On a Fair, Sick Night

Releasing writer’s block can be a bit like getting wax out of an ear – difficult to successfully accomplish with brief, half-hearted attempts, and really requiring a period of dedicated attention. This can be applied to blog tardiness, or academic work in general. There’s a piece of knowledge (or is it wisdom, B O’D?) for nothing.



All is ticking along here. Time is flying by so fast that I’m surprised that I’m not registering just a series of bright flashes and dark spells to signify the passage of days. I can’t believe it is March already.



Work is going well, but frustratingly the study is awaiting the all clear to get up and running again. It has been on hold since the New Year seeing as our results were decent enough to prompt us to change our protocol to try to address slightly different issues. We are awaiting the approval from the 3 different regulatory bodies involved in our study (Malawian, UK, and US) before we can restart enrolment. [almost there, though].



In the mean time I have been keeping busy with time on the general wards, preparing for the next step, and working on our results to date. It has been educational and enjoyable to have been able to take specific responsibility for one of the wards and keep tabs on exactly what is going on. I am seeing a lot of textbook HIV-related cases and stereotypical issues regarding management in resource-limited settings.

The typical day begins at 8 am with the handover from the intern who had been covering the night before. [Funnily enough, this is perhaps the only meeting in Malawi that I am aware of that starts right on time daily. For most other appointments the well-worn tag of “Africa-Time” is often rolled out]. An account is delivered of all the admissions, discharges and deaths with a more detailed review of the sicker patients. Much of the information presented is taken from a ward handover book of dubious reliability filled in by the nurses. It gives updates on the sickest patients, the admissions and deaths. I am quite taken however with the phrase that completes most entries: “All of the others had a fair sick night!” To me “On a Fair Sick Night” sounds like it would suit as the name of an epic poem about the trials and tribulations of an Irish doctor in Malawi.



Ward rounds, and outpatient care in our clinic room keeps one busy until lunch. After lunch the jobs are a bit more haphazard and less structured, but usually keeping things going for the afternoon. When my crypto study is not running, it is rare to have to stay late.



It highlights to me that what keeps a team really busy in Ireland and similar countries relates to having extra resources: organising a scan does not take time if the scan is not available in the first place, if you get my drift. The same applies to getting specialist reviews of your patients and most paramedical aids. Unfortunately this logic extends to treatment decisions also: with a limited repertoire of medications the choices are less.



It also helps time-keeping to have a smaller physical area in which the patients are cared for than in some of the massive hospitals I have worked in back home. We have 2 public medical wards – 1 male and 1 female with a corridor linking them. They accommodate about 50 patients each, including the overflow patients that are out in the airy Khonde (a covered veranda/porch/balcony area). There is also a private ward upstairs with similar care, but a better nursing ratio, and less crowding.



I am enjoying this hiatus, but also busy preparing for our coming step of the study – implementing new protocols for treatment of our studied meningitis. It is good to have this period to iron out any teething problems before the regulations of a study.



Socially things have been good too.



The rainy season is petering out. Less frequent rains, lighter showers. We even had a false alarm recently where it seemed as if it was over. There were quite a few worried looking Malawians, concerned that the crops hadn’t matured enough and that it wasn’t time for harvest. Thankfully it has picked up since.



The rains have changed Malawi hugely. What used to be a backdrop of scrub vegetation and predominantly red dirt is now a lush and verdant countryside. Where you used to see dry ditches and dead grass is now 8-foot tall maize and vines. The difference is astounding.



It was especially notable a few weekends ago when 6 of us took a weekend off to go to Liwonde National Park for a brief safari. I hadn’t been sure what to expect from the trip. One of the few things I knew about the park is that there are no lions or big cats, and to me it seemed that these animals are synonymous with safari. Perhaps a “safari” without cats is just a drive in the fields? How wrong I was!



Apparently going in the dry season leads to more big animal sightings because of the necessity for them to frequent the same watering holes. Regardless of this, we got see our fill of hippos, crocodiles, elephants, a variety of deer-like creatures and warthogs (with their glam rock hairstyles). We even got to see a big family of elephants and some night mongooses (?mongeese?). There were also myriad interesting birds such as eagles, kingfishers, falcons, and grouse (no choughs, though).



