by Holly Watt
They climbed into the car. ‘Right,’ Kizzie said. ‘And now I will show you the consequences.’
She chucked the zentetra on to the dashboard, and handed round a bag of oranges she had bought from a woman squatting at the side of the track.
‘Let’s go.’ Casey leaned forward, ‘Please.’
‘This is my first day off for months,’ Kizzie said to herself. ‘I can’t believe I’m spending it in the wretched hospital anyway.’
‘Thank you.’
With the car key still in her hand, Kizzie fixed Casey with a stern stare. ‘I’ll take you to the hospital, Casey. But you have to promise me you won’t write anything bad about it. St Agnes caters to some of the poorest women in Zim. We are doing our best, but it is an impossible situation, you understand?’
‘Yes,’ said Casey. ‘I do see that.’
‘Good.’ Kizzie brightened, ‘I’ve told the matrons that I have two visitors coming. Wealthy philanthropists who want to see the work of St Agnes’s Hospital first hand.’ She looked Casey up and down, and laughed. ‘I suppose you’ll have to do.’
36
There was a piece of paper sellotaped roughly to the end of each cot. Each torn page had a rough scrawl: a name and a weight.
Fadziso, 2,156g.
Precious, 1,982g.
Tawana, 1,763g.
The babies were wrapped in unmatched blankets, and they were so small that each cot appeared to hold only a little heap of rags. As Casey watched, the blanket nearest the door began to wriggle, and a small brown arm reached out and up to the ceiling. The baby started to cry, a thin, lonely wail, and then stopped again.
The white cots were less than a foot apart, standing in rows of fifteen. There were dozens of babies in the room, and only one nurse.
‘It is very basic,’ Kizzie had warned them beforehand. ‘It is hard in these hospitals.’
The nurse stepped across to the cracked basin by the door and turned the tap. She made a gesture of frustration.
‘The water must be out again,’ Kizzie murmured. ‘That happens all the time here. She can’t even wash her hands.’
In silence Casey walked slowly down the long corridor. No one asked what she and Zac were doing there, the few doctors and nurses hurrying from room to room, too busy to glance up.
On either side of the corridor, there were five big rooms. Each of the ten rooms had a large window from the corridor, allowing Casey to stare at the rows of small, bewildered babies. The corridor was hot and airless, the half-hearted air conditioning humming away somewhere in the background. Sunlight seared through the external windows into the wards. The floor was a peeling grey linoleum and the paint on the door frames was flaking.
Two incubators were parked in the corridor, and even Casey could tell they were broken, random wires sticking out.
‘The equipment here is rubbish,’ said Kizzie. ‘A few weeks ago, we had twins with jaundice. We put them under a heat lamp. It’s completely standard. The sort of thing you’d do without thinking in the UK. But the lamp malfunctioned … and both the babies burned. They burned and they died.’
Kizzie turned away sharply.
Casey looked through the glass into the second ward. In this room, a doctor had his head bent over a tiny baby, hands moving quickly, precisely. The baby screamed and screamed. In the cots on either side, the babies wriggled miserably, distressed by the howls.
‘A minor procedure,’ said Kizzie. ‘The mothers can’t afford scans, so they don’t pick up congenital disorders until the babies are born.’
‘Where are the mothers?’ Casey asked.
‘They have to stay in the wards downstairs,’ said Kizzie. ‘They’re allowed up every three hours to feed the babies.’ Kizzie made a face. ‘The women have to walk up four flights of stairs to get to their babies, even if they have just had a caesarean section. Then they have to carry those wooden benches into the wards, and sit there, on those hard benches, trying to get the babies to feed. Then they have to carry the benches out, because there’s not enough room otherwise. I’ve tried to get them to change the rules, but … ’
She shrugged.
Halfway down the corridor, a girl – maybe fourteen – was sitting on one of the benches that lined the corridor. She was wearing a rough brown gown, and looked utterly exhausted. The girl had leaned her head back against the glass partition, her eyes closed. Tears were trickling down her face, and her lips moved as if she was praying.
