Last Day at Mosvold

Well, tomorrow we are off to Durban and then we begin our lovely twenty six day holiday. We are very much looking forward to Cape Town, Namibia and Kruger.

However, we feel great sadness leaving Ingwavuma which has been our home for nearly a year. The beauty of this place never ceases to amaze me. The Lebombo mountains, the magical sunsets (and sunrises if I am up in time), Fancy Stitch, the children playing, the cows and dogs surviving in the road and the hustle and bustle of life here. I will miss greeting everyone with ‘Sawabona’ or ‘Yebo’ and I will miss the laughter.

The past four weeks have been my busiest as a doctor. I have been on-call ten times in four weeks. There have been many sleepless nights but my highlight came on one of my on-calls. I was working a few weekends ago when a child was handed to me in my arms from one of the ambulance men. I was alone in the resuscitation room. I looked down to see a blue baby gasping. His mum was crying in the background. Both she and I knew he was going to die very soon.

I immediately took his clothes off to find non-stop diarrhoea. His Mum admitted to giving an enema a few hours earlier. I told the ambulance crew to stay with me and began to resuscitate him with oxygen and fluids. My heart always beats a bit quicker with the prospect of securing intravenous access on these four month frought babies. The child was shocked so his veins in his arms and feet would be hard to find. Often, it takes me seven or eight attempts before I get the cannula into the vein. IV fluids is the only thing that may save the baby. I did not have the time for several attempts. Amazingly (and very luckily), I was successful on my first attempt. I took some blood to send it for basic tests. We secured the drip with cardboard, bandage and tape. I asked one of the ambulance women to stand on a chair and squeeze the fluids into the vein. We drew up the necessary antibiotics and gave them to the child. He had survived the first ten minutes in hospital, there was hope.

The bloods came back thirty minutes later and they were dreadful. He had severe metabolic acidosis and his potassium was dangerously low. I gave him IV potassium. He survived for first hour and I sent him to the ward. The next morning, I went to see if he had survived the night. He had. Eight days after coming in – Wonderboy (his Mum named him appropriately) went home. I took a photo of him and me. He looked so well – unrecognisable to how he arrived. The Mum told me she would never give an enema again – I hope she does not.

I have so enjoyed my work here – the wards (Paediatrics, Isolation, Male and Female), the variety of our outpatient department and the clinics have been my favourite. Today at lunchtime, the staff on female ward are throwing me a ‘surprise’ farewell party – such a nice touch especially as many of them have so little. We will sing and dance and laugh. They have also invited Henry.

On Tuesday after my on-call, we had Sophie and her daughter over for one last lunch together. Sophie is our cleaner, handwasher of clothes and so much more. She is my Zulu mum here and I love her to bits. Henry and I decided to give her everything that cannot fit into our backpack. So, she received over half of our clothes, most of our shoes, our bedding and kitchen stuff. She and her daughter are thrilled. Yesterday, whilst I was busy on my ward, Sophie popped her head in and pointed to her feet. I looked down to see my very old shoes on her feet and a big smile on her face. She was thrilled. Sophie is an incredible woman. She has had a tough life but has never complained. She has raised four children who are all doing well. I will miss her very much.

Tonight we are having a farewell braai and we are looking forward to having all our friends around. This is what I will miss most about this place – the amazing friends we have made. Nat, Ty, Bee, Bird, Sarah, Bjorn, Kath, Emma, Donne, Toni, Marge, Megs, Ruth, Simon, Smah, Swifty, Bridget, Janet, Andries, Bernard, Pheobe, Daniel, Maryna, Holger, Sam - thank you for your friendship, kindness and generosity. We will miss you!

Leaving the mountain of the leopard

My last day at Ntabayengwe should have been a time of sadness. And it was. I will greatly miss the teachers and the grade 7 students. I know many of those that I taught this year will go next year to the nearest high school. There, the most able will rot. Many of the girls will become pregnant. Many of the boys will drop out. Much talent will never be fulfilled.

However, I have faith that at least one or two will overcome the obstacles. They will pass their matriculation (equivalent of A-level) and will get better paid jobs in the local community – as a nurse, teacher or policeman.

This helped me to overcome any feelings of despair.

Further cheer was provided by my parting gift to the school. As you know I have been in correspondence with a regional newspaper about the school’s water shortage. Thanks to pressure exerted by the Zululand Fever, a team arrived earlier in the week to investigate the problem. They identified the cause as being a broken pipe running under the playing field. Yesterday, they returned to fix the problem.

Today, I arrived to find children drinking from the tap and filling buckets for the classroom. So the school now has functioning electricity and tap water. And it only took one year!

School chicken

With my last day at Ntabayengwe tomorrow, our South African adventure feels near its conclusion.

The school has provided me with much more than a year’s worth of interest and reward. And it has provided me with so many amusing moments. Yesterday I had another to add to the list.

Walking across the school I noticed a chicken being kicked by some of the children. It was surrounded and squawking. It looked greatly in need of help. I immediately ran to intervene on behalf of the bird.

One of the older boys saw me coming and, like the best turncoat, suddenly started protecting the chicken and fighting off his peers. When this failed, he dived on the chicken, putting his body in the way of the feet. As I reached the action, the boy scrambled to his feet with chicken tucked under his arm – like a rugby ball.

I demanded to know why the chicken had been attacked.

The answer was simple. It had been trying to eat the vegetables planted in the school plot. Thus a kick was the least it deserved.

Still feeling sorry for the chicken, I mandated its release. I began to explain that this would require the boy walking the bird out of the school gate to put it on the other side of the big perimeter fencing. However I didn’t finish my sentence. Instead I watched an alternative approach.

With his back to the fence, the boy with the chicken in his arms, suddenly launched it as high as he could skywards. Up, up, up, went the chicken. Higher and higher and higher. Until it was at least 35 feet in the air. And then the descent began.

The stunned chicken was clearly as surprised at me. For the first half of its downward journey it seemed paralysed by shock. But as the ground approached rapidly, it opened its wings and brought itself gently to earth on the other side of the fence.

The boys left the scene – disappointed not to have taught the chicken a more memorable lesson.

Press campaign

I have mentioned in previous blogs about the problems we have at Ntabayengwe getting water. I discussed the problem with the incumbent local councillor in the hope that he might be able to sort out the situation. Unfortunately he has just lost his seat.

So now I have written to the local paper 'Zululand Fever' in the hope that they might take some interest. They have run recent stories on similar themes. I will let you know if they respond to my email, copied below.

'I'm writing in response to the article I read in Zululand Fever on June 3 2011 entitled 'School given 'filthy' toilets'. I am a secondary school teacher from the UK and have a volunteer teacher for the year at Ntabayengwe Primary School, teaching grade 7. The article about the school toilets at Umfolozi Primary School reasonated loudly given my experiences. At Ntabayengwe, we have school toilets built by a local NGO. These are often in a disgusting state. Nonetheless, they are not my primary concern. Instead, my great preoccupation is with our water supply. We have been without tap water since before Christmas. As a result we depend on water from jojos. This often runs out. We then rely on a water pump situated about 100 metres outside the school. This usually has water, but has run dry. When out of water here, I bring water down in containers from my jojo at the hospital.

Being without water in the tap and in our jojo results in appalling sanitary conditions for the children. We have no toilet paper in the toilets. And the children eat with their hands for their meal at 10.00. It also means that they must last through the school day without drinking any water. It is well recognised that being hydrated is an important factor in learning. For this reason, most children in the UK bring water bottles with them to lessons.

I would be very grateful if you were able to investigate why it is not possible to fix the tap at our school so that we have our own supply of fresh water. In addition, I am sure that we are not the only school in our area to be regularly without water. For this reason, I think it would be very helpful for you to press the munipality to set up a telephone line for schools to use to report a problem with their water supply.

Having spent a year teaching at Ntabayengwe, I am due to leave at the end of this month. It would be of huge comfort to me to know that I will leave the school with the water supply functioning again.'

Lesser spotted buggeralls and the ubiquitous pod mahogany

We have just returned from a glorious two week holiday with Mary’s parents-in-law. In 14 days we visited Tembe Elephant Park, Kosi Bay, Kruger Park, the battlefields and the Drakensbergs. Having visited and written about most of these locations already, I’m not going to spend any time describing each one. Instead, I have a list of moments from the holiday:

Eating leaf for aphrodisiac – The power of a game ranger to make tourists do stupid things is immense. It is a trusting relationship. They decide where it is safe to get out the vehicle. They decide when an animal – or more precisely an elephant – is posing a threat to the vehicle. And they can even decide what bits of the bush to feed to their guests. In Tembe, we all showed ourselves happy to munch away on leaves supposedly used by local healers as aphrodisiacs. Well, either our guide picked the wrong tree or Zulu bodies behave very differently. For the rest of the evening, I had intense stomach cramps followed by running stomach. Needless to say Aphrodite (or Mary) wasn’t on my mind as I lent over the toilet seat.

Into the jaws of the lion – Some camps in wildlife parks are electrified. Others are not. Those which are often create a superficial sense of safety. Tembe’s camp is electrified. But the biggest elephant in the park knows how to trip the circuit without shocking himself. He did this during our first night and spent an hour of it terrorizing mum and dad’s tent. Those camps without electric fences are obviously open to all. These camps, especially if private, usually have lots of safety precautions about when and where guests are allowed to walk. All of these are fine if you have a sense of direction that allows you to navigate yourself from the bar to your room. But dad fell foul of the ‘toddler’ danger by heading off out of the camp in search of his room. Fortunately, he was saved by his watchful companions.

