Across the Wide Zambezi: A Doctor's Life in Africa (40 page)

     For the Mandava clinic had long
been a sore. When I arrived, there was not even a waiting room. The patients
stood outside in the hot sun and the rain and the cold of winter. After several
years’ battle with the town council, I got one built, before independence. But
the clinic was still hopelessly small for a township of 16,000 people. I had
long ago applied to have it enlarged to at least twice its size, or a second
clinic built in another part of the sprawling township.

     My wishes were overtaken by events.

     Some restless or embittered souls
took it into their heads to stir things up against the hospital, which was
hardly to blame for its own inadequacies: but hospitals make convenient
whipping boys throughout the world. Who has not heard murmurs about their local
hospital, even in paradisal England? And the restless souls had two restless
groups to work on: the Women’s League and the Youth League - both branches of
what we now knew as the ‘ruling party’. The women had the traditional trials of
women in Africa to keep them on the boil, and the youths had found their
expectations of independence bogged down in massive and growing unemployment.

     The first I learned of the
gathering storm was when I was informed that the mayor of Gwelo was waiting in
outpatients and wanted to see me (
he was a union leader
)
. The mayor was a figure who added much colour to
local public life, mainly through his personal style, which chiefly consisted
in knocking people down - at any rate, if they were smaller than him, or
female, and preferably both. He was a chunky figure with the face of a Stone
Age boxer, and I went to meet him, bracing my spirits, as I imagine our
forebears in the service of empire went to meet the local cannibal chief.

     In the event, he exuded oily charm.
He was accompanied by two surly companions: the combination of oil and threat
being a well-known one in the more rebarbative political systems. One of the
surly companions I recognised as the district administrator, the new form of
the fatherly old DC, who was now a political person.

     The immediate matter in question
was about a mini-bus load of party workers who had been overturned while about
their self-appointed business and been admitted by Jock over the week-end. Jock
was not the most congenial host the workers could have chosen; but that was the
least of their complaints.

     I went to the ward with the trio,
and they interviewed the comrades in their beds. The African deputy matron was
also present. The comrades waxed bitter about conditions in the hospital - tea
cold, meals late, cheeky nurses: quite unprovoked, of course - all of which did
not please the deputy matron, or a number of nurses who were discreetly
listening.

     After we had heard the complaints,
we repaired to my office, where a map, still bearing the guilty title, RHODESIA,
was pointed out by one of the surly companions as the sort of thing the people
were objecting to. Another was the absence of what he called the ‘Party flag’
from the pole outside, which had stood empty since independence for the simple
reason that nobody had sent us anything to decorate it with - a deficiency he
gracefully promised to repair. By the ‘Party flag’, he meant of course, the
national flag, and seemed to think (perhaps not without cause) they were the
same thing. The mayor interrupted this fascinating discussion to inform me that
a demonstration had actually been planned to take place at the hospital that
morning, and he was off to try and turn it back. He got into his car with his
two friends, and drove away.

     He did not succeed. Shortly after,
a column, mostly women and youths, came prancing and chanting up the hospital
road towards the entrance, where Jock had now joined me along with the white
matron, now a nice little Welshwoman, called Liz Jones. We all felt like
General Gordon on the steps at Khartoum, and hoped we would not share his fate.

     The mood of the crowd was
good-humoured, but a crowd can change unpredictably, especially an African
crowd. They mostly danced about and chanted. Some ladies wiggled their bottoms
in our faces. A number of banners was displayed, of which not the most
encouraging was GIVE US OUR OWN DOCTORS.

     Presently, the mayor and his chums
returned in his car. They got out. The mayor stood on a wall and harangued the
crowd, no doubt with great promises for the future. He seemed to satisfy them,
for they soon turned about and galloped and chanted back to wherever they had
come from.

     After which, the mayor took a cup
of tea, and looked forward to happier relations in the future - the cheeky
blighter! The glum companions drank their tea in silence.

