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What 's new since November 2011? Lots!

Briefly, we've left Lesotho. I had a major disagreement with the minister  of health about her lack of treatment for new TB and HIV patients.

Here are the details:

On the 5th of November 2011 enough parents had complained about their children's lack of TB or HIV treatment, that I thought I should tell the Ministry of Health, and Dr Ramatlapeng, the Minister of Health. It being the job of the minister to supply all hospital drugs and childrens’ vaccines.  We weren’t allowed to supply the drugs, because  the ministry of health hadn't got around to signing the licence allowing us to prescribe the drugs. Some of the children had died or been permanently disabled by the lack of TB treatment. I passed on the parents comments to Dr Moteetee, and Dr Bridget Maama, whose job it was to supply the TB medicines. Dr Moteetee forwarded my email to her good friend, the Minister of Health Dr  Mphu Ramatlapeng. She felt the email was disrespectful, and asked for my dismissal. Here is Dr  Mphu Ramatlapeng's email:

Dear Prins, (Dr Prins is the Chief Executive of The Queen Mamohato Memorial Hospital, where I worked)  Good morning and thank you for coming up with the referral protocol for VIPS to Queen Mamohato Memorial. I have just been shown this string of emails from one of the recently appointed doctors to QMMH. My understanding is DR. Dearlove is a VSO volunteer but what is perplexing is how an artificial shortage of T.B. drugs within one month of opening the hospital can result with the insult of the senior official of Government of Lesotho and indeed insult of the Government. It may not be clear to some people but that hospital is the property of the Government and People of Lesotho. 

If anyone  you disrespects the people they serve then their  motives are questionable. 

I trust that you and the UN / VSO will take appropriate action  

Dr. Mphu Ramatlapeng 

Dr Ramatlapeng. didn't do anything about improving the children's treatment. But sure enough, VSO London, the UN and the Hospital didn't worry about that, and off I went.

But I did have time to write to the Prime Minister.

The Right Hon. Dr Pakalitha Mosisili, MP. 

Here's the letter.

Your Excellency, 

Re. The lack of TB, HIV drugs and vaccines for children at the Queen Mamohato Memorial Hospital. 

As the only general paediatrician working in the new Queen Mamohato Memorial Hospital, I am sad to be leaving Lesotho.  

I was dismissed by the Minister of health because she felt that I had been disrespectful to her, Dr Moteetee her Director General, and the people of Lesotho. This was because I had said that patients had complained that the Ministry of Health should have supplied life saving drugs and vaccines to children in the new Queen Mamohato Memorial Hospital. Yet the ministry of health did not. Some children died or were permanently damaged because of this action.

How could this have happened?

It is because the Ministry of Health had not given our hospital a licence for these life saving medicines and vaccines. This lack of treatment resulted in a number of children either dying or getting worse. As the head of paediatrics after Dr Phiri’s sudden departure, I contacted Dr Llang Maama, and Dr Moteetee, asking that these drugs should be available to our patients. I even suggested that I drive to the old Queen Elizabeth II Hospital and pick up a few boxes of them lying around in the ward store cupboard. The ministry’s response was to suggest a meeting to discuss things. Meanwhile, the children suffered from TB and HIV, the babies did not get polio, TB or Hepatitis vaccines, and parents had to walk to Senkatana TB clinic or the Baylor Centre of Clinical Excellence to get their children’s medicines. Parents could see what was happening and started to complain. Dr Ramatlapeng and Dr Moteetee replied that my emails were sarcastic or disrespectful but made no comment about supplying effective treatment to ill children. Other than dismissing the only general paediatrician in the hospital.

The questions that parents asked were very simple.

1.   Why weren’t the licences signed and the drugs and vaccines delivered before the new hospital opened?

2.   Why was Queen Elizabeth II Hospital allowed to close if these treatments were not available at Queen Mamohato Memorial Hospital? 

