcat strike.

In healthcare nationally South Africa is wrestling with the prospect of a possible withdrawal of PEPFAR, the US presidents fund which has underpinned so much of what has been achieved in making such huge inroads into stemming the AIDS tsunami. In passing it is an interesting thought that it will be a strange paradox if Bush is remembered for introducing PEPFAR and Obama’s legacy is its withdrawal.

The other big news here is that President Jacob Zuma is having 238 million rand spent on his house in KwaZulu Natal for ‘security’ reasons. Against what sort of threat this level of ‘security’ is required is difficult to imagine: – nuclear attack? Armed insurrection? Namibian expansionism? In what is known as ‘pork’ in the US, another town is also being built in his homeland at a cost of I billion rand, but at least that may benefit others. When the bill finally comes in it is a reasonable prediction that one quarter of a billion rand is going to be spent on this one man’s home.

The government is spending nothing on HPV vaccination.

With the money that is being lavished on the Kwa-Zulu bunker, a rough estimate suggests that the government could fund a vaccination programme against HPV for all the 10-12 year old girls in South Africa (ideally the boy as wells; vaccinating both is what is really needed to stop these viruses). There are of course other equally deserving health targets, but the principle is the same and the inequity in resource allocation is starkly and offensively visible when young people are dying of a disease that is preventable by an affordable vaccine. It was not us that were too late to help our patient on Friday it was this country that was far too late for her, and for thousands like her.

The departure of apartheid was welcomed worldwide. It was an abusive inequitable race based system, morally corrupt and with no virtues. Its legacy is still here in the persistence of large white-owned farms and businesses and a persistent maldistribution of wealth. According to the World Bank, the richest 10% of the population earns 58% of national income while the poorest 50%, earn just 8%. This is changing, but rather too slowly, and the plans to begin a redistribution of farmland (another major enthusiasm of Malema’s) have triggered serious fears of a Mugabe style populist eruption. There are far more sensible evolutionary schemes which could achieve the same ends while keeping the farming wealth intact and avoiding a repeat of a Zimbabwean style agricultural meltdown and the subsequent economic catastrophe.

If the government here really do want to erase what might be construed as remnants of a discredited political system then it is not the smartest of moves to invoke a Kafkaesque law from that era after shooting dead unarmed strikers. It also seems blindingly obvious that they will be far better able to achieve those ends, and gain international respect, as well as encouraging prolongation (and a desperately needed increase) of international aid for health if they can demonstrate that they themselves occupy the moral high ground. What will international aid agencies think as they look at the excesses of the Zuma ‘pork’?

Those of us who are exposed to the sharp end of health care here can only hope that international funding agencies will focus on the real issues facing the country. HIV has got to be held in check before its lethal partner in crime, tuberculosis, generates a plague to dwarf AIDS and one which doesn’t just affect those whose behaviour has put them at risk of infection. It may already be too late. The humanitarian impulse must outweigh reservations triggered by the appalling self-seeking behaviour of the (relatively) few.

Racial apartheid may be history but this situation is merely a different form – political apartheid. The new ‘haves’ are politicians hell-bent on a bloated lifestyle of privilege and giving themselves all the luxuries they can while turning a blind eye to the consequential creation of new inequities in the distribution of wealth, and ignoring the health needs that are screaming out throughout the country. Political apartheid also isn’t above considering the use of laws against which those currently in power campaigned so vigorously.

The current situation brings to mind the bleakest scene in Orwell’s ‘Animal Farm’ when, at the very end, the assembled animals are watching through the window as pigs and men are companionably drinking, joking and gambling. The poor South African black would be forgiven for looking from pig to man and man to pig and pig to man again and realising that they too could no longer tell the difference.

