Blog 4

8/11/08 ' The Mango Season'

It is the beginning of the Mango Season, which is important for at least two reasons!
When we arrived the mango trees were heavily laden with small green fruit.

Green mangos a little bigger!

We have watched them grow and begin to turn yellow and have used the shade from the trees to walk to the hospital. They are large very attractive trees with fairly dense and deep green foliage providing deep cool shadows.

We play a game when we are out walking to see how far we can get without being in the sun. The difference it makes is well worth the effort. The direction and shape of the shadows change rapidly as the sun moves across the clear blue skies from being very long and pointing to the west at 7.30am in the early morning to pointing east in the late evenings at 18.00hrs; yes that is late as it is dark by 18.30hrs. To our delight and surprise it is directly over our heads at mid-day which means our bodies cast no shadows in front or behind and a tree’s shadow covers a much smaller area. We thought this only happened at the equator and we are 1,500 miles from it! However the maestro, of course, worked out that as it is winter in England at the moment, the earth must have been tipping on its vertical axis to the north, putting Zambia (in the Southern Tropics) directly under the sun at midday. This is why it is Zambia’s hottest season at the moment and we walk directly on our head’s shadow in the middle of the day! As the earth tips back to the south it will get cooler here, the sun will not be directly overhead at mid-day and our shadows will reappear. We will continue to observe and report back on this in six months to see if this is correct. What it is to rediscover what has been known for 400 years and must have been so exciting for the first people to realize the implications of this!

Back to the Mango Season!! The shade they provide aren't one of the two reasons it is important!

The first is because we can add mango

to our home made natural yoghurt, bananas and honey for breakfast and the second is the increase in numbers of children with a fracture of an arm, “the mango tree injury”! Boys and girls are falling out of mango trees in increasing numbers hanging on to their mango with one hand while breaking their fall and arm with the other.

Climbing is not confined to children. This guy was climbing a tree just inside the hospital gates in the hospital grounds!

And this guy was somewhere else!

We will be doing some research to see if there is an increase in the ratio of fractures in dominant and none dominant arms. (this was never done)

Eventually there was a third benefit of the mango season; Judy made some delicious mango chutney which we ate with cheese and gave to others as presents.

Work on Saturday in Monze!

As today is Saturday we had a lie in. In spite of this but after a fairly energetic start, making the tea, watering the garden, hanging the clothes out and having a bath I (M) felt exhausted and light headed and thought I must be developing malaria. The clue was I was also hungry and after a large breakfast I made a rapid recovery from “hypoglycemia”. We are eating much less and I think I am suffering from salt depletion! I still have not been adding salt to my food but we must be losing increased quantities so I will start adding a little. My BP yesterday was 90/65!!

We went for a barbeque with Dhun, Natasha, Anthony and Sarita and MB (the gynae surgeon) at M and N’s home, sausages and rice. salad followed by banana, nectarine and pear sponge cake. Very tasty. They are from France, are Catholics and work for the Bishop of Monze. N's father was American, mother was Italian and he was brought up in Paris. He has been in Zambia for 18 months and is finding things difficult at the moment.

After lunch we went for a swim at the local campsite pool out of Monze on a farm - Moorings. We travelled there in a truck, the five women in the covered bit and the three men in the open back of the truck, which amused many of the locals. It was a very refreshing ride for 11 kilometres. After the swim we had a beer as we watched the very red sun begin to set behind the trees.

Many trees add brilliant colours to the landscape most of which is brown apart from the green leaves of the trees. The four most colourful are red, white, blue and yellow, respectively flame and flamboyant trees, white beautifully scented frangipanis, jacarandas, and unamed yellow flowered trees.

These may be flamboyant?

Sarita and the red flowers

Frangipanis at the hospital

Jacaranda seen in the streets on our way home

In the hospital grounds!

The garden where we swim is so far the only place we have see blue Agapanthus Africanus. Hannah do you remember the family story of you in LA reciting this on the back of my bike?

On Sunday an early short jog because my left knee is playing up and I am jogging at 3,000+ft, the height of most of Zambia apart from that close to the mighty Zambezi which has another 2,400 feet to drop as it leaves Zambia before it reaches the Indian ocean across Mozambique. I jog on a road which runs alongside the golf course, where the greens are brown and is nothing like as grand as I suspect it was before independence. We went to the hospital chapel at 9.00hr. The service was in English and Tonga and the singing was light, tuneful and with drums. We met Xavier again, a Frenchman working for the Catholic Diocesan Centre who we met on arrival in Monze. He is here for 2 years with his wife and five young children. Together with

N and M, one or two Italian Sisters and the Italian Bishop they make up quite a European enclave! It will be interesting if we can get to know them better and find out what inspired them to come.

