I’m off sick today and what better opportunity to tie off a few loose ends?

Having arrived back on Saturday, I felt fine until a couple of days ago when I came down with a cough, headache, diarrhoea, fatigue and a temperature. Perhaps I haven’t escaped the dreaded tropical lurgy after all, I thought to myself, and went to see the doctor for a malaria test. The first one came back negative and I had my second today. (You need 3 tests on consecutive days to rule out the diagnosis.) Giving a stool sample was rather less pleasant; let’s leave it at that. I had a full blood count done too (which looks at the numbers of different types of cells in your blood) and my monocyte count (a type of white cell) is markedly raised, so the doc reckons I might have glandular fever. It’s pretty endemic in the developing world apparently, though I never diagnosed a patient with it – probably because everyone gets it when they’re very young, i.e. long before they make it to an adult ward. I’m getting the test tomorrow. To be honest, I’d rather go with the malaria…!

A few people have asked me about culture shock on returning to the UK. In fact I’ve asked myself the same question. Well, not much to report actually. The main thing has been a sudden awareness of how much less simple life is when your worldly belongings aren’t restricted to one and a half rucksacks (and a cowhide cowboy hat that’s far too hot ever to wear) and you’re not doing one thing in one place with one set of people at a time. Perhaps symptomatic of this is that I’ve so far eschewed the dreaded hillock of post that has built up on my desk over the summer. Otherwise the surroundings here appear pretty much as they ever did. I have, however, noticed myself behaving rather strangely, e.g. not just grunting a “Hi” to Tesco till attendants but smiling disconcertingly at them and asking them how they are, in good Zambian fashion. Responses so far have been encouraging so I reckon I might as well keep going with it. I suppose not all habits are bad.

Speaking of Tesco, we’ve got a new black security guard at my local. In the hope that he might be a Chewa Zambian I asked him a question about the presence of unlabelled strawberry and banana smoothies in the reduced-to-clear section. I was happy that he turned out to be African – and very much enjoying Edinburgh – but sad that he was from Nigeria and not Zambia. Ah well, if you know any Zambians in Edinburgh, please send them my way as I’m feeling a little homesick.

Something I forgot to mention in any of the two or three entries I’ve made recently is that I performed my first piece of solo surgery a couple of days before I left SFH. The operation was the removal of a large (approx 10x10x5cm) lipoma from the back of an old woman’s shoulder. Before you get all excited about me saving lives, I should caution you that while a lipoma is the tumour it sounds like, it’s about as benign and non-life-threatening as such things get: an overgrowth of fatty tissue beneath the skin; just very unsightly really. I did the procedure under local anaesthetic with a theatre nurse to hand me the instruments, dissected out the impressively large growth and sutured her up beautifully, if I do say so myself.

To top that, on my final day I was due to carry out a plastics/grafting operation on a man who’d lost most of the skin on the top of his foot and ankle due to an infection (the result was a wonderful anatomy lesson to say the least…) while the other surgeons were doing some orthopaedic cases. Much to my disappointment though, the extra theatre was not available due to a staff shortage so the patient and I had to forfeit. It’s a shame as it would have been a great chance to put my new-found plastics skills into practice. Oh well, next time.

On that note, lots of hands-on training in specialist burns/plastic surgery wasn’t what I was expecting when I went out to Zambia, but it was a very rewarding and useful experience. Skin grafting, while very much a specialist surgical area, is hugely important in a context where there are so many open fires, road traffic accidents and untreated infected wounds around. And precise suturing practice doesn’t get much better than sewing skin grafts onto a woman’s face – not to mention the job satisfaction of 100% graft take: you’ve just given someone back their face.

Going back to incidents with open fires, in our experience at SFH, these are frequently associated with the high level of undiagnosed/untreated epilepsy in the community: people who fall into fires are often fitting epileptics. The problem is compounded by the all-too-commonly held traditional belief that the fitting person is possessed and should therefore not be touched during the fit for fear of spiritual contamination – leading to absolutely horrific and often fatal results. Certainly down the list from other dangerous health beliefs, e.g. the classic “sleep with a virgin to cure yourself of HIV”, but it should certainly be a target for public health campaigning nonetheless. (On a positive note, the cited HIV-related one is currently the focus of such a campaign in Zambia.)

Speaking of HIV, I don’t think I ever mentioned the stats. Nationally, Zambia runs at somewhere between 15 and 20%. Locally this is nearer 20, and amongst hospital in-patients it was as high as about 70% of those on St Augustine’s, the male medical ward where I worked for 3 weeks. A bit lower among the surgical patients but still substantially higher than the local average. Needless to say, we did our level best not to get our fingers stuck on the end of any needles… Lest that sound a bit rock and roll though, such bravery is nothing compared to that of doctors and nurses, both African and foreign, who treated patients day in, day out long before today’s reasonably effective post-exposure prophylaxis was available.

On to a more cheerful subject, I think the name Adam is fairly unusual among the Chewa people (in fact among other Zambians, Malawians and Tanzanians too) as at least half of the people I met must have made a comment about Eve when I introduced myself. On the other hand, I think it would make a good alternative to some of those we encountered at the hospital. Here’s a hall of fame:

• Immaculate
• Danger
• Actress
• Ghost
• Shoes
• Simple
• Bachelor
• Bishop
• Obvious
• Change
• Doctor
• Anurse (i.e. a nurse)
• Bornface (what?!)
• Memory
• Guilt
• Doubt
• Dying

And my personal favourites:

• Crankshaft
• Toolboy
• Robots
• Fatness
• Laziness
• Accident
• Problems

In contrast to the intriguing variety of Christian names, surnames are in short supply, almost everyone being a Banda, a Phiri (pronounced “Peeree”) or occasionally a Tembo. Speaking of Banda, Chris Nickson – the New Zealander to whose elective report I have previously alluded – claims to have met one Elasta Banda. Too good to be true? Yeah, that’s what I used to think too.

Before I go on to talk about my overall take on the Zambia experience and what I think I might do with it, I should fill you in on the rest of my holiday. I believe I left you in Nkhata Bay on the shores of Lake Malawi. There’s not too much more to say about that – I could bore you with the beautiful setting, unique hostel, great food, lovely people (including quite a few I’d met already in Livingstone and/or Lilongwe) swimming in the lake, dug-out canoes etc but I won’t. Suffice to say, Mayoka Village, Nkhata Bay: recommended. One thing worth remarking is that I’m now much more knowledgeable about Rastafari, thanks to Kelvin, a local adherent and very fine chef, craftsman and conversationalist into the bargain.

I also came across this fantastic sign in a local health clinic (if Livejournal will let me post it). To put it in context, at the moment it’s about 300 Malawian Kwacha to the pound, i.e. these prices are heavily subsidised. Malawians are similar to Zambians in generally taking a rather more direct approach to life’s taboos than we Brits.



The journey back to Dar was arduous: two days (7am day one till 9pm day two) four taxis, three buses and one night in the World’s Skankiest Motel. There were highlights though, in particular having done my homework so as to be able to tell the man who was trying to cheat me with poor exchange rates at the border, “Your rates are terrible and I don’t like the way you do business,” before turning on my heel. The guys I ended up changing money with on the bridge between the Malawian and Tanzanian border posts (why do they let hundreds of these characters hang around in such places all over the world?) tried all sorts of stunts during our 50 USD transaction, first of all agreeing to my suggested exchange rate before, most insultingly, presuming I couldn’t do the very simple arithmetic to figure out that 50,000 wasn’t, after all, 50 multiplied by 1,200. Then the guy started counting out the 60,000 in 500 Shilling notes, which I quickly put a stop to. At long last he reached for his 10,000s but somehow or other two of the six notes he passed me just so happened to be Zambian 100 Kwacha notes – of a similar size and colour and about a 15th of the value. At this point I’d had enough of him, told him so and did the deal with one of his pals instead. I took great pleasure in the sense of injustice he seemed to feel about losing my business. Even this new guy wasn’t averse to a swindle though and came running up to me a minute after I’d walked on saying that the serial number on my (100% kosher) 50 was bad – no doubt hoping to get a refund during which he’d give me back one of his own dodgy 50s rather than my original one. I declined, ever so politely.

Perhaps even better was the experience at the Dar Es Salaam bus station. Seeing 4 rucksack-laden Europeans coming towards him, the taxi driver clearly figured his ship had come in. Which it had – if only he’d been honest about it. We asked for the price to the Safari Inn; he said 5000, at which point I put on a puzzled expression and said, “My friend, are you sure you know where it is?” He says, “Yes.” I add, “You know, I really don’t think you do.” He is adamant he knows. “Because,” I add, looking mystified, “it’s only a kilometre away.” He protests ad nauseam that this is the price. I put my arm on his shoulder and say, in my most charming tone of voice, “But my friend, you see, you can’t do this to us. We’ve been to Dar Es Salaam recently, we’ve taken a taxi to this bus station, we know what the prices are.” Being caught at it is clearly getting to him, so I ram home the point: “In fact, I come from London, one of the most expensive cities in the world, and that would be expensive even for London.” Backed into a corner, he had nowhere to go but stick dumbly to his line – losing our business. Meanwhile we soon picked up another taxi for half the price. When you’re on the tourist trail, your sense of fairness inevitably takes a battering; once in a while though, you score a small victory in the cause of honesty in human relations.

But I jumped ahead there: I missed out The Motel. On the bus to the border (standing room only for 5 or 6 hours) I met a couple of German girls. Well, it’s a good thing I did because they’d run out of cash so had to borrow some from me to get to Mbeya, across the border in Tanzania, where we were to stay the night. I had planned to go to a reasonably nice place 15 minutes’ walk from the bus station, but when we arrived well after dark and a friend of theirs who’d got there ahead of us had booked rooms in a place across the road, I was inclined to go for it. Well, two rooms quickly turned into one room, turned into one room in which something must have recently died and not been entirely removed, with two stained single beds and one dirty blanket. The four of us were equal to it though, gleefully shoving the beds together and all squeezing on. The Germans had sleeping bags so I had the dubious privilege of the blanket.

In case you’re munching on a biscuit while eating this, I won’t describe the toilet.

On the bright side, we did have an edible meal together along with a few beers – though not without the delightful experience of the waiter vehemently attempting to charge us three and a half times the price advertised in 6 inch chalk on the opposite wall. Yeah, superb. A lesser piece of entertainment was being harassed by a tout who swore black and blue that the Scandinavia Bus to Dar (the one all the tourists go for due to its justly acquired Lonely Planet reputation) was full, before, surprise surprise, trying to take me to another office. I put on my best Clint Eastwood demeanour and said, “Yeah, we’ll just see about that.” Needless to say, he was lying through his teeth.

The Scandinavia Bus lived up to its reputation the following day, getting everyone to Dar safe and sound. I’ve mentioned some of the swindle tactics you experience on the tourist trail, but I should balance it up with some of the good stuff. Best is the kids on the buses. They’re always up for waving back at you and making funny faces. And, best of all, you can smile at them without people assuming you’re a paedophile. Your fellow travellers, as well as sitting on your lap when required, or squashing you and your bag into square footage you never thought possible, are often very generous. I was offered (and needless to say accepted) food – variously a stick of barbecued meat and a banana – on the two longest bus rides, and people are always willing to talk. It should also be said that you do often come across bus companies, bus conductors and taxi drivers taking a stand against the let’s-rip-people-off culture by charging you fair fares.

Speaking of children, a digression here: something I noticed time and again in every area in which I travelled was how almost universally content the infants are - unless seriously ill. I put this down to them always being so close to their mothers, carried around on their backs and just a deft rotation away from a breast. Additionally, I'm not sure I ever saw two children arguing, never mind fighting. Almost makes me think I'd actually enjoy being a schoolteacher out here, something which I'd never dream of taking on back in Britain. I'd certainly enjoy the chance of doing some paediatrics next time I'm in Zambia.

Back to the story: after all this, being back in Dar Es Salaam in a clean hostel room was really rather boring – though the lack of a properly hot shower and the following sign at the bottom of the stairwell to the rooms went some way to making up for that.



And then it was time to head home – with mixed feelings: looking forward to catching up with family and friends, escaping the African midday sun and getting stuck in to the term ahead (yes, really…!) but already missing my Zambian friends and Zambian people in general.

So will I go back to Zambia? Yes, I very much hope so. Having said that, I don’t think it would be worth going for anything less than 6 months, maybe more like 9. That would give me a chance to get to grips with the language, making me both a much more effective clinician and exponentially increasing my participation in and enjoyment of both clinical and social interactions. Fortunately, Nyanja doesn’t seem too hard – and it comes with the bonus of being very similar to the Chichewa spoken by the majority of Malawians.

But why do I want to go back? Many people talk of Africa getting under the skin. But it wasn’t the landscape and geography that got under mine – although I’ll admit that Zanzibar, Vic Falls, the Zambezi and some of the other places I visited were strikingly beautiful; but I’m much more of a mountain, snow and lakes kind of guy. It was the people. I’ve never been anywhere away from home where I felt so at home, so genuinely and warmly welcomed, so much part of the family. It helps that people often call you “brother” – and mean it. There’s an artlessness in the way people treat you which is irresistible. Human to human, straight up.

On my final night at the hospital, one of my (stone cold sober) Zambian colleagues in surgery said to me, “You have really been one of us,” which was about the best compliment I could think of. He went on to say that although I would be thinking that I’d learned a lot from him and his colleagues (if you’ve read the rest of this blog you’ll know how true that is) they’d learned from me too, watching the way I would relate to patients, explain things to them, investigate the options and politely stick my neck out if I felt their best interests were not being served, go the extra mile. Yeah, it’s a bit embarrassing to write this, but maybe it’s not always good to be so British about everything. It’s part of my story, after all.

