I am midway through my time at Zithulele and a ‘half term’ break seems appropriate. Taking an extra few days around a weekend gives me time to make a serious trip up to the Durban area and to visit one of the very many game parks with which this country is blessed. The journey is long and I set off at dawn with the aim of getting through Mthatha before the crooks are out of bed. The roads are empty apart from the odd cow or small flock of sheep. I get through Mthatha in record time. Deserted it has a charmless post-apocalyptic appearance, empty streets with rubbish and paper on the pavements and blowing across the road. It has rained recently and the tarmac shines and for once there are no swirls of red dust from the back streets and dirt tracks.

I am relieved to watch the town recede in my mirror and to be on my way north again on the N2. It is a grey morning with quite strong winds sweeping cloud in from the sea far to the East. This mist and fog blankets the high hill tops on either side and sometimes descends low enough for the powerful drizzle to make driving difficult.

As I go along I note, as an aside, another aspect of the mysterious traffic planning here. In places the road spreads into three lanes with a central overtaking lane for one side or the other to use. Bizarrely however priority is random; sometimes it is for the lane going up the hill but just as often it favours the descending traffic. The latter leads to a single file of cars and taxis labouring up a steep incline trapped behind a smoking truck or coach; meanwhile in the opposite direction speeding down come two lines of traffic: the trucks which can virtually freewheel at the speed limit and the cars which now have to break it to get past them. There are endless lunacies about traffic here. On one hill, where it is the right way round, just as you begin to accelerate into the middle lane going up the hill you hit a helpfully planted series of speed bumps…..

The journey is largely uneventful except for the inevitable stop at the Go/Go section just before the Port Edward turnoff. I am well up the queue this time and I can see the lorry at the head of it only some 20 vehicles in front. It begins to move and I swing out a little to deter taxis from coming up and overtaking me from behind. As I do this I notice that each vehicle in front of me is pulling out too to overtake a stationary vehicle in the queue. As I pass the 4×4 which is causing the obstruction, the uniformed figure of the driver is visible, leaning back, mouth wide open and with the rhythmic peaceful breathing of someone dead to the world. The lurid letters on the side of the vehicle tell me that I have just been delayed by a real sleeping policeman.

Progress continues to be swift and the cross country drive through the high steep grassy hills over towards Port Edward eases as the fog lifts. I pass through Bizana. It is the same genre of poor down and out town as Mthatha but it is somehow less threatening and more characterful. The names of the shops are a delight: The ‘Ding Dong Shop’ with the encouraging phrase written below ‘Have a Ding Dong Day’. At first sight calling a store ‘Love Tombstones’ seems a little incongruous but I guess there is a logic in there somewhere. A sad reflection of the AIDS crisis is the inordinate number of funeral parlours, one of the few growth industries. The word Jabulani is a common title for a shop. Loosely translated it means ‘Rejoice!’ I am amused when I spot ‘Jabulani Butchers’.

Approaching the coast in the daylight I am better able on this trip to appreciate the slow transformation in the scenery from the vast steppes of the interior to a much more compact rolling hilly landscape with deep green woods scattered across the hillsides. I am suddenly reminded of summer in Nidderdale in Yorkshire.

As I cross the large girder bridge spanning the wide Mthamvuna River and head into the KwaZulu Natal province there is a definite change. The road surface improves, the houses are larger and more often Western in design; there is an immediate feeling of having passed into a more verdant and more prosperous region.

A quick coffee and petrol for the car and I set off up the coast road to Port Shepstone towards Durban. The footprints of the British are apparent as I pass signs to Trafalgar, Margate, Ramsgate, Windsor-on-Sea (!), Kelso and Ilfracombe. The inexpensive toll road is superb and I reach Durban faster than expected. The pervading sense of wealth increases as I drive through Durban. Wide streets are lined with huge extravagant mansions with sea views. The cars look new and the streets are clean. I stop and eat in the Umhlanga district. I could be in central London.

I drive a little further up the coast to my hotel and stop in Ballito. The shopping mall there wouldn’t be out of place in a fashionable area of any wealthy Western capital. It features bijou art galleries, specialist shops and chic coffee bars spaced around open seating areas with large department stores behind them. In the cafes and shops the overwhelming majority of faces are white, apart from the waiters and shop assistants. The large shiny land cruisers drawing up at the petrol station are driven by whites and they are served by black petrol pump attendants. It is difficult after 6 weeks in the Transkei to believe one is in the same land. There is a sense that time has stood still here and that the people are in denial that apartheid is over. The appearance is of the whites having decided to carry on just as before and simply not to engage with the black population. Ready ammunition for the Malema’s of this world. I reflect with some chagrin that I am effectively colluding with it.

The hotel accommodation is spread out over a large wooded park on both sides of a valley flanking an estuary and I am driven to my room on the back of a golf buggy. My driver is a cheerful man bearing a name badge telling me his name is Inkosi which is a royal name in isiZulu. He has a large smile which reveals abundant bleach-white teeth. He also has a driving style that would be competitive at Le Mans. I sit on one of the two open backward facing seats. On the slim upright bar which rises between them, and which is the only thing to hold on to, I read a short, uncompromising notice: ‘Falling out of the vehicle could lead to serious injury or death’. As Inkosi Schumacher does what seems like a handbrake turn going downhill round a 120 degree bend with an adverse camber my knuckles gleam white on the metal bar.

In the morning after breakfast I stroll past the infinity pool which looks over the estuary down to the sea and continue down a trail through the hotel grounds aiming for the beach. The vegetation is rich and green and there are high trees and dense bushes with lush palms. A flock of bright yellow village weavers are nesting in the tree on the small island in the estuary. You hear their constant screeching and twittering long before you see them. Their nests hang like bulbous fruit from slim woven cords at the very tips of the branches. There is furious activity around the nests suggesting hungry chicks inside. Perched above them are regal white breasted cormorants. The raucous ‘Ha Haaaa’ of Hadeda ibises echoes across the scene and the striking pale patches near the ends of the wings of a low flying raptor announce a long crested eagle is on the prowl. A brisk wind has raised whitecaps on the blue Indian Ocean. The beach is clean and almost empty. It is idyllic and it is tempting to spend a day or two here but I have to set off again to my game park destination.

For the first hour or so the scenery on the drive north is completely dominated by tree plantations. This is unexpected and even more so is the fact that they are all Eucalyptus, mile upon mile of them. Eucalyptus must be the most successful Australian export ever, after Rolf Harris. People I know bemoan the fact that the Australians are so fiercely protective of any foreign plant or animal crossing their borders from elsewhere, yet their gum trees and wattle have colonised half the world. I can see advantages in the choice of these trees as a crop; they grow fast and can be planted densely, a meter or less apart. Their trunks are also very straight and I notice later that the roof beams of the game park buildings look to be made from eucalyptus trunks. They are apparently a major source tree for the paper industry here too. Pretty, however, they are not and the landscape is mind numbing.

