No comparison

Travelling african style
Any pretension I may have held about being hardcore in my travelling, based on previous journeys, has been turned on its head after my latest flirtation with the African road. “African” I say without fear of over-generalising as the latest epic took 4 countries in its stride: Malawi, Mozambique, Zimbabwe and South Africa. 30 hours each way to use the typical term for distance measurement here, and that comprises a generous chunk for the sole purpose of negotiating border bureaucracies- or should I say idiosyncrasies! For those of you who still perceive distance in kilometres, then the grand figure of 1500 each way would be a rough ballpark figure!
Unwittingly, I started the journey with a self-inflicted hangover following England’s disappointing game with Algeria the night before. At 8.30am in Blantyre, a strange combination of moths (taking cover from the daylight), flies (trapped inside the bus and trying to escape), mosquitoes (from the nearby ditch) and butterflies (in my tummy, in apprehension of this unknown factor ahead) marked the start of this trip. An hour and a half later, after all procrastinations were done with, we were finally en route. I got a nice seat at the front and was pleased to have a friendly neighbour. Hardly 10minutes into the ride came my first and most dreaded challenge- the bus music/noise. Pure wailing Malawian gospel, absolutely identical, even the videos, which were being projected on a screen at the front. Unfortunately, changing seats so that I would be farther away from the epicentre of this cacophony was not an option, since each seat was specially endowed with its own speakers, with no individual volume or ‘off’ switch. Competitive inhibition was the only solution as of now, meaning that I would have to rely on my personal music to be blasted loud enough by my earphones to override the surrounding music. Every now and again, even through this, I could hear the bus noise and even worse, a certain high pitched beeping which could go on for an indeterminate length of time. At first I thought the sound system was defective, as is often the case in Malawi and that I would simply have to brace myself and suffer. But then I found out this was a speeding alarm, which indicated to the driver that he was going over 110 Kmph. Despite liking the idea in its concept, I was all too aware that, to the Malawian driver, such a deterrent would be as useful as Chambo steak to an edentulous! Noise encourages Malawians on the contrary! But prolonged exposure to an insult can ultimately condition one to it, and insofar as I can be conditioned to noise, I was. I sat at the back nonetheless on the way back, swapping toilet for beep, but still had a nice neighbour!

In Mozambique
Another unexpected inconvenience along the way turned out to be a mal-functioning AC or one cranked up sadistiscally by the driver, on pretence that it would keep him awake. I couldn’t argue with that one! This kept the entire bus shiveringly awake on the way down. On the way back though, probably from the aforementioned overuse, AC did not function at all and sweaty came to replace cold and dry. All the same, the latter was more comfortable as one can always open the air hatches.
Our first border crossing would be that between Malawi and Mozambique at the Mwanza/Tete immigration point. That was the scene for one great big- and expensive- surprise to me. My Mauritian passport would be categorically declined. Indeed I ought to consider myself lucky not to have ended up behind bars, as having two passports is considered illegal here. So I was forced to go on my British passport, which attracted the plump sum of ~$25 each way. Might not seem so much, but in the context of VSO wages, you will see that the cumulative effect of those payments (4 times in total only for transit visas) amounted to roughly what I had saved by opting for the road instead of simply flying down to South Africa. All this for that glamorous passport which I had to wait 12 years to get in England and which I’ve never had to use in Europe! To think that the Mauritian passport used to be my worst nightmare whenever it came to travelling in Europe, thanks to the ultimo of travel deterrents- Schengen Visa- , and now it’s that same passport I wish I had entered Malawi with! Too late. But I’ll be philosophical about it. I might have lost out in this situation (from oversight mostly) but in all fairness, I don’t think any European/Muzungu is in the right to moan about being imposed this charge. Not even at the slowness of processing the visa in actual fact. My bitter experience in Europe has had one single positive effect, which is to give me the opportunity to compare the way an African is treated by the usual European immigration system with the converse scenario. To get a Schengen visa in the past, I had normally to apply to the country’s embassy which I would be visiting first, at least a month in advance. This would have to be done over the phone at the premium rate of £1-£1.50 per minute, each call lasting around 2ominutes. During this call, it would be highly advisable for you to have your detailed agenda at the ready, where you have minimised any commitments for the ensuing month, as the time and date you are allocated are purely random. If you happen to be busy on the date given to you, then you have to keep the call ticking till a more acceptable one is offered you. Once you have the appointment, you have to also make the travel to the single place in England or Scotland (even though they can turn you down if you’re based in England, albeit next to the Scottish border) where they process these visas, early enough in the morning, so as not to miss your chance. There are usually loads of people there on the same desperate mission as you. I remember once queuing outside the French consulate in London from 5am, only to get to the counter at 10am. Once you’ve tackled this appointment hurdle, comes the more thorny issue- the right documents. Not only do you have to produce a return ticket (with no guarantee of even being allowed to travel) but you need a formal invitation letter from the town hall office of your host, or a hotel reservation. This invitation letter usually takes your host about a month to process, at least 2 trips to that office and 30Euro at least. Consider yourself lucky to have got those, you also need a travel insurance, a letter from your employer (job contracts don’t count) and proof of finances (bank statements don’t count). Financially, excluding your plane ticket, the whole process can set you back £150-£250. Damn that £1 Ryanair fare! Meanwhile, in Mozambique/Zimbabwe/Malawi, despite the greater threat historically posed by a European on these soils, it took us less than 1 hour to have the whole lot done and an upfront payment of $20- $30 (~£15- £20). On one occasion, it did take 2 hours but that’s because the English traveller ahead of me was visibly infuriated by the process and decided to get confrontational with the immigration officer. Consequently, everyone with a foreign passport was punished.
Border crossings constituted one dreary, heart-sinking moment of the bus journey. Each crossing required a visit to both countries’ immigration offices to have your passport stamped. Leaving was usually swifter than entering a country, naturally! Except, of course, if one of your fellow passengers decided to overstay his keep in the exiting country. Dealing with this situation is very crafty. Bribes are eminently du jour and they are not negotiated in any direct way at all. There’s no asking price here. The offender simply leaves a note in a page in his passport. The officer actively searches the passport for it, and if discontent with the amount presented, grumpily hands the passport back. A few minutes later, the offender, after having scrounged for some extra dosh, presents the cash in a similar way, and this strange bargain can go on a number of times until the passport is finally cleared or singularly dismissed. Somehow, in the latter case, the offending individual then simply vanishes into ether and the bus decides to leave him/her behind. Next thing you know, maybe 5Km or even 50Km into the next country, the person will reappear at some road junction and hop back on the bus. This s/he might not be allowed to do, in which case they will appear at the final station, again inexplicably, and collect their luggage there! The most remarkable example for me was a woman who sneaked past the Zimbabwe/South Africa border with her baby and was refused back on the bus, but somehow beat us to it at the terminus!
My experience of the borders was nowhere near as exciting but worth a mention. When leaving Malawi, one is allowed a maximum of Mk3000 and I had around 6000. So I had to spend the excess (in fact more like the whole lot) on wooden artefacts around there, only to find myself burdened with this extra weight, which I intended to leave with the Mauritian connection in South Africa.
One way bridge
Going through Mozambique, an additional delay declared itself, in the form of a single lane crossing across what is apparently the longest bridge in Africa- not the widest that’s sure! If you happen to be that first person to be held back after a batch has been let through, then I’m afraid you might as well take a little nap or get your Sudoku out. They rotate hourly here!
We're in Zim
In Zimbabwe, the immigration officers were exceptionally efficient and, on a personal basis, not adverse to foreigners at all. However, the intimidating presence of Robert Mugabe was distinctly manifest in the picture frame hanging behind them on the wall. That man decided that British travellers ought to pay the same numerical amount as others (Europeans/ Americans) except that the amount would be in pounds rather than dollars! Once again, I shot myself in the foot by using my British passport. There was also a strange incident of a stranded bag hanging on a tree outside the immigration office, that left all of us somewhat insecure. The bag -lady’s handbag- looked like it might have been left there deliberately, possibly to lure curious fingers hence, warranting an arrest, or, heaven forbid, waiting to tick down to a boom! At the South African border, my luggage got searched along with a number of other passengers’. Interestingly, I was made to go and register my wooden curios, while the guy next to me had all varieties of fish and vegetables stuffed neatly between his trousers and shirts and sailed through! The way back across the borders blended into a fuzzy dream for me, having exhausted myself to the limit in South Africa. All I remember was that the Mozambican immigration guy recognised me as the ‘Mauritius one’ and, on the other side, I (unethically!) used my status of (male) doctor needing to get back to work, to speed my baggage check through so I didn’t have to wait for all the luggage on the bus to be individually checked until we got to mine. This is what normally constitutes the longest delay in the whole return trip and I was in no mood for it. Malawians are renowned for their ability to shop till the last mm2, for absolute nothings most of the time, when travelling back (a bit like Mauritians used to do in the past/?still). I made a list of such improbable items crowding the interior of the bus and racks: large crisp packets, large pop bottles, oranges, bags, oil, biscuits etc.. I decided to alight here rather and make my own way back on Malawian public transport. This, I delayed till the next morning as a very important appointment was also waiting for me in Mwanza just as I cleared customs- the Germany v England game.
More on the South African world cup next....

