Leaving Mpanshya

3rd June 2007

Sunday morning, and I am standing at the back of the church with Bernadette, clutching a large bag of rice. One of the regular features of mass in Mpanshya is that after the offering is collected in cash, some of the women from the village dance up the aisle bearing gifts of food for the priest. Every time we have watched this ritual, Bernadette and I have said that we will do it ourselves one day. There are only two Sundays remaining before I leave, so it’s now or never. We consulted earlier this morning over what we should wear for the occasion, and it was agreed that we should both turn up in traditional Zambian dress. Bernadette is clad in a tasteful brown chitenge suit, but I have selected a slightly more colourful ensemble. I look like an oversized Quality Street. And nobody else seems to be gathering at the back with us, so it appears our dance will be a pas de deux rather than the more anonymous collective effort I had envisaged. We whisper urgently to Mathilda and Agness, and they agree to rescue us from our imminent humiliation by dancing in ahead of us.

The music starts, the congregation stands, and we process down the aisle together. We are a little out of time, but we make it to the front without falling over. Our efforts are greeted with some hilarity by our fellow worshippers, but I think they are laughing with us. I hand over the rice to a slightly surprised Father Leszek and then wonder what to do next. The others are still dancing by the altar, but I have lost my momentum, so I just sway aimlessly for a bit, hoping that the music will stop soon. Luckily it does, so I sprint back to my pew, glad that my performance is finished.

But it is not over yet. At the end of mass, Elias reads out his usual lengthy intimations, and then without warning, starts to talk about how I am leaving. He says in English, “Could Dr June come forward to say a few words?” There is no escape. I trudge back to the front, deliver a short speech (three sentences of nursery Chinyanja without taking a breath) and receive an equally brief round of applause. I return to my seat next to Chas. He leans towards me and whispers “What was that you said?”

5th June 2007

Today is the day of the staff photo. Chas and I decided that the time most people would be likely to come would be just after 7 am, when all the general workers report for work. I have put a notice up in the nurses’ station to let everyone know when it will be happening. I have appointed Brendan as official photographer. I have also had a short debate with Webster as to whether or not the nurses should appear in uniform (I thought not, he disagreed). But no one has ever attempted to take a staff photo at St Luke’s before, and I have no idea if anyone will actually turn up. (Although there have been encouraging signs: yesterday I spotted Brenda from the hospice at work with her hair in rollers.)

So now, Chas and I are out in the morning sunshine, dragging benches into place in front of the hospital with the help of Isaac and Evaristo. A few of our colleagues idly wander over to take a look at what we are doing. It is still not clear if anything will actually happen. And then suddenly, about thirty people arrive, ready to be photographed. The nurses are gleaming in their starched white uniforms. Everyone starts to take up a position on the benches. The photographer arrives last, bleary-eyed and unironed. Within five minutes, the photo has been taken, and everyone has been ordered back to work by Sister Sabina. It is the greatest display of efficiency I have ever witnessed in Mpanshya.

9th June 2007

Our goodbye party is today. Being no great fan of parties in general, and also having spent the previous week constantly feeling like I am about to burst into tears, I am rather ungraciously dreading it. Chas is not looking forward to it either, but as we will be publicly thanked whether we like it or not, we dress up and walk over to the training centre, where the festivities are to be held.

Being the guests of honour, we get to eat at a table with the retired archbishop of Lusaka, who is a charming man, and also the only Zambian I have ever seen consuming nshima with cutlery. Everyone seems a little subdued, and when the music starts up, no one takes to the floor. Luckily, Goliath, the inappropriately named mortuary attendant has had a few beers, so he kicks off the dancing, thrusting his wiry frame around with gay abandon, and some others join in.

Mr Phiri is the master of ceremonies for the day and he ensures that the programme of events does not deviate from the time-tested Mpanshya routine: music, speeches, and then cake. The dancing in of the cake is performed by the hospice dressers, followed by Sister Angelica and Webster, who have been assigned the role of presenting the knives. Webster is sporting a shiny shirt, cowboy boots and a pair of sunglasses that might have been discarded by Deirdre Barlow sometime during the last millennium. He is clearly enjoying his moment in the spotlight, and treats us to all his raunchiest moves, while Sister Angelica bobs demurely beside him. By the time they reach the stage and finally hand over the knife, I am sore with laughing.

