I must apologise for the long delay between Parts 1 and 2 , but the hold up is due to the festive season followed by a bit of COVID while trying to set up my new blogsite as well as finalise Book 1 of my trilogy for publication. I hope you enjoy the new website and the current read. If you enjoy the read, then please like and share on your social media posts. Keep well.
Bad times and good times in a Kwazulu/Zululand mission hospital. (Part 2)
People often collected water in a variety of containers, ranging from traditional clay pots to plastic containers. On their way home, the large vessels were usually balanced on their heads as they walked along. For me, a unique sight was of girls strolling with a bottle of water balanced upright on their heads. Though I never saw one falling, I often wondered how often the bottle broke.
Zululand was a land of absentee fathers who worked mainly in South Africa's mines. The women had to look after the children, livestock, and tend the land. Maize meal, the staple diet for these destitute families, was a poor food, deficient in certain essential, protein-building amino acids.
Their diet resulted in what I regarded as the malnutrition syndrome in which the child had life-threatening protein deficiencies like marasmus or kwashiorkor, and the mother had pellagra from a vitamin B deficiency. This combined adult and childhood malnutrition usually presented towards the end of the dry season because their staple diet was maize meal with little or no added nutritious foods. It was devastating to face a mother with the 3D's of Diarrhoea, Dermatitis with peeling, weeping skin, and Dementia (Death being the fourth), while the snotty-nosed, apathetic child on her lap inevitably let out a sad, weak cry. The distended belly was from fluid retention related to low serum protein. Even the blond hair colour is due to an inability to produce melanin for normal black hair; the skinny limbs are the result of poor muscle development.
This mother-child malnutrition complex always saddened me as these were citizens of Africa's wealthiest country. In the 1970s, South Africa had the third-worst under-five mortality rate in Africa, behind the poverty-stricken countries of Liberia and Chad. By contrast, two decades after the collapse of apartheid in 1994, the country rated third best after Mauritius and the Seychelles. For all that's wrong in present day South Africa, this improvement speaks volumes about the differences since the 1970s.
Scurvy was the killer disease of ancient mariners whose vitamin C-deficient diets followed their long days at sea without fresh fruit or vegetables. The British were nick-named "Limeys" when they took limes on board to prevent the disease. Sadly, this was not the case for the local Zululand coal-miners who presented to our hospital with their poor oral hygiene and legs as hard as wood due to the bleeding into the leg muscles from the Vitamin C-deficient disease. Yes, this was in 1972 in a country famous for its export of Outspan oranges. It was not uncommon to see young children's X-rays with long bone features typical of the disease. I had the same experience as a radiologist in Cape Town, close to the country's epicentre of citrus fruit production.
In other malnourished infants, vitamin D-deficient rickets was common. To see this in a sunshine-rich environment was a sure indicator of a diet lacking in fish, breakfast cereal, eggs, nuts, …
The commonest causes of childhood deaths in malnourished kids were gastroenteritis in summer and chest infections in winter. Whooping cough was another killer disease along with measles. The latter had a ten per cent mortality from bronchopneumonia, whereas it was nearly zero for White children in South Africa. Measles is one of Africa's leading causes of blindness. In Cape Town, there was a popular township belief that visual impairment resulted from exposure of the measles-affected eyes to sunlight, whereas washing the child with water could cause fatal bronchopneumonia. Consequently, they kept the unwashed sick kids in a dark room and never cleaned their eyes of the purulent discharge from their conjunctivitis.
Between my medical dramas, I had enough time to enjoy an unaccustomed family life, including teaching my daughter to ride a bicycle on the firm-packed red sand pathways under jacaranda trees in the hospital grounds.
In a country of thunderstorms, lightning strikes were frequent. To get my fearful offspring accustomed to the sound of thunder, we often sat on the verandah in the rain. One day, a flash of lightning, with its preceding loud boom, struck the wire fence about ten metres away from us. There were large eyes all around, but to lessen their fear, I started laughing while letting out a loud "Wowww!" despite my palpitations. It worked, as they also started laughing, nervously. To this day, they still do not fear thunderstorms, I think!
On the same fence, we once saw a black mamba - Africa's deadliest serpent bite, like the cobra, could cause paralysis and then death within 30 minutes. At about the same time, an isolated farmer in the country's north survived a mamba bite to the finger by shooting off the affected digit!
Africa's prettiest and best-camouflaged snake is the continent's leading killer - the puffadder provided us with a few patients every year. Unlike the more poisonous mamba or cobra bites, puffadder mortality is about 50%. We saw the survivors of adder bites with tissue necrosis of skin and underlying muscle and soft tissue, for which we performed skin grafts of the affected areas. One such bite to the face caused a hole in the underlying cheekbone in a young child whom we sent to Durban's King Edward Hospital for plastic surgery.
The adder is still the one snake that scares me the most as it has such superb camouflage. Even in Australia, the puffadder's smaller cousin, the death adder, is a master of disguise amongst tree leaves, twigs, bark and stones. When I play golf, I always carry a club in my hand when searching for a wayward golf ball in the bush. My search is cursory with a quick declaration of a lost ball. New rules allow play from the fairway - the preferred and much safer option, especially as I am allergic to horse serum from the days when tetanus antitoxin was given prophylactically for open injuries. Mainly horses and also sheep are used to produce snake anti-venoms.
As can be seen from some of the cases described, my CMH experience required me to be everything - surgeon, paediatrician, physician, obstetrician, anaesthetist … As a gynaecologist, I feared the ruptured ectopic pregnancy the most as patients often presented late and quickly used up the hospital's limited supply of blood of which we only carried a few units, brought in weekly from Vryheid - about two hours of gravel road east of us. The thunderstorms meant we were often cut off for days at a time during the summer months. It was not unusual for us to have to auto-transfuse the shocked patients during surgery by collecting the liquid blood and blood clots from the belly, straining it through surgical dressings into sterile containers, before putting the liquid, clot-free blood back into the patient's veins. It was always gratifying to see the patient's pulse rate and blood pressure return to normal in these nearly dead patients.
Black South Africans bore the brunt of apartheid's inequities with burgeoning crime, violence and severe health issues as noted earlier. The scourge of tuberculosis was rife in the cities and rural areas. We looked after TB patients at the neighbouring Thulasizwe Hospital. As a university student, for five years I always had an annual negative tuberculin skin test. After a year at CMH, I had a blistered skin response to the test - yes, a maximum 4+ positive response for which I declined the recommended INH therapy and lived to tell the tale. My CMH and later Cape Town experiences with TB meant it was a bit of a breeze for me to diagnose TB of the kidney when I did my British Fellowship finals viva in 1980. After describing the case, I continued with a comment: "In Africa, where I'm from, this is TB. No doubt it's the same here in London".
Similar to the "Dog Tax", the old "Hut Tax" introduced by the British in 1849 was a ploy to force indigenous men to work for money to pay the tax. To reduce these payments, the men built fewer huts, used almost as separate rooms of the house. In this photograph, the central, dark area, surrounded by the huts, is the cattle enclosure. Larger huts are for the parents, smaller huts for the kids.
The overcrowding in fewer huts contributed to a boom in the spread of TB. Eventually, with AIDS, TB is worse than ever, including drug-resistant forms. Fortunately, my time at CMH long preceded the AIDS era.
(PART 3 of my CMH sojourn will follow later.
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BOOK UPDATE. For those of you interested in the effects of the apartheid years, crime and tense action, then Book 1 of my trilogy of thrillers is having a final proofreading. Book 1, Fury and Revenge in Cape Town will be published in the next few weeks - so watch this space!
