The Daktari Is In
By Patrick Neustatter
The early afternoon sun was blinding as we stepped out from the Medical, Dental, and Allied Professions Council office in Zimbabwe’s capitol, Harare. My wife, Robin, and I were elated.
It was 1985 and I was brandishing an elegantly calligraphed, temporary medical license, the last hurdle between me and my fantasies of being another Albert Schweitzer—and taking up the offer from the Association of Church-Related Hospitals as a replacement for a doctor who needed time off from St. Luke’s Hospital in the rural hamlet of Lupane in northwest Zimbabwe.
Robin and I had spent four months journeying from Europe, through Egypt, and down through east Africa. It was a red-letter day when we were finally on the train from Livingston, in Zambia, to Harare, crossing the famous Victoria Falls Bridge high above the Zambezi River, and just upstream from the “the smoke that thunders,” the 5,600-foot-wide, 350-foot high cascade that dwarfs North America’s Niagara and Horseshoe Falls.
The trip celebrated my completion of a medical residency program in New York—two years in medical purgatory as a prerequisite for moving to, and practicing in, the U.S., despite my having worked as a doctor for 13 years already in England.
We were following the footsteps of my mother’s rebellious brother Guy, who had been imprisoned then deported many years before by the apartheid regime that had controlled the country known as Rhodesia until 1980. His crime: running a multiracial farm where whites and blacks worked together and were paid the same.
Guy had been seen as an ally by Zimbabwe President Robert Mugabe, and is the only white man buried in Hero’s Acre in Harare—though I fancy he would be turning in that grave if he could see what had become of Mugabe and the freedom fighters by the time Robin and I arrived.
It was a bit early for a beer as we walked down Harvey Brown Avenue, so to celebrate my appointment at St. Luke’s, we opted for the inviting shady terrace of the Spring Fever Café, taking a table next to a couple of classic white colonial Zimbabweans, he in khaki shorts and bush shirt smoking Everest cigarettes, she in a ’50s-style floral dress.
Overhearing that we were obviously visitors, they struck up conversation, and we went through the usual questions about where we were from—Robin obviously American, me from the U.K. They then asked us about our plans. I proudly showed them my license and told them we would be spending the next few weeks as medical missionaries substituting for a doctor on temporary leave from St. Luke’s in Lupane.
They looked dubious.
“Lupane?” they asked.
“Yes. It’s some place on the road from Bulawayo to Vic Falls.”
“Yes, yes,” the man said. “But you know that’s in Matabeleland?”
“Matabeleland?” I repeated. “No, this is in Zimbabwe,” I said, thinking these were a couple of burned-out colonials, probably too fond of the gin and tonics.
“How long are you going to be there?”
“A couple of months.”
They looked even more dubious. He stubbed out his cigarette. She smoothed the hem of her dress.
“Matabeleland is the tribal lands of the Ndebele people,” the wife told us, looking at Robin, who was now nervously playing with her napkin. “There’s still a lot of fighting.”
“Fighting?” we asked. We were aware there had been a lot of conflict during the War of Liberation, but that had ended five years before.
Seeming like anxious parents, they explained how Robert Mugabe and the governing Zimbabwe African National Union were all from the Shona tribe and the central part of the country around the capital. But Matabeleland to the west, where we were going, was controlled by the Ndebele tribe and the opposition leader Joshua Nkomo.
“Just recently there were six tourists abducted,” they told us. “Taken as hostages by insurgents on the Bulawayo Vic Falls Road while on a safari. They were all killed in an attempted rescue.”
“I’d give it a miss if I were you,” the man told us as they rose to go.
Foolhardy or otherwise, we swallowed our misgivings and found ourselves a few hours later on the night train to Bulawayo, the largest city near our destination of Lupane. We took comfort in the old-fashioned rolling stock reminiscent of my childhood in England, and tea served on linen tablecloths.
The servers reminded me of schoolkids I’d seen in blazers and straw boaters—“More British than the British”—on other trips I’d taken through India, Burma, and Kenya.
Arriving the next morning at Bulawayo, we were tired and disheveled and met by Thomas, the hospital’s gofer, who was there to drive us to St Luke’s in the hospital’s decrepit Austin van. The hours-long trip took us over potholed roads through an arid, red-dirt landscape dotted with scrubby thorn trees and houses with cinderblock walls and roofs made of beaten-out oil cans, which Thomas assured us were middle-class dwellings.