And so the party goes on. The music continues, Chas and I are presented with an extraordinary copper clock in the shape of Africa, and we have a partially successful attempt to teach our colleagues some Scottish dancing (at the beginning of Strip the Willow the floor is filled with enthusiastic learners, but by the end there are only eight still standing). In short, against all our expectations, we have a fantastic time.

10th June 2007

Our last day in Mpanshya and we have packed nothing. We spend all morning in dispute about what stuff is destined for home, what should be given away, and what belongs at the bottom of our rubbish pit. We have finally agreed that the enormous drum that Chas inadvertently purchased from a man in Kamwenshya is coming with us, although we are uncertain how this might actually happen.

Deciding to throw things away is much more contentious, and in some cases, actually impossible. I am sorting through some photos when I come across a DVD that my sister sent me, containing photos of my niece set to music. Being in no mood for sentimentality, I chuck it in the pit. Within a few hours, there is a knock at the door, and we open it to find two children standing there. They are holding up the same DVD. The older girl says “You lost this”. They must have been rummaging around in our rubbish, and their mother has told them to bring it back. They hand it back over, and are about to go when the little one, Moses, says excitedly “I saw you!” They have obviously managed to find someone who could play it for them, and as the only photo of us occurs in the last ten seconds, it also appears that they have watched it in its entirety. Somehow, we manage to maintain straight faces until the door is closed again.

At midday, we escape the chaos of our home and head over to Maggie’s for lunch. The hospice dressers, Brendan, Joost, Bernadette and Chris are there as well. We eat in the sunshine, and then the dressers get their drums out. They perform Soli dances for us, which are amazing, and people from the market start to gather to watch. Then some of the patients from the hospice arrive. Yotham, our resident musician, has come with his guitar. He sings one of his own compositions; I don’t know the title, but it could perhaps have been called The Doctor June Song. He strums and sings, and the dressers join in, dancing around him in a circle. Chas and I get up to dance with them, but suddenly it all just seems a little overwhelming. In the interests of averting a public snot-flying incident, I sit down quietly in a corner, and they carry on without me.

But I manage to recover my lost composure quickly, which is just as well, as the repertoire of songs-with-our-names-in keeps on going for some time. (Should we ever wish to run a dictatorship within, for example, a former Soviet state, this afternoon will have been excellent preparation.) It is unbearable, and lovely, and funny, and sad, all at once. I wonder if they have decided that if they massage our egos sufficiently, we might change our minds and stay. Or maybe they are just enjoying the singing. But as we dance with them for the final number, a song about how everyone is crying because we are going, I think that it is the best party I ever had.

And now, kwasira, it is finished. Over the last year, I often thought about and looked forward to leaving, but now that it is happening I’m not so sure I want to go. I am a bit exhausted with saying goodbye, and some of the farewells have been hard. A lot of patients responded to the news of my impending departure by asking me to give them a gift, but a few said chaipa muzayenda [it’s too bad that you’re going]. I don’t know if they thought I was any good as a doctor. I’m not sure that they’d recognise a bad doctor if they saw one. There’s not much scope for comparison, given that there isn’t another one for about 100 miles in any direction around here.

The truth is, I was pretty ill-equipped for working here, and on the whole, I liked writing about being a bush doctor more than I liked having to be one. I was indecisive, I was short-tempered, and at times I was just plain frightened. But I did do this job when nobody else wanted it, and I took responsibility for people who were vulnerable and without other choices. And I think that might amount to more than the sum of all the lopsided surgical scars and badly-set fractures I have left in my wake. The sense of not being good enough was very real and difficult to cope with, but I tried, and sometimes I did get it right. Maybe it was okay in the end.

Since I’ve been in Zambia, I have had the same conversation with other volunteers on a number of occasions: everyone talks about the importance of family and friends understanding what it is like to be here. There is a long precedent for this: Jon Snow wrote of his time in Uganda in the 1960s “In part, VSO inspired me to write, almost every other day I was there, nothing more than letters to loved ones, but each chronicling the smallest detail of everyday life.” This blog was a substitute for postcards home, and we are grateful to everyone who kept reading it, through our black moments and intermittently purple prose. Knowing that other people are interested and supportive of what you are doing is helpful in any situation. In a strange and slightly overwhelming environment it takes on a new importance, and we were both very glad to have people from home travelling some of the way with us.

