Is it very rural? [+ return of the chickens]

Since we arrived I'd been hoping to spend a day with the HIV Outreach team. Four or so days a week a team of Nurses, Counsellors and Dispensers travels to different health centres around the district to enable HIV positive patients in the rural communities to receive free ARV treatment and check ups.

Some of these clinics are more urban than others (e.g. Katete Urban Health Centre - just down the road). Really I wanted to go to a Clinic further afield to see what the conditions were like. Ideally I would also love it if someone could show me around a typical village and explain how it worked and what all the different structures were used for.

As often happens, despite my 'best' efforts, the job was left until the last week of our stay. The only day that Natalie and I (accompanied by Will and Nat's Mum) could do was Wednesday (yesterday). I looked on the rota in the ARV Dispensary and asked 'Where is Kasenengwa? Is it very rural?'

My friend Jacob started to answer with a description of where it was but soon handed me over to a gentleman who had been waiting for a print out. I didn't know who he was but I was soon to find out.

'No! It is not VERY rural' [And so began a reasonably long description of what very rural constitutes in his mind. I knew I was being chastised for being sloppy with my language - I had been talking to friends originally. Before we came my father had suggested that people might find my description of Katete as 'the middle of nowhere' slightly offensive. Here I was demonstrating the point very nicely and justifiably getting my comeuppance. I listened attentively]. 'There are places that are very rural where the villages are cut off for 3 months of the year by the Luangwa river and they have to survive with no contact from the outside world and only a few radios. That is very rural. Kasenengwa is not.'

When the gentleman left my friends laughed. 'I'm sorry about him. He wanted to be MP for Kasenengwa but he wasn't chosen. He was quite rude to you... It is very rural!'

And so it turned out (apologies to the local aspiring MP). We drove halfway to Chipata and then turned off the road onto a dirt track for at least half an hour. We were well off the electricity by then, and, that's my definition of very rural!

The health centre looks reasonably newly built. It is large and well appointed. Actually we thought it might be a little better than the current OPD at St Francis'. The Clinical Officer was away so the Nurse gratefully took up Nat's offer to assist in seeing patients.

This left Will, Nat's Mum and I to entertain ourselves. We went for a little walk but, not knowing much Nyanja, we weren't able to discover much about how people lived. I made friends with some school children (standard) and we found ourselves sitting about.

I knew I needed to ask someone to take us around but people were still getting established and the clinic was busy. I've also learned that these things tend to sort themselves out one way or another and I shouldn't worry about them too much (something that the Healthcare Partner at work has tried to teach me in the past :) ). Eventually the others got restless so I approached Jacob. Shortly a man was found to take us around.

I was expecting a short trip to the nearest village and a cursory look at the living conditions. But after village 1 (where we'd got to go inside the cooking block, which was formerly a bedroom) we were taken to another small village then the largest nearby village. Everything was explained with great attention to detail and only a few men sat around a pool table had asked us for money.

I got to ask all the questions that I had! Which must have seemed many to the others, for Nat's Mum observed 'It's funny, Charlotte, you are interested in very different things from us' and 'You are very nosy, why are you asking what they are cooking for lunch?' Well, I wanted to know! I didn't want to come and live out here and spend 6 months in a brick building with a tin roof, running water, flush loo, electricity etc and not understand properly how the majority of the locals lived. So now I've seen it and asked about it and I can go home feeling that I have some reasonable understanding of what it is to be a poor Zambian.

Chickens

You might remember that we bought 2 live chickens for Christmas but ended up not using them. One was eaten a while ago as curry but the other has been waiting in the freezer for a prime moment. The freezer did look a little odd given that it contained a chicken, sliced bread, ice cubes and two different types of gin.

Last night it was my turn to turn the dressed chicken into lumps suitable for a chicken 'stew' [Nat's mum doesn't like curry]. We had tried to defrost it in the fridge but clearly there hadn't been any power cuts yesterday because it was still mostly frozen. I put it in the sink and took our little vegetable knife (the only sharp knife we have). Something wasn't quite right but Geoff was busy. I made a deep cut along the middle but then couldn't work out what to do from there. The legs also looked funny. Time to call in the back up...

'You've got it upside down' Rigghhtttt, that would do it. I turned it over - that looked better. I tried the same cut - 'No! you need to go to the side of the midline - that's just bone!' This was not going well. After a short while I revealed the breast but it took a long time to get the meat off and I wasn't sure I'd got down to the rib cage. I tried to remember what I'd been taught by Surgeons about considering the anatomy of the muscles and cutting sympathetically, but with a tiny knife and frozen meat it was harder than they made it sound. The leg in particular seemed to be mostly tendon. Eventually I finished side 1.

Emboldened I decided to be more decisive the second time. I cut down hard on the breast - there was a load bang sound and the knife jolted down. This time, it transpired, I had not only found the rib cage but cut through one of the ribs entirely. :) Oh well, at least I'd got all the meat off the breast. I have a new found admiration for butchers, although I think the chicken had mostly frozen my hands by this point!

Eventually enough meat was removed to feed us all. I was reminded of Abraham's comment that I should really have learnt how to do all things chicken in my time here. I think I'm happy to understand how Zambians kill chickens, how we kill chickens (in factories with machines), and what to do with prepared chicken. Chicken to eat comes from the supermarket... not the garden

We are still here!

Apologies for the break in communications. Don't worry, we are still OK!

Both of us have been battling this week to try and close off the loose ends that we have with our various projects. Somehow whilst we were away I forgot that I can't expect to work as efficiently as I would at home, so I've been a little frustrated with progress this week.

Today is a case in point. On Wednesday afternoon a cable blew up outside the Accounts department - severing the electrical connection between the hospital and both Zesco and the back up generator. It was unfortunate that the Accountant and I had just spent an hour and a half working on various things without hitting Save. In the moments after the power went off I sat very still until I thought it was safe to speak. Rodgers (who like Abraham is in a wheelchair) was motionless until I'd finished - upon which he banged both fists on the desk and swore loudly. I'm going back on Monday to get the last few bits and pieces. After a few hours power was restored but there was a question about whether the generator would kick in as required in future.

Back to today - the power went off across the whole hospital at about 7am. This isn't that unusual but such an early start is suggestive of a fault rather than routine maintenance. We all carried on as if nothing had happened, although the back up generator did not power up (I can't hear this from the house so assumed that it had). By mid-morning the Surgeons had given up on operating for the day. The battery back up on the Surgical wards was beeping alarmingly when I passed (it normally only has to work for 10 mins before the genset starts) - without reconnection shortly the Oxygen concentrators would turn off and critically ill patients will suffer.

There was no point going to Medical Records to get the data I needed as the computers wouldn't be working. So, reluctantly, Geoff and I returned to the house.

Strangely, when we arrived the power was on and has remained on throughout but the hospital is still without power as I write. I don't know how they fed the patients at lunchtime without power. I don't know how they will cope this evening if it isn't fixed, when all the batteries will have run flat and the hospital could be in complete darkness. But what I do know from experience is that these things generally work out, perhaps that's why the Zambians were quite relaxed about the whole thing.

My only gripe is that the water pump for our area is clearly the other side of the fault. After exercising this morning I discovered no water anywhere (something that hasn't happened for months) and I found it no less upsetting to have to get dressed sweaty today than I did then! In fact it's got to the point that when it started to rain a few moments ago, I put out the laundry bowl to try and catch some water - I'm thirsty and would like to wash my hands! The rain has stopped and I only have enough water either to drink or wash my hands... now that's a dilemma!

The final countdown...

As I write, it's almost exactly 14 days until we will chuck our bags into the back of Will's car and head for the Malawian border for a weeks' holiday before flying back to London.

We chose to come for 6 months because we thought it would be just the right length to let us settle in, learn about the culture but not become too frustrated by it to sour our experiences. And so we are looking at the next 2 weeks with a mixture of happiness and sadness. The chosen length has worked.

I'm keen to get back to the flat and discover what our lovely flat sitter has done. We know that she's managed to change the source of the TV (thankfully now corrected by Lt Muir), not found the cooking utensils for 2 months (I'd hidden them in a pot next to the hob) and only just found the dumbbell that's been under the sofa the whole time (I take it I won't be needing to change the hoover bag...). How she tuned the radio to Radio 4 is a slight mystery! And before you complain about being picked on, it's not like I've named you, An... ooppsss :D

But seriously, we are looking forward to getting back to the UK, whatever you say about the weather!!

We have just been on holiday for 2 weeks. Transportation uncertainty meant that we had to stop over in Lusaka for a night at each end. We picked a hotel a bit like a Holiday Inn, which is on the edge of a brand new shopping complex.

It was like heaven - there was a TV! and a marble bathroom with a power shower!! Then we went to the shopping centre and ate a pizza with real cheese on it! It was a little overwhelming, we were surrounded by smartly dressed people and we were in our bush clothes with muddy walking boots. It all felt a bit daunting.

We went to see Skyfall (Lusaka is our nearest Cinema!) and weren't disappointed. At times I felt like I was back home and I took great comfort in seeing that the buildings and roads and Underground were still there. Although I knew full well it had been filmed before we left! There's something very comforting about James Bond in a well fitting suit when you've just been out in chaos.

I was glad we had the time to mooch about and reacclimatise before heading onward to the Falls and then Botswana. [Photos will follow] We even had burgers and a proper Indian meal in a restaurant run by Indians, decorated like they are at home! Amazeballs, as the young people say these days.

