Words and Music, Medical and Other

I am dictating this article on Freedom Day 2019. It is 25 years since my mother-to-be was born, a freedom baby. My due date is May 8th 2019, Election Day. I am likely to come into the world as you are voting. How are you going to vote? Will you vote? Will you think of me?

I won’t have a vote. Nor will about 20 million children in South Africa. I wonder how much you have thought about us as you think about your vote? Because your choice plays a part in determining our future, you should, I think.

I know that it is not so easy to choose how to vote in 2019. I feel my mother’s stress hormones every time she thinks about it. This is on top of the other stresses she feels from money and food worries, violence etc.. We depend quite a bit on government grants and free services to get by. In that way we are not exceptional: more than 60% of South Africa’s children live in very poor households. I feel stressed too.

Vote for me! Vote for us! Not-so-easy, you say. I agree. Let’s think about it.

Not to vote is a cop out: a negative statement of the heart, not a thoughtful action. It won’t help me to grow up in a better environment than my mother did. Don’t abandon hope.

Spoil your vote? Perhaps in a local election as a protest where all the candidates are disasters, but to do it in the national election would be the equivalent of not voting.

Tactical or specific vote? I see these as equivalent (just because I am small, don’t assume that I cannot think). So the next question is ‘heart or head?’. I think you know how I think – it’s heads every time. An emotional vote will increase the chances that either the extremists or the old guard will increase their power – to be avoided! An emotion-led vote is also more likely to be a selfish use of your vote: ‘me and mine’ before ‘country and community’. Even if you are emotional about the difficult lives that so many of South Africa’s children live, you need to turn that into a thoughtful voting response. No cross crosses on Election Day, please!

So let’s think together. How much is your vote for you, and how much is it for others? As a future citizen of South Africa, I urge you to consider the future of all children in South Africa above yourself – and not only your own children, if you are in the minority of well-off South Africans. The median income of South African households is about R1 200 per person per month. Are you in the 50% of people who are below or above this line? Most children are below this line. Look across the line and think.

What would a vote with children (the voteless) in mind look like? It would be one that would increase the likelihood that our best interests would be served. That from conception through infancy, childhood, adolescence and adulthood our physical and emotional development, our resilience, our education, our health and our opportunities (including the disabled among us) would be given the best chances. So very many of us are losing out on these things in 2019. Vote for change. Even, change your vote!

So what would need to change? We need a much less unequal society. There are millions of have-nots who have almost nothing, like my mother. For almost all of us, this is not our fault. Not to vote with this in mind is to recklessly wreck millions of children’s futures – and wreck the country as this situation is a breeding ground for dangerous demagogues and communal violence.

Apart from being an effect of our history, 25 years of crazy levels of inequality (a lot of it led by unemployment) relate to greed and its first cousin, selfishness. Too many ‘haves’ have and hold. Economic growth, even if we had it would not be enough to overcome gross inequality on its own. More must be shared. I don’t think that most ‘haves’ see their having as greed. If you don’t believe that it is, ask the planet (but more of that later). Let’s call it ‘unintended selfishness’, being generous but firm.

Greed also results in persistent inequality via corruption: those who steal and cheat and those who encourage them to do so and benefit thereby. The huge economic toll of grand graft leaves insufficient resources for our many pro-poor policies, including those that could increase youth employment.

That brings me to poor governance. What is the use of progressive laws and policies if, through corruption, weakness and incompetence, their fruits are never tasted? Economic growth, employment prospects and greater equity are strangled at birth. My birth! You might as well strangle me.

(I continue to dictate from the safety of the womb.)

What else needs to change? Almost every aspect of the environment I am to be born into! Pervasive violence and abuse. Only policing it better (I hear a lot about this in election discussions from inside here) will not get at the root causes. Inequality and broken communities need fixing. Who is talking about community mental health interventions? They are not in any party manifesto. It is the same for drugs (including alcohol and nicotine) in my future environment. My mother doesn’t drink or smoke. She doesn’t let anyone who smokes get near me. Thank you, mama! And here we find greed again – tobacco companies and drug barons, for example.

Passing over air pollution, plastic waste and chemical toxins (I wish I could – they are everywhere), I move to a change that will blight my life if it itself is not changed – climate change. My future and that of South Africa’s children is bleak indeed if you don’t vote for change, and change yourself. I’m talking to you ‘haves’ mainly: what you have is unaffordable.

So inequality, unemployment, greed and selfishness, poor governance, our environments and climate change. All needing change if children are to thrive in South Africa. Where will you put your cross?

In choosing a party or a person (even if you vote for another to get what you want i.e. tactical voting), what do I suggest that you look for?

Honest and people-centred leadership (no demagogues in there – that narrows the field!), track record and the spirit of the party or personal manifesto. The manifesto-writing can be clichéd, derivative and trite (unlike my dictation, I hope), but there may be vital positives and negative pointers in them, so have a look – sometimes between the lines. All three of these are unlikely to be found in any one party or candidate, so weigh up the pros and cons of these three essential considerations for your vote.

Mr Smiley’s party manifesto says many things that are good for children and has done many good things for us while in government. They have signally failed on the good governance front in recent times allowing grand theft from the young and our futures, as well as huge slippage through incompetence and greed at municipal level. And Basic Education? Do you think Mr Smiley’s team can change tack and call its troops to order?

One party took the EFFrontery of poverty and inequality and turned it into a form of politics whose radical EFFrontery would have us join Zimbabwe with an economy unable to get off its knees, if their manifesto and shouting is their true intention as a party in government. They say they will give me and all children a tablet to use when I go to school, and many things like that. Mama is thinking of voting for them. Think, mama. Vote for me!

What about the da DA? I like their children-specific claims and aims – first thousand days, early childhood development, education (also found in Mr Smiley’s manifesto) – but I really hesitate at their reactionary health policies. Not child-friendly. Nice energy and climate friendly policies, Mr M. But I worry about your big business links. Is tackling inequality really in your sights. Will your partners (predominantly ‘haves who want to hold’) give you the leeway to improve living wage employment? Better marks for governance (but blotted your copybook with your silly wranglings in the Cape). I might suggest that people give you a thought for local government and be tactical for national.

