Mountains, Malawi and Medical Stores (Very) Limited

I write at our chitenge covered table, at the end of a hospital day filled with laughter and the first goodbye. It’s been a long time since either of us have written, sorry! That’s been down to all kinds of trips and visiting, seeing friends, exploring more and obviously, working hard. But now, as I sit with a mugful of velvety coffee, hopefully I can give you an idea of some more of what we’ve been up to.

 

More and more in hospital it’s hard to remember what working in the NHS must be like. What will it be like in a hospital where we don’t live two minutes away so we can go home for lunch together? In a hospital where every female (and Zambian) staff member isn’t referred to as ‘Sister’? A hospital without the Tuesday morning updates on which drugs and which lab tests have ‘in stock’? At the minute, these lists don’t last too long – with only five blood tests available (kidney function and liver function amongst other things are out of stock) and an increasingly sporadic supply of medication. Having different antibiotics available each week, weeks with no insulin and a varying supply of blood pressure medications presents a massive challenge in trying to manage people’s conditions, which rely almost as much on consistency of treatment as the treatment itself. Whilst we grumble about the NHS, seeing first hand how difficulties in procuring medicines quickly translates to patient care, makes me realise how lucky we have it in the UK. Here, the difficulties stem from the necessity to buy all medicines and equipment through Medical Stores Limited (MSL), a company who have a poor track record at managing to obtain the right medicines themselves, which begs the question as to why the Zambian government doesn’t change supplier, perhaps it’s related to the amount of control USAID has over MSL? But that’s not a question for here, just that we’re lucky to have a stable and constant supply of these medicines back home that are essential for people’s health.

 

The last few days have been a calm after a month of great fun, travelling and time with all manner of friends. The hospital (or the Medicine and Paediatric wards at least) currently has a relatively small number of inpatients and lots of doctors, meaning that we have plenty of time to chat to patients and families as we do our rounds, have some banter about our language skills (Ali and I discovered just yesterday that ‘brain’ in Chichewa is ‘bongo bongo’, no word of a lie), and have our mid-morning break complete with boiled eggs and Apple Max. The challenge of diagnosing and therefore treating people seems to be becoming more difficult as one by one our lab tests have run out, followed by the X-ray machine breaking this week. Perhaps it’s just that we’re becoming increasingly aware of all the conditions and problems that people here may have – not just TB and HIV with all their potential complications, but the same conditions that we have grown used to at home, yet present in different ways here and at much later stages. Even today there’s been an elderly man admitted with 3 months of having an increasingly huge abdomen. In the UK I suspect at the first hint of something being wrong, a man of his age would have gone to his GP, had a scan and been referred a long time ago to the surgeon or cancer specialist. Here, he presented with an abdomen that is massive and tight with fluid inside it. I suspect from his story that he has a liver cancer (there are lots of risks for liver cancer here – not only lots of alcohol problems, but lots of viral hepatitis and worms that can cause long term liver damage too). He has so much fluid in his abdomen that the ultrasound scan we’ve done hasn’t helped us much, there isn’t any X-ray to tell us whether it’s spread to other parts of his body and the blood tests for the liver have all run out this week. We’re going to try to take some fluid off, from his abdomen and the rest of the body, and give him some painkillers, but it’s tough to be presented time after time with a situation where someone is so far down the path of a disease that very little can be done to cure it, whilst not being completely sure that that even is his problem. It’s very interesting to be in this situation, but also gives new perspective on how lucky we are to have a health service which is free at the point of access (One of the reasons this man has presented so late is that he lives so far from his local clinic that he had to raise money to get there. It took him a month to raise enough money) and that looks to pick up and treat conditions early by screening, quick referral pathways and early specialist care. So, it’s strange to think of life back in the UK, but I’ll go back with a new perspective on some of the NHS’ massive achievements and contributions to advances in health in the UK. Don’t ruin it Mr. Hunt. And stay away from No. 10 too.

 

Still, though it seems like longer, we’ve only been back in the hospital three weeks since our latest trip took us to wonderful Malawi to visit friends, the famous lake and Mount Mulanje, a huge massif in the south of the country. Rach had been to Malawi on her last trip to St. Francis’ four years ago and ever since we knew we were coming again it was straight onto the calendar. Brilliantly, two great old friends from Edinburgh, Angus and Hannah, had moved to Malawi three weeks beforehand and so we met them at Lake Malawi for our first few days. The journey in itself was an adventure, and having negotiated the border, a policeman looking for drink money and the switch from Zambian to Malawian kwacha (an exchange rate of about 1 Zambian to 66 Malawian, great fun trying to work those conversions out!) we got our 5 hour minibus involving chickens and children on our knee and a rickety bus swinging round hairpin bends going down a mountainside (don’t worry Mum, very safe, no risks…), before arriving at Cape Maclear for sunset on the backs of motorbikes. We spent a brilliant couple of days with Hangus, wandering the beaches, snorkelling amongst tropical fish, probably getting schistosomiasis and eating lots of excellent food on the edge of the beautiful lake, where each morning loads of Malawians came to wash their pots and plates with the most beautiful of backdrops.

