Blog 7

15/12/08 Two months in Zambia.

Things don’t change - we have an industrial dispute! The six medical licentiates, equivalent to the house men/basic surgical trainees in the UK have gone on strike because the hospital will not pay for their on call, which they say is not in their contract. They will therefore only work from 08.00 till 16.00 hrs.

A large self setting sunflower on waste land grew to over 6 foot and flowered in 3 months from the start of the wet season. An exotic weed.

The management have just put me on the surgical consultant on call rota for four days this month. At 65 I have finally returned to being a houseman again and with no European directive so I will have to work the next day! The consultants will have to come in to change catheters, put up drips and be first attendants to the emergency admissions. I don’t think I will be on the rota next month! This is all very bad for morale and the dispute has been dragging on since June.

While Judy was away I took Dr. Penlope Machona, and two medical licentiates, Theresa and Captain Banda (she is in the army), the leaders of the strikers, out to dinner and learnt a bit about them. Note that in this male dominated society the 2 medical licentiates and doctor at the centre of the dispute are all women. One curious thing I learnt was how strictly their parents treated them all before they left home, with very restricted contact with boys and all meetings outside the family home chaperoned. Some young adults in Zambia, possibly only a minority seem to go from Victorian traditional morality at home to almost complete sexual freedom with more than one partner at a time when they leave. However these young Zambians were clearly all brought up in educated and probably strictly christian families not typical for most young people in Zambia. The vast majority are brought up in rural areas with a more traditional culture.

There has been an article in the BMJ on HIV/AIDS, which suggests the reason for the epidemic in sub-saharan Africa may be because Africans have multiple partners at the same time, which spreads the virus much more quickly than serial monogamy which is more the western style. On average Africans finish up having no more partners in a lifetime that in western cultures.

The visitor for this month.

We had a very interesting lady to stay with us called Hilary. She was in her 50’s had done six years in Belize, starting with two years as a VSO volunteer, some years ago. She is now permanently back in England with her mother and sister. She had been married but was divorced and that was partly the reason for her doing VSO in Belize. She had previously worked in human rights and that’s what she did in Belize, mainly with children. She was visiting Monze because her brother had done VSO near here forty years ago. He had then gone to Cambridge and in his first year died in a climbing accident in Derbyshire. She had been able to meet people here that he had met and worked for and even managed to find the house where he and two friends had lived for a year. Hilary is also a course facilitator for VSO so we had a good discussion on what VSO is all about and what it hopes to achieve. She has met other VSO people in post including Jane Lichenstein who is in Livingstone and is the wife of Sir David King previously the government’s chief scientific advisor. The Daily Telegraph did an article on her that Gill and Dean sent us before we left. In the article it describes her as previously “a highly paid lawyer running a commercial litigation team in Cambridge and is now a charity administrator on £24 per month". Jane's social life consists largely of her Dutch flat-mate, Irma; Irma’s dog, which eats cushions and howls in the early morning, and several hundred Zambian orphans”. Our two new “daughters” Dhun and Natasha, VSOs who live next door to us in Monze have met her on a visit to Livingstone and think she is fun.

Natasha has just borrowed another K50,000, an onion and just enough milk for a cup of tea all in the space of 48hrs. Some things don’t change!

Judy’s trip to the UK 6/12/08

We had bought our tickets for the bus to take Judy to Lusaka and the airport the first part of her journey and then at the last minute got a lift all the way to the Christian Brothers retreat near the airport, where we were staying the night before Judy’s early morning flight to the UK.

The ride was in a very large and luxurious land cruiser (leather seats and air con.) driven by Brother John who is in another brotherhood called the Holy Family. This is an Irish charity based in Dublin that runs homes that treats physically handicapped children. Michael Breen who clearly is well known by all these organizations tipped us off about the lift. Brother John was taking two Irish people to catch the same flight as Judy. John, one of the passengers was one of the people who runs the charity and raises money to fund it from Dublin, and the other a very lively 50+ Irish physiotherapist called Theresa who is going to manage and work at the Holy Family in Monze for 2 years.

She plays bridge so she was very happy to play bridge with Mike and to share a gin with Judy. The second aim was achieved but we never got our act together for the first! Perhaps it will happen when we are all back in England/Ireland. We all became very good friends, Theresa, her husband Mo and the various people visiting and working with the St John of God Brothers in Monze.

We had very many happy times together including regular visits to Moorings swimming pool and of course the campsite bar with much drinking of gin and beer sitting around the barbeque in the warm African evenings after watching the sun set.

A not so warm evening later in the year!

We had supper that evening at the Retreat in Lusaka with the brothers. An omelette, chips and some vegetables with the three brothers dressed western style, Michael, Joe and a young native born Zambian. We had fresh fruit for pudding and instant coffee. The simple rooms faced inwards to a grass covered cloister type square shown above with deeply coloured bougainvillea. We had hot showers and had to be up again at 5.30 to help ourselves to breakfast, including boiled eggs, and for Brother John to pick us up at 6.30 for Judy's plane to Heathrow.

It took me almost the rest of the day to get back to Monze with Brother John who had several jobs to doin Lusaka. I did some more shopping including the rare treats of sweet corn, gin for Xmas and a tin of golden syrup. I also had time to read a book by Peter Godwin, 'Mukiwa a white boy in Africa' really Zimbabwe. It’s a great book for us to read here lent to us by Michael Breen.
For me, Judy’s week back in England to see our new grand daughter Celina born just before we left for our year in Zambia and who is now just three months old, started slowly and it was good for me to get used to it. At least there was release from playing canasta every evening! However, and don’t tell Judy, I think I’m missing it??

A boy’s night out!