     I had to report on all this, and
our superiors soon demonstrated the power of the profession even in socialist
Zimbabwe. The district administrator was cooled off in the provincial office
for a year or two. The mayor became such an embarrassment, even to his party,
that he soon fell from office and was more or less forced out of its ranks.

     It remains to be said that the mayor
underwent some kind of reform. At any rate, he turned into a doughty fighter
for political freedom in Zimbabwe; even if, not the less, perhaps, because he
had been diverted out of the main stream.

     As to practical causes and results,
I can only say that I shortly after opened the new outpatients, as I had
intended, and we had no more trouble thereafter.

In 1978, the World Health Organisation
held a conference devoted to the development of primary health care. This means
the point and level at which the patient or public makes first contact with the
health services; or otherwise considered, the grass roots of medical care. In a
country like Zimbabwe, in terms of personnel, this means nurses (or medical
assistants, the two now becoming blended in fact as ‘nurses’), and public
health workers. Even general doctors function at secondary level - the specialist
or hospital level of Europe.

     When this conference was held
(abroad, of course), and its policies emerged, Zimbabwe was still in the throes
of civil war. Existing health programmes were curtailed: there was no question
of developing new ones. But in 1983, the thing happened.

     It started with workshops. These
were not very welcome at first to working doctors, who do not like being pulled
out of their practices or districts, having a feeling that everything will
collapse without them, especially in a country where locums are rarely
available and one has to leave colleagues with a double burden. But soon I came
to appreciate them. In Africa, the general doctor feels very much in control:
he is that unique thing, a big fish in a big pond. In Europe, he is a small cog
in a large and complex machine. Most of the machine does not even touch him:
his interest in it is largely academic, and academic interest tends to atrophy.
In Africa, the country doctor, as I have repeatedly shown, is vitally involved
with every part of a machine which has been admittedly simplified by what is
called ‘appropriate technology’, but which stimulates his learning interest in
every area. In short, never before or since did I know the joy of learning my
trade as I knew it in Africa.

     The workshops introduced the new
programmes. The first was the Extended Programme of Immunisation. Then followed
others on diarrhoeal diseases, tuberculosis, management, and more. The first
workshops would take place at national level, and were attended by the
provincial officers, who in their turn, organised provincial workshops to
instruct district officers and staff, who finally organised district workshops
to instruct their own people. A simple and enthralling example was the devolution
of the total management of Tb to the district staff, again, by the traditional
method of protocols.

     Moreoever, curative and public
health services were at last combined at district level, so the DMO became his
own medical officer of health, and supervised, at any rate, the public health
programmes - shades of the ‘latrine boys’ of Samreboi! But here was a highly
structured system, with full national support, not the haphazard and limited
efforts of those days. Even in Zimbabwe, where decent public health systems
already existed, these were energised considerably by the involvment of local
agents.

     We discovered clinics in our
districts we did not know existed, which had been managed before with
difficulty by the provincial staff. Now I would visit them every month. In my
district, there were ten - again, the smallest number in the country. I would
take in two or three a week - on a Friday - and so get through them all in the
month. I used the same methods at them as I did when visiting the rural
hospitals. But first we had to find them in the network of dirt roads that ran
round the tiny fields and rocky hills of a countryside very like the west of
Ireland in the old days - even to the donkey carts.

     And we discovered the old-world
manners of the country people, who lived in a world where people still had the
leisure for good manners; indeed, where being in a hurry was considered the
height (or depth) of bad manners.

     The community sister (a new
appointment) and I were looking for a clinic for the first time. We saw an old
woman gathering firewood. We stopped, and the sister leaned out of her side of
the Land Rover to ask the way. But not so simple as saying so.

     ‘Good afternoon, grandmother,’ said
the sister, in Shona, who well knew what was expected.

     The old lady straightened her back
and greeted us with a sweet smile that lit up her leathery face.