It is only when I get closer to the cluster of game parks in the Hluhluwe region that the typical African coastal bush country and bushveld appear, cut across by ribbons of dune forest as the numerous huge rivers pour eastwards from the Drakensberg to the nearby ocean.

I find my turnoff and after a drive along a bumpy red dirt road with a high electric fences on either side I reach the electronic gate. It slides open at the keycode and I drive in. Almost immediately animals appear, impala, kudu, and nyala. The ground is covered with a thick layer of fresh grass almost half a meter high, the thorn trees are in leaf and some are coming into flower; the game looks healthy. It is a long drive to the lodge but the room is nice and lunch is waiting.

The lodge only takes a small number of guests. There are an elderly South African couple and others from England and Africa and a large family who have come up for one night only. In addition there are two people who are very quiet, speaking in low tones to each other. I catch a few sounds and place them as Western European, Swiss perhaps. They turn out to be German. I christen them Hans and Lotte.

Our first game drive is at 4 and we assemble outside. The game truck with its tiered seating appears driven by our guide/ranger and driver, an African who I will call Jonah. We get into our seats. Since I am carrying my large spotting scope I volunteer for the back seat and some extra space. At once there is a problem. Hans has discovered a tick on his leg. He is very worried. Lotte is also worried. They ply Jonah with questions. Jonah is not very worried and makes some fairly cheerful but dismissive comments which he obviously thinks will reassure. This they signally fail to do and for the next fifteen minutes, as we drive along looking out for game, Hans and Lotte spend the time scrutinising each other’s legs in minute detail and picking out whatever fragments of insect they think they can find. They are talking continuously about it and are oblivious to the beauty of the scenery. Their furrowed brows radiate concern. By the time the first serious game appears they have settled a little although I still hear the word ‘tick’ and ‘fever’ sprinkled through their conversation.

We are lucky, there, munching the long grass as we breast the hill top is a black rhino. It has a calf and it allows us to come quite close. Hans whips out his camera with its giant lens and begins snapping. In the old days the number of photos he takes of the rhino and offspring would have bankrupted him but with digital you just click and click and discard those you don’t like. Even allowing for this it is pretty extravagant snapping. As time passes there is a sense that the others in the truck are starting to worry that we will not get much further tonight. After he has the rhino pair immortalised from every possible angle we drive along a little further and bump into a herd of white rhino. Neither are named for their colour. Black, Jonah tells us, comes from the Black Mfolozi River although my sources suggest it was to distinguish it from the White rhino which, everyone agrees was nothing to do with it being white, it is grey, but was a corruption of ‘wide’ from ‘wide-mouthed’ rhino.

Hans is getting into the photography groove by now; the staccato clicks of his camera come thick and fast like a BB gun. I begin to wonder if he is conducting a census of the rhino population here. Meanwhile I am pleased to see my first woolly necked storks which are big enough for everyone to want to wait and watch.

We stop after an hour by a water hole for the traditional pre-ordered ‘sundowner’. Jonah sets up his bar on a table with a cloth and ice bucket and asks whether my G+T is to be a single or a double. He slips a notch in my estimation.

Hans and Lotte are having another wobble about the tick. Jonah starts saying comforting things like you don’t get tick bite fever from just one tick bite you only get it if you are bitten by lots of ticks. This gives the impression that it is the frequency of bites that matters. This is not going down well as we can all work out that your chances increase per tick bite but you might just have the unlucky lottery tick with the first one. Jonah changes tack and says that he doesn’t think that that particular tick was carrying disease. This evidence-free speculation simply does not wash with our slightly health obsessed German pair and they look very miserable and apprehensive.

Behind us there is a loudish cough. Lotte jumps like a scalded cat. We turn and see some kudu about 50 meters away. ‘They are worried that we are at their usual drinking place’ says Jonah; not half as worried as Lotte who is now peering out anxiously from the safety of the truck.

On the way back it gets dark and Jonah hands out two spotlights for people in the front seats to scan the dark bush on either side. Red eyes are what we are looking for, not white or green, red eyes are the predators. The African lady shouts out as we bump through the darkness, she has seen something. We stop and reverse slowly. Her eyesight is very impressive, there, about 50m away in the spotlight we see the mottled slinky figure of a leopard slipping through the grass.

Dinner is supposed to be alfresco with tables set up around the wood fire but an invasion of flying beetles means it has to be swiftly resited indoors. Jonah is among the serving people and afterwards insists on walking back with me in the dark, guiding me with his torch. Apropos of nothing he starts telling me about how one of the guests has asked him how much he earns and how he just felt obliged to tell her, and how dependent he is on tips. I get the sensation I am being softened up. I had not until this moment thought that after paying for an all-in package, of which the game runs are the major feature, that the drivers would expect a bonus. I decide to judge on how good he is the next day.

The morning is taken up with a bush walk; three hours marching through green, knee-high wet grass behind a new guide, Andrew, who carries a rifle. He is a fair haired gentle giant of a chap, well over 6 feet tall, who speaks slowly and has a habit of saying ‘Hah’ at the end of a phrase for emphasis, or to make sure we realise he has said something funny. He gives us the ground rules and the hand signals that he may use. We are forbidden to talk as we follow him in single file. Finger clicking is the only way to draw his attention. I wonder if my fingers will be under enough control, or just too sweaty to click if something large and predatory comes up behind us when I am at the back of the line. ‘Important rule’ he adds ‘never run in the bush, you always come second. Hah!’ He tells us always to keep behind the rifle – totally superfluous advice in my view. ‘If necessary I will despatch the animal’ he reassures us ‘but I have never had to shoot an animal yet, only a guest. Hah!’

These guides must go through the same set of anecdotes about the plants and animals on their patch every week. He shows us tracks. I can see the hippo print but the baboon handprint is just so many random lines out of which Andrew draws some fingerprints with a twig. Frankly he could be telling us it was Yeti as none of us can argue.

We march on through the grass, our trousers are now soaked up to the knee and the rubbing together of the legs has probably announced our presence to every animal within a mile. Andrew draws us to a halt under a tree. ‘This leaf sap’ he says breaking off a leaf and showing us the white latexy fluid ‘three drops of this will kill you, Hah’.

Stalking on foot does have more of a feral feel to it than careering round in a truck. You might just come across some lions although any tracker guide worth his bullets will probably lead you away from these without telling you – they are not going to go looking for trouble. Prey are a better option than predators and we get some nice close ups of giraffe, including a baby which has walked straight out of the cuddly toy store. Those eyelashes – they must spend hours with the mascara. More impala, nyala, zebra and rhino. I have a grudging respect for zebra ever since I discovered that they just can’t be broken and ridden like other members of the horse family. It seems like the deity is telling us that not everything is for us and we don’t understand it all. How can black and white stripes be good camouflage? The meat tastes bad too. These are animals which are designed for us to look at and puzzle over.

After a three hour trudge we find we are back at the truck. It has been a good walk and we have seen quite a lot albeit not too close up. It is surprising however how large wildebeest seem when you are on foot. On film they look like the hapless victims of any casual lion attack and their skittish behaviour and narrow pinched snouts reinforce the impression of them as the brainless losers of the bush. From ground level the horns are suddenly larger and three of them staring meaningfully at you and letting you know, as they walk slowly towards you, that this is their land, not yours, is considerably more daunting and engenders in me a new respect.