It was an amazing experience to be trundling around in our big safari vehicles without the animals being unduly scared – I presume we represented a single, clumsy looking, rather innocuous beast as opposed to a group of ignorant bipedal predators. You would think an engine would be startling to the animals, but no – it was just our noise, like a funny barking or braying. This meant we got to drive very close to many of the animals – closer than the people who decided to go on the walking safari, who obviously were seen as more of an intrusion by the wildlife.



I confess that was thankful for the lenses of my binoculars and video camera. Despite feeling a bit like the stereotypical [*insert your least favourite nationality here] tourist who videos the cathedrals and cities without looking at it with his eyes and experiencing it, I was absolutely converted to the benefits of digital technology – who am I kidding? - I have always been on technology’s side. Anyway – I had fun videoing things and stitching the highlights together on the computer – perhaps to be inflicted on the less fortunate of you.



On an unrelated topic – the rugby is super, isn’t it? A few of us have been getting together to watch the Irish games and can’t believe how well things have gone for us to date. In any case we are in for an exciting finale, I’m sure we all agree.



Just finished The Poisonwood Bible – phenomenal book, set in the Congo from the 1960s. I fully recommend it to seasoned African travelers and armchair explorers alike – in fact anyone who likes good quality writing.



That, I’m afraid is my brief update on things – strictly PG rated, if even. I can already almost hear one tall blond Galwegian cardiologist’s condescending comment of: “Very nice … any more short boring stories?” For any details on the more salacious or scandalous events that may be going on in the Lilongwe social scene, I’ll await specific enquiries – although the old adage of “Ask no questions, hear no lies!” may well ring true.

On raining, cats, and dogs

Apologies for the delay in updating this. Here's a start:

We are entering the rainy season here (less ominous sounding than the Scandinavian “Dark Period”) and the old adage of “When it rains, it pours”, rings true. We have been treated to a well-received drop in max temperatures (almost unbearable 3 weeks ago), blustery conditions, and occasional spectacular electrical storms. When it rains, it is liable to dump buckets on you - this coincided nicely with our football game the other night where we got as wet as can be above sea level.

Another interesting side of it all is the increase in general activity one sees around the place with every able bodied person trying their hand at part-time farming. Areas that previously appeared to be wasteland now seem decidedly arable and are planted all around the city. People are fixated on maize, the staple, despite appeals from certain food agencies to get people to switch to a more efficient and economic crop. Maize is used to make nsima the Malawian equivalent of Mashed potato/stodge, but apparently it is a very time- and resource-consuming process. Nsima is to Malawi what potatoes are to Ireland.

To call it the “rainy season” may not stand up to analysis by Irish natives. Even in this time, it does not rain every day, and the sun is often out and very hot. “Unfair” I hear you mutter, as it sounds more appealing than the June – June rainy season of home (without the hot sun).

Work is going well. We are [nearly] up around our expected targets for the study and general ward medical work is amassing. Since the change in weather there has been an increase in admissions – mainly due to an increase in gastroenteritis and malaria. We expect to see an increase in our cryptococcal meningitis pick-ups too, just due to the sheer increase in numbers of patients admitted – we actively go looking for cases with symptoms suggestive, even if the admission diagnosis is considered as alternative (occasionally the working diagnosis is “surprising” to say the least).

We are about to do an interim analysis if the results to date and if there are highly significant findings we may be in a position to adapt the study further.

I did a peripheral hospital visit with the medical department to Dedza, a rural town about an hour from us. It is a weekly visit by a couple of senior staff from the medical department to a district hospital. They have a rota of sites to visit, so each institution receives us about once every 2 or 3 months. These places often have one or 2 doctors, at quite a junior level, minimal investigations, minimal therapeutics, poor decision-making, and a few clinical officers (a grade we don’t have in Ireland – not quite a doctor, but almost (it is a shorter degree course)). It was a clinican’s playground with unbelievable pathology on display. It felt like membership exams again, with a quick round of the sickest patients and an impression/analysis and management plan. We saw all manner of cases in a whirlwind morning, and arranged for transfer of one or 2 of them to our facility. It really was full-on African district hospital medicine in the extreme. We saw TB, strokes, cardiomyopathies, motor neurone disease (!), metastatic cancers, and a ?subacute combined degeneration of the cord (!!).

Since my last notes I have managed to see a bit more of the country – from the rugged mountains overlooking Zomba, to the steep cliffsides of Nkhata Bay, and various mountains and plains in between. Some of the lakeside areas are truly idyllic.

