We pass a group of ancient-looking women gathered at the outpatients’ department of Mseleni Hospital, in the hot, far north of KwaZulu-Natal. Hunched and bandy-legged, they move slowly, each aided by two walking sticks.
“Look at their faces,” says Dr Victor Fredlund, superintendent of the 184-bed hospital, as we pass. “Some of them are not that old at all.”
Most of the women are only in their 50s, but severe arthritis has crumpled their bodies and made them appear thirty years older.
Mseleni, near the tourist paradise of Sodwana Bay, has such a high incidence of arthritis that the disease has been renamed Mseleni Joint Disease (MJD). By the age of 50, half the some 75 000 people who live here suffer from some form of arthritis, which usually begins causing pain from their twenties. Twice as many women as men suffer from the disease.
No one knows why Mseleni is so badly affected by arthritis but is a difficult affliction in the vast scrubland where walking long distances through thick sand is a necessary part of daily life.
Fredlund, a short, forceful man who has been at Mseleni for 22 years, is not the kind of person able to sit back and watch people suffer.
“One of the good things about being a medical practitioner is that you can help people and alleviate their sufferings,” says Fredlund, who was named rural doctor of the year by the Rural Doctors’ Association of SA (Rudasa) last month.
Hip-replacement operations, where the hip ball and joint are replaced with a prosthesis (see box), is one way of offering relief to those with arthritis. It can buy 10 to 15 years’ of pain relief for patients before the prosthesis start to loosen and revision surgery is needed.
Usually it is a two-hour procedure performed by orthopaedic surgeons at tertiary hospitals. It would be unrealistic to expect a small rural facility with only seven doctors to have the capacity to do hip replacements.
So, for a time, Mseleni patients needing hip replacements went to faraway Ladysmith Hospital. But this was unsatisfactory as the need was too great and opportunities too few. Patients were often forced to wait in the town for months before surgeons could squeeze them in.
Then, in 1994, a Pretoria surgeon, Dr Christoph Meyer, heard about MJD and travelled to Mseleni over weekends to perform the operations with Fredlund assisting.
After Meyer was killed in a plane crash in 1998, Fredlund appealed to the University of Natal’s orthopaedic department for help. Twice a month, junior doctors and registrars from the university fly up in the Red Cross plane to Mseleni. But it is they who are helped by Fredlund, as he teaches them how to perform hip replacements.
“Everyone told him there was no way that he could do hip replacements at Mseleni because you need fancy theatres and hi-tech equipment,” says Professor Ian Couper, head of rural medicine at Wits University.
“But he was determined to offer patients this procedure and when referrals didn’t work, he found another way.”
As a general anaesthetic can be complex, the Mseleni version of the operation is done under spinal anaesthetic. This means that patients are awake while the cutting, sawing and grinding take place.
“They don’t seem to mind, and some are very relieved that they will not be put to sleep,” says Fredlund.
There are almost 900 patients on the MJD clinic register, but Fredlund says there are “probably about 2 000 more people living in the community who could benefit from the operation”.
Fortunately, the disease seems on the wane as Fredlund has started seeing fewer young people with arthritis these days. Again, it is impossible to identify a specific reason for this as “so many things have changed” over the past decade, says Fredlund. But the improvement in living standards is certainly an important factor.
In most government hospitals, the wait for the specialised operation can be years. But between Fredlund’s determination and the provincial Department of Health’s provision of special funds to buy the expensive prostheses, Mseleni patients wait only a few months.
Fredlund has performed about 200 operations, and is currently doing about six a month. His post-operative results compare favourably to those from the most advanced hospitals worldwide, with only 1% developing post-operative complications.
He estimates that it costs around R10 000 per operation, with 80% of that amounting to the cost of the prosthesis. The remainder covers time in theatre and an average seven-day stay in hospital.
In a few hours’ time, Junior Manzini (53) will have a new left hip joint.
“I started having problems and pain in my hips when I was 15,” says Manzini, who had her right hip replaced in 1999.
“After many years the pain became too much so I went to the hospital. They said I should come for the operation.”
“The new hip is fine”, says Manzini. “Look, it is straight,” she says, patting her right leg it is stretches before her in the bed.