On the afternoon game run Jonah is determined to find the lions that the other group saw this morning from their truck and we go down one densely wooded track after another with thorn bush branches sweeping along the side of the truck and springing into the passenger area. We see nothing. Those in the side seats are getting a little weary of ducking the lethal branches. Jonah’s tip is starting to look shaky. We pull out of the thick scrub into more open ground and start to see animals again. He and all the rest have worked out by this time that I am looking for birds. They have got used to staring through their binoculars out one side of the truck and turning back to find me with the scope pointing in the diametrically opposite direction.

Jonah and I have a minor disagreement about a kingfisher. It eventually turns out to be a difference in the pictures in the bird spotting guides that we both have. I think he is starting to worry about his tip though because at sundowner time he corners me and tells me how he is saving up for some decent binoculars and if he gets enough tips he will be able to get the pair he wants.

As we are standing there chatting I note that Hans and Lotte have been deep in conversation for quite a while. Lotte eventually asks if there are wild dog here. Jonah confirms there are sometimes and asks why. She tells him that she has seen a pair of dog-like ears in the distance and after a detailed consultation with Hans they have both agreed they were indeed ears and that they have now moved away. Jonah agrees they may be wild dog and, deciding we should check out the sighting, says ‘Everyone back in the truck’. Lotte is already there, the thought of encountering wild dog inspiring her to break the world record for the 10 yard dash by a sizeable margin, and without starting blocks. We join her and, leaving the drinks table behind like a colonial remnant, chase along in the direction the ears went. Jonah assures us they are almost certainly black backed jackal ears as he knows that there are jackal around. We drive for about ten minutes and see nothing. We stop, turn round and head back towards the bar. From out of nowhere in the tall grass to the right of the truck and not two metres away, the elegant frame of a cheetah appears, stares at us briefly and strolls off aristocratically into the long grass. We are all spellbound, they are much taller than I had imagined but otherwise totally unmistakable. What must it be like to be aware, even dimly, that you can run faster than anything you see? Jonah is meanwhile telling us that he thought there were cheetah around which is why he took the sighting seriously and followed up. Glances are exchanged amongst the guests and there is a familiar agricultural smell – bullshit.

On the way back it is Hans and Lotte’s turn with the searchlights. Lotte is not great at this and on her side the light seems to be shining mainly on any game which we were in the process of running over or actually already had, with occasional flashes out into the distance. Hans however takes to this like a natural, quartering the land on his side of the truck in a methodical and thorough way. Nothing would have escaped had there been anything to see. Sadly the animals have got the message too of an old searchlight pro at work and have melted away into the night.

Next morning it is the truck again. Jonah has turned up with six bird spotting guidebooks determined to show his mettle and to his credit we see a good number of birds including the gorgeous bush shrike (‘gorgeous’ is, quite justifiably, part of its name), scarlet chested sunbirds and the stunning violet backed starling. The rest are showing some growing enthusiasm for particularly jewel-like birds, of which there are plenty, especially when the bigger game is sparser. A secretary bird appears and lopes along the track in front of us like a cartoon character sprinting along under the path of the falling tree and avoiding the obvious strategy of dodging to the left or right. They remind me of the road runner cartoon bird; just like wily coyote we never catch up. We see plenty to satisfy the animal hunters too, but no cats.

We stop for coffee and biscuits. Jonah starts rambling on about how much he has to keep an eye out for people’s safety which is why he made us jump back in the truck so quickly yesterday evening. I feel he is probably working on getting a better tip from the Germans. I need to ‘go behind a bush’ as the phrase goes here. I wander off and return about five minutes later. Jonah is busy telling everyone how he prioritises the biscuit choice for the break. He hasn’t noticed my absence at all.

Off we go for the final run, some more rhino materialise conveniently, and the giraffes, complete with baby. Wallenberg’s eagle, white backed vultures and bateleur soar above us. Eventually it is time to go back for lunch. As Jonah stands by the truck we all climb down and thank him. He is no shrinking violet and tells us that although there is a gratuity box for all the staff he would prefer to have cash in hand directly from us.

It is time to leave. As I drive out of the park on the track in front is a last treat, a pair of Natal francolins with 11 miniscule chicks, each barely two inches tall.

I take to the main road and make my way back to Durban past acres of gum trees.

I am staying another night because I want to see one more special sight. Moreland Farm just outside the city is on a high hill overlooking a huge valley to the south. At the bottom of the slope far below is what looks from the top like another sugar cane plantation but is in fact a vast reed bed. Each evening at dusk, birdwatchers come and sit in seats set into the hillside to watch an estimated 3 million barn swallows (the common swallow in the UK) come in to roost. It is a truly amazing sight. The first few shoot in low over our heads and then they are materialising from all directions. There is a slight haze so the numbers are not obvious until you look through binoculars; then it is like locusts. They don’t appear to have quite the close swarming behaviour of a murmuration of starlings, probably because they fly so much faster and need more space, so one does not see black clouds sweeping across, but there is still the same sensation as waves of knife-winged, streamer tailed black dots swarm to and fro.

After about twenty minutes of high speed formation aerobatics they swoop down and melt into the reeds and are gone in an instant; surely one of the great sights of nature.

It is time to go home. The journey seems very long as the fog has descended again across the high hills separating the coast from
the inner valley where the N2 runs. I spend two hours with a visibility of about 10 meters driving up and down steep winding hillsides. The trucks and coaches I get stuck behind crawl up the inclines at 10 kph and then rocket down the other side at 110. It is frustrating driving. Eventually I turn into the hospital compound. It is dark and pouring with rain. Memories of the hot sun and blue skies and exotic birds and animals of KwaZulu Natal seem to have already acquired a dream like quality about them.

Amazing Grace

When we have very seriously ill patients requiring advanced ICU treatment, or more than simple surgery, we have to refer them to our specialist centres. There is a reluctance to use our local ‘centre of excellence’ and for the very seriously ill any excuse which allows us to send the person to East London is permissible. For patients who need intubation for severe breathing difficulties or those who need to be deeply sedated and ventilated, a trip by ambulance for many hours is far from ideal and the helicopter team can be called in. One young pregnant lady with eclampsia and a blood pressure which put her into flash heart failure was sent off a few weeks ago. Sadly neither she nor her baby survived.

This week the helicopter was in action again. Everyone’s favourite security guard David (see Domesticity at Zithulele) arrived at the hospital late in the evening with a severe attack of asthma. Providentially Ben Gaunt was still in the hospital on call and bumped into him on his way home and found him barely able to breathe. Within a short time David had collapsed and in the outpatient clinic late at night, surrounded by staff who are, to put it kindly, not ATLS trained, Ben set about resuscitating him, aided by a continuous stream of advice by cell phone from a colleague anaesthetist in Pietermaritzburg.