On our return, Lusaka looked a little different. We caught a plane from Livingstone, which had some very interesting passengers. In the waiting area I spotted a smart businesswoman in a shift dress, very high heels and an iPad in a smart leather case. There were others with similar displays of wealth. [She didn't do so well when we landed at Lusaka and it was raining cats and dogs and there were massive puddles, but it got me thinking].

Now when we got to the shopping centre it felt different. The diamonds were still in the jewellery shop. The 60 inch TV was in the window. The clothes in Woolworths were still clearly M&S from last summer. But the combination felt somewhat distasteful. We walked around the Food Lovers Market where there was an abundance of fresh or exotic items, I felt like I was on the 5th floor of Harvey Nicks or in Selfridges. And this wasn't nice, this was a problem.

And the problem is this - whatever your view on inequality in the UK, it's so much greater here. Of course there have always been wealthier people - the Missionaries had house servants and lived better than the locals. But, they didn't have 60 inch TVs and marble bathrooms and Mercedes Benzs.

The changes in Lusaka have been dramatic. The changes in Katete far less so. The rural people here still have no running water, no sanitation (they dig their own long drops), no electricity, only mud huts to live in. The only significant change amongst the majority of the rural population since Independence is the mobile phone (which they have to go out to charge) and the occasional solar light.

There have been any number of debates about Africa and how to develop it. I'm not about to join in right now in any depth, there's a significant ennui here associated with well meaning Muzungus trying to tell them how to do things better.

One thing I am certain of is that there will be development, it will be at a pace that most Europeans would find frustrating and it will be done in what is considered an idiosyncratic way. However, at the moment it appears also to be happening significantly at the expense of the rural population and precedents suggest this will be the cause of some discomfort in the future.

The rural population can't and don't travel to Lusaka often. They don't have internet or much TV. They don't know what's happening there. Even if they did go, I expect they'd feel too daunted to walk into the shopping centres and look at the marble bathrooms. But they shouldn't have to.

I'm still a capitalist but I've always considered the role of Government to be to work in the best interest of the whole country. The accumulation of extreme wealth in Lusaka is not to the benefit of the whole country - there are bright motivated people in the distant provinces - they need to be supported. The first thing they could do is build some decent roads - the Romans worked that out for us!

Perhaps some decent tarmac on the main road to Dar Es Salaam would be a good start.... then at least we might not have been close to death so many times yesterday..... as ever, it all comes down to self interest :)

Who to trust?

Learning who to trust is an ongoing task for everyone throughout life. The more time you spend in London, the more you can think that trusting pretty much no one is the best way to go.

Changing to a different country, with a different culture makes the whole task more difficult. Particularly where there is a large wealth gap and some expectation that you should be giving people things just because you are white.

I wrote early on about the bars on all the windows and how this gave us comfort, rather than feeling like a prison. But you can't keep the door shut and everything in sight all the time. So who can you trust? And which requests for 'assistance' should not be turned down?

Children

At home I'd probably err on the side of trusting most children. I certainly wouldn't assume that every 7 year old I saw was out to nick things from me. Here it's slightly different. I am directed not to trust them by a sign on the back of our door. I am not allowed to let them loiter (although it doesn't say how to do this) and I'm not to let them in under any circumstances.

For the past few months I have been plagued by a particularly delightful young boy (known affectionately as 'the scrote') and his friends. I work with my back to the open door so I normally hear him coming before I see him. 'Oi, stingy!, give me a biscuit'. Right, it never works out that well for him calling me stingy as an opener. He hasn't heeded a single word I've said and normally just laughs in my face. On one occasion he and a friend managed to get in before I realised what had happened - it's tricky keeping an eye on two people at once. They normally want toys, biscuits or pens. They get nothing but mild abuse and told to go away.

The nicer children also get nothing as a gift but more time and consideration. A few months ago, a group came and asked me to teach them to read. I was busy and thought they were just wasting my time so I asked them to come back the next day, which they did, to my surprise. So I sat out for an hour and half going through things with them. When it got dark I suggested they should go home or their mothers would be worried about them. It was dinner time anyway. They left but said they would come the next day.

They turned up again, by which time I'd got proper books from the school at Tiko. Although they were slightly late so I nearly missed my sundowner! At the end I was trying to arrange the next session when one of them said 'When I got home yesterday there was no food for dinner' in as plaintive a voice as he could manage. Unfortunately he misjudged me. The day before he'd told me his dad was a security guard at the hospital, he was well dressed and went to an expensive school. The attempt to extort money was rumbled quickly.

So children - generally not to be trusted

Adults

This one is a bit murkier. Surely there are some adults that you can trust?

The slightly troubled men that wander around the hospital area (one of whom calls me 'Mummy') are generally to be trusted if they are outside your house. They are honest about what they want - money, plastic bottles, water, food, your shoes etc. And generally respect your decisions on the matter.

Complete strangers that knock on the door as soon as they see a white person are often given short shrift as they look inside eagerly. "Is that a laptop? Can I have it when you go home?" as if somehow I wouldn't be needing it there!

But what about the gardener and maid?
When we got Moffat (the gardener) he'd been unemployed for over a month, where previously he'd worked every morning Monday-Friday. He was desperate so I (naively) thought he'd be quite grateful when I sought him out to give him a job. Even though our garden is tiny, we agreed to pay him for 2 mornings a week. I even persuaded Fi and Rory to take him on.

In the beginning, I thought that some of the things he quoted were quite expensive but I didn't want to be too suspicious and they weren't excessive amounts of money. I did ponder about why we needed an ox cart (at 50 pin) to bring the bundles of grass but when another one was needed to bring some additional sticks we didn't get charged.

Then it was planting time. In two of the beds he'd put the seed packet at the end. For the other beds there was no seed packet. Mysteriously plants only grew in the beds with seed packets at the end...

He needed money for fertiliser for his crops otherwise 5 children and 3 orphans would die. He needed 8 bags at 220pin each. But if Fi and Rory paid for 5 and I paid for 5, that would be OK. Yes, it would be for him, it would also be 10 bags. I asked in Pharmacy and they said that would cover a Hectare, which seemed excessive. Plus bags were only 190pin this year.

We gave him money for 2 bags (£50). He said that would be OK if Fi and Rory did the same. Later we offered to pay him for 4 weeks in advance so he could buy another bag. To his credit he came back and didn't just run off.

We'd heard from Fi and Rory that he had a tendency to make off with their bananas and mangos and just laughed when they expressed annoyance.

He hit on a new way of getting money out of us. He had a funeral to go to. A few weeks later he tried it again (why not? it worked first time). Only this time he had two separate funeral stories - one for me and one for Fi and Rory. As if we might not confer. I wondered if I was employing a toddler.

Gemma wanted the fence extending. This was going to cost more money. We needed more grass - why? I asked, we had plenty left over from last time. Oh! Well, we need money for bamboo slats? Why? I didn't pay last time! It was only £4 so Gemma paid him. Then he wanted money for nails. Why? For the gates! he said. Right, nobody else's gates have nails - the hinges are made of bark strands. I'm not building Buckingham Palace.

Next came a demand for a Christmas bonus. I said I'd think about it. Unfortunately for Moffat, Geoff and I were looking for the slasher (used for cutting grass) that weekend for a photo. It wasn't there. John the engineer told us that his gardener was forever selling his garden equipment. Moffat claimed to have taken it home to sharpen it but the returned article is a different shape and colour...

My patience is running a little low. I don't think it is my personal obligation to give everyone that asks money. If I am going to do it then I wouldn't choose Moffat - he has good clothes, a very nice bicycle etc. There are more needy people in the villages. I'm waiting for him to come and demand a 'Remembrance' from us, as he did to Fi and Rory. Perhaps I'll give him a copy of the photo I took of him in the garden...

Not wanting to let this experience jade us, we decided to trust the maid. We didn't have much choice. The first day she came we needed to go to Immigration before she was done. We locked the cupboard with the valuables in and left her in the house with a key. She'd done a super job by the time we returned. John raised his eyebrows at us leaving her alone.

And this attitude is a problem. None of the ex-pats are prepared to have anyone in the house - so they can't employ a maid (and help local people) - and this is because some people have had things taken. It turns out that our maid probably took some batteries from John one day. The Mess staff took batteries and a mobile phone from the students. There's a general mistrust.

This week a lady knocked on the door and asked if we needed a maid. I said I didn't - I already had one. Abraham caught me later and asked if any of the doctors needed a maid. This lady had hit hard times. She's alone and has 2 children, she really needs work. But without any guidance on who is and isn't trustworthy, she isn't likely to find it amongst the ex-pats.

One person that can be trusted, of course, is Abraham. If you lend him money he will always pay you back :)

People who are pleased to see you...

As expected, people in the hospital are pleased to see us. Patients assume that any white person is a doctor and express gratification freely. I am frequently asked how I am by complete strangers as I pass. What I didn't expect was that we could make an impact more widely...

In the run up to Christmas we either went or sent a shopping list to Chipata most weekends. The logic is the same as in the UK when people choose big supermarkets. Many of the items were cheaper and better quality, plus there were the items you can't get in Katete - like semi skimmed milk. It was easier to buy lots of things than pick and choose. So we stopped buying Coke at the Chada, for example, because it was more economical to buy a 2.5L bottle in Chipata.

I didn't really think about it more broadly. I was still heading to the market for fresh veg and a few other items, like bread and eggs when needed.

