Riding on...

Sequel of an episode started a long time ago in Malawi.
This is one of the final stages in the creation of MOMOCO i.e Malawi Orthopaedic Manual for Orthopaedic Clinical Officers. Interestingly it has been rebranded since as "Orthopaedic Care at the District Hospital".
The very last Malawi Ulendo blog will surely have to be about the epic journey that that was... Watch this SpacE!


CYCLE-RADIO 101! presented by Ashtin Doorgakant
EPIC BIKE NEWS FROM SADDLE-SORE ASH

Dear friends and family,
After some three months of serious training, interrupted only by overriding commitments such as those related to the book or on calls, my efforts have finally paid off. Literally! As you know, yesterday I rode the Shropshire Mynd… with the sense of awe it deserves. I’ll be honest, I never realized the beast that lay ahead of me until my penultimate training session. To those familiar with cyclo-jargon, that ride covered a whopping 75 miles with 4000ft of ascent. And that certainly took its fair share of teeth-grinding out of me. What I was going to reckon with next would be a 101mile mammoth, with over 7000ft of ascent. Take the second figure out and I could do that in my sleep any day, with that training. Put even half of 7000ft with 101 miles- you’re talking proper cycling. Not to blow my own trumpet, completing yesterday’s ride represented the “pinnacle” of my cycling career! The focus suddenly shifted from trying to get the best times or best stats on Strava . This time, it was about pure survival, i.e. being able to cross the finish line. And oh! did I think I wouldn’t make it after I bonked at 40 odd miles! I was told that this intense feeling of helpless hunger and heaviness didn’t tend to happen until at least two thirds into the ride. But here I was at the start of Kerry Hill, the longest-drawn of the entire event, which would stretch out for a good 14 miles, feeling like I would not last a single more. But before I knew it, the gradient let up and my energy bars kicked in. There has never been a more noticeable second wind in my sporting life…
The pun was intended here to introduce the concept of the weather in this, so far, fairly benign-sounding excursion of mine. But such was not to be my luck, especially if I had to demonstrate a certain element of hardship in order to rightfully earn the support of my sponsors! Not only was there rain for 75% of the entire ride, but it was of the very horizontal lashing quality at times, creating a particularly obnoxious glaze on my glasses, let alone when combined with sleet. Gale force winds would introduce yet another level of difficulty, with a certain predilection for the most inappropriate spots, that is the steepest climbs. There were those that went up to gradients of 20% and I wish I could claim never to have put a foot down but, being a mere human, I did so twice. But it was only 1 foot, while I paused. The second foot remained clipped in, waiting, eventually urging first foot forward again, not allowing there to be any walking- that would surely be cheating in a cycling event! That was the last drop of dignity left in me on those maliciously vertical sections. The last one of those unfortunately would not appear until well into the last 25 miles, giving my already depleted legs and back yet another bit of soul-searching to do in order to muster the strength to come through in one piece! The tail wind we were promised for the second section sadly never materialized!

… But here I am 24 hours later relating that story to you with a certain fondness! We’re all masochists on them 2 wheels! It’s as if I completely forgot how I came off at full speed twice, having misjudged the bend in the road and the limits of tyre-road friction. Escaping unscathed, miraculously. It’s as if I didn’t care about plodding on for 8 hours with cold and wet pants and socks. It’s as if I’d completely forgotten the desperation with which I awaited every distance sign to tell me I was that bit closer to the end! It’s like I hadn’t kept reminding myself throughout that “YOU HAVE TO FINISH THIS TO BE WORTHY OF THE SPONSORSHIP”, knowing full well it wasn’t true!
Yet, in the end, these are the very emotions that contrived to make this experience so amazing, and that added to the elation and satisfaction of completing it.
I owe you all a huge thank you for your support in this endeavor. Beyond the emotions that I’ve described in this “bike-blog”, no other could have kept me going more than the knowledge that so many people were behind me on the day and had faith in me. That’s you. But really, I needn’t to look far. Having been served the best carb-loading feast the night before and having the mightiest porridge delivered on a plate for me on the morning of the ride by Janet, while Nina put on her best behavior for me, is enough to remind me how lucky I am. I’m indeed lucky to have such a great bunch of people around me. This is to YOU ALL!
Thanks
Zikomo Kwambiri
Mersi Bokou

(Fundraise update: £1500 raised so far [less GiftAid]
The site remains open for another month if anyone’s missed the race deadline but still wants to contribute
http://www.justgiving.com/ashtin
If all goes according to plan, the book will be ready for release in Malawi next week- there will be a free e-book in due course. Look out for it: Orthopaedic Care at the District Hospital)

Malawi in the news (previously unpublished)

(purely my views, accurate or not)
Malawi is rocking the BBC world service station as we speak and this is owing to a rather unexpected uprising of this usually extremely tolerant and patient people. The reason why it’s come to that (riots) is clearly that the critical point has been reached in the system, and as with any system, the valve has blown eventually. But let me tell you, one could see this happening a long time coming.

The president of Malawi, BWM, according to locals, seems to have embarked on a delirious mission since his being elected with a majority government for his second term in office 2 years ago. With that absolute power came absolute madness, with which he has implemented a series of controversial bills, without consultation. As I witnessed all this happening since my arrival in Malawi, I couldn’t help thinking “why is no one protesting about this or that appalling state of affairs?” The first few weeks since my arrival saw a state wedding for the ageing premier, with a royal banquet for 5000 guests being paid for by tax payers! All this amidst the most flagrant publicity, with ‘invitations’ even being sold off to the public. From then on, every single event relating to the president has been similarly surrounded with pomp and public praises from various parties in the local media. That was a most bizarre observation for me, indicating a certain fear among people who were overly cautious not to go out of favour with the main man. These events included Bingu’s award for a professorship from some dodgy Chinese, then Indian (can’t afford to lose ground to their communist neighbours!) university. Bingu also won some international award for best agriculture minister, which filled up the newspapers with praise messages from all his government departments (I wonder if the money for these actually came from the respective ministerial budgets)! Bingu then released a book (The African Dream) a couple of months ago and that filled the papers with similar tributes... except that this time some papers actually starting publishing less flowery articles on him too. That was no coincidence since early this year, Bingu announced a new law empowering the information minister to shut down any newspaper which he judged not right for the nation (amendment of Section 46 of the penal code)! Interestingly, the newspapers had already got a chip on their shoulder mid last year in an earlier attempt from the president to thwart them. He circulated an advertisement ban throughout his ministries to boycott the Nation publishers company (this is a newspaper that attempts to give a balanced picture of the reality in Malawi, while government owned TV and radio fill the population up with trivial functions of such and such minister). It came as no surprise that with the president’s popularity declining, the papers took the opportunity to have their own back.

Now let’s go back to the tirade of abuses of power that have accumulated in today’s overflow. Soon after state wedding came a saga about the flag, which I cautiously made reference to before. Almost everyone I know in Malawi thought that the idea of replacing the national flag was preposterous. If it ain’t broke don’t fix it! But Bingu insisted the country needed to revamp its image and that the new flag with it sun turned white and whole in the middle would represent the economic progress from the days when the sun was red and on top (very similar to a former ruling party’s emblem)! So despite widespread calls, including from the church, to refrain from this unnecessary waste of public money, he went ahead and changed the flag anyway around July last year. It has been the rumoured that the contract for providing the new flag was attributed to one of his relatives. Soon after that he realised that his name was no longer up to date on the countless portraits of him hanging in pretty much every office of every public building in Malawi. He was now no longer simply Ngwazi Dr Bingu wa Mutharika, but had become Ngwazi Professor BWM and all these frames should be amended accordingly! Maybe that was the reason why he also decided to upgrade from 1st class VIP status passenger to actual private jet owner instead...

Meanwhile the new Mrs Mutharika wasn’t staying in the shadows as she leapt into the limelight as the champion of the new Safe Motherhood campaign. Of course such philanthropic gestures are most welcome here, until it leaks out 10 months later that our magnanimous benefactor was going to be awarded 9million Kwachas in arrears for her “charitable” work! Meanwhile also, other reports of corruption were being announced, including allocation of land titles to his brother (tipped to be his successor) and other close associates for massively discounted prices. By then, the vice president decided she’s had enough and splintered off to form her own political party. Smelling competition and a threat to his now established autocracy, Bingu began to obstruct her, by slowly but surely withdrawing priviledges of office to her, while simultaneously cutting her budget off. That surely set the wheels in motion for civil society leaders and the opposition in getting today’s protests so remarkably finetuned.