Those of you who read the blog often may have wondered where Chas had got to. It must be said that after a fairly enthusiastic start, he decided to adopt a minimalist approach to blogging. Being the show-off of this partnership, I was delighted to fill the gaps with long anecdotes about myself. But although writing about our life in Zambia was largely a solo effort, actually living here was very much a shared experience. At times, neither of us found being stuck out in a rural village much fun. Having someone else around to help you locate your sense of perspective when you’ve lost it, and to make you laugh (admittedly, not always intentionally) was essential, as much as was having a large bottle of mosquito repellent or a Swiss army knife. So even though I did most of the telling, I think the story was definitely ours.

Occasionally people said that they found the stuff I wrote about hard to read. I’m not sure what to say about that, other than if I had I hoped for any reaction from you at all, it was probably your anger that I wanted. That a child might die for want of clean water is more injustice than tragedy. It shouldn’t be this way, but it is, and after witnessing it, I felt I had to try and document it somehow. When you live in a small, safe corner of the world, where hunger is only ever a transient state, and the medicines never run out, it is difficult to comprehend the hardship of living in a place like this. I still don’t really get it, even after being here for a year or so. Now I am leaving, maybe only with half an understanding of the things I have seen, but also with the obligation not to forget, and to carry on working for people in Mpanshya. And I think that you have to keep remembering too.

But for now, we’re on our journey home. Two days ago, we took the train to Tanzania, and I’m writing this, my last post, from Dar es Salaam. Last year, just before we left for Zambia, we arranged a screening of Some Like it Hot to raise some funds for VSO, so it seems appropriate that we should have finished off this adventure with a long train journey to the coast (although Chas did decline to travel in drag a la Tony Curtis). So, we’ll be seeing you very soon, although after a year in the bush, our social skills are not what they were. Just humour us for a while. Pretend you haven’t heard all these stories before…

Pimm's and twins

Chris masters lighting a fire with a plastic bag















Mum visits Mulamba school

29th April 2007

Sunday morning in Mpanshya, and I am in isolation ward, along with fourteen cases of suspected cholera. The outbreak began earlier this week, and patients began coming to the hospital on Friday. I have never seen cholera before, but it presents unambiguously and is therefore not hard to recognise. One by one, the patients have arrived, clammy, prostrated and groaning. Everyone who made it to hospital has survived so far, largely thanks to the efforts of the staff, who have worked all day and night. They have kept the IV lines going continuously, and are trying to enforce infection control measures. This is not easy – patients’ relatives wander in and out of the ward, and one woman is insistent in her efforts to keep breastfeeding her baby (despite being in a fairly advanced state of dehydration). My role has been much less hands-on, but all the same, I scrub my fingernails assiduously and disinfect my stethoscope whenever I can. A dose of cholera is not an attractive prospect.

I am just leaving the hospital when a delegation from the district health management team arrives. They have displayed an unusual interest in the hospital during the cholera outbreak; yesterday they came to see us twice. One of them introduces himself to me as Mr Choongo, and asks me to accompany them to isolation. The visitors bustle round with clipboards in hand, surveying the chaos within. Mr Choongo stops by the bed of one of the female patients and interrogates her about the appearance and consistency of her diarrhoea. He considers her reply, and then pronounces that this is not in fact cholera but malaria. Having no particular opinion on the diagnostic relevance of stool colour, I nod silently and follow him as he moves on to the next ward.

Later, I find out he is the human resources manager.

3rd May 2007

It is 6am, and we are at the airport waiting for Mum, Aunt Dianne and Christine. The flight they are arriving on is an auspicious one – not only is the Duke of Gloucester on board, but Sister Sabina is returning from Poland as well. The arrivals hall is full of nuns, not just from Mpanshya, but also from the sister congregations in Makeni and Chilanga. Eventually, I spot my mother in the crowd, warmly embracing Sister Josefa. I wave, trying to attract her attention, “Remember me?” Aunt Dianne follows, trailing an illegal quantity of luggage behind her. “Isn’t this great!” she exclaims. The shabby interior of Lusaka International can seldom have seen this much excitement.