On Thursday I met the “boys” for a drink and a meal at Nzango Gardens, which is one of the best eating places in Monze. The boys are regular customers of the Gardens. Crispin works for World Wildlife Fund and lives intermittently in the single story house behind us as a part of our small three-housed walled compound. His wife works for the UN and lives with their three children and a nanny in Lusaka and comes to stay in Monze for the occasional weekend. Perry is single and the eldest son of the very large Cornhill family, who have much land and many farms around here. Kitty is a 40+ Zambian born Indian who has a transport business carrying, for example coke (the fuel variety not to drink or sniff) from Zimbabwe to the Congo. They finished off at least one bottle of whisky between them. I stuck to Mosis (Zambian beer) and only succumbed at the end of the evening. Nzango Gardens is always very poorly lit so as well as the usual difficulty I have in understanding their English I couldn’t see their darkened faces and didn’t catch their names which had to be sorted out later. The conversation was also difficult but Perry, who spent some time in England at public school on the Welsh borders was a keen soccer fan (supported Tottenham Hotspur can you believe?) and rugby so we had a very animated talk about that and whether soccer was a more skillful game than rugby! However the food was good, T-bone steak, nshima (mashed maize) spicy sauces and very little if any vegetables. They also invited me to a barbeque on Saturday at Kitty’s “workshop” which I thought must be just a rural barn perhaps with a few animals wandering around and a few haystacks just north of the Golden Pillow. I was much mistaken, but more of that later.

I went for swims on Saturday and Sunday at 16.00 hrs at Moorings' pool. This is surrounded by palm trees and jacaranda and is very peaceful apart from the noise of the guard dogs and cockerels. We always go for a drink afterwards at the campsite bar, which is idyllic! I always have one Mosi and Michael Breen one ginger beer. He never drinks alcohol, in contrast to the manager of the campsite, Dave, who drinks long whiskies with ice and water, only interspersed by taking long draws on a cigarette. His head is shrouded in smoke after each exhaling. Occasionally the young Zambian employees come up and sit on the concrete platform as we sit on our chairs to discuss their work. He deals with them very firmly in a gruff manor but criticizes them in a teasing way usually about money and they go away chastised but laughing. He has good eye contact with them but less with us, chatting about when to set the seed and maize for the growing season, critical to its yield, while peering, unsmilingly out into the paradise of trees grass and brightly coloured flowers beyond the veranda. For us it is extremely relaxing.

Saturday 13th December. “The workshop barbeque”.

Kitty picked me up at 20.30hrs in his very large 4WD vehicle, which coped well with the speedy 30mph exit from the police camp, the name of the area we live in on deeply rutted sandy tracks. Five minutes later we pulled up to some very large locked and battered high iron corrugated double gates and within seconds of sounding his car horn a tall slim Zambian (I will call him John) opened the gates making their characteristic deep loud reverberating drum like roll.

We drove into a secure fenced 2-acre site with a large 20 foot high covered workshop at one corner. There were offices down one side of the structure open on the other three. It had a grey concrete base half covered with parked trucks, one very long one stacked with bags of coke for the Congo. Most of the rest of the 2 acre site area was filled with broken down trucks and other heavy vehicles needing repair. At the edge of one side of the covered area a flat brazier lit by strip lighting was intermittently attended by John who emerged on Kitty’s bidding from the deep shadows in the otherwise completely darkened compound. The “work shop” was just that and not specially designed for late night entertaining although all attending seemed to think it was an appropriate place for a Saturday night barbeque.

Standing by the brazier was Marina, Kitty’s friend and neighbour who frequently gave deep loud chuckles. The only other person present at the start was Deepak, another Indian who was very quiet but I think, had prepared the marinated chicken and salad that we were to eat. As the evening wore on there were further arrivals all let in by John who emerged from the surrounding darkness at running pace to the sound of a car horn. Perry, still in a suit from a wedding, another Zambian and his tall elegant Angolan wife, another Indian whose family was in England, and two younger Indian women one of whom we had seen in the local Indian “supermarket”. Her small boy seemed somewhat bored by the whole evening and didn’t really know what to do with himself. The saving grace was his hand held computer.

Distracting himself with computer games the same the world over for the richer kids

The music came from the 4WD I arrived in which was left with all its doors open so we could hear the music which was mostly western pop. The chicken was very spicy, hot and delicious. There were one or two plastic chairs on which the women eventually sat. The conversation was mostly about the difficulties in the local area and quite a lot about corruption, which seems deeply embedded in almost all activities. It is probably an integral part of any very poor society and can destroy all traces of trust in almost any situation. Perry was supportive of Mugabe and feels he has had a bad press from England!

Kitty continued to cook layer after layer of chicken, the local supermarket manager brought some bread rolls and very long thin sausages which respectively were toasted and grilled and between us including John and some rather scraggy timid well nippled dogs who also intermittently emerged from the outer surrounding darkness onto the strip lighted covered concrete platform managed to make sure that neither a tender morsel nor a chicken bone was left. I was taken home at midnight and I gently refused an invitation to go with Perry and a friend to the club at the back of Tooters fast food restaurant, of which I would suspect most respectable residents of Monze were completely unaware. Perry and his friend assured me I would find very good company there!

3 days to Judy’s return on Tuesday

A lot of my spare time this weekend has been spent doing the washing and ironing which I have enjoyed. I took full advantage of the electricity and water, both on, and took a chance with the weather and was lucky although it required one or two dashes to save the washing from the rain. Anyway the house is as clean as it gets and there isn’t a dirty sock, shirt, sheet or towel in the house. Overall it was good drying weather.

