The most unkindest cut

It is my last week in Zithulele and I am entrusted again with the charge of the Male ward. My work entails a daily ward round accompanied by a senior nurse, which occupies either the whole morning or afternoon, and clinic, either outpatients or HIV, filling the remainder of the day.

There are around 26 inpatients and their conditions cover the complete range of medicine with some orthopaedics and a sprinkling of general surgery. The range of complexity and severity is huge from young otherwise fit men with a fracture through to the majority who have advanced medical conditions, commonly infectious but also severe chronic cardiac and respiratory disease. Around a half of the patients have HIV; it may not always be the reason for their admission although it commonly is, particularly as TB accounts for another significant and mainly overlapping diagnostic group.

This week I have two teenage boys in my charge who have injuries from attempted self circumcision. I have looked after one previous case of a botched circumcision which required catheter drainage from directly out of the bladder while the healing, or rather scarring, process took its course. These two boys are sat out once a week on a bench in a side room with their handiwork exposed for medical inspection. In one of them the end of the penis is pink and healthy looking. He must have pulled the foreskin forwards away from the penis, but too far, and then cut off the loose skin neatly with something sharp and clean. He has a neat ring shaped area of skin about 3cm wide missing from below the end of the penis. This in fact looks promising as the foreskin itself is still intact and some skilled surgery could pull the loose skin back to cover the raw looking gap and meet the rest of the epidermis on the shaft of the penis. He is able to pass water normally.

The second boy is not so lucky. His attempt has become infected and the end of his penis is now gangrenous. He has already been through the hands of the urology team at Mthatha who managed to compound the damage further. He now has a catheter protruding from the base of his penis on the underside. He has about 4 cm of penile stump which looks like it might survive but the terminal half is black and shrunken and is going to self amputate sooner or later.

The origin of the practice of circumcision is lost in the mists of time. Its historical antiquity is well established and it goes back over 1000 years. Why humans should decide in the absence of any precedent in the rest of the animal kingdom to mutilate their genitalia in this way is perplexing. It is certainly good evidence of our distinguishing capability of making tools. Its role as a mark to differentiate one tribe from another, or the sexually mature from the immature within a tribe is widely recognised.

In recent years circumcision has attracted a great deal of attention. The ritual practice of female circumcision which occurs mainly in Africa and the Middle East is perceived as mutilating, oppressive of the female gender and intrinsically dangerous. Perhaps because male circumcision is so widely practised in the West – around one third of the males in the world are circumcised – male circumcision is accepted as a norm and has strong religious and cultural associations. The appearance of HIV has reignited the debate with clear evidence showing a 38-66% reduction of virus acquisition by a circumcised as against an uncircumcised man. As such the practice is being publicised and encouraged. The ‘Right to Care’ charity in Jo’burg will counsel a new male client about it on first registration and if the message is warmly received the patient will be asked to sign consent forms for an HIV test and to be circumcised and both will be done at that first visit. As a day case procedure in aseptic conditions it is safe and takes a matter of minutes.

Circumcision is a rite of passage for Xhosa males. Boys who have reached sexual maturity go off to a circumcision school (an umkwetha), spending a period of time, sometimes out in the wilds, and returning minus a few square inches of flesh.
One boy in my outpatient clinic was visibly excited that he was now old enough to be circumcised and we went through how he should manage his diabetes during his time away in the forest.

Circumcision is performed independently of the health care system here. There is no licensing or regulation of umkwetha and they are commercially run so that a cheaper school may attract more clients. It is not inexpensive and cost is as important a driver of where the boys go as any skill or reputation of the school ‘surgeons’.

Unless you have been brought up with it, the social pressure to be circumcised is difficult to understand or to overestimate, as are many ‘cultural’ issues here, and elsewhere. Both my patients had caring and worried parents who had told them of the danger of circumcision and had refused to let them go to an umkwetha. For both, accepting this would have led to intolerable peer pressure. I am guessing that the taunts of cowardice, sexual immaturity and being babyishly obedient to their parents would have been amongst the abuse they would have had to endure. Kids are cruel; here no less than anywhere else. To learn to swim here boys are taken by their slightly elder peers to the river and thrown in and pelted with stones until they swim to safety.

Two unfortunate individuals then; one of whom may be salvageable, but there is the skill of the Mthatha surgeons to survive yet, and one whose life is blighted forever and who for the rest of it will be left with a penile stump and having to urinate through the base of it while seated.

The statistics say that circumcision is very safe and that the complications of bleeding and infection occur in 1% or less of patients. These are global figures from sites where health statistics are reliable. The morbidity and mortality in the Eastern Cape and KwaZulu Natal far exceeds this because of the unlicensed cowboy setups who do it. December is circumcision season. In the outpatients this week five boys have been seen, all of whom are from the same umkwetha. Four are going to lose their penis. The statistics here are anecdotal but the informed estimates are that hundreds of septic complications, including septicaemia, are seen throughout this region during this time and that the number of deaths is in the tens; somewhere between ten and a hundred culturally accepted, nay encouraged and pressurised, cases of manslaughter every year, not to mention hundreds of painful complications with long term deformities and functional abnormalities. The psychological trauma can only be guessed at.

It is ironic that the month preceding this is ‘Movember’ where males, to show their solidarity with mens’ health issues grow a moustache. It is even slightly competitive in a jokey way as to who can grow the best one in that time. Social pressure and harmless male testosterone fuelled boasting at the mildest end of the spectrum. At the other end – deformity, dysfunction, humiliation, sepsis and even death are the common end results of the same hormone related sexual sparring.

It is difficult to know how to finish this posting. There will never be any widespread protest from the victims of this carnage, at least not in the foreseeable future. It would take a huge level of courage to make public the sort of anatomical mayhem that they live with. Things ‘cultural’ are in many ways sacrosanct and massive political vote losers to oppose or campaign against, so the chances of action at governmental level (even if there was a government in place which was not the exemplar of flabby, self-interested, corrupt, indecisive incompetence) are zero. International health bodies are similarly touchy about intervening in anything which has a ‘cultural’ epithet or justification.

