Far, far away

John Wright reassesses his priorities

The town still had that Wild West frontier look to it. One main street of heat and dust. Nothing had really changed. Only the hedgerows of advertising hoardings that had sprung from the red earth. The growth industry--funeral parlours. One business was doing well, then.

 
The grave of a 34 year-old woman from Kwazulu - Natal province who died of Aids (RAJESH JANTICAL-STR/AFP)

It was four years since my last visit - my third in a decade to where I had once learnt so much of my medicine and healing. It all seemed so familiar, so quickly.

The hospital was swollen. Just too many patients to squeeze into ancient beds and along dark corridors. There had been a veranda to which all the wards joined. During the day the children would escape their cramped prison and play hide and seek, scampering between the legs of the women with babies on their backs; the laughter from both groups melting together in the African sun. It had been bricked in now. Rows of mattresses with their immobile occupants. "It's our hospice ward,'' one of the nurses told me. I felt awkward, intrusive. A grim spectator.

The mental unit had been commandeered. One day all the psychiatric patients had been told to go home. There was just no room left. This was a much more pragmatic approach to care in the community than I had seen at home. In their place an army of patients with tuberculosis, coughing, spluttering, wasting away.

"Hau. This disease. It's killing us." The hospital administrator replied to my polite inquiry. And she was right. The list of names of friends and colleagues who were now dead was long and painful. A whole swath of people gone. Empty space. It was as though a great war had taken place in the past few years and these were the survivors with whom I now shared brief memories.

"Is it like this in England?" the pharmacist asked me as I walked around the overcrowded wards. I was embarrassed. No, it's nothing like this. This is a different planet. A different universe. "Why?" I don't know. Because we're lucky. Because we're rich. Because you were the first. And although we think we know, we have no idea, not an inkling of what is happening here. It's a long way away, you see. She showed me the headline of the morning's paper. "4% of the population will die each year between 2000 and 2015." Underneath a picture of a cheerleader practising in some school field. So, something to be happy about. One third of the adult population is infected with HIV. Is there a Parkinson's law for death? Do we weep for individuals, and grieve for a dying few, but when it comes to numbers beyond our comprehension do we just click our tongues and turn to the sports pages?

In the classified section of the paper columns of young, smiling faces stare out, recalling happier days. Brief epitaphs provide clues to these disappearances. Friends and relatives are notified. Mandla, Siphiwe, Sbongile, Thembinkosi, Jabulane, Fakazi, Samson, Bhoboza, Nozimbo, Sonnyboy, Faith. It was untimely, unexpected, unspoken. Rest in peace. Teachers, soldiers, labourers, technicians. They leave behind the precious skills they had learnt and the precious children they had hoped to care for. Tomorrow they will be replaced with new faces as the next recruits go over the top.

It's not a war or a drought or a famine, so we don't hear much about it. There is no natural disaster to provide media images to prick our guilty consciences as we munch our breakfast cereal. No evil tyrants to blame it all on. There are no emergency supplies of food and blankets to parachute in. Boxes of condoms would just not have the same appeal. This is a plague and its impact is so much greater, yet so much more insidious. And because it is a disease, we can hand over responsibility to the health services, already overstretched and with no hope of funding expensive cocktails of antiviral drugs.

Back home it's hard to get worked up about sildenafil (Viagra), the latest statins, clinical governance, or primary care groups. The big health issues of today? Hmmm, I don't think so.

I have to tell everyone I meet: listen to my awful secret; hear my helplessness. I wonder when I next go back how many more people that I know will have died. I feel like a reluctant voyeur, watching a flower die in heart wrenching, time lapse photography. Still it is a long way away. Half a day away. Too far to hear the cries.

John Wright, consultant in clinical epidemiology and public health, Bradford


studentBMJ 2000;08:45-88 March ISSN 0966-6494