When it comes to medical practice, if this trip has confirmed one thing to me, it’s that in order to practise effectively you need to build good relationships with your colleagues. And that’s also what brings some of the greatest pleasure – and an amazing sense of belonging. That sounds cheesy, but while I’m not being British, I’ll leave it in.

I'm writing this seated in the shade on the top deck of the Ilala, a boat which plies its way up and down the ports and islands of Lake Malawi. As it got progressively colder and windier last night I elected to pay the extra 50% for a cabin rather than the hard floor of the top deck. Absolutely no regrets there: I think I might have rolled into the lake in the early hours as the ship tossed and turned, trying to get comfortable on the heavy swell. And there's the added advantage that I can lock up my bags and hang up the 40 minutes' of washing I did this morning.

Breakfast this morning was the best I've had in Africa, thanks largely to the miraculously good chips the galley serves up. A contrast to yesterday morning when I spent a good hour waiting for an eatery - any eatery - to open in the centre of Lilongwe, though the samosas at Ali Baba's were almost worth it.

But I should backtrack a bit.

Livingstone was fantastic. I hadn't expected to be as impressed as I was by the Falls, and the white water rafting more than lived up to billing.

According to some of the other customers who'd rafted elsewhere, it's one of the best in the world. Moreover, at this time of year the Lower Zambezi offers an ideal combination of hugely dramatic rapids (up to Grade 6, though we walked round that one) and a relatively high water level meaning that there aren't lots of exposed rocks waiting for your - albeit helmeted - head should you go in the drink.

The scariest moment was probably being thrown out near the beginning of a long Grade 5. I was underwater for I don't know how long. I'm used to getting put in the washing machine when surfing, but this was something else and I was beginning to wonder how long I could hold my breath for. Eventually I did pop up, gasping for air, only to be confronted with another torrid 9-footer about to chew me up. Things continued in this fashion, flying down the river - drinking plenty of Zambezi - until I managed to grab on to one of the rescue canoes. Quite entertaining, all in all.

After that, we capsized once but I managed to hold on to the safety line and stay with the raft. Still not a very relaxing experience, but less of the being-under-5-tonnes-of-raging-water-for-20-seconds. I fell out once more on a later, easier rapid but this time managed to grab onto one of my boatmates' paddles. Unfortunately she decided this would be a good time to let go of it rather than rescue me, so I had to swim back to the raft.

There was also some attempted somersaulting off the bouncy, inflatable raft once we got into calmer waters, plus the odd bit of good-natured dragging someone backwards off a neighbouring boat. There was the odd croc sunning itself on the banks but you can't let things like that get to you. Expect live action photos on Facebook some time in September.

The journey back to Katete was gruelling but uneventful: I got up at 5am and arrived shortly after 10pm at Tikondane, the local community centre/restaurant, where a party was in full swing. It was great to see everyone again - I made the rounds of the hospital the following morning - and I had a fascinating and inspiring tour of a nearby community development project the following morning. It's been set up by David, a hugely energetic Congolese SFH anaesthetist, to help local youth, most of them orphans (often due to HIV/AIDS) with a holistic programme of sustainable agriculture, education in farming and animal husbandry techniques, carpentry and other skills, school building, health education, sport and hospitality for tourists. And all this with the blessing and participation of the local chief (who has donated a large area of land) and the local community. I hope to raise some funds for them (thus far it's mainly been supported out of the pockets of David and one or two other hospital workers) and spend time there when I next visit.

It was sad to say goodbye to the hospital and so many people there for the last time. I do very much hope to return in a few years when I'll not only be more skilled but also have more time to offer: ideally a good 6 months so that I can spend the first couple focusing on my Nyanja.

The journey to Lilongwe was pretty African: the 20km taxi between Chipata and the Malawian border had 8 people plus two children in it. They know how to get bang for their buck over here that's for sure. Speaking of which, I was very pleased when I found out, on reaching the (highly recommended) Lilongwe hostel, that I'd paid well under the odds for a taxi from the bus station, having given it a fair bit of recalcitrant haggling.

It's quite a contrast being back on the tourist trail I must say, though in the case of Mabuya Camp it seemed to be decidedly more of a medic trail with a good two-thirds of the bar being British students working at Lilongwe hospital - a number of whom I'm due to bump into again this weekend when we get to Nkhata Bay where we're all staying at the same Lonely Planet recommended hostel. I was pleasantly surprised to again run into 3 Edinburgh students whom I'd met on a river cruise in Livingstone and rafted with the following day. One of them and I recognised each other in the queue - from ultimate frisbee of all things.

I can't say too much about Lilongwe itself. Though a bit nicer than soulless Lusaka, it seems pretty much just another African city. What I can say is that I've never seen so many taxis and minibuses in all my life. I have no idea where they find enough people to fill all of them; perhaps some are just ornamental.

Yesterday's journey to Chipoka to catch the boat was blissfully short after travelling in gargantuan Zambia. There was a bit of nail-biting as I waited for the minibus to fill up (this was one boat I really didn't want to miss) but it was plain sailing after that: when I got off at Salima an hour and a half later I pretty much hopped straight onto the back of a very speedy flatbed truck that was going all the way to the port.

Embarkation was typically chaotic. I asked around as to where to buy a ticket only to find out that the office was closed. So I muli bwanji'ed the captain up on the top deck who shouted back just to jump on board. Which I did, literally - throwing my bags ahead of me and jumping from the quay into the bows. I'm not sure if a gangplank ever made an appearance for the sake of the more senior among the passengers.

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So now you're up to speed on the latest (which is that we're docked in Mozambique as the ship's boats spew toxic fumes over the water, ferrying the usual assortment of men, women, children, chickens and customs officers to and from the shore) I should get around to keeping my promise and tell you about work at the hospital.

I think, rather than presenting you with a retrospective view, the best way to do this will be to give you a couple of hopefully interesting excerpts of the diary I've been sporadically keeping. Warning though, this covers 8 weeks so please don't try to read all of it at once!

A bit of background: my intention was to do 4 weeks of obstetrics and gynaecology (which I'd just rotated through back in Scotland and am thinking of doing as a career) followed by another 4 in general medicine.

24/6/08

My first day: enjoyed the tour of labour and maternity wards, SCBU (special care baby unit) and theatres, though did wish at various points during the day that I could just hang out with the midwives. Much more fun - and patient-centred. Speaking of which, the thing that made most of an impression on me was the way that obs/gynae patients are treated in the OR when under spinal anaesthesia. No careful, reassuring anaesthetist presence and sensitive focus on the patient - which I think we do so well back in Edinburgh and which was one ot the things I really enjoyed there in O&G. Instead all the boys stand around the stark naked patient talking about football and occasionally politics as if they were down the pub. Well, that and the fact that there's no diathermy in the gynae theatre! (I'm sure cautery was one of the earliest surgical inventions...) Still, I've been fairly impressed over the 2 days by Dr Makukula. He must indeed be a rather unusual chap to have trained up to a high level in the UK and then volunteered to come back here. Funnily enough, physically he reminds me of John Simpson [my (Scottish) respiratory medicine consultant in Edinburgh] We got off on the wrong foot due to a confusion as to who was operating, scrubbing etc (the usual surgical niceities) but I redeemed myself by putting in a sterling performance at a 2.5 hour vaginal hysterectomy and anterior repair.

So far today has been a bit dull. Apart from getting to write in the notes a couple of times on the ward round - bit of a challenge given that I've pretty much never done it before back home, never mind being unfamiliar with the notes, handwriting, conventions and abbreviations here, and that I couldn't understand most of what was being said (even some of the English - only gradually tuning in to the Zambian accent...!) To be honest I feel as though I'm being just like a med student back home, except that I'm not even getting to see any patients by myself for learning purposes. Just sitting in O/P [outpatient] clinic in the afternoon not having a clue what was being said. Although to give Dr M his due he made the effort to explain whenever possible. As well as giving a 20 minute tutorial on the physiology of menstruation while the baffled patient sat waiting for it to be her turn again! He also asks lots of questions of us on WR [ward round] which is good - obviously keen to teach - and I like the approach he has of getting you to figure out WHY things are the way they are, not just accepting the facts. Definitely a man after my own heart in that respect.

Well, we'll see. If things don't pick up in a week or two I reckon I'll ask to transfer to something else. There's now 2 other O&G trainee docs here, so I don't think I'm going to see much of the action, but who knows. If I could at least be given some responsibilities on the ward, or see a few patients in clinic, that would be cool.

25/6/08

Eugh. Just come back from a mammoth theatre session. Pretty fed up to be honest, like I'm in a dead end on this O&G placement. I didn't come all the way out here just to stand around watching things.

Having said that, the enormous pelvic abscess I just saw drained was pretty impressive. So much pus - cool! Hopefully the patient will do better once she's on some ART and TB meds...

Have been practising some Nyanja phrases which David [one of the O&G docs] has helped me translate. Made a list last night of all the stuff I'd like to be able to say to patients. Was fun to ask a little boy his name outside the hospital today. Any human interaction - really that's what I'm looking for, and what I enjoy about medicine. It would be so much better to actually be doing something. As it is, I'm not being of any use whatsoever. And that's certainly not benefiting me either. What do I actually want out of my time here? I reckon doing some ward rounds and clinics by myself, or with another student, with someone more senior to ask if I need to. Working stuff out. Or doing some rural outreach clinics. So far my expectations of being some use and getting on with things are definitely not being met! I can certainly kiss goodbye to my notion of learning practical O&G skills, being hands-on. Better to find out early I suppose. Save the training till when I'm back at the Royal.

Thinking about longer-term stuff... I reckon this sort of thing would only work for me if I spoke the local language well enough to be able to build some rapport with the patients and the local staff in general. Perhaps that points more towards central or south America. On its own, the business of medicine does not really do it for me I don't think.

Right, buck up your ideas and get on with something useful. (So far the most useful thing I've done here has been to fix the shower. Certainly not about to save any lives!) Actually having said that, at least I've gone for a couple of runs. And my mosquito net, bed-sheet-tie and bathroom clean have all been raging successes.

The people here are certainly very warm. I do enjoy that aspect of it. Waving to children on their way to school, or hospital staff arriving for work while out for a run. And the food, mess and our little cottage are all very decent. I just wish I could actually put my brain to some use.

26/6/08

Wow, I finally did something useful today. I was in gynae OPD with David and a nurse. They were talking away with the patient for a while and, getting bored of not having a clue what was going on, I asked. They said she was 10 weeks pregnant but was upset because she didn't want to have the baby. The nurse explained to me that SFH won't do abortions, and that in fact it's illegal in Zambia full stop, apart from in very exceptional circumstances. At this point I realised that I really ought to do something. So I asked the nurse what there is available locally in the way of adoption services. Nothing. Not surprising when you consider how many AIDS orphans there are in this country, but still, we're talking here about adoption of a newborn, non-HIV baby which is a different kettle of fish. I asked the nurse what sort of support the woman had at home, from e.g. family. Turns out she's already got 5 or 6 children. It was unclear whether relatives would be supportive, so I asked how old the oldest was (with a view to suggesting that the older ones can help with the younger ones if she's feeling overwhelmed by the economic or social burden). The oldest is 18 - potentially promising. But her conversation with the doc and nurse still seems to be going nowhere. So I ask them to ask her what she's most concerned about with regard to having the baby. The answer? No, not economic or social considerations for a poor mother of 5 or 6 as I'd assumed with my British mindset; no: epilepsy. On detailed questioning this looked much more likely to have been eclampsia, and we were able to reassure her that good medical help would be available and that she didn't have to worry.

This is the sort of scenario that makes me ashamed of being British and shows how much Zambians have to teach us, as well as illustrating the vast differences available in the way of healthcare. Back home, it's not uncommon for people abort after their perfect 2 or 3 children because in spite of a dual income (and/or numerous child benefits, excellent free education and healthcare etc etc) they don't think they can afford a third. (Perhaps Disneyworld and Caribbean cruise-liners don't offer large family discounts...) Here on the other hand was a woman on a thousandth of the average UK salary prepared to look after whichever children came along but, through her experiences of lack of basic healthcare, scared to bits at the prospect of going crazy or dying in childbirth.

But for 15 minutes there, I felt I'd actually made a bit of a difference. Not enough to tempt me to go back on my plan to get out of O&G asap though. Explained things to Shelagh [the medical director] and she was very understanding. One of the other Irish guys is going on to surgery next week so I'll be able to take over from him on one of the medical wards, where there'll be English-speaking docs - and therefore English-speaking ward rounds and clinics! I can't sit through another 7 hour day of wall-to-wall Nyanja.

1/7/08

Plenty to report. Had a great weekend at S Luangwa, complete with adventurous return journey/near death experience when a bolt in the taxi's front right axle fell out causing us to fly off the road. We were rescued by a family of white Zimbabweans in a 4x4. Then ensued a rough, very fast ride, clinging on to the sides of the pickup so as not to fall out while Marijke did very well to have a pleasant conversation with the son of the family whose views were decidedly to the right of her own. Meanwhile Leonard, our not-very-English-speaking driver, had managed to find a mechanic from whom to buy a replacement bolt (in the middle of nowhere, with no phone signal, it should be added) and came to collect us from just outside Chipata. The rest of the journey was uneventful. Oh, I should have mentioned that, in the 4x4, we almost ran over a young boy who was playing daredevil. The brakes were suddenly slammed on, leading to a feeling of impending doom in the back seat as dust flew everywhere and we contemplated which of the truck's open sides we were most likely to fly out of, and we saw a boy just make it to the far side of the road on a bicycle. We turned around - full of concern - only to see him running frantically away from the scene, leaving his bike on the side of the road. Apparently this behaviour (the daredevil stuff) is all too common, and the usual reward for the would-be macho man is a sound beating from the driver.