It was late afternoon when we reached Lupane and turned in through the heavy iron gate to the hospital’s walled compound. The staff were in a screened gazebo—grandly called “the Summer House”—having tea, a quaint vestige of European culture and privilege.
We were welcomed as conquering heroes by one and all, but especially by Dr. Johanna Davies, a German physician who had founded the place in 1947 following her imperative as expressed in her autobiography “to practice for the poor, following the call of Christ,” and who, slightly stooped in her white coat, looked careworn and older than her 66 years. She was surrounded by nurses, and nuns from the Sisters of the Precious Blood, an order founded in Switzerland that vowed that not one drop of Jesus’ precious blood would ever be spilled in vain.
We were given the royal tour, around a collection of whitewashed buildings that housed chaotic wards, segregated only by gender rather than, as in the “civilized” world, by pathology. Beds with two patients head-to-toe. Other patients under the beds who had to be coaxed out, like a hermit crab from its shell, to be examined.
More camped out on the cloistered walkway, and on the scrubby lawn by day, making the patch of ground outside the obstetrics ward, with colorful dashikis and sheets drying in the sun, look like a refugee ship.
This, as it was explained to us, was how a hospital built to house 250 patients was able to regularly accommodate nearly twice as many. “How can we turn anybody away?” Dr. Davies asked plaintively.
We soon discovered that there were even more people at the hospital than those 500 patients—a lot more—as everyone admitted apparently came with a friend or relative who looked after them, these attendants often seen bent over fire pits outside, worrying blackened saucepans full of steaming sadza, a mush made from maize flour. Most were women, many of them with babies strapped to their backs.
Shortly after our introduction, Dr. Davies saw us looking at a photograph of an elderly white woman hanging on the wall of the entranceway.
“Dr. Johanna Francesca Decker,” she said wistfully. After a moment, she told us that Dr. Decker, another German mission doctor, had been shot and killed when a hospital she ran was attacked by insurgents and burned down. Dr. Davies wanted to be buried next to Dr. Decker when she herself died.
Tired, and once again anxious, we were shown to the guest bedroom of Bernard, the youngish German surgeon for whom I would be standing in. We were also introduced to Bernard’s ferocious pet monkey, Mozart, who we would be baby-sitting and who was quick to bite anyone too slow with the next peanut. Robin and I lay on the bed for a long time with the lights out, listening to the unfamiliar sounds of the night and discussing just what kind of a mess we had gotten ourselves into.
The days that followed were punctuated by the sounding of a gong made of a piece of truck propeller shaft. This usually meant it was time for meals, which were plentiful—for the staff: morning tea, lunch, afternoon tea, then supper. We felt a certain discomfort at all this eating when we learned the government forces were using starvation as a weapon against the locals, and when we saw severely malnourished kids with pot bellies and stick limbs being admitted to the hospital to be fed.
My entire training and orientation took place the second day at St. Luke’s when I accompanied Bernard to check 160 inpatients on rounds, which often was nothing more than a passing nod. That was all we had time for when we saw the elderly guy with leprosy, camped out for years with his bed on one of the covered walkways.
At one point, Bernard slowed down to show me two elderly women, sitting side by side, with massively protuberant stomachs, looking like pregnant twins if not for their age and their sallow complexions.
“They have what in Germany we call ‘aszites,’” he told me. “I don’t know in English.”
“Ascites?” I volunteered. “From cirrhosis?”
“Ah, yes. Is cirrhosis.” He exchanged a few comments with the nurse, who translated to the women, who held their abdomens and looked pained.
Later I did a paracentesis on each, drawing out several liters of straw-colored turbid fluid with a none-too-sharp and probably non-too sterile large-bore needle, a giant syringe, and an old newspaper for what should have been sterile drapes. It was a procedure that would normally be done in a super-sterile operating room or radiology department because of the grave risk of contamination causing catastrophic peritonitis.
We also stopped to examine two other women with plaster casts on their forearms. At Bernard’s prompting, they demonstrated how they had gotten injured, holding their arms over their heads as if warding off blows.