Can we go home now – Africa isn’t usually associated with cold. And rightly so. We have been hot for about 9 months of the time we have been in SA. However, early mornings and evenings in winter are not warm. They are even colder when doing game drives. We seemed to experience particularly cold nights for our evening game drives in Kruger. The result was that we ended up dressing like Eskimos – only allowing our eyes and nose to be visible. We also seemed to have particularly bad luck for two of the nights spotting animals. Thus we spent many hours driving round the bush, in pitch black, seeing only the Lesser Spotted Buggerall. We consoled ourselves with the comfort that at least we were providing some amusement for the animals.

More trees please – Most people visiting Kruger Park have greatest interested in seeing ‘the big 5’ and friends. As a result, the guides are attuned to finding them. They consider success or failure to be based on their ability to deliver. Unfortunately, some are less good when having to adjust their focus. In other words, they were not prepared for Roger Toulson. Daunted by the need to demonstrate some knowledge of flora and fauna, the less good guides hit upon a strategy – ‘it’s a pod mahogany’. In a devastating blow to the biodiversity of the park, all of the trees suddenly became one species.

Chemistry – What some of our game guides lacked in knowledge, they made up for in their wonderfully ill-judged remarks. One revealed that he had an only sister who was studying law. Poor thing, he commented, ‘Who would want to spend their life stuck with the head in legal books?’

Dangerous walks – We had a couple of stunning days walking in the Drakensbergs Mountains. The views were magnificent and the colours incredible. However, there was one small safety risk. State licensed arson. Winter is the burning season. Understandably, this is done to prevent devastating summer fires. All well and good. Except if your route happens to take you through the middle of a blaze. Our walk on the first day did just that. Arriving by the flames, we were greeted by some very friendly locals walking round with paraffin sprays on their backs. They cheerfully encouraged us to walk through the fire and carry on yomping. Being wimpish, and concerned by the swirling wind, we decided against.

It's good to walk

On Friday, our car was finally ready for collection from Richards Bay. So, with great excitement, I set about finding transport to get me there (it’s about 220 km from Ingwavuma). None of our friends were heading down. So I ‘opted’ to take a lift with hospital transport.

Hospital transport runs patients from Mosvold to other hospitals in KZN. Transport doesn’t necessarily go every day. But I got ‘lucky’. On Thursday evening I found out that a driver would be going down, departing at 0400. Despite the unpleasantly early wake up time, I immediately signed up. I took little notice of the warnings from other doctors about the quality of the drivers.

Well the journey was memorable. We began uncharacteristically, by leaving on time. But my relief diminished when we headed left, instead of right (direction of the main road), out of the hospital gate onto dirt road. The driver spent the first hour driving round Ingwavuma honking at bushes. I assumed he had instructions to pick up patients. But nobody emerged from the undergrowth. Eventually, having forced our way all the most impassable roads, we then returned to the hospital. There some of the patients who’d got in an hour earlier, got out and left. Seemingly, they had just come for an early morning drive. My amusement at this helped offset the frustration of having wasted an hour of sleep. After ten minutes, we set off again.

And very quickly I remembered the warnings from the doctors.

I’m not sure how many times I have cheated death. I remember a near encounter with a motorist, while cycling on a country road in France. Rounding the bend in the middle of the road, I met on an oncoming voiture. Despite the speed of the approaching vehicle, I somehow managed to manoeuvre into the hedge – accompanied by the beautiful sound of Renault car horn. Mon dieu et sacre bleu! I had survived.

On the hairiness scale – that was high. It was matched by the fear I felt on my journey to Richards Bay. Several factors contributed to my sense impending death. The first was our vehicle. It was a bright yellow mini van dating to somewhere before the South African declaration of independence. It looked ancient, even by African automobile standards. Indeed, I have seen several vans abandoned around the local area that look more roadworthy.

Yet, despite the appearance of the vehicle it could still reach top speed. Just over 140 Km/h. I know this for certain, for I was seated, next to the driver. Except I wasn’t really seated. For there were no seat belts. Instead, I and the rest of the passengers, spent most of the journey airborne. They were completely anaesthetised to the danger – either through habituation or because of the ketamine still in their bloodstream from Mosvold.

Driving 140 km/h in a dilapidated vehicle on excellent and straight roads during the daytime would have been dangerous. But we were driving down mountain roads, often occupied by animals or people, covered in pot holes, in pitch darkness.

Sitting beside the driver, I did attempt to explain to him that we’d all rather arrive alive. However, each time he tried to respond to me, he turned to face me. Keeping his foot flat on the pedal. As his concentration was all that kept us from oblivion, I decided to shut up.

Hoping to be distracted by some escapist literature, I got out my book. But my idea failed spectacularly. Somehow I completely forgot that I had just started reading J. G. Ballad’s ‘Crash’. For those who haven’t read it, it is a dystopian novel centred on characters that seek sexual kicks from partaking in road accidents. The obvious thought crossed my mind. I looked across at the driver trying to decipher any eroticism on his face.

In the darkness I could not tell. Perhaps. Perhaps not. Was there a smile of excitement as we narrowly avoided going over the mountain edge? Was there a hint of a thrill as we drove through a herd of cattle with the horn on full blast? Was there a whimper as we overtook two cars, going downhill on a steep mountain pass? Perhaps. Perhaps not.

At least it gave me a possible explanation for the way he was driving. For the speed we were travelling bore no relation to the urgency of our business. This soon became abundantly clear as, half way into our journey, we ran close to empty in petrol. I pointed to the gauge and suggested we needed to stop. Pulling in, we filled up with petrol. And then our driver paid. Except he couldn’t pay. He had left the petrol card in the hospital. So somebody from Mosvold would have to bring it to us.

Two and a half hours later, somebody from Mosvold arrived. And off we went again. On better roads and in daylight, the journey became less dangerous. Could I sense boredom from the driver? Perhaps. But his boredom was my life. Leaving the minivan in Richards Bay, I vowed to walk back to Ingwavuma if our car was not fixed. Thankfully, it was.

Kate who?

As the BBC’s Ingwavuma correspondent, I can report (belatedly) that there were no excited street scenes in response to recent world events. On the day itself, I heard mention of the royal wedding on a Zulu radio station on the way to school. In addition, patients and doctors (mainly Mary) at the hospital were able to watch coverage on the televisions in their wards. But there were no other signs of the madness taking place in Britain. (This should be comforting to the royal couple as they fret about the likelihood of finding a honeymoon destination away from the media glare. They could walk completely unnoticed down Ingwavuma high street.)

News of the death of Osama Bin Laden was equally low key. (How he must now wish he had sought out the anonymity offered by Ingwavuma.)

The news of interest to Ingwavuma is all provided by the upcoming local elections. These are a very dirty affair. One of the hospital staff was instructed to attend a ceremony to open a local school. She was expected to provide specialist auditory assistance. On arrival she found that there was no school opening. Instead it was a front for an ANC rally.

We happened to come upon (it was staged outside the hospital gates) a t-shirt rally for the IFP. Their candidate is the current incumbent and was present at the clothing give-away. I was successful in securing a promise from him that he would organise for water to be delivered to Ntabayengwe. I am hoping that the proximity of the elections and his desperation for votes will result in some action.

Our car situation remains unresolved. It is eight weeks since the computer in the car failed. I have been on the telephone to one or other garage almost every day trying to fix it. Below is an outline of events:

1. Car breaks down
2. Car is towed to Jozini (R3000)
3. Car computer is sent to Jo’burg to be fixed
4. Car computer cannot be fixed and is sent back from Jo’burg
5. Second hand computer is ordered from Durban (R2500)
6. Computer is towed to Richards Bay to have computer fitted (R1000)
7. Car is delivered back to us
8. Car is clearly wrong and I drive it back to Jozin
9. Mechanic in Jozini cannot find the cause of the problem
10. Car is driven to Richards Bay Ford specialist
11. Richards Bay Ford specialist say wrong computer has been fitted to the car
12. Second hand computer is taken out of the car and sent back to Durban
13. Durban man tells me that he only has one second hand computer for our model of car but it may not work as it is very dented

(Rand to pounds = 11:1)

We are currently giving Durban man some more time in the hope that he can identify a second hand computer that isn’t dented. If he can’t locate one, then we will either need to gamble on the dented computer (R600 at stake) or buy a new computer (R7000).

We have loved our time in South Africa but we will not miss the politics or dealing with car mechanics.

Excuse me officer

We decided to spend the Easter weekend in Swaziland at a game park. Choosing a destination outside of SA at Easter seemed wise. It meant avoiding the carnage on the SA roads (even more accidents happen at Easter than Christmas) and the SA holiday hoards (strangely unattracted to Swaziland). So, on Friday evening, we set off for Mkhaya Game Reserve, chosen especially in the hope that we would see two rare antelope (not that we have become spoilt).

Unfortunately, we failed to factor in ‘likely chaos at the border post’ in our decision to head to a neighbouring country. There were two main contributing factors. Firstly, the Swaziland border post had made no extra provisions for Easter. In fact, they had generously (or cruelly) given holiday to all but one man. They had left him with the world’s slowest computer to input all passport details. Secondly, unbeknown to us, Easter is a time for all South African Zionist to visit their Swazi brethren. Both entering and exiting Swaziland, we were behind at least three hundred of them – dressed from head to foot in green outfits. Thus we queued twice for at least a couple of hours under the very hot sun.