From the play Schlageter by Hanns Johst, performed for Hitler, comes the quote misattributed to Hermann Goering “Wenn ich Kultur hore..entsichere ich meinen Browning!” [Whenever I hear of culture.. I release the safety catch of my Browning!]
On this one occasion and in this unique context I can almost empathise with the sentiment.

Perhaps the least one could aim for would be some sort of regulatory oversight of the umkwetha. The governmental failure to control other aspects of the Health care system here however does not inspire optimism for this approach (see ‘Strikes’, ‘Strike Two’ ‘New Depths’). This area of Southern Africa is stiff with churches, missions and evangelical ministers. Could they not preach that it is time for humans to progress from Genesis 17;14 to 1 Corinthians 7;19

Middle Earth

On my penultimate weekend in South Africa I decide, despite uncertain weather predictions, to risk a trip to Hogsback which is claimed to have been an inspiration for Lord of the Rings. I set off on Friday afternoon leaving behind, with some misgivings, a rare stunning blue sky and the azure sea and green hills of the Eastern Cape coast.

The drive from Zithulele takes me south west down the R61, a secondary road running parallel to the N2 but further inland. I have taken advice that Butterworth on the N2, a town that at the best of times reeks of evil and is a traffic gridlock, is almost impassable on a Friday afternoon. Joe tells me he once spent two and a half hours there sitting in a traffic queue to get through a town which is the size of a modest English village. There was no specific obstruction, just too many cars and an Eastern Cape specialty mix of robots, ‘give way’ and ‘stop’ intersections and an overall lack of traffic control. Like squeezing honey through a capillary tube.

The R61 is a good choice. Much of it is very straight and visibility is good, so even though it is mainly single lane there are plenty of chances to overtake the trucks that slow to 20kph on encountering the slightest incline. On one of these I note with amusement that the disappearance of words like ‘freight’ and ‘transport’ from the logos on these vehicles is not just a UK phenomenon. The smoking old wreck behind which I crawl up one hill has the sign ‘Value Logistics’ emblazoned on the back.

The road runs along the floor of a very wide valley occasionally rising on hills that protrude from the Drakensberg to the West. The ‘Dragon Mountain’ is called in isiZulu uKahlamba ‘barrier of spears’. The range towers over the whole of the Eastern Cape. On a previous trip I turned further inland to climb up one of the roads leading towards Lesotho. At the top I was rewarded by some wonderful views down vast green wooded valleys pleasingly bereft of any sign of human habitation and spent a pleasant 15 minutes watching brown coloured rock martins playing in the gusty warm wind that rose up over the edge of the cliffs.

Today the weather can’t decide what to do. At one stage the AC is full on and the temperature gauge reads 33 outside, next minute a bolt of lightning streaks down behind a nearby hill, the temperature plummets and the wipers are on at full pelt to cope with the tropical deluge. Mostly it remains clear and although the drive is long, much of it is through wild rugged attractive scenery and there are no serious delays. Bird life is surprisingly scarce. Pied crows and white necked ravens float around the road edges seeking roadkill. I spot a solitary raptor sitting on a telegraph pole.

I cross over the various tributaries to the Great Kei River (Black Kei, White Kei – all muddy red brown) and the houses begin to look more solid and the road improves. The ‘friendly’ N6 is a nice new highway and I pass through Cathcart (named after a governor of the Cape of Good Hope) which seems quite a smart place with wide streets. The turnoff for Hogsback arrives suddenly off the R351 just outside the town; and then it all goes wrong.

The road is appalling. It is laughably termed a ‘gravel road’. In places there is some gravel but overall it is 30% pothole and 30% deep ruts and the remaining surface is a mixture of mud and loose stones varying from huge boulders to shingle. Pebbles thrown up by the tyres make an alarming sound as they hit the underside of the car and I envisage holes appearing in the sump and the radiator. I recall the sign said 49km to Hogsback and I brace myself for a long haul over a surface that this saloon car was never designed for. The scenery is wonderful but my focus is on avoiding the largest rocks and the deepest gulleys. The zigzagging probably adds another 5km to the distance. The sky is crystal clear which would normally be a bonus but there is a long long stretch when I am driving up slope after slope with the sun beaming like a laser directly down the road towards me just above the crest of the hill, headache inducing and blinding me to the state of the road surface. Eventually after what seems like an age but is about an hour, I start the downward run towards Hogsback. I have passed no dwellings of any sort; had I broken down it would have been a long and dismal walk.

For a period of about 15 minutes as I descend I have the benefit of the evening sunlight on a view of green fields, and distant woodland and a hint of mist wrapping around lines of tall poplar trees. It is very atmospheric in a difficult to describe way; perhaps Turner could have captured it. This is followed all too soon by the dusk and I plunge into the cloud bank that engulfs Hogsback. It gets darker and the fog reduces visibility to almost zero.

I breathe a mental sigh relief as lights begin to appear through the mist. Rarely was the word ‘Welcome’ on the ‘Welcome to Hogsback’ sign more meaningful. Half way down the main street I see the sign I am seeking and turn into my Hotel

A young man finally appears some minutes after I have tinged the bell on the desk. I look around. I get the sense of an English pub that has fallen on hard times.

He takes me to my room. The bedroom is smallish. I have not seen Crittall metal framed windows in a hotel for a long time. They add to the impression of a rather seedy seaside guest house back home. It is the small things that do it. The four plugs jammed into a splitter from a single ancient electric socket, the broken bathtub plug chain. The beige wall tiles in the bathroom not quite meeting the darker beige vinyl floor.

