A white coat on red soil

Here is a little update about what has been going on in the hospital over the past few weeks. If you are interested in some general things about Mercy Ships, head to the Guinea home page where I have updated some of the info.

My job is still really fun. It is not as stressful or busy as my job in Zambia. This is partly because the ship is not a true hospital. Technically it runs more like an elective surgical unit, with a GP clinic for crew on board. Therefore patients are generally well by the time they have their operation. Some patients have problems which are picked up in screening and hopefully rectified, or if they cannot be, they are sadly declined surgery. Thankfully this is rare, as our anaesthetists and surgeons are pretty happy to give things a go and work outside the normal limits they would do back home.

I have had my own episode of illness. It was the kind where you are sitting on the toilet farting out water with fragments of haricots verts and then you feel the familiar sensation rise up your torso and out pours smoothie-consistency vomit. Thankfully it only lasted about 24 hours, but Ship rules are such that you must remain in your cabin for 48 hours after your last abnormal gastrointestinal movement. Friends were so kind in bringing me food, company and general morale-boosting. When I was feeling better but still under isolation rules (you are allowed to go outside for fresh air, just not any public spaces), I escaped to the deck and we did a puzzle at sunset.

The other hospital physician Dr Mark left last week, which is six weeks sooner than planned because he wanted more time with family in the UK. They have not been able to fill the gap, so it is just me and Alex (ship’s GP) covering the on calls! So far it has been okay managing admissions, the wards and the tents during weekdays, and even feels a little easier because I know what is going on with most patients. There are another three weeks to go until the new hospital physician arrives.

Mark’s premature departure has meant that I have been able to extend my stay by two weeks to cover the cross-over with the incoming physician. Now I will be here for my birthday and leave on 6 April! Thanks to your generous donations, my extra two weeks of crew fees ($325) are covered. I am also very grateful that I don’t have a job back home, so that I can be flexible to stay and help.

As for next year, I have committed to coming back for three months of Senegal’s field service! The ship will leave Guinea in June, and sail to Las Palmas for two months of maintenance, where it will spend some time in dry dock. Subsequently, it sails to Senegal in August to begin the next Field Service. I will be back for the same period: January to March 2020. I am looking forward to it because it will span some blocks of really interesting surgery: craniofacial, goitres, plastics and maxillofacial. And lots of friends will be back again too!

This post covers a couple of the types of surgeries we have had over the past few weeks: cleft lips and palates, and goitres. I had intended to include plastics, but this post turned out to be too long.

One thing I find totally inspiring and mind-blowing is the quality of surgeons who come to the ship. Not only are they incredibly skilled with a knife, but their faith, passion and dedication is inspiring, and it is a joy to get to know them personally!

Cleft lips and palates

One third of the craniofacial surgical team is David Chong. He is a plastic surgeon from Australia who specialises in cleft lips and palates, and is an absolute legend. He works in Aus for nine months a year, and spends the other three volunteering with Mercy Ships and Operation Smile. As well as working with Gary Parker (maxillofacial) and Shailendra Magdum (paediatric neurosurgeon) making new faces for kids with parts of their brain poking through their skull (read about the craniofacial craic here), he has repaired a few facial clefts! Clefts are his jam.

Cleft lip and palate happens when the pieces of the face do not develop properly in the womb. An embryo starts off as a three-layered flat pancake and very cleverly rolls into a tube to form a spinal cord on the inside, the squishy bits in the middle and the skin on the outside. The head and neck comes from one end of this folded worm-like creature, which undergoes some impressive origami to form the necessary structures. Within the first eight weeks of pregnancy, the facial features are created by two sides twisting and flowing into the centre. This migration has to be coordinated in order to make a symmetrical face. If they do not fuse properly and one or both sides stops moving too soon, you can be left with a cleft palate or lip, depending on the stage in development the migration stopped. What causes facial clefts remains a topic of discussion, but seems to be a mix of genetic and environmental factors.

In the West, cleft lips are repaired by three months of age, and palates at one year old. This is before the child is even aware that they look different to other babies. Yet in countries where they do not have access to healthcare, children with clefts grow up being looked at and treated differently because of the way they look. The general population in these resource-poor countries often have little education about health problems and sometimes believe that the person is cursed, or that they will catch their disease. As a consequence, these children are ostracised from society, and grow into adults who do not belong to regular society. It is noticeable how differently babies with clefts behave and interact with people compared to grown-ups with clefts. Adults often do not make eye contact, look down, are very passive and do not make attempts to engage. It is as if they are ashamed to be present. Young children are not aware of how they look and still smile and laugh and engage and play, while their parents are the ones who bear their pain.

This slideshow requires JavaScript.

Chongy gave one of the medical in-service talks, “Changing faces with a smile”. He talked about his own childhood and how he came to do surgery and become involved with Mercy Ships. He moved from Malaysia with his Chinese Malaysian parents and sister when he was a little boy, and settled in to Perth in Australia during a time when there were very few Asians. He encountered some hostility just because he looked different to most other Australians, and struggled with how people thought they knew who he was just because of the way he looked. You can read more about his story here. He attributes those feelings and experiences to part of the reason he is so motivated and passionate about repairing clefts. And it is incredible! To be able to change someone’s life, and how they will be treated by and interact with the world for the rest of their lives in just one short operation is truly amazing. And to see the relief on parents’ faces too! It is like you have taken a huge weight off of their shoulders and instead replaced it with a shining cape of joy and rocket-booster shoes of hope. Here is a video of a little girl from Brazil, whom Chongy met in Brazil with Operation Smile:

It is amazing to see how he interacts with patients. While his French is pretty impressive for an Australian, a language barrier remains. Despite this, it is clear he connects with them on a different level. The stereotypical surgeon has a reputation for being task-focused with poor interpersonal skills. Yet the surgeons who come to the ship are like no others I have met before (except maybe KP and Mr Aleem from Jersey, and Dr Kumwenda from Zambia, who are all legends). It makes me want to do surgery! And Chongers is so much fun. He is the first doctor I have met who goofs around just as much, if not more, than I do! It might be because he is actually a super experienced and good surgeon and I am a lowly junior doctor, but I am impressed that he is still taken seriously! I have had comments over the years which suggest that I joke around a lot, don’t know where the line is or have “so much energy” (statements which can be interpreted differently depending on who said it). But he proves that you can be a really good doctor AND not take yourself too seriously! Maybe that is why I enjoy working here and in similar settings, because I feel like I can be myself at work. It is even encouraged! It is okay to look a fool, make silly faces, put on funny accents, be chased down the corridors and be piled on by a crowd of toddlers. It is a different style of professionalism!

Speaking of fun, I joined Chongers in the OR! It is pretty difficult as a physician to get time in theatre, but we had joked for a long time how awesome it would be if I could assist him in an operation! I could not believe it when, on his last day, we got the go-ahead for me to help with his last case, an atypical facial cleft revision. I was so excited! In retrospect, probably a little too excited. The night before, a group of us had been out for some drinks at the port bar (70 cents for a beer). Liz is an obs/gynae doctor from the UK and here as a full-time mum, but also helps in theatre when she can. She had been re-counting what it was like to operate with Chongers. With his fancy loops on, he enters “his hole” and goes silent and focused until he has finished doing whatever tricky cutting and sewing it is. I was feeling the pressure to be a good assistant and not mess up his delicate job of making someone a new face. I scrubbed in, stood next to the table, heart-pounding and face-grinning but trying to act cool, all ready to hold a bit of skin out of the way, when the familiar feeling of light-headedness came over me. I politely asked if I could “put my head down for a little bit…” and the next thing I remember, I awake feeling refreshed from a pleasant dream about driving a lorry, and am horizontal on the floor staring up into the face of a strange lady in a scrub cap leaning over me. I glance over towards the bright lights and recognise the two gowned figures of Chongy and Megsy (legendary scrub nurse). “Oh noooo it happened!” I was overcome with embarrassment, and overwhelmed by how much sweat had managed to exude from my body in such a short space of time. I even left a wet patch where my back had been on the floor, and that was through a scrub top and gown! They told me, between their fits of laughter, that I had hit the floor pretty heavily, my head making a wincing “thud!” when it made contact. Once my blood pressure had recovered (my dignity has no chance of ever recovering), I watched the rest of the operation unscrubbed and marveled at the mastery of repositioning bits of the face to make it normal-looking. Conversation oscillated between retelling the fainting story, each time focusing on a different detail, and other surgery-related things. We discussed various celebrities’ plastic surgery. I learned that black and Asian people have an equal ratio of volume between their upper and lower lips (i.e. the same size), but white people are more like one third on upper and two thirds in the lower lip. That’s why white people look silly when they overfill their upper lips. And the best way to tell someone’s age is by their eyelids. So, overall, along with learning not to go out the night before an operation nor be overexcited, a very educational session.

The great news is that Mercy Ships aims to do themselves out of a job. Over the last few years, two Guinean surgeons here in Conakry have been learning to do cleft surgery through the Medical Capacity Building mentoring program. When the ship was last in Guinea in 2012, there was a huge number of patients needing cleft repairs. In the last year, 323 cleft operations have been performed by these two surgeons, which meant that only six turned up to the big screening day in Conakry. There are still plenty of patients from the upcountry rural areas to keep our Mercy Ships surgeons busy!

Here is an artsy, emotive time-lapse video of repairing a cleft lip (it is not gory!):

Goitres

A goitre is a big swelling on the front of the neck due to an enlarged thyroid gland. It is rare to find them back home in the West because they would be picked up and treated before they had a chance to grow to any decent size. As you have probably guessed, for most of the rest of the world, this is not the case. These are the biggest goitres I have ever seen!! It is funny because, in medical school, we are taught how to perform an examination of a neck mass/goitre. Yet I have almost never used it back home because you just do not see them. But over here, testing for things like superior vena caval obstruction is actually relevant! (It is where you ask the patient to lift their arms above their head, and you see their veins bulge and face turn purple, because you are blocking the flow of blood back into the heart.)