My 30-minute jogs on Sunday mornings get easier and my knees now don’t play up at all. The skin over my knees has healed after being caught and tripped up by three dogs 2 weeks ago. The dogs didn’t appear today!
I wondered whether the jogs are easier because of all the gentle exercise we do walking or perhaps I’ve just adapted to the 3,000 feet and it is much cooler with the great increase in cloud cover. We sometimes walk 6 miles per day when we go up to the Golden Pillow for the Internet. I jog under trees providing deep shade lining an avenue to the golf course, which I’m sure has seen better times.The road has tarmac and a line of high stooping gently leaning but elegant poles with lights that probably haven’t worked since independence in 1964. This is probably where all the Europeans lived in colonial times and where the Italian Bishop lives now. At this time of the year the roadside is littered with the stones from mangos still partly covered by the bright yellow fruit, which when I try to eat, irritatingly leaves fibrous strands between all your teeth. You rarely see a child not eating one now. They must be a great treat for hungry kids and are so easily available from trees which grow everywhere in great numbers. On the golf course side of the road the locals have built up the soil in a series of longitudinal ridges to grow potatoes. I’m sure this never happened in colonial times when the houses opposite the golf course with names like Fairview were occupied by the colonial masters.

On the jog I also saw two classic African/Zambian scenes. One an old man wearing a smart black suit and huge smile perched on the carrier over the back wheel of a bike, both legs out front to clear the ground, holding a motionless live chicken by its wings in one hand and a cheap bright plastic case held out in the other as if to balance himself and the chicken. The second was a tractor pulling an open trailer transporting khaki green uniformed prisoners to do some public works. They must have regarded me, a white haired old man jogging in skimpy shorts and shirt at 8 o’clock on a Sunday morning with equal incomprehension. They didn’t make any comment. We greeted each other with stares and silence.


One bit of bad news is that Andrew Moulson, a GP and Gabby his wife assigned by VSO to St Francis Hospital near Katete, who we have mentioned in previous blogs, have gone back to the UK because they did not get on with the surgeon and administration running the hospital. It is a great shame and surprise as, if anything, they were more determined and excited about doing 2 years than we were, and they had previously worked at the same hospital many years ago when they had a young family.

Clinical Work

Clinical work for M remains interesting but not much of it. The 10-month-old baby with pyloric stenosis went home and somehow they got some money for a taxi to avoid the 5-hour walk. Mum and baby were very happy.

My right hemicolectomy went home in 5 days not quite up to the standards of an enhanced recovery programme and I did an 18cm diameter retroperitoneal tumour in a 23-year-old HIV positive woman. The only work up she had for this easily palpable tumour was an IVP, which showed the ureter draped around it. It also had the external iliac vein and artery stretched over it. Fortunately it shelled out relatively easily and was either a liposarcoma or a lipoma.

She is recovering quickly. Almost the only other surgery I do are on patients with piles and fistulae most of whom are HIV positive and hernias and persistent processus vaginalises in young boys.

Judy makes it back safely 16/12/08.

I arrived back safely, with no problems getting my two heavy suitcases filled with medical equipment on the plane. I was within two kilos of the forty-six kilogram allowance for the flight. I was fortunate with my trip back to Monze with all of it. First of all there was a taxi ride to the very hectic and African bus station in Lusaka.

Michael had said, “find a friendly taxi driver you can trust”. Well, they were all friendly – but as for the rest! The asking price for the 30 minute journey was expensive at K150,000 (£21) but I explained I was a resident volunteer doctor working in a rural hospital and the price was reduced to K100,000 (£14). In actual fact that did only leave me just enough for the bus fare and possibly a taxi in Monze. At the bus station I boarded a down market Zamsef bus to Monze, a three-hour journey for K65,000 (nearly £10). Otherwise I would have had to wait another hour or two for our usual bus, Mazhandu’s Family Service. I was met by Michael at the Golden Pillow, the bus station just a half a mile outside Monze, which also has a hotel (of internet fame).

We shared a very tasty chicken pie with a bag of chips and red sauce, at the Golden Pillow’s fast food emporium, an extension of Tooters’ Centre of Entertainment in town, and then were able to use the motel internet to book our holiday in Livingstone. We have booked with Tongbezi for three days over the New Year in a thatched cottage by the side of the river Zambezi; it is very expensive but includes all food which is said to be excellent, river trips to see the sun rise and set and canoeing up the river! It will be our Xmas present to each other and will include the trip to Livingstone Island and a swim in the Devil’s Pool I mentioned in Blog 6.

Well J’s asleep on the settee at 20.30 after her big adventure. She has nearly un-packed, the lens filters are on my camera and its time to finish this blog. Many thanks Emms!


So with the rattle of our corrugated iron gates in the wind its goodnight from me, and kamucaala kabotu (keep well) from both of us until the next blog.
(Kabotu pronounced ca, as in cat bot as in bottom and oo as in too. Tonga for good as well as other things!)

It will be quiet here with just Christmas Day as a holiday, and the majority of folk too poor to buy decorations or presents, even if there were shops selling them. We will miss family and friends greatly, but not the hectic run up to it all and the cold weather.

We wish you all a Very Happy Xmas and Healthy and Prosperous New Year.
(as much as that is possible).

Blog 6

Mosi-oa-Tunya 'The Smoke that Thunders"

Sunday November 23rd 2008

Judy gazing into the crack in the earth into which the mighty Zambezi pours from the right side. It is the dry season with not much water at the Zambia end of the falls partly because some water is run off for hydroelectric generators. Less smoke and little thunder.

We returned from Livingstone and one of the Seven Wonders of the World at 1730hrs, tired and a little bemused. The three hours in the Mosi-oa-Tunya National Park (the smoke that thunders; the traditional name for Victoria Falls) was great and we saw and learnt a lot about the animals but Mosi-o-Tunya (also the name of the Zambian beer) was not quite what we expected. The Falls are really just a huge crack in the earth about 1,700 metres wide and 100 metres deep, which the mighty Zambezi meanders up to and then plunges into.