Then I stopped at Theresa's shop to buy some things. She didn't have a lot of her usual stock. I was a bit surprised, she's normally really good. Then she said 'You are still here then?' Yes, why? 'I thought you'd gone. You were an expensive customer [by which I understand her to mean that I was a good customer]'

This brought it home. I used to go to Theresa's once or twice a week and spend nearly £8 each time. This might sound a bit pathetic to you, but there are low end supermarkets in Northern England where the average spend per transaction is £4. So, even there I'd be a valuable customer. And then I'd just stopped. It hadn't meant anything to me, it was just a matter of convenience but it was clearly having a big impact on Theresa, especially considering it's rainy season and the hospital in general is quieter.

Since she pointed it out I've made a point of going to her more often. The large bottles of Coke have gone. Our consumption of eggs has increased so much that we'll probably have a heart attack shortly. But she's got her expensive customer back, for now. All I have to do is persuade the others to shop there after we leave... but perhaps the lure of Chipata will prove too much!

Some of the people that are pleased to see you are less obvious. I went to the lab recently to ask them for some data. It wasn't a planned trip so I was surprised when I entered the office to find everyone smiling at me and the In Charge saying he was very pleased to see me.

He invited me into the lab and listened very patiently to my request for statistics. Then at the end he started explaining about the FACS count machine, what it did [they use it to measure the CD4 count of HIV patients] and that it needed to run a control test every day.

'The control test needs to be someone that doesn't have HIV and I am tired of giving my own blood. Please can I have some of yours? I will tell you your CD4 count!'

Now I understand why they were pleased. They'd been arguing in the office in Nyanja about who should have to give blood that day. Then they saw me and clearly thought that they'd found the solution.

Sadly for them, they hadn't. The guy looked at me a little blankly when I explained that I don't like needles, I don't give people blood unless I absolutely have to (it's only happened once and it took 3 doctors nagging me to do it) and I was wearing a tight long sleeve top so the logistics weren't simple either. Even his pleading that he only wanted a small amount didn't work!

I felt a bit bad as I ran away through the rain but, blood and needles, that's just one step too far!

Breastfeeding

This might seem like an odd topic to select for its own blog post, but there is a good reason why I've chosen it.

In the UK, there is an ongoing debate about the acceptability of breastfeeding in public. Plenty of restaurants and pubs have been vilified in the press for refusing to let mothers breastfeed in the open areas, however discreetly. It seems to be an odd thing to quibble about - I've never really understood what the objections should be - done well, people barely notice. Banning it is effectively telling mothers they can't leave the house for 6 months without the hassle of expressing.

In Zambia, the view is much more liberal. There is no concern about breastfeeding, in fact I don't think there's anywhere or anytime when it's deemed unacceptable. And before any of you generate the naive notion that these ladies are doing the dance of the seven veils with a Chitenge, let me put you right. They aren't.

Most Zambian women, particularly the poor, do not wear bras. This and, we presume, multiple pregnancies from a young age combined with breastfeeding each child for more than 6 months (more on this later), mean that the women are able to articulate their breasts in a way that most British women would wince at. For example, it's perfectly possible, when wearing a polo shirt, to breastfeed your child without removing your top - just pull whichever one you want out through the slit at the neck and move the child in the Chitenge.

One evening I walked past a lady who had been doing this, but when the child had finished and she'd put them back on her back, she forgot to return the breast to the inside of her top. I didn't know what to do. I don't have the Nyanja to say 'Excuse me, Miss, but your boob appears to be hanging out' and I didn't know how she'd take it. I chose to walk on, hoping that someone else would mention it before long.

In fact, they are so comfortable with breastfeeding that they happily sort the child out whilst having a conversation with someone, even a stranger like me, without batting an eyelid at exposing the entire breast. I suppose this isn't that surprising in some respects, women on the wards are often half naked from the waist up, without seeming worried.

I don't know when they stop breastfeeding - I've seen quite large children still suckling. In OPD on one of my tours with new students, I saw a child of about 3 run across the floor to his mother, reach into her t shirt and grab her. She bent down happily to accommodate him as he stood on the floor in front of her. I was reminded slightly of Little Britain.

And it's not as if you get a respite after your last child. Grandmothers are frequently called upon to help out with the next generation. The Physiology of this is confusing to all of us. The Medics claim to have seen a grandmother produce milk on demand...

So what can we conclude. Part of the difference between the views is that in Zambia breasts aren't seen as sexual organs particularly. The men are much more interested in what a woman is like from navel to knee. Hence there is no embarrassment about public displays of breasts.

In the UK, this is not the case and therefore breastfeeding will always be emotive, as if the baby is interloping where it shouldn't be. This is also why there is a stigma around breastfeeding a child for too long - I imagine this will never change.

However, I think there is a happy middle ground that could be reached where new mothers wouldn't feel embarrassed or ashamed to feed their newborns in the natural way pretty much wherever they felt like it. As long as they didn't give any innocent bystanders an eyeful!

The role of women in society

It can be difficult to assess subtle cultural norms when you arrive in a new country. No one is going to tell you explicitly unless you ask some pointed questions or it just happens to come up in conversation. Sometimes the stories people tell are the most useful way of assessing what goes on, so I thought I'd tell  you a couple of stories.

I've come across a chap that works in the hospital that I'm going to call Dave, safe in the knowledge that there probably isn't a real person called Dave! Dave is a borderline functioning alcoholic. I have seen him in the middle of massive DT episodes as he withdraws after a big night out or weekend but there are other days where he doesn't make it to work at all.

Most of the time he's a lovely smiley man and therefore is good company, on the withdrawal days he's a bit more introspective, probably because of the discomfort of his symptoms.

One day I asked him about his home life. He is married and has two children, one's a toddler and the other is about 9 months old. They live in a house the other side of the Great East Road. His wife doesn't work and she keeps a close eye on the cash. So far, so good.

So what do you do when you are at home? 'Oh, I'm hardly ever there!' Dave's routine runs like this: finish work, go home, spend 10-15mins there with the kids, go out to a bar with his mates, drink Kachasu (lots), come home when the household is asleep, go to sleep. In the morning he says he plays with his baby in the bed whilst his wife makes his breakfast. Weekends is similar - always in the bar, hardly ever at home.

Do your children even know you? 'Oh yes, when I get home they come rushing up, shouting Daddy Daddy Daddy' He laughs, completely oblivious to the undisguised look of contempt on my face - it's not that I'm not sympathetic to the problems caused by alcoholism, I am, it's just the lack of insight or care that bothers me.

I feel sorry for your wife. 'Why?' he looks a bit taken aback but not much 'She knew what sort of bloke I was when she married me.' There's a pause whilst I consider my response to this excuse. 'And, her parents really like me. They are forever telling me how grateful they are for how I look after their daughter. They even give me money when they come sometimes, I use it to buy beer!!' he says, nearly falling over with laughter.

Why on earth would any father be happy that their daughter was married to a bone idle (in terms of domestic/family responsibilities) alcoholic? And why would he give the guy more money for drink? It is Abraham that explained the pieces of the puzzle. Dave's wife comes from a very poor family. They couldn't or didn't afford to send her to school. Therefore she had no job prospects and was just a burden to them. They were happy that Dave took her away and put her up in a house and gave her a family. As far as they can see, Dave has a good job and he doesn't beat her, so it's all good... This is why many girls are 'married' off at 15 or so.

In Tiko's the other night we got some first hand evidence of the fact that there are worse husbands. Elkie (the owner) said she was expecting a very angry husband, who she alleges is guilty of gender based violence, or what I'd call domestic violence. The wife in question has been admitted to a local hospital and all of her belongings have been removed from his house.

When he arrived it wasn't hard to work out who he was. He was shouting a lot and clearly very angry about what had happened. His version of events is that it's all Elkie's fault. :) Because Elkie had the audacity to give his wife a job and coach her and then supported her to leave him. Elkie should spend some time thinking about the terrible thing she has done.

It's an interesting argument and, as Fi said, it is not false. Unlike most of the other women in the local area, Elkie enabled this woman to be independent of her husband for shelter and food - at that point she was able to leave him - and when he behaved unreasonably, she did. Elkie held the moral high ground until she lost her cool and shouted at the guy to 'shut up!'

Women in authority and even just in the workplace are much rarer here than at home. Without access to free education that situation is unlikely to improve in the short term, but that doesn't mean that even uneducated, unemployed women don't deserve to be treated with respect. There are many men in Africa, in general, that could do with learning that lesson. I hope that, as in India, increasing affluence will allow for larger numbers of televisions in rural areas and women will learn that they could/should be treated differently and start to rebel...

Going back to Dave for a second, he caught me in the corridor the other day to tell me about the trouble with his youngest daughter. She is very troublesome apparently. The trouble manifests itself as a refusal to sit quietly on her mother's back in a chitenge. She wants to be held at the front or, better still, left alone to be independent. I've heard stories about a similar little girl so the answer I gave him was simple. 'This isn't a problem. This means that you have a very bright daughter. You need to start saving now for her school fees and then in the future she will make you very proud...'

Solar cooking and plastic surgery

Last week I had the opportunity to see some new and exciting things, which really epitomise why we wanted to come out here.

It's pouring with rain as I write so I'm typing quickly to try and get done before the power goes off as it no doubt will.