     ‘Good afternoon, young lady.’

     ‘Have you spent the day well?’

     ‘I have spent the day well if you
have spent the day well.’

     ‘I have spent the day well.’

     ‘Then I have spent the day well.’

      And only then:

     ‘Is this the way to Mutambi
clinic?’

Among other duties, I would inspect the
clinics and note their requirements. In time, all got telephones, which were a
great boon: the ambulance could be easily summoned for emergencies which had
previously depended on local means for transport - usually the local
headmaster, who was the only one likely to own a motorcar. For less urgent
cases, bus warrants were issued, but that charity went back to pre-independence
days. Incidentally, then and later, the waiting time for, say, a hernia
operation, in that country of one doctor for 50,000 people, and one specialist
surgeon per million people, was two days. Explain that, ‘developed’ Europe! The
patient would present himself to the clinic, be given a bus voucher by the
nurse, arrive at the district hospital within twenty-four hours, and be
operated on that day, on my afternoon list. The provincial anaesthetist advised
that a patient should enjoy at least one night’s rest after his journey, so the
waiting time shot up to three days.

     I would take note of such
requirements as new chairs for Murowa clinic - the most remote, the poorest,
and most beautiful corner of the district, in the wide open country under the
shadow of Buchwa mountain. There was but one chair, which the doctor was
honoured with. The nurse-interpreter stood by, and the patient sat on an old
cooking oil tin. Alas, the services of the council (or the system) were slower than
those of the hospital, and moved at the more traditional pace of Africa. Month
after month, year after year, the request for chairs would appear in my monthly
list; and month by month, etc, the cooking oil tin sank lower and lower, like a
concertina, until it was level with the floor, and the act of sitting on it became
a mere ceremony, whose original meaning was lost in the mists of time.

     On the road out of this clinic, I
had to cross the ‘Devil’s Bridge’ - a name I gave it myself, which soon passed
into local usage. This, and the road itself, came under the railways; and a
sign, RHODESIA RAILWAYS, survived unnoticed many years after independence. The
bridge was of concrete and passed over, or more often, through, a small stream,
for its back had broken long ago; maybe even blown up in the war. I had to inch
the Land Rover gingerly down to the fracture, manoeuvre it across, then
scramble up the other side, in imminent danger of overturning the vehicle into
the river. Monthly letters went to the railways about this matter, but for all
I know, bridge and tin are the same to this day.

     The clinics had consulting and
treatment rooms, and a few beds for short-stay patients and deliveries. They
were staffed by two nurses and a nurse aid (unpaid, in line for nursing
training); a general hand, whose main jobs were fetching water and tending the
garden; and the sanitary assistant, who looked after the wells and latrines, Tb
programme, etc.

     The clinic was supposed to serve a
radius of five kilometres and 10,000 people, but it usually covered much more
of both. It was, in fact, an African country practice. As well as curative
services, it conducted maternal/child health clinics, including family
planning, immunisation, and educational sessions - simultaneously, on what was
called the ‘supermarket system’, so people did not have to travel more than
once for all their requirements.

     The general hand fetched water in a
donkey bowser (two drums drawn by a pair of donkeys) from the nearest dam or
river, sometimes miles away. The newer clinics had wells or bore-holes. None
had electricity. Vaccines were kept in a gas fridge. Non-disposable instruments
were boiled over open fires, and there were disposable syringes and needles.
From time to time, a wicked nurse (in town and country) was caught conducting
his (or her) own private practice with a stolen (and unsterilised) syringe.
This happened only once in my own bailiwick, and that was at Marandellas,
during the early years of the civil war. The culprit was not dismissed the
service (not my business, anyway), but sent, like Uriah the Hittite, to the
‘sharp end’, where at least he survived, and his sentence soon became less
meaningful as the war engulfed the whole country. But on the whole, they were
devoted folk - local, most of them, who lived at the clinics with their
families.