The not so mighty Zambezi showing its way out of the crack into Zimbabwe on its way to the Indian Ocean.

It flows out of one end of the crack or gorge. It is so large that even with little water at the end of the dry season it generates a lot of spray. The border between Zimbabwe and Zambia is arranged so that 66% of the Falls are up stream and 34% down stream in Zambia and the reverse in Zimbabwe. This means that it is difficult to appreciate its full size and structure without walking on the Zimbabwe side. However visas are required just to go the few hundred yards across a bridge, roughly the length and appearance of Bristol’s Clifton Gorge Suspension Bridge, to get into Zimbabwe and the visas are very expensive.

Mosi-oa-Tunya in the wet season showing the suspension bridge into Zimbabwe just right of centre at the bottom of the picture. Zambia has 66% of the upstream part of the falls on the right including Livingstone Island and Zimbabwe 66% of the downstream on the the left. The Zambezi flows out of the crack and under the bridge and runs between the two countries into the vast man made Kariba lake and eventually through the Kariba Damn and finally to the Indian ocean.

David Livingstone first viewed Falls from the up stream Zambian side on an island which now bears his name and to which you can be taken on a day’s trip. The most exciting trips are from the Zambian side but we are prejudiced. This can include a swim in Devil’s Pool, which extends right up to the edge of the Falls and from which you can look over their edge! We intend to do the trip in December/January before the Zambezi reaches its full spate when it is still possible to get to both the Island and Devils Pool. The island is right in the middle of the falls and the views from it are said to be spectacular. At this time of the year around the start of the rainy season the water levels are low enough to walk all the way to the island over large rocks

Tourists walking on the edge of the falls in the dry season.

whereas when the river is in full spate it is not even possible to get there by boat and it is impossible to swim in the pool. The waters are also lower on the Zambian side because a lot is diverted for hydro-electricity. However in spite of all these difficulties it is a lovely walk on the Zambian 34% down-stream side and we have taken some photos of people walking right up to the edge of the falls on the up-stream side (see above) and the bottom of the falls you can't see in the wet season. We had to negotiate a small suspension bridge and some aggressive baboons to get this picture.

It is impossible to go anywhere near the falls without getting saturated at the height of the rainy season. We should be able to get some very instructive ‘before and during the wet season’ photos although it is difficult to keep cameras dry even in plastic bags.

On the 3 hr trip around the Mosi-oa-Tunya safari park we saw elephants, rhino, hippos, crocodiles, giraffes, zebra, buffalo, impala, warthog, large monitor lizards (which eat crocodile eggs), wildebeest (type of deer) and lots of birds, all from an open land rover in large very

comfortable arm chairs. There was a slightly threatening sky but it remained dry, very warm and mostly sunny. All the vegetation was fresh light green after all the rain we’ve had in the last few days. The ground was mostly sandy and is now starting to look like a newly sown lawn.

However the rest of the weekend was cooler (26-30 degrees Fahrenheit) with the odd shower and mostly cloudy.

Our hotel had rondavels with ensuite accommodation and was really very comfortable. A mixture of slightly plush and ethnic but a good bathroom and tea/coffee tray. Sadly it didn’t have a particularly good restaurant as was advertised.

The journey to Livingstone with about a hundred passengers packed into the 'luxury' blue 'Family Mazahendu' bus was a mostly comfortable experience taking over 4 hours to get there and a similar time back. There were 3 seats one side a very narrow central isle and two seats the other. The seats were less than one shoulder width in size so we had to sit slightly overlapping. The problem was one third of the journey was on unmade roads over which even I couldn’t sleep. There were great potholes full of rainwater. We caused cascades of yellow ochre coloured water as we went through, as the earth was no longer red. At one point in the middle of nowhere and still on the unmade road the bus came to a halt with the engine running.

The driver’s head slowly descended to the very large steering wheel followed by the drivers mate’s head going through the same procedure. The driver and his mate rapidly regained their composure and reassured us the problem, something to do with the alternator, was solvable. Initially it was thought it might require repairing with some modified barbed wire found at the roadside although this was never used,

as the true culprit was a loosened wire, which took 2 minutes to repair!

The bus is so shaken on the unmade roads it is amazing that it doesn’t just fall to bits as it rattles and rolls along occasionally at over 60mph, when allowed by other traffic. The road surface doesn’t seem to be a consideration in determining the speed of the bus!

The bus pulled into the Golden Pillow car park as it was getting dark and so ended another wonder filled weekend.

Clinical Cases

And so back to the tales from work.

Man’s cruelty to man is understandable and even occasionally acceptable but man’s cruelty to children is difficult to understand in any culture. An 8-year-old girl has been on the ward for some days with abdominal pain for which no cause has been found. As she is not seriously ill we have suggested she goes home and be followed up in outpatients but she and her mother have been reluctant to accept this. On the ward round on Friday, before we went to Mosi-oa-Tunya it was revealed that she was HIV positive whereas her mother and a sibling were not, suggesting that the patient did not acquire HIV at birth. It was also revealed, and we confirmed, that she had extensive warts over her perineum, which is usually sexually acquired. Her father died 3 years ago and when we asked the child’s mother what he died of she just said he was sickly. There is a myth amongst some Africans that having sex with a virgin can cure HIV/AIDS and this may be one of the reasons that Zambia has a very active campaign against child abuse. Many kids in Zambia have such a tough time, even without any abuse it is a small wonder that many survive at all. The development of coping mechanisms must take a toll and abdominal pain may be one of the consequences.

The ward round also provided two more mango tree injuries, one an overlapping femoral fracture in a young girl and another severe posteriorally displaced supra-condylar break. There was also another snake bite and two more severe burns one in a small girl whose dress caught fire.

