Miscellaneous

I am sitting drinking a hot cup of tea, wrapped in a sheet with odd socks on under my skirt. Winter has come to Zambia and we are all unprepared. Having believed the childhood lady bird picture book that life in Africa would be continuous hours of sunshine and zebras we have all bought with us only summer clothes and now the nurses laugh at us when we emerge onto the wards cocooned in whatever various layers of scarfs, socks and leggings we can find.  They also are taking winter dressing very seriously. Most of them are wearing whatever coat they found at the market which include full length fur jackets obscuring their white nurses’ uniforms or the more glamouous Paeds nurses who just bring the malnutrition room heater to the nurses’ station and sit cuddled around it. It had been sunny up until now but a few weeks ago the weather made a turn. This was inextricably linked in my mind to the day the EU referendum results came out and we were all awake from 3am with an increasing feeling of dread and cold worsened by looking bewildered out the windows at a grey and misty Zambian dawn, shivering in our sleeping bags.

Since I last wrote we have had a wonderful time on holiday in Malawi risking our lives on motorbikes over mountains as the sun was setting, wandering in green tea plantations under mountains and spending very precious time laughing and catching up with old friends. D has told you all about it in his writing last week, it was a lovely break from our little well-trodden routes around the hospital here and we arrived back full of energy for our last 6 weeks here.

The hospital has been a little quieter recently as it is cold and harvest time so people are staying at home. This has given us a lot more time on my wards to talk to patients and the nurses. The mothers on SCBU (our baby unit for babies who are very premature or who have infections or didn’t get enough oxygen at birth) especially the ones who have babies who are premature can end up staying with us for a very long time – the longest at the moment is a shy 17 year old mother whose little baby weighed 900grams at birth and is now on day 51. We get to know them quite well and whilst Dr Z (the Ukrainian doctor on our ward) likes to tease them by telling them they are going to stay up to Christmas (which backfired last week when one burst into tears in response) I prefer to try to persuade them to give their babies hilarious names fitting to their time in SCBU – Patience for the one who has been here 51 days, Rachel for one I resuscitated, Peace for one who cries a lot – you can see the hilarity. The mothers humour me but actually babies aren’t normally named here until they get home from SCBU and then the first child’s name is chosen by the grandparents who have to bring a gift for this privilege. The name has normally been chosen by the time they come back for review and I love finding out what they have decided on – the nurses tell me off because I get more excited about this than the actual weight of the baby which I am supposed to be checking. My favourite so far is twins called “Sarah” and “Same”.

Women have children very young. If they are in school when they get pregnant the father is meant to pay them “damages” for disrupting their education which is often calculated in number of cows. Money is also paid by a man to marry a woman – I discussed this during a break time conversation with three of the nurses which also included questions about the value of the pound, why refugees are leaving Syria and the social welfare system in the UK – all of which are quite tricky concepts to explain it turns out. The nurses were very excited to hear how much D. had paid for me and when I told them “nothing” they were horrified. Mrs P. one of the slightly older nurses who is especially motherly and kind exclaimed that she didn’t know how I could bear to live in a country “in which woman were treated as completely worthless like that”. I tried to protest that – no no – we actually quite liked it that we were not paid for like something to be sold – but this fell entirely on deaf ears and she just gazed sorrowfully at me as if I had been completely brainwashed by the “entitled men in my society”. D has gone down significantly in her estimation ever since.

A collection of my favourite moments:

  • – I was called to see a newborn baby in SCBU, he had been placed wrapped in a green theatre cloth on the resuscitaire – pale, cold, not breathing. For once it was one of those babies who has read the Newborn Life Support protocol and started crying and wriggling after my first 5 rescue breaths. I popped out of the hot room to write something in the notes and when I returned a slightly older woman wearing the hospital red and blue gown was stroking the baby with tears running down her face saying to me “Doctor! A beautiful baby! Look he is a beautiful baby” repeatedly over again. It is rare to see mothers being that affectionate with the babies in SCBU and I was quite taken aback. It turned out this mother had 4 babies die previously and had seen this baby hadn’t cried when it was born and so had come to SCBU resolutely ready to collect the wrapped body of yet another dead child. Instead had found her baby – bright and eyes open.
  • Babies over 3.5kg (about 7.5lb) are rare for us to see here. L and I came across one who looked monstrous in size – pink and chubby and screaming, wrapped in a giant flowery furry blanket – we had taken a full history from the mother about the possibility of diabetes, examined the baby in detail for any dysmorphic features – before we registered that this was just a normal sized baby. Babies in the UK will be a shock.
  •  We have a Paediatric clinic once a week where we bring complicated children back for review and counsel parents about children with chronic disease such as Downs Syndrome, Cerebral Palsy and Epilepsy. Last week I saw a 3 and a half year old little girl with beautiful braided beaded hair and a puffer jacket coat who had a huge mass in her abdomen – I was able to make a likely diagnosis of a particular type of cancer, explain this to the family and then arrange for her to be transferred to a Lusaka for treatment. The father had a lot of questions and it was lucky that our one other child who has the same cancer but who now comes back weekly for chemotherapy was on the ward at the same time and I was able to put them in beds next to each other to make friends and share experiences. It’s rare for us in the UK as junior members of the team to be able to manage the whole story of a patient from presentation to treatment plan and it was very rewarding. The clinic is one of my favourite parts of the week because we also get to see some children coming back who we have spent hours with, sick and unconscious, not walking again after severe malaria, quiet and apathetic with severe malnutrition who are now cheerful, smiling, playing. Particularly recently has been an extremely cheeky little boy called ‘Happy’ who perpetually wears a pink velour tracksuit who came in a wheelchair puffy and swollen up with Nephrotic syndrome (a condition where your kidneys leak out all your protein) and spent a week in our ICU. He came back skinny last week with his devoted parents who faithfully record all his treatment in a dog-eared exercise book, high-fiving the nurses and telling me “hello Dr Laychel – we should cut off some of your hair and stick it to my head”,.

