Across the Wide Zambezi: A Doctor's Life in Africa

by Warren Durrant

  I explained this to Jock, and pointed out that Percy had undertaken the total care of the pensioners. It really would be better for them that way: if Jock wanted to admit them, he would have to surrender them to the mine hospital, anyway, unless he intended to treat them in the ‘African’ wards.

  ‘We have no right to expect Percy to take them,’ protested Jock, with an irrelevance I did not choose to argue with.

  Then he took to seeing them in his own house. As this was government property, he was still breaking the rules; but I was not going to make an issue of that.

  Now I had thirty empty beds to dispose of. In fact, we needed them. The ‘black’ maternity ward was overcrowded, so I moved these ladies into the old white hospital, and formed a new lying-in unit (this, in fact, was the solution adopted in similar situations throughout the country), where they were delighted with their improved accommodation. The old maternity ward became a children’s ward: the children previously being admitted to the female ward.

  And now also we had an empty outpatient department, which itself became a source of bitterness. I proposed to turn it into a secondary outpatient department for patients referred from the clinics, including the township clinic of Mandava. (I hope the reader is still excited by all these administrative events, which I wish I could make even half as interesting as Trollope made the similar invidious business of The Warden: indeed, I was beginning to feel like the Reverend Septimus Harding, myself, and Jock was beginning to loom like Archdeacon Grantly. At any rate, if the reader is not excited now, he soon will be.)

  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 sho
wn, 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.

  The garden fed the staff, and also served to educate the people in what foods to grow. Western people have pious ideas about African diet, which is supposed to prevent most of the diseases we suffer from. It could do, but they are learning bad habits, especially in the towns. The diet of most towny child malnutrition cases was ‘buns and Coke’, which was thought very ‘smart’ by their young unmarried mothers. Even the staple maize meal can now be refined out of existence, and the ‘super’ forms are preferred by the city folk. The rough ‘straight run’ is sold anyway only in 50kg bags, which become weevily before they are a quarter used, and is fed only to cattle. The country people grow their own maize and take it to the local mill, where they get the good stuff.

  But only in Africa is white maize still grown, and the people are very conservative in their habits. In the drought years of the eighties, maize was imported, and, of course, it was yellow. The starving people complained like finnicky children about this; although the doctors pointed out that it contained vitamin A and would wipe out xerophthalmia (dry eye disease, which was the principal cause of blindness); and the commercial farmers pointed out that the yellow maize was drought-resistant, and some brave ones even grew some themselves - and lost money by it. St
ill the people were not persuaded: the government even had to mix the yellow maize with what remained of the inferior white stuff.

  Now Zimbabwe is growing oil palms. But will the people use the oil (loaded with vitamin A) for cooking, as in so many parts of Africa, where xerophthalmia is rarely seen? I doubt it. The stuff is produced to make soap, anyway (I have since learned that the scheme failed, the climate too dry).

  And with independence, the Swedish missionaries returned to Jock’s district, like the swallows (who had, of course, been back several times), and inspired Jock’s naughty humour again. There was some confusion over the jurisdiction of the clinics; these missionaries being a new lot. Jock described how ‘I was doing a clinic at Jeka, when this Scarwegian bint came in and said it was their clinic. I said, “Look, mate, where have you been the last three years?”’

  The devolutionary changes did not please everybody. I was driving home from a workshop on Tb with Mr Kazembe, the health inspector. He told me that he had noted looks and murmurings of discontent among the provincial health assistants, whose previous duties took them on quarterly visits to Shabani at government expense, including spending money of ten dollars a day. ‘And I happen to know that there are many unattached young ladies in Shabani, which these chaps used to stay with. Now they will have to stay in Gwelo with their wives.’ Mr Kazembe was such an obviously solid family man himself, it gave the lesson added force. I was also intrigued to learn that what I had taken as the one-horse town of Shabani was seen on another plane of existence as the Paris of the Midlands. In fact, it suffered (or enjoyed) the usual social consequences of an African mining town with a large migrant labour force.