Life on St Augustine has been good so far. Long days which haven't dragged - always a good sign. I feel I'm being useful on ward rounds, writing in the notes, making the odd comment, filling in x-ray request forms etc. At least it seems to expedite the process and I'm learning a lot about how medicine is actually practised. Hopefully after a few more days I'll feel confident enough to have a go at a few of the patients on my own. Still, it's very daunting seeing people in outpatients where it's a mad rush to reach a diagnosis and management plan amid vague histories, poor English if you're lucky, and a lack of experience of local epidemiology: important given that the majority of people simply need a bit of reassurance that it's nothing serious, which you can't give them if you know that you don't know about bizarre infectious diseases x, y and z. Still, I'll hopefully start getting the hang of it, perhaps teaming up with another student, e.g. Even (must learn how to spell that [it's actually Aoibheann]).

I had my first wet-eyed moment yesterday. It was the cheerful bravery of a woman nursing her HIV +ve husband with horrendous KS [Kaposi's sarcoma] on his leg. She was doing so well, but it's one of those times when you know that even all the love and care in the world might avail nothing. Poignant. I suppose it reminded me of Mum and Dad looking after me when I fell off the roof. I really felt for her and hope that we can do a good job by her husband.

Right, time for bed. Oh yes, our shower's been fixed today - wahey! Hot shower tomorrow post-run.

2/7/08

Whoah, feeling quite frazzled today after long afternoon in clinic. Was seeing a few patients by myself but in at the deep end! Brain goes to jelly when confronted with real life situations, especially when you can't communicate very well with the patients. I think I did a good job of taking a couple of very thorough histories. I feel this is important for a couple of reasons, even though it's not the way forward for the docs in a very time-pressured OP clinic. One is that I really don't know what I'm doing at the best of times, so having as much info as possible is bound to be good, whether I'm going to decide on treatment myself or seek a second opinion. Second is that people here present pretty infrequently, so often have a number of things wrong with them. Third is the lack of a clear PMH [past medical history]. Still, when you actually have to make the decision it's a bit flummoxing. I'm finding that a lot of it, rather than really getting to the bottom of what's going on, is a suck it and see approach: try some treatment which has some chance of doing some good, given the history, and see how the patient gets on with it. Which actually is what GPs do back home a fair bit of the time I'm sure. I'm sure I'll gradually get more into the swing of things. Will be good to identify a system that works though. Perhaps go in with Vinny or Aideen [Irish docs] and ask to take the history every 2nd or 3rd time.

It's a bit of a shame not to be doing O&G, but then again what I'm doing is so diverse (too diverse, given my now very apparent lack of knowledge!) that I reckon I'll be more than happy staying on medical here for the foreseeable future. It may be the case that they'll need help over on surgical once the Irish guys have gone, and it would be good to get some suturing practice in, but I reckon I'll be able to be much more involved on the medical side. And that's what counts at the end of the day.

5/7/08

A striking encounter with a patient yesterday: a lady came in to OPD carrying a note from the ultrasound scanner. She had come in because she knew she was pregnant, but at just over 5 months had become concerned that she was not feeling the baby moving. The scan report conveyed the bitter news: gravid uterus, no cardiac impulse, blighted ovum. I ran off to try to track down one of the gynaecologists in order to ask what needed to be done, and fortunately found one. Then went back, examined the abdomen (16 week uterus) and had to explain to the mother, via a translator, what had happened. This is one of those moments when the difference between here and medicine back home is so apparent. At home I would have been able to sit down with the woman for a good 20 minutes at least and talk things through, allow her to ask questions, begin to process things. Here it had to be a quick, "please tell her that I'm so sorry but..." On the other hand, there's a much greater acceptance here that pregnancies don't always work out. But I find myself rebelling against that: it shouldn't be that way.

Yesterday was pretty good, by-and-large. I think overall I prefer ward rounds with Mel, because she's a bit more laid-back than Vinny who can be hard to keep track of sometimes! Having said that, he's very helpful and loves teaching, so I'm definitely learning some useful things. Had a go at an ascitic tap. Wasn't successful, but hopefully next time. The afternoon was good. I shared a desk and a translator (Irene, who's always smiling!) with Aideen. It worked pretty well as whenever I was unsure of something, or wanted confirmation that I'd done the right thing, I could check with her. Will hopefully be able to do that again.

And we had a great meal last night at Tikondane - though I was a little bit tired from the week and coming down with a cold Feeling a lot better this afternoon though. Best conversation last night was with Marijke, talking about obstetrics. I really do like those two [Marijke and Alyson, Canadian midwifery students] I must say. And I'm still pretty keen on the obs and gynae direction. The disadvantage to it here is definitely the language barrier - particularly since one of its biggest attractions is the caring and sharing aspect - but I can imagine that if I were to learn Nyanja then it would be fantastic. So much good work to be done here.

I can definitely see the attraction of medicine too though: the diagnostic and management challenges, getting to the bottom of what's really going on and fixing it, which is probably more often possible here than back home where what we're dealing with are chronic problems like COPD, atherosclerosis, ... Plenty more reversible causes going around in these parts - if you can identify them.

I'm glad of a lazy day today, especially since I'm not feeling that well. And it'll be fun going to church with Dr Makukula tomorrow. Looking forward to that, definitely.

6/7/08

I found myself in OPD on Friday in the strange situation of asking a middle aged woman if she had pain on intercourse. Well, nothing too strange about that, I hear you say [it's a standard question in a gynaecological interview, particularly if you're suspecting pelvic infection]. The catch was that this was in front of another doctor, the translator and another two patients who were being attended to separately, though sharing the same translator. I then had to ask whether she felt the pain superficially or deep inside. What was interesting was that she didn't seem embarrassed. I think in some ways the women here are less inhibited/embarrassed/ashamed of their bodily functions. Another example of this is "ladies' day" whereby women are allowed to take a day off work at the start of their period. Must suggest this at a suitable moment back home :o)

We had a lovely barbecue last night. Vinny did a great job as chef and there was a huge amount of meat going around: delicious beef sausages, steak (ranging from tough to extra tough) and even some chicken (thankfully very well cooked). The company was good too, with the addition of James and Faith Cairns and their son. James was the main doctor and surgeon here at the hospital from 1958 to 96 and it was very interesting hearing a bit about how he ended up here. It felt like I was in the middle of the history of Saint Francis', with Ian and Shelagh there too.

I'm also very satisfied at yesterday's cleaning efforts: I borrowed a broom and dustpan and brush, and I think I may finally have knocked the toilet odour on the head via two cloths, a bucket and lots of washing machine powder. Once my nose clears I'll no doubt find out.

This afternoon promises to be fun, either going for a walk up the local hill, or (hopefully!) watching the Wimbledon men's final. Predictably Nadal and Federer, but the result will be anything but.

10/7/08

Few days no diarying. Was very disappointed at not being able to watch the tennis (found TVs with satellite, just not the right channel). Will have to see if can download it when I get home.

Church service with Cairns' and Monday evening reception [BBQ/party in their honour with lots of hospital staff in attendance] both good fun. Enjoying the feeling of being part of a community which is both medical and Christian in identity - for the first time. Met Ben, the surgical registrar. He ought to be a good guy to work with once the Irish guys have gone and he's all on his own, plus or minus a licentiate. Seems they've been getting to do a lot.

This afternoon in clinic was great. I feel I'm starting to get to grips with things now in terms of taking a good history, doing a decent exam (so long as it doesn't involve too much neuro: even if my memory of the exam were better it would still be tough with a translator and an elderly patient!) and coming up with some sort of reasonable management plan. Admitted my first two patients today, one with an HIV diagnosis as of yesterday with a probable pneumonia or possibly TB, the other with high blood pressure and a possible nerve palsy (not very satisfied that I didn't really get to the bottom of that on examination. Should've asked about sensation...)

13/7/08

Friday (the day after that described above) was a strange day. The afternoon began well. Saw a couple of reattenders in clinic who'd come back despite treatment and I think was able to get to help them, one by diagnosing GORD rather than the PUD she'd been unsuccessfully treated for, the other by asking her if any of the meds she'd been given had helped, to which she said Brufen. Prescribe prn [as required], problem solved. (No significant pathology in that case.) I then stepped out to chase blood results - successfully, now that I'm on terms with the most useful chap in the lab. I came back to find all the rooms full, so sat in with Mel, which was useful. I like working with her as she's good at teaching, asking me questions, and pitching it at about the right level. My rather basic knowledge of epididymitis came in handy at one point.

The strange consultation occured after clinic was over. I bumped into Emmanuel [my favourite nurse on the medical ward and attender of the Pentecostal church which I visited a couple of times] on the way out and was standing outside St Luke's talking to him when a woman came up to me and started speaking in Nyanja (the first clue that something was amiss!) I asked Emmanuel what she was saying and he said, don't bother with her, she's here all the time always complaining of different things, just give her two paracetamol and tell her to go home. Now, a significant part of me really did feel like doing this - after all, we'd just got off early for the weekend and I could tell that if I did take this one on it would be taxing and time-consuming, plus I trust Emmanuel's judgement. But then I thought, no, you can't go writing someone a prescription without taking a proper history and getting to the bottom of things, you wouldn't do that at home (no - you'd tell them to come back on Monday and get an appointment!) and at the end of the day this is a patient who is asking for your help. So I took her inside and got Deliwe, one of the translators, to give us a hand. She and the other people in the room told me the same thing about the patient as Emmanuel had, so I was puzzled by the fact that she had a clean outpatient card. The explanation was that she repeatedly lost or threw them away. There was also some mention by the staff of chlorpromazine [an anti-psychotic drug] on a previous occasion. The PC [presenting complaint] was 6-8 months of lower abdominal/pelvic pain accompanied by a sensation of movement inside. On closer questioning it became clear that this had begun shortly after an "abortion" - which I take to have been a miscarriage (abortion is illegal here - or at least not allowed at St Francis - but the word is generally used to mean miscarriage). I asked if she had had any previous pregnancies and miscarriages. No previous miscarriages, but 8 children, the youngest of whom is now 8. I started getting a bit suspicious at this point (she was 36 according to her date of birth) so asked how old the eldest was. "Born in 1980" was the reply. I then asked her (all via Deliwe of course) to make sense of the fact that she was born in 1972 (which she had confirmed). No answer was forthcoming, confirming the decided impression of something psychiatric going on. I asked if any of the treatments she had had for the problem had helped. She said she had been on lots (which I could well believe, if she'd been presenting very frequently - we medics have a tendency to try to squeeze the odd-shaped problems with which patients present us into the square holes of simple diagnoses and send them away with a supposedly curative treatment) but that none had helped. So I decided to try a different tack and ask her what she was most worried about (given that this was almost 100% likely to be a functional problem - I'd already established that the pain was pretty non-specific and that there was a minimal, non-bloody PV discharge, plus if the problem were anything physically serious then 6-8 months of it would've by now taken a noticeable toll). She answered - as by this stage I had guessed she would - that she thought she was pregnant, and that the pains felt like labour pains.

At this point what had been happening over the preceding months became clear: she'd probably been variously fobbed-off, inappropriately treated for various medical conditions or told she was bonkers. Not the best approach to a delusional patient, but perhaps understandable in an overstretched, medicalised environment. In such situations (actually in any situation) you absolutely have to treat the person with respect and show them that you're taking them seriously, otherwise how can you expect them in turn to take you seriously? They're not about to be reassured by someone who doesn't listen to them and demonstrably thinks they're an idiot. That sort of approach is guaranteed only to add further fuel to the delusion.

My first tactic to try to convince her that she was not a number of months pregnant was to ask her about her LMP [last menstrual period] which she confidently replied had been last month. I then carefully explained that this meant that it was impossible for her to have been pregnant for a number of months, but the delusion was clearly not shifting. I actually didn't think of offering her a urinary pregnancy test (which of course you'd have a crack at back home) - they're scarce and very rarely used here - but even if I had, I probably wouldn't have bothered suggesting this to her as how is a delusional person supposed to take seriously a test they've probably never even heard of that involves something as bizarre - to the non-scientist - as pissing on a stick? So here's how I figured my options lay at this point: a) examine her abdomen, which, while having the advantaage of showing her I was taking things seriously would not get us anywhere as no doubt she'd have had this done before, never mind probably obsessively palpating her own abdomen b) do the above followed by a clearly inappropriate referral to an already oversubscribed gynae clinic having, moreover, not properly examined the patient myself c) request a pelvic USS [ultrasound scan] from the overworked technicians without having first bothered to do an examination (surely a hangable offense) - especially as this would simply have been to reassure a delusional patient without having exhausted other options d) tell her she's imagining it and either fob her off with some paracetamol or take drastic action and inappropriately (in my view) put her on chlorpromazine or haloperidol. (I certainly didn''t have the facilities, in view of the language barrier and my relative cultural naivety, to conduct a full psychiatric assessment, she wasn't to me showing other symptoms of psychosis, and the clinical officers who specialise in psych would only be available at that stage a week later as an inpatient referral service, i.e. I'd have had to admit her to one of the overpopulated medical wards for a whole week.) Or e) give her a full abdo and pelvic examination with the following advantages: firstly, she was keen that I take things seriously and examine her, leading me to hope that this might provide the reassurance she was seeking, particularly since the internal examination involves to-the-patient demonstrable palpation of the size of the womb (i.e. physical language which a non-medically literate person might be hoped to appreciate); secondly, in the very unlikely event that there were some genuine physical pathology, I might discover evidence of it - and ruling this out would surely be the only responsible thing to do; thirdly, that I could then justifiably refer her on to ultrasound (or, in the unlikely event, gynae) having properly assessed the patient first myself. I don't know how many times it's been drummed into us that you don't refer a patient without first taking a full history and doing a full examination. To do otherwise is lazy, irresponsible, wasting of your colleagues' time and disrespectful to both them and the patient. [I labour the point as there was some debate afterwards about my course of action.] So I chose the latter option, having asked the lady if this is what she wished. The examination itself was uneventful. Deliwe acted as nurse, the patient seemed completely at ease with the scenario and I detected no abnormalities on abdo exam, speculum or bimanual [internal examination], the only things of note being a parous cervix [meaning that she'd at least once given birth] and a very slightly enlarged uterus (perhaps suggestive of fibroids). I carefully explained to the lady (with hand gestures!) how I had felt her womb between my hands and showed her the size, and that this meant that she could not possibly be a number of months' pregnant as the baby just would not fit in there. Unfortunately she remained unconvinced, so as a last ditch measure I rather reluctantly asked her if she would be if we did a USS which could take pictures of the inside of her womb, and that if it showed it to be empty would she be happy not coming back to see us, to which (thank God!) she finally said yes. We explained that this would have to be on Monday.