We were doing the ITU ward round last week when we turned around to see 5 police men and about half a village crowded into our little treatment area around a small bundle which contained a little baby covered in mud who had been found abandoned in a ditch lying there for what we were eventually worked out was about 24 hours. We gave the baby a hot bath still scrutinised intently by the village who seemed to have set up camp in the ward – this clearly being equivalent of reading the Daily Mail for them – before they were ushered away by one of our stern kitchen staff. The family of the baby were identified and managed to bring in the mother, a school girl who had reportedly panicked as she didn’t want to tell her father she was pregnant, and had thrown the baby away. This presented the social work team with a dilemma. Put the woman in prison as the police were suggesting and the baby would likely starve. Formula milk here is very expensive. You also need clean water to make it which means more money for firewood. Families will often over dilute it to make it go further.  We see babies in malnutrition whose mothers have died and have been fed nothing but milkshake and yoghurt because the one tin of formula milk they can afford has run out. In the end the baby was sent home with the mother after counselling from the police and social work team who told me “we decided forgiveness is the most important”. Families here make huge sacrifices for their children but amongst them are a few who are neglectful or abusive. This is something I have found difficult to deal with – repetitively trained as we are in the UK to “safeguard children” “information share” and pick up on any possible signs that a child is at risk. I see these signs all around me but there is very little to do about them. L and I are looking at our management of malnutrition for all children admitted in the year 2016. We particularly remember being asked by our nurse in charge “Do the children with malnutrition in your country often die?” He was disbelieving when we tried to explain that we don’t see cases of severe malnutrition often, if ever.  One child who has stood out to us is a little girl with HIV, TB, the child of a young single mother who was charming and spoke good English and who was admitted twice and then died on the third admission. Retrospectively we can recognise signs this mother was not feeding or looking after the medical problems of this child. The unanswered questions of how we could have better protected this child do weigh heavily.

This is our last week in Zambia! Coming back to the UK seems a little daunting although top on my list of things I am looking forward to is eating strawberries. Our life here is in many ways very simple and well defined. People right in front of you need help, you can help them in a small way. For a short time you can pretend there are no more layers of complication than that. Going home means we need to face normal life and challenges which seem much more blurred and harder to fix. A lot of my friends at home are disillusioned with our systems and decisions by our leaders. It is easy to feel downhearted but I hope that we can be determined as a generation to not run away from things because we are disillusioned about them but to have courage to make kind, wise and thoughtful decisions as we try to navigate the way forward.  One thing I want to be better at when I get home is holding things lightly. Knowing that I am happy to be able to experience what for so many is an inconceivable privilege – a peaceful walk, a hot shower, eggs and coffee on a Sunday morning, a warm scarf on a cold slanting day, the opportunity to study in a library full of books or walk between the multiple rooms in my house – to enjoy these things – not to feel guilty about them – but to recognise that if in the blink of an eye they were all removed from me I would still be luckier than an immeasurable number of the world to have experienced them in the first place.

Thank you so much for keeping up with our time here and all your kind words and support. We are so excited to see friends and family at home again. I will write to let you know when we are back home – we have a few more weeks before the interlude is over and the next scene begins*

 

*D dared me to use that line. Analogy at it’s best.  

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“We can’t let the perfect be the enemy of the good” or Stories of language and orange seeds in jam jars.

I have never noticed before how the patterns of the seasons in the UK help me orientate myself to the time of year and how time is passing. Since our arrival we have gone through the rainy season and we are now in the cold season. It seems that the cold season brings similar phenomenon across the world over – old people are coming in with hypothermia, babies all have bronchiolitis, people complain about the weather and don’t want to go outside. The confusing factor here is that it is still perpetually blue skyed, windswept and sunny and up to 30 degrees in the day and only down to 12 at worst at night. The words ‘March and April’ seems meaningless to me without connecting them with frosty mornings, wet shoes, grey skies, daffodils and scarf wearing. This means that we have sped through these months unaware and have now somehow arrived totally disorientated in May and over half way through our time here!

Life here is becoming more normal and so I forget which moments are ones to write down or try to remember. So just a few stories from the hospital. We had an experienced HIV consultant visit from the UK for a week who in one of his teaching sessions told us ‘We can’t let the perfect be the enemy of the good’. It has stuck with me as a way of expressing the balancing act of looking after this patient in front of you as best you can and at the same time trying to ensure that the children who come after this one can also have the best care possible. How long can I ventilate this baby for using a bag and mask only with 40 other children who I am also responsible for waiting to be seen? Can I put this 900gram baby on IV fluids for the 4th day running when I know there is only one nurse and having to do one and a half hourly fluid boluses will take her attention away from the 19 other small babies in the little hot incubator room? How much of our only Salbutamol inhaler should I use up on this 7 year old with an acute asthma attack? We are lucky in that these questions are not as loud for us as for some as we are working in a setting which in comparison to some other African contexts has relatively good staffing and resources but the questions are still there. To what extent do we focus on an individual or do we try to get the greatest good for the greatest number? In some ways a wider version of these questions have been in the back of my mind for years : is it better to have a doctor right here right now who isn’t from your country, doesn’t speak your language or wait and try to invest in building a stronger health service for the future. Is aid helpful? What problems does it cause in the long term? I still don’t know the answers. But I have noticed the value of being there for this person, in this place, in this time. For that person you can change something. Whether that is enough to justify the other unanswered questions I cannot say.

One night I found particularly difficult this month was an on call where I was in the hospital most of the night with a beautiful 2 year old who eventually died of croup. I had convinced this was the one child I was going to save – I had managed to track down and make up some nebulised adrenaline at 2am and gave her a lot of steroids- she had the most terrible stridor for hours I have ever heard but then she didn’t make it. The mother was distraught – screaming and wailing so I had to get a hospital guard to go and get her own mother from where she lived luckily nearby to take her home in the middle of the night and calm her down. I always feel extremely frustrated at my lack of language skills at times like this. I have to rely on the nurses to translate for me and they are often too busy or don’t see the point of explaining things in detail so I often have to try and sum up everything I want to say and how sorry I am just by saying “sorry” and standing there looking sad. So inadequate for what I want to express. Sorry we can’t intubate your child because there are no doctors trained and then no ventilator available. Sorry you child is being looked after by an English SHO when they deserve a full ITU and anaesthetist. Sorry you would get that if you were born in another country. Sorry you actually managed to get your child enough food and clothes and that they were growing well and walking and talking and you tried really hard with the little amount of things you have and still they died when you thought they had made it past the risky time. Sorry your child just died scared and probably in pain and I couldn’t stop it and I am getting in the way of you trying to grieve by coming along and listening to their chest and just writing a lot on my piece of paper with no explanation to you. Sorry.

