10 things I'll miss about South Africa... And 10 I won't.

So the time has come for the final installment in my not-so-regular blog. I don't think I'll turn into a regular blogger, but it's been a useful experience for me, cathartic in a way. And I've enjoyed reading over what I've written over the past year, and remembering just how great a year it has been, for all its highs and lows. Amazing how the vivid colours of what goes on in your life can fade into a kind of monotone in your memory when you try to think back on it - so it's great to have had to record it so I remember even just a few of the unbelievable experiences I've been privileged to enjoy this year. And I've really appreciated everyone who's written to me to comment, ask questions, or respond to what I've written. Thanks guys.

Last time I blogged I was just about to work my final weekend on call at Isilimela. The lady I wrote about turned out to have both cryptococcal and tuberculous meningitis when her cerebrospinal fluid sample came back in the end. It's been a more-or-less constant source of surprise to me just how sick people with HIV can get. I spent all weekend being called to her bedside to put in new drips because she kept pulling them out in a delirium - I ended up putting both her hands in plaster of paris mittens to try and stop her pulling at them, but she outsmarted me by grabbing the infusion line in her teeth and biting through it... Crazy, but still smart. Anyway the other thing that has continually surprised me this year is how dramatically these young patients with HIV who look like they barely have minutes to live can recover with treatment, which is often given fairly blindly because we don't have time to wait for results of tests. This particular young lady made a fantastic recovery, defying a disease for which only a few years ago there was no treatment. It has been such a privilege to witness that miracle, time and again, this year. Of course the real miracle will be to see whether we can change behaviour on a population level and prevent people contracting diseases like HIV and TB, but it's baby steps - and things like that are instrumental in convincing a population who still don't all necessarily believe that AIDS exists, or is caused by HIV.

It's now been 2 weeks since I finished my contract at Isilimela, and the last few weeks have been spent reflecting on this year, on the experience I've had, and on going back to the UK. I will miss South Africa; the people, the places, the job. But I'm also really ready to come home. I was mentally making a list of the things I'll miss, and those I won't. There are hundreds of things, some of them I'm not sure I'll even realise until I'm actually back and into the swing of normal life in Edinburgh again (possibly when I wake up at 6am in November and have to get on my bike in the cold and rain to go to work, a few things will occur to me...) Anyway I've made a list.

Things I'll miss:

The people. I have the pleasure and privilege to work and with some amazing people this year - some of the nurses in particular are just pure gold. I don't know how they do it. But so many South Africans have been so friendly and helpful this year, I'll miss the openness and the readiness to have a laugh, and the willingness to make a friend of anyone.

This beautiful country. Everywhere you turn there's something new and different and simply stunning. So many hidden corners of wilderness - from semi-desert to rainforest, from majestic mountains to idyllic coastline. And so easy to explore - good roads, good guesthouses/backpackers lodges and great people to do it with.

That beach. Our local beach at Mpande is probably one of my favourite places in South Africa now - and it's a 20 minute run from my doorstep. Crystal clear water, coastal strelitzia and river euphorbias crowding down to the pale sands, waves crashing and the air thick with sea spray. I feel so blessed to have had it to myself on so many occasions this year.

Related to the last two things - the sense of space. South Africa is not a crowded country, and you can go the beach and see no-one, or go hiking in the mountains for days and not see a soul. Such a contrast with Europe where even in February in the English Lake District you can meet hundreds of other hikers on the same mountain.

Amusing signs - it sounds stupid but it's one of the things I've really enjoyed. I've seen road signs warning me about hippos, warthogs, spotted toads and even dung beetles. Not to mention such commercial gems as "God Loves a Sinner Hair Salon" and "PARANOIA Laundry and Clothes Alterations." Still brings a smile to my face. Trucks which are unusually wide have "ABNORMAL" printed on them in big red letters, and in Botswana they make a small car with red flags and flashing lights, also with "ABNORMAL" signs go in front of the truck in case you don't notice the massive HGV. Yesterday, in Namibia, I passed a sign saying "Road Experiment" - I have no idea what the experiment was. Seemed like perfectly normal road to me. Anyway I love the fact that these things are only really amusing to foreigners - no-one here gives them a second thought.