Solar cooking

On Wednesday evening the couple from MSG (a Dutch charity that supports the hospital) asked if I would like to accompany them on a solar cooking demonstration the next morning. It would mean being ready for 8am so I'd miss my usual lie-in :) I agreed.

We drove 6km up the Great East Road towards Lusaka and stopped at a centre for children in distress. It has a wide remit - predominantly involving teaching the local villagers how to help themselves be more prosperous.

The teachers for the day were a lady called Beatrice (the hospital social worker) and a lady called Scholastica (who works at Tiko's), who have been trained to use a very simple solar cooker designed by a Dutch NGO. There was a large crowd watching - both men and women, interestingly.

First of all they explained the principles and then set about making a demonstration chicken stew. Beatrice cut up the dead chicken - I noted that she didn't strip the meat from the bones of the wings and leg but rather cut through it and put the whole lot - skin, bones, flesh into the pot. To which she added some tomato, some onion, water and Portugese chicken spice from Shoprite.

The pot was set in the cooker before 10am. Then all we had to do was wait. [and wait and wait - I entertained myself by wandering off with the camera to photograph the nearby homes]

Of course then the clouds came over, which meant that the food wasn't ready until 12ish, but still, it was a very low effort way of making lunch. Some minor cheating happened when the rice was cooked on a wood stove but overall the ladies seemed impressed. Them men didn't want to pay the 70pin (c.£10) for the contraption and thought they should get them free....

It's a great idea but perhaps more relevant in 6 months and not at the beginning of the rainy season!

Plastic surgery

On Friday the visiting Serbian plastic surgeon was operating. He'd very kindly said I could watch a case involving a child that had burnt the palm of its hand. When the wound was healing the child was more comfortable having a closed fist and the skin of the fingers merged with the skin of the palm, meaning that they were now permanently locked down. Goran was going to release them and put a piece of skin from the boy's tummy onto the palm of the hand - it means the boy will have a brown palm permanently but it's better to have usable fingers.

I was told where to stand out of the way. 'And if you start to feel unwell...' 'I will leave the room' I finished. 'No! Squat down. Do not try to leave, you will fall over before you get to the door and delay my surgery even more!' OK then :)

I felt fine throughout - a tourniquet meant that the hand didn't bleed much and it was fascinating watching him carefully removing the skin and stretching out the fingers. It wasn't necessarily ideal watching them screw wires down the fingers to keep them straight but he did it with such precision that it made up for it.

'We need a photo!' he said, brusquely.

I looked around wondering who had clean enough hands to touch his camera - everyone had gloves on.

'Camera!' he shouted. Everyone turned to stare at me. Ooops.

'Now press the round button slo...' I pressed the button 'NO! NO! Slowly - you must wait for the squares and for me to say it is OK' Now was not the time to tell him I'd seen the squares and the first shot was fine. Better not to argue with the surgeon, I find.

The conversation got around to how difficult it can be to arrange immigration papers for sick Africans seeking treatment (paid for by charities) in the UK. Goran believes it's easier for Indians and Pakistanis to get in.

The anaesthetist piped up 'Of course, it's because the colonialists took everything with them when they left'
I was just wondering how we had taken the abundant sunshine, the fertile lands, the copper, the precious stones, the hydro electric power, when Goran responded 'That was 50 years ago - what have you done since?'

'But they took everything, the colonialists took all the things we had, that's why we are in this state now'

'I was in Grade 1 when you got independence. What have you done with it?' Goran repeated

I would like to be in the Zambian Government if you can just blame the British for anything bad that happens on your watch - but I'm pretty sure that's not how it works. No clearer answer seemed to be forthcoming.

'Perhaps if you stopped complaining about things that happened 50 years ago and started doing something about it you would find yourself in a better position. Plus, India and Pakistan were colonies of ours too...' I said

'Exactly' said Goran.

Then I went to Theatre 1 to see the inside of a cyst they'd taken out of a lady's abdomen. It was full of hair.

There quickly followed a Caesarean section. Geoff was convinced I'd feel faint at that but I did not. I wasn't necessarily keen on it happening to me though - there's a reason the drapes are there. I was quite surprised to see the uterus lifted out of the body and put on the tummy to aid stitching up [although Fi has seen that in the UK too] - but it was a good opportunity for a quick anatomy lesson and now I know why ladies that have just given birth still look 3 months pregnant.

It was also really nice to see the baby being swaddled by the male midwife and taking its first breath.

The next day I went to the ward to record the C sections and for the first time I already knew one of the ladies there.

How the hospital works (Part 4)

I think the time has come to talk all things Maternity. I still haven't seen a delivery yet, I'm waiting for a medical student to tag along with, but my daily trips to 'Bethlehem' have equipped me with the knowledge I need...

I don't have exact figures for the local area but my experience suggests that most mothers do not give birth at home. The first port of call (if no high risk factors are identified ante-natally) is the rural health centre where the midwives and clinical officers will assist with the delivery. For some women, St Francis' is their nearest centre and they will come in labour. If any rural health centre has any concerns then they will refer the lady to the hospital for treatment.

However, these are not the only ladies that the hospital treats by a long way. Ladies from further afield with a POH or BOH (Poor/Bad Obstetric History) or where there is some concern for the birth can come and wait to give birth. They are known as the Waiters and have their own accommodation block behind OPD. Here they stay for sometimes many weeks just waiting to go into labour. Then hey presto they waddle over :)

For women where the concern for their health is more acute, there are two bays of beds in the ward reserved for them and they get to sleep more comfortably until the day comes. The ward is a large open rectangle, bays are marked out by waist height walls only. So these ladies have to wait in a room with new born babies.... it's not exactly peaceful at times! And the showers at the far end seem to fill the ward with hot steamy air so it feels a bit like a rainforest in there at the moment.

When the woman is in fully developed labour she goes to the delivery suite. At home this would be a set of relatively large private rooms (yes, I have been watching one born every minute) where the woman and her relatives can pass the time. In SFH, there are no men (excl staff) in delivery and rarely on the ward. The suite is actually more like a corridor with bays coming off it, that have a bed and a chair in, but are completely open. Rather unthinkingly the first time I went looking for the delivery book I set off down the corridor only to see out of the corner of my eye that the first bay was occupied by a very naked lady - I averted my eyes and walked on quickly. Most women have their mums (I assume) with them on the ward, so I'm guessing the mums are also in delivery sometimes but I don't know this for sure yet. The process is done quietly - any shrieking is discouraged by the midwives so all that can really be heard is heavy breathing and some mild wailing. It's a bit eerie to listen to from the office as I collect info.

If the birth goes well the woman stays in delivery for about 2 hours before getting dressed, picking up her things and the baby and walking to the main ward. Yes, that is what I wrote. Very often she is sent home that day, carrying her things, with the baby in a chitenge on her back (or front or side).

Sometimes things don't go well. SFH delivered 3,176 live babies in 2011. Of these, nearly 700 had to go to SCBU (Special Care Baby Unit) and of those nearly 150 died. A further 192 were stillborn.

There is a 'myth' at home that giving birth is a natural process and therefore it must be relatively low risk and African ladies can do it alone safely. This turns out not to be true and the hospital lost 11 mothers last year. The Caesarean Section rate is over 25%, almost as high as in New Zealand (28%) and just above that of the UK...... In Holland it is c.6%.

Why is this? A number of reasons. Some C sections have to be done for reasons like the baby being breech or getting into distress. Without the detailed ante-natal care at home some complications that could perhaps have been picked up on are not found until the last moment and the mother's life is at risk pushing the emergency rate up a bit.

But, unlike at home, a lot of the sections are in relatively young women, by which I mean 14-22 years old. These girls have had some degree of malnourishment for their whole lives and are relatively small, they may not even have stopped growing - even at 22. So a normally sized baby just can't fit out through their hips...
And once you've had 1 c-section, the likelihood of your uterus rupturing if you try to give birth naturally the next time is higher, so some doctors like to be very cautious and swap them to c-sections for life. I'm reliably told that this is OK up to about 4 but becomes increasingly suspect after that point.

After a c-section the baby/babies (I've seen lots of twins!) and mum are kept in for 6 days. This isn't strictly necessary but the Consultant likes to give them a rest from home. When I collect data I can see how many children each lady has (and whether they are still alive). The most I've seen so far is 10 but over 5 is very common. Survival varies considerably, some ladies have had 10 children only for every single one to die. And some ladies had 10 and they all survived!!! Football team here we come!

I'll write a separate bit on breastfeeding because it's a whole topic in itself but it is encouraged immediately and can continue for a number of years from what I've seen! The ladies on the ward seem quite relaxed most of the time. Even when the babies are crying. They work methodically through - hungry, needs changing, cold/hot, needs a cuddle. If none of that works they just put the bundle back down again and carry on with what they are doing. I also often find the beds occupied solely by a baby swaddled in a chitenge or blanket with the mothers outside or in the shower room. It feels like a long way from the 24 hour attention advocated in the UK. Thou shalt never let baby cry or be out of your sight...

I imagine that having so many mothers so close together is a good way for new mums to learn the ropes - especially if their mum isn't there. But it has its downsides - specifically around privacy - there is none. The other day a baby started crying loudly on a bed. I looked over to see what the mum was doing and she was sat bolt upright on the bed staring away from it. She didn't look round or even seem to acknowledge the noise. After a few minutes another lady (too young to be her mum) came with a chitenge, swaddled the baby, picked it up and started giving it water off a spoon. Even your troubles with your baby are not private.