Thyroid surgery is not a case of just slicing open the neck and removing the gland. Most of these patients are thyrotoxic; that is their body is producing dangerous levels of thyroxine. Thyroxine is an important hormone which is essential for life and regulates appetite, body temperature, heart rhythm, mood, and more besides. There are many reasons why these patients develop goitres. The most common worldwide is Grave’s disease, which is an autoimmune disease whereby the body attacks the thyroid gland and makes it produce too much hormone. These diseases predominantly affect women more than men, so goitre clinic becomes like a monthly Women’s Institute meeting. They become close friends and enjoy having a catch up with other women who understand what they are going through. There is something quite regal about a line of ladies gliding into clinic and parading with their large goitres (although sometimes they wear scarves to hide them).

So when the goitre surgical block finally comes around for three weeks in January/February, it is a big event! These patients have been coming to clinic every month since September to have blood tests, pregnancy tests, check up on symptoms and to have their medication adjusted. We try to give them anti-thyroid drugs to normalise their thyroid hormones pre-op. The prodding and poking can cause too much thyroid hormone to be dumped suddenly into the blood, which, in extreme cases, can be potentially life-threatening. It takes finely tuning the dose of medication each month according to their blood results. (That is where my role comes in to play!) It is a momentous occasion when it is finally time to enter the OR and say goodbye to this huge pendulous weight dangling from their necks.

In a similar way to the maxillary and mandibular tumours (read here), these patients are more likely to die from suffocation than any other cause. When they come in for assessment, as well as the usual questions about palpitations, voice changes and heat/cold intolerance, the screening nurses do the ‘5 minute lie-down’ test. They lie on their backs and see how long it takes before they start to feel breathless. Some women cannot even lie on their backs, and instead have to sleep on their side or upright. This is because the mass is so heavy that it exerts enough force to squash the windpipe. It must be a terrifying feeling. Sometimes the windpipe is pushed out to the side and takes a convoluted course to the lungs, and you can actually feel the rings of cartilage on the side of their neck, as opposed to front and centre. This makes it pretty tricky to intubate! AJ Collins is the main thyroid surgeon on board, and he gave one of the weekly medical in-service educational talks. He told of one patient whose adaptation to this breathing problem was to lie down on the ground on her side every 10 steps to catch her breath. She had a ‘positional trachea’, i.e. a windpipe that works only in certain positions. On another patient, they spent three hours trying to intubate through the mouth (the normal way) before giving up and trying a surgical airway (through the neck). The windpipe was just too small and wiggly. So they decided to cut open the front of the neck and go through the goitre to access the windpipe (cricoid thyroidotomy), which in this lady meant going 5cm through the goitre! It must have been a tense moment in that operating room. A lovely lady in this Field Service, with bulging eyes and a croaky voice, had her neck held permanently in extension, her face looking upwards, because her chin is physically pushed upwards by the mass. Her blood oxygen saturations were in the low 80s (normal >94%) after walking up the gangway, even stopping after every two steps! See the photo from screening below to see her sitting down in the queue. Another lady a few years ago arrived for her operation in a wheelchair, because her thyrotoxicosis from Grave’s disease caused her to have an irregular heart rhythm (atrial fibrillation), which meant she was unable to walk. It must have been an amazing sight to see her dancing off the ship on two feet!

On top of the physical weight and inconvenience of having a giant lump hanging off your neck, it comes with psychological stigma. Some husbands divorce their wives. In Congo in 2014, Maman Claire was a little old lady about 4 foot tall with a ginormous goitre. She had had six children, two of whom had died and three of whom had disowned her because they thought she was cursed and would bring bad luck on their family. The good news is that she had one other daughter who was able to help bring her to Mercy Ships to receive help.

It is amazing to see the change in these women before and after their operations. They are literally dancing out! On one morning, I was with a patient down in the rehab tent on the dock, where all the physiotherapy happens, and the door burst open and in walked three women who wanted to show off their new necks, and high five and dance with everyone. They did not seem to mind that they had never entered, or had any reason to enter, the rehab tent up until this day, but seemed happy for yet another willing crowd to join in their celebrations! If these ladies appear regal before their operation, the way they waltz around afterwards, with a huge smile across their face and bright eyes — they are truly majestic!

Apologies for ending on a sad note, but I cannot help but think about all those patients with goitres who were unable even to be screened for an operation. There are only enough spots in the surgical schedule for a small number of goitre surgeries, so once they are filled, the screening team must turn away anyone further. On the big screening day in Conakry in September, where 6000 people arrived to be seen at the People’s Palace (read more here – scroll down to Screening section), there will have been people with goitres whom had to be told that there were no more spaces. And those who were at the back of the crowds might have been there because it was just too tough for them to fight their way to the front because they were too breathless or weak.

Plastics will have to wait…

I had intended to include all the amazing stuff with the plastics and reconstructive surgery in this update, but alas I think this one is already too long! So it will have to wait until my next post…

I have been trying to write about time off for a while. But every time I nearly finish a post, the weekend happens again and there is more to add! So here is a summary of some weekend fun… It is a long one but comes with lots of pictures!

Finding rest

At the weekends, I try and escape the ship even for short trip. I thought I would feel more claustrophobic living here, but my only bout of serious cabin fever struck me during my 48-hour isolation for diarrhoea and vomiting. It is surprising how easy it is to live on the ship in terms of facilities and social activities. I sometimes feel like it is living in Legoland, or one of those fake villages they have made inside Dutch nursing homes to help patients with dementia feel like they are getting around town. There is a cafe where people congregate, bump into each other, a TV area you can watch sports on (Six Nations!), and a library. It usually takes a long time to get anywhere on the ship, because there are lots of people to chat to on the way.

Maybe it is more like a summer camp. Life on board is pretty intense and bubble-like when you live and work together, and things happen at a fairly fast pace. There are people to hang out with or things to do at any moment of the day. There are amazing things about living on the ship together, but there are also challenges. An example of the difficult times are days when you are not having a good day and have had conflict with someone. Knowing that you will see them around the ship — in the laundry room or in the canteen or even wandering in PJs at bedtime — provides a large incentive to ensure you make up and straighten out any communication issues! I heard one person respond to the question, “What is the best thing about Mercy Ships?” with “The community!” And to the question, “What is the most challenging thing about Mercy Ships?”, again they answered, “The community!” Sometimes it is hard to get fresh perspective on things when you are inside the bubble.

Therefore a trip off ship into town or to an island is usually a welcome break! Sometimes it is a difficult choice: I want to escape the ship and be refreshed, but going outside or into town is often dirty, dusty, smelly and polluted and sometimes more exhausting. Despite Conakry being on the coast, we cannot swim at the local beaches because they are mainly clogged with plastic and rubbish. I am trying to find little corners of quiet on the ship for some downtime.

Ship Holiday weekend

This weekend is a ship holiday. Every six weeks there is a ‘three day weekend’ where the Operating Room and the dockside tents are closed to give people extended rest. Some people use the time to escape Conakry altogether and explore up country. I have stayed on the ship this time, but it has been a great weekend anyway.

On Friday a group of us took a boat to Kassa island (one of the three nearby islands), and enjoyed playing Spikeball with beers on the beach. It was a bargain day trip: $4 for a return boat ride, 60 cents for the tourist tax and $1.50 for a beer! Kassa Kounki is a little bar with friendly staff and sun loungers and hammocks. The beach is not as idyllic as it may sound, because the water is full of plastic and general waste. It is a sad sight to see, and makes me want to give up plastic forever!

This slideshow requires JavaScript.

On Friday evening, back on board, a good friend April hosted a karaoke evening up on top deck for her leaving party, which showcased some of the excellent talent among the crew. Move over, Spice Girls!

Yesterday, a nurse friend from Australia, Kelly, hosted a brunch in the Queen’s lounge with homemade granola! All four flavours were delicious – raspberry, apple & cinnamon, peanut butter and candied nuts – and topped with fresh pineapple, mango and banana. A very wholesome start to a Saturday.

In the afternoon, Vivien (Screening team nurse), Ash (Head of Ponsetti clinic) and I made the big trip out to Madina market. It is one of the largest markets in West Africa and I can believe it! It is the kind of place you need to be in the right head space for. It is heaving with people, stalls, kids, dogs, beeping cars, motorbikes weaving through narrow passageways, women carrying anything from sacks of grain to stacked handcrafted wooden stools on their heads, and babies on their backs, people washing their feet and selling individual bags of water in buckets of ice (single use plastic!!). We were on the hunt for fabric, and weeks ago Viv had been to a building with stall after stall of colourful fabric. Finding the same building again was going to be tricky! We asked various sellers of fabric, but we got the classic African response of not wanting to say they did not know, but told us to carry straight on and ask someone at the corner. We eventually found a nice man who spoke English and was kind enough to lead us around. He took us to one building, up concrete stairs with abandoned corridors and the occasional sleeping body, and busy tailors on the second story balcony. Sadly it was not the one we were looking for, but it was a great opportunity to take photos of the street from above. Most people do not like their photograph being taken, hence I have very few from out and about in Guinea. As we were descending the stairs feeling a little disappointed, we spotted rows of fabric stalls through a hole in the concrete wall and wound our way through to the adjacent building. We had made it! It was worth the convoluted treasure hunt. All the fabric was wholesale price ($2.50 for two yards), so no need to haggle, and the ladies let you peruse in peace. It is still pretty noisy with the constant background hum of whirring sewing machines overhead. Once we had explored every nook and cranny, we climbed the concrete steps up to the second story.  There was a sea of men and a few women hard at work, sweat running down their faces, necks craned, with mounds of textiles piled next to their treadle sewing machines. It was oppressively hot and humid beneath the corrugated metal roof with little air circulation, and dusty from the fabric fibres, the cobwebs dangling from the rafters and occasional birds flying overhead. I have a pathological obsession with fabric. While away, it has replaced my pathological obsession with purchasing greeting cards and post cards. I had promised myself I would not purchase any more African fabric, having filled my suitcase to the brim with fabric from Zambia last year, yet there were a couple which caught my eye and evaded my self-restraint. I was actually on the hunt for some of the local Guinean fabric, which is of course unique and therefore does not have a purchase limit. My favourite are the ones from the forest region, which are essentially brown bed sheets, sometimes even with the buttonholes and buttons still attached, with stamped patterns in black. Traditional local textiles are harder to find and are considerably more expensive, but I managed to find a lovely Mama who gave me a good price as well as a photo! I have had one tunic-dress made by the ship tailor who comes on board every Thursday evening, and intend to make some dungarees. Our exit from the market was fairly uneventful, once we had declined some taxis who offered to take us for four times the going rate. I felt slightly sorry for the driver we did go with, who picked us up at a busy roundabout, where cars are not supposed to stop. Police officers let out the air in your tyres if you pause for too long. The rear tyre of our taxi took his punishment, but a short shout exchange while driving past a tyre/garage en route home reassured our driver he could travel on safely. Always grateful to arrive home with all my personal items still in my possession, I was ready for air conditioning, a shower and a proper scrubbing of feet! Oh how soft I have become…!