Driving in Malawi is worryingly very like playing a video game – oftentimes you bounce either side of the midline, take shortcuts cross country, flicking on your car horn like a joystick trigger. “Creative driving” and freedom of expression is encouraged in traffic. I was behind someone in a car park the other day who decided to slow to a halt and then get out and lock-up. I am not one who usually succumbs to road-rage, but was incredulous and incensed seeing as he was right in the middle of the thoroughfare and I was directly behind him, now blocked. He even looked half-heartedly at me and with what would have been an acceptable Gallic shrug pointed back, suggesting that I reverse back out the way we had driven in. Much beeping and shouting through my broken window led to a change in heart – he drove forward 10m into a perfect parking space, freeing up the road again. For anyone familiar with Africa, I’m sure there will be no major surprise [although I will try to refrain any more African-bashing stories, which unfortunately are staple ex-pat anecdotes].

I have had a couple of run-ins with the Gardai Siochana (or the Malawian Branch of it). The first was due to having a faulty brake light, the second for not wearing a seatbelt. Both times I was told I would need to attend court the following morning. Both times I managed to get away scot free, without [really] resorting to bribery, and with a total time expenditure of about 35 minutes of debate. The content of my plea-bargaining was pretty similar, and shameless, both times. I discussed my case, the wonders of Malawi compared to home, and the superiority of their police force. Mentioning HIV patients and ward rounds was not beneath me, and on one of the times I went as far as to suggest that the 2 policemen come for pizza to continue the debate. The downgrade of the punishment both times was to give the guards a lift to another part of town (they have no police cars), with light-hearted banter about the similar problems facing Malawi and Ireland – dodgy politicians, bad roads, poor healthcare administration. Disgraceful behaviour, I know, but anyone I know that has had to go to court on such charges has had unbelievably frustrating inefficient hours whittled away in stifling, crowded heat and mind-boggling infuriating beaurocracy.

I did have an amazing time recently out at the Kamuzu Dam, where we often go to spend a few hours on a Sunday. I was taking out a canoe for general paddling about and wondrous amazement at the dappled early evening sky. I passed a fisherman in a dug-out boat (actually a hollowed out tree-trunk – very wobbly, but they make it look easy) and had a quick intercultural exchange with nods and pleasantries – the extent of my Chichewa language. I then went further across to the other side of the lake, where it looks like undiscovered territory further down. I heard shouts, and calls from my friend in the dug-out and saw him animatedly shouting at me. I though he was either in trouble, or needed help in pulling aboard a big fish. As I went back to him I established that he was suggesting that I go no further to the big hippo that would have been in my direct path! I saw him then, and watched him yawning and grunting at me, while splashing about in the water. Before anyone questions my eyesight, sanity, or judgement, rest assured that the closest that I made it to him was 50 metres. Amazing, though. Of note, hippos kill more people than any other large animals in Africa.

The Lake of the Stars music festival was unbelievably good in October. Imagine a casually dressed Trinity Ball lasting 3 days, at the beach, costing very little in glorious weather. It was something like that. Further stories on request only.

We have had a couple of cats introduced to the household. Kittens, to be precise. I have never really been a cat liker/lover, but must say that I find these guys intriguing. After our puppy died, and we were all saddened, we said that we would try not to get attached to any more animals until they proved that they could survive to adulthood. These guys are great to watch hunting spiders, mice, and fighting each other like boisterous kids. [On that note - we had a kid goat for less than 24 hours – his bleating was horribly shrill and human-like – he was barbequed that evening and was very tasty, perhaps all the more so for having woken us all at 530 am].

Apologies in advance to Catherine for this next couple of paragraph. Anyone with a serious insect aversion skip ahead. The bugs that have emerged since the onset of the rains are really impressive. Centipedes thicker than your finger and 6 inches long, spiders bigger than the palm of your hand, and giant beetles (who seem incredibly poorly equipped to get off their backs – a fact which could be used by either side in the creation/evolution “debate”, I’m sure) to name but a few. Some of the centipedes have far bigger body mass than the little birds you see zooming about.

Last week there was the night of the flying termites – where they all hatched and were absolutely everywhere for one evening. Gross, but amazing to see. The next day there were insect carcasses everywhere, crunching underfoot, the following day all that was left was their wings scattered around, the rest having been scavenged by other insects. People delight in this annual hatching, and even consider it a delicacy to eat. Our guards left the door open with the light on in their work station. A bucket of water was placed underneath and as the hundreds of flying termites fell into the water they were scooped up and stored for later frying (although some were eaten raw/alive – I joke not).