Our visit to Mkhaya was very special and well worth our problems at the border. We managed to see Roan (but not Sable) antelope. We also had intimate moments with Rhino, buffalo and elephants. But enough of that.

Our journey home was made memorable for our Swazi police encounter. Swaziland has very low speed limits that change almost every 200 metres without reason. And they have very active traffic police. The combination of these, together with the immaculate condition of Swazi main roads, means that there are far fewer accidents than in SA. For this they deserve much praise. However, the abundance of traffic police meant that we (or our friend driving) was caught driving slightly over the speed limit. And so we enjoyed another quintessentially African experience.

The first part of the scenario was as you might expect in the UK. A cop stepped out into the road and waved us down. Giving us Easter greetings he pointed towards his speed camera and informed us that we had been travelling 10 km/h over the speed limit. We owed 60 Rand (£6). Recognising our culpability, our friend immediately began paying one of the policeman. The other resumed his camera work.

So far so good, for African policing and law enforcement. But, midway through payment, another car zipped past the police, far faster than we had been travelling. Out stepped the policeman, only to receive a smile and wave without deceleration from the motorist. Into the distance went the car, without any response by the police. Suddenly, Mary was outraged.

M - ‘Why didn’t you stop that man?’
SP – ‘I tried to but he didn’t cooperate.’
M – ‘But why don’t you chase him?’
SP – ‘We have no car to catch him.’
M – ‘But we are now being punished for stopping.’
SP – ‘Don’t worry. I am sure we will get him when he comes back from the shops.’
M – ‘But, if he does return, he will just wave at you again.’
SP – ‘No, I am sure he will stop.’

The conversation was only halted by the approach of another motorist, clearly speeding. Having lost all faith in the traffic cop, Mary jumped into the road to wave him down. The bemused man was then told by a gleeful Mary that he had been speeding and must pay a fine. She showed him his speed on the speed gun. Attempts by the man to cut half-price deal were thwarted by Mary’s insistence that such negotiations were outrageous.

Eventually the man paid up, clearly worn down by the plain clothed and strange accented new Swazi police recruit. The joyous expression on my wife’s face told me of a career option overlooked. It took some persuasion to get her to curtail her work and return to the car. Eventually she agreed, satisfied that some justice had been done. And Swaziland’s motorists took a collective sigh of relief.

Female Ward and Erysipelas.

Over the past two weeks, I have taken over the running of female ward. I was sad to leave Male Ward but also excited to take on a new challenge. Female ward is the biggest ward and divided in three sections – A, B and C. Sister Qwabe is the operational manager of the ward and I enjoy working with her very much. She proudly rejoices daily about her short height and rotund tummy, and isn’t afraid to call a mango, a mango.

Female patients are very different than my Male ward patients. Most obviously, I am dealing with lots of miscarriages. My challenge is to recognise which cases to medically treat and which to take to theatre for an evacuation. I had a woman on my ward in my first week that I discovered had a 25 week extra-uterine pregnancy (i.e. ectopic pregnancy)!

When I started two weeks ago, I had 8 cases of cryptococcal meningitis (all in section A) – a meningitis that only HIV patients get and that I had never seen in the UK before. It took me some time to remember who was who given they were in beds next to each other and many have the same surname. The treatment of choice is an IV antibiotic named Amphotericin B. But my use of this depends on stock levels. When out of this, I need to make a plan (as they say in SA). So far I have been relatively lucky despite not having the full course of this drug. One of my eight died (she also had TB meningitis and Bacterial meningitis) but the other 7 have gone home. Most of the women acquire this serious infection because they stop taking their anti-retrovirals.

Careful thought goes into deciding the location of each of the sections within our ward. Sister Qwabe explained that section B was behind the wall because they often have their breasts out and this would not be good to shock our visitors. It seems to me as if all the patients have their breasts out all of the time, but Sister Qwabe feels gogos are particular culprits.

I have 6 patients presently in my gogo section. One with a pelvic fracture (who will need to be an inpatient for 6 weeks for bed rest), an uncontrolled hypertensive (who did not know she needed to repeat her anti-hypertensives), a gogo (mother of 13) who surprisingly is HIV free, but has end stage cervical cancer, a paranoid schizophrenic who tries to escape every morning, a stroke patient and a t-cell lymphoma patient.

Section C is quite far away from the rest of the ward (where the nurses are) but has the new admissions, orthopaedic cases and the theatre cases. I feel these patients should be in Section A (given this is where we start the ward round each morning after we see the two ‘high care’ patients) but achieving change of this sort is a delicate process.

Another aspect of Female ward that I enjoy very much is the amount of singing and dancing. The sister and nurses love when I sing and especially when I dance with my bum out (Zulu way) – as you know I am completely tone deaf but they do not seem to mind. I reserve this for a daily special occasion – on Friday I had a young girl with a snake bite so we all started singing. The gogos love it and I think it makes patients feel more comfortable. Otherwise, I keep it as a treat at the end of the ward round.

Recent ward rounds have been more difficult because I have a swollen ankle. It is caused by a rare condition called Erysipelas. I knew I hadn’t injured it so the initial pain was very mysterious. I took a course of antibiotics and it has now almost completely disappeared. Hopefully my Zulu dancing will benefit from my added mobility.

Megaphones and t-shirts

It turned out my Easter holiday was a week long. And wasn’t an Easter break. I was back at school last week but now have a long weekend.

During my week of holiday, I visited some of my Grade 7 pupils at home. A while ago, I committed to providing the school I taught at in the UK with stories of the home lives of some of the children at Ntabayengwe. So I set off with camera, mouth and ears, to snap some pictures and chat with them about their home lives. Predictably, it made me all the more amazed by their resilience and spirit. A few of the kids live in houses. Some of these have electricity. The fortunate have a jojo to catch rain water. However, most live in mud huts, walk a distance to fetch water and cook on an open fire each day. Days during the holiday are obviously very long, hard and boring. Not much sign of the new South Africa making a difference here.

Next month we have local elections. And suddenly the ANC is in town every night. With very loud megaphones to shout slogans. And some free t-shirts. Sadly this mega sophisticated style of campaigning seems to be more than sufficient to pick up votes. I am tempted to ask them whether they have any plans for fixing the main road (causing deaths each week), fixing the water supply so that local schools have taps with running water or improving the local hospital. But I think I already know the answer. We happen to know the ANC candidate. He ‘works’ in the hospital

I have just finished reading a book looking at the failure of African capitalism by an economist called Moletsi Mbeki (brother of the ex-President and one of his fiercest critics – especially for his treatment of Mugabe). It examines South Africa as a case study. It didn’t leave me feeling very optimistic. In summary, South Africa is still being run like a colony. By far the largest part of the economy is mining. From the huge profits made, relatively little is reinvested in infrastructure for the long term benefit of the country. For example, the public transport system has deteriorated in the last 25 years. Money that remains in South Africa (40% of all SA capital is kept outside the country) is instead pumped into the benefits system. There are now over 12 million on benefits (versus approximately 3 million in 1990). Many people in Ingwavuma receive these tiny benefits. And they have become completely dependent. Disincentivised from finding work many find a way of surviving on tiny amounts of rand a month.

Meanwhile, the soaring price of commodities has allowed the country to neglect the country’s manufacturing sector. South Africa once had a very promising textile industry. This has dwindled. Many skilled jobs have been lost. Thus, again, mining is undermining the long-term prospects of the country.

Sadly, corruption is also on the rise. South Africa has dropped about 20 places in the league table on honesty. Success in business and friendships at high or low level in government are very connected. Seemingly, bribery of the politicians was engaged in on a massive scale on the transfer of power in the 1990s as the wealthy white business elite sought to insulate themselves from the political earthquake. The culture of backhanders, cuts and deals with friends has grown fast.

Even at a low level, contracts from the different departments seemed to be tendered on friendships. A couple of weeks ago, I got a lift from a white guy from Jozini. He told me he had started up a business delivering food to local schools. He delivers food one day a week to three schools that are close together. Per school, per drop he makes 4400 rand (over £400). It means he and his business partner are making over 500,000 Rand a year profit from one day of work. He got the work because his business partner has friends in the department of education. Obviously these deals harm both private enterprise and the state services.

In theory, the impressive higher education facilities in South Africa should be making a big contribution to transforming the country. The country’s universities churn out 40,000 graduates each year. Positive discrimination means the black population makes up a large percentage of these. However, many graduates leave very quickly. And there is increasing evidence of the lowering of standards. Durban’s university has a particular reputation for not failing doctors with the right skin colour.

There are solutions offered in the book. But all are dependent upon South Africa developing a political system which requires their politicians to listen and act in the long-term interests of the people. The megaphone and t-shirt approach seems unlikely to achieve this.

A Hard Week at Work

This past week has definitely been my hardest here at Mosvold Hospital. It started on Monday afternoon when I (unadvisedly) swallowed some blood from an HIV positive patient. How? I was trying to get a cannula in the worst Stevens-Johnson Syndrome patient I have ever seen. From head to toe he was covered in lesions and there was only a bit of free space on the dorsum of his right hand. It is important that SJS patients get lots of IV fluids as they can (and often do) die from renal failure (not actually from their severe skin rash). I had got a drip in during the morning so thought I would be able to emulate it again. I was wrong. I have been taking ARVs (anti-retrovirals) since Monday evening when it happened on a precautionary basis.