Everything conspired against him. No clinic room was thought to have two functional electric sockets said the staff, who had to be told to go round and test the sockets until they found one. There is no nebuliser in the hospital; luckily a staff member has one at home for their own use so this was summoned. The oxygen cylinder which was temporarily disconnected from David while he was moved was twice dutifully taken away and put in its storage position and had to be recalled. To keep his airways open David was sedated with hefty amounts of unconventional and conventional drugs, and pure adrenalin used by infusion – no other intravenous asthma drug was available. Eventually he was transported to the theatre suite where the halothane gas was able to ease the breathing a little. The staff priority on hearing that he was to be moved there was to go and fetch green scrubs….

Despite this (and much more), aided by Becky Kemp from the early hours, and with a telephone lifeline of practical textbook and non-textbook ‘tricks of the trade’ advice from afar, Ben kept David going, against the odds, through the long hours of the night.

We arrived for the morning meeting and it was all hands on deck. The helicopter had already been called and reputations put on the line for demanding East London over Mthatha (you would be amazed how often the local weather round Mthatha makes helicopter landings there impossible). Building work had left boulders on the helipad so a team went off to clear these. The sense of desperation to save someone so universally loved was palpable. Becky said David was the only guard her son liked, referring to all the others as ‘Not David’.

There was some Heath Robinson rigging of the ventilation tubes and a moment of panic as his oxygen level fell inexplicably, relieved when the sharp eyed Karl noticed that in his last tube manipulation the oxygen had been temporarily switched off.

The helicopter had arrived by now with the competent paramedical team. David was still struggling for breath but perhaps slightly less so and he was as stable as it was likely could be achieved. He was strapped on to the stretcher and the trolley was wheeled down the bumpy path to the chopper. As we approached the pad the door of the pathology lab swung open; a delivery boy emerged with a large box leaving the open door completely blocking the way. We shouted, he looked and ignored us and went on down to his van to load up. We negotiated the obstruction and after some sharp exchanges the van, which was parked perilously and stupidly close to the helicopter, was ushered away. David was strapped in.

Everyone wanted to wish the unconscious figure well, whether or not he could hear them. I whispered ‘Good luck umhlobo wam (‘my friend’, a phrase he had taught me the previous morning as he greeted me on my way to work), see you soon’.

The helicopter rotor gathered speed and the doors slammed shut. The wind from the blades blew in our faces and then achingly slowly it lifted from the ground and suddenly, as if becoming unstuck, rose up, tilted forward and swept off.

People stood round watching it disappear into the distance, lost in their own thoughts and prayers

The news is good. David was extubated later that day and is now awake and talking. Ben sent round an email saying God is amazing. Another view is that he works through some amazing people.

Fingers in the dyke

The HIV clinic at Zithulele runs on Wednesday and Thursday and is a bustling place where people come to start their HIV treatment (ARVs), some as outpatients, some in their nightclothes directly from the wards; most however are attending for their regular follow up checks, blood tests and to collect their new prescriptions. In times past, before the majority of patients were devolved or ‘down referred’ to the eight peripheral clinics, it was ‘hectic’ (a term widely used here to describe almost anything that is extreme). I am told it is quieter now although it stretches the definition of quiet. Piano it certainly isn’t, nor even mezzo piano. I would rate it as mezzo forte for most of the time with occasional forays into allegro fortissimo con fuoco.

I am timetabled to be in the HIV clinic for the whole day today, sharing the morning clinic with an experienced colleague and flying solo in the afternoon. In a themed clinic where the HIV related clinical problems are effectively managed algorithmically it is not too intellectually taxing but there are challenges. Patients have a tendency to try to use this specialist clinic as their GP surgery, something that happens quite frequently in the UK too, and not all clinical problems are so easily addressed in that setting. There are logistical issues like taking blood from infants, which is better done by those with more practical experience. Another skill is learning to fill out details of the consultation on a variety of different assessment forms; this relates to which one was current when that patient began on ARVs and what stage they have reached in their treatment. Each has a slightly different format with different boxes to fill in. No two patients are exactly the same and all have their own unique problems, so like generic forms everywhere they are great as an aide memoire but can be cumbersome in practice. However it is the logistics of health care that are my main area of ignorance:- how far away the peripheral clinics are, how easy is it to travel to them, what does one do with the possibly moderately unwell patient who you would like a second look at in three or four days but who lives miles away – the wards as usual being full to bursting.

The first stanza of Auden’s poem ‘Leap before you look’ has been a recurring thought since the Zithulele expedition was still only at the planning stages; this is another instance when it seems very apposite.

The translators again demonstrate their value, reminding me, if I forget, that each person needs at least three different pieces of paperwork filled in. The system is really crying out for computerisation. Sadly health care and computing have often been poorly matched partners – ask anyone who works at Addenbrooke’s. But the remarkable setup at the Right to Care charity in Joburg where 600 patients are processed paperlessly every day, or the incredibly efficient fingerprint based method, pioneered by Dr Jan Pienaar at the Anglo Coal health facility which tracks patients (and staff) in real time continuously, both in the main hospital and at all the peripheral clinics, are two shining examples of where it really works. Investment in good functional infrastructure like this is never wasted.

Perhaps the most striking variable in this clinic compared to others is the attitude of patients to their care and their degree of involvement in it. Many of them are old hands and virtually run the consultation, often answering the questions before being asked. These are also almost inevitably individuals who are the most disciplined at taking their medication, reliably reminded by an alarm clock or mobile phone every day. The results can be spectacular. Some of the fit cheerful people I have seen there have been – according to their notes – wasted, debilitated individuals at death’s door when first diagnosed with HIV. They are now back living full lives. Understandably they are also very switched on about risk behaviour. This is how it should be, the doctor providing support to a person who has engaged with and is concerned about their condition and takes responsibility for their own health.

For a fair proportion the complexities of taking three different tablets in a slightly different combination twice a day, or even three once a day is more than a brain teaser. Their numerical skills may not always be great but more often it is their comprehension of the need to take a combination of drugs at such precise intervals that is the barrier. As I have said previously (‘Community outreach’) this sort of obsessional behaviour is not required for the usual run of the mill treatment course for many conditions, a few hours here or there or the odd missed dose matters very little. If you are taking analgesic medication, where the regularity does matter, then you are forcefully reminded by your own nervous system that something is overdue. Failing to take ARVs has no subjective consequence, other than the counterproductive one of reducing the side effects. The longer term disaster of the virus becoming resistant to the drugs is completely inapparent for many years. Well educated Westerners often struggle with it too so there is nothing unique about this.

For a very few people, here as elsewhere, it is all too much. These are the heartsink serial defaulters whose medication has to be changed and changed again as the virus becomes resistant, and then the options run out. When it really fails it is profoundly depressing, but there are often more complex pressures on people underlying the bad adherence; failure to share the diagnosis, external stresses from partners and unsympathetic family backgrounds and the like, so it can’t automatically be categorised as simple amnesia or recalcitrance.

