Strike Update

As you may know, there is a national strike going on in South Africa at the minute, which originated with government employees but seems to be spreading to take in workers from every sector. From my point of view the most significant aspect is that healthcare workers are also on strike – as I work in a government hospital, almost everyone here is a government employee and hence on strike. Today (Thursday) has been declared a day of ‘total shutdown’ by the unions and the vast majority of hospitals in our region have already been forced to close, many by rioting mobs. This week, the closest hospital to ours was attacked, forced to close and one nurse was badly beaten by a mob (which included workers from the Department of Health, no less) who believe that if anyone is working it weakens the strike.

Our staff here are understandably very scared and many left work without authorisation yesterday. We have had several staff meetings to try and determine a response to the crisis, which is affecting us on several levels. The hospital manager has received anonymous threats over the telephone this week as word has got out that we are still working here. Many of our staff are on strike and levels of care are consequently suffering. Furthermore, our supply lines have been cut since the beginning of the strike (over a week now) and we are running out of food and medicines.

It is very difficult to formulate an appropriate response. I wholeheartedly support my colleagues in their quest for more adequate remuneration for the job they do, which is often far from well rewarded. Especially as, if the union members here can be believed, the government and President have awarded themselves around a 50% pay rise this year. However, how can I support a strike that is violently and forcibly closing government hospitals, which are the only source of medical treatment for the poorest members of this society? There is no doubt that people are dying as a result, and more are likely to suffer in the long term from, among other things, the consequences of being unable to get their antiretroviral or anti-TB medicines. Similarly, the public health consequences in the future are hard to quantify but are unlikely to be insignificant.

We were informed this morning that the hospital only had food supplies for another 2 days to feed the current number of inpatients, which has already been substantially reduced. Only those who are critically ill or requiring daily injections have been kept in the hospital. The really difficult thing is that it seems to me to be a choice between allowing extremely sick people either to take their chances without medicine if we discharge them prematurely, or else allowing them to starve in the hospital – patients who are almost all malnourished already. The obvious solution is to buy food ourselves to feed those who must stay. However even this suggestion was met with limited approval, as our transport manager is reluctant to send any of his drivers to town to get food, and our hospital manager is happy for the foreign doctors to spend our money on food for patients if we wish but does not wish to contribute on the grounds that it is “not sustainable.” I can’t believe that we were talking of the sustainability of feeding people who are entirely dependent on us – it seems supremely callous.

The compromise solution was to discharge every patient who could walk, take oral medicines, had a home with food to go to, and could understand the situation. It breaks every principle we’ve ever been taught to send someone home who has not completed a course of antibiotics (for some TB treatment patients need to complete 2 months of daily Streptomycin injections). But if you can’t feed your patient…? And if they want to go home because they are aware that the hospital is unable to provide adequate care or even security? You let them go home with the best possible treatment you can organise and as much good advice as you can offer. We will buy food for the rest.

The whole situation is wholly unsatisfactory. My South African colleagues seem divided – those who are frustrated that they cannot fulfil their duty of care to patients, those who feel strongly that this is the only way to get through to an irresponsible government, and those who are terrified of the wrath of the trade unions. We all have to walk a fine line in trying to fulfil our legal, professional, and moral obligations whilst also striving for equality in this country of stark inequality. I feel my own frustration with the system failures here is only probably a filtered product of the intense frustration felt by people here for years which has boiled over into this strike. And who knows what you could be driven to if those who are supposed to be your allies – for me, the health service, and for ordinary working South Africans, the government – seem so woefully incapable of doing their job in supporting you. In 1995, they went on strike for 3 months…

So we were expecting my first shift on-call to be quiet, as even the taxis are on strike today. However that hasn’t proved to be the case, starting with having to discharge half the hospital this morning. Since then, I’ve had a 4 year old in status epilepticus, a man who had been stabbed through his hand, a malnourished and dehydrated baby, possible cryptococcal meningitis, jaundice/hepatomegaly and 5 ladies in labour to deal with (one stillbirth, one Caesarean, and three still going, hence being up at this late hour.) Plus: parents demanding to take their extremely sick son home against medical advice (apparently, legally, I cannot prevent them from doing this – very frustrating); a ward sister with severe back pain; and another of our nurses going into labour (she is number 5).

Anyway I wanted to let you know what the situation was like on the ground here. Thanks for your support and your prayers – I really appreciate it. My internet credit is running out so bear with me if it takes a while for me to get more – once I get some money in my bank account I should be able to top it up via my mobile but the likelihood of me receiving a salary this month is diminishing by the day!

Beginnings...

So... Welcome to my South African blog - and sorry it's taken me a while to get here. It's been three weeks since I arrived at Isilimela Hospital to begin a year of working as a Senior Medical Officer here. I'll try and give a bit of an overview though as I've been pretty incommunicado since I left.

