Nkangala to Capricorn

Glossary

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”.