I am just in time for supper but my starter and main course arrive simultaneously. It turns out the barman ordered as if there were two people dining. They take away the main course to keep it hot, which helps puree the vegetables. I finish my meal and head off for bed.

Next morning I am the first into breakfast. There is a cost cutting feel about the dining room exemplified by the single jug of lurid pink fruit juice and the first toaster ever invented. I am served by a local girl. Her English is fine and she smiles and responds to my Xhosa; when serving however she has obviously been taught the exact words to use as I hear her parroting the identical phrases to others as they join the breakfast. Her speed at clearing things away is electrifying. People are taken aback as, having taken the last mouthful, she whips away the plate as the knife and fork touch down on it and before the chewing has barely begun. There is a sense of not quite ‘getting it’ about her performance of these correct but badly enacted duties.

The weather is not promising. Mist and fog hover outside and I suspect the views will be poor. The landlord and his wife are an odd couple. She is a large rounded cross between Hyacinth Bucket (body and demeanour) and Sybil Fawlty (voice) and he has a slightly shifty car dealer feel about him; Arthur Daley without the humour. I ask whether the fog is likely to persist. ‘Can’t say really’ he replies, avoiding my eyes ‘this is Hogsback, four seasons in one day sometimes’. This evasion doesn’t inspire hope but I decide to go for a walk anyway and take a chance with the weather.

I stroll down the road using a basic map which Arthur has kindly provided. It has all the names of the shops on it. The Hogsback and Lord of the Rings themes are done to death. ‘Hair on the Hogs’ is the local hairstylist; ‘The Hoggest shop in Town’ is the proud boast of the gift shop which sits next to ‘The Enchanted Gallery’; my map shows ‘Hobbit Lane’ and ‘Rivendell camping’. Even the bottle shop is called ‘The Ring Liquor store’.

I turn off down a side road where, at the end, a back packer’s hostel named ‘Away with the Fairies’ sits at the beginning of a walking route. Its chalets have titles like ‘Bilbo’s room’. On the way a colourful Chorister Robin peers at me from the hedge. On the ground outside the reception entrance two huge hounds lie staring at me. They raise themselves slowly to their feet, there is a brief moment of indecision when I wonder if they are guard dogs and will take a dislike but they stroll towards me and demand attention. The reception lady is a nice African girl who points me in the direction of the start of the walk. The two dogs decide that this is an adventure and, along with a third that has materialised from somewhere, they become my uninvited travelling companions.

At first I have some feelings of reassurance. Perhaps having large dogs along is good for safety, although this lot wouldn’t harm a fly by the look of them. They soon turn out to be a menace. The path through the forest is narrow and steep and consists of mud made very slippery and porridgy by the rain, interspersed with large puddles. On one side there is an almost sheer drop and nothing to hold on to. The charm of my three canine companions rapidly wears thin as they turn out to be quite boisterous. They push past me then stop abruptly so I can’t move. Then they start having play fights. This is great fun if you have four feet. You can afford for one to slip over the edge. We bipeds are different. Any chance of spotting bird life with three barking canines has dropped from slim to fat to no. I last about another ten minutes of buffeting before I throw in the towel having been almost pushed to my death for the fourth time; I turn back. The dogs look disappointed.

Back at the hostel I take the alternative route which is signposted ‘viewpoint’. It is a short walk and I hear the voices of a young man and woman giggling ahead of me and some splashing. Puzzled I edge forward. There, cemented into the edge of a cliff with the tap end actually overhanging, is a bath, a normal porcelain bath such as one expects to encounter in a bathroom, not on a cliff. There is a large stove for heating water plumbed to the bath. A young couple clad in swimwear are immersed in the warm water while taking advantage of the view. The land falls steeply below them and opens out into a wide valley with the opposite tree clad slopes rising to cliff edges topped with white cloud. At the end of the valley one can see paler sunlit green fields of the distant lowlands. It is a beautiful and, dare I say it, a storybook view, but there is something bizarre and Alice in Wonderland like about the presence of a bath.

I walk back to the village. One of the dogs has adopted me and follows. The tourist information is open. The lady inside has a strong Afrikaaner accent and is clad in a long cheesecloth type dress, draped with beads and bangles, her hair tied up with an odd sort of ribbon. She adds to the general hippyish atmosphere and from her maturity could almost have been on original flower person.

Hogsback probably gained part of its Tolkien reputation by the opening of ‘Hobbiton on Hogsback’ soon after ‘The Hobbit’ was published. It was and is an outward bound school for deprived children, where they could come on summer adventure camps. The couple in front of me have two young girls; all four are loud. The man turns out to have been a ‘Hobbiton boy’ and he regales the information lady with his life history. They talk about people who were here when he was, some of whom are still living in Hogsback. He is an enthusiast and warms to his theme and she being polite and probably interested engages in the tale, although she must meet many revisiting Hobbiton boys. After ten minutes or so they eventually buy a map and leave and it is my turn. The lady is very keen to help. I buy my permit and get suggestions about where to go. All her recommendations seem to be commercial outlets rather than viewpoints or interesting walks. I mentally delete the ‘Ecoshrine’, the traditional potter and the ‘House of Mirrors’ from my itinerary. As I leave I mention the dog who is sitting outside waiting patiently for me. ‘That’s Snoopy’ she says ‘It’s a village dog’. It is an interesting reflection of how small and parochial a place is where everyone knows the stray dogs by name.

I go back to the hotel and get in the car to drive to a reasonable spot from which to start my walk to one of the better known waterfalls. Snoopy realises the game is up and looks around for another friend. A short drive later and I am at the start of the steep steps down to the Madonna and Child Waterfall. Hobbiton boy and family are here too and I pause to give them a fair start to let the disturbed birdlife settle before following them down.

