Five go to the beach

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What larks Timmy

New depths

This very brief posting is merely to relay, to anyone who is interested, how appallingly it is possible to behave in pursuit of one’s own financial ends.

The nurses at Mthatha are still out on strike and, as far as I am aware, the same holds at Bizana too.

The ambulance strike is still ongoing.

Clearly the ambulance crews felt that the stoppage was not getting enough notice. Sadly, there is a tradition here of the authorities buckling in response to intense industrial action, rather than doing what would send a very clear message to the strikers (and everyone in a Trades Union here who goes out on unofficial strike) and that is to sack them forthwith.

It is no longer enough to put people’s lives at risk and, let us be clear, people are dying through this irresponsible industrial activity. No indeed, one must make absolutely sure that the action is effective and damn the consequences.

The strikers have now trashed the control centre from where ambulances were coordinated, presumably to prevent anyone else from trying to do their job. No one would because it is clear from other developments that it would put them at risk of their own lives.

An ambulance which was going out to an emergency was shot at.

The last line of help is the helicopter service. These are only called on for extreme cases where specialist advice and care are essential such as saved the life of David our security guard two weeks ago.

The helicopter pilots have now received threats – and these are never to be taken lightly. Understandably they have stopped flying.

Congratulations all round: to the ambulance staff for showing us just how low one can go, to the local administrators for not having the guts to deal with this, and to the government for tolerating, in full knowledge of events, this abject uncivilised obscenity of a situation.

Strike two

The Greek philosopher Heraclitus supposedly once said ‘War is the father of all and the king of all’. He believed in perpetual change ‘nothing ever is, everything is becoming’. He might have used Zithulele as the exemplar of his thesis. Continual change is the watchword and it is perpetually like wartime.

Our pharmacy supplies are starting to trickle through and the drug charts at the end of the patients’ beds now more often have medication signed for and given rather than bearing the OOS (out of stock) acronym, which was becoming worryingly common. Many drugs like Ciprofloxacin and Diazepam however are still absent.

The excellent news is that injectable antibiotics are back in stock.

The anti HIV drug Efavirenz has been at critical levels. All patients on anti HIV drugs in which Efavirenz is part of the combination (which is the majority of the 3,000 patients receiving therapy here) are going to be at risk of failing treatment. The virus will potentially also develop resistance to the other two drugs they are on with Efavirenz and all three then become ineffective. If it does run out a rapid and potentially risky switching of regimes will have to occur; a large and very undesirable exercise, medically and logistically.
As an amusing aside, in training patients to take their HIV medication they are expected to remember the names of their pills. The fact that many Xhosa words begin with ‘I’, especially borrowed words (ibhokisi – box, ibhasi – bus, ikeyiki – cake) means that the name Efavirenz has mutated into iFiveRands.

Mo the indefatigable (and eternally cheerful) pharmacist, another hero of the conflict, tells us today that intravenous fluids are going to be tight since the depot only sent one twentieth of the order she had requested.

Despite this there is a cautious degree of relaxation around as the resources filter back. Just like wartime there are rumours of larger change at higher levels which foster some hope in the long term; not just long overdue peace talks but structural change to the system. It’ll all be over by Christmas – as they said about World War One…..

On the ground strikes are still ongoing at Mthatha, and the conflict has spread to my friend Amy’s hospital in Bizana where the nurses are also up in arms about money. Amy now has a single nurse on her ward and nothing gets done after 4pm. The sum of salary money involved is something like £50. Yet for this, peoples’ principles of care for the sick turn out to have the durability of tissue paper in a monsoon.

At Zithulele the nurses are working normally. Like nurses everywhere there are grades of commitment and excellence. Some feel that seniority brings with it an absolute right not to get physically involved in patient care. There is nothing unique about this; nursing staff worldwide include those who from the start are wannabee managers. I have sympathy with not wanting to do heavy lifting of patients as the years pass. The attitude of some that it is unacceptable soiling of their hands to do, or even contribute to, hands-on dealings with patients, because that should be done by their juniors, leaves me sad at the arrogance and loss of perspective. Although there are similarities between here and Cambridge, my nursing colleagues in Addenbrooke’s don’t have the same level of concern with their own dignity that I see here, nor do they revel quite so much in hierarchical self-importance. One nurse in maternity here was busy on the phone and declined the request from the doctor to get the urgently needed oxygen during a desperate resuscitation of a baby; to do this being clearly below her station.

I digress. The latest ‘carers’ to get the industrial action bug are the ambulance crews.

At its best this service is unreliable, hopelessly unpunctual and frustrating. To transfer a patient to another hospital one has to phone the ambulance service directly; something only the referring doctor is permitted to do. It can take literally hours to get through. You are obliged to provide vast amounts of information about the patient that you want transported, and about yourself. They take your cell phone number and the phone number of the doctor to whom you are sending the patient so that they can ring that person to check they are expecting them.