 

After Hannah and Angus headed off back to work 3 hours away, Rach and I had a couple of days lounging around, reading, kayaking in a double kayak in a true test of marital harmony, and sampling more of Cape Maclear’s food, before heading south, with the help of a few more minibuses, towards Mt. Mulanje, and another great friend from Edinburgh and Liverpool, Isobel, who somewhat unsurprisingly, has become ingrained and is flourishing in a mission hospital at the foot of the wonderful mountain-scape, amongst the tea plantations. We loved having the chance to see a hospital similar to the one we’ve been working in and share guitar playing duties (we have about 6 chords between the three of us) during Iz’s breaks. Rach and I spent a morning wandering through tea plantations, perfectly green against the strikingly grey mountainous backdrop, whilst Iz saved some lives, before we headed to a mountainside hotel for dinner. As we sat down to get a drink and watch the sunset, suddenly some familiar accents, unmistakeable even five and a half thousand miles from home, rang through the air, as “Chantelle, it’s a badger!”, “Sharice, baa…baa…” shrieked out. A group of schoolkids from Glasgow on a school trip playing Heads Up on their phone would sound the same wherever they were. Still we pushed on through and forced ourselves to eat some more delicious Malawian food next to them.

 

The next day we headed a little way up the mountain, to Likhubula Falls, a beautiful pool and waterfall halfway up the west side of the mountain, led ably by our Malawian guide Robert, who proudly sang us Flower of Scotland to keep spirits high as we climbed. Arriving at the beautiful waterfall and pool (allegedly bottomless), our guide stripped off to his boxers, climbed a rock face like a mountain goat and launched himself in, issuing a challenge which unfortunately I couldn’t refuse and which, literally, took my breath away, thanks to the sheer cold of the water. After nothing more than a few minutes in the water we wrapped up and had our picnic looking down a natural wonder to the tea plantations below. Our time with Isobel and Hannah and Angus was a special time of sharing our experiences and lots of fun with old friends as we all live out some dreams here and learn an awful lot from it – medically and far beyond that.

 

There are far more stories I could tell, but I’m sure I’ll write to you once more before we head back to the UK, in just over three weeks now! With that will come all kinds of new challenges and adventures as we come back to new jobs, a new home and to see lots of you again, but for now we’ve got a few more weeks of fun to have here yet!

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Boat trips with Hannah and Angus
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Wandering through Mulanje Tea Plantations
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The edge of Lake Malawi at sunrise
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Trekking down the mountain with half a tree on your shoulder.
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Likhubula Pool!
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Chilling with Iz
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Phones, Football and Fairness


 

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I’m sure life in Katete must have been very different a few years ago. Almost everyone who wanders along the red sandy roads, perilously dodging cars and with hundreds of bicycles flying by, has their mobile in hand, staying in touch with friends and all the goings on in the world, and more importantly (certainly to some of the nurses on my new ward, Augustine) keeping us up to date with the impending and eventual success of Leicester City (pronounced Lie-ses-ta). The latest football scores have greeted me on the ward every morning without fail, “Doct-a-ta, Leicester, they are champions! Tot-ten-ham have been beaten” the gleeful cry around a week ago, and somewhat concerningly, that particular nurse seems to know more about the scores than the patients! Maybe it seems like I have completely lost touch with what it’s like back in the UK, but actually I think I just expected us to feel further away from the rest of the world than I have.

 

Maybe that’s part of the reason life in Zambia seems “normal” now, a prospect which even six months ago seemed almost unimaginable! It’s not a boring normal, rather just life which we have settled into and become very happy in. The simplicity of it is something I have come to love and am sure we will learn from when we head back home. Living in our little house which, though our ‘bedroom’ and ‘open plan kitchen/living/dining space’ are separated by half height walls, is effectively one room, we don’t have loads of room but everything we need to and most things we want to are easy to do. We have plenty of books to read, our cooker (latest projects are flatbreads and Rach making all kinds of delicious loaves) gets a lot of use, we have better internet access than most of Scotland – what is it that we need back home that means we have so many things and need so much space in our house? We are spending lots of time outside, in our garden (probably the most successful we’ll ever manage, already flush with cucumbers, beans, basil and rocket) and going for walks around the hospital grounds and all its houses, to Katete town and across the Great East road to big fields of sunflowers, rows of cotton and villages with mud huts and alive with the shouts of children – ‘Azungu, azungu, how are you?’, even branching out to playing some basketball and football with some of the other doctors, Teege and Chris, and a few Zambian 15 year olds – we showed them how to win.

 

Football has also been key in my friendship with Tony, a 9 year old, the son of one of the nurses, Cecilia, who works with Rachel. For the last couple of weekends we’ve visited each other’s houses for a couple of hours, and Tony, who three minutes into arriving at our place for pancakes, asked me “Uncle, do you have a ball?” and I have become firm friends. Even walking back from Cecilia’s family home, along the sandy paths through a field that in a distant past was the hospital’s football pitch and past the police post, having a ball meant two kids who looked too shy to talk to us started playing against me, followed quickly by some of the student nurses and then one of the gardeners!

