Yet even if they did remain, their futures in the clinic system were insecure. If the nursing profession is indeed a quasi-military hierarchy, young and assertive laypeople have no place in it. Their assertiveness offends. While Hermann was around, they did their work under his authority. Nurses did not dare throw them out of their clinics, for if they did, they would have to answer to Dr. Hermann. With Dr. Hermann gone, the laypeople would have to fend for themselves. And if nurses obstructed their work, it would not take much for them to pack their bags and leave; Hermann had trained them well, they had transferable skills now, and so they could move to more satisfying jobs.
MSF’s rebuttal to this unhappy prognosis was both simple and expected: the people, the ARV users themselves. The activists Hermann placed in the system were merely the vanguard of a phalanx, MSF argued, a 2,200-strong phalanx of ordinary Lusikisiki residents whose lives were saved by the drugs, and who would fight to keep them coming. That, indeed, was the article of faith animating the entire treatment movement that had grown out of South Africa’s AIDS epidemic: that as bearers of the rights to life and to bodily health, ordinary citizens would force their health-care system, with all its decrepitude and its lethargy, to deliver.
Whether they were right I truly did not know. Hermann had told me jokingly that the book I was writing about Sizwe was irrelevant. And yet when I spoke to him about my travels with Sizwe, it sometimes seemed that I was bringing him news from another planet, that Hermann himself lived in a charmed circle of activists and converts. Out in Sizwe’s world it was not clear at all that people would fight for ARVs. And my own reactions in the presence of the ill, such as the man with the neck bandage whom I had estranged with a force that shook me, had given me an inkling of why creating solidarity in the face of this epidemic is not a simple task.
I WOULD BE doing Hermann Reuter himself an injustice if I did not press home the fact that even while MSF was in Lusikisiki, with all its will and its efficiency, with its proud claim of 110 new ARV users every month, people died horrible deaths every single day because the clinics were under-resourced, the hospital beds full, the medicine inferior.
In late 2006, shortly before he left Lusikisiki, Hermann witnessed one of those deaths in the rawest and most brutal circumstances.
He had gone to one of Lusikisiki’s remoter clinics, Bodweni, with Mrs. Sapepa, the manager in charge of HIV treatment in the district, for a supervision visit.
“There was no nurse when we arrived,” Hermann told me a few days later. “There is one professional nurse in that clinic who moonlights, and she was on leave. The assistant nurse was on a training course. The counselors had kept four or five of the patients who’d turned up that day because they knew there would be a supervision visit with a doctor.
“When we walked out to leave, there was a family waiting outside. They had heard a doctor was in the area. Could we visit the daughter? She was very sick and could not speak anymore. It was raining hard, but we went anyway.
“I looked at her, and she was very, very sick. She looked to have TB. I picked her up, put her in the car. There was also another patient I had agreed to transport to the hospital. She was psychotic. We had a small car, a Toyota Tazz. In the front seat was me and Mrs. Sapepa. In the backseat was a psychotic patient with her mother, and a dying patient with her mother.
“As we were about to drive off, an argument started among the woman’s family. Should they actually take her to the hospital? She will probably die, and if the patient dies in hospital, the undertakers charge a lot of money for fetching the corpse, and they don’t have money.
“There were negotiations for about half an hour. I was the doctor: I took the position of, you know, if we can help we should try. I was also uncomfortable about having the conversation in front of this person. She was probably still hearing: that is the last of the senses still functioning in a dying person. In the end, the family decided to trust the doctor and take her to hospital.
“When we arrived at the hospital, she was dead. She had died in her mother’s arms in the backseat. So we unloaded the psychotic patient and took the dead patient to the mortuary so that the family would not have to pay for that: me and Mrs. Sapepa in the front, the dead woman and her mother at the back.”
It was late at night when Hermann told me this story. We were conducting the interview in his bedroom. My Dictaphone lay on his bed between us. The noise of a DVD, which his housemates were watching in the lounge, joined us in spasms.
