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?!

Blog 11

Another trip to Mosi-oa-Tunya and lots of visitors 1/3/09

Vicki and James arrive on Monday 23/2/09!

It had seemed a long wait for Vicki and James’ visit but suddenly after being in Zambia for almost 5 months there they were, in the arrival lounge at Lusaka International Airport.

They had had a fantastic time at a wedding in Kenya in a game reserve and had also been on a safari in the Masai Mara with all the guests.
As the bus we had booked to meet them would not have got us there in time M.B. had very kindly offered his dilapidated Japanese car, (reminiscent of ‘Dukes of Hazard’ meets ‘The Hill Billies’) in which we swept them off to Monze from the airport in the hope of showing them around the hospital and Monze town that afternoon, before going down to Livingstone the next day. The journey went relatively smoothly apart from paying K100,000 (about £16) to persuade a policeman to let us continue after stopping us. He wanted to fine us K180.000 for skidding dangerously to a stop when he flagged us down. He informed us we were not speeding but was fining us because of the way we stopped! I’m still not sure what all this was about but was glad to get away quickly although it cost £16. Needless to say we didn’t get a receipt.

We arrived home for lunch after a short shop in our nearest supermarket Shoprite in Mazabuka 40 miles from Monze. After a quick tour of our 4 rooms and some unpacking we took them for a whistle stop tour of truck stop Monze, its typical urban dusty open market and the Mission Hospital.

We introduced them to some of our colleagues in the hospital and to friendly Joyce from whom we buy a lot of our vegetables.


We had invited one of my surgical colleagues M.B. and our new VSO daughters to dinner. However Dhun couldn’t come as she was back in India following the death of her G’ma but Natasha came




and we had a lovely meal with interesting company and Vicki on very good form.

We were up early the next morning with a taxi booked with Proven to get to the Golden Pillow Mazhandu Family Bus station, for an early 10.30 bus for the bumpy four and a half hour drive to Livingstone. At 9.30 we were called to be told unless we were there at 10.00hrs for an earlier bus there were no spaces for the rest of the day! In a mild panic we were ready for Proven at 10.00hrs for the 5 minute trip but predictably Proven was late. He eventually turned up 20 mins later after a second phone call but we still managed to catch the earlier bus because it was late! A case of two lates make you early in Zambia. We had our lunch on the bus which required extraordinary skills and co-ordination to get our sandwiches and coleslaw to our mouths between the bumps without sharing it with the other passengers. We were in spectacular Tongabezi on the banks of the mighty (and mightier than our last visit) Zambezi, in time for tea.
We had a great time talking to Vicki and James, and again watching the sun rise

and set on the silently flowing Zambezi, apart from the birds, hippos and occasional rapids. Our thirsts were quenched once again with either Earl Grey tea on the early morning sun rise boat trip or a slightly dilute (for us!!) gin and tonic with ice and lemon watching the sun set on the Zambesi. The food was consistently superb for all meals, but particularly for lazy lunches with excellent wine, on a wooden platform almost hanging over the river looking across to the Zimbabwe side. We sat in the warmth under vast open skies of towering white clouds with a backdrop of deep blue.

This alone would have replenished us for another month or two in Monze but we also saw a much wetter Mosi-oa-Tunya both from the air in an unbelievably expensive, but probably worth, it thirty minute helicopter ride

This shows the wide meandering Zambezi above the falls, the long narrow gully it falls into and the previous gullies it previously created now in Zimbabwe

as well as from the end of David Livingstone Island and looking at the rainbows directly over the edge of the falls,

and getting absolutely drenched by the thundering spray while walking on the other side of the falls.
We dried out in the warm sun sufficient to burn MRT.’s bald patch while Judy, Vicki and James spent a long, long time bargaining to buy the right hippopotamus at the right price.


We also had one evening meal at Tongabezi on a floating platform lit only by candles ten yards from the bank, with food and wine ferried to us in a boat.






We were serenaded by some of the staff who came out to us in a boat and sang a welcome to us at Tongabezi. Some of us thought this was very romantic watching the electric storms lighting the sky on the Zimbabwe side but unfortunately the candles attracted tens if not hundreds (and thousands) of unwanted flying alternative guests of varying sizes so that at least one member of the party had difficulty in getting her food to her mouth through the small gap she had left between the edges of her scarf which otherwise completely covered her head and upper body.