“It is the government forces trying to get villagers to tell where the insurgents are,” Bernard said. “Or it’s the insurgents trying to make them not.”
After rounds, we ended up in a cement block room that had all the charm and comfort of a bus shelter. This was the clinic building. It held a few metal chairs for the patients and a desk for the doctor, who, once Bernard left, was usually me.
My big anxiety in taking on this job of mzungu doctor—mzungu being a Bantu term used for whites which literally means “someone who wanders aimlessly”—had been that I would be unprepared to help patients with things like kala-azar, bilharzia, tsutsugamushi fever, and schistosomiasis—tropical diseases and parasitic infestations we had to learn about in medical school, and about which I promptly forgot after graduation.
My fears were never realized, though. Instead there was trauma, albeit sometimes exotic. Like the man who was bitten by a crocodile. Or the guy who spent two days on the bus getting to the hospital after an argument with his neighbor who had stuck him through his axilla with a spear. The hole in his chest wall put him in imminent danger of having his lung collapse, but he was the beneficiary of some ingenious bush medicine. Rather than a chest tube and an underwater seal, which the hospital didn’t have, he was patched up with duct tape.
Then there was the 7-year-old girl suffering severe burns from falling in a cooking fire. Her charred flesh needed debriding, a painful process normally done under general anesthetic, only no proper anesthetic was available at the hospital at the time. What was available was a bottle of cough medicine that contained codeine, and after a carefully calculated dose, the young patient dozed peacefully in her mother’s arms while her burns were debrided and dressed. And she never coughed once.
Few procedures were as peaceful. When I had to incise a nasty abscess on a 4-year-old boy, he screamed and protested, while the attendant held him in a firm embrace. “I will tell my grandfather!” he shouted, according to the attendant, who translated for me later. I was never sure how worried I should be about the odd threat.
In addition to these trauma injuries, many of the illnesses we saw were tied to sex and procreation.
Women with complications of pregnancy. Or women with a form of psychosomatic abdominal pain from not being able to get pregnant. Men—often scary soldiers in battle fatigues with automatic rifles—complaining of “the drip drip,” which was not a sinus infection, as I soon found out, but rather a lurid name for the urethral discharge of gonorrhea.
Probably the most common of all the afflictions we treated were people of both sexes suffering from dizziness, achiness, coughing, and vomiting—a combination considered the sine qua non of malaria. Treatment was easy—we dosed them right away with antimalarials—and I loved the brevity of the recorded diagnosis. The admission “history and physical” in most of these cases was a scrap of paper on which I would write, simply, “malaria, chloroquine.”
An all-too-common scene, though, were the large red and yellow local buses dropping patients at the hospital gate at odd times, many of them mothers with lethargic or comatose children—a sure sign of often fatal cerebral malaria, which develops when the illness is left untreated for too long.
One of the nurses, Sister Anna—Dr. Davies’ sister, who had also answered the call to “do the bidding of Jesus”—would become apoplectic with rage at the cotside of these desperately ill children, angry with their mothers for having taken them to village healers, n’anga, instead of straight to the hospital or clinic.
These indigenous healers would give the kids muti, a homemade medicine, that Sister Anna claimed was poison and that clearly didn’t work.
I was interested to find out more about the n’anga, though the claim was they could also cast harmful spells. The locals had a distinct respect if not fear of them, and one day when
Thomas was going into Lupane market, we asked if he would take us to meet one. Though usually resourceful, for some reason Thomas was never able to find one in the village, so he took us to a muti shop, a kind of demonic pharmacy, instead.
There were scary carved wooden masks on the walls. Strings overhead with mummified carcasses of unidentified rodents and toads that got tangled in our hair. The back wall was lined with jars that looked like they should be full of candy or bath salts, but instead held sinister looking fungi, seed pods, and more animal carcasses. It all seemed to reinforce Sister Anna’s oft-repeated assertion that “All muti is poison.”
Another part of my duties at St Luke’s was to go to the outlying clinics, driving to the local health departments in a Land Rover over rough terrain where there often was no road. Much of this was doing well-child checks, primarily weighing babies to see if they were falling off their growth curve, which meant suspending screaming infants in a basket under a hanging scale like prize pumpkins.