Before our trip away I went into the Maternity ward first thing - just after 7am - to collect the data from the night before, just in case the ladies had been discharged before our return. I could see the ward-round in progress, but thankfully they had cleared the first bay of beds where I was headed, so I sat down with the first set of notes. A high clear male voice filled the air, it was hard not to listen so I tuned in 'the baby was found motionless at 23.10. It was declared dead at 23.30' I looked up to see who was talking 'the other baby was moved to SCBU'. Throughout, the mother sat at the head end of her bed, facing away from the group at the foot end of the bed, staring into space. Even your grief must be shared...

But it's by no means all doom and gloom and I enjoy seeing the new babies all wrinkly being held so tightly by their mothers. And there is comedy to be had in OPD as well.

One particularly fraught and busy afternoon Rory called the next female patient:

Rory: what can I help you with?
Patient: I have swollen legs
Rory: anything else?
Patient: a swollen belly
Rory examines the patient
Rory: you know you are pregnant?
Patient: yes!
Rory: that probably explains the abdominal swelling? it will go down after you give birth....
Patient leaves
Next patient enters
Rory: how can I help you?
Patient: I want to have a baby...
I'll leave the rest to your imagination!

How the hospital works (Part 3)

I know we have both made some mention of HIV in previous posts but this has always been about the sick HIV patients. The reality is that many HIV positive people in Zambia are perfectly well because they have access to ARVs (anti-retrovirals) locally, free of charge (see below for the details).

Before we came out I read an article in the weekend paper about a lady who cycled from village to village dispensing drugs and educating people. The other day I saw a CHAZ (Churches Health Association of Zambia - Zambia's largest health NGO) lorry parked by the hospital. Abraham told me that it often delivers bicycles. What for, I said, completing forgetting the article! Doh!

The latest stats we saw suggest that the HIV positive population peaked at around 23% and has fallen to around 16% currently. This is partly because of treatments but considerably driven by premature death. Many families in the vicinity have taken in orphaned children - no mean feat when they often have 8 of their own.

The prevalence means that people's status is not far from the mind of doctors on the ground, both to aid diagnosis but also for personal safety. So how does the system work?

For most people, the first step in finding they are positive comes when they visit a VCT clinic. This is voluntary counselling and testing. At St Francis' this clinic is based by Xray. The hospital completed almost 10,000 tests last year for all purposes. From there they would be referred to the Sandy Logie Clinic in OPD. This clinic is named after a Scottish doctor who contracted HIV (and died) whilst volunteering at the hospital in the 1990s. His wife still has close links to the hospital and was here in September.

At the SLC they get a review (including of their CD4 count, which is used as a measure of the progress of the disease) and the correct medications for their particular stage and responsiveness to treatment are prescribed. There are two schools of thought when it comes to privacy and Zambians' desire to keep their status private. Some think that people are very open and others suspect that some people lie and/or are embarrassed. I think it's a mixture of the two, the problem is that in over crowded places, privacy is hard to come by.

The queue for the SLC is on the other side of the old OPD from the medical and surgical queues. It doesn't take a genius to work out who is positive. I am told that the new OPD will work differently and it won't be so easy. However, once they have their prescription they must head to pharmacy to pick up the drugs...

The room nearest the stores (ie furthest from the outpatient dispensary) is where the ARVs are kept and dispensed. There are two benches outside the room where people queue - in full view of anyone walking round to x-ray or paeds or maternity or surgery or theatres. It is far from private.

The room itself is a box room. The back wall has shelves covered in drugs, in front is a large table used as a desk. To the left of the door in a gap as wide as they are are 2 chairs at 90 degrees to the desk. The far right hand corner has a sink and behind the door is Abraham's computer and a small chair.

It's not ideal for a number of reasons. The door is not closed between patients. Abraham and anyone helping him are in the room most of the time and when he has to get out the patients have to squeeze out of the way so he can get his wheelchair out. There's often another member of the pharmacy team in with the dispenser. Occasionally there's another member of staff sat on the chair nearest the desk so the patient has to lean over them to get their notes to the desk :) And then there's the muzungu that hangs about!

But it's a great room for seeing what an HIV positive person looks like and I can report that they look perfectly normal. Some are fat, some are thin, some are rich, some are poor, some have well behaved children, some have monsters, some can understand when to take the drugs, some can't. But they are all there, about 100 per day.

One day a man in a wheelchair with two stumps where his thighs would have been came into the room. I was a bit surprised because I hadn't seen him in the queue when I'd walked up a few minutes earlier. There was some shouting from outside. Upon seeing me he started speaking in English (I think to show he could). 'Disabled people should be able to jump the queue shouldn't they? Always??' Ha ha ha. I said that they did get privileges in the UK, yes. Mr Nyirenda dispensed his drugs and said 'Next time, Mr Zulu, you will queue like everyone else...'

Yesterday I was tucked on the little chair behind the door (effectively invisible to everyone) when I could hear 'muzungu' in the conversation. Then Luckson, the dispenser, requested that I come out from behind the door because the little girl (silent) wanted to see me. I got up. She just looked at me and didn't even smile! The cheek! I suppose it was better than the last request I got which was that I should give the lady my ring - 'but that's my wedding ring! I can't give her that!'

One thing that has impressed me is the time taken over each patient to explain how to take the drugs. A great number of people can't read and can't tell the time. Some tablets must be taken twice a day, others once. I've watched everyone going through this patiently over and over and over again, without a hint of frustration. And simple solutions are the best - one line on the box means one tablet a day, two lines means two. And timings are done off meals.

So where do these drugs come from? Simple answer is - The Americans. The money comes from PEPFAR to CRS (Catholic Relief Services - US NGO). At the moment CRS coordinates everything in Zambia and set up all the logistics to get the drugs and support money to where it's needed. However, the US Govt has stipulated that more control must be passed to local organisations and the Americans should start to withdraw control. The aim is to make the local Govts start to contribute. In Zambia this means that CRS is passing control over to CHAZ. So far so good.

There's just one concern. For some reason (as yet not fully understood) hospital Management believes that the CRS funding is disappearing at 20% per year and they will have to make drastic cuts! This isn't what the PEPFAR website says, it isn't what CHAZ says and the chairman of CHAZ is Joop the O&G doctor. Quite who is maintaining this myth and to what end is yet to come clear... However, all the SLC patients can sleep easy, their drugs will keep coming.

Zambian culture is very different from the UK, right?

There are quite a few ways in which Zambian culture is very different from UK culture. We have already mentioned a few but I thought I would summarise some more ways here.

The first that we've covered is clothing. Women shouldn't show their knees or stomachs - this prevented me from showing Abraham how much darker my arms are than my tummy! Although it seems that richer Zambians (probably those from towns / cities) are more relaxed as there are a few women around the hospital that wear skirts on the knee and in Chipata the swimming ladies had short shorts on. But in general it's very conservative.

Men are the leaders of the family and it's rare for there to be a woman in authority. There are no female Zambians in any role in Theatres and only 1 female Zambian doctor. Any woman wanting a sterilisation must first have her husband's permission (and before you get too irate about that, it's worth pointing out that this was the case in the UK when I was born).

Music plays a very important role but it's not the type of music popularised by Paul Simon. It tends to be either gospel music or country music! They seemed surprised when I said neither was particularly popular back home, particularly not with people in their 20s. 'You mean you don't have any Dolly Parton? or Kenny Rogers?' [I have one song from each, I can hear my friend Dan Caines groaning at this as he has spent a lot of time trying to educate me about proper songs :) and he's doing an amazing job] I just laughed at them. 'Why don't you like country music?' Err, because it's depressing and it's always about some guy who wants to marry his dog! There is a Zambian pop star - I don't know his name but everywhere I've seen music videos there's always been this one guy on there - he is slightly plump and has many silly hats. Not keen on his music. Anyway, exactly like at home, people wander around playing music out of their phones. There's one key difference - the EU rules about hearing loss and maximum volumes don't apply here - trust me, this EU rule is really a blessing. You could happily join in a phone call here from 10 meters away and be able to hear both sides of the conversation perfectly!

The gospel music hints at my next comment - Church. Religion and going to church are very important.   There are many churches to choose from - in Katete there's a road dedicated to churches and some mad race to see who can build the largest - the bigger your church, the bigger your congregation... Sunday best is still worn to go to Church. The community is still conservative in many ways beyond dress, homosexuality is illegal, for example, which can make some hospital consultations difficult, also it's very frowned upon to have sex outside marriage - Dr Amy treated a lady who was bleeding very badly (I'll explain in a second) who nearly died because she was too ashamed to admit what had happened to her. It was only in theatre that Amy discovered the source of the blood and could save her life.

There's an interesting interplay between abuse against women, HIV/AIDS and marriage. There was a BBC News article from India this week that was similar to what I'm going to say now but without the HIV/AIDS. Each week the hospital sees women (and a distressingly high number of young girls) who have been attacked (sometimes sexually, sometimes not) by 'known' or unknown persons. There are public awareness posters in Chipata urging the community to stamp out this behaviour. Near the administrative centre in Katete Boma there's a painted sign that says 'Rape is not only a violent act, it spreads HIV/AIDS.' I'm not sure whether they think the blokes care more about giving the woman AIDS than mental scarring or whether they are suggesting the women have AIDS and will harm the rapist. Whichever way round, it is clear that rape is a significant issue locally.