For many patients the attitude to health resembles the relationship between the UK public and the NHS up until the last third of the twentieth century, one of acceptance of paternalism with no wish or expectation to have to contribute to decision making. ‘I’ll just do what you say doc, you know best’. In many cases there is no point in fighting this too hard. No matter what the preachers of health emancipation may tell us, some people just need (and want) to be told what to do.

At the other extreme there are one or two folk who have taken the health care consumerism message firmly to heart and are set on being totally in control. One young woman, quite smartly dressed and fluent with answers, and who probably does take her medication regularly, tells me that she doesn’t have time to have the regular blood check today. These tests are essential to detect drug side effects and to make sure drug resistance hasn’t developed in the virus. This can occur even with the most perfect of drug compliance. I tell her how vital this monitoring is and fill in the necessary forms for her to have her blood checked before she picks up her regular supply of tablets. She argues. I explain patiently why it is important and she agrees it is and still refuses. She stomps out. As I talk with the next patient I hear her voice shouting in the corridor. This petulance has obviously been a pretty successful strategy as, according to her notes, she has avoided blood tests for a very considerable length of time. Eventually the noise dies down. I discover later that Rona the estimable volunteer has patiently stood her ground and declined to give out the drugs until the blood tests are done. The girl has wasted a good twenty minutes arguing and eventually had the blood taken, which takes two minutes. It is pointed out to me in conversation with colleagues afterwards that perhaps it is a good sign that people are losing their passivity and taking charge of their health. Possibly so, but understanding what one needs to do to be in charge of one’s health and doing it sensibly is not the same as this sort of sheer wilful stupidity. In all probability it reflects some lingering element of denial.

The translators are also the HIV counsellors who take the patients through sessions preceding the initiation of treatment trying to make sure they understand exactly what the purpose is and why it is so important to take ARVs very regularly. They drill the patients with a set series of questions and answers. ‘What does the treatment do?’ ‘It suppresses the virus but doesn’t get rid of it’ ‘What does this do to the body’s ‘soldiers’?’ ‘It makes them increase and recover so I get well’ ‘How long will you have to take treatment?’ ‘All my life’, and so on. Patients also have to recognise their tablet types from a pile of random ones. This is not entirely straightforward since one of them comes in four different shapes, sizes and colours. They must also have a ‘Treatment Partner’ with them when they come to embark on therapy, to whom they have disclosed that they have HIV. This is their trusted buddy. Despite these hurdles it is a testament to the counsellors, and to the practical nature of the system that most people start treatment at the first attempt.

Sometimes the translator working with me, as today, is the one who counselled the patient in the first place. This can lead to some slightly tricky conversations if the patient hasn’t understood that we have to test their knowledge before starting treatment.
‘What do the ARV pills do?’ ‘You told me they suppress the virus’
‘What does this do to the body’s ‘soldiers’?’ ‘Why are you asking me? You told me what it does’.
The translator is visibly struggling and tells me the way that the conversation is going. I venture ‘Tell her that I want her to tell me what the treatment does for the body’s ‘soldiers’’.
This is relayed back and the reply comes ‘She says that since I know the answer and you wouldn’t understand her, why don’t I just tell you myself?’
This flawless logic can be difficult to get round but we eventually achieve our aim and she correctly picks the tablets out from a sweetshop pile of assorted ARVs. The abundant paperwork is completed and off she goes to collect her first prescription.

The next patient in is a young lad in a dressing gown. I will call him Sipho. I recognise him from the paediatric ward. His is a sad story; a mother who abused both alcohol and him and from whom he acquired HIV. He is short for his years, possibly contributed to by both of the latter, and by a tough deprived upbringing. Despite that he is a cheerful, alert chap with occasionally a slightly wicked smile flicking about the corner of his mouth (brief tip for the bored, try looking up synonyms of ‘wicked’ on Microsoft Word). He is about to start ARVs too. He is well drilled. He sits in the chair next to me and answers everything faultlessly. His is a life potentially wrecked by such an unpromising start, but is now in a state of possible rescue since coming to the hospital, although many problems remain. We go through the routine and I swivel round to fill in the paperwork on the desk. The next minute my world becomes unstable and I feel my seat plummet. I instinctively grab the desk which has shot up to meet me. What on earth….

I turn back to see that young Sipho has a particularly amused expression on his face. He has deliberately flicked the seat height adjuster on my chair and it and I have responded meaningfully to gravity. The translator is barely controlling her mirth.

Next in comes a Sangamo or traditional healer. She is coughing and looks to be walking with some difficulty. She tells us she was hit by a cow. Clinically she has a broken rib. She also has a fever and there are some noises in her chest suggestive of an infection. Her HIV medication is a routine for her; she is good at taking it and it is working well. I hope that her chest infection is something simple and not the first sign of TB. When I see her the next time it has pleasingly responded to the simple antibiotics I gave her. I wonder at the thought processes which must go on when she is plying her trade. ‘This medication is what you need to get better’ ‘This however is what I need’. The same mild schizophrenia pervades the ‘complementary medicine’ community in the UK who peddle their expensive bottles of water to the credulous public while getting vaccines, antibiotics and cancer treatments from the NHS.

The clinic eventually winds up very late. The war analogy I floated in my last post seems less than fictional at this moment.

In the HIV clinic (although not only there) what can sometimes come to mind is the legend of the little Dutch boy who noticed the leaking dyke and blocked it with his finger. As the hole grew he put firstly more fingers, then his arm and eventually his whole body into the gap to try to dam the water flow. Eventually he is discovered and the dam is repaired. He is proclaimed a hero for preventing his village from being inundated by the deluge which would have occurred had the dyke broken sooner.

We usually use the phrase ‘finger in the dyke’ to describe a temporary fix for something bad that is going to grow and grow and ultimately needs much more drastic action to cure it, commonly with the implication that this may not materialise. The HIV clinic gives one exactly that impression of having one’s finger in the dyke. It would be nice to envisage that the positive take on the story, the fact that the boy did eventually hold things together until proper help arrived, will also be the outcome here.

The real solution to the leaking dyke however is education. It is great to see people living normal lives on regular ARV treatment. it is good to know that even critically ill people with AIDS can now be brought back to health. The problem is not that HIV is untreatable; the ongoing tragedy is that young men and women (and old) are still getting infected. As a salutary example I added an extra question of my own to the pre-treatment grilling that one 28 year old had. She had answered everything perfectly. I said I was very impressed but had she understood about how you catch HIV before she actually caught it. ‘No’ she said ‘I only learned all this from the counsellors’.

South Africa has travelled a long way from the dark days of beetroot, garlic and lemon juice being recommended at governmental level for a disease that was pronounced as not being due to HIV. In educating its people however it would appear that it has in places barely crossed the start line.

In the UK we face a problem of treatment having become so routine and benign that the fear of catching HIV, at least in certain groups, has fallen. As a consequence risk taking behaviour is in resurgence. Here it is another educational problem, but a different one, which in addition has a cultural side to it, much of which revolves around gross gender inequality. A touchy subject for another time.