I can’t give space to all regional, sectional, personality-driven and weirdo parties. (It is nearly time for my sleep). Avoid the religious ones. Mainly use these smaller parties for tactical votes, unless the candidate is a great soul. If you want a flutter and really care about climate change and children and you live in the Western Cape (where they are on the list), you might give the Green Party a nod. Their policies are even more radical than the EFF’s – radicalism is required in this arena. Your votes are meaningless if, by 2030, we all are headed for environmental catastrophe anyway. You can ‘vote for me’ by being decisively green whoever you vote for. Out with coal before I turn 11! Nice to see this sentiment in other manifestos – carbon-free is becoming mainstream in thought. Now for action, those who win on Election Day!

So, please vote on my birthday. A thinking vote. A vote for my future and the future of all South Africa’s 20 million children.

Thanks for reading my manifesto from the womb.

Vote for me! Thank you!

See you soon.

Thembile

Chris Hani 1993. Sri Lanka 2019.

Darkness tries to extinguish Easter light.

Guns blaze, bombs flash,
using light to bring death
                     on Resurrection Day

Hate spits its fire into the Easter dawn;
Hellfire, to burn down pillars of hope;
To bring nation-building crashing down,
To smother hope in the smoke of destruction.

But…..
hope cannot  die
hope will not die 
light cannot be extinguished
light will not be extinguished

Hate, hellfire, destruction, death – all are broken!

This is the victory of Easter
This is the power of Easter

Hold the line.

Where are we headed as humanity? I rather enjoy books that look back, look the present in the eye and look forward. Jared Diamond’s books are a good read, giving pause. Collapse gives climate change a grim context. Alvin Toffler’s Futureshock I read when I was a teenager. I only remember the ‘Mozart on the run’ chapter now: we were playing music at ever faster speeds, he told us.

I have just completed reading Yuval Harari’s Homo Deus, having found it on my son’s bookshelf last year. A fascinating read, the book analyses trends in early 21st century science, thought and especially digital developments. There are twin theses: humans are not special, and we are moving towards a world (a galaxy?) in which humans (merely a set of algorithms) are either unnecessary or a means to an end for silicon – based artificial intelligence (AI) for which consciousness is an optional extra. Harari does not say that this de-humanised future is inevitable; he points to its possibility and implications for the present.

Well, technically it was Delilah in this instance. I was driving to the accompaniment of Delilah (in the form of a Russian mezzo-soprano) singing ‘Mon coeur s’ouvre a ta voix’, from Saint Saens’ opera ‘Samson and Delilah’, with its sinuous descending scale tune. I was enjoying the composer’s wonderful skill and the soprano’s interpretation thereof when it occurred to me that I was hearing it in Saint Saens’ chosen key of D flat major. No suggestion of neighbouring D major. Samson and I were seduced by D flat major all over again.

My father died on October 5th 2016.

Here is the Eulogy I gave at the funeral.

It is, of course, a privilege to be able to deliver a eulogy on my father, Harold Hughie Westwood Esq – I thought that the word ‘eulogy’ was derived from two Greek words, ‘good’ and ‘word’. But as my father would have told me and my daughter did tell me, the ‘eu’ is a prefix rather than a word. So a eulogy. Not a panegyric (another Greek-derived word) because, wonderful as he was, dad was not perfect and, for the sake of old boys of Plumtree school (known as Old Prunitians or OPs), I must not hold back from pointing out just a few imperfections, as he freely would point out theirs. As Roy Jones, ex-pupil and former colleague, has perceptively pointed out, dad was ‘one-of-a-kind’. Yet I wonder if this son of the English Midlands (or the Black Country as he delighted to call it when living in central Africa), if this Oxford graduate in the Greats ( Latin and Ancient Greek) would have developed this unique set of characteristics if Felix had not dragged him from his native soil and planted at him in the tropical sun she sought, on the edge of the Kalahari Desert – the little town of Plumtree

As I think back to dad’s intellect and cleverness, his ability to absorb facts like a sponge and marshal them into squadrons, I can imagine him as an Oxford don with students around him being challenged, affronted and delighted. What he got under the Rhodesian and Zimbabwean sun forced a different response from him, but it was no less challenging, affronting and (from the many comments from OPs over the years and in the days since he died) delightful to the teenage sons of the central African soil among whom he was transplanted.

This brings me to important aspect of HHW’s nature – a lack of ambition. A quiverful of curiosity, but no driving sense of impetus or direction. Do what you do well, yes, – ambition with a small ‘a’ certainly – but the aim is not to get ahead. Hence the 39 years given to where he landed in 1958, what he found there. Bravo, I say! Turn ambition on its head and we have enviable capacity for contentment.

Of course there is another factor in this ‘one-of-a-kind’ equation and that is Felix. With mum behind him and next to him with her energy, her restless energy, his remarkable gifts – verbal, intellectual, creative, imaginative, – saw expression in the Plumtree milieu – plays at school and with the Plumtree Players, play readings, writing playlets and sketches, articles, clever words; producing dozens of musicals turning boys into maidens, ruffians into love-lorn heroes; and the church, the school as a whole, our home that welcomed everybody – so much was done, given – achieved even, but dad would never have accounted these achievements in a notching up kind of way. That wasn’t his style. Ask him to teach French, History to help out – of course and with aplomb. He even coached waterpolo for a term though he’d never learnt to swim!

Harold and Felix, Felix and Harold – yes!, Remarkable, God-given. Immensely appreciated by so many.

Now I’d like to close the doors and bring your Harold and Felix into the home; father, mother, 4 children. Hush the busyness of school life – the bells, the choir practices, house duties, the societies – out please, it’s just us now. Family time.

Dad is reading Robin Hood to Peter for the Nth time, changing the words to side-splitting effect. An audibly vigorous and typical riff-like pat of Honey, the labrador. Oh, but now it is time for the news on the BBC World Service. Oh no, they’ve got their facts wrong again! Dad rubs his hands together, the manual equivalent of grinding his teeth. There will be a letter to the BBC in consequence. Maybe they’ll read it out on air. Once they phoned dad for his viewpoint. Now dad has made a wonderfully fluffy cheese omelette. Come suppertime there will not be a scrap left on his plate, a wartime habit. Dad enjoyed his food to the days before he died.