 

The last few weeks though, both in and out of work, have shown me more of what life is like outside of our ‘normal’ bubble inside the St. Francis’ grounds. On reflection, maybe some of the feeling of unexpected normality of Zambia is down to some of the relative luxuries we manage to pick up, like balsamic vinegar and non-UHT milk. As it’s got a bit cooler, I’ve built up some enthusiasm and Rach has ‘encouraged’ me, I’ve headed out after work running a few times. At the end of the day running round villages just five minutes away where people are living in such tiny mud huts, cooking outside because there is no electricity or money for candles inside. One of the nurses even asked me, “Doct-a-ta, in England, do all the houses have electricity?” and wouldn’t believe and laughed at me when I told him they did. I’ve seen locals walking along the roadsides and selling their wares for very little for four months now, but recently, since exploring some of the villages nearby more and realising how different a life people are living to us even in the hospital here, I have almost a sense of guilt, at least of discomfort seeing the disparities.

 

In work for some reason recently the unfairness of being from a village in the Eastern Province has reared its head a few times too. St. Francis’ does not ask people to pay for medicines, tests or their stay, whereas nearly every other government hospital in Zambia does. So, once we have done the tests we are able to, but still a patient is becoming sicker or needs more advanced tests they need to go a bigger hospital – either Chipata an hour away, or for most things Lusaka, the capital, six hours away. This entails a lot of money being spent by the family. Let me give an example. About three weeks ago we had a young lady (32, 4 children) with a funny collection of symptoms (for the medics – bilateral limb weakness, change of affect, urinary retention) which unfortunately probably mean she has something wrong in her brain, spine, nerves or a combination of those three. She desperately needs a scan of her head to work out what’s going on in there, amongst other tests. She won’t get better without it and will almost certainly progress, and quickly. Once we’d done the tests we thought could enlighten us a little we brought up the situation about travelling to Lusaka with her family, gently gauging how possible it would be for them to afford to have more investigation and treatment ‘that side’ (our hospital provides transport for emergencies). The response was like so many others – “Doctor, we just cannot afford to go. Even if we get there will she get better? What will we have to pay for the different tests?”

Initially I wondered, surely can they scrape enough together to get to Lusaka? (around 150kw/£10 for each relative that needs to go as well – they have to look after the patient in hospital) But gradually I’ve realised the situation here in Eastern province – that often that amount of money is often far too much for a family to spend on one person, especially if there are also four hungry mouths to feed at home. Even if the initial costs are manageable, often people have to pay thousands of kwacha for scans, blood tests or equipment like pins or rods for their subsequent operations. So, despite knowing that this lady has debilitating problems that we can barely treat, this family, alongside many others, chose not to travel for further tests, accept their disease and deal with it as best they can.

 

In this circumstance what do we do? It’s easy for me to say “You need these tests”, but when I think about it and am pinned on it, I don’t know that this lady going to Lusaka will make her better – maybe it will give us a more likely diagnosis, maybe she will get some surgery or other treatment to improve things, but what about those children and the rest of the family staying at home? Who am I to say that the necessity for this person to have treatment or investigation warrants the impact having even less money will have on the whole family? It’s not my decision, which is why we ask families, but even then putting these huge questions onto families, who have often had very little education, is that really fair either? Or is it that just being born somewhere different, meaning you have less food and worse provision of healthcare isn’t fair?

 

These are some dilemmas, amongst quite a few that happen across the hospital I’m sure each day. Alongside these big challenges and personal pressures which I am learning a lot from, we’re still having a lot of fun. Having now moved again, into the Outpatients Department (a combination of A&E and GP), there have been a lot of funny and interesting moments. Just a couple to tell you about. One of the best moments I’ve had here came on a day when every old lady for miles around seemed to come for blood pressure review on the same day. This one lady, let’s call her Fatness, came scuttling in, hunched over her wooden stick, and gradually sat down in the most contorted way before giving me a beaming smile of her few teeth. As I asked her what she’d come in for I quickly had to ask the translator for help as she started making a collection of noises that sounded nothing like Chichewa, English or anything I could comprehend, in fact sounded more like someone trying to beatbox. Only once the translator broke down in a fit of giggles did I realise that it was, in fact, just a collection of noises – “chaca, chaca, chaca” and “zut, zut, zut” (I think) were her trying to tell me what her heart palpitations felt like, although amidst everyone’s laughter at this 91 year old, toothless, beat-boxing, great-great-grandmother some things were likely lost in translation.

 

Just a couple of days beforehand, I had arrived in OPD when some of the other doctors were having their mid-morning break. As I walked into the room where we see the patients there were five student nurses standing there with two patients in wheelchairs (usually a sign that someone at some point has thought the person is sick), looking slightly blankly and slightly relieved at me. I quickly had to work out and scope out who I should help first. One didn’t seem to be moving much at all, and sadly gave me the answer as to who I should be focussing on, as I listened to her heart and lungs and realised that there were no sounds and so nothing really I could do for her, especially in the context of someone else who I’d seen signs of life in that I should probably help right now. The second had just a faint pulse and was only making a tiny few groaning noises, and unfortunately had come in with a neighbour who had no more story about what had happened than “I found her like this at home this morning, she’d been complaining of some tummy pain for a couple of days”. The only thing I could find wrong was a really low blood pressure and so, after assessing her as fully as I could we rushed her to ultrasound (back home there’d be one in A&E for situations exactly like this), and luckily found the cause of her collapse – a huge ectopic pregnancy which had burst into the abdomen. She managed to go to theatre 20 minutes later in as slick an operation as I’ve seen here and by the next day was sitting up eating nshima again. Ten minutes longer though and she may well have been the same as the other lady. This was a particularly dramatic moment and whilst not as good for the people living here, not having a reliable ambulance service or GPs like back home means we are thrown into a vast range of scenarios, unlike any thing we’d experience back home.