Needless to say we asked to be ferried back to the shore for coffee although some of us found our flying visitors seemed to be less of a nuisance as the wine rapidly evaporated in the wonderful warm air over the gentle waters of the Zambezi. We slept very contentedly to the music of the Zambezi. Next day after breakfast by the Zambezi

Vicki and James flew back to Lusaka, then to Nairobi and finally home. We treated ourselves to an extra night at Tongabezi before taking advantage of the Mazandu Family bus back to Monze.

Visit to Chikuni Village and Mission Community

We are still meeting new people, visiting new places and learning more about the country. We were offered a trip to see Chikuni Mission Hospital, and managed to arrange to go when we both had very little in the way of other commitments. Chikuni is about twenty kilometres south of Monze and about ten kilometres along a very rough road, off the main road from Chisekesi and across a river by means of a ford. It is run by Claudia an Italian doctor, who has been there for several years. She sometimes brings cases into Monze in a 4WD such as complicated obstetrics and car accident victims and so is quite well known by the medics in Monze. We approached the isolated village along the uneven road and saw several streets of well kept single storey modern dwellings with neat gardens. It was very different from Monze, Fratton to Hambledon in about the same distance! We were welcomed by Claudia and shown around the hospital. It has been built by the Roman Catholic Church and has quite a European feel to it. Everywhere was clean, light and well maintained. The wards, lab and x-ray department all open onto a large courtyard garden, with a huge majestic tree in its centre. The new HIV/AIDS centre was opened last year and even has a well-equipped waiting room for children. This area has the atmosphere of an open-air café with seats and tables under umbrellas. There is even a meeting room where an educational day conference was taking place. We were asked to introduce ourselves as we peeped in, and so discovered we were interrupting its recording. This was being done by the local radio for broadcasting later! Claudia also proudly showed the building extension to the existing operating theatre. The new complex is of considerable size and we could see quite a lot of equipment there waiting to be used.

The whole hospital appears to be run by Claudia. She is the doctor in charge with the help of two or three clinical officers. She organises the maintenance and building works as well as all other administration. She keeps meticulous records and seems to know most of the statistics off the top of her head. It is all incredibly impressive particularly the data about HIV. Accurate positive rates are very difficult to establish in well defined complete populations but in Chikuni in pregnant woman they seem, as in all rural areas to be lower at about 16%. When she finally goes she will probably be replaced by three other people. Her enthusiasm and energy is impressive but she did look tired and seems to have little support.

After this we were taken to the local radio station.

This is a state of the art broadcasting and recording building, set up by the Christian Brothers, who run the Catholic Church here. It is run by an Irish Brother who is self taught, with a back-



The Irish brother with Violaine and second son (right) and Claudia the very hard working doctor running Chickuni Hospital.

ground in electrical engineering. There are educational and public service broadcasts, used by the schools and quite an emphasis on music, as the radio organises a Tonga Pop Music Festival in August to which thousands of young people come. They also offer work experience to older school children. After this we had lunch with Claudia, who offered a pasta course as well as chicken and vegetables. There was chocolate mousse for pudding, and coffee – a sumptuous feast for lunchtime – or indeed anytime here! We were joined by a Cambridge medical student who is doing his elective with Claudia and cooked most of the lunch. If he only sees Chikuni he will probably never know what the real Zambia is like.

Our transport had to leave after this, so we lost the opportunity to visit the Cultural Centre and excellent bakery. The hospital seems to be funded by Christian charities and run by Claudia, and we wonder how long it will take for the local people to take it over and run it in such an effective way. We are sure the folk there appreciate and contribute to it all but when will they be able to run it themselves without all this input and financial support? The community, mostly the women I would guess, are also developing income generating schemes, selling packs of vegetables that they have produced having first dried them. But where will they be sold other than as currently in the Diocesan Centre and who will buy them other than ex pats and volunteers? Without vehicles it is a long trek to Chisekesi. There now seems to be more invested in education and health than in the past, but is it just a form of neo-colonialism? It is just by accident that Chikuni Hospital is so remote – as the local Chief had got muddled as to which religious group he had sold his land to.