“So, ja,” he continued, “they say eight hundred people die of AIDS in South Africa every day. That was the one I experienced. You know, I looked at the clinic card…” He meant to interrupt himself with a giggle, but what came out was a hollow snort, a mixture of sadness and disgust.
“What was on the clinic card?” I asked.
He stared at my Dictaphone. “You know…Ja, um, she had been to the hospital twice that week. Discharged both times. I told Dr. Thomas, the hospital superintendent, about it. I got so sad telling the story and he was getting sad also. He said every day he sees people discharged from the hospital who cannot walk home, going home on a stretcher. He said the hospital doesn’t have beds, and you cannot keep people with a poor prognosis. But it’s still sad when you see people with HIV considered people with a poor prognosis, especially when their problems were treatable and no proper diagnosis was done.”
He paused for a long time and stared past me. “One can hardly blame Dr. Thomas,” he finally said. “If the government were investing in its clinics, that woman would not have had to go to the hospital in the first place. She should have been treated at the clinic because there should have been a drip and an x-ray machine at the clinic. If she had lived in Cape Town she would never even have gone to a hospital. Think of the Bodweni clinic you know: a queue around the building in the mornings. Half a nurse running the show. Think of Bodweni with polished floors, a computer at the front desk to clock your patients in, pot plants. If that’s what Bodweni clinic looked like…” He waved his hand dismissively and fell silent.
Good-Bye, Dr. Hermann
In June 2006, some four months before Médecins Sans Frontières’s scheduled departure, the National Health Department in Pretoria began to enforce, without warning, a rule barring nurses around the country from prescribing ARVs. They had always been Schedule Five drugs, prescribable only by doctors, but until now the stipulation had not been enforced.
It was a crushing blow for the Lusikisiki program. Nurse-initiated treatment at clinics, rather than doctor-initiated treatment at hospitals, lay at the very heart of MSF doctrine. Nurses at all twelve Lusikisiki clinics had been initiating patients onto ARV treatment since the earliest days of the program. Hermann was leaving in four months, and no other doctor came to the clinics. The national instruction threatened to end ARV treatment in Lusikisiki in one fell swoop.
Hermann was incensed. “It is a definite attempt to block access to treatment,” he told me. “It is always convenient to say there is a law stopping this, but, I mean, last year there was a new pharmacy law that was supposed to come into effect in June saying only hospitals and clinics with dispensing licenses can dispense any drugs at all. Ten days before the new law was passed, the director-general of health issued a memorandum saying that in the government sector we will not penalize nurses who prescribe. So here is a postapartheid law that can be ignored, and yet this old apartheid law is suddenly so important. This is a way of blocking access to drugs, of putting a bottleneck in the system.”
After a relay of meetings between the local district and the provincial health department, two doctor’s posts were advertised for the Lusikisiki clinics. It would be the first time in its history that the Lusikisiki primary health-care subdistrict would employ doctors at all, and it would save the ARV program.
The posts were filled in the late winter of 2006, one by a Congolese doctor, another by a local man. Hermann began to withdraw from the clinics. The two new doctors took his place. For patien
ts and staff, the change was a rude awakening to how spoiled they had been. Instead of Hermann’s sixteen-hour-a-day dedication, they were confronted by two ordinary work-to-rule doctors both new to ARV medicine. They sometimes arrived late, sometimes left early. They made mistakes. When a drug was out of stock, they did not give the head nurse a mouthful; they shrugged.
At the clinic support group meetings I attended during that period, ARV users complained volubly. They were getting their first taste of ordinary, state-delivered medicine, and they didn’t like it at all.
“I’m lucky I started treatment while Dr. Hermann was still here,” a woman remarked casually. “There were complications. I had peripheral neuropathy. If it had been during Dr. Freddie’s time, I would have died.”
