Mandela's Last Years: In the bleak midwinter

Mandela's Last Years by Vejay Ramlakan

Published by Penguin Random House

R230

It was before dawn on the wintry morning of Saturday 8 June when I sent an SMS to Mac Maharaj containing a draft press statement about Mandela’s admission to Mediclinic Heart Hospital. It ended with the words ‘He remains in a serious condition.’

South Africa and the world woke to this news that surprised even Mandela’s close family members. My focus, however, was on our patient. Some serious abnormality had caused Madiba to stop breathing that night. Over the past few days, he had oscillated between being okay and being sick. The incident had taken us all by surprise. What had happened?

Mandela was again on the second floor of the hospital, which had been cleared to provide accommodation for nursing staff, sleeping quarters for Mrs Machel, space for family meetings, a rest area for the medical team, a dining room, a ‘duty room’ for the police and space for meetings with VVIPs. The ward normally catered for twenty-two intensive-care patients.

By now Madiba was reasonably stable clinically. In short order, he was X-rayed and his heart and other organs checked. From our investigations, we could see that there were signs of blockages in his respiratory tract. But this was not all. He also had ulcers and had developed a pleural effusion, which was now drained.

On the previous night, we surmised, a sudden ulcer bleed and the concomitant lung infection had probably caused an aspiration from blood that was being regurgitated. His respiratory passage would then have closed off instinctively and involuntarily. Only the intervention of the medical team had caused him to resume breathing. Most older people, let alone a ninety-four-year-old, would have died during that situation.

There was constant media attention throughout the day, but this was all handled by the presidential spokesperson, Mac Maharaj. The exact hospital was never named, but a large contingent of international and local media had gathered outside Mediclinic Heart Hospital. When, and completely coincidentally, Deputy President Kgalema Motlanthe was seen leaving the hospital in the afternoon, the media presumed that he had been there to visit Madiba. The news of this ‘visit’ brought overwhelming global support and best wishes. The UK prime minister, David Cameron, took to Twitter to say that his thoughts were with Nelson Mandela. When the press learnt that Motlanthe hadn’t in fact visited Mandela, they explored another angle and suggested that the family was preventing senior government leaders from visiting him. Obviously, this was strongly denied by the family and the ANC.

By the Monday afternoon we were pleased to see that the stomach bleeding had stopped and we could now decrease the sedation and wean him off the ventilator. That night he slept well. As I was told the next morning, ‘Vitals all stable.’ Later that morning, Madiba was successfully extubated and was breathing on his own. His chest drain remained in place. A man who had technically ‘died’ was now living.

By late afternoon, he was fully conscious and able to warmly greet President Zuma by shaking his hand and smiling broadly. He had recovered from the anaesthetic and it was his first fully conscious interaction. Afterwards, I briefed the president on the incident, ending with the words, ‘Mr President, sir, I am not able to make any kind of prognosis or make a prediction of future outcome. As you know, it is Madiba and he will always surprise us.’ Madiba had come close to death, yet here he was, warmly greeting everyone.

That evening, the clinical panel decided that whatever had taken place on the Friday night had had no permanent impact. Madiba was now sitting in a chair and, although still on oxygen, was breathing on his own. He looked comfortable and was doing well. Mrs Machel was full of smiles as she chatted to Komati after we had briefed the family, which included Winnie Madikizela-Mandela and Makaziwe Mandela.

Controlling the flow of information again became a major concern. The media were putting on the pressure, and there had even been a scuffle outside the hospital when a journalist from the Pretoria News punched a hospital guard. I also learnt that accommodation was being booked in Qunu against the possibility that Mandela might die. Madiba’s neighbouring relative, Nonkumbulo Mandela, had had five of her thirteen rooms booked by an international news agency way back in 2010 with a deposit of R15 000.

Working within the ring of intense media surveillance was not pleasant. Again, speculation about our patient’s condition was rife, with some reporters wanting to know if he had suffered cardiac arrest. I advised that his medical details were not for public dissemination. But all this meant that we had to apply stringent security measures a distance away from the ward. All electronic devices were to be surrendered, cellphone communication was forbidden and cameras were prohibited.

Despite these measures, journalists were found walking through the hospital under the guise of being visitors. Consequently, strict instructions were given to clinical staff not to discuss Mandela’s medical details outside the panel meetings. Likewise, special care had to be taken when briefing family members.

In the past, some security leaks had been identified as coming from sources within the police, particularly if the officer had been with Mandela a long time. I requested that certain police not be allowed to perform guard duty at the hospital, although they could still be deployed at the Houghton house. This created some unhappiness.

Meanwhile, there were messages of support from the cabinet and from around the world. The family visited, including Mandela’s daughter Zenani, who was ambassador to Argentina and who flew home from Buenos Aires especially. Mandela’s condition was improving, and at the evening clinical panel discussion it was agreed that if there were no new incidents, he would be discharged within forty-eight hours.

But the improvement was short-lived.

That night, Madiba began to cough severely whenever he attempted to eat solids, although he had no problem with drinking. His breathing also fluctuated during the night: sometimes it was slow, sometimes rapid. Doctors had not noticed these apnoeic attacks at his home, except for the one that had necessitated the hospital admission.

