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.

Blog 10

The trip to Masuku Lodge. February 7th

Our treat for Jan/Feb was planned a while ago. We had hoped to go to Masuku Lodge for the New Year but Sue and Bill Somerset, who run the lodge, were in the UK when we tried to book. That was when we had such an amazing time at Tongabezi instead!
Masuku Lodge is north of the Monze-Livingstone road on a farm in the Nkanga River Conservation area; the turn off from the main road for the lodge is 20 kilometres north of Choma, which is about an hour and a half from Monze. There are a group of farms run by white Zambians who have developed the conservation area, which is especially good for birds in the wet season, the 4th best area in Zambia. A dam they built has created a small lake

which is overlooked by 5 thatched Rondavels.
We set off from Monze, after working on the Friday morning, to catch our now very familiar Mazhandu Family Bus. Sadly a non-executive, five seats across bus, so rather cramped, but when it’s all in the line of pleasure we aren’t too bothered. We were being met in Choma by Bill Somerset who was then giving us a lift to the Lodge. Bill was also meeting his son-in-law Tom who had come from Pretoria via Livingstone to join his wife for the weekend. Tom picked us up while Bill was finishing the shopping so our heavy book laden bag joined the crate of beer and other supplies (plus obligatory Zambian employee) in the back. Bill is an ex-diplomat (1st secretary at Embassies) who has over the last 20+years worked all over the world including Zambia, Ghana, Moscow and Eastern Europe. He retired early and couldn’t stand the idea of the “restrictions and weather in England” so looked elsewhere to live. He and his wife had fallen in love with Zambia and had lots of friends from their time in Lusaka so they decided to retire here. The Zambian Government would only allow this if there were some financial investment hence Masuku Lodge. As he only had the land on a long lease all that he has done in the way of buildings, fencing and road building will eventually go back to the owner of the land. However the main house only cost £15,000 in materials and labour is very cheap. He made all the bricks in his own self-built kiln from one large anthill on the farm.

As the ground around the lodge is sand based and flat, making roads is often only a matter of choosing the routes over the highest ridges to avoid the flooding in the wet season , clearing them of bush and driving on them. The roofs are all thatched using straw from the surrounding area. It all looks great and would fit into any holiday resort in the west.

Bill’s background from a secondary modern state school in Derbyshire, getting A levels after leaving school and while working, isn’t what one would normally expect of the criteria to get into the foreign office, and he hasn’t lost his accent.
Tom, we learnt, married to Karen, Bill and Sue’s younger daughter had worked for the UN in Lusaka, and now, after a period of unemployment had a posting with them in Pretoria. We also learned that we would be joined by Laurie and Kevin; she works for the Canadian Embassy, and also Carolyn Davidson and Tom, who are job sharing as the British High Commissioners which is what ambassadors are called in commonwealth countries. It all seemed set to be a stimulating weekend. The only down side was that it was to be diluted by six young children!
The road from Choma was mainly firm gravel on sand and relatively smooth. The Lodge seemed like a large farmhouse with a straw-thatched roof,

and our accommodation was in one of the thatched rondavels. There was a superking-size bed with a very large mosquito net that reached to the floor. At home in Monze we have to tuck it in under the mattress. There was a stylish but very simple en-suite and a veranda over looking the bush. The area around the Lodge had quite a park-like feel as it had been cleared and some beautiful flowering shrubs had been planted. We joined the family for tea and cake; it had been Tom’s birthday the day before, and met Sue, Karen and the children – Will almost two years and Ella, eight weeks. It all seemed very familiar!
We then unpacked and relaxed, looking at such a tranquil view, as the sun set. We wandered back to meet the rest of the party for a pre-dinner drink of beer. We had met Carolyn and Tom before at the High Commission reception for our group to celebrate fifty years of VSO. They said that they had remembered us – I said they had been well briefed. In fact we had talked to Tom’s mother predominantly at that event. She had been visiting and it transpired that her brother, a gynaecologist married to a doctor, had gone out to Cambodia as a VSO volunteer (after retirement) in the eighties. They had persuaded VSO that the elderly had something to offer and were pioneers in that area. They continued to go back for many years and in fact we hope to visit them when we come home.
Supper was at a long table in a room not unlike our skiing lodge in Breckenridge with a high gabled ceiling and everything in wood. We sat with Tom and Carolyn and their boys Mark and Matthew (in that order!), Laurie and Kevin and their daughter Alice and son Oliver Tom and Karen and Will (with Ella being breast fed) and Bill and Sue at each end of the table.