 

Again, I’ve chattered on too long but we’ve just had a really fun weekend chilling out and climbing hills nearby (hopefully you can see some photos). We are loving being here more and more and whilst we’re looking forward to seeing people more again, knowing that we have two months left is creeping up on us and we’re trying to make as much of each second in this brilliant place as possible.

Family, Food and the Falls

 

After three months in Zambia, plenty of work and a couple of trips back to the UK which have (eventually) yielded great jobs for both of us next year – Rachel in Paediatrics and myself in Core Medical Training down in South West England – we’ve just got back to St Francis from a brilliant week exploring more of Zambia.

 

A couple of weeks ago we had a great weekend making the most of a fine Zambian day with no power after another storm! Any production intended for Saturday obviously could not happen without power and so, Rach and I, with Jess and Heather (fellow Square-ites) spent most of the day eating and chilling in the sun, pretending that all the eating was justified by making lunch for Lindsay and Ali, the hard workers that weekend. We had such great satisfaction at making good food with a small gas cooker, a braai and funny combinations of food left in fridges, as we somehow created a plethora of culinary delights between us – from pancakes, to feta, rocket & tomato salads, throw in some aubergines, wine and chocolate, and you get the gist. It was exactly what weekends should feel like, probably made all the sweeter by having worked the weekend beforehand! The simplicity of not being able to look up guidelines, or to write applications without computers, charged phones or even boil a kettle, gave us a perfect, chilled out day with some of the great friends we’ve met here!

 

As we embarked on another week of work, my sister Ruth arrived from the UK for a two week stay, with very little of her own luggage and a few stocks for various people, including a patient, let’s call him one-legged Jim, who had managed to co-ordinate supplies for him being delivered to Ruth before she flew. His disappointment wasn’t too obvious when he received insulin needles and dressings when he told me he’d been hoping for an iPad and a new phone!

 

The first week Ruth was here gave her a chance to see what life is like in and around St. Francis’, after a true Zambian experience on the 7 hour bus trip to Katete, complete with its distinctive (I’ll let you interpret that as you wish) smell and sights. Once she arrived we took bike taxis to Katete, bartered for fruit and explored the chitenge stalls in the market before visiting Mr Tembo and Abraham, two tailors frequented by St. Francis’ doctors, for an array of wares – skirts, dresses and ties to start with. As Rach and I worked away during the days, coming back and forth from the hospital, Ruth managed to have some chill time away from any of those little things we always ‘should be doing’ in time off back home! And in the meantime made us some great treats – cakes with delicious cinnamon icing and a great spread of lunch items, pieced together from increasingly frequent trips to the chadda (the little row of shops nearby) and pickings from our garden which, under the care of our gardener Nelson is producing some great results. Much to Rach’s delight that includes the flowers that she chose, though Nelson was less than impressed with them and asked me to bring back some “real seeds” when I went to the UK.

 

Once we’d ticked off our final on-calls of the week (after a beautifully quiet Friday night) we headed off on more adventures, a whistlestop tour of Zambia for just over a week.

 

Our first stop, after an exciting journey involving Pineapple Fanta (who knew that existed!) and a Zambian 16 year old falling asleep on my shoulder, was our lodge at South Luangwa. After our incredible first experience of safari we knew we had to take Ruth, and Easter weekend seemed like a perfect time for it! We arrived to riverside drinks and our raised, wooden chalet overlooked a vast expanse where antelope and monkeys ran around all day, where hippo wallowed past at 4am to much excitement (mainly from me!), and where in every second there seemed to be a noise, a call or a squawk telling a story or calling a friend. With sun splitting the sky and Scottish volumes of suncream applied we set off on the first of our two game drives of the day. I won’t list all the animals (though you can see some photos hopefully) but highlights of the drives were being right next to an elephant giving himself a dust bath and in the evening staking out two lions, who after much searching for, wandered across right in front of our truck, climbed a log and stood posing as the sun set whilst we silently peered at them in awe. The African sun roared through the day too and between drives we lounged lazily by the pool, Ruth and Rach managing to read half a library’s worth of books between them in double quick time. We kept our food and Easter supplies well hidden though after a monkey raid on one family‘s cool box left them Easter egg- and cheese-less. On our final morning, as we got ready to leave, Ruth and I surfaced early and wandered down to the rivers edge, meeting a troop of monkeys on the way all seemingly teaching the one, tiniest, youngest monkey of them all how to walk, with limited success as he seemed to be encountering gravity and trees for the first time. It was another special time on safari, seeing lots of brilliant creatures and feeling a million miles from anything but nature.

 

The next stage took us the 1172km and couple of days to Livingstone, stopping back home in Katete and whistling through some of Lusaka’s hipster delis in between discouraging Rach from buying a rabbit. However cute ‘Cloud’ was, as she’d already named it (I preferred ‘Storm’), he wasn’t likely to survive our travels I assured her.

