Circumcision Day

In Africa, it has been shown that male circumcision substantially reduces the risk of HIV transmission from women to men. Of course, using condoms will reduce the risk even further. The Ministry of Health has set Kakumbi Rural Health Centre a male circumcision target, and Nurse Martin Mwanza intends to meet it.

When I arrived at the health centre, there was a group of sheepish-looking young men, aged 18-21, waiting outside the male inpatient ward. Mr Mwanza was going through the consent form with each of them and getting their signed agreement. He did look the part, wearing pressed surgical scrubs and face mask. I asked him if he needed any help and he gladly accepted my offer.

This is the queue the following week, mainly young boys. They look very happy.
This is the queue the following week, mainly young boys. They look very happy.

The operating table was an inpatient bed. It was about 30cm too low and I could see that the surgeon would be very uncomfortable operating at this height. The louvred windows were partly covered by makeshift curtains, which let in some light but prevented curious bystanders from peering in to watch the show. Although this is the beginning of the cool season, the rooms in the health centre are very warm in the middle of the day, and the curtains did keep out any breeze. We were sweating.

Although they had been fully briefed about what would happen during the operation, the lads looked very apprehensive. A few of them were wearing football shirts, usually Manchester United, Chelsea or Arsenal (Liverpool is not so popular here in Zambia). Just to lighten the mood, I cruelly would suggest that the operator was a strong supporter of a rival team, but that this would in no way adversely affect the surgery…I could see from their faces that they were seriously considering this, until I clapped them on the back and started laughing.

I will not bore you with the precise details of the operation, other than to say Mr Mwanza took a great deal of care over each patient and did an excellent job. The local anaesthetic dose was rather higher than we would use in UK, but at least the patients felt no pain. For each operation, there was a specially-made up sterile pack. However, this did not contain instruments (blade, gallipot, toothed forceps, artery forceps, needle holder and scissors). I had to hunt through a large drum of tangled ironmongery to find the right tools. There were about fifty artery forceps, but only three pairs of scissors, one of which broke when we tried to use it. There were ten lads having surgery, so we would have to sterilise the scissors several times during the day.

This pretty young lady is waiting for her beau to have the operation, sitting outside the health centre.
This pretty young lady is waiting for her beau to have the operation, sitting outside the health centre.
And another expectant girlfriend.
And another expectant girlfriend.

Mr Mwanza had wisely kept aside a pack of gauze swabs, to avoid the problems I had using makeshift swabs from bandages (see “Mosi oa Tunya”), but there was no paraffin gauze. I found some in a huge plastic carrier bag, stuffed with donated dressings, which were being rationed to the health centre. We used this to prevent the dressings from sticking to the suture line. Instead of using paper micropore tape to secure the dressing, Mr Mwanza used thick, strong zinc oxide strapping. This would certainly ensure that the dressing remained in place, but I would not like to the patient when the dressing was being removed.

As a final flourish, Mr Mwanza manoevred the penis upright, keeping it in position by attaching two wings of strapping on either side, reaching round to the loin. Keeping the penis upright used gravity to reduce the oedema and swelling. “But how will he pee?” I asked. Mr Mwanza showed each lad how to peel the tape off his belly to point his penis downwards to pass urine, and then to pull it up again. Ingenious, really. They got a strip of 10 paracetamol tablets and instructions to return in a few days to have the dressing changed and the wound inspected. They were aware that they would be “off games” for about six weeks, until the wounds had healed and the catgut sutures had fallen out or been absorbed.

I pulled back the cardboard box containing the operation packs, which was keeping the door closed, and the boys greeted their soon-to-be-operated-on colleagues with a show of bravado. Of course, in Africa, male circumcision is often considered a rite of passage on the way to becoming a man. This usually takes place with a group of boys, who go into the bush for a few days to learn the rituals and intimate knowledge of their tribe. It is much more than male-bonding. Now I could see why it was so important for the group to wait outside. It was almost traditional. Much better than being given an appointment to turn up for surgery starved at a certain time.

