Linda Murray suggested writing down ‘what I expected to find’ during the flight to South Africa. Nearly twelve weeks later, reviewing page one of my Black n’ Red notebook… A few ticks and no, the newer protease inhibitors are not yet visible in primary health clinics. What I truly underestimated was the impact of Atroiza the fixed dose, triple combination antiretroviral pill that is equivalent to Atripla in the UK. There are public information advertisements about FDC as it is universally known, thousands are successfully taking it, and word of its availability has brought patients back into treatment.
What did I find out about myself? Toiling over my final report I couldn’t help remembering Meredith Belbin’s team roles exercise from a course in the eighties which identified completer finisher as one of my weaker suits.
Reflecting on my last twelve weeks working as a FPD evaluator: fascinating, fruitful, I’m amazed at what’s been achieved… but at heart, I’m a nurse. My highest highlights were in clinic rooms, sitting in during consultations, especially if there was a chance to chat with the patient.
Kruger Impala; with David and a glass of Windhoek, Sophiatown Bar
That should not be interpreted as churlish because it’s been another wonderful experience, immersed in South African primary health clinics and a fantastic chance to broaden my professional horizons. I’ve loved discussing HIV and mentoring with professional nurses, roving mentors and enjoyed travelling with such great teams, visiting so many clinics, interviewing so many people… The world’s largest HIV treatment programme has come on like an impala’s leaps and bounds.
David’s kindness, friendship and supervision have been superlative. He and Sue were so much more than an antidote to the loneliness of the long-distance evaluator. Reflecting on the differences with the 2011 experience: in Graaff-Reinet I had a small number of day-to-day contacts with people who became familiar – and some of them friends. During the last twelve weeks I had transient relationships with far more people. I might have struggled more without the anchor that David in particular, Sue and the FPD Evaluation Unit provided.
We rounded off my final weekend with a trip to a huge exhibition of mostly black and white photographs, The Rise and Fall of Apartheid at Museum Africa in Johannesburg. We’d seen it previewed in The Mail & Guardian and it didn’t disappoint: there were images of quotidian life under segregation; intolerance, violence, pain; the glamour of Drum magazine models, township singers and musicians… and for a UK visitor, Catherine Ross’s shameful shot of demonstrators against Margaret Thatcher’s 1991 visit to South Africa – she refused economic sanctions and viewed the ANC as a ‘typical terrorist organisation’.
The Rise and Fall of Apartheid exhibition; My Darling Clinic sign
On to the Workers Museum, housed in a way-below basic former hostel for municipal workers – Lewes Prison cells would be preferable – then Johannesburg Art Gallery, before edging through streets more congested than an early twentieth century municipal worker’s lungs for lunch in the Sophiatown Bar.
The assignment in numbers
1 white face in the 15,000 crowd: Polokwane City 1 v Orlando Pirates 0
2 PowerPoint presentations of my findings
3 run defeat in World T20: South Africa 196 (for 5) v England 193 (for 7)… or was it a victory..?
4 weeks in Limpopo
5 5:30 am: brisk walk with David every morning of 5 weeks in Pretoria
6 6:00 pm: check-in at Oliver Tambo Airport; 6:35 am: arrival Heathrow Airport
7 May: when Jacob Zuma will almost certainly win the general election despite wrongly spending R240,000,000 of public money on upgrading his home
8 blogs before this one
9 of us in FPD’s Evaluation Unit office: David, Promise, Shehla, Dawie, Alet, Renee, Nomsa, Frances and your blogger…
10 … if Fritz ever turns up
12 South African novels read
65 blog comments and lots more emails – thankyou all
94% of South African nurses feel more/much more positive about providing HIV care in primary care thanks to clinical mentoring
94% of South African nurses feel more/much more confident providing HIV care in primary care thanks to clinical mentoring
127 minutes: three focus groups
173 semi-structured interviews
526 km: Hyundia i20
2290 km: Ford Figo
8996 words in the final draft of my report, now with FPD managers
I leave behind the report, new and old friends, the Eastbourne Borough shirt on Chris’s back and their badge on the Evaluation Unit office teddy bear. And so much more. But my thoughts are turning to departure and return. Let’s hope that the dead hadeda ibis outside David’s drive is not an omen for tonight’s flight.
They say something about behind every great woman there’s a man trying his best. I’ve been here thanks to Angela’s support so I’ll leave you all with a song for Angela first heard on the shores of Nqweba Dam outside Graaff-Reinet in 2011. Its line, the loneliness was about to make me lose my mind resonated when I was ‘Lost in Limpopo’ (blog 03/03/14).
