Blog 12

Ku-omboka “To get out of the water”

April 28th




This is one of the greatest traditional celebrations in Zambia and we were told it was not to be missed!

It takes place in the far west of the country close to the border with Angola and is based on the movement each year of the Lozi King (the Litunga) from the flooded Barotse Plain at Lealui to his dry palace at Limulunga. The Barotse plain is a vast flat area of land on either side of the mighty Zambezi which floods during the wet season to produce an extensive lake with narrow deeper channels between tall reeds.




There are very few trees, no hills, merely mild elevations on which people live in fairly primitive huts, apart from the Litunga who lives in more substantial single storey buildings.

When on the flooded plain in a boat there are uninterrupted 360 degree views to the far horizons, which meet the intense blue skies giving a feeling of great space. Amazing light is reflected off the water and the dark green reeds, which bend in gentle warm breezes. The water is pale green but crystal clear and up to 12 feet deep in the channels shallow enough in the reed

areas to allow “punting” in canoes made from hollowed tree trunks.



Before the wet season the Barotse plain is completely dry and travel is relatively easy by dusty tracks. However when the plains are flooded by the surging waters of the increasingly mighty Zambezi, travel is only possible by boat and as for some reason the King seems to leave his escape to the latest possible time, all his chattels, family and retainers have to be transferred out by boats hence the tradition of “getting out of the water” or Ku-omboka.





This is a major logistical exercise all carefully organized by ancient protocols. Drums are used to tell the people when the Litunga is about to move.

The time varies from year to year according to the height of the flood, has to be at full moon and often occurs with only 2 weeks warning. The drums are played at every part of the meandering 6-8hr journey across the lake often accompanied by dancing in the boats. The crossing is in an assortment of 12 official royal barges and canoes. These are propelled by large numbers of oarsmen and punters with great skill in traditional dress.

Nalikwanda

There is a complex set of rules for selecting the oarsmen who are subject to many behaviour codes. For example all the Litunga’s subjects must kneel or sit as he appears and he is treated like a medieval King. This is probably why on his boat, the Nalikwanda he has an area covered by a white sheet on top of which stands a model dark grey elephant. His wife travels in the second royal barge the Mbolyanga, which is mounted by a bird. There are also rules regarding the passage of the boats, which, by protocol can only turn to the right. Thus to turn to the left they make great loops and circles, making the journey longer and more complicated.

We first had to get to Mongu, which is 750 kilometres, two punctures and 12-13hrs from Monze over some dubious roads.

Our puncture

Someone else's puncture!

On the way back another puncture. How many people does it take to mend a puncture in Zambia?

ONE who knows how to!!

It did have one or two compensations with good company, high spirits and travel through one national park with lots of impala, velvet monkeys and wart hogs to see.

Our accommodation was depressing and superficially dirty because the walls were left unpainted. There was no running water, no flushing toilets, no food and outside hot showers with grass floors using water heated by the “staff” on open wood fires! Middle class Africa!

And that wasn’t the worst of it! The prices were about 4x the usual amounts. We didn’t think we could stay more than one night but survived two and met some interesting people.

So what made it all worthwhile?




Just before sun rise still not having eaten!



Definitely the boat trip across the vast Barotse water plain to the Litunga’s dry season residence and back to Mongu harbour after watching him leave his island with all his oarsmen, household chattels, suitcases and family! And we were told it was a spectacle not to be missed?!

It was a unique experience. We had to get up early without food to get to the boats at Mongu harbour and arrived as the sun rose on a what became a long and very hot day, our heads only covered by the traditional red hats.

Sarita

Tasha and friend





Dhun

Sikopo our Losi clinical officer anaethetist. He was highly effective and should have been retired but is irreplacable. He organises a bus trip to Kuomboka every year for his Monze friends

As the sun was initially low in the sky a lot of what we first saw was chiseled out or silhouetted against the sparkling water, green reeds or blue sky dotted with white clouds. The very tall isolated trees mostly palms, were striking, and seemed to reach to the sky. The primitive dwellings on the few elevated strips of land uncovered by water were lined by waving residents, black Lowry figures, adults and children bent at various angles of excited animation and outlined by the sun’s horizontal rays.

The great expanses of reeds stretched to the horizon, but most spectacular were the dugout canoes punting down the edges of the narrow open tracts, some of the boatmen seemingly



unsupported and partially hidden in the reeds, with invisible canoes but still with their punting poles driving them forward.