Now dad has gone into the garden. He is standing next to his dahlias, as tall and upright as he is. Now the mielies – his ‘corn is as high as an elephant’s eye’, as Matthew Silcock was trained to sing in 1968. Next it is to tend his prolific veggies, and inspect his beloved compost. Contentment again, no hurry, no rush. Now there’s a broken teapot lid to be glued – delight indeed. Next a chair needs repair. Etc etc, to quote Henry Olonga in The King and I.

Shift the focus a bit and Harold’s 4 children are married: he has acquired 4 outlaws, two of whom (fittingly) are OPs. Now, to misquote the Pirates of Penzance, comes a train of little laddies – seven grandsons and three granddaughters. I think dad was a little more comfortable with these young people once they were verbal and able to have conversations than when they were at their vigorous noisy preschool age. A particular delight to him came last year when Sarah and Ursula won scholarships that allowed them to follow him to Oxford University, 70 years on. And then this year in pops the tiny Quinn, Alex’s grandchild. Dementia could not dull dad’s connection with this little bundle.

But dementia performed the Benjamin Button act on dad – as it progressed his life connections (apart from direct family) moved backwards. In the difficult final months, Cape Town disappeared, Bulawayo faded, Plumtree’s details grew dim. We find ourselves before Oxford in his last weeks, dad riding his bicycle around central England as in his youth – an explanation for the 89 years achieved by largely sedentary adult, perhaps – and at the end he asked Peter when his father (an undertaken by the way) – when his father was coming. Well, dad, I believe you’re now with your two fathers who art in heaven. Happy thought.

As I draw to a close, some apologies & some thanks.

To all the blithering idiots, morons and cretins who seemed to pepper Plumtree school in dad’s time, my apologies. I remonstrated with him after I encountered a flesh and blood cretin at medical school. To those who sometimes couldn’t get a word in edgeways, I sympathise. He met his match in Joan Suttle! To those whose anecdotes I could not include, apologies, but there will be time enough for those many stories from many people.

Our thanks to many, many people, friends, colleagues, pupils. What a rich life you gave to dad. To Rosedale, who gave Felix and Harold a new community after the dislocation of Zimbabwean refugee-hood. To Ward and Sheila Jones who took them in at the start of that traumatic time. To St Thomas’s Church – another home from home provided. Dr Charlie Miller, consummate family practice and personal care – thank you so much. To the staff at Doordrift Lodge – you knew dad in the most difficult two months of his life. Your professionalism and warm care despite his anger and intolerance is so very much appreciated by the family. Special thanks to the old Prunitians who stayed in contact and supported dad and mum over many years, and have said and written such wonderful things about dad in his last days. To Peter and Caroline and what you have done for dad and mum since illness separated them, and long before: you have demonstrated all the fruits of the Spirit, most especially patience and love. Thank you from all of us. To mum – you were the pole star in dad’s life. He could never have been who he was to all of us without you. 61 years of marriage and the time before that is evidence of an exceptional relationship, not always peaceful – you had to harry Harry at times, didn’t you? – but always deeply committed and generous.

The last words, good words, I give to dad:

My favourites among his many rhymes: new words for ‘Rapture, rapture’ from The Yeomen of the Guard for George Meakin and Johnny Silcock to sing to a delighted Beit Hall: ‘Georgie Porgy quite uncivilly kissed the girls and made them snivelly’. Written in the guestbook of my aunt and uncle, Ursula and Frank Allen, who lived in a hamlet in Scotland called Machrihanish: other spots like acne vanish when you’ve been to Machrihanish.

And to be fair to dad’s character as known to many of us, I read in toto (Latin ablative case, but also his nickname from me for a while, forgotten till I came to write this) – I read in toto one of the letters that made him famous (or infamous) in Rhodesia and Zimbabwe, and lately in Cape Town. The Bulawayo Chronicle eventually refused to publish HHW so he used pseudonyms (another word derived from ancient Greek) but the style was always recognisable. Behold the man:

Your correspondent asserts that the name Africa isn’t African. The Afri lived in what is now Tunisia and the land was called Africa by the Romans, a name which spread as their knowledge of North African spread, as Libya might have if Alexander the Great had lived. Knowledge of the continent halted at the Sahara for centuries. So Asia was a small kingdom in what is now Turkey (Asia Minor), bequeathed to Rome by its ruler Attilus in 133 BC. Africa only existed when the Cape was circumnavigated by Diaz. It was a close thing; the Arabs coming the other way might have called it Kaffiristan, the land of the unbelievers. The Portuguese and Dutch got the word from them.

Continents are oddly named. Europe is named after a Middle Eastern woman who fled west to escape rape. America is named after Amerigo Vespucci, an Italian mapmaker, his name being latinised. Australasia was named the land of the south wind from Auster, the Mediterranean breeze. Antarctica faces the great North Bear. Open bracket – in Greek, arctos – close bracket, full stop.

Harold Westwood

I think that I have done this before: listen in sequence to Chopin’s 24 Preludes for piano while documenting the keys that they sound in. The opportunity came today while listening to Through the Night on the BBC Radio 3 website.

So here we go, starting with the Prelude in C major (if it was):

• C major – solid, no change
• A minor – solid, no change
• G major – ditto
• E minor – ditto
• D major – shifted to E flat major as the opening material re-appears a few bars into this short piece
• B minor – solid, no change
• A major – here this little jewel was set its A major ring
• F# minor – this furious piece had moved into G minor by the end
• E major – was in F major (though with significantly more sonority than I associate with F, a weak key sonically
• C# minor – D minor with a feeling of sharps around
• B major = C major
• G# minor = A minor
• F# major = G major
• E flat minor – moved to E minor half way through
• D flat major (Raindrop) – D major with middle section in D minor rather than the C# minor it is written in
• B flat minor – this wild composition was of uncertain tonality except where a few bars should have been in D flat major and were in D
• A flat major – the song was in A major at the start. At the recapitulation of the tune it sounded in A flat but felt as if it was courting disaster until the last section where it was fully A flat major – perhaps the effect of the pedal low A flats in the left hand
• F minor – no key identifiable
• E flat major – largely undefined but occasionally the colour of E flat was discernible. It did end in E flat.
• C minor – solid chords of C minor
• B flat major – in key including the G flat major section
• G minor – the first note of this Prelude is the B flat of the previous Prelude, so heard in sequence this was grounded in its flat key
• F major – no threat
• D minor – indeed, ending with 2 powerful Ds at the bottom of the piano.