Looking forward to Christmas. I will be home in Cork on the 21st Dec. Between then and the 3rd Jan I plan to be in Cork, Kinsale, Galway, Belfast, and Dublin. I’ll have my phone, so be in touch. Until then – Tioanana!

On becoming independently mobile

Well folks – try as I might, I can’t keep putting off this next bulletin. Here goes.

A lot has happened, but the rush to tell everyone has worn off: no longer does the sight of a bicycle on the back of a bicycle strike me as odd; no more do women carrying half their bodyweight on their head get a second glance; nor does the sweet refreshing nectar of Carlsberg Green bring a tear to the eye these days. Now don’t think for a minute that I am getting jaded or sick of it, but I can now confirm a sense of having become a more hardened local, with the necessary accompanying steeliness – some might describe an “Indiana Jones meets Laurence of Arabia meets Gorrillas in the Mist” character (meets Morgan Leafy, of course).

The biggest step has been getting my own car – a faded beauty you might say. I looked at a number of potential vehicles but settled on the absolute bargain basement. It had a cracked windscreen, faulty (uncloseable) driver’s window, dented door, faulty lock, faulty boot (unopenable), dodgy seatbelt (but functional), leaky differential switch, and countless miles done (faulty odometer) – did I mention it was a bargain (relatively)? All this lends it a certain “cool”, you’ll surely agree – as does the 4x4 nature and its almost 19 years of experience to impart to me – what a team we’ll make! Oh, to those of you interested in details it is a Suzuki Vitara (dark blue).

I have had no problems to date, and have really put it to the test on a few dirt roads – 4x4 is a must at times and we haven’t even reached the rainy season yet.

My first anecdote relates to driving and work. Our study is going well, but had been languishing a bit recently with a drop in the frequency of enrolments (a recent flurry of activity has us almost back on track (like the stock market? – or should I not mention the big elephant in the corner)). I heard from the lab that a sample of spinal fluid had flagged positive later than usual. I raced to the bedside, excited, in an attempt to find the patient and start the process of engaging her in our care. No patient! No notes, no contact information. Word was that she had been transferred, not unreasonably, to the TB hospital (TB is the next most likely diagnosis without the vital chunk of information to which I was privy).

So I grabbed our study nurse, Julita and zoomed off in a flurry to the dreaded TB wards. This was a complete disaster as no one had heard of her bar one sick patient who vaguely remembered a young one who had passed through quickly and had been discharged early. No relevant records/notes were to be found and strangely there was no nursing staff.

The TB wards are 2 adjacent bungalow buildings (male and female areas) with 2 rooms in each. One room for the more infectious “smear positive” patients, and the next room for the less infectious “smear negative” patients. Overcrowding was obvious with about 10 patients per (small) room and the 2 wards sharing an atrium, with no doors or windows. A gentle breeze ensures a homogenous mixed airflow for everyone (i.e. giving the same (high) risk of transmission for everyone). Almost all of these patients are HIV positive, but despite this there was a great sense of buzz to the ward. They seemed to have been left to fend for themselves for the night but most seemed to be “walking wounded” and, dare I say, in good form.

The sun was setting. In Malawi this means that any hope of accomplishing anything requiring organisation has evaporated. So I took note of a few faces and aimed to return the next morning in an attempt to trace our patient. Just before 8am the following day I arrived to find a team of nurses who denied any knowledge of my patients, backing up their claims by the gaping lack of records. I argued, they argued, I argued some more. We then checked out the outpatients TB set-up – no record of her either. I then grabbed a young Malawian student/intern who spoke good English and told him that he would be helping me for the foreseeable future. We went back and interviewed the ward again, to hear the same story of a transient admission to the ward. Very confusing/frustrating until one nurse informed us casually that she had “decided not to admit her but just to give her a bed for the night” until the outpatient clinic in the morning.

We interviewed one of the TB meningitis patients who had been in hospital for 2 months and found out that she actually knew the mother of the patient, but not the patient herself. A clue, at last.