After returning to dry land in Mongu we managed to break our fast at about 15hrs and then rushed by road to the Litunga’s dry residence at Limulunga north of Mongu. It was still not quite in time to greet his and all the royal barges arrival back to his private harbour, probably the most spectacular of the day’s events. However the Litunga hadn’t disembarked to walk up the hill to his dry palace and we were able to join the happy excited if not exalted red-hatted mob lining the route to watch the spectacle.

Zambia’s President Rupiah Banda also joined this stage of the celebrations arriving in a large 4 wheel drive car.

One of my (MRT) main aims of coming to see this spectacle was to get a photo of the Litunga in his famous admiral’s uniform or that is what his subjects universally believe it is. The story is worthwhile telling. The Litunga’s grandfather was invited to King Edward VII’s coronation and he was offered a spare redundant diplomatic uniform of a British Ambassador to wear. Edward was keen on designing uniforms and because he had designed new ones for his ambassadors there were some unused old ones. As the old one had a cocked feathered hat, which resembled an admiral’s, the legend developed that the British government had made him an Honorary admiral.
It seemed appropriate that he should also wear his uniform on the occasion of his only boat trip across the mighty Zambezi’s flood plain each year - in this land locked country!

As you can see he leaves his marooned palace in his traditional costume, which includes a kilt like skirt and matching waistcoat,

The Litunga

and his luggage!

and after boarding Nalikwanda the elephant mounted royal barge, at some point in the 7-8hr winding journey through the reeds he changes into an honorary admiral.

We did try to persuade Jonathon Band to come and pay his respects. Perhaps next year??!!

We eventually arrived home from the Litunga’s dry palace after a reasonable meal in Oasis, the best restaurant in dusty Mongu, which has the atmosphere of a western frontier cowboy town in the States. We slept surprisingly well for a second night in our semi-open bedroom, which had no ceiling. This allowed conversation with unseen other people in other rooms including babies, young children, young adults, husbands and wives and many others. The acoustics were such that your voice carried very well to all corners of the single story house after bouncing off the uncovered corrugated iron roof. The only rooms with a ceiling were the bathrooms with unflushable loos, from which hopefully the air and sound weren’t as easily transmitted as the sound from the other rooms.
We had initially planned to stay for three nights but it wasn’t a difficult decision to return home after two.

At the end of another virtually non-stop 11 hour journey, with a little shopping for the grandchildren on the way, the last two and a half hours from Lusaka to Monze was in the dark

and in very unsafe conditions. It was much less enjoyable than the journey in the other direction to Ku-omboka. We watched one car hit by a drunk driver who, after trying to escape, was jailed and after another African style mending of a fellow traveller’s puncture we arrived home safely but exhausted. Michael also began to be ill with diarrhoea, probably from having breakfast in the best restaurant in Mongu. Our heads are still buzzing from this trip with all its highs and lows and with images and memories, which were well worth the effort, quite different from the effort of skiing or sailing!

Hey ho we have passed the 6 month mark, we are still well, apart from M’s problem with diarrhoea at the time of writing, happy, and looking forward to the next 6 months from which we will be taking most of our annual and study leave in coming home in June/July for the arrival of Hannah's baby and permanently in October.

Perhaps our next time volunteering should be something more challenging like the USA or Outer Mongolia?



Food Fest and Social Life and Mary Lee

I (Judy!)have gradually been able to increase the range in my cooking and have learned to make a meal from what is in the fridge and market without using a cookery book. Fortunately onions, tomatoes, green peppers, cabbage and potatoes have never been out of season. Now we also have aubergines, french beans and very recently sweet potatoes. The cabbages are especially good and we use them for coleslaw as well as stir fried with onions, tomatoes and turmeric. At the moment large tomatoes cost 30p for four large ones while fairly small onions are 3p each. A very large cabbage is 30p as is a small pack of french beans. The mushroom season was poor this year and we saw tea-plate sized specimens being sold on the side of the road for £1.50 each – too expensive for us! I have bought some dried ones however, which tasted different but worked well.
The meat we usually get out of Monze at Shoprite a South African supermarket chain. The nearest is 45 minutes away so we wait to go with someone else by car, and stock up our tiny freezer. We have bought sausages and kidney for a casserole, and also liver at the local butcher, all from cows, but still quite palatable though a different taste to us.
We were left a whole range of spices by Katie who was here before us. I have been able to identify most by taste and or smell. Fenugreek had me stumped! They have been incredibly useful and have given us great variety. I made my own mango chutney when the mangos were in season and have just made guava chutney with fruit out of the garden – we have a glut.