My motorbike. I loved that wee bike, and am still a bit cut up about it's untimely demise. I still have some beautiful scars on my knee to remember it by though, from when I had to pull an emergency stop on a gravel road because Sushi decided to stop right in front of me, and ended up flaying a large portion of the left side of my body.

The weather. Say no more, really. And as a consequence, the fruit and vegetables - those grown in our garden and the ones bought from the supermarket, or by the side of the road. Awesome.

The problem solving, can-do, "we'll make a plan" attitude. I've done, or supported, things in the hospital which I never would have dared do at home; of course only because there was no-one else to do them. But there is very little which is more satisfying in work than being thrown against a problem which you have to fix with your own resources and wit, and ultimately coming out on top. I remember near the beginning of the year spending a long time with Bregje trying to rig a system together so we could provide nasogastric feeds to a patient who was unable to eat anything, because we had no feeding lines. It involved a frankly ridiculous amount of small medical plastic items connected in unlikely combinations, and I was inordinately proud of it. My pride was somewhat deflated the next day when I came past and found her cheerfully munching on a sausage - first lesson in understanding that 'being unable to swallow anything' in Xhosa is perhaps best not literally translated.

Having to know, or learn, about all aspects of medicine, surgery, paediatrics, ophthalmology, psychiatry, gynaecology, obstetrics, anaesthetics, and the rest. Of course it's a bit tiresome as well, and an impossibly tall order. But there's so many fascinating things you see - I've got to diagnose panhypopituitarism, systemic lupus erythematosus, juvenile dermatomyositis, pulmonary hypertension, cerebral toxoplasmosis, necrotising fasciitis of the scrotum (Fourier's gangrene), as well as innumerable cases and manifestations of HIV and TB, to name just a few of the interesting things. Practically, I've had to do lumbar punctures, large bore chest drains, ascitic/pleural drains, suprapubic catheters, set fractures, stitch complex wounds, excise various lumps and bumps, and extract babies who don't want to exit the womb using various methods. I've done scores of spinal anaesthetics and a fair number of general anaesthetics, and performed a number of gynaecological surgical procedures, including once having to suture a complex cervical tear which had caused a major post-partum haemorrhage, a procedure which is way beyond my level. And it's been terrifying, but exhilirating.

Walking 2 minutes to get to work. Now that's a commute.

Things I'm really looking forward to:

Seeing my fiancee more than once every three months and not needing to communicate via Skype, which allows us an average of 6 minutes conversation before it cuts out and she has to redial.

Proper cheese rather than yellowish artificially flavoured milk solids. Although I'm not quite such a cheesophile as the Dutch, I can't deny that South Africa hasn't really mastered this essential gastronomical discipline.

Drinkable tap water. Ours is fine, really, but it's only when you drink mineral or rain water instead, or go back to Scotland or Ireland that you realise how good proper water can taste. Also water shouldn't turn white when you pour it into a glass and need about a minute to settle before it turns colourless again, should it?

Electricity and water that don't randomly go out, for days or even occasionally weeks at a time.

Not having a cleaning lady who randomly 'tidies' things into places where you can't find them, or decides that your house's feng shui is not quite right so rearranges it. And helps herself to pretty much anything she likes in the house so you never know what's going to be in your fridge when you come home.

Not hearing comments like, "I don't understand how the pulse can always be the same as the heart rate, when you measure the heart rate on the heart, and the pulse on the wrist" from nurses. OK, so I'll miss it a little bit - I've been giggling about that for about a month, but it's not funny when you're stuck in theatre trying to do both anaesthetic and surgery and your only assistant doesn't understand that the heart pumps blood around the body, let alone basic concepts like sterility and calculating drug doses.