I will preface the next session with the fact that this delightful middle-aged rustic TB meningitis patient, Teresa, was quite gutsy and sprightly for her 58 years (very old in this neck of the woods), and was obviously very bored of being in hospital for so long. When she suggested that she could deliver us to the mother, I could only wholeheartedly agree. So I piled her into the back of the car, my new “employee” (I’ve no idea what his real job was there, but he didn’t appear busy) into the passenger seat, and we blazed off into the dusty distance (3 heads bouncing in time to the tunes of Johnny Cash on the radio – ah how music crosses cultures!).

We headed away to a “suburb” of Lilongwe. Most suburbs, if any distance off the beaten track of the diplomats and NGO expats, would qualify as bona fide African villages. This was one of them, with bustling markets, dirt tracks, crowds of people, all around 5 miles from LLW itself. 4 wheel drive was a welcome addition with huge potholes to contend with. A white fella like myself and a 4x4 car were pretty pass-remark-able to all around, especially, as mentioned before, anyone under 10 years old. “Mizungu, Azungu” was chanted as my “stealth mission” was being blown.

Teresa disappeared off down a back alley with a vague hunch that the house was around there somewhere. She reappeared 15 minutes later, just as I am drafting my defence/resignation speech to the Ethics committee/College of Physicians for the kidnapping of patients with CNS infections, telling me that the patient’s mother would be joining us for the next leg of the trip. Cue more Johnny Cash and a conversation about the merits of country and western versus religious music.

20 minutes later we found ourselves in another suburb on the opposite side of town (ironically within a couple of miles of our hospital). Pulling up outside a brick house we spotted a comfortable, relaxed lady leaning against the wall enjoying the sun. I was glad of a translator to explain to her that she wasn’t quite as healthy as she had thought, or had been told, and a-la-Arnold Schwarzenegger that she had better “come with me if you want to live” (not quite that bluntly, but you get my drift).

Great way to spend a morning for me, Teresa, and the young fella (I never did really find out who he was). You’ll be glad to know the patient is doing quite well now.

Only one story of many. But time does not permit me to continue. A proper update to follow.

Arthur

On becoming an ex-pat

Olympic tennis in the background [editor’s note – email obviously started a few days ago], wireless broadband dominating my foreground – the tropics aren’t quite as daunting as Heart of Darkness had me expecting. I sit here swiping at a few rogue mosquitoes and scratching Julep, the 3-month-old mongrel we have adopted in the guesthouse, who lies panting sleepily beside me.

I’ve settled in, to some degree. By many criteria in any case: head above water at work, regular football, tennis, rugby and sailing (I know, I know – how bloody ex-pat stereotypical!) regular parties, and making new friends.

There’s been a big flux of residents in the guest house. We now number 6, with more arriving soon. Great bunch, really.

Currently reading about the recent history of Africa, since the time of independence for most countries – bleak reading for the most part, but almost obligatory for ex-pats like myself. Plenty of upsetting information, no definite answers, nor a thrilling but successful finale. Looking forward to a good novel next – anyone have any suggestions? [confession – Catherine – I left Leo the African on the plane, before starting it – I thought I’d tell you here, in public, so you couldn’t make a scene].

I cycled out to the local dam/sailing club – great fun, sweaty work for 1 ¾ hours, most of it on dirt roads. Great attention from the local kids. The ego is boosted when the little ones run out to you screaming “Mizungu”, desparate for a wave or a “Hello”, and delighted when you manage to comply. One is a little saddened by the circumstances that lead the older ones to shout out to you “Give me Money”, with their hand out, their only English phrase.

My bike made noises similar to a sailing marina in a gale force wind for most of the trip – not sure were it is coming from, but possibly the front derailer (a word I am proud of, having learned it this year). The back gears slip making gears 1, 2, and 3 unusable – but this only developed for the last 10 km. I had been advised to buy Indian-made, not Chinese-made, but this was the only green one (half truth). All in all, not too bad, though.

Kayaking the reservoir/lake was exciting – I went right to the edge of the dam, where there is no wall, and concrete encasing holds the water in place – flush with the lake surface, like an infinity pool. A 60-ft drop on the other side is enough to keep one alert, and the views are superb.

Followed by sailing, barbequed burgers, cold beer, and a contented lift home.

