Cato Manor

(written 26 September, 2006)

After a week at KwaMashu, Cato Manor was like a different planet. This clinc is brand new. Returning to maternity, I spent time in the first place that remotely resembled an American hospital. It was squeaky clean, with shiny white floors and a well aerated breezeway between departments where patients could come in from the rain, or weather even before the clinic opened it’s doors. The delivery rooms were private and had blue plastic lined squishy delivery beds, complete with detachable stirrups and could be set to any angle of incline. Mothers were counseled in PMTCT (Prevention of Mother to Child Transmission) at their first appointment.

In the four days I spent at Cato Manor, I only saw one mother come in the beginning stages of labor. She was taken to King Edward hospital to deliver, because her CD4 count was 5.

Cato Manor looks like a well funded facility. It is clean, and the doctors, nurses, and midwives who work there, are very good at what they do. They have an operating theater, but it is used for storage, because they cannot afford to hire surgeons. They have capacity to house some of the overflow from KwaMashu, but their hallways are empty by noon. They have an x-ray and ultra sound machine, but cannot employ technicians or radiologists. They have the facilities for a fully running lab, but they send their blood and sputum cultures out, increasing the waiting time for lab results. The labor ward was mostly empty except for twenty or so mothers visiting for their first appointment.

The sisters at Cato Manor offered to let me draw blood. They handed me the needle, and pushed in tightly into the end of the syringe. Breathe, I thought to myself, don’t shake. I gently tucked the needle under the skin. The vein bulged and the top of the mouth of the syringe changed color as blood flowed in. I placed my thumb over the needle and re-positioned my right hand to pull back on the stopper, I pulled gently and blood flowed in. I let it rest and the negative pressure continued to fill the syringe, I pulled back some more to fill it above the 5cc mark, Done. I pulled off the tourniquet with one hand and brought a cotton ball to the needle entrance sight as I released the needle from captivity under the skin. I then ejected the blood into two test tubes trough clay plugs, and into both preliminary HIV antibody tests.

KwaMashu

26 September 2006

To:
The concerned citizens of the World,
I am writing to inform you of the irreparable damage done to the KwaMashu Polyclinic, outside of Durban South Africa. As a pre-medical student from the United States I had the opportunity to spend a week working side by side with the sisters (midwives and nurses) in the labor and delivery room of the maternity ward. This polyclinic serves the entire township of KwaMashu. The last census here estimated their population to three hundred and fifty thousand people, but the census does not account for people in “informal settlements.” My guess is that there are at least another hundred and fifty thousand people in KwaMashu who make their homes in shacks along the hillside, and the census counts not one of those homes. The whole polyclinic has no more than 6 functional buildings. Upon entry my first morning, we had to wait in the van for a guard to unlock the chain and padlock. The pedestrian entrance was a metal turnstile, surrounded by chain link fence and barbed wire lines the wooden fences that encircle the campus. Twenty cars gridlocked in a stalemate with literally, a mob of patients in need of care gather towards the buildings. From the outside it almost looked like a riot scene full of chaos and a fight for a place close to the front of the cue (line) when the building opens. Some of the patients here walk a full day just to get to the clinic. They sometimes spend all day in line and are then turned away because they did not make it to the front, or the few doctors who have committed themselves to the completely underserved population, have gone home.

Understaffing is only one of the problems that KwaMashu Polyclinic faces. The allocation of funds meeting, which some of my colleagues attended, gave us some clarity and a new frustration as we understood underlying issues. It seems the clinic is under-spending in every department. One of the problems is that the directors of the departments are nurses who already have full time jobs, doing nursing work. When their proposals for money or Equipment are turned down, they are asked by the clinic administrator (in a condescending fashion) where their paperwork. Nine times out of ten they have no response, the paperwork was lost or never turned in. All the miscommunications and unused resources added fuel to my fire. In my time at KwaMashu, I became extremely frustrated with the void of educated health care administrators, and staff to support the nurses, doctors, and midwives, who have made KwaMashu their home.

The poor management trickles right down to the physical condition of the clinic. Honestly, It doesn’t look like any kind of facility I would ever take my child, partner, or parent. The entire facility needs a coat of paint and new tiles for the floor. The tiles around the edge of the room are broken, rotting, and unsightly. As I sat in the labor room patiently waiting for a baby to be born, I looked around. There are six beds, each two feet apart, hardly big enough for a rolling IV drip stand to fit it’s wheels between. The eight or so nurses and midwives share one stethoscope. Joan, one of the girls in our program has her own blood pressure cuff, one of the nurses offered to buy it off her. The sphygnomometer that I used had a poor seal on the bulb end and my hands were polluted with melted glue stick-em when I was done inflating the cuff. The Sharps container houses a colony of ants that trail around the room. It is by no means sanitary.

If you are not a midwife or an OB/GYN or have never been pregnant in South Africa, you may not be aware of how much a fetal heart monitor is used here. The entire clinic has ONE only one that functions. It works sometimes and was probably manufactured in the eighties. It is not cleaned between patients and there is only one elastic band that also looks as though it is never washed. They could use three in the labor room and three in the pre-natal care room. There is no ultra-sound machine. But if there were one I suppose people who have to be trained to use it, which would cost more money. “Come hear the baby’s heart,” calls a nurse, motioning to my from behind a curtain. She presses a rubber cone shape against the pregnant woman’s swollen belly. I’m skeptical that the blue rubber cone will amplify anything, but to my surprise I can hear a rapid healthy fetal heart beat.

