Which is better? Rural Zambia or Rural UK- a Grumpy Old Man blog

As I am leaving Africa shortly to come back to the UK and resume my GOM persona, I am tending to compare the two places (more specifically Mfuwe and Brigg which have similar populations) and here are some of the results.

Traffic jams - somewhat less in Zambia- ditto parking problems

Politeness - Zambians are never rude, and in my experience never swear.

Difficulty of getting an appointment with a doctor. In Zambia - there is no problem - you just turn up. You are also more likely to get an antibiotic! 

Cycle path network - there are vastly more cycle paths than roads in Zambia

Obesity prevalence - much less in Zambia- possibly related to low car ownership and high bike ownership

Breast feeding prevalence - roughly 100% in Zambia - where breastfeeding in public is not a problem. 

Children able to play outdoors without danger -Zambia is better as there is always a group of kids and a granny or two to supervise. 

House prices relative to incomes. I was talking to a waiter who earns the minimum wage of around £70 a month. He has recently built a new house for himself for around £300 - the plot cost him zilch. So he has a house for under 5 months wages. Whereas in the UK - the average house costs around 4 years of average wages. 

Carbon footprint - the average rural zambian has extremely low CO2 emissions - a bit of wood for cooking which is renewable to some extent, clothes that are recycled from Europe so just have transport related CO2, very little motorised transport, and food production basically has zero emissions here. 

Immunisation rates - All the children i see in the clinic bring their child health cards with them and i have yet to see a child who was not immunised up to date. I have not heard any parent refusing immunisation. 

Medication use - In Zambia old people are not poisoned by large amounts of supposedly preventative medication. 

Pointless signs and warnings - In Zambia people know that rivers, bridges, etc. are dangerous - and roads are not cluttered with annoying signs. 

Personal injury litigation - (possibly related to the item above) - this does not so far seem to be common in Zambia. 

Wildlife is beautiful everywhere - but probably Zambia has the edge!

Endangered species - including homo sapiens

The South Luangwa national park is the most peaceful place one can imagine. It is 7am and a gentle sunshines on the river, and all is quiet apart from birdsong and the odd snorting hippo. Across the river there are lots of elephants and impala and giraffe - with improbably large birds in many of the trees. It is a delightful place to spend time and the sense of peace and relaxation is wonderful. For pics see http://www.robinpopesafaris.net/camps/nkwali.php

But in fact we are in a war zone. There are lots of people who have no job, no land, and need to eat, and there are also lots of people who are greedy. Elephant ivory and bush meat from the deer are tempting poachers in to the park with primitive rifles and modern AK 47’s. Rhinos have been wiped out in most of Africa.  Despite a lot of support from western donors the Zambian wildlife authority struggles to cope, and large areas of national parks - especially away from the main tourist spots- are heavily poached. There is  also a lot of illegal tree felling of what should be protected forests. 

The underlying pressure is population growth. For Africa in general this has been around 2.5 to 3 % per year for a long time. It doesn’t sound a lot - but half of all Zambians were under the voting age at the recent elections- and that even if fertility reduces to replacement level - 2 children per woman - there are so many young women that numbers will continue to rise rapidly for another generation. At present rates of growth Africas population, which is now just over 1 billion - similar to India and Europe - will reach over 3 billion (i.e. equivalent to half of the worlds present population) by 2050!

It is hard to see how large areas of land can remain untouched by these extra people - even if the pressure on resources does not lead to war between countries. So, if you are a pessimist - (someone who thinks we live in the best of all possible worlds) - don’t put off your african safari trip for too long. 

About food and health - and nothing to do with Zambia

And now for something completely different -as I am due to return to civilisation!?in 3 weeks, I have been looking at the medical press and there is some medical research you probably will not hear on the TV or read about in the press, but which is really good news for those of us who like good food. 

http://annals.org/article.aspx?articleid=1846638&resultClick=3  This is a review done by Cambridge University and funded by the British Heart Foundation which was published in the American College of Physicians Journal - the Annals of Internal Medicine. (i.e. This is solid science not far out crazy stuff)

They collected results from numerous research projects into dietary fat intake and coronary heart disease (heart attacks and angina) involving over 600,000 patients in all. High animal fat intake was NOT associated with an increased risk. A high intake of trans fats or hydrogenated fatty acids - (fats that are artificially solidified by injecting hydrogen) that are found in margarine, and fast foods, was associated with an increased risk. 

So dairy farmers, and lovers of butter, cheese, cakes and baking (who does that leave out?)  can celebrate with a good conscience and no adverse effect on their health. Food factories churning out rubbish however, better get ready - because transfats should probably be banned universally - as they have been in many parts of the world. 

So why did we (both doctors and the public) get conned into the whole animal fats cause high cholesterol causes heart disease? Good question, and I do not think there is a simple answer. In the 50’s when Heart Attacks became common it was observed that diseased arteries contained lumps of cholesterol, and foods with a lot of cholesterol also tend to have a lot of saturated fats (carbon hydrogen chains with all the hydrogen slots filled up). But fatty acids and cholesterol are chemically completely unrelated, almost all of our cholesterol is produced by the liver and not dietary. It is extremely hard to reduce cholesterol in the blood by altering the diet. Also rising animal fat intake in the developed world has accompanied a massive decline in heart disease over the last 30 years. 