 

With all the time we had on the bus, amongst watching the various and strange loads being put on at each stop, and all the unofficial passengers without seats hiding under a seat at a police check point, we planned out our next couple of days around the Falls. So, when we eventually arrived in Livingstone, we barely had time to throw our bags into our room at Fawlty Towers (no Spanish butler sadly) before heading out for delicacies such as crocodile pizza, real cheese and a few drinks. As we headed to bed we were already looking forward to the next day – a trip to Victoria Falls themselves!

 

Bright and early we excitedly piled into a minibus, with what seemed (after three months in Zambia) like an overwhelming number of Muzungus! Rach had been to the Falls before but during the dry season (October to December). She assured us meant there had only been trickles of water falling. As we arrived it was hard to believe that there are ever only trickles falling as thousands of litres (one million if you believe Lonely Planet’s accuracy) of the Zambezi crashed over the falls every second. Later in the day, on the Victoria Falls Bridge (also the border between Zambia and Zimbabwe), a Zambian man told us proudly “in Zimbabwe you see the Falls, in Zambia you feel them”, and whilst I can’t say what it would be like seeing them from the Zimbabwe side, we certainly felt them in Zambia!

Initially it seemed though maybe we might not get very wet, but as we wandered closer to the Falls and increasing numbers of people appeared looking as if they’d come out of the world’s most drenching shower we realised how wrong we were. You walk around 20m away and parallel to the Falls, though it was difficult to tell through the immense amount of spray, opposite the top of the 108m drop and across Knife Edge bridge, where the spray hits its peak. The power of the Falls was incredible and as we stood watching it, spotting rainbows pop up here, there and everywhere in the mist, and being soaked we couldn’t do anything but be amazed at this wonder of the world. No photographs could do it justice, but it didn’t stop us taking a few! After drying off a little we took another wander through the greenery (and baboons) to the giant pool at the bottom, the Boiling Pot, where all the water swells and crashes together after falling down, in the shadow of the Victoria Falls Bridge. It is another incredible spot as the spray from the falls passes through under the bridge as you watch the bungee jumpers…which cunningly leads onto the brilliant final part of our day, which Rach, when she first heard of the plans, said was “the most ridiculous thing I have ever heard” (not one ever prone to exaggeration to be fair). Ruth decided to bungee jump from Victoria Falls Bridge! As she booked in, I almost got roped in too, but frankly chickened out and can’t say now that was a bad call. As Rach and I watched on, Ruth took a zip slide across the gorge and then threw herself (with a lot of help from Abraham) off the bridge not once, but twice, on a bungee and then a giant swing. Mental! We let our folks know once she’d made it. It seemed like a ridiculously fitting end to a majestic day, as Ruth assured us that the view was even better from below the bridge. We believed her without question. That night we filled ourselves full of delicious lasagne and pizza at Olga’s, an Italian restaurant, and went to bed suitably amazed.

 

Our second day we wandered through Livingstone town, a shock to the system with its Western norms like street lights and pavements. Bartering for presents and wares in the curios markets revealed another of Ruth’s talents – a truly Scottish stinginess. Anyone who gets two wooden ornaments down from 300 to 50kwacha + two hair bobbles has to be admired! Being called David, a doctor and coming from Glasgow worked handsomely in my favour amidst the Livingstone market sellers. After heading home with our takings, we made the most of our last afternoon in truly British fashion, by heading to the Royal Livingstone Hotel for high tea.

 

We arrived into seemingly another world, with wooden roof fans everywhere, hotel staff dressed in leopard print dresses and hundreds of spotless towels lined up at the side of the huge pool for hotel guests! And as we sat down for afternoon tea on the terrace looking out to the Zambezi River, hearing two elderly Americans say to each other as their chicken Caesar salads and sparkling mineral water arrived, “Now I really feel like I’m in Africa”, we couldn’t help but laugh at how alien this seemed compared to the brilliant dustiness of Katete. It didn’t stop us embracing a buffet wholeheartedly though, and after we had filled ourselves to the brim of capsicum scones, cucumber sandwiches, pear bourdaloue and biscotti, we sauntered down to the river’s edge and the sundeck to drink mojitos and watch the sunset. With the spray of the Falls half a mile in the distance and the golden sun setting over the far side of the river it was a magical way to finish our time in Livingstone.

 

We had almost reached the end of our holiday and time with Ruth. On our final night in Lusaka we reminisced over more great food about what Ruth claims was “just the best holiday ever”. Spending time altogether exploring with Ruth around this exciting country we’ve been lucky enough to get to call home for these few months has been great fun and special to get to show one of our family exactly what life is like.

 

We met our friend Lindsay, who had just got back from holiday in Sierra Leone, back in Lusaka backpackers and it was so nice to meet a friendly, smiling face from St. Francis’ before heading back together. As we said goodbye to Ruth the following morning, as she spent the day in Lusaka before her flight back to the UK and we headed for our bus back, it was great to share some our stories and hear about Lindsay’s holiday as we all headed back to (if you can call it) normal life and work in Katete.

Downpours, Down Tools and Disease

Right now I am sitting watching the most impressive rain storm I’ve ever seen outside the window. I escaped from the hospital just in time, whilst lots of fellow Muzungus are still pinned in – by a combination of torrential rains and lightning strikes, which taken down a papaya tree, a fence and a few other things into the bargain so far.