The nurse came out of a ward and muttered a few words. The girl stared at the nurse as if she had been punched, her eyes desperate, pleading: But this is my baby. My baby. Mine. You can’t say that my baby is dead. It cannot be. My baby. How could the world continue to turn if such a thing were true?
The nurse stood there implacably. The girl dropped her head into her hands and started to scream, a rising howl of agony. She rocked to and fro, her fingers tearing at her face, her wails echoing down the corridor.
Moving briskly now, the nurse forced the girl to her feet and marched her along the corridor towards a flight of stairs. The girl could barely walk, doubled over with grief. There was a dark stain on the back of her gown.
If this candle is burning, parents are saying goodbye to their child …
The staircase door slammed, and the babies’ cries filled the air again.
Casey peered into the room that the nurse had just exited. In one corner, there was a row of babies, separate from the rest. A woman was bending over one of the cots, picking up a small covered body. She moved quickly, tenderly.
‘What’s happening to those babies?’ Casey asked.
Kizzie’s eyes were dark. ‘That row of babies … ’
Kizzie stopped. ‘What?’ Casey persisted.
‘If a baby is born in this hospital and he or she weighs less than a thousand grams,’ Kizzie said quietly, ‘there isn’t much we can do here. We make them comfortable, try to let them know they are loved, but … ’
Kizzie folded her arms firmly. Casey stared at the little row of babies, the little row of lives. Tiny babies, left to die.
For a moment, Casey thought of Professor Jalali marching down the corridor in Tooting, looking on death as merely a challenge. Fiercely, ruthlessly, wilfully determined to keep every one of her small patients alive, regardless of the odds. Deploying every known medicine, and commandeering every piece of hugely expensive, impossibly complex equipment in that quest.
Casey thought about the nurse in that London ward, moving in that balletic routine just to wash her hands. As single-minded as Jalali in her focus on protecting her charge, and defending the infant from an unseen enemy. And that nurse in Tooting had been looking after one, maybe two, babies. Not dozens.
In America, they had saved babies weighing less than 300 grams, Casey knew. She looked at the small doomed row, and imagined the mothers trying to feed these tiny babies every three hours. Not knowing they were already condemned. Not knowing it was hopeless. Like trying to hold water in cupped hands, impossible, watching those little lives ebb away. Her throat closed up.
‘Surely there must be something … ’
‘These babies won’t survive here,’ Kizzie said evenly. ‘Not in St Agnes. And even if they made it through these early weeks, they wouldn’t survive life in the extreme poverty of this bit of Harare. We can either throw all our resources at that row of babies, or we can help dozens of children with a real chance of surviving. It is that simple.’
Kizzie spoke firmly, coolly, but Casey saw her eyes flicker. Impossible choices, every day. ‘So they’re all going to die,’ said Casey simply.
‘Yes,’ said Kizzie. ‘They are all going to die.’
Casey turned towards Zac. He had his forearm up against the glass partition to the ward, his forehead leaning on his arm as he peered into the ward. His face was only a couple of inches from the partition, so she couldn’t see his expression. But his fingers were a fist, as if he might punch through the glass.
‘Zac.’
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br /> When he looked towards her, his face was devoid of cynicism for once.
‘What, Casey?’
‘I suppose this is all quite a long way from the Renaissance,’ Casey said pointedly. ‘A long way from the beach bar at Le Morne.’
His eyes sharpened. ‘Yes, Casey Benedict from the Post. It most certainly is.’
But as he moved away down the corridor, his face was still turned towards the rows of tiny babies.
The nurse who had escorted the young girl away was trotting down the corridor towards them. ‘Good morning, Anenyasha,’ Kizzie said brightly. ‘How are things going today?’
Anenyasha was short, with over-plucked eyebrows and a wide face. She was in her forties and she looked shattered.
‘It’s not good, Doctor. It’s not good at all.’
‘What happened to that girl’s baby?’
Anenyasha turned to look into the ward. Her elbows were bent, hands held stiffly in front of her, instinctively trying to minimise the risk of touching anything.
‘That girl’s baby was born late last night,’ the nurse said quietly. ‘The little one fought. She really tried. But it was hopeless. You could see it. And we don’t have … We don’t have anything.’
‘I know,’ said Kizzie. ‘I am sorry, Anenyasha. We are really struggling with infections at the moment.’