Saved in translation

The Eastern Cape is where Xhosa is spoken (or isiXhosa as it is more properly called); a very small proportion of locals also speak English. Some residents whose origins are from further afield variously speak isiZulu, Setswana, Ndebele and the like, but Xhosa is the lingua franca and the language of business and social interactions. All languages have their historical quirks – the locals here would no doubt find it amusing that we name the days of the week after mythical Norse gods and Saturn, the Sun and Moon. Xhosa is no exception; my limited knowledge of it already reveals it to be a language which is heavily embedded in local culture and daily life, sometimes in a rather homely and engaging way. The full word for noon, emini emaqanda, means ‘the eggs will have been laid (by now)’. Xhosa sometimes uses animals in a quasi-allegorical fashion. Imfeni lakho indala means ‘you are late’ but actually says ‘your baboon is old’ whilst imfeni lakho iyaphala congratulates you for being on time by observing that ‘your baboon is running’. Onomatopoeia is deftly employed; ngqonkqoza means ‘knock’, with the two clicking ‘q’s making a ‘knock knock’ sound’, and one of the most gloriously descriptive phrases, when everything is in confusion is ngumdodo wamasele – ‘it is a dance of frogs’.

The senior doctors and many of the other health care staff here speak Xhosa to a greater or lesser extent, although even they will sometimes ask the translators for assistance when communicating more complex issues and to ensure their health care messages are getting across. For those of us with no Xhosa the problem could be considerably greater than it is. I have begun to learn some basic words and phrases in the hope that it might enhance my ability to take a clinical history from the patients, and to communicate what I wish them to do when I examine them: – khamisa ‘open your mouth’, veza ulwimi ‘put your tongue out’, phefumla ‘breathe’, as well as words for ‘sit up’, ‘lie down’ and the vital ‘umntwana shukuma kakuhle?’ – ‘is your baby moving (kicking) well’. My attempts seem to be warmly received although whether this is because I am making the effort to speak their language or (more likely) that I have inadvertently said something bizarrely funny or inappropriate is not certain. My grasp of Xhosa at this stage is little more than an ice-breaker and I could not function clinically without a translator.

Amongst its many motivated and remarkable staff groups Zithulele has a team of translators to help out the linguistically challenged newcomers such as myself. All those that I have met so far are young women in their 20’s, fluently bilingual in Xhosa and English. They are without exception a cheerful, smiling, bright and empathetic group of individuals with a well-developed sense of humour – but at the right time. They are serious as befits the circumstances – and there are not infrequently sombre moments. They lack even the merest hint of superiority at their linguistic skill and how this contrasts with my own stumbling simplistic efforts. They do their job well and are respected for this and we try to do ours well which they in turn respect. In writing that last sentence it dawns on me that this simple reciprocal appreciation of each other’s worth is in decline in the West, but I can simultaneously feel accusations of a selective and nostalgic recall heading my way.

These girls* have a huge responsibility; not only must they translate accurately in both directions whilst at the same time traversing major cultural differences and negotiating subtle social nuances, but also on their young shoulders rests an enormous burden of confidentiality. Daily they elicit privileged information, which may often be relatively innocuous, but can on occasion include details of less savoury issues such as rapes, stabbings and family violence.

In the UK, with the increasingly cosmopolitan hospital patient clientele, we are routinely turning to telephone based translation services when, for example, monoglot Amharic speaking asylum seekers or East European migrant agricultural workers are admitted to the ward. However in cases such as this the translator doesn’t know the patient and confidentiality is enhanced by the remoteness of the telephone link. The Zithulele translators all live quite locally. Some must know personally the families whose lives and troubles they are translating into English, yet in the patients from whom they are translating I have never thus far sensed the slightest hesitancy to disclose information; the abiding impression is that they are all both absolutely trusted and discreet.

For those of us who need their skills they are the oil which keeps the health care engine turning smoothly. Ideally one eventually will acquire enough Xhosa to manage largely independently since, however good they are, it must be better to speak directly to a patient rather than by proxy, but that is still a very distant prospect. Until and unless that unlikely circumstance pertains I shall continue to be indebted to the translation team, as I suspect are all the patients that I see. Without them other health care professionals would be distracted from their real jobs in order to translate. Without them medicine for newly arrived doctors would be veterinary. To make a diagnosis there would be the bare minimum of verbal clues and far too much reliance on the imprecise art of clinical examination. The time that is saved by having instant translation is incalculable but it also allows every doctor patient relationship in Zithulele to be exactly that – a relationship – rather than, at worst, it being reduced to something resembling the interaction between a car mechanic and a gearbox.