All the children had met before and were very well behaved.
The meal was exceptional with pumpkin soup, beef and fresh vegetables, and the highlight, homemade meringues and guava ice cream all cooked and served by aproned cooks and waiters/waitresses under Sue’s careful supervision. A change from Michael’s usual pudding, yoghurt, banana and syrup!
In spite of the children, who wandered off a lot of the time the conversation on the first and second dinner the following night was amazing; mainly about trips they all had had in Africa and their jobs. They were very interested to hear about our work in the hospital and our meetings with AIDS patients out in suburban Monze and the villages. They are far removed from such meetings with the people who are supposed to benefit from aid given to Zambia by the British and Canadian Governments, but have considerable responsibility to make sure that it is used effectively.
They were interested to hear that although some of the money seems to be spent quite legitimately on meetings to which all and sundry are invited including those who could barely benefit it is not likely to result in any great benefit to patients . The meetings are usually held in the place that provides the best food and they merit the payment of an allowance for having a day off from work! They are very well attended!
Otherwise the chat ranged from their meetings with the likes of Kenneth Kaunda (>80, still unrepentantly left wing and heavily criticized for impoverishing the country but now much respected for gracefully stepping down and remaining in Zambia helping to fight AIDS unlike his neighbour Mugabe), their governments attempts to overcome the corruption which is endemic in Africa and to what extent this is related to poverty, and the very great difficulties of Africans moving away from their traditional culture to one which will provide all the benefits achieved by the modern world.
What is becoming clear is that in the 40+ years since independence, most African countries have found this very difficult to achieve and many of the successes of the now much criticised colonial period in agriculture and food security, wealth creation, transport, electricity, clean water, managing urbanisation, building and maintaining attractive houses and hotels, education, health and political stability has gone backwards. Much of Zambia is now run by Zambians but with a great deal of aid particularly in health and particularly in managing HIV/AIDS one of their greatest threats. However there is no going back and Africa has to, and I increasingly believe, can overcome these problems to move into the modern world. It may take a long time and it is still far from clear whether and how richer countries can help.
We felt greatly stimulated and entertained by the conversation at dinner, making us think the unthinkable, that the west should at least consider completely withdrawing from Africa and letting Africans sort out its problems in its own way. Colonialism is deemed to have failed. The question is, “is the new post colonial system any better: are we still doing more harm than good?”
More of that in later blogs!
We walked back to our rondavel after dinner in almost complete silence apart from the bush crickets, under a clear sky and the overpowering scents from the night flowers. All such common experiences in Africa. This is in stark contrast to the current suburban way of life of many Zambians who so recently lived in such a “perfect” rural environment.
We were awoken next day by early morning tea being left on the veranda. It was fine with a partly cloudy sky but still warm of course.
Breakfast at the lodge was continental with boiled eggs on offer. The grapefruit was home grown and “proper coffee” delicious. Interestingly we have learnt since being here that many of the fruits we see are not indigenous. Thus the words in Tonga are maorange, malemon, mamango and quite a few others.

We walked for two or so hours that morning,

and saw the most remarkable insects,






and butterflies








everywhere and more wild flowers than we have seen before.

MRT was busy recording all with his camera – such a fantastic present. We find that when we look at the details on the computor screen we can see so much more than with the naked eye. Butterflies are furry, flowers geometric wonders and grasshoppers like the most inventive brightly coloured plastic toy.

Tell Graham Trim that we too have photos of copulating insects!

Lunch was a very sociable homemade pizza which at first we were afraid was in short supply but after the sixth or eighth, Sue could only cook two at a time, we had more than sufficient and feeling decidedly “retired” had a post-prandial read and nap. Tea came only too soon, but to work up an appetite for supper we walked down to the hide over looking the lake.

The lake has been formed by damming a vlei - stream – to encourage birds and wildlife. Our untrained eyes didn’t see a lot but the lake was beautiful, with white waterlilies that closed as night approached and the skeletons of trees and spectacular sky reflected in the still water.