This little girl had extensive burns on her abdomen and legs here being debrided and after skin grafting with less than 50% take.

I also saw what I never thought I would see in Zambia, a glowing electric fire.

This was in ITU just for warmth in the cold time of year.

It is also used in the children's burns ward when children are nursed naked and who need the extra heat in the shade of the hospital even though the weather outside is really very hot.

This week they asked me to re-operate on an old man of 60+ who had a colostomy for bowel blockage from a large bowel cancer. I attempted this in the hope we would be able to close his colostomy. However the cancer was very fixed and after a trial dissection I decided we would do more harm than good from taking it out, particularly as blood for transfusion is in short supply. Two days later he was, somewhat remarkably back on his feet and is surprisingly cheerful. I met him on the corridor just after he had cleaned his colostomy site.

There are, of course very few colostomy bags, he just covers it with cotton wool, a sheet of material that women use for a wrap and then covers it with a plastic sheet, which keeps most of the flies off.

He was actually smiling when I met him after having a good wash.

This patient's kit (plastic container and bowel) for cleaning his colostomy and its cover for keeping clean.

Dr Engulula, the Congolese surgeon, after seeing the video on my computer of James Robertson Justice in the Carry on Doctor film doing an old style surgical ward round and teaching medical students by humiliation, thought that we should copy this and proceeded to do so on a case of appendicitis demonstrating some now little used physical signs. The VSO idea of disseminating skills sometimes runs a tortuous course!

Tuesday 2/12/08

Six weeks into the struggle of learning how to cope with the HIV/AIDS clinic, just before lunch the counsellor acting as a translator asked Judy if she would see a lady who wanted advice about getting pregnant. Forty-five minutes later we were all a little wiser about the difficulties of these clinics even leaving aside the problem of language. The patient was a small bird like, pretty woman in her early 20s who initially was a little shy to discuss this, perhaps because of the male counsellor and myself. She placed on the desk one sheet of paper, which was the incomplete clinical record of a four year old child. As the child had her surname we wrongly assumed it was her child, not as it transpired, her dead sister’s. It was pointed out that we needed her own notes not the child’s. So after obtaining her number Judy retrieved a set of notes from the file store as the record clerk had gone to lunch. These appeared to be the correct number but were the rest of the wrong child’s notes. After obtaining the correct number Judy found the correct patients notes. Together with these and through the translator we established she had been on anti-retroviral treatment (ART) for 2 years, had two children aged 7 and 10 years and that in spite of having unprotected intercourse with her HIV positive husband for the last 2 months she hadn’t become pregnant.

The advice to HIV couples even when they are both “reactive” (HIV positive) is that they should continue to use condoms until they want to have a child and that they should only try to have a child when their CD4 counts (a measure of special white cells in the blood) are high indicating a low viral load. This means the risk to themselves from each other and to the planned child will be lower and is acceptable. We were surprised that the treatment with ART has become so well established and successful that the ethical dilemmas of taking the risk of bringing an HIV positive child into the world is now sufficiently small for this to be the standard advice. This is because the life expectancy of parents on ART is greatly extended and that Prevention Mother To Child Transmission (PMTCT) can be effective. This is why it so important for all pregnant woman to be tested for HIV and if positive to be treated with specific therapy. All their babies are then given a short course of ART and are then tested at six weeks which is the earliest it is possible to establish their viral load.

The patient then asked about whether she should breastfeed and we had to make sure, through the interpreter that she realized breastfeeding wasn’t the only way she could give her baby HIV. The other two ways of mothers giving their babies HIV is during pregnancy and at the delivery. However once in this situation it is safer to breast feed than not as they can better avoid gastrointestinal and other infections caused by giving formula milk, and not getting the mothers anti-bodies through the breast milk.

The final plan therefore was to organize for both she and her husband to have their CD4 counts checked and if they were sufficiently high to have unprotected intercourse, she was also advised that it might take longer than 2 months to get pregnant. If after say 6 months they were still unsuccessful they would both have to be investigated for infertility. The need and pressure for an HIV positive mother of two to have more children may be mainly cultural as if she can't it might drive her husband to find another more fertile wife.

At the end of this long consultation the patient then asked for an ART prescription for the child whose notes she initially presented to us. We explained that it would be better for us to see the child particularly because the child hadn’t been brought to the last appointment. It was at this point that the patient revealed it wasn’t her child but her dead sister’s who presumably died from AIDS. Athough our patient is the guardian the child lives with the patient’s mother, the child’s grandmother, who lived one hour by bus from Monze. They found it difficult to bring the child who apparently is otherwise well on treatment. Judy agreed to prescribe another month of drugs but said the child should be brought to the clinic next time if at all possible.

This case demonstrate many of the frustrations of this clinic; the random way the patients enter the consultation room unannounced, sometimes two at a time, occasionally with the wrong or incomplete notes or without them at all, the lack of support staff to find the notes and the occasional problems of trying to understand the expectations of the patient with the almost insurmountable problems of language and culture. It is impossible to get annoyed with any of the staff as they are also struggling to cope with the large numbers of patients.

HIV Reception desk in Monze Mission Hospital who do their best to find the right record for the right patient; not always easy or possible to find what the clinician needs when surrounded by lots of anxious patients and badly filed medical records.

The most numerous of the workers are the counsellors, who are all HIV positive and are my translators. The whole clinic is under resourced and undervalued by the hospital, which is very shortsighted as these resources will be needed more and more in the future. I can’t help wondering how much this is due to the fact that the hospital is underfunded or because it is now run ultimately by an elderly Italian Bishop who seems remote from the problems of the hospital, and passes many of them on to his PA who seems equally out of touch with the hospital's problems.

Blog 5

18/11/08 The rains begin with a vengeance and a mourner is struck and killed by lightening at a funeral!