You will note that I said the hospital ‘has’ a team of translators. The hospital does not employ them all, it is the charity which the modern-day medical pioneers of Zithulele, Ben and Taryn Gaunt and Karl and Sally Le Roux, manage, the Jabulani Rural Health Foundation**, which employs a significant number of them. Whilst it is almost impossible to imagine working adequately without translators I find it equally bewildering that the government does not provide funding for them. Any audit that was performed of the time that is saved, the better use of resources, the enhanced quality of care and the general patient (and doctor) satisfaction would reveal unequivocally what amazing value for money they are.

If my UK neighbour Anne Corsellis, who is Vice Chairman of Council of the Chartered Institute of Linguists and who wrote the definitive textbook ‘Public Service Interpreting’, reads this, I hope it will provoke a pleased (never smug – she is too gracious) smile. As an ex Magistrate there may also however be a raised eyebrow as she notes the striking parallel with the UK where the government, in a stellar example of myopic, dogma-driven cost cutting, has decided that state-run translating services for the Law Courts are too pricey and could safely be privatised. Perhaps it was just the triumph of hope over experience but the result might be described as ngumdodo wamasele

* Update – there are splendid male translators too


Coffee Bay

The residence compound at Zithulele is a pleasant little community of low sandy coloured brick bungalows and houses, each subdivided into smaller living quarters. Our bungalow comprises three similar sized dwellings. The houses are well spaced and there is a large central car parking area. The concrete road going from end to end is a great place for toddlers to shoot to and fro on their assorted bikes and scooters. On one side ‘Morning Glory’, bejewelled with gorgeous indigo flowers cloaks the fence between us and the mission house, in whose large garden a productive vegetable area is intensively farmed. Surrounding the compound on the other sides is a wire fence, topped, unfortunately, as a precaution, with circles of the barbed variety.

In the mission garden there is a small selection of farm animals including chickens. In charge of these latter, and with no intention of letting anyone forget it, is the local rooster. When I first drove up here two weeks ago, amongst the general roadside hubbub of people, dogs, taxis and caravans selling food, from inside of which erupted rumbling rock music, the sound which pierced my psyche immediately was the cockerel.

Whoever it was who first described male cockerels as saying something as benignly and pleasingly rhythmic as ‘cock a doodle doo’ was either hearing impaired or owned a bird with a speech impediment. There is sometimes a slight hiccup towards the end of the third syllable but in my (growing) experience this is often barely detectable. But it is this crescendo/decrescendo screech, out of the whole penetrating ululation, that is the longest of the three (or four) sounds. It is the one which has always triggered a specific sound receptor in my inner ear that renders it impossible to ignore. I don’t believe I am alone in finding that the crowing of a rooster at its customary (rather short) intervals can get on ones nerves, and that it worsens with repeated exposure. Were our rooster the only one within crowing distance he might restrict his territorial and matrimonial fanfares to the occasional ceremonial affirmation of his status but sadly there are at least two others somewhere in the vicinity. I can only just hear them but if you are a rooster this is pretty much the only sound of any importance to listen out for and he responds to the flung down gauntlets of his neighbours with tireless vigour.

He is an early riser, in fact my suspicion is that he does not sleep but stands in the dark waiting for the tiniest vestige of light to appear in the East at around 4 a.m. and then launches forth with all the stored up energy of the previous few hours of darkness.

This weekend seemed like a good opportunity to get away. Perhaps ten days behind the wire or the cockerel made minor contributions but, whatever were the reasons, I set off for Coffee Bay on Saturday. The road from Zithulele to the Coffee Bay/Mqanduli junction is new and sweeps up and down, zigzagging smoothly over the hills through picturesque countryside. From the junction onwards the view gradually becomes spectacular as the road rises slowly and then runs along the crests of a series of hills with breathtaking views on either side.

The hills are huge and roll in seemingly endless green waves of precipitous grassy slopes, with occasional woodland, off into the hazy distance where even higher peaks loom; the valleys are vast and disappear down beyond sight. The landscape resembles the foothills of the Alps or the tea plantation highlands of Sri Lanka but the scale of the terrain here is much grander. The hillsides are speckled with pale emerald-green or buff painted rondavels sometimes with no apparent routes of access. Houses and rondavels also form clusters along the roadside and at these the drive becomes a life sized video game of swerving to avoid cows, goats, sheep, horses and mules which hesitate and then stroll slowly but deliberately into your path. The deep valleys are very picturesque but the sight of a line of women snaking at snails’ pace up the hillside with containers the size of dustbins on their heads containing water from the river at the bottom is a reminder that beauty is very much in the eye of the beholder.