The day was really hard work. I was exhausted and dehydrated by 12:30 so I went home for lunch. When I came back at 2pm, Mr Mwanza was still struggling on, by himself. I asked him if he had stopped for a break, for a drink and a bite to eat, but he said he hadn’t. He had asked his wife for a cold Coca Cola, but she brought him a can of Coke Zero.

“What’s the use of that?” I asked. “What you need is a caffeine and sugar boost, and this has neither.”

“My wife doesn’t want me to become a type 2 diabetic,” he replied.

We had a good laugh about this, and continued operating through the afternoon. We didn’t manage to do all ten, however. Some young men were very disappointed to be sent away still intact, but Mr Mwanza said he was on night duty the following day, and he would continue to operate in the evening as the workload was very light after 4:30pm when the consultations ceased.

His back was aching from bending forward during the surgery. I asked Daillies if we could move the patients’ lockers underneath the bed frames to raise them up. I also suggested we could put concrete blocks under the legs of the beds to do the same thing. When I returned the following morning, the beds were up on blocks and had a locker supporting each end of the bedframe.

Raising the beds to save Mr Mwanza's back. It is a bit Heath Robinson, but it worked.
Raising the beds to save Mr Mwanza’s back. It is a bit Heath Robinson, but it worked.
Daillies is cleaning the mattresses prior to the circumcision operations. I like her Piet Mondrian inspired dress
Daillies is cleaning the mattresses prior to the circumcision operations. I like her Piet Mondrian inspired dress

I have seen two young men with recurrent preputial herpes in the last week. I have recommended that they have male circumcision in an attempt to reduce or eliminate outbreaks. We used to think that the herpes virus lodged in the dorsal root ganglia of the spinal cord. Now we know that the virus lives just under the skin where it erupts, so surgery might be a simple solution. I don’t think I will be here long enough to find out if I was right, unfortunately.

The last time I did a circumcision was in 1987, so it was an interesting day which I had not expected to be involved in before coming to Zambia. But I do have a lingering doubt that having been circumcised, the lads will not bother to use condoms in the future.

Great caption for a tee shirt. But if you look closely, it is from a girls' school. He probably got it from his girlfriend.
Great caption for a tee shirt. But if you look closely, it is from a girls’ school. He probably got it from his girlfriend.
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Mitsubishi Pajero

Who advises car manufacturers about the names they give their cars? An advertising agency? A focus group? Well it certainly wasn’t anyone who speaks Spanish. Check out what “pajero” means in Spanish using Google Translate. Or read on and I will tell you at the end of this piece.

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I’ll bet they didn’t sell many cars bearing that name in Hispanic countries.

This is my (t)rusty vehicle. I have nicknamed her Phyllis. She is still going strong, even though she has done 109,000 km since leaving the production line. For any petrol heads who read my blog, she has a 3.5 litre engine DOHC24v – Double Over Head Camshaft with 24 valves. The engine is probably turbocharged too, because if I put my foot down, she goes like s*** off a shovel. Unfortunately she burns oil and drinks petrol. She has survived dozens of doctors who have worked in the Luangwa Valley, even one who nearly drove her into a hippo this morning. (Well, it was a very early start, there was a hint of dawn mist, and the track was twisting and turning. I saw the hippo in good time and did an emergency stop. We were both covered in dust, but that was fine for her as she was on the way back to the water.)

This hippo was out for an early breakfast at 5pm. The sunset creates great light.
This hippo was out for an early breakfast at 5pm. The sunset creates great light.
Hippos are huge. You can see how broad in the beam this female is in a view from Luangwa Bridge. There is a baby hippo in shot, too.
Hippos are huge. You can see how broad in the beam this female is in a view from Luangwa Bridge. There is a baby hippo in shot, too.

There are a few dings in the bodywork, the sealant around the windscreen has come off and a few wheelnuts are missing. She is a pretty shade of dark blue, but this is the colour which most attracts tsetse flies. These are a real pest on a game drive. They can bite through clothing and are ambivalent to powerful insect repellent, like DEET. Being aware of this problem, I had packed a secret anti-tsetse weapon. I’ve got one of those battery-driven, fly-frying gadgets which look like an over-strung tennis racquet. As sold in Pound Shops everywhere. It has had so much use I am on my second lot of batteries. It broke yesterday and required splinting with zinc oxide tape. It works, but even after sparking and emitting smoke, some of the tsetse flies refuse to die and make a miraculous recovery. Those which do succumb I have seen being carried off by the resident ants which live in the vehicle’s ashtray. Rather appropriate for a cremated fly, I thought.