I wonder how this compares to my previous exercise with these Preludes (heard on an aeroplane flight, I seem to remember)?

A minor second is the musical term for the two notes that are next to each other on the 12 note ‘chromatic’ scale. The descriptions in this series of posts are of the changes I am experiencing as my auditory apparatus and my brain are moving all my hearing of music up a minor second – or a semitone, the term I have used in these posts till now.

My use of the term ‘minor second’ in this post represents my marking of a significant milestone in this journey. The odl note is gone; the new note one step up has taken over. Colonised first and now wiped out the original inhabitant. Genocide.

In the last month or two, a majority of pieces in my weak keys (those that have been most prone to the gradual change I have been describing)  now start out in the new key, a minor second up from their written key. There is now no equivocation, no variation. From the first note or chord, the pieces are in their new key and there they remain. The first piece to do this, I noted, was Elgar’s Salut d’Amor. F major instead of the E major he chose as the key of love for his wife. E major has been in the vanguard of these changes, but is no longer alone in being a ‘lost’ key.

Yet all is not lost. It will be lost, but it is not yet. Yesterday I started listening to the Finale of Dvorak’s New World Symphony half way through. The recapitulation of the slow second subject on the celli was in F major. It should have been in E major, but I was not surprised at how I heard it. Yet when Dvorak had returned to E minor, the symphony’s key, in the Coda, I heard it as E minor. TO end the symphony he switches from the minor to the major. E major stuck till the end of the movement – a feature i have noted before, and has not (yet) changed.

By chance the next piece on the FMR playlist was a Mozart aria from Don Giovanni. The soprano sang brilliantly in E major. But I knew that she was cheating – well, she wasn’t, my brain was: Mozart wrote it in E flat major. This borrowed E major I don’t want. It is a minor second fake.

A wonderful Welsh tune used not only for Alleluia, Sing to Jesus.

These B flat trumpet parts are moderately difficult. The descant is Betty Pulkingham’s.

Alleluia sing to Jesus – Trumpet Alleluia sing to Jesus – Trumpet Alleluia sing to Jesus – Trumpet

This is talk I gave to the Department of Paediatrics at the University of Cape Town last year as part of a series in which we grapple with issues of transformation in South Africa, in the university and in our department.

Now it’s typical, isn’t it? You have hardly started a transformation process to deal with the current consequences and sequelae of past injustices predicated on race and in muscles a white male, whose voice he feels, must be heard. Given half a chance he will probably use his assumed centuries of privilege to start telling you what to do.

How this came about – the justification, if required – is either offensive to all or a reasonable part of the process that is within the aims of our departmental initiative. I perceived that, as with South African society in general, a certain amount of the response to the initiation of the Transformation process had gone off screen. A sense of threat and hurt was being expressed by some of those the process has identified as beneficiaries of that past injustice. So as a previously and currently advantaged white male, I asked the Transformation Committee if I could join the Voices programme. An additional motivation was that I had been having a personal eye-to-eye with Cecil John Rhodes and his legacy, and the long legacy he now represents for a couple of years before the shit hit the statue. I had been turning “all Rhodes lead to“ into a musical as part of that engagement with what that means for me. So here we are….Speaking for myself, and no-one else.

Power & privilege – shorthand and proxy for Race in this context. I plan to face that squarely while acknowledging (as we as a Department have agreed) that it cannot be the only item of the Transformation agenda. Race itself is a proxy for so many aspects of Power & Privilege that I will acknowledge its value as shorthand in this talk, and hope that others will understand this reasoning, uncomfortable though it be.

Power & Privilege – Not so far from Pride and Prejudice.

This talk could be ‘Power and privilege, but….’ – an attempted justification for who and where I am.

Or, ‘Power and privilege, how you see me’ – but then there is no point in me being the Voice.

Approaching this task/opportunity/responsibility, I decided the following:

It will be ‘Power & Privilege, so……’. I will describe my P&P – probably revealing my Pride & Prejudices on the way – and explore the implications.

I have made the following additional decisions in approaching this task:

My past has bequeathed me the power of a very large vocabulary and a word-smithing gift in a language that has a massive hegemonic impact. Rhodes recognised this as one basis for his broad planet-annexing vision for England. The dangers of manipulating with, confusing with, hiding behind such facility I saw as real; the danger of falsity, of not being myself if I changed language persona to a group of colleagues I also recognised. So I decided to be who I am while staying aware of the dangers; language is powerful and it can shut people down or out.

The irony in my first paragraph today will not recur. Ironic humour is a standard means of messaging in my culture, but its capacity to be mis-directed and misunderstood is so great that I have not allowed it breath.

The other decision was to pronounce the word British as Breeteesh. This is Robert Mugabe’s pronunciation of the word. I use it here not to ridicule him (he’s arguably also one of Rhodes’s legatees), but to give voice to the troubled context of my charmed journey in life. The parallel voice in today’s Voices input.

In this talk, Rhodes is sometimes a shorthand for British imperialism or white supremacy. Context should tell you when I’m referring to the man.

I also need to express an anticipatory apology for unintended hurt, heavy-footedness, and offence that I may cause. Transformation talk takes us into awkward territory; often unspoken but deeply felt shoals lurk in the waters. Words spark fires, as St James tells us; the Bee Gees bleated that ‘it’s only words’. Oh, no it is not!

Generally my writing tone tends to lightness; please do not mistake that for lack of application or seriousness. So here we go: Westwood through Rhodes-tinted spectacles.