The road descends steeply into Coffee Bay and the last part is liberally peppered with potholes the size of footballs. However it runs alongside a pretty reed fringed river. Coffee Bay appears in every backpacking book and magazine about the Eastern Cape or the ‘Wild Coast’. As a result it has a number of backpacking hostels and shacks. Surf bums come here for the reliable supply of rollers sweeping in from the Indian Ocean. It is strikingly beautiful and extraordinarily peaceful. From the North end where a dark cliff brings the beach to an abrupt halt the sand curves round the bay to the South where it meets the river. Beyond this a green hill rises, really just a continuation of the river valley, and extends out into the sea to form a promontory. From the base of the hill a low plateau of rock stretches further out into the sea providing some degree of shelter to the bay, but not enough to stop the biggest waves from crashing over it.

I cross an old bridge and arrive at my destination, the Ocean View hotel. The Ocean View is the prestige establishment here. I am not against staying in cheaper accommodation but the Ocean View is already very reasonable indeed and I am given a room on the first floor with a white painted Mediterranean style stone balcony overlooking the garden and the beach,. The room is homely and very comfortable. I walk down to the beach and am tagged into conversation with a young local girl who sits outside the hotel beach gate next to a cloth spread on the sand which is her ‘shop’ displaying her shell and bead jewellery. I manage a few Xhosa phrases and discover that her name is ‘Min’ and that she lives over the hill. Her face is painted with a white pigment. It looks strange and ritualistic. I decide it would be rude to enquire what it signifies and I pretend to ignore it. I promise to return the next day to buy some of her wares. She sits down again on the log she has been squatting on all day.

I sample the cool, but not cold, Indian Ocean and then go for a walk down the beach. The sand is soft and pleasant to walk on barefoot, with pebbles confined to the landward edge of the beach. I wade through the river and up the hill where I find the coastal path which takes me through to the next, very rocky and sandless bay. Hiking the Wild Coast is popular and this brief taster explains why. It is hundreds of miles of unspoilt and scantily inhabited coastline of pristine beauty. The bird watching today is moderate but from high on the hill as I point the binoculars out to sea a shape breaks the surface; it is only about 400m out but probably invisible to those on the beach. A fin appears and a confirmatory spout of spray. For the next half hour I watch a group of at least three humpback whales apparently playing. Flukes appear and white underbellies. One seems to be smaller than the others, perhaps a calf, but I am guessing.

Next morning I decide a run along the beach would be a fine thing to do before breakfast. Min is already there with her shop set out. We exchange Kunjani’s and I note that today her face has no paint on it. Again it seems intrusive to ask why. I set off. I have the beach to myself and eventually arrive back at the hotel in a sweat ready for a shower and breakfast. Returning to my balcony I can see Min down below at the beach gate and she can see me. There is something symbolically unsettling about sitting high on a balcony in the best local hotel and her sitting patiently down on the log for hour after hour. My attention is diverted however as I spot, just beyond the rocky promontory, a triangular fin cutting through the water. Unbidden, and as testament to the potent influence of cinema, the ‘Der Der Der Der’ theme of Jaws springs into my mind and I scan the water quickly to see if there are any swimmers or surfers out there. As I watch, more fins appear and then a reassuring spout of spray and what turns out to be the first of three schools of dolphins swim leisurely past. The fins are so close together that they must brush against each other the whole time as they swim. Two leap out of the water just because they can.

It is time to leave. I check out and go to visit Min for the promised purchases. I think by this stage we are well enough acquainted that I can broach the issue of her face paint so I ask hesitantly ‘You look different today?’ and then more boldly ‘What was the white colouring?’ ‘Calamine’ she says with a smile ‘It protects me from the sun’.

An unhurried drive home with a stop by the river; the birds are fabulous – a giant kingfisher, a colony of yellow weavers and a fan tailed cisticola amongst others.