I walk down the steep slippy uneven steps and along the wooden walkway. Behind me is a man about my age with binoculars. He turns out to be the local birdguide and we strike up a conversation, he introduces himself as Graham. The waterfall when we reach it is charming with a rock formation protruding through the cascade which plausibly resembles a mother and child. Graham and I climb back up together. There is a chirping sound very similar to an English Nuthatch in the background. I ask Graham if he is good on bird song. ‘That one?’ he asks ‘It took me years to work out it was the Hogsback frog’ he laughs. ‘I went through all my bird recordings time after time. It still fools people’.

The waterfall was a steep climb down and we are breathless by the time we get back to the top. He points out a Drakensberg Prinia and we chat for a while. If the weather is good we agree to meet up the following morning.

Hobbiton boy and family arrive panting away and father engages Graham in conversation, or rather launches into a monologue identical to the one I heard in the Information shop ‘I was a Hobbiton boy you know’ he begins. I see a cornered look appearing in Graham’s eyes but am helpless to rescue him. I wave goodbye and drive off with the voice still babbling on.

The cloud has settled firmly down, obscuring the view; a walk in the woods is the only answer. It is a long hike and I arrive back in the Arboretum where I started some two hours later thoroughly soaked with a single new species in the bag, a Star Robin.

All through the forest, even what must be a mile or two from where I started I can hear the booming bass of some loud rock music. In the Arboretum some locals are having a picnic. This turns out to be the source of the noise pollution. The car has all its doors open and the music is full on, the bass pounding everyone’s ears. Three teenagers are standing at the back doing weird dances in time to the music. One of them seems to be the centre of attention as he gyrates with his feet together and his knees opening and closing, his arms making a similar flapping movement with the elbows moving in and out and his trunk weaving from side to side. His head is looking downwards and sideways to emphasise how cool he is and that he merits watching. They have been doing this for hours judging by how long I could hear the sounds.

In this beautiful setting which was designed for peaceful strolling this seems to me pretty crass but I realise I live in a different world to these people. My suspicion is that my enjoyment of the natural beauty around me is unlikely ever to impinge on them. Similarly the endless rhythmic gyrations that they are going through and which are the height of wicked to them, will never seem anything other than a grotesque waste of time to me – not to mention the unthinking intrusion on other people’s quiet afternoon. Thank goodness I never again have to worry about being cool.

Back at the hotel Arthur and Hyacinth are chatting at the desk. They greet me and ask about my day; they are looking shiftier than usual. I go back to my room and find an envelope, hand written, addressed to me. Inside is a message from Arthur to all residents telling us that an electricity outage is due from 6 am next morning for 12 hours for planned repairs to the grid. This explains the forced cheeriness of their greeting. It is difficult to believe that this wasn’t known about when I booked less than a week ago. I decide a hot bath is the answer. I have noticed a few times earlier small black spiders on my sleeve and trousers and have brushed them away. As I lie in the bath I realise that they are ticks as I have one firmly clamped on to my chest wall. I pull it off and wash the site. Hogsback is turning into a place of fateful misfortune.

At supper in the bar the feeling of a Wild West town after the gold has run out is added to by an ancient American who appears to be a long term guest. He has long wispy white hair and pulls out a harmonica and plays some soulful melodies. Charming, but I am shocked to note that he is chain smoking too and no one seems to think it is odd or wrong. The sense of a land out of time deepens.

Next morning I am up at 5 and check the weather. The 5.30 rendezvous with Graham is conditional on good visibility. No hope; the fog is so dense I can barely see the edge of the windowsill. I do some work on the computer and at 6am on the dot the lights go out and a silence falls, broken a few minutes later by the sounds of a generator starting up. In the shower I find my tick bite site has not disappeared and I dig away at it eventually removing what are probably the remains of the insect head parts.

Breakfast is an even sparser affair than yesterday but their gas cooker means I can get a healthy fry up so I go for the full Monty.

I am in a mind to make tracks straight back to Zithulele but I decide to give the place another chance and I drive to ‘The Edge’ which is a hotel restaurant and viewpoint. The cloud lifts tantalizingly and blue sky appears and some cavernous expanses of wooded valley appear and are as quickly gone. I drive back down the road and as a final gamble turn down a road which is signed to an Azalea nursery which has been recommended. I arrive and am greeted by the inevitable enormous Baskerville hounds which bark their heads off and turn out to be completely docile. There is a nursery but I never get to it as the free entry garden is simply lovely. It is on a slope and is laid out like an ornamental English garden packed with roses and other English and native flowers and ornamental trees and water features. The owner has silenced the dogs and the peaceful beauty of this little Eden is just wonderful. The fairyland effect is added to by the bright species of birds which would never grace an English garden: exotic sunbirds, waxbills, bright yellow weavers. To add to it the mist finally lifts and I get a view across one of the vast Tolkienesque valleys where it would not be out of place to see a line of Elves on horseback padding slowly through on their way to Rivendell.

The idea that Hogsback was the inspiration for Tolkien’s Mirkwood in Lord of the Rings is debunked firmly and unequivocally in the excellent Wikipedia article. The South Africans however cling on to this myth with a touching ferocity and it is true that, had he ever seen it, it could have been. It is a strange land of very old forests, waterfalls, huge precipitous drops with sweeping views and a microclimate of persistent mist and cloud which can change in an instant to blue sky to reveal the panoramic scenery. It has, reluctant though I am to concede it, a rather mystical atmosphere.

Time is moving on and I leave the village by the southern entrance avoiding the gravel road. Looking back I can appreciate the steepness of the slopes clad with native trees, and the peaks disappearing into the cloud. Another large dog appears loping along in the grass next to me. I suddenly realise it is a baboon, one of a large troop. The eyes staring at me down the long thin snout and the flash of teeth (longer than a lion’s) are a salutary reminder that I am in a wild place.

I drive round a huge loop of road which goes West, North and then East to rejoin the road to Cathcart. It is the Amatola mountain route and the scenery is breathtaking.