It was hard convincing parents that their children hadn’t “caught” malnutrition or been cursed, and that all they needed was more food. The ones that were really bad we brought back to the hospital to be admitted and fed a brown concoction made of peanut butter, milk powder, oil, sugar, minerals, vitamins, and protein, and affectionately known as “plumpy-nut.”
I was horrified to find that my duties also included dentistry, dentists and doctors always being two completely divergent tracks in the “civilized world.” Fortunately I was introduced to Sister Regina, who had been designated as the hospital dentist, possibly because her bulk was helpful for the challenging work of tooth extraction.
Sister Regina’s operating room was an an old, beat-up dental chair hidden behind a dirty sheet she had hung from the ceiling for a screen. The first time I went in to observe Sister Regina at work, the patient was a very apprehensive middle-aged man in a Grateful Dead T-shirt, ragged pants, and no shoes. He needed a tooth removed, and Sister Regina was going to show me how to do it. First she infiltrated his gums with local anesthetic—emphasizing its cost, and the need to use as absolutely as little as possible—then, grasping the offending tooth with dental forceps, she leaned in and heaved back and forth for a disturbingly long time until finally surfacing with a look of triumph and a bloody tooth.
“It is very necessary to have the horsepower, doctor,” she told me. I was surprised and pleased to find that pulling a tooth was not actually too hard, providing it didn’t disintegrate.
While I was quite enjoying myself being a daktari, Robin was becoming restless—and probably a little resentful of my playing the hero doctor while she rolled bandages and counted pills. But that all changed when the nuns told her about their discomfort with a certain part of the medical curriculum they had to teach to the young Zimbabwean men, so-called “barefoot doctors,” studying Western medicine at a school that was part of St Luke’s.
Male genitalia was the stumbling block. But Robin offered to take on the job. “Something I know about,” she explained.
Seeing the starving kids and the locals with their injuries from being beaten reminded us we were in a war zone. One of the nuns had her front teeth knocked out with a rifle butt. Another had her car shot up by a soldier looking for insurgents. And, of course, there was the reminder we saw every day when we walked past the picture of the murdered Dr. Johanna Decker.
Robin and I got anxious whenever a police patrol barged into the hospital compound uninvited, but Thomas quickly reassured me. “The police are our friends. They are protecting us from the army.”
I got even more anxious one day when an armed personnel carrier, looking like some prehistoric animal with a carapace of steel, rumbled into the compound. This was the army.
I happened to have my camera out at the time, taking some pictures around the hospital as mementos, and I snapped a discreet photo of the army vehicle to show my friends when we got back home.
Suddenly, though, I found myself confronted by a wild-eyed soldier who appeared from out of nowhere. “You took a picture of the vehicle. That is not allowed,” he snapped.
I had recently read Alexandra Fuller’s book Let’s Not Go to the Dogs Tonight about growing up in Rhodesia and living through the war of independence. She described how fearful she had been when heavily armed rebel soldiers turned up at her white Rhodesian family’s farm, often drunk or high on marijuana, and very unpredictable—passages that now unnerved me, too. I found it impossible to judge just how much authority this soldier had, or how intoxicated and violent he might be.
“No, no,” I lamely insisted. “I was just taking a picture of the hospital. Just the buildings,”
“You, give me the film,” he said, holding out a large brawny hand.
“I didn’t take a picture of the vehicle, really,” I told him. “Just the buildings.”
“Give me the film,” he repeated, looking more threatening.
It was a standoff worthy of a spaghetti Western. We were glowering at each other, neither quite sure how much authority the other had—though only one of us was armed.
Fortunately, the personnel carrier started to slowly make its way toward the gate, and rather then stay behind to force me to give up the film, the angry soldier marched off to get on board.
I was beginning to think it wasn’t a case of showing my friends the pictures when we got home, but if.
Not finding myself in some Zimbabwean dungeon, I plodded on, getting more comfortable about dealing with the different medical issues and able to see far more than my share of the St. Luke’s patients, which I soon realized was necessary as Dr. Davies, known for her dithering and indecision (and who Robin christened “a Flatterkopf”) was painfully slow.
I got the impression that Bernard, who by all accounts was a decisive surgeon, would see very much the lion’s share. My concern—all of our concern—was that with him being away, what was going to happen if anyone needed surgery now?