These medicines are available elsewhere in Maseru. So why has it taken the Ministry of Health more than six weeks to make them available to patients in the Queen Mamohato Memorial Hospital? The new hospital has been on the drawing board since 2006. Lots of time to plan.

3. Parents asked about vaccinations. This is very important. During the six week delay about 750 newborn babies did not get their protective vaccines against Polio, TB, and Hepatitis B, or their medication to prevent  them getting HIV from their mothers. In years to come there may be polio outbreaks amongst these children, if they live in remote areas and remain unimmunised. For a Ministry of Health to deliver such a low standard of health care needs an explanation, if only to the mothers of these vulnerable babies.  

Many thanks for your time in reading this.

Yours sincerely,

 

Email. john.dearlove@virgin.net

22/11/11

And did advocating better treatment for these children achieve anything?

Possibly. The day before I was fired, TB drugs and HIV meds. for the hospital children mysteriously became available.

Have an adventurous 2012! And see you on Facebook. Many thanks for supporting us, John

 

A tale of two Lesotho hospitals. 5/11/11

the story so far...

We are driving to our new hospital. Our King is going to open it. Queen Two (The old Queen Elizabeth II Hospital, 1958)  is dead. Long live Queen Mamohato! In the last month we have moved from our cockroach infested, derelict and dirty Queen Elizabeth II Hospital to the brand new, state of the art Queen Mamohato Memorial Hospital, named after our King’s mother. Although it’s built by the Ministry of Health, it is run by a very successful private organisation from South Africa called Netcare. It is as if BUPA ran Yeovil, or Dorchester Hospitals.

Yes, fantasy is creeping in, and we’re in little Lesotho. The size of Belgium, with the worst maternal mortality rate in the world, number three for HIV deaths, and number eight for Tuberculosis (TB). And there are no children’s anti TB drugs, or HIV drugs or even vaccines in our brand new hospital. Why not? Because the Ministry of health hasn’t issued us with a license to use these drugs.   Why not?  TB, HIV and vaccine preventable deaths account for most of our admissions. And deaths. It’s not as if the hospital suddenly jumped out and surprised us all.  The hospital has been on the drawing board since 2006. And the private public partnership deal since 2009. Well, the rumours all end at the Ministry of Health and Social Welfare. Obviously they forgot that their new hospital was being built. And well over a month from the King opening the hospital, there  are no children’s TB or HIV medication. So children get worse. Some die. Yet only a couple of  mothers have raged at how inattentively their countrymen are treating their children. So far, little has been done about this. Lots of meetings and talking, but no action. .

We drive past a large bill board planted next to an enviable keyhole garden. The billboard asks us to Send a Cow. Where? We’re in Fantasyland. The cow could go anywhere in Lesotho. Queen Elizabeth II hospital didn’t have any contented cows munching around the well tended rose beds.  But they are trotting towards our brand new Queen Mamohato memorial Hospital, twenty minutes drive across town. I know this because I have seen a skinny Maseru cow hanging around someone’s garden opposite Senkatana, the city’s main Tuberculosis (TB) clinic. Later, I note that the cow is still there. We eye each other suspiciously. Even cows get Tuberculosis, and a doctor on a hot afternoon afternoon stroll has to be on his guard. The cow  isn’t coughing, but she is thin, and her skin  is matted. An uneducated guess is that she has got it. Equally ill informed, she’s probably checking me out for HIV. She may be a conspiracy theorist cow. And knows that HIV is an American plot to mutate Hepatitis C virus, and dump it on the rest of the world.  Or so Dr Logic, our paranoid Zimbabwe intern informs us.