We proceed to the shopping centre, where Aunt Dianne obtains an outsized fly swatter for the purposes of cockroach control. We then board the minibus for the drive back to Mpanshya, which takes slightly longer than anticipated. Just outside Lusaka, we stop at a roadside market to buy tomatoes. Aunt Dianne purchases some inedible-looking roots from one of the stalls. I have no idea how to cook them, but somehow she manages to get the vendor to mime a recipe. Further down the road, we have a tyre blow-out when Chas accidentally hits a pothole at high speed, and we have to enlist the help of a passing cyclist to get the wheel off. I assign myself the task of erecting the emergency triangle, which is about as far as my skills extend in situations such as these.

When we finally get to the house, we are greeted by Corinna, our new cleaner, who has killed a chicken for the visitors. (Chas employed her after getting thoroughly sick of washing clothes by hand in cold water; we don’t really have enough domestic duties to justify having hired help in five mornings a week, but luckily she works slowly.) Aunt Dianne shows her the roots she bought and she wrinkles her nose in horror. Shortly afterwards, there is a similar display of disgust from the guests when they are presented with the cooked chicken. It may only have died this morning, but they reckon that it was likely to have been born many years before.

But everyone is pleased to be in Mpanshya. Chris fulfils her dream of sitting out in the African sunshine, drinking rooibois tea. Aunt Dianne, who has conducted a lifelong crusade against waste, is delighted to discover that the shredded tyre from the minibus is being rapidly recycled into footwear by the general workers. And I am happy because never before was there any prospect of obtaining a decent Pimm’s around here, and at last, this regrettable situation has been rectified.

17th May 2007

I am finishing work for the day when Catherine approaches me in the office. She asks me to see a woman who has arrived in labour. I tell her to get the nurse on duty to see her, but apparently Odesta has gone for one of her extended breaks. With some bad grace, I go to see Joyce, who is heavily pregnant and appears to have left a trail of meconium when she entered labour room a few minutes before. Despite her obvious state of discomfort, she is apologetically wiping it up of the floor.

A quick examination reveals that the umbilical cord is prolapsed. The baby is breech but still alive. I tell Catherine to run for help. I am trying to manoeuvre Joyce so that she is kneeling on all fours, when suddenly the baby’s foot falls out. At this point, it seems that things cannot possibly get worse. Then I discover that nobody actually knows where the keys to theatre are. Mr Phiri has gone to town for the day, and the only other person who has keys is Sister Josefa, who is in Poland. I stare at the little purple toes, hanging in mid-air, and suppress the urge to scream.

Luckily, the ambulance returns from town shortly afterwards, and Mr Phiri is hastily pressed into service. An hour after her arrival, Joyce is wheeled into theatre. It takes me several attempts to get the baby out, because the placenta is lodged in the lower womb, and there is a lot of bleeding when I open it up. We deliver him eventually, but still, something doesn’t seem right. There is a large sac pushing out through the wound. Initially I think it is an ovarian cyst. I am trying to replace it inside her abdomen, when I belatedly realise what is going on.

I say “I think there’s another baby in here.” The sac bursts, and a fat-cheeked girl emerges in a gush of fluid, gasping for air. We had only brought one blanket to theatre, and Esther (the midwife) is still resuscitating the first baby, so Sister Valeria (the anaesthetist) improvises with a discarded gown. I check inside again; definitely no more, so we close up.

As we are putting the final sutures in the skin, Phiri says regretfully that he didn’t bring a camera to commemorate my last operation in Mpanshya. I look down at my bloodstained gown, and tell him that there are some things I’d prefer not to remember.

Three go wild in the Namib Desert

On a mokoro in the Okavango Delta, Botswana













In the Naukluft Mountains, Namibia












13th April 2007

Chas and I are in Botswana, travelling from Maun to Ghanzi. We have travelled on many buses this week, but none quite so uncomfortable or dilapidated as this one. Chas is sandwiched between me and an enormous woman who spends most of the journey in loud dispute with the ticket collector over her fare. His misery is palpable.

I am hoping we will reach Ghanzi in time to get a bus to the Namibian border today, so that we will be able to meet Simon in Windhoek tomorrow. However, our attempts to procure a bus timetable have proved fruitless, so we have no idea if there is a connecting bus today, or whether the border will still be open when we get there. The three hour bus journey is still in progress after four hours. I slouch in the corner, watching the flat scrub go by and silently cursing Lonely Planet.