We’d got away with it for awhile—until a patient Precious Ngadya changed everything.
She was 16, pregnant, and arrived on her own on one of the buses. She had a note from one of the nursing outposts which said “Due date—full term, repeated bleeding vagina.”
It was succinct, and enough to make me fear she had a placenta previa, a complication that can cause catastrophic bleeding if the woman goes into labor—and which requires a cesarean section.
The girl, Precious, looked pale, but it was common for pregnant women in Zimbabwe to be anemic due to poor diet and blood loss from intestinal parasites like hookworms—and, of course, that ultimate parasite that nature has arranged to get preferential treatment over the mother for nutrients like iron.
After a tense discussion, the only option was for us to section her. Dr. Davies told me she hadn’t done a C-section in years, and she insisted she would be my assistant. I had done various minor surgical procedures as a junior hospital doctor in England and had observed several C-sections, but the idea of doing one myself—of cutting through this woman’s abdomen, finding her uterus, hacking that open to deliver the baby—was a very different proposition.
However, I soon found myself standing next to Dr. Davies, scrubbing up together at the sink in the sluice as the nurse infiltrated Precious’ ripe abdomen with what seemed a totally inadequate quantity of local anesthetic.
Taking the scalpel, I hesitantly cut a large, crescent shaped incision, being reminded that human skin is a lot tougher than you might think. Tying off the bleeders as quickly as possible with Dr. Davies’ help, I found the lower pole of the uterus.
You might think a pregnant uterus is like a ripe fruit—one nick and the baby would just pop out like the scene in Alien. In reality I was having to saw through the thick muscular wall, careful not to stab the baby within, trying to get away with as small an incision as possible but big enough to pull the baby through.
A turbid gush of amniotic fluid poured out when I penetrated the amniotic sac and began fishing around to get a grip on some part of the baby. I was finally able to grasp the slippery head and winkle it out through the incision. After checking that there was no umbilical cord around the neck, I applied gentle traction, bending the head and neck first one way to get one shoulder out, then the other, extracting this thing that looked like a cross between an alien and Golem.
Everyone held their breath.
It was a boy, and he was laid on a probably not very sterile towel and rubbed vigorously to get the blood flowing. Perhaps realizing at some instinctual level that he was forsaking the warm, safe environment in utero for the big, bad world outside, he started to scream bloody murder.
And at that point, everyone else began to breathe again, followed by whoops, hugs, high-fives and ululations. The slimy, blue-black thing, covered in white cheesy vernix and meconium—fetal poop—was handed to the young mother, who smothered him with kisses.
This, as it turned out, was a bit of a grand finale, as it was time for Robin and me to stop being missionaries—which, for the two most agnostic people in the world, had been a bit of a joke anyway.
After Bernard’s return to St. Luke’s, we packed our things and accepted the offer of a ride to Bulawayo by Dennis, a mining engineer from Texas who was advising the government and had been doing some business in Lupane. We were sad to leave but glad to be finally moving out of this war zone.
Dennis arrived early the next morning, looking immaculate in freshly laundered bush shirt and pants—at least in comparison to our travel-weary attire. We threw our packs and a few other assorted souvenirs into his white Toyota Land Cruiser and were off on another spine-jarring ride on potholed roads and more arid red-dust landscape.
Our trip was congenial enough—until Dennis started in.
“Apartheid was the smartest thing the Rhodesians ever did,” he said, waving his hand for emphasis, too focused on the road to see the horrified glance that Robin and I exchanged. “Look at what a cockup these muntus have made of the farms they’ve taken over. It’s the same over the whole of Africa!”
It made me think of Alexandra Fuller writing about how her father and his buddies talked about how you could never teach the indigenous people to farm properly—an idea that my Uncle Guy, with his multiracial farm, had demonstrated was patently untrue.
Dennis’s attitude bugged me. True, we had seen evidence of some of the infrastructure degenerating and heard people complaining about the endless tribal wars and corruption since independence, but just as it took Europe a lot of time and wars—centuries—to get to its current level of civilization and achievement, things weren’t going to change in these newly liberated African nations overnight. And the European colonials, when they lost power and control, hadn’t exactly fallen over themselves to educate, share resources, or follow policies to help the indigenous populations.