Dinner was again full of interesting talk and this time preceded by a gin and tonic. Kevin is passionate about conservation. Laurie has a job connected with Canada’s donation for health to the Zambian Health Department. She has also been involved in selecting projects and volunteers. Tom (UN) has a job helping set up businesses to do with social enterprise? and doesn’t really know how the recession will affect it. Bill and Sue seem very happy running their lodge, enjoy meeting people but don’t make much money out of it. We will certainly be back, so relaxing and friendly, and we would like to get to know them better when things are not so busy.
Early Sunday, after M had had a thirty-minute jog at 06.30 and after our early morning tea, we said goodbye to Karen, Tom and family who were flying back to Pretoria from Livingstone. As brunch was not until ten we decided to try and walk round the lake. In theory there was a track but the directions given seemed rather vague. We set confidently off, dawdling over amazing plant life

and insects. We had about two hours for our walk, but after three quarters of an hour we seemed to be further away from the lake and not actually going round it. There was no clear view as bush, 10-foot grass and small trees surround it. We couldn’t work out the direction of the sun, which is backwards anyway, and almost overhead a lot of the time.
We decided to retrace our tracks and then came across the turning we should have taken. How did we miss it?! It was slow, muddy and very muddy, but well worth it. Probably better in the dry season, so will definitely have to come back again. Also then, as all the water dries up, the lake is the only watering hole and lots of animals are seen there. Made it back only ten minutes late for brunch (not Zambian time) and felt we had really earned it. Full English breakfast available this time.
Just to make a brilliant weekend even better Tom and Carolyn offered us a lift, as they pass through Monze on their way back to Lusaka, although they couldn’t actually remember it on their way down. Much though we love our buses, car is better. On the way we all visited the Choma Folk and Crafts Museum. The best we have seen yet but only tiny. There is quite a lot of information about the old Tonga way of life, some of it not changed a lot. There were two striking things. Firstly, that it was the tradition to get one’s two top teeth removed and secondly, the women used to wear very, very short grass skirts. This seems remarkable when they are so careful to wear long skirts now and exposed thighs are considered to be very erotic. Perhaps Victorian Colonial influence!
Tom and Carolyn insisted driving us to our door over an increasingly sculptured and exceedingly bumpy, puddled and muddy road. They accepted a cup of tea and looked around our home, which must bear a strong contrast with the Lusaka High Commission with its lovely garden of monkeys, a chameleon and swimming pool. The boys played with Natasha and Dhun’s kittens which, fortunately we haven’t been able to shake off yet!

Early one morning outside our door on our welcome mat where they weren't!

When they were older still sleeping together for warmth at night.

Another use of an umbrella for a two headed cat!

The boys were forbidden to take up our offer of taking them with them!

So ended another amazing weekend and we wondered how difficult it would be settling back into “truck stop” Monze again and clinical work Zambian style.

The weather and the skies!

We now feel it is a little cool if the temperature drops below 27 (80) in the shade, especially if there is a breeze. M feels he has to put a tee shirt when it drops to this level. Today the temperature hit 35oF (54o C) in the sun. We walk home at lunchtime in temperatures of this level and no matter how slowly we walk and under umbrellas it still raises a considerable sweat and it takes at least fifteen minutes to cool after taking most of our clothes off. Arriving back to the hospital after lunch is more of a problem when we have to keep our clothes on!
The horizons here are vast, wide open for miles, broad flat plains of bush with no hills, stretching into infinity and consequently the perspective of the clouds seems quite different from the UK. We can see the clouds approaching as in ranks, or planes landing at Heathrow, regularly, one after another. The flat grey bases follow of the curve of the earth until they reach the horizon. Because of the flat plains and unobstructed views they seem to be ordered in regular rows with only the first in full view the rest partially hidden behind each preceding rank. The straight rows of clouds are just an illusion, as when the clouds arrive they are much more disordered with a lot of irregular broken up blue between the billowing mostly white clouds. The first rank of clouds catch the sun often giving a 3D effect by highlighting their edges as they tower into the blue. I suspect these spectacular skies, which we see every day and are enhanced at sunset and sunrise is because it is the wet season. It difficult to capture the vastness and distance in a photo but here is an attempt

They have a remarkably uplifting effect on us and we never fail to comment on them. It makes our sweaty walks worthwhile. They are so different from the pure blue we saw for the first two months. It does of course also rain a lot and on occasion we have gone two to three days without seeing the sun, but this is unusual. Most of the time it doesn’t rain.

Back to work.