 

In the time I was back in the UK the rains have properly arrived, a couple of months late, though thankfully it sounds like all the maize crops haven’t been totally ruined! There’s nothing Scottish about these rains it turns out – none of the persistent drizzle for days on end, or the rain you barely notice yet soaks you through. Here a storm lasts minutes, yet everything is drenched – including the cats who run around lost, spreading their soakingness to anyone’s house daft enough to have left their door open.

 

Whilst in hospital we time our trips round the hospital to dodge the rains (pretty hard not to think of Toto while the rain’s stoating off the ground…in Africa). Wanders to the lab to see if any blood has arrived (only once in the last week!), to other wards to see referrals, to OPD to help out with the ever growing number of patients sitting on the stone steps, or the 11am Fanta break – an essential part of any day. We all sit on a wall along the hospital pathways with our ice cold drinks (as long as the power has been on) taking stock of where we’re up to after our respective ward rounds. Usually it is a mix of batting ideas off each other about our complex patients, excellent stories from the last 24 hours on each ward and comparing the great names some of our patients have: Proficiency, Limited and Fatness three of my personal favourites so far!

 

Working on the wards here keeps bringing a lot of fun and a lot of challenges. As I spend more time getting used to the conditions we encounter here I am realising how differently people here in Zambia experience and deal with ill health and disease. Team Monica (Laura and I) have been keeping a record of all the diagnoses for the patients that have come on to our ward (not surgical problems…most of the time) in the last six weeks. In the UK it would probably be heart attacks and chest pain, coughs and pneumonias at the top of the list. Here we have seen one heart attack in six weeks!

 

How can Zambia possibly have so much less heart disease than back home? Is it the lack of a chippy for 300km? Is it that there’s much less obesity in Zambia? Is it that only a few people have cars so they have to walk further? I don’t think so, or at least these things aren’t the whole story. I think the real reason shows hugely what life is like here for the majority of people that we are serving.

 

Angina doesn’t kill people. Big heart attacks do, and even in the UK, these people unfortunately don’t make it to hospital in time. Over the last 20 years public health in the UK has massively educated everyone so we know that if you have pain in your chest, get it checked out, and quickly! Here, there has been none of that. People vaguely know your heart is in your chest but don’t really associate it with pain there. They’ve never seen a billboard picture of a man with a belt tightly fastened round his chest telling them to phone an ambulance as soon as they can when they feel pain like it. For me, the things that public health and health education has taught us – smoking causes lung cancer, cervical cancer rates can be massively brought down by screening – have been so ingrained in British society, from bus stops to billboards and TV adverts, that we don’t realise how lucky we are to have been given that knowledge that saves lives.

The other reason people don’t come in is that if it doesn’t kill them, it doesn’t stop them working. Yes it might be really painful, they might have twinges in their chest every day, but ultimately people can still work and often until something is serious enough that it stops them from working they won’t present to hospital. Life is very much lived in the present amongst most people in the Eastern province – if they can’t work they don’t earn. There is no sick pay, there is no other option than to work even if you’re in pain. And this means we see the end stages of conditions coming into the hospital – when in the UK we would pick up problems really early, through a combination of public health knowledge and the opportunity to have things screened and investigated further.

 

There is a huge challenge here in Zambia, and by no means (even before the last year of crushing Tory destruction of the NHS and public sector) have we got it perfect in the UK, but there are huge benefits to those public health campaigns that have gone on in the background for years, meaning that people and their health conditions can be picked up earlier and treated earlier, saving vast numbers of lives.

 

The fun continues soon as Ruth, my sister arrives, and have a week’s holiday where we’ll be travelling round Zambia for safari and to see the Victoria Falls, amongst spending a lot investigating how good Zambian bus services really are! Cannot wait!

 

For now though, the difference in being here for coming up to three months already has been wonderful. Back home months can often seem to pass in hospital quickly and one month can seem pretty much the same as the last. Here, almost every second seems like a new adventure and is pushing us to think differently, act differently, and realise who we are, is a tiny yet vitally important piece in a giant jigsaw.

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SMILES, SAFARI AND SCOTTISH TRIPS

Sitting on the kerbside as I wait for my bus to Lusaka, before the sun rises with the sounds of hundreds of crickets, and chickens crawing away, it feels as though the first chapter of this Zambian adventure is drawing to a close.

 

Today I head to Lusaka, then Glasgow (via Dubai) for real chocolate, an insulin stock-take (those two are an unashamedly ironic pair) and my interview for a job from August.

 

February has disappeared in the blink of an eye. Last time I wrote we had had our first couple of weeks and the rest of the “revolution” (as Jess likes to call us) had just arrived. That seems a long time ago now as we are settled on to our wards and our ways in the hospital – Laura and I on St. Monica, Heather and Ali on St. Augustine and a raft of great doctors – Teege, Rach, Anne, Lindsay and Manon, working on the Special Care Baby Unit and Mbusa, the paediatric ward.

 

In the square where we live, of four houses with bunting strung up between them, Heather has just moved in to join Chris & Katie, Jess and Rach & I and the three cats – Mitten, Kitten and Frank, who seem to have the right to any house with the door or window open! We feel really settled here and whilst going back to the UK this week will be a lot of fun, it is with a little bit of sadness that I go, being away from life in St Francis’ and all that entails for a couple of weeks.