One example of the destructive European legacy we had seen, and dealt with firsthand, was the indigenous people’s reliance on maize as their primary and sometimes only source of food—a grain that is deficient in a variety of vitamins and minerals and if not supplemented will lead to deadly pellagra.
We saw far too many kids in Zimbabwe looking like Save the Children advertisements with sticklike limbs, pot bellies, and other symptoms of pellagra, which is often typified by “the four D’s”: dermatitis, diarrhea, dementia, and sometimes death.
To try to reverse this, the hospital staff had begun showing mothers how to grow traditional crops like finger millet, known as rapoko, pumpkins, which could be smushed into an orange goop called nhopi, and ground nuts to supplement the sadza diet.
I gather maize became so popular because it is easy to grow, and easy to store, so was an ideal food for slave ships.
From Bulawayo, we journeyed on to South Africa, Australia, and across the Pacific back to the U.S., where I ended up joining the Pratt Medical Center at the north Stafford office and settling into medical practice and mzungu life in the “civilized” world.
It was then that some of the significance of what we had experienced really came home.
For one thing, compared with the people I was now treating, the Africans seemed to have great natural immunity—like the guy stuck with a spear or the kid with the abscess we drained who threatened to tell his grandfather. They both bounced back in no time. Maybe the absence of the over-the-top hygiene of our society with our antiseptic toilet seats and wipes for the handles of our grocery carts had something to do with it.
I missed the inventiveness of bush medicine and marveled at the lack of common sense of the recruits to our medical group who had to go through years of training, but who still seemed to end up complete idiots. Would they have had the ingenuity to prevent a collapsed lung with duct tape, or to use codeine cough medicine as an anesthetic?
There was also the satisfaction that all we did in Zimbabwe was of immediate benefit to the patient. We weren’t ordering tests for fear of malpractice suits, or fighting with insurance companies over pre-authorizations. No computerized medical records with 10-page admission notes. No HIPPA regulations. No DEA. None of the other innumerable aggravations that make medical practice in the “civilized” world so onerous.
Practicing in a completely different culture helped me broaden my empathy, communication, cultural sensitivity, and compassion. I was also intrigued by the influence of the n’angas and the power of belief—which I found is also a significant factor in treating patients in America.
I was already aware of the placebo effect of medicines, but the n’angas themselves seemed to have a strong placebo effect in Zimbabwe, which they enhanced by dressing in animal skins, tusks, and horns.
It was Robin, whose father like mine was a psychiatrist, who suggested, “If doctors in the U.S., and especially psychiatrists, would only dress in skins and terrifying objects they could really enhance their placebo effect.”
***
Robin and I had mixed feelings as we drove off from Lupane with the odious Dennis. But, unknown to me, we left with a memento of our time and our simple lifestyle and occasional boredom at St Luke’s.
In Johannesburg, Robin told me she wanted to go shopping, but didn’t say what for. “Why don’t you stay here and catch up on your diary?” she suggested. My insistence on needing solitary time to compulsively record our trip had been something of a bone of contention, so this seemed a little out of character.
When she came back, she went straight to the bathroom, then came out brandishing a test strip very like the ones we have all become so familiar with when testing for Covid.
Instead of the red line indicating the virus, though, this was a pregnancy test—and it was positive.
Conceived among the Sisters of the Precious Blood, our first child, Tegan was on the way.
***
Patrick Neustatter, M.D., was born and educated in England where he held a variety of medical jobs in and around London including a stint as an editor for Medical News. He also practiced medicine in Canada, Zimbabwe, and Australia—and, for a short time, worked as a flying doctor in the Australian Outback. After extensive travel in Asia and Africa, he moved to the United States with his first wife, completing his residency in New York before settling in Fredericksburg, where he was a family physician with the Pratt Medical Center for 24 years. Since retiring in 2010, he has served as medical director of the Moss Free Clinic while continuing to write monthly medical and health columns for The Free Lance-Star and Front Porch Magazine. He is the author of Managing Your Doctor, the Smart Patient’s Guide to Getting Effective, Affordable Healthcare and maintains the website Managing Your Doctor to promote the idea that patients should be empowered and in charge of their own healthcare. He has two grown daughters, Tegan and Alexis, and lives on 30 mostly wooded acres in Caroline County with his wife, Paula.