But of course, one knows that such events described so far merely amount to petty corruption, which is widespread in bottom billion countries, and don’t normally give rise to such uprisings. So what’s happened that’s caused the balance to sway this time? Well the answer is I think in this sequence of events. End of last year, a national scandal arose as a university lecturer got arrested for using the example of the Egypt uprising to illustrate one of his political science lectures. This information got leaked by a police student implanted in his class. He got summoned by the Inspector General of Police, incarcerated without charge and eventually released. That caused a furore among university lecturers, who saw this as a direct threat to their academic freedom and demanded an official apology. As this never came, but instead further insults from the defiant premier, more than once, they organised protests. These got stopped by the police and a new billed got speedily drafted in requiring a payment of 2million Kwachas and a long process of police approval in advance for any public demonstration. The lecturers now had to resort to strike action. Bingu retaliated to that by closing 2 of the main university colleges. The status quo got maintained for months while the suffering students grew increasingly irate and impatient.

Seeing all this and Bingu’s persistent attack on homosexuality (since he was forced to pardon the couple having staged the first official gay wedding in Malawi), the British envoy to Malawi criticised the president for failing to uphold democratic principles in his country in a leaked cable. Bingu was particularly incensed by this remark and summoned the envoy to give him a piece of his mind. He was declared persona non grata in Malawi and packed his bags back to the UK. As it is with these childish disputes, it became a matter of tit for tat and Britain retaliated with all its superior economic might by suspending all aid to Malawi (the big bully decides to twist the neck of the little boy who scratched him in the schoolyard!). The implications of this decision have been catastrophic to ordinary Malawians. In a bid to stand on their own 2 feet, the Malawian government (rightly or wrongly) decided to pass an austerity budget last month by filling up for the deficit left by the donor shortcoming with increased taxes and reduced public spending (including ministerial ones). It is said that 40% of Malawi’s budget is provided by donor grants.

Now Malawians, who mostly live on less than $1 a day, are being made to pay more for their bread, milk, salt, water, sugar and other basic commodities. At the same time, the economy has been performing pretty badly (for a number of reasons attributable to both the government, foreign investors in Malawi and the international community, to remain impartial on that one) and the last few months have seen some pretty dire fuel shortages causing a lot of angst across the board. Instead of owning up to his government’s part in this crisis, Bingu again denied all responsibility and laid the blame squarely on others. A rather disenchanted population, as we now were clearly getting, didn’t need much to be pushed into a coordinated antigovernment protest by the opposition, on the very day that the president thought of coaxing the population further with a “public lecture”.

So Malawians took to the streets today. And met with a lot of resistance. And, as with all riots, there are bad seeds and these are intent on vandalism. The government, pretending to be primarily concerned about this, resorts to desperate measures to quell the situation and inevitably aggravates it- sending out threatening messages, banning live coverage through the media, shooting teargas and bullets at crowds etc. But this is the moment for Malawians. It has happened in Tunisia, Egypt and Libya (partly). It is now time for it to happen for the first time south of the Sahara (Uganda wasn’t a national protest). Good luck Malawi. All the best to all you amazing Malawian people! May history be on your side.

Back ‘Home’

Long delayed finale..
Lots happened since I wrote this piece for VSO 3months ago..
So much that a finale redux might be in order...
Till then this is it!

Home is where the heart is they say. My heart is my home however. And my heart finds it challenging to suddenly let go of a place it fell in love with. Especially after a 2 year divorce with its former partner, going back to it can feel somewhat counter-current… a necessary sacrifice. It only takes a day to realise the causes of that divorce.
Coming back to the UK has been no honeymoon. The way in which it had to be done also did nothing to ease things. I had to bring forward my flight from the booked date to accommodate 2 interview dates. Both fell in the week just preceding it and I only found out about this some 10days earlier! The opportunity to get straight back into a training job in the UK after 2 years abroad felt incredible. I chased documents and references frantically in my last few days in Malawi. I wrote reports and worked on new things to add to my CV constantly, essentially consolidating my 2years in Malawi in the space of a week. Janet and I had to vacate the house and send whatever savings we had back to the UK. We held a massive house clearance sale, essentially giving away or selling every last bit of stuff we had less our packed suitcases. It was truly like a boxing day sale at Next! Of course, we also had to say our farewells to all our friends. We had to get a police report at short notice on a rainy bank holiday. We had to plan ahead of where we’d be staying in England and how I’d get to the interviews. It was one finely tuned machine of a life in operation that needed all the components to work optimally. With our experience of the unpredictability of things in Malawi and the excessive bureaucracy that normally accompanies all official matters, we thought that nothing short of a miracle would be required. I look back and realise what a miracle it was that got me and Janet here in one piece and ready for that interview. A miracle and a hell of a sleep deficit.
Thankfully the first interview went well and I got offered the job before my second interview was due. What that meant was a massive sigh of relief and a chance to organise our lives again before the job start date. I had 3 weeks to get back to some sort of normality here and thought I’d use it to relax and travel a bit. Once I started sorting things out, I realised that even 3 months rather than weeks wouldn’t be enough to get ALL of it done. The list seemed to get longer everytime I got back to it to assess the progress. The first priority was to find a place to live. With Janet working in Oldham and me in Chester, we had to find a place as close to the midway position as possible to allow both of us to commute within reasonable distance and time. Affordable furnished places to rent were so limited that we had to hold our breaths till a few days before our work start date and only managed to move in the night before! With a broken down boiler! But all it took to steel ourselves to the challenge was to recall how luxurious even this situation would have been in a Malawian context. In that time, we also had to sort out things like getting our car back on the road, our bank accounts working again, a new phone, computer and internet connection to name a few. All these things you normally don’t see as a big chore in your day to day routine. But that’s because you normally take your time to do them and you don’t need them done all at once and asap! On top of that, that bad old friend called British paperwork made its reappearance in force to us with all the pre-work checks that had to be done. I never thought I would say that but I missed the Malawian style, albeit much less efficient, of shortcuts. But there I was, getting used to being back in the UK. The saving grace was that I had been mentally prepared for it. So I simply got on with it.
All this was to be merely a taster of what it really takes to settle into a surgical job back in the UK. Since starting work in Chester, I have effectively gone off the volunteer link radar, with so many things taking priority suddenly over it. Once in a training job, a whole new string of responsibilities come with it and pretty much every day and evening, there’s something to read, write or research. Of course, that will ease out with time, but with the extra prerogative of relearning the job and catching up with latest developments I’ve been cut off from for 2 years, I cannot say I didn’t expect to have to bury myself in books for at least 6months.
But the whole experience is really rewarding. I view it as part of the whole volunteering experience. To say 2 years in Malawi is an understatement. I’ve already been doing this for 3, if you count the year of intense preparation that I went through before flying out and expect at least another till I can feel reintegrated properly in the UK. And then of course, I have built up a working link with Malawi as well now which I very much intend to revisit as much as my work and life will allow me to in the future.
And now to conclude, just generally on ‘life’… Life in the UK. That can mean both an exam that foreigners need to take to get British Citizenship or in my case, a life test that British Citizens have to take to get back to their normal lives after living in a developing country for 2years. It’s certainly not the most positive experience of all. It involves a serious infatuation with the colour grey and a suppression of certain human behaviours that attract the wrong sort of attention… like saying hello, how are you and how is your day going to people! I miss that about Malawi very much. Alright there were loads of challenges in human interaction and indeed so many aspects of it are, in my opinion, better here like women’s rights, gay rights, accountability etc. But at the very basic level of communication, the common denominator for mankind, which is greetings, the warmth and naturalness of Malawian interaction is something I would really like to see imported here. I miss the blue skies, the fact that a rainy day doesn’t mean a freezing day on top, the fresh fruits and vegetables, the joie de vivre, the “craig” of Malawi. But I’ve done my time there. I’ve lived it to the full. I’ve achieved what I went there to achieve. And it’s time for me to move on. Good memories it has left me with and I will cherish them forever. Wherever it is I end up, I will keep these memories and invoke them when I need a bit of heart warming.
Tionana Malawi. Ndidzakusowa! (Till we meet again Malawi. I shall miss you.)

Clinical Digest16 A retrospective

It feels strange writing this blog now and thinking back at the time I first set foot in a hospital in Malawi during this placement. Trying to link it all and witness this incredible journey and the transformations it has brought both to my personal and professional life. Trying to think about the impact it has had on the people of Malawi, and beyond if any. Trying to think of other ways I could have done it. Trying to summarise what the Malawian health care system is really all about and what the future has in store for it. Ultimately trying to work out if my presence here has overall been beneficial or not. I might not be able to answer that yet, because for the retrospectoscope to work best, time needs to elapse. Right now my subjectivity and sentimentality about leaving soon will no doubt introduce a certain bias. But lets try anyway.