The corrugated roof of our house, which is the standard covering for most Zambian dwellings, was strangely silent this morning. It normally expands and contracts with murmurings, grumbles and intermittent loud cracks twice a day as the unforgiving sun rises and sets, and even with the occasional passing cloud. However this morning we and the corrugated roof were protected by heavy cloud which has persisted most of the day and now at 13.30hrs the impressive thunder and lightening has released huge quantities of water creating a totally different deafening noise like trees in a gale as well as instant puddles streams and rivers.

The house lights flash on and off with the lightening for some reason. I have changed over to the lap top battery, so that I can switch off and protect the surge protector! The storm has made it impossible to walk back to the hospital for the afternoon’s ward round and clinic. We would get soaked getting to the hospital transport just outside our bungalow if it was available which it isn’t!

A much regarded 48 year old nurse with bad hypertension has suddenly died and for the last three days most of the hospital employees have been ferried to and from the “funeral” which takes much time and is a Zambian cultural tradition with a significant cost to the economy and the individuals involved. For the three days before the actual ceremony people visit the home. This has to be done properly both out of respect for the deceased and also to make sure her spirit is appeased and put safely to rest. We were warned about this and it is impolite for even quite distant aquaintances of the deceased not to pay their respects at the wake and close relatives may have several days off work to attend the funeral travelling long distances occasionally on foot.

Later on in the day when I eventually get to the hospital we hear that a mourner was struck and killed by the lightning while visiting the deceased's farm. This means the hospital transport will probably be in short supply for another week!

It is now 15.00hrs, the roar has decreased and the rain after 90 minutes may be slowing although it is still very dark. We have had quite a bit of rain intermittently over the last few days but never as continuous as this, with such determination, dark skies, thunder and cool air.

It’s difficult to believe that the sun and heat are so completely obliterated by the cloud, that it is still up there and will probably be out before the close of the day. At least it has allowed me to start our next blog!

The grey skies over the Lusaka to Livingstone railway and the road crossing close to our home across which we walked across most mornings. The trains were so slow and long it could be a long wait to cross the lines on occasion.

We may have to make a dash for it to the hospital if it stops, especially as it is the orthopaedic surgeons’ monthly visit and I will be sorry to miss them.

It is amazing how quickly our moods swing at work, even changing within one day from resignation that we have very little to contribute to rising enthusiasm that we can. This is mostly related to our relationships to individuals rather than the overall objective. VSO did warn us about this.

Arranging post graduate teaching and more clinical cases

We have religiously attended a Thursday morning 7.30am post graduate meeting set up by Tom Lavender which is very popular and well attended.

Unfortunately it eventually petered out during the medical licentiates strike shortly before we left. However this morning I was disappointed that two of the trainees only saw difficulties in setting up some extra teaching sessions. They couldn’t make a session over lunch because they have to go home to eat nshima and they weren’t keen on a session immediately after the ward round in the afternoons. Nshima is rather like mashed potatoes but made with ground maize or “mealie-meal”. It is used as a mop or is molded to scoop up fish or meat, usually with their fingers; it has more stickiness than mashed potato. Later on that morning I had another talk with the Congolese Consultant surgical colleague Dr Ngulula who was interested in getting some teaching going and seemed keen to learn new techniques, which raised my mood again.

Later on mainly with the encouragement of Michael Breen who put the materials together we had two basic surgical training sessions to teach the medical licentiates how to do anastomoses using pig/cow bowel. These were very popular and well attended.

Dr Machona

The general surgery consists mainly of small operations. Most of the major surgery is either obstetrics and gynecology which is well covered by Michael Breen or major orthopaedic procedures on failed conservative treatment of fractures which is done by the monthly visiting orthopaedic surgeons from Lusaka. Other cases, right outside my expertise are also done by visiting surgeons such as hare lip and prostatectomies which I would probably do if there was no alternative. However we may have a rectal cancer to do and we have at least interesting general surgical emergencies including 'intestinal obstructions' once a week.

So far his week I have done are two fistulas and two hernias apart from the rectal cancer, which was initially presented to me as a fistula and, then corrected to needing a sigmoidoscopy and examination of the back passage. This was difficult as there were no properly functioning biopsy instruments so I diagnosed a rectal cancer on simple examination with a finger, which could have been done in outpatients! I did eventually manage to take a biopsy blindly using a short scope and a torch only to be told that they had no formalin to preserve the specimen so all my efforts had been a waste of time. The diagnosis and treatment plan has to be based on a simple clinical examination. Dr. Ngulula did an orchidectomy or removal of testis in an older guy just to cure his rather large and probably long standing hernia!

Over to Judy.

At last I have been able to visit some of the rural communities with the outreach HIV/AIDS workers. The first time it was with the PMTCT (Prevention of Mother To Child Transmission) Group who are based in the Maternity Unit and encourage mothers to get tested so that they and their babies can get treated.

Sister Hangoma co-ordinates all of this and took a group of four other women with her including a nurse. The three lay women were all HIV positive mothers who she is training to do outreach care. At the risk of sounding boring and repetitive we were late starting, gave two hospital workers a lift home, filled the Land cruiser with diesel and stopped yet again to buy lunch (e.g. chicken and chips!) for anyone going who wanted it.

There is only one main road through Monze, north -south from Lusaka to Livingstone and we set off north and turned west just outside Monze. Of course, it would be correct to say that the north south road was built by the British for taking products from the Copper Belt and agricultural areas of the north to what was then Southern Rhodesia and S. Africa, as was the now almost defunct railway

but which still runs but at snail’s pace. The British were very good at organizing the transport of exports for a colony but road building elsewhere was not a priority.

Fairly quickly we were on a wide dirt track, not too pot-holed but very dusty, so that we left a red “vapour trail” behind us and became choked if a vehicle came the other way.