Chocolate is the answer who cares what the question is?
(Birthday card from Angela)
As Barry Jones has pointed out today I’m the same age as Colo, the oldest gorilla living in captivity. Erm, thanks Dad. It’s my first birthday not shared with a political hero, the late Tony Benn, the first British MP to table a motion concerning apartheid. Last night David and I celebrated early in a pizzeria with a couple of Windhoek beers on the side as he’s out this evening. At work I set a quiz inspired by a recently read novel, The Restless Supermarket‘s central character, a retired Johannesburg proofreader. There was a prize for the most accurate corrections of typos from my focus group transcripts and Jones-baked millionaire shortbread all round.
A thorn between Ria and Lisl: mother & daughter on their way to Graaff-Reinet’s first lesbian wedding; on the road in Capricorn
Even before that fun I confessed to FPD’s journal club, where today’s academic paper concerned HIV testing that I’ve been around long enough to have requested ‘HTLVIII’ when testing was first introduced. I’ve enjoyed my first South African birthday with two cards, numerous emails and Skype with Angela, Brigid, Steve & Chris. David wrapped some real coffee – hooray! The nut that holds together the cafetiere just went down the plug hole – boo!
Of late, report writing has occupied most waking hours. I’ve a vast data set and my 11th April flight north looms ever closer so it’s taken all my blogging and much of my emailing time. Apologies Will you settle for now for some pictures (paint a thousand words) and tables?
|Mentoring clinical mentors||Evaluating clinical mentorship|
|1 town and its environs||5 districts in 4 provinces|
|85 nights at Aa’Qtansisi Guesthouse, Graaff-Reinet||7 nights at Aa’Qtansisi Guesthouse, Graaff-Reinet|
|9 primary health clinics||78 PHC|
|4 pills-a-day first line antiretroviral therapy (TDF, 2x 3TC, EFV)||1 fixed dose combination pill: welcome Atroiza|
|£1 = R12||£1 = R18|
|“We cannot manage HIV in primary care” (Professional Nurses)||“I am empowered to handle patients with care and love” (PN)|
Why not? If I hadn’t returned to the Valley of Desolation, location for my previous experience of NIMART mentoring, how would I have known that those nervous – some of them resistant – professional nurses were confidently managing hundreds of people living with HIV?
A great deal has changed in three years. I’ve compared it to seeing a friend’s children after a long interval: you notice and remark on how they’ve grown. So it’s been in Graaff-Reinet and the surrounding towns’ primary health clinics.
Nthabiseng and Marlene, colleagues then and now; the road to Steytlerville.
When I blogged in September 2011 I cited trombonist Jonas Gwangwa who said of South Africa:
When you plant a seed, it decays a little bit before it grows.  We achieved so much following the end of apartheid. Now we are going through some rot. It is this that bothers us: how long is it going to stay this way before we sprout?
Friday was South Africa’s Human Rights Day, a public holiday commemorating 1960’s Sharpeville Massacre, one of many rotten episodes in the apartheid era. On its first fifteen pages today’s Mail & Guardian documents today’s rot at the top. President Jacob Zuma’s licence to loot is exposed in the public protector’s report into massive inappropriate expenditure of public funds on his personal home. What must the struggle heroes be thinking? With a general election on 7th May, many South Africans crave an end to such rottenness. Even with its leader mired in controversy the ANC seems unassailable: how long many wonder before an end to post-1994 decay?
Returning to the Horseshoe, Kroonvale, Umasizakhe and other clinics where we planted seeds three years ago has been a delight. The tattiness of out of date posters on peeling paint has been replaced by light, bright modern-looking clinics that seem fit for purpose. I’ve been hugged and had my hand shaken by staff that I worked with before. And how some of those seeds have grown. As one nurse said in her interview, “once we were just issuing ART; now it’s comprehensive care”. Such is the progress they’ve closed Ithemba, the antiretroviral clinic at Midland Hospital, Graaff-Reinet. There’s more to do but seeds have sprouted.
Sister Bosch in Umasizakhe Clinic; Nthabi, Vicky, Martin, Dolly – Vicky & Dolly unable to find suitable employment after completing assistant social worker training; Umasizakhe Clinic 2011 & 2014.