About Malawi

The anticlimax set in rather quickly following Janet’s departure 3 weeks ago, her last week culminating in a crowning finale as we got to watch Lucius Banda in concert (second time for me) right next door to Ntcheu, i.e. his home town Balaka! This was made even more symbolic by the fact that most of our roadtrip had been animated almost entirely by him singing on the only player we had in the car- a cassette player, with the only cassettes available to buy here being local Malawian or Zambian music. It would be unfair to isolate lack of choice as the reason for listening to him though, as he is really good. Interestingly, he is also running for president it seems. Unfortunately, his party aren’t really showing much of an interest, while the current president has brutally sidelined him in response to a song on his latest album, where he indulges in a rather defamatory soliloquy on the president’s unpopular politics. Hence not only does the album get banned from airing on Malawian radio, but the entire artist’s work. To his relief, that doesn’t stop him being played all day (and night) all over Malawi on CD (...and tape)!
That sets the scene nicely for me to talk a little about politics for the first time here. Yes, it takes less than a week here to crack that one, but has taken 4 months to put in words. We have what is officially a democratically elected president in multi-party style election. Except that around the time of the elections, he, Bingu wa Mutharika, has quasi-monopoly of the media and the country’s resources. He is in his second term now, and won the last elections in December with an overwhelming majority. Since then, he has imposed himself in somewhat more of a dominant style and has been pushing for some changes that never really seemed to have any public consent. For one he is planning on changing the Malawian flag to one that suits his own eccentric taste- a move that will cost a small fortune to the economy, without any economic benefit as far as anyone can see it. Rumour has it the flags are already here in containers, while awaiting for the final bill to be passed. Secondly, as in many African countries, the president tends to affirm his authority by displaying pictures of him looking imposing in every office in every town. He is also on billboards everywhere boasting about some achievement or other. Whether this serves as a reminder to everyone that he is there watching you or mere propaganda I can’t tell. But what I can predict is that soon these pictures (must number thousands) will all have to be taken down and replaced with new ones, because, he has just been awarded some dubious professorship in China. He now boasts the title of Prof in front of the already present, Ngwazi Right Honorable President Dr... Ngwazi in fact being an appellation the former leader/dictator Dr Hastings Banda used to connect himself more to his people. Bingu now likes to compare himself with this still very popular past leader (remembered by many guide books for banning long hair for men, or skirts for women, or worse even the song Cecilia from S&G!). Bingu, of course, is also famous for the latest gay marriage saga that even made it to the European news. In a 180 move, highly likely to have been motivated by a strong pressure from the UN chief, Bingu pardoned the gay couple, who a week later had been sentenced to the severest possible term- 14 years IHL. The ensuing week, he declared publicly that for such “evil acts”, the law rightly punishes but God forgives! Speaking of marriage, Bingu too made the news this year at the grand age of 75, when he decided to get engaged on Valentine’s day and remarried in April. He hosted a royal banquet, paid by the state of course, with more than 5000 guests, and turned up in a flashing new Limo. All the papers had messages for each of the two events posted in them for the happy couple, most of them being from government offices and parastatals! The TV channel at that time, played similar reels of repetitive messages as much as they did actual programmes. Meanwhile, special glossy magazines were printed and distributed to remind people (in case they lived under a massive rock that only allowed glossy mags in) of that holy union. Let me not get too carried away with this bleak analysis because I might get expelled from the country soon. In his defence though, from talking to a few Malawian friends, a lot of positive changes have been made since Bingu’s arrival (“his predecessor was essentially a shameless thief who would even circulate counterfeit money in the country”), especially the quality of the roads. But when you ride a motorcade of 15 shiny 4x4s everytime you travel, if you’re not in your state-purchased private jet, you want your ride to be a smooth one!
Besides politics, one other item that’s featured prominently on the agenda here has been football. Of course there’s the world cup, but personally, I’ve also managed to join the hospital team lately and am finally back to weekly matches. Last time I was doing that goes back to more than 10 years ago and it feels great. As for the world cup, I shall save that for the next time, when I have fresh news from the hosting nation itself. Pepani!

Roadtrip / honeymoon

This week we took to the Malawian roads. This was also the first time I got to properly drive around Malawi (omitting that sedate and carpeted drive from when I picked Janet up from the airport). This time we had an altogether different mix of terrain, landscape and weather. I think this must be the longest drive I’ve ever done in my life, taking in at least a half of Malawi’s vertical diameter and combining high alpine plateaux with basking lakeshore escapes! Each day in this last week has been so rich in stimuli, interactions and discoveries that an individual page is what’s really needed for each. We shall endeavour to relate them to you each as a paragraph instead, which is going to be no mean feat.

Lilongwe Market
This will surely qualify as the first leg of our epic odyssey, even though Lilongwe was only intended as a practical stopover before springing up North. The decision to go and explore the market came almost naturally as we finished our overwhelming supermarket raid to stock up for the journey and felt in need of an antidote. Even though I’d already explored this market twice before, I never tire of going back there to be completely captured by the buzz of human activity and the profusion of colours, smells and sights. A kick to the senses really. From the meticulously stacked displays of fruits and vegetables at one end to completely dispersed messes of clothes and paraphernalia, we meandered along countless aisles, which revealed the true expanse of this deceivingly enormous market. The skill of bargaining quickly turns into an art here, and to any poker enthusiast I strongly recommend a visit sometime. Not even getting your shoes shined comes without some element of it! Having negotiated that little exchange, we proceeded to a systematic exploration of the specialist sections of the market and that took us along the traditional medicine quarters (be aware that taking photos on the sly might set you back a good few Kwachas!), the food “pavilion” where not a single part of an animal gets wasted except for bone maybe (by that of course I mean the inedible cortical part, not the marrow!.. and then again, I stare at my necklace pendant wondering which bone went into making it!), the tailoring&repairs, the kitchenware, the hardware and the megaphone-animated flea market style clothes areas. The market is such a beautifully organised mess that it is bound to lure you back any time you’re in Lilongwe. All the more so if you have a sense of adventure and decide to cross the flimsily erected paying bridges across the river that divides it in two (surprisingly it was not us getting paid for risking our lives on it but the astute architects of these totally uninspiring pontoons).