Last week, I had a lesson from Donald, the mechanic who drives a white RangeRover, on how to maintain the car. I nearly collapsed laughing when he said I had to top up the radiator with anti-freeze. It was 30C at 8:30am. But he explained that it should be called “coolant” and it prevented rust forming. Fair enough. I know about brake fluid and gear box oil, too.
I was taught how to change a wheel. The tyre spanner has been rattling around in the boot/rear compartment, and the jack is behind the driving seat. I know where to place the jack – worryingly, this is right underneath the front of the car and beneath the axle in the rear. The spare wheel is dodgy, but it should get me home if I have to use it.

The ground clearance is massive and with her short wheelbase, we can go pretty much anywhere. I can manage the four wheel drive, but shouldn’t need it at this time of year unless I get bogged down in a sandy river bed. I know where the MOT/Service Certificate is, and the car has its road tax proudly displayed on the windscreen for 2014.

I am logging and paying for all my private mileage, for example, when I go on game drives or to visit people socially. Fuel consumption is 6km to the litre, which costs roughly £1.20.

The guys at the Lodge are not very busy at the moment, so my car was washed and cleaned, inside and out last week. Of course, the tracks are so dusty that Phyllis looked as though she had never been showered and valeted by the time I reached the health centre.

For those of you who couldn’t be bothered to look it up, Pajero in Spanish means “w*nker”

My Father

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Today is my father’s 90th birthday. It turns out he is just one day older than Kenneth Kaunda, the first president of Zambia, where I am writing this tribute. He has had an amazing, full life.

He was born in Ferryhill, and has always lived in County Durham. Whilst still at school, he started work as a butcher’s apprentice. During World War Two, he volunteered for the Royal Air Force and flew in Avro Ansons, for Coastal Command. After the war, he became a “Bevan Boy” and worked as a miner, fixing up the pumping system to keep the pit dry. He married Phyllis, from another mining village, Easington Colliery, and they moved into a house shared with another family, in Gordon Terrace. Next month, they will have been married for 66 years.

For most of his life, he was a dairyman. He started off using a horse and cart, later a van, to deliver milk to the village. After he sold the business, he trained as a health inspector, and then in electronics, but finally he worked as a postman until his retirement.

He is very fit for a nonagenarian. He enjoys walking and can still do 20 press ups! But unfortunately he has become very hard of hearing. This is sad, because he loves music and cannot play his electronic organ. He can’t use the telephone, but he has become a “silver surfer” and keeps in touch with me and his granddaughters via the internet.

I regret that I am not able to be with him for his birthday. He knows I love him very much and greatly appreciate all the love, help and support he has given me over the years. He is a wonderful man and I wish him many more birthdays to come. I am sure his three granddaughters will join me saying this.

Crack open that bottle of single malt I gave you, and pour yourself a wee dram, dad. And congratulate yourself on a life well lived.

Vaccination Clinic

Nurse/Midwife Regina Banda looked resplendent in her white uniform, starched white cap and a garish yellow apron printed with slogans from Zambia’s eradicate polio programme. “I want to ask you a favour, doctor,” she began. Tuesdays are outreach clinic days, when a nurse travels to a nearby village to vaccinate the children. Nurse/Midwife Grace was scheduled to do the clinic, but she had not yet returned from annual leave. Mr Chulu, the public health inspector, would have stepped in and done the clinic, but he had gone to the District Health Head Quarters at Mwambe to get essential supplies. Each clinic has a budget for buying cleaning products, but often these are not available locally, so he was looking to save some money by purchasing stock at a cheaper price. But he wasn’t here to do the outreach clinic. The nurse on night duty, Mr Mwanza, was sleeping and had other business to attend to.