However, a simple story can ignore inconvenient truths, most clearly when many cholesterol reducing drugs were found to have no benefit, and the bandwagon really got going when the pharmaceutical industry (firstly Merck, and then Pfizer and Astra) did find that statin drugs prevented deaths after heart attacks, and then various nutriceutical companies started making Flora and Olivio etc. The market for statins alone is over $20 billion, so the simple Myth that eating fats turns into cholesterol which then clogs up your arteries has had powerful support from advertising (both to the public and doctors) and has limped on despite being scientifically shot to pieces.

There is more on this at http://drmalcolmkendrick.org/ - but meanwhile - could you send some ice cream and brie?

By the Grace of ...... (controversy rating - MAX)

I APOLOGIZE FOR ANY OFFENCE CAUSED BY THIS BLOG WHICH DEBATES RELIGIOUS BELIEF.  YOU MAY WISH TO STOP READING NOW. 

There is an issue which dramatically divides Zambians and many Europeans, and that is Christianity. It is a sensitive subject, because people here believe very strongly. There are a great variety of churches even in this small town, and they are mostly full on a Sunday. Many people spend several hours each week at services, and pay quite significant amounts to support their church. In fact church buildings and ministers of religion seem to be a success story here - both often bursting at their seams, and the only fat child I have seen in Mfuwe is the daughter of a pastor. 

I of course believe in the enlightenment, Hume and Locke, and from there to Darwin and in modern times to AC Grayling and Richard Dawkins. I think that religion held back the development of science and freedom in Europe. So is Christianity helping or hindering Zambia and Zambians today?

Usually, I try to be diplomatic - when in Rome etc, but today the issues were impossible to ignore. A 30 year old woman with 3 children was brought into the clinic feeling weak and dizzy. She was extremely pale, and our lab measured her Haemoglobin as being 4.3. (normal is from 11 to 16). Haemoglobin is important stuff as it is the chemical that carries oxygen around the body. I have never previously seen anyone with a level under 6. She had been bleeding for a few weeks, and was dangerously ill. I explained that she needed to be sent to the hospital urgently to have the bleeding stopped, and for blood transfusion. Anaesthetics are very dangerous for patients with severe anaemia, so if she does not have a transfusion, her chances are poor. 

I was then told that she was a Jehovah’s Witness, and would not consent to a blood transfusion. I explained (nicely I hope) that this refusal would be likely to result in her children becoming orphans. The response was that they would trust in God, and that with God’s help she would survive. 

I did not say so, but this comment strikes me as crazy, given that everyone here must be only too well aware of many many Christians who have manifestly not been saved by the Almighty from the scourges of HIV, car crashes, crocodiles etc. When I ask the clinic staff how they square this fact with their beliefs they say that those people died because “their time had come”.

The overall philosophy seems to be that one has little direct control over one’s destiny, which is mostly a matter of fate. Maybe prayer helps, and maybe it helps people to accept what happens in life. To someone with my background, this is shockingly fatalistic, and I cannot help blaming the apathy I observe among the clinic staff on their religious faith. 

My interest in this issue gained me an invitation to the New Apostolic Church in Mfuwe last Sunday morning. About a hundred people crowded into a small hall, with about 40 more outside. The service was conducted by the elder along with several deacons, and an unaccompanied choir of about 15 with bass tenor alto and  soprano parts sang a whole succession of hymns beautifully - without the benefit of any sheet music. The service lasted a couple of hours and was in a mixture of Njanja and English. At the appropriate moment all newcomers including me had to stand up and announce themselves. At the end of the service the whole congregation formed a line in order to shake hands with everyone in turn. 

There seems no doubt that people find their religion a great support and a comfort. It is also true that there seems to be very little violence in society generally here, (wife beating excepted) and that people are polite and very friendly. Otherwise moral failings seem generally about as common in Zambia as elsewhere, although a sense of duty and responsibility among  those in authority, ie teachers, nurses etc. seems particularly lacking. The churches have clearly been an obstacle to progress over issues such as the use of condoms, HIV testing, and contraception. 

In the absence of a controlled experiment, we will never know whether Christianity does more good than bad. We may perhaps! see how the present situation pans out over the next 20 years or so. Meanwhile we can speculate and debate. 

Volunteering - or Voluntouring?

Who I am doing this for? myself  - or the people of Zambia, and if it is the latter- exactly how much am i giving up in order to help them? 

Here in Mfuwe I am staying at a lovely budget lodge/backpackers called Marula Lodge - (marulalodgezambia.com). I am living out of a pretty small suitcase but I have a computer which plays DVD’s and I obviously have a intermittent internet connection. Electricity does disappear now and then, occasionally for a few hours, but the water runs reliably. There are a few things which i am looking forward to renewing an acquaintance with when i get back - such as chocolate, ice cream, non instant coffee, non white bread, a bath ….but the list is pretty short. 

This is of course a subject which is constantly discussed among volunteers, and Marula is visited by a constant stream of volunteers of all sorts. Some of them are doing mainly a tourist thing with a bit of work thrown in, often helping some sort of educational initiative. Some are working for big NGO’s and turn up in big 4X4s and seem to be living quite a ‘bwana’ (boss) lifestyle. However, many are coming here to the lodge for a break from a very tough existence living in primitive conditions for long periods of time. For example, I have just been chatting to a girl who is doing something I could not even cope with for a week. She is from California, and works for the US Peace Corps. She has been living in Zambia for the last year and a half without going home. She lives in a village which has neither electricity, nor running water, nor proper toilets (obviously). Even more impressively, she lives 12km from her nearest fellow volunteer, and there is only one man in her village who speaks English. She has a phone which she charges with a small solar panel. Her transport is by bike.  Once a month, she goes by bike 19km along dirt roads to the nearest town once, and then takes a bus to her HQ for a weekend, the journey taking most of the day. She is only here this weekend because her Mum is visiting. 