Donija Nkhoma

On Sunday, we did our first drive section to a community project called the Donija Nkhoma village. Thanks to my expert co-pilot, we experienced our first emotional moment when, at 110Km remaining to the destination, I was informed it was only 11Km away. Imagine my joy (read heartsink¬) after I discovered the stranded zero! Donija Project is essentially a close up look into the way traditional Malawian communities are organised, by staying and eating with them in their houses in the village. We had a fascinating guided tour around the different nuclei of the village to see how all these things come together- the nsima, the mudbrick or wooden houses, the ingenuous water supply and the wicker pens for cattle and corn. We also visited a fishpool constructed by the villagers miles away from the nearest lake, and learnt about the role of cattle as dowry! We were treated to a true delight of a traditional dance, where the women could best be described as yodelling, while the chief dancer gyrated and shook in his soft-drink-bottle-metal-cap-studded outfit at a speed my eyes could not fix. The sound was an eclectic bojangle beat.

Vwaza Marsh

After a very comfortable hospitality with some VSO friends in Rumphi (amazing food, courtesy of Marianne!), Vwaza was our next stop and first taste of a nature reserve. The road north form Rumphi becomes a dirt road for 100s of miles further, and really tested the car and Ash! The car resembled a pile of red dust by the end of this portion of the route and amazingly still has all its bits attached (which goes for us too!). Its original blue also proved to be the perfect lure for the millions of Tse-Tse flies colonising the marsh, which would come tick-ticking loudly at the windows in desperation for some human blood. Hence all windows up in the stifling afternoon heat while we attempted a mini-drive safari of the place.
Vwaza is a marsh surrounding a lake, where we stayed in a wooden hut on sticks, overlooking the lake. We were treated to the amazing sites of the park and got within arse-slapping distance of elephants (which Ash was very suspicious of their potential as man squashers [thanks to Janet’s white bait of a shirt!], though luckily we escaped unscathed). Also on the tick list numbered an entire herd of impalas, bushbucks, kudus, baboons, hippos and so many birds I couldn’t begin to name them (but there was a wicked Ibis couple in there).
A cook was at our service that evening, who conjured up some wonders out of our very sophisticated tinned offerings. As the night, its silence and crazy sounds closed in around us, we enjoyed the delight that be our candle-lit hut in total outside darkness and the sweet hiss of Malawi Gin with sprite.

Nyika Plateau- nature walk
Nyika rightly deserves the title of our ‘piece de resistance’ for this trip. It was, after all, the ultimate destination around which we constructed this sumptuous itinerary. Nyika is Malawi’s first and largest National Park, most parts of which are still inaccessible today, but to the most diligent and researched explorer. The motor-able route up put our dare-devil off-roading in Vwaza to shame, with the car threatening to skid off the road at least twice and forcing a maximum speed of 40Kmph on us.



Once you get to the plateau, you are immediately enveloped by a magical feeling of escaping to another world. In all truth, for Ash, it strictly represented the first time since in Malawi, where he felt altogether free from noise (Vwaza was a close contender, except that, of all days, ours was when the village gathered for a very rare mourning ritual on the edge of the park). In Nyika however, there prevails that silence which magnifies every other natural sound to its absolute sweetest (little wood insects, rustling leaves, water streaming etc). The setting is one akin to the highlands of Scotland, with one slight difference: inamongst the bracken (and seasonal orchids), there’d lay a herd of zebras (my favourite) or bucks or Roan antelopes staring at you with that quizzical face that says “friend or foe?!”. We managed to get close to the animals (including an elusive scrub hare just for Ash) on the first afternoon with the help of a local (black) guide by the name of White. It was an absolute treat to be able to not just see but also learn about so many species of animals, birds (herons, buzzards, bustards, cisticolas etc) and plants in one single day. And that made our day. Or maybe was it the delicious concoction created by our dedicated chalet keeper-cum-chef, Moses, who performed what can only be described as alchemy on the sweaty ingredients we’d be dragging along from Lilongwe. In this season, at this altitude (2000m), even in Malawi it gets pretty chilly. What better way to feel smug then than by a local firewood fireside with some more of that Malawian gin and real tonic before hitting a perfectly manicured bed...

Nyika Plateau- cycle ride/ village walk
Day 2 up Nyika was pedal powered along a myriad of paths and viewpoints onto vistas of the order only gleaned at on 'Planet Earth' or the like on TV. My position as the pack leader entitled me to the honour of approaching the animals first along the trip, often seconds only before they would rush back t o “security”, away from my trailing bike partners. White was again very useful in his local insight, even though that did not suffice to bring out the elands for us. Having exhausted ourselves to smithereens, we opted for the lazy stroll in the afternoon, which took us to the well kept secret that be the workers’ village on the plateau. That proved to be a great cultural extra (which we’re always keen on here) and also such excitements as crossing a derelict wooden bridge and balancing our bodyweights on some felled pine trunks near our chalet. This you need to picture as an amazing cabin warmed by an enormous central hearth and almost fully wood fuelled, including hot water (delight!)! Large windows let in plenty of light and gave us views out into the dense conifers to the back and into the small valley with its dams in front of us. As you guessed, dinner was consumed by the warm fireside, as prepared by Moses, and this time he managed to make us some bread and a perfect stir fry out of the fresh ingredients he sampled from a high up garden.
For two days, Nyika produced what would be best described as a little piece of heaven for us.


Nkhata Bay
From alpine silence and cool to humid lake-bound bustle, the transition could not have been starker. But then again a Malawian road trip wouldn’t be complete without including at least one stop at the lake. As it is clear to me by now, each bit of the lake has got its own personal character and charm. Far from the tranquil repose of Mangochi, or the posh resort of Cape Mcclear, Nkhata bay’s distinct appeal lies in its cliff-perched villas flanked by lush green wilderness. Once you’ve eliminated the thought that crocodiles might lurk somewhere in that water, it becomes one of the best for snorkelling haunts I’ve seen so far. You can really get close to those cyclet fish (which are unique for the propensity at evolution and rapid selection) and swim long distances without having to worry about tides or currents. If you’re lucky you’ll find a parked boat which you can climb and dive from... Simply ecstatic!

Senga Bay
In search of a more sandy version of the Lakeshore, the next day found us trekking another 350Km or so to Senga Bay, which is otherwise known as the capital’s swimming pool. This is where all these executives and short stay tourists rush to for a quick chance to immerse into Malawi’s biggest gem. However, partly owing to my state of sheer exhaustion and partly from a less than optimal choice of lakeside to stay at, Senga Bay will probably not remain etched in our hearts and minds as the preceding 6 days will. As for tranquillity, it certainly surpassed our expectations and we were glad to have a peaceful last night of a truly amazing holiday, recapping and recharging our batteries.

Lilongwe to Ntcheu- Public Transport2
Taking hitch hikers en route had become customary for us by now and the last leg of our journey was no exception. It was a reluctant reminder to us that our time of enjoying this luxury (lift offering) was also coming close to an end. The keys of the hired car would be handed over soon and we would become the ones either hitching or screeching and squeezing aboard a bus back to Ntcheu. This was precisely what happened after we managed to dodge past the horde of would-be porters to our bus. There we sat relieved that the bus was already full and ready to depart. Or so we thought. I was sat on the engine box at the front (my backside being guarded from smothering to an ash [!!] merely by an aptly placed wet towel from the morning’s swim!) and Janet on the steps. In the next 10 minutes the bus managed to fit another 10 or so passengers and within 10 miles of Lilongwe, it made this unexpected stop, where one person boarded together with their life’s belongings, followed, to our disbelief, by another, and another... until a miraculous 15 other passengers (less kids) found a space to stand somewhere aboard this bus. I don’t know how we managed to breathe after that. I think that if a preacher had joined us at this time, I would have stood up and preached back something about existentialism or some unintelligible metaphysical subject just to get it off my chest. Thankfully, the drive was quick, the music not deafening (thanks to my premier position next to the driver, hence controls) and the sun-setting scenery over the mountains of Dedza and Ntcheu an absolute treat for at least two exhausted contemplators.