“The mothers are still waiting in the hot sun with their babies for their vaccinations, doctor. Will you help us?” said Regina. How could I turn her down?

It had been a stinker of a clinic, after the long Easter break, with no full clinics on Good Friday or Easter Monday. Just when I thought the queue was diminishing, more people would turn up. I was left on my own without an interpreter (Daillies, my usual helper, had been dragooned into being the pharmacy dispenser). When the patients arrived, they were asked if they could speak English. Those who could were diverted to my room; those who couldn’t, saw Regina. As the morning wore on, some patients were tired of waiting and decided their English was good enough to see the doctor, who had a shorter queue. This led to some interesting conversations.

Dr: “How did you get a black eye?”
Patient: “What?”
Dr: “Sorry, what happened to cause your eye to become bruised and swollen?”
Patient: “I fell off my bike.”
Dr: “When did this happen?”
Patient: “In Lusaka.”
Dr: “When were you in Lusaka?”
Patient: “I have not been to Lusaka.”
Dr: “Do you have any other injuries? Your hands look normal.”
Patient: “No, just my eye.”
Dr: “How did you manage to fall off your bike and only damage your eye?”
Patient: “I cycled into a pot hole.”

By the time Regina and I finished off the last few patients, it was 12:50pm. We had been consulting non-stop since 8:15. It felt like I was back in the NHS, consulting under time pressure in the surgery. I asked Regina to get the vaccines and supplies ready as I tidied up my room. We drove 5km down the road towards the airport and Regina indicated that we should turn off into a small village. But there was no turn off; it was just a gap in the long grass. The car bumped down a makeshift track for 100 metres, swerving to avoid tree stumps and chickens, finally arriving at the vaccination arena. All the children had been weighed, their health cards marked up, divided according to what vaccine they required. “So we have 14 children for measles vaccine?” I asked. “Oh, Doctor Ian, I didn’t put any measles vaccine in the cold box. I will telephone Daillies to cycle here with it.”

Some of the mothers are very young
Some of the mothers are very young
Mothers are keen on vaccination and as a result, the coverage is close to 100%
Mothers are keen on vaccination and as a result, the coverage is close to 100%
Perhaps the children are less keen on vaccination. His mum is trying to keep him from seeing what is about to happen, but his eyes tells us he has a good idea
Perhaps the children are less keen on vaccination. His mum is trying to keep him from seeing what is about to happen, but his eyes tells us he has a good idea

I reassessed the situation and decided it would be better if I drove back to the clinic and got the vaccine. Regina sent a volunteer lady with me so I wouldn’t get lost. By the time we returned, the immunisations were well underway. I drew up the vaccines, Regina stuck them in babies’ thighs. She also administered the oral vaccine (polio and rotavirus).

Most countries use injectable polio vaccine, but Zambia still has oral. No sugar lumps for this baby, though.
Most countries use injectable polio vaccine, but Zambia still has oral. No sugar lumps for this baby, though.
Mothers waiting their turn, sitting in the shade, having their hair done by a friend
Mothers waiting their turn, sitting in the shade, having their hair done by a friend

One of the vaccines came as a single dose ampoule, the other as a two dose ampoule. I was a bit confused by this, and thought I might have thrown a half-used ampoule of vaccine in the sharps bin. I caused consternation when I dismantled the cardboard sharps container to see if there was any liquid left in the ampoules. There wasn’t, but it took the volunteer fifteen minutes to put the container back together again (there are ten specific moves you have to make to do this).

Nurse Regina giving a baby combined vaccine into the thigh
Nurse Regina giving a baby combined vaccine into the thigh
Measles vaccine administered by Nurse Regina
Measles vaccine administered by Nurse Regina

We were nearing the end of the clinic, and just needed a few more syringes. The box was marked 0.5ml, but inside were 0.05ml BCG syringes, with tiny needles. Another SNAFU. But we improvised using bigger syringes and needles, and set off back to the health centre at 14:10 to do the afternoon consultations and look in on the three patients in the wards. By the time we had finished, it was 16:30 and I felt completely bushed. No lunch or tea breaks, not even a drink of water. I hope it calms down tomorrow.