I've been planning to come to South Africa for this year since January 2009, so you'd think with 18 months worth of preparation I'd have got my mind into the right gear for it when it came to leaving. But flying to Johannesburg, coming over the southeastern coast of Africa into Mozambique and then Zimbabwe before crossing into SA, and looking down at the vast empty expanses below me I have to admit I was surprised at how suddenly anxious I felt about it all. Turns out that agreeing to work and live in a remote hospital where you know no-one, have very limited access to the outside world, and being sundered from the people you care most about, is a pretty big deal. In retrospect, I can almost hear the sound of my carefully-constructed walls of denial crumbling into pieces. But you know, a hefty dose of reality only really strengthened the sense of this being the right thing to do, a massive opportunity and a massive challenge, albeit with a significant emotional price tag.

I have always found travelling alone to be a productive time for introspection, and to be honest I really felt the benefit of a few hours alone in Jo'burg airport to think and pray. So by the time I was getting on the little twin-prop, 15-seater plane which was to take me to Mthatha I was really feeling pretty peaceful again, although it's a shame that wasn't true for all my fellow passengers, some of whom refused to board once they saw how tiny the plane was! But then the sight of the jagged Drakensburg mountains, snow on their southern slopes, huge river gorges coming down from the Lesotho plateau, and the semi-desert Karoo to the west really heightened that sense of peace, with a contrapuntal sense of adventure to set it all off perfectly.

Driving from Mthatha to Isilimela is following the descent of those rivers that run from Lesotho down to the Indian Ocean, so you start in fairly flat, featureless terrain dotted with little round huts (rondavels) which are almost all painted, for some obscure reason, in either salmon pink or mint-choc-chip green. Then the road starts to wind and descend some fairly dramatic hills and you're into the Wild Coast proper, with the same rondavels on every hill, but this really dense, dramatic forest poking out of every valley. About 13 miles before Port St John's there's a turn off down a dirt road and it's 7 miles from there to Isilimela. These have to be taken pretty slowly due to the potholes and rivulets cut in the road by the rain, but also due to the local love of speed bumps which have helpfully been raised at any point where it might be possible to build up some speed! But the views are pretty stunning and apparently due to get much better soon once the rains arrive. It is the end of winter here and there's been no significant rain for months so everything is a bit brown and dusty. But a few of the trees are signalling their intent by blossoming furiously - particularly the coral trees which have put out clusters of fiery orange or red flowers on every branch, but no leaves as yet. The hospital itself is perched on a hillside, and you can almost see the sea from just behind it. It's perhaps another 3 or 4 miles to the beach at Mpande.

I've been adjusting to life here quite well - it's a completely different rhythm though. Work starts at 8am when the doctors (there are 5 of us currently - two Dutch, a Belgian, a Nigerian, and myself, although we'll be down to 4 from the beginning of September) meet to discuss any patients admitted from the day before. Then we each go to our own ward - I've been looking after the General ward which is mixed Medicine, Surgery, Orthopaedics, Gynae, Psychiatry etc - basically anything that's not Paeds, Obstetrics, or TB, which all have their own separate wards. After a ward round, we go to Outpatients and the rest of the day is spent doing a mixture of General Practice and Casualty work - basically seeing mostly patients who are there for review of chronic conditions (largely hypertension, diabetes and epilepsy), emergencies, or new admissions (generally TB or AIDS-related). There's very little elective surgery here but we have a fair number of emergency Caesarean sections so I've also been helping with those either doing (spinal) anaesthesia or assisting the surgeon. Ultrasound is a major diagnostic tool so I've been using that a lot too - and have just been to Durban to complete some basic training in it which was very helpful. The day finishes really when there are no patients left to see in OPD - usually between 4 and 6. It's dark not long after 6 which doesn't leave a lot of time to do anything outside unfortunately. I have been to the beach a couple of times in the evenings - it may be winter but it's still warmer swimming here than it was in Scotland in July!

While everyone here has more experience than I do, none of us are very senior, and in fact (for what it's worth, which is not very much) I actually have the most experience working in internal medicine as the others have been trained in surgery and Ob/Gyn primarily. It means we have a fair number of diagnostic as well as management dilemmas which we struggle to get any senior opinion on. Our referral hospital is in Mthatha and while some of the consultants are apparently very helpful, my own experience of asking for advice from there has been very frustrating. The pathology is very diverse and patients tend to present very late - often with CD4+ counts in the low teens and twenties (i.e. well-established AIDS for the non-medical among you). TB presents in all sorts of ways as well - from the malnourished child to the elderly with meningitis, to the HIV positive patient with cauda equina syndrome from TB in the spinal discs. I guess it's an uphill struggle all the way, compounded by the fact that death is such a feature of life here to the extent that life is treated as if it's very cheap. Though I am assured that things are a hundred times better than when the first two foreign doctors arrived here last year, the nurses still often fail to give essential medicines like antibiotics, or don't inform you when a patient is unwell (they waited almost a full day until a ward round to tell me that a patient had a BP of 69/36, a pulse of 158 and a temperature of 39.7 degrees - all assiduously entered in the notes without so much as a 'doctor informed' - and were surprised when I asked them to get me a bag of intravenous fluids asap). Pain management is also not a priority and usually doesn't extend beyond Paracetamol, even for palliative patients with extensive metastatic cancer. The spectrum of psychiatric pathology is also quite different from what I have seen in the UK and we have had to admit a few patients with quite dramatic physical presentations which then turn out to be entirely functional. We don't have a laboratory (although I'm trying to see if we could get the one microscope here up and running to be able to do Gram and possibly India ink stains on CSF) and any investigations take between 3 and 4 days to come back - so by the time we get the results the patient has already got better or died in many cases.