They also taste good when soaked with a brandy syrup. Puddings are few and far between, though Michael often has bananas, homemade yoghurt and golden syrup – a real lifesaver for him as he always has syrup on porridge. The small sweet bananas are always around and I have made Banoffee Pie though sadly with tinned cream on top. I have also made vanilla icecream twice - there is none in Monze - and was very disappointed when it tasted just like the bought ice-cream at home, although it was made with fresh cream. I have just started making bread as we can only get synthetic sliced loaves. So far I have made pitta bread for guacamole and a curd/chilli/feta cheese dip, and pizza to take with us on our trip to the Western Province for Ku-omboka.

It has been good fun to entertain; no Zambians yet which is a real failure, but ex-pats and volunteers from various countries. Fairly recently we had Mary-Lee and Jocelyn to supper.



Mary Lee






Jocelyn and Judy plus Peter Blackwell-Smythe's head!

They have been living at Moorings (where we swim) for six months.

Mary-Lee is the daughter of Lee Savory who first settled there and built up the farm, and whose grandfather surveyed the area in the early 1900s and told his son it was a good area for a farm. Tom Savory, Mary-Lee’s brother, who was running the farm, was shot and killed at home by two Congolese last year. The men were caught and the motive assumed to be robbery. The farm has been run by a manager since then, but he has just been fired for alcoholism. Thea, Tom’s second wife lives in the farmhouse with their two teenage sons but is often alone there as they go to school in South Africa. She is Dutch, a doctor who seems to work with HIV/AIDS on farms around the area. Thea was Tom’s second wife and quite a bit younger than him. His first wife either died from Ca breast or committed suicide, although I am inclined not to believe the latter. Tom’s father, Tom and his first wife are all buried on the farm at the end of a long avenue of trees planted by Tom’s grandfather although he never actually settled there.

We are discovering that most white Zambians seem to take a lot of responsibility for their workers and their families. Moorings runs a school, a clinic for the families, has an educational

and social programme for the adults and helps the women with income generating activities.








The workers live in their rondavel village near the farmhouse and farm buildings, so we see the children - always boys, playing and cycling around, as the girls will be helping their mothers.

Mary-Lee feels very strongly that the women are used and abused and that empowering them is part of Zambia’s development.

These seemed a very happy and gentle group of men at Moorings who managed the vehicles and machines for the farm and lived in the village on the farm. Are these the guys ripe for a change in culture and attitudes to women??

A purple lily in the pond at the front of the farm house near the pool. The farm's gardens were filled with beautiful flowers throughout the year some of which are in other blogs.

Mary-Lee could remember the beginnings of Monze and one of its few roads here was still named Savory Road after her grandfather. Her grandfather, with a neighbouring farmer, built the Protestant church in Monze, which is behind the Golf Club and really out of the way for any Monze Zambian who wants to go. It is easy to imagine that back in the day the white Zambians would drive into Monze for church and a round of golf; all meeting together and socialising at the bar with a picnic lunch or possibly a brai.
Mary-Lee has been very hospitable and we have met several times for supper as well as the odd G and T after swimming. She is an exceptional and charming woman, was sent to boarding school outside Johannesburg (as they mostly were, and still are) from the age of eight years, brought up on the farm and married locally. Her early married life was in Zambia as her husband worked for the government before Independence. They moved around the country quite a bit but eventually emigrated to Canada with their four daughters after having been more or less forced to move out. This happened because of Kaunda’s policy of “Zambianisation” (her husband, not being black, could no longer work for the government)
One daughter has married in Zambia and lives about 30 miles from the farm here, while the others are in Canada. She and her husband eventually split up in Canada, but she has always been involved in teaching and took herself off to Japan to teach there for two years. She says her Japanese is really better than her Tonga! Over the last few years Mary-Lee has started returning from October to April each year. This is not just for pleasure for she actually works quite hard while she is at the farm. She has been involved with a lot of the women’s activities, organised the building of more toilet blocks at the school as well as a kitchen, as the government has said it will give food to schools with one. She says it is quite exhausting but at least this year she has had the company of her daughter, Jocelyn.
Mary-Lee has lived through exceptional times and is fascinating to talk to. We had a glimpse of how it must have been when we went with them to a music recital at Mazabuka, about thirty-five miles away. This was organised by white Zambians at the social club there. There was one black person but no Zambians except those clearing up. Folk had travelled quite a distance and most people knew each other. From the atmosphere and listening to the chatter it was difficult to believe we weren’t back in England. Most seemed to be farmers and many came from the original families who had colonized Zambia. They can no longer own their land or have dual citizenship, but are totally committed to the country. We could have been a million miles from Monze as we ate the most delicious food cooked by the members and listened to four members of a South African company known as the Black Tie Ensemble.
As we drove home we could see the waxing moon awaiting Ku-omboka.


