Blog 39: Visas, viruses and outreach challenges

Four years ago, in 2016, I started this adventure when as a physiotherapist when I came on the ILO (International Learning Opportunities) program with Wales for Africa to work with children with disabilities. I am now coming back again on the same program as I enter my fifth year of consecutive visits to Lesotho. There hasn’t exactly been a five-year plan, as there have been some unexpected events on the way, but over the course of each visit the physiotherapy and care of children with disabilities has improved at Saint Angela and Phelisanong children’s centres and I am hoping to continue to build on the progress made. 

After battling through the floods of Wales and being kindly dropped off at the airport by the lovely Jean Louis, my next obstacle to continuing this work comes as I stand at Birmingham International trying to check in. 

“Have you got your entry visa?” asks the lady on the desk. 

“No, I’ve never needed one before,” I reply puzzled, “it’s always sorted out for me once I get into Lesotho.” 

“Well it says here you need one in advance,” she replied pointing at her computer screen, “I’ll have to call my supervisor.”   

“Yikes,” I think, as I answer the lady’s questions on where exactly Lesotho is. The supervisor comes over and agrees that the computer screen does say I should have a visa in advance but decides this is only advisory and waves me through. Breathing a sigh of relief, I breeze through Zurich and Johannesburg airports and arrive in Maseru on time. 

Moshoeshoe International airport is a small runway which receives a couple of flights from Johannesburg a day. As I get off the light aircraft and walk over to low grey brick building, it has taken on the appearance of a centre for advanced chemical warfare. A man with hand sanitiser and face mask stands by a plastic barrel with a tap. He squirts my hands with sanitiser and watches suspiciously as I turn on the tap and demonstrate my best NHS hand washing technique. Inside the building all employees are wearing a face mask.   

I get to the check in table and through her mask the lady asks me in a muffled voice if I have an entry visa. “Err no, but I’ve been here lots, of times before without one,” I say hopefully. I see her mentally calculate how many hours/days/weeks of paperwork this potentially may take her to sort out and she waves me through. Relived I get past the next lady with a computer screen who makes a joke through her mask, but I can’t hear what the punch line is.    

Moshoeshoe airport has had a makeover, not only are there two people sitting at desks with computer screens but there is a luggage carousel. The masked baggage attendants chuck the luggage on the floor as usual. Either they haven’t done their carousel training or have decided that two dozen passengers have no need to watch their luggage go around in a circle. 

Outside I meet Veronica, who is visiting Lesotho as head of the Dolen Cymru charity, who have supported me in the past. Dolen also help coordinate the ILO program through Manyayne, who is away this weekend, so Veronica has stepped into the breach. We go straight to the mall to get a sim for my phone. On route Veronica fills me in on the current political situation, which is that the prime minister faces a vote of no confidence tomorrow as he awaits trial for conspiring to murder his x wife with the help of his current wife. I realise how much I have missed Lesotho politics and how boring Brexit has been in the interim since my last visit here. 

We arrive at the mall to find Vodacom has decided to shut at 3pm. Undeterred Veronica kindly offers me her second phone to use, which I politely turn down as it is an android from the stone age and I can’t even see the screen. We go to plan C which is to extract the sim from her android and hope it fits my phone. For some reason we carry out this procedure using a bin as a table top and watch horrified as the sim flicks into the air, does several summersaults and narrowly avoids disappearing down the rubbish hole. Having been saved from trawling through the rubbish to find it, we happily find the sim fits my phone and communication links with the outside world are restored.  

Next a visit to Pick and Pay for some basic supplies and then I transfer from Veronica’s hire car to the optimistically named Perfect Taxis and bump down the potholed roads to Justices guest house, a 5-minute walk from Saint Angela. I am greeted by his lovely mother, who is babysitting, as Justice and his wife Thato are away for the weekend. Restored by a goodnight sleep, I am grateful for a quiet Sunday to catch up with all the admin I need to do to try and start on the front foot on Monday. 