From the front line

I have already made reference in a previous posting to the problems that Zithulele and other hospitals experience when they refer patients to Mthatha hospital, and the knock on effects that the strike at Mthatha is having.

What I should also have mentioned is that probably the most significant effect is being felt on access to the supplies that are needed to run Zithulele as a hospital. All of our pharmaceutical supplies and sterile materials, intravenous fluids, needles, intravenous lines, urine bags – in fact everything I take for granted every day in the NHS – come from the depot at Mthatha. Since September 11th there has not been a proper delivery from there. Initially they were stocktaking and now the strike has meant that there are two managers trying, and failing, to keep up with orders. Our pharmacist has been over there in person three times and been allowed to bring back minimal quantities of drugs.

There is a morning meeting of some sort here every day; a journal club or a morbidity and mortality meeting and sometimes just updates such as on Monday morning after the weekend’s events. Since I arrived at the beginning of October it has been a feature of these to have listed what drugs are out of stock, and (sometimes quicker) what is left that we can prescribe for a particular condition. I joked a few weeks back that it was like being in a war zone, or Berlin at the time of the airlift, with the daily update of what munitions and food had made it through and what the strategy was for keeping the war effort going in the face of severe shortages.

Unfortunately the joke has worn thin. Day by day the number of medicines unavailable or worryingly low has grown. Aspirin was out for a while and is now back, coinciding with paracetamol running out. Neither of these is a huge inconvenience in a rural practice compared to treatments for the many immediate life threatening diseases. The state of far more important supplies is now however critical. In the next few days or weeks the end of the line is in sight for many vital drugs. There is enough 50% dextrose to treat three patients whose blood sugar drops dangerously low, and enough magnesium sulphate to treat 1.5 (yes, 1.5) women with eclampsia. Ciprofloxacin (basic antibiotic), Flammazine ointment (first line for the many burns we see), as well as the first choice suture for closing a uterus at Caesarean section are just three of the 19 basic items that are completely out of stock. For only three of the 11 standard antibiotics is there enough left to treat more than 10 patients. For some there is literally one course remaining.

I think I was not alone in imagining that this was a relatively short term problem. Strikes which endanger human lives should never happen anyway and the very gravity of it would have triggered adverse publicity and prompt (and panicky) political action in most democracies. The occasional delivery fostered hope. I was expecting to write, under this title, an amusing tract about how we made it through, in the form of a wartime spoof, Dad’s Army style. No way.

There is no decrease in demand for healthcare either. Last weekend there were almost as many patients waiting in outpatients for admission (and being treated there) as there were beds in the hospital. That won’t change much, but the suboptimal (bordering in some areas now on sub basic) care we are able to give reduces the successful discharge rate and means the availability of beds declines except where people vacate them in the way we least want.

The Mthatha depot at its best is not great. They have a habit of sending us supplies a few weeks before their expiry date. They presumably reserve the newest for themselves. Using a drug at or after its official expiry date is a gamble; a gamble with a person’s life.

Here in Zithulele, an extraordinarily resilient, positive and motivated staff is having their best efforts stymied. It gives the appearance that other people don’t think what they are trying to do is worth bothering about; certainly compared to important things like performance related pay. There is great leadership here and fantastic spirit and optimism. It is a potential tragedy of huge proportions when the wilful and selfish action of others raises the risk of eroding that.

The dazzling irony of the current position is of course that all the supplies that are needed are already sitting at Mthatha. If they didn’t exist people would just hunker down and do what they could with a philosophical resignation but with the knowledge that it was out of everyone’s control. This scenario is like the parched man who can’t quite reach the glass of water. Or rather the stupid, self-centred and thoughtless person holding it just out of reach. This situation could be remedied in a couple of days with a couple of large trucks.

South African people did not vote for this. This is not what the electorate in this remarkable country expects or deserves. No one believed that a utopian society would emerge miraculously overnight after apartheid fell. But people should not to have to put up with a supine, impotent administration turning a blind eye to the inconvenient truth of poor folk dying for lack of access to something that they have a right to, because it is locked up in a depot a few miles away.

Driving conditions

People adjust quite quickly to the scale of their environment. In London I automatically allow an hour to get anywhere and when living there it wasn’t a big deal to drive for that length of time to visit people. In Cambridge, unless I have to, I am reluctant to travel all the way to the north side of a town which is barely 3 miles in diameter. The Americans are legendary for travelling miles and miles for a day trip. Here it is similar; the huge distances mean that you accept that to get anywhere necessitates you spending hours in the car; it is just a way of life. One UK expatriate who worked here some time back is remembered fondly for exclaiming in frustration half way from Zithulele to Durban that wherever he was going in the UK, he would be there by now.

I am going to Port Edward to meet up with Amy and visit her hospital at nearby Bizana. According to Google Maps it is 370km from Zithulele to Port Edward which doesn’t seem too far.

I have begun to enjoy the drive to the N2 from the hospital; the scenery is a pleasing mixture of unpopulated wide swooping valleys and small collections of farmed areas. The weather is beautiful as I set off; the sun is hot and the countryside at its best, a rich greenness spreading as far as the distant hilltops and a blueness to the sky that you find only in places like Northumberland, well away from the hazy pollution of towns.

Approaching Mqanduli the road is in poorer shape and there have been repairs ongoing for many months. These involve a local specialty of traffic control. Superficially it will be familiar to UK residents as it is a version of the single lane contraflow with Stop/Go signs. One lane of the road under repair is made inaccessible with some cones and barriers but the innovative deterrent here is the deliberately scattered boulders the size of house bricks which pepper the unfinished side of the tarmac. Traffic takes turns at travelling along the intact lane and the whole operation is policed by a quite substantial number of people at each end, equipped with mobile phones, whose job it is to speak to each other and, between them, coordinate the turning round of the Stop/Go signs to let one or other traffic stream move. The phones are needed because the repair companies work on very long stretches of road at a time and one cannot see from one end to the other. All this sounds conventional until you realise that the team at each end treat their job primarily as an excuse for a social gathering; the road control is an incidental nuisance which drags them away from chewing the fat and generally catching up.

It is nice to see a group of people clearly enjoying themselves whilst at work; their roars of laughter echo out across the scene. I stop where indicated and wait while a small line of half a dozen cars, vans and taxis comes through in the opposite direction. The traffic stream peters out and I put my car in gear ready for the off. I wait for whatever straggling vehicles might be on their way but none come. Time ticks on; the amount that has elapsed would have been enough to empty most of the M25. My empathic pleasure at the bonhomie in front of me begins to wear thin. Suddenly one of them jumps up as if stung and, remembering why he was here, clamps his mobile phone to his ear and marches forward to swing the sign round from Stop to Go. He returns to his seat on an oil drum and the laughter resumes.