She is helping to train local volunteer health workers, mainly to do health education talks to the villagers.  HIV and Malaria prevention and encouraging Ante- natal care are among the most important issues. She says that Africans are generally happier than Americans, which is not intuitive, considering that they face major threats to their most basic needs, such as how to feed my family and keep them healthy.  She personally is ‘as happy as I have ever been’. The only way I can explain this is that she is feeling that her work is worthwhile and fulfilling, and that her relationships with local people are authentic and rewarding. In both cases - this is of course relative to the US. 

So my minor degree of deprivation of a few favourite luxuries pales into insignificance by comparison. But, I am outside my comfort zone quite frequently in my work in the government clinic, both in terms of my skills and ability, and in terms of the lack of drugs, equipment, and referral options. So, although I am having a hugely interesting human experience as part of my trip here, I think I can say that I am not just a voluntourist.

Bike blog - please excuse some technical language

It is 7am and rush hour in Mfuwe - there a few cars but hundreds of bikes, with an average number of passengers of around 2. The bikes look like a throwback to the 1950’s - in that they are generally black in colour, and have cows horn handlebars and old style brakes which use rods and levers instead of wire and cables. The marketing is all about reliability and strength, rather than style or speed. Typical brands are “Atlas Super Strong’ or ‘Buffalo’.  The bikes are made generally in China and come to Africa in a rather crude and unadjusted state. They retail here for around 60-70 pounds when new, and the quality is appropriate to the price. Nonetheless, the ownership of a bike shows that a family is pulling itself off the breadline and is a potent status symbol. The bike will then be used by the whole family, with the luggage rack at the back usually carrying a passenger (ladies decorously riding sidesaddle - like some Victorian film), or a woven basket up to 2m wide with vegetables, or a heavy load of firewood. Children often perch on the cross bar- sometimes even infants. Not surprisingly, this is well in excess of the design parameters and when you throw in the state of the roads, it all adds up to some sick bicycles. The common issues are - brakes - often non existent and usually not functional (luckily Mfuwe is very flat), and seats - often leaning sideways at a crazy angle or not existing at all, with the rider either just standing up, or sitting on the luggage rack leaning back as in an Easy Rider pose.  Pedals are a common problem with kids often riding in flipflops just on the pedal axle which looks painful. There are of course neither lights nor reflectors. 

So roadside bike repair workshops and bike spare suppliers do a roaring trade. They will respoke a wheel quite happily with no equipment to speak off just sitting on bare earth. They also specialise in a very african bike modification which seems to be aimed at reinforcing the front forks. Hammers seem to be used for bike repair surprisingly often, but they get results! 

So Kakumbi clinic has no patient car park, but lots of bikes outside, and when the mobile HIV clinic comes to town - it looks like Amsterdam railway station - well almost. (Why HIV patients are more likely to have bikes we will discuss another time). 

It is hard not to approve of this development. It would be nice if the bikes were made in Africa so that the money is not being sucked out of the economy, but who could compete at that price? The local people have an effective, non polluting means of transport, so they can get to school, healthcare, shops, work,etc. Loads including sick patients are transported by someone walking beside the bike while the wood or patient sits on the rear carrier. Obesity is rare. 

So what are the drawbacks? There are conflicts over bike ownership, - including at least one divorce recently! but the main problems are very similar to with cars - and obviously less severe. Cyclists seem to get hit by cars even more than pedestrians do, which is a tragedy that is mainly caused by the standard of Zambian driving. Men fall off their brakeless bikes when drunk and their bare feet suffer very nasty wounds, which we struggle to keep dressed and clean. But the main problem is when the kids get their feet in the wheel. The results can really make me wince. 

Joy

xxx rated xxx blog stop reading if the thought of blood etc. is upsetting.

During my spell here i have been taken under the wing of the clinic Midwife  - a larger than life character literally - called Grace. Perhaps unwisely, I told her that i was interested in brushing up my skills in the Obstetric department.  Since then, when opportunity arises, and the clinic is not too busy, she throws me in the deep end and sees how i cope. 

In medical education in the 1970’s, students had to spend many hours with women in labour and actually deliver babies. I found it fascinating and rewarding, being granted an intimate view (literally) of the emotional lives of patients at the most significant event in their lives. I still remember some of those women 30 years later. I then worked as a junior doctor in the UK and I was also in charge of the maternity ward during our spell in South Africa, and I am still proud of our results there, including a zero death rate for mothers. 

But that was a long time ago, and I am very rusty indeed. So when I was asked today to assess a patient I was a bit nervous. A 25 year old  who was in her 4th pregancy had been in labour for the last hour or so. She was accompanied by her Mother (the thought that husbands should attend births is bizarre to Zambians). She was having quite frequent contractions but not making a sound, despite no painkillers at all (as is the norm here). I checked her tummy. The babies heart rate was fine, and I could only feel less than half of the babies head, which meant that the head was likely to be well down into the pelvic canal. Internally the waters were bulging and the head low down, and neck of the womb fully open. 