First weekend

Going back to my first weekend, I went to visit one of the orphanages with which Mercy Ministries partners. We did some crafts, cuddled babies (cringe), and sang some songs. All fun, but by far my favourite part was the ball games and girls versus boys competitions at the end. We nailed ’em!

A taste of Guinea food

A few weekends ago, April (physio from Aus), Trancy (hand therapist also from Aus) and I went on the hunt for some Guinean food. One of the day crew from admissions called TBD (his initials and also his nickname, not that he cannot decide what his name is) took us to a local restaurant which felt like miles outside of central Conakry. It was delightful! It was quiet and right next to the sea, and even had a little hammock. We tasted tori (dumplings made from cassava in sauce), fogne (a kind of white couscous also from cassava), ketoun (stew) and dappa (mush made from maize). I am grateful for the opportunity to taste local food, especially not having tried much West African cuisine, but I don’t think I could live on it!

Coyah

Last weekend, four of us escaped the city centre and travelled to Coyah which is one to two hours outside the hub-bub. It was great to be somewhere surrounded by trees and a river, and walk on woodland floor. We stayed at an environmental NGO eco lodge in a little round house and moved our mattresses into one room to enjoy a girly sleepover. It was strange not having the constant white noise of air conditioning and pipes, and sleeping in humidity with the occasional mosquito. But at least the mattresses sagged in the middle and cuddled you like the ones on the ship. On the Saturday afternoon we went for a little hike in the surrounding hills, and bathed in the fresh stream on the Sunday morning. Delightful!

This slideshow requires JavaScript.

Swim club

My new favourite weekend activity is Sunday morning swim club! We also meet on Thursday after work, which is a little rushed as we have to make it back to the ship in time for the community meeting at 7.30pm. On Sundays there is time to read and have proper coffee. Swim club is pretty exclusive and you have to be invited. My fundraising challenge bought me an invite. We go to a local hotel, which lets Mercy Shippers use the pool for free. It is an impressive 25 metres, and fills up with families during the day at weekends, but at 8am on a Sunday it is deserted and idyllic. Thursday sessions are slightly more crowded, more so around the pool than in it. With each breath, you get the sound of Rihanna’s greatest hits blaring from the restaurant speakers and a lung-full of shisha from the crowds of men lounging on the sofas.

Church

As for church services, I am putting off experiencing a local church for as long as possible (!). I feel I have had a fair share of 5-hour church services in Kenya and Uganda during my year out before university. That said, I have been along to the Hope Centre church. The Hope Centre is a building where patients from upcountry, who do not have family in Conakry, can stay before their operation during screening and afterwards for rehab. Some orthopaedic and plastics patients can be there for months, as they require almost daily rehab visits to the dockside tents, or two planned operations during the field service. They host a service every Sunday morning for the patients which is also open to Mercy Ships crew. It is very convenient because it is a 15 minute walk away, lasts strictly an hour, and it is translated into English! It is actually translated from French into three different languages, so there are four translators roaming between the congregation and you have to tune in to your channel. It is a very happy service and great to see the kids whom you have seen or looked after on the wards. Lots of them become close friends and it is great to see mamas of babies with facial clefts who bond and realise they have experienced the same pain and stigma.

There is also a service on Sunday evenings on the ship with worship and a talk by one of the chaplains, with quite a chilled vibe. Afterwards, the Brits crowd into the Clear family cabin for tea and biscuits, to chat about the weather, the perils of Brexit and to delight in hearing people pronounce things correctly.

Miscellaneous fun (the best kind)

There are many more fun things to do on the ship. We celebrated Chinese New Year with a dumpling cookery class by some Chinese-Australian/Americans on board. There was a Valentine’s Soiree last week with quizzes, competitions between the married couples and some “impromtu” (read: thoroughly rehearsed) cheesy singing. I made it to frisbee one Friday evening and was astounded by the speed and agility of some of the kids! The Six Nations are shaping up to be a great weekend highlight, and brings together the predominantly English crowd with a few Aussies and Saffas thrown in. On Monday evenings I have joined a book club working through “Muslims, Christians and Jesus”, which is pretty relevant as Guinea is 98% Muslim.

Frisbee Friday

So there you go. Hopefully interesting to know what I have been up to outside of the hospital. This coming Friday all the British crew have been invited to have drinks at the British Embassy, which should be fun! I will report back…

For two weeks in January, a good family friend was on board! John met my mum at Medical School in Sheffield and became great friends and housemates with my dad. He is actually American (despite having represented Great Britain in basketball), grew up in LA, raised by English parents, came to university in the UK, then went back to LA for residency, and now lives in Seattle with his wife and grown-up kids. He is an ENT surgeon (ear, nose and throat) and has been volunteering with Mercy Ships for many years. In fact, he is also bezzie mates with Dr Gary who has been living and volunteering with Mercy Ships for 32 years! Dr Gary is a Mercy Ships legend. More on him later…

It has been an absolute joy to have John around. While I don’t (or didn’t!) know him that well, he was kind enough to host my friend Gemma and me when we were travelling across Canada and we popped down into Seattle for a few days. I have also enjoyed many a Christmas letter and the odd snippet of Rowland news via my parents. He climbed Kilimanjaro last year, so I knew he was a bit of a legend! He has been enormously generous in supporting me with my crew fees, for which I am super grateful and it was great to be on board together. (He may have even arranged it, that’s how much of a big deal he is).

I was hoping for some juicy stories from my parents’ time at university, like my mum riding around in shopping trolleys while high on drugs or my dad getting a tattoo on his buttocks, but sadly none of those came to light. Instead, I heard about that time my dad covered John’s entire bedroom with newspaper, how they had snuck in a piano to surprise their other housemate and how he used to tell ironic Winnie-the-Pooh stories at parties. It was great to hear a different perspective on my parents from someone who knew them as a friend and way back when. It was inspiring to hear what a steadfast, caring and fun friend my dad was, and what a dedicated and hardworking medical student my mum was!

At the weekend, we managed to escape the ship and head to a nearby island for a cycling experience that will be hard to forget. We hired a local guide Keita who gathered bikes from all corners of Conakry and loaded them onto the boat. The Ship’s Captain had warned the crew about local boat safety: at New Year’s, a local ferry boat had been overloaded and ran into trouble with two people dying. Needless to say, health and safety is pretty relaxed/non-existent. The island is called Tamara or Futoba which means the white father or priest, in reference to its Anglican church. It was formally a temporary landing spot for slaves from the continent to be brought before being moved on to the colonies. As a consequence, the resident islanders do not know their original ancestry. We unloaded the bikes and had to carry them up the gazillions of rubbley stone stairs to the starting point of our adventure. The bikes were of varying quality, brakes and gears not guaranteed, and included town bikes with baskets, miniature children’s mountain bikes, a couple of ropey road bikes, and, my personal favourite, a special monster fat tyre bike. There were not quite enough bikes for everyone, so the remainder rode in the back of the quad bike trailer and one crazy person decided to run. We were promised it would be 10 kilometres to our end point at the other end of the island. The tracks were mainly sandy rock and were the main highway used by islanders on motorbikes and on foot, weaving through little villages. We arrived at the bottom of the lighthouse, and were told we must carry our bikes the rest of the way because the incline and rocks were not passable ‘par velo’. This was probably the most arduous section of the day. It was only when we were a few metres from the top, panting, dripping in sweat and near-collapse, where we asked whether we could just leave the bikes by a tree and collect them on the way down. A nonchalant nod from Keita signalled the end of our pain. We admired the view, snacked on a leftover egg from breakfast (we were told lunch was included but timings were clearly very flexible), and posed for some great photos. The journey back was slightly easier (at least we knew what we were in for), and included a quick detour via a beach with very red sand. We had lost Tracey by that time, so our seaside frolicking was curtailed by breaking out into search and rescue mode. Thankfully we found her under a tree laughing and chatting with the locals, back at the start of the turn-off to the beach. She denied sampling their palm wine… We re-traced our steps (or tyre tracks) back to the church near the main village, and stopped for a delightful lunch with a beautiful view. It was just like the meals I had eaten twice a day for the whole of Madagascar! I was secretly proud of myself for how developed my skills of deboning a fish had become. The boat journey home was pretty relaxed, all a sleepy from our day’s exertion, and we saw dolphins riding alongside the boat!

This slideshow requires JavaScript.

During the week, John managed to wangle me time in the OR (or “theatre” for the UK peeps)! It is pretty hard for physicians (Alex, Mark and I) to make it into theatre, as the staff are very strict on numbers for infection purposes and because the room is very small. There is no separate anaesthetic room. Medical Capacity Building (MCB) forms a large part of Mercy Ships’ work, and involves training up and equipping local surgeons and centres to perform operations. One part of that is having local surgeons and anaesthetists (and a translator for each) come to assist or watch in our theatres. It is understandable that the room fills up quickly!

The list that day included a young boy with a dermoid cyst on the back of his head (a type of growth which can have teeth and hair inside – similar to what Aunt Voula describes in My Big Fat Greek Wedding), a lipoma on the back of a man’s head, and a giant submandibular gland mass which genuinely looked like a pert breast hanging from his chin (there was a scar in the centre which looked like an areola). The little boy had a haemoglobin of 6.7 g/dL, which had not responded to parasite treatment and ordinarily would have precluded surgery. Here you go with it! I loved it! John was great at pointing out anatomy and surgical techniques, and I became very familiar with retracting using a cat’s paw, an army-navy and skin hooks (delightful name), and even sutured a little! I got into trouble only a couple of times, once for disposing of my gown incorrectly, as well as a gentle reminder from the friendly anaesthetist to stop leaning on the breathing tube. Apparently, in previous countries, the used gowns and bloodied gloves have been found, washed and repackaged, in local markets. So now we rip the gowns in half and anything bloody is incinerated. 