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Mosi oa Tunya

Mosi oa Tunya, the smoke that thunders, is the local name for Victoria Falls. It is also the most popular brand of beer in Zambia. If you are of a squeamish disposition, stop reading right now.

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“This one’s for you, doc,” said Nurse/Midwife Regina. “I don’t know what it is or what to do with him.” I looked at the cheap school exercise book which we use for patient records. There was a single clinical entry, “Chest pain, swelling.” I ushered the gangly 16 year old boy into my consulting room and asked him what was wrong. “Chest pain and swelling,” he replied, pointing to his lower left ribcage as far as his right hand could indicate.

When he took off his shirt, I could see a fat, sausage-shaped swelling, following the line of his lower ribs. The front part of the swelling felt fluctuant, as though there was some fluid inside it. The sides of the swelling were firm, almost hard, and difficult to define. It looked as big as a 500ml bottle of water.

“How long have you had this?” I asked.

“Four months, since I fell off my bicycle,” he replied.

“Four months? Why did you wait so long to come to the health centre?”

” I did come, but they said it was fine and it would get better by itself. Now it is paining me.”

My first thought was that it was an abscess, but there were other diagnoses to consider before I attacked it. I stuck the fattest needle I could find into the part of the swelling which felt softest, and tried to aspirate pus. Nada. Nothing. Not a sausage. This might be because the pus was too thick, or it was loculated and I had missed the collection. Or I might be completely wrong and it could be necrotic fatty tissue, damaged in the accident. And really low down on the list of possibilities was a primordial neurectodermal tumour (Ewing’s) attached to rib. I have seen two of these in young people in my career, and it is a condition one doesn’t forget.

The queue was getting restless, so I asked him to return in the afternoon for minor surgery under local anaesthetic. I thought this would give me some time to prepare, and I wouldn’t feel pressurised.

I asked Daillies or Regina if they wanted to see what I was doing, but they declined. I asked for some sterile instruments, and these were removed from a metal tray which had been covered by a blue drape. Goodness knows when they had been sterilised. I got some local anaesthetic and a blade, but when I asked for gauze swabs, I was informed that these were “O/S” or out of stock. I would have to make my own, using a gauze bandage. Daillies likes cotton wool (I hate it; it sticks to everything). She put a large handful into the kidney dish.

The young man got up on the examination couch and took off his shirt, scrunching it up for a pillow. He lay down on his right side and I painted the swelling with iodine. I injected 10ml of 2% lignocaine local anaesthetic and picked up the scalpel blade. One thing I have learned about minor surgery is that skin is often thicker than it looks, so I cut a deep incision into the same area where I had tried to aspirate.

This time there was a gush of pus which quickly overwhelmed my scrawny, self-made gauze swabs. I reached for the kidney dish to catch the effluvia, but it was too late. A fountain of pus was spurting from the wound. I shouted for some help, but no one came. This was odd, because there are no ceilings and you can usually hear what people are saying in nearby rooms.

The lad looked down at his side and said, “Mosi oa Tunya!” Well, I wouldn’t say it was that impressive, but he was insistent. “Have you ever been to Livingstone and seen the Falls?” I asked. “No, but I have seen the picture on the beer bottle label,” he replied.

By now, the kidney dish was overflowing. The wodge of cotton wool was worse than useless, sticking to his skin in thick whisps. His jeans were getting soaked and I just hoped he had not put his mobile phone in his right jean pocket.

Once the flow had eased, I slipped an artery forceps into the wound and broke down any pockets of pus, then I cut up a piece of sterile dressing to make a wick. This would prevent the wound healing over prematurely, trapping pus inside.

Daillies finally came to my rescue and was transfixed by the scene. Pus everywhere. The patient was beaming in delight at seeing all the corruption which had burst out of him. And I was wondering about the wisdom of wearing a white shirt to work. We applied a dressing and asked him to return tomorrow morning. He was smiling, despite wearing jeans which had been soaked in pus.