Shortly afterwards, with no further sound from her, a nice big baby boy was born. He did make a noise! We got the cord cut, did the injection of oxytocin to help the uterus contract, and gently delivered the placenta, while Mum lay exhausted. 

It is obviously a primitive rather than a rational response, but I found the experience deeply joyful and uplifting. I am grateful to those involved for letting me share it. 

Job satisfaction - or not?

Fulfillment, self - actualisation, feeling worthwhile. Are these things more important for doctors than for other people? Probably not - but certainly during our long medical training we long to stop being spectators, and to do something useful. We want to help - and if that help is appreciated that is also nice. 

But then we can often find that many aspects of our work fail to live up to our expectations. There are many patients whose degenerative disease we can do very little for. There are probably even more patients who come to see us with symptoms that have more to do with their psyche and their place in society than with classical diseases, and whom we are also poorly placed to help. We also become painfully aware of all the patients whose problems are actually caused by medical treatment in the form of harmful drugs, harmful medical tests and failed operations. We know that our efforts in preventative care with respect to diabetes, blood pressure, cholesterol, cervical smears etc. only help a small minority of patients. Even when we do the right and helpful thing for example stitching up the head wound of a drunk - he expresses no gratitude, and we can get a bit fed up with the likelihood that he will be back soon with the same problem. 

So perhaps the answer is to go and work somewhere like Africa where one can prevent needless deaths and suffering by diagnosing and correctly treating curable diseases such as infections which might otherwise have gone untreated. The patient says thankyou and comes back and is better - and a warm glow spreads around. 

That scenario does actually occur - sort of. It is common for patients to come into the clinic complaining of ‘malungu’ (malaria) which consists of ‘mbepo’ chills, ‘kupyay’ fever, and ‘muto’ headache. I do the rapid test for malaria and sometimes it is positive. The patient gets better quite quickly on co-artem treatment (based on artemisia a chinese herb!) What is not to like? Well, just that there is not a lot of skill or training or experience involved so one does not feel particularly useful. The clinic receptionist could maybe do it as well. 

More serious harm to the self image of the hero helping his poor african brothers comes from some basically fit and well africans who have a bit of a cough and a cold. They come to the clinic for some strong Mzungu (i.e. white) drugs,  and possibly a sick note, and perhaps understandably, do not sympathise with my wish to mainly see patients whose life i am going to save! Explaining to them that they will recover with no treatment does not go down that well and scores zero on the fulfillometer. 

Then there is the not so rare occasion in which my skills and training and experience are simply not up to it in this environment. I am pretty baffled several times a week. Partly there are things i just am not experienced in, like HIV treatments or Sexually transmitted diseases, and partly it is things like skin rashes on black skin. 

Last in the frustration game is when i know the right treatment - but we do not have it in stock at the time, or we never have it - i.e. Asthma inhalers, or decent wound dressings. Or when the patient needs to go to hospital an hour away and they have no money for the journey. A woman aged 40 or so came in today, known HIV, on ARV drugs but looking unwell, feeling weak, but with no obvious specific diagnosis. I did a referral letter and drove her back to her home about 2 miles away as she was too weak to walk back. I am hoping that she manages to borrow the money to get a lift to the hospital but I have no idea if she will be able to do that. Even if she does get to hospital it is likely I will never know what happened to her, as this usually relies on someone physically delivering a discharge letter back to the clinic - which is rare. 

But there are some patients that i can help, who probably would not get that help if i was not around. A tonsillar abcess, pneumonias, ear infections, wounds that need stitching, probable stomach ulcers.  And every now and then a life is saved! Yesterday a young girl of 21 came in. ‘Pregnant and dizzy‘- were the symptoms. Not obviously exciting. But then I felt her hand, which was very cold, and it became clear that she was seriously ill. She had had low abdominal pain, and was very pale with a weak pulse and a very low blood pressure.  A ruptured pregnancy in the fallopian tube with internal bleeding was the obvious diagnosis. Luckily I managed to get an IV line in and gave some saline, and the relatives understood the need to get her to hospital quickly. She had a successful op at the local hospital and she is doing well. 

Without my presence in Mfuwe  she would certainly have died. Which I cannot often say in England!

Culture and Fashion

Ackim - who runs the bar at the Marula lodge where i stay - started doing this job a couple of months ago. He is in his early twenties and has been born and brought up in this area of Eastern Zambia. He has therefore not been in close contact with Europeans (Mzungu) before. So he was not well prepared for the shock of seeing women in bikinis lying around the pool. In Zambia, noone exposes skin between waist and knee, and for a woman to do so in particular is an invitation to a man. He found it therefore a bit unsettling seeing bare thighs - but luckily not too bad - because after all, as he put it -  ‘white flesh is rather unattractive isn’t it!’ So no matter how hot the weather - legs remain covered. 

On the other hand - there is absolutely no shyness about exposing breasts, and hearing that white women would hesitate to feed babies in public amazes Zambians. So different cultures have very similar concepts of dignity and modesty but completely different ways of   

expressing them. 

One of the most important symbols which women here use to demonstrate style and status is by using elaborate hair styles, often involving wigs or hair extensions. The majority of women who have a job wear these. They usually need doing every couple of weeks or so and involve a lot of time (4 hours or so) and expense - from about 10 US$ per month upwards.  And then we are in a seriously hot country! 

But then they do not spend a lot on make up and handbags!

Bushwalk

I am working at Kakumbi clinic which serves the people who live in the flattish land of the Luangwa valley, which is a floodplain of mostly productive agricultural land on which the local people grow their maize, cotton, rice, and pumpkins. 