The cow and I part company. We have agreed that neither of us have the medication to treat each other, even if our unlikely diagnoses were correct.  I cross the road to the old Senkatana Clinic. And peeping out from behind a neat new razor wire fence is another donor organisation billboard, proclaiming that they run the next door hospital. It’s the Multi-Drug Resistant TB Hospital for the whole Of Lesotho. I’ve never heard of it. And I’m trying to get on The World Health Organisation’s course on Multi-Drug Resistant TB, designed for consultants who treat lots of TB. That’s certainly me, I think. The MDRTB course is held at the best hotel in town, and starting tomorrow. My level of ignorance doesn’t surprise me.  What’s a surprise is that I’ve been invited. Despite being unable to open the WHO email, the tag line has the phrase “invitation to the opening of the Multi-drug Resistance Tuberculosis Course for Consultants.” So I’m very excited. Dr Maama, who runs the Ministry of Health’s failing TB program counsels me not to get too excited.  She points out that it’s only an invitation to the opening, “To show respect to the minister of Health,” who is opening the five-day freebee. Not an invitation to the course. Even so, five days seems a little long for a topic that takes two and a half lines in the excellent WHO hospital manual for low resource hospitals. However, the minister of health didn’t show for her key note speech at the three day Bloemfontein Health Summit, earlier this year, so five days may be more realistic approach. Also I’m reminded that my spate of emails about our lack of children’s vaccines, TB & HIV drugs and testing equipment in our brand new hospital, are unpopular. Despite it being the Ministry of Health’s job to supply these drugs.

Here I am in the splendid dining room of the Maseru Sun Hotel. And I’m right. I haven’t been invited. Dr Maama patiently explains that I’ve got it all wrong. A consultant is not a doctor, but a person who consults with the local government. And tells them how to do things better. Like manage TB or HIV. Or perhaps malnutrition, our top admitting diagnosis. But Dr Maama won’t swallow the bait. Our eyes wander over the Maseru Sun Hotel’s splendid buffet, and the happy TB consultants So perhaps my invitation has been withdrawn, and I've turned up like some grumpy old fairy at the Ball, flapping my wand over the food and good cheer, and generally being Dr Killjoy advocating better treatment for Basotho babies. Nothing happens. The pharmacy shelves of the Mamohato Memorial Hospital remain empty, and the parents tramp over to Senkatana pharmacy on a Tuesday or Thursday to get their children’s drugs. Or to The Baylor Centre of Clinical excellence for HIVs. Or nowhere for vaccines.  Time for action! 

 

Friday, 30 September 2011

 And it is Queen 2’s last full day as a living, breathing- we hope- organism. And it will be a breathing day. All our patients, including five year old Tsietsi, should be breathing. No RIPs.

Tsietsi and his Problem are characteristic of our sick patients. He’s from the Maloti Mountains. Breath takingly beautiful, its somewhere near where the Michael Caine’s cult classic “Zulu” was filmed. The real Rorke’s Drift is miles away, and nothing like the spectacle of the Maloti and Drakensberg mountains. Back to Tsietsi. He looks wonderful, dressed in an ochre version of his father’s blue corn row blanket. He wears a yellow woolly hat .Underneath his colour co-ordinated tradition Mosotho clothes, is a Manchester United Red sweat shirt. And jeans. Dr Phiri would have noted his broken down boots.  No footwear is pretty accurate as a marker of extreme poverty here. He is not the deep mahogany of his sinewy father. And between bouts of wheezing he will try a whispered “Lumela, ntate” which is more than his father manages. Even the social welfare officer had difficulty with his father’s dialect. But the medicine is very straightforward. He arrived early this week, with episodes where he wheezed, coughed, went blue and vomited. These all started when he swallowed his pink plastic lucky Long Life and Good Health necklace charm. He coughed and got a pain in his chest. Since then he wheezes and goes blue, when he runs, or exerts himself. This is often if you live on the side of a mountain.

We manage a chest X-ray. No radio opaque objects in his lungs. He needs someone in Bloemfontein University Hospital (South Africa) to look down his lungs with a fibre optic bronchoscope, and pull out the lucky charm.