Ulodzi! – That’s the working name of the musical – was going to end with Cecil John Rhodes dying under a hot tin roof in his hut in Muizenburg, Dr Jameson at his side. We hear the arrhythmic beating of his failing heart. In comes a young Sol Plaatje – he who chronicled the devastation wrought to indigenous African peoples by the 1913 Land Act. He starts to dance around the deathbed. Gradually in the band the rhythm of Cecil John Rhodes’ irregular Sino-atrial node is taken over by the young beating rhythms of Africa. Sol spins. Sol stamps. Sol shouts. The drumming rhythms rise, Rhodes dies, the roof opens up to high blue African skies. Africa’s rhythm is now the only rhythm. It spreads from the south-western tip of the continent. Rhodes has died! Africa lives! Long live Africa.

But it doesn’t, couldn’t end like that, or not yet. Here’s a hypothesis: I am living proof of that.

I am not going to try to disprove or prove that hypothesis today. I’m going to explore the questions that the British Rhodes and Boralong Sol Plaatje are asking me.

I’m nearly 60. Career-wise, a late phase. A senior paediatrician, nationally, provincially, academically. An inevitable look back: a view sharpened and refined, re-calibrated by the Transformation imperative. The retrospection will be followed by a current situation analysis, then a look forward.

Marc has read you my potted biography. I will plot the “favouring gale” that has “wafted” me “to a height that few can scale”, to quote Gilbert and Sullivan’s Lord High Executioner. Yes, I have flapped my wings but all the time under those wings were warm breezes, most but not all breathed by British imperialism and Rhodes.

My maternal grandfather’s Indian Army background, through Imperial contacts, facilitated my parents leaving British mainland (as Rhodes had intended people like them to do) to join colonial society in central Africa. The thing sought by my parents was sunshine and Central Africa, bought and fought for by Rhodes, had that. Inevitably my parents got so much more. Part of the design. Tony was the next generation of colonial society; colonial formal education (with pictures of the Founder in the Alfred Beit-endowed school hall) gave him the edge. It did by a good margin. He got one of the places reserved for Rhodesians (white Rhodesians) at UCT Medical School; apartheid South Africa opened its arms to its presumptive ally – me.

Dr Tony returns to Bulawayo in 1980 as an intern just as Zimbabwe was born. Down with the British; replace with the Zimbabwe flag. Rhodes’ statue in Main Street moves to the museum. But Rhodes is still there for me. I want to be a paediatrician; my wife is from Cape Town (she is classified white). It is so easy for me to come to better myself. We don’t see UDF marches and witdoeke as an impediment; the chances are that I will be safe. Anyway, I am only coming for higher training. Then we will return.

Some wonderfully generous zephyrs within the Department of Paediatrics UCT give me great learning opportunities, despite my colonial persona. Thank you.

Making economic decisions I see being made by young parents of all stripes even today, Jean and I put our children’s education ahead of our African contribution in Zimbabwe (good schools in southern suburbs, can’t afford the “good” ones in Bulawayo on an early 1990s Zimbabwe public doctors salary). I become an economic migrant.

Next thing Mr Rhodes turns up again. I’m offered a paediatrician post at this hospital. Recruitment: “Won’t you come to my office?” Interview: “Would you like this job?” Selection: “May I think about it, but yes please”.

If it is very important for me to say that I’m not biting the hand that fed me. In the decision some of us make, Mr Rhodes is much more present than we may think he is. My recognised merits are not all of my own making. Their expression has been facilitated by history. And that has continued to the present. Our children are beneficiaries of the continuing influence of this history.

Before I can assess the present, I have to go back again. I have had a parallel education that was certainly not typical 1960s/70s Rhodesian or colonial. Through the church we met and socialised with black Africans in our home, not a Rhodesian standard. We would never have been allowed to use the epithets others use so freely and intently to demean members of indigenous communities. Trevor Huddleston’s “Naught for your Comfort” was on my mother’s reading list for me. People tried to get my father to stand for Parliament in opposition Ian Smith’s Rhodesian front. But Doris Lessing-like radicalism was not to be found there. Nor here now.

Anglican connections when I was an undergraduate at UCT continued this attitudinal training. I demonstrated on Jammie steps – vaguely aware that Jameson had raided something at some time. (Sorry, irony crept in, but at least it was aimed at myself). In the late 1970s, my letters home were addressed to Zimbabwe. So I was ready in 1980, I thought, to be part of that country’s formal African life. Working in Zimbabwe under black consultants from there and from across Africa was formative, probably more subtly, re-formative. As was the first phase of white returnees and British doctors who were definitely not Breeteesh coming to a free Zimbabwe.

I’m going to telescope the last 20+ years in South Africa into the present. This is an acknowledgement of the limited change for many, many in South Africa and unfinished business that the Rhodes Must Fall movement is highlighting; and a tacit statement that I too may have been marking time in some important ways.

So, to now, the present. I’ve asked myself a few questions. Mr Rhodes and Mr Plaatje I’m hoping to silence. I stand alone.

Am I a racist? I cannot assume that I am not. Am I a sexist? I cannot assume that. I am an not. Elitist? Myopically class conscious? I know that my upbringing in colonial and Apartheid central and southern Africa have made me an agile classifier, and hard on the heels of that, unless I’m very careful, is a stratifier. In there are the seeds of prejudices if given any quarter. So I have little doubt that there would have been not a few actions, omissions, assumptions along the way that would demonstrate prejudicial discriminatory-isms. Pervasive? I trust not, but here’s a story within our department that may illustrate some of the things I need to think about. In synch with the overall theme, I call it ‘Ralph and me’. When I was a registrar here pre-1994, I used to see Ralph coming to Respiratory Clinic for his session. So friendly but his anger at Apartheid’s bitter consequences was palpable to me. Later I went on outreach to Worcester where he was the sole paediatrician. So welcoming. Later still I was part of the interview panel for the post he took up under me in Ambulatory Paediatrics. My partner and colleague. After I left Red Cross and he stepped into the senior role, there was one issue regarding service provision that we found that we did not agree on. When I look back with Rhodes-tinted spectacles, I see two things: I may well have behaved like a supremacist, not giving quarter just because I’d been around longer and felt a right to my wisdom and authority. I also know for a fact that I did not engage at the right level because I was not certain that the things that Rhodes has given me would not poison the atmosphere. What right had I, who the system had favoured, to confront someone who had had a harder journey to where he was? What would happen to us if I did push through? I let things drift. I do not know what Ralph felt about our differences on that issue (and we only crossed swords on that one), but I cannot impute to him anything I have found in myself.