Every Wednesday there is an informal lecture about a medical topic given by one of the surgeons, and it is open to all crew. So far they have been inspiring and super informative! It is mind-blowing what can be achieved through surgery. The second ‘in service’ during John’s time was given by his mate Dr Gary Parker. He and John go way back, having first met at UCLA hospital for residency, and only then discovered that they had been to the same primary school one year apart and even attended the same judo class! Dr Gary is a maxillofacial surgeon who first came to the ship in 1986 and has been here ever since. He met his wife on board and has two children.

His talk this time was on maxillary tumours (growths that arise from the cheekbones/upper jaw), which can get so big it is like having another head on your face. He opened with a quote from Napoleon: “A man becomes the creature of his uniform.” If someone has a huge tumour growing on their face, they become marginalised, they don’t fit into society, and they are denied a place at the table of the human race. People think they are cursed, or have committed something evil, are scared of them, or afraid that if they touch them they will ‘catch’ whatever it is. The surgery can remove the tumour, correct the deformity and give them a normal-ish face again (which is incredible in itself). But the transformation has to happen on the inside too. Patients are given their own mirrors in their Mercy Ships goody bags, which is a small part in re-introducing them and inviting them to have a seat at the table. When they look into the mirror, something is changing in their brain. As Napoleon alluded to, just as a French peasant can put on a military uniform and believe he is capable of being a soldier, so changing the uniform or face of someone allows them to believe they can be welcomed back in to normal life. Even before the operation, just by looking into someone’s (good) eye and shaking their hand, talking to their eyes and not focusing on their deformity, tells them that we know they are in there. And thus the transformation can begin even long before they arrive in the OR. Generally, the older a person is, the longer this transformation takes. One elderly gentlemen had lived his whole life with a cleft lip, where it looked like the front portion of his face was bursting open. On one ward round he was curled up in bed on his side crying, and the translator explained “because he is so happy”. The strange thing was that he looked genuinely sad. They did not look like tears of joy, but perhaps he was finally allowing himself to release years’ worth of pain.

Above: the goody bags given to every patient, donated by Johnson & Johnson, which contain towels, soap, toothpaste, a mirror and other items

He went on to explain the difference between benign (non-cancerous) and malignant (cancerous) tumours in Africa compared to the West. It is a strange world to live in where it is better for your tumour to be malignant than benign: you will die from both of them, but at least with malignant ones it is relatively quick, but benign tumours mean a slow death. Benign is only good news if you have access to care. People with maxillary tumours (upper jaw) generally die from starvation, and with mandibular tumours (lower jaw) they die from suffocation. They will also have severe anaemia from chronic bleeding into the tumour. But a lot of benign tumours are caused by fibrous dysplasia, which grows in response to growth hormone. So, provided the surgery is performed after 21 years of age, roughly when growth hormone levels drop, the tumour should not re-grow.

He led us through the complex process of removing a maxillary tumour, complete with gory photos and a prop of a trachea with Bjork flap (hole in your neck to put a tube into). These operations present huge challenges. First they need awake fibreoptic intubation because accessing their windpipe is almost impossible, and the tube must be sutured into place in several places. Even tracheostomy (tube into the front of the neck) is sometimes impossible because the tumour is so big it covers and compresses the neck. They open up the face using incisions which will later be hidden within normal skin folds, try to find some normal bone amongst this huge tumour with distorted anatomy, cut out the abnormal stuff, avoiding getting involved in the skull base and carotids, and gently roll the tumour away taking only small pieces of good bone. He showed us one example of a tumour in a boy (whose Hb was 4g/dL), which was extending all the way into the naso and oro-pharynx, and even attached to the optic nerve. Because the maxilla is a bone which helps separate your facial features, when they take out the tumour, it leaves the mouth, nose and eye open and connected to each other. Pretty hard to talk or eat… So they take a piece of bone from the skull to graft a small cheekbone and take a muscle flap from the temporalis muscle (across scalp) and fold it down to become the floor of the eye, the wall of the nose and the roof of the mouth. The body is so incredible! The skin is left saggy because it has a memory and will eventually shrink back (see above photos). The muscle on the roof of the mouth, which is made from muscle, will slowly grow mucosa over it.

Mercy from November in Guinea

On the ward

At home again

These surgeries take hours and look super complex. In the West, most of these tumours would be cut out when they are the size of a pea, but here they grow to be up to 6kg. The great thing is that Gary has trained local surgeons to do these operations who are now doing them here in Guinea, as well as Togo, Cameroon and the DRC.

Gary is super passionate about giving people hope. People who are living in poverty need hope in order to overcome poverty. But for hope to be credible in the future, it needs to be tangible in the present. He explains:

I see people who seem to just sit and wait and don’t take the action needed to create a better tomorrow. And there’s actually a reason for this. They’re not lazy. They’re not unintelligent. They have all those things … but they lack hope. You could enter a poor village and say, “Let’s work together and see if we can get your water systems sorted out, and get a better school for you and a better hospital. We can do all these things, and tomorrow will be better!”

And the villagers would look back with those sad and apathetic eyes and basically say, “What in our life experience gives us any reason to believe that you’re telling us the truth. We have never been helped. We have struggled. We haven’t been able to get anything that will ease our suffering.”

But when people come to the Mercy Ship, they see the impossible happen. Hope is born! For hope to be credible (believable) in the future, it must be tangible (experienced) in the present.

Well, that was quite the emotional finish! Back to some lighthearted fun. John’s final night was celebrated by a meal at a fancy restaurant in town with a handful of the OR team and some friends. It was super fun!

Next to a photo of Zakael whose tumour he removed!

Saying goodbye on the dock

I really love my job here! “Hospital physician” is not a name we are familiar with in the UK, but it could be compared to “medical doctor” or “senior house officer”. There is another hospital physician called Mark, who is English but has lived and worked in Australia as a consultant in a private ED for the past 16 years and is in his early sixties. Alex is the “crew physician”, the head of physicians and is the ship’s GP for the crew and day crew. As such, he is less involved with the patients coming for surgery, but comes along on morning ward rounds and is on the on call rota. There is a mish-mash of cultures here: in America doctors are referred to as Dr Surname, but mostly in the UK and Australia it is First Name only. As a compromise, we are called Dr Mark, Dr Laura and Dr Alex. Dream. Team.

What I particularly enjoy is that I float between all areas of the hospital system. I meet patients at all stages of their journey and witness the roller coaster of emotions: the anticipation of the screening process, where they are worked up for surgery (mostly nurse-led), the apprehension of admission day, doing the final checks and preparations for the big day, and during the hungry times of “nil per oral” on the morning of surgery. And then after the operation, seeing them return to the ward a little drowsy and tired, the day when they take off the bandages and look in the mirror after their face has totally changed or take off the eye patches after cataract surgery. Once they are discharged, I may see them again in outpatients to review a wound or a complication post procedure, or if they present with a fever or scabies or cough, or if the physiotherapists have a concern in rehab. And the patients range from a few weeks old to the doddery elderly, which I love. 

Not only is my job great because I see patients’ journeys, but I get to make friends with the huge numbers of staff and day crew who work in each of those departments! While I don’t belong to a “team” as such, I love that I interact and work with so many different people each day, pop in and out of the tents and wards, and feel a small part of each team. The day crew are an asset, and Mercy Ships would not be able to do what they do without them. There are approximately 250 day crew: locals who are employed and paid by Mercy Ships to work in various departments, but who do not live on the ship. In the hospital, their role is mainly translating, and have been trained to do things like basic observations. The official language in Guinea is French, but there are six other national languages, and a heap more regional languages. I am enjoying practising a little French, and like the accent here. My favourite so far is Krio, which is a kind of pigeon English. I had to stop myself laughing when I first heard it while clerking a new admission. “Are you married?” became, “You gat wife?”, and “Any loose teeth?” was translated, “Ida teeth dat shake?”

Fridays is funky scrubs day!

The wards are great! It is similar to a ward back home, except caregivers sleep under the patient beds on a mattress with linen (unlike the cardboard of bedsiders in Zambia!), there is air-conditioning, the beds are closer together, worship music on YouTube is often being played, and balloons, crafts and games are in abundance! Being on deck 3, there are no windows but, for those patients who are fairly well, there is the opportunity to go outside to deck 7 for an hour in the afternoons to sit and watch the sea or play with some toys. Caregivers sometimes escape the wards to pray on mats (salat) under the stairs. As for the language of the wards, I am slowly learning American: theatre = the OR, QDS = QID, naught = zero, observations = vitals, and my personal favourite MRSA = Mursa (just like our beloved ‘Murca)! Some units are different too, like blood sugar is measured in mg/dL rather than mmol/L.

Mercy Ships has a very organised schedule of surgeries. They are very specific about which surgeries that they can offer. This is mainly based on which surgeons are available during the field service, and most of them are returners who come every field service. The ideal operation is one that is a once-off treatment that will not require much follow-up afterwards. And there are plenty to choose from! Before Christmas, there was a long block of orthopaedics, where they straightened lots of children’s legs who had windswept or bowed legs like this. In the last four weeks, while I have been here, we have had ophthalmic, maxillofacial, ENT, craniofacial and general surgeries. Think of cataracts, facial tumours, cleft lips and palates, congenital deformities, lumps on the head and neck, lipomas and hernias. In the last week we have had the first lot of plastic surgeries, which include things like burn contractures, where the scar tissue from a burn has caused a deformity like this. These patients will be on the ward for a long time while skin grafts heal.

Craniofacial surgery

There is an incredible craniofacial team on board at the moment. They have just finished two weeks of surgeries for things like encephalocoeles. They are a type of congenital neural tube defect due to lack of folic acid while the embryo is forming in the first few weeks (usually before someone even knows they are pregnant). The brain protrudes through a permanent hole in the skull and looks like a lump on the head with normal skin over the top. The danger is that there is no protective barrier between skin and brain, so if they get a simple cut or skin infection, bacteria could easily spread to the brain and cause serious, potentially fatal, infection. So while they may not die from having a hole in their head per se, the consequences could be deadly. One of the ‘medical in-services’ was a talk by paediatric neurosurgeon Dr Shailendra (affectionately known as ‘Shels’). His normal job is at John Radcliffe Hospital in Oxford, and spends three weeks a year here as one third of the craniofacial team. In his lecture, he used the analogy of the brain being sausage meat, the three protective coverings on the brain are the sausage casing (pia mater), the clingfilm it is wrapped in (arachnoid mater), and the sandwich bag (dura mater). All of which is stored inside a hard lunchbox (the skull). He showed some gory photos of faces being pulled down, just like a scene from Mrs Doubtfire, and explained how he cuts out a bit of brain and sews the layers back up. In the videos you could see the brain pulsating. The rest of the craniofacial team, Dr Gary the maxillofacial surgeon and Dr David the plastics surgeon, get involved when they take some bone from the orbits (eye sockets) to make a new bridge of nose, so that there is no longer a gap in the skull. The patients end up with the coolest scars, a zig-zag across their skull from ear to ear and the tiniest little line across their nose. Two patients currently on the ward had pretty much identical encephalocoeles in between their eyes and have matching scars. We joke that they are brothers, and the older one enjoys teasing the younger one, opening the dividing curtain in the middle of the night and shouting his name.

Giving sight to the blind

There has been two weeks of paediatric ophthalmology, where they remove cataracts in little ones. Some of them have been born with them and some of them develop in early years. One of my favourite patients was a six year old girl who was also deaf and mute. I will do a separate post about her. I wish I could post pictures, but Mercy Ships have a strict policy on photography. Only official photographers may take photos of patients to ensure patient privacy and dignity. Seeing kids have their eye patches taken off the day after their surgery is nothing short of a little taste of heaven on earth. Each day, the numbers on ward rounds grew as people wanted to come and witness that special, holy moment.

Admissions

Admissions is a fun place to meet the patients the day before their operation. It is one room with a few tables for nurses to go through their questionnaire and an examination cubicle where we physicians can examine them. Everyone who is having an operation has to pass through there and it is the final step before they go onto the ward. Most patients will have waited months for this day! They have passed through many screening processes and overcome many hurdles to be here. Some of them are super excited, some are a little nervous and quiet, and some seem like they do not want to believe it is real, in case last minute we say we cannot perform the operation. Among the toddlers, reactions vary from laughing at everything to being terrified of the white people. Each child is given a teddy bear to keep, which are lovingly knitted by the Women’s Institute back home! For many people who come from small rural villages, coming onto the ship and down into the hospital would be like stepping into Pandora in Avatar. There are stairs, lino floors, solid walls, plastic everywhere, bright lights, instruments and strange things dangling from the ceiling and wall, oxygen pipes, suction containers. It makes me think back to some adult patients in Zambia who were afraid of sleeping on a bed, never having done so, in case they fell out.

While there is usually some time pressure to get through the patients in a timely fashion, there is a chance to hear a little about their condition and life back home. One man was having a large keloid scar removed, which was growing out of the side of his face like a giant horn. I asked him how many children he had and he had to count them up from each wife – 32 in total between three wives! One mother brought in her little baby who was born with a nasal deformity, which looked like there was a little flower-shaped growth in the middle of her face. The mama started crying when she explained that, when she had left the village to go and be screened by Mercy Ships, by the time she had arrived home, the father had already left and married another woman. One 14 year old girl, who sustained horrendous burn injuries to her arms when she was younger, could not read or write, and had never attended school because her family did not have the means to pay for it. Her mother felt angry that she had not been to school. There were tears in her eyes and she was looking into her lap. I imagine the shame the girl must carry with her everyday, as she hides her hands behind her long, billowing head scarf. In addition to her daughter’s burden, I imagine the guilt and pain her mother has carried since the event. I feebly tried to encourage them that what happened is no one’s fault, and that her mother had brought her up as a lovely, kind girl. When it was translated, the girl burst out laughing! She replied that she does not think she is beautiful but if I say she is beautiful, then she is happy.

Tent life 

Mark and I alternate roles each day: one person is based in admissions on the ship, while the other person is working on the dock covering ‘the tents’. There are three tents: screening, outpatients and rehab. Each day many patients arrive at the gates and wait under the shelter for their scheduled appointment in one of these tents. Patients are given bread and butter and water for lunch, since a number of them wait around for hours. Children can play with the little bikes and toys on the wooden platforms. It is very organised! Patients are even given a time to arrive and are seen in blocks e.g. 8am, 10am, 1pm, 3pm. It is very different from Zambia where you would give someone a clinic date in one month’s time, with no specified time, and they would sometimes arrive a few days afterwards, and would queue from early hours of the morning and be seen in order of arrival.

The gangway is the only way on to and off the ship, and its incline varies depending on the tide. It is good exercise at high tide when the steps are steep! I much prefer covering the tents than being in admissions, mainly because I can escape outside for some sunshine, rather than staying in a windowless room. But it is always so hot and humid! You instantly start sweating when you leave the cool, dry air conditioned reception. The friendly Gurkhas (my favourite is Min but shhh) supervise the scanning in and out with ID cards. Thankfully the tents are air conditioned too. Inside they look and feel a little like a military field hospital.

Outpatients tent

The things I am called about are varied indeed. Often in ‘outpatients’ (patients who have had their surgery) it is to review wounds or post-op swelling or pain, prescribe malaria medication, follow up on pathology reports (e.g. breaking bad news of cancer tissue diagnosis) or review a patient with a fever.

On one occasion, I was asked to see a tiny seven week old baby with a fever. She was the little sister of an orthopaedic patient being seen for wound dressings. I had actually seen the same baby two days prior but she had seemed well. This time, she was acutely unwell and thought could probably die without intervention. She was struggling to breathe with signs of respiratory distress, as well as a super high temperature. In the UK, this baby would be sent straight to A&E for immediate assessment. We discussed it among the team and some bosses, and sadly we could not offer help on the ship. It is a long and complicated system, developed over many years; we sometimes give out medicine for caregivers, but we cannot admit anyone who is not a patient. We tried to stress that Mama needed to take the baby to the local hospital straight away, but we feared that she might not have enough money. It was so hard to break the news that her tiny baby was really sick, and I felt very fragile afterwards. I was worried that Mama would try to get the baby through one more day before seeking help, or it would take too long to find enough money to go to hospital, or that she did not realise the severity of the situation. I questioned my decision making from two days earlier, whether, had I done something sooner, the baby would not have got into this state. It sounds like a copout, and I understand that for someone without faith, it seems pathetic, but all I could do at that point was pray and ask God to jump in (not that he was not already fully in). I had visions of the boy, the baby’s older brother who was an orthopaedic patient, returning for his next appointment with his Mama but no sister. I felt guilty and on edge. So it came as a huge surprise and relief when, two days later, at their next appointment, I received a phone call from outpatients tent to say all three were back and the baby was much better! Apparently they did go to hospital and were given medicine, but not even admitted. Phew!

Screening tent

In ‘screening’, the problems are more diverse, since they are seeing patients before their operations. Things include reviewing rashes (generally either ringworm or scabies), coughs, conjunctivitis, chest pains, abnormal ECGs and blood test results (anaemia is very common), performing physician reviews for craniofacial babies, prescribing medication for high blood pressure and hyperthyroidism, performing gynae examinations, and reviewing new diagnoses of HIV. The idea of screening is to find and solve any problems which may prevent or delay surgery, optimise patients ready for surgery, and identify patients who are not medically fit for surgery. One example is HIV. HIV positive patients must have been on antiretroviral medications (anti-HIV meds) for at least three months and have a CD4 count (immune cell) of greater than 500. This is because the risk of post-op complications is so high in patients who are immunocompromised. In screening the other day, the HIV test of a four month old baby came back as positive. This means that the mother is HIV positive and the baby has been exposed, but is not necessarily infected. Sadly we had to say no to the baby and referred them for HIV treatment at a local centre.

I enjoy the screening tent for a few reasons. First, it is staffed by extremely competent and efficient nurses who are super fun. Second, the patients are so varied: from tiny babies to elderly, and each age group or surgical problem presents different challenges and considerations. Third, there is a general buzz of anticipation around it. Everybody is hoping desperately to pass through to the next stage of the process, one step closer to having their operation. And it is a long process!

The patient’s journey begins even before the ship arrives in a destination. Mercy Ships advance teams travel months, even a year, before the arrival date to do a needs assessment and advertise across the entire country. They work with mobile phone networks to get the word out, write to clinics and medical facilities, use pictorial posters, all the while working closely with the host government. It clearly works because the ‘field screening’ days are absolutely rammed with people! On one day in Conakry, over 6000 people queued up outside the People’s Palace to be seen by the screening nurses from 6am until 8pm. While the photos make it look like an orderly line, this was only after people were let through the gate from the main road into the venue. Some of the nurses have told me heartbreaking stories of finding people trampled and injured amongst the crowds, so desperate to be seen. There were four other ‘field screenings’ which took place ‘up country’ further inland at four large cities. The days were even longer — from 4am until midnight! At this initial screening, 90 per cent of people are turned down. Most of the time it is because the condition is not surgical, but it could be a long-term medical problem like diabetes or epilepsy. Sometimes people come with lumps and bumps, but on questioning and examining it is very likely cancer, and generally we only operate on benign tumours.

People lined up outside the Palais du Peuple to be seen by one of the screening nurses at mass screening.

People lined up outside the Palais du Peuple to be seen by one of the screening nurses at mass screening.

People lined up outside the Palais du Peuple to be seen by one of the screening nurses at mass screening.

After they have made it through field screening (10% of people who show up), they are invited to an assessment day, usually very soon afterwards, where a more detailed history and some basic observations taken. This is to gather more details about the patient and identify possible barriers to surgery. Once they have made it through that, they are invited to ‘nursing diagnostics’ which happens in Conakry on the dock in the screening tent. At this appointment, a full assessment is performed and a full blood count and HIV tests are run. Sometimes I am asked to prescribe medication for blood pressure at this stage. Generally, the aim is to flag any potential problems, but we cannot treat them until they are actually given the go ahead for surgery. The ultimate decision is made by the surgeon on ‘surgeon screening’ day which is yet another appointment in the screening tent on the dock. This is usually very hectic! Generally, surgeons arrive on a weekend, screen all their patients whom they will operate on for the next two weeks on the Monday, then spend the rest of their time operating. Each of these processes has to be timed in line with when different surgeons are around. You can see why everything has to be planned to a T months in advance!

So that’s why I love my job!

It feels great to be “working” and using my brain again after not really doing so in Madagascar. I absolutely love this kind of medicine. Seeing the surgery here, and the permanent difference you can make to the trajectory of someone’s life, is awe-inspiring. It makes me want to go into surgery! Working with patients like these is rewarding and fun and enjoyable. And it is a privilege to be working alongside such awesome people and leaders, too. I have caught the Mercy Ships bug. I feel it deserves a whole blog post to itself!

I have now been aboard for four weeks! It feels like I have been here forever, yet at the same time these four weeks have flown by. This weekend I am on call, so cover the hospital and any crew sickness, which means I have to stay on the ship. Time to catch up on my blog!

I am becoming accustomed to living on a ship (see below), and settling in to and enjoying my job. The past couple of weekends were spent exploring local markets, churches and a cycling trip on a nearby island. The best thing so far has been a good family friend and surgeon John on board!

The first week or two was mostly spent meeting new people and having the same conversation over and over. “Hi, I am Laura. What’s your name? And where are you from? And what is your role here? When did you arrive? And when do you leave?” It might be easier to have a stamp on your forehead with the necessary information: “Laura, UK, hospital physician. Arrived at New Year. Leaving end of March.” Part of it is deciding who to be friends with. It is important to be strategic. I have met so many long-termers, here for the whole field service, who say they have had too many sad goodbyes from amazing new friends! In some ways, I expected everyone to know everyone else on board, but realistically you cannot be friends with everyone! People are always coming and going. Some people are here for years at a time, some just for the Guinea field service (ten months), others for a few months (e.g. nurses for 4-5 months, housekeeping for 2, me for 3), and some for a couple of weeks (e.g. some surgeons and anaesthetists). In general, it is possible to come for a shorter time if you are an alumnus, whereas first-timers often need longer stints to learn the ropes. You can distinguish an alumnus from a first-timer by the colour of their lanyard: blue for newbies, and bright green for old-timers. That said, there is someone who arrived ten years ago and is still on a blue lanyard!

It is bizarre living permanently on a ship. To me, it seems just like a cross between a P&O ferry, a Royal Naval ship, and being at summer camp.

Frequently I am reminded of the many ferry journeys my family and I took to France. For the first few days, it felt like the longest journey ever, and my mind was very confused, wondering when we were going to arrive at Le Havre. There is the familiar smell of fuel and constant background noise: if it is not the engine, along with its vibrations, it is the air conditioning in every room, or the loud monster-growl sound of the suction toilets, just like on an aircraft. There is a high step between rooms, doors that can be clipped open, and fluorescent emergency exit signs lining the corridors. And there are so many stair cases! It was easy to get lost at first, but I think I have orientated myself now. It is very handy living one flight of stairs away from the wards, my commute literally taking a few seconds, and four flights of stairs from the swimming pool. There are ship-specific health and safety precautions: the electricity automatically cuts out in the kitchen every 15 minutes unless you manually turn it back on. Then there is the occasional military vibe to the ship. The location of a room or someone’s cabin is described in terms of forward, aft, starboard and port. People in uniform or coveralls with epaulettes on their shoulders stroll past looking official. You have to wear your ID card wherever you go. There are weekly random cabin inspections to ensure rooms are clean, tidy and free of fire hazards. And just like in the military, meal times are so early! Who eats dinner at 5pm?!

A notable difference between here and my previous experience on ferries is the experience of going out on deck. Normally it means donning warm clothes and a fashionable cagoule to survive the biting winds, but here you go from cool air conditioning to sweaty, humid heat and blindingly bright sunshine! It is usually 100% humidity according to the weather updates on the screens. While sometimes I crave fresh air and sunlight, going outside often just means sitting, sweating, and breathing in the polluted air of the capital’s port and engine fumes.

The ship was built in Denmark in 1980. It was called Dronning Ingrid (Queen Ingrid) and was originally a rail ship which carried trains and passengers between the islands (see route map below). The very lower deck, which is now the hospital, still has the remains of the rail tracks, along which the trains used to run. The Queen frequently travelled on board and even had her own quarters, now called the Queen’s Lounge on deck 7. In 1999, it was purchased for $6.5 million by Dame Ann Gloag, who owns Stagecoach bus company and is a very wealthy Scottish businesswoman. At the time, Mercy Ships had the Anastasis which was a much smaller ship and they were looking to expand. She loved what Mercy Ships was doing, so paid half of the $60 million required for the renovation and conversion to a much larger hospital ship. The hospital is on deck 3 and has five operating theatres (or “OR”s in American), an intensive care unit with four beds, isolation rooms, four wards with space for 80 patients, an eye unit, a CT scanner, X-ray, portable ultrasound machines, laboratory with blood donor services and pharmacy. Outside of the hospital, there are 126 cabins for 484 crew members.

It is amazing working in a place where there is access to all sorts of tests and treatment. We can measure electrolytes here! And life on the ship is actually very comfortable. I don’t really feel like I am in Guinea. You are surrounded by Westerners. There are hot showers (two minutes maximum!), no mosquitoes, reliable electricity, and incredibly good WiFi! There is even a special Mercy Ships Netflix equivalent with TV and films you can stream.

And the fooooooood! It is so far from the rice, nshima, beans of before. There is a rolling eight-week menu and it is fairly Westernised food, apart from Africa night on Wednesdays. All of the meat is shipped from the Netherlands. There are some vegetables but mostly from frozen with the occasional fried plantain thrown in. My favourite meal is breakfast: porridge with an impressive array of nuts and seeds to add at will, boiled eggs on toast with Vegemite. The “galley” feeds an impressive 450 people at breakfast and dinner, and approx 700 people at lunch which includes all the day crew. In 2018, the ship consumed 274,310 eggs! (and enough toilet paper to run from Conakry to Dakar… hopefully no correlation). It would be very easy to gain weight here, affectionately known as “Mercy hips”. While there is no pudding with meals, there are always baked goods available at the cafe (along with popcorn Mondays and waffle Fridays), snacks in the ship shop, and ice cream after the Thursday community meeting (photo below).

To maintain a healthy balance, there is opportunity to do exercise! I have been enjoying the morning aerobics session three times a week. I am yet to try volleyball, frisbee, basketball or running clubs. I try to swim in the pool in the evenings most days, and get to enjoy a beautiful sunset. It is Harmattan season at the moment, which lasts for about three months and is when the northeasterly trade winds blows from the Sahara and carries with it lots of dust. It is often very hazy, and the cars and outside decks are coated in a fine dust. 

Sometimes it can feel a little claustrophobic on the ship and I experience the rumblings of (literal) cabin fever. I have tried to get off ship at weekends if not on call, and occasionally midweek. In my second week there was a team from Spring Harvest UK visiting and Mercy Ships UK office treated all the UK & Ireland crew to a meal out at a fancy hotel restaurant. We are allowed to use Mercy Ships vehicles, which are fun 4x4s (28 in total) and have radios to communicate with the ship reception, which make you feel like you are part of the secret service. Must be back on ship by the 11pm curfew!

So really life on board is pretty easy and comfortable! As long as you don’t need long showers, lots of personal space or time and like meeting lots of new people!

The windy season is here! We have had some days of super strong wind, to the point where we cannot dive. We did try a few times but had to abort the dives immediately because the visibility was about 50 centimetres (and if Saova can lose his buddies in 20 metre viz, I would hate to think where he would end up on occasions when you can barely see your own hands). Usually the windy day coincides with the weekend so it has become a Sunday tradition that we have to cancel our sunset sail, which we have been trying to do since arrival! So what do we do on weekdays when we cannot dive? Well, for starters, we are allowed to have more than one beer at dinner!

When you are in the middle of nowhere, you have to make your own entertainment. We had a fun pub quiz one evening, and a bonfire another. We were struggling for a while to light the pile of twigs and palm leaves we had collected, until one of the Malagasy guys fetched some boat fuel and set it ablaze in seconds! It reminded me of the time on the DTMH when we were camping in the Serengetti and we Westerners spent ages trying to get some kindling started. Tapiwa, from Zimbabwe, was looking on in quiet sympathy, and finally offered his assistance. I was expecting him to mould the kindling in a special way or use some sort of fancy billowing technique. But no, he reached for a plastic wrapper, burnt a corner and let it drip onto the kindling!

We had already had one wood-carving lesson at the start of the expedition during a mini sandstorm. Dupon, one of the guardians, is pretty handy with an axe and knife (helpful for a security guard) and taught us how to carve boats. The second wood-carving session was led by the compressor guy Sasha, who specialises in mini baobabs. It is amazing what beauty can be crafted using a £1 8-inch kitchen knife purchased from the Women’s Association shop. The most impressive of Sasha’s tools was definitely his ‘sandpaper’, which was actually a stingray tail! It turns out wood carving takes a lot of patience and determination, and some of us took more interest than others. Mine are still works in progress…

Zoe’s perfect baobab

Another day, another skill. The following day, we learned how to make the infamous boko boko and fish samosas by the best maker in town Hortensia! It was amazing to watch her roll the pastry paper super thin in a mini mangle and perform origami magic to fashion a perfect little pouch for the fish and onion filling. As for the boko boko, I had always tried not to think about what they were made of. It was impossible to ignore when, right in front of you, you see a giant bowl of flour and water mixed in to a dough, formed into little balls, with a little square of chocolate pushed inside, then deep fried in oil. So delicious!

Photo by Zoe

While we were waiting for the samosas and boko boko to pass through the frying pan, one solo pirogue came ashore. At that time, the village had not been able to fish for the previous couple of days, and even two days without fish takes its toll. A typical day’s diet would be boko boko and sweet tea for breakfast, fish, beans and rice for lunch, and the same for dinner. 99 percent of these coastal villages’ animal protein intake comes from fish, with the other one percent being goat. Everyone rushed over to the pirogue and peered inside, sweeping their hands through the cloudy sea water in the bottom to pick out fish. I tried to understand the system: it seems you gathered the fish you wanted, brought it just inside the fence to where the fisherman’s wife was sitting with a weighing scales, then you bargained your price. That day the price was 4000 ariary (90 pence) per kilo, but normally it is 3000 (67 pence). It was quite a performance! Lots of shouting, jostling among the crowd, mainly between women. It was a proud moment for feminism to realise that these women were the business-people of their families – this was the equivalent of Wall Street! Towards the end, the woman was getting frustrated, and my Malagasy friend Li translated her snappy rebuke, “Do not bargain if you are not going to buy!”

I have arrived on board!

I was dropped off at Heathrow at 4.30am by my dad’s cousin, her husband and their dog, who live 15 minutes from the airport. I was very grateful for the lift at such an unearthly hour! The flight was eventful… We were delayed in Paris because apparently one passenger was a minor and being sent to Guinea alone from the US by her parents, but had never been before and evidently did not want to go. Every time the plane was due to taxi or line up and wait, she would refuse to fasten her seat belt and stand up! Eventually the Parisian gendarmes came on and escorted her off. The police were nearly called again during our stop in Mauritania, when some passengers were aggressive and threatening the staff. They were angry at the further delay because someone had not checked passengers getting off and coming on to the plane, so it meant all of our boarding passes had to be checked twice. Even a pilot came out and had to raise his voice, accompanied by tannoy announcements literally shouting, “MESDAMES ET MESSIEURS! ASSEYEZ-VOUS!” Chaos, but all rather entertaining. The sceptics among us had suspicions some passengers were stalling to push the delay beyond three hours, so they would be eligible for compensation… Eventually we arrived in Conakry International only two hours late.

I met some other Mercy Ship crew in the immigration line, spotting the “FREE VISA” paperwork in their hand. After collecting our luggage, nine of us clambered into a Mercy Ships minibus and headed for the port. Beyond port security, we weaved in and out of shipping containers, cranes and dry docks, illuminated by massive orange street lamps, which could be the setting for a gang kidnapping scene in a film. We rounded one corner and caught sight of the bright white ship with neat windows and huge “m e r c y s h i p s” lettering along the side. Heaving our bags up the gangway, we were greeted by the friendly Nepalese Gurkhas on security and directed inside to the cool, air-conditioned reception. Some signatures and ID card photos later (why it must be after nearly 24 hours of travelling I do not know!), we were shown to our cabins. My door was decorated with welcome notes from the UK team and the hospital team. Lovely touch!

The following day was New Year’s Eve which was a Ship Holiday. Although the theatres have been closed for elective procedures since Christmas Eve, there are five orthopaedic patients who remain on the ward who have had complications with recovery (infections etc.). Throughout each field service, i.e. when the ship is docked in a host country, there is a rolling schedule of surgical departments. For example, orthopaedic operations were from September to December, ENT surgeries for two weeks in January, general surgery on and off, and maxillofacial surgeries are ongoing throughout the field service. I joined the ward round and was amazed that it was so similar to a ward back home, except the beds were slightly closer together, and there were lots of balloons, a few more American accents, and fewer windows (or rather no windows). There are four wards A to D, each for a different surgical specialty, with a total capacity of 80 patients. D ward is the only one currently in use while the others are being deep cleaned and prepared for the next batch of surgery. The hospital is all on deck 3 and includes four operating theatres, offices, a radiology department (with CT scanner!!!!), laboratory with a blood donation service (from crew!), pharmacy and the crew clinic (equivalent of GP surgery). It is strange to live one flight of stairs away from the “hospital”, but very handy indeed.

After ward round, we newbies were given the official ship tour. It is amazing! It is all so well organised and there are so many facilities! You can buy a latte for 75 cents from the Starbucks cafe on board. You can buy washing powder, snacks and shampoo from the Ship Shop, as well as postal stamps for home. If you fancy a workout, the gym is on deck 2 (just above the engine room so very hot and noisy!) or the pool is right at the top of the ship (more on that later). If you fancy some chill time, there is a library where you can borrow books, or the kids’ games room, the prayer room, and meetings rooms to watch films. If you want to work or play games, there are cupboards full of cards, puzzles and board games in midships with sofas, tables and a computer suite. If you need to do some laundry, there is a whole facility with washing machines, dryers and irons. If you fancy baking a cake, there is a crew galley with multiples ovens, fridges and sinks. Some people make treats to sell in the cafe and the money goes towards their crew fees. We were briefly shown the Academy which is the ship’s school for children up to 18 years. There is a playground up on the top deck, and kids often run or rollerskate around up there in the evenings to let out their energy. I was so impressed by how organised everything is: you scan your ID card when leaving the ship or coming back on board; sign up in advance for a slot to use laundry facilities; there are folders to sign up for on-ship and off-ship activities (weekend trips etc.); you scan your ID card to pay for drinks from the cafe and the money is debited from your ship’s bank account.

The cafe and Ship Shop are closed at the moment and there are not many people on the ship, due to the holiday season, but lots will be arriving at the weekend. There are normally about 400 crew who live on the ship, and many more day crew who are locals recruited from churches, who work in all departments from engineering to housekeeping, catering to translating/assisting on the wards.

My cabin is lovely! It is much bigger than I was expecting. I have a cabin to myself, a fact I have to keep on the down-low. Most nurses and theatre staff share cabins even though they do night shifts. Apparently solo cabins are allocated on a ‘responsibility basis’. The biggest cabin is a 10-berth! My next door neighbour is Canadian and teaches in the Academy. We both have doors off of our rooms into a shared bathroom. I am becoming accustomed to the two-minute shower rule! And remembering to unlock my neighbour’s bathroom door after I have finished… I have brought along fairy lights, photos and bunting to make my cabin homely. There are no windows, which is strange not knowing what time or weather it is outside. I think I will be craving sunlight! The previous occupant has kindly left me a poster of a window looking out onto a forest to try and trick my brain into thinking there is greenery and nature!

In the afternoon, I wandered up to the pool and did a few laps. It is only about 12 metres long, and I am used to 33! A mile is 133 lengths! It is a nice space to sit and chill outside. In the evening we had a short service introducing the new reading/preaching theme, the Sermon on the Mount. It was followed by a little party with karaoke, and then we all went out on deck to watch the fireworks over Conakry. Move over Sydney Harbour Bridge – you have competition!

Can you see the little flashes in the distance?!

The pool!

On New Year’s Day, I had my first experience of “open cabins”, which happens at Christmas, New Year and Easter. Crew sign up in advance, and a list is published of all the cabins which will be open (20 this time), and then everyone else gets to wander around the ship popping in to each cabin. There was SO much food! It was like a polite version of going trick or treating. The selection ranged from cookies to cakes, popcorn to sweets and nuts, and even pretzels with vanilla and cream cheese sauce. Some cabins offered flavours from their home: Chinese nibbles, pineapple chunks from New Zealand, banana custard pudding from Texas. The main focus was of course to taste as much food as possible, but the secondary aim was to have a nose around as many cabins as possible. As such, we had strict time-keeping, five minutes per cabin, one minute for transition, and if there were too many people in one cabin to access the food, we would mark it to come back later. The family cabins were incredible! Some have three bedrooms off a central room, some have two, and most of them have windows! For some families with three children, the parents have to sleep on a sofa bed in the living room. They were decorated so nicely and even had IKEA furniture, because apparently there is an IKEA in Gran Canaria, where the ships spends three months a year for maintenance. Some of the couples had met on the ship, and the longest-serving couple I met had been there for 14 years! Everyone has to have a job on the ship (limited bed space) unless the child is three years or younger, when one parent’s role is “primary caregiver” (“PCG”, as you often hear). It is very strange to hear some of the kids of English parents talk – in an American accent!

I am due to be on call tomorrow, Thursday and the weekend. Hopefully no major crises!

The second homestay experience was a little different to the first! This time I was paired with Jos, and we were matched with a local geezer and his wife. On Friday at lunchtime, we were met at Nosy Cao classroom by Nadia, a friendly 18 year old in a bold red dress, who led us back to her place right on the beach just beyond Zizian’s bar. We met her husband Hussein who is 29 and a “trader” in all sorts of things like spices, fish and other commodities. From the sounds of things, he was pretty business-savvy. Nadia is a student at a school in Morombe which is 40 kilometres away, so stays away from home a lot. We were joined by Hussein’s son from his previous relationship, Mustafa, who is 12, and we enjoyed a delicious lunch of rice, beans, fish and (duck egg) omelettes, and some thirst-quenching rice water. We could tell these guys were relatively wealthy because we ate at a table, they had sofas in the living room facing a small colour television, which was snuggled into the giant cabinet and framed by two ma-husive speakers the height of a human (with stunted growth). They had a separate bedroom and cooked outside on charcoal stoves. The walls were adorned with large posters of tables laden with food and drink. It was a bizarre choice of art: a photoshop-ed image of a gingham tablecloth laid with a jug of orange juice, burger and chips, pizza, croissants, coffee and popcorn.

Nadia spoke English fairly well and was able to tell us how she wants to go to university to study Medicine. She and Hussein had got together three years previously, when she was just 15 and he was 26! It was not long before the standard topic of love and relationships arose, and she was amazed that I was still single. “But do you want to get married? Do you want babies?”! She clearly loves a party; she needed minimal encouragement to put on songs and sing along, as she was coming back and forth clearing the table. Little did we know that that was just a foretaste of what was to follow.

Later that day, on our return at dinner, Nadia informed us that she had just received the good news that she had passed her Baccalaureate. That called for a celebration! Our hosts seated us in front of the television and we spent the next 45 minutes watching cringe-worthy Malagasy music videos, accompanied by Nadia singing along with the occasion twirl or emphatic arm gesture as she moved between rooms preparing the table. The pumping speakers were so loud! It could give the two nearby bars a run for their money. We thought the music would pause during the meal, but actually it remained just as loud throughout the whole thing. Needless to say, it was difficult to have a conversation! (But was a welcome break from the ping-pong style of questions and answers taken from the translation sheet)

On Saturday, our breakfast of boko boko was interrupted by a fisherman arriving with a bag of fresh fish. Hussein and Nadia weighed the catch on their scales, which was about 10 kilograms and consisted mainly of emporers: blackspot, orange-stripe and pinkear. (Yes, I am in the fish team). They paid the fisherman his portion, which was no doubt less than the couple would receive from selling the fish in the market later. So this is one way they made their money!

By the time we had finished breakfast, it was too windy for fishing but Hussein offered to take us out snorkelling with his brother and his pirogue. I felt a little bad that we were taking up their time to go and snorkel on reefs just off the beach where we normally snorkel/dive/swim anyway. His brother seemed to enjoy it though, borrowing Jos’s mask and fins, and at least it was not too taxing for fragile Jos and his dango dango.

Jos hang(over)ing with some giry giry

Hussein’s brother paddling at the rear

Pre-snorkel

For our last meal together on Saturday evening, by way of a thank you and congratulations for passing her Bac, we brought beers for Nadia and Hussein, and coke for Mutafa. We had checked at lunchtime that they drank alcohol. It did seem a little strange that Hussein kept saying he didn’t, but Nadia insisted that he did. Perhaps foolishly, we ignored this incongruity and brought bottles anyway. Nadia was in good spirits and seemed to enjoy the beer in between her bursts of songs. It was only after the meal that we learned that Hussein is actually allergic to beer, and comes out in a rash and has abdominal cramps. Oops! We made a swift exit, feeling grateful for their hospitality, but concerned that we were potentially leaving our host in grave danger, and may never see him again…

So far there has not been any medical issues, apart from the usual stubbed toes, cut feet and conjunctival haemorrhages. Thankfully no emergencies either. The extent of my medical services have been doing a stock-check of the medical kit and creating a kind of inventory, observing the medical evacuation (‘medievac’) scenarios and teaching on the Emergency First Responder course.

Every expedition, the staff team practise two medical evacuations: one on land and one at sea. I was asked to observe and give feedback on what happened from a medical perspective. It was a lot of fun! For the land-based scenario, Valerie, the expedition manager, had fallen out of a hammock and was unresponsive. Accidental hammock ejection is a common incident here – when you reach the point of maximal relaxation, you lose all body tone and flop out of your hammock. Apparently she was also not breathing either, so she was pretty unlucky that a one metre fall caused her to break her neck and knock out the breathing nerves, or have a massive brain haemorrhage with coning… It was actually really funny to watch! And for once it was fun not to be the one being examined in a scenario. Jacks was leading, and did a great job of delegating people to run to collect the oxygen, trauma kit, wooden stretcher, and hold down a panicked friend Rachel who found Valerie in her moribund state. My favourite quote was, “Let’s get her onto the stretcher. Someone call a zebu cart!” No fancy ambulance around here, just a stubborn ox attached to a creaky wagon.

The medivac at sea was equally entertaining. The simulation began just like a normal dive: briefing at sunrise, casually wander down to load the boats with kit and head out to one of the reefs. Buddy pairs were Bic and Valerie, and Patricki and Freddo, and they all rolled off the boat without incident. Rachel was dive marshall, and so stayed on the boat keeping a watchful eye on the surface marker buoys (floating orange blobs), along with captain Narcisse, Joe and me. After 15 minutes or so, Valerie burst to the surface in a panicked flurry, an eruption of bubbles, thrashing around her arms and legs, and screaming, “He’s dead! A turtle has got Bic!” Valerie refused to get in the boat no matter how many items were thrown to her or encouraging instructions were issued. Rachel used the satellite phone to inform Clara, who was back at base as shore marshall and prepped the stretcher. Narcisse did the emergency recall signal by revving the engine repeatedly. Patricki and Freddo came up shortly afterwards and were sent straight back down to do a search and recovery to look for Bic’s fragmented body parts. They soon re-surfaced with an unresponsive Bic. They did an excellent job of CPR on the boat! Unfortunately, the scenario had to end prematurely; the boat headed in to Andava beach, which is the beach closest to the village, rather than Halfmoon beach, which is sheltered and only visible from our huts. Apparently, the last time they ran a medievac scenario on Andava beach, the village thought it was real, they went crazy and all came down to help. On arrival on shore, Bic miraculously came to life! It must be why he is called Wolf of the Sea…

Dive brief at sunrise

Buddy checks on land

Walking down to the boat

Loading boat

Buddy checks before rolling in

Freddo and Valerie saving Bic’s life

As part of the Rescue diver course, divers must complete the Emergency First Responder course, which is a one-day basic life support and first aid course. It is very obviously American! They have to learn the opening line, “My name is … and I am an emergency First Responder! How may I help you?” (right before checking for health insurance details..). In a similar vein (pun intended), the field scientists wanted some training on using the trauma and medical kits, so we covered anaphylaxis, acute asthma and head/spinal injuries.

Bic

Jos assembling the oxygen

Lewis modelling a sling

In other medicine-related news, we paid a visit to the Vezo Hospital just at the edge of the village. It has been running since 2008, predominantly by Italian volunteers, and runs exclusively on donations. It serves the population within 200 square kilometres. While that number is much smaller compared to St Francis Hospital in Zambia, it was interesting to compare and contrast facilities. When we arrived at the end of a working day, the doctors and nurses were playing what looked like a serious game of volleyball against the locals on the sand court outside their accommodation. We were treated to a video to give a little background on the hospital [you can watch it in Italian here] before being shown around by one of the pharmacists. It is very small yet has such amazing kit and stocks! It has only 11 inpatient beds (St Francis has 400), yet there are two X-Ray machines (one portable), a great lab, a ‘resus’ A&E room, a dental department, a couple of operating theatres, spacious clinic rooms and a well-organised full pharmacy. Specialist surgeons visit for short periods to perform elective surgeries. However, the sad side is the story of HIV. Valerie tells me that the prevalence in the village is low, but the hospital are not allowed to test for it since they have no way of providing treatment and follow-up. Instead, patients have to travel to Morombe clinic which is 40 kilometres away – a long way if you have to travel by pirogue on the sea or zebu cart on land! And there is still lots of stigma attached to HIV and STIs, despite everyone knowing that both men and women have multiple partners and that they are very accepting of openly gay people in the community.

One of the BV presentations included one by Safidy, which means “choice”, and is the Ministry of Health clinic at the office of Blue ventures in the village. Their scope of work is enormous. They encourage and support family planning and have a full-time governmental midwife who does antenatal clinics. Not only that, but they cover sanitation and health education in the community, teaching even basic concepts like hand washing and sewage management. If I were to go back to Madagascar, I would love to get more involved with this project. There is so much potential! You can see some photos and videos and read more about it here.

We dive five days a week, sometimes on Saturdays if we have missed a day during the week. Sunday is everyone’s rest day, and is usually the day given to recovery from “dango dango” (hangover). I really enjoy that word. Interestingly, lots of great Malagasy words are doubles: Mora mora (slowly), giry giry (duck), vao vao (what’s new?), faly faly (happy), dala dala (crazy)… On these days, we arrange something fun to do through Jacks, the Michael Jackson dancing crazy man, who gives us a good deal with his trusted buddies (e.g. 5000 ariary for a 3 hour pirogue trip = £1.12).

One weekend we sailed by pirogue to one of the nearby islands called Nosy Hao. Our drivers Gilde and Remy were lovely but spoke no English or French, so we had to communicate by sign language. They were still able to tell me to climb and sit on the wooden balance beam thing. It was a chicken and a burley demi-god short of a scene from Moana. I hope it was because it was something fun for me to experience, rather than they required a large weight to balance the pirogue and chose me after witnessing me devouring my portion of fish samosas. We had 10 each for lunch which were delicious! We lounged on the deserted beach, listened to music and enjoyed a little snorkelling. The reef was quite a way from shore, thus sadly I saw only sand, sea grass and the sunglasses which had fallen from Jenna’s head during her paddle around. It took about an hour and a half to reach the island which is approximately four kilometres away, having to tac across the sea, but only 20 minutes back thanks to the wind. (Thanks, fish samosas.)

Another Sunday, Cameron, Jos and I went for a little jaunt into the spiny forest to climb some baobab trees with Jacks (our unofficial friendly tour guide). We made the 4.5 kilometre journey by zebu cart. I sat facing the two boys in the direction of travel, and the boys facing backwards. I think I was lucky because although I could see the giant gaping anus of each zebu, letting hot air escape at regular intervals, I was not whipped by the bristly tails matted with poop. The journey was an experience: whenever the zebu eased off the pace, the driver would shout out aggressive Chinese-sounding words while whipping them with tree branches. On arrival in the spiny forest, Jacks led us through the dry bushes and many cactus-like shrubs, taking care to teach us which ones have poison strong enough to kill humans, and the one whose poison naughty fishermen (generally from inland) use to catch fish by throwing the liquid into the water and waiting for the dead fish to float to the surface. We sampled fruit from the tamarind tree which has the texture of earwax but has a lovely sharp taste (would make an excellent marmalade), and the stones make great chewing objects once all the earwax has gone. Lots of villagers use the bark of baobab trees for their homes, and have carved little footholds in the huge trunks to facilitate climbing to pick fruit. They are sometimes called ‘upside down trees’ because their irregular spindly branches look like roots growing upwards. Jacks was a master of climbing the baobabs! After the boys’ embarrassing attempts, he demonstrated how easily you can scramble up barefoot. On the return journey, we had a go at driving the zebu cart, and our speed noticeably dropped; the zebus were not in the slightest bit persuaded by these strange Vazah vocalisations and gentle tapping on their rumps with the aforementioned tree branch. As we were coming back through the village at sunset, enjoying pleasant tunes drifting from our speaker, mentalist Jacks hopped off the back and danced his way through the sandy tracks. For a moment, I thought pre-skin colour change MJ had come back from the grave!

It seems almost every weekend we have attempted a sunset sail by pirogue, but, without fail, it has been too windy every weekend to attempt it. Apparently our expedition has been pretty unlucky with the weather! On one of those windy days, we visited the mangrove forest just one kilometre around the coast from Andava. Blue Ventures is big into mangroves and the carbon offset they provide. We saw lots of mud skipper and crabs (to Cameron’s delight) across the swamps. Jacks told us all about the four species of mangroves, and their pneumatophores, which are the roots which grow up through the sandy mud to reach air, and how locals use the bark for their face masks, medicine and painting their houses. It was a long and windy walk back but obviously the company was delightful.

On one of our final weekends we walked to a fancy hotel called Laguna Blue, just beyond the mangrove forests. We had a delicious lunch including salad and vegetables! The journey home was by zebu cart, but by then we were used to the rickety, squashed wooden half-box on the back and the warm, fart-scented air gently blowing from the zebus’ rear end (the countryside’s version of a steam train). We had Cameron’s playlist (and inane chat) to distract us!