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

Blog 3

3/11/08 The Zambian Presidential Elections and more adventures

The sun continues to burn us and the earth with a vengeance. Much around is brown and the animals are drinking muddy water. The rains are two to three weeks late and we hope there will be some relief in the next day or two. It will then rain on and off for the next six months. This is the growing season when much food needs to be grown and the fields become green again.

We have done very little over the last four days because of the fourth Presidential elections. Voting took place on Thursday and VSO told us to stay at home on Friday in case there was

trouble.

The guys watching the result of the election at our local bar Shakalima's over a beer or two.

Rupiah Banda from the ruling party MMD was elected Zambia's 4th President.

The main challenger Michael Sata who was only 30,000 votes behind (810,000-v-780,000) is very angry because he says the voting was rigged.

In Monze everything has been very quiet so far and most people seem to accept the result including Kenneth Kaunda (KK) and the second President Chiluba as well as the Bishops and the Attorney General.

Swimming at Moorings

We have used the spare time over the last 4 days to catch up on our emails, to do some more shopping, play canasta and ago swimming at a local campsite called Moorings!

The owner of the campsite, which is on a farm, was shot and killed in January 2008 by burglars who were subsequently caught and said to be Congolese. Apparently it was widely known the owner Tom Savory kept cash in the house to pay his farm workers. His family were originally from England and he was the third generation in Africa The family had run the farm for a 100 years and it is now run by his Dutch second wife, with whom he had a second family; two sons now young teenagers who go to boarding school in South Africa. The wife has employed a manager for the campsite. The pool is in front of the family house but the wife is very generous and allows many friends to come at all times to swim. The pool is smaller than ours, is outside but it is very refreshing particularly when followed by a Mosi (lifesaving Zambian beer) at the campsite. The farm was called Moorings by the original owner because he had travelled all over southern Africa but finally moored on this land.

The swimming pool at Moorings

A meeting with the past and more of the present.

On the way home from work recently, having a Mosi in Shakalima (a bar) we struck up a conversation with a Joe Simiegna who was in Kenneth Kuanda's (KK’)s first cabinet as an economist. He had lived in England for over 10 years mostly lecturing in Cambridge. I suggested we meet again but although he grew up and has a house in a local village he spends most of his time in Lusaka so he politely refused but told us he has 8 cars and a chauffeur.

Clinical Cases

Today for the first time we got to grips with some patients! I went to theatre to watch Dr. Engulula (Congolese surgeon) with two of the junior staff, one Doctor Machona

Dr. Machona examining one of the many children with fractures

and one medical licentiate mainly putting plaster of Paris (POP) casts on young children with fractures of their forearms and their legs for club feet.

Supra-condylar fractures before and after reduction!

POP for a club foot. Not so common in our area compared with Northern Zambia where it has a much higher incidence.

They had accumulated (12+ of them) over several days because they had run out of POP,

Michael Breen in another theatre operated on a vesico-vaginal fistula and then helped a medical licentiate do a hysterectomy for cervical cancer.

The theatres work reasonably well with an old but still functioning excellent central sterilising department and once you are operating it feels no different to being in theatre in Portsmouth.

The staff coffee room for nurses and doctors and all others

Scrub facilities. Although there were taps, water rarely flowed from them and we relied on bowls and jugs of water pored over our hands.

The waiting room and recovery also acting as a corridor!

Theatre clogs and storage

The theatre register which contained accurate records of all operations done.

The steriliser kept working by Tony Brand










Irreplacable

Expensive endoscopy kit rarely needed or used. Mostly given to the hospital paid for by various charities.

And finally an operation is achieved!

In the afternoon. after lunch at home and 15 minute walks both ways, mostly in the blistering sun, both Judy and I went on a ward round. Most cases were again orthopaedic or other simple problems but also included a woman who survived a crocodile bite which are apparently highly infective if you survive the immediate assault and a young woman with a very large thyroid goiter.

Tonight was a typical night!!

The electricity went off at 1900hrs before the meat was cooked. The water pressure went down and was off at 20.00hrs. Candles were lit, baths were cancelled, Judy went to sleep after some work on her Apple

and I started this blog until the lap top battery power failed at 21.00hrs. Energy but no water was restored at 21.25hrs. Baked beans on toast were a compromise for dinner with coffee, fritters (a bit like doughnuts but tougher; everything is!) bananas (very good) and treacle and canasta for desert. Judy won for a change. I have never had worse cards, which is the only reason for me ever to lose?!

It is now 23.52hrs so off to sleep under the mosquito nets with the sound of dogs cool air and still no rain. At least we will sleep well and up tomorrow at 0600hrs. for more surgery. An incisional hernia etc (subsequently cancelled 2x and still not done by Thursday. The crocodile bite also needs debriding and has also been cancelled and probably won’t get done until next week.

Tuesday to Thursday 4-6/11/08 The weather changes and we start to do more clinical work

We exchanged our sunglasses and hats for umbrellas on the 4th as it was cloudy and cooler and we thought, to our great relief that the rains were arriving. In fact they didn’t until Thursday the 6th. Better late than never.

Clinical Cases

Today (Tuesday 4th) I (Mike) continued to get a much better idea of the mix of clinical work here. It clearly reflects the age of the population and their activities as of course it does in the UK! The two biggest groups are children and young adults with trauma and women with obstetric and gynaecology problems.

The orthopaedic problems are mostly forearm fractures and nasty humeral supra-condylar breaks in children and equally nasty tibial fractures in young men from sliding tackles in soccer and jumping out of the back of trucks about to go off the road. Some of these fractures penetrate the skin resulting in some cases of osteomyelitis.

Osteomyelitis

The lack of kit and expertise leads to interesting ways of managing these cases from no treatment in very old with impacted inter-trochanteric fractures of the neck of the femur (one old lady actually refused skin traction and said she would crawl home if she couldn’t walk; she wasn’t on the ward the next day!!) to one girl with severe skin abrasions over an open fracture of the forearm draping over her arm over her head as the best way of keeping it out of the way and comfortable while nature takes its course! I don’t know how long she will stay in hospital.

There are a few cases that seem to have no diagnosis and it is just a matter of wait and see. One old unconscious man with severe urinary sepsis, no urinary output and a high blood sugar we tried to help. He took 48hrs to die never regaining consciousness although his blood glucose came down with insulin and we did get a pulse back with a large amount of intravenous fluid. We had no potassium to give but managed not to put him into heart failure and achieved a very small urinary output before he succumbed. He probably died of an arrhythmia of the heart.

There were two men, one young and one old with hemi-paresis (paralysis down one side of the body) after falling off a bike (old man) and being beaten up (young man).

Two patients had snakebites one in a 3yr old girl (possibly from a puff adder) who required an amputation of her arm just above the elbow.

The mother had kept her at home for 1-2 weeks before bringing her to Monze and the arm was mummified, hanging on just by by dead skin.

The other was a young man also bitten by a puff adder who had to have a high, lower limb amputation. Although we had other patients having snake bites these were the only two in a year in Monze.

I operated on my first cases on Tuesday both hernias. The first was on a 5yr old patient called Desca Hakabonze. I operated with Mr. Minyoi who made the incision too lateral. He is a medical licentiate, not a doctor but bright enough to be one.He has a very good manner with the patients who clearly like and trust him and he is very keen to learn. I will enjoy working with him. The licentiates are trained to be able to cope with everything from paediatric orthopaedics to neurosurgery to all medical emergencies and general surgery! Their initial training is for 3yrs followed by a further 3yrs in a recognized hospital after which they go to a specified hospital to work as a generalist. I took over from Minyoi and spent an embarrassing few minutes getting back on track.

The second case was an obstructed hernia on a patient called David Lice. He must have been obstructed for several days and had had a local remedy consisting of multiple superficial cuts to the skin across the lower part of his abdominal wall.

They followed a regular pattern were shallow, close together and skillfully done. They didn’t seem to have drawn blood nor had they cured him!

Mr. Minyoi towelled up for a laparotomy on another patient, he was also cross-matched by the anaethetist who was obviously anticipating some blood loss. However I was able to do it all through the groin and didn’t spill much blood although the tissues were very congested. The trapped bowel was purple but pinked up as soon as it was released. There was then the difficult decision on whether to cut out the damaged bowel but we decided it was safer to leave it and kept our fingers crossed. It was very difficult to dissect the sac off and close it. I did a simple repair of the posterior wall and tried to get him home 2 days later but he was very reluctant because he thought the journey home would be too bumpy and uncomfortable.

In out patients I saw a patient with an anal fistula and a lady with a fairly extensive anal cancer. There are many patients with carcinoma of the cervix and I have also already seen a patient with liver cancer and another with a big spleen.

Last night (7/11/08) I was up until 3am operating on a young boy aged about 12yrs who had a complete obstruction of his bowel due to it being stuck together from chronic appendicitis. His bowel was grossly distended and filled with partially milled maize seed. It took a long time to milk all the seed through the blockage into the colon and fluid and gas back up into the stomach to be aspirated out through a nasal tube. He is recovering well so far!

This morning we had to try to sort out a young woman with a very large heart in failure with renal failure and a severe iron deficiency who was said to have the nephrotic syndrome and had virtually no urinary output!!? Needless to say we had to go to the text books which weren’t much help so blood transfusion diuretics and steroids and prayer was the order of the day.

The variety of clinical work is amazing and a great challenge to a UK GP and specialized colorectal surgeon.

Barack Obama's Election

It was great to be in Africa for the news of Barrack Obama’s election as the 44th USA President

on 5/11/08, Bonfire Night in the UK. It is tremendous news and has been very greatly welcomed here particularly by young people. I’m sure it will be a great boost for the popularity of the USA in Africa and for the great value of democracy.

I, (J) had had a community trip planned for Monday morning – organized by Sister Kapapa

Sister Kapapa and Judy at Monze Mission Hospital shortly before she left.

who is in charge of a drop in centre called Buntolo, meaning Oasis. She is a very enthusiastic fifty-year-old traditionally built woman who is also the daughter of a local chief. Sister Kapapa is mainly interested in caring for the OVC (orphans and vulnerable children; their parents having died of HIV/AIDS) and started to collect a register of them She collected 800 names, but soon realized that there would be no way she could help them all.

About five years ago she started a scheme to maintain the orphans in the community, looked after usually by grandparents or aunts and uncles. All she is able to support is about 65 orphans in groups of around 10, each of which has a Guardian acting as a group leader. These are local women who are trained at the centre and in turn help the relatives raise money to help support the orphans and extended families. Sister Kapapa also realized how important education is for these children and has helped encourage this by helping with fees, along with providing mealie-meal (nshima) as a staple food.

Children collecting food from Buntolo while eating mangos.

This is either given to the orphans on the way to school or on the way home. It means the children know each other and can build up a social network; they work better because they aren’t hungry and they don’t worry about their next meal. The food programme is important, as these children are not always treated equally by their families. Many of these children are HIV positive. Sarita Brand has stated teaching some of the relatives of the orphans food security, that is how to grow sufficient maize and vegetables without fertilizers, which they can't afford.

Sarita Brand (see below) in the back garden of Buntolo in front of the rapidly growing maize which eventually produced at least 4 cobs per plant using only water, sun, good method and compost!

The Guardians have also been taught additional skills such as beadwork, basket making and tie-dye cloth. Some have also been given maize or vegetable seed and this is all used to generate a little income. The whole programmed does rely on donations however and they seem incredibly precarious.

Judy and Dhun greeting the care givers at Buntolo

Buntolo Centre provides a focal point for the Care Givers and Guardians who are also struggling to grow vegetables in the dry red earth and this is with the help of a VSO volunteer, Sarita (Nepalese) – another story! They also have 248 chickens (2 died) which lay eggs to sell. However these are sold at the current market price and there is no profit. The Peer Educators are also based there, as is the food for distribution. It is an incredibly basic structure with small rooms cramped with chairs, desks or milled maize and other areas with plastic barrels filled with water when it is available. It looks incredibly poor to our eyes, and slightly chaotic, but given the resources that they have it is quite inspiring.

However the chaos is not all of their making, and I was told at 1130h that the trip was cancelled as transport was not available. Petrol is as expensive here as in the UK so causes major problems in funding.

Our frustration is also caused by the intermittent water supply - cold and hot, at different times and also the electricity supply. So Tuesday morning there was no water and none again in the evening. We collected a dribble of cold water in the bath and I had a shower using a jug. Wednesday morning there was hot water at last so caught up with some clothes washing before work. Wednesday evening we planned to go out for supper so it didn’t bother us too much when the electricity was cut at about 1830. It was still off at 2130 and no water – so early to bed. Not so good when we still had no supply this morning. Bananas and homemade yoghurt with OJ for breakfast and yet another cold wash! At least the weather is still warm. Same situation at midday but finally power restored at 1630 though still no hot water. At least we are fortunate in having access to these services. Many still collect from standpipes, and pumps in the rural areas with no electricity.

The hospital also suffers during all of this. They do have a generator, which is started up, for emergencies and Tony, VSO volunteer (he also has a story to tell) – married to Sarita is the hospital engineer in charge of this. It is very costly of course to run so the theatre lists were cancelled and only emergencies could be done.

I have been trying to work out where I can best use my skills – or at least what I might do that is transferable and could be sustained when we leave.

There is no doubt that the HIV /AIDS issue pervades everything. Cultural beliefs go alongside religious beliefs. The no sex before marriage and faithfulness message is lost, and superficially it seems that all the men want to believe is that they shouldn’t use condoms and they have a right to sex. Certainly it is heartbreaking in the clinic to see a 21 year old HIV positive woman who is about to break off her engagement because she cannot tell her fiancé of her status. He has been married before – she thinks he might take medication but she has had previous affairs. The counselor was very empathetic (he is HIV positive) and said that it didn’t mean she couldn’t fall in love and marry, but it did mean any partner would have to always use condoms. Pregnancy was not discussed. The clinic sees these sorts of people all day everyday – babies, children, young and old. There is often no privacy and they may wait for hours. It’s difficult to know where to begin.

Tomorrow I hope to go on the community trip- transport willing and see some more rural life.

Well its time to finish this epistle. We think about you all a lot and know even more how lucky we all are. It’s now 21.30 we are tired and its time for bed. It rained a lot this afternoon with thunder and lightning and the difference in temperature is such a relief. When I went out for the Mosi-oa-Tunya it was quite refreshing!