The R61 is again kind and although it is a long drive I have become accustomed to sitting behind a wheel for hours by now. Above me soars a huge Cape Griffon Vulture taking advantage of the thermals of hot air rising from the valley and effortlessly drifting in wide circles, banking once sharply enough to reveal its pure white back.

I find Zithulele wet and shrouded in mist. It turns out that Saturday here was indeed a blisteringly hot and beautiful day, but Hogsback, despite its rather down at heel and forgotten feel was worth the trip.

Transkei woman

There is a huge backlog of unprocessed legal cases here in South Africa. This country is not alone in having that problem; in India it can take fifteen years for a criminal case to make it to court, even something serious like rape or murder.

The ANC led government have recently proposed that one solution to this logjam is to devolve more of these pending cases to the ‘chief’ system (see ‘When you come out of the storm’). This will mean that there will be no legal representation and the traditional male dominated culture will rule. Women’s groups are vociferous in attacking this proposed devolution of yet more power to a local and highly chauvinist authority. They have reasons for their concern.

Women are still largely second class citizens in much of Africa; in rural areas of the Eastern Cape their status is variable but there are many examples of them being treated almost like property.

One in three South African women is said to have been a victim of rape. Some of the cases that occur locally come to Zithulele and there is a set protocol for doctors who have to manage rape cases. Violence is not something that anyone likes dealing with and documenting it in a consultation is traumatic for patient and doctor alike, but the handful of cases that are seen each month are quite likely only the tip of the iceberg.

The hospital notes are sometimes graphic and disturbing. The cheerful young woman sitting in the clinic in front of you doesn’t appear to be psychologically damaged by the previous occurrences described therein which recount that she had a sack placed over her head and was repeatedly sexually assaulted by who knows how many young men. It surely cannot be the case that it is so much the norm that it traumatises less. Tragically perhaps it is that she has so many female friends who can empathise and with whom she can share this horrific experience.

In times past rape was a way to stake one’s claim to a female, as the loss of her virginity made her ‘damaged goods’ and unacceptable to all but her assailant. Here still, in the 21st century, in the Eastern Cape, it can happen that should a young male decide that a particular female is to be his and he gets her to his house and rapes her then a negotiation ensues, adjudicated by the local headman, in which she stays with her new conqueror in exchange for a suitable sum of money paid to her father.

The lack of female empowerment can be shocking. A 16 year old girl was brought into the hospital with a miscarriage. On probing the background and apparent lack of family involvement it turned out that she has a 47 year old ‘husband’ to whom she was sold by her family in exchange for six sheep.

Abduction of girls against their will is a well-recognised phenomenon here. They commonly come from very poor families. If, as sometimes happens, the girl absconds and goes to the police she may not receive the warmest of welcomes when she returns to her family since the sheep have to be returned too.

Perhaps the need to grow up very quickly is the reason that women in the Transkei seem to transform from schoolgirls into mature women in a remarkably short space of time.

When they do get married and go to live in the house of their husband’s family they may become the resident slave, certainly to their mother in law. The giggling girl in coloured school uniform becomes the serious-looking, patient, solid motherly presence dutifully fulfilling her role in her adopted home. Despite the seriousness however these delightful people are on an absolute hair trigger for fun, and peals of laughter accompany most conversations.

Solid is a word that describes Transkei women well. Wherever you are they can be seen clad in their multiple layers of rainbow hued clothing surmounted by the inevitable heavy patterned blanket round their shoulders and each with their own unique knotted turban headscarf. They walk slowly and deliberately, through fair weather or foul, as though made of something denser than normal flesh.

If you are following one of them down a corridor in the hospital you notice more acutely the slow ambling pace and the large amount of physical space they can occupy despite not being of great stature. However much of a hurry you are in it is no use trying to overtake; you may as well slow down to their speed. There are aeons of experience and history in that steady purposeful walk.

The stature and measured pace conceals a remarkable toughness. They are the workhorses of society. One colleague said she would love to see what would happen here if one day all the women went on strike. Everything would grind to a halt.

Like many African women they carry items beautifully balanced on their heads. It is common to see women toting bags of provisions the size of cement sacks in this way (which, incidentally, obviates the need for an umbrella). Faggots of firewood can be seen perched on their heads making them look from a distance like a weird sort of see saw. (The term ‘Faggots’ suggests some small bundle of kindling or twigs but these are big – see photo – some weighing up to 40kg). Realistically it probably is the only way to carry something of this size without a cart.

Within their numbers are some remarkable survivors. In the outpatient clinic recently a stretcher was wheeled into my room on which lay a feisty little sparrow-like and very alert great grandmother, pushed and accompanied by three family members all clearly concerned about her. She had slipped and fallen and had a pain in her knee. It is a long time since I did orthopaedics but the story of pain in the knee sometimes being ‘referred’ pain from a hip sprang to mind and the classic look of the left leg which was apparently shorter than the right and with the foot pointing outwards (‘shortened and externally rotated’) was an easy spot diagnosis of a fractured neck of femur. Sometimes you don’t need an X-ray – which is lucky as we still don’t have them.

I looked at her notes and past record: date of birth – 1922, previous medical attendances – nil. I questioned this as sometimes the actual birthday is very different from that on the hospital records. She produced her own identity cards going back some years, all of which confirmed the date. She was probably also born at home and may have given birth there too so this might be her first ever admission to hospital in 90 years, despite living in a seriously harsh environment through some very fraught political and economic times. Someone should sequence her DNA; she clearly has all the genes you need for survival against ferocious odds.

In 1922 in South Africa, the year she was born, the Rand revolt reached its climax. White miners were striking against the promotion by the mining companies of cheaper paid black workers into traditionally white jobs to offset the fall in the world price of gold. The strike became a national rebellion supported by the Communist Party under the banner “Workers of the world, unite and fight for a white South Africa!” It was crushed by the premier Jan Smuts so violently that he lost the next election. As a consequence white trade unions were recognised and the colour bar reinforced. The mines are still such a major focus of unrest and influence on national politics and there are some curious parallels between then and now.