Second question. Am I an African? Some may see it as an H word, hubris. How can I a white person from Breetain answer that question? Others would see it as a long-since answered question that it is foolish to bring up. I consider that I can and must answer that question (with its resonances and sub-questions) myself if I am to be a prepared and thoughtful part of our shared re-designed future. But I have – with the opposite H word, humility – to put myself through a number of tests, and I believe that I am. Perhaps a superficial example. Can I love the music of Gustav Mahler (who probably never gave the needs of Africa a thought while the king of the Belgian was raping the Congo Free State) while not being able to name a Kwaito star and call myself an African? It depends how that love for Mahler is expressed. To adapt St Paul: if I give all my money to the Cape Philharmonic Orchestra but have not Africa in my heart, I am but a sounding gong and clashing cymbal. In other less poetic words, being an African in Africa is about a deep commitment to the people and continent, I believe. “Je suis Africain” I stated to a group of French MPs who visited Somerset Hospital under the auspices of Kidzpositive. I had restitution by a colonial power in mind. Was I a hubristic poseur? A self-deluding Romantic? Do I, like Shakespeare’s Portia, “protest too much”? Can the same words come out of Africanist Thabo Mbeki’s mouth and mine? I believe so.

“Words, words, words! I’m so sick of Words!” sang Eliza Doolittle. “Show me!” And that’s where I move from present to future. In looking forward I must not assume that because, in the new South Africa, I work for and with largely poor and needy children in the public sector as a white South African that this cancels out or assuages the consequences of my privileged past. If I think that, I am undertaking an accounting exercise. My medical, academic and policy-related work is or can be part of the post Rhodes and Race R-words – restitution, reparation, redemption of the past (Michael Lapsley’s phrase), redress, re-distribution. But those R words must walk the corridors with me; they must go home with me; they must pervade my choices (he who has been bequeathed choices in almost every sphere of his life). Choices in what I do with ‘my’ time, ‘my’ money must also be guided to a significant extent by those R words. Most of those “my’s” have been bought with a price. White guilt? White reality. White liberation, I would say. Our shared future demands these responses of me, work and play.

Here’s an example: I am both discouraged and angered that our government granted an unaffordable pay increase to civil servants. I further regret that the obvious re-distributive and restitutive step of giving smaller increases to people at the top (like me) has never been taken. What I can do is to take that tainted gain (and any other such gains, financial, skills and other – present and those stretching into my pre-history) and plough it and them personally into reparation and redress.

So I hope to be guided by some words in thinking this through and acting.

H words: Hubris – out. Humility – in. The other silent H word, honesty – with myself and with colleagues and friends and everyone!

R words. I won’t spell them out again, but they all begin with R and E, thanks to the way the English language works.

The academic in me is screaming at this point because I have not had time to construct a neat ending to this talk. But this is probably just as well.

R is for Raw. So let me leave a raw, ragged and bleeding end to my Rhodes and Me talk. It may be a fitting metaphor.

Thank you.

INTRODUCTION

The subject for discussion

Is the little child who vomits,

Who throws up all her food with the

Trajectory of comets.

But first we must distinguish,

As you’re sure to come across it,

The differences between this and

The gently brought up posset.

The child who only possets

Never puts you in a spin

For she deposits but a drop

Or two upon her chin.

The vomiter however is

A child you can’t ignore

As her most recent meal ends up

Upon the kitchen floor.

A posseter you reassure;

A vomiter – find out more.

Why do children vomit?

Well, like you and me,

When the stimulus is there

It’s a reflex, don’t you see?

Signals from the gut

Or deep within the brain

Go to the medulla

To initiate a chain

Of events that are directed

By a centre that is known

By the sweet nonscanning title of

Chemo-emetic trigger zone.

What follows? Need I tell it?

The stomach will expel it.

It’s vital to remember that,

Like fits or halitosis,

                                    Vomiting’s a symptom and

                                    Is not a diagnosis.

I’ll say it once again

Though it might induce hypnosis:

                                    Vomiting’s a symptom and

                                    Is not a diagnosis.

So don’t be tempted just to give

The mother’s head a pat

And dose the kid with Stemetil

Or nostrums such as that.

A CLINICAL APPROACH

A good history and examining

Will help you find the pieces

That fit together giving you

The cause of the emesis.

Thus a clinical approach will in all

Cases give the answer

Which may vary from a sore throat to

A cerebellar cancer.

Yes, causes may be minor

Like an earache or a cold

But miss a mass within the brain

And there’ll be strife untold.

The most helpful thing to aid you

As you search to find the reason

Is the age at which the child

NEONATE                Has now presented. In the season

Of the first week of the neonate

What they swallow during labour

Gastric                        May cause some irritation and

irritation                      Get tossed out like a caber.

Liquor, blood, meconium

Upset the stomach lining

And make the baby puke

And vomit after dining.

Feeding                       Also difficulties feeding may

problems                     Upset the infant gut.

These symptoms usually settle and

The baby then thrives, but

Don’t forget that in this period when

The baby very light is

Infections                     She’s prone to get infections:

Septicaemia, meningitis.

Here the septic babe

May cry too much or go

Too quiet and apathetic,

Her temp is high or low.

Should these things occur,

Then you must be quick

To do your cultures and begin

An antibiotic.

Congenital                   Also at this time the gut is

gut                               New and is untried

anomalies                    And there may be an atresia or

Stenosis deep inside.

Many’s the congenital

Obstruction that may show

Soon after birth with vomiting.

So don’t be slow

To think of duodenal or other atres-

ia, meconium ileus or Hirschsprung’s disease.

If you’re in a bind

And just can’t find

Which part of the babe the trouble is in

There’s a chance it may

Be the DNA:

An inborn error of metabolism.