How different it would have been if they had been close to the main road instead of forty minutes by car down a rough track. Claudia’s dream of doing more than minor surgery in her new operating theatre will never come true unless it has the support of the Health Ministry, and patients with more than simple problems will have to continue to face a difficult transfer. We wouldn’t have missed the experience for the world, and it would be interesting to know how many of these small ideal enclaves there are scattered over Zambia.

The Holy Family looks up!

Another new person in our small world is Theresa, who has come to take charge of the Holy Family Centre, which is a rehabilitation centre, mainly for children, and focussing on physiotherapy, which is her background. Judy had met her when travelling back to the UK in December. She is very lively with a load of energy, and charged with updating the facilities at the centre as well as improving and expanding the services. Maggie, a friend, was with her for the first three weeks and it was very impressive to see how much was achieved. As well as discovering disused buildings that should be demolished, a container with sixty-five hospital beds (she plans to sell most of these), wheel chairs and bicycles, she also found two eighteen year old boys who had been abandoned by their families and were living with the young mothers when they brought their children in. She could see a scandal in the making. Like a whirling dervish - yes, she has lived in Egypt - she has sorted all this out, renovated and redecorated her own bungalow plus accommodation for volunteers and generally has an iron fist in a velvet glove. As Maggie left, Mo, Theresa’s husband arrived, plus two volunteers, Aidan and Maeve. Mo seems to be a displaced person of the first order, and has Irish, Canadian and Egyptian passports! He is Palestinian by birth – still has family in Gaza – but his immediate family has finally settled in Cairo. He met Theresa when they were both in Canada, where she first worked after qualifying. He is older than her, and her first home with him was with his family in Cairo, where she seems to have learned lots of skills for life here. They seem to have spent a lot of time in the Middle East and Mo has now retired, but still with some business interests. Theresa still has a lot of energy and is clearly not ready for retirement yet and we suspect she and Mo will greatly change things at the Holy Family. We have continued to be constantly entertained and informed by numerous visitors which seems to be so much an integral part of being an ex-pat in Africa. We mention Brad and Tom in the clinical part of the blog who have joined us at the parties, BBQs and swims with our new friends at the Holy Family, Theresa together with Mo, Maeve and Aidan, and Eric and Carol from the States who have been working with Natasha and Francis in sports for kids.


Brad on the right, Mo front central Tom and Michael between Mo and Brad. Thersa,Carol and Aidan facing out from the back. Judy front left with ? Maeve behind!

This weekend Tom has visited from Lusaka. He is doing VSO work coordinating NGO’s who are trying to mitigate the effects of HIV/AIDS in women, and is also the chairman for the VSO volunteers in Zambia at the moment. He travels around Zambia meeting the volunteers so gets a very good overview of what is going on. He met Jane L (volunteer in Livingstone), who, with her husband, had had dinner with the very young President of Rwanda, who persuaded them that they were now determined to put an end to the Hutu/Tutsi genocide war by peaceful means. Let's hope he is successful. We also talked a lot about how important it is to minimize the harm that can be done in trying to help Zambians move into the modern world, which is now so evident to all of them through all the new methods of communication including satellite TV. Satellite dishes are growing like maize in a good wet season.

Clinical Cases

I was hoping that after the busy weekend of the gunshot wounds that the next 2 would be quiet. This was not to be.

Sigmoid Volvulus: a twisting of the gut!

The following weekend I had to see 2 cases of sigmoid volvulus late on Friday evening and could not operate on either because we ran out of oxygen at 02.00hrs Saturday. One died on the table later on that afternoon because of bleeding from the spleen and because we had no blood for transfusion!
Both cases had extensive necrosis of the sigmoid colon but the second also had severe damage/ischaemia to the rest of the colon, which led down the path to attempts to remove it resulting in damage to the spleen. This was partially calcified and severely stuck to the diaphragm. Although we eventually controlled the bleeding from the diaphragm, (the splenic vessels weren’t a problem) he had probably bled down to 10% of his initial blood volume, which we could only replace with simple saline (no blood).
In retrospect I should have left the “bad” colon in and taken the risk of it making him very ill subsequently, rather than taking the risk of blood loss from removing the colon without blood for transfusion. These are new clinical scenarios for me and hopefully I will make the right decision next time. Fortunately I was joined by Mr. Banda to explain to the distraught relatives of this man that he had died inspite of all our best efforts. His bowel might have been in a better state and not needed removing if we could have operated on him 12hrs earlier, if oxygen had been available in the early hours of the morning.