Not your run-of-the-mill consultation.

14/7/08

2 English students arriving over the weekend. Looking forward to that. Will be nice not to be the outsider (although the Irish folk are very nice). I'm planning on switching over to surgery as Ben seems like a good guy and there'll be plenty to do once the Irish guys are gone and he's left on his own without Dr Jaap and only the new licenciates. He's been very up for letting the boys get hands-on, which should suit me down to the ground. I may go back to medicine later on, but after another week I'll probably be feeling like a change.

16/7/08

Have really enjoyed [ante- and post-natal] rural outreach. Sitting writing this having finished for the day in the small brick, twisted beam and corrugated iron church in the village we went to. Did lots of palpating [of pregnant women's abdomens], weighing, listening to FHs [fetal hearts], giving out vaccinations, taking blood, and saying hello to lots of women and children and taking plenty of pictures. I haven't really taken any in the hospital. Although quite a few of the other guys have, I don't quite feel right about taking pictures that I wouldn't take back home. It feels a bit wrong to effectively be saying to someone, Can I take a picture of you because you look so gross/because you have a rare incurable disease?

Sun 20/7/08

Have at least had a very good cleaning sesh between yesterday evening and this morning. Will the toilet finally succomb to toilet duck, brillo pads and Domestos??

Football match yesterday afternoon. Lucy had organised it to raise funds for the football team to travel to Mfuwe for a match. Unfortunately only 4 of us played in the end but it was actually a lot of fun. Found I wasn't too bad in defence then played decently well in goal. We won 3-2. Will hopefully do that again - though the ground is bone hard so murder to dive on!

Didn't really enjoy Wednesday night ["cultural experience"] at the village. I was just too tired so not really in the mood, which was a shame as the villagers were lovely. The women's dancing was certainly good craic though (including [names deleted] topless!) and the food superb. Lovely too to have kids come and hold your hand, sit on your lap. So warm and friendly. I could really have gone home after dinner though rather than sit through an hour and half of ghost dance in the freezing cold. 45 mins each way in a hard ox cart too!

Very quiet without the Irish guys here. Hope these two English girls turn out to be sociable!

22/7/08

Just finishing 2nd day on surgery. So far not much of a wow. Renewed visa yesterday morning, borrowing Lucy's bike to ride to the Boma - very nice. Saddle still way too low but everything else working decently well. Got the usual chat about "not working" etc. Goodness, can't believe this wasn't explained to me before I got here. Could have been turned back at the border. In fact, was talking yesterday about putting together an information pack for elective students coming out. Have started work on it. "Everything I wish I'd been told before I left for Zambia."

I went to surgery after I got back but didn't get to scrub for anything as the morning was well on, plus the 2 licenciates were there. Popped in and out of a c-section too. After lunch I helped put on some plaster of Paris (POP) - first time I've done that so a useful experience.

This morning was the dreaded ward round: all of Kizito and Mukasa so probably approaching 100 patients. I didn't really pick up on too much of what was going in. Felt quite in at the deep end with the sheer proportion of stuff that's orthopaedic. (Was never much of a one for orthopaedics, having not really enjoyed it much at the Borders.) Having said that, it's gradually becoming clear that treatment for practically anything that can't be sent home in a cast is traction. Then this afternoon I got to put on a couple of back slabs. Again, useful experience, even if it's hardly my favourite specialty. The one plus point about surgery is getting to do hands-on stuff so hopefully that'll happen. Sam and Henry certainly seemed pretty keen to get me doing the POP stuff, putting in cannulae etc so fingers crossed. Sam wants me to be on call with him tonight which could turn out to be interesting - or tiring! Hopefully there'll be a chance for some suturing. I think I'm gonna get on well with those two.

Was a bit concerned earlier today wondering about how much I'd really care if patient x or y died. I think it came partly from a sense of disempowerment on the ward round: when there's nothing you feel you can do you detach yourself. And I really do miss being able to talk to people. Something I think will be missing on surgery is the continuity of care of at least eyeballing a patient once every day or two on rounds.

24/7/08

Got to help out this arvo with an interesting procedure. I was the anaesthetist (using the ketamine) for a young woman who needed her dressings changed. She didn't look bad from the front, but it was when, having sedated her, we rolled her over that the reason for the anaesthesia became apparent: absolutely horrendous road-rash all over her back. She's completely lost the skin on at least 50% of it, plus some areas on her legs. Fortunately the wounds look fairly clean, and they're obviously taking good care of them. But oh my goodness. Quite a smell too...

Found myself wondering earlier today how much good I'm doing here. But then I think of e.g. Joilos [a 12 year old boy with a hugely enlarged spleen whom I'd been taking a keen interest in as he'd previously been on the medical ward]: there's no way he'd be on that list tomorrow unless I'd asked Isaac [my mate in the lab] to do the manual platelet count, etc. Or making a fuss about the woman with the cannula problem. And keeping an eye on the obs charts of the surgical patients. I started a surgical patient on aspirin and bendroflumethiazide today too, which otherwise would probably not have happened, and you never know, it might make a difference. Plus trying to ensure patients are getting adequate analgesia - not really top of the priority list here. I'm also really learning a lot about how to actually diagnose and treat people in practice, both in outpatient and inpatient contexts. This will be really good prep for being a proactive 5th year student.

It's sad that Aly and Marijke are leaving on Saturday. It's been great getting to know them - they're defo the people I've connected with the best - and I'll miss having them around. Very much looking forward to visiting them in Canada though!

So all-round I reckon surgical's gonna work out well for the next couple of weeks. I feel as though I'm already catching on re how people are managed (usually CST [continue same treatment] if they're in traction!) and am starting to get an idea about wound care, which of course is very important stuff. My orthopaedics is gradually coming back to me too. Still, it would be nice to have a couple of classic general surgical cases. And I really want to get to do some stitching at least - which I'm sure Ben, Sam and Henry will be up for.

A big question though is, would this be the kind of work I'd be happy doing longer term? I think part of the answer lies in the language issue. If I could chat to the patients I would enjoy it so much more. There's also a sense of often not having enough time - and sometimes of pissing in the wind, e.g. with chronic medical conditions. E.g. psychiatric problems: there's no way I could start someone on a hardcore drug like chlorpromazine without knowing that they'd be getting regular check-ups by someone who really knew what they were doing. One would be violating prima non nocere [first, do no harm - a fundamental ancient medical principle] in a big way. Psychiatry here is a massive challenge, one that will take more than one or two committed doctors to begin to sort out.

It might also be a bit of a lonely existence in a place like this, with people always just passing through. You'd need to feel part of a real community of similar people. Having said that, as a family I can see how it could work, e.g. look at the Parkinsons and their kids: what a great way to grow up. Still, I'd much rather do something like this as part of a dedicated team. You'd need to feel that the other people involved are as committed as you are, that you can rely on them, that it doesn't all come down to you.

Speaking of which, something I'm learning about myself is that when I have any responsibility in a medical context, I have to discharge it well, otherwise it really bugs me. I've got to feel that I did all I could have.

25/7/08

Today's been good actually. Only knocked off for lunch at 3.30 but seem to have managed to escape clinic this afternoon. This morning was mostly taken up with one big surgical case: removing a very large cystic kidney via a midline abdominal incision. Took ages, but quite interesting for the most part. I was scrubbed and did a lot of the suctioning (both with actual suction and 60 ml syringe when that wasn't working!) and diathermy too. What was cool was that at the end, when Ben left us to close, Sam told me to start suturing the cutaneous [skin] stitches from the bottom, working up the way, so we'd meet in the middle. My first time suturing an actual patient! [Those of you at home, don't worry, I have practised on models!] Put in at least 12 and did a pretty decent job, so I thought. As an added bonus, I'd seen a girl on the ward earlier in the morning who'd just been admitted following a bike accident. She had a clean 3cm laceration to her thigh which I reckoned just needed a couple of sutures. So I put the proposal to Ben on the way back from theatre, who asked me if I'd done any suturing before, to which I replied yes - though I did fail to mention that the first time had been about half an hour ago. He had a quick look at the wound and agreed, so I did that, having carefully injected a fair bit of local first. In the event the girl (8 years old) was fine with it, and I told her afterwards that she'd been very brave [by the translator's reaction, never said round here!]

Unfortunately due to that very long case most of the list was cancelled. Having said that, Joilos is first up on Monday. Looking forward to that one.

I seem to be fighting an interminable battle with the wasps in my chalet. About 15 dead on the windowsill today. Still don't know where they're coming from - but it is quite fun to zap them with the super-strength DOOM. I was letting them go for a while but then realised they'll just come straight back in: my only hope is to try to exterminate all of the brutes.

Really hope the electricity comes on at some point: could really use a shower. It wasn't on either last night or this morning and seems to have been off most of the day. Even the theatre lights went on and off at times.

2/8/08

I haven't written anything here for over a week. Probably a combination of not really being bothered enough, plus am reading a page-turner at the mo (John le Carre - the Mission Song).

We did get to Joilos on Monday but unfortunately it wasn't possible to rermove the spleen. The splenic vein was absolutely huge and behind it was what Ben reckoned to be an AV malformation [something weird going on with the blood vessels]. Wisely he decided he wasn't the man for the job, but he's confident there's a decent vascular surgeon at UTH [main hospital in Lusaka] who could manage. We were worried about Joilos for a while afterwards as his wound kept oozing. I was sent to check/suture it along with Henry and felt really bad that he was in so much pain. I kept asking about morphine (while also being worried it might do something strange to him - stressing) so eventually the nurse brought some which I gave him. They really don't have a good attitude to minimising patients' pain here. Plus given my personal connection I felt very bad about it - and helpless in the sense that I couldn't talk to him, apologise, reassure, sympathise... I did tell Henry afterwards to tell him he'd been very brave, which was the best I could manage.

Fortunately after a couple of days he's now doing much better, so I'm really hoping he's able to be transferred soon and gets his op.

We've been much preoccupied with the lady on whom we did the abdominal washout. We took her to theatre on Monday again and spent 4.5 hours doing a couple of tricky anastomoses, one of bowel onto stomach, the other of duodenum onto bowel lower down, to allow the passage of bile and pancreatic enzymes. Unfortunately this did not seem to help, and and Thursday morning even a cut-down drip had tissued. She was able to take oral fluids, but these were probably not being absorbed to any great degree. Sam and I spent about an hour after the round trying to recannulate, I on her arms and he on another cut-down [opening the skin near the ankle to expose a sizeable vein an cannulating under direct vision] both unsuccessful. During that time at a couple of points she seemed to be making intermittent respiratory efforts, and I thought she might die on us there and then. Not surprisingly we were called back to her bedside shortly afterwards. Pupils were fixed dilated and there was no pulse, breathing or heart sounds. I suggested that we sew the abdomen up - figuring that at least this was something I could do for the grieving mother - which we did. In such circumstances you feel that you want to at least do something. One thing that was odd was that her eyes couldn't be closed in standard movie convention.

We washed out the abdomen too, took her catheter out and splints and bandages off, and cleaned her up - not pleasant, poor thing. A sad end to the story - but at least we (and the family) could know that we really had done everything in our power, rather than many of the deaths on the medical wards where you really just don't know what happened, whether you missed something... Awful when you hear about people dying who that morning had seemed well and healthy, e.g. the diabetic whom we discharged and who came back in with hypoglycaemia and died.

Tim, my new roommate, arrived on Tues. He seems like a good guy. We're all going to Burning Bush [local - very lively - Pentecostal church] tomorrow which promises to be good.

Have been enjoying working with Sam, Henry and Ben. Getting on well with those guys. And even though I don't bring much knowledge to the table when it comes to surgery, I reckon I'm pulling my weight, learning a lot and becoming a good assistant in theatre - as well as getting to do the odd bit of closing. I'll be performing my first operation next week: a circumcision on a guy who came into outpatients yesterday.

Had some great news yesterday from Deliwe, who was translating for me in clinic: apparently the woman who thought she was pregnant came back on the Monday, got her ultrasound scan, came to St Luke's to get the report translated by Deliwe and co and went away satisfied - and hasn't been seen since! Very chuffed indeed about that one: my take-the-bizarre-patient-seriously approach seems to have paid off, not to mention the outlandish request for a USS!

[Unfortunately I found out shortly before I left that the lady had just come back in with the same problem. The cure was only temporary - but hopefully a step in the right direction. 4 or 5 weeks' non-attendance would certainly seem to have been a record for her.]

I'm looking forward to my last couple of weeks here - perhaps one in surgery and a final week back on medical - before heading down to Livingstone. Pretty keen to do some of this white water rafting.

7/8/08

Been enjoying table tennis with Tim. Might play some more when he gets back today.

Finally got some more blog up the day before yesterday on Lucy's computer. First internet access in over 2 weeks in spite of trying in Chipata, Katete, the post room, at SFH on the weekend... That was after I'd cycled to and from the Boma twice due to my forgetfulness in not bringing the receipt for my traveller's cheques. Must've covered over 40km altogether on Lucy's bike - saddle way too low!