After our amazing trip to Livingstone we returned to basic living and work. I am finding the clinics rewarding and have become better at identifying illnesses such as TB, or Kaposi’s sarcoma. Not something I had a lot of experience of in Fratton. I have also become used to the drug regimes, which are pretty much protocol driven. The whole country uses a standard procedure so in theory gathering data should not be too difficult. The clinic has a lot of frustrations however and could run a lot more smoothly with just a bit more involvement from the nurses and HIV medics (probably less than a specialist nurse). We are constantly running out of the correct sheets for the notes so have to adapt inappropriate ones. Height, weight and pulse observations, which are taken by reception (counsellor, nurse or HIV medic), are at best inaccurate, and at worst seem to be total works of fiction. I have had notes where the height of a patient has varied by as much as five centimetres, over several visits, and in both directions. I would never ask them to check a blood pressure, as it is invariably 120/80.
In spite of all this the clinic does function with little work on 2 afternoons. The patients are all seen albeit there may be long waits for clinicians, counsellors and pharmacy and the drugs always seem to be available. The cost of these anti-retrovirals would be about £400 per month per person in Fratton, which is probably beyond the Zambian economy to sustain.



This is a woman and her unmarried son who very successfully run a farm. She is a patient with HIV that we visited at her home. She was widowed probably because her husband died of AIDS when her son was quite small and I suspect she has increasingly relied on him to run the farm.




Dhun and Judy on a wet day visit the home of an HIV patient.

However as ARV drugs in Zambia are mainly financed by the Melinda and Bill Gates and Bill Clinton Foundations this is not a problem but we wonder how many Zambians understand this or at all grateful for this type of aid. Ironically this sum (£400) is more than Michael and I each receive each month from VSO, which is meant to be the same as the local wage for what we are doing.
We are beginning to learn just how poor even professional people are. A teacher earns a million Kwachas a month – equivalent to £160 (£1,920 per year). This is also meant to include a housing allowance and is just possible to live on with no extras such as alcohol, travel or holidays. Many teachers are absent from the classroom for some of the day as they have a second job in order to earn more money. A clinical officer, who has had three years general training, earns Kw 1,470,000 a month (£250) of which Kw 200,000 (£32) is meant for housing. This may cost considerably more if it has not been provided by the hospital or clinic. Mr. Mazabuka who runs the ART clinic must be on this basic salary. The hospital staff however seem to be very good at organising workshops and meetings in work time which earn extra cash. In fact it never seems to be a problem if they have to miss work.
Medical licentiates (ML), who have done a further three years training on top of their clinical officer training, are paid Kw 2,700,000 or £400 basic salary per month plus free accommodation. It is highly competitive to get on such a course, and they would probably be doctors in the UK. This does not include anything for out of hours on-call. This has to be negotiated locally and as Monze Mission Hospital has said it has no money, the trainee MLs have withdrawn from night duties, and only work from 0800h to 1600h, although that does include Saturdays and Sundays every week, no week ends off and few holidays. They are a particularly bolshie lot at the moment and find a lot to grumble about. The Zambian Government has been quite clever in creating the licentiate qualification, as it is non-transferable. These medics are unable to practice abroad so they are unable to join the brain drain to South Africa with its much better paid workers.
The work ethic is quite different here and takes a lot of getting used to, and then just tolerating. Perhaps we aren’t quite as much in retirement mode as we thought we would be. We say over and over again to each other (hoping to reassure) that it is the culture and we aren’t here to change that. The plain truth is that they do not work as hard as we would, and who can blame them in this heat? Lunchtime is sacrosanct, usually two hours, when eating nshima (ground maize a bit like mashed potato with less water, less mushy, more sticky) is almost a holy ritual.
I was not particularly made welcome at the ART clinic or offered a room to work in, and even now I have no examination couch. I know the hospital is poor but they did ask for a doctor to work in the clinic. It also seems a very secretive hospital where we are not really told what is going on. The licentiates with whom Michael is involved are not eager to learn and would rather he did the work and not involve them. And VSO’s aim of “sharing skills – changing lives” is a million miles away from where we are. No one has ever asked me for my advice about the clinic, which could be made so much better in a lot of simple ways and I would be very tactful. All I can say is ask me in six months time and my opinion might be very different. They are not bad people, they greet effusively, laugh a lot and it is “as long as it gets done”, “when” is not a priority.
The fully qualified doctors have a basic salary of £500 a month with another £500 for being on call. As it happens they are all earning their money at the moment as they are now first on call instead of second, because of the MLs “work to contract”.
Very few Zambians drink much alcohol or smoke simply because they can’t afford it.
Michael and I are greatly advantaged by two salaries but could not have the trips we do relying on that alone.
Halfway through January Michael Breen left here for Uganda in order to do an unbelievable number of operations for the hospital there. He was away for two weeks and was disappointed to do only did ninety operations including repairing fistulas between the vagina and bladder and rectum caused by obstructed deliveries in young women. These usually result in dead babies and necrosis or death of the tissues around the vagina due to prolonged pressure. This leaves them continually incontinent of urine and sometimes faeces and this would not happen if they had access to caesarean section. Very few fistulas he does in Uganda are straightforward as the simple ones can be done with little training and only the complicated ones would have been saved for him.
Just before Michael Breen left Peter arrived,