Here is the rub. He needs a passport. And the recent history of Lesotho’s passports makes grim reading. Everyone blames something or some else.  The world football cup hosted by South Africa is the usual culprit. Until then passports were easy to get and cheap. But then everyone abused the facility. Everyone in Lesotho wanted to play football and move to RSA? Whatever. But South Africa put a stop to easy passports. And a beginning to the medical tragedies. All our patients had to have a passport, (R100) an official photo (R30), and most important a chit signed by the medical director and someone in the ministry of health and social welfare, saying the Lesotho government would foot the bill.  Then the ambulance fee from Maseru to Bloem. Possibly free if you have another piece of paper signed by the social welfare officer saying that you can’t pay. This involves proof. Such as phoning the village chief.  There’s one hard working social welfare officer. And it’s a 9 to five job. Unless you glue messages on her door like “Abandoned baby. Face eaten by rats. On baby unit.” (True) Getting that lot took days, weeks or months, depending on whether you or your relatives had the money. Then you need your appointment time and date at Bloemfontein’s two excellent hospitals. That takes minutes. And you are ready o go!

Suddenly in the middle of this year, Lesotho government immigration department decided that the cost of passports would rise 500%. And a short time later, that no passports would be issued. Then, yes there would be passports. But the wait would be for a year. At least.

An emergency with a wait time of a year seems an oxymoron. No matter, the medical director took it calmly. “Write a letter, Dr. Dearlove e, and I will phone the border post at Maseru Bridge to tell them that the ambulance is coming. This worked like a charm until the ambulance drivers started packing the ambulances with friends and others. And smuggled or illegal goods. Or so I was told. So now, no letters saying why the child is in the ambulance needing an emergency transfer. And it’s back to the photographs.

And this would explain why a child without a passport would have an enormous delay before life-saving treatment.  Or why Tsietsi is still sitting on the ward, patiently waiting.

And will he ever get there? Let’s see what happens today, the last day at Queen 2.

 Thursday 29.September, 2011.

 

The last days of Queen II hospital. we close on Saturday 1 October

Queen Elizabeth II Hospital was opened in July 1957. Money was spent on it. 25 year old Mrs Tsbane remembers starting work in a busy city hospital that was well staffed by local Basotho nurses and even doctors “People came back to work here. We even had a little intensive care unit.” But there were previous examples of surprisingly good facilities. The earlier hospital had X-rays in 1911, when such investigations were unavailable in similar UK hospitals. And medical life must have been very different, in 1957. Imagine saddling up your horse to ride down Kingsway to work.  Admittedly the daughter’s memories may be tinged with nostalgia for her father’s love of riding rather than necessity.  As the years passed, the standards remained high.  Politicians, tourists and whites still used the obstetric service in the nineteen eighties. Has anyone seen a local politician sitting outside casualty lately?  So what happened to prosperous little Lesotho, with its Casinos and nightspots, and good tourism? And a safe clean Queen 2 hospital?

In the 1980’s apartheid disappeared.  In 1994 South Africa became independent, with Mr Mandela elected president. The embassies, charities and donor organisations moved back to South Africa. And with them, most of t he money. There was no need to visit Lesotho to have fun at the weekends.  But why wasn’t Lesotho ready?  It had plenty of warning. Its last budget surplus  was in 1928, exporting potatoes, cabbage and carrots to the world’s biggest hole in the ground, at Kimberley, across the border in South Africa. During the good times, enough money wasn’t spent on roads, schools, and services. And the dependence on a medical donor culture had already taken root in... , Over the years blossoming with foreigners, charity workers, social minded Cubans and Chinese providing services to both Queen 2 and the Lesotho district now.

So what is happening now? Well, Its Thursday today. We leave with the children on Saturday. 7am.