I am getting there with communication slowly though. Last week a little girl went home after being with us for almost 3 weeks. She is a very elegant, thin and self-contained 9 year old who came in actually the same night as my croup child with her intelligent and kind Grandmother who always wears a head scarf and a yellow chitenje, with a month of shortness of breath, weight loss and night sweats. We initially thought she had TB until we sent her for an ECHO (an ultra-sound scan of the heart) in the hospital Chipata –an hour away- which demonstrated a very severe dilated cardiomyopathy- her heart now so floppy that it was only pumping a fraction of the normal amount of blood around her body with every beat. We are not really sure what caused it but possible a viral myocarditis – an infection of the muscle of the heart. Since then we have been trying to get her better on medication here but with very little success and the only option really in any country would be a heart transplant. (which on an incidental note is a very interesting thing to try to explain to Zambian nursing staff who slightly concerningly believed that in the UK robbers just took hearts from people they caught in the street and then we as doctors would transplant them for a fee) Both her and her Grandmother were so patient and uncomplaining and little A. even got to the point where she would answer my stilted Chechewa questions on my ward round with her whispered answers: ‘how is the cough?’ ‘a little better doctor’. I am very attached to her. A few days ago the Grandmother asked me if she could go home seeing that A. wasn’t getting any better and from what she understood there wasn’t anything else we could add. With a nurse we managed to have a half an hour conversation about where would be best for this little girl to be and how we could achieve that and in the end decided that going home was the best decision. Although a very sad situation I felt we were able to give the family the power to make a decision which would hopefully result in the most dignity and least suffering for this lovely little girl.

One of the Scottish doctors working with me on Paediatrics for the last 3 months has now switched to medicine. The nurses had noticed our style of working which was basically just affirmation of each other at all points or trying to hug cute children and one of them commented when L. left ‘I wonder how you will cope Dr Rachel without her – I notice you two love each other so much’. Instead I have been joined by H. who is also from Scotland and is here for a year and lives next door to us in the square. She is wonderfully kind, genuine and straightforward, and likes (amongst other things) ants, knitting and talking about Shetland. The other doctor with us is a brilliantly eccentric Ukranian doctor, new to the hospital, who is employed by the government and has worked in Zambia in various hospitals for over 20 years. She has a slightly different approach to patients than our very British one and the other day to see if someone was breastfeeding she without warning picked up their breast and squirted the nurses and the mother with milk whilst shouting at them in a mixture of English/Ukranian and Chichewa. No one seemed to bat an eyelid but I thought it was hilarious and couldn’t stop laughing in the corner. So we are quite a mismatched team but get on well.

Outside of the hospital I am enjoying how life is simpler here. There are less things to do so I end up having time for things I always wanted to do at home but felt I never had time for – like reading books with cups of tea, planting orange seeds in jam-jars, trying to make sloe gin from an unidentified berry I was sold at the side of the road (I haven’t sampled this yet so will have to keep you updated on it’s success) and enjoying things like eating chips made by a 10 year old boy running his own chip stall and buying tomatoes from the market. We have been befriended by a beautiful nurse C. who works in SCBU (special care baby unit) with me. Her and her 5 children, Esther, Tony, twin 3 year olds with spaghetti-like hair – Gloria and Patience and 6 months old Hastings came round for pancakes, painting, guava tree climbing and football with ‘Uncle Doctor David’ last Saturday and this weekend we were invited round to their wonderfully slightly ramshackle house and fed eggs and chips in one of their 2 rooms and given gifts of orange lemons. The children were excited to show us all the best parts of their garden – my favourite of which consisted of Tony’s (8 years old) little garden patch which was completely empty so far but apparently growing lemon seeds, T proudly explained ‘I think this is the best part because it’s got lots of soil in it’. I had been off work for a few days with a bad cold (I told you – it’s the ‘cold season’ I was just getting in the spirit !) so had knitted Hastings a little stripey jumper (whilst using precious internet to live stream one hour of radio 4 as a treat) and C is making D and I matching chitenje outfits. It was lovely to spend time with people outside our little circle of doctors and feel like we are making some Zambian friends here. D and I borrowed two old mountain bikes a few weekends ago and we went cycling along red dust tracks past sunflower fields under wide blue skies and through little villages consisting of round thatched huts and wandering pigs where children scrambled to the edges of the path to wave frantically at us and call out the infamous cry of ‘Mzungu how are you ?’ I commented to D that I felt like we were in the Tour de France because of how celebrated we were as we reached every village. That was probably where the similarity ended.

This has already got too long so will have to write more next time. We are happy and enjoying life. Thinking of our favourite doctor friends in the UK a lot with all the strikes and pressures there. We have been looking at old photos of everyone so now feel very nostalgic and missing friends and family at home. We think of you often and love hearing from you.

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Orange lemons!
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David and the twins
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Outside the Paediatric ward
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Me and our new breakfast club friends
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Jumper for Hastings!
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Most recent garden triumph. Seeds from Lidl.

 

Colours

I have given D the blog baton for a few weeks now but he is getting such a positive response from his writing and even known by some of the other new doctors here “as the one of us who writes” that out of slight panic at having my role overturned I have decided to write an update. So much seems to have happened since I last wrote that it is difficult to know where to start. Time is flying by and our days have fallen into a gradual blurred routine of starting work at 8am on Mbusa and SCBU (the Paediatric and Neonatal wards) or D on the adult female ward Monica, eating rolls with basil and avocados from our garden in our sunlit house before going back onto the wards in the afternoon. One of my favourite moments of introducing D to Africa was when on the flight D kept worrying that he would feel claustrophobic under a mosiquito net despite my many reassurances When we then arrived he watched in amazement as I hung up our mosquito net on hooks over our bed and he told me that for all his life he had thought you just covered yourself with the mosquito net like a blanket. A misunderstanding which is one of the perils of marrying a boy from central Glasgow with a girl who was home-schooled and sent to China alone by her parents aged 13.

I am loving the hospital and working on Paediatrics and so feel increasingly happy with my decision to accept the Paediatric job I was offered in Bristol from this summer. I work with another doctor from the UK L and a Zambian medical intern H and I feel that we have built up a great team. L and I are probably overly supportive of each other’s decisions and will occasionally continue to write down the other ones unlikely impression out of “loyalty” but it’s such a treat to work with someone else who you can discuss ideas and thoughts with about tricky patients and decisions. H tends to look on in bemusement as he sees patients at a much quicker rate mainly because L and I get sidetracked by picking up cute babies at regular intervals under the pretence of “weighing them to help out the nurses”.