‘We are,’ said Anenyasha. ‘I don’t know what we can do any more. I don’t know what … ’
‘We keep trying,’ said Kizzie. ‘It’s all we can do.’
‘But it’s the babies,’ Anenyasha said. ‘The babies are dying.’
37
‘Bacteria are complicated little buggers.’ The three of them had squeezed into a small, shabby office at the end of the ward, and Kizzie was making tea as she spoke. ‘One of the ways bacteria spread antibiotic resistance is by transferring DNA between themselves. That’s called conjugation, and it means that bacteria can pass on resistance to different antibiotics – in the form of DNA or plasmids – to other bacteria. Do you see? Essentially, bacteria can pass on genes. Mutate.’
Casey nodded uncertainly.
‘The plasmid carries the code for blocking antibiotics,’ explained Zac. ‘So for example, you have your Mycobacterium abscessus – the one your beloved sister Flora suffers from – and by conjugation, that bacterium can pick up a plasmid that makes it resistant to, for example, clarithromycin.’
‘I’m sorry to hear about your sister,’ Kizzie said to Casey.
‘I don’t have a sister called Flora.’ Casey glowered at Zac.
‘OK.’ Kizzie rolled her eyes at them.
‘I was seeing quite a thick girl in my first year of medicine,’ Zac reminisced. ‘And back then I explained it by saying, basically, your bacteria can put on a blue coat, and that protects it from, say, vancomycin. And then it can put on a red rain hat, and that protects it from tetracycline. And then it can put on yellow wellingtons, and those protect it from zentetra. And, given the right conditions, at any time it can duplicate the yellow wellingtons or the red rain hat or the blue coat and hand them over to another bacteria to let them do the same thing. Mind you, she flunked out at the end of the first year. God, she was dim.’
‘In so many ways,’ said Casey.
‘The problem now is that in St Agnes,’ Kizzie said hastily, ‘we are seeing a massive rise in resistance to zentetra.’
‘Zentetra is a crucial antibiotic in hospitals all the way around the world,’ Zac explained to Casey. ‘When you’re treating bacterial infections, you have your first-line antibiotics – that’s the first line of defence. Those antibiotics are usually cheap, easy to give to patients, and because they have low toxicity it means there isn’t much in the way of side effects. The amoxicillin we just bought at the market is a typical example. Then you have the second-line antibiotics. Doctors move on to those after the first-line drugs have failed. Then there are third-line antibiotics and lastly, there are the drugs of last resort. The drugs of last resort are precisely as bleak as they sound. After you’ve tried those, there isn’t really anything else left. Those are drugs like colistin. And now we’re even starting to see plasmids that carry colistin resistance.’
‘So bacteria can transfer resistance to these antibiotics between themselves?’ Casey felt as if she was wandering in a fog.
‘Yes,’ Kizzie said with satisfaction.
‘And now you’re seeing resistance to zentetra in the hospitals?’
‘Exactly,’ said Kizzie. ‘And the problem is that the plasmid that carries resistance to zentetra – your yellow wellingtons – seems to be excellent at transferring itself on to other bacteria, and it also blocks a whole range of antibiotics.
‘Like cephalosporins?’ Casey remembered a part of her conversation with Brennan.
‘A bit like that, yes. So suddenly all the diseases that we would have been able to deal with using zentetra are unstoppable. And we dealt with a lot of things with zentetra.’
‘Is it only affecting the babies?’ asked Zac.
‘No.’ Kizzie looked bleak. ‘We had a nurse come down with a bacterial pneumonia last week. It was resistant to everything, including zentetra. We’ve informed the authorities, but … ’
‘What happened to her?’ asked Casey.
A pause. ‘She died.’
‘It’s going viral,’ said Casey quietly.
‘Well,’ Kizzie put on a schoolmarm voice, ‘it’s going bacterial, really.’
In a hospital, thought Casey, which didn’t even have any water. She reached into her bag, pulled out a bottle of hand sanitiser. It seemed puny.
There was a knock and Anenyasha put her head round the door. ‘That man you were asking about, Doctor,’ she whispered. ‘That man is here.’