Further away from the river the land is rocky, sandy, and hilly and is mixed grass and woodland. The status of this land is as a so called “Game Management Area’ , it is not actually in the National Park but the animals and trees are protected. There are very few or no tracks or paths and no signs. It really is wild bush, with a huge variety of indigenous trees. 

With some local mzungu (whites) I set off early on Sunday morning to explore this landscape. After a serious 4 wheel drive trip fording some streams we set off into the bush,   

watched by a large family of wart hogs - which are certainly the most cheerful animals in africa.  

Some of the time we could follow elephant or buffalo tracks, but often we were stepping from rock to rock up and down some very bumpy terrain. I spent some time nervously scanning the grass for snakes - a total waste of time!  We could usually see the next hill  

often around 50 to 100 yards away - but seldom further than that.

At regular intervals we could see sawn off tree stumps and usually nearby there would be 

a saw pit. This is a rectangular hole about 10 feet  deep, 3 feet wide and 10 feet long. It will have been dug by hand through the rocky ground and then the hardwood tree trunks will have been rolled into place and cut into planks using a double ended hand saw with one man at the top and one at the bottom. After this prodigious job the planks are carried out of the area by hand across the rocky and hilly terrain. 

But no longer- Steve Tolan, an ex UK policeman who is with us on the walk, has caught some of the culprits and as a result they have decided to stop logging in this area. 

 After a couple of hours we reached some the highest point in the area. and climb the highest rock and take a few pics and enjoy the view.  We decide to do a bit of a loop along a ridge and then go back to the car from there. We see rock hyrax(closest relative to elephants!) and find a cave which was inhabited hundreds of years ago and has old and faint paintmarks which have been attributed to the unknown inhabitants - possibly pygmies - who were here before the present zambian race. We have a bit of a rest and head for home, which we know will involve crossing a small river which meanders back and forth across our intended path. 

So we cross the river and then come to it again- we think it must be a loop in the river and expect to meet another crossing soon. But we don’t - which is odd! as are we not supposed to be getting to the other side? We suppress our doubts and press on. Then we see a rocky outcrop and the truth dawns slowly. We have spent the past hour going in a circle! 

Cue a rest and then luckily there is a place where we can climb up and get a view. Using the sun to guide us is tricky - as it is shining from directly overhead. But we try to keep on the same heading nonetheless and eventually to our great relief Steve announces that he is on familiar terrain and that we should just keep on for about 2 more miles and the car would appear. 

Which it indeed did! So only a couple of hours behind schedule we got home. Somewhat tired!

Guns, Germs and Steel -relevant to Africa today?

In his iconic book -  Jared Diamond (my hero) postulates that civilisation developed first in the Middle East and then in Europe because of the presence of easily domesticable tools in the form of plants (wheat) and animals (cows and horses). Many other parts of the world lacked them and hence never moved beyond a mostly nomadic hunter-gatherer existence. It was luck - not any particular culture and certainly not any difference in genes  (the human race is in fact very genetically homogenous). The presence of the right plants and animals enabled population growth, and a society in which a proportion of the population were spared from the need to work in the fields and they then became administrators, inventors etc. and that led to slow and gradual economic development which took centuries. 

Rural Africa’s problem is how to get the tools to develop, and how to short cut the process so that it takes generations rather than millenia. This part of Zambia is still a basic agricultural society, with a productive food crop in the form of maize (that came from America), but no beasts of burden, or their modern equivalent - the tractor.  Fields (usually around half an acre) are tilled by hand using a sort of mattock - which has a metal spade type blade at right angles to a wooden shaft. Weeding is done literally by hand. Fertilisers are used very little. Many families main sustenance is the maize and ground nuts they harvest at the end of the rainy season - which must last them for the whole year. They also try to grow a cash crop such as cotton to get cash to buy and maintain their bicycles and buy airtime for their phones. If they have poor rains, such as happened last year - they run out of maize well before the next harvest and those who cannot somehow borrow or sell their labour somewhere in order to buy flour (which of course has gone up in price) end up going hungry. 

As well as the minority that are not getting enough food, there are many who cannot afford transport to get to hospital, or HIV clinic to get their drugs, they cannot afford to send their children to school or if they can, they cannot afford to buy books for them. They cannot afford candles or lamps or books so the kids cannot read or do homework, so they are less likely to pass their school exams and get a reasonable job in one of the lodges. Some girls are tempted or forced into prostitution, which contributes to the appalling HIV prevalence, and some people stand in crocodile infested rivers fishing with nets. If the rains are delayed ( as they have been this year) there is major anxiety that things might be even worse next year.

So much for the idyll of the rural life. Rural poverty is depressing, and many people have tried to help Africa short cut the long painful development that Europe went through and give them a leg up to civilization with various forms of aid and assistance. Some things have clearly been helpful - roads and electricity and a legal framework, for example - some things probably harmful - did colonialism teach paperwork and obedience rather than the entrepreneurial spirit? Some of the money that could build capital in this society is ‘wasted’ on phones and satellite TV . Tourism does bring money into the area, with the safari guides being the top of the social ladder. But the overwhelming impression for me is that even with the tools that can lead to development - it is by no means inevitable, and things could easily get worse rather than better, despite all the Aid.