Today it will be business as usual. We admit only emergencies. Well, we do that normally. We don’t run western style clinics. Like a d diabetes clinic. There’s only one diabetic child in Maseru, population half a million. No prizes for guessing where the others are.  Thato is a small fourteen year old orphan. He is HIV positive, and has been treated for TB. All orphans are at the bottom of the health pile. So they have been reclassified as Orphans and Vulnerable Children. (OVCs) Thato doesn’t know that he’s become a slightly unhealthier health statistic. Or even a source of money to a donor organisation. (UNICEF, VSO etc.)  He gets his actriphane, syringes and urine tested. He also gets soft porridge, with long life milk, lots of sugar and brown bread. And an apple. This is the ward breakfast. He tells me that he takes his RHZ tablets, Ethambutol tablets, and pyridoxine tablets for his TB. Then Combivir and Efavirenz twice a day for his HIV. And he tops it all with long acting Insulin. He even carries this lot in a small dirty rucksack. I’m dumbstruck. Not because he has such an enormous “pill burden”, more jargon for lorra pills. But that he’s still alive. Both of us know that he can’t possibly take this mountain of tablets every day. He doesn’t have access to running water. He must be surviving because he doesn’t get ketotic easily. Ketosis is the killer in diabetes. And Thato doesn’t seem to get this until his blood sugar is really high. Does he realise what a lucky lad he is? “Oh really, doctor?”  Diabetes, TB, HIV, and an orphan. What sort of luck is that?

 

 

July 29. Its now almost a month since Dr Phiri left after 16 years as the only paediatrician employed by the ministry of health. Read about it in  http://www.nytimes.com/2011/04/03/world/africa/03aids.html?_r=1&pagewanted=all. But we are surviving. Dr Unni Wariyer OBE is revolutionising our baby unit, (See the response from our mothers). and we are all thinking, planning and hoping that the move to the new Referral Hospital up the road, is going to be a Big Success for the children. er, and us too!.

July 1. A good week for four sick children with no passports, and no money to buy them.! Our hospital administrator Dr Mojela, got on the phone to the Maseru Bridge border crossing. And through they went. The children, that is. Admittedly it took most of the day to get it organised, and some of the mothers began to lose hope. But the story ended happily .  

28 June, and we're back from our daughter's wedding.They fly back to earthquake Christchurch. And a mini earthquake has happened here. well, two! Firstly, no passports are being issued to very sick children. Before our holiday, the passports were issued sluggishly. But now-none.So the children who need specialised emergency or Intensive care, heart surgery, neurosurgery or any service that we don't have, can't get treatment. Unless poor Dr Mojela, our head administrator, phones up the border post at Maseru bridge to let the children through. And it still costs the mother 150 Maloti (15 pounds) for the transport to Bloemfontein..and that leads us to earthquake number two.The private Netcare/ministry of health hospital has started running.Its going to be very exciting and could be a huge success for our children. It looks unbelievable compared to poor leaky, freezing draughty Queen Elizabeth II. We're in the middle of winter with brief day temperatures almost up to 16, and nights to freezing. Everyone wears wooly hats, thermal vests, scarves and fleeces for the sartorial wardrounds. And the three-way fight for the single electrical plug is between the elderly bar heater to heat the malnutrition ward, or the queues of mothers arguing about the single plug being used for charging their cell phones . Or to turn on  the Xray viewing box to see if their child has TB or just severe pneumonia. So our new hospital is bound to have more than one electrical point in each ward. And anyway, should a charity worker like me, be signing a contract with a private hospital.? So lots to think about. But I recommend Icebreaker 200 thermal vests,  M&S wool polo necks topped by a wool pullover.You may look like a whale but you stay warm.

 

2011 and its May already...

How is Amor? Amor is just fine. Her thyroid is pretty normal too. But her English is wonderful. And her command of medical cliches has to be heard to be believed. "Oena Amor, U phela juang?"  Are you well today, Amor? And then, in a perfect west Dorset Beaminster school accent Amor replies "Oi'm as well as can be  expected, Doctorr Dearlove."

And here is more good news. The Halstock carol singers funded a baby pulse oximeter. Its working hard, guiding our treatment of the babies deadly chest infections and pneumonias. The babies's mothers quickly grasp that the higher the oxygen number, the better their babies are doing.