Clinical cases and sharing skills.

We continue to see amazing cases and add schistosomiasis, Kaposi’s sarcoma, extensive skin infections with herpes simplex and various fungal infections (we will show in a later blog) and an extra-uterine pregnancy which is when a baby takes root outside the uterus and the placenta develops on another abdominal structure usually the the broad and round ligaments as in this case but can be the bowel mesentery or the bowel. These are some pictures of the one we saw.

Patient positioned on the table to take the pressure off the vena cava the main vein in the belly

The baby lies free in the belly after rupture of the membranes and is simply removed from the abdomen

The baby out before cutting the umbilical cord

Cord, arising in this case from the left broad and round ligaments cut freeing the placenta which is then delivered

A rather grey baby who unfortunately only survived 12 hours. MB has looked after several of extra uterine pregnancies only a few of which make it to 'term' and only 6 have survived.

We also continue to add rare tumours to our catalogue of other people’s woes.

2 cases merit more description.

First an 83 year old that only just made it following ileocaecal intestinal obstruction (bowel blockage) from a carcinoma but with a Kehlett type enhanced recovery.
This case makes the point of how the management of these cases is really a team effort and how we take for granted good anaesthesia.
Diagnosis and surgical technique were easy and routine and we should have achieved a rapid postoperative recovery. However the patient was intermittently awake during the operation, particularly difficult for the surgeon when trying to close the abdomen as its contents keep getting pushed out or into the needle used to sew the muscles together. We eventually achieved this but then the patient wouldn’t wake up or breath adequately without supportive ventilation. The anaethetist correctly kept the patient intubated and for a short time oxygenated in theatre. She then disconnected him and wheeled him into the corridor where there was no oxygen, or at one time any staff at all, even just to stop him falling off the trolley. The anaethetist then promptly left with instructions to take him to a very basic ITU with oxygen but no facilities for supporting his breathing. I knew that by the time they delivered him to ITU he could have died from lack of oxygen.

All this was totally avoidable and in an 83 year old that had been obstructed for at least 2-3 weeks with grossly distended bowel, severe dehydration and probably malnutrition after a major operation lasting 2-3 hours, was at best reprehensible. I grabbed the trolley and dragged him out of the corridor in theatre to outside under the sunny late afternoon African sky and into ITU and reconnected him to the oxygen. He was hypothermic (difficult to achieve in Africa) and also short of fluid but was breathing spontaneously just enough to maintain his p02 on pure oxygen.

It took another 4-5hrs for him to wake up, three litres of home made normal saline and one of Ringers lactate (no other fluids available) to maintain his blood pressure at 70/50, several episodes of untreated arrhythmias and one very effective dose of lasix which both restored his p02 and corrected his anuria. After 5 hrs the anaethetist reappeared to take out his endo-tracheal tube and he never looked back. In spite of his very dilated small bowel, considerable age, malnutrition, challenging operation, hypothermia, long and difficult peri-operative recovery, we removed the tube draining his stomach the next morning and as per H.Kehlett he started eating straight away and was ready for discharge 5 days later.



Second day post op

A case which demonstrates the strength and endurance of even very old African patients, and that the greatest resource in a hospital are its human resources, doing very simple medicine that even a retired general surgeon is capable of doing, and the magic of enhanced recovery programmes. They really do work even in Africa. We must tell Henrik!

A hazard writing the notes in Africa!!

A death on the table from extensive surgical bleeding (the second case)!

One complication that has to be avoided at all costs in Monze is persistent intra-operative bleeding. Blood for transfusion may be very limited or non-existent, and the anaesthetists do not have the experience to deal with it.

The first case was mine who died because the spleen had to be removed as a result of possibly removing more colon than was necessary; this caused severe bleeding from unexpected dense diaphragmatic adhesions and there was no available blood for replacement.