Enjoying having the American burns team here. Barbara is pretty impressive. Looking forward to seeing her in theatre tomorrow. She's getting on well with Ben, Sam and Henry, taking a good approach, which is very important. Very useful for me too to be learning about burn and wound care as I know next to nothing about it.

Have the odd moment - usually on ward rounds or in long theatre sessions - where I'm not enjoying the surgery very much, but overall I think it's very useful experience, especially when I get to do hands-on stuff.

Had a patient abscond on me today: needed debriding of a doxorubicin-induced ulcer (extravasation during previous chemo sesh). The plan was lidocaine [local anaesthetic], but I've never seen anyone jump so much as when I began infiltrating - especially unusual as the patients here are generally remarkably resillient. Also, the area was very indurated [hard] so the drug wasn't going in, and would probably have been too large to cover anyway - plus the fact that she'd have been watching me slicing her hand up. So I decided to switch to Special K and got Oliver (table tennis man) to explain to her that I'd put her to sleep so she wouldn't feel any pain. However, I think she got cold feet when she saw me drawing up an enormous syringe-full of saline for flushing it through and left, saying she was going to give her handbag to her aunt to look after. That was the last we saw of her!

Went online and contacted Fawlty Towers [hostel in Livingstone]. That'll be great too - just to relax for a couple of days, do some white-water rafting, eat some good food :o)

12/8/08

Just found out that Lucia, the little girl whom Barbara and I spent so much time resuscitating yesterday, died - not 15 minutes after I'd last seen her. Quite a blow. I just couldn't believe it when Henry told me. It just didn't seem possible. She'd fought so hard and was recovering so well, urine output was just about where it should be... It just didn't make sense.

Other than that, the last few days have been pretty good. Getting to actually do much of the burns surgery has been excellent - by far the most hands-on I've been. Barbara's an excellent teacher.

I'm feeling ready for a break though. The ward round really dragged today and it'll be great just to get away from everything. Have got my booking through from Fawlty Towers - first night in a private room which'll be good, though a bit more expensive (not planned...!).

Friday night should be a nice BBQ - though I've a lot of packing etc to get done before then.

Well anyway, had a good time at Drums [the local "night club"] though it was defo a bit much to do more than once. So many people clamouring for one's attention the whole time, dancing with everyone in the house, male and female. BBQ beforehand was very nice. (Food has become a major focus of my life here!)

It'll be nice having a few of the Zambians along on Friday. We don't seem to invite them much which I don't like. It's partly to do with the fact that all of us westerners eat together, so we're the people we know best. But it's also to do with whom we identify with, whom we feel we have common ground and shared experience with. I think my faith has made a sizeable difference in that regard: I share something with the majority of the people here which is absolutely central to both them and me, which counts for a lot.

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Well, if you're still reading, that's where the diary stops and the story resumes a couple of blog posts earlier. I'm typing this overlooking Lake Malawi at beautiful Nkhata Bay (thanks, Rosie, for the recommendation). I've met lots of nice people, had plenty of good food and drink, seen fish eagles, cliff-jumped, played frisbee and generally feel very well-rested - almost ready for the 2 day journey on various buses to Dar Es Salaam on Wednesday. It would be nice to stay here another day but I'd be cutting it very fine and running late while waiting for (or even whilst on) an African bus is not a good state of mind to be in.

I promise I will shortly get around to posting on what I've actually been up to for the last 8 weeks in the hospital (in fact a lazy day tomorrow's looking promising) but meanwhile I really have to tell you about my day yesterday.

I'm writing this from the comfort of a Livingstone pizza bistro. How I came to be here wasn't quite so comfortable.

The day began inauspiciously as the alarm woke me at 4.30 in order to pack. I'd gone to bed pretty late the previous evening after a farewell barbecue so this didn't feel like the pleasantest time to be conscious. At any rate, I managed to get out onto the Great East Road for 6, the time when most of the morning buses running from Chipata to Lusaka go past. I managed to flag down the second one, though the bus was quite confused by the Britishness of my "Stop, bus!" gestures so I had to run 100 yards down the road to catch up with it as it had taken the driver a while to figure out what I actually wanted. Next time you're hitching a ride in Zambia, move your straight roadside arm up and down, palm-side down, at a rate of about 60 waves per minute.

All was going swimmingly as the bus hurtled along over the potholes until 9 or so when the unwelcome sight of an enormous doubly articulated lorry, expertly jack-knifed so as to obstruct the entire carriageway, came into view. There was already a big crowd, what with two other buses already in attendance, one on each side of the lorry. On closer inspection it became apparent that there was room only for small vehicles to squeeze along the thin strip between lorry and precipice. The uphill side was completely impassable.

But what to do? What everyone in Zambia does on such occasions: wait. Patiently. Very patiently, as the drivers of the buses on either side of the lorry entered into a prolonged, convoluted passenger-exchange negotiation worthy of an EU agriculture summit, while a van with a crane on the back that on a good day might have got a dry-weight Vauxhall Corsa out of a ditch gamely speeded onto the scene.

Things were really a little more urgent for me though as I needed to be in Lusaka soon if I were to stand a chance of making it to Livingstone that evening. I was contemplating lying down in the path of the few vehicles that were making it past in a deperte attempt to force someone to take me with them when salvation appeared - in the form of a white Toyota. As it went past, I recognised the man behind the wheel: David, the obs and gynae registrar at SFH. I ran after the car and ecstatically banged on the window.

Four hours later we were in Lusaka. At 2pm, it wasn't as early as I'd have liked, but I reckoned I had a fighting chance at Livingstone - still at least 7 hours away. I made what at first I thought wasn't the most judicious selection of bus: it only looked half-full at best; but at least it was shiny and white and had seatbelts and a TV. And it turned out I was in luck as the bus suddenly seemed to fill up and we were on the road at 2.50. (I had feared we wouldn't leave before 5, 4 at the earliest.)

All went well for a few hours (as well as a bus journey can go when Rambo is playing full blast on the TV) until nightfall. All the guide books tell you that if you're going to die in Africa it will happen on a road, specifically on a road after sunset (although personally I think the potholes are much easier to see under horizontal lighting conditions but there you go). The number of RTA victims on our surgical wards would certainly seem to bear this out.

We were quite happily cruising along - I was at a critical point in my Dave Gorman book - when there was a sudden jerk accompanied by the sickening sound of breaking glass, immediately followed by an eruption of crunching tyres and screaming passengers as we were thrown forward against our seatbelts (or the person in front if you weren't wearing yours).

Fearing the worst, I went into medic mode and with LED headtorch in hand and "ABCDE" running through my head pushed my way off the bus. The view outside was pretty horrible. Right up against our bumper was a perpendicularly angled car, its driver's side completely stoved in. And not just any car: a highway patrol car. I made my way around to the front of the mob outside the passenger side and shone the torch in an attempt to help the folk trying to extract one of the policemen. They managed to get both him and the driver out. The passenger didn't seem too bad - wincing in pain but on his feet and clearly compos mentis - but the driver collapsed on the ground shortly after being pulled out. I went over and satisfied myself that he was in possession of his faculties and his airway - it looked like his biggest problem was likely to be some fractured ribs - and shortly after that another car appeared into which he was rather unceremoniously bundled in order to be transported to the nearby hospital.

And that's when we waited some more. A lot more. 7.30 became 8.30, became 9.30 etc. There was quite a lot of confusion about what had actually happened and whether the bus would be able to continue on to Livingstone, particularly if its driver ended up in the VIP suite at the local police station. (Apparently broadsiding a patrol car doesn't come high on the list of ways to stay out of jail in Zambia.) Of course, all of this was going on with zero communication from the bus staff. After about half an hour at the scene the bus's engine started up - oh joy! - only for us to 3-point turn and head back to the police station in the town we'd just passed. And that's where the rest of the waiting happened. I figured that sleeping was probably the best way to deal with the situation and eventually the waiting paid off - at about 11 I think.

We managed the rest of the journey - albeit it with one headlight and a number of screams from the passengers in the back as our driver attempted to make up for lost time over the final - and most potholed - 100km of road. I slept blissfully through most of it and woke up as we came to a halt in Livingstone, the wrong side of 2.30am.

Luckily I found a cheap taxi and two friendly security men on the gate at Fawlty Towers (yes really) who were still expecting me.

Today I've had a nice shower and a nicer breakfast (first cooked breakfast in I don't know how long) followed by the second half of the service at the local Catholic cathedral. As ever, beautiful congregational singing, everyone throwing in harmonies and gently moving in time, and friendly kids to smile at. After the service I made the acquaintance of quite a few people, including - much to my joy - a few Nyanja speakers. Along that line, I've established that the receptionist and one of the cooks at Fawlty Towers are also Chewas. (Think "CHAY-wa" rather than chewer, or Chewbacca - though incidentally tobacco is one of the biggest industries in eastern Zambia, though very few Zambians actually smoke.) I'm already missing the folk at St Francis so it's been great to already meet other friendly, warm Zambians here to whom I can, with near perfect diction, say good morning and apologise for the state of my Nyanja.

The plan for the day after tomorrow is white water rafting, when I'll get my first sight of Victoria Falls. (Don't worry, Mum and Dad, we don't actually raft down the falls. Well, I don't think we do anyway.) Meanwhile, using the very detailed, up-to-date information in my roommate Tim's Bradt Guide to Zambia, I've made a list of all the best eateries in Livingstone. Though the food at the SFH Mess is decent, it's not exactly the finest or the most varied so I most definitely plan on ending the cullinary drought. That pizza was good and I reckon it's Chinese tonight. Mmmm.

Very sorry for lack of update. I've been foiled in posting this on numerous occasions. Internet access here is a disaster!

Before I go on to describe SFH, I forgot to tell you about my helpful neighbour on the bus trip. He turned out to be a border security guard looking for a career change. I asked him what he made of Kenneth Kaunda's views on the American presidential race. It seems there's a fair bit of optimism going around about Obama. Optimism about politics is something that is rather hard to fathom when encountered in Africans. Still, it's probably better for one's health.

So, Saint Francis' Hospital. The first thing you'd have to mention in any description of it would be the red sandy dirt which coats every bit of the landscape and finds its way inside shoes, pockets and houses at any and every opportunity. There's a lot of red brick here too, usually topped by corrugated roofing, so at first glance it's not the most aesthetically pleasing environment. However, you soon get used to that as the friendliness of staff and patients alike and the ubiquitous sunlight recolour the scene.

The hospital is actually pretty well put-together and decently equipped. In brief, there are two medical wards, Saint Augustine and Saint Monica - male and female respectively - each with about 45 beds and seemingly limitless expansion capacity in the small areas of floor between them. There are likewise two sizeable surgical wards, Kizito and Mukasa - I'm afraid I can't provide translations - a large paediatric ward, Mbusa, and Bethlehem: you guessed it, the maternity ward. There is also St Luke's: the outpatient clinic/pandemonium central, a laboratory, excellent ophthalmological and dental clinics and a very good physiotherapy department. (The physio even turns his hand to orthopaedic surgery on occasion.) There are two theatres, only one of which has diathermy at the moment though. A small digression here, but I'm sure cautery was one of the earliest inventions in surgery, many centuries if not millenia old... Having said that there are only two theatres, anaesthetic procedures are not necessarily limited to their confines. For instance, the other day I gave a patient a pretty big shot of ketamine in the middle of the surgical ward to knock her out while we changed her dressings. The reason for the general anaesthetic became apparent when we rolled her over: she had completely lost all the layers of her skin across at least half of her back and much of her left thigh, having been knocked off her bike by a speeding car. Horrific. Even with morphine the simple procedure of changing dressings would have been tantamount to torture.

There is no ICU, or rather there is: the first 6 beds nearest the nurses' desk on each of the wards. Certainly no ICU facilities: no i.v. monitoring of vitals (and not even pulse oximetry except as a one-off test); no ECG (there is one very dodgy machine in the hospital which I have never seen function correctly) and certainly no invasive ventilation unless you're in theatre (the best we've got on the wards is 5 litres/min oxygen via face mask), dialysis, cardiac pacing etc. There's not even a single defibrillator in the whole hospital. When it comes to theatre, monitoring of patients under anaesthesia consists of a pulse-oximetry probe which provides oxygen saturations and pulse. And that's it.

We're also a bit short on the labs front: the FBC machine has been broken for most of the time I've been here so it's either just Hb or a very special request for a manual count on blood film in exceptional circumstances. (I've strategically made friends with one of the main guys in the lab for the sake of those potentially life-saving occasions.) This is something of a problem given the prevalence and variety of anaemias in the hosptial population, and potentially dangerous when e.g. deciding whether someone has a high enough white cell count to get chemotherapy for their Kaposi's sarcoma (a tumour commonly found among HIV positive patients; type it into Google images and you'll get an idea of what we're dealing with). Electrolyte levels have never been available: they did have a machine but apparently it broke down after a fortnight. This is likewise a major problem as many of our patients come in, for instance, very dehydrated and/or malnourished, and there's a lot of kidney failure going around too. Speaking of the latter, fortunately we can do urea and creatinine. (Stop press: the creatinine reagent has run out!) LFTs are available, though some of the reagents are out of date leading to results which are untrustworthy at best and at times frankly bizarre. X-rays and ultrasounds are, however, available and of decent quality, as are microscopy, culture and sensitivity of various bodily fluids (though the latter two don't usually seem to yield much!) The most frequently-ordered tests, apart from an Hb, are thick blood slide for malaria and sputum for acid fast bacilli (TB). CD4 count (an important indicator of how HIV positive patients are doing) is usually available.