Africa and the harms of progress

Today a car stops outside the clinic and a man is carried into the small ward and onto a bed. He is only just conscious and smells of alcohol. The story is that he has driven off the road into a tree. There are no obvious major injuries. I am concerned that he may have had a head injury, and tell them he needs to be taken to the nearest hospital an hour away, although i know that they will only be able to provide basic care. 

Then the police arrive in a pick up. In the back lies an obviously dead body of a young woman. She was unlucky enough to be in the way when this drunk man lost control of his car. My sympathy for my patient evaporates. He begins to wake up and complains of pain in his ribs which are likely to be broken. Because of a possible head injury I should not give him painkillers, which is good because I do not want to. This is the second fatal car crash ( I avoid the word accident because I don’t think it is really) in this small area in a week. Last time it was an overtaking car taking out an oncoming cyclist. 

I ask the staff at the clinic what is likely to happen in terms of punishment. The general answer is that the justice system does not really work and that he is likely to be able to pay people off quite easily to evade sanctions. Furthermore it seems that the common way to get a drivers licence here is just to pay for it with no instruction or testing!

Transport is a big problem for most people in Zambia. There are very few private cars and people take minibuses or cycle, or in many cases they walk long distances along the verge of roads that are only just wide enough for 2 vehicles, but not wide enough for 2 vehicles and a line of people walking along both sides. There are lots of rivers which cannot be crossed in the wet season and few bridges, 

which means long detours. 

So it seems particularly cruel that people with little access to cars themselves have to suffer the risk of injury and death from the small minority of car owners, some of whom are careless in the extreme, have never been taught to drive, and whose cars are often in poor shape. If an accident occurs, the ambulance service is non existent and the medical care very basic, so the risk of death or permanent disability is high, and if you are disabled there is no safety net to provide for you, apart from your family who probably simply cannot afford to. 

 As so often in Africa - the problem is easy to diagnose - but  hard to treat.

HIV - the growing problem

An emaciated young man is carried into the clinic - barely able to talk - he is breathless and looks desperately ill. His pulse is fast and weak. The story is that he has had HIV for 4 years - and has been on the usual combination of drugs which he is reported to have been taking regularly. He attended a routine clinic only 4 weeks ago at which his CD4 count was measured and was found to be over 400 - not normal but not the sort of level where major trouble is expected, and he was told that he should be ok for another 3 months. Then he started to get headaches and a poor appetite, and by today his weight had gone down from 50kg to 45 i.e. approx 8 stone to 7. There are no breath sounds over the lower part of the left lung. His blood pressure is drastically low. He may have both meningitis and pneumonia. 

We arrange transport to the hospital an hour or so away and put up a drip and give him some antibiotics intravenously. I am afraid that i doubt he will survive. Why was he not brought in to us earlier? I have no idea.

This is the scenario that I had thought I would be seeing on a regular basis- but actually it is uncommon. What I am seeing often is patients who look well and come to see me about minor conditions who tell me (only on direct questioning at there is still stigma attached) that they have been on ARV’s (antiretrovirals), often for several years. I recently met a patient who told me that he had had HIV since 2000. 

So this is in a way a success. The problem that is obvious from the clinic is that we are diagnosing new patients most days. Today i saw an 18 year old girl - looking very healthy and smartly dressed - who came with the ‘usual’ complaint of headache. I had a feeling there was more to it and eventually the real problem emerged - genital warts. This is often a sign of HIV so we did the test and of course it was positive. 

Our medical education makes quite a big deal about how to go about breaking bad news - checking what people want to know etc. But with her basic English and my pathetic grasp of Njanja all i can do is hold her hand and sound sympathetic.  It sounds as if she has actually had very limited sexual experience and has been tragically unlucky. So we refer her to the ARV clinic.  If she attends it will be obvious to everyone what disease she suffers from. What will she say to her sister with whom she lives? and what to her parents? And we have no effective treatment to offer her for the warts! Poor kid. 

 So, unless there is change in the culture of promiscuity here the prevalence of HIV and hence the  burden of patients needing retroviral treatment is bound to rise. (That sounds as if we are not promiscuous in the developed world, which is of course nonsense.) How long will the drugs remain effective? How long will the donors generosity last? Is there any chance of a medical breakthrough in preventing infections?  I have asked around and it seems that noone is even asking these questions. 

We really don’t know how lucky we are do we?

To Give - or not to Give

What should be the response of the wealthy of the world to the suffering of people in Africa? We like to come and look at the animals and we are very keen to preserve the natural heritage that we Africa has in terms of wildlife. We also sympathize with people who find it difficult to feed their children properly, and cannot afford light to read after dark, and have no money for transport to get to hospital to give birth or to have broken limbs treated. 

We tend to gloss over the suffering and hardship the wild animals cause to the local people both in terms of risk to health ( there is usually a death or two a year here in Mfuwe from elephants and hippos and a similar toll from crocodiles), and damage to crops and property. Of course it is true that the camps provide employment - but the majority of people living in the area are not directly employed in the tourist industry. They are small scale farmers and fishermen and traders of various sorts. 

The various Safari Lodges, which are mostly but not all run by Europeans, try hard to help the local community in various ways. One way is to arrange for a Mzungu (i.e. white) doctor i.e. me to come from abroad to help at the rural clinic which would otherwise be run by nurses who have a pretty basic education. Another is to provide public health measures such as impregnated bed nets to prevent malaria. 