In the second case there was probably sufficient blood available but too little was given too late. The reduced availability of blood for transfusion and quality of anaesthetic services means that the balance of risks and benefits in deciding what operative procedures are safe and should be attempted, are very different in Monze as compared with Portsmouth.This current case also died during an operation, and is another example of this clinical dilemma. The problem was an extensive tumour of unknown histology in an 18-year-old woman. Attempts to completely remove it should, in retrospect, have been abandoned before blood loss became uncontrollable and fatal. It was probably a chorionic carcinoma, which is treatable and sometimes curable with chemotherapy alone, and usually without surgery.
Resident Zambian surgeons and anaethetists may not have some of the sophisticated knowledge and skills of western clinicians but a part of being a safe surgeon is to operate within the resources available and the skills they can acquire. They are generally very skilled at making these difficult clinical decisions.
Another example of this is the way local surgeons use mainly blunt dissection to the extent of tearing rather than cutting tissues; blunt-v-sharp dissection. This is particularly dramatic in the way hernias are repaired and the way the abdomen may be opened, which amazingly, they can do largely without scissors, knife or diathermy. One local surgeon’s final approach to opening the abdomen (after knife to skin) is to make a very small incision in the peritoneum and transversalis fascia, and with the assistants help he literally completes the incision by tearing the wound open. Similarly the cremasteric fascia is literally torn off the inguinal sac in pieces, in inguinal hernia repair, and then the sac cleaned entirely by forceful rubbing with a gauze swab. This is partly due to the fact that this technique causes very little bleeding compared to sharp dissection without diathermy, because torn blood vessels go into spasm more quickly than vessels that have been cut cleanly. It is much slower to have to catch each blood vessel that is cleanly cut with forceps to stop the bleeding when diathermy is not available. Diathermy is not available in both theatres in Monze and probably in Zambia generally.

Further for a doctor who is not a full time surgeon that has to be taught to do hernia repairs in a rural hospital on a part time basis (the most common situation in Zambia) it may be safer not to teach the more sophisticated techniques that are only safe and appropriate for full time professionals specialising in surgery working in a western country.

During a hernia repair in an elderly man which I was doing with a medical licentiate (who normally used the tearing technique, even in babies) I quickly realized he did not have the skills required to do the sharp technique when he cut the vas deferens or sperm duct using the sharp technique. He quickly and perhaps more safely reverted to his tearing technique, which I must say does seem to be very “safe” and seems to work.

One important lesson I have learnt is before one makes any suggestions about how surgical technique may be changed for the better a long period of observation is required to really understand the reasons different approaches have been adopted. The reasons for these differences may be difficult to identify and understand and therefore it may be dangerous to change.

“Sharing skills and changing lives”, the VSO mission statement can be very complex and difficult to achieve, and it is important never to forget the risks of doing more harm than good. This may delay rather than accelerate progress to new ways of doing things that are in keeping with the local economy, way of life and natural customs.

However I am not pessimistic. We have met many Zambians who are well trained in many spheres, the like of whom did not exist at the time of independence 40 years ago. These are the people who can and will change Zambia and many are impatient for change. The political system may be a little more corrupt than ours but they do have a democracy and a free press which is full of debate and criticism of politicians, which I think can improve the system over the years. What may have to be accepted is that change in the right direction will be slow but it must be in the hands of Zambians and any efforts from western democracies must be at their request and under their control and freely given.

However I do believe that the western democracies should be very selective in what it supports, learning from past mistakes. One guiding principal is that professionals coming to the south should largely work along side Zambians who are already making progress at their request and to solve specific problems through skill sharing. Giving large amounts of money for albeit clear and compassionate reasons without knowing how it is actually used at the coalface can be very risky and result in great harm. We have seen evidence of this at first hand; for example, giving free food to HIV/AIDS patients in Monze and more controversially even the provision of free ARV drugs, which may work against persuading young people to change sexual behaviour. The BMJ has reported that young gays are now less likely to practice safe sex because they believedAIDS can be cured, or at least people with HIV live long healthy lives on treatment.

These examples again demonstrate that we should at least be able to discuss the unthinkable; that the safest way to help poor undeveloped countries is to stay out and let them to seek their own solutions. In the long term, “pain” may be their greatest spur to change and current aid may simply delay the process by reducing but not permanently and completely eradicating the problem causing the "pain".

Well this has been a long blog but we hope not without some interest and a little humour amongst all the woes and dreadful problems our patients suffer so stoically?!