Machines breaking down is a big problem here as skilled technicians are not exactly to be found around the nearest corner. For instance, the non-diathermy theatre mentioned does have one, but it's been broken for at least a couple of months. Fortunately the surgeon who operates from there is a very skilled obs/gynae consultant who manages rather well without - impressive. Drug and laboratory reagent supplies can be rather erratic too. It all really makes one appreciate the work and organisation that must go on behind the scenes back home in our NHS hospitals.

For more information, pictures and videos I very much recommend the hospital's website: http://www.saintfrancishospital.net Don't bother reading most of the elective reports there: they're rather generic. The exception is a website put together by Chris Nickson, a New Zealand medical student who was here in 2004. He writes excellently, including about the wide variety of medical conditions we come across here. I thoroughly recommend that you pay it a visit and read whichever bits look interesting to you: http://homepages.paradise.net.nz/cnickson/medicine/acic_8.htm

The biggest change - nothing short of a paradigm shift - since he was here has been the introduction a few years ago of free anti-retro-viral drugs (ARVs) for patients with HIV, thanks largely I think to the Americans. This has absolutely revolutionised healthcare for those with the disease, enabling people who would otherwise be dead or dying to lead active and productive lives. The term "Lazarus effect" has been used by observers as emaciated, bedridden shells are transformed into people at whom you wouldn't glance twice on the street. For instance, the fiercely energetic young manager of the outpatient department is openly HIV positive, as are a number of the nurses and other members of staff.

I've just realised that, for those of you who don't know, I haven't explained how I came to be at SFH in the first place. Just over a year ago I began (early as I thought) contacting hospitals with regard to my 8 week elective placement. Having been to South America, sub-Saharan Africa was the next place I really wanted to visit, especially from a medical point of view. Since starting medicine I've often thought that this is the sort of work I'd like to be doing longer term, in one capacity or another. I decided that a missionary rather than state-run hospital was the way forward, both from the point of view of hopefully seeing an example of a more holistic approach to medicine, encompassing a spiritual dimension, and, personally, wanting to experience being part of one faith-and-work community rather than the perhaps necessarily dichotomous setup we have back home. Additionally, mission hospitals are almost always better run, better funded and better staffed than state hospitals which are all too often in the grasp of the dead hand of African politics. To add to the list, I was keen to work somewhere rural: African countryside is a lot more beautiful than African city and I didn't want to get lost in an enormous teaching hospital. Oh, and preferably English-speaking. So I wasn't asking much really. Unfortunately, on writing to lots of suitable-looking institutions in the likes of Kenya and Tanzania I found that hordes of super-organised German students had beaten me to it by 6 months or even a year. I was running out of A-list options when I happened to talk to Esther, wife of my friend Paul and herself a medic. I ran through my ideal criteria and to my surprise she said that the place she'd been to on her elective a number of years previously ticked all of them. I got in touch and Saint Francis' replied saying they'd take me. There ensued 10 months during which I heard nothing from the hospital in spite of numerous emails and even an actual letter. Radio silence was only broken once I'd touched down in Dar at which point I was rather pleased to find that I was still expected.

Over the last year I've discovered one or two other connections with the hospital. Mike Jones, an infectious diseases specialist who lectured us on the dangers of swimming in Lake Malawi (complete with gruesome pictures: Google images schistosomiasis - but not before or during dinner) and who runs the travel clinic at Edinburgh's Western General Hospital, has worked out here among other African hospitals. He was inspired to come here through his friendship with one of his patients, Sandy Logie, a Scottish physician previously of the Borders General Hospital who worked here in the early 90s. Tragically, he contracted HIV via a needlestick injury here and died back in Scotland about 10 years later, though not before returning to SFH more than once (in spite of the dangers to his fragile health) both to again serve medically and to highlight the plight of Africans denied anti-retroviral medications. I have not yet read them, but it would be worth looking up the articles he wrote for the BMJ about the experience, including that of "coming out" to the rest of the profession in Britain in 1996 - when things were much harder for HIV positive doctors even than they are now. Fittingly, the HIV clinic at the hospital is named after him, and his widow, Dorothy, herself also a medic, maintains a close association with the hospital, getting out here about once a year I think. In fact, while out here I received an email from her (Brian Magowan, obstetrician and gynaecologist at the BGH, put us in touch) in which she mentions working on proposals for Scottish Executive funding for the hospital and the agreement to a formal twinning arrangement between SFH and the BGH. Hopefully this will facilitate the exchange of plenty of staff and knowledge - in both directions - in years to come.

Well, what's it actually like being on the wards? English is the official national language of Zambia since there are so many different tribal languages (at least 70 I think - so a bit like Britain) none of which is predominant, so all the staff of the hospital speak it and children are supposed to learn it at school. Having said that, in my experience very few of the patients that we see have much English, perhaps because this a very rural area. The local language here is Nyanja, closely related to the Chichewa spoken in Malawi. I'm may be out by a few hundred years here, but the majority of the local inhabitants are decended from Bantu invaders/migrants who came to this part of Africa from further north and west about a thousand years ago. (Don't believe anyone who tells you colonialism started with the Europeans!) The language barrier is an enormous disadvantage, both in complicating the taking of a good history from patients, and because it makes establishing a personal connection so much harder - and that's the bit of medicine I enjoy the most. Having said that, people respond very warmly to an enthusiastic "Muli bwanji?" ("How are you?") and I've learnt how to make standard NHS banter along the lines of "Muvi konda vya kudya yam chipatala?" ("What do you think of the food in the hospital?" - believe me, NHS patients don't know how lucky they are.)

Something I really do enjoy is the way Zambians speak English. Even those who don't speak much are often able to respond to the question, "How are you today?" However, said response will invariably be rather quirky. The accepted options are, "Just OK," which, although it sounds as though the person is barely keeping their head above water, actually means something more like, "Just hunky-dory." Then there's the wonderful, "A bit fine," which means just that: kind of OK. If they reply, "At least," that's good: it means something akin to, "At least I'm getting better." Perhaps appropriately, if they're not doing so well they can't find an English phrase to express it (after all, we Brits are incapable of answering such a question in the negative) and usually reply, "Pangono," meaning really not too good. So actually the response you get is probably more informative than that which a patient on an NHS ward would give you to the same question.

Other entertaining quirks include adding the sound "ee" to the end of words, e.g. then-ee, and-ee, abdomen-ee (in Nyanja, every syllable ends with a vowel), saying "what what" instead of etcetera/and so on, and referring to people as "this one"/"that one" rather than him/her. The word "actually" is liberally applied to the end of sentences while "so" is often stuck on the front. Put it all together and you get such gems as, "So this one-ee had an acute abdomen-ee actually so we took her to theatah what what."

I'll have to sign off there for now. Hopefully the next update won't be so long in arriving!

So to continue the story (hopefully I'll get a chance to post this on the internet soon...)

One of the highlights has definitely been travelling on daladalas - the Tanzanian version of public transport - crammed into a tiny minibus or on the back of a truck with 15, 20 or even 30 men, women, children, rice bags, chickens and bicycles with not another tourist in sight. Being asked to pay what the locals pay (there's something dignifying and inclusive about that - rather than getting charged "tourist price"). Getting covered in dust and sweat - not all of it your own - you feel like you're dipping your toe in the inside of life here. The open-sided ones are particularly good, heads and necks open to the harsh caress of the elements, the road.

Continuing the comparison with Sri Lanka (where I travelled 3 or 4 years ago) what makes the two places so different are the people. It may partly be down to the ubiquity of the English language here, but I feel considerably more in common with Tanzanians than with Sri Lankans (although the people here are, for instance, considerably poorer on average). There is an openness on the part of people here such that one doesn't feel an inevitable outsider. Perhaps that's partly down to the pronounced heterogeneity of Tanzanian culture, both in present times and historically: the country is a melting pot of religions, tribes, races, languages, so there's room for one more - a bit like London perhaps. People are more genuinely warm and friendly here; you feel as though you could get to know them, whereas in Sri Lanka that was rarely the case unless there was a pre-existing personal connection. It felt like there was always a veil between you from them. It makes me wonder about how I treat foreigners when I'm back home: which of these two different cultural attitudes do I adopt?

Going back to the daladalas, our first and most memorable experience was in our second week on Zanzibar. Having decided to go to Jambiani, a beach on the east coast, for our remaining couple of days on the island, we duly showed up at the daladala terminus (market would be a more accurate term). According to a couple of people we asked, the last one to Jamibiani had already left. Of course, you can't take this as read as said informants want to give you a ride on their bus instead, but we couldn't see any likely looking buses anywhere so decided to accept the suggestion of one going to Paje, another beach a few kilometres to the north of our destination. This particular daladala came in the form of a converted, beat-up flatbed truck, benches along the sides under a makeshift roof which in turn was festooned with an enormous cargo of sticks.

We were a little surprised when the vehicle left with only ourselves and perhaps 3 others on board: normally in Tanzania a bus only departs when full - or rather when it's full and then 5 or 10 more people have been squeezed in or on. But we thought no more of it, simply pleased to be on our way somewhere, if not exactly to our desired destination. Judging by the sun (navigation is very easy in cloudless Zanzibar) we were heading in a promising direction, before taking a turn onto some very potted backstreets. No problem, we thought, this is where the sticks are headed. Sure enough, they were duly unloaded at a ramshackle dwelling and we headed back towards the main road. The first odd thing was that by this stage we were the only passangers. The second odd thing was that when we hit the main road we seemed to turn west (back towards Stone Town) rather than east. My heart sank further and further over the succeeding 20 minutes as it became abundantly clear that we weren't heading the right way. And sure enough, half an hour later, we were back exactly where we had started at Daladala Market.

Africa has a strange effect on you though: you begin to expect everything to go wrong, not to work, not to be on time - although maybe not to go in circles it has to be said - but at any rate you develop a wonderfully accepting attitude towards the whole thing: accept the things you cannot change. Or "hakuna matata" as Swahili would have it. So we just had a good laugh (what else can you do?) and decided to await the next act of the farce. Fortunately this time we - and a whole village-worth of goods and people - really were heading to Paje, where we arrived as the sun was setting.

Was it Bilbo or Frodo Baggins who said, "Don't adventures ever have an end?" Either way, ours was by no means finished for the day. By the fading twilight we consulted the Lonely Planet and set off in search of a Japanese-run establishment on the other side of town. Unfortunately night was falling in earnest and there were no functioning street lights to guide us. Additionally, most of the hostelries are accessed from the beach, not the main road, so we were in the position of not knowing whether we'd walk forever without finding this place.

And then Jimmy showed up: our New Best Friend extraordinaire, he really wouldn't take no for an answer, clearly wanting us to lead us to whichever guesthouse would give him the handsomest commission. To make things more interesting still, in the pitch darkness on the far side of town a flashy pickup truck with blacked-up windows screeched to a halt beside us, the 3 or 4 occupants shouting at us to get in and that they'd take us to a hotel. We politely said no, but they repeatedly reversed back up the road, following us and reiterating their agressive offer. Fortunatetly no guns were pulled and eventually they drove off. Meanwhile Jimmy, no more than a scrawny 5'5", was assuring us of his protection, that he was a "well respect man" etc etc. It really was quite hilarious. Fortunately we finally did make it to our destination, though not before hesitating as to whether to turn back towards town or head further into what was fast turning into the Heart of Darkness, in the hands of our potentially criminal guide. A small victory was even scored in the name of honesty in human relations when I refused to pay Jimmy for his repeatedly-declined services: "Jimmy, we agreed: no money."

We were very kindly received by our Japanese hostess and treated to a fine oriental dinner by rechargeable-solar-lamplight. The next day was absolutely beautiful, eating breakfast while the sun silhouetted seaweed collectors wading on the gently shelving beach and fishermen preparing to cast off for the day's work. We started our walk back into Paje along the sand and then cut inland back to the main road. This time we were successful in catching a daladala to Jamibiani (though not before spending 15 minutes repeatedly saying no to a guy who wanted to take us in his taxi. I've probably used the words "No thank you" as many times on Zanzibar as in the rest of my life put together.)

The Coral Rock Hotel in Jambiani turned out to be a very nice place with, importantly, good food and also imported South African cider thanks to one of the owners. I had a bit of an adventure, borrowing some snorkelling gear and wading out into the shallow low-tide sea for a good 20 minutes, before swimming a further 20. There's a reef perhaps a mile or more off-shore, covered in huge breakers, which I was hoping to get to. I found some nice copses of coral along the way, but when something stung me on the shoulder it suddenly occurred to me that I was well over half an hour from shore and further still from medical attention (though I did reassure myself that in the event of anaphylaxis I'd be able to ram the snorkel down my trachea, swim back to shore and get someone to give me a couple of my chlorpheniramine pills per rectum, or at worst ground down and shoved down the tube. Be prepared.

At any rate, fortunately none of these elaborate measures were, in the event, necessary and I made it back safe and sound, borne along nicely on the incoming tide which I'd made slow progress against on the way out. I saw some wonderfully big red starfish and discovered quite a few different shapes, sizes and colours of other sea creatures hiding amongst the sand, rocks and coral.

Alas, Zanzibar couldn't last forever and we headed back to Dar early on a Tuesday morning having spent just under a week on the island. The crossing on the way back was a bit gruelling: even my stomach didn't feel entirely at ease, seated as I was in the bows as the small hydrofoil heaved precipitously up and down on the heavy sea. Additionally, the crossing is never quite as quick as the advertised 1.5 or 2 hours. So it was with some relief that we finally docked at Dar on an atypically dreich morning and headed straight for a French brasserie for breakfast. Said breakfast was great, although the chilli sauce didn't seem to want to come out of its squidgy bottle; I was gradually squeezing harder when suddenly all hell broke loose over my plate, coffee and trousers. Turns out it had chilli flakes in, one of which must've got stuck in the nozzle.