Leaving my work behind when i go home instead of knowing that the phone can always ring any time of day or night, whether or not you're on call. And if you're on call, it's pretty much bound to at some point wake you when you're mid-REM cycle and least prepared for it.

Properly functioning internet and telephones. Even our cellphone reception randomly cuts out on occasion, sometimes for days. And the internet seems fairly weather-dependent - if there's a thunderstorm brewing, you'd better hit send pretty quick.

Drivers who have licenses, insurance, cars with lights, and perhaps an idea of the rules of the road. Not to mention a healthy disdain for driving while under the influence of alcohol.

A health service not held to ransom by doctors who are by and large entirely unregulated - private doctors who prescribe/diagnose anything provided they get their fee, and public doctors who get away with shoddy care because the system is so swamped and the patients so downtrodden that nobody ever complains. I'm sure my frustration with this system, and with my medical confreres elsewhere in the region, has come across before. But it is definitely a defining feature of this year. As well as a bottomless frustration with an ambulance service which barely understands English, let alone the medical conditions to which they are supposed to respond, and which almost universally fails to provide anything resembling a reasonable standard of care to their patients.

Having written all that, I don't want to finish on a low note. The frustrations of working and living here have been part of the joy and the challenge and the adventure, and I'm almost grateful for them as well. In small ways, I've tried, and at times, successfully overcome these challenges and that's been great. Besides, I'd never have come here if I didn't want a bit of a challenge.

I'm not going to write a lot about my travels the last couple of weeks - although that's been great too. I've been through Swaziland, the Kruger Park in South Africa, to Victoria Falls in Zimbabwe/Zambia and the Chobe National Park in Botswana. I've been in Namibia for most of the last week, travelling through the desert and Etosha National Park and now in the capital Windhoek. There'll be photos on Facebook as soon as I can find the time and a decent internet connection, and if you want to hear about it - ask me, I'll be glad to regale you with tales :)

So I'll leave it here. It's been great. Thanks for your support, and looking forward to seeing/hearing from you all a bit more closely when I get back to Blighty.

A mixed bag...

Roll opening credits... And it's time for what is most probably my penultimate blog from Isilimela. I have just over 5 weeks of work left here, it's amazing how quickly a year has gone in. I guess my emotions are mixed; I'm really keen to get home for obvious reasons, but will miss South Africa and many of the people who have welcomed and supported me here. The work is fascinating and highly rewarding, but also intensely frustrating - my tolerance threshold for spending half an hour on the phone trying to refer a patient to a department which refuses to answer its phone, for example, is waning. And much as there's very little in me which relishes the thought of coming back to the UK's micro-managed training programme with its endless assessments, paperwork and variety of hoops to jump through, I am really ready to be back in an environment where teaching, and feedback on how you're doing, are normal.

I'm on call this evening but it's been strangely quiet all day. I actually had to attend court this morning in Port St Johns about an assault case back over New Year where I treated the victim at the hospital afterwards. In fact, they had told me the wrong day to attend and I have to come back for the actual case in a couple of weeks' time. But I managed to miss 3 hours of work and still come back to a relatively quiet hospital. I've only had one patient to see since 3pm - I've just come back from assessing a patient with known AIDS and TB meningitis, and now possible cryptococcal meningitis as well. She actually looked really well apart from refusing to speak, but I did a lumbar puncture just to make sure. Anyway the cerebrospinal fluid was hosing out through a little spinal needle - we'll have to wait for the lab results but something's up. You really never know with these patients where the immune system is totally wiped.

