Glimpses of life found in the midst of tragedy

Andrew Brent reports on his South African elective

Even before I arrived at Edendale Hospital its reputation as a war zone had reached me in the civilised corridors of Oxford's John Radcliffe Hospital. The worst excesses of violence during the Apartheid era had marched through the hospital's departments. Gunshot and stab wounds are still the bread and butter of the surgical outpatients department.

I was there to do paediatrics and had only just arrived when I found myself caught up in the pace of the place. Minutes after climbing the seven flights of stairs to the paediatrics ward on the night I arrived, I found myself running after my registrar to resuscitate a neonate just delivered by caesarian section, and then another and another. This opportunity to be very involved was a hallmark of my time at Edendale and contributed greatly to making it a very rewarding and educational experience.

Teaching ward rounds each morning were excellent, and afternoons were spent in the paediatrics outpatients department, which serves as a joint accident and emergency department and clinic. You could expect anything to walk through the door, and the sheer variety of medicine was fascinating. There were, however, many common themes.

Malnutrition is rife, and the depths of deprivation and starvation in which many families live is harrowing. Often a whole family's income is only Gogo's, or grandmother's, disability allowance that is barely enough to feed one person. The devastating sequelae of protein energy malnutrition affect every system of the body, stunting growth, causing painful desquamating skin rashes, and suppressing the immune system, leaving children susceptible to infection.

It is not, of course, just malnutrition that undermines the immune system in many of these children. From day one I became accustomed to feeling for an enlarged spleen and lymph nodes in any child, for in sub-Saharan Africa these are the characteristic signs of probable "retroviral disease": HIV. AIDS is very prevalent in the hospital population. I recall the morning when one of the doctors in the paediatric gastroenterology ward got back a negative HIV test result on one of the children. The doctors were so surprised that they were talking about it for days. The cynics treated the result with caution, advocating the more sensitive polymerase chain reaction test. So familiar is the story that suspicions are raised immediately any child is brought into hospital by Gogo. Where is the mother? All too often she has died, leaving her child this deadly legacy.

The devastating effects of the disease itself are matched only by its catastrophic effects on society, owing to the many children orphaned and money earners lost to families. Despite its massive prevalence the stigma of HIV is huge, and many victims have suffered violently at the hands of their neighbours because of their positive status. The resulting secrecy pervades all tiers of South African society and facilitates the propagation of the disease. Overcoming this stigma will require a concerted education programme and a substantial cultural shift. However, this will be one of the most important battles against AIDS in South Africa, as well as one of the toughest. There are signs that at least some small progress is being made, with one prominent judge making public his HIV positive status while I was in South Africa.

As in any developing country, the role of education in health care and specifically in combating HIV is paramount. Without a complete medical understanding of the disease, communities have been left at the mercy of superstitions to explain the terrifying reality of AIDS. It is thus a commonly held belief in many townships and rural communities that one can be cured of the virus by intercourse with a white woman or with a virgin, fuelling the country's rape statistics. Unfortunately, to ensure that their victim is a virgin, many men are turning to children, sometimes even to girls as young as 3 years old.

As bleak as the situation seems there are glimpses of life so priceless that I wonder why we sometimes need to be surrounded by tragedy to see it. I don't know why one particular little boy with AIDS stands out in my mind. There were many like him. When he was admitted 4 months previously no one had expected him to survive the week, but he had. And standing him up in his cot and seeing him smile, I felt the glint of hope reflected in his infant eyes and thought: "this is why." Medicine may not be winning the war against AIDS yet, but it is winning important battles.

My elective in South Africa has given me more than I can describe in this short report. The medical experience and knowledge I gained will undoubtedly be valuable in the future. However, I think the greatest opportunity the elective provides is for us to explore something different, both within and outside the realm of medicine, and in so doing make us richer as people and as doctors.

Andrew Brent, surgical house officer, Royal United Hospital, Bath
Email: andrew_brent@hotmail.com


studentBMJ 2000;08:259-302 August ISSN 0966-6494