a retired GP, Clerk in Holy Orders and HM Assistant Deputy Coroner for Cornwall. He had come to stay with Michael and run part of the licentiates’ obstetrics and gynae course. Michael trains all the licentiates in Zambia in this speciality and has three different groups over two years. Peter was originally from Northern Ireland. He was a vicar before a doctor and did that partly because he didn't think his science was good enough. After a spell as a hospital chaplain in New York, he decided medicine was his first love and did more “A” levels at the local school, while working as a curate. In Monze he was also being left in charge of the obs/gynae service while Michael was away. He did find it a huge responsibility but was an excellent clinical teacher and supervised the routine operations during the day and emergencies day and night.
We discovered that he enjoyed beer and wine and also company at the end of the day. He was shortly joined by Steve a seventy-year-old equally sociable Irish gynaecologist friend of Michael’s,

who also enjoyed his drink and with whom he shared the house and Phallice (pronounced phallus!) Michael’s excellent house keeper. She used to work for the last relatively young Zambian Bishop and current elderly Italian Bishop of Monze but after the first younger one died in a road accident at which Phallice was devastated and it was also noted that she had five children by different fathers after the Italian Bishop came into office she was quietly transferred to Michael’s home where she has proved to be irreplaceable, being a wonderful cook as well as an excellent housekeeper. This is a good example of a clash of cultures which must have made it quite difficult for many Zambians to completely convert to a Catholic way of life. I think Steve came mainly for the sun and company as he is a widower although he did do some operating. We had an extremely sociable two weeks with the two of them, heard their life stories and went to Moorings swimming pool

most nights followed by a beer or two, and then home in Michael Breen’s old Jap car, driven by Peter at a less reckless speed, (not as speedy as Michael) back down the very straight road to Monze either at or soon after sunset.

Clinical Cases, gunshot wounds at dawn (by the time we had fixed them!).

The most exciting cases this month happened last Friday. Again, after going to bed early at ten o’clock I was hauled in by hospital transport at midnight, after an hour’s sleep. This was to see a 16yr old boy from a local, very good private boarding school with bowel blockage from a strangulated inguinal hernia (rupture). As he didn’t have this I thought I would be able to go back to bed. However they had just brought in a man and a boy who had been shot. The man in the head and the boy in the belly. I therefore stayed until 04.45 hrs to help Mr Banda sew up the holes and to stop the bleeding. James Banda is a senior medical licentiate who does advanced surgery very well but is not medically qualified and who was 1st on call. We didn’t operate on the man even though two of the bullets were lodged in his brain (see Xray).
Amazingly he had no excessive bleeding and no loss of consciousness or nerve deficiency. The boy however had two holes in his stomach, four in his small bowel, and had bled from his small and large bowel mesenteries where the bullet had passed through clipping but not opening his small and large bowel (descending colon) as it left the abdominal cavity. It had done all this damage by passing from its entry point through the middle of his upper abdominal wall just below the breast bone to finish up on the left side buried at the side of his back bone (see Xray).
Later the man was able to tell me that he thought the assailant was trying to kill him for food and the child got in the line of fire. It all fitted with sites of their injuries and that they were standing side by side.

This is a picture of them 56 hours after the shooting, both progressing very well.




Gun shot wounds to belly and head; 4 days after the event! You can still see the plaster marks each side of the boy's nose for his naso-gastric tube. They both went home after 4 days in hospital.


We also continue to treat patients with sigmoid volvulus and this is a picture of the only one I managed to decompress by untwisting the sigmoid using sigmoidoscopy. Watched by Steve.

Well it is time to close this. I hope you like the pictures, it takes a long time to load them but it may lighten the long text, which we hope you may find of some interest. It is really a diary for ourselves and the girls but thank you for getting to the end!!

The trumpet Flowers.