“But this left one is not good. It doesn’t want to do anything. The other one carries it so I thought I must come back and have this one done.”
It’s a daunting prospect. Manzini knows only too well that she will have to learn to walk again; that it will be a painful, slow and tiring process.
Physiotherapist Verusia Pillay, who is doing her community service at the hospital, says that patients are up and on a walking frame on the third or fourth day after the operation. They learn to walk using parallel bars, and on the seventh day, they are discharged on crutches and return once a month for check-ups.
When Fredlund and his wife Rachel came to Mseleni from Britain in 1981, they expected to spend about five years at tiny rural settlement.
Instead, they have spent almost a lifetime there, raising three children and immersing themselves in the community. Rachel runs the local orphanage and is involved in orphan care, mostly of children who have lost parents to AIDS, in the communities around the hospital.
Their home, a hop and a skip from the hospital’s administration block, is always full of children; orphans who have popped in from the home and children boarding with them so that they can attend the high school.
The family has remained, Fredlund says, because “there are always new challenges”; new ways in which to give concrete expression to their Christian faith.
The latest to absorb Fredlund’s energy is how to introduce anti-retroviral drugs through the eight clinics that fall under the hospital.
He also tells me, his eyes shining behind his glasses, about a new plan he has to improve facilities. “I want to raise funds for a swimming pool so that the hip patients to do hydro-therapy. But I also think it’s time we had a community pool.”
Coupling hospital and community development is typical of Fredlund’s approach. In the late 1980s, frustrated at having to treat diseases caused by dirty water and a lack of sanitation, he simply organised for the hospital’s water pipes to be extended, first to the local school, then for 10km north, south, east and west. Taps were attached at regular intervals.
The community water project now employs two plumbers and a clerk from profits made by extending pipes to the homesteads of those who can afford to buy the pipes and fittings. Plumber Aaron Manukuza says that about 1 000 homes have water, and the extensions cost around R200 and labour R30 an hour. Those without means get water from community standpipes.
Fredlund also helped to start a toilet-building project, and is chairperson of Vuka Mabaso, the local community centre. In a narrow room under the community hall, students gather around the one Internet-linked computer for which they pay R12 for 30minutes’ access.
“They mostly use it to email their assignments to institutions or to register for courses,” says 23-year-old Jabu Ntuli, who runs the “Chips and Bytes” computer centre.
Ntuli is enthusiastic about Fredlund’s involvement, describing him as “very free to the community and a friendly person”.
In an argument with a provincial bureaucrat concerned that Mseleni may have circumvented certain computer procedures, Fredlund snaps: “You are a bureaucrat but I am a pragmatist. I want to get things done.”
Couper, who ran neighbouring Manguzi Hospital for nine years, describes Fredlund as “an example to all of us”.
“What impresses me about Victor is his commitment and dedication. At times, he was the only doctor at Mseleni but he never lost his vision of providing a service broader than just medical work. He has always been involved in community development.”
Explaining hip replacements
The hip joint is where the thigh bone (femur) meets the hipbone. The femur is a long bone with a ball on one end. The ball fits into the acetabulum, a cup-like socket in the hip bone. This ball-and-socket joint allows us to do a range of things such as walking and sitting. In healthy hip joints, cartilage coats the bones and enables them to move easily. Arthritis occurs when cartilage wears away, exposing bone. The bones grind together and cause a great deal of pain when a person tries to move around. During hip replacement, the surgeon cuts the damaged the head off the femur (the ball) at the femoral neck and scrapes out the acetabulum (the socket). A polyethylene cup is fitted into the socket and the ball is replaced with a steel ball, attached to a long stem. In order to secure the ball, the stem is knocked into the femur and cemented into the bone. After 10 to 15 years, the prosthesis (artificial parts) may loosen and revision surgery may be needed. Because of the cost, Mseleni does not offer revision therapy. However, in cases where the loosened prosthesis is causing a lot of pain, it is removed altogether. This is called a ‘Girdlestone’ procedure. Scar tissue develops between the upper end of the femur and the hip bone and allows the person to move with little pain. However, the femur is shortened, and the leg is weak and people usually need to walk with the aid of a stick or crutches.