For some time I was interested to understand why HIV spread so quickly through Africa. It's easy to point to a lack of education (true), lack of availability of condoms in remote areas (true) and the fact that it went unnoticed for many years before being detected. All of these are correct. But, in normal (as defined by Western practices) consensual sex the chance of passing on HIV is relatively low (falling to 1/900 if the infected person is on ARVs). However, if there is significant tearing on either side and blood to blood contact then it's much higher. It seems to be the preference of men here for that sort of thing to happen (remember the lady earlier) so the chance of spreading the virus is much higher.

It is pushed higher still by the richer men from the towns that come out to the villages with presents to try and procure sex. And some traditional healers still tell people that sex with a virgin will cure them of the virus. Not desperately helpful. There are lots of health posters around the hospital urging women to wait and not to accept presents, to think about their future and career aspirations.

And because unmarried women often feel ashamed of what has happened to them (whether they consented or not) there can be a significant delay in seeking treatment which can, unfortunately, have serious consequences on their health.

But it's not all unlike at home. The other week Nat was approached by a mum who said that her 15 year old daughter had been 'defiled' and she wanted a medical opinion on her police report. Sometimes it can be tricky to be certain of what has happened, particularly if there is a late presentation. In this case the girl was mute in the presence of her mother. Nat despatched the mother to the end of the ward and suddenly it all came out. She hadn't been raped, it had been consensual (if illegal), she was in love with a married man of 22 and she was going to have his baby... Nat had a little feel of her tummy and, yes, more than 20 weeks gone, she was indeed having a baby. Well, that made the police report easier to fill in at least!

A taster of the rainy season flora and fauna

I should really be rinsing my clothes but we seem not to have any water at the moment, which isn't in any way convenient but I guess I would be more annoyed if I really needed a shower.

Anyway, it gives me a moment to write about the flora and fauna of rainy season. I'll start with the flora (briefly) as I guess people will find that less interesting :). When we arrived, the Jacarandas were just starting to flower. Amazingly the two waves have kept us surrounded constantly by purple flowers all the time. On the way to the Mess we walk over a carpet of purple flowers - it seems a shame every time Alick sweeps them up!

A few weeks ago the Frangipanis started to flower. Nat has one in her garden and when we arrived the weekend before last she had a flower in her hair - very exotic. Last Friday morning I noticed that the leaves were coming out on the Baobab on the running route - I'm sure they weren't there at all on the Wednesday, so they must have started quickly. I'm really looking forward to it getting its full complement because I've never been in Africa when they've had leaves before!

Most recently a tree with bright red flowers has flowered. Nat refers to them as fire trees, but I'm pretty sure that's not their real name!

All of this activity points in one direction - the rains are coming soon!! Everyone tells us the 24th of October and we've only recently realised that this is because it's Independence Day!

And we've noticed a difference with the animals too. The prevalence of snakes has definitely increased over the past couple of weeks. Nat nearly trod on one. We saw one on the way back from Tiko's the other night. Two people were bitten on hospital grounds this weekend. There was one wrapped around the loo seat at the students' house and they found another this evening. Things are waking up.

Unfortunately this also extends to the spiders. The students first, with another of the big spiders with ultra long front legs that we saw at their party. They are known round here as Red Romans or Sun Spiders - they are Solifugae and, if Wikipedia is to be believed, can travel at 10mph! Except if Pete has splatted them with his shoe.

Next to 'benefit', as some of you on Facebook know, was the Roberts household. Yesterday morning Geoff got dressed only to make mad shaking movements as he attempted to get a spider off him (it was on his clothes when he picked them up - a common trick apparently). This was soon dispensed with.

In the evening I was sat by myself doing some data entry for our study. Geoff was on call and had headed in to see a fracture. I saw something move out of the corner of my eye - normally this would be a cockroach or lizard. Tonight it was a rather large (but I have to admit not one of the two largest sorts of) spider. It saw me see it peeping out from around the half wall to the bedroom and quickly made a dash for the shoes. A cunning move designed to prevent me from arming myself. I thought I had outwitted it by reaching for the bug spray that works 'ultra fast'. I sprayed the offending area only to see the spider shoot out of its hiding place and return to the bed area (where there is still no light!). This was not ideal.

I returned to my chair to work out what to do. I decided that I could see the main aisle from my seat and  that it was likely to try and come back towards the shoes shortly. So I should just sit and wait. I forgot to arm myself with a shoe. Just as I realised this mistake it came peeping out around the wall again. I flinched towards the shoe at which point it made a break for it, heading towards our bed on the other side of the room. I decide that this is unacceptable. I'm not having it sneaking around my bed so the bug spray will have to be used again. I sprayed it hard. Nothing happened. I sprayed again. It did a forward roll. I sprayed again. It did another forward roll. [I'm waiting for it to do what everything else does and flip on its back.] More spray. This time it lies on its belly and lifts all its legs in the air. Maybe this is what I've been waiting for. Now is my chance to whop it with the shoe but I remember that Mum wanted a photo of the spiders and I can't splat it! Not much of a photo. As I'm debating whether it's safe to turn my back it starts to move. Very slowly it lowers each of its legs in turn and crawls off under the rucksack. This is too much. This spider is immortal, unkillable and like a zombie. It is also, clearly, a man eater.

I retreat to my chair and lift my feet off the ground. Who knows where the bloody thing is now? This is the first time that part of me wishes I was back in the UK and another part of me is quietly pointing out that I laugh at anyone (mostly girls) that say they stand on chairs to get away from spiders until their boyfriends return. However, I'm not getting down until back up comes. Suddenly I hear a noise over my left shoulder and on the floor is a large cockroach being chased by a very small lizard. I'm in a zoo!!

I have chronicled the events on Facebook and, just as I text Geoff to tell him my position, I get a call from Nat offering to be back up for me - as long as I kill the cockroach! I get off the chair and do the deed - simple enough. When she arrives we decide that she should have the weapon (her own bug spray) and a torch and I will have a torch and the mop to poke the rucksack with. We prepare for the worst (OK, I prepare for the worst and Nat is left wondering why I've allowed the bodies of 3 dead cockroaches to remain under my bed - in truth, I thought there was only one (and I was leaving it as a warning to others, as you would a dead crow) and now I can see the dust under there I'm a little embarrassed). Anyhow, I poke gingerly at the rucksack and immediately it becomes apparent that the spider crawled under it to die - for there it is just twitching slightly. Nat sprays it with Doom for good measure and it becomes motionless.

Now it's safe to photograph (see below - yes, I know, there's no scale). On reflection, I might have overreacted slightly but I still insist that holding a torch, a weapon and a poking device is really a 2 man job - plus two sets of eyes to watch the crafty things are essential! In the past 24 hours we have sealed all the windows and ventilation bricks with mosquito netting and blocked the gap under the door - take that, suckers!

Man eating spider - was about 4.5" across fully extended

Pet frog turning black, showing it is coming out of hibernation

Where did my dinner money go?

I had intended to keep a weekly food diary to let you know what the food is that we are getting out here. I did keep the diary but never made time to write it up, but you've probably picked up on the references to goat by now. In truth, we aren't 100% sure it is goat but it doesn't look or taste like beef and it certainly isn't pork or lamb...

However, what used to be a plentiful if a bland, unimaginative, repetitive repertoire of food has become markedly depleted over the past couple of weeks (in portion size as well as content). We get dinner free every night, which is a main course and pudding. I eat the lunch there on operating days - which also normally has pudding although this was bananas pretty much every day for the first 6 weeks.

The first thing to go was jelly. (Yes, we loved getting jelly 3x a week, it was like going to a child's birthday party all the time, ahem). Then the custard mysteriously stopped, so the rather dry cake became somewhat inedible. I think to placate us they hit on the bright idea of serving it with hot milk. The first night no one touched the milk but tonight it all went! We are getting somewhat desperate.

Inadequacies in the puddings can be coped with as long as the main course is fine. However we appear to be suffering from a major chicken shortage. It started on Friday a week ago. Friday is a chicken night but there was goat again. We grumbled - this isn't fair! We put up with the goat because we normally then get lots of chicken to make it all right.

But it's OK, Sunday is always roast chicken night. We piled in eagerly to find 3 small chickens to feed 19 people... the grumbling got a lot louder. Portions had to be re-divided to stop fighting breaking out. We decided we would really complain if they didn't give us rice pudding. Miraculously (perhaps they heard us), rice pudding was forthcoming. The riot was averted.

There was no chicken all week and it became clear that they are running short of lots of other basic ingredients too so the goat stew became the daily staple. At day 4 some people just walked straight back out of the Mess. Even the chips (first time in 2 months) on Wednesday lunchtime didn't placate the students much.

Thankfully, for Nat's birthday today, we had cheeseburgers and chips for lunch followed by the chocolate cake that Geoff and I made secretly yesterday. One of the students told us to expect chicken for dinner - we hoped that normal service had resumed. We bundled in together (there are now 21 of  us) to see 2 small chickens.... um... 'there's also some beef'. Nice beef? Nope, about as tough as shoe leather.

This isn't funny because we have almost no alternative. Tonight for example, the power was off from 6.30pm until 9pm and we only have electric ovens. Also, it's really difficult to get the ingredients that you need. Really you have to go to Chipata, which is ruinously expensive if you don't have a car. We discovered last week that we can get meat in Katete (and none of us died) but you have to trust it's been kept frozen since processing and with all the recent power cuts that's not really feasible. None of us has the skills to buy a live chicken and turn it into diced chicken... even though we could have a chicken for 30pin (c.£3.50).