If I’d never driven back over the impressive Ravelskloof into Camdeboo I’d never have known. I’ve loved the familiar semi-desert that reveals its springbok, kudu, ostrich in a way that denser bush up north does not. It’s been a week of reunions with guesthouse owners and staff, former colleagues, people – friends – I met along the way; so different from the lonelier weeks living out of a suitcase and speaking to nobody outside working hours. As my Aa’Qtansisi host Ria welcomed me last Sunday, “you’re back home Martin”. I’m so pleased to have had the opportunity to go back.
Back in the world
Back in the world
Back in the world
Back in the world
Crawlin’ through the trees
Stuck in mud up to the knees
There’s a Curtis Mayfield song, Back to the World (YouTube link below) a movingly soulful tale of a soldier’s troubles reconnecting with life back in the USA after serving in Vietnam. While a few weeks’ impersonal hotel living with weak internet signal cannot compare it’s the tune in my head now that I’m back at David & Sue’s in Pretoria. The further north I stayed, the weaker my internet connection and the greater my disconnection from you all. It’s a salutary reminder that some of the things that I take for granted at home are less widely available – or not available to all – in South Africa. This weekend’s M&G reports that in the provinces I’ve visited, the percentage of the population who have flush or chemical toilets or ventilated pit latrines is: Gauteng 88.9%, Mpumalnga 57.3% and Limpopo 37.9%. Be careful what you grumble about, blogger.
Bungeni Clinic cabin, delivering HIV care to 913 clients including 70 children; FPD bakkie with Donald Fraser Hospital roving team.
Many who know me will know that I dislike driving. Today I’ve driven 466km, the equivalent of motoring from Eastbourne to Folkestone, through the Chunnel and south beyond Paris. After five weeks and 2290 km I’ve returned the Figo to Avis. Ms TomTom twice Ms-directed me into on-coming traffic on a motorway slip road and ordered impossible right turns across solid barriers on dual carriageways but was an otherwise reliable companion. And some days the only person to speak to me.
Added to the Figo’s kilometrage, in the roving teams’ bakkies I’ve (pace Mr Superfly) been crawlin’ through the bush, stuck in mud up to the knees… as we daily traversed the lumpy, bumpy, at times close to impassable gravel roads to the backends of Nkangala, Capricorn and Vhembe. Here’s a suggestion for a simple infrastructure improvement from a mentor: the Government should build a tar road to every primary health clinic. FPD bakkies spend several hours a day crawling long distances in first & second gear; add in every delivery, laboratory courier – hours of staff time spent in vehicles – and it would pay for itself in no time. Out of an eight hour working day, four may be spent in transit. That’s sixteen hours a-day if you multiply for the doctor, nurse & health information system mentors and the data capturer.
The final interview at Tshiungani Clinic; Jones C & M Jones (Jones is a Zimbabwean waiter at Ambiance Restaurant, Polokwane, Martin is your blogger.
After one hundred and fourteen interviews in sixty-six primary health clinics I feel that this part of my research has reached saturation point. And I don’t just mean the torrential tropical downpours that can turn gravel roads to rivers in minutes; I’ve stopped hearing new things from NIMART nurses and their clinic managers. My next tasks are enriching the data by involving some of the more senior players and analysing it. I’ve a comparator week with a roving team from a different NGO in the Graaff-Reinet area: back in the world that I vacated in December 2011. It will be fascinating to see how those once familiar clinics have developed and delightful to hook up with Ria & her staff, MieMie, Rachel & Sylvia at Aa’Qtansisi Guesthouse; Maryna, Marlene, Nthabiseng & Vicky from the original mentoring team, the ‘Pioneers girls’ including Almarie & Rolien and hopefully others from the cast of three year old blogs.
Highlights of the far north? My final two days in the field with Sister K who changed a month of solitary dining, providing friendly company over fast food in Spur Steakhouse where Bafana Bafana 0 Brazil 5 was on the big screen and for a balmy evening on the lawns of an Italian restaurant where baboabs were dotted around a pool and fountains tinkled. In Vhembe’s furthest reaches and after hours driving past bush, we concluded our clinic visits close to The Big Tree, a 1500-3500 year-old baobab.
The Big Tree; Lord Greystoke; Guide and Sister K; baobab at The Guesthouse B&B, Musina.