As Madiba had not had a proper meal since admission, a programme of aggressive nasogastric tube feeding was introduced. This method by-passes swallowing, as the liquid food is tubed directly into the stomach. The coughing stopped. The family were now worried about the number of tubes entering Madiba, as this was the first admission in which he was in full intensive care.

We held a family meeting in the side ward to brief them fully on what we were doing medically and what information we were releasing through the presidency. At these meetings, Mandela’s granddaughter, Ndileka Mandela, a former ICU nurse, would often ask penetrating questions about the ICU protocols, and these had to be delicately handled as they covered issues not usually discussed with families. I would allow some of her questions, but on others I would beg indulgence, as the family were now entering into the technical medical issues.

Such was the concern for the icon – not only within the family but also across the country and internationally – that religious leaders from all faiths were gathering at St George’s Cathedral in Cape Town to pray for Madiba. Bishops from the All Africa Bishops Conference had also gathered outside the hospital to pray for him after a call from President Zuma to join hands in prayer. Earlier, there was a vigil held at the side entrance to the hospital, at which blue and white candles were lit. The hospital boundary walls were adorned with messages from many organisa-tions and individuals. Blue balloons festooned the place. Love for Madiba surrounded all.

And then I received a message from a journalist at The Star about a story they were to run based on allegations made by Warrant Officer Shaun van Heerden, who had been a bodyguard to the former president. Van Heerden felt he had been badly treated by me when he had been removed from the hospital guard contingent.

I consulted Zola Dabula, who was our liaison official with the police. He advised that I was not to speak to the journalist as this was a security matter that spoke ‘volumes about the conduct of the member in such an operational environment’.

The next day, the Saturday Star’s front page carried a photograph of Van Heerden alongside his allegations that the medical team had imprisoned Madiba and prevented his old friends, such as Ahmed Kathrada and George Bizos, from visiting him. There were other remarks about our allowing photographs with Hillary Clinton and getting Madiba to sign books for friends. He seemed most peeved that it had been suggested that he had leaked stories to the media.

There were follow-up articles the next weekend seeking to justify press concern for Tata and to mitigate the charges that journalists were ‘vultures and stalkers’ only interested in selling stories. The general consensus in the family was that Shaun van Heerden was simply bitter and aggrieved. But this did not stop CBS from showing a fifteen-minute interview with Van Heerden conducted by Debora Patta. In this, he spoke about Mandela’s poor short-term memory and concluded that he would not make his ninety-fifth birthday.

He also alleged that something serious had happened to Mandela on the night of Saturday 8 June. His view was that Mandela and his entire medical team should be relocated to Qunu. Proper care would include free unrestricted visits in Qunu so that Mandela could sail off into the sunset. A few days after this interview, Van Heerden also tried to get into the ward but was ushered away by one of his colleagues.

Here was a former member of Mandela’s security staff speaking without permission to the media and making wild allegations. That he had broken the primary creed of the bodyguard did not seem to trouble him.

As if dealing with embittered former guards was not enough, we were now taunted by a hoax caller. This person phoned the hospital alleging to be from the fire department and claiming that the hospital’s anti-fire measures needed to be inspected. It was a Sunday. Not only that, it was 16 June – National Youth Day and a public holiday. The Pretoria mayor was off at a youth function; his staff had their phones on voicemail. I was left to make a decision, and that was to instruct the hospital that anyone claiming to be from the fire department be denied access to the hospital. This calmed down the situation. The following day, the mayor apologised for being unavailable and confirmed that no person was due to inspect Mediclinic.

Finally, to cap that day for me, a policeman at the hospital security gate stopped my car and would not let us through, as they had received instructions not to let in anyone, and especially to make sure that a person named Ramlakan was not allowed to enter. Clearly there was some breakdown in police communications, but here was an obedient and disciplined policeman. It took a phone call to his boss to rectify the matter.

When Mandela was hospitalised briefly in Cape Town in January 2011, there were press statements from the ANC asking the public not to panic. This time there were no such references for national calm and yet there was much speculation in the press about what would happen when Madiba died. An article posted on 20 June 2013 on the International Business Times website wrapped up the sentiments.

Among those quoted was Father Sebastian Rossouw, a black priest at the Regina Mundi Catholic Church in Soweto, who had told The Australian that ‘Many of us fear that what he stood for will also die. It’s a concern that when Mandela goes, there will be a threat of civil war. People are con-cerned that if he dies, will we still have democracy? Will we still have peace?’

It was also reported that the British writer and biographer Fred Bridgland, who had written on the Angolan Civil War, had contributed a column to Scotland’s Herald citing Mandela as the ‘last reason for restraint’. Similarly, David Blair of the UK’s Daily Telegraph blogged that ‘For as long as he lives, South Africans breathe a little easier and believe in their country a little more. When the day after Mandela dawns, that belief will be shaken, not dramatically or immediately, but slowly and perhaps imperceptibly. South Africa will, quite simply, be a different country.’

There were also quotes from alarmists saying that groups of armed black men were massing, intent on slaughtering white people. Fortunately, there were many voices deriding this extremism.

The report also quoted columnist Max du Preez’s summation: ‘I suspect the only consequence of Mandela’s death is going to be a period of sadness, nostalgia and a feeling of national coherence. It will remind South Africans of all groups and persuasions of the almost miraculous transition from apartheid to democracy and of the golden era under his presidency after 1994.’

- Vejay Ramlakan is South Africa's former surgeon general and head of president Nelson Mandela's medical team.