After being a participant on the training program l ran last year Thato has continued to work as the physiotherapy assistant at Saint Angela. As well continuing her training and assessing all the children and sorting out their physiotherapy programs, I am hoping we can launch a physiotherapy outreach program. This will involve visiting the communities the children come from and working with their families to improve the children’s independence and access to facilities at home. 

Disability is not only a factor of the impairment a person has, but the environment, context and attitudes that surround them. While the Lesotho government signed the convention on the rights of persons with disabilities (CRPD) in 2008, as yet it has done nothing practical to support those rights. The CRPD clearly states that limitations on resources is not an excuse to delay implementation and there should be strategies targeting low cost programs. I am hoping that the physiotherapy and outreach program can help the children at Saint Angela claim their rights to equality and independence in Lesotho and work with their families to support and encourage them at home.     

Monday morning starts with catching up with Thato before we go for a meeting to the new head nun at Saint Angela, Mamokojo and the Saint Angela coordinator Mamokhosi. My history of relationships with the nuns at Saint Angela has not been a glorious one. I hope for better things with the present incumbents, certainly some interest and help with the physiotherapy program would be good. Momokojo and Mamokhosi say yes to every request and we are off to a positive start. 

Next to the physiotherapy room where I am immediately distracted by the amount of equipment cluttering the room which used to be stored in the adjoining rooms, which are now being used as accommodation. Happily, we secured 2 unworking toilet blocks to store our equipment, unhappily they are full of junk and dust. A major reorganisation and cleaning program follow. In the midst of this the kids pile into the room and by the time I am out of the toilet block covered in dirt and carrying an obsolete computer, the kids are in a neat row doing high kneeling exercises lead by the head boy Kats. 

A few weeks back I had messaged Thato that we should have a head boy and girl physio helpers and she has already got the kids to choose a boy and a girl. I didn’t know they were leading sessions and I am quite blown away by what I’m seeing and how well the children are doing. It is a magnificent sight and I feel my physiotherapy heart fill with pride in all of them, particularly Kats, who I have known since I first came here. 

At the end of the session Thato tells me that Alex wants to speak to me, another boy I have known since 2016. He has Osteogensis Imperfecta, OI, more commonly known as brittle bone disease. He has the most severe form of it with broken bones badly set, deformed chest and spine, the muscles of legs wasted away dangling useless as he sits in his wheelchair. I have a kaleidoscope of memories of him doing wheelies in his wheelchair when I first met him and my horror of what might happen if he tipped over, demonstrating to me his Taekwondo punches and taking part in the Taekwondo lesson the following year, laughing as he dangled upside down from the therapy stairs, telling jokes, making complicated mecano models with his skilled hands. Anyone that has visited Saint Angela and has met him, will remember him. 

Sitting in his wheelchair I notice he hasn’t joined in the session. He pulls up his sleeve to show me a bone in his forearm sticking out over an inch at his elbow, barely covered by paper thin skin. Then he pulls up his trouser leg to show me a similar situation with his lower leg. Below his knee is actually a Z shape it is so deformed. “He was wondering if we can get anything when we go to town on Wednesday to protect where the bones are sticking out.” Thato interjects.  We discuss options on what this might be as I continue to examine the sickening deformities.

I can’t quite get my head around what I am seeing and revert into physio speak as I wonder how Alex manages to cope with the pain. In physiotherapy we usually try and get objective measures when we assess someone. When dealing with pain we might use a visual analogue scale (VAS). This is a simple scale going from 1 to 10, 10 being top pain. I ask Alex if he can score his pain from 1 to 10, and what activity causes him most pain, he looks at me puzzled. I ask him again, thinking he didn’t understand me “10 would be like me poking your eyes out.” He gives a small smile before replying quietly “It just hurts all the time”

He winces, and I have a glimpse of the constant pain he is in which can never be measured on a VAS. Feeling rather stupid and insensitive I say, “I’ll see what we can find,” having little idea what that might be. The next day I am fiddling with an old back brace, wondering if I can adapt parts of it to help him. I decided to go a talk with him again, he is sitting outside by the chicken shed wearing a large green soft top hat. I examine his arm once more. “I want an operation” he says in a determined voice. “Okay” I say, having no idea how this might happen, who to ask, how it will be paid for, or if his fragile body can cope with a general anaesthetic, such is life in a country without the NHS. 