38
‘He has been coming for weeks now,’ said Kizzie.
They were sitting on the wide old daybeds on the verandah at Kewlake. All around them, the garden was darkening, the shadows swallowing the marigolds, the msasas, the cassias. The drowned magic swirl of a nightjar floated through the trees.
Kizzie had left the office door open as she walked out to meet the man in the long grey corridor of the St Agnes neonatal unit.
‘Can I help you?’ Kizzie spoke in brusque tones, in English not Shona.
‘I’m here to pick up the samples.’ As Anenyasha headed back to her ward, Casey had watched through the hinges of the office door.
The man was slight, forgettable, wearing neat little glasses. Around forty, he had a high forehead and wide cheeks, giving the impression that all his features had gathered together at the centre of his face. His skin was dark brown and his eyes were bloodshot, whether from exhaustion or illness, Casey couldn’t tell. He wore a neat white coat and in one hand, he was carrying a medical cool box, dotted with gaudy stickers.
‘What samples?’ Kizzie demanded.
‘It’s part of the Black Heart Fund’s work.’ The man gave a small smile that didn’t show his teeth.
‘I have not heard of this Black Heart Fund,’ Kizzie said briskly.
‘Everything we do has been approved by the medical director of St Agnes.’ The man allowed himself some hauteur. ‘Thank you for your time, Doctor.’
And with a brisk nod, the man had headed for the double doors at the top of the ward.
‘I don’t know what he wants with those samples,’ said Kizzie now, lighting another candle as a mosquito whined closer.
‘What,’ asked Casey, ‘could he be doing with them?’
‘Who knows?’ Kizzie stretched out her arms, palms turned up. ‘The medical director is off sick, so I can’t check with him easily.’
Kizzie had asked around the ward afterwards. The other doctors were too busy, too exhausted to do more than shrug. One nurse, looking thoughtful, thought the man came every three or four days. ‘He’s interested in samples from the babies with the zentetra-resistant bugs,’ said the nurse. ‘But those bugs are just bouncing from baby to baby anyway at the moment … It’
s a nightmare, the whole thing.’
‘Do you often get people coming on the ward like that?’ Casey asked now.
‘No,’ said Kizzie. ‘Not often. I know St Agnes looks like chaos, but everything has to be signed off, and the matrons are stri-ict,’ she elongated the word, ‘so he must have got permission from somewhere.’
‘So what do we know?’ said Zac. ‘We know that Adsero sent millions of doses of zentetra to a refugee camp in Mozambique during a flooding crisis. And we know that Adsero and the aid workers lost control of the shipment, and that the whole lot probably just disappeared into the black market, and it is still floating around. We’ve seen zentetra for sale on a random stall in Mbare – and that situation is probably being replicated all over this part of Africa – and now there is a major spike in zentetra resistance emerging in Harare.’
‘We are seeing a zentetra-resistant form of several diseases,’ said Kizzie. ‘Which leads to pneumonia and catastrophic damage to the liver in healthy individuals, among other things.’
‘Although these diseases would never normally cause serious infections in a healthy patient,’ added Zac. ‘They usually only cause problems for immunocompromised patients.’
‘Alcoholics,’ Kizzie explained to Casey, ‘Diabetics. CF patients. The very old. Loads of people carry these bacteria anyway. In their mouth, on their skin, in their intestines. It’s when it gets into your bloodstream or lungs that it’s a problem.’
Like Flora’s disease, thought Casey. Just about survivable when it was in her lungs; a killer in the bloodstream.
‘Have you reported it?’
‘We have,’ said Kizzie. ‘But after Covid-19, all they’re interested in is viruses, not antibiotic resistance. Even though we know that antibiotic resistance has the potential to be far worse. And the authorities here … Well … ’
‘They won’t be able to do routine operations anywhere in the world in a few years’ time,’ said Zac bleakly. ‘At the moment, you’re given antibiotics if you have a minor operation on your knee, right? But with antibiotic resistance, we’ll get to the point where any operation would lead to an insuperable risk, like before penicillin. We’ll be going back to the Dark Ages. You’ll have to hop your way through the rest of your life because no one will pick up a scalpel unless it’s life or death.’