Although, now I've cooked in the Mess kitchen, I do wonder if I shouldn't be seeking an alternative. I'm not sure what I think is the worst of the following points but, as far as I could see, there's no soap, there are ants and flies on everything, there's a hideous stench of rotting meat coming from somewhere and they are clearly comfortable with rats. When we said there was a rat in the dining area last night (second night in a row we'd seen it) the guy came out and said 'Oh, it's only a small one'!?!? Yes, my friend, it is small but it's still a RAT. He then came out with a broom to kill it. Unfortunately it escaped but it was amusing when he shouted in rather broken English 'Oh!! I missed it!'.

Not that this is the point. Doctors contracts include the provision of food (which we assume is funded in the same way as salaries - with money direct from England) and the students are paying £8 per day for their food and board (which is much more than they cost the hospital) so there is no excuse for the food running out. So my question is - where did my dinner money go?

How the hospital works (Part 2)

So last time I spoke about patient recruitment and how patients get admitted. This time I thought I'd cover the Medical Wards (St Monica (F) and St Augustine (M)). They are positioned in the middle of the hospital and are long 'Nightingale' wards. Some of the young doctors here think they are very old-fashioned, which they are, but you will still find them in the NHS - at Whipps Cross and Leeds for example.

St Monica

The picture (courtesy of the incredibly talented Will Burrard-Lucas http://www.burrard-lucas.com [do you think this is enough of a plug given that I didn't technically ask to use his pic?]) was taken on an unusually quiet day with the back half of the ward not in use. Will was at the main door to the ward, in the foreground is ITU. The only difference between these and the other beds (leaving aside the severity of the patient's illness) is the proximity to the nurse station (halfway up on the right). There is a side wing that runs along the ward that was previously a covered colonnade - the TB patients are here where there is better ventilation. It is a touch ironic that it's been closed in given that drug resistant TB is increasing along with the number of vulnerable patients with HIV...

The ladies that you see sitting at the end of the beds are called 'bedsiders'. Each patient needs one because it is their responsibility to do a lot of things you'd expect a nurse to do at home. They bring food (the hospital provides 3 meals a day but they only amount to 1000 calories and 40g of protein), do basic cleaning and generally assist the patient to get up and down, go to radiology etc. Patients without a bedsider tend to struggle but the nurses do try to help - the Prof's wife also brings food parcels for them and patients whose families can't afford to buy food at the Chada market...

At night the bedsiders sleep next to the bed (often on the floor). There are 3 visiting 'hours' - actually 45 mins - that are identified by a man hitting a cut off length of scaffolding pole hanging from a tree with some rebar (we can hear it from our house - a nice 6.30am wake up call!). If you try to enter or exit the hospital around the start or end time you have to fight through the throng!!

Illnesses

There is a suggestion that the average patient on St Monica isn't as sick as that on St Augustine. I'll discuss why this might be the case in a second. Common to both wards are Malaria, TB (often secondary to HIV), AIDS related diseases like Kaposi's Sarcoma and 'overdoses/poisoning'. Lots of patients claim to have swallowed insecticide in a bid to kill themselves. They are treated for organophosphate poisoning even if their symptoms are exactly opposite organophosphate poisoning because it's not possible to work out what else they drank. Often they make a full recovery.

On St Augustine they also see men who have drunk the locally brewed drink (Kachasu). The problem with it is two fold - no one knows how strong each batch is so it might be nearly 80 proof for all you know and it might be meths not ethanol, which would be unfortunate. All we know is that if you drink it and come to the hospital because of it you aren't going to be the same again. The majority leave as vegetables, maybe they can walk with assistance, maybe they can't. I think they see at least one a week, mostly young men. Such a waste.

But, the reality is if you come with something identified above, or inoperable cancer, it's unlikely you are going to make a full recovery. Yes, there is some chemotherapy for the sarcoma but the greatest role is often palliation. It is frequently heard at dinner at the end of discussing a case 'We did all we could for them so we've sent them home to die' because, frankly, that's preferable to dying in the ward.

Now, what about these other ladies on St Monica? Well, two things - there's the worried well - as in Europe, women present earlier than men with complaints. And some of them don't really have anything much wrong. However, this is still preferable to the men who present too late and have to be palliated in pretty much every case. The other type are the women who are escaping their abusive husbands. They have terrible non-specific systems whenever he's in sight but as soon as he's gone they smile and are happy. The hospital provides a few days of respite.

Patients are moved around the ward as their status changes. If you get better you move further from the door, if you get worse you move to ITU near the door. It took a few days for Nat to work out what was happening to her patients and then why. The nearer the door you are the less disruption is caused by the  coffin trolley. Deeply practical.

Each ward has one oxygen concentrator (or there might be 3 between the 2 wards, it's not clear). These machines concentrate the oxygen from the air and mean that the hospital doesn't have to store oxygen cylinders. It looks like in the past there was one large oxygen concentrator that pumped oxygen through tubes around the wards. The doctors must assess who their sickest patient is to make sure they get the oxygen. Sometimes this can mean taking it away from someone else that they know would benefit. It's a tough call every time. But quite often the patient or their family won't accept it because 'oxygen kills you'. Correlation is not causation but most patients that go on the oxygen die... it's the same with lumber punctures and some other procedures.

At the bed

Being ill can be a great leveller so I guess it's human nature that people want to be able to retain some of their social status in the ward. This is done by bringing your own blankets. The more fluffy blankets the richer the patient. We find it slightly baffling given that many of these people have fevers and it's over 37 degrees anyway - but blankets there are!

On St Monica you have to be particularly careful of a pile of blanket. Because it might not be that at all!

As Nat is beautifully demonstrating, it might be a baby! Mothers with young babies have them in the bed with them either in a separate bundle of blanket or breastfeeding! This is often a great surprise to the doctor doing an examination on the ward round :-D

The blue nets above the bed are the mosquito nets. Only about 10% get used on the adult ward. We have heard lots of explanations - the people sleep soundly under them, dream and then think they are possessed by evil spirits, they are too hot to sleep under, the adults all have malaria anyway. Fine but for every patient carrying the parasite that doesn't use the net the greater the chance is that I get bitten by a mosquito with it. This is selfish behaviour. And it's very ironic given the number of staff wearing t-shirts urging the use of the nets... This story is repeated in the villages. I'm sorry if you have donated money towards providing mosquito nets but I guarantee you it isn't being used. They use them to make bags and ropes and best of all fishing nets!! They make great fishing nets until you realise you've completely emptied the lake of all fish...

What happens if there isn't a free bed?

When the ward is full, they squidge the beds up closer to each other and put mattresses on the floor. When that's not enough? Then they put two patients on each mattress - starting with the smallest. On St Augustine a couple of weeks back they were so full they had two fully grown men sharing a mattress. No one complains because they are getting the treatment they need, given by a Muzungu, which is why they came here. The rest is just fluff.

Am I a voluntourist? Does it matter?

Ever since the Prof raised the issue a few weeks ago in Tiko's I've been thinking about it. At the time we asked him how long he thought someone had to stay here before they were not considered a voluntourist, he laughed and said '7 months...'. His position was clear, although I think that has softened slightly over the past couple of weeks as he sees how much Geoff is actually helping.

But is he right? I think it's too early to come to a definitive conclusion on this one but I thought I'd share some of my initial thoughts. In due course, I will extend it to how I think help should be provided to the hospital in order to maximise its impact - but for a number of reasons, including the forum in which I write, that shall be put aside for now.

So, am I? It really depends how you define voluntourist. Online you can find a number of positive definitions that equate the term to 'crowd-sourcing with an incentive'. You have a dull but earnest task that needs doing - like counting fish in a coral reef - and it would be helpful if 100 people came to do a couple of days' work each and then spent a few days just lying on the beach. As long as the quality was fine, everyone's happy.

For the Prof it has negative connotations. He is using it for people that come solely to make themselves feel better, almost to gloat. And whose contribution to the running of the hospital or the lives of the patients is so minimal as to be insignificant. He would rather have their airfare and foregone wages as cash so that he can make the changes he needs to in theatres. His number one aim at the moment is to make them insect and animal free!! And of course if you pay locals to do what voluntourists do, that money feeds into the local economy.

I can entirely see his point of view. If I am honest, I knew that I could not, under any circumstances, make a significant change here in 6 months. I'm not sure I could do it permanently (i.e. such that it would continue in my absence) in 6 years. But I would quibble with him about whether that means I should not have come. Much of my time over the last couple of weeks has been spent writing surgical protocols or, more recently, amending protocols that he has written. None of this would have happened without me being here - there is no one in the hospital with the time, the IT capability (why is it that Word randomly adds funny lines in the text every so often?) or the medical language understanding to do these. Yet they are required by the Government. And how long would the pharmacy have gone on thinking they couldn't add new products to their stock keeping software if I hadn't taken the time to read the manual and find the correct button?

Of course this all has to be balanced against the 'tourist' bit. Is it a coincidence that I love Africa and we are in Africa? No. Is it a coincidence that we are only 4 hours from a National Park? No. Do we intend to visit the park a few times? Yes, tomorrow being the first! So there is a definite upside to us being here that I would never attempt to deny. I am loving all the smaller animals around the hospital and being able to watch the sun setting in the massive sky. But we've been here 6 weeks now and, illness aside, Geoff has been in the hospital practically every day, with operating lists double the length of UK ones 3 days a week. So I think a short break is deserved in anyone's book.