The Big Tree guide took us slowly around its contorted trunk pointing out innumerable protrusions said – by him – to resemble a multitude of animals, not to mention – actually he couldn’t stop himself – genitals, breasts & buttocks a-plenty. His twenty minute tour included more sex talk than witnessed in six weeks in sixty-six primary health clinics delivering HIV care… I learned from a fellow B&B-er at Musina that as they age, male baobabs remain shapely and upstanding, while female trees droop, gnarl and the trunk expands – on International Women’s Day I have no more to blog on that subject.
The other thing I missed after Polokwane was exercise. I couldn’t work out if Thohoyandou and Musina felt entirely safe for walks and the ‘well-equipped gym’ in the former was inaccurately advertised. As Curtis reminds:
In these city streets everywhere
You gotta be careful where you move your feet…
I didn’t want to end up lamenting a leg stretch:
I been beaten up and robbed…
So it’s been work, telly and reading. Proteas v South Africa was a three-match test series that demanded five, two wonderfully compelling climaxes in the sporting world’s greatest format and a perfect hotel time filler. Then, just as I was beginning to believe that I might be becoming unhinged by Unchained Melody on a flautist’s compilation every breakfast time, I’ve returned from South Africa’s most northerly town, fast-forwarded through the Verwoerd Tunnels, up and down the spectacular passes of the Soutpansberg, dodged baboons on the motorway, re-crossed the Tropic of Capricorn, stopped for a reviving americano in familiar Polokwane before cautiously negotiating sluicing rain with extremely poor visibility in northern Gauteng. Now, after a pleasant evening’s brisk walking in Faerie Glen’s hilly streets I’m…
Back in the world
Back in the world
Back in the world
Back in the world…
Did you think your blogger was lost up the Limpopo seeking Mr Kurtz in Africa’s heart of darkness? Thankyou Marilyn for asking. Since the Big Game blog I have visited some remote corners, been one clinic from Botswana, gazed into Mozambique from Kruger National Park and next week will be close to the Zimbabwean border at Musina. Unlike Kurtz I left the ivory attached to its owners. More below.
In truth I have been somewhat lost. Outside FPD offices the wifi signal is feeble at best, struggling to support Hotmail – none for three days now – let alone Google or wordpress and Skype is out of the question. There have been occasions when I’ve been close to uttering Kurtz’s final words, “The horror! The horror!” The impersonal nature of hotel existing without the modern communications that I take for granted is salutary.
Thohoyandou’s roundabout welcomes you; Kruger elephant passes Ford Figo; Luvuvhu river looking west; Watering hole with zebra, impala
From Polokwane and Capricorn the Figo has taken me north to Thohoyandou, mouth-wateringly described in The Rough Guide to South Africa as “not a place you’ll want to spend time in. If you’re heading on to Kruger, you’ll be thankful that the road bypasses the centre of town.” Ah well, only ten nights in a town whose name means ‘head of the elephant’ and whose greatest charm is a roundabout (pic. above) on said bypass. Maybe a twinning opportunity for Slough? Non-UK readers, my wife Angela’s home town features prominently in a humorous guide to some of the UK’s less loved locations, Crap Towns: The 50 Worst Places To Live In The UK.
On Saturday I rose at 04:30 and headed to Kruger for dawn opening at Punda Maria Gate. Really I was happy that I’d been to Adoo National Park in 2011 but weekends need to be filled and the descendants of the little game that eluded Paul Kruger’s double barrels are on my doorstep. I can report dozens of delightful impala, zebra, giraffe and excitingly close up elephant sightings along with an array of beautiful birds, sadly unidentifiable without a Roberts Bird Guide of Southern Africa. My personal highlight was ten minutes watching through binoculars a woodland kingfisher dive repeatedly into the Luvuvhu river. Roberts is beautiful but costs more than entry to Kruger and is heavy.
I’ve been asked by David and by my son Chris how my work is going. Let’s put this into the context of this week’s Budget Speech. Handily the National Treasury inserted a People’s Guide to the 2014 budget in Friday’s Mail & Guardian. Within its big five headline statements for ‘improving the quality of primary health care’, number four spoke to me:
Over the next three years, government will allocate a further R1 billion for the HIV & AIDS conditional grant in 2016/17 to continue the rollout of antiretroviral treatment. A total of 2.5 million people are currently under treatment and 500,000 new patients are expected to join the programme each year.
Sounds good. However the same M&G ran an article, Health services too sick to mention based upon the ‘people’s alternative budget speech’. According to this it is only the success of ARV rollout that is improving overall life expectancy along with infant, child and maternal mortality rates. Critics of Finance Minister Pravin Gordhan paint a more depressing picture of South Africa’s health system citing mismanagement, rampant corruption and poor performance.