No sooner had the two doctors arrived than both left, one after the other, the first at the end of September, the second at the end of October. The problem was simple. The posts the district had made available were Grade 10, the lowest grade for a doctor in the state sector. Both new recruits began looking for better posts the moment they arrived, and with doctors in short supply all around the country, neither had to look very hard. The Grade 11 posts they found were, of course, at hospitals, not clinics. After they left, both their posts remained vacant. Once again it was the government’s underinvestment in clinics, the heart of MSF’s complaint, that threatened the future of MSF’s own project.
Lusikisiki’s district management approached the superintendent of Saint Elizabeth’s Hospital, Dr. Thomas, cap in hand. They asked him whether he would lend them his ward doctors. It was not a light request. Of the twenty-four doctor’s posts at the hospital, only nine were filled. But Hermann had built a good relationship with Dr. Thomas over the past three and a half years, providing the hospital with ARVs before it was accredited to receive them, for instance. And Dr. Thomas obliged. Doctors from the hospital would visit two clinics once a week, and another five clinics once a month.
It was hardly ideal. The founding principle of the program was decentralization to the lowest level, ARV drugs within walking distance of everyone’s home. Now some clinics would have to begin referring patients to other clinics. Bottlenecks would develop, waiting lists grow, despondent patients explore other remedies.
I met during this time with Mrs. Sapepa, the manager in charge of HIV treatment in the district, the one who had been in the car with Hermann when the young woman died in the backseat.
“Don’t you feel sorry for us here?” she asked. “Aren’t we pathetic? We can’t run this place without doctors. What if the ones Dr. Thomas releases to the clinic are stubborn or lazy doctors? What if they are not cooperative? Then what do we do?”
In October 2006, the month MSF left Lusikisiki, the clinics put fifty-three new patients onto ARV treatment. The monthly intake of the first quarter of the year had halved. It seemed the program might die an unceremonious death.
“Why does government continually underinvest in its clinics?” I asked Hermann shortly before he left Lusikisiki. “It is not wickedness or evil. It is surely a blind spot.”
“Why did the Israelites spend forty years in the desert?” he replied. “Doesn’t that story strike you as odd? You read the Bible and you just take it for granted—oh, the story says forty years in the desert. But why didn’t they just leave? Nobody told them to stay in the desert. It was a mental block.
“Same with our health administrators. They have a mental block. They think if you put resources in the clinics they will not be used.”
“Because?”
“Because they don’t trust that nurses can do anything proper. Because our health managers come from a hospital-based system. They see a mess at the hospital, they say that is what we must fix.”
“What produced that prejudice?”
“There is this thing that health care must need technology. There must be an x-ray. There must be machines and specialists, otherwise it is not proper medicine.”
“And that’s when paranoia about African inferiority comes into play,” I said. “Health administrators say to themselves: In Europe they would never have laypeople and nurses dishing out these drugs from prefabricated buildings in villages. They would have proper doctors.”
“You do not need doctors for this,” Hermann said, repeating his oldest mantra. “You don’t even need nurses.”
ON THE MORNING of October 12, 2006, a crowd of some two thousand people gathered in a community hall on the grounds of the Eastern Cape Department of Health’s offices in Lusikisiki. The vast ceiling of the building had been draped in red and white cloth, and a deejay pumped music from outlandishly large speakers. Outside the building, a motley collection of the town’s street vendors had set up shop, selling everything from goat meat to bananas. The billing of the event had been filtered through the fraught and sensitive politics of the provincial health department, and MSF was barely mentioned in the program. Instead, the posters invited all and sundry to join the government in celebrating eight years of partnerships with NGOs in the fight against HIV. Among the list of advertised speakers was “Dr. Herman, MSF—an example of a partnership.”