The following day, the wound looked clean. The swelling had disappeared so I could examine him better and try to work out what had happened. This was probably a haematoma, a blood clot, caused by falling from his bicycle. The clot had subsequently become infected, causing the abscess. The hard areas around the swelling were healing broken ribs, which were lumpy with excess disorganised bone. It should eventually remodel into a smooth rib again. Unless the irregular bone represents osteomyelitis, and this is a “sequestrum” of dead bone. It would have been useful to have some imaging but the nearest X-ray facility is 55km away. If it heals nicely, my working diagnosis is correct, but if it forms a discharging sinus, I will give him a long course of antibiotics.

Easter

The five year old boy being carried into the health centre in patient ward looked worryingly ill. His mother said that he had been feverish for 24 hours but this morning, he had had a seizure. He was twitching and staring blankly into space, mouthing silent words.

My first thought was that this was cerebral malaria, but malaria is so prevalent at the moment that I needed to rule out the possibility that he had two diseases – meningitis and malaria. Trognes, the lab technician, was not at work today, so we performed a rapid diagnostic test for malaria. You expose a drop of blood to the reagent and one line means negative, two or more lines means positive for malaria. This was positive, but did not give us an indication of the severity. For example, we had no way of knowing what percentage of red blood cells were infected, and whether there was a reduction in the platelet count.

When you haven’t got lab support, you have to concentrate on your findings on physical examination. The boy’s neck did not feel stiff as it usually does in meningitis. There are several tests named after eminent clinicians, such as Kernig and Brudzinski, but my way is simpler and is usually more child-friendly: Ask the child if he can kiss his knee. The boy and his mother did not speak English, so I asked the nurse to translate my words. The nurse just looked at me blankly, but I insisted that she translate my instructions. The mother and her supporting retinue looked back at the nurse blankly. Eventually, I showed them myself what I wanted the child to try to do. They did nothing. I gave up, and did Kernig’s and Brudzinski’s tests, which were both negative.

I went back to the general examination. There were no localising signs of any other infection causing his condition. I went through a neurological exam, which is difficult when the patient is not co-operative because they don’t know what you are asking them to do. The boy stared at my face intently and reached out his hand to stroke my nose and cheeks. Then he gently rubbed my arms, pulling at the hair and smoothing it down.
When he first came in, I thought he was delirious and hallucinating. But now he seemed more focussed on me, almost beguiled by the colour of my skin. My daughters have inherited my hairy forearm gene, so they might reckon that obviously the boy was fascinated by my weird, localised hirsuitism.

He needed effective anti-malaria treatment immediately. He had been vomiting, so I wanted to give the medication into his bloodstream. The clinic ran out of intravenous fluids last week. They had been on the monthly order, but none had been received. Perhaps we could convince him to take the Coartem tablets crushed in water? They taste awful and, not surprisingly, he refused, part spitting and part vomiting the medicine down his shirt. Our last option was intramuscular quinine, which is really painful and not a reliable way to get the drug into his bloodstream. He also needed some glucose, paracetamol and, if he started fitting again, diazepam.

The father had arrived by now, so I asked the parents to consider taking him to the nearest hospital at Kamoto. Transport would be expensive. The health centre had been criticised in a recent letter for excessive use of the ambulance. It is only to be used for obstetric emergencies.

I felt we had no option but to give what medication we had, and hope that he recovered. I am not supposed to use the LSAMF vehicle to take people to hospital. It sets a precedent and it puts the doctors who work here after me in a difficult position. I left Marvis in charge and told her that she could call me if his condition deteriorated.

I was deep in thought as I drove home down “Church Street”, when I heard the sounds of choir practice from the Roman Catholic Church. I stopped the vehicle to listen. There were three crude wooden crosses outside the church, and to my surprise, the central cross was occupied by a young man. Two other men joined him as I walked up. We talked about the number of crosses on Calvary, and they suggested I might like to stand in for Barabas. I declined, but we all had a good laugh about this.