Work is good, except that we are in a bit of a lull from a study viewpoint. We are desperately trying to enrol patients, but exclusion criteria keep arising. Never fear, when the rain comes, it will pour (metaphorically). In an attempt to boost referrals to our hospital, I have started “The Roadshow”, where I visit all the regional clinics, giving a powerpoint presentation about cryptococcal meningitis, and specifically about our study. It is interesting to see the running of these smaller clinics run, which are mostly funded by NGO or foreign money. They are found in the surrounding areas to the main city – some on the outskirts, some in separate villages, most on dirt roads. I got completely lost on my first visit to one in Lilongwe and pulled in to ask a well dressed guy the way. I was very impressed when he told me that he couldn’t explain it well, but would jump in the car with me, seeing as he had nowhere to be that day, being unemployed. It was great – I wouldn’t have found it without him (and yes, I offered him some monetary recompense, which he initially refused, and then gratefully accepted).

We are kept busy with non-study patients, and admin stuff still sits ominously in the corner. We informally look after most of the cryptococcal meningitis patients. We are getting great experience using Ampho B recently with a whole whack of relapses needing treatment (and one very sad case, a pregnant lady, who eventually died after 3 weeks care). I am getting good experience with this and with placing central lines – valuable lessons.

Seeing some textbook cases too – I had pure pus dripping out of the spinal needle the other day (usually CSF looks like crystalline mineral water). Management is pretty good, with most necessary antibiotics available to us, although ICU beds are almost impossible to get for medical (non-surgical) patients.

We have acquired chickens at home. John, a surgeon who is living with us, has bought some and has gone from novice to somewhat expert on breeding them, medicating them, quarantining them, and unfortunately having to slaughter a few. One of our guards/handymen is very knows the business and gives pointers. Apparently an unfortunate occurrence was when John tried to put one dying chicken out of its misery, western style (humanely, by wringing the neck). However just as he was half-way through the throttling Bright, the guard, screamed out in protest – it wasn’t the Hallal way, and so the startled bird was brought back from the brink while Bright went off to find a knife. Poor chook! I have refused to eat any of the chickens killed due to disease, but had a great tasting one for dinner the other day – reminiscent of the BK mountains 1998 – still a bit stringy and gamey, though, Matt.

Near future plans – hiking the nearby hills/mountains/rocks (strange looking and hard to define), another trip to the real lake, visiting Blantyre, which is the Cork of Malawi as far as I can tell (real capital, and all that …).

Best wishes, and keep well. Feel free to drop me a line – always nice to get a message!

Arthur

A reasonable man in Africa

- Our local restauranteur - a bit of a character!




Dr Leafy reporting back. Apologies for the delay. Where to begin?

All good, and very promising. Settling into Lilongwe social life and work is interesting.

Lilongwe itself is a strange enough place, for a capital city. It is one of those artificial towns, having been created as a capital for the new republic of Malawi. Therefore there is neither very little colonial architecture nor signs of the ancient alongside the new. Just the absolutely poor and decrepid alongside the new.

It is spread out, in the vein of a sprawling American city - that is where the similarities end. Lilongwe gives the feeling of being in the suburbs, or in a small sized county Carlow town for 90% of the time. The main roads link these sprawling randomly assorted numbered "Areas" (districts). What strikes me as most unusual for a city is that it is very rare for a shop/house/business/anything to be down at the roadside. Usually the roads are sided by a dirt pavement and trees. Buildings are very much set back from it, often in complexes. There is one small city centre area which is what you might expect (if you had very low expectations). It does feel more like it is from the era of A Good Man in Africa. Google maps demonstrate 1 forking road - like a mercedes sign. Not a fair representation.

There are plenty of ex-pat bars and restaurants (well - maybe not plenty, but a few, enough to go a week or so without having to return). I usually have lunch in the local market set up beside the hospital. It caters for the hospital and university crew - I'm sure a few of you saw the photos. It is pretty ramshackle, to put it politely, but the food is excellent - I have paid huge money in Dublin for meals I enjoy far less - the Grilled Chicken special (flame-grilled chicken, killed that same day, with veggies, sauce and Nsima (local stodge/starch dish which is a cross between mashed potatoe, porridge and dirt) is to drool over. This lunch sets you back about 75 cents. To my great delight I found a cafe there today: the back of the market has a coffee shop with cappucino advertised on a chalk board outside. It is a hut, not unlike one I found once in northern India (1998) halfway up a Himalayan foothill, with a tin roof, dirt floor and stone bench. Unfortunately he is out of coffee, tea, milk, water, sugar and fire. He advised me to come back in a week or so, but was very happy with my promised custom.The shops seen in the picture sell all the necessary groceries, at a basic level. I usually go to the big western supermarket chain a mile away, to be honest, though.

