Flying into Lesotho you are immediately struck by the amazing network of dark lines zig zagging their way all over the ground below. I later found out that these huge crevasses were called ‘dhungas’ and they are one of the more visible signs of the devastating soil erosion that takes place every year during the heavy summer rains. The Lonely Planet Guide to this part of the world goes so far as to suggest that by 2042 there will be insufficient amounts of top soil in Lesotho to sustain its farming industry.

I was due to spend the first couple of weeks of my eight and a bit week stay with the medical superintendent and his wife. They lived in a lovely bungalow in the far corner of the hospital complex looking over a deep valley set against the backdrop of an awesome mountain range.

That night I wriggled into my sleeping bag and thought about what the next couple of months might hold, what I might see, what I might have to do, my main thought was could I cope? Would God protect me and keep me healthy amidst people that were really sick? They were all questions about me and they were mainly all centred on my doubts and my lack of faith. The truth was though, that I really had no reason to be confident in my own abilities, I had never done anything like this before. I’m sure that God knew I was going to be feeling like this, more than a little lost and more than a little out of my depth. He didn’t exactly make those feelings go away. I still knew that I was out of my depth, but God gave me the feeling that if I were to stand on His shoulders I would manage to keep my head above water. I fell asleep listening to various animals soloing outside my bedroom window. This was definitely Africa.

The hospital situated on the outskirts of a small town at an altitude of one thousand six hundred metres. The hospital serves a rural population of some one hundred and twenty thousand individuals. The hospital itself sees around six thousand five hundred admissions each year, performs over two thousand operations, delivers over two thousand five hundred children and runs fourteen out clinics treating a further one hundred and thirty five thousand patients annually. The hospital employs five full time doctors, nine registered nurses, six registered midwives and twenty nursing assistants, and also runs a nursing school for one hundred and seven nursing students.

I remember my first patient had ophthalmic zoster but his face was so swollen that I was concerned he might have a periorbital cellulitis as well. This case would later come back to haunt me as after his week long admission the gentleman couldn’t pay his bill for the hugely expensive treatment his condition required and he felt that he had been mislead as to how much his treatment was going to cost. I remember returning to the hospital after lunch to find him arguing with some of the nurses working in OPD. I was sure that he had been told that his treatment was going to be expensive but that it was essential he receive it. He saw things a little differently. We eventually came to some agreement over how he could pay his bill over a number of weeks but I was truly saddened by the fact that the cost of such essential treatment should cause so much distress, and he was one of the lucky ones as he was currently working. I later found that paying hospital and medical fees was a huge problem for most of the people attending the hospital. Many patients or their relatives ended up doing some sort of manual work around the hospital to pay bills.

TB is a common illness in Lesotho, as it often coexists with HIV/AIDS. After a couple of weeks the picture of a patient with several months of weight loss, a productive cough and night sweats became a very familiar one. The presence of TB in a young person would inevitably make us suspicious that the patient might also be HIV positive and thus we would offer an HIV test. Many said yes and so they were sent to see one of the hospitals HIV/AIDS counsellors. These wonderful people provided all patients with suspected HIV/AIDS with pre and post test counselling. They also did a huge amount of work in the local community educating people about HIV/AIDS and counselling those whose lives were affected by the disease.

Its effects on women were particularly difficult to cope with, as it seemed to hit them so hard. I lost track of the number of women I saw that had amenorrhoea because they now weighed less than thirty-five kilograms. Many came into hospital in wheel chairs simply because they were too weak to walk. Others were unable to eat because of overwhelming oral and GI candidiasis. When seeing case after case like this I found it incredibly hard not to let my despair show through when I was examining patients and talking to relatives via one of the senior nurses. It’s very difficult to put into words, but it makes you want to cry, pull your hair out and curl up in a ball and give up all at the same time.

The most difficult day of my visit came about six weeks into my eight and a half-week stay. The day started as usual with a ward round which I did with one of the other doctors before he left to do one of the out clinics. I was just finishing seeing a patient before going to lunch and I was called to see an emergency on one of the male wards as all the other senior doctors had already left. I shall never forget the sight that greeted me as I walked onto the ward. I was met by a team of four nurses desperately trying to resuscitate one of the youngest of the TB patients who should have been discharged that morning.

There was blood all over the patient’s bed and at the end of his bed was a kidney dish full of what looked like large clumps of pale pink jelly. I was quickly informed that the gentleman had been paying his bill in reception when he had suddenly started coughing and this had then rapidly progressed to him coughing up blood. He was rushed back to the ward where he then proceeded to cough up large clumps of blood and lung tissue. Attempts at resuscitation had been going on for about ten minutes before I arrived.

I was so shocked that I initially just stood and tried to take in the events that had taken place. The patient can’t have been all that much older than me. One of the nurses then turned to me and asked me what I would like to do. I thought about it for a few seconds, felt for a pulse, there wasn’t one and he wasn’t breathing. Lots of things went through my mind. Could we get and IV in to boost his circulating volume? Could we ventilate and defibrillate him?

In the end, I knew the answer to these questions. I turned to the nurse and said that I would like everyone to stop. There really was nothing we could do that was going to change the outcome here. I’ve thought about it many times since and I really feel that was the right thing to do. They all agreed and I turned to leave the ward. As I did so another nurse from the paediatric ward called me to say that there was now an emergency on their ward. I knew which child it would be straight away, a little baby, about nine months old with a horrible chest infection that wasn’t responding to antibiotics.

I walked quickly behind the nurse to the side room where the child and its mother were staying. The room had been filled with hot steam; a technique often used in the hospital to try and improve the breathing of children with chest infections and bronchiolitis and so it was like walking into a tropical rainforest. I just remember thinking that it was my worst nightmare coming true. The baby was lying in its cot gasping for breath at an incredible rate, hot and covered in moisture and my first thought was that the child was going to die; I’d never seen anyone so small look so sick. A small facemask was providing oxygen from one of the hospitals few oxygen condensers.

Very small, very sick children are incredibly frightening to me, I guess they are to most people and, as with the gentleman I had just seen, for a few seconds I just stared at this incredibly sick baby and its mother. I thought about things for a little while and realising that I was totally out of my depth, so I tried to ring some of the other doctors to get their advice on the best course of action. The first said that there was little else that could be done for the child and that I should convey this message to the family and nurses. Still panicking I rang another doctor to see if he could offer any more hope. He suggested that I try a huge dose of steroids to try and clear fluid from the baby’s chest and that he would come and review the child after lunch.

I really couldn’t believe how calm both the doctors were about the nightmare that was unfolding before my eyes and I have to say that I was pretty angry at being left in the position I was. They had of course been exposed to such situations numerous times before; indeed they had witnessed the deaths of many young babies whilst working at the hospital. Most of all I felt so sorry for the baby and its mother. The child should have been in a paediatric ITU bed, being ventilated and instead it was lying in a cot in a dark little room, soaked in warm condensed steam with an ill-fitting oxygen mask on its face. It all just seemed so totally unfair.

That’s one of the biggest problems I had when I was working in Lesotho. So many things just seemed so ridiculously unfair to me. So many of the patients that I saw lived lives that are so immeasurably more difficult than mine it makes me feel ashamed. I felt ashamed that I am part of a world that allows this to happen, that my privileged existence must in some way be responsible for the staggering inequality that stands before me each day.

It was with a mixture of great sadness and some relief that I began to pack my bags to leave Lesotho to make my way back home to London. It was and remains by far the most important thing I’ve ever done in my life and for that I owe a debt of gratitude to God and all the staff and patients that I will never be able to repay.