Later that day we spent 4hrs on the inter-net at the Golden Pillow (GP) and finally, Dhun, our young Indian VSO colleague arrived to help us set up our blog “Mwabonwa Zambia”. We hope that all family and friends can tap in to see what we are doing, if they wish!

Monday 10/11/08 Clinical Cases.

One month in Zambia and a down day for Mike. Firstly he had to do two groin hernias on a 60yr old because the wrong side was done first, a sueable offence in the UK. Secondly he pricked his finger through his glove. Fortunately the man agreed to be tested and was HIV negative.

Michael Breen was doing much more interesting cases in the other theatre with Christine Evans.

The two Mikes assisting Christine Evans who is holding up a penis she had circumcised. She told the patient it was now looking better than it had ever done! It was done under local anaesthetic.

Christine is an English urologist who works in Wales and is colloquially known as the “Dick Doc”. She is a good surgeon who has been visiting and operating all over Africa for over 18 years. She did a Boari flap for a uretero-vaginal fistula in a woman post caesarian section, an open prostatectomy, an open reconstruction for a uretheral stricture and open exploration of a bladder for a stone. Subsequently on Friday, just before she left Monze, we had a very entertaining BBQ at our favourite (and only) swimming pool, campsite and bar.

Apparently Christine is quite a well-known personality; she has been on the 'Weakest Link' twice, and was more than a match for Ann Robinson. On the strength of her first appearance she was invited to make programmes for Channel Four concerning some of her more “interesting” procedures such as penis enhancement and gender reassignment - pictures stored on her camera to prove her point. She is now sixty-five and has probably just done her last operation ever with Mike assisting. She is keen to continue coming to Africa as an examiner so will continue to entertain and educate. She is a fascinating character – drinks whisky, smokes cigars and is retiring to be a county councillor in North Wales. She is obviously very proud of her Oxford (St. Edmunds) graduate daughter who plays rugby for Wales.

It was another idyllic evening and a good start to the weekend. Christine was off to Bulawayo by overnight train from Livingstone the next morning, which she said was a terrible journey she had done before and only made tolerable by the whisky she will drink and the fact she has the whole of Sunday to recover before teaching the Zimbabwean medical students on Monday.

Tuesday 11/11/08 Surgery isn't always straight forward and the Anti-Retroviral Therapy (ART) clinic.

I (M) had a better day today doing a hernia in a baby and division of a persistent process’ vaginalis neither of which I had done for about 20 years. I then did a very superficial anal fistula again in someone who was probably HIV positive. None of the operations were straight forward all having an African slant for different reasons. The only diathermy was in the other theatre, I had scissors that didn’t cut and even the scalpel was blunt. I am learning fast.

In the afternoon after a surgical ward round that produced no further surprises I joined Judy in the Anti-Retroviral Therapy (ART) clinic. Over to Judy.

I have spent a lot of the last two days in the ART Clinic. I sat in at first to try and make sense of their systems, forms and drugs. The clinics are dark, cramped and extremely basic. The narrow corridor to the consultation rooms is used as the last part of the waiting area. It has benches on each side and not only do people sit on these but also stand between the benches so that walking through is almost impossible. The remainder wait outside the clinic along a narrow verandah, and get soaked in the rainy season.

Inside on the left and outside below.

The consulting rooms are scruffy, with no running water, and no niceties such as paper on the couches. There are other small even darker rooms for counselling, lab. tests, data entry and records. The counsellors are brilliant, all are HIV positive and very supportive of each other. I sat in for a short session and saw a real cross-section of society.

A lot of good work goes on and some of the clinics are very busy and staff work late. Unfortunately timekeeping is a real problem (I can’t quite believe I am writing this), and I think morale is quite low. We said earlier how four administrators from this department and a hospital accountant have been arrested for fiddling the books. This includes the person in overall charge for all the HIV/AIDS programmes at the hospital and involves large sums of money, which will probably never be recovered. Next door to the present clinic is a less than half built extension which will now have to wait a considerable time to be finished. (Promised to start in March of '09, but in fact no work done by Sept.) The frustrating thing is that no one talks about the problems and there could be many reasons for this. It does however make me feel excluded and wonder if I or Mike will ever win their trust. What is also rather devastating is that we have just learnt that Sister Kapapa is also moving on. We think she is great and had set up some really good schemes with the orphans and the drop-in centre.
There is no doubt that the clinics could be more efficiently run and much better use made of the nurses. Tests and appointments could be better co-ordinated so that patients have fewer visits – some may take half a day to walk to Monze from their villages. The head of the clinic is a clinical officer and not a doctor and may not have the authority to try and re-organize things. I have talked to him in the clinic and I know he would like things to change. He is so busy - not only there – but also at meetings and workshops - which most of the staff love but I think he finds it easier just to get on with the work. M and I discuss endlessly what could be done if we had everyone’s agreement but we think it will be a long slow process. They will have to see the need for themselves and even to suggest a meeting to discuss any of this would seem to be too critical at the moment.