So at the end of the list

And not to be missed

Some rare faults exist

For the biochemist

Such as hyperammonaemia

Where blood ammonia’s high

And, if treatment isn’t given,

The baby may well die.

EARLY                      Vomiting’s a common symptom in the

INFANCY                 First few months of life

And it causes much alarm to many a

Mother or a wife.

Feeding                       Commonly it’s met where feeding

problems                     Isn’t going well.

The baby’s swallowing air and is

Creating merry hell.

She eructates or burps

And the milk returns at speed.

The whole thing is repeated then

With each and every feed.

Or perhaps the hole that’s in the teat

Is made too big and wide;

Gulped air and milk distend her gut –

She can’t keep them inside.

Thus careful note you need to make

Of mum’s technique of feeding

So you can find the faults and change

Disaster to succeeding.

GOR                            Quite common too is GOR,

That’s gastro-oesophageal

Reflux where the babe returns

A portion of each meal.

She brings her milk up with no strain,

Of bile there’s not a trace,

But on the carpet there’s a stain;

Despair is in mum’s face.

But your job is to reassure.

“She’ll grow out of it”, you say

But check first that she’s growing well

And that her chest’s OK.

For reflux may result in a

Failure to gain weight

And, in others, food’s return

May make them aspirate.

A variation on this theme

Of GOR is seen when haem-

atemesis gives mum a fright. This

Brings to light oesophagitis:

Acid burn of the gullet

Needs antacid to dull it.

Infections                     Also you will often see

An infant with otitis me-

dia, the common cold or such

Presenting ‘cos she vomits much.

Infections present commonly

                                    With vomiting in infancy.

This aphorism’s worth repeating

Over and over if kids you’re treating:

Infections present commonly

                                    With vomiting in infancy.

Always thus you must consider

Maybe bugs will give a kid a

Gastro or a meningitis,

Chest infection, hepatitis.

Don’t forget the UTI

Lurking unsuspected by

Those not versed in little tricks,

Eg. the using of dipstix.

These causes – feeding, GOR, infection

Are the commonest in this section

Less common but now needing introduction

Intestinal                      Are some syndromes of intestinal obstruction.

Obstruction

Firstly and most common is a

Major diagnosis:

That’s infantile hypertrophic

                                    pyloric stenosis.

The cause of this phenomenon,

The pundits now assure us

Is that nitric oxide synthetase is

Low in the pylorus.

This is four times commoner

In boys than little girls.

It can run in a family. The

Firstborn often hurls

His milk across the room in

A projectile fashion.

It’s sudden and complete – he

Then wants his next ration.

The vomiting is not always projectile,

Don’t be caught,

But it occurs soon after feeds;

His mother’s overwrought.

The baby doesn’t thrive, he

May go slightly yellow

And it is quite obvious he’s a

Hungry little fellow.

The clue, apart from hist’ry, you will

Find if you can feel

A round mass, olive-shaped, as the

Baby takes a meal.

Here is how

To do it now:

The baby feeds on mother’s breast, re-

laxed (there is no hustle).

You gently get you fingers to the

Right of rectus muscle.

You’ll feel it then. Your eye may catch, as

It so smoothly pulses

Across the epigastrium, the

Gastric peristalsis.

The other helpful clue to

Make the diagnosis

Is a hypochloraemic hypokalaemic

Metabolic alkalosis:

For –

Although he’s dehydrated, it’s

Acid that he’s lost

And trying to correct, potassium into

Cells has crossed.

The diagnosis is confirmed with

Ultrasound or barium

And with a pyloromyotomy you’ll

Get your honorarium.

The name of the operation I’ll repeat now

Nice and slowly:

You cut the muscle lengthways –

Pyloromyotomy.

OLDER

INFANTS                  In older infants it’s the in-

fections that are major

Infections                     Causes of the vomiting in

Children at this stage. A

Child of this age also tends to

Pick things up and swallow

Poisoning                    All sorts of things that do no good.

Emesis may well follow.

A tablet, insect, leaves and sticks

Enter the oral cavity

So think of poison when she throws up,

Defying gravity.

Rumination                  The ruminator brings it up in

to his mouth, rechews it,

Swallows it again or, at

Times, will choose to spew it.

This can be normal but may show a

Child who’s life is boring;

Who’s parents do not stimulate or

Actively ignore him.

Stress                           Likewise the infant who has had an

Early life of tension

At times of stress may make a mess;

Vomits to get attention.

If you have been sleeping

Please wake up and listen

As I introduce

Some important conditions.

Concentrate now! Do not doze

As words of wisdom I propose:

Surgical                       In the first two years there occurs

causes                          A vomit which the surgeon

Would maintain is his terrain.

One is an emergen-

cy, the midgut volvulus.

Here there will exist

A malrotation of the gut which

Gets into a twist.

The circulation to the bowel is

Compromised and should

This state continue long that

Bowel will be no good.

The child with this will vomit bile, goes

In and out of shock, but

Distension’s rare, the stomach’s soft, not

Much to point to rotgut.

To diagnose the midgut volvulus

Make it certain that

A child who brings up bile must have a

Barium meal and that stat.

To be complete,

I must repeat:

To diagnose the midgut volvulus

Make it certain that

A child who brings up bile must have a

Barium meal and that stat.

The other thing that’s surgical and

Vomits at inception

Is telescoping of the bowel that’s

Called intussusception.

This occurs at many sites, is

Often ileocolic.

The baby has a bloody stool and

Pain that’s diabolic.

These times of pain are episodes of

Gut contraction when

Ischaemia is occurring at the

Site of obstruction.

Apart from the history and the

Pain, the sign you try to find

Is a sausage-shaped abdominal lump

Either ill- or well-defined.

The management, I’ll briefly say, is

To attempt reduction,

Under X-ray control,

with careful introduction

Of air under pressure

In the colon with a pump:

And with a bit of luck

You’ll get rid of the lump.

Should this fail

It will entail

A surgeon’s knife

To end the strife.

Please make it a rule – if

Money you would earn – you

Must never, never miss an in-

                                    carcerated hernia.

You’ll be alright

If in each mite

You carefully check

Each hernial site.

CHILDHOOD           The older child she vomits less. The

Causes are not many.