I add it to the list of things revolving around my head as I go to town with Thato for a meeting and to buy various items we need for the physiotherapy room. When we come out of the mall Thato greets a man and tells me he is a doctor. As they exchange pleasantries my brain ticks over and I smile at him and say, “I wonder if you could help this boy at Saint Angela?” and launch into the Alex story without further ado. I am totally shameless when it comes to taking any opportunity that might assist the kids. 

“Ah no I cannot help, you must go to the ministry of health and they will pay for him to go to Bloemfontein to have this operation, this is why I pay my taxes.” he says. By happy coincidence it turns out I am actually speaking to the former minister of health which is how he knows this information. Thato decides we must go straight to the ministry, which rather alarms me as I have a vision of an endless queue of coughing people trying to get through the door. This nightmare is quickly dispelled as we skip unimpeded through the revolving door and up the stairs. We stop to visit the ladies on route, as surely the best place to use a toilet in Lesotho must be the ministry of health. 

Neither cubicle has any toilet paper and in the cubicle I use the top of the cistern has fallen off. The sink does have an old water bottle with liquid soap in it, but the hand dryer doesn’t work. Still trying to dry my hands on my dress we exit the bathroom and walk into reception. 

“The minister is not here today” says the lady on reception. “Maybe you can help?” I say smiling sweetly “No I am not the minister she replies quickly dismissing my outrageous suggestion. Before she can turn her attention to the coffee her colleague is brewing up, I launch into the Alex story. She looks a little more interested and says we should go and see Dr M. 

“Do you have his contact details” I ask trying not to drum my fingers on the desk. There is a pause while she considers this and then says, “I will call him”. She dials, it rings for a while and she is just about to put the phone down when he picks up. After a short conversation she turns back to us. “He will see you with the boy at 9 o’clock tomorrow.” We walk out of the office and back down the corridor. “Yes!” I say clenching my fist and giving a small arm pump. Its minor triumph but an important first step in hopefully bringing about some improvement in Alex’s suffering.    

The next day we arrive in good time at Saint Angela to find the vehicle has a puncture and the driver must take it to be fixed in Ha Pita. It takes too long for the garage to sort, so we transfer into a taxi and only arrive 10 minutes late at the hospital. Hundreds of people are queueing outside and inside, jammed down every corridor. We get directed to a corridor and a door where our new contact, Dr K is in a meeting, Dr M now being somewhere else. We are pinned against a wall with a woman coughing opposite us and people with various aliments either side.                                         

We decided to use the time to have a catch-up meeting and make a plan of work for the next few months. An hour later, having reached the planning month of June, the door opens. Before it can close again, I get through the gap and establish who Dr K is, make eye contact with him and let him know we are here for our 9 o’clock meeting with Dr M, which is now with him. Looking a bit taken back he says he will be with us after his next meeting. “How long will that take?” I ask “About 15 minutes” he says. Amazingly it only takes 20 and finally the three of us are in a cubical with him. Result! 

He does a though examination of Alex which take over an hour by the time there have been several phone calls and interruptions through the curtain. The bone sticking out of Alex’s elbow is at such a strange angle Dr K wonderer if it could be overgrowth of the lateral condyle. He asks Alex how much pain he is in on a scale of 1 to 10 and Alex once again unable to answer this question. He tries again and Alex decides that presently his level is 4 but goes up to an unbearable 10. Dr K doesn’t know whether it will be possible to operate but agrees Alex should go to Bloemfontein to find out and will try and get him there in the next few weeks.  