 

The friendliness and chirpiness of Zambian people – the staff, patients and families – has played a huge part in settling in so quickly and is something brilliant both to watch and be part of. I haven’t yet found if there’s a word for “banter” in Chichewa but if there is St. Francis’ is full of it. Let me use our friend from the last time to illustrate the point – the lady with anaemia who I was struggling with not having the blood and resources to deal with her condition. Thankfully she was discharged not long after the last update (some blood arrived and we pleaded her case!) Yesterday she was back for a blood check and this time her Hb was good enough that she does not need a blood transfusion for the first time in months. The scene in OPD I hear was one of great joy – dancing, laughing and also of her telling Chris (who worked on Monica before we arrived) that she’d proved him wrong not having to go to Lusaka after all to get better.

 

Chris thought this was too good for more people not to see so sent her to Monica to share the good news. Yet instead of just coming into the ward, waiting at the desk and telling us the good news in the proper, inoffensively British manner she took a new approach. As the ward round carried on and we were squinting at the light box interpreting X-rays we became aware of someone behind us, peering over our shoulders having a peek at the X-rays too (though not offering a lot of interpretation)! We turned round and who was it but Mrs P, breaking out into her celebratory dance and thrusting her results towards us, chuckling away as she did it. The only way to deal with this kind of situation I’ve come to realise is to chuckle as well, offer the old hearty handshake and exclaim “bwino bwino!” The smiles on faces and joy of people despite some of them having terrible conditions and who often have very little to live on day by day puts into perspective some grumbles I have each day, here in Zambia and even more at home in the UK.

 

The fun in the hospital continues but we’ve also had great times exploring around Eastern Province – from buying chitenges and bartering for avocadoes in the market a couple of miles away, to trips to Chipata, the city an hour away with Wifi and yoghurt on sale. Then, last weekend Rach and I, with Sinan and Jess travelled three hours, to South Luangwa National Park for a weekend of chill and safaris.

 

Though metaphorically chilled, the sun-kissed(/burnt) shoulders I am now sporting are testament to how hot it actually was. We stayed in a lodge on the banks of Luangwa River, one of the big rivers of Zambia which eventually runs into the Zambezi, the first night in a tent until an ant infestation meant we ventured into a dorm for the second night. The pool was clear blue, and the loungers and seats by the river gave us plenty of space to laze around, read books and Kindles and even an attempt at doing some work for the interview. Yet as wonderful as that was, the real excitement was on Saturday, heading off on safari – for me for the first time.

 

Starting at with a knock on the tent at 5am, followed by dodging a decent-sized monitor lizard on the way to breakfast, we made it quickly out into the jeep to see what we could spot. We started as the sun rose and a few impala and blue-headed guinea fowl wandered or leapt past us, followed by distant sightings of elephants. Once we were in the national park more and more animals that we realised seemed almost fictional kept appearing one after the other. Having spotted the hippos as we drove over the river, we came across a clearing with what must have been 60 impala and the same number of zebras happily munching away and playing. The sightings escalated – monkeys, baboons, elephants (with a few babies in tow), hyena, lions and even some wild dogs (which are apparently pretty rare) by the end of the 4 hour morning drive. In the afternoon Sinan drove us back through the park (not without risk particularly as we were without a spare tyre after a spectacular blow out on the way to the park on Friday!) and we added waterbucks, warthogs, a leopard (!!!), a single giraffe (didn’t get its number for you Iain – sorry!) and another sighting of the supposedly elusive, but beautiful, wild dogs to the list. It was brilliant. I wonder if safari is something that seems so much less to me when I describe it than what it was actually like that I should just say to do it yourself. Sitting in the truck with the sunrise, then heat of the African sun beating down on you, with wind going through your hair watching all these majestic animals so close by in their natural habitat was pretty special!

 

After a weekend like that it seemed funny going back to the hospital again on Monday, just like it had been any other weekend, but the hospital and working there has its own majesty about it. No elephants, yet something which is making me realise how much more there is to learn, to see and to explore here in the few short months we have together here.

 

I shouldn’t put off reading about ‘clinical governance’ and ‘power verbs’ any longer I’m afraid so thanks for reading another update. Rach was so glad of all your texts and messages around her interviews and she’s going to write really soon to tell you her stories. Thanks for all the other emails, messages, thoughts and prayers that we’re being sent. We love reading them, hearing about life in Scotland, South Africa, England and South Sudan, wherever you are, and sharing this with you and with our new friends here!

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BLOOD, BEDSIDERS, BWINO BWINO

BLOOD, BEDSIDERS, BWINO BWINO

As I sit here writing after another day’s work in this brilliant hospital, long haul flights, emergency landings and life outside Zambia’s Eastern Province seem a long way off for one of us at least. (Rach has ‘popped back’ to the UK, a trip complete with emergency landing in South Sudan which I’m sure she’ll tell you more about in her next blog).

The three weeks since we left the UK have flown by in some ways and in others it feels we have been here for years. My Chichewa (the local language) has made it to the point where I can almost scrape through a ward round as long as each patient has normal bowels (Chimbuzi bwino bwino), are eating and drinking well (mukudia bwino? mukumwa bwino?) and aren’t from Mozambique (where pidgin Chewa/English can’t hack Portuguese being a second language). My learning/trial and error is being deservedly chuckled at along the way but I take that as a compliment, and so far it’s only ‘Sorry’ (pepani) and ‘Breathe’ (pomani) that I keep getting mixed up, nothing important in a hospital really.