The bus eventually pulls into Ghanzi station. The only other bus there turns out to be leaving imminently for the border, so we retrieve our rucksacks hurriedly and clamber on. The sign at the front of the bus tells us that it was built in Botswana. I wonder if this is a statement of pride or a health warning. However, the journey is uneventful, until we reach a town called Charles Hill, where everyone apart from us gets off. Chas gives me a wary glance. We carry on for ten minutes or so, and then the bus grinds to a halt. This appears to be it. We climb off, and walk towards the border post. We are in the desert, and there is nobody here apart from us. Chas raises his eyebrows at me, and we both start laughing uncontrollably. Maybe this was not one of my better plans.

And then, suddenly, an enormous truck carrying assorted Volvos appears beside us. The driver leans out and asks us what on earth we are doing. We tell him that we are going to Windhoek, and he offers us a lift. We hesitate for a moment, but then we both decide that despite years of maternal advice about situations just like this, an offer of a free ride in the middle of the Kalahari should not be declined. We hang around outside Namibian immigration while he clears customs, and then we climb into the cab together and set off into the dusk.

The journey is memorable for intermittent sightings of kudu at the roadside and also for our driver’s surprising taste in music. As we reach the suburbs of Windhoek, it is late, and the disco version of “Don’t Cry For Me Argentina” is playing for the third time. But we do get there, probably in spite of my planning efforts rather than because of them. After finding a hostel, we celebrate our arrival with pies and beer from the all-night garage, and promise each other never to do this again.

16th April 2007

The alarm goes off at 4.30am. I wake up in darkness and try to remember where I am. Then I realise that I am in tent on top of a 4WD in a campsite in the Namib desert. I also recall the argument that we had the day before, when Chas wanted to stay in Sossuvlei to watch the sunset over the dunes. (Simon and I didn’t, so we made a rather rash offer to get up for the sunrise instead.) Finally, I remember all the wine that was consumed with Simon’s astonishing one-pot cuisine last night. But anyway, a deal is a deal, so I wriggle out of my sleeping bag and set about packing up to go.

After fifteen minutes of stumbling about in the dark, the tents are folded away and we are ready to drive off. I turn to my slightly dishevelled fellow campers and ask who has the car key. Apparently I do. Chas and Simon ignore my muttered apologies as we unpack all the hastily stowed bedding and rummage below the car seats. After what seems like hours, the keys are located at the bottom of my sleeping bag. We jump back into the car and drive into the national park as fast as we can, hoping that we will beat the sunrise despite the false start.

We make it to the dunes just before the morning comes. We march up to the nearest vantage point, sliding in the sand as we go, only stopping when Simon has an attack of petulance and announces he is going no further. We sit together, and we wait for the dawn. Slowly the valley floods with sunshine, illuminating the dunes with a deep red glow. We watch a hot air balloon drifting across the horizon. Eventually, Simon says "Actually, this was worth getting up for."

Abidah's party

7th April 2007

Today Bernadette and I are going to Abidah’s kitchen party in Lusaka with our colleagues Esther, Odesta and Mrs Mwale. Abidah worked in Mpanshya as a pharmacist until a few months ago, when she left to join her fiancé in the Copperbelt (to the disappointment of Chas and Joost, who still go slightly misty at the mention of her name). A kitchen party is a kind of bridal shower, where all the female friends of the prospective bride get together and present her with gifts. I have dressed in accordance with the directions on the invitation (which specifies that the colour scheme is black, white and silver) and I go to meet the others at the hospital entrance, only to find Mrs Mwale resplendent in a blue chitambala. Apparently the colour scheme only applies to the gifts. It is too late to change, so I get in the minibus and set off for Lusaka with the others.

We arrive at the address on the invitation to find that the party is being held in the garden rather than the kitchen, so we pick a shady spot and watch the other guests arriving. Soon the garden is full of women in elaborate wigs, tottering round in jewelled sandals and swigging Fanta out of glass bottles. We wait a couple of hours without anything much happening. Then some women begin drumming, and suddenly there is an outbreak of free-form dancing on the lawn. A lady in a red kaftan jigs past, blowing on a whistle. She is a vision of exuberance, apparently oblivious to everything around her her, but she suddenly notices that I have a camera in my hand. She breaks off her dance to pose for me, and then disappears briefly, returning with her friend for a second photo.