The rains haven't yet dispensed with the dust! Soon we turned off this onto a much narrower and rougher surfaced road which in parts was just sand. As we got deeper into the bush, tracks joined and left us apparently randomly. It would have been impossible to give anyone directions. There were also footpaths leading in all directions but not many dwellings to be seen. Signs pointed to schools, just about visible, and goats and a few cows moved out of our way. When we did see a small homestead it consisted of what are called rondavels, which are the typical round mud huts

(though now sometimes concrete blocks or large bricks are used) with fine grass thatch. There are often small round woven enclosures which are on stilts and which are used to keep the chickens and goats safe from snakes and other predators.

The village pump is always surrounded by a fence of tree trunks and has a

convoluted entrance, possibly to try and deter animals. Eventually after about 20 km in total we arrived at our rural clinic.

These places are very impressive. They are single storey concrete buildings with solar panels, which the government was obviously keen on at one time, almost certainly from overseas funding. One long building had three doors from the outside and these were labeled antenatal, labour ward and post-natal. Each was a small clean room with one bed. There was also another building with male and female wards in a similar vein (two beds each) and attached was the medical officer’s room and a pharmacy. This was really quite well stocked with basic medication, which the medic can prescribe after 3 years training. In this community it is a husband and wife team and she is the midwife.
Some local pregnant women had been gathered together. It seemed they were HIV positive and were being trained to talk to other women in the area to encourage VCT – Voluntary Counselling and Testing. They all seemed enthusiastic in spite of their situation and it really is encouraging to see the interest in a plan that is sustainable. The remains of lunch and some drinks were shared around and promises made to return at a later date.

We travelled on to one more village with similar infrastructure but the women we had hoped to meet were not there, possibly as our schedule was running very late. It was a hot bumpy journey home but a fascinating insight into their work, life and society.

My second trip out was in a large pick-up/open truck with the VCT team and also the Peer Educators.

Fortunately I was in the cabin with one of the co-odinators! We were off in a different direction but with the same backcloth. We arrived at the same type of pristine rural clinic where the nurse was doing her ante-natal clinic outside in the sunshine. More of a chat than a check as we know it. The group of women and men in the Peer Educators group with us had announced our progress along the track with drum beating and singing. Finally as we got nearer a megaphone was used to attract attention and encourage folk to come.

The Peer Educators are again a voluntary group who may go from door to door and meet with groups of families, or may go out in a large group and try and attract attention.

They tackle many issues apart from HIV/AIDS. A lot are to do with gender issues such as “widow cleansing”, the tradition of having sex with a male relative of their dead husband, inheritance by the husband’s family rather than his wife and children, which many widows are frightened to challenge, early marriage and disclosure of “reactivity” or having a positive HIV test to a husband or wife. They convey all of this in songs and small plays. They are naturally good actors and very confident, so that watching them is very entertaining. A good trip overall, though the community should have been forewarned, and only four came for VCT, all negative.

We were back later than planned, but the rain came on time, so those in the back of the truck were probably well washed of the red dust by the time we were back in Monze. They continued singing and drumming right to the end.

The rain didn’t stop and it went straight from being dark to night and the rain continues now 9 hrs later.

Clinical Cases

I (Mike) eventually got to the hospital through the rain in hospital transport, Jasper in the Land Cruiser, and met the orthopaedic surgeon called Alan Norrish about 40+ very confident trained in Cambridge, hadn’t met Scott and brought with him 2 Americans. He works from The Beit Cure Hospital in Lusaka, which is funded by an international Christian charity with headquarters in America. He is currently away for two weeks visiting and operating in rural hospitals. We had two patients for him, both very expertly dealt with. The first had a bad compound fracture, which had pushed through the skin of the ankle. The foot was displaced inwards with a fragment of bone, the medial malleolus floating free. He had brought with him an extensive collection of heavy black metal external splints some of which were selected to be fixed to the outside of the ankle using four needle like pins two through the bones in his ankle and two through his shin bone.

The granulations in the open wound were removed, a few stitches inserted where the medial malleolus had floated free and the wound left open. It was remarkably successful in spite of the medical staff being worried about infection through the pins. Re-aasurance for this was via texts by mobile phones to Alan Norrish. The wound cleaned up very quickly after spending 3-4 weeks on the ward going nowhere and eventually the pins were removed and replaced with a POP cast.
During the operation there was raging thunder and lightning, the lights went out as the electricity failed and for a full five minutes the operation continued with poor illumination from a torch, with hardly a hesitation and absolutely no complaints. Tony Brand’s gaunt face appeared at the darkened theatre windows on one occasion to check that his diesel generators had once again saved the day. Public electricity wasn’t restored until after the operation had finished. The other patient was an ancient crone who had severe shortening of her leg after a bad fracture of her hip at the inter-trochanteric level. Norrish put a Denham pin through her tibia just below the knee with a plaster over it both to get the leg stretched and the plaster to stop the pin rocking and working loose. Apparently this idea was given to Norrish by a retired Professor Jellis aged 70 who still does charity work by flying himself all over Zambia where he has worked all his life. He takes passengers in his plane and is a very good pilot. He is an old colonial, owns a large farm and is very sociable.

It’s amazing how time slips away when doing this blog. It is still pouring with rain and Judy has resorted to playing patience after losing at Canasta, again!! It is now 23.20 hours and we have to get up tomorrow at 6.30hrs so off to bed after a bath.
In fact it rained most of the night. In the morning there were puddles and mud everywhere, it was still cloudy but much lighter and had stopped raining. During the day there was very little sunshine and just a little rain.