Earlier blogs preceded Gordhan in praising the progress in primary health clinics’ (PHCs) management of HIV since 2011. Perhaps progress in South Africa’s PHCs shares similarities with my drive through Kruger’s northernmost tip. I passed a lot of inert bush to reach of one of the big five. I wonder if much of the healthcare system is crawling through the bush in second gear even though progress in my ‘big one’ – HIV care – is as impressive as getting up close to Kruger’s elephants. I’ve visited more than fifty clinics already and I could tell Gordhan that there’s scope for improvement.
On a positive note, one reflection is of the impressive effort to ensure equal access to antiretroviral therapy for all who need it no matter how remote the village – and of the roving mentors’ efforts to supporting this. FPD bakkies have hopped the crags up gravel roads that wind in the shadow of the Soutpansberg mountains. If Thohoyandou town is unremarkable, the surrounding rural landscape is its counterpoint: lush, green with traditional Venda round houses dotting the hillsides, waterfalls tumbling over dramatic cliffs, tranquillity, beauty.
Donald Fraser Hospital, Vhufuli, Limpopo –‘I stand tall because I know my [HIV] status’; Makhaya Clinic entrance with health promotion notice about malaria; View from Lambani Clinic and on the road between Lambani & Thangawe Clinics
We visit clinics that are built to a modern template and older facilities, some barely fit for purpose. A regular media theme throughout my first six weeks here is of poor public service delivery with community protests and horror stories a-plenty, none sadder than the death of six year old Michael Komape who fell into his Limpopo school’s pit toilet and drowned. To accompany My Darling’s poor water supply (see Big wins), this week in Vhembe I’ve witnessed bare bottomed boys in school uniforms squatting to defecate in the field beyond their school, bare breasted women laundering in rivers and shortages a-plenty in clinics. To my considerable discomfort, I have entered a cramped, older building through a maternity room where two women nursed babies born the night before, a clerk sat working at his computer and privacy was non-existent; witnessed child health clinic taking place in another clinic’s corridor and more than once, two nurses conducting separate consultations with two patients in one room.
Have I answered David’s and Chris’s question? Briefly since this blog’s already nudging nine hundred words (each lovingly chosen for you, dear blog follower): my work’s generating loads of data indicating excellent working relationships between FPD and clinic staff, greater independent initiation and management of ART by nurses who describe NIMART as a vocation. However, to quote from a prevention mentor, “the [DoH] baby does not want to be prised off the [FPD] nipple”. There’s still a lot of metaphorical bush for those FPD bakkies to drive through. A map to the elephants may be emerging. And while there’s still darkness, there’s plenty in the HIV programme to warm the heart.
Stay with this blog football dislikers as there’s plenty for everyone. But on a Saturday afternoon in mid-February what else would you expect me to do other than support my local football team? Local to me right now is Polokwane City, recently promoted to South Africa’s Premiership.
I bumped into the Peter Mokaba Stadium on an early morning walk, towering over parkland not far from my two-week residence, Rustic Rest Guesthouse. In 2010 it hosted Algeria 0 Slovenia 1 in England’s Group C and three other group matches.
Peter Mokaba Stadium; Eastbourne Borough man with vuvuzela
According to Wikipedia Peter Mokaba was a hero of the anti-apartheid struggle and a deputy minister in Nelson Mandela’s government. His entry additionally reveals much about South Africa’s awkward history of HIV denialism:
Mokaba was HIV positive, but refused treatment because he viewed pharmaceutical drugs as poisonous; he died in 2002 of AIDS-related pneumonia. According to Mokaba, anti-Aids (sic) drugs had no benefits “beyond profits for the pharmaceutical industry”; the fight against these companies, he said, should be waged with the same intensity as the struggle against apartheid. Privately, he assured supporters that the HIV virus and Aids (sic) were part of an “international Western plot” to decimate blacks and “regain colonial control” in Africa.
A local rumour shared with me is that his political enemies set him up with women known to be HIV positive.
Out in Capricorn’s clinics, my host and area manager Pepe set an ambitious but fruitful programme: fifteen primary health clinics in four days ahead of an office Friday, which allowed for a focus group. The FPD bakkie has crawled past donkeys, cows and goats – what else in Capricorn? – blocking thoroughfares and vibrated bum numbingly over 200km of sun-baked gravel roads in Blouberg, its blue mountains an impressive backdrop. We stopped at a shockingly basic village water supply where driver, prevention mentor and football buddy Chris suggested a photo having asked permission first.