The afternoon was a classic African experience. In fairness, we did arrive at the Tazara train station prepared for something of a wait, though I'm not sure I'd entirely believed my Dad's stories of people, on asking when their delayed train would leave, being told that it probably wouldn't be today as yesterday's still hadn't left. (He lived in Tanganyika, as the country was known before uniting with Zanzibar, for a year.) On getting there we were very pleased to find that 1) there was a "First Class Lounge" and 2) there were excellent little samosas available at about 8p each, plus cold soft drinks at equally reasonable prices. Of course, the First Class Lounge turned out to be anything but. I almost sat down on a free seat when the adjacent person gestured to the ceiling: I'd be sitting right under one of a number of leaking sections (goodness knows where the water was coming from). We did have fun chatting to a very nice bunch of English gap year volunteers who'd been teaching up in the north of the country for a few months and were now travelling. One of them had been hospitalised at one point with malaria which we thought was pretty bad going, although I've now changed my mind having seen at least 3 of the foreigners at Saint Francis come down with it - prophylaxis notwithstanding.

At any rate, we (and about 1500 others) waited around from 2.30 till about 7, when a railway company employee paid us a visit to announce that the train had been delayed due to an "accident". When we asked when it would be leaving he said, Same time - on Thursday (two days from now). The interesting thing is that this just didn't bother me at all. If this had been the UK I'd have been ready to give someone some major GBH of the earhole, but out here I just didn't mind. I found myself reassured that although I'd only been in Africa for a week, my body clock had well and truly adjusted itself to the local pace of life. It reminds me of hitchhiking actually, where you have to have a similar attitude if you're going to get by with some sort of peace of mind: let life come to you; enjoy whatever comes along. Don't expect things to work out but be happy when they do; be prepared to take the rough with the smooth; enjoy the surprises.

So we headed back into Dar for 40 fairly uneventful hours, barring a visit to a casino which the English folks had mentioned to us. As promised, entry was free, as were the G&Ts I was very attentively plied with all evening at the roulette table. We'd decided to spend a maximum of 10 USD each, so were rather pleased when we walked away with about 70.

Thursday afternoon found us back at our favourite spot in the First Class Lounge. We were again treated to an afternoon of inactivity, but this time the train really did show up and boarding/scrummaging commenced at 7.30pm. Unfortunately the train only made it about an hour out of the station before derailing, but at least we were on the road - and in reach of a buffet car with a good selection of local beers.

The delay had the additional advantage that, once the train was finally fixed a couple of hours after dawn, we were able to pass through a national park in daylight rather than overnight. Giraffes galloped away from the train and numerous antelopes lined the way. Heather even spotted a couple of hippos.

The train is actually quite comfortable. The line was built by the Chinese with the aim of giving Zambia an export route for its vast copper production. This was during the era when the Cold War was being played out by proxy in economic, political and military conflicts across the developing world, and this was part of China's bit for influence in the African sphere. It was they who built the train too, and it shows: its sparse, rectangular functionality echoing the aesthetics of communist Eastern Europe. However, at least the first class cabins had fold-down "beds" to lie on which were long enough to accommodate my 6'2", and there were locks on the windows and doors to prevent robbers plying their trade at midnight stops.

The cooks did a good job too, given the facilities, and we ate a few nice meals in the buffet car, getting to know some of our fellow travellers, including Pascal and Jenny, a Frenchman and a French Canadian woman, both travelling round the world for a year. I won't in a hurry forget his glowing recommendation of Guatemala as the most beautiful country he'd seen over that time. I've wanted for many years to visit Central America and, fingers crossed, once I graduate and finally get a proper job I'll be able to make it over there.

Heather and I parted ways just before the Zambian border. The 150 USD visa was just not going to be worth the money for a stay of only a couple of days, and either way she'd have difficulty getting a train back to Dar in time to catch her flight home. As I write, she is safely back in the UK, though no doubt cripplingly jealous of me still being out here.

At long last, two and a half days after it was due to arrive, the train arrived in Kapiri Mposhi at 4am Sunday morning. KM is a pretty God-forsaken little place, but it's the end of the line, still a good 180km short of the capital, Lusaka. Fortunately an enterprising couple of guys had showed up with their minibus, clearly at least one foot (or wheel) in the grave. But it looked like a much better option than sleeping on a station floor so we piled in. Alas, I ended up with my feet on the wheel arch, so spent the next 3 hours with my knees at my chin, but it got us there - right to the international bus station, conveniently enough. I said my goodbyes to the Pascal and Jenny and headed off in search of a bus to Katete.

Unfortunately, since my Lonely Planet had been published, the recommended company seemed to have stopped doiing this route, and the bus of the other company mentioned as a second-best option had left earlier in the morning, so I had no choice but to put myself in the hands of the local touts. These guys were at least a bit more convivial than their Zanzibari counterparts and I ended up getting a reasonable deal on a vehicle which had all its wheels in the correct places. As ever, the bus wouldn't leave till full, but that only took a couple of hours, and then we were off, finally on the road to Saint Francis.

The country we passed through on the 7 hour journey was strikingly beautiful: rolling hills and wide-open landscapes alternatively recalling the Scottish and Argentinian highlands. The road itself - the Great East Road - is actually in pretty good shape for much of its length, though at times we were down to 10mph negociating pothole after pothole. The horn got a lot of usage too as cyclists, goats, children, cows and monkeys were ushered out of our path. At one point we stopped for a break and I was overjoyed at not being hassled for anything even once during the 10 minute stop. I'd finally left tourist Africa behind.

The driver and the chap sitting next to me were both very friendly, and when I told them where I was going they assured me that they knew the hospital and that they'd drop me off at the side of the road at the appropriate place.

The sun had set beautifully, away back on our left, about half an hour previously when we pulled to the side of the road in front of a big white sign which reassuringly read "Saint Francis Hospital". I retrieved my rucksack from the hold (which unfortunatley now smelt very strongly of fish for some reason), waved goodbye to the bus and applied copious amounts of DEET before hoisting my rucksack to my back and setting off down the small dirt road that leads into the hospital, lined by the occasional white street light.

Arriving at the hospital under cover of night was actually very atmospheric. For the first time I really noticed the Southern Cross which I'd become so familiar with travelling in South America. With no background radiation the sky was suddenly full of stars, the milky way gently brushed across it. I walked up to the main entrance of the hospital and was met by Saidi, a very friendly security guard who ushered me to the staff mess where - joy! - roast dinner was about to be served.

And that's where I'll have to leave you for now! Hopefully more to come in the next week, or at least next weekend when I plan to return to this internet cafe in Chipata after another game of golf. (There's a story in there!)

This morning I was due to go on rural outreach with one of the midwifery students but have been kept at base camp by an attack of the katetes. Three trips to the toilet, a couple of chapters of Blood River and a few games of Palm solitaire later, I've exhausted the entertainment options available in my small hut so, I thought to myself, what better opportunity to finally blog something?

I've been in Africa just over 4 weeks now, the first 2 of which were spent travelling in Tanzania with Heather, my erstwhile travel companion on the South American adventures detailed previously on this blog.

We arrived in Dar Es Salaam on 11th June, 20 hours after setting out from Edinburgh; our luggage was less fortunate. The hiccup occured during the 2 hour connection in Nairobi. The plane taxied to a stop and we emerged to find a long red carpet snaking its way from the bottom of the steps out to a military-looking installation at the perimeter of the airport. We later discovered that the President of Tanzania had been one of our fellow travellers. Unfortunately for the less able-bodied among us, this particular perimeter was a good half mile from the terminal building. At any rate, amid the VIP-induced chaos, our rucksacks didn't quite make it. Miraculously they did turn up the following day at Zanzibar airport, whereupon we immediately chartered a taxi and wept tears of joy on being reunited with our 50% DEET insect repellant.

Meanwhile, back in Dar, we had managed to get a taxi to the railway station, bought me a "first class" ticket on the 40-hour sleeper to Zambia for the following week and headed to the port. I've experienced hassle before as a tourist in the developing world, principally in Sri Lanka - South America is refreshingly free of this sort of thing - but nothing could have prepared me for the treacle of touts in which our taxi found itself mired the moment we arrived. Immediately 10 different people were shouting at us, clamouring for our attention, business, tips, offering to be our new best friends, demanding that we go with them to the "real" office, that this ferry rather than that was about to sail, etc etc. There are about 4 different ferry companies which sail between Dar and Zanzibar, and our 2-year-old Lonely Planet couldn't be guaranteed to have up-to-date information. Imagine our additional confusion then on seeing about 10 or 12 rather than 4 offices. We were initially herded into one whose handwritten sign didn't inspire confidence and quoted 40 USD each. We managed to politely decline and went off in search of other options. Eventually we found the official office (this must be done on your own as anyone you ask for directions or any other help will insist on following you there and demanding payment or a commision) and got them for the real price of 35 each.

After that, the crossing was an oasis of peace, standing up on deck of the hydrofoil, spray in my face, watching the sun set as Zanzibar came into view.

To make matters interesting though, we were arriving about 1 month into a power cut. The immediate downside of this was having to make our way in almost pitch darkness from the ferry port to our guesthouse, over a mile away through the narrow, winding streets of the old Stone Town, again without asking any directions for the reasons stated above. On the other hand, the local touts seem to keep daylight hours so we were blessedly unencumbered on arrival at the dock and made it to Garden Lodge - a very nice place with a good cook and an all-important generator - safe and sound.

Well, first impressions of Dar and Zanzibar. Both places, in colour, climate, smell and atmosphere, remind me very much of Sri Lanka. The same hustle and bustle over broken pavements; a confusion of shops, street stalls, beggars and dodgy characters clamouring for your attention. The same hot tropical sun that seems to move through the sky improbably quickly, setting in a sprint finish.

The drawback is the touts. They're particularly bad in Zanzibar, coming up to you and not taking no for an answer but instead often following you for 5 minutes at a time down the street in hope of a tip, some unearned commission or a quick swindle. It's very sad to see people giving away their dignity in this way, trailing after tourists like stray dogs. It also undermines any possibility of detente with the local population as it makes one very unwilling to stop and ask anyone for help - since likely as not it'll either be one of these touts or one of them will overhear the conversation and hijack the interaction. And if anyone appears friendly one is immediately suspicious of them. All the more of a shame since the majority of Tanzanians I have met have been incredibly helpful and hospitable. You really see here the difference that one's mindset makes to one's poverty. People who throw away their dignity to come begging to you for money may get more at the end of the day, but they are humanly poorer for it: they'll always feel less than the richer people they're begging from. Whereas the man, woman or child who is prepared to interact on level terms, with no money or power differential involved, maintains their dignity and their human wealth. How true this is back in the UK too. So many people feeling poor, that they don't have enough, and allowing this to determine their identity and self-image - from muggers and drug dealers on housing estates to, no doubt, many stock brokers. Short of lack of food, water, shelter and basic healthcare, poverty is an attitude much more than a physical state of affairs, as evidenced too by my experiences in San Mateo, the very poor fishing village where my aunt lives in Ecuador.

Having said that, touts aside we had a wonderful time on Zanzibar. Based on what I'd heard from friends, going to Africa, I had prepared myself for a purgatorial diet, but the fare on offer on Zanzibar is anything but: a fantastically varied and creative mixture of Arab, African, Indian and European cuisines with the local ocean and agriculture furnishing the finest raw materials. A particular highlight was "Two Tables Restaurant", literally two tables - in the dining room of a family home. We were sat next to 4 other Brits and served course after course of delicious local delicacies by our host. I could see this sort of dining experience taking off in the UK (though at exorbitant prices) although health and safety/disabled access regulations would probaby throw too many spanners in the works.

A couple of days into our stay we rendezvoused with 2 of my coursemates, also out in East Africa for their electives, and visited Prison Island, home to a big family of even bigger tortoises. Amazing creatures, they come from the Seychelles and are apparently second only to the Galapagos tortoise in size (we're talking up to a metre and a half long and well over twice my weight). They're very used to people and one or two were positively curious, particularly about my trainers which one fellow nibbled at before taking a big bite into. I'd forgotten how thin the uppers were and squealed like a girl. We also got to do some snorkelling, though my hope of going swimming with turtles remains unfulfilled.

At this promising juncture the narrative - such of it as I have been able to recover - comes to a prematurely unfortunate end. For reasons presumably known to himself, the author did not continue with this most entertaining series of vignettes; either that or the remainder has been lost. However, unable - on my own behalf as much as on yours - to leave my ignorance as to the rest of this most diverting tale unsullied, I undertook to discover of it what I might.

After much travail it pleased the internet to give up from its depths that which I sought: a series of blog entries (no longer extant) by the hand of a self-effacing Spaniard who appears to have accompanied our intrepid adventurers for an undisclosed portion of their journey. I have spared no effort in translating what follows with the utmost accuracy, but I should caution the credulous reader that while everything he has read preceding this point is certainly as true as if George Washington himself had written it^[1], he ought to bear in mind the well-known fact that all Spaniards are liars and scoundrels who should sooner be taken even for gentlemen than taken seriously. I therefore leave the reader to draw his own conclusions as to the veracity of what follows.

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[1] The employer of this comparison is clearly a simpleton as had George Washington indeed written the aforementioned history nothing could be as certain as his mendacity.

This entry is being written in a hospital, high in the Ecuadorean Andes - at least three countries ahead of its contents, I am ashamed to say!

I had promised a literary tour de force in the last post, but am rather tired so, much to your dismay I'm sure, will have to postpone it, ideally to the environs of a comfortable internet cafe in Quito. In its place, I propose to entertain you with these somewhat more terrestrial musings.