There are also Charity run feeding programmes for schoolkids and there are several organisations that sponsor schoolchildren by paying fees and providing textbooks and uniforms to children that otherwise could not afford to go. Furthermore the supply of drugs to Zambian hospitals and pharmacies especially for HIV and Malaria seems to be largely funded by overseas aid from the developed world. There are lots of churches in Mfuwe - but to my perhaps jaundiced eye - their well fed pastors do not seem to be a help to their poor parishioners - perhaps the opposite, at least in material terms. 

But are the donations wasted and does all this help lead to a culture of dependency? And might Zambia be better off without all this charity? 

My suspicion so far (after just over 3 weeks) is that there is not a huge amount of waste at but that the dependency culture is a problem, and also the western derived culture that tells them that a government office job moving paper (or its modern equivalent ) about is the ultimate aim of all education. But it is also clear that in a society which is based on manual labour based agriculture - there is no way they can afford many of what we would regard as absolute necessities - and the conditions of life are still pretty brutal for most people despite the largesse of the west. Small contributions which would make no difference to our quality of life can really help here.  For  example charities such as Project Luangwa http://www.projectluangwa.org/ 

Health and Safety

This is a sad and shocking blog, which raises interesting comparisons between Africa and the UK and the way we deal with risk. 

Today I was having a short rest after lunch in my little semi detached one room bungalow at Marula Lodge, which is beside the Luangwa river and just outside the National Park, when I heard someone deliver a very large load of bricks from a huge dumper truck. Then the noise got louder and I realised that dumper trucks here just aren’t that big. I rushed outside and looked and saw that a large tree had just fallen and demolished the restaurant building. I guessed that there would be multiple casualties and I thought s..t - as this is possibly the worst place in the world outside antarctica to try and deal with such an event. The total sum of medical resources within 5 hours drive being me and a trauma bag with 2 litres of saline and a very small amount of morphine and an ambu bag and mask to help people who are not breathing.  If said casualties are trapped inside an unstable building with a very heavy tree  weighing it down it doesn’ t help. Then I thought maybe there was in fact noone in there - but a moment later it became clear from an impromptu roll call that one guy was missing- and a closer look revealed a still human form. After checking that that part of the building was stable i managed to get in to him. I could see one arm and the back of his chest. There was no breathing, and there was no pulse at the wrist. I had to tell everyone that he was dead and not to try to evacuate him, as it looked impossible and the attempt would be dangerous. It sounds terrible to say it but in a way I was relieved that I would not have to attempt the impossible, and that I had done  something that wasn’t hard but which I was probably the only person who could do with confidence and that was to confirm death. I was also relieved when I saw that he had had a massive blow to the head and chest that no one could have survived. 

The tree is a winter thorn - and after it fell it was clear that it was completely rotten with some sort of fungus at the base with most of it in fact hollow. It had also been dropping a few branches, but on the outside it otherwise looked healthy. People who have lived here for a long time said that they knew that they do sometimes fall over. However, there are lots of them dotted around various tourist lodges! 

The attitude here is that bad things will happen if they are fated to happen, not because we fail to prevent them. In the 3 weeks i have been here the local town (Popn 20,000 roughly) has experienced 1 drowning, 1 man killed by a hippo, 1 death from snake bite, 2 children brought into the clinic dead in the night from some sort of disease, and several aids related deaths. People expect to be killed by elephants, crocodiles, malaria, childbirth, road accidents etc. They do not seem to worry about risks, and do not bother taking precautions against any individual risk - perhaps because of fatalism, perhaps because trying to minimise so many different risks would be a 24 hour job.

 But in this case  I personally would have preferred it if a health and safety guy had visited and condemned the tree a while ago.

Kakumbi clinic - can I make a difference?

Every morning around 7 a mass of people make their way to a ramshackle rectangular single story building to wait in waiting areas in the open but under a roof. The clinic has 3 offices, a dispensary, 3 wards - one for children to be observed, one for women, (?where men go i havent worked out), and one for women in labour. There are 2 consulting rooms,  both of which are so small that the patient has to clamber around the doctor to reach the examination couch. UK infection control nurses would have a fit over both of these rooms. Then there is the pharmacy store- which is the only room to have air conditioning - so it is visited very frequently for consultation with the pharmacy technician, and a roomy and neat lab - ruled by a very neat and tidy lab technician who glories in the name of Troglet. 

This lab is an exception, as the other rooms are grotty, and not too clean, with paperwork, supplies of syringes, needles, malaria testing gear, instruments, iv fluids etc. all lying in a random mess. The walls go up to about 8 foot high but are mostly open at the top which doesnt do a lot to help confidentiality, and this is a Christian country in which we have to ask about sexually transmitted infections, and HIV in most consultations. Probably it doesnt matter as the doors tend to be left open anyway, and the next patient will tend to stand right by the doorway, so any attempt to preserve secrecy would be doomed to fail. 

Fortunately the light in the daytime in Zambia is strong as very few lights in the building are working- strangely these seem to all be in the offices! Even the offices cannot be protected from the other main logistical problem which is that the water tank which is up on a platform above the clinic, is leaking badly, and the budget of the clinic is not sufficient to pay for a replacement. 

People have a card with a number on to identify them, and this number then allows the right medical file to be found on several rows of shelving. Often patients forget their number and lose the card, so they can end up with several different copies of medical records. The obvious alternative would be to file by name, but surnames are mostly Banda   or Phiri and with no records of date of birth - the confusion between different Thomas Banda would be a huge problem. Also patients like the ability to lose their records as it allows them to get a second opinion every 3 months when the new doctor arrives. 