In Lepelle Nkumpi staff bemoaned their old, barely fit for purpose clinic buildings that were in contrast with some of the newly built facilities I visited elsewhere. The operational manager in one had persuaded his community to follow democratic processes for improvement rather than burn down the municipality offices. The latter approach has been deployed elsewhere in the country in recent weeks and widely reported in media coverage of public anger at the ANC government’s failure to improve infrastructure and public services.
Village water supply, My Darling; Maraba Clinic consulting room
Returning to the beautiful game, Saturday’s match against the superstars of Orlando Pirates was crackingly entertaining. Tickets had to be purchased in advance at Checkers – think Asda – a palaver since the store was off-line on my first visit. For a top flight match, R40 (£2.18) is an undoubted bargain – that’s Asda prices – Eastbourne Borough in tier six of English football costs £12.00. Chris collected me an hour before kick-off for the short drive to the stadium.
It was more Notting Hill Carnival on Wembley Way than Priory Lane, Eastbourne: orange (City) contrasted with red and black (Pirates); African dancing, singing, swaying, vuvuzelas playing; the fever pitch of a joyous be-costumed football crowd… with one white face in it. Apartheid may have fallen but the white population of Polokwane is not drawn to its magnificent stadium on a perfect Saturday afternoon for football. As if to emphasise the challenge of increasing social mobility across races that remains for South Africa, the only other white people that I saw in the stadium were the managers of the two clubs… Not that the English game is in any position to blow its own vuvuzela with only two black managers in charge at the 92 top clubs.
Thrillingly the entertainment on the pitch matched that in the stands. Despite their big name pedigree Pirates were outplayed by the home side with your blogger out of his seat on more than one occasion: for Sicho Jembule’s twenty-seventh minute goal, two should’ve-been-scored one-on-ones, an overhead effort that went close and a couple of centimetre-wide free kicks as third from bottom City deservedly won one-nil. To avoid accusations of one-eyed reportage, Pirates fluffed a couple of good chances before the Polokwane winner.
Chris Makhanthisa at Polokwane City; Polokwane Game Reserve
Observing the racial divide at work, the public sector primary health clinics are staffed by and serve an almost exclusively black population. The only exception so far was in Sub-district Six of Pretoria/Tshwane, whose community includes a poorer white population and a single interview (out of forty-three) with a white nurse. It is South Africa’s black population that is disproportionately living in poverty and reliant upon government services.
The progress in HIV care that is driven by the highly motivated Professional Nurses in primary health clinics that I’ve been interviewing could equally have me leaping from my seat in appreciation. Reversing the HIV/AIDS denialism espoused by Peter Mokaba and some of his contemporaries, I’ve been told by several nurses that their progress under mentoring is winning the confidence of their communities. HIV testing is widely accepted; local people with HIV who once attended distant hospital clinics or who entrusted their care to traditional healers are increasingly happy to be receiving antiretroviral therapy in their local primary health clinics. That’s another big win for the local teams.
With the stands of the Peter Mokaba Stadium visible above its acacia trees, Polokwane Game Reserve was my Sunday destination. A hot 21km hike on the White Rhino Trail included sightings of eland, steenbok, waterbuck, red hartebeest, nyala, a sable antelope a warthog, several ostrich and, saving the best till last, four giraffe in my final kilometre. Big game Saturday and Sunday. Impressive results at work and play.
Bakkie [noun: pick-up (US) / ute (Aus)]
Challenge [noun: applied universally in South Africa to any problem / deficiency / etc. faced by FPD or health service staff.]
FPD [abbreviation: Foundation for Professional Development, my employer]
Roving mentorship team [noun: a collective comprising doctor, nurse, data capturer and health information mentor (HISM) providing technical support to a sub-district’s primary health clinics.]
Torrential downpour from Watervaalboven Clinic; outside FPD, Witbank
The Nkangala adventure finished up at the evocatively named Watervaalboven (‘Above the Waterfall’) Clinic. Fortunately Dr Tema drove us in a four-wheel-drive bakkie beyond coalfields, through agricultural megacorporation Alzu’s boundless agricultural fields and up into the hills of Mpumalanga: a two hour journey, the final thirty minutes on gravel roads in sluicing rain that had taken its cue from the Elands Falls at our destination. I know that Britain is flooded so I’m not even beginning to grumble but I was relieved not to be in my little Ford Figo.