The hospital is split into four main specialties – Medicine, Surgery, Paediatrics & Neonates and Obs & Gynae, as well as a big, bustling outpatients’ department – and is run by half foreign volunteers and half Zambian doctors. The two medical wards (St. Augustine and St. Monica) are across the hospital’s central walkway, with red stone floor, tin roof and open sides, from each other. The long, open arrangement of the medical wards is much like I imagine wards in the UK were like in years gone by. Both have an offshoot, Khonde (meaning verandah in Chewa), where there are 4 beds for patients with TB to be cared for.

Each patient has a bedsider, a family member who stays and nurses them throughout every minute they are in hospital, sleeping on the floor beside the bed at night, washing, feeding, turning and doing every personal task with and for them. Often I feel as though I get to know the bedsider even better than each patient, as they remain well and I chat to them each day about their patient and condition. They build up quite a community, often eating their nshima (the staple maize dish in Zambia) together, and with the ward being so open they seem to not just know their patient, but also plenty about everyone else! I did feel pretty sorry for the 16 year old girl who, when she found out at the weekend that she was ‘unexpectedly’ pregnant, it therefore wasn’t just her own bedsider (her mum) who berated her but around 20 other bedsiders as well. She went home pretty early the next day!

Rach works on Mbusa, the Paediatric ward whilst I am on Monica, the female medical ward, with a friend from Liverpool, Laura, and sometimes Gilbert Simbaye, a jolly Zambian man with glasses the same colour as his blue scrubs. At weekends, of which I’ve just finished my first fairly unscathed (the patients did too), we stretch to covering both medical wards and for nights we add Paediatrics & Neonates into the mix too – just to keep it interesting.

Medically it has been a big change, a lot of fun, a big challenge and full of invaluable experience already. With different and limited resources I have found it tough to work out what it is specifically that we are trying to do for each patient. I hope this example will be clear to medics and non-medics alike:

We have a patient with anaemia, a low Haemoglobin (Hb), in Monica, a lady with a big smile which still beams even though there are just three teeth involved. She has an Hb of 2.6 when she was admitted two weeks ago. In the UK as a rule we would give blood to anyone with Hb less than 7 and roughly 1 unit of blood adds 1 to your Hb level, so we’d give her five units of blood back home just like that. Here we have had no blood available for a week in the province.

We think too that she has cancer in the lymph nodes in her chest causing her blood to break down. In the UK she would have a CT scan, a biopsy, some blood tests and might be able to have some chemotherapy if our theory was proven right. Here, the only way to do this would be for her to travel to the capital, Lusaka, six hours and a few hundred Kwacha away, have a scan and biopsy and then we could maybe give her some treatment, or at least we would definitely know why her blood count was falling. She can’t afford that trip and so the reality is that we’ll keep her here, wait for some blood, treat what we think is happening but she will get worse gradually and we can’t do anything about that.

For a doctor who has grown up in a system where even the most complex and advanced tests and treatments are available fairly readily, working out how to best serve a patient who at best we are treating for the right thing with no hope of curing a condition I am used to being able to do a lot more for is a huge change of mindset. I know Rach has so many similar situations on Paediatrics, with various children and conditions, and we are both learning lots about the practicalities of medicine and how people interact with the health service here.

There are lots of stories like this – no blood, we have just two machines which can deliver a small amount of oxygen in the hospital, the X-ray machine has been broken for the last 10 days – and it’s the challenge of getting my head around all this I’m trying to illustrate. It doesn’t seem hopeless. It does feel unfair and frustrating (for the patients) at times that we don’t have seemingly simple things but it is also the most exciting I have found medicine. We are learning massive amounts about previously unseen conditions every minute, managing these situations and using much more purely clinical judgement than we have to in the UK, working with brilliant teams of nurses and doctors, and loving life in the red brick hospital where a greeting consists of huge smiles, laughter and the heartiest of handshakes.

Outside of work, we have had some great celebrations with lots of new friends – barbeques to welcome us and other new doctors whilst saying goodbye to ones that have come to the end of their time in St. Francis, film nights projected onto bed sheets as a big screen and Friday night drinks with our doctor friends from Liverpool who all arrived at the end of last week.

We are settling in and making our little house feel like home, enjoying our lunches of wonderful fresh rolls and occasionally Sprite from the mess together at our table in the sunny window looking out across the square.

I am especially struggling to cope with what must be the world’s most confused cockerel, who usually starts his song at around 4am for half an hour, before having a rest while the world wakes up around him and kicking off his second tune of the day around 10am. Rach says I’m being dramatic.

I have rambled for too long and being two hours ahead I really should be heading to bed. Thanks for reading all the way through. Like Rach said we love hearing your news too, hearing from you and are thankful for thoughts and prayers. (Mum your birthday card is on the way, sorry I didn’t quite factor in Zambian postal timings well enough!)

Rach has an interview each day for the rest of this week in the UK for our jobs starting from August and so would love a little text or message to keep her spirits high through these three interview days. Thanks!

We are living a dream right now out here (as a clichéd as that may sound) and it’s already beginning to feel like six months is going to be no time at all.