As one might expect - every day brings a few patients who are much sicker than is common in the UK. Patients arrive looking very unwell with Malaria and are simply given a few tablets of Co-artem and are sent home. In my first couple of days work i have also seen a really nasty tonsillar abcess (it was really gratifying to see how much good a big dose of Penicillin in his bum did), a child who was generally looking ill with an infection on his scalp - but sadly whose HIV test was positive, an old lady with a stroke, a very old lady with acute heart failure and probably a cancer in her abdomen, and a man writhing in agony with kidney stones.

Which leads on to the next big problem with the clinic, which is lack of drugs and dressings. There are barely any of the latter, and in a country full of dirt and insects that is not great! As far as drugs are concerned, there are plenty of HIV drugs and we seem to be ok for Malaria, and we have Aspirin -(useful for the stroke), but otherwise very few, and nothing that could be expected to treat renal colic for example,or anything very helpful for palliative care. I suspect that there is a logic to the extremely limited drug supply, which is that the culture fully embraces polypharmacy  (just like the uk! ) and the general attitude is 1 drug good - 4 drugs better! so some nurses will prescribe for dizziness for example - panadol, an antihistamine, valium/diazepam, and multivitamins. So perhaps the idea is to restrict the supply, then we can restrict the harm! Perhaps we should adopt this principle in the UK?

So, should one try and do something about these issues, - or just put up with the deficiencies of the system, learn to accept them,  and do the best i can with the tools available,  and then go back to the UK having learned how to implement that passive strategy. We shall see how I manage. 

Bikes and phones- reasons to be cheerful

2 technologies are dominant in the streetscape in zambia, the mobile phone, and the bicycle. Mobiles are a must have and if possible people seem to spend even more time texting here than in the uk. There are a surprising amount of Blackberries here, sometimes owned by apparently quite poor people, and generally the phones seems quite neat and smart. There is a 3G network which has pretty good coverage and allows skype voice calls and mobile internet services. In only a decade or so they have caught up to a level of communication that took the developed world a century of hard work to achieve. 

Bikes are a big contrast - they look like the bikes from the 1950’s mainly, almost all black, with old fashioned handlebars that look like a bulls horns, only male type frames, a carrier on the back - often with a basket made of reeds, and a heavy looking stand, and no gears. They need to be strong, as most bikes have a rider/pedaller, and a passenger, either on the rack at the back, or riding ‘croggie’ sitting on the crossbar trying hard to keep both legs raised out of the way of the knees of the person who is pedalling. In the absence of a passenger, surprisingly  large amounts of firewood or fruit or veg can be transported on the back. If you are on a bike alone and you want to look like a bit of a dude, you sit on the rack behind the seat and pedal from there like Peter Fonda in Easy Rider on his customised Harley Davidson.  There are no lights, no bells, and i haven’t seen anyone use any brakes, either. Luckily this part of Zambia is so flat it makes Lincolnshire seem like the alps. The bikes are a brilliant solution to the problem of how to get around in a hot flat poor country. Unfortunately bikes have one huge disadvantage in this area, which is next door to South Luangwa National Park ….. They are not popular with Elephants. For reasons that are unclear, the sight of a bike induces a similar reaction to that observed in owners of Chelsea tractors in London. Both become enraged at the image of effortless progress and jealous of the low fuel consumption(I am guessing about the Ellies) and charge. Unfortunately, the result can be a pile of junked metal and at best, a badly injured cyclist, so sadly I have been advised not to try riding a bike in Mfuwe  (or London), especially as my possible sources of medical assistance are few to say the least. 

Both bikes and phones have spawned an array of supporting businesses. About a quarter of street stalls sell top up vouchers for the phones, and many of the rest sell bicycle parts - tyres, tubes, seats, puncture repair. There is quite a bit of broken glass on the roads and i have a sneaking suspicion about who puts it there! 

It is extremely easy to be very pessimistic because of the huge problems that Africa is facing- AIDS, corruption,  and  population growth being the most obvious. But seeing bikes and phones, 2 things that have clearly made life better for most people, and have not depended on charity, does allow one to have a little hope that progress can be made.

Africa - tragedy or farce?

Is africa a comedy or a tragedy? The answer of course is that it is both at the same time. Today I have been helping at an outreach clinic (as i am not really supposed to be doing a doctors work because the lady doing my authorisation in lusaka has for some reason not been into work the last few days!)
At both village locations I caused great delight. My attempts at saying' very well thankyou' to their zambian 'how are you' - were met with uproarious laughter - followed by a song of welcome. The children all wanted to touch my skin to see if the colour would come off. Smiles all round. The ability of people to take pleasure in small things here is humbling.
But then we came to weigh and record the children's weights, and a worrying pattern emerges. The babies are all breast fed and put on weight very well for the first year or so. After that typically, weight gain is very slow indeed or non existent so that a child who has been of average weight aged 1 is down around the bottom 3% by age 4.  Very often one can see why - as  beside the 2 or 3 yr old child is a mum with a new baby on her back.
So - what is happening with contraception - and what do people want? - i don't really know except that the morning after pill is not available at the clinic - nothing official it is just O/S out of stock.
What is clear is that the rapidly growing population puts huge strains on the demand for everything - but jobs in particular. I am sure that i will be seeing the consequences for peoples everyday lives in stark reality in the clinic in the next few days.