At this stage all should be well but I move forward tentatively. The Doctors at Zithulele refer to these not as Stop/Go, but as Go/Go, roadworks. This is because at any stage you may encounter vehicles coming towards you, usually at high velocity, commonly the minibus taxis, jammed with passengers. The conclusion must be that the coordination between the teams at both ends is somehow not quite perfect. I creep forward along the narrow single lane, a steep slope to the right and boulders to the left, wishing I was in the Night Bus from the Harry Potter books with its ability to squeeze through impossible gaps. I eventually get to the checkpoint at the other end where a line of traffic sits. The drivers are visibly drumming their fingers on the steering wheels in tight lipped sufferance at the hysterical laughter from the traffic crew at this end. The unworthy thought pops into my head that they might be laughing at the setting up of the near misses that they have engineered that day. My paranoia centre is obviously in overdrive, surely no one would…. would they?

As I approach the main N2 trunk road I pause briefly at the ungated single track railway line with its easy to ignore Stop sign. Only one train passes each day but the local traffic police have a favourite pastime of hiding nearby and pouncing on forgetful drivers who drive straight across, at which point the choice is between either a trip to the police station or their much preferred on the spot cash fine.

I turn on to the N2 and head for Mthatha. On a clear morning the view to the West can be magniificent; the wall of peaks of the southern end of the Drakensberg rising out of a layer of low cloud. Today the there is too much heat haze to see that far. The traffic is reasonable and the road generally good providing one keeps alert for the many and often mysteriously sited traffic calming devices. The most obvious are the sleeping policemen rising from the tarmac, conspicuous with their white diagonal stripes. There is no uniformity about these, either between groups or within a group. You can be lulled into a sense of security by the gentle undulation of the car as you cross them and then, at an unexpected interval one much bigger than the rest rocks your suspension and tosses your luggage into the air. The only trick I have learned is, as I approach, to examine the tarmac in front and beyond each bump to see how much it has been scraped by the undersides of previous vehicles. Often these humps are neither painted nor signposted and it is only the sudden slowing of traffic in front that provides the warning. They also have rumble strips. These are not the gentle auditory reminders I am used to in the UK which make a short ‘diddley diddley dit’ as you cross them. Here they are laid in wide serried ranks with each strip the height and diameter of a broomhandle; a blatant conspiracy with the dentists to make all your fillings drop out.

I negotiate the hazards to and through Mthatha and set out North on the N2. The scenery becomes rugged and Pennine-like but with the ubiquitous tough grass instead of heather. At its best the road is fast and smooth. The landscape of vast ranges of towering hills stretching to the far West to the smoky blue peaks of the distant mountains of Lesotho would grace any Lord of the Rings movie. Yellow billed kites soar past occasionally with their instantly identifiable forked tails.

It is late in the afternoon and the sky dulls with gathering cloud. The drive has already been long with only one brief stop. I come to a lengthy Go/Go section where the traffic comes to a halt and I can see the stationary queue curving up the hill to the left in front of me for at least a mile. The old hands switch off engines and get out. We are a long way from the actual Stop/Go sign and the road is still two laned although the oncoming right side is of course empty. As if from nowhere a group of locals, mainly women, appear, brightly clad in wonderfully unmatching primary and pastel coloured tops, skirts and headscarves, carrying trays and bags in their hands or balanced securely on their heads. It is the local service station that has sprung up in response to the regular lines of stationary traffic. They have drinks, fruit, lurid bags of sweets and gifts to sell. One man is carrying what looks like a bunch of long strings of liquorice. On close inspection these turn out to be in-car chargers for virtually any make of phone you can name.

The food sellers do a relaxed but reasonably successful trade with the drivers. There is no pressure, they know they have plenty of time for people to change their minds even after a first refusal.

After about 25 minutes I spot some forward movement of the trucks at the very top of the hill. Like the old Le Mans race start we all run to our cars and get in and optimistically switch our engines on. At this point I am stunned as all the taxis take to the right hand lane and start shooting up the hill overtaking the queue and then forcing an entry back in as they approach the roadworks. The bare-faced cheek of it leaves me speechless with indignation. Luckily I just make it through and I fume impotently for the next half hour.

The road is very high up now and far off to the right out of the corner of my eye I catch a flash of light. It looks like lightning. I reach my turnoff and settle down for another long stretch on the road to Bizana and thence to Port Edward. The road winds to and fro through darkening countryside. Bizana seems a lot further than I thought. Again out of the corner of my eye a see a flash in the sky. It is probably a storm at sea as the coast is in that direction but luckily it seems further south than I am aiming. Another hour passes and the flashes continue. I have a rising sense of unease as the road direction slowly but inexorably inches round to the right. The flashes gradually move from my peripheral vision until they are dead ahead and it dawns on me that the storm is at or near Port Edward.

By now it is pitch dark and I pass through small villages of rondavels and houses with pinpoints of lantern light in their doorways. The road slowly and then more rapidly descends as I approach Port Edward and the storm becomes more and more visible. It has been going on for an hour already and for the next hour as the coast nears it gets more and more vivid. There is barely more than two or three seconds of darkness between each spectacular flash which lights up the whole sky and the clouds above the now visible sea. The cracks and rumbles of thunder follow at shorter and shorter intervals. It is as though Thor and Zeus have come head to head in the final of ‘Strictly Come Bolting’. ‘Take that, Nordic punk!’ ‘Huh that little fork, weaker than your Greek economy; follow that!’
I have never experienced a storm like it. Mercifully, I muse, the rain is all out at sea, but as I pass the sign saying Welcome to Port Edward huge beefy drops begin hitting the windscreen and soon the wipers are full on and barely keeping up with the deluge coming down from above.

I have a mental map of where the hotel is and at the ‘robot’ I turn off down the road signed to Port Edward. The road winds down through a progressively more deserted housing estate and reaches a dead end. It is still absolutely pelting with rain. I recall that I cleverly left the hotel details in the boot of the car. Luckily I have their phone number so I call. An urbane African voice tells me, a little patronisingly perhaps, that I shouldn’t have turned off down this road. I am to go back to the junction and turn right at the robot and continue up the road about one and a half kilometres where is a neon sign showing the name of the hotel right by the turnoff. I drive back and turn up the hill as instructed. For the life of me I can find no sign, neon or otherwise. About 3km further on I pull off and phone again. ‘I seem to have missed the sign’ I say ‘I am at a sign saying Glenmore’. ‘You have gone too far’ he says smoothly ‘you will have missed the hotel sign because of the power cut’, ‘Has that just happened?’ I ask. ‘No it has been out all day’ he says.

Seven hours after I set out I finally reach my destination where the welcome is warm and the room is superb. Supper settles the stress and it is bedtime.