We are lucky that the Zambian nurses on our ward are wonderful. The head nurse is a young and increasingly (as he knows us better) sarcastic male nurse called Mr Sakala who seems to very much enjoy his role as “in charge” and I hear “Dr Rachel” from him multiple times throughout the day. As the senior paediatric doctor is away for a few months L and I are also part of some general running of the ward and join all the nurses at 7am on a Wednesday for a ward meeting where we discuss issues

which range from the next cockroach spraying timetable to discussing the latest HIV testing guidelines. We also have a joint hospital meeting twice a week where we present mortality for each of the wards and where the pharmacy and lab update us on what we have in stock. The list of out of stock medication is read out as a monotonic list by a quiet timid man who rattles off essential items such as “Insulin, IV fluids, Gentamicin” with a completely deadpan expression. The irony of having no insulin and only 10% Dextrose as a fluid was not lost on us.

The nurses are excellent although very overstretched – overnight there is just one nurse for a ward of often about 40-50 children some of whom are desperately unwell. This is possible mainly because of the role “bedsiders” or the parents play in the care of their children. It is something I have come to love about medicine here that the responsibility for the recovery of the child seems to be shared between us, the nurses, the parents and also just general fate or spirits or God. Parents do all the washing, cleaning and feeding and are responsible often for complicated feeding and fluid plans. Nurses do all the bloods tests, get dragged by us in all directions to act as translators when our list of one word questions in Nyanja (similar to Chichewa) is exhausted, give all medicines and the checking of “obs” (which is just that the children get their temperature meticulously checked every 6 hours). Sadly this lack of other observations means that often when a child dies overnight you have no idea what happened in the intervening 8 hour period between you seeing them on the ward round and the doctor certifying the death except for a religiously recorded set of temperatures. When children die the shared care means that parents are often very understanding and accepting – and often heartbreakingly take time to thank us for “doing everything that can be done”. This is particularly poignant for me when I am so fully aware that there is so much more that exists that can be done, just not in this setting.

Life here seems to be one of extremes. We are in many way living a completely idyllic dream where we travel on safari to see ladybird picture book animals, we have ‘film nights’ in the square where we use the hospital projector and the blank whitewashed wall of one of our houses to make an outdoor cinema under the stars. We spend a lot of evenings eating lots of chocolate by candlelight and creating inventive meals and cooking pancakes on gas stoves while the power is off. On the other hand we are faced every day with extreme sadness and at times feelings of futility as children on our malnutrition ward die of literally nothing to eat while we struggle to manage the complex balance of their conditions with only a handful of medicines or investigations. Or frustration as we try to explain to the parents of children with severe malaria and anaemia (often with Hbs of 2 or 3) that we don’t have any blood in stock not because there is none available but because the country has run out of the reagent used to test if the blood is safe to give or not. However there are moments where we are filled with happiness on the hospital ward too: when a 5 year old boy I admitted overnight with seizures lasting several hours and who remained unconscious for a week comes back to see us in clinic now able to walk and talk, when a tiny baby who L and I looked after as a tiny skeletal 1.5kg creature wrapped in layers of cloth pulls through, puts on weight and starts looking around, when all the mothers laugh at you when a tropical rainstorm catches you unaware on your on call or when at night you walk to the hospital under a wide dark sky with luminous stars. When I tried to explain this difference in life here compared to life in the UK to another doctor visiting he questioned whether in fact the beauty and colour we experienced in life here was more obvious because of the other extremes of hardship we are witnessing too and after thinking it over I feel that he is probably right. Things feel much more colourful, all shades of dark and light and the darkness seems to make moments of light all the more vibrant.

We are loving reading the stories from all of you wherever you are in the world. Thank you for messaging us and for your post and thoughts. We miss you and are inspired to hear of your adventures.

A 79 hour journey and a sunny arrival

We have heard rumours that it is snowing in the UK which seems inconceivable as I write this from our little sunlit courtyard of 4 brick houses with tin roofs in Eastern Zambia. All the windows are open wide and a slight breeze is blowing through the bunting some of the doctors who have been here for 6 months already had made at a tailors in the market and have strung up. We are on our third day at the hospital after quite a dramatically long journey – leaving our Felixstowe house being waved off by my family in Poffley tradition running along the train station platform at 13.30 on the Monday and finally reaching St Francis’ at 20.30 on Thursday. We had decided much to the dismay of D’s mum to fly with Ethiopian Airlines and were busy taking pictures of our comfortable and spacious plane and delicious food to prove to her that her worries were completely unfounded when an announcement was made that we were going to do an emergency landing in Athens due to a technical fault. We landed safely half an hour later at Athens, normally closed overnight and were met by multiple fireman and police. Ethiopian Airways do not normally fly to Athens and so the Greek staff there, called in urgently overnight, were a bit unsure what to do with us so the rest of our journey involved a 7 hour wait in the middle of the night in a Greek departure lounge, a two hour period in a fancy Greek hotel, another flight to Ethiopia and then again an overnight stay in a huge deserted orange hotel which resembled the one in “The Grand Budapest Hotel” if any of you have seen that film. We finally were put on a new flight to Zimbabwe and then finally Zambia. The final leg of our journey was a 6 hour ride in the back of a hospital LandRover along the newly renovated Great East Road which we flew along at a consistent 100km/hr regardless of the number of potholes or other vehicles, bikes or pedestrians. D, myself and a wonderful doctor J who has worked at the hospital already for 2 years were all in the back sitting on two little benches with our luggage, 20 mangoes and 3 boxes of drugs for the hospital piled up with the disconcerting effect that we could not see the driver or the road in front of us and only out the back window where we could watch cars swerving as we hurtled past them.

Our house is a perfectly rectangular one room with our kitchen, bedroom and living room all open plan. I really like it. We have already started to make it feel like our home with pictures on the wall, a wooden table we brought from a carpenter cutting down trees on the side of the road and a collection of sunshine yellow tin bowls from the market. We have an overgrown garden which apparently we should get seeds for and ask a mythical man named “Nelson” to transform into a patch where we can grow flowers and lettuces. Our house is in a courtyard with 3 other identical house all facing inwards to make a square which is very sociable and we share with four other doctors, 3 kittens and several bedraggled chickens. The hospital itself is a beautiful red brick building with large airy archways and white washed walls and a red stone floor. We spent our first day on Friday D on the medical wards and myself on the Paediatric one with another beautiful Dutch doctor A. The most senior doctor on the ward, a Zambian paediatric registrar is going on annual leave for 2 month from Monday so spent all of Friday trying to convey all possible information to me before she leaves the ward and SCBU in the care of A and me. There are other doctors working on the medical wards and outpatients who have been here a lot longer and are a wealth of practical information so it always feels we will be able to ask for advice which is very reassuring. D and I went into Katete on Saturday to sort out internet and phones and buy pineapples and eggs, we travelled on the back of bicycle taxis which consist of a rickety bicycle with a cushion on the panier rack and are a very common mode of transport, I absolutely love riding on them although they are slightly precarious. I also enjoyed the fact that me and my driver got to town a good ten minutes ahead of D’s poor driver.