Various visiting dignitaries and local figures spoke—the provincial health minister, the chief director of HIV/AIDS in the province, a founding member of the Lusikisiki branch of the Treatment Action Campaign. Then the master of ceremonies called Hermann Reuter to speak, and before he could get to the podium some two dozen young people materialized from the crowd, beaming and giggling, and made for his chair. They surrounded him, obscuring him from view, a swarm of benign and hungry bees launching on their honeycomb. When he finally emerged he was dressed in traditional Mpondo garb, a kerchief around his head, baggy, multicolored trousers, a white cape of raw cotton with the word HERMAN hand-stitched across it in red thread. It was a fine honor indeed to bestow upon a white man.
The ones who had outfitted him now led him to a raised platform below the stage where he was joined by a troupe of Mpondo dancers. The deejay turned up the volume until the music drowned even the roar of the large crowd, and the dancers danced around Hermann in a frenetic rhythm, their arms and shoulders glistening with sweat. Suddenly they all came to a standstill, turned their backs, and jumped off the platform, leaving Hermann alone. Now the crowd was louder than the music; they were calling for him to dance. His face reddened with embarrassment. He took two or three uncertain steps, then fled to the stage to deliver his speech.
Amid the crowd, I spotted Kate Marrandi. I waved to her, my arms stretched above my head, and I finally caught her eye. Opening her face into the broadest of smiles, she raised a clenched fist into the air, threw her head back, and laughed without inhibition. There and then, she seemed to me an emblem of that moment, of all the people in that hall. They had come to pay tribute to a man they had grown to love, a man who had come among them to fight like a single-minded maniac against death.
At the VIP luncheon after the event, held in an enormous tent outside the hall, I caught a glimpse of Hermann in earnest conversation with the district health manager, a woman with whom he had fought bitterly for nearly four years. That was the last time I laid eyes on him. He had fallen in love with an MSF colleague from Ethiopia; come November, he was going to get into his car and drive north, arriving in Addis Ababa in January, just in time for his wedding.
New Year
I returned to Lusikisiki two weeks before Christmas. It has an odd feel about it at that time of year. It is at once fuller and quieter than usual, fuller because thousands of migrant workers have returned home for Christmas, quieter because fewer people are at work. As one moves from place to place the air seems to hum.
I had set up appointments with about a dozen people, all of them in the health-care system, about half of them adherence counselors, pharmacist assistants, TAC activists—Hermann Reuter’s people.
Just before he left South Africa, Hermann had attended a national workshop on AIDS medicine in rural settings. At that workshop, the chief director of the HIV pr
ograms in Eastern Cape, Nomalanga Makwedini, who had invited MSF to the province and had been the Lusikisiki program’s staunchest supporter, announced that she would countermand the national instruction prohibiting nurses from prescribing ARVs. Where nurses had been initiating treatment successfully, she said, they would continue to do so.
Now, two months later, I arrived in Lusikisiki to discover that nurses were still not initiating treatment. Mrs. Makwedini, I was told, had not come to town to instruct nurses in person to resume initiation, and the district health manager would never carry out a decision like that on her own.
“But senior personnel from the district were in the meeting when Mrs. Makwedini announced that nurse-initiated treatment would resume,” I said.
“Yes, but the district manager needs Mrs. Makwedini to come and say it here.”
“When is she coming?”
“I don’t know.”
“Why can’t she just write the instruction in a memo?”
“I don’t know.”
When I spoke to one of the senior district officials who ran the HIV program, it was clear that she had long ago resigned herself to a world in which nurses no longer prescribed ARVs. Indeed, she had talked herself into believing that it was right.
“You know,” she told me, “I don’t want to put nurses down, they do a great job, but the truth is that there are even opportunistic infections they have been misdiagnosing. So maybe they must be patient with ARVs. Maybe they must first go on a course, a long and thorough course, on antiretroviral medicine. We must stress quality: quality before numbers.”
This was the manager whose job it was to support the work of her medical personnel. If the nurses who ran Lusikisiki’s clinics had been listening in on our conversation, I wonder whether they would have bothered ever to treat a case of AIDS again.
Sizwe's Test: A Young Man's Journey Through Africa's AIDS Epidemic Page 30