At tea time I walk down a hall and heads turn following the tails of my white coat. A doctor, the people must be thinking, maybe the cue will move faster. And I wish I could start triaging down the line. Close to five hundred people snake across benches in fifteen rows. Each one has an eager or tired face. I smile, sometimes they smile back. When I hear someone coughing across the room, I hold my breath. It probably does me no good.

Back in Labor and delivery a midwife gets out the instruments for a delivery. They are wrapped in green paper, and she touches them with gloved hands only, but clearly they have been used before. They are stained and not shinny. I can’t even see my reflection in the metal. There are no computers here, and the women must bring their green pre-natal care folder that contains their medical history to each appointment. The daily logs are kept in the admins book. It is like an oversized ruled notebook, and each page has hand drawn columns with a red pen and a ruler. I bet you won’t be surprised when I tell you who cleans up the beds. The same women who deliver the babies mop the floor and change the paper covers, and wipe down the rubber mat that lies across the bed. The sheets are not changed all day, and multiple women share the beds, during a heart monitoring session, false labor, or a pelvic exam. (All of which were demonstrated with verbal instruction, followed by a hands-on test of skill.) I also learned how to palpate and measure a dilated cervix.

This clinic has five or six other departments that are in similar disrepair. The meager staff is committed beyond expectations, but I am still frustrated beyond belief with what these people don’t have. I feel somehow that even if ultra-sound machines, and fetal heart monitors, and shiny new instruments were provided it wouldn’t be a completely justified act because it would be too much at once. The women who work in the Maternity ward are very comfortable working with what they have, and perhaps and abrupt attempt overwhelm a developing country with modern instruments and complex machines that are hard to implement and harder to maintain would be detrimental. I hope someday I figure out whom to send this letter to. Today, I am not sure.

Timon and Pumba's Safari Adventure

September 28, 2006

Last weekend we hired two cars and drove, Yes on the left side of the road about three hours up the coast to St.Lucia Wetlands and Wildlife reserve. Monday was a National Holiday so we had four days to play and have a mini holiday of our own.

We got into St.Lucia a bit later than planned. Surprise, surprise, eh? We pulled in after dark and headed down to the beach for a bonfire with other people from our hostel. We stepped onto a pitch black, slightly moonlit beach where the waves of the Indian Ocean kissed the shoreline, and made music for the backgroud to our campfire. We joked into the night about the Crocs and wild hippos that roamed the beach at night. I don't think it was much of a joke though because the estuary houses both animals and pours right into the sea near our bonfire spot.

After a late night we rose before the sun at 4:45 and drove an hour and a half to Hlhluwe Game Reserve Park in order to arrive by 6 when the park opened. Brekfast was peanut butter and honey made by Chef Nahzi in the backseat. We spent the first three hours of our adventure stopping the car almost every five or six minutes. Zebras on the left! Elephants on the right. The Elephant proceeded to cross the road only a few few behind our cars! And they weren't the only trafic. We saw our fair share of warthogs, tails stick straight as they scurried ahead of us. We eagerly asked "pumba" where he thought timon might be hiding.(Lion King reference)This was followed by a ten minute disscussion on exactly what type of animal timon was. Merecat?


The next day after our trip home from the beach we spotted more than a gaggle, perhaps 35 or so little brown creatures crossing the road in the middle of town! "What is it?" we asked Ian, who was driving, and we sped up for a better look. "IT's Timon!" he replied.



Create Your Own!

The Burg

The sun bakes us, we breeze through the land of stereotypical Africa. No cars in sight, we're the only one, baby clothes on the line, huts with grass roofs or corrugated sheet metal, I don't think it's called that. and women carrying water in clay jars on their heads. One woman carries a cow hide, a full flat, dried cow hide. It's brown and spotted. The head is still attached, well, parts of it.

The sky clouds over us as we follow the windy road, adorned with potholes, as the sign says, "POTHOLES, NEXT 30 KM." In the distance children are playing in the road. They see us before we see them. Two or three thrown themselves down on the road, knowing from experience that we'll brake for them. As soon as I slow down the car they jump off the ground and come running towards the car, shouting "Sweets, Sweets!" Our fears keep us moving. We've been warned that even the smallest children can be good pickpockets. So perhaps our prejudice too, accelerates us down the road, leaving the children to try again for the next car.

Today is our second day hiking in the Drakensburg Mountains, fondly referred to as "the Burg" and after yesterday's rainout an hour from the trail head, we're thirsty for more. WE climb down the valley and over a small river, and then up a red rocky hillside that will become a slip'n slide on the way down. I'm lagging today, behind the group, and I don't know why. When we get to the crest of the hill, we realize that we may have gone too far.
Our aim was the Bushmen paintings, ancient world heritage rock-art, still visible. Electric charge in the air begins to raise our hair, so we opt to descend and try looking for the caves along the valley/ protect ourselves from a lightning storm.

Eventually we find the caves, and scrape together a hundred and twenty sopping we Rand for a guided tour of the rockpaintings and a history lesson, from the Zulu tour guide. Our hike out includes what might as well have been the magical fairy jungle forest. The moss and ferns were illuminated by the bright gray skies and dripping clouds. Magical. Thanks for reading.