Sadly this lady’s future is very unpromising. All fractures requiring surgery under general anaesthetic have to be referred to the local orthopaedic centre, Bedford Hospital in Mthatha. They are serial offenders at sending people back without being seen and they are in trouble themselves as their own X-ray equipment has been out of action recently. This lady would probably survive a hip operation as successfully as someone half her age. However she will have to sit at Zithulele in traction until she can be transferred. This can take months. In the current crisis and with the resulting backlog of cases, it will be hard to persuade surgeons there that someone of 90 should be prioritised.

This tough old bird has probably flown for the last time

2012-11-21 12.41.352012-11-21 12.43.13

Therapy without drugs

There is a sense that some things are getting back to normal at Zithulele; normal being merely ‘hectic’ on the basis of the superabundant health needs and the finite, not to say limited resources. All health systems face this type of mismatch. In this environment however, unlike the UK, there are fewer people who come to hospital without a very good medical reason. People here are ill, often desperately ill, and they have frequently left things until very late until they decide that they need help. This is sadly often because of the simple lack of the wherewithal to get there.

There is now more than a trickle of drugs arriving thanks to MSF; we have ambulances (perhaps MSF could be persuaded to take them over too), and there are some green shoots of resolution appearing in the local situation. Notwithstanding this it will never be a lavish health system. A large discrepancy between need and supply is endemic and a striking disparity in resource allocation between rural and urban medicine exacerbates it.

The medical staff have been learning to do without investigations and drugs but this post is not about them. It is about the team of therapists here who perform minor miracles (and some major ones) on a remarkably frequent basis using devices, exercises, innovation, sheer know-how and ferocious dedication. They are so much an integral part of the health care team it is difficult to imagine how it could function without them but Zithulele boasts a team of diverse therapists which is the envy of other rural hospitals. In terms of their skill and achievements I do not think I have ever seen a team to beat them.

I am referring to them generically as therapists although they are individually specialists – occupational therapy, physiotherapy, dietetics, speech therapy – but the teamwork makes it seem like one multitalented multitasking unit. Day to day the interactions between us are busy. We get detailed physical analyses of neurological cases and accurate opinions on the likelihood of conditions such as spinal TB being the problem. The time they spend with their patients elicits vast amounts of information which we fail to. The real number of fits the epileptic is having; the practicalities of getting about in a rondavel on a remote precipitous slope; what the social situation is really like. The examples are legion. Watching them mobilise severely debilitated patients along the ward, the patient using their tray table as support, the wasted matchstick legs gradually getting more confident, is a small wonder in itself.

Their contributions to the community are also huge. Despite disruption (See ‘When you come out of the storm’) they triumphantly pulled off the Christmas party for 30 children with cerebral palsy and their mothers.

Recently at a morning meeting when the daily gloom about no drugs was at its peak the therapists presented us with a case of theirs complete with storyline and videos. This was an 18 year old boy with cerebral palsy whose mother had been sent away from hospital when he was much younger having been told there was nothing that could be done for him. He is seriously disabled and virtually immobile, needing to be fed, dressed, washed and toileted. His mother has been doing all of this and carrying him on her back for the last 18 years. He is quite large now.

He came back to medical attention as he is now 18 and as an adult he will qualify for a disability grant. His mother will more than merit a carer grant.

The presentation was spellbinding.

Firstly there was a demonstration of his life before he arrived at Zithulele, which was one of confinement to one area of floor in his house and virtually complete dependence on this rock of a mother.

He was booked in for a short intensive course of therapy. He was supplied with a rural wheelchair. These are amazing three wheeled devices with the front single steering wheel a long way forward from the rear two. This makes them both very manoeuvrable and extremely stable on rough surfaces like grass and dirt roads. His very limited movements meant that at first he didn’t seem to get the idea that he should propel himself forwards and we watched him on the video rocking back and forth, a few inches forwards and a few back. It was pointed out to us watching, what seemed like a frustrating performance, that the very movement was so novel for him that he was enjoying the to and fro movement and it was quite deliberate. Soon however with the encouragement of the team and this remarkable mother, he was wheeling himself around and got better and better. He was taught to transfer, bed to chair and back. His physical skills and dexterity were honed up by exercises such as sorting objects and he began to be able to feed himself. My recollection of all the various inputs of all of the team is incomplete (and probably inaccurate!) and there was much more. The signs of delight on his face spoke volumes and the sense of wonderment in the audience watching this transformation was palpably emotional. Seeing someone grow up concertinaed down from years into days was almost like time lapse photography.

Eighteen years carried on his mother’s back and in a matter of days a life completely transformed. Two lives completely transformed. Everyone watching in that room’s life transformed.

Humbling, and just simply glorious.


When you come out of the storm


It is another day of bad weather much like the vast majority since I have been at Zithulele. Overhead the blue sky of the morning has gone and in its place dark storm clouds have gathered. Deep rumblings of thunder are echoing out over the valleys and the rain is coming to join the gusting wind which slams doors shut and whips curtains about.

The hospital staff community and non governmental organisation (NGOs) staff have just met to discuss the situation that is affecting us all. An update from Ben Gaunt has apprised of us what is going on and what we might expect in the next few days.

The drum rolls of thunder from above have a particularly ominous feel about them today.

This is nothing to do with health care, absent drugs or lack of X-rays or ambulances. Remarkably the ambulances are back (to their previous hopeless normality) and 29 staff from the Mthatha drug storage depot have been suspended and Medecins Sans Frontieres staff drafted in to cope with the drug distribution emergency.