1st week in Ntcheu... together

Today I will add a twist to this latest entry as I have in my company a guest appearance by the name of Janeti! She will hopefully confirm such concepts as the “sound of Ntcheu” and “public transport” for you here but also provide a very fresh insight into life and work in Ntcheu, with her original views.
So here I am, and I has perfectly become we again, which is just great! We are sitting here together eating Lilongwe strawberries from today’s tour around the city’s market, in the best room in the VSO guesthouse. We’re preparing for our epic trip to the North which starts tomorrow, after a lot of organising from the well connected and diligent husband. So to take things backwards first, perhaps you all might like to know the other half of the Doorgakant’s impressions of Malawi...
It’s fairly impossible to know where to start, and even when you do start you can only make crazy generalisations anyway, so I’ll keep to the facts- I arrived in Lilongwe after a long but smooth flight via Addis Ababa, most of which I slept through after hauling an unfeasible amount of luggage down to London and then optimistically turning up with it all at Heathrow, only to be relieved of a significant portion of it at the gate (thanks Saj!), allowing the plane to actually take-off. It seems I’m not yet Mauritian enough to be able to get all I intend on a plane!

The happiest and most brilliant bit yet then came being reunited with the husband in the airport- you can all picture him there I’m sure, standing out in his brown felt hat! You’ll all be pleased to know that he’s the same as ever- full of energy, life and enthusiasm, but with one significant change, which I’ll leave you to ponder...and challenge you to spot on proceeding photos. (something quite bizarre, that I can’t explain- he puts it down to the washout of accumulated e-numbers and oestrogenated tap water from the UK!)

Back then to Ntcheu after reuniting my tastebuds with Nsima. It’s a long town based around a main road. I’ve seen the infamous Uncle B’s, I’ve climbed up the Mt. Ntcheu telephone mast (battling [psychological] heatstroke), heard the dog chorus, admitted that ‘yes’ there is quite a lot of noise pollution in Ntcheu, tasted the homemade marmalade, and loved meeting some of the great people already mentioned in this blog.
Briefly, to stop this being a complete epic (there are other things to do than write blogs on a Saturday night!) I’ve enjoyed seeing a little of how the lab works in the hospital, after very kindly being allowed to spend most of last week shadowing the work there. There is a main multidisciplinary lab for malaria films, FBC, some biochemical tests (depending on reagent availability- also less U&Es) CD4 counts, and then a micro lab which mainly can deal with CSFs and TB smears. One of the main challenges has been dealing with Dr Ashtin’s varied output ranging from specimens in contravention of the lab acceptance policy, to trying to get samosas through the door (also against the rules of the labarotory). In only 4 days it’s really opened my eyes to the realities of work here, and I’ve also been very impressed by the standard of the staff. I’ve also made media, which is something never really done in labs in the UK now, so a good education for me. I could write very much more, and will talk very much more, but for now back to this blog’s real author.

In case you’re already conducting an internet search to find out which newspaper or TV programme my illustrious wife has appeared on, let me clarify that by media she meant this funny plastic dish full of microbes, which gets microbiologists all excited for some reason! Never made my life easier as an orthopod because the next thing is usually a diatribe of Latin and Chinese to tell us that we need to use the antibiotics we were intending to use anyway. In any case, Ntcheu only has 3 or 4 on offer!
Also to get back to the Samosa event, let me just add that after spending your lunch hour doing your second operation of the day (the first one having been a killer in its own rights), namely a hydrocoelectomy turned Orchidectomy because the booking clinician had no clue about testicles, the very thought of even thinking of sharing the only bit of food you could lay your hands on before rushing back to theatre ought to be met with better gratitude... even if the offering was made on the threshold of a microbiology lab! At least it was not inside the lab, next to the dissected testicle!
Anyway, you’ve heard it from a second source now, Ntcheu rocks, but Ntcheu also needs a certain level of decibel tolerance and Ngoni-style energy. This is the local tribe around here, who really deserve a good few paragraphs of their own. Let’s just say for now that late night partying and heavy drinking aren’t exactly alien to them. It’s really been great having the wife around to see what’s going on in the hospital too. It surely wasn’t easy to spring into the same familiarity with it all as I have developed in at least 3 months, in less than a week, but she’s done pretty well indeed. She even knows more than me about what tests can be done here now and is able to give me insider information on how to find out when they’re available!
I won’t dwell too long on this first duo-blog because there’s a big trip ahead of us, which stills needs quite a lot of fine tuning doing on the organisation. One of the good things about being in Malawi though is that last minute planning tends to be the norm. Somehow or the other things just work out... I hear Bob Marley’s lyrics... but is it me musing or is it the Lilongwe Uncle B launched for the night!?

Clinical Digest 6

Another 3 weeks gone in the hospital and so many new surgical adventures to recount. The nature of operating has not exactly changed, in that it is still mostly salvage surgery, but a few items have been added to the repertory. One of them is split skin grafting. Since I got to Ntcheu I kept hearing that we had the kit for it but I was yet to put it to the test. I judiciously chose a small case to be my first one. The surgery was uneventful, although remarkably slow, owing to some issues with positioning and kit. The knife in question is a donation from a very enterprising Dutch doctor who pioneered this new model based on its resemblance to the “Schick” razor and even uses the blades for it. Only drawback is that it only allows you to harvest tiny grafts which you then knit together on the wound. As it is, the wound on our patient in question was right over his Tendo Achilles and the anaesthetist was not happy doing him prone. So I kind of got him supine with a figure of 4 crossleg, which made the actual job of the final stitching tediously slow. It’s a question of time now to find out if it takes or not.
My level of amputation has also progressed and I now count a below elbow amputation in my logbook. One must wonder whether all this is really necessary or whether we could just debride radically and wait. Well that’s precisely what we were doing at first and discovered we were being too conservative and had to take patients back. Just to contradict this pattern, then came a case of a grossly septic leg which we were very close to performing a through knee amputation on but had to hold back as the patient refused surgery at the last minute. What ensued was rather enlightening. To my consternation, this leg which I had, by now, consigned to an irrevocably doomed fate, started to get better with stringent wound care alone. That threw me back to the original question of “to chop or not to chop”. I guess that there will always be cases, especially here, which behave differently from the norm. The actual protocol of practice however, should, I believe, be based on the average (which time and experience will aid my clinical judgement of) rather than special cases. And indeed, that below elbow amputation was another special case, which I thought was amputated high enough. Yet it gave me reason to worry that it was still infected, ie I hadn’t gone high enough. Thankfully, aggressive wound care sufficed.
By the way, you will have also noticed that we are consenting our patients, but the process is a far cry from our 4 pages of carbon-copy material plus all the other forms in England. The form here resembles more like an 8th of an A4 page with the following signed statement: “ I hereby consent to have an operation on any part of my body as deemed necessary by the surgeon,” or something similar!
The degree of sepsis encountered here is something of a completely different order to that found in the UK. Whether this is explained by the virulence of the pathogens or toxins (as in the few snakebites I’ve already dealt with) or by the time it takes to get to the hospital, or even by the time it takes from admission to get to theatre, or by the stubborn stoicity of the people who have faith it will get better by itself, if not with the assistance of the greatly revered witch doctor (whose involvement is often recognised by the tell-tale abrasion scars on the skin), I can’t really tell for sure, but it is likely to be a combination of many if not all of the above. The management of such sepsis is a real challenge and necessitates intervention on a number of different levels.
My latest case in theatre was a surprise last minute one I only picked up the day before and planned for the end of the 3rd week: an index finger drop. The patient had been severely panga-knifed, sustaining bilateral Tendo Achilles divisions as well as multiple scalp and bilateral forearm wounds. Poor chap (19yr), he looked like he’d just come out of a sarcophagus, with all the bandages around his body! (He was approached by some ruffians who wanted a mobile phone from him, which he didn’t have. So he ended up paying for it in the form of these unwarranted lacerations). The hand on the non-operated hand was afflicted by an ulnar nerve palsy beyond repair. The other hand needed an extensor tendon exploration and repair, which I had only ever assisted in them in the UK but never done one alone. Technically though, there was no reason why I shouldn’t be able to do it. So I approached this case, made more complex from the fact that he had two potential wounds on the dorsum of his hand/wrist where the tendon could have been divided, not to mention the fact that he was almost a week from the time of injury (hence starting to retract). I was quite pleased when I finally freed both lacerated ends of the tendon, although I only had a flimsy silk suture to reapproximate it. My first independent case of reconstructive surgery, provided the best booster at the end of this 3 week stretch I could ever wish for. And now also, my interest in hands has been properly rekindled.
Besides operating in the main theatre, minor theatre has also provided its fair share of excitement in the recent weeks. I embarked upon a poster teaching session forced by some of the practices I had witnessed earlier by the student staff. Hence we drew posters on safe administration of local anaesthetic and the differences between common lumps and bumps (a description which caused hours on end of giggling here). The rules behind the dosing of LA and its limits were completely alien to this staff group who had been administering them liberally for months if not years already. Being low resourced is not an excuse for letting your standards down on such an easy-to-implement concept. As for the lumps and bumps question, we now have a readily accessible chart to differentiate between them. This is been a welcome addition to the trauma room, where hopefully lipomas will now be diagnosed only when they are actually lipomas and not cysts or nodes or pseudoaneurysms anymore! As a real coincidence, that same day, we received a serendipitous casemix to examine in our clinical area: a real lipoma (which was enormous and I only just managed to excise under LA), a ganglion, a scalp sebaceous cyst, a skin tag, a histiocytoma and a pyogenic granuloma! What were the chances of that? What I found with the style of the teaching is that it is very participatory and depending on how it works, I can surely see myself exploring a wealth of topics during the year to come. Next one is already lined up- aseptic handling and sterility. The microbiologist in me, not to mention the one attached to me, could faint at the way some instruments and specimens are handled here!!

Aphiri

That’s Chichewa for mountains. That was also the fortuitous nickname I earned at the ART course from the Malawian candidates. Pretty fateful, since, now the rainy season is pretty much behind us, more and more unsuspecting people are being dragged up these breathtaking heights with me. The last time was Zomba with Caleb, Corrie (a VSO from Holland), and Claire and Nicole (CNN for simplicity- visiting Dutch medical students, who are a real laugh by the way). This weekend was the second ascent of “Mount Ntcheu Telecom Mast” as I shall name it, for want of an official name. My victim, for the second time in a row, was Caleb and his unpreparedness for this expedition was obvious from his power shirt and the NASA-mission-looking DocMarten type shoes he was wearing (only slightly worse than the ones that crawled up Zomba plateau in - so I thought he’d manage)! In the interest of variation, we chose an alternative descent route, which is what made this time around more memorable. Of course, the ascent involved the same toil of sweaty gradients and tall grass, with inescapable reminders of snakes lurking amidst the thick canopy. After losing his body weight in sweat and CO2 and demanding almost the same amount of time in rest as in actual walking, Caleb unbelievably made it to the top. Once we started our descent, the functional uselessness of those very shoes became apparent. The arch-less insoles, smooth as a baby’s ass caused his whole foot to keep sliding on the downward slope, with his great toe constantly abutting against the tough inside. Oh did it hurt...and slow us down. We were now taking longer for what ought to have been the faster leg. And how things weren’t helped by the fact that, unbeknown to us, this alternative route was some 7-8Km longer than the ascent route!! We found ourselves contouring the foot of the mountain towards another town some 7Km from Ntcheu. (I know of an old hiking partner who’ll spot a few similarities with some big hills once in Scotland!) We were on the flat now with the sun right above our heads, still clueless about the remaining distance to the main road. Our attempts at gauging it from the locals in our broken Chichewa attracted answers ranging from ½ Km to “forever”. So we thought it might be wise to hail a passing vehicle and cut short Caleb’s blatant suffering by now. The first vehicle was an ambulance driving too fast to be safe, which didn’t stop even though I was signalling quite desperately that I am a doctor!!! By the way, ambulances in here are mostly used for staff as opposed to patient transport. We passed on the second option, a pick up truck, with some 30 people sardined in the back, screaming some songs; alcohol-fuelled and football-related we concluded (some things are the same anywhere in the world). We finally met with better luck with our third vehicle, if luck it can be called. It was a relic of a 4x4 with the back loaded up to the top with sacks of potato, atop of which were some 6 opportunistic travellers like us, as well as a bike. Considering the rocki-ness of this dirt road and the local driving style (which is one of my main sources of work in the hospital!), we thought we’d negotiate a place in the front. There was already a passenger there and at a push (literally) it would accommodate another one. Its door was not closing and had to be held closed with some old tyre strips (the favourite strapping material in Malawi). Somehow we set off with 3passengers and a driver in the front, the far-side passenger (myself) hanging on fiercely against the door which my bum was pushing open, with my hand at the top straining feverishly to close the gap! It turned out we were only 3Km away, but given the state he was in, even that would have been too much for Caleb to leg. Thence we caught our final minibus ride home to Ntcheu, in search of food and more food. As it is, getting on a minibus is not something I take too lightly, given its high contribution to the Malawian trauma statistics. The driver is normally subjected to a breath test by me (both ways it stinks, but the alcohol-imbued one a bit more) and the tyres inspected for the adequacy of the treads. Today, despite bypassing all of these checks, it felt like the safest ride home that I’ve ever had....

Written upon Caleb Muchungu's request: VSO Volunteer at Domasi- and slowly becoming a seasoned mountaineer.

D-day -10

This is one is for my lovely wife, akazi kokongola Janeti!! Today is exactly 10days before she comes down for her first visit and it will also represent a symbolic 3months since I've been in country.
I might have made scant mention of our long-distance relationship till now but it's been a really important aspect of this experience of mine. Janet's support is largely responsible for me remaining upbeat through it all up till now. So a big thanks to you here Janet and I look forward to welcoming you soon to this great adventure/work/personal development...

A Zombie in Zomba

Caleb and I
Okay.. this time I won’t mention the lake! Too late! I went up to the mountains instead. Zomba plateau to be precise and immediately after heading down to Blantyre first on the Friday and waking up super early the next morning for my lift to the base town- hence the zombie state! The route to Blantyre was in honour of my educational meeting at CURE hospital for the complex cases discussion from Ntcheu. I almost didn’t make it because, en route, my minibus hit some pretty severe weather in the form of a flash storm, where we had a gobsmacking downpour of hail with a visibility of less than 5m, and streets being flooded on both sides. That didn’t stop our driver from keeping going, nor did my constant shouts and pleas from right behind him!
Flash Storm
Zomba is this picturesque mountain city, the old capital of Malawi in fact before Banda relocated it to Lilongwe, with limitless vistas onto the fields around and further onto the lake. The route to the top was essentially a road with few shortcuts off the beaten track. My intention to do the whole thing along a potato path obviously went wrong somewhere, but did nothing to curb my enthusiasm about rising up in altitude. At some 1800m in height, the air feels somewhat fresher and the heart lighter. I really enjoyed being back in that element as evidenced by the pictures. The temptation was there to stay in a hut at the top but unfortunately they had a rallye the same day and all accommodation was booked. So we decided to go back down and in the end that move paid off. I stayed at my mate Caleb’s house in a nearby place called Domasi and it was just the most fitting escape for me, as concerns the nightly drumbeat cadence of Ntcheu. There, I stayed on the veranda, fenced by a fine metal mesh, which kept the mozzies away. It was quite frankly like being under the stars, and what more, without disco noise but the natural roosting and humming and click-clicking of the myriad creatures around. Caleb was in top form and is currently working with the Malawian Institute of Education to enable them to produce some educational videos etc. His interest and knowledge in African current affairs is astounding and these insights are even available in electronic format on the web. Just type in Caleb Muchungu and you’ll be exposed to some real African views rather than the typical whitewashed one we often get.
From Zomba.. with awe
After my fix of altitude and silent night, I made my way back to Ntcheu on the minibus, which was another great incursion into the world of African transport. In other words, never run a tight schedule if that is your chosen mode of locomotion. It waits at every station to try and collect that one extra passenger at the detriment of the available bum space in the already packed vehicle. It slows down at the sight of every potential passenger along the way, to reaccelerate to some wild speeds I wouldn’t do on a British motorway, once it’s figured out that person actually prefers walking to being a passenger of theirs! It then always gets halted at road blocks, where policemen eagerly scan the vehicle for the slightest flaw to impose some fine. And that negotiating can take up to 30min easily. But the fun lies in the witnessing of all this crazy rigmarole and the ample opportunities for conversation with Malawians. Not only is it a great way to get to know the culture better but it’s also an opportunity for you to be an accessible muzungu as opposed to the convential image of a 4x4 barricaded white face in a segregated shopping complex car park, where they sell cheese, chocolate, pizzas and the like. The minibus, in a figurative way, allows people to see there are also tourists/expats who eat nsima and usipa (the local tiny fish from Lake Malawi which I had the priviledge to eat, as prepared by a local Malawian friend of mine according to a traditional recipe- truly succulent I thought.. although my other friends didn’t seem to agree so much). I think I am now starting to see beyond my Bradt guide... and for myself. Oooh Malawi!

Clinical Digest5

If, by now, you are starting to expect some clinical stories from my new front, you’re right. For I’ve been in Ntcheu for 3 weeks already and have not sent any reports yet. That is partly because I was busy assimilating it all, and working on the contrast there exists between here and Lilongwe, sorely aware of the extreme contrast even this state-of-the-art centre presents next to the UK.
However it has not felt like a gloomy debut at all. There are so many facets of working in this environment that would make Lilongwe blush with envious shame, let alone the UK. For one the people working here are all approachable, all eager to help and all extremely welcoming. Despite there being a significant deficit in knowledge and skills, largely attributable to the resource-stretched training reality here, the affinity to learn on the job is remarkable in so many clinicians. The latter group comprises in order of seniority student medical assistants, student clinical officers, medical assistants, clinical officers, specialist clinical officer, medical interns and doctors.
The clinical highlight of my first week was really ward rounds and clinics, with little theatre work, besides assisting (mostly C-sections and a hernia). Orthopaedically, we did do one knee arthrotomy and washout for the management of a septic knee joint. I also saw some interesting cases of gross mal-union [a harsh reality of ORIF (metal implant)-deprived settings] and deep burns turned necrotic.
The second week saw me finally getting to the knife, performing salvage operations mostly. First of all, I did a below knee amputation (BKA) on a 3yr old for a necrotic snake bite wound on an ankle which had turned completely septic. My main concern about her management came intra-operatively when I discovered some suspicious looking fatty tissue as far up as the knee. I was not prepared to escalate to my first through-knee amputation though, with no guarantee that even that level would be adequate. So a careful decision was made to wait and see how the BKA alone would fare. By the day 10 mark post-op, I have to admit that, to my surprise, encouraging signs of healing were showing. The next operation came in the form of multiple disarticulations required on a man with severe septic eschars on his dominant hand from a burn injury. I did it under a wrist block (my first ever), which was somewhat helped by his HIV associated peripheral neuropathy anyway. In the end, after more tissue had to be resected than originally intended, he was left the best semblance of a hand that he will ever get. Time will only tell if that will survive or he will end up losing even that rudimentary pincer grip we have tried to preserve.
The second week also saw some colourful moments in minor theatre, which is essentially a treatment area, where most wound management is done. Most of it by junior clinicians, often unsupervised. The result of this state of affairs revealed itself to me in a pretty hairy manner, as I unintentionally found myself taking over a few times (at lunchtime as it typically happens) from struggling clinicians, completely out of depths. Firstly there was an excision of a dorsal wrist ganglion misdiagnosed as the universal lipoma! An unmounted blade was the instrument of choice for plane dissection and a big question mark on the clinician’s face, the method of choice to dissecting it out! Another case was the excision of an actual lipoma (correct diagnosis for once, even though they were unable to distinguish it clinically from a pseudo-aneurysm), over the radial artery territory. It came out very satisfactorily as a whole and so was the ultimate state of the radial artery. Finally, the scariest bail out of all was for a “lipoma” dangerously close to the femoral artery which the clinician was blindly pecking away at. This is a case I would of course have chosen to do under GA/Spinal in majors. But here I was using a tiny incision, to limit the damage done and resect as much of a pus filled lymph node (?TB) as was actually possible. The femoral lived on... by a very close margin!
Week two ended on an especially convened clinical meeting, at my request (excepting the timing), on the Saturday morning. This is a quality control exercise which is very laudable in its concept, the effectiveness of which remains to be seen. It should normally be conducted monthly but often months can go by without one. Most pertinently, it is a hospital-wide clinician reunion, where issues are raised by everyone on their own or their department’s behalf. The size of the institution in Ntcheu is really what allows for such an exceptionally democratic and wide-ranging meeting to take place. We discussed myriad issues relating to hospital organisation and the dichotomy between volunteers and locals was again starkly drawn out. Whereas we were banging on about issues of accountability, initiative and quality control, many of the points raised by the locals pertained to remuneration, satellite TV subscriptions and free diagnostic kits! Thankfully, the chair, a local Malawian doctor, was very impartial and did pick out priority issues for the main agenda and left “social” ones to be discussed as AOBs (any other business). I left with an overall satisfied feeling and a great urge to put our resolutions into practice.
Last week (week3), was when things really started to come together a bit more neatly. This was in part helped by competing operators being away at a training (ETAT- emergency triage assessment and treatment of under-5s). I therefore managed to get into theatre a bit more and to get to grips with the booking process and how to expedite work. My two main operations were both on hands for, you guessed it, necrotic wounds. With a slight difference, the first one was not a burn wound but a infection secondary to a foreign body. It’s worth remembering that tetanus is a real danger here and can kill pretty quickly too. This patient was not such a case but his middle finger needed amputating. With poorly functioning tourniquets and less-than-optimal lighting, ligation of tiny bleeders can be one serious challenge here. We had to leave the stump to heal by secondary intention and it will be quite a new experience to see the natural progression of such management on the ward in days to come. The second operation was almost a carbon-copy of the previous multiple disarticulation mentioned. This guy was not as lucky though and was left with only his thumb, which itself is unlikely to survive. We’ll be preparing for a definite below elbow amputation next week, rather than allow the infection to spread more proximally. The wards meanwhile, were being populated with an increasing number of people on traction for a number of different diagnoses. We had tibial skeletal traction for a couple of femoral shaft fractures (treated with skin traction in children), skin traction for femoral neck fractures and an amazing case of 900/900 traction through the tibia in a 60 yr old man with a femoral fracture but bilateral knee and hip contractures and shortening, secondary to multiple bony epiphysiodeses. What I particularly enjoyed was giving instructions to the elderly patients in skin traction regarding, regular exercises to avoid DVTs, as low molecular weight heparins are something of a distant dream in Ntcheu. The week was concluded by an educational visit to CURE hospital in Blantyre, which proved to be so useful and insightful that I’m going to be making of this a regular occurrence, with huge benefits for my patients.

Some things are more plain sailing than others

Hmmmm
El Capitano
Yellow submachine
For fear of including only jealousy provoking blogs about my lakeside evasions, I shall make this one only briefly and leave you with photos rather. Yes, I went back to the lake on Easter weekend. The appeal was too great, despite my rather shattered physical state (after the Lucius escapade!). It was in honour of a long-awaited reunion with my main contact in Malawi from my previous trip- Mr Neville Bevis. This man needs a full blog to merely paint a superficial portrait of his oh-so-varied-and-amazing life. In just a few words, he is a 60 odd year old widower and retired teacher from Harrogate, who’s been in country for >10years running an ‘orphanage’ by the name of Open Arms. He has recently opened a new branch in Mangochi, near Lake Malawi, and that is no mean feat. The level of organisation and dedication it takes to run even one of the ‘orphanages’ in Blantyre would scare the hell out of most normal good meaning people I can think of. He hates the term ‘orphanage’ with the same passion my friend Caleb hates ‘AIDS orphans’. Not least because, over here, these terms attract stigma and, rather than help, simply exacerbate the problem.
Besides his charitable credentials, Neville is also an experienced sailor and has spent the last couple of years spending his retirement money on his dream, that of building a sailing boat. That, he did pretty well here using local people and materials as much as possible. And this weekend was one of the early trial runs of his new baby. With his physically eager ”moussaillon” it was only a question of shouting out the orders before the sail was raised skywards, the anchor swapped (requiring an acrobatic and divine dive into the deep lake to reach it) and the catamaran moving (with the anchor-boy back on board after a rather Latissimus-testing scramble). The rest was a fairy tale fuelled by a heat-induced partial delirium and lack of food! Let me add that that was not our intention . Food we brought with us for sure, but little had we anticipated the spillage of fuel that turned our bread and cheese sandwich into a highly flammable carcinogenic timebomb... Not that I didn’t try to eat it at least, but the violent rejection from my tastebuds was a reaction I could hardly ignore!
What better way to test our weakened, beer-thirsty souls then, after some 4hours hard sailing and boiled lake water drinking, than to put a squall just at that spot where we decided to take down sail. I had no idea what and where it came from but it was like we suddenly left the eye of a cyclone to get right into its chopping jaws. How we managed to bring the sail down without getting hammered to death by these raging metal-fringed canvasses is a mystery to me! By then I was on my very last legs indeed and all that kept me going till the coast was a beer-gilded mirage. And Oh did it taste good!

Next day, we had a renewed trial with an additional member. By then, thankfully we had ironed out most of the teething problems from the day before (I’d like to take some credit for this). And this time we did have a plain sailing venture into the vast lake... under the same beating sun and drinking the same lake water tea, but less the squall. We had Mwera instead (a localised bad weather formation on the lake) in the morning but wisely waited for it to abate. By the next morning the Bwera had scaled up a few notches and any sailing would have been beyond our wildest ambition. But there was no need for any such death wishes then, because we had done the sailing we set out to do and it was our time to head back home anyway. This we did along some pretty fascinating Bwera-free landscapes environing the exquisite natural gem which is the Liwonde National park. I was one satisfied and sore-boned terrestrian stung by the sailing bug! PS: I do apologise for failing in my aim to keep this one brief, but I hope you’ll understand why I couldn’t!
escape...

Tribute to Arnol

3weeks’ worth
It’s been hectic since I left this blog last. To try and recount all these events would make it far too long, so I shall simply summarise them and expand on a few. But before I do anything, allow me to pay tribute to a newly-met VSO friend of mine, who succumbed to a fatal road traffic accident on his motorbike only days after the annual conference: the exceedingly nice Arnol Pajaron, VSO volunteer from Phillipines who was working in Secure Livelihoods towards agricultural improvements in the district of Thyolo. May you rest in peace Amigo.
This was very much the first event since the conference. Sadly so, because I met him there. During the week that followed, I also undertook my last week of orientation at Kamuzu Hospital. This was mostly a week of wrapping up and refining some of my skills acquired so far- amputations, debridements, hydrocoelectomy, as well as clinic work. The visiting Orthopaedic surgeon, Sven Young, left at the end of that week, leaving the department without an orthopaedically-trained doctor anymore.
On the weekend, I went to Blantyre where a memorial service was being held in honour of Arnol. It was a truly moving service, where the close-knittedness of the Filipino community and their generosity were revealed at their best. The wider support of VSO was also evident, with more than 40 of us travelling from up and down the country. Probably the most humbling part of the service came from the very people Arnol worked with, the farmers, who also made this difficult trip to Blantyre just for him. The rapport he had developed with them and the fruits of his hard work were obvious from the brief but honest speech they did there. A slideshow of his time in Malawi, compiled by his best friends, concluded the service, with most of us struggling to hold back tears.
After this rather traumatic patch, my next week started afresh with a rather peculiar training for an orthopod- Anti-Retroviral Therapy provider certification (ART). Peculiar is starting to look like the norm now for me at this rate! ART is seen as being beneficial for anyone on the delivery side of health care in this country as I should hope “to become a player in the efforts to bring down the HIV/AIDS epidemic”. I use this very turn of phrase here to highlight a major division that manifested itself uncomfortably to me during the course: the cultural divide between Malawian and VSO participants. There is something that VSO volunteers very often talk, in fact, moan about, and maybe understandably so. It’s the allowance culture. Many key health care staff we work with are often absent from work, under the guise of such and such course. They get paid a hefty bonus (given as incentive) and generous living expenses for going to the courses. It often happens to be the same people who tend to go away on courses, such that they’re away getting trained rather than putting that training into real practice. The striking difference between “us” and “them” screamed out when we all got asked to express our expectations from this course at the start. Quite puzzlingly, the principal points raised by the Malawians were to do with their “accommodation”, “food” and even “allowance”. So, one of the VSOs finally added that we were also here to learn and develop our skills or something like that and I came up with the aforementioned quote! What tipped the balance of hostilities though was a complaint from the Malawians, who were being put up in a not-bad-at-all establishment. They found that room sharing was unacceptable, the water supply not good enough and the tea cold! This didn’t go down well with one of the VSOs who answered them back saying “they should stop complaining and get on with it like the rest of us are!”. This was a difficult one as that VSO would clearly not have interjected in such a way had some westerner raised this complaint in the west. Yet, given the economic situation in Malawi, having such high standards for educational meetings appeared to be somewhat eccentric. Point taken but still most of government meetings take place in one of the high-end hotel chains (which, I discovered, is owned by the government, hence attracts a massive discount) and civil servants want to have similar privileges. As for the allowance side of things, again I find that difficult. On the one side, I have depicted how they can represent a financial drain on institutions rather than a gain if the designated trainees are too frequently away on training. However, I also sympathise with them a bit as indeed, this is the only way they can acquire more skills to operate at a more advanced level, as required. Most won’t have had the privilege of a university education or tertiary diploma. Also, saying that they’re most of the time away on courses is probably an exaggeration (based on other volunteers’ experience), which I’m yet to assess for myself once I’m settled in my job. Regarding the financial reward involved in attending courses, one can hardly blame them, if one only looks at the gulf between their actual wages, all allowances included, and ours in the west (not our stipend here which is largely unrepresentative). Finally, there is a real problem here in the form of brain-drain of talent, as the highest skilled Malawians are often recruited abroad or in non-governmental organisations, leaving the government ones like hospitals starved for qualified staff. How can one blame the government on the one hand for not remunerating the staff well enough to ensure retention and, on the other, for giving them allowances to boost their wages? One is tempted even to congratulate them for attaching the financial reward to an actual educational activity rather than simply raising wages. Everything in perspective I think and whatever judgement be made, it ought to be made with due consideration of all relevant nuances. After the uncomfortable start though, the week eased off with some lighter humour and me acquiring the honorific of “Aphiri” probably for making sure I stayed neutral in that original rift. The amount of new information being force-fed into my brain was phenomenal, considering how detached I had become over the years from virology and infectious diseases (being married to a microbiologist unfortunately didn’t impart a chip in my brain with all this wisdom!). So the test in the end was something I was seriously apprehending. Thankfully they made it easy enough even I cleared it. So did the whole class!!
On this end-of-week note of success, I took myself down with some other vols to a bar in the capital city to watch the first of my Malawian music gigs. The band was The Black Missionaries, one the most popular bands around and they were supported by Anthony Makondetsa. Both were quite groovy, with a very typical Malawian beat to them (that one that unfortunately resonates every night on my bedroom floor in Ntcheu!) The crowd was equally interesting and I automatically made friends with some locals who were loyally ensuring my enjoyment throughout. There was none of this uncomfortable pressure of asking for things which I really like with Malawians. If anything they might ask for a beer maybe in exchange (which I would have offered anyway) or the chance to associate with the muzungu female company I was with (which of course, I had no control over!).
Next day, Saturday, was a memorable day as I finally set my bearings on Ntcheu for good, without any more orientation or training to do elsewhere. The settling in was invariably coloured by my very own priorities. Noise reduction and kitchen sorting strategy before house furnishing. I’m still working on both at the moment but hopefully will find a right balance. The location is simply great and it would be a shame to have to move. On Sunday (Palm), I went to my flatmate’s church out of curiosity and also because I knew a few people there from my short in Ntcheu already. It was an mind blowing experience to say the least. The church is a Born Again Christian one and the praying style is very much one of intense singing and going into transe, somewhat intoxicatedly. Also there was a strong focus on fund-raising (remember that previous do I went to? That was this church’s bishop’s wife). They had just acquired a set of drums and now wanted to get a keyboard. They pride themselves about having built everything themselves including the church building and essentially want to keep on upgrading... To get some balance back, that afternoon I saw my first ascent of the Ntcheu mountain with some other vols. It was a most rewarding experience, a mini-breakthrough in that it seemed like the rainy season had finally made way for some dryness. Unfortunately we were proven wrong from the very moment we began our descent... The view from the top alone would justify the climb and it took us less than 4 hours, so not too much of a pull for my aspiring visitors. Ntcheu Mountain Kids From the TOP
That done, I finally began working as a proper doctor IN Ntcheu district hospital this Monday gone. Hooray! It certainly feels like a big step forward for me with my numerous new roles and responsibilities waiting to be discovered. My job description is exactly defined and, for the rest of the week, I’ve been trying to find a way of making optimal use of my skills for the whole hospital. I have to, at once, try not to overlap with the other 2 doctors there, one obstetrician/surgeon, and 1 paediatrician (no problems there), and bear in mind that I will probably inherit some of the workload as they leave 4-6 months before me. Simultaneously, I’m also getting working on this project for which I got given a grant by VSO. I was exceptionally lucky to get this at such an early stage, and I’m going to use it to upgrade the orthopaedic department (ie replace rusty blunt instruments with one that cut). My clinical digest for this first week includes several Orthopaedic ward rounds and clinics, with little surgical work, except for assisting in an inguinal hernia and a Caesarean section.
The week ended up nicely at the DHO’s (district health officer- aka hospital chief) house on Thursday night, early start of the weekend courtesy of Easter. He is a 26yr old doctor who finished medschool 2 years ago, but is now looking forward to resume proper clinical duties once his term finishes next month. What started off as a few quiet drinks evolved into a full on night out, with us hiring out a minibus with driver (sober) to take us to the next town for some concert action. The big man from Balaka himself was performing on his home turf- Lucius Banda. So we couldn’t miss it. The socialising with locals was very much identical to the Black Missionaries do, but our own company was completely different. Loads of hospital staff- COs, medical assistants, doctors- and some non-medical people, the whole lot numbering 12. The one that stood out was the anaesthetic CO, who decided to hit on one of our female VSOs. Of course, he was married and she clearly indicated she was attached too and not interested, but the very fact she was chatting back to him nicely earned her the honour of being his girlfriend for the night... at least until it was time to get dropped off back home and hey presto, who was awaiting at the hospital gate?!!! None other than his fat angry wife, who announced her discontent by stamping solemnly into a water puddle before charging onto our bus. Little did our man know that she was not rushing in to join him onboard with loving cuddles, but with a vicious grip to drag him out! Ouch! As for the rest, your guess is as good as mine.

Beach Conference

In the hammock
Kande Beach
15/3/2010
This blog is one I knew I’d be writing for some time, but had also secretly been dreading for one simple reason: this blog will tell of some well good beach times, replete with all recognisable clichés of indulgence like day-long beer drinking, midday swims and hammock lounging... which to some will sound like I’m on some kind of sponsored expat vacation, instead of doing the hard surgical work I’m here to do!! But let me at least justify it. After 5 weeks in country spent mostly attending intensive induction lectures, acclimatising, settling into a new (crazy) town and workplace, attending a busy central hospital from 7.30 till 5pm most days for 4weeks now and trekking around on long distance bus journeys to establish some of the projects I’m working on (applying for a development grant [which got accepted by the way], set up of a trauma registry and joining a teaching programme), a 3 day weekend at a beach resort to recharge my batteries is hardly asking much I would hope!!
Especially since that weekend also happened to be the official annual volunteers’ conference with your VSO-type information overload packed in during the day; also bearing in mind that getting there and back alone could easily require 3 more days’ break to recuperate- 4 hours’ rough driving, the forward journey being notable for its 5am start. That didn’t stop the location being absolutely idyllic- Kande Beach along Lake Malawi- and the company simply wicked. And what’s more, the house rules weren’t the stuck up ones I’m so used to at home. This time they were so relaxed no one would actually notice if you went missing for part of or the whole day, which some certainly took advantage of, but not me. I was happy enough being near the bar, with most of the sessions being held in the open air just around it, and the beach being a few metres’ walk away. The session intervals were fairly generous and allowed for a dip now and again. The opportunity to discover all the different cultures that make up VSO in one place so far removed from home was to me a truly fascinating discovery. I’ve realised there are many different categories (if such a word can be used) of expats, each country having its own peculiarities. Many insights also were brought out into the balance between wealth and poverty, education and lack thereof, community and individual etc, which I’m only beginning to scrape the surface of. Incidentally I was rewarded for my interest by being made a VSO rep for my region. Actually the truth is that no one else wanted to do it!
The evenings were in a different league altogether, the first night being elevated to its unforgettable status by some pretty frantic Karaoke-ing by a motley crew comprising nostalgic Brits, Americans, Kenyans and Filipinos. The second night provided the scene for some fierce inter-volunteer competition fuelled by a very VSO-esque pub quiz (which my team won- only cause we managed to gather about twice the number of participants as any other team, had a VSO insider in it and a representative of every different country that VSO recruits from!!!). All this combined with regular rounds of Greens and Kuche Kuches happily turned every second of the last five weeks into a sweet drone of peace!

That certainly could be said for the live planetarium that was on display high in the sky, with many a constellation recognisable by anyone with an interest in astronomy. For those without, like me, the sheer immensity of it all and the profusion of shooting stars had all the magic one could possibly conceive of in their dreams. On the horizon, a different kind of spectacle was being played- that of the nighttime fishing tradition of the locals. They use a strong light to lure the tiny fish called Usipa or Katempa, and the turn it off before throwing their net onto them. (The catch is pretty good but the taste is very much an acquired one. These fish represent one of the main protein intakes of Malawians and are usually dried and salted by the time they’re sold. Of course, that’s next on my list of tastebud dares.) From a distance, at night, sat on a deserted soft sandy beach, this human milling looked just simply surreal, a bit like a lantern procession with the occasional firework. A Dali painting come alive if you may... That had to be my favourite part of the weekend.

Wifey and Hubby!!