Finally Abidah is led in to the centre of the circle, her face obscured by a sheet draped over her head. Zambian tradition dictates that the bride should not look up at her guests, so she keeps her eyes fixed on the ground when she is unveiled by her elders. I struggle to follow most of what follows, but there seems to be a lot of advice given to Abidah on how to keep her husband happy, accompanied by a generous measure of illustrative hip shaking. Everyone laughs and shouts; I feel like I have stepped into a slightly bawdy cartoon. The party carries on even when it starts to rain, encouraged by the woman with the whistle, who declares defiantly “It’s not showers! It’s blessings!”

And then St Luke’s are called forward to present their gifts. I have been briefed on kitchen party etiquette, and I know that I am expected to dance before handing over my coffee pot. I also know that I’ll never be able to shake it like the Zambian girls, but I’d hate to be accused of not trying. So, under the scrutiny of our fellow guests, I dance for Abidah with my colleagues. I catch her glancing upwards as we strut our stuff, and am grateful to note that she is trying not to laugh.

Stopping TB

Acting














Dancing













Posing


9th March 2007

I am seeing a patient in the hospice office this afternoon when there is a knock at the door. I open it to find Vincent, who is beaming and clutching an enormous tortoise. He holds it up to my face so I can have a better look. He asks “Is Mr Charles here?” I tell him Chas is in Lusaka and he looks slightly crestfallen. “I was hoping he would take some snaps…” I reassure him that on his return, Chas will come over with a camera, and he goes away again, quite happy.

24th March 2007

Stop TB day. I am waving a visitor off when Sister Valeria comes over and tells me that Mr Phiri has included a speech from the medical officer in his programme for the day’s events. I tell her that this is the first I have heard of it, and then trudge over for the morning round.

By ten-thirty, I am wrestling with a wheezy baby in the nurses’ station. Although he is very breathless, the combined force of three adults will not persuade him to accept a spacer mask on his face. And then Mr Phiri appears. He tells me that he sees I am very busy, but I must come along to the celebrations and say a few words. I tell him that I have no intention of repeating my public speaking disaster of Stop TB Day 2006. He doesn’t give up. Maybe if I would just say hi to the crowd, he suggests. The idea of doing a faux-rock star “Hello Mpanshya!” is not without comic appeal, but I stick to my better instincts and turn him down.

I finish work at the hospital shortly after this, and then walk over to where the celebrations are being held. As usual, the VIPs are on a platform at the front, with the spectators sitting on the ground. I try to settle down unobtrusively on a patch of grass at the back, but the women seated next to me start nudging one another and giggling. Mr Sikazwe spots me and comes running over with his camera. I suddenly realise that because of the way I am sitting, my knickers are probably on display and I attempt to move my legs quickly to avert embarrassment. I am midway through this manoeuvre when I hear the click of his shutter. The women beside me are now snorting with laughter. Then Mr Kapembwa comes to tell me that I must sit on the platform, so I get to my feet as modestly as I can and follow him to the front.

Anyway, aside from this momentary humiliation, it is a good day. The sound system screeches incessantly throughout the proceedings, and every now and then, the stage is invaded by a wandering drunk. But the drama and dancing are great, and everyone seems to be having a good time.

30th March 2007

At 6.30 this morning, I am standing at the kitchen sink, trying to tidy up before driving into town for the weekend, when one of the mothers from children’s ward knocks at the door. She tells me that her daughter Victoria died overnight. I start to tell her that I am sorry, but she is not listening to me. She has come because she needs to get home with the body, and she wants me to help her. I agree to take her, and she nods briskly, as if we have just made a deal over transporting of a piece of luggage, and then she leaves again.

The minibus is overloaded with patients as usually, but the mother and grandmother squeeze in, one with the surviving twin sister tied to her back, the other carrying Victoria wrapped in a sheet. I drive them to Chimusanya and drop them off at the market. I try and offer my sympathies again, but they don’t particularly want them. Limp condolences don’t have much currency around here. Bereaved women seem to alternate between two states: silently busying themselves with funeral arrangements or wailing with grief for hours on end. There isn’t much space for words in between.

