KLERKSDORP, SOUTH AFRICA — Klerksdorp, South Africa-- --Before he can tend to the sick, Dr. Ebrahim Variava must make an accounting of the dead.
"Nice way to start the day, hey?" he says, his thin smile fading as he records the causes of five overnight deaths at Tshepong Hospital, where he is chief of internal medicine.
One patient died of heart failure, another of complications from diabetes. Three succumbed to infections after being weakened by AIDS. On average, 20 percent of the people admitted to this hospital die here, the majority of them because of AIDS and the infections it invites.
South Africa, by far the wealthiest country in sub-Saharan Africa, has a health system that is the envy of the continent, with better-trained doctors and more of them, per capita, than any other sub-Saharan nation. And since the end of apartheid in 1994, treatment has unquestionably improved for the long-neglected majority black population.
But the quest to provide quality care to the continent that needs it the most is daunting, as doctors and their patients can see at this well-regarded provincial hospital 100 miles southwest of Johannesburg. It embodies the tensions between a population's acute needs and the painfully finite resources of even the region's most developed country.
Variava and his colleagues treat a community of 1.5 million people. Their task is complicated by shortages of experienced staff and, at times, competence. Though their work is a glimpse of medical care in southern Africa at its best, it shows the large gap between aspirations and reality on a continent wracked by AIDS and malaria as well as a plethora of illnesses common to the poor the world over.
One of Variava's favorite words as he works in the 513-bed hospital is "nightmare." Another is "disaster."
His day begins in his second-floor office with the paperwork recording the five deaths. Downstairs, the hospital's waiting area and hallways are filling with walk-ins. There are dozens of new admissions to the wards. The five-bed intensive care unit is full.
Threading through the crowd, Variava reaches his exam room and meets Engelbertus de Lange and his bad heart.
De Lange is 65, a retired gold miner and, like most whites in this area, an Afrikaner, descended from Dutch settlers who trekked to this land in the 19th century. . During apartheid, he would have gone to the white hospital downtown, with its white doctors and white nurses, part of a system that provided a First World standard of care for the 15 percent of the country's population allowed to use it. Tshepong, a low-slung brick complex built in 1978, was the black hospital, which during apartheid gave a standard of care well below that of whites but still deemed generally good for the Third World.
In 1999, the two hospitals, though five miles apart, merged to form a single 875-bed operation. The walk-in clinic went to Tshepong, in Jouberton, a Klerksdorp township of shacks where blacks had to live during apartheid. De Lange, who during apartheid would probably not have ventured into the township, is seen by Variava, a South African of Indian descent, and black nurses.
De Lange's visit will cost him $3, including X-rays and other tests. He took a seat before dawn and waited 4 1/2 hours to be called.
"I don't know why I cough so much. I cough until I almost faint," de Lange says inside the exam room.
De Lange has been having chest pains. Variava asks him to step onto a treadmill for a stress test. As de Lange takes his first strides, the doctor is already directing his attention elsewhere.
His second patient, Josephine Melato, 65, is scheduled for gall bladder surgery. But the results of her electrocardiogram troubled another of member of the staff, who asked Variava to have a look.
Variava is not a cardiologist, but the Tshepong-Klerksdorp center does not have one on staff. Variava and two other senior internists handle the cases involving hearts and lungs. They also are the designated specialists for kidneys and livers. They also take virtually every other case deemed too complex for the junior physicians.
Melato hoists her considerable girth onto the exam table. Variava sits next to her in front of an ultrasound monitor that allows him to see an echo of a pumping heart and its expanding and contracting chambers and its opening and closing valves.
Her heart is fine, he concludes. Her weight is not. She has "the American sickness," Variava says quietly, holding his arms out from either side. He arches his eyebrows. "Too many of the chains have come here - Kentucky, McDonald's."
He asks a nurse to explain to Melato in the Tswana language - one of four heard in the room that day, along with English, Afrikaans and Xhosa - that she must try to lose weight.
Next patient: Joseph Mashatha, 38, weak heart. Next: Yvonne Modisane, 49, strong heart but advanced breast cancer. Next: Blue Ntlhane, 49, spiffy wingtips, tweed cap, floppy mitral heart valve.