Vignette 1: the changing colours of Africa

Awake. My first morning in Africa. The night before, my journey from the airport to the hospital had been a nightmare. In a decrepit truck, with companions who spoke no English. On rough roads, in a dense darkness the like of which I had never experienced before. It had taken hours and I had never felt more alien in my life.

The scene that next morning, as I wandered across the mission hospital campus, is etched in my mind. The very light itself was different. A cloudless blue sky. Deep red earth carpeted with purple flowers that had fallen from the jacaranda trees. The pinks, purples and reds of the bougainvillea. And, of course, the smiling black faces of the nurses contrasting with their radiantly white uniforms. Yes, this was where I needed to be.

Vignette 2: on practising “grass roots” medicine

Vusi was 22 years old and had been caught stealing. He was brought into our rural district hospital in poor shape, with a spear through his abdomen and lower chest — some punishment. However green I may have been, I was the only doctor available and so, with help from the nurses, I stabilised him in the emergency room before moving him, as quickly as possible, into theatre. I knew there were only two units of blood in the hospital that weekend. I intubated and anaesthetised him and handed over his care to the student nurse on duty. Then, scrubbed up and with a theatre nurse assisting, I opened his abdomen and repaired multiple small and large bowel lacerations and a liver tear. Vusi left hospital a week later and, in subsequent years, I was often greeted cheerfully by him as I moved around the village.

Vignette 3: from patients to protocols and programs

Mhlambe watched me, disinterested, with a dull, glassy stare. Eighteen months old but very underweight, he had all the stigma of kwashiorkor — peeling skin, oedema, and thinned red hair. He had the worst type of malnutrition, kwashiorkor plus marasmus. Malnutrition was our second most common paediatric problem (gastroenteritis was the most common). Mhlambe prompted me to develop an evidence-based protocol for the management of malnutrition in place of the previous ad hoc approach, and mortality rates fell as a result.1 A few weeks later, Mhlambe was discharged well and went on to be treated for tuberculosis through another newly developed community program. He finished treatment successfully and his mother became involved in a women’s group developing a vegetable garden and making crafts, helping to address the underlying cause of Mhlambe’s admission — poverty.

Vignette 4: evolving research

A lazy Saturday morning spent mulling over the events of the week. Obstetrics had been busy that week — I had done 15 caesarean sections, two vaginal breach deliveries and had successfully managed a shoulder dystocia. But I had also signed six stillbirth certificates on Friday. None of the bereaved mothers had been seen antemortem by a doctor and I could still hear their wailing. Something was not right.

I wandered over to the obstetrics ward and made a list, from the maternity register, of all the perinatal deaths I could find in the previous 3 months. Then, on to the medical records office where I could obtain and examine the records of these deaths. I estimated the perinatal mortality rate to be about 60 per 1000 (about 10 times higher than the best in the UK at that time). Most of the cases had never been seen by a doctor and it was obvious that at least a third were associated with an error or omission in care. Without knowing it, and with no training, I was doing some health systems research.

In response to my findings, I wrote some simple protocols, developed a training program for midwives and doctors in the hospital and village clinics, and visited all clinics monthly to implement the protocols and support the staff. I was doing public health medicine.

Within a few months, perinatal mortality was significantly down and hardly any deaths were classed as avoidable. Most importantly, we embedded the changes into routine practice, disseminated our results through publication, and helped others implement similar programs.2,3

Completing one of the 2000 caesaean sections I did during my 12 years in Africa.

Vignette 5: engaging the community

Petros, thin as a rake, was coughing, bent over, almost retching with the effort. We saw hundreds of cases of tuberculosis each year; the incidence had risen dramatically as the prevalence of HIV increased. A simple audit showed that only about 20% of diagnosed TB cases could be shown to have completed the prescribed 8 months’ course of treatment. Clearly, the practice of 4 months’ hospital admission followed by 4 months’ treatment through the village clinics was not working. First, we adopted a shorter and simpler 6-month drug regimen with admission for only 2 weeks. Then we developed community-based, directly observed treatment using village clinics, with community health workers and a wide range of lay people as supervisors. Documented treatment completion rates rose to over 80%.4 The benefits of community participation included managing an ever-increased disease burden, at lower cost, and with much improved outcomes.6