5th April 2007

I am in the back of the nurses’ station with Maxwell and his mother. Maxwell came to hospital yesterday, he is horribly undernourished and dehydrated. Today he looks like he is dying. Over the last month I have seen countless children in the back of the nurses’ station, and most of them have been in a similar condition. (The locals call this time hunger season.) The routine is generally the same; I will spend hours trying to locate an entry point in their collapsing circulation. I know that the amount of time spent on this effort is inversely proportional to the chances of success, but I keep doing it anyway. The mothers and I are in collusion; we are both aware that the child will die even if I find a vein, but somehow it makes us both feel better if I keep trying. It’s usually too late for the baby (what exactly am I planning to inject him with? A cure for poverty?) so we might as well console ourselves with some purposeful activity.

Anyway. Today, the cannula eventually goes in. I give some antibiotics, quinine and fluids. I ask his mother if he has been baptised. And then I leave them alone to do the last bit together. Doing these things never feels enough. It isn’t, of course, but it’s not nothing either.

Fernando

Five-a-side Mpanshya style

28th February 2007

Three years ago, St Luke’s bought a second-hand minibus in Lusaka for staff transport. It subsequently broke down on its first journey to Mpanshya. It was towed back to the garage, who failed to repair it, or to come up with a refund, despite the best attempts of Sister Sabina. By the time we arrived last year, everyone had just about forgotten this sorry episode. But inadequate transport for hospital workers remained a huge problem, and so last April, Chas was assigned the task of trying to get the vehicle (or the money) back.

This dispute was not resolved quickly. Chas made many visits to the offending garage, and every time, he came back more exasperated. The proprietor started blocking his phone calls. The lowest point came when he turned up for an appointment he had made with the manager to find that the business had relocated to the other side of the city. I think they thought he would go away eventually. But as any North Ayrshire housing officer who has attempted an illegal eviction of a council tenant during the last five years will tell you, he is not someone who gives up easily. The finale was a stand up argument during which Chas accused the manager of swindling the sisters out of their money. Miraculously, the allegation of cheating members of a religious order worked where threats of legal action had previously failed, and the vehicle was returned in something close to working order.

So, today, Chas and Brendan made the maiden voyage back from Lusaka in the minibus (henceforth known as Fernando). It could not be described as the smoothest-running vehicle in the world – the engine generated enough heat to keep the adjacent sausage rolls piping hot until they reached Mpanshya. But it got here this time, and its arrival feels like a small victory for the hospital.

2nd March 2006

Eva and Maria leave Mpanshya tomorrow after two months of making beds and scrubbing floors. They come round to celebrate the end of their voluntary hard labour with pizza and beer. Tonight, everyone is talking about the arrival of the witchfinder in the village. I have heard nothing about this, but I suppose I am regarded as the local woman of science, and am thus kept in the dark about developments of a supernatural nature. Fortunately, Joost seems to be particularly well informed on this topic. The witchfinder has already identified several people as witches, and they are being kept in his custody until they come up with some kind of payment. (Coincidentally, every one of the detainees is in some kind of paid employment while the peasant farming majority have somehow avoided suspicion.) Everyone in the village who has not yet been accused of witchcraft is now going to see him for testing – a procedure which involves having a white line drawn on your forearm while your guilt or innocence is pronounced. Not to go would be a clear admission of wrongdoing, so no one refuses. As an outsider, it’s quite funny to find yourself living on the edges of this, when colleagues whom you regarded as quite rational start re-enacting scenes from The Crucible. But it’s deadly serious for people here, and I can’t begin to understand it.

The Money

22nd January 2007

Monday morning at the height of the rainy season, and I am just emerging children’s ward after a particularly challenging round. Malaria is rife at the moment, so it’s standing room only, and the febrile Mpanshya tots greet me with the usual chorus of screams. On this ward I am the bogeyman, and I have long since learned that no amount of gentle coaxing will persuade these children to sit nicely while being examined. But an hour of restraining protesting toddlers is not a good way to start the week.