I knew Tuesday would be hard as I was on-call. We were short of five doctors and so the workload increased dramatically. I was scheduled for theatre and was the anaesthetist. Unfortunately, the baby from our c-section came out without a heart beat (fresh still birth). I ran the neonatal arrest for over 30 minutes (managed to secure the intra-uterine line, intubate, and give the adrenaline) but we never managed to get the little heart going again. It is the first time that this has happened to me in theatre and was obviously very sad. My colleague continued with the c-section and no one told the woman until she got back to the ward. Theatre is usually full of life here at Mosvold with singing and laughing. It was a very sombre few hours.

The rest of Tuesday dragged. The RU was heaving and I was the only doctor in outpatients department (OPD) for the afternoon. I worked all afternoon and night but eventually managed to get into my bed in the early hours of Wednesday.

For the first time since being here, I spent some of Wednesday with a Psychiatrist (consultant equivalent). As Male Ward doctor, I feel some despair for my acute cases. I have found that there is a lack of options for medical therapy and there is not the support system than exists in the UK (Community Psychiatric Nurses). It was wonderful to spend hours with the psychiatrist learning new things.

Thursday was supposed to be spent at two of our clinics. I had to drive a ‘vintage’ 4x4 again. The bumber was falling off, the bonnet didn’t close, my ring mirror was smashed, the passenger’s one was falling off, the horn didn’t work (necessary with the cows in the road) and the brakes worked intermittently. It took 2 hrs to find a very small piece of plastic which I was promised would hold the bumper together. The rest didn’t seem to concern our transport office. Given the lost time meant I was only able to visit one clinic.

Ndumo clinic is right near a game reserve with the same name. It is very close to Mozambique – close enough to confuse my primitive mobile phone. (I like to be able to use my phone when at clinic to ring specialists accessible on hotline numbers.) I saw just over 20 cases and admitted one - a little child who was 7 but looked 3 and had not been in school for one year due to his severe rash on head and neck. His skin was falling off and Gogo didn’t think it was a problem. It will most likely be HIV related but I thought he needed a bit of a sort out and convinced Gogo and child to come back with me to Mosvold. He is doing better on Paeds ward but it will take a long time.

Friday was alright. Male Ward is full at the moment so ward rounds are taking a long time. I managed to get to OPD for the afternoon where I saw a variety of cases. Unfortunately, we are having some difficulties with the nurses there at the moment. Circumcision camps are happening almost daily and we are all short staffed. The nurses are not helping the doctors and often the patients. I feel patients are suffering and would really like to stop the circumcision camps. I continue to do my best in an increasingly difficult set-up.

I was on-call all day Saturday - from 8.00 am until 5.00 am this morning. Lots of OPD cases, maternity challenges and sick patients on the wards. The low point was spending two hours from 1.00 until 3.00 trying to get a 25 year old’s foreskin around a very swollen penis gland. I tried everything brute force, ice, sugary solution and a penile anaesthetic block but could not manage it and had to call in the acting medical manager. Luckily, he was understanding and found a solution in 15 minutes. Not sure how he did it but it involved lots of blood. Still, the episode provided lots of laughter for myself and Rosie. The nurse and patient found it less amusing.

Despite this difficult and trying week, I still love it here. Today has been really nice. I managed to get some sleep and enjoy a lovely swim at the dam with Henry and Rosie. Lots of my colleagues were about giving us a chance to socialise and forget work for the day.

* Rosie is a Warwick Medical School elective student who has been with me all week. I feel sorry she has had such a tough first week on her elective. She has been great company, really helpful and I have been lucky to have her around.

Train him up

Easter approaches and so we are into school holidays. This means I’m at home doing jobs and reading about near nuclear catastrophe (excellent book called ‘The Dead Hand’ about cold war relations - thanks M&D).

One of my highly important holiday jobs has been making fruit juice. We have lots of fruit trees in the holiday grounds. Getting avocados can be tough as the trees are close to the sleeping quarters of the heavily pregnant lady unit. And they are extremely good at hoisting themselves up the trunks at the first sign of pickings. Fortunately, they are less keen on limes.

Last week, Mary and I picked a bag full of limes. And I went to work in the kitchen. After an hour of de-juicing, the mixing began. Into a big pot went 1 1/2 litres of water, 2 kgs of sugar, citric acid, something else acid and some baking soda. And then onto the big hob. An hour later I had four wine bottles full of lime juice. Initially I was under whelmed by my work. Surely four wine bottles worth would be drunk in a couple of days? But then the delight. I had apparently been making concentrate. So a week on and we have drunk less than half a bottle. Furthermore, the flavour of the drink is highly commendable. Definitely worth a prize in the Woodstreet Village Show. With some potential for development as an alcopop.

I sense that I may soon be called upon for even more serious work. For this week we are very short of doctors. There were due to be three doctors on holiday. However, another has fallen ill and her partner (another doctor) is with her. Meaning we are down to five and a half. Resources are being stretched further by pressure on the hospital to meet its circumcision quota. At the moment, this seems to be the only health target of interest to the politicians (they see it as a way of reducing HIV; in fact the benefits of reduced infection risk are highly likely to be offset by misconceptions in the community that it results in immunity from STDs). As a result, one of the two most experienced doctors remaining is being forced to go to circumcision camps all this week. Thereby highly jeopardising lives of patients in the hospital. I think the solution is to send me to do the circumcisions. I'm sure I'd manage. And I've got a favourite joke I could tell to help settle nerves (‘What do you call a cheap circumcision? A rip off'.)

At last

On Saturday/Sunday we drove down to Hluhluwe-Imfolozi Game Reserve. We were accompanied by two other doctors. Having previously stayed on the Hluhluwe side, we had hoped to find accommodation this time in Imfolozi. (The two were once separate parks. For some time they have been joined. However, the landscape is quite different. Imfolozi is flatter and less spectacular but the terrain is more conducive for spotting cats). Arriving just before nightfall at our accommodation in Hilltop (Hluhluwe), Mary enquired about vacancy at Mpila (Imfolozi) and she was thrilled that there was! We accepted their offer of transferring our booking and set off for the other side of the park.

Strictly, only game vehicles are allowed to drive through the park at night. But this was waived for our 50k drive to Mpila. Driving for twenty minutes we spotted a number of hyena. Thus we were completely prepared to see another as we rounded yet another bend. And there it was, walking in the middle of the road. Looking for food.

But then the strangest thing happened. For the hyena turned. And on turning, we did behold a great miracle. For it was not a hyena. But a leopard! Yes a leopard! Definitely a leopard! Orange. With spots. And a white dot on the tail. Smaller than a lion. Not as slender as a cheetah. Hooray! Hooray! Hooray! Feeling great emotion, I wanted to get out the car and kiss this legendary creature. Or at least greet it, formally, ‘Mr Leopard, I presume?’ And then pass on my regards.

Unfortunately, the leopard was in no mood for niceties and quickly returned to his night time exploration.

We followed it for about a minute. Initially, it disappeared into the bush. Then it reappeared and walked a short stretch before disappearing for good. Nevermind. I know I will only wait, perhaps another twelve years for a glimpse.

The rest of our 24 hours in the game park were packed with animal sightings. Having had several extremely hot days, the temperature had suddenly dropped. Predators that had not eaten for several days, were ravenous. Close to our camp, lions and also wild dogs had both had successful killing sprees (we saw the lions; we missed the wild dogs as they had been chased away by hyenas). Both sites attracted huge numbers of vultures – fighting each other for any available scraps. In addition to the carnivores, we saw buffalo, rhino, elephants and much more.

Still without our car, we drove round the park in our borrowed Mercedes. And we got to enjoy all its quirks. A light spell of rain revealed the windscreen wipers did not work. We also learnt that the electric windows functioned only when I opened my car door. And sometimes they would not close. But why would we need windscreen wipers and windows on this glorious day?

Driving home, we got our answer. Reaching Jozini at 1700, 70ish kms from home, the heavens suddenly opened.

Immediately, I pulled off the road. Parking one wheel in a ditch. There we could wait for the rain to pass.

But after half an hour it was clear the rain was not going to pass. Worse, the previously empty ditch was now a metre under water. Fortunately, we managed to get the car back onto the road (two of the wheels were still on tarmac so had good traction).

Now we were in the middle of a narrow road. Our hazard lights were working. But we became a challenging obstacle for a drunk Zulu driver.

My initial suggestion was that we call a friend from the hospital to come and collect the three doctors. I would then stay with the car and drive it back when the rain stopped. I realised that I might be there until morning. But I had a book and food. And I was fearful that the car might be treated as loot.

Once our friend had arrived, the plan changed. Outvoted on my ‘sit-tight’ proposal, all the others felt that we should drive slowly back to Mosvold in convoy.

And so began another truly African experience. With the rain pouring down, I could still see nothing through the windscreen. But by opening the window and leaning out I could drive slowly and see the road, potholes, cows and other drivers.

There is definitely a technique to driving with your head out the window in the rain. And slowly, I discovered it. The heaviness of the rain fluctuated quite a lot as we began to drive. And at times it whipped into my eyes. But, once I had formed an effective visor with my left hand, and got my eye in, I was able to drive at 40-50 kms.