My lack of ability to communicate in Xhosa (it's that language with 6 clicks in it which seem to be almost unpronounceable for the European tongue) is also very frustrating. For example, I have a patient who was sent from our referral hospital where he had been sent for dilatation of a malignant stricture of his oesophagus. Unfortunately they don't have any balloons to do the dilatation there so they sent him back to us with succinct instructions to give him IV fluids and morphine. After careful questioning, it appeared that at no point had anyone explained to him that he has cancer which cannot be cured and that this is why he cannot swallow solid food and has permanent pain in his throat. He had been complaining every day about this, and believed that once they got a part for a machine which he didn't quite understand, he would be cured - hence wanting to stay in hospital rather than going home to his family. Trying to break this news to him through a translator was extremely difficult. Especially as I'm not sure how the nurses translate it, but going by the amount of talking amongst themselves and giggling, I guess they probably wouldn't pass a communication skills OSCE station. Then again, I often have to take a step back and admit that I don't know this culture, I don't know how people here want to be treated/spoken to, and perhaps this is the culturally appropriate way to do things. But that doesn't change the fact that it just feels wrong.

Thankfully, I've been given a bit of time to adjust before having to take on full on-call duties (although I have had to get up and assist in theatre overnight a couple of times), but my first 24h on-call is on Thursday. I'm particularly worried about the Obstetrics as this appears to be a bit of a black hole in my medical repertoire, and there is a lot of Obstetrics going on here. Particularly, the women seem to develop eclampsia astonishingly quickly and start fitting at the drop of a hat. Without the capability to do general anaesthesia (currently but hopefully in the future) here we then have to transport them to Mthatha for Caesarean, which can take hours to arrange as we don't have an ambulance service.

Another huge frustration here is the paperwork. Basically I'm still not formally employed here despite receiving a job offer in May for a job starting on the 1st of August for which I have submitted all the requisite documents months ago. It's hard to understand but believe me, much as I may have complained in the past, bureaucracy in the UK is nothing. As many of you will no doubt be familiar, developing countries have embraced the concept of bureaucracy wholeheartedly - they seize on the opportunity for paperwork, letterheads, stamps, meaningless job titles, clasp it to their bosoms and nurture it like an only child. I had a job interview on the day I arrived where I was asked a bunch of ridiculous (and quite amusingly abstract) questions by people who have never before held a job interview in their lives. Said interview questions were the result of a full morning's worth of meeting to plan and devise them. Apparently the fate of my employment currently depends on a signature on a memo which, at the last update 5 days ago, was on the desk of the correct person whose hand is able to provide the required signature. No word has been forthcoming as to whether this hand is temporarily incapacitated or perhaps as to whether the memo is drowning in a sea of other memos from hospitals who wish to perform other routine tasks like purchasing medications or needles or loo roll, which all also require signed memos. Lack of official employment has made it difficult to get a bank account and hence register for a mobile phone and internet access which partly explains the delay in achieving these goals - however I decided to fight fire with fire on Friday and took every official document I could procure to the bank, replete with as many rubber stamps as I could get it stamped with, and they appeared to not notice that I didn't have a contract until my colleague politely asked, "should he bring his contract once he gets it?" Thankfully at this point the account had already been opened...

Anyway apart from attempting to practise medicine and wrestling with bureaucracy I've been able to travel a little bit - I've stayed one weekend at the Kraal backpackers which is just at the end of our road, on a small peninsula between the beach at Mpande and another beach. Every morning, a school of dolphins patrols back and forth just at the edge of the peninsula, so you can watch them as you eat your breakfast on the veranda. The annual migration of Southern Right Whales is also taking place at the minute so I've been lucky enough to see a few of those too. Last weekend I went to a place a few hours up the coast towards KwaZulu Natal and stayed in a really nice hotel - it was a collection of thatched rondavels in traditional style right on the beach, in the forest. Really nice to walk along the coast, see the whales, watch the Wild Coast live up to its name (the waves are pretty spectacular). And then just this weekend I was in Durban - which feels like a trip abroad, it's a completely different experience. The city is huge with massive freeways, enormous suburbs, and the biggest mall I have ever been in. I don't even know how big it is as I never actually saw the end of it, but it's apparently the largest in the southern hemisphere. Certainly I walked in one direction for about 20 minutes and didn't come to the end.

I think that's more than enough for now - I'm not sure how many people will read this, or what proportion will actually make it through to the end but it has been quite some time since I've been able to communicate with most people so I thought it's worth writing a decent update. I was also wondering about maybe putting a few of our difficult diagnostic cases on here, maybe some X-rays to see if any of you medical minds could offer any suggestions? We shall see. Anyway thanks also to everyone who has written/messaged, sorry I've not responded to very much at all but I will be working through the backlog over the next wee while. Keep in touch and of course, visitors would be very welcome!