I arrive back at Zithulele. As the gates swing open the air is suddenly rent asunder with ‘cock a dooooo….’

Domesticity at Zithulele

After a chaotic first few days doing clinical work of a variety I have not experienced for many years – I can’t remember the last time I treated scalp ringworm in an 8 year old, and I haven’t managed porridge burns previously – the weekend has arrived to provide a welcome breather and a moment to reflect and to appreciate the incredible peace and beauty of this place. The rolling green hills to the North and the fall of the land down to the sea to the East are surprisingly reminiscent of the Yorkshire coastline. It is the scattered rondavels and the distant dirt road that remind you of where you are. In the UK it is difficult to get away completely from a background of occasional car sounds or the hum of a faraway motorway and the hush is prone to be broken by distant jet aircraft or small low flying planes and helicopters. If you take that away however what is left in Yorkshire is what I can hear now – the baaing of sheep in the distance, and birdsong. The birdsongs are different of course (if you routinely listen to things like that as I do). The swallows building a nest above my kitchen door are the lesser striped variety and they perch engagingly on the washing line not two feet from the kitchen window each with a beak full of a ball of mud to add to their rapidly assembling home.

Saturday morning includes a walk round the residence compound with a long chat to the security guard, an intelligent and articulate man who left a better job in Jo’burg to return to his family home. He talks to me in English and Xhosa and teaches me a new Xhosa phrase (‘I am telling you!’); one to be brought out perhaps with the next recidivist patient who needs reminding of the importance of taking their HIV medication. It is bright and sunny; time to open windows, air clothes, dry towels and clean the bedroom floor.

Bird watching from the patio in the sun and among a whole slew of new sightings; the bold yellow and black of the village weaver bird, the lipsticked scarlet beak and eyes of the common waxbill and the gorgeous iridescence of the amethyst sunbird are highlights.

Dr Le Roux (Karl) calls past and suggests I might like to join everyone at 5pm for the Springbok/All Black game in the communal room and we chat about rugby.

I decide to make some toast at lunch and can’t get the bread in the toaster to stay down despite changing sockets and all manner of other manipulations. I try the kettle to check which way is ‘on’ for the socket switch and that doesn’t work either. The lack of noise from the fridge is suddenly deafeningly obvious and it dawns on me that the power is off. On cue the clouds begin to gather and it gets cooler. My take- for-granted reliance on computers and phones now suddenly seems less secure. Sally (Dr) Le Roux is walking around and tells me it is a general ‘out’ which is a minor relief in that I have not fused my flat alone. She mentions that this can sometimes go on for days so it’s camping mode time. What of the rugby though?

Karl calls back later – I am sensing a certain degree of rugby fanaticism by now – to tell me that he has arranged to borrow a generator from a local farmer and we drive off down a road which varies from smooth concrete to mud and rubble and which is also the way to the beach. We pull off and drive over a few fields to the home of a delightful local family who lend us a generator. Many kakuhle’s and enkosi’s later we drive back and get the generator set up with seconds to spare before the start of the match. Everyone gathers to watch the large plasma screen. The Le Roux children sit round a low plastic table and eat supper in front of us. The generator cuts out a few times at critical moments but the playback and fast forward buttons mean we see it all. The room is as partisan as any group of Welsh supporters I can remember. It is interesting to see that referee Alain Rolland is just as one sidedly inept against the Boks as he was with the English against France last season. Every refereeing mistake provokes howls of indignant disbelief. Match over, the Boks have been beaten by a professionally clinical New Zealand although the scoreline would have been closer with a real referee.

It is very dark outside with a heavy drizzle. The generator has done its job and we disperse to our various residences by torchlight. Still no power; the chili con carne supper remains uncooked. I was never a great fan of camping and even indoors it has no charms.

Lest I mislead

In writing a blog for public consumption (even if the public consists of a single individual – or no one) there is an easy trap to fall into which is that it is cool to be critical. We can get lulled into a feeling of intelligent superiority by our ‘sharp’ observations. It is the case that one is drawn to pointing out the failings and negatives of things partly on the same principle that drives the television news (the bad news as my parents were wont to refer to it) which is that good news doesn’t get people’s attention in the way that disasters or major crimes do. We all experience schadenfreude to a greater or lesser extent but most of us are also genuinely sympathetic to the plights of others and thankful that it didn’t happen to us. At its extreme it triggers, by accident or design a wish to help the victims.