I am all for double checking but there are few jobs less replete with satisfaction here than ordering an ambulance, so why I would deliberately do it for a referral that was fraudulent is beyond me. Why would I want to send a patient whose interests I am trying to advance on a fruitless trip up the N2 to a Consultant who didn’t want to see them? I have far better ways of spending my daylight hours than making fake bookings.

After having made the booking (not to mention the number of times the line goes dead or the ambulance control phone reception decide they need to tell their life story to a passing friend while you are holding), after that there is still a sporting chance that nothing will arrive; frustration for us, frustration for the receiving team, and an appalling way of treating someone who needs help.

One day last week I had spent a goodly part of the afternoon negotiating with the ambulance ‘control’ (hollow laughter) centre and had finally confirmed that one would arrive the next day to take a patient with a gangrenous toe to the vascular surgeon at Mthatha. After a few tries I have learned that one must ask the name of the person you are speaking to. They don’t like giving it out, since a request cannot then be conveniently or carelessly lost anonymously, there is now a named person responsible. Taking their name and saying thank you and that you are writing in the notes that so and so has confirmed the ambulance will arrive seems to raise the concentration level a little.

In spite of this precaution, no transport arrived the following day. I phoned the control centre again and after an initial brushoff got more attention when I mentioned the name of the person who had taken the booking. There was much fluttering in the dovecotes and a promise to ring me back when they had traced where the request had got to. Remarkably within 10 minutes I got a call to say an ambulance was on its way.

Said vehicle arrived at 10.30 am and two young male ambulance staff swaggered on to the ward, took one look at the patient and said he didn’t need an ambulance. Anyway, they added, the surgical clinic closes at 11 so we can’t get him there in time. At this the nursing sister, Sister Kakele, who for me rates amongst the best nurses I have ever worked with anywhere, let off a stream of invective in Xhosa which had them reeling as though tongues of fire were licking over their naked flesh. I took a step back myself. This charming, superbly competent, quietly spoken mature lady with a gentle, slightly mischievous smile had metamorphosed into a latter day Boadicea and was at them on her chariot, scythed wheels whirling furiously. One of them made a brief and ill-advised attempt at a rebuttal and she merely turned up the volume and speed of delivery and he retreated, a withered charred shadow.

I decided to leave the carnage and went out to phone the relevant Consultant, a delightful man. I said the ambulance had said his clinic closed at 11. He was incredulous ‘They are talking nonsense’ he said (‘talking nonsense’ is a big insult locally as it hits the red dignity button squarely).

I returned to the ward to find the patient being meekly shepherded out by the ambulance crew. It was barely necessary to add my information, but I did for good measure, and it prompted a further furious tirade from Sister Kakele.

The two ambulance staff with the patient in a wheelchair disappeared down the corridor, tails between their legs, followed by a final stream of fiery advice from the Sister. I would love to have understood even half of it. My guess is that those two won’t want to come back to Zithulele.

They certainly won’t be back anytime soon as they are now on strike and we are without ambulances. Helicopters can be called for vitally urgent cases but other than that if our own patient transport vehicle is full then no one can get a ride to Mthatha without paying and we can send no urgent cases there such as acute appendicitis, road accidents, acute brain haemorrhage etc.

It is remiss of me not to have mentioned before now that we have no X-rays. This has been the case for the last three weeks. A replacement part for our machine has to come from Japan apparently and the situation wasn’t helped by a missed or inadequate service, I forget which.

When it is in operation the X-ray department is a hub of activity. At any one time you can meet one, two or more of your colleagues there perusing the films of their latest patient. Without it we rely entirely on clinical examination. Chest examination is doable without X-rays (note to students – never forget vocal fremitus, it can be critical). Suspected limb fractures are trickier. Abdominal distension due to intestinal obstruction, when it next occurs, will be a challenge since we can’t get a radiological diagnosis – but we can’t send anyone to the referral hospital anyway.

It is predicted that we will be without a functioning X-ray machine for another 4-6 weeks, so I may have seen my last Zithulele X-ray.

It is odd and somehow alarming how one just adapts to not having a facility whose temporary absence from a UK hospital would provoke expressions of amazed disbelief and a complete shutdown of clinical activity.

At least the pathology lab has been working – until this morning when the computer went down. Samples can be sent but no results from the last 48 hours are available. The result of the lumbar puncture I prided myself in doing last night in the patient in whom I suspected meningitis, and from whom the spinal fluid did not look normal, is as inaccessible to me as if I hadn’t done it.

The only choice is to treat with intravenous ‘domestos’, a combination of drugs which will treat all the probable causative infections.

Luckily injectable antibiotics are back in stock


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.