Now the problem is a local one; however it is symptomatic of several much wider issues in this society

Although this is a democracy, and proudly so, power on the ground in the Eastern Cape is still dominated by tradition. There is a system of ‘chiefs’ based on family ties. The local chief is the ‘headman’ to a group of the population and although the land is government owned it is kept in Trust by him making him effectively the local landowner. He is subservient to the Great Chief (a sort of regional manager) who can overrule him in most if not everything. The exact details are obscure, at least to me. Notwithstanding this the headman is a locally important figure and largely responsible for the welfare of his community. He should know about all the important events and problems of his people. The hospital admission sheet documenting the patient details such as name, address, date of birth and religion (of which there are a remarkable number of variants) also has a section for entering the name of the person’s headman.

The thunder is getting louder. It is strange how primal is the sense of unease it engenders

None of the land on which Zithulele stands is therefore owned by the hospital. It has been ‘lent’ to the Church to build on to provide the healthcare facilities. The actual partition is complex with at least two local chiefs owning areas which adjoin on the hospital site.

The local chief is a young and rather hot headed man regarded by many as a trouble maker. His territory includes some of the community usage properties which have been used by NGOs and the hospital for community based projects and work. He also has a long running dispute with the Pastor of the church overseeing Zithulele. This relates to a disagreement over a tap, and a goose which was run over – clearly world shatteringly important issues.

Lately a very small but vociferous section of the local unemployed and disaffected ‘youth’ have got it into their heads, encouraged, or at least certainly not discouraged, by the local chief, that the NGO staff and volunteers are living on land next to the hospital which should be returned to them for ‘youth’ activities. Additionally (they say) the NGO staff have taken jobs which the local people should have.

We have had an uneasy few days when a number of our colleagues who are doing utterly splendid work in the community and the hospital have had to face somewhat hostile locals asking for their keys. Some of these are girls in their teens on their first volunteering attachment overseas. No keys have been handed over but it is more than unsettling working in this remote region to be confronted by aggressive local teenagers.

The thunder has been joined by visible flashes of lightning and the gap between is narrowing. The storm is gathering over this little community.

One can sympathise to an extent with the grievances. They see little that is positive in their own future and therefore take out their frustration on an easy local target – externally funded organisations providing outsiders with jobs and having accommodation while living on ‘their’ land. This simplistic and erroneous perception is creating a difficult situation.

It is perhaps symptomatic of the educational level here that there is so little understanding of how much good these people are doing and how many locals they employ, whose jobs would also go if the NGOs closed down. Over 100 locals are employed because of the presence of the NGOs.

There was a belief that the local chief had been put under pressure of some sort. That was until today when, at a meeting ostensibly designed to discuss the dispute, he stage managed it to restrict who could speak and what they could say. John, who represented Zithulele, apparently made a crystal clear and compelling presentation of the position as it really was and is, but the meeting had been prearranged in terms of the agenda and the attendees (no locals other than the troublemakers). The chief at one point said that ‘even if we go to jail we should not be afraid because it is our land’.

After this ‘meeting’ the chief and his cronies went to stand outside the wire fence surrounding the disputed buildings and his followers waited for him to show he really was prepared to go to jail. Strangely the presence of the police, who have been a magnificently calm and really reassuring presence, suddenly seemed to drain his resolve and he decided that cutting the fence and risking incarceration perhaps could wait for another time.

Throughout the week appeals have been made to the Great Chief to make a final judgement on the situation and meetings too tedious too enumerate have been occurring daily.

The local chief has made a few errors so far. He has recommended repossessing land and buildings which are actually on another chief’s territory. A climbdown ensued.

Today he demonstrated his humanitarian concern for ‘his’ community and their welfare in the most graphic way.

The therapists here had organised a Christmas party for all the children with cerebral palsy. Thirty mothers and their children from the rural population, who it has to be said live some of the toughest existences around, were gathered for a party in the Community Centre when they were ordered to leave forthwith. They were told they were not part of ‘the community’. Certainly it is a show of unarguable bravery and boldness to take on thirty women and their disabled children. It is the mark of a man of courage and vision and my level of respect for him has changed significantly as a consequence.

The thunder is right overhead. A simultaneous enormous flash and deafening crack of thunder and the lights flicker off momentarily

At the meeting today we were updated about the current status. It is thought unlikely that anything serious will actually happen. For reassurance however those volunteers and NGO staff who live in hostels on church land have been advised not to stay there tonight. Spare rooms and sofas are fortunately available in other flats in the main residence compound.

If there is no action taken to avert this latest episode in a chapter of unbelievable events that have been occurring at Zithulele – even in my short time here – then the local people are going to be the main and very serious, losers.

The irony is that if these few activists were taken out of the equation the last thing that the vast majority of the populace would wish for would be the disruption of the only competent health care facility for miles around.

It is now dark and the rain is beating down; a sound that has become almost background noise for me since I arrived.

The police force in the UK call rain ‘the policeman’s friend’ as crime falls in wet weather. Let us hope that it dampens the local hotheads and there is a dawning of common sense and common purpose.

Surprising to an outsider like myself is the bizarre level of autonomy afforded to a loose cannon like the local chief, making it seem to all intents and purposes a mediaeval society; surely not an image that the South African government want to portray to the rest of the world.


“When you come out of the storm, you won’t be the same person who walked in. That’s what this storm’s all about.”
― Haruki Murakami

Five go to the beach

It is a Friday afternoon and today Zithulele has been blessed with a perfect blue sky, warm sunshine and the gentlest of breezes. Swallows are criss-crossing high overhead. There is a clear view from our hilltop across to the next range of hills and beyond. The zigzag line of the dirt road to Hole-in-the-Wall climbing up the opposite slope can be seen distinctly. Two tiny figures are visible walking along it. Through binoculars they turn out to be women carrying brightly coloured bundles on their heads.

It is the end of the working week for everyone except those scheduled for weekend cover in the hospital. A mention is made of drinks on the beach and five of us make plans to go. Two of the girls want to run down. Rona, Joe and I go down in Joe’s car to meet them there.