We start on the wards properly tomorrow but have felt very happy to have the weekend to feel much more settled. We are apprehensive about the medicine but think we will get used to things and learn quickly. Five more doctors who we were friends with in Liverpool arrive in two weeks times and we are looking forward to seeing them again too. Thank you so much for all your texts, whatsapps and messages and prayers. We love hearing from you. Please keep telling us all your news! We don’t have a huge amount of internet so we are so sorry if we haven’t yet replied to you!

Christmas and new beginnings

I am writing this on the first leg of our journey making our way across the world from winter rain in Scotland to tropical rain storms in Zambia. To save on train fares we decided to take a route which has the advantage of letting us personally experience the platforms of over 6 stations in England but the disadvantage of taking 11 hours and therefore almost as long as our flight towards Africa. D has joked that we are carrying out a stepwise approach to adjust ourselves from a delightfully luxurious time with his family (which included having a second Christmas day, lots of tea and cake and an endless supply of home baked chocolates always displayed on a star plate which became infamous) to our Zambian life by going home to my Suffolk family for a weekend before we leave. I am not really sure how to take this! Since finishing what was an amazing diploma of tropical medicine in very early December and saying an affectionate farewell to Liverpool and all our new friends we both travelled back to Bristol for two weeks of locum work at our old hospitals covering the joyful options of Geriatric rehab and psychiatry whilst catching up with lovely old friends. We then took full advantage of not working over Christmas this year and spent a whole full 9 days at each of our families which has been a huge treat.

Some memories which spring to mind over the last few weeks have included –

– visiting Berlin with M to see my grandparents, where we stayed one night in a community house of 33 people which had been originally claimed by squatters and which still involved a lot of graffiti and bare light bulbs and was much too cool for us. We reached my Grandather’s by taking a subway and a ferry where we spent several minutes taking photos and waving at a lovely elderly couple dressed in grey and green wool with felt hats before we realised that G and I were actually approaching from another direction! We stayed up late with them in their beautiful minimalistic wooden apartment eating gherkins and poring over photo albums from over 60 years ago. We then travelled down on Germany’s equivalent of a Megabus to Dresden which was all lit up with warm Christmas lights and people drinking mulled wine where we stayed with my Grandmother in her little new studio apartment and had lunch in the Steiner old peoples home next door.

-windswept walks on the beach with my family who were all reunited for Christmas in Suffolk discussing B’s recent and exciting international engagement, laughing at J for being the perfect-peter child, extremely competitive tournaments of ‘Ticket to Ride’, squash, table football and scrabble – which were won almost exclusively by an increasingly smug 9 year old N or 27 year old D. We drank sloe gin round the wood burning stove into the night whilst talking about the year of 2015 and reviewing L and S radiant wedding photos whilst eating hundreds of satsumas and German biscuits.

-watching in complete bemusement as K one of the 15 year old Eritrean boys who lives with my family took full advantage of the buffet at a Boxing day party and we found in the kitchen gobbling down a plate of raspberry panacotta combined with a third of a circle of Brie cheese all lathered generously in double cream.

-having a second Christmas morning in Glasgow with towels wedged into all the living room windows to stop the rain pouring in through a leak in the roof whilst S sat on the sofa completely unperturbed wearing a banana onesie, a flat cap and reading the newspaper.

We have felt very happy and lucky over the past few weeks to see so many of our families and friends in between a few stressful moments applying for jobs for next August, final exams at Liverpool with obscure memory techniques to try to hold on to snippets of the vast array of information and D having to put up with me waking up in the middle of the night to remind him of our “Zambia insulin plan” or the fact that we need to buy another metre of string as we finalise packing for going away.  It has been lovely to have the time to have long conversations with people, to start thinking about things completely outside of medicine again and for D and I to discuss what we have learnt during the first half year of our adventure and what we are looking forward to as we prepare for the second half.

We fly to St Francis Hospital on Monday and I am hoping to keep up writing more regularly over the next 6 months. If you want to find out any more about the hospital there is a link to the website here: http://www.saintfrancishospital.net/

Thank you so much for being interested in the small detail of our lives, we would love to hear from you all too and how you are. Hope you are all feeling hopeful at the start of this new year, 2016, with courage and strength whatever it make bring. We have been thinking a lot about the prayer read at our wedding which I wanted to share with you.

Disturb us, Lord, when
We are too well pleased with ourselves,
When our dreams have come true
Because we have dreamed too little,
When we arrived safely
Because we sailed too close to the shore.

Disturb us, Lord, when
With the abundance of things we possess
We have lost our thirst
For the waters of life;
Having fallen in love with life,
We have ceased to dream of eternity
And in our efforts to build a new earth,
We have allowed our vision
Of the new Heaven to dim.

Disturb us, Lord, to dare more boldly,
To venture on wider seas
Where storms will show your mastery;
Where losing sight of land,
We shall find the stars.

We ask You to push back
The horizons of our hopes;
And to push into the future
In strength, courage, hope, and love.

Sir Francis Drake – 1577

 

Milestones

This last week has marked two significant points in our little year of adventure. We have now crossed the half way point with our diploma! Time has done that characteristic thing of lulling you into a false sense of security by initially creeping by, each day full with new faces and facts but then speeding up into a crescendo, rushing along in a blur. This half way point has also marked the time when I feel that it is critical for me to start trying to make headway into consolidating, sorting and attempting to commit to memory all the overwhelming, colourful facts and pictures and stories we have been taught over the last 7 weeks. We have been told about an infinite number of worms by a sincere young Welsh scientist who frequently punctuated his lectures by doing impressions of tiny worms trying to survive in harsh grassland. His personification of the story of these creatures made me feel momentarily quite sorry for them, until we were shown videos by a lecturer who obviously felt gleeful in finding the most shocking youtube videos ever – of what appeared to be piles of spaghetti being pulled out of children’s tummies in operations and crawling out of eyes – when I returned to feeling nauseated.