While Dr K is on the phone both Thato and I agree we are impressed with him and adopt a joint charm offensive immediately he puts the phone down, suggesting he should come and visit all the children at Saint Angela as soon as possible. By happy coincidence it turns out he first trained as a physiotherapist before deciding to become a doctor. We bond over his physiotherapy past and sympathise with his lament over the lack of physio’s in the country and lack of specialist health care. As there is no medical school in Lesotho most doctors do not return after their training and find richer pickings abroad. 

Dr K is a new breed of young enthusiastic doctors from the county who are returning to do an internship in Lesotho. He would now like to train as an orthopaedic surgeon to help youngsters like Alex. We hope to see more of him and finally leave the hospital at lunchtime and head back to Saint Angela. We got off lightly with only a morning spent at the hospital, with Alex now set to go to Bloemfontein, a potential useful contact established with Dr K and a productive meeting with Thato, its already been a good day. An afternoon of physio and fun with the kids follows and we are all set for our first outreach visit the following morning.  

As it turns our first outreach visit is to Alex’s home, on the outskirts of Maseru. We bump down a badly rutted road and have to park about a hundred and fifty metres above the house. A steep rocky path leads down to a basic brick build and the driver has to tilt Alex right back in his chair to avoid him falling out. When we get to the house there is a small concrete ramp leading to the door, which is too steep and broken for Alex to use. We spend some time trying to work out the logistics of how much concrete it will take to build a ramp that will allow Alex to use the ramp independently. His father turns up and we have a discussion on if we fix the ramp how will Alex get down the 50-degree slope to the long drop toilet. The father says they are going to put in a path, but even if they do it looks like a major engineering project to negotiate the slope safely in a wheelchair. 

We ask to see the toilet, which is a good height for an able-bodied person, but I can’t imagine someone of Alex’s stature being able to reach. The driver gets the wheelchair to the toilet and Alex does an incredible climbing manoeuvre called a mantle shelf, which I would have been proud of back in the day when I was climbing to a reasonable standard. There’s still no way a safe path can be built to the toilet so we revert to the original plan of trying to improve the wheelchair access to the house and then potentially building a toilet opposite which Alex can access. The driver thinks this will take 6 bags of cement and 6 bags of gravel and rough sand. Its looking like a much bigger project than I originally anticipated. 

Exhausted by the discussion we clamber back up the slope to the van where Thato, ever practical, suggests we visit Kats home which is only 10 minutes away. We arrive and find a fairly smooth, level, mud path to the door where we meet his father, mother and grandma who is child minding half a dozen small children on the porch. Initially access seems easier than at Alex’s home, until we realise that Kats has to get to the toilet by crawling about 40 metres down the path, covering in him in dust and mud when it rains and cutting his knees with small stones. The same happens when he has to crawl to get to the road to go to clinic. 

On top of these problems yesterday Kats mum was laid off from the factory where she works. It has closed down due to the coronavirus as they have had to stop importing materials from abroad. Kats father is disabled and hasn’t been able to work for years due to lymphoedema, which he believes is due to a curse from jealous neighbours. The only source of income now coming into the family is the grandmother’s child-minding fees, but this may also be affected by the coronavirus if other factories have to close where her clients work.   

I am used to the complications of working in the community as back home I travel all around North Powys visiting people’s homes. The difference is back in Wales there are whole teams of people and resources to help solve the problems I come across. Here, there is just me and Thato standing in the baking sun and the dark shadow of the coronavirus, whose implications are now reaching out to touch a people already stricken with poverty and the legacy of a much more deadly virus, HIV. Trying not to be crushed by the enormity of the problems we go back to Saint Angela to get Kats to work on improving his upper body strength so that he might, given time, be able to use a walking frame and lift himself off the ground. It’s a metaphor for everything we are trying to achieve here.