The weekend's trip referred to in the last-but-one entry was to Los Penitentes, a ski resort favourably situated just a few miles from Aconcagua, the highest mountain outside the Himalayas I believe at 22,834 feet. The first indication of a dent in the wheel came at the bus station in Mendoza, where we were casually informed (in the usual rapid Spanish of course) that our vehicle might not make it all the way to the resort because of weather conditions. However, the prospect of skiing will make a man do strange things, and without hesitation we jumped on the bus for a 4 hour ride into the night. Unfortunately, courage is no proof of success, as Captain Scott would no doubt have told us, had he too been at the bus station, and as we were soon to find out, specifically when, having driven the last mile through a blizzard, the bus ground to a halt. Confusion reigned for the next five minutes, as it gradually became clear that we could go no further. The options at this point ranged from bad to tolerably unpleasant: go back in the bus to Mendoza, or walk 9km through deep snow and a blizzard to the "resort" (inverted commas were definitely becoming obligatory) with all our luggage - in our case two rucksacks - one of which being enormous - each.

Well, dear reader, you may take pride in the fact that your correspondent chose the road less travelled. (The expression, "Doing it for Britain" may have been uttered. Heather's attitude was more along the equally patriotic lines of "I'm just going outside; I may be some time.") What ensued was a bit of a Mexican standoff in the nearby National Guard hut: they insisted that there was no way we could get to Los Penitentes, but neither could they very well throw us out into the snow. Meanwhile I went in search of a telephone, stumbling through a graveyard of stranded lorries in pitch darkness. On finding one in a charmingly archetypical truckers' cafe I called the hostel we'd booked, and attempted to convey the nature of the situation in my most dramatic broken Spanish. They weren't overly enthusiastic when I suggested that they might have a four-wheeler in which they could come and get us, but my crazed assurance that we would walk if necessary seemed to make a bit more of a dent, and my interlocutor promised to go off in search of one, asking me to call back in a few minutes. Fortunately this was not to be necessary: on my return to the hut it had become clear to the guardsmen that we were more than prepared to outlast them, and faced finally with the prospect of sharing their already meagre lodgings with 7 or 8 insane tourists, they realised on which side their bread was decidedly not buttered; magically, a hitherto forgotten 4-wheel-drive materialised, we piled into the back and within 20 minutes were at the hostel.

Alas though, all our heroism was to be in vain. The following morning's declaration of "too much snow" put me in mind of a memorable Scottish skiing non-experience, though with considerably more cause this time: there was a heart-breaking metre of powder, but while it was still snowing the officials insisted that they couldn't open the ski area. We stuck it out for one more day in the tiny hostel, amusing ourselves by digging snow caves and throwing snowballs at dogs, but the following morning brought only news of further weather deterioration. Meanwhile the water supply to the resort had failed, or frozen, or something, and the toilets were backing up considerably - possibly in no small part due to the hostel's cuisine - so we decided to cut and run. Fortunately the snow plow decided to make a belated appearance, and the exodus began in earnest. We got excedingly lucky: the first car with a modicum of space stopped for us. It also happened to be an extremely comfortable 4-wheel-drive Mercedes with a true gentleman behind the wheel: not only did he speak excellent English, he dropped us at the door of our hostel in Mendoza 3 hours later. The daughter of the family was less than enamoured at having to share the back seat and her parents' attention with us, and kept asking in Spanish (which I presume she thought we couldn't understand) when they were dropping us off. Very entertaining all round.

On the bright side we had two days left in Mendoza, one to visit even more vineyards, the other to have a go at paragliding, jumping straight off a mountain commanding fantastic views of the city and surrounding plain in front and the Andes behind. We must have soared up a good further 200 metres or so on the thermals before gliding down for 15 minutes to the landing site, skimming radio masts along the way. If I had any money at all I'd be addicted.

The evening found us boarding yet another 20 hour bus, this time to Salta in the north of Argentina. It was a bit of a last minute scramble aboard: I had to go off in search of change for a 100 peso note to pay the taxi driver (if I haven't mentioned it already, nobody in South America ever has any change; in fact the phenomenon is so ubiquitous that one begins to wonder whether it is for religious reasons) while Heather was hassled by a couple of bus station kids, but in the event we made it safely aboard, even, in my case, one litre of chocolate milk and a few empanadas to the good. (Empanadas are fantastic little things: mini-pasties containing egg and olives as well as the usual ingredients.)

I must leave you though to imagine the delights of the ensuing journey: another lunch beckons!

Our travels encountered a temporary hiatus two days ago when first Heather and then I came down with a good old case of the Bolivianos. This is how we think it happened.

It was our last night in Uyuni, having just got back from the Salt Flats (to be detailed in a later edition). Heather and I were more than up for a decent dinner, but one of our companions was awfully keen to save money and to meet up with a girl that we'd met earlier in our travels. A bad combination, as it turned out. The moment we walked in the door of the establishment it was clear that the chicken had been lying around for longer than some of the dead dogs we'd passed earlier in the day. Rice - presumably having suffered the same comfortable climatic maintenance between lukewarm and tepid - was also to be served. We should of course have said no immediately, but it felt as though it would have been petulant and rich-western-tourist to do so (our keen friend was an Argentinian) so with the manners that made the Empire great we soldiered on. In fact I think we were the only ones who deigned to finish the soup, served with a garnish of chicken's feet. (Yes, really - the only vaguely redeeming feature, if only for comedy value. Photos shall follow.) I didn't eat much of my chicken, once I got beyond the 5 minute line and realised it was pink beyond. (I'm such a polite chap I felt an awful snob for leaving it, even then.) Heather's appeared to be better done and she finished it. We both avoided the rice. Definitely the worst 50p I've spent in my life. We then went straight to the original decent restaurant for a fantastic meal of peppered llama steak which cost all of about 2 quid each.

Well, the effects began to come on over the next couple of days. It was Heather who bore the first major advance though - at over 3800 metres, with ahead of us a 3 to 4 hour hike across a hilly, illogically pathed island on Lake Titicaca. (The timetabled boat turned out not to exist, in predictable Bolivian style.) Heather, with heroism worthy of that guy in Gladiator, made it back to the island's main port - albeit having left some evidence of her passing - where yet another boat appeared to have encountered an ontological crisis. After some haggling - aided by the spankingness of my 10 dollar notes (Marks and Spencers be praised!) - we chartered a vessel for the mainland. Fortunately my stomach held out long enough to find us our very own toilet in a fantastic hostel.

Heather went straight to bed (about 3/4pm) and I went out to get some food, having not eaten anything during the day except two biscuits for breakfast. It was only as the last morsel of beer and pizza went down that I realised it might have been a bit of a mistake; the next minute I was making liberal use of the restaurant's facilities and the last two or three pages of Alan Hollinghurst's "The Line of Beauty".

The rest of the night was spent in a delirium of half-waking dreams - dreadfully complicated conspiracies which had caused this end-of-the-world scenario - punctuated by exquisitely painful abdominal cramps, slightly unhinged chat and taking turns at keeping the toilet seat warm while perfecting the ultimate groan.

Come the morning, following a record breaking 5 in 10 minutes "streak", I decided I'd had enough. In the end it took 4 loperamide, but I slept like a baby for a good four or five hours. And that's when the trouble started. I suddenly got really cold, shivering in the middle of the day inside a 3/4 season sleeping bag, 2 enormous blankets and a duvet. My face turned green, which is really rather exciting! Heather improvised a hot water bottle out of a water container which was a great help, and two hours later the floodgates opened, as it were, much to my relief. Immodium - never again! After that things improved nicely, and ere long I was taking immense pleasure in my first standing-up piss in 24 hours. Hurrah!

After a pretty good night's sleep that night we headed over the border for Cusco. Not before doing a bit of gringo-wannabe spotting in Copacabana first though.

Sorry, I should backtrack. Copacabana was a bit of a shock initially: absolutely overrun with tourists, far more so than anywhere else we'd been. But it wasn't so much that which lent the place its sinister atmosphere. We were making our first acquaintance with the Traveller/Wannabe species. The streets were lined with skinny westerners/Brazillians gone native in frighteningly predictable style (dreadlocks ubiquitous, Rastafarian hats essential uniform, "ethnic"-jewellery-selling only acceptable profession, teenage sulk honed to perfection). My faith in human nature was deeply shaken.

Another nadir was a snack in what turned out to be an exclusively gringo-populated restaurant. The conversation at the next table was superlatively inane. Various Brits and an American or two right-on'ed at great length about just how awwful it was trying to get away from all these gringos, and how it was all about meeting REAL people yah. A somewhat unlikely prospect, unfortunately, in their case given that the next speaker apparently believed she was still in South East Asia, nonsequitorily gushing, "Oh! I'm starting to believe in Kaaaaaaarma!!" I'm sure that she would equally enthusiastically advance the universalisation of native Bolivian Buddhism and hair beading as a marvellous prospect for world peace - at least until she gets home and finds she has a whole three months of unread Heat magazines to catch up on.

On the subject of inanity (among many others) I have here decided to go off on what I hope will prove to be an interesting tangent. No time to write it now, as yet another wonderful dinner beckons, but to whet your appetite, it will be on the remarkable similarities - both in theme and characterisation - between the unlikely couple of Brett Easton Ellis's "American Psycho" and the afore-mentioned "The Line of Beauty".

Till then though, dear readers, stay away from dodgy chicken!

I'm aware that my public has been on tenterhooks for almost two weeks now, awaiting the next installment. Indeed, I have it on reliable information that sales of valium have tripled across western Europe as the great unhosed, driven to desperation in anticipation of their next fix of blog, have run into the soft embrace of oblivion.

OK, I may have got a little carried away there. Doubled would be more accurate.

At any rate, dear readers, fresh from digging myself out from under a mound of serialisation offers from national newspapers, here I am again, labouring heroically in a dirty internet cafe for your reading enjoyment. Actually I'm only here because the restaurant was full so we had to make reservations for half an hour from now, but I really shouldn't have told you that. Reality can be so dull!

Well, unfortunately the above attempt at an update came to nothing with the arrival of dinner, so I am now continuing this a week and many events later.

But enough preamble - let's get to the chase.

With regret in our hearts at having eaten our last Alberto's steak, we left Bariloche on another 20 hour bus ride, this time to north to Mendoza. The journey was unremarkable, excepting the first 5 minutes of Scary Movie 2(?) a marvellous parody of The Exorcist featuring James Woods as a very foul-mouthed incarnation of the priest. I was most taken aback, having been underwhelmed to say the least by the original Scary Movie. Unfortunately a scratch on the DVD put a stop to the hilarity, so I can tell you no more.

Mendoza is a fantastic city: bar the open sewers (why??) I'd unhesitatingly recommend it to anyone. Broad leafy streets, shops and restaurants galore, a huge park and an enviable climate: it was between 20 and 25 for most of our stay, and that in the middle of winter.

The staff at Hostel Lagares could not have been more warm, friendly, helpful and informed, not to mention their excellent English. In fact after an adventuresome weekend away - details to follow - we were welcomed back like long-lost family. Top prize for best hostel staff ever.

In spite of their best recommendations though, we failed to find a steak to match Alberto's. However, the wine tour they hooked us up with went some way to consoling us. Argentina is the world's fifth wine producer and Mendoza is where most of it happens. Aptly named Bikes and Wines rents you a bike for the day and you go off and explore whichever of the local bodegas take your fancy. A far better approach than the standard bus tours as it's all at your own pace, not to mention the pleasure of riding in bright sunshine through the beautiful countryside; and arriving on your own increases your chance of a one-to-one tour. In the event, we took at least a day and a half to see, or rather drink, everything we wanted.

Among the highlights was Tempus Alba, a new bodega set up by the latest generation of an old Argentinian wine family who own a number of other vineyards. We were lucky enough to get shown round by one of the owners. Malbec is THE Mendoza grape - the dry, hot climate suiting it ideally - and this brother and sister are making it their life's work to find the perfect plant, growing hundreds of vines from all around the world and running all sorts of complicated laboratory tests on them. They estimate that the project will be finished in 30 years - soon enough for their children, perhaps, to reap the benefits. A very different way of doing business. Look out for Tempus Alba Malbec Reserve in 2040. You won't have to wait that long to taste some amazing wines from them though. Eight of us lounged on their elegant patio for a good hour and a half as the sun lowered towards the horizon, drinking the best red wine I've ever tasted. Cream of the crop was the Reserve, an 80-20 blend of malbec and cabernet sauvignon, aged in brand new French oak, etc etc. I hate to think how much it would set you back if you were fortunate enough to come across it in the local offie.

My other favourite was La Carinae, an old bodega recently bought by a French couple and completely renovated after years of disuse. We were fortunate enough to get a one-to-two tour from the resident English speaker, Sebastian - an 18 year old Frenchman working there with his girlfriend for the summer - who could not have been more enthusiastic or knowledgeable about his subject. We spent a good two hours with him, learning all sorts of things about the myriad ways wine can be made. The methods on hand here made for a fascinating contrast with Tempus Alba's hi-tech approach, with results that were almost as good. We ended the tour by eating lunch under the warm afternoon sun: a delicious plate of hams, cheeses, bread and olive oil accompanied by their best wine. Life really does not get much better. Heather even managed to get me to eat some of the cheese; good wine, ham and bread certainly have a beneficial effect vis a vis helping it go and stay down.

We had a couple of missions to accomplish in the city itself: one was to restock on English books, the other to find the ultimate gaucho hat. We encountered the second at the back of a hat stand in a leather shop. My first reaction was hysterical laughter and Heather observantly noted that it seemed to "still have the cow attached". Of course, it had to be tried on for comedic purposes. The great surprise was that it actually worked - in a pimped-to-the-max kind of way. Subsequent photos will no doubt feature "El Vaca".

Mission number 1 was completed next. Heather managed to find an imported British copy of The Lord of the Rings - though it was soon to meet a rather unfortunate end - and I got a translation of a book of Borges short stories. I've since picked up a copy of the same collection in the original Spanish and have been having much fun trying to read it.

And now, with so much more to tell, I regret that I must sign off. Another dinner beckons!