Evening meals are either cooked at home in our nice digs, or in one of the aforementioned restaurants. Some great food, very cheap. Someone must have lied to me coming out here that I would lose 15 kilos. I'll be lucky if I break even. [that said, I have yet to crack into the local soccer scene - 5-a-side on Tuesdays in the British High Commission, and Sunday league 11-a-side; and I have yet to become acquainted with the local parasitological fauna, I think]

The accommodation is good - it is like living in an American dormitory house near the hospital - for the summer it will be very full with ins and outs of elective students from the University of N Carolina. There are a couple of more long stayers like me, but most are here for a month or 2 at a time. The plus side is that tt is great having people to hang out with and chat to for now. The down side is that things can get a little crowded. Because I am more permanent I don't have to share a room, which is a nice plus. We have a car or 2 (depending on availablity from the University Project) to share - vital.

Work is excellent - running the study into Cryptococcal Meningitis in Kamuzu Central Hospital. I have a team of a nurse, clinical officer (a medical career which has no Irish equivalent - they choose not to finish the last 2 years med school, so work as doctors, but cannot progress beyond intern level, and do no call), and a domestic aid. We are responsible for the cryptococcal study, with that as primary responsibility. We also round with the medics when free, and help out, primarily with cryptococcal patients that didn;t meet our study criteria, and with other stray outpatients (i.e. those that stroll up with a complaint and find you instead of attending the A/E, ward, or OPD - there is a method to the madness, as well as decided madness to the method - but I haven't figured it out yet).



The study patients are a sick bunch - about 40% of them die. We have had a bit of a lull over the past week, after a busy first week clinically - at least it gave me time to get organised, as you'll hear. The work will be part admin, part clinical, part lab based - with occasional covering in OPD clinics for the HIV clinics.

My first week I was auditted! Sounds worse than it was. The designer of my study protocol is an English SpR in ID, doing a PhD in Cape Town, in the same sort of research as this (big coincidence - his father is a public health doctor, and his grandfather was a medic in WW2 in N Africa - just like mine!). He came up to see me at the beginning of my stay and audit the project to date with one of the official project internal auditors from the UK. I was not really to blame for the (minor) faults, so I didn't take any flack. The project is in good shape really - but needed a big administrative-style shuffle: file compliation, paperwork, beaurocracy - no better man than Jackson for that sort of stuff. I have spent most of the week, when not doing LPs, running from Billy to Jack, getting certificates, proofs, documents and filing them in the Trial Masterfile - my creation this week. While my instinct is telling me to roll paper into a ball and throw it into the nearest muddy ditch, I am refraining and the Masterfile is taking shape. It may be the beginning of a new me ...?

The hospital is very under resourced - mainly from a diagnostic viewpoint. Most basic therapeutics are there, but you really feel the lack of decent radiology or serology. I hate to say it, but ... I'm sorry for all I said to/about any of you Radiologists, all is forgiven. There isn't even a CT scanner. For absolutely necessary cases (which by necessity cannot be vitally urgent) an ambulance brings them 4 hours away to Blantyre. It is often cancelled for myriad reasons, and only takes up to a maximum of 8 cases (where 10-20 a day could be sent, really, from medicine alone). There are 2 senior physicians running the medical side, with one new one to start soon. One is a Malawian of a similar age to me - a very likeable, good-natured, principled man. We get on well. The other is a super German physician who has lived in Africa for a long time. He is excellent too. There are dodgy interns and a few registrars too.

I'm getting tired so I'll switch to consice form:

Highlights so far:

Joining the local sailing club - a 30 minute drive away, mainly dirt roads. My first weekend in town, I was brought out to Lilongwe Sailing Club by a couple of friends - good fun. Arrive upon this small reservoir, a few km by a few km in size. Nice little "clubhouse" - very open plan with a large veranda overlooking the lake. To one side is a permanent barbeque. All it takes is a phone call to the caretaker, who will have boats ready for you. The boats are well maintained dinghys - Megan and I were in a Miracle - a 2 person boat. It was fantastic to be helming and zooming around in such a responsive toy. Great wind and great fun. The only words of warning prior to setting sail related to the local hippopotamous who has been implicated in the killing of a few fishermen! Like all good troublemakers, he hangs around at the corner - probably peddling dope too, I'll bet! We didn't see him. Joined for the rest of the year (unlimited access to the clubhouse, boats, sails, everything) - 14 euros!