And thinking of pneumonia, all of us were impressed that the UK is following Bill Gates's advice to give our overseas aid to immunisation for diarrhoeal disease, and pneumonia. Its far better to turn off the disease tap with effective immunisation, than to have to treat the disease once it occurs.I reviewed our last two years admissions, And the vast majority of babies we admitted have diarrhoea, or pneumonia.Mass immunisation will make a huge difference to our babies, and it can be measured as to how succesful its been.

15/6/11.Its so soon, and more excellent financial news from four friends, Chris, Lesley, Dave & Prema. Now we have enough money to buy a portable blood pressure monitor, And start a trust fund provisionally called "Passports2health" (If you're reading this from the top- Thank you! and you're travelling back in time. The passport news gets worse.)But why do we need a blood pressure monitor? We don't have one, and have to borrow one from the TB ward, or the surgical ward.But theirs have adult size arm cuffs, as big as blankets for some of our small babies. Here is a simple story of blood pressure success.,

Lerato, five, helps the herdboys with the five family sheep. But then he starts to get headaches and pass Coca Cola coloured urine. He has a convulsion, and then another one. His teen sister takes him down the mountains to the local hospital. He's got a rash like little bruises. They give him lots of anti epilepsy medicine, and antibiotics.. But he has more fits.And is not very awake. He is transferred to us. He is very pale, especially the palms of his hands.His sister tells us that he's not from Germany and never eats Lower Saxony bean sprouts. We find a blood pressure monitor on the obstetric ward. It doesn't work. We find the surgical one. It doesn't work. We look at it. Its connected up incorrectly. A simple fiddle and thirty seconds later it records a dangerously high blood pressure. He gets blood pressure lowering medicine, and his fits stop. He gradually wakes up. Some months later he's completly normal and we're stopping his blood pressure medicine. We all breathe a sigh of relief, and make sure that our nurses can use the BP monitor correctly.

Many thanks for all your help! John and Bridget.

"9/1/11. It’s the hot and stormy new year of 2011. Stormy ,hot and hyperthyroid  Amor is going to be cured at the nuclear medicine department of Bloemfontein University Hospital.  It’s the radioactive iodine drink  that’ll do it. Why can’t we do it? We’re too poor! Besides, Amor needs a passport to go from Lesotho’s mountain Kingdom, to brainy Boer Bloemfontein. And we’ve all contributed to the 200 Maloti (£20.00) passport to get her over the border half a mile away..

This passport problem applies to all our emergencies that we can’t handle. So, over Christmas a teenager came in with the biggest brain abscess you’ve seen. Her picture is on the Pix Page. She gave full permission. We can do neurosurgery for gunshots, knobkerrie beatings, and so on. But she needs more complicated things, especially as the abscess will discharge through the bump on the right side of her forehead. Look carefully! She needs something done now! But a passport takes a week, if you’ve got the money. It’s about £20.00. But waiting a week for an emergency, Er,   isn’t an emergency, its half the NHS waiting time of non-emergencies. (Aren’t you glad you’ve got the NHS? Emergency treatment really is immediate treatment) But our teenager had the best Xmas present. A £20.00 granny, who had already got her granddaughter a passport, for a school trip a mile down the road to the Republic of South Africa . So, off she went to a successful treatment and recovery at Bloemfontein.

A wonderful success, but very rare.

And here is some more good news! The Halstock Carol Singers are going to give us a baby finger tip oxygen saturation monitor! Currently we use an adult one, and try to get the baby's foot into the device. Chloe, our daughter gave me that one for Christmas. She'd got one free . Probably from a company making retrovirals to treat HIV/Aids.  But back to those plucky Halstock songsters. They braved the snow and cold, trudging around the lanes of pretty Halstock, singing so heartily that  we will now be able to check the oxygen levels of  newborns as well as the toddlers and children. The Carollers are thinking hard about a truly Dorset Carols CD. Maybe next year. But thank you to all of you singers!

John & Bridget,

Ps, Just to remind us all how lucky we are in the UK to have the NHS, and well funded, excellent hospitals, here is a link to my old hospital at Yeovil,  http://www.yeovilhospital.nhs.uk/

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