Loose ends

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.