Lilongwe- 6weeks

When I look back, this was one of the most fascinating times in my entire medical career. It spelt a complete new start, clean sheets, the beginning of an era. The mix of uncertainty and excitement was almost toxic, yet I’ll admit, somewhat intoxicating too. I’m sure that this wouldn’t constitute most people’s fix but for me, there was a certain thrill about deciphering the meaning of all of it then that kept me going. I found myself in areas I had not ventured into for months if not years, like the urology theatre or the labour ward. I found myself doing circumcisions and Caesarian sections. I found myself finding operations I would rarely see in the UK suddenly becoming routine, like limb amputations on young adults, sequestrectomies and bone drillings. I found myself in a maze of new pathology, using an almost entirely new medical vocabulary, approaching management from a totally new perspective. I was making a choice to unlearn some of the rigid set ways of doing things as I used to back home so I could integrate into this new system. It was intense and challenging but it was with one safety I would soon leave to enter the wild world beyond: consultant supervision.

Ntcheu- 1 year minus 6 weeks

My first day at work in Ntcheu. Surreal. A week’s orientation visit during my in-country training did hardly anything to lessen the shock. I was now an official employee about to work alongside everyone rather than a mere observer. I had to get to grips as quickly as I possibly could with all the intricacies of this new world so I could start operating within it. Lilongwe I found out was a very far cry from it. It gave me a good flavour of the Malawian health care, but had very little in common with the district setting. I would soon be reminding everyone about this so they don’t get misled by their placements in central hospitals that this is the standard of care most Malawians are receiving.

Ntcheu, my new workplace, opened my eyes to many challenges and led me to develop new skills to tackle them. For the first time ever, I would become a departmental manager, a data collector, a policy maker, a networker, an inventory maker and a procurer. I began working alongside maintenance to repair, improve and create equipment we needed. I became an advocate for improved sterility standards, almost in the style of the notorious infection control nurses I used to scorn at in the UK. I learned how to talk, present and teach in a completely new way, one which would make sense to Malawian students. I did all the usual things too, like ward rounds, theatres, clinics but developed a completely different approach to fit in with this entirely alien setting. I realised the need to balance efficiency with practicality. Never has the expression “more haste less speed” seemed more true. I slowed down, became more flexible but made sure to maintain my standards in the context of the hospital. I had to accept certain failures, but only if I could use them to change things so they wouldn’t happen again. Teaching by example became a very important philosophy of mine. I wish I could have done so without ever losing my cool at the heights of my frustration (which I won’t hide), but then that would be claiming to have cracked one of the most complex challenges of Malawi within a single year. In all truth, a lifetime might be too short.
Ntcheu, because of all these things, was my first in depth insight into the Malawian way of doing things, which would help me adapt my style to fit in better with the healthcare system, thereby enhancing my impact on it. Ntcheu, no longer so alien anymore, reshaped me for the better. Ntcheu prepared me for the journey ahead.

Blantyre – 1 year

This was in a way my graduation into the higher strata of tropical orthopaedics. Whatever little I had seen in Lilongwe seemed a long way back, and whatever I’d done in Ntcheu was a long way from this level I would be diving into. The learning curve was vertical, exponential, dizzying to say the least. My 2 hour lunch breaks were shrunk to minutes. My evenings of leisurely reading and work preparations were to make way for some of the most hectic calls I’ve ever done and assiduous reading about new operations and approaches. My very much self motivated presentations about topics of my choice to general clinicians and nurses were alchemised into specific lectures to medical students, trainee orthopaedic clinical officers and other doctors. My research imperative was cranked right up. With internet at work, no matter how intermittent and temperamental it might have been, I was able to get much more done in much less time. In addition to this Blantyre was also a city where I would be able to run projects on a different scale, with readier access to partners and resources. Hence I got the tricycle project going, thanks largely to your very generous support. I also got specialised splints made for traction patients, again with the help of sponsors from home. And above all, I got things moving like I could never have done in Ntcheu for the one biggest project of all: the editing (and future printing) of the Orthopaedic Resource Book. Right now, I am engrossed so much in this project everything else suddenly seems to have been put on hold. It is by far the biggest undertaking I have ever dealt with and its completion here or back in the UK will be my single biggest legacy to Malawi, in the name of my VSO placement.

All my time in Queen’s has also consisted of the bread of butter of orthopaedics naturally and on a scale that puts a lot of my previous work placements to shame. My operative logbook has benefitted from no less than 300 new cases, a lot of them being ones I would not have been able to perform before arriving in Malawi. I have received some of the best supervision ever from truly dedicated consultants here, both permanent (Dr Bates & Prof Mkandawire) and visiting, adding further to the wealth of that experience. My calls have brought me face to face with many socio-economic realities of Malawi: the political riots, the poverty that resulted in many patients presenting late with inadequate primary care, the fallen down houses and walls during the rains, the extra-ordinary motor vehicle accidents, to name a few. I became very much a frontline trauma doctor with a new sense of cool I will always be grateful to Queen’s for. My ward and clinic duties have assumed a higher level of responsibility which should see me evolve much more smoothly into registrar training once I get back to the UK. Beyond teaching, this notching up of my seniority has earned me the honour of presenting at some fairly high level fora such as the COSECSA (College of Surgery of East Central and Southern Africa) and Surgical Association of Malawi annual meeting, as well as the AO training for the Malawi Orthopaedic Association annual meeting.

I conclude this clinical digest feature today (having as yet failed to produce one on the complexities involved in dealing with convicted patients in Malawi) on an exceptionally high note. My 2 years in Malawi, and particularly my year in Queen’s haven’t completely gone unnoticed by my colleagues. Thus today I had the nicest sending off I have ever received from any workplace. The whole department gathered to say thanks for my work done and to wish me well in my future pursuits. It felt like a real tribute,indeed an epitaph to look back on, when doubts may arise about whether I made a difference or not. I know at least, I’ve touched my colleagues and, through them, I can be pretty sure, my working environment too. But above all, let me say this: it me who has benefitted the most from this incredibly rewarding time I’ve spent in Malawi. I’ll be a new person, a new doctor when I get back home.
Thus, today’s final review of Malawi signals more a new beginning to me than a conclusion...

TOP 10 MALAWI

Slowest internet connection ever today... photos will have to wait a bit!Happy Christmas to ya'all!
(chronological)
Lilongwe 6weeks
My arrival in Malawi. Simply awesome. No time I look back upon compares with this period in terms of the pace of learning new skills, insights, ideas and expectations for the 2 year period here. The feeling of awe and excitement of being in this strange new country without knowing exactly how it’s going to pan out is one that can only be experienced, not described. Stranger in a strange land, with one difference. A very willing stranger.

Everest night out with Dutch students
This episode never made it as a feature on my blog, probably because I was too dazed for too long afterwards to write it up. Now is the time for it to receive its rightful accolade. For anyone who remembers the Carlisle church flat, one will remember how it’s the amazing parties it hosted (Knocking on heaven’s door, Heaven&Hell and Trilogy) that raised it to the legend status it still now boasts in our collective memories. For Ntcheu, it will certainly be the Everest nights out that will occupy that space. To be honest, it was probably a Friday night like most others in the Everest night club in Ntcheu. But somehow, it combined so many elements which, when mixed, gave the perfect cocktail. First ingredient of course was the novelty. Novelty always dies out, but then it was still fresh and exicting. Then came the build up. All good parties have a prelude. That night out had been orchestrated for a good few days and everyone discussing it at work that morning. Last but not least, the company. It’s rare for all your buddies to be around at the same time in Ntcheu. At least 1 person usually has a wedding, funeral, family trip of some sort or other thing going on in the home villages that they have to leave Ntcheu to attend. That night everyone was there. And what more, we had visitors. Special visitors. Everyone loves visitors in Ntcheu and the rest of Malawi too. 2 wickedly friendly medical students from Holland was one rare treat for the local crowd at Everest and it certainly got everyone one partying like there’d be no tomorrow that day. For my part, I was totally absorbed in the vagaries of this new culture and was quickly substituting one form of dancing (salsa) for a new one (local stylee)!
This one goes out to Craill and Nicorr!

Nyika trip with Janet (bike ride)
When you find out a few months later that the trip you’ve just been on actually features in the “Rough Guide to the planet- 1000 things you should do before you die”, you simply lick your index finger and draw a tick in the air! Nyika, Rough Guide or not, was the trip of a lifetime. The journey (but then again very much the destination also) was what made it. My first steps into the wild north were simply amazing. The different sceneries, villages, climate and people, not mention the fact that Janet was over for her first visit made for a holiday spirit that’s hard to match from our existing repertoire. To top that up with a ride on one of the highest, most idyllic plateaux of Malawi (often compared with the rolling hills of Scotland) on mountain bikes that worked elevated it to one of the top rungs surely of this retrospective blog today. When I dream of escapes from reality, Nyika lives on as that place I once visited that I would happily never want to come back from.

SAafrica
Okay, this one is not truly Malawi, but it encompasses a lot of Malawi and it would most certainly not have happened had I not been in Malawi at the time: Ayoba time in South Africa. Journey beat destination again. The start of it all was not surprisingly at Everest night club for that legendary launch concert (Black eyed peas, Shakira, K’naan). The spirit then just got better and better by the day. By the time I was on that epic bus journey, I was already in the zone. Then came the border crossings through Mozambique, Zimbabwe and Beitbridge in SA. Awaiting on the other side was the best football company ever- me bro Su, cousin Randhir and other friends and family. Roughing it in Jozie before a smooth finish at Cape Town was simply amazing. The utter football party spirit that reigned supreme is only possible for a world cup I think. But South Africa as a whole was a treasure I had not expected it to be. To say that it has whet my appetite for further exploration would be an understatement.

Lake of stars (both)
The 2 blogs already dedicated to this event attest to the sheer grandeur it boasts in my mind. Hence, I shan’t go on much more about it, but to say that this festival is not just the best I’ve been to in Malawi but certainly in the world too. I might not have done Glastonbury yet but this mixture of good people, good acts, good weather and a simply magical backdrop is definitely gonna be hard to beat.

Thyolo walk with Matt and Bex
Aloha Matt ndi Bex! Guys you simply treated us to one of our best walks ever in that post-apocalyptic period we were treading at the time. ZK! The lush green carpets of Thyolo tea estates were revealed to us in a way simply not given to outsiders. What with Mulanje lurking majestically, yet discreetly in the distance. Our passport into the estate was Matt who must have had the coolest VSO placement working there. No nook nor cranny seemed unknown to him and with him as guide, we were in for a treat. Out of this world!

Kamba
Now this one is an insider affair. It’s the bottlestore par excellence of Blantyre. It is a shack to be honest. But it is the closest thing to a good old old-man’s-pub Malawi can offer in my wide experience! Your local crowd in there ain’t the usual yobos and trouble-makers but a rather elite group of men (even in such a place the women haven’t made it yet) from different walks of life with a somewhat intellectual slant. The name “Silvergrey” kind of gives it away when I look back. This is the sort of place you have to be taken along to by an insider as otherwise you would simply walk on by, without ever being tempted to go in. The Friday night post-work sessions I’ve enjoyed in there with my mate Chris, topped up by the full on Malawian-style pool rounds, will live on sweetly in my memories.

Mulanje (the Lujeri trip)
This one again has it fair share of dedicated entries to its name. Its omnipotence in the Malawi skyline is on a par with the place it occupies in my consciousness. The one trip that remains most etched in my memory of it has to be the utter physical challenge we undertook on a short weekend to get up in and down in 2 days while bagging the highest point in Malawi- Sapitwa (literally “don’t go there”). That was the May trip to wish farewell to our Norwegian friend, Tor, great companion of ours in this Malawian journey. Little did we know that in his pre-retirement period, his legs were very much still at work like a Klipspringer one might say, in remembrance of this rare sighting we made during that hike. The combination of sceneries from the Lujeri tea estates, through the mountainsides, plateau and peak will be my live equivalent of the Shire in “Lord of the Rings”!

Monkey bay surprise boat trip
And this one will go down as my live equivalent of the beach scene from “The Beach”. Having decided to divert from the classic tourist trail that invariably ends in Cape Maclear, not out of choice so much as out of vehicle incapacity, we found ourselves taking the path down Monkey Bay with both Janet’s and my parents for a bit of discovery. To arrive just on time for the impromptu boat ride that was leaving the backpackers where we were putting up at was pure and serendipitous luck! Nothing could possibly have been a better welcome than this after a long and sweaty car journey, considering food and booze were to be found onboard too! My excitement would be manifested as manic backflips and rooftop dives from this party boat, but there was definitely something for everyone. Both Purcell and Doorgakant progenitors I’m certain will testify to this with the incredible lakeside landscapes, close up sightings of Pied Kingfishers and Fish Eagles and pristine waters on offer!

Boadzulu island trip
Back to the lake for this latest top-tenner of our Malawi sojourn. This was a truly personalised and magnificent send off from our friend Neville Bevis, director of the Open Arms Orphan Care that he runs with great passion. How our paths met typifies the way the greatest travel friendships start, that is a chance encounter. We were picked up by him some 4 years ago on our first trip to Malawi as we were walking back at dusk to our lodge located next to a township. He thought this unsuitable for us to do given the number of recent muggings of foreigners in that area. We exchanged ideas during that brief encounter and they must have been good ones since we have kept on exchanging them since. Our year in Blantyre really brought us closer to him and his Malawian partner, Enipher. To wish us goodbye in style, he invited us for a trip aboard his catamaran to an island off the Mangochi part of the lake, Boadzulu. To sum up how amazing this was, try and conjure up images of pelicans and terns, a cliff-side colony of cormorants, beautiful clear waters that felt warm as you swam through them and just stretching out in the breeze with a drink to savour this fabulous environment. Contentment in Malawi cannot be said to be complete without a last tribute trip to the lake. That one will certainly live up to the occasion.

Cross cutting themes (to use a perfect VSO jargon):
Meeting people and expanding world view
Today’s blog even surprised me when I read it back, as I noticed how intricately linked it was to the people we’ve met here. One can safely conclude that without the human factor, much of the above list wouldn’t have made it to the top ten. And likewise, with a good human vibe, rather dull moments can be transformed into memorable ones. The people we have included so far have been mostly fellow foreigners like us, with something in common, be it our desire to learn this culture in Malawi better, to work on restoring some balance in the world or indeed, a shared love for birds and animals. But what I don’t want to leave out just because we don’t go on trips with them are the unique and amazing people of Malawi. This sounds cliché and I won’t dwell too much on it for fear of reinforcing that cliché with more cliché words, but I have come across a form of friendliness here that I’ve never seen before. Although some of it has undoubtedly been out of self-interest (associate with the “rich” and you’ll get something), I am quite confident that most of the time, this welcoming attitude was genuine and truly selfless. Malawians have taught me lessons in humility, generosity and joie de vivre I will never let myself be distracted from again. Poverty, as has been proven here, is no obstacle to the achievement of these core human values.

Birds, animals, wildlife at so close range
A cursory glance at my blog so far would have given it away without me having to dedicate a special section to it today. Suffice to say that I have graduated from a Planet Earth documentary fan to a real field admirer of wildlife through Malawi. My appreciation of the delicate balance required to maintain such beautiful biodiversity has really been refined over here. The constant confrontation between the (allegedly) highest member of this ecosystem and the other members is clear to see. Developing a true love and knowledge of birds and mammals and fish and trees has brought me into an intimate relationship with the world where the concept of respect can stand out supreme. Respect surely can have wider applications.

...And that’s not even mentioning the joys of Zomba, Chilwa, Majete, Liwonde, Gongonya village week in Madzanje, the Blantyre arts festival and fantastic times with loads of other friends for life: Klaas and Gerdien, Sajir, Hanna and Raz, Helen and Mike, Marieke, Liora, the Bates etc.

Clinical Digest15 Cutting

The blog Not Made in China produced the desired response (largely due to its controversial nature). The controversy was without a doubt about Gaddafi and I deliberately did it and I'm glad I engaged some minds in debate. So I'll start with a little disclaimer to clarify my thoughts on him. I'm no starry eyed fan of no ageing dictator who's held on to power for far too log (even 10 years is too long for me), with an appalling record on human rights. But lets face it there is no leader white, black, yellow or brown worldwide that can claim a clean record. Western leaders often get praises for the good they've achieved (such and such peace deal or economic prowess) instead of being forever damned for their records on arms trade, secrecy, covert human rights abuses, economic subjugation of the world etc. So make no mistake about it (Bushism!), Gaddafi is no angel but he's one guy who has stood up against the unjust global power system. He's literally torn the UN constitution in a statement that's been mocked by those it blamed for maintaining such a fake global democracy. He has pulled Africa together across tribal divisions more than any other living person and formed the albeit flawed African Union. And if even Mandela sees him as a friend (he was a major international driver in the overhaul of apartheid in SA while Western leaders were still pontificating on such and such legal loophole!), lets place credit where it is due. Cause if we can give it to the likes of Thatcher, Bush, Churchill (not exactly famous for his racial ideas), Mitterand and the rest where they're deemed to have been successful without provoking such controversy, then I think we can grant Gaddafi his claim to fame..


Cutting!


Is it right to come to Africa for cutting? This is an oft-bandied about expression from home, referring to the benefits of doing elective or other work abroad when you’re a trainee surgeon. It usually goes:
- “I don’t know what the interview panel will think about the experience I gained abroad, given it’s a different system.”
- “Don’t worry about it! You’ll have loads of “cutting” and they’ll be well impressed.”

Thus as a trainee surgeon, one embarks on this mission to get cutting as much as possible so that they can go back with an extensive logbook to prove their diligence away from home. Befitting my general cynicism on the over-competitive UK training system, I came here with a much tempered sense of necessity to acquire this cutting experience, unless of course, it formed a natural part of my work. Cutting, especially unsupervised, for the sake of cutting in an environment where adequate safeguards might not be in place is akin to human experimentation. Thus, despite doing some rather cutting edge cutting (involving unfamiliar territory like urology, gynaecology and general surgery in addition to orthopaedics) in my very first weeks of induction in Lilongwe, my logbook numbers dwindled significantly while in Ntcheu. In fact all I was cutting was the numbers! But that was fine then and I got a chance instead to deepen my understanding of other areas of management, which frankly I would have missed out on by coming straight to Queen’s. These include the technical aspects of conservative treatment and above all the insight into wider aspects of organisation such as procurement, maintenance, theatre safety, data management, networking etc.

But now I’m at Queen’s, the nature of my job has been radically transformed. There are designated people for all of the above tasks, who need very little input from me and the need for my skills is very much at the service level, the shop floor, the wards and theatres. And let’s not forget the classes, as the academic department staffing required to meet the needs of the ever-growing student population at the adjoining medical college is very much stretched to its very limits. And every visiting doctor automatically gets a timetable of lectures as part of the package. Mine has recently been expanded that little bit more, with the arrival of the TOCOs (Trainee Orthopaedic Clinical Officers), such that the only free half-day slot left in my weekly schedule, that of Friday afternoon has now been filled! But then again, I love teaching. As Martin Luther King Jr. said "the function of education is to teach oneself to think intensively and to think critically"...

But let me cut the chase and come to the point again, that is cutting. That’s what I do at least 3 days a week now and on occasion 4 or even all 5. Let me tell you that I’ve never done so much operating (to use the official term for cutting) in my life before, let alone so much new operating. My learning curve is near-vertical now and my brain is quickly replacing old cells (probably devoted to such past idlings of my mind as French literature or German speaking- sorry continentals, nothing personal!) with new ones packed with pictures of approaches, exposures and metal implants not to mention the long paragraphs that describe them! I’m quickly tackling operations like forearm and ankle platings, intramedullary nailings of femurs and tibias and external fixations, not to mention skin grafting and soft tissue procedures like tendon repairs with greater degrees of independence. To have leapt to that level in such a short time is quite phenomenal and not without its challenges (an all-encompassing term here in Malawi which I’ll tackle bit by bit now). Well the first challenge is really that: is that surgeon competent enough to do all these new cases? Well the simple answer is no! But then there’s challenge number two, how do we provide an essential service when there’s not enough hands on the ground to provide it? Should we use people with some but not full training and crash course them into doing the job? To that, considering that’s what I’m undergoing, I’ll have to answer yes, with the proviso that the trainee is responsible enough to recognise their limitations and do their homework rigorously. That’s what happens naturally back home, and that’s what the stringent UK selection process (when not marred in favouritism and nationality biases) endeavours to achieve. And that’s why no trainee surgeon will be allowed to operate unsupervised until they’re consultant level pretty much. And that introduces the third challenge which is supervision. I’ve already said that every member is stretched almost to the point of having their limbs dismembered here. Hence a surgeon might feel the pressure to do most of the operating themselves, so that they can get all the cases done rather than painstakingly take trainees slowly through the processes. Thankfully that’s not what happens at Queen’s and for that reason alone, it deserves a 5 star grading as a surgical training institution. What’s more, it constantly receives visiting surgeons from various schools of surgical thinking (German, Dutch, English, rest of the world) and each one has a different way of doing things. This, when one doesn’t get confused instead, imparts an overall diversity which absolutely enhances understanding, probably better than having 10 supervisors who all have to follow the same approaches back home. So the issue of unsafe operating is taken care of by the system I think, but the problem remains that there are very few trainees coming through. Lack of competition and the pressure to produce more surgeons to cope with the ever increasing demand makes it very difficult to turn applicants down let alone fail them during training. Yet again, Queen’s has a very impressive academic record, and at least the graduates that have entered into surgical training (as opposed to pen-pushing jobs of DHO for which they are not qualified) are in my opinion, of the right ilk. The question is how do I, and the like of me fit into that system, especially the likes of me with a real hunger for cutting?! Are we depriving the local trainees of adding up their own numbers or are we providing much needed competition so they can up their game. I’m lucky to have come into Queen’s at a time when the number of local trainee is very low, hence there is enough work to keep everyone busy. But this is bound to change with time, at the rate at which the College of Medicine is churning out new graduates, and with all the DHO posts already taken up.

So, to cut a long story short, my point is that coming here for cutting is an ethical dilemma the visiting trainee has to address thoroughly in advance, lest they slip into human experimentation and disrupt rather than benefit a system.

Just like cutting in surgery, the role of volunteers in all lines of work needs equal consideration before rushing to the conclusion that being a volunteer is, de facto, a good thing that benefits a poor country. There are many challenges in all areas (culture, language, expectations, let alone technical ones specific to the subject) that might make the work of a volunteer ineffective, if not even negative. The standard of personal responsibility and social awareness of many volunteers (especially VSO as we get training in these areas before coming here) works as a natural check that’s often enough to mitigate against such adverse outcomes. But these days, there is a certain romance associated with working abroad (especially in Africa) and people embark upon such missions either for adventure, to meet a challenge or simply get a job/ experience with the job opportunities suffering back home. I warn against volunteering on these grounds. Doing a paid job is another thing. The main motivation in volunteering should be that of bringing positive change to the place and people. Should one feel they’re not achieving that, then they should change what they’re doing or step away rather than continuing for the other reasons. Especially relevant in this context are the very short term exchanges that abound in health care where people come here on glamorous (all inclusive) grants for 6-12 weeks and expect to change things in that time. I think these brief visits should be exclusively for observational/ research purposes and the volunteers ought to be briefed in advance that this will be their role (unless undertaken by experts, especially ones with experience in Africa, providing consultation). Their work has to be supervised and they should assist rather than take over things.

That is my 2-ish years’ worth on the subject and I’m certainly still learning the system more than I’m running it. I might have got it wrong in my analysis but these are my thoughts heretofore and that’s pretty much the only place I can record them.

Cut!

NOT MADE IN CHINA: MIXED MEDIA

Not a blog really. Not an essay. Maybe I’m putting it down here as a record of a creation on Malawian soil. Which will remain on Malawian soil (? indefinitely).

Not Made In China (J&A Doorgakant, October 2011) - made with china mostly and from [Made in China] materials:
• cardboard panel (broken ceiling board) [origin unsure]
• oil paint [Processed in Malawi- Chinese chemicals]
• contact adhesive [Made in India]
• broken china cups and plate [Made in China]
• broken orange glass plate [Made in China]
• paintbrush [Made in China] bristles which came out during the painting

Not Made In China came about as a bud of an idea of mine at least 4 years ago, in the heat of the Beijing Olympics. At the time I joined the massive street protests in London when the torch-bearing parade was intercepted by Free Tibet activists (under my very own stare). I was fuming in those days about the oppressive Beijing government and its abject violation of Tibetan people’s rights. I still am but my sentiment has evolved.

I always believe that one’s opinions ought to be dynamic, without this necessarily weakening the value of them- i.e. one should be entitled to hold a strong view on an issue, even if the very next week that view switches to a diametrically opposite one, held with an equal intensity. The crucial element in validating such opinion change is reason, often in the form of newly-acquired knowledge or similar knowledge acquired from a new angle. Without this, we wallow in the realm of the arbitrary without much more than personal bias informing our judgements. To expose one to maximum new knowledge is one way of ensuring continuous opinion change, the degree of which generally becomes subtler and subtler with time, i.e. tends towards refinement. It is the reasonable evolution of opinion.

One very effective way, possibly the most, in exposing one to new knowledge or angles thereof is travelling. Travelling to Malawi has opened my eyes and mind in ways I could not have anticipated 2 years ago. It has given me a new understanding of the world, challenged many pre-conceptions of mine and taken apart so many over-simplified beliefs I held with great assurance. I found myself suddenly reading different newspapers and magazine, watching news from different broadcasting corporations, talking to people with completely different views of the world to the one I’d become accustomed to hear among my group of friends back home. These views were challenging but they provided a great insight into the process of opinion making. What we think is so largely influenced by what media we are exposed to. It’s inescapable and that is the reason why governments around the world spend so much money and political leverage on media-control. What I used to see as a great all-rounded source of information on the world, The Guardian newspaper, suddenly seemed like nothing but one of the less biased but still biased papers, where the boldness to tell things as they truly are is still largely lacking. People like to read what they believe. So in the market-dominated society, even a paper like the Guardian will respond to the interests of its government (propaganda) and its audience: the ‘left’. But this concept of the Western ‘left’, which I used to view as the forward-thinking solution to many things, is what I’ve come to challenge radically since arriving in Malawi. This ‘left’ might well think very differently from the conservative ‘right’ but they’re still closer to the latter than to a balanced view of the world. A more balanced view of the world requires adequate discussion of global issues, past and present, a constant debate on how the world is governed and indeed a greater call for justice. Selective campaigning on issues that would seem to benefit oneself too (such as the attack of the western ‘left’ on China; and the one on capitalism only once the banks began to collapse and their prosperity bubble burst) may seem as nothing but mere enlightened self interest to me! If the same debates were accompanied by a true call to question of the western governance style, its economic system, while not simply dismissing the damage caused by slavery and colonialism as a regrettable mistake of past rulers, then these campaigns might seem to stem from a true aspiration for the global good. Unless one argues from this premise, one cannot expect anyone from outside to support their views. This is not to say that there aren’t good campaigns from the West. Indeed most good ones do come from there but they sadly are not enough and are too often stifled by politics.

Hence the paradigm shift when I came to executing this evolved version of ‘Not Made In China’. I might have been banging on about the evils of the Chinese government 4 years ago, but now I’ve come to realise: the evils of government are universal. Where else to analyse evils of government better than in sub-saharan Africa, I might ask? So the government of Malawi (and many others) is anti-progress and guilty of misappropriation of funds, based on the majority of sources (including lefty ones) in England. What about the UK’s role in this? What are they doing to empower poor countries they stripped off any dignity and wealth in the days of colonialism and slave trade? Maintaining trade barriers, political and military threat and a continued pressure to promote British interests while holding on to their illicitly acquired land there (hence the great attack on Mugabe even in the Guardian)??? The French are no better, with their record in Ivory Coast and West Africa and their famed colonial pact, which is literally the signing away of all economic autonomy for the sake of independence! The Germans meanwhile still pretty much own Namibia and natural resources are still largely being extracted for a pittance, hence the Belgian love for the Congo (DRC) and the Dutch one for South Africa. Inamongst all this the Americans are busy with their mission of thought control, particularly important now that China is making inroads into African development. It won’t be as easy as taking down Patrice Lumumba or dislodging Kwame Nkhruma anymore I guess. But maybe it will be, as we saw recently with the assassination of Gaddafi. This guy’s record on African development is remarkable and unprecedented. All that seems to have come out of western media about this legendary pan-Africanist (lefty sources indeed) is the fact that he is a warmonger who had no qualms on attacking his own people. I dare say that till any country gets its own house in order and truly comes clean, then the authority to interfere abroad is absolutely impermissible. As long as the US keeps on sponsoring the war on Islam through Israel and its new blank cheque, anti-terrorism, then it should have no say whatsoever on global, let alone Arab politics. This is why my rage against China has been tempered so much in the 2 years I’ve been in Malawi. China certainly has a more liberal aid programme within Africa, with hardly any of those Western strings attached. The quality of the development may be poorer but it’s also not claiming to be better than what it is. The job creation opportunities might not be the same with Chinese labour being largely imported for these contracts but the job is done. What China does not do is tell everyone how to behave or else... Because China knows it’s not in any position to pontificate on government behaviour. So why pretend? The west want to keep on pretending they have the key to global harmony through one over-simplified concept of democracy which they are intent on imposing forcefully onto all. Yet that dream is best achieved through economic empowerment and not interference. This is precisely what Africa is not getting from them...


PS: The box has finally landed (12 weeks since the order!)

A certain tolerance of (gross) imperfection

There is an anecdote recently from work that encompassed so many aspects of this feature so Malawian that I really have to elevate it to the status of case study. It is about a phenomenon that us foreigners find so hard to understand and accept. It drives us up the wall, it’s probably responsible for the majority of instances where we lose it with Malawians (and then repent shamefully for weeks!) and it certainly provides an incredible insight into the Malawian psyche, let alone socio-economic reality. It is the way imperfect results, systems, jobs you name it, are so coolly tolerated here. This will without a doubt sound like a litany of criticisms of the Malawian way of doing things. Indeed I was first to have this reaction when I landed here. But really I’ve moved from that stance to be closer to understanding what it really tells us. It tells us a lot about Malawi, the country and the people for sure, but it also tells us about ourselves quite a deal. For if tolerance of imperfection makes us flinch so much, then it somewhat suggests that we are more inclined to the opposite... and in that I read intolerance!

The story is that of a box! A box I tried to get the hospital maintenance department to make in order to enable us to run a nurse-less clinic. Indeed the situation in terms of nurse staffing is so dire at Queen’s that we run all our clinics ourselves as clinicians. Also our orthopaedic ward staffing has recently been culled such that there is now a single nurse for up to 70 patients on nights. So I devised a compartmentalised box which would contain all the materials (gloves, dressing, slings etc) we need in clinic and all the ward nurses would have to do is to keep it stocked up in between clinics. So I drew up a model of the box in the question and handed over to the maintenance big guy as I would have done in Ntcheu. To my surprise he directed me to the main guy for the specific section: carpenter. I automatically assumed that this must be a big enough unit to deal with quite a volume of work. So I gave the model to the chief carpenter and got the assurance that this is a very simple job indeed which shouldn’t take more than a couple of days to complete. So 2 days later, I drop in on my way to the clinic and can’t find the box. I find the subordinate carpenter instead who informs me the chief carpenter is on a bigger job and has delegated this job to him. But he had decided not to make a start on it until he got a chance to check on specifics with me. Fair enough! So I went through the very basic features of this simple box and got told to come back at the start of the following week. It turns out I was very busy that next week, so I gave the carpenter ample time to do the job well. Come Thursday, clinic day, I stumble by the department again and find no signs of my box yet. The subordinate, it turns out has gone off sick. Can’t help it, so I ask the chief carpenter to reassume responsibility of the job if the other doesn’t come back soon. Next week I go there to enquire and still find no progress on the box. The chief carpenter is not around, he’s gone off on another more important job again. Fair enough, the corridor connecting the surgical annexe to the main hospital has caved in! It started as a crack in the wall and before we knew it, the wall was on the ground with a big chunk of floor attached to it! So that’s another week at least before chief carpenter gets back to ‘little jobs’ again. As for his subordinate, he’s not back yet. I’ve seen it so often here and it saddens me. Young perfectly able-bodied men and women, look smilingly at you one day full of life and the next day they’re in the throes of a terminal illness, out of which many don’t make it. There’s a lot of serious infections that go round but I don’t agree that they should claim such a big death toll. Poverty among low grade health staff is really heartbreaking and results in life being, to put it bluntly, devalued. So I gave my carpenter man, now working all by himself, another 2 weeks instead of one to get back to the task. So the next time I go there, I have an OMG moment when I see him actually displaying the work he’s done. He’s come up with a list of materials that he will need to make the box and is waiting for me to provide the cash. And I find out about this 4weeks from handing the job in! So I ask why is this not covered by the departmental budget and he tells me he assumed I wanted it done quicker to save going through the procurement process. That’s when I find out that this guy is working without tools essentially. Every new job has to go through an inconvenient approval process, including the very nails he needs. Thankfully the list of things we need for my box are internally stocked and can be procured within a week. So next week, I drop in, you know the next bit... to check on the progress with the box. We now have the wood cut up in the component pieces and enough nails to connect them, but something else is missing. A hammer! If I had one I assure you I would have hit my own head with it! The carpenter shows me the one he’s using, which is the equivalent of a fork without prongs essentially. There’s a handle attached to a headless hammer that’s only got the nail-pulling end still on. He must have had this for years without being replaced and he still uses it to hit big things. But nailing I’m afraid can’t be done lest we want a fingerless carpenter to stick to the theme! I’m assured though that there is one that been ordered a while ago and which has been approved for external sourcing finally. Another week I say, that’s okay I’m busy anyway. So next week, (...), and I finally find a hammer next to the nails and cut up wood blocks and can only express my puzzledness to the carpenter as to why the hammer hasn’t driven the nails into the wooden blocks yet! And I’m told that he wanted to check everything with me first before ‘committing’. This isn’t amputation surgery, but I guess that when he’s handling material that’s so difficult to acquire as in this case, he wants to treat it as if it was. And indeed, upon checking, I find out my cursory initial explanation had been misunderstood, but there was no need for him to ask for clarifications then as he would have forgotten it anyway by now. This happens a lot here, for that precise reason: predictable unforeseen reasons! So one more week I delay and go back to find my man. Hallelujah, I see a box! But is has no lid. Why? He didn’t realise I wanted it so I could keep the box locked when not in use, even though it was on the drawing. So another week goes by and predictably, there’s a finished box with lid and even a lock , which I haven’t had to wait another week for. I reach out for it and realise it’s not ready yet. No! It’s yet to have the final touch applied. Polishing and lacquer. But hey, a large piece of sandpaper only cost about 25Kwacha (10p) and he can’t get it procured fast-track. So this time, I fish for the cash from my pocket and say get it when he’s in town. Next week, I find the box in the same state it was the week before. I’m told there is no sandpaper in town! I can’t believe it. But I just remembered I had some at home. This I bring to him the next day, but it’s not the right one and not big enough. So next week when I find him, no progress still! I’m baffled, not sure what the next move is. So I just leave things to move at the default pace of external procurement. Luck has it though that I had to go to town that week and in the shop where I wanted to buy paint, I find sand paper also on sale. Can you believe it? So I race back to Mr Carpenter and hand him by new found treasure. Why he couldn’t find it is a slight mystery but the following reasons are likely to be contributory. Currently a lot of shops are out of some stock or other because of the acute fuel shortage and his shop, probably the only one he’s allowed to procure from for the hospital doesn’t have it. Because initiative is not rewarded and he doesn’t dare to bypass the authority of the hospital even though I gave him the money (read job insecurity despite pathetic wages), he simply assumes the same situation applies across town. He’s probably been told that by the shop guys anyway. The frequency of stock shortage and malfunction (of equipment/ system) has over the years slowly eaten away at that vital human attribute called initiative. It is (sometimes rightfully) perceived as a waste of time, which could be better spent elsewhere. It is used by some to get on with personal errands that they would otherwise not have time to get done. Do you know that most Malawians I’ve worked with hardly ever take any holiday? They are entitled to it but because of their pathetic wages, often prefer working them so they can earn some locum money- and don’t be fooled into believing this is the same overinflated locum wages as replacement staff get in UK. This locum is a fraction of their normal wages. Each time I hear expats call Malawians lazy, I feel like suggesting to them to drop their wages to a measly £200 a month and do away with holidays for an indefinite period! Circumstances force a different work ethic within which opportunities are created to avoid burn out simply, e.g. a looser adherence to punctuality, extended lunch hours, time off for training and the all-notorious allowance culture. I’m under no urge to adopt these ‘mental-state-sustainability’ measures for I, like most expats, am only here for a couple of years and can work myself to the limit in this time. If I were told to continue at this rate for longer, I would certainly burn out.

So even as we speak (10 weeks on), the box case ain’t closed yet, as the final stage of lacquering is still underway. But the shift of perspective it has engendered is quite apt, since I’ve literally had to think outside the box to even begin to comprehend the complexity of issues at hand here. Is there a part of it even I’m responsible for? I for all I stand: the Mauritian- African, Indian and muzungu all at once, the aid worker, the idealist, the perfectionist, each aspect coming with its own threat of interference. When so many external influences as we see in Africa more than anywhere else in the world come in conflict, one can see progress might be hampered rather than enhanced in the end. To simply bandy concepts like Dead Aid, neo-colonialism, slave trade legacy, economic and cultural invasion, global village, China in Africa and the state of international trade rules in one line is exceedingly inadequate. But for sake of illustration, it does the trick, that is to start thinking that all might not be due to the Malawian personality, including that of its leaders. Very importantly too, there’s a lesson, we, from the West, can learn from here- to be more patient, relaxed and tolerant of human imperfection. The right way is always somewhere in between.

The world is like the human body, where each part is linked and crucial to the functioning of the whole. It has been so since the beginning of times, way before anyone coined the term global village. The little toe going black is often not due to the toe having done anything wrong itself- it was dependent on blood flow to it being adequate...

Lake of Stars 2011

I am aware that most of my latest entries have borne a reference to a similar period from last year. In fact I can predict that if I stayed here once more year, the same would hold true for next year’s entries around this time. Yet this in no way makes me reluctant to write about them again for fear of repetition. This time of year is momentous for me in Malawi and each year it represents a climax, with very different elements to it. The work climax that recently was has properly made way for the post-climactic chill which could find no better embodiment than this certain festival known as the Lake of Stars. This year’s event was an entire journey starting as a post-nightshift blues on a typical sequence of public transport modalities (taxi, minibus, matola). Having worked from 7.30am the day before to noon the same day, clearing up an unexpected theatre list, I was ready for a major showdown. So was Janet, equally saturated with work over the last few weeks. Despite having had to cover the last 20 or so Km in the back of a pick-up truck in pitch black darkness, and then get accused by the driver and some drunk conductor of damaging one the windows, once we reached the place, it was like someone had reset the time to start from scratch in our minds. Within seconds, we were captured by the spirit of the festival. This remained so for the next 48hours where every minute was simply unique. Now I don’t go on describing festivals from the UK with such exuberance, despite probably being more excited about some of the main acts on show. But when you have sun, sand, a cool lake and funky laid-back people in abundance, it almost doesn’t matter what music is on offer for you to have fun. Now imagine the prospect of still having great music with all these ingredients! Could you blame me for banging on about it?! Now for the geeky bit- my favourite acts this year. Take note. From Malawi, all the regular crowd pullers were there: Maskal, Lucius Banda, Theo Thompson, Dan Lu and Black Missionaries. But it’s the new discoveries that always stand out and this year it’s a band called Mafilika that really dazzled me, not just for their talent, but for the fact that this talent was in the genre so rarely heard around here which is ROCK! Yes Mafilika rocked and indeed reassured me that somewhere in everyone, there is a dormant rocker waiting to be awoken. Another beautiful discovery was of the 79year old acoustic artist called Giddes Chamalanda, who simply eased me through a somewhat dreary mid-Saturday state of exhaustion before the major line up. His original take on classic and original rock blues was just great. My excitement at seeing the main Malawian singer I was waiting for, Maskal, was unfortunately tainted by a slight incident in which I got pick-pocketed of my phone. But that doesn’t lessen the quality of his performance, hyped by an impressive advertising build up from his sponsor distributing free T-shirts and all. And that brings me to the next band I wanna talk about: The Very Best! Not the very best name for a band by far, but the elements that made it up were fantastic, namely a Swedish DJ, an English rapper and a Malawian hip-hop singer, all complete with dance troupe. Again the publicity from free T-shirts flung into the crowd worked quite well. But above all the music was very original, and you must believe me because I am very partial with this genre. As for the international line up, this is the bit I get most excited about, because you hardly get such a diverse mix of origins in a UK festival (even though I’ve never been to Womad- so hold me back on that one). Here there must have been a good 10 countries represented, each with a special twist to their music. Rwanda was represented by Sophie, playing a string instrument called Inanga, Namibia by a troubadour reminiscent of Tracy Chapman, by the name of Shishani and Kenya by a most energetic designer/singer called Liz Ogumbo. England was definitely there in the bodies of Mercury Award winners of this year: The Foals, which is probably the longest uninterrupted metal rendition Malawi has ever heard in its history. The fact that I didn’t exactly connect with them straight away is quite telling about how distanced I’ve grown from this style in my time here. However I was reminded there about how much I do miss it. Again from England we had soul queen Beverley Knight, whom I’d never really attached any memorable songs to before... until last night of course. She was just brilliant. It makes such a difference seeing what they call a Diva performing in front of you, as compared to hearing it from a tape or disc. I now admit there is an incredible talent in getting a human voice to do such things. There were also acts from the US and France that I missed. Now for what I considered the cream of the International line up, an international band in itself, who alone would have justified my cross-countrying all that way to the festival: Freshlyground. This was in many ways a new discovery because I only got listening to them in the build-up to the festival, apart from a few faint snippets I’d had from other people’s musical selection before. The band is from South Africa and they literally took me back there in the tantalisingly electric spirit of the world cup. The musical scene I discovered there had significantly marked me and I’ve been sampling more and more music from that country. Last night’s addition will remain on the playlist for a while to come now. The band is real encounter of artists and instruments, not least of which is the amazing voice of the main singer. The guitarist, a Mozambican, particularly stood out for me and gave that final eclectic quality to the band. So look out for them if the name is new. To wrap up, I’ll just have to mention one last artist, who is not a singer in the precise use of the term, but without a doubt an expert lyricist. Lake of Stars like all good festivals had more than just music on show and the guy I’m gonna talk to you about added an incredible sense of brilliance to the poetry scene this year and he goes by the name Q Malewezi. His style is his own creation and defies any attempt at classification, however intent I might be at rounding him up with the slammers. I do insist, probably more than for the set of musicians I’ve described above, that you go and look him up! And better still watch him perform (Blantyre Arts Festival next week). So that was the Lake of Stars in a more of a watermelon- than a nut-shell! But this event is so exciting that one can’t help recounting it other than with the most elaborate descriptions. And I assure you, even so, I’ve missed out loads more. Sophie wih Inanga

Local instruments

Freshlyground

Iwes

Hattrick!!!

Enter Chilldom

You can plan a nice long relaxing weekend up Mulanje mountain with plenty of time to recover or you can tag it on to the end of an epic conference at least 6 hours away, while being the official team medic for an expedition of 18 women! Guess which one I chose! It was certainly not for the 18 women that I did it, let that be clear, as really I would rather be with 18 loud and smelly Mauritian men, if only for their ability to get up and go promptly. But I did it the way I did mainly because it had long since been planned and it was only in the very end that I got double booked with the conference (the dates couldn’t be conveyed further in advance).


Just a quick note on the conference even though it was probably the highlight of my research interest for this year. The reason is that I’ve already told you most about this project in my last entry about Lilongwe. The latter was essentially a dress rehearsal for the more dedicated platform that it was targeted to- MOA: the Malawi Orthopaedic Association annual gathering. This is again an event you’ll have heard about to length in an entry almost exactly a year ago and indeed this year also things weren’t that different. One difference though was that I was invited to join the faculty on the AO (Arbeitsgemeinschaft für Osteosynthesefragen!) training day, which was a huge priviledge and responsibility. This is the first part of the yearly meeting and it really is the perfect opportunity to get those CPD (continuous professional development) points in orthopaedics across to our OCOs. The second day, I was awarded the key note address after the original speaker couldn’t make it. This was again a great opportunity to enhance the impact of my research project. I undertook a pilot project into an improved data collection system that would work for the districts, with the hope of reducing duplication of work and registering more accurate data to inform planning and prioritising within the speciality nationally. Big words I know but when you have the health PS among your audience, you really got to seize your chance with both hands. And this I certainly did by promoting my other big project at the moment which is the publication of a multi-author manual to common orthopaedic problems in Malawi. Unfortunately, at that point my heretofore very successful conference came to a premature end. I had to excuse myself to attend to that other commitment I had made ages ago!


So, after a 7 hour transfer, including car, minibus and legs, I reached my lodge in Mulanje ready for the next days’ adventure. I made the acquaintance of my 18 strong woman team that night for a medical briefing and ground testing. The girls had actually come as part of a “responsible tourism” initiative to raise money for a financial project supporting microloans for the less well-to-do. What’s most laudable about the way they’ve organised it is that they’ve included a trip to the actual place in their itinerary. They were certainly a great laugh to hike with, and maybe also good that they didn’t push me anywhere near my physical limit, as that might have slightly impaired my medical faculties. Thankfully, those weren’t called into action much, save a few sprains and a nosebleed that I was one of the only ones not to have witnessed! The route itself was the old classic to the hut adjacent to the summit Sapitwa. The latter we had to skip to accommodate the team’s pace. Thereafter the route changed to incorporate brand new territory for me in the form of the Scorpion path, West peak and the Milk run. 3 days, 2 nights in total and a total body meltdown after those last few months of intense build up to the conference.


PUBLIC TRANSPORT 4
No big trip in Malawi is complete without a new insight into the idiosyncracies of its transport system. This time it was the return trip from Mulanje to Blantyre that provided the new wisdom. It is a poorly understood paradox as to why minibuses seem so reluctant to depart from the depot, yet turn into land speed record contenders once they get going. You’d think, ‘they’re full to the brim when they leave and surely will pick up people as their exiting passengers make way for new ones. Why the rush then?!’ Well competition as you probably imagined is the key. But why this particular route and particular time? That’s where my insight came. Around 5-6pm is when a lot of tea/sugar estate workers commute back home. This means they’re scattered along the route and their journeys are usually short ones. Thus if one minibus stays ahead of another throughout the trip, they get to pick most of these short distance travellers and take the lion’s share of the booty. Once one’s minibus is overtaken, one notices an immediate escalation in tension as reflected by the speed. Unscrupulous tactics are adopted by the one in front to prevent loss of their advantage- lane straddling, indicators to indicate ‘not safe to overtake’, blocking exits at stops etc. Overtaking becomes an all-enveloping obsession for the one behind and the slightest mistake made by the rival can be fatal to him. Sadly this metaphor so suited for the race strategy described above, often ends up also being true in the literal sense!


I should have felt refreshed to resume work in the best of shapes after this escapade, but this was so brief that it merely served as a sore reminder that Janet and I are due a more proper holiday very soon to beat this recent drawl of work-dominate-life routine!!! The lake of Stars (my second and Janet’s first) fortuitously is just round the corner now. Maybe that’s what we need to kickstart our long awaited descent into chilldom! Highlights guaranteed to follow...

Team posing with Jacaranda

Porters celebrating West Peak

Dramatic Mulanje

Outside Lichenya before final descent

Glorious Mulanje

Lilongwe meets Blantyre

6 months on from my arrival in Blantyre, my outlook on the city has changed tremendously- almost to the point where I wish I could go back and edit that first entry, in which I thankfully predicted that this would be the case. Some things are still the same though, for example the extreme gap between wealth and poverty that’s in-your-face. Well the thing that got me thinking about this again was a trip to Lilongwe this week where I experienced some déjà-vus of the time of my original arrival there some year and a half ago. I found myself taking the same routes to the hospital from the same guesthouse where I was living then. I was presenting at a conference for the Surgical Association of Malawi this time, where I also joined the faculty of COSECSA for a day teaching orthopaedics. There, I met a lot of the same people I’d met 18months ago, like Dr Muyco, Sven and the Lilongwe OCOs. As a treat, Steve Mannion was also there, organising the orthopaedic training training day, as well as moderating some of the sessions for the conference. All in all, it was a pretty intense week, with an equally intense build up to it, where the presentations and research for it was being undertaken (hence the paucity of blog entries- there’s always a reason!) As you can imagine, once all this hard work was unloaded, I switched straight into “off-work” mode and took the opportunity to maximise my time with Steve and Sven. Nostalgia and anticlimax weren’t long to kick in. I felt the sweet vibes of my first time in Lilongwe, its sweet mix of the terrifying unknown and an all-capturing titillation of the senses. I really felt at home in this city, Lilongwe. It is indeed one of my favourite cities in the world. It is a vast expanse of green with distinct areas strangely numbered in the order in which they were built, as opposed to their geographic location. But that adds to the quirky charm of it. It does not feel the need to be defined by an outsider. It has its own character. Unlike Blantyre, it is the administrative hub of the country. It boasts a different spectrum of the commercialism that somewhat defines Blantyre. For Lilongwe, it manifests itself more in the form of posh hotels, springing up all the time and good eateries- essential exigencies for the host of expats and diplomats released on its streets daily from the country’s major airport. As a result or not, Lilongwe also feels a notch more peaceful. In other words, the constant banging of undisciplined bottle stores and bars with outside speakers doesn’t follow you into every nook and cranny as it does in Blantyre. What better way of demonstrating that than by the greater presence of birds all over Lilongwe. And yes, that is now one of my chief delights in visiting the city. Not that Blantyre doesn’t have them, but in comparison to Lilongwe, that’s a mere fraction. And to exacerbate the difference in greenness further, Lilongwe also boasts a wildlife sanctuary in the very heart of the city. I won’t go on any further lest I be called a tree hugger!

So that’s how it felt being back in the capital, home of the VSO office and guesthouse- my first bases in Malawi. But of course, times have changed and contrary to expectations, my affinity for Blantyre has also grown greatly in my time there. I might not have become immune to its riot of decibels but I certainly have got a feel for the character of the city. And this I owe in large part to one thing I never had at first in Lilongwe- companionship. With Janet here and both of us equipped with bikes, we’ve stroked the asphalt of most streets within a mile radius of our house at least and many more beyond. We’ve come to meet people very different to the stereotypical arrogant rich I’d at first got fixated on. These lot exist in every place in the world, Lilongwe as much as Blantyre as much as Manchester, Port Louis and Bombay! Thankfully they exist less in places like Ntcheu and I guess I’d forgotten what it’s like living alongside them until I got to Blantyre. But now I’m used to them again, I can easily blank them from my field of vision and focus back on the joys of being here: satisfaction from work, culinary discoveries courtesy of Blantyre market and the local spice haunts and the great new joys of gardening. And then also I ask “what more do I need when you’re an hour or less away from such classics as Mulanje, Majete, Thyolo and Zomba plateau?”

It's gonna be hard to leave...

Lilongwe's just too cool!

COSECSA faculty and audience

Tree hugging!

Mousebird