Therefore, as I sit here right now, I think the answer is 'So what if I am a voluntourist? I am still helping at least as much as I am benefitting.'

Day to day in the hospital this week

For a little while now the hot topic at meal times has been the impending shortage of salt based IV fluids. Preferably those without dextrose (Dex) in. There was debate about whether best practice is to resuscitate with Ringer's Lactate or pure saline - it seems to vary by NHS hospital and department and internet source - but ultimately everyone agreed that they didn't want Dex-Saline or Dex.

I overheard the Acting Medical Superintendent asking the pharmacist about the fluids when he took me to pharmacy the first time last Tuesday. The response was that he had plenty of Dex-Saline. Quietly the AMS said 'but sometimes they can't use that.' Soon the wards ran out of saline, there were rumours of pockets of it - a nurse on the men's medical ward had 'found' a box of Ringer's Lactate that was being reserved for the really sick. Everyone else was getting Dex-Saline. The level of concern at meal times increased.

When I went to pharmacy this Tuesday I needed to ask when the delivery was expected this week. I have promised to help the stores boy with the data entry to make sure the prices are recorded correctly. The pharmacist's response surprised me a little "We aren't expecting a delivery from Medical Supplies [the Govt company] this week and I haven't placed the order for the other things we need yet." When do you think they will come? "I don't know, I will send word when I need you." The little voice in my head was screaming 'Why are you so calm? why haven't you placed the order? I was stood next to a trolley covered in fluid bags - all 10% Dex. The hospital has now run out of all saline IV.

And the Govt inspectors are here this week. In the weekly meeting the Acting Medical Superintendent let people know what they are checking for. 1) they are checking that protocols are being used correctly. A medic asked what protocols they should be using, she hasn't seen any. 'If you can find a hospital one, use that, else use a Zambian one, failing that a WHO one'. OK (but in fact there is a book full of hospital protocols which we use) ... 2) they are checking that staff are wearing their name tags. Same medic (she's persistent) states she doesn't have one. 'No, you don't. We haven't had any new ones printed for 2 years'. OK...

At dinner on Wednesday the Prof and his wife join us in the Mess. We talk about a lot of things and then I get in trouble for trying to organise/help (depending on your point of view) the Prof as he serves the pudding. His wife says 'do you think you would make a good Medical Superintendent?' I said that I thought I could make some positive changes. 'Yes' she says 'I told [the son of the English couple that used to run the hospital] that they should appoint you.' Whatever can she mean? She's only met me about 5 times!

Juxtaposition of real Zambia against some luxury

On Friday night the resident Dutch Obs and Gynae doctor (Joop) arranged to take us to a Zambian restaurant in Katete. The proprietor is a lady called Phoebe who is probably in her 50s and is half Portuguese half from Mozambique - but really looks more Asian in descent. We had all signed up on a sheet a few days earlier, keen for the genuine experience.

When we arrive we are the only punters and are sat at a long table made of lots of other irregularly sized tables pushed together. We have had a small adventure getting here - squashing into Joop's car with 4 of us across the back seat and an extra row on the seats in the boot. We stopped to gather the visiting Orthopaedic surgeon in our convoy and promptly reversed into a tree in the roundabout at the front of the hospital. A few moments later a car is parked clearly going the 'wrong way' round the roundabout - Joop complains about the poor driving. Before I can stop myself I hear my mouth saying 'I'm not sure you can claim the moral high ground if you've just driven into a tree....' The packed car fell silent...

So I'm glad to reach the restaurant and seat myself at the other end from Joop [No harm done though - he invited us back to his house after dinner for drink!]. Shortly a trestle table is loaded with a buffet. We make our way up to have everything explained. I spot the Nshima at the far end (standard) and the beans at this end. So far so good. Now Phoebe starts to talk - these are fried flying ants (hhmmm), a green vegetable mousse, the little fish from the market, some white aubergine, offal, baloney (described as a vegetarian sausage) and then the piece de resistance - trotters/hooves [There has been debate subsequently as to which animal these were from].  I realise a few things at this point 1) I didn't have a clue what to expect and should have asked, 2) I have no idea how much it's going to cost and 3) I'm a bit wet really. I'm keen for a real Zambian experience as long as it doesn't involve me eating things that I wouldn't normally eat....

Nat is in front of me and I watch her load her plate. Then I start. The pots look small so I don't take too much of anything. I avoid the fish (I just don't do fishy fish particularly not small ones that you get the whole of - these look to be mostly eyes, skin and bone). I look closely at the offal, am heartened by Rory saying 'great! Sausage meat!' but then spot a piece of colon sticking out of the pile and decide to move on. Similar story at the trotters - part of me wants to try it but then I look too closely and can't face lifting one onto my plate. As Nat and I turn back (she has fish and a trotter but no offal) Fi comments on the 'cordon bleu' portions. I decide to watch her closely.

As it happens the ants were just fine - they were just crunchy but didn't have a strong taste. They actually make a good accompaniment for Nshima as they give it texture. The fish were deemed to be very strong - well avoided. The trotters caused contention. Nat attacked hers with a knife and fork, managed to get the skin off it only to discover nothing particularly edible underneath, so gave up. Fi piled her plate high with things and I hear her ask Joop how to eat the trotter. I look up with interest. She has it between her forefinger and thumb, touching it as little as possible - exactly as you might a damp old rag of unknown provenance. She brings it close to her face and sticks her teeth out as far as they will go to take the tiniest nibble. Clearly she misses or fails to get anything off so she tries again. Fails again and gives up - down it goes! I feel better. She still has the high ground, it got on her plate, which was better than I managed. Although I do clear my plate.

NB: The only people that ate the trotters were Geoff and Joop. Geoff subsequently got the trots and Joop hasn't been seen in work today (Monday) either..... coincidence?

Luxury

Those not working have arranged to go to Chipata. Will's away and Nat's working so we have to go by 'taxi'. Geoff stays behind because of his sudden affinity to the bathroom. I feel a little guilty but he wouldn't have fit in the two cars anyway, so perhaps it's a good thing. Halfway the car in front suddenly makes a small swerve and slows rapidly - puncture! These must be common because the two drivers have it changed in about 5 minutes flat.

The next 'issue' is the Police roadblock. The rules on taxis appear to be the same as at home - you need a licence and special insurance. Will and the rest of us normally get waved through the block easily but today things are different. We are ordered to pull over. Rory asks if it's just because someone wants money - they do want money but it's legitimate - sort of. It's quite clear that a beat up car with one local driver and 4 muzungus in it isn't a group of friends on a trip. Two cars in a row makes it even more obvious. Technically I assume the drivers should have been arrested but instead they hand over some money (I didn't ask how much) and we carry on to the hotel!

The pool is so inviting after the heat of the car that we all get changed straightaway and jump in! Lovely! And so much warmer than a few weeks ago! Great. After a short while we get out to warm up. The wind gets up and the parasol I am hiding under makes a bid for freedom, nearly decapitating Fi in the process! We decide to get back in the water - it seemed safer! Just as we leave again we hear splashing behind us. A little boy is climbing down the steps - he appears to fall off the last step (it's hard to see - Nat fell off it last time) and now he's out of his depth. He starts to flounder. His mum yells at us from her sunlounger at the far end to 'help him'. For a moment I'm frozen, time moves slowly, and his eyes suddenly open really wide. Fi has managed to make her legs move before I do and she's down the steps by the time I can reach his arm from the side. He says nothing as we drag him out... and neither does his Mum! Charming!

We eat well before heading to the shops. As seems common, the power is down so only the big supermarkets and petrol station are open (they have back up generators). I buy lots of cheese as a present for Geoff. I considered buying the 2kg block of Gouda but it was 190 pin - well over £20! I get a box of red wine instead 135 pin for 4 bottles worth - bargain!

On Sunday we have a lovely risotto for lunch cooked by Fi. Sitting on their porch in the warmth with a glass of wine is idyllic. There's even a small bat clinging to the bricks supporting the roof!

What can I carry on my bicycle?

I think there's enough variety to warrant an occasional column on the correct use of the bicycle. At home you generally only see a single rider. Occasionally smaller children will have picked up a passenger - perhaps on the back or sat on the seat whilst the rider stands. It is clear that we underestimate the usefulness of this humble means of transport. Here are a few things I've seen:

• Another bike - either crossways across the pannier rack or tied on with the back wheel as an extra axle
• Various lengths of 2 x 4 - strapped longways or crossways depending whether you want to lance pedestrians or just take their legs out
• An unfeasibly large number of large whicker baskets (fine until the wind blows)
• A live chicken held in the right hand of the rider, who is also holding the handle bars with that hand
• A live goat - tied across the pannier rack with bungee cord (note: it will bleat every so often, which could be annoying / distressing)
• A dead pig - on the pannier rack but you might want to cover it in some green vegetation so that passers by are not offended. [I was laughed at by a lady who saw me staring to try and work out what was going on]
• A couple - sit the man on the cross bar by the handlebars and the lady on the pannier rack
• A breastfeeding lady - side saddle on the pannier rack, obviously
• A whole set of garden tools tied on in various places
• If you are the rider and have a baby then just tie them to you with a Chitenga - perhaps on the front so you can keep a better eye on them...

Perhaps you don't need cars after all!!