We have also been told about sandflies, ticks, mites, lice and fleas. All of which carry a complicated life cycle, Latin names, transmit long and difficult to spell neglected and mysterious diseases in African, South American, Asian and Middle Eastern countries and apparently can be easily differentiated from each other. A fact which they further attempt to convince us of in our lab sessions where we wear our white coats and dutifully look at various examples of lice down microscopes, try to persuade ourselves we can see more hair or hard shells on different male and female examples of tiny creatures. It is fascinating and slightly overwhelming to be presented with a whole host of new diseases and symptoms and medications to try to learn. Little is known about some of these and the fact that they are found in far flung corners of the world means that the drive to investigate the diseases, develop treatments and try to prevent sickness and death is intermittent at best, if not completely absent. We learnt one disease, sleeping sickness, a disease named because infected patients sleep in the day and are awake at night, spread by the bite of a Tsetse fly and learn about doctors who have to face giving the only treatment for it, a medicine which one in ten times will kill their patient in front of them within hours but with an alternative of a fatality rate of almost 100% if left untreated.

Outside of the world of tropical medicine we are getting to know each other on the course more and more and I feel I am learning as much from some of the people on it as from the lecturers. Listening to everyone’s thoughts on medicine and on life, I feel like I am trying to squirrel up ideas and perspectives and enthusiasm from people and store them up for later. There is a huge variety in experiences, expertise and strengths. Like I. who continually questions the wider background and causes behind things by keeping the lecturers on their toes with perpetual questions about poverty,  to those like H. who are applying to work with MSF and who clearly feel most at home giving immediate medical care for those who need it – in a forthright, kind and capable way, to another C. who is fearlessly and determinedly moving to South Africa with her husband and toddler to continue her dreams of working in a hospital there, to those who have years of experience in British hospitals which they share and are examples of what the best kind of medical care can look like, which we should be aspiring to give no matter what the context.

We are finding it hard to find time to study with all these fun and exuberant people. D. is part of a Wednesday night football group, one of the girls A. teaches us yoga on a Monday (although classically my slightly too long limbs get in the way of me becoming an expert at this). R. and I went to see The Suffragettes, and I spent a lot of the film thinking how much I liked the costumes which I don’t think sits well with the moral of the courageous story depicted in it.  Last week we went to see Holst’s ‘The Planets’ played by The Royal Liverpool Philharmonic Orchestra. To the shame of Pa and years of classical music and ‘Friday night is music night’ on Classic FM I didn’t’ recognise that the first half was actually a completely different piece of classical music and all of us there kept turning confidently to each other and assuring each other that what we were listening to was obviously “Earth”. When we did actually get to the right part of the concert my favourite was Saturn – the bringer of old age.

The second milestone which I mentioned in the title was D and my one year wedding anniversary on the 11th of October. We spent a lovely weekend in the Peak District in a beautiful stone cottage decorated overwhelmingly perfectly for me in all dove grey paint, stone floors, whitewashed wooden floorboards, white towels, wool blankets and a wood burning stove. We also brought our guest book from the wedding which we looked at over wine given to us by lovely friends in Bath a year ago for this day and laughed a lot at people’s increasingly emotional messages as the evening went on – from H declaring that she now believed in love, to A assuring us that ‘we were the best people he had ever known’, to T (aged 12 at the time) wishing us a ‘wonderful life with your darling husband and your darling wife’. It was lovely to remember how happy and loved we felt on that day and all the effort put in to it by so many to make it what it was. We also were very excited to receive a video of our wedding day on our anniversary from the wonderful L, which we watched four times in quick succession. (And which you can see below.)

A lot has happened in this year for D and I moving from Scotland to our first attic home in Bristol, to Liverpool and through our first few years as doctors. I have learnt more about being kind to each other, noticed how much I love washing laundry –“I just can’t wait to get home to put on a blue wash”, learnt that just because someone doesn’t know all the names of wild flowers and likes things other than neutral colours they can still be your best friend.  Pa reminded me on the phone whilst I walked in the cold on my way home through potholed streets of Kensington that the first year of marriage is apparently ‘the hardest of all’ so I feel relieved to get through it so unscathed!

Thank you for reading as always! I miss you all who are not in Liverpool hugely.

https://vimeo.com/142067296 – Video – David and Rachel – 11th October 2014

View from our Peak District cottage
View from our Peak District cottage
Autumn walks
Autumn walks
Guest book one year on and lovely present from Sophie, Danielle, Martin and Alec
Guest book one year on 
Attempts at self timer
Attempts at self timer

Three weddings and a protest march

I apologise that I am a week behind in writing this, I know that this is something probably only I have noticed! In fact D has reminded me when I fret about it that people probably have been surviving this week perfectly capably without feeling the need to wait by the computer for my weekend blog post.

The last three weeks since I wrote have been a bit of a whirlwind of weddings, exploring Liverpool, making new friends, lectures and hours of looking down microscopes. In fact since arriving in Liverpool I have not yet spent a weekend here and D and I have developed a regular Saturday morning routine of getting up in the crack of dawn at 4am to stagger blurry eyed out of the house and onto various forms of public transport. The second of these was on the 19th of September when we flew to Northern Ireland for the lovely wedding of Harrison and Emma, friends of ours from Edinburgh Uni. We stayed with some family friends of D, a picture perfect family with four children all under the age of 10, home-schooled, owning chickens and kittens – like my own family when I was growing up but with more matching kitchen crockery. We pick up our faithful friend S, who in a hangover from the days when he and D were inseparable “let’s spend all our free time at university playing computer games and sitting on sofas and eating Greggs” companions, always follows us to wherever we are staying for weddings. P the lovely mum of the home we were staying in pulled me to one side to check if it was “definitely ok” for “Stuart to sleep at the foot of your bed” which apparently D had assured her was “completely fine” in advance! The speeches at E and H’s wedding were very emotional, they are a couple who are extremely kind, make you feel happy and genuinely interested in everyone and this was reflected in the speeches. At the end the hotel kitchen manager took the microphone to say with tears streaming down his face that “this was the loveliest wedding he had ever been at” – it felt like we were in a film!