In that last paragraph lies one of the challenges facing FPD’s roving mentorship teams. Outside metropolitan areas such as Tshwane, the clinics are far flung. Teams can spend four hours a day on the road, halving the time available for actual mentoring in the primary health clinics that they partner. On top of this there are many clinics in each sub-district, spreading the roving team thinly. In remote South Africa patients are affected too: a local nurse remarked to me that they can spend R100 on the round trip to their ‘local’ clinic 50-70km away.
Our visit to Watervaalboven revealed another recurrent challenge. When we arrived the clinic was in disarray without a person in charge, the professional nurses all absent and a long line of patients waiting for the relief nurse to arrive from Middelburg, more than 100km away where she’d abandoned her plans. Tema could do little other than roll up his sleeves and deliver primary health care, with no NIMART nurses for him to mentor or for me to interview. At one o’clock, according to institutionalised practice our assisting enrolled nurse disappeared for a long lunch leaving patients to wait for sputum pots that we were unable to locate for TB screening, X-ray forms, etc.
Condoms at Dithabeneng Clinic; plaque at Nobody Clinic taken on the anniversary of Nelson Mandela’s release from Victor Verster Prison 11/02/1990
The other side of the coin for NIMART mentees – the clinic Professional Nurses – is that there are multiple demands on the roving mentorship teams. In the three weeks that I’ve spent in the field I’ve witnessed mentors drawn away from their schedules for In Depth Reviews – several days helping to audit clinics’ performance against national standards – Stocktaking – two days presenting plans for the year – Action Research – a whole day polishing research proposals such as promoting MMC (Medical Male Circumcision), increasing cervical screening in women with HIV, testing babies at age eighteen months, etc. It’s not hard to imagine the frustration of clinic nurses who book their challenging cases to review with their mentors, ask patients to repeat their long, expensive journeys (see above) – there may be loss of pay on top – only to find that the agreed schedule is postponed.
All these counter demands on the mentoring teams are important. Without audit, how will South Africa know whether or not national standards are maintained? Auditing in partnership with the Department of Health demonstrates that service improvement is the goal of both parties and secures joint working. Without agreeing their plans roving teams risk “running around like headless chickens” which was one senior interviewee’s assessment of their early operation. With seventeen initiates dying in the mountains of post-operative complications following traditional circumcisions in Mpumalanga last year, promoting MMC is imperative; and when another interviewee – a clinic sister – expressed amazement that asymptomatic women with HIV had abnormal cervical smear results this is another intervention that will save lives: waiting for symptoms will often be too late for successful treatment.
Beyond my work, South African President Jacob Zuma has announced that the general election will be in early May. Despite widespread disillusion in the comment pages of national newspapers he seems certain to lead the African National Congress into his second term. Rows about corruption, high unemployment, poor public service delivery, may surround them but the ANC know that there is no opponent with a hope of winning.
Anticipation of the Proteas v Australia three-test cricket series that starts on Wednesday is intense. With Valentine’s Day marking the first anniversary of Reeva Steencamp’s death there is OJ Simpson-like attention on the Blade Runner: The Oscar Pistorius Trial: A Carte Blanche Channel will broadcast twenty-four hour coverage of the Olympian’s murder trial.
Roving team at ThubeLihle Clinic, Nkangala; view from Malemati Clinic, Limpopo; Pepe outside Dithabeneng Clinic, Limpopo; Cool street name, Polokwane.
I’ve carried out 70-80 interviews, visiting thirty primary health clinics with names that are sometimes bizarre – ‘Nobody Clinic’* – other times prosaic – ‘Extension 6’, ‘Zone 2’, etc. – and often evocatively South African – see the photos. I’m staying in Polokwane’s Rustic Rest Guesthouse, just around the corner from Peter Mokaba Stadium, a World Cup 2010 stadium that I discovered on a six a.m. power walk. Next visit: Saturday afternoon, Polokwane City v Orlando Pirates when the congregations of crowned plover that flock to the surrounding grassy areas in the quiet of first light may not be so evident. It’ll be hot for football in Capricorn, this district is named for the Tropic of that passes right through it – which is something that I did today.
Yours in the Tropics.
* The Operational Manager at Nobody Clinic told me that once, the road simply ended there. Travellers would come to a halt saying “Nobody here”.