Though the journey was still very slow, it was also exciting. We had little celebratory snacks as we reached different landmarks (although eating biscuits without removing my visor added extra challenge). And, with my head out of the window, I could keep a good eye on road life. Imagine my joy, then, when I got a particularly fine sight of a long bright green snake crossing close to the car. My best sighting so far.

The final part of the journey was particularly interesting – up narrow windy mountain roads in thick fog. Thankfully there was little else on the road, so we could keep a reassuring distance from the drops.

And so, after a couple of hours of ‘head out of window’ driving we reached home.

More car troubles

So the car saga continues. Nearly two weeks have passed and we are still without our dearly beloved. So here is an update on the story. But before reading it, to help you empathise with the frustrations we have been feeling, you must know that we have had to sort out everything over the mobile phone. In an area of the country with almost no reception. Using a phone with a very limited battery life. Meaning almost every call has broken up several times. And with regular confusion caused by very different English accents. Anyway, here we go.

So, in a previous posting we mentioned that our car had to be towed to Jozini (about 70 kms from us). Unfortunately, the mechanic there was unable to fix the problem with the computer. Instead, he decided to send the computer box to Johannesburg to a specialist. This took several days to happen. On arrival in Jo’burg, the specialist took little time to pronounce it permanently broken or more precisely f….. (a word that many English speaking Zulus believe translates literally as unfixable). Worse still, a new computer for the car would cost us approximately £550.

Given that we are in the land of the unnew, I set about trying to find a second hand version. Today, I had a triumph. I have found one for the bargain price of £285. Unfortunately, the garage is in Durban. The garage itself cannot fit the computer. And it doesn’t offer any courier service. But by great good fortune, one of our friends is going down to Durban this weekend. So she will purchase the item (a Bosch 1S6D12a650AV) and bring it up to the mechanic at Jozini. The car and computer will then be driven down to Ricards Bay (about 200 kms from Jozini) for a fitting. Assuming all goes well, it will then be driven back to Jozini. And I will then fetch it.

In the meantime I have (very generously) been lent the use of one of the doctor’s cars. Indeed it is Baba Heese’s car. Baba Heese and his wife are true Ingwavuma legends. He has worked at Ingwavuma hospital for several decades. In that time, she has set up a secondary school, a craft/stitching cooperative and Ingwavuma’s only restaurant. Anyway, his car is an early 1980s Mercedes. Painted a classy olive colour. And while its engine may be past its prime, its character lives on. However, there is one draw back to the interior design. Its leather seats. Today the temperature was 45 degrees and I was unable to park the car in the shade at school. As a result, I had to peel bits of flaky leather from my back when I got home.


School life continues to delight and depress – in equal measures. In the first camp, we have been practising for an inter school athletics event. We have three ‘track’ events. One hundred metres – or once across our field. Four hundred metres – or once round the field. Eight hundred and 1500 metres – two and four times round the field. Practice takes place during the middle of the day. Yet nobody grumbles about setting off for four laps round the field. Our jojos are almost empty so there is a shortage of water for the runners.

Staying on the positives, we have recently planted about 20 saplings around the school to try to create more shady places. There are currently almost none.

And now to the downbeat stuff. Lessons for lots of the children have been very disrupted recently. We only have sufficient teachers when all are present. At the moment teachers keep having to attend workshops – cleverly scheduled during the school day. These seem to be absolutely pointless. The only thing my colleagues take away from them are big handouts containing masses of indigestible information about how and what they should be teaching. This makes no difference to their performance in the classroom. But it means days without classes for some of our children. Complete madness!

More depressingly, our local NGO visited last week to bring new uniform to the orphans at the school. I’m not sure how many we have in total. But the Principal’s room was full of children trying on clothes. Many of the parentless seemed to be in the bottom grades. If I were able to post pictures of them (especially dressed in their new attire) you’d get a good idea of how moving I found the spectacle. But I didn’t have my camera with me.


This weekend is likely to involve a trip to the city and a visit to a game park. Once again, I’ll let you know if we see a leopard.

Back to Reality.

Henry and I are back in Ingwavuma after a lovely two week holiday in the UK. It was a very busy time seeing family and friends but great fun. Thank you to all for your kindness and generosity. Of course we are already missing you.

We arrived back to Ingwavuma on a Sunday night and I was straight back onto my ward (Male) on Monday. There had been a big Motor Vehicle Accident (MVA) the previous Friday which resulted in my ward being full. The driver of one of the vehicles arrived with the side of his skull missing. Travelling at over 100 km/h his head had bounced and scraped along the tarmac. Every morning as I approached my ward, I hoped he would still be alive and we could continue chatting about things. By the Thursday, I had eventually convinced our referral hospital (3.5 hrs away) to take over his care. I look forward to having him back after the plastic surgeons somehow reconstruct his skull.

Last Thursday, I went to my clinics – named Nondabuya and Khwambuzi. Every three weeks, I am responsible for driving to them (I feel like Mma Ramotswe in the Number One Ladies Detective Agency books as I battle the potholes in the dodgy 4x4) and then seeing the patients that are waiting for me. The nurses at these clinics are meant to prioritise the complicated cases for me to see. We should only be seeing 20 patients at each clinic but often we see more – especially the children waiting for anti-retrovirals. One interesting case involved a child of three. It is often difficult to know if an infant is a girl or a boy because they all tend to have short hair and aren’t dressed in blue/pink. Anyhow, the nurse presented the case to me and said the child was a homosexual. I looked up baffled. First of all, homosexuality ‘does not exist’ in rural South Africa. Secondly, three year olds don’t tend to have a sexual orientation. It took some time (and confusion on my part) to clarify that in fact the child was a hermaphrodite. I examined the child to confirm and suggested they saw a surgeon. I can only imagine how much trouble the child and mother will receive in their community.

Being responsible for approximately 20 men on my ward, I expect smelliness. In fact, I have found Zulu patients to be much cleaner than UK patients when it comes to daily washing. However, given many have limited access to sanitation facilities and lack shoes, I regularly see very smelly feet. For the sake of the audience, I think it is best if I do not describe the amount of pus that I often extract from these wounds.

Despite my exposure to manky feetitus, I am still occasionally shocked. Over the past two weeks, I have had a patient who was missing a fair amount of skin on his foot because of an infection. Given this, we treated him with antibiotics, debrided the wound and gave him a skin graft. We then left the wound for one week before seeing if the skin graft has been successful. This past Thursday, my patient informed me that the wound was itchy. As I unravelled the bandage and took off the gauze, I saw approximately 40 maggots on the wound. I felt like vomiting but instead took forceps and removed each one. The patient did not seemed fussed at all. In fact, he told me the next day, that he thought they had cleaned up the wound nicely. Male Ward is dominated by male nurses. Yesterday, I was told by one of them in front of the others that they had been very impressed with me the day before. This is a massive compliment from a Zulu man!

I am working this weekend and so far the hospital has been relatively quiet. Long may that continue!

Vomit, Jellyfish & Dolphins

On our arrival in SA, Mary and I set ourselves a mini Phileas Fogg challenge. It involved seeing all the countries of Southern Africa by the end of July. We set our goal knowing it should be achievable without high drama. Indeed we built in lots of cheats. For example, we visited several countries (Zimbabwe, Botswana, Zambia, Malawi, Tanzania, Kenya) in a previous trip to Africa. We gave ourselves a year instead of 80 days. And we excluded three countries Angola, Congo (both too dangerous) and Madagascar. All this means our escapades are unlikely to become the basis for a great work of fact or fiction. But what does that matter!

Up to last weekend, we had visited SA, Swaziland and Lesotho. Mozambique became our fourth ‘conquest’. Conquest in this context means that we travelled 10 kms into the country travelling up from the southernmost tip to the nearest beach – at a place called Ponto D’Ouro. (Before we receive complaints about the legitimacy of claiming this constitutes ‘seeing a country’, please know that it does. Particularly in the case of Mozambique. As there isn’t much to visit other than the beautiful beaches. And these are all very similar.)

There are three main obstacles to visiting Mozambique. Firstly, they like to shut the border at 1700. For us this meant a race after Mary had finished work. Secondly, they charge lots to enter the country. Unless you are South African. Or you are friends with the men at the border post. As we weren’t able to prove we were actually mates with Carlos, we paid £40 each (but felt less aggrieved when we got a big visa stuck into our passport). Thirdly, we needed a 4x4. Fortunately, our weekend away had been arranged by a friend. And he drove us in his big car. Once past the border post, there are no roads for us to use (there are some in other parts of the country). So anything without 4 wheel drive gets stuck in the sand.

The relatively recent civil war in Mozambique means that the infrastructure of the country is very basic. And signs of the war are still visible through the bodies of the locals and their missing limbs. However, it is one of Africa’s fastest growing economies (albeit largely because it is starting from such a low base and is up against a weak field). And there is a great sense of freedom to the place.

Our main aim for the weekend was to swim with dolphins. We organised this for Sunday morning. On Saturday, we arranged a dive. The reef at Ponto is a continuation of the one we dive at Sodwana. And the experience was quite similar. We had worse visibility but saw an amazing amount of life – moray eels, octopuses, turtles, scorpion fish, sting rays. Unfortunately, Mary felt particularly sick during the dive. Bringing an 80% vomit success (or perhaps failure) rate into the dive, this had crept up to 83.3% after we had finished.