One area of the ART programme that has been heart warming to see is that of Home-Based Care. This is run by carers who at the moment work mainly in the urban areas. They are male and female volunteers, usually HIV positive, who monitor their patients in the community. The urban catchment area has a radius of about 10 km and the carers often travel long distances on foot to see patients or collect drugs for those too sick to travel themselves. The few in rural areas travel even further of course.

On Wednesday morning we went out with Ringness, a carer, and one of the counsellors, to see some of her patients. We were welcomed into homes, all of which were spotless, in spite of the all-pervasive red dust. They were not the poorest of homes, and that may have been deliberate, but none minded invasion of their privacy, and were happy to answer questions.

Visiting HIV positive patients and their families with Home-Based Carers.

Clinical cases

There continues to be an amazing variety of new clinical scenarios, which bewitch and worry us. An 11yr old girl died after a snake bite on the way to Lusaka in an ambulance after being admitted to Monze and in spite of having a tube inserted to help her breath; a young man died after having a burr hole done in his skull after falling out of a truck; another child was half scalped after falling of a bullock cart; a young woman presented with jaundice from massive enlargement of her liver and spleen thought to be due to a lymphoma and a sigmoid volvulus was decompressed with a naso-gastric tube! Another 11 year old died from a tension pneumothorax, after falling out of a truck, which wasn’t sufficiently decompressed.

On Thursday a series of simple cases were done, some with questionable indications. Several circumcisions seem to be done in babies ostensibly for phimosis (tight foreskin) but really because their fathers have heard it reduces the risk of HIV, a breast lump was done under LA with far too much breast tissue taken fairly roughly and two young men returned to theatre for re-manipulation of badly displaced mid-tibial fractures which should either have had open reduction and fixation or traction using a Steinman pin through the heel bone. This place would greatly benefit from having an orthopaedic surgeon here for a time, what do you think Scott? They have visiting orthopaedic surgeons once month and I will get them to give me a tutorial when they visit next week.
I then did an orchidopexy for an undescended testis with Jamie a visiting urology registrar. He is a UK trainee but started in Nairobi with Hindu Indian parents and is visiting Monze with Christine Evans. Two hours after arriving he helped Michael Breen do the burr hole at 2 am in the morning. We were a good team, neither had done this operation recently, he for four years me for probably 18 years.

On Friday I assisted the “Dick Doc” do a circumcision on a man with a penile ulcer and non-retractable foreskin.

Christine then did an exploration of a kidney in 30-week pregnant woman through the loin and did not find anything wrong in spite of an xray and ultrasound scan suggesting a stone. I hope the patient comes to no harm. The previous day they had explored a hydronephrotic balloon like kidney, again in a young pregnant woman but using the wrong approach (the loin) because the blockage was at the level of the bladder and the incision was too high to get to the bladder. Nevertheless they drained 2 litres of urine and left a drain in her kidney until she has delivered. Then they will be able to remove the blockage so hopefully she also won’t come to too much harm.

Charity football and netball matches.

We had another very interesting but long tiring and very hot day in rural Zambia 15 km from Monze along a dusty unmade road to watch football and netball played for prize money supplied by “Shoprite”. The hospital used the event to promote their voluntary counselling and testing (VCT) programme for HIV and a Zambian non-governmentalorganisation (NGO) Matantala, which relies on Norwegian financial backing (the Ambassador from the “Royal Kingdom of Norway” was there) funded the whole day.

The hospital VCT team including Mrs. Yamba the hospital executive secretary and her son set up their session under what else but a Mango tree heavily laden with fruit and, without stopping for lunch saw and tested 64 people away from the main activities and four (5%) were positive. The test they use for HIV can be done anywhere including in mango groves and they get the result almost instantly; a little red line to the left as well as the right on a small thin plastic strip. The reactive people were counseled and will attend the HIV/AIDS clinic on Monday. Most of these people would never have taken the long journey to Monze so this sort of opportunity is great to raise awareness and get people tested. The positive rate was reassuringly low in this very rural area but can be as high 30% in urban areas and in pregnant women in Monze. As positive or reactive mothers can give it to their children before and during birth or through their breast milk (slightly less common), such children are assumed to be infected and are treated until they can be tested at 6 weeks. Fortunately although the anti-retroviral drugs can make you feel sick and have side effects these are relatively mild.

Again I am getting tired, the dogs have stopped barking, the frogs seem to have disappeared and the girls have yet to return. Natasha was out to 5am last night with Crispin, they have borrowed money, rice and bread from us, they introduce us to all their friends and they are coming around to dinner tomorrow night. It is just like living next door to two daughters!!

Hibiscus