Fortunately the second case did very well and went home a week later. I did a temporary colostomy that we can close in 6 weeks time.

I tried to deflate both cases from the lower end but the twist was too tight in both and at any event it was clear the colon’s blood supply had been compromised as shown by bloody mucous in the lumen of the bowel. It is said that it is possible to decompress the majority of these and avoid major surgery but I have succeeded in only 1:4 probably because they mostly present much later in Zambia.

Although I had a very quiet week, the weekend was again busy just before Vicki and James arrival on Monday for our week’s holiday!

First of all I was called in early on Saturday morning before breakfast while we were doing some gardening before it was too hot. I quickly shaved and had breakfast and as the hospital transport had still not turned up in-spite of two phone calls I walked in under the now burning sun. I arrived drenched in sweat to find M.B. had already removed another necrotic sigmoid volvulus in a 41-year-old 29-week pregnant woman. The problem was that she also had dead and twisted 60cms of terminal ileum and ascending colon. Around the very large uterus we removed the dead part of the bowel joined it back up and also joined the 2 open ends of the colon left after removal of the twisted sigmoid. We decided not to do a stoma, as it would have been very difficult to site it. The next day she was looking very well, was eating and drinking very quickly and although she went into labour a week later and had a healthy live baby who is doing well it means so far, 200% survival.

A 12 year old with possible re-perforation of small bowel typhoid ulcers.

MB and I were looking at this woman in ITU on Sunday morning after mass and congratulating ourselves on her excellent progress following resection of small and large bowel, when we noticed a very sick 12 year old boy who had had surgery for a double perforation of his small bowel, probably secondary to typhoid 3-4 days previously. He had green intestinal contents coming from his wound and as he had had a join (anastomosis) in his bowel we thought it must have been leaking. I phoned the surgeon who had done the previous operation and together we did further surgery after persuading a very reluctant anaethetist to put him to sleep, especially because he had already had a cardiac arrest during his previous surgery. In fact at operation we found he had not leaked from the join in the bowel but had a further perforation beyond the sutured join in his bowel. His tummy was full of intestinal contents with severe peritonitis for the second time, his blood pressure was very low 50/20 but he rallied quickly after washing him out. We did a further resection of his bowel and then brought an end out as a stoma as we didn’t think it was safe to join him up again. We will be using stoma bags supplied by Carol Sturgess given to Vicki by Emma to be delivered the day after the operation!! Great timing! Thank you Carol and Emma. He has survived the week and I will be seeing again him tomorrow.

Simon under the watchful care of his grandma

10/3/09 The boy continues slow improvement although the whole of his wound has fallen open,

there is little healing and he remains very weak. It’s a good job no further anastomosis was done. I am encouraging him, with the help of his grandmother his only visitor who always greats me with a short bow and speaks no English, to eat his nshima including salt and “porridge”. Porridge is simply dilute ground maize compared with thicker stickier nshima. However as with the malnourished babies the nutritional nurse from the paediatric ward is arranging for his 10.00 hrs feed it to be supplemented with soya bean milk. I have also bought him a bottle of golden syrup to put on the porridge at which his very large and at the moment sunken brown eyes lit up with a smile for the first time.

His best hope for survival is being able to eat as we have no other forms of nutrition available like intra-venous feeding or even an elemental diet. He and we live in hope and I suspect a considerable amount of trust. His ileostomy is difficult for him to accept and the nurses to manage but at least we have a great supply of ileostomy bags, which are keeping most of his bowel contents out of his wound. We are now encouraging the ward staff and his grandma to take him out into the sun in a wheel chair. He still cannot walk or stand, that is the next step and then will come the difficult decision of when we should close his stoma, a smaller operation but still not without risk if we close it too early. The problem is that if we send him home with an ileostomy we may create even bigger problems. He may live in a rondavel in a hamlet, several hours from the hospital with no running water, a lot of dust and no support. I will let you know how he gets on in future blogs.