It's totally different these days being on call - I really notice the change of season. It's getting dark before 5pm now, and it's pretty cold in the evenings. When I walked down to the hospital this evening, the stars were burning in the sky in that fierce winter kind of way, and the silence is really noticeable. Whereas in summer there are always noises, whether it's local guys with kwaito music on their car stereos, or the nurses giggling in their houses, or insects buzzing or dogs barking - everything now seems to shut down at sundown. But strangely, the botanical shutdown you associate with the onset of winter in Europe doesn't seem to take place to the same extent here. In fact, this part of South Africa seems to be having some kind of paradoxical springtime. Everywhere there's new flowers coming out - blue lupins, massive yellow daisies, pink and red solanum, and there's even a poinsettia in bloom just up behind our house. The coral trees have burst into bloom with clusters of crimson blossom on their bare branches. It's quite incredible. And as you walk from my house down to the hospital at night, there's an amazing fragrance from night-blooming flowers on the other side of the road. If only there were more daylight to enjoy it - I'm feeling a bit deprived at the minute as there isn't really time before or after work to run to the beach and have a swim in daylight.

Last time I blogged was from Cape Town in March I think. It's been a busy few months since. Over Easter I headed back to Cape Town but overland this time, with Annelieke's sister and brother as very welcome company. Unfortunately the enormous 4x4 pickup that Annelieke and I had bought was in the garage waiting for parts from Japan which were delayed due to earthquake-related supply problems, so we rented a little Hyundai Getz and set off, stopping with Dr Smith in PE and then hitting the garden route. I was a bit underwhelmed by the famous Garden Route, as it turns out. But the route inland from to Cape Town from George is stunning - you're on the edge of the Little Karoo which is the arid semi-desert in the interior of South Africa. The terrain and the colours were just fantastic - bright green and blue grasses interspersed with pinks and oranges, and dry, rich yellows through to reds in the earth. Plenty of distractions en route as well - great food and wine in sleepy little whitewashed villages, ostrich roaming around in fields near Oudtshoorn, and the magnificent Cango caves.

Cape Town didn't let me down either. It's such a great city. I was there to run the Two Oceans Half Marathon - billed as 'the world's most beautiful marathon' it didn't disappoint, although I'm sure the ultra marathon (56km, or 35 miles) would have been even more spectacular as the route for that took in many of the most beautiful stretches of road around Cape Town. I hadn't done a lot of training so wasn't really expecting to run it in under 2 hours, and preparing for it by running 5k then hiking over Table Mountain the night before was probably not the best plan, but managed it in 1h58 which I was pleased with - it's a long way off last year's time in Skye but I felt much better afterwards than I did then. I got to the start line a bit late (poor planning - should really have checked where it was before we had to leave at 5am on race day for a 6am start!) so was at the back of the pack, but running through a city in the dark at that time in the morning surrounded by 14,000 other runners is something else. All you can hear is the sound of trainers hitting the tarmac - the only thing I can compare it to is the sound of rain hitting the windows in a thunderstorm. Incredible. The other highlight for me was rounding a corner on the lower slopes of Table mountain to see the sun coming up above the mist out in Table Bay with its rays being pierced by the tall trunks of cypress trees. Absolutely stunning. They also had some excellent motivational posters on lampposts and pylons from the event's sponsor - my favourite said, "Pain is temporary - Glory is forever." Priceless.

Unfortunately, our trip back from Cape Town was marred by an encounter with one of South Africa's many drunk drivers. We were driving on a single-lane road out in the country in the pitch darkness, and saw headlights coming towards us. As it was so dark it was impossible to tell until he was quite close that he was driving on the wrong side of the road, and both of us were
going at speed. He didn't show any sign of returning to his own side of the road, so at the last minute our driver swerved on to the other side of the road to avoid him. Unfortunately, at the exact same moment, the driver appeared to notice his own error and decided to move back into his own lane and within a few milliseconds had crashed straight into our bonnet. My own recollection of how much we spun is not all that clear as it happened very fast and I think I may have briefly lost consciousness. But when I emerged from my airbag we were in the undergrowth on the wrong side of the road, facing the opposite direction, the car bonnet was smoking and hissing, and my door wouldn't open as the whole left hand side of the car and most of the bonnet were crumpled. Amazingly, we all walked away from it although one of the girls in the back had a severe concussion and a nasty facial laceration. The guys from the recovery crew who came to pick up the cars (both completely written off) said they'd seen much less serious accidents where no-one had been left alive. All I had was a bit of neck and back pain for a few days and a bit of dried blood in my nose the next day. Plus some fairly traumatic memories. But extraordinarily grateful that we are all alive.