Third wedding on the 26th of September started with a 5am nap at Nuneaton station and then an arrival into a deserted Coventry town centre at 8am, D and I made our way to what brother B highly recommended as “the only acceptable coffee shop in Coventry” and I decided in a fit of exuberance and early morning delirium to have a Bloody Mary to drink with my mushrooms on toast. Bonny and Laura, who were getting married in a sunny marquee on top of rolling hills past an old English pub next to a canal bridge, are old friends of ours from growing up and so happily this was the first wedding for a long time that our whole family in its newly expanded state of 12 was invited too! It was a great honour to be invited as we made up almost a fifth of the wedding guests! We were all gathered from all over the country, L and S arriving glamorous and glowing from first few months of being married in Sheffield, B initially in Grandfather’s painting overalls because J was “bringing his purple velvet jacket” coming from London with glitter still on his face from a night out. All of us were coincidentally wearing various mismatched items from a combination of either L or my wedding day outfits. B was best man and him and Bonny wore beautiful matching wool suits with Indian moccasin slippers! B spoke extremely eloquently in his best man speech, perfectly combining being very funny and exceptionally kind and also somehow even managed to embarrass me by bringing up a childhood plot he and I had to try to “get rid” of Bonny who consistently and disarmingly tried to befriend us after moving from India. At the time for two teenage home-schooled siblings trying to desperately climb the social ladder – if felt we could not afford any hangers on! It was a wonderful day full of laughter, old friends, fire-works, dancing and slightly inappropriate impersonations of Indian accents. I also got the chance the next day to see one of my oldest friends E who came up from London for the day, E and E make up what we affectionately call ‘the tripod’ and are perfect examples of the saying “it doesn’t matter where you are but who you are with” (if that even is a saying?) as the three of us often dedicatedly track across the country to meet up on train station platforms, park benches and now Coventry town centre!

The last three weeks at LSTM (Liverpool School of Tropical Medicine) we have covered ‘The Big Three’: Malaria, TB and HIV. Together these three diseases are responsible for huge numbers of deaths worldwide each year and the majority of these deaths happen in Sub-Saharan Africa. The highlight of Malaria week for me was the series of lectures on the biology of mosquitoes, which were delivered by a slim auburn haired American woman wearing a mustard yellow top who I immediately, in my usual measured and unexaggerated style, decided was “the most beautiful lecturer I had ever seen”. In addition to this she was able to bring the subject of telling one mosquito from the next to life and I enjoyed her personification of different mosquitoes. She had a particular favourite species and when showing us a picture of it would turn to us to make sure we agreed saying: “this is arguably a very attractive mosquito”. During TB week we were shown a film which shadowing the lives of three patients with a type of TB that is resistant to the current medication we have for it – MDR TB (multi-drug resistant), their stories were shown with great attention to the details of their lives such as love of football, dancing, humour and family loyalty that stood starkly against the desperation of the disease and it’s archaic and protracted treatment regime which involves up to four different drugs for at least 12 months. We also learnt in HIV week about the fascinating history of a disease which, for the majority of us in the room, did not exist before our birthdates. A real case study of the way our world responds and adapts to a very present threat to a huge number of lives. In some area’s incredible progress has been made due to the dedication and commitment of many unknown individuals worldwide and because of amazing discoveries regarding ART (anti-retroviral therapy). However this week highlighted again how we have also failed to react as we should. One film which I would highly recommend called “Fire in the Blood” details the horrifying way that pharmaceutical companies denied countries in which HIV was most present access to the drugs that could save literally hundreds of thousands of lives because of concerns about profits and patents. More sobering was the involvement of international agencies and governments who facilitated the continuation of a case where a drug which could be made for 365 dollars a year per patient was being sold under patent at 9,200 dollars per person.

A thread which runs twisting throughout these three weeks has been that of inequality. We were shown a graph of rates of TB worldwide and interventions attempting to reduce TB incidence. Out of all these attempts what has had outstandingly the most impact on rates of TB and deaths from TB was not anything to do with advancements in health care systems but instead the economic growth of the country. Another observation made continually on the course, very familiar to some, is that within cities and countries there is huge variation in how long someone can be expected to live based entirely on where they live, how rich or poor they are. Despite the first glance implications of this, money does not necessarily seem to be the answer. America, which spends almost the highest amount of its GDP on healthcare ranks below many European countries on factors such as childhood health. What seems necessary for true stability and development and health in a country increasingly clearly seems to be equality between people within a country.

On Monday last week a group of us from the course spent our lunch time scavenging for cardboard boxes from various supermarkets, sticks from skips and marker pens to make signs to take to a protest march in Manchester against the government’s current plans for a new junior doctor contract (junior referring to anyone from just graduating medical school up to any doctor until they are a consultant). Ironically, now that we are all out of the NHS for a year we had significantly more time to dedicate to composing what we thought of as hard hitting and witty slogans for our signs, this was summed up well by one doctor’s placard which said “this protest would be twice as big if half of us were not on call”. I have included some short links about the new contracts below but in short it changes rules about our working hours, dramatically cuts doctors pay especially in already overstretched areas such as A&E and GP and the way it has been enforced is hugely demoralising to NHS staff who are already holding together services through their own generosity and dedication. Heads of different specialities in the NHS have described that this new contract would: “severely damage morale of trainees and jeopardise the future of the NHS. It could lead to a brain drain of the brightest and best of our….trainees. The detrimental effect of this would result in the closure of many hospital emergency services and adversely affect the quality of patient care”.  There is another deeper fear that these changes are gradually step by step a move towards privatising health care and the loss of the NHS as a free at the point of care service which is so wonderful and unique. A service which allows our old to die with dignity regardless of their ability to afford pain relief or care, which treats those who arrive at its doors with the upmost quality of care whether that person sleeps in a castle or on the streets.  In TB week we learnt about the idea of “catastrophic costs”, when families have to spend so much of their income on health care that it pushes them into poverty. We currently live in a country where despite its many flaws, people are able to access care when they need it irrespective of their ability to afford it.  I think that any step away from this vision which this contract seems to threaten would be a great step away from equality and justice within our society.

Our weeks are full of stories and I feel this post has already overextended its welcome so will stop here and report more next week. We have finished ‘up-cycling’ our table now so I have no excuse not to work and write more. Please message me if you have any questions/disagree entirely/want more facts and less emotion about anything I have written. Thank you for reading this far, it means a lot to me!

Social injustice is killing people on a grand scale – Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health

A nation’s greatness is measured by how it treats its weakest members –Ghandi

Further reading…

http://www.theguardian.com/science/brain-flapping/2015/oct/01/nhs-junior-doctors-contracts-strike-dispute

http://www.theguardian.com/society/2015/sep/29/junior-doctors-contract-row-nhs-explainer-health

http://fireintheblood.com/

http://www.gapminder.org/

Junior doctor march in Manchester
Junior doctor march in Manchester
Reunion at Bonny and Laura's wedding
Reunion at Bonny and Laura’s wedding

First Impressions

If you have come to read this expecting to be regaled with dramatic tales of our adventures in foreign lands, I’m afraid you are going to be disappointed -please come back in 6 months. Surprisingly however, despite its location only several hundred miles above Bristol, our re-location north has felt like a very foreign experience. Please bear with me while I sound overly southern, but this is my first experience of living in a north of England city and we did step down very quickly from attic flat on the crescent in Clifton to urban Kensington. Liverpool seems to be a unexpected mix of beautiful tree lined parks, a plethora of cool coffee shops and bars, incredibly friendly and kind people and lots of boarded up houses. On our first walk on arrival we explored our immediate surroundings which consisted of a completely deserted but fully built and functioning, even down to the cycle tracks and and traffic lights, industrial park named “Innovation Boulevard”, a meat market, an ASDA with a distinct absence of fruit and vegetables and a row of completely boarded up houses, terraced red brick homes with all their doors and windows replaced with metal or wood waiting for some long lost “council regeneration scheme”.