Once more infections dominate and

Basically are any.

Infections                     Some are less than obvious, re-

quire a little looking

To find the underlying germ, to

Ascertain what’s cooking.

Examples here are hepatitis

That is anicteric

And once again the UTI. And

Then there’s mesenteric

Adenitis that presents with

Pain that on the right is,

Similar to that found in

Acute appendicitis.

Binges                         Don’t forget that little kids are

Greedy little devils

And often bring up after being at

Birthday party revels.

Poisoning                    Now, to those children with a fixation that is oral,

                                    Here are some statements; each one with a moral:

The child that reaches for green peaches

Learns the lesson that this teaches.

Likewise she who chews dad’s pills

May go green about the gills.

Nausea and vomits follow

Kids who sundry poisons swallow.

Raised                         A group we must not fail to mention

ICP                              Have intracranial hypertension.

Infections, tumours – all may cause a

Puke with no preceding nausea.

So always probe for symptoms that

Point to trouble ‘neath the hat.

Headache, squint, a change in form, a

Fit, ataxia or head trauma.

Cyclical                       Now, cyclical vomiting. I’ll

vomiting                      Try to give you a notion of it:

A child who’s well will, like hell,

Suddenly, profusely vomit.

She may get so dry

She may need I

V for rehydration

Yet in a day or so

She’ll want to go

Back to school and her education.

She’s well again, as right as rain

Yet she will be back

Puking like a drain, sunken-eyed again

In the midst of another attack.

The reason why this happens

I wish I could explain

But we know the child may go

On to suffer from migraine.

The recurrent nature of these bouts,

The rude health in between

Should rule out most of your doubts

And keep tests to the routine.

Psycho–                       Some problems with the psyche

logical                         And certain states of mind

problems                     May make a child quite likely

To vomit be inclined.

A sight, a smell, excitement, joy,

The fear of a needle’s prick

May make a little girl or boy

Quite literally sick.

If an older child comes with vomiting

And the reason seems something of a poser

Just take note

Of the finger in the throat:

It’s a case of anorexia nervosa.

I’ll go on now we’ve been through

Causes and ages

And take a trip through all the

Clinical stages.

HISTORY                  History first. We want to know

More about the vomiting so

Quantity                      We ask a few questions. Quantity first.

Is it enough to cause a thirst?

Does it dehydrate the child?

Is this major or only mild?

What proportion of each feed

Is returned and at what speed?

Character                    We’ve partly discussed this –

Projectile or posset?

Is it forceful or with ease

That she manages to toss it?

Contents                      And what’s in the stomach contents as they’re

Ejected or released?

Is it bile or blood or old food or what re-

mains of her last feast?

If blood, think first it’s swallowed

Eg. when a nipple cracks. This

Is like the older child who

Has an epistaxis.

But, as in older folk,

Vomiting blood may be no joke.

It may be from burst varices

Or bleeding peptic ulcer disease.

The presence of a green tint, bile,

Should make you think obstruction;

It may be paralytic il-

eus – needs drip and suction.

But it could be mechanical

Below ampulla of Vater

Where surgery is called for and

Medicine’s a non-starter.

Associated                   Nausea we’ve discussed. It’s

symptoms                    Presence is suggestive

Of trouble that relates to part

Of the tract digestive.

In its absence, don’t be dull —

Think of trouble in the skull.

Associated symptoms

You need to find to sew up

The underlying cause that

Makes a little child throw up.

Diarrhoea would suggest the

Cause is enteritis.

Fever, stiff neck, crying point to

Likely meningitis.

A little trick- if a child is sick

As each new day is dawning

She may be in the grip of a postnasal drip

With a gut full of snot every morning

EXAMINATION      Examination. There are two

Questions to select:

One: what caused the vomiting? and

Two: what’s its effect?

Hydration                    Two first: Check the child for the de-

and                              gree of dehydration.

nutrition                       Is she still well nourished or

Showing emaciation?

A weak child may be short of

Ions: potassium, sodium, chloride

And may need their replacement intra-

venously supplied.

General                       Examination takes the form that

You’ve been taught so well:

All systems of the body may

Have a tale to tell.

Jaundice – that’s the liver;

Fever – that’s a bug;

Neonate, distension that could

Be meconium plug.

Abdomen                     The abdomen’s the focus of your

Int’rest like as not.

Can you palpate an organ?

Is there a tender spot?

Gaseous distension an

Obstruction would suggest

And peristalsis you can see will

Help you in your quest.

Don’t forget the rectal – it can

Help you when one sees

A low intussusception or per-

haps Hirschsprung’s disease.

Other                           Don’t ignore the ENT,

systems                        Otitis you may miss

But I can’t talk of everything in a

Paper such as this.

SPECIAL                  Investigations are dictated very

TESTS                       Much by what you find

But here are some remarks which you

Ought to keep in mind.

Always test the urine; Acid–

Base if weak or dry

Along with the electrolytes which

May be low or high.

X-rays may be plain or contrast,

Use mainly in obstruction –

Barium can go in the top or by

Rectal introduction.

Ultrasound has got a place for

Seeking out of masses

That may cause copious vomiting in

Little lads and lasses.

These days its use for intussus-

ception or pyloric

Stenosis, GOR is nothing

Short of meteoric.

Other tests you order will re-

late to your conclusion

As to where you think the trouble is – of

These there’s a profusion.

But all in all our main help is

                                    Always to be found

                                    When hist’ry and examination

                                    Are complete and sound.

Now remember at the start

Of this great work of art

A sentence that I’d like you

To learn off by heart.

Open your eyes

And lift that drooping ptosis:

Vomiting’s a symptom and is

                                    NOT a diagnosis.

TREATMENT          So – Management is One: General (re-

plenish body stores

of fluid and electrolytes);

Two: Specific (treat the cause).

Just one more thing: resist the urge,

Though mother may be keen,

To stop the kiddy’s vomit with a

Phenothiazine,

For Stemetil or Valoid

Are toxic to a baby

Or child and could produce a

Dyskinesia maybe.

So treat the cause and you will win

And baby’ll keep her dinner in.

So ends this thesis

On childhood emesis.