I was only back at work then for a week and a half before heading back to the UK. It was so good to be able to spend that time with Gemma, as well as hang out with her family and mine. Especially great to see my sister and brother-in-law who are expecting their first child in the next few weeks... We also did a bit of a blitz on wedding plans - it's amazing how much you can organise in a week, without really even working that hard at it. It's the little things that keep surprising me though. Like spending £48 on postage stamps. Yikes. And apparently wedding cakes cost about £300 - who'd have thought??

Just before I left Isilimela it was, very sadly, time to wish Annelieke, my colleague and housemate, farewell. She finished up here at the end of April and headed off to New Zealand. It was a sad day for the hospital who have lost a very talented and incredibly hard-working doctor, and for many of us who will miss a good friend. But she has seen the hospital through an awful lot of difficult changes on its road to improvement and I think is entitled to rest on her laurels for a bit!

It's also been election time here in South Africa. The weeks leading up to it were interesting - I didn't hear anybody talking about any political issues like you would in the UK before elections, and indeed I'm not sure people cared that much. It's a real ANC area here so perhaps no-one really bothers because everyone knows what the result will be. Every time I see Jacob Zuma's face on the posters it reminds me of an anecdote from the Hitchhiker's Guide to the Galaxy where the story is being told of a planet where the human inhabitants are ruled by a minority class of lizards who they all hate but continue to vote for, regardless. When someone asks why they keep voting for the lizards, someone says that if they didn't vote for a lizard, then the wrong lizard might get in. A fairly apt description of why we vote for any politicians at all but Zuma in particular strikes me as particularly lizard-like - even his smile on those posters is completely disingenuous. It's very easy to criticise another country's political system, and I know my own country's is far, far from being perfect. But things here just seem to be almost comic, if they weren't so tragic. For example, a senior ANC figure publicly claimed that Nelson Mandela's health would fail if people voted for anyone other than the ANC. It just seems such a cynical ploy to exploit people's lack of education by appealing to their emotional tie to the person they see as the father of the nation. I guess these types of issue are probably inevitable in a nascent democracy, and no-one would by any means want to put the clock back to the days where the majority of people in this country had no political voice at all, but it is so disappointing to witness the irresponsibility of politicians exploiting the very people they are meant to represent with that kind of underhanded tactic.

Reading back over what I've written, it seems pretty clear to me that this whole year has been a pretty informative experience, on so many different levels. I'm really grateful for what I've been able to experience here and for the small amount I've been able to achieve. People here are so grateful - even today when the police officer in Port St Johns found out I was leaving Isilimela for good at the end of next month he was extremely, almost unnervingly, upset. So I'm planning to enjoy my last few weeks and get as much out of it as I can. Thanks to everyone for keeping in touch, and stay tuned for the final installment some time next month...

A few significant events...

The stars have aligned and it's time once again for my increasingly irregular blog... The stars in question are slowly tracing their arc over Table Mountain just outside my window as the full moon illuminates Table Bay beyond the orange sodium glow of Cape Town's city bowl. I'm in Cape Town for a long weekend and loving everything about it at the minute. Everything just works in a way things don't seem to in the Eastern Cape. I left yesterday on the motorbike heading for Durban, and even there, as you cross the Mtamvuna river into KwaZulu-Natal, you notice an immediate change. The roads are better, the towns are better organised, the fields are divided into regular units with orderly crops, and there aren't random huddles of semi-domestic animals blocking the roads when you come round a corner. And then you arrive in Cape Town which has a well-signed road network, a much more acceptable ratio of kamikaze minibus taxis to normal traffic, decent customer service in shops and cafes, and of course an absolutely stunning setting. Even racial integration seems to have taken hold in a much more solid way here than what I have witnessed elsewhere in South Africa - although that is admittedly based on quite a short acquaintance with the Mother City, and perhaps comparisons with the Transkei, for example, are far from fair.