We are living in a similar (but non boarded) terraced brick house with a pretty garden with a tree which miraculously grows both apples and pears. We are lodging with a kind and cheerful couple and eat dinners with them via a complicated blackboard system to signal who is going to be in or out. Our room has one arm chair in the corner which D and I argue about who is going to sit in. Initially after D and I seeing each other so irregularly at work in Bristol it is quite strange to be spending so much time together and at lectures we have overly elaborate discussions about whether we should sit together or separately.

D and I are studying for a Diploma in Tropical Medicine and Hygiene and both wore accidentally matching blue outfits as we walked in for our first day of school. We spend almost every day in a grand Victorian building in a new lecture theatre or in the lab. Our first day we all introduce ourselves to the rest of the class of 91 as our names are called off a register. These are called out in no discernible order and so I felt quite on edge trying to prepare my speech in front of everyone which I then promptly forgot when it was my turn. We discovered 4 other doctors all coming to work in the same hospital in Zambia as us in January and D attempted to make a joke about his role in the “Britain –Zambia take-over bid” which was met with nervous laughter from some who clearly felt it was too close to colonial past. We are surrounded by doctors at a huge range of various levels of training from immediately after F2, right up to a retired GP who announced “I’m liberated” during his introduction, a paediatric consultant who loves wild swimming and an army doctor who has spent the last few years in Borneo. There are several countries represented including Oman, Germany, Japan, Sudan and Afghanistan. The majority of people are taking several years out of training and it is a relief to be surrounded by those who view it almost an anomaly to take only 1 year out rather than expecting you to be racing up the ladder to consultancy.

Our working days consist of a combination of lab work and lectures. In the lab we are each given our own microscope with an allocated number and matching lab coat and numbered coat hook. I am especially happy about this primary school style numbered coat hook which I feel I missed out on in home school. Apparently we will spend over 60 hours at this bench over the next 3 months and M our dark haired lab teacher assures us that soon we will be rushing to our microscope at all hours of the day and night. I am sceptical but find I surprisingly enjoy searching through my eye piece and finding what I at first only see as stunning patterns and pictures all contained within a tiny spec of slide. Later in the week I gradually begin to pick out shapes which I can vaguely identify as parasites and protozoa- with a lot of help from lab staff and mutual reassurance that what we are seeing is not just a bit of plant from N my bench partner, a bright, chatty and very friendly anaesthetic/ITU trainee who has spent the last few years in Australia.

During lectures everyone gets out a sea of mac devices, initially D and I block the view of the powerpoint screen with our clumsy oversized old laptop screens until my sister L lends me her ipad so I can gleefully  get out although it actually just ends up sitting beside me as I prefer to write paper notes anyway. One of our favourite lectures so far was given on a Friday afternoon by an inspirational GP who had move to an incredibly remote corner of Afghanistan with his wife and 4 blonde haired children primary school aged children to set up a health care system in mountainous villages with absolutely no health care provision. The talk was 3 hours long but we all were mesmerised, hanging on to his every word. He mostly taught us through stories and pictures and I especially liked hearing about his ingenious use of his medical knowledge and the resources around him to find solutions to problems. For example using different coloured bags of sand to construct a growth chart for illiterate health care workers and using a pendulum to monitor respiratory rate. He also spoke beautifully about how easy it is to view people in another country or our own patients as separate and different from us rather than as people who share the same hopes, who laugh at jokes and who worry about their children. In medicine I think we often do this as away of protecting ourselves but he argued it was essential to identify with people to really be in a position to offer support and kindness to them and to try to give what is actually needed rather than what our perception of their need is. I also enjoyed his slightly dark sense of humour which peppered most of his stories, when asked about concerns regarding safety in the region he told us a story about how he had been instructed by the NGO he worked for to write down his emergency escape plan which he diligently recorded as “I will drive my truck to the end of the road and then climb over the mountains with my wife and children singing ‘The sound of music’”.

D’s and my other favourite lecturer is an American suave man who is a professor in public health. He initially lulled us into a false sense of security in his first introductory lecture in which he canvassed the room to see who had worked where – responding to everyone by nodding intently and making remarks such as “Oh Kenya—I love every bit of that country” and “Oh yes South Sudan, I set up their health care system” but now spends hours rattling through complex equations and statistical methods for gathering accurate data about whether a project is working or not at a speed which makes me feel that I have to sit upright on the edge of my seat incase I miss a word and then am lost for the next few hours.

Everyone on the course is extremely sociable and there is always a flurry of whatsapp messages daily about various activities, events and in-jokes. We have been to a yoga class with an 85 year old wizened old woman who looked like a Disney character, went to what was a combination of a night out and food festival in a warehouse, walked in the peak district and are currently upcycling a table. It has also been a lovely treat to spend time with some of our long lost favourite friends from Edinburgh H, A, I and R who are all doing the course with us and of course K who is living in her urban Manchester 15th floor jungle, decorated in the very modern colours of yellow and grey. I am loving having time to think properly about things like how much water you need per day per person for a refugee camp, how to co-ordinate aid agencies arriving at an airport in a disaster, how to identify different types of flies, what white blood cells look like down a microscope and what the budget of UNICEF is.

Will share more of these thoughts next post, thank you for making it this far and for taking the time to read.

Nearby Peak District
 Peak District
Adventures in nearby Sefton Park
Adventures in nearby Sefton park
Our new home
Our new home

Introductions

Hoping to use this as a way of getting back into my love of words and writing over the next year and to share what we are up to with our lovely family and any patient friends who are interested in reading it. I am hoping to post fortnightly. David and I are taking a year out from NHS medicine and, after a sunshine August in Poland and with Suffolk family, the first step is a Diploma in Tropical Medicine and Hygiene in Liverpool starting on the 1st of September.