I press on to female ward, but before I get there, I am intercepted by Emmanuel, who has come out of the labour room looking vaguely worried. Jenny has just been brought in by ambulance, and she gave birth on the way. The baby is fine, but forty-five minutes on, the placenta has yet to make an appearance. She is bleeding. And everyone is looking at me.

Usually, in these situations, I like to start off by bleating that I am not an obstetrician, before grudgingly doing something, but the gravity of Jenny’s condition precludes even the briefest protest. Ten, long minutes later, I am holding the recaltricant afterbirth in my hands. (I will spare you the details of how it got there.) The bleeding has stopped, but Jenny is still shocked, and needs a transfusion urgently. She is unconscious, so I inform the relatives, thus provoking a heated quarrel between her Catholic granny and her Jehovah’s Witness mother. I stand in the corner, watching despondently as the debate proceeds. My resuscitation efforts are about to be scuppered by some obscure piece of theological hokum. But luckily Rome wins. It usually does around here.

31st January 2007

Today, our CD4 counter is working for the first time. It arrived three months ago, and has been sitting in the corner of the lab, draped with a tea towel, unused. Our donors neglected to buy us a vortex mixer, so we had no way of processing our samples for analysis. During this time, we have been sending samples to Lusaka for testing, an unsatisfactory arrangement which generally yields about one result for every three samples dispatched. So most of our decisions we make about our HIV patients are based on educated guesswork, which has its limitations. But no more. The vortex mixer has arrived, and the tea towel has been cast aside. Flouting infection control regulations, and causing mild alarm to Mrs Mwale, I dance into the lab bearing the tray of blood samples. This is real progress, a good day for the ARV clinic.

1st February 2007

Last week, I admitted an elderly man by the name of Cement. He has a multiplicity of medical problems, including, I think, a collection of fluid at the base of his right lung. I asked Elias to X-ray him a couple of days ago to confirm this, but the film he produced only shows the top half of his chest so I am none the wiser. (This is not entirely the fault of Elias; for months now, we have only had comically undersized X-ray films in stock, so imaging an adult chest in its entirety is a tall order. I have protested about this to Sister Sabina, but she insists that these are the only ones available in Lusaka. So, for the time being, I am stuck with peering at tiny, smudgy X-rays, which more resemble Monet miniatures than anything to do with human anatomy.)

Rather than sending Cement back to X-ray for a complimentary film of his lower chest, I decide that I will confirm my suspicions by trying to draw some fluid off his lung with a needle and syringe. I am slightly disconcerted to find that only air is coming out. But there are many more patients to see that morning, and I move onto the next one without giving it much more thought.

Shortly afterwards, Mr Phiri comes rushing through to get me. He tells me that Cement is having an asthma attack. He is in a bad state when I go back to him, hunched over and gasping for air. I check his windpipe and, finding it deviated to the right side, I realise that I have given him a tension pneumothorax. This is a medical emergency, and I have only a vague recollection of the physiology involved. I know that I need to stick a wide bore needle into his chest to relieve his breathlessness, but in my panic, I can’t remember in which side it is meant to go. Eventually I decide on the right, and as I sink the needle in, there is a loud hiss of air, and he is breathing normally within ten seconds. Much relieved, I then set about making an improvised chest drain with a suction catheter and sticky tape. Throughout this debacle, Cement and his wife keep thanking me for all my attention, despite my attempts to explain that I actually caused the problem in the first place. It just proves that the second inverse care law is an international phenomenon: the more disastrous your interventions, the more paradoxically grateful patients tend to be, everywhere in the world.

2nd February 2007

Chas comes home from Lusaka late this evening. Joost and Bernadette are round at the house when he arrives, spilling out of the back of the overloaded ambulance like a veal calf escaping its crate. He had a meeting in town today with a representative from a medical charity to discuss his eye clinic proposal. We ask him how it went, he makes vaguely positive noises, and then we talk about something else.

Later, when J&B have gone home, I ask him again how the meeting was. He is much better at feigning nonchalance than me, but he can’t keep it going any longer. He fails to suppress an enormous grin. “They like it, and they’re going to fund it.” No polite refusal this time. This project, which Chas has spent more time on than anything else in the last year, is going to happen. It is too good for our own words, so we celebrate by reading aloud the new Oor Wullie annual (recently arrived, thanks Henry and Sheena) over large measures of whisky.