Anyway it's great to be in such a beautiful city, and it does throw into sharp relief all the things which don't work back in the Eastern Cape, but that's not to say I don't also love the Transkei wholeheartedly. Just more of the incredible diversity with which this country is blessed. Of course a major part of the Transkei's charm is it's lack of development. You can't fail to laugh when you see "BP machine O/S" (O/S = out of stock) written to explain why the nurses haven't taken a blood pressure. But then, it's more tears than laughter that I've been moved to the last couple of weeks as our X-ray machine has been "O/S" because the stores department failed to renew its maintenance contract. Now we have to wait while they get three quotes from different companies and then get the Provincial Department of Health to rubberstamp the cheapest of them - before anything can happen to repair this one machine on which we are quite dependent.

So last time I blogged I was preparing to come home for job interviews. The journey home was somewhat eventful in that about an hour after I set off for Durban the rear tyre on my motorbike blew. It wasn't really a surprise - the tyre was pretty nigh on bald as a coot. I'd actually arranged to leave the bike at a garage in Durban for a full service while I was in the UK, and had pre-warned them it would need a new tyre. Sadly, however it never made it that far. Thankfully some friends were in Port St Johns with a pickup, and rescued my bike while I hitchhiked to Mthatha. I was picked up by a senior nurse who travels the province following up patients with multi-drug resistant TB (MDR-TB). Really interesting guy, and really kind of him to pick me up. When I got to Mthatha I'd missed the last bus leaving for Durban, and the bus to Johannesburg was fully booked. There is another bus company, but their ticket office was closed so my only option was to wait for 7 hours until 2am at the N2 truck stop until the bus came and hope there was space on the bus. Anyway to cut a long story short I did get that bus and got to Durban in time for my flight, made it home but not in tip-top condition given that I'd had two pretty much sleepless nights, one in a truck stop and on a cramped bus, and the other mostly in Dubai airport.

In spite of that, the interviews went ok, and I ended up getting offered a job training in Anaesthetics in Edinburgh, which is what I'd eventually decided I wanted. But the major highlight was that I asked Miss Gemma Cunningham if she would be prepared to marry me, and she, unbelievably, agreed! We got engaged on Gullane beach just to the east of Edinburgh in a beautiful spot looking across at the Lomond hills in Fife where we'd had our first date. The ring is a South African diamond which I'd bought in Port Elizabeth back in December, hence the need for the (somewhat ambitious, or even foolhardy, as some have suggested) motorbike trip to PE in January to pick it up. We had a great time just enjoying being together again, sharing the news with my family back in NI, and a very brief but beautiful trip across the border to Donegal for a bit of rest & relaxation. We're planning to get married on the 10th of September so we're keeping the ambitious (possibly foolhardy) theme going - but seriously, how hard can it be to organise a wedding? Even if you do live in the middle of nowhere on a different continent with somewhat unreliable lines of communication? (I can almost feel the scorn from my married friends who have been through all this before...) Thankfully Gemma's family are more than up to the challenge, and I (bravely) seem to have taken on more of a consultant role. Hmmm...

It was a bit of a whirlwind though, getting engaged and getting offered and accepting a new job, all within the space of a week. From having a fairly nebulous concept of the future, it suddenly gained a location, a career, and above all, a face... All very welcome changes. In comparison, life at Isilimela has seemed quite routine and even, at times, a little mundane! It has been a fairly quiet season at the hospital the last few weeks in any case, though. The general adult ward which I look after is rarely operating at any more than 50% capacity, which is very unusual, whereas we have had a real spike in paediatric malnutrition cases and our Paeds ward is full to overflowing.