Our diving with dolphins experience did not start well. After an hour driving up and down the coast looking for flipper, we had not seen one. This had though, been plenty enough time for Mary to vomit again (now 85.7%). Obviously fearful that we wouldn’t see anything, we were encouraged out of the motor boat to enjoy some snorkelling. Seeing any sea life was utterly impossible, given the depth of the water and the visibility. It did though give us ample opportunity to be stung by the very abundant jelly fish. So began an experience equivalent to running scantily clad through a field of stinging nettles. After ten minutes we got back in the boat.

Having almost given up hope, some flippered friends turned up. And our experience was transformed. Into the water we went. And for the next ten minutes bottlenose dolphins (the most intelligent and playful) swum round us. Swimming extremely close, we followed previous instructions not to try and touch them. Instead we gawped as they swam round and round us. Thankfully, the cost, the jellyfish and the vomit had all been worthwhile. Eventually the dolphins swam off. We caught up with a second larger pod ten minutes later. But they were less curious.

And so ended another weekend in SA. Mary is on call this Friday and Sunday. So we are unlikely to get away. We will spend some of the time planning our trip to the last target on our Southern African hit list – Namibia.

Back in the Bush

Our return to SA after a two week absence was made very special by a surprise on the road up to Ingwavuma. Driving the last bit of the journey from Durban to the big ‘I’ in the dark, we rounded a bend to begin our ascent into the mountains. And lo and behold! For sitting in its usual spot, was Ntabayengwe School. But lit up spectacularly by a beautiful outside lighting arrangement. The following day, the Principal confirmed the exciting news telling me with great joy, ‘Mr Toulson, do you see we now have electricity.’ I told him about my wondrous experience the previous night. Unfortunately, we currently have no use for our power supply, other than night time illumination – the one time that children are not in the school. But, we are working on changing this.

Other than the arrival of electricity little else has changed. This week has been unbelievably hot and we have had no rain for three weeks. And, to welcome us home, our car has begun playing up again. This time it is the immobiliser that is faulty – something I find intensely irritating. There are two obvious reasons why our car should not have an immobiliser device. Firstly, it is rubbish (even by South African standards) and so low risk to break in or theft (a great pity!). Secondly, it has so many other unintentional immobilising devices. Now the car has been towed off to Jozini (70 kms from us) to have a new part fitted and key made.*

This weekend we are going to Mozambique with friends. There are three main reasons. Firstly, to say that we have been there. Secondly, to sing the Bob Dylan song. Thirdly, to try and swim with dolphins. My wife has been particularly looking forward to number 3; I will be quite satisfied with numbers 1 and 2. We’ll let you know what happens.

* Please note that favourable car reviews are likely to follow in the next few months to coincide with our attempts to sell the car; any praise will be entirely fictitious. UK doctors coming out here have been directed towards our blog to get an insight into life in rural SA. We will be aiming to sell the car to one of these unlucky sods. Hence the need to create a false impression.

Ntabayengwe hit the beach

A while ago we received two cash donations. The first was from Ashlawn School to be spent at Ntabayengwe. The second was from a mystery source to be spent on something for either the school or the hospital. After much discussion Mary agreed that I could use all the money to fund a school trip.

For some time I had been keen on taking Grade 7 (the class I teach and also the oldest year group in the school) on an excursion to the beach. Most have never been, despite living only 60 kilometres away.

So began an investigation into the logistics. First I approached the nearby Sodwana Bay Nature Reserve to ask for free entrance into their park. Firing off a number of emails to locals I got lucky. Back came a reply from the resident conservation officer, promising me not only free entrance but also guided activities. Guhle Kakooloo (excellent). Step 1 complete.

Next, I began the process of gaining approval from the Principal, teachers and local educational chieftains. Having fabricated minutes for fictitious meetings and completed a thorough risk analysis, I submitted my paperwork for inspection. Verbal assent was granted on condition that nothing should go wrong. Step 2 complete.

Onto informing Grade 7. Cue joyous scenes and huge excitement as I distributed letters to be taken home and signed. All 24 letters were returned with signatures from home within a couple of days. Step 3 complete.

Finally, I sought out the most reasonable local taxi/minivan operator. Wary of striking an overly good deal and landing up with cow drawn carts, I may have overpaid. Nonetheless, with a week to go before B(each)-day, all was in place. For the next five days I rang the taxi company to remind them of my booking and the importance of arriving at our school by 0630 (60 minutes before actual departure time to give full allowance for ‘Ingwavuma time’).

As Friday drew close, I was not without reservations about Ntabayengwe’s first school trip. Would our taxis arrive, and at what time? How roadworthy would they be? Would the children enjoy/be able to follow the educational activities set up for the morning? Most importantly, could we get 24 children with no swimming experience, in and out of the Indian Ocean unharmed.

My concerns were slightly allayed by my success in persuading my wife to accompany me on the trip. Now I had a doctor and Baie D’Urfe Pool’s winner of the 1997 Life Guard of the Year Award (still seemingly my wife’s proudest moment).

The Thursday before the day of the trip, the Principal was in gloomy mood and using the language of his favourite Shakespearean doom mongers. My attempts to remind him that everyday life (especially for our local children) contains huge numbers of risks, only seemed to unnerve him more.


Arriving at the school at 0650 on Friday, I was greeted by a wondrous sight. Two taxis and 22 children. The two missing students were to be picked up from a bridge two miles up the road. Some of the children had managed to find other clothes to wear for the trip; about half could only wear school uniform. All looked deliriously happy.

I had identified two big risks for our excursion. The first was getting safely to and from our destination. Thankfully both of our taxis were very (by Ingwavuma standards) new and had seat belts. A complete novelty to the children (they rarely use transport of any kind and would never have been strapped in) Mary and I made sure all were fastened.

So, with trepidation, I gave the signal to the drivers to start the journey. Immediately, the music system was turned up to the max. And, despite being on a relatively smooth section of Ingwavuma road, after two minutes the vehicle was lurching up and down. Slightly puzzled, I turned round to see all of the children dancing wildly. Still within their seat belts they were jiving left, right, up and down. Faces were beaming. My attempts to tone down their bouncing failed completely and thus we hopped our way to the beach.

We had a brilliant morning with our educational supervisor picking up very weird organisms from the Sodwana rock pools (see our pictures of some of nature’s less attractive participants). By late morning, having eaten, our guide moved onto a talk about turtles. These come and nest on the beaches. Again, pictures are attached.

And then, the moment the kids had been waiting for – swim time. Setting up a 10x10 metre corridor with me at the front and Mary at the back we advanced into the sea. Again, the pictures tell the story. None were hurt, no lives were lost – though plenty of items of ‘swimming costume’ (pants and bra) regularly disappeared as the waves crashed. Fortunately, Zulus aren’t body shy.

And so, having safely negotiated the SA roads for a second time, we arrived back at the school. All happy and exhausted and very keen to go again next week.

Rights and wrongs

We often feel as if we lead double lives in SA. During the week we see many examples of people desperately struggling to cope with the realities of abject poverty. Then at weekends we disappear off to enjoy one or other extraordinary location. Sometimes the clash is contrast is particularly shocking.

Last week at school we ran out of water. It has been extremely hot (about 40 degrees) in the last couple of weeks and hasn’t rained much. We have been without water from our tap since the beginning of the year. Without tap water, the children rely entirely on the JoJos for drinking and washing. On Thursday our supply of rain water ran out. The same day, a nearby water source also dried up. Worse still, we also ran out of toilet paper.

Without water the school ‘ladies’ explained that they would also not be able to cook for the children. A number of our children are orphans and receive one meal a day.

And so we faced the prospect of dangerously unsanitary conditions and desperately thirsty and hungry children.

Fortunately, the ladies were able to get water the following day. I was also able to bring 50 litres down from Mosvold in the back of my car. Meaning that we had enough for cooking, washing and drinking. And I can now bring the same amount of water each day until a weather change.

Nevertheless, the episode highlighted the complete absence of emergency contingency plans in the area. There seems to be no telephone number to ring to report the problem. Nobody to contact to find a solution. Instead each community is left to cope as best they can. Until such help exists, the theoretical rights of the children (that they learn about in Life Orientation classes when studying the South African Constitution) will remain very meaningless.

Siyabonga

Having neglected blog duties for the last two weeks I have much to report. A week ago we were very generously put up for a night at Hluhluwe River Lodge by Aunt Annie and Uncle Peter. Both were on top form – albeit in their very different ways.

Travelling to the lodge I had some apprehension about how we would fill our time. Having put forward a number of options for activities to my Aunt, none seemed to appeal to my very open minded Uncle. My trump card was a game drive round the world famous nearby Game Park. What could possibly be disagreeable about sitting on a game drive vehicle, surveying the beautiful countryside, birds and animals? But no. Apparently this would bore and reduce time spent at far more interesting watering holes.

Fortunately, we managed to identify an ideal afternoon activity that would ideally suit my uncle. Horse riding to the nearby lake for a drink at sunset. With great relief we all walked off to find a stable companion. And off we headed into the bush. Everyone extremely happy.

Having ridden for a couple of hours we reached our destination. There with a big grin was Uncle Peter – drink in hand and unsaddled from his chrome nag.

The evening was spent out on a deck under the stars recounting our stories about life in a rural South African hospital and school. It also provided an opportunity to pass on some basic Zulu to my inquisitive Uncle. Latching onto the word for ‘thank you’ (siyabonga) he immediately developed great confidence with the locals. This was continued throughout the stay. Attempts to speak other words were less successful; so instead words like ‘adios’ began to appear.

During the evening, my darling aunt organised for the following day, an hour long plane ride over the local scenery. And thus, Mary and I were able to go to sleep dreaming of recreating a favourite cinematic scene – Redford and Streep flying over the Kenyan bush.

In the morning we said goodbye to Peter (happy not to come having fallen asleep last time he took a sight seeing flight). The airfield was located in the middle of Phinda National Park. Teaming with animals we were able to spot giraffes, wildebeests and elephants taking off and landing. Once in the air, we flew across the biggest salt water and fresh water lakes in South Africa. As we flew over these we could count dozens of hippos parked together in different parts of the water. And we then headed along the coast. Looking down we spotted schools of dolphins diving in and out of the Indian Ocean.

The Out of Africa re-enactment was completed as we flew over the coastline. There it was, that the pilot asked if I would like to take control of the plane. And so, with a great sense of excitement, I began to manoeuvre our bird like machine. First a tip of the wing left to look down into the sea. Then a tip of the left wing to observe the coastline. Pushing the steering wheel away took us downwards a hundred feet. And then almost immediately, I pulled it back to soar up again. Turning to share my delight with my wife and aunt I was just in time to see Mary vomit several times into her reinforced (thank you Aunt Annie) sick bag. Guiltily I handed back the controls. There ended the flying lesson.

Despite the vomit moment, the flight now belongs on our list of top moments in SA.

Sadly we were unable to host Annie and Peter in Ingwavuma (as had been the plan). This was a particular disappointment to the locals, many of whom had been given advanced notice of the visit of a great English chief and his wife. Tales of his wonderful grasp of the local language will, though, live on.

Only in Africa

Have a look at this story from the BBC website - Africa section. Your challenge is to read it and to keep a straight face.

The article

Two of Malawi's most senior judicial officials are arguing over whether a new bill includes a provision that outlaws breaking wind in public.

Justice Minister George Chaponda says the new bill would criminalise flatulence to promote "public decency".

"Just go to the toilet when you feel like farting," he told local radio.

However, he was directly contradicted by Solicitor General Anthony Kamanga, who says the reference to "fouling the air" means pollution.

"How any reasonable or sensible person can construe the provision to criminalising farting in public is beyond me," he said, adding that the prohibition contained in the new law has been in place since 1929.

The Local Courts Bill, to be introduced next week reads: "Any person who vitiates the atmosphere in any place so as to make it noxious to the public to the health of persons in general dwelling or carrying on business in the neighbourhood or passing along a public way shall be guilty of a misdemeanour."

Mr Chaponda, a trained lawyer, insists that this includes farting.

"Would you be happy to see people farting anyhow?" he asked on the popular "Straight Talk" programme on Malawi's Capital Radio.

He said that local chiefs would deal with any offenders.

When asked whether it could be enforced, he said it would be similar to laws banning urinating in public.'


What price MR Cameron responding to the story by calling for a national debate in the UK. Might the idea be a vote winner? I'm certainly a supporter of Chapondaism.

Ntabayengwe, T20 and Russian Romance

It is Friday and I have just completed the second week of the new school year. I have the following to report:

1. I am enjoying teaching my top year group – year 7. I taught them last year and many have made good progress. They tolerate my eccentricities and try hard.

2. I am haing a much tougher time with grade 6. Most are shy and very reluctant to contribute. And a couple have behaviour that belongs in an English school.

3. The Principal continues to amuse me. At the end of the last week I had a free period and was reading in his ‘office’. Midway through the Russian revolution (I am onto my last book – Dr Zhivago) he asked if I could hear the noise,

‘What noise, Mr Mkumbusi?’
‘The sound of the young hyenas calling.’
‘No, I cannot hear them.’
‘Listen carefully.’
‘I still cannot hear them.’
‘Eish Mr Toulson. I am not being serious. Can you not hear the grade r children howling for their mothers? How we all must suffer!’

4. I am making progress in organising a school trip to the beach. The education department policy document requires me to set up several committees. Rather than doing this I have produced a couple of sets of fictitious minutes. These give due consideration to the ridiculous guide lines on safety precautions. One section reminds trip coordinators that not all areas in SA have mobile phone reception. Thus alternative means of emergency communication should be considered. I am still wondering what they have in mind.

5. We lost our first – T20 – cricket match of the year. We spent a couple of afternoons this week training. All toiled hard under the midday son. And I promised the boys that their hard work would be rewarded.

Opting to bat first, we suffered several early wicket losses. Fortunately our steely middle order offered resistance and we ended up posting a competitive 43 run total.

Taking early key opposition wickets, confidence grew among Ntabayengwe. Only for their coach to insist on a suicidal ‘everyone must bowl strategy’. The unforgiving umpire (also their coach) then proceeded to award the opposition nearly 30 no ball/wides.

A string of sporting clichés helped to reduce the disappointment on the faces of the Ntabayengwe boys at the end. As compensation for my part in their downfall, I have promised to arrange another match soon.

This weekend

Away from school, Mary is on call this weekend. So we have nothing exciting planned. I foresee a weekend of Siberian love and romance.

Ingwavuma Buffalo

The last couple of weekends have brought us very close encounters with two of Africa’s biggest animals.

A number of the local safari parks run animal projects. Sometimes these focus on the observation or reintroduction of an endangered species. For example, Tembe Elephant Park has just released a number of African Wild Dogs into their park. These have been eradicated from most of the parks in SA. And hence conservationists are trying to intervene. Success will depend on their ability to coexist with the lions in the park. This will require them to learn, very quickly, to stay clear of the king.*

Another local park is looking after two injured elephants – one male and one female. Both elephants narrowly escaped a culling programme in Zimbabwe. Their rescue as youngsters familiarised them with humans. They now live a nearly wild existence. They roam free with other seven tonne wonders happily grazing, sleeping, fighting and mating. But, each morning they come to a specific location in anticipation of some treats. Last weekend, we were able to go to the park and feed them.

On arrival, we were greeted by the sight of the two elephants waiting for food. And they had a surprise for us. For between them was a new addition. A nine month old baby. Their baby.

So began an hour of elephant indulgence. Holding food in our hands we watched as two of the elephants used superb trunk control to transfer large quantities of oats to their mouths. After a while of this, the elephants were commanded to stick out their tongues. Being very obedient, they did as asked. And so we put hundreds more pellets straight into their mouths. Jubulani, the calf, was less adept at using his trunk or at showing his tongue. He spilled much and consumed little. But fortunately he has a much smaller belly. And he still receives gallons of milk from mum. So his messy eating will not hinder his growth.

Almost exactly on the hour mark, having been given water, the elephants disappeared back into the bush.

This weekend we headed to a very secluded part of the coast for a weekend at a place called Thonga Lodge (only look it up if you want to feel extremely depressed). Used to trying to stay at places far out of our budget, Mosvold Doctors have become great hustlers. And so we were able to spend a night in luxury. Situated by a pristine beach, the Lodge is 100 metres from the ridiculously warm Indian Ocean (only truly appreciated if you began swimming on holidays in North Wales). A couple of miles away lies the biggest freshwater lake – Lake Sibiya in Southern Africa. Full of hippos, crocs and birdlife.

On Saturday evening, we drove to the shores of LS to enjoy sundowners (drinks consumed when watching the sun go down; isn’t South African English complicated.) Driving around, our guide looked for the perfect location. This took time. First we had to stop to watch an immature Fish Eagle eating the remains of its supper. Eventually we found a spot 15 metres from the water edge. The perfect location to watch hippos playing in the water.

There we sat enjoying the sunset. And the scene must have looked idyllic. For after not very long, we heard splashing in the water. And out came a hippo, keen to mow the grass in front of us.

Now ten metres from a hippo is less than the recommended safety distance. For, as everyone knows, the hippo is the mammal that kills most humans in Africa each year. And for this reason we were right to feel scared. But we were not in great danger. Firstly our vehicle was close-by to us. Secondly, we were not between the hippo and the water – an extremely dangerous predicament. Lastly, the hippo was completely oblivious to us. For though they have excellent hearing and smell, they can see less well than Mary (who, without contacts, struggles to see me lying beside her in bed; she, too, relies on hearing and smell).

For two or three minutes our hippo merrily chomped the grass. And then suddenly it heard a noise. In blind terror of meeting an animal larger than itself (something that can’t happen often for hippos) it turned and bounded into the water. Leaving all of us very touched by its great sensitivity.

Having previously walked with rhinos and lion cubs, we now have one last close encounter to engineer. The buffalo. But neither of us is overly keen. We think we might settle instead for the dopey Ingwavuman cow. We’ve passed them many times. And on a cloudy day they look vaguely buffaloesque. Time to fabricate a photo.

Bumper cars

Another depressing discussion topic in SA is road safety. I happened to buy a paper yesterday in Spar (in fact I was forced to buy it; I was told to wait ten minutes before being served at the meat counter; so I browsed a daily; apparently this is not allowed).

One of the articles in ‘The New Age’ was about road traffic accidents. Statistics have just been published on accidents and driving offences over the month of December across the country. They are chastening. Put simply, SA is by far the most dangerous place to drive in Africa (and therefore the world?). As evidence, it has 20% of the cars on the continent but 60% of road accidents.

The most terrifying time to drive in the country is over the Christmas period. This year the number killed over the month of December was 1551 or about 50 people everyday. This number does not include all those seriously and permanently injured. The only good news is that this represented a fall from the previous year – 1761. The highest rate of deaths this year was in our province – 232 or about 8 per day.

It is not difficult to explain the reasons for the massive number of fatalities. The first, and most obvious, is the level of driving proficiency of many behind the wheel. Every journey we make is littered with near hits. Overtaking manoeuvres are regularly undertaken on the brow of a hill, round a blind corner or in spite of fast approaching on coming vehicles. Around Ingwavuma, we drive on mountainous roads with tight sharp corners. Drivers often seem unaware of the need to slow down for bends and so swing across the road. Estimates are that 80% of all accidents are due to driver error.

Thus bad driving is one big contributory factor. Poor visibility (particularly bad on some days in the mountains that surround us) and pot holes (especially craterous in KZN) are estimated to account for 8% of accidents.

Another big cause is unroadworthy cars. Understandably vehicles have much longer lives here. Though all of them should receive annual MOTs, many do not. For this is expensive. Many are old pick-up trucks. They can often be seen transporting 10-15 people – most standing up in the back. The doctors at Mosvold regularly treat patients who have fallen out the back.

The final noxious ingredient is drink driving. I’m told that motorist in the cities are randomly breathalysed. But it doesn’t happen in rural areas. As a result, there is little concern in rural KZN about driving under the influence.

And so we can now formulate the equation. Bad driving, bad roads, bad vehicles and alcohol = 1551 dead in December.

If the first stage of the solution is recognising the problem, then SA is making progress. Indeed, as already mentioned, they have reduced the number of road deaths from this time last year. And the police focus particularly hard on the problem. But the challenge is huge. Over December they stopped one and a half million motorist. One third of these were found to have violated the Road Traffic Act.

All of this has two consequences for us. Firstly, we wear our seat belts. Secondly, we are after a good medical kit for the car. Thus far, Mary has yet to be first on the scene for any road accidents – though we have stopped at many. This is almost certain to change.

Anyway, next blog entry I promise to write about something cheery.

Vile-ence

Having spent nearly six months in Ingwavuma, Mary and I have been completely won over by the people and the setting. We feel great warmth from the wider community. And, while remaining cautious, we feel safe when out and about. However, even in rural KZN, violence remains frighteningly frequent.

One of the most depressing aspects to working as a doctor at Mosvold, is the workload generated by sexual violence. Gang rape and attacks on minors seem to be particularly prevalent. Presented with the victim, the doctors investigate physical evidence of the crime on their body. The police then search for the perpetrator. The police have a good reputation for catching those responsible. Their work is visible to the doctors because the accused are regularly brought to the hospital for DNA testing. (This also presumably explains why so many rape victims come forward.) Nonetheless the assaults continue.

The depth of the problem is massive. A recent article in The Guardian Weekly contained details of a survey by the Medical Research Council. In this, 28% of men from KZN admitted to rape. In Gauteng (the wealthiest province) the rate is even higher at 37.4%.

This violence has its roots in rotten gender attitudes. These were also investigated in the survey. Of those asked, 55% of men thought that rape within marriage was a crime. Over 30% considered the promiscuity of a woman to be relevant in the assessment of whether rape had taken place.

Unfortunately, efforts to combat the problem currently seem doomed to fail. If there are public campaigns they are not heard in Ingwavuma or other rural areas. Very few people have access to the media.

Sadly, what is well known, even here, is that the President was accused of rape and acquitted. It is also common knowledge that his defence was partly built on provocation – the female involved was wearing a certain type of cloth. (Incredibly, Zuma also revealed under cross-examination that he had taken no precautions despite the lady having HIV. He felt it unlikely that a healthy man could contract HIV. He also had a shower afterwards.) Guilty or not, it makes public pronouncements on the issue by the ANC somewhat awkward.

The principal/only real vehicle for change is the education system. Written into the text books are lessons on achieving gender equality. These try to challenge traditional views. However their success depends firstly upon having an enlightened teacher. Otherwise they can easily be skipped. Secondly, they depend upon the school reinforcing the message within the school ethos. Does the school, for example, expect all the children to sweep the classroom floors or just the females. Finally, the lessons need to withstand contradictory messages being received at home.

Perhaps the education system can help to win the battle in the long-term. But not before many more badly injured women have been treated at Mosvold.

Ntabayengwe reopens for business

School restarted last week. The teachers returned a couple of days before the pupils. We had three things to sort out – the timetable, responsibilities and the allocation of stationary.

The timetable was drawn up quickly after a decision was taken to reuse the one from last year. Huge relief all round.

Discussion of responsibilities went well. I am now in charge of school excursions. Until now, we have never managed a school outing. The biggest obstacles are money and red tape. But I have ideas for overcoming these. I’ll let you know how I get on.

The allocation of stationary proved most problematic. I didn’t get too involved in the discussion. Instead, I spent the time browsing through new text books sent by the education authority. And I quickly became depressed.

Each year we are sent a random selection of slightly revised text books. Typically we receive ten copies of each book – far too few to use with classes of 30-40. Anyway, we never ask for these text books. And most we do not need. Often, they replace text books received the previous year of similar quality and still in perfectly good condition. As a result our out buildings are overflowing with bonfire material.

I am convinced that we, and all the local schools, are victims of a giant scam. There must be private publishing companies making a huge amount of money from contracts with the educational authorities.

A superficial glance through some the new text books creates a positive impression. The new grade 7 English book is beautifully presented. Each page is full of colour. Unfortunately, the content has been thrown together with no thought. There are a few very random grammar and vocab lessons. These are interspersed with a huge number of idiotic sections that serve no purpose. For example, one of the early chapters requires the children to identify correctly letters from different world alphabets – Arabic, Japanese, Hebrew, Mandarin, Hindi and Russian. There are no clues given as to how they should go about doing this. Many other chapters belong in other subject text books – e.g. identifying circuit symbols, classifying animals into kingdoms and species, matching up flags to countries.

Other text books are slightly easier to follow. But many are very dull and pitched far above the ability of the children. Few children even in the top year at primary school have a reading age above 6-7 in English. Yet, for example, the citizenship text book encourages the children to analyse the merits of the South African constitution and to consider the different clauses contained in the Bill of Rights.

And now to the crux of the problem. A large number of teachers in South Africa do not have degrees. A teacher is only required to have passed their matriculation (equivalent of A-Level). This creates a heavy dependence on the text book. Where it goes, they follow. Believing whole heartedly in the importance of the knowledge contained in their teaching aid. Even if it means exercises in distinguishing between Arabic and Hindi.

Time for a South African version of the Pink Floyd classic. ‘Text books, leave those kids alone.’

Male Ward

I have now been the doctor in charge of male ward for three weeks. We have twenty five beds and after my first three days on the ward, the ward has been full and remained full. Last Friday, the ward was so overfull that I had eight men waiting outside on chairs. I was a bit overwhelmed but managed to

o transfer two to bigger hospitals (one had large bowel obstruction which is a surgical emergency and another one had not been able to walk for six weeks and was awaiting an MRI scan),
o discharge three
o give two pass outs (which means they go home to take care of things for a few days)

Unfortunately one patient died (my first death on the ward and completely inevitable). This movement freed up sufficient beds to empty the hall way.

So far, my patients on Male ward are a huge mix – neurology problems (a few unable to walk), severe gastroenteritis (usually Stage 4 AIDS and therefore very close to death), surgical problems (two men with the worst smelling feet I have ever experienced – one waiting for a below the knee amputation and one with gas gangrene), orthopaedic injuries (lots of people chasing cows and fracturing bones) and young HIV men with bacterial meningitis.

I am really enjoying the ward. My nursing colleagues are great and the work itself is very challenging. Everyday, I find myself laughing about something. Here are just two examples:

When I took over the ward, I also took over the care of a psychiatric patient. As a doctor working in Africa (both South Africa and Ghana), I have encountered far fewer patients suffering from mental illness. This is partly explained by the link between affluent societies and increased stress levels. However it is also because of the limited medical resources in Africa. Here, very few patients with invisible illness/injuries are admitted.

Anyhow, back to my story, which is that my patient was admitted due to an episode of acute psychosis (he is a known schizophrenic who is not on any treatment). He smokes too much dagga (marijuana) and drinks too much alcohol. He is a very intelligent man who is quite bored with life. I kept him in as a patient until last Wednesday (I was waiting for the Psychiatric Nurse to see him). During this time, he explained that he was using the time wisely. To find a wife. Predictably he quickly became a menace. Anything female was a target. Except for me. Thankfully I was exempt from his charm. For I was his doctor. What a relief!

2) One of my young men with bacterial meningitis was desperate to go home having received only one day of IV antibiotics. I told him, very assertively, that he would be staying for minimum seven days. Immediately he looked very upset. Now there is no such thing as confidentiality on wards in Mosvold. Everyone gets to listen in as a patient is spoken to by the doctor. On this occasion, the Umkulu (old man) who was on the opposite side of the ward and seven patients away, shouted out that ‘Even though she is a woman, you must listen to her.’ Feeling greatly respected, I looked back at the patient. With back up from an elderly male, the patient acceded.