I’m here

There may be something a little distasteful about the whole thing, this sort of reverse medical tourism. Well-off western kids strutting across the world to gawp at and have their consciences titillated by genuine poverty and pain and squalor and violence and suffering. The kind you read about and see on the tee vee. But then I’m not just gawping I guess. I just got the results of my finals. The General Medical Council and two Universities have decided the last six years were not entirely wasted. Weird as it sounds, I’m a Doctor. And this guy on the trolley in front of me, who’s thrashing around and bleeding profusely from his scalp, he’s my patient I guess. This is what I came here for.




Soweto

I’m in the Gauteng Province of South Africa. The Sesotho word Gauteng means ‘Place of Gold’. It was the discovery of Gold and the establishment of mines here in the 19th century that led to the founding of Johannesburg. Forbidden by Apartheid laws from living in Johannesburg, black men (men only) were permitted to live in squatter camps and settlements south-west of the city.

The South Western Townships now sprawl over more than 180 square kilometres. The official estimate of the population is around 4 million but it’s probably significantly more. Immigrants from surrounding countries tend to end up here, seeking work in Johannesburg – the capital city of South Africa and one that generates over a third of the country’s wealth. Soweto supplies much of the labour force for Johannesburg. Sowetans say – ‘Johannesburg is the heart of the country and Soweto its pulse.’

Apartheid is officially over but you will not find many white people living in Soweto. It’s finding its feet - not quite a city, but more than a shanty town. A great number of residents still live in ‘Informal Settlements’ – rows of simple shacks. There is little electricity beyond what can be diverted illegally from the street lights. Electrical burns are common. Cooking, heating and lighting are with coal or oil. The burns that shack fires produce in these settings are unforgettable.

A single water tap may serve a whole street or block. The government has started a scheme to provide chemical toilets to each house. New housing is under construction but many people here will never qualify for it.




Baragwanath

Founded by the British in 1941 to provide medical care for the Imperial Army, the Baragwanath hospital is now one of the largest in the world. An excellent essay on the history of the place is available at their website. The name of the prominent anti-apartheid activist Chris Hani was added after his killing in 1993.

‘Bara’ as it’s known locally is the only public hospital serving the population of Soweto. In the Apartheid era it was a blacks-only hospital and the majority of patients are still black. The surrounding area has one of the highest rates of rape, murder, assault and other violent crime anywhere in the world. The violence is almost entirely black-on-black. I ask many of the people I see what it was about, what the argument was. Women, dice, money are common answers. Football results. Simple mugging. One man who was almost stabbed to death told me it was for his mobile phone and the money in his pocket, 20 Rand. That’s about £1.25 or a little over $2. Puza is another common answer, one well-known to anyone who’s worked in an Emergency department. Puza means ‘drink’.

Morbidly, all this violence makes the place a magnet for doctors - particularly aspiring surgeons. Military surgeons from around the world come to train here. There aren’t so many places outside of active war zones where you can be pretty much guaranteed to see a number of severe burns, gunshots and stabbings every day. And largely in English.

I’m on a one-month placement in the division of Trauma Surgery. The Trauma emergency room is known as ‘The Pit’. I see lots of Trauma, you can imagine. We learn to perform procedures they’d never let us near back home. Not without a few dozen more letters after our names. Chest drains and central lines and suturing and suturing and suturing. But let’s draw the curtain. Patients are entitled to privacy. If you see me coming out of the cubicle you’ll notice my shoes are bloody. I liked those shoes. The cunning thing to do would have been to don a couple of pairs of the overshoes they wear in surgical theatre. Some things they don’t teach you.

They do tell you, before you come here, that the incidence of HIV in people coming through the door is around 40%. We had a talk from the medical school on transmissible infections before we went off on elective. They gave us more statistics and sombre words.

‘The profession whose ranks you are shortly to join, ladies and gentlemen, is still esteemed in some circles’ the Prof said. ‘It is esteemed in part, because in past pandemics your colleagues have had the choice of staying at home and ensuring their safety and the safety of their families – or treating patients. They have historically made the choice to treat their patients. Some of them have paid for this with their lives… I fully expect you to make the same choice.’

The rate of occupational transmission from an HIV-positive source is believed to be 0.3% for a percutaneous exposure and 0.09% for a mucous membrane exposure. The rate of transmission from a hepatitis B-positive source to a nonimmunized host is 6-24% and 1-10% for exposure to hepatitis-C.

Percutaneous exposure in this context means needlestick - being pricked by a contaminated needle. Mucous membrane exposure means getting blood or other contaminated fluid in your mouth or eyes. With blood and scalpels and needles flying everywhere this is a real risk. Workers who are exposed make a decision to start or not start anti-retroviral treatment. The beatific calculus. The course is one month and reportedly makes you sick as a dog. It is meant to reduce the risk of seroconversion but this isn’t really the sort of thing you can run double-blind placebo controlled trials on.

Risky business, this. In real terms, if you’re sensible the risks are low. We went to speak to the Prof after the talk, rattled. He told us to observe universal precautions - foremost of which was to keep everything zipped away - and we’d (probably) be fine. There are much higher-risk activities after all.




Bla Bla Bla

And again I wonder if it’s the right thing to come here, me, some middle-class prick from another hemisphere. Sitting in the evenings with friends, sipping tea that I packed and brought with me or imported Tanqueray and Tonic or wine from the vineyards of Stellenbosch and Paarl, thinking of the people I’ve seen today, shot and burned and stabbed and broken, many of them my age. I’ve had too much wine I think, that wasn’t sipping was it? Thinking of what they went home to – the ones who went home. The Place of Gold. How much have we changed since the first hominid saw something glinting in a rock and thought – oooh… pretty… shiny… and his brother hominid cracked him in the goddamn eye with a dull rock and took the shiny rock from him? I’m the same age as many of these people, I think I said already. Some are younger. Young men and women in their prime - with everything before them. With nothing before them. We’re all going straight to heaven. We’re all going straight the other way.




Opinion

It’s 3 in the morning at Bara. The shifts here are 24 hours, 7am to 7am. After hours of carnage, the Pit is quiet for the moment so I go to the Doctor’s break room. I brought a bunch of books with me travelling as you do. Fiction, non-fiction. I’m too tired to read but some things stick in the mind and come back. This is John Maynard Keynes, you may have seen it before.

 

We may still have to time to reconsider our courses and to view the world with new eyes… The events of the coming year will not be shaped by the deliberate acts of statesmen, but by the hidden currents flowing continually beneath the surface of political history, of which no one can predict the outcome. In one way only can we influence these hidden currents – by setting in motion those forces of instruction and imagination which change opinion…

In this autumn of 1919 in which I write, we are at the dead season of our fortunes. Our power of feeling or caring beyond the immediate questions of our own material well-being is temporarily eclipsed.... We have been moved already beyond endurance, and need rest…. For these reasons the true voice of the new generation has not yet spoken, and silent opinion is not yet formed.

If you can keep busy enough you forget other aches and troubles, they’re carried along with everything else. But when you have a moment of peace in which to rest they begin to settle out again, sinking in the heart like gravel. You close your eyes a moment and old old songs are heard again.

But troubles will soon be over. Besides, there are many who have it worse - who have more pressing troubles. I’m not in the break room for long before one of the Nurses comes in.


“Doctor?”




Sources

  1. Chris Hani Baragwanath Hospital official website
  2. Emedicine Needlestick Guidelines
  3. Holiday reading included The New Penguin History of the World by JM Roberts, which quotes from John Maynard Keynes, The Economic Consequences of the Peace. The complete passage (p296-8) of Keynes’ book is available on Google books and is worth a read.

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