A wake or traditional Zambian Funeral. Wednesday 19/11/08

We arrived at the hospital to find most people were being mobilized for the burial of the much beloved and revered ITU nurse who had died suddenly on the 16th. We had met her only briefly but Mrs. Yamba felt it was appropriate for us to take part. This meant leaving our clinics, which would be run on skeleton staff but only after the communion service in the hospital from 10 to 11am. I would guess about 30% of the hospital staff were then transported out to the husband’s farm. The deceased hadn’t lived at the farm during the week, but in the centre of town, probably because the farm was through the market and down 15 km of unmade roads. The final cortege of trucks, buses, 4WDs, cars and motor bikes, about 20 in all, that finally went to the farm

was quite impressive snaking across an otherwise relatively deserted, wide open, very flat brown going green countryside with a few spectacular trees under threatening skies.

Multiple footpaths lead off from the “main” track as Judy has described and as we got closer to the farm long lines of people emerged from small hamlets and single homesteads. We were given a lift in a lorry but were allowed to travel in the cabin, which was fortunate as it rained quite heavily on the way home 4hrs later.

You can see Judy's leg and arm still in the cabin! There was standing room only on the back!

The hospital employees travelling in the back of the lorry, including Sister Juunza pronounced Joansa, sang quiet subdued tunes not quite a dirge but not the cheerful songs they normally sing.

There was a published timetable for the day:

Burial Programme for the late Mrs. Lute Zulu Hamachila

Burial of the late Mrs. Lute Zulu Hamachila who died on 16th November 2008 will be on Wednesday 19th November at the farm.

09:00 HRS - Mourners assemble at the mortuary

09:30 HRS - Preparation of the body

09:50 HRS - Body viewing

10:00 HRS - Church Service (Hospital Chapel)

11:00 HRS - Departure to the farm

12:00 HRS - Body viewing

12:15 HRS – Commital – Prayer - Burial

12:40 HRS – Laying of wreaths

13:00 HRS – Life History by family representative

13:10 HRS – Speech from the council chairman

13:25 HRS – Speech from village headman

13:35 Hrs – Speech from the employers

13.50 HRS – Speech from the Royal Highness – Chief Monze

14.00 HRS – Speech from the District Commissioner – Monze

14.10 HRS – End of Programme

May her soul rest in eternal peace

We eventually arrived with over 200 others and the wailing began with close family “body viewing”. Most attendants were not family and stood a respectful short distance away. We stood all around the farm buildings, including the building that had been struck by lightning in the storm the previous day, killing one of the visitors. The walls were charred and all the grass and wood immediately around was burnt to charcoal. We wondered what the locals felt about this and whether they thought it was a portent from above.

The effects of the lightning strike the previous day.

We then moved off for the burial some 5 km away from the farm. This was the deceased’s family burial site, a small clearing on a slightly raised mound surrounded by a circle of bushes and small trees through which you could catch glimpses of the surrounding miles of flat empty plains and fields. It was very silent and peaceful apart from the occasional wail and bird flying high over us.

The commital was in a small area surrounded by trees and was just for the burying of family members.

The ceremony started in a quiet and restrained fashion although the youngest son seemed angry and had to be ushered away. However after the lowering of the coffin in the previously dug 6 foot deep trench and packing the soil on top things became more relaxed with one of the main funeral directors rubbing talcum powder on to mainly men’s heads and faces as they came forwards to plant cut flowers (mainly plastic) over the burial mound. This caused much merriment. The main culprits were a formidable woman Mrs. Sikopo the wife of one of our senior anaethetists, who sported a full beard and moustache, and I think her much younger and prettier sister. The prank with the talcum powder was not completely without reason. It is traditional for close male relatives to rub white powdered maize in their faces as a sign of respect.

As always none of the deadlines were met and it wasn’t until 16.00 hrs that people started drifting back to the vehicles. The journey back to Monze was slow as we kept stopping, first to secure people on the back of the truck from falling off and then to drop them off in a planned way as we passed close to their villages.

Another amazing experience, again restricting our work to less than 90 minutes for the day but well worth it for ourselves at least.

As the funeral progressed the sun was seen intermittently and the day warmed, although tonight it is again almost cold enough to require woolly cardigans. The variation in temperature in the last 48hrs is remarkable and probably simply because we are living at 3,000 feet and when the sun goes so does the heat.

Clincal Cases

Finally for this blog two more patients; one a more serious “mango tree injury” in a 13 yr old boy who fractured his spine at the chest level and is at the moment paralyzed from the mid trunk downwards.

He has an indwelling urinary catheter and has to be turned every few hours to prevent pressure sores. His chance of recovery is small; a big price to pay for a mango.

The other, a baby of 10 months who hasn’t really eaten properly since birth had a complete obstruction to the outlet of the stomach. She was just skin and bones. I operated to widen the outlet to the stomach. It is called a pyloroplasty.



Mother with baby waiting in the entrance to theatres with tubes to drain her stomach.




Mike operating with Dr Engulula

Widening the outlet from her stomach

Three weeks later eating normally and putting on weight fast!

We are off to Livingstone tomorrow Friday at 11.00 by courtesy of the Mazhandu Family Bus Service, big blue luxurious coaches.

The view from the bus at a stop on the way to Livingstone.

We will be getting our first look at the mighty Mosi-oa-Tunya, smoke that thunders or the Victoria Falls in the relative dry season and will be staying at the Wasawange Lodge one of the most expensive hotels in Livingstone with a good restaurant so we will be probably having our first bottle of wine since we left England. The bus fare for the 4hr journey one way is expensive, K70,000 or just over £10. The hotel is also expensive at K470,000 or just over £75 per night for a double room including breakfast. It will be an expensive weekend on a VSO salary! Our next blog will therefore all about our adventure getting to and back from Livingstone and if we are lucky our first look at one of the Seven Natural Wonders of the World.
Judy editing the blog during a power cut!