I'm not sure if I'd mentioned before but since Christmas we've also started regular outreach visits to the primary healthcare clinics, supporting the work of the very hardworking nurses and midwives there. I have been visiting two clinics, each for a day once a month. The day after I arrived back from Scotland was my second visit to Ludalasi clinic where they had 51 patients for me to see! And I thought GP's had it tough back in the UK with their 10 minute appointments. No real time to explore ideas, concerns and expectations anyway. I was back there again this week where I had a much more manageable 35 patients to see, although 4 of them were acutely unwell and required transfer to hospital. Despite requesting the ambulance at 0930, it still hadn't arrived when I was leaving the clinic at about 1530 so I bundled the patients into the back of our little pickup - a veritable African tiny white van - and rumbled my way on the dirt road back to Isilimela. So I can now add ambulance driver to the list of the many roles that I have had to take on out here!

I was also very touched when at the end of the day the nurses invited me to come for some food which they had prepared - chicken and bread. After the meal, one of them said to me (in slightly guilt-ridden tones), "You know, doctor, this is your chicken." I had no idea what she was talking about so asked her what she meant. It turns out a patient from that village had been an inpatient in my ward before Christmas with cryptococcal meningitis, and had been very close to death before making a fairly miraculous recovery. When he heard that I was coming to the village clinic that day he'd brought a chicken to say thank you and given it to the nurses who'd promptly got one of their assistants to cook it up as a snack!

It's little things like that which remind me that yes, I am still in Africa. I also had a beautiful experience while out running on Sunday in the early morning running through little villages, hearing the cockerels crow and seeing the bananas ripening on their palms, and just thinking how bizarre it is that I do in fact live in Africa. My parents had come to visit and we were staying in the luxurious bungalows at Umngazi, just along the coast from Isilimela. It's so beautiful there and it was really fantastic to have a bit of time with my folks. But also bizarre to realise that once you step outside the boundaries of the resort you're in a rural African scene which could almost be any sub-Saharan African country.

We've been busy at the house as well and Annelieke (my housemate) has built a large wooden bench outside where we can sit and watch the sky darken - we don't really see the sunset as it sets behind the hills. But it's been great for G&Ts and we had an inaugural braai (barbecue) last week. I also spent my last weekend on call constructing a dog house for Sushi which I'm quite proud of. He was pretty skeptical for the first few weeks, but all it took was one serious rainstorm and he's a convert. So now he's sleeping outside and barely acknowledges you as you go out to answer a call at 2am. I've decided I'm definitely going to take him back to the UK as he's totally dependent on us and I can't be sure that there'll always be someone happy to look after him. So he's booked in for 6 months' quarantine in Scotland in July - he won't know what's hit him once the Scottish winter sets in!

Well I'm going to take advantage of the full-speed internet connection here to upload this blog without (hopefully) several hours of waiting and false starts when my uploading is thwarted by "attempting to connect" error messages. Thanks for reading, and keep in touch.

Summer time... and the living is, well not half bad actually.

Greetings once again from Pondoland! It's sizzling hot here at the minute, between 25 and 30 degrees pretty much every day, and humid. It's actually been raining quite a lot here for the last few weeks - we had one week where we were entirely cut off from Port St Johns as one of the rivers burst its banks and made one of the bridges on the dirt road impassable for a few days. It meant we had hardly any patients for those days as it was only people who lived on the far side of the hospital who could get here - I don't think anybody was sorry when we weren't getting called at all hours of the night because the ambulances couldn't get through either... I've never been in the situation where ambulances have to divert away from the hospital I'm working at before - it always seems to be the other way around.

Last time I blogged I was about to start my weekend on call over new year's and expecting it to be a total shocker. It was ridiculously busy but not for the reasons I expected. I didn't have a single stabbed chest the whole weekend - unbelievable! Plenty of stabbings in other parts including one man who'd had most of the skin and muscle over his shoulder flayed - ten out of ten for originality, if nothing else. But the real issue was, as usual, obstetrics. In particular we had one horrific caesarean on new year's eve where my colleague who was operating just couldn't get the baby out of the uterus, which eventually tore and bled profusely. I was anaesthetising and having to manage a very unstable patient with only two units of blood available for the whole hospital, for the whole weekend. We lost one patient over the weekend because we didn't have adequate supplies of blood. Very traumatic for all involved. There was one fatality in Port St Johns from a shark attack, but the patient was dead at the scene so they didn't bring him here in the end.