Amazing/Strange experience: Going to a local African [non ex-pat] bar with friends - booming place - loud music, lots of beer, lots of drunk African men wanting to talk to the "Mizungus" [white people]. Absolute dive really. Heaving with people, any of the very few, non-Mizugu females present were there "on business" if you get my meaning. One of our friends (female) came back from the bathroom commenting on "how sweet it is to see all the kids making out outside the back". We pointed out the the walkway in question was the entrance to "Angel's Restrooms" [emblazoned on the wall in 4 foot, fancily painted letters] - the local brothel. Around the corner was the big nightclub - excellent fun - a mix of ex pats and Africans - an outdoors area not unlike Leggs, except the chicken is far better. I will get to know it better.

Last night went to the movie night being hosted in American Ann's house, in a distant suburb. I texted Ann saying I was running a little late - and arrived in with the Dundee students and 3 pizzas while the lights were down. We shuffled in and sat near the front of the living room, on the floor, in front of the wall/screen (the film projected up onto the whole wall of the room - excellent). Unfortunately the film was a quiet intense French artsy thing (excellent, if you're asking), so there was never an opportunity to open the pizzas and eat. So we sat starving beside steaming, but cooling food. Surprisingly when the lights came up I recognised noone (apart from the Dundee students), and found that I was in a room of strangers. The ex-pat group I had thought were hosting the night were not, and I introduced myself to a completely different American Ann than the one I had presumed. Kind of embarrassing/funny.

I was at the real lake Malawi too; local beer tastes great; weather is OK; all worth a comment but I've written too much.


Cheers,

Arthur

Joe and Guisi in our local restaurant.


Keeping my calories up ... too well.


Impressive.


KCH main ward corridor.


Nice village shot.


How about this one! Lake Malawi sunset (90 mins drive away).



Our local shopping mall. Restaurants, groceries ....





Typical road scene - except the road is good.

The Real McCoy

Here at last. The Real McCoy of Africa. Underlined by views of arid plains sparsely covered with scrub stretching in all directions around Lilongwe, as seen from the descending plane.

Arrived this afternoon after what seemed like weeks of intermittent napping on planes broken only by one call for medical help from the arline. Step in yours truly - diagnosis of vasovagal/panic attack in a 50 yr old African lady on the way to her father's funeral - then back to Stilnoct induced hemi-slumber (or maybe I dreamt it all, with the Lariam?).

Disembarked to blue skies, gentle breeze - about 22 deg C - this is as good as it gets for me. However for the locals this is the bleak mid-winter complete with the occasional winter woolly jumpers.

Accommodation seems super - a secure, enclosed quadrangle bungalow development with 2 major "apartments" facing the lawn. Each apartment has about 4 bedrooms, I think. I seem to have landed on my feet getting allotted the visiting Professor's suite until one of the other guys leaves (in 4 days) - until then I have en suite facilities and plenty of space.

I wandered up to the hospital shortly after being dropped off at the Guest House. There I found the department head, a senior American ID doctor, who was finishing a clinic. She showed me around to the admin people and made introductions.

Then my first medical work - at about 530 pm. Dan, the physician who has been covering the project prior to my arrival, came by with news of one of our patients who was in acute renal failure and vomiting. She is Day 26 of the study and recently had a UTI, but did not take the required antibiotics. She has advanced HIV with CD4 under 40 and looks like she weighs under 40 kg. She came in vomiting, febrile, anaemic, with a Creatinine about 6 times the upper limit of normal and a dangerously high potassium. Fluids helped somewhat, but not greatly. We performed a LP to outrule other infection and to document her opening pressure (due to vomiting) and started iv antibiotics prior to coming away. Most likely diagnosis of acute renal failure secondary to urosepsis.

The hospital is impressive - 4 storeys - open plan, central courtyard. No luxuries, minimal necessities. However when it boils down to it, the role of the hospital is to house the patients near the facilities and staff. We did the same procedure, more or less, for this young lady than we would have in an Irish hospital. She also received the same antibiotics and fluids as she would have received elsewhere. Monitoring and diagnostics are less available, and certainly choice of medications is not always as well matched, however. We'll see how she gets on overnight - touch and go, really.

I'll leave it a bit till my next post. Maybe a few pictures to add. Certainly more and better stories than these ones.

Keep well!