Before going to sleep I consult Google Maps which tells me that the drive to Port Edward from Zithulele takes 5 hours 38 minutes (precisely). Perhaps it is tiredness from the journey but this suddenly seems hysterically funny and I start to giggle. 5 hours 38 minutes – for Luke Skywalker possibly…


The industrial unrest in the mines is still big news here. The headlines are dominated by claim and counter claim and some very high profile politicians are wriggling uncomfortably in the spotlight. One minute everything is resolved and the miners are all going back to work and the next there has been some new development (usually involving further violence) and they are back to square one. The families of the 34 miners shot by the police at the Marikana mine were offered financial help to attend the hearings. This was then withdrawn but now a contribution to the costs is back on the table. There are allegations of the police arresting and torturing miners who might be called as witnesses of the police killings. The enquiry into the shootings of striking miners has begun although the major focus appears unexpectedly to be on the three policemen who were also killed and ensuring that everything possible is done to bring their killers to justice. Weighty comments are being made about lawless armed strikers. The part of the investigation which concerns why the police felt authorised to shoot the miners seems to be taking a back seat. One slowly emerging connection is that Cyril Ramaphosa (who is being nurtured by Zuma as a possible successor) was quoted before the killings as saying that the strikes ‘are plainly dastardly criminal acts and must be characterised as such’, adding that the response to them must be by ‘commensurate’ or ‘concomitant’ action (depending on which article you read). Ramaphosa is a very wealthy businessman apart from being a very big wheel in the ANC from his high profile activities during the struggle against apartheid. The finger is being pointed at him as sanctioning from within the ANC the excessive response of the police. Why should someone with such an active Trade Unionist history have such a bias against the ‘working class’ miners? Could it be anything to do with his company holding a 9% stake in Lonmin, the owners of the Marikana mine and him sitting on the Lonmin Board?

There is much else of this ilk if one has the stomach to wade through it. It strikes me again that George Orwell would have felt prophetically vindicated with the situation here, and Tom Sharpe, if he could find the energy to write about the post-apartheid era as well and as prolifically as he did about the apartheid era, would find no less fertile material for his penetrating satire.

By contrast another strike has generated virtually no publicity. It seems not to have been in any of the media. There are no queues of journalists jostling for unique ‘angles’ and churning out copy with every trivial new development. Friends elsewhere in South Africa are completely unaware of it and yet it has almost certainly killed many more people than died at Marikana. There will be no judicial enquiry when it is over and none of the relatives of those who have died will be in any position to take action against the perpetrators for the loss of their loved ones, let alone receive financial support to do so.

In the UK when the nursing profession have in the past even mentioned industrial action it has excited polar responses of sympathy and censure. Nowadays the Royal College of Nursing in the UK has a ‘no strike’ policy. This is for the very reason that a stoppage by these pivotal individuals most affects those least able to help themselves. Lives would be at risk.

No such concerns cloud the brows of the nurses at Mthatha hospital – or to give it its full name The Nelson Mandela Academic Hospital – who have been on strike now for 5 weeks. In this time they have comprehensively crippled the hospital and have wreaked havoc on all of the smaller hospitals, including Zithulele, for whom NMAH is the major referral centre.

This strike is also over pay. One grievance is that the nurses’ night allowance money was not paid. This was because the hospital authorities noted that the pay claims being submitted for night duty payments included the names of people who were on leave at the time; perhaps a reasonable concern and worth investigating. Subsequently this same group of staff at what is widely known as the worst performing hospital in the Eastern Cape continued to strike because of the hospital withholding their performance related pay (sic). They are still out and there is little sign that a return to work is imminent.

Time and space (and a limited lifespan) prevent me from detailing what a disgrace and a disaster the normal level of treatment at this hospital is usually like. It is telling that, unlike other hospitals in the Eastern Cape, they don’t use the standard audit tools to assess their own performance. There are a few good conscientious people among the medical staff (and probably among other groups there too) but the overall standard is below what I would inflict on my worst enemy.

They have radiology services which we don’t; at present not only is the ultrasound machine at Zithulele on indefinite strike but the X ray machine has broken. Sometimes our patients’ management is critically dependent on a scan. More often than not the hapless patient pays for transport for the two hour drive to go to Mthatha only to be turned away at the door (and this is when they aren’t on strike).

A few other choice examples of their standard of ‘care’ out of very many:-

A patient coughing up life threatening amounts of blood is referred there for an opinion and treatment and sent back to us the same day because the doctors there say they could not make an assessment without a chest x ray. The machine to do this five minute investigation is an integral part of workings of the chest medicine clinic to which they went.

A patient with a plastic tube draining inflammatory fluid from their abdomen (which was needed because it was collecting in huge quantities) comes back to us after a request for a scan and a medical opinion with a note saying that ‘the colostomy is functioning well, no further action’. It would be funny if it wasn’t so tragic.

One man whose feet needed amputating, because of gangrene caused by long standing disease of his arteries, eventually went to the surgical team there after over a month of requests, debate, argument, persuasion and pleading. Conventionally a leg amputation is performed just above the knee or just below it as this makes fitting artificial limbs easiest and gives the best hope for being able to walk again. In the operation it is important to remove more bone and muscle than skin so you have a large flap of skin which you sew over the end of the stump to cover it and allow it to heal over. Leaving bone and muscle exposed means it will just get infected and never heal. I apologise to those with weak stomachs for the appended picture showing the handiwork of the Mthatha team in pioneering a novel operation – the ‘above ankle’ amputation, which cannot heal.

With the onset of the strike Mthatha has now gone from merely dangerously incompetent to simply awful. Today we tried to send a newborn baby there because her blood oxygen level was extremely low for no obvious reason and we suspected a congenital heart defect. The (very good) paediatrician there advised us, nearly in tears, that it would be the worst thing possible to do as he was acting as doctor, porter, nurse and clerk and that babies were dying all around him. The baby died on her way to a more distant, but much better, hospital; one which would normally not accept referrals from so far away.

Nobody would dispute the right to protest in a legitimate way for a living wage. Few people here are well paid and the average black wage is about one fifth that of the average white. Ironically though some of the best paid staff are government employees, including nursing staff. So to add to the obscenity of the ‘caring profession’ abandoning the helpless, we have some of the best paid workers in the most secure jobs going on strike from a job (which some of us naively think of as a vocation) and causing direct harm to those much worse off than themselves.

Like people in other countries who work for governments, however badly they perform these nurses are generally almost unsackable. As occurs elsewhere (including the UK), the contortions that must be gone through to prove that an employee is not competent at their job are Byzantine and exhausting and often make the effort so out of proportion to the benefit of a successful result that it is just not worth the candle. However these nurses are on unofficial strike so the authorities would be completely within their rights to dismiss the lot of them.

We will never know how many peoples’ lives have been damaged irretrievably and how many have died because of this action. No administrator would dare attempt to quantify it and no politician would risk professional suicide by being implicated as a part of a government which passively sanctions such appalling malpractice. Whatever the death toll is eventually it will dwarf that at Marikana.

It may be very convenient for a government to have a high profile industrial dispute on its hands occupying the headlines, especially one which has an undercurrent of the privileged white company owner and the poor underpaid black. Admittedly the political fallout is probably not quite what they expected in Pretoria. What is not comfortable for these same politicians is for the general public to hear that nurses are behaving abominably; the well paid inflicting discomfort, danger and death on those who need them most. Nor is it attractive to them for the generally dire predicament of the state run health services in Mthatha to be made public. Call me paranoid but the complete lack of publicity about a situation that verges on genocide does not seem to me to be an accident.

How not to amputate

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