He was eventually transferred to the Holy Family for convalescence and feeding up! He really rapidly improved, gained strength, his wound healed with the careful care of one of the nursing brothers and was eventually re-admitted and had an uneventful closure of his ileostomy putting him back to normal. The Holy Family bought him a bike, paid for him to go to a local school and arranged for him to live with his uncle in Monze closer to the school. Over all a great success and it was a privilege to be able to help him. I hope the medical staff understod what can be achieved by persistence, good surgery at the right time and the importance of nutrition.

I hope the next few w/ends will be little quieter. (They have been so far!! 10/3)

Two Cases of imperforate anus (IA) repaired at Monze Mission Hospital (MMH)

In a previous blog I recorded I did a trephine colostomy in a newborn girl with imperforate anus( IA) and MB had a previous case now 3 years old also with a colostomy waiting for definitive surgery. MB had told the mother to bring the child back on the first of March 2009 for surgery and had written this on a torn piece of brown cardboard paper. He was worried when she didn’t turn up on the first but his delight was clear when she did arrive on his doorstep one early morning a week later clutching the piece of cardboard with a small baby on her back and the patient walking at her side. She had not knocked on the door just waited anxiously until he emerged, said not a word, presented the piece of cardboard and watched MB as in his delight he checked the child’s tummy for a stoma. She never spoke and I suspect she couldn’t either speak nor understand English. MB immediately organized her accommodation.

Imperforate anus is when children are born with no opening at their lower end and have a complete bowel blockage. They have to have emergency surgery at birth to relieve the blockage with a colostomy or they would die.

One of MB’s many talents is to arrange for a stream of various specialists to visit MMH. This time it was Brad F. a very experienced paediatric surgeon from Minnesota, who is a colleague of Stanley Goldberg and David Rothenberger.



He was visiting Zambia with a church group, including a young Welshman called Tom from Swansea. The group was seeing patients in clinics in Lusaka and Tom was introduced as a pharmacist, as he helped distribute drugs at the clinics. MB had arranged for Brad to come to Monze to do the I.A. cases, of which he had great experience, doing around eight to ten a year in the States

The first case, in the baby I had done a colostomy at birth went well.





The second unfortunately died on the ward less than 24 hours post operatively.

Both cases were relatively straight forward although in the second we had great difficulty in catheterizing the baby pre-operatively because of the recto-uretheral fistula

Repair of IAs are now done by exposing the rectum through a long mid-line incision in the perineum and completely dividing all the sphincters and the ano-coccygeal raphe. An amazingly bold approach but much simpler than I remembered from many years ago. The first case we also dissected the rectum off the posterior wall of the vagina and in the second a recto-uretheral fistula had to be divided with repair of the resulting defects in both tubes.

The pelvic floor muscles or cone, including a very dispersed stretched out external sphincter is then snuggly re-constructed around the lower rectum/anal canal. The rectal mucosa is sutured to the buttock/anal skin at a site identified before an incision is made. In the second case the area where the anal opening should have been had the appearance of a splayed out anus with the anal ruggae still just discernable.

Apparently reasonable continence is achieved in the majority of cases in-spite of any really obvious external anal sphincter and anal canal. However, although the first case seemed to have reasonably good muscle and will probably have a good functional result when the colostomy/stoma is closed in 2 months time, the boy in the second case had a much less chance of being continent although it is difficult to know without closing the stoma.

The second patient never fully woke up after surgery and MB first learnt of his death when the patient’s mother again turned up on the doorstep of his house early the next day, in tears with another torn off piece of cardboard with a very different cryptic message. It simply gave the number of the child’s place in the mortuary.

She had no where else to go before going home so she sat down outside the house silently weeping intermittently breast feeding her new baby still wrapped closely to her.

Well that’s all for the moment. We are almost half way through if we allow for our accumulated leave. We are beginning to yearn for a bit of snow and our two weeks skiing (at least) with the Penns next year and to see you all again.

We are expert canasta players and Judy wins almost as often as I do so it was just the cards before or has she just learnt to play like me!!??

However we are not missing the weather and may be going to a meeting in southern India in February next year so hopefully skiing trips can be either side of this.

We remain well and happy.

See you all in June.