This brief ramble reflects the fact that I am aware that most of what has appeared in this blog to date may be read as having a trace of cynicism in it. This is an unbalanced reflection of my thoughts and experiences on this South Africa trip and from previous ones, so to redress this I should say that in the middle of what is a major health crisis, that of AIDS, in this country there are many very remarkable organisations and literally heroic individuals doing things which are quite extraordinary.

Here are just a few examples. Many have websites so Google them and read and admire; in no particular order:- Hugo Tempelman and the Ndlovu health care project, the Right to Care charity and the monumental contribution to HIV clinical care in places like Jo’burg, the incredible taxi rank project, again in Jo’burg; it would be invidious not to name Brian Brink who, amongst other pioneering acts, engineered Anglo American to provide anti HIV therapy to all employees and their families – this at a time when the politicians were saying HIV didn’t cause AIDS.

Finally in this short posting, in the few days I have been here, the staff at Zithulele. The positivity and enthusiasm and the sense of a team with a purpose infuses the whole place. Whatever it is that drives each of them, all of these are good and inspirational people. The world needs more like them.


Flying into Johannesburg it seems like any other city. It is a sprawl of mainly low-rise buildings and there are sizeable green areas which don’t look like formal parkland, with fingers of modern uniform suburban housing spreading out into them. Green felt golf courses with mature trees and a sprinkling of well spaced out mansions with blue garden swimming pools speak of wealth and leisure for many. There are strange and sometimes oddly symmetrical rocky outcrops rising from an otherwise flat looking terrain. In the distance and through a little haze, either African dust, or exhaust emissions, or both, the inevitable city centre skyscraper skyline comes into view with irregular blocks like three-dimensional Tetris and a few bulbous telecoms masts. Three lane motorways snake through the city and the unmistakable straight or gently arcing pencilled railway lines with their bulges of parallel storage tracks are visible adjacent to what look like large areas of warehousing or industrial estates. Some of the suburbs look neat and leafy, with symmetrical houses intersected by evenly spaced grid pattern roads.

Then suddenly something catches your eye and is quite quickly gone and you think it was nothing. Then another one comes into sight and it looks like someone has miniaturised a town. A random patchwork of tiny roofs has been squeezed together with no streets or even visible paths. At first you dismiss it then you see another and you think the plane must be further from the ground than you thought because they look like human dwellings but they are far too tiny. Another appears and another, always surrounded by a margin of red-brown soil but with no hint of tarmac or trees. The contrast with the adjacent housing estates and their ‘normal’ sized houses is suddenly striking. These collections are each the size of a small suburb and squeezed into odd corners here and there, at road junctions or on barren areas of land. It is as though there is some chaotic Lilliputian society with tiny towns scattered here and there inside the real city – a Lord of the Rings landscape with hobbits and humans living side by side. It takes only a few moments to realise that these are where people with no real houses live, tin shacks and shelters made of any sort of material jammed together into shanty towns. They are officially termed ‘Informal Settlements’, a neutral and cosmetic description with a hint of Newspeak about it.

This is, for the first time visitor, an unsettling and humbling sight. When you have seen them a few times from the air, the impact lessens. No doubt if you live with them they are just part of the scenery and are probably not even noticed by many. The remarkable proximity of high-rise office blocks, expensive suburbs, small but neat working people’s housing adjacent to these collections of corralled humanity living on society’s edge, shouts social inequality and teetering societal instability. It is not the same as the drunk down-and-out pictured at the base of the Empire State Building. These represent whole colonies of people living in the heart of a Westernised town, but functionally outside of it and with their own code and culture. Except where they encounter health care provision or the police they are largely invisible. An IS won’t appear on a map, despite being of equivalent size or population to many named suburbs.

As the plane gets closer to the ground it becomes easier to see the height of the walls, all topped with wire, that surround every building that is not part of an informal settlement. This is a city and country where the ‘have nots’ experience en masse the contrast between their lives and that of the ‘haves’ in a very direct and undiluted way; and the ‘haves’ are extremely aware of their own vulnerability.