Joe’s little Suzuki 4WD is a legend. It has done a vast mileage and the inside is the equivalent of a bachelor’s pad, minimal luxury and lots of useful things and some rubbish. Rona climbs in the back and I sit in the front. The back seat is of the minimalist variety and is concealed under papers, the odd tool and bits of fishing tackle. My seat in the front has a novel auto recline function which catches me by surprise and I find I am looking at the car roof unexpectedly. I sit back up and scrabble to join the seat belt with its insertion clip. All that remains of the latter is the red push button and the catch, on a wire frame. I eventually get clicked in.

We set off from the hospital and turn off down the dirt track to the beach. It is a steep winding road which passes several isolated rondavels. At one point it curves round past a rise to suddenly reveal a spectacular view. In the distance down to the right and far below us the wide smooth Mncwasa river splits around an island and then rejoins before finally twisting into the ocean across a beach. The river is surrounded by dark green wooded hills and a steep slope on the far side. This estuary doesn’t feature on any tourist guide, nor is it exceptional among the many parallel Eastward-flowing waterways along this coast. Were it in the UK however it would be a national beauty spot. It is accessible only on foot or by boat. So few people are lucky enough to get this view; I feel very privileged.

We climb up the next slope over some serious boulders, teeter at the top and then, roller coaster fashion, plunge down the opposite side. There below ahead of us is the long strip of flat white sand with a tall hill at the far end and the blue Indian Ocean rolling in with pure white topped waves. Lubanzi, we treat it as our private beach. Occasionally a few backpackers turn up and there is a small hostel for them nearby. Most of the time it is completely empty

The sun is quite low and there is that magical early evening light slanting across the hills adding a brightness and slight yellow tinge to the green of the grass and lighting up the sand with a golden glow.

We share the view with a raptor which hovers motionless above us for a few seconds before banking off to the left. The fingered feathers at the wingtips and the very short tail identify it as a bateleur.

As usual we have the beach to ourselves. We park on a small flat area facing the sea and quite close to the edge and scramble down the steep grassy slope and across the line of stones at the back of the beach. The rounded smooth grey boulders near the slope slim down to small rounded pebbles where the sand starts; hopeless for skimming, perfect for juggling. I took three home last time and left them on the windowsill. A furious hammering on the window announced a crow trying to get at the banquet of unguarded eggs inside.

We are in the sea within minutes. The water is slightly cool at the first splash but then pleasant to swim in. The two girls arrive a short while later and we spend about 20 minutes getting exhausted diving through the crashing surf and body boarding the big waves. The undertow is powerful and at one point I feel myself being sucked along towards one end of the beach. Time to get out and we sit around on the rocks sipping beer and wine and nibbling water melon as the sun finally sets behind the hills.

The sky begins to haze over and a sea mist gathers. It gets cooler and we gather up our belongings and all cram back into Joe’s car. The three girls squeeze into the back on the seat or floor. I strap in again. The bare simplicity of the car is like a Spitfire cockpit. The impression is strengthened as I notice Joe bent over outside fiddling with the front wheels. All we need is a cry of ‘chocks away’ to complete the scene. He scrambles back in and explains that since we need four wheel drive on the way back he has been adjusting the nuts on the front wheels to engage them with the drive shaft.

The engine roar reinforces the Battle of Britain feeling. The clutch engages and we shoot forward for take-off towards the drop leading to the beach.

Joe brakes, apologises for the wrong gear and we reverse slowly back to the road.

We start up the steep slope in rally style the four wheels grasping for purchase on the loose boulders and mud. The little car has a fair load of humanity on board but Joe is confident about its capabilities and tells me that he has used it to pull other cars out of holes before now. I develop a growing admiration as it copes with the off road conditions well. The slope steepens and the wheels are bouncing and sliding a bit. In the back the girls are chatting away while clinging on tight as the car buckets along. There is a sudden exclamation from all three as we hit a particularly steep and rough patch; it distracts us both in the front. I swing round ‘What is it?’ I ask, hoping everything is all right; but perhaps they have seen something remarkable – another eagle?
‘A baby donkey – it is sooo cute’. My shoulders slump with despair as I turn back.

For comfort I am holding on to the dashboard. I feel grateful that I had my microdiscectomy earlier in the year. My back is holding up well; six months ago this sort of pounding would have had me clinging on to the car roof by now.

We hit a flatter patch and Joe pulls to a halt to get the car out of 4WD mode as it doesn’t perform at its best like that and is only used when necessary. He adjusts the wheels again, jumps back in and starts the engine. He reaches this time for the 2WD gearstick and it comes off in his hand. I look down through a sizeable hole in the floor where I can clearly see the potholed road surface.

Joe is unfazed, this is apparently a normal occurrence and he has a variety of tools to sort this out, including a spoon. The gear stick is eventually reinserted and the engine revs up. Joe lifts the clutch pedal and the gears engage – or not – as a higher pitched, very fast whirring screaming sound emerges from beneath our feet. I recognise the noise as identical to the time I stripped the gears on the Black and Decker drill, the sound is unmistakable. These gears are tougher though, a couple more roars and then reluctantly they engage and off we go.

It is getting dark and groups of young men are materialising out of the gloom, off for a Friday night out no doubt. Joe hoots at them to warn them we are coming in case they haven’t spotted the single working headlight. I rate this as pretty superfluous as the engine noise must be audible in Durban, but it does at least add to the variety of sounds the car is making.

We get back to the hospital and pile out, breathless and almost helpless with laughter (and relief?). I have a new respect for the Suzuki.

We separate and reconvene later. Joe has produced an excellent poike, a traditional Afrikaaner stew where everything is cooked together in a large cast iron pot, usually over an open fire.

A battering by the waves, a driving adventure and a hot tasty meal – as potent a combination as one could imagine for an extremely sound night’s sleep.

What larks Timmy