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I stood at the entrance to the church and listened to the choir. One of the crucified lads insisted that I go to the front of the church to hear and see properly. When I got to the altar, I caught the choir master’s eye, raised my camcorder and my eyebrows, and he nodded his approval. He looked like an animated funeral director, wearing a black, slim suit, bobbing up and down to indicate when a particular voice should come in. There was a small band of musicians, a girl hitting a string of beads with a baton, a man playing a makeshift horizontal harp, three men playing home-made guitars, two on bongo drums and one running a stick on a corrugated piece of wood.

The choir were learning a new song, but I could only see two songbooks being shared among forty choristers. The style of the music was that one or two singers would start singing a refrain, and then the others would join, in close harmony. The others could easily pick up the chorus between verses and it sounded very proficient to me.

I left the church after a few songs and my thoughts went back to the boy in the health centre. Perhaps I said a little prayer before I got into my car to drive away.

Footnote: He got better after two days and went home. Lucky boy.

I’m in a dancing mood

I suppose it’s an embarrassing dad thing. My daughters would call it “inappropriate”. Showing off my moves, throwing some shapes, getting down and groovin’ to the music. Except that I do it when I hear certain funky cell phone ringtones. They just set me off. I was consulting with Nurse Marvis Mwanza in Kakumbi Rural Health Centre last week. (That is how her name is spelt, by the way.) Her phone’s ringtone is a cracker, and I couldn’t stop myself from bursting into dance. Not wild Fergal Sharkey moves, but more subtle, shades of Prince in his heyday, action. The patient and Nurse Mwanza looked at me in horrified fascination. It only lasted ten seconds until the nurse hurriedly pulled the phone from her bag and answered it, but it made a lasting impression. Crazy Doktolo.

I don’t mind being thought of as rather strange. After all, I am a stranger, from a different culture. As Sting would sing, “I’m an alien, I’m a legal alien.” I feel it gives me a licence to do odd things. I use humour a lot in consultations when the patient speaks good enough English to understand. I challenge the usual way of doing things. For example, when I started working at the health centre, the staff must have thought, “Great, another pair of hands, that means less work for us.” But I wanted to work with the nurses during their consultations so I could find out what they were doing and teach informally, solving the clinical problems. This meant that we see fewer patients, so obviously, I have to take into consideration the length of the queue.

At the end of morning surgery, Marvis asked me, “Doctor Ian, do you take beer?” At first I thought she was asking if I wanted a drink at lunchtime. She is married to the other nurse working at the health centre, so I was just about to turn down her offer of a boozy session at the local pub, when she continued, “If you like dancing, and alcohol, then you must be aware of the Guest Houses,” she said. “There are many harlots in this town and they will entice you into their houses, and once you are there, you will find it difficult to come out.” I thought it was an interesting use of the term “guest house” to mean bordello, given that there are a dozen genuine guest houses in the town.

I reassured Marvis that I was a responsible drinker and that it was very unlikely I would be stepping out at night in the local hostelries. Not even to the legendary “Twobeers Pub”. (At first, I thought it was a BOGOF pub (buy-one-get-one-free), or two beers for the price of one. Then I found out that this establishment was meant to be Tobias’ Pub, but the spelling was phonetically mangled.)

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Other bars include “Obama”, “Shining Star”, “Cobra”, “Uncle Rich” and round the back of “Captain Biggie’s”. There are fifteen official bars for a town of just under 10,000, which seems quite a lot to me. The available beers, Mosi (local), Windhoek and Castle (imported), are relatively costly, but there is a wide range of locally made spirits which are gut-rottingly cheap.

The local music is surprisingly good. I really enjoy the gospel songs which Chanda, the unpaid volunteer at the health centre, plays from a USB stick attached to a fake Coke tin speaker, when he is working in the lab. Trognes, the lab technician, belongs to the Seventh Day Adventist Church, so she plays religious songs previously broadcast on radio on a continuous loop. There is also the close harmony church choir music which I hear when driving down “Church Road” (the Roman Catholic Church, Reformed Church of Zambia, Kingdom Hall of Jehovah’s Witnesses are all within a hundred metres of each other) on my way back to the Lodge after work.

More funky is the unique blend of African and European rock music which has developed here, known as Zamrock. Open a beer and check it out on YouTube. Perhaps you will like it. Even if it could lead you into the grasp of harlots.