It's been quite a busy month at the hospital all round, even now that most of the tourists and migrant workers have gone home. We did have one notable achievement in that we performed our first ever hysterectomy at the hospital for a lady with uterine fibroids and chronic bleeding. I think we were all quite nervous as it is a fairly major operation and I was certainly extremely nervous about the anaesthetic. All went well in the end, although there was one slightly panicked phone call to a consultant anaesthetist when I had a problem with the anaesthetic gas causing abnormalities in the ECG trace... It's just great to see that patient happy and healthy and not bleeding for the first time in years though.

I heard today about a patient I'd seen over the festive season who'd been bludgeoned with a knobkerrie (half club, half walking stick - bit like a shillelagh for the Irish) and stitched up at the local clinic, then referred to me as he'd had a seizure. I inspected the wound and discovered the stitches had come loose so was just planning to stitch it up again, but thought I'd give it a good clean and inspect it first. Anyway as I felt the edges of the wound with my finger I felt a few bits of broken bone and then suddenly hit something soft and squidgy - not good! I initially thought I'd just stuck a finger in his brain but quickly realised it was probably just clotted blood sitting on top of the brain. Still not good, so phoned the neurosurgeons who refused to see him, then the general surgeons who also refused and finally managed to get the surgical officer in A&E to accept him for transfer. Anyway he came back today, still doesn't know who he is or where he is - they apparently diagnosed a "minor head injury" without taking the dressings off his head and sent him home. Eh???!??! This is tertiary referral centre for the whole region.

Also this week I had an elderly lady transferred back from the orthopaedic hospital who'd waited here for almost two weeks before they had a bed for her. They'd admitted her and discharged her 4 days later, writing on the discharge summary that they'd done a hemiarthroplasty (half a joint replacement). Unfortunately they didn't transfer her back here for another 2 weeks after discharging her (and they wonder why they have no beds?!) and when I decided to inspect the wound discovered that there was no wound/scar. They'd done precisely diddly squat. When I phoned for an explanation they said they must have confused her with another patient... Would you trust these people to look after your granny's broken hip? I certainly wouldn't. I phoned the superintendent of the hospital to ask him to investigate but I don't have high hopes that anything will change.

I've been working at Isilimela for 6 months now - the longest period of time I've ever worked anywhere. It's been really good to settle into the job and form good working relationships with people. But I suppose the longer you stay the more the total lack of management becomes apparent. A far cry from the NHS where the very word "manager" was almost always uttered under your breath, I really notice the lack of any coherent system of management here. Nobody takes responsibility for things that go wrong, particularly when supplies run out of essential items like Oxygen, batteries for blood glucose monitors, or swabs. The wards are frequently abandoned as all the nursing staff take their lunch and tea breaks (of indeterminate duration) at the same time. The doctors are just as bad really - a case of too many chiefs and not enough indians meaning that nobody really takes responsibility for us either. We really need a senior doctor in charge.

Outside of the hospital, we've been up to our usual gallivanting of course. The first weekend after the new year I headed to Cintsa, near East London, which is yet another beautiful Wild Coast beach town. Even though we're only 4km from the beach here, there's something really cool about waking up and stepping onto a beach in just a couple of minutes. And if I'm honest, it was fantastic to have a nice bar where you could sit outside in the evening, have a few cold ones, listen to some normal music (not the weird fusion of Afropop/garage/house music called Kwaito that's usually blasted on car stereos around the hospital in the evenings, usually two or three songs on loop) and share a few laughs. There's also a private game reserve there with loads of game including white lions which were truly impressive. I'm also strangely fascinated by giraffes - they are just so graceful - and they were there in abundance.

The weekend after I decided it was time to put the bike through its paces and did a 1200km (750 mile) trip to Port Elizabeth. Really good to get a bit of wind in my hair, get away from the hospital and the hