Blog 8

Christmas in Tonga land. 26/12/08

There appear to be no words for wishing someone a “Happy Christmas” in Citonga, the common local language in Monze! This could be because their language has not changed since the arrival of the Christian missionaries with David Livingstone or because they are so poor that they can’t celebrate as we do. It is a one-day holiday with no Boxing Day, it is difficult to find any sign of Christmas decorations or any Christmas goods in the shops and although families get together there is neither special food for Christmas dinner nor many presents exchanged.

The hospital did give away 20+ live chickens as staff presents but I don’t know how they decided who should get them. There was quite a melee to get the fattest with more than the chickens having ruffled feathers.

We eventually found, on Christmas Eve some shop assistants in Santa Claus hats, the only visible evidence together with one poster advertising Christmas entertainment at Tooters that Christmas was almost here in Monze!!

As we had had no invitations we were planning to have our Xmas dinner with Natasha and Dhun our VSO colleagues. At the last minute however we were invited to a Christmas Eve barbeque, a Christmas dinner, a walk by Monze’s reservoir before dinner and finally a party organized by Sister Bertha in Mazabuka on the 27th. The Christmas Eve BBQ was at Kitty’s workshop

Kitty on Christmas Eve

The lorries loaded with charcoal for the Congo

in the 'workshop'.

Laura (our neighbour, Crispin's wife) and friends

on the outskirts of Monze, with a spit roast lamb (was more like a sheep!) and goat cooked over charcoal.

Much booze, mainly spirits and beer was available and the party was attended by many of Kitty’s Asian and African friends including Perry, Crispin and the local bank manager.

Some younger native Zambians tried to gate crash, and unfortunately friends Natasha had invited were sent packing also (a case of mistaken identity).

The meat was more spicy than the conversation, we met some more of the locals who were very friendly but the evening was otherwise uneventful and we got home at midnight.

Perry, Judy and Dhun chatting over beers Xmas 2009

On Christmas morning we attended mass at the hospital chapel at 9.30 with typical Tongan worship, drums and all but no carols.

The one and a half hour walk by the reservoir later that morning was luckily in the sun, immediately preceded and followed by torrential rain. As we approached the river and dam by car the light went, the surrounding trees began to disappear in a Scottish mist and it rained as can only happen in the tropics, with huge drops capable of drowning anyone daring to emerge from shelter with or without an umbrella. However after a short wait the sun re-emerged and in a lovely rain cooled breeze we started our walk. Michael Breen told us they had seen crocodiles there before and we had wonderful views of the very green and wet countryside surrounding the reservoir. Some locals lived close by in what appeared to be idyllic rondavels with easy availability of water for their crops. The walk gave us a good appetite for our Christmas dinner at 15 hours.

Our dinner was at Sisters Mary and Barbara’s home with Sister Bertha from Mazabuka and their close friend Michael Breen who had engineered our invitation, “the best Christmas dinner in town”!

We had a lovely meal with chicken, stuffing, ham, jacket potatoes, rice, cranberry sauce, onion relish, maize, peas, and carrots and a tasty South African red wine shared between four of us. The wine, after three months without it tasted wonderful and was enough to make MRT merry. We sang grace, Rejoice, rejoice and again I say rejoice and then helped ourselves without further prayer to food, Mike T had seconds and thirds and Michael Breen was well into his meal by the time Mary arrived at the table with hers. The conversation was easy and we learnt that Sister Mary at the age of 70+ was doing a new job as an archivist reviewing documents recording the early RC church in Monze with some help from a Jesuit priest. She had been so successful at the Diocesan Centre she was being transferred, after forty years in Monze, to do the same in Lusaka. She didn’t seem to be the least bit phased by this and seemed to feel this was quite a normal thing for a nun to do. Sister Bertha at the youthful age of seventy-eight ran a catering school for young people in Mazabuka and was on some executive caring for orphans, which seemed to be more than a full time job for a 78 year old.

Pudding was not neglected either. There was trifle and Christmas pudding with brandy cream. The Christmas pudding was to be brought in flaming, and we had bets as to how many times Sister Mary would attempt to do this before she succeeded. In fact she did it on the second attempt with a not inconsiderable amount of brandy. Fresh coffee to follow, made in a cafetiere, is a rare luxury and we were also offered Obama whisky to go with it. This had been bought at our local ‘supermarket’ and on close inspection was noted to be 75% proof. So one dinner had given us fresh cream, fresh coffee and whisky – courtesy of Roman Catholic nuns!
They told us that some previous guests to their Xmas dinner had died soon after. It caused great hilarity when Mike suggested they probably shouldn’t have told us this. Over all it was great fun to be with them, and have an insight into their lives. I am sure they don’t normally live as luxuriously but it was fascinating to be with three seventy-plus year olds who have no retirement plans!
The entertainment was to be repeated at the party in Mazabuka on Saturday 27th, also said to be the best Xmas party to be invited to in the area.

Nuns dancing

Brothers singing

Michael drove us the forty-five minutes to the party at Mazabuka. On the way we did a shop at Shoprite for some of the nice things in life which you can’t get in Monze (wine, butter, and yoghourt) as well as the basics before arriving at a house about 3 miles out town in the middle of a sugar plantation. This is the home for mostly Irish nuns. There were about thirty people at the party, half of whom were nuns, mostly Irish, dressed very simply in civvies with about 5 Zambian nuns dressed traditionally and four to five Irish “brothers” dressed in a very relaxed style! There were about eight Zambian brothers dressed in smart trousers, shirts and ties, one Asian Christian family in saris (at least the women!), a Ukrainian surgeon and his 8yr old son who was to play a key role later on in the party and ourselves with Michael Breen. The sun was mostly out and not too warm, about 75 degrees centigrade, the meat was barbequed which together with lots of good salads was very enjoyable, particularly as it was followed by a very tasty traditional Christmas pudding with either brandy butter, fresh cream (only the second time since we arrived in Zambia) or custard. MRT had two large helpings at the nun’s insistence and omitted the cream the second time round. The drinks flowed freely although it seemed to me mostly water was imbibed, Only the very bold had one or two glasses of wine although Judy seemed to have no embarrassment in knocking back Mosi beer straight from the bottle. We were just wondering how we could fill the rest of time until we were taken to our lodgings for the night at the Christian Brothers home/school in Mazabuka, when the entertainments began. It was like Xmas at home in the 1950’s with songs and simple games each one present being gently encouraged to do their party piece. Fortunately for us, although it was very much a minority we weren’t the only ones gently refusing. Our excuse was that we would do something next year if invited!
The entertainment started with the Ukrainian surgeon’s son who re-appeared very smartly dressed in a light beige suit, the jacket fully buttoned, matching shoes and dark hair combed and flattened with a parting, He was ushered in by a nun who apologized on his behalf for his recent lack of practice. He seemed very confident in spite of this, gave a short bow with a completely serious face and continued without a word for the whole performance. He played a medley of songs including a carol or two and Jingle Bells without a seconds break on an electric keyboard. He retreated from the room to great applause after one or two hesitant bows never to be seen again for the rest of the evening. I have to say he reminded me of the son from the Adams Family (apologies to Hannah and Scott). This certainly got us in the mood. We had an Irish Brother and a Sister from New Foundland on guitars, playing and singing mostly Irish songs some plaintive and sad and some jolly.

We all joined in with the chorus. There was one nun who had a very good voice who sang very long religious songs with very high notes, which made it difficult to join in. We finished with some interactive games such as hokey pokey and songs such as “pia, pia, piano I am a music man, I come from down your way and I can playay”, with the response, “what can you playay?” and other party songs to catch you out. I once again tested Maji’s toes in a waltz to music produced by the brother and nun’s guitars.

The nuns obviously had a great time and enjoyed every minute. It made us wonder whether they look forward to this all year, as it obviously has become a great tradition, or whether they have sing songs, dancing and get togethers with the Brothers at other times of the year. After Sister Bertha’s last song the party was called to a close and we all left at the same time.

Sister Bertha on the left leading us in the last song

We spent a very comfortable night in the bridal suite (Brother Michael’s terminology) at the school the Brothers run. We had a breakfast of porridge, and by 8.15 after helping with the washing up were in the car back to the Nuns’ house for a short service. This was a very simple communion, followed by another breakfast if we wanted it (we did have the fresh fruit and coffee). It transpired that most of the Nuns were too late to have breakfast before the service as they had been watching the DVD of “Mama Mia” until after one am. and had overslept. They thought it was a brilliant movie, though MRT thought they didn’t appreciate how anti-men it was. He is very sensitive about such matters. The service was very domestic in their lounge and intimate, quietly conducted with surprising confidence in view of the expert congregation by a young Zambian father home on holiday! The wine and bread was passed around of which Maji and Paji did not partake. Michael Breen said it was the most enjoyable and meaningful service he had been to during his 8 years in Monze.
On the way home we stopped at Shoprite for the perishables not bought the previous day. A short walk followed this on the Mazabuka golf course

where we closely inspected a huge Palm tree with enormous fruits;

then home to Monze after a very full and alternative Xmas, interspersed with the clinical work on Friday, Boxing day - a normal working day.

Clinical Work over Christmas.

At 22 hrs on Christmas day I regretted offering to be on call for all the bowel blockages over the holiday period particularly as there was no junior medical cover from 16 hrs. The nurse from the male ward rang to say there was such a patient and should she send hospital transport? Fortunately the 2 glasses of wine I had had at Sisters Mary and Barbara’s Christmas dinner had pretty much worn off. Although I was in no mood to go out I put on some more formal clothes and went to see Cliff Haninmyi, a very miserable, and probably frightened twenty year old who had blocked bowels for two days. The x rays weren’t typical

and as he wasn’t too unwell I felt that as it was now 23.30 he could wait until Boxing Day. After an x ray of his bottom and a failed attempt to unblock him by inserting a tube into his backside we managed to get him to theatre at 15hrs.
He had a very severe twisting of his bowel, which I had to remove and then leave him with a stoma or bag.

His parents were appalled at this idea and were only partially reassured by the fact it would be possible to close it in 6 weeks. The patient remained very miserable but rapidly got better and went home eating normally 6 days after the operation. In the UK this sort of procedure is not unusual but occurs almost exclusively in older patients. The reason it happens in young folk here is not known but it is worthy of some speculation. This patient’s bowel was abnormally large and not just due to the blockage. Although he may have been born like this I would speculate that it is acquired perhaps because of previous damage to the nerves or muscle in the bowel by an infection some years ago. This would predispose to the development of a mega-colon and the twist or sigmoid volvulus is merely a reflection of the vulnerability of long baggy and dilated bowel to twisting. The lumen of the bowel also contained much undigested fibre from the mango fruit. Is this another downside of Mangos!?

Unfortunately he “fainted” the day after his discharge home and was brought back into hospital dead. He was buried without a post mortem 2 days later. It is difficult to be sure why this should happen in an otherwise very fit young man but it is most likely that he had a massive pulmonary embolism or the breaking off of blood clot which can develop in the leg veins and then travels centrally in the veins to completely block the blood vessels to the heart depriving it and the brain of any blood supply. His very devoted parents will be devastated and I wonder whether they will blame the hospital or me for some omission. They were a well-educated couple but this doesn’t mean they will not invoke some local customs to explain these tragic events! Subsequently I learnt they said it had happened to a previous relative which, if it did, makes it more likely that it was a clot breaking off as this can run in families.

On the Sunday after Xmas the baby girl I had operated on a month ago for pyloric stenosis

As she was when she left hospital before Xmas

was readmitted with large bowel obstruction or blockage, at least this was strongly suggested by an Xray.

She had been very well up to 2 days before this admission, was eating well, putting on weight and was apparently opening her bowels normally. I tried to operate on her before we caught the bus to Mosi-oa-Tunya but couldn’t as she had just eaten porridge. This was a little surprising as her little tummy was very distended but it meant that we couldn’t operate for at least 4 hrs by which time the bus to the Victoria Falls would have left. She was subsequently operated on the next day by Dr. Engulula who found she simply had bad constipation with faeces impacted in her lower bowel. These were simply squeezed through and removed without opening the bowel so I hope she now gets better. I also hope she doesn’t have some congenital abnormality in the functioning of the large bowel to go with her congenital pyloric stenosis.

These two cases show surgery is never easy or straightforward even when you apparently do all the right things. It can be stressful for the surgeon as well as being very rewarding.

Over Christmas we have also agreed our final programme so our introductory period is officially over and although our work won’t greatly change we do have support for both Judy and myself to do out-reach HIV/AIDS clinics in the more rural areas.

So on to the New Year. We have treated each to an expensive three nights in Tongabezi Lodge including a new years day swim in Devil’s Pool right at the edge of the Victoria Falls if the mighty Zambezi River hasn’t too strong a current after all the rain we have had! They usually don’t allow this activity beyond December. Keep your fingers crossed for us. More of all that in the next blog.
We would like to wish Family and Friends a very Happy and Healthy New Year. Don’t feel you have to register comments on the Blog, but we hope it gives you some entertainment and perhaps insight to life here.

Blog 7

15/12/08 Two months in Zambia.

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

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

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

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

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

The visitor for this month.

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

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

Judy’s trip to the UK 6/12/08

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

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

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

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

A not so warm evening later in the year!

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

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

A boy’s night out!

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

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

Saturday 13th December. “The workshop barbeque”.

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

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

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

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

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

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

3 days to Judy’s return on Tuesday

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

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

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


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

Clinical Work

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

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

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

Judy makes it back safely 16/12/08.

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

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

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

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


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

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

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

Blog 6

Mosi-oa-Tunya 'The Smoke that Thunders"

Sunday November 23rd 2008

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Cases

And so back to the tales from work.

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

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

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

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

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

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

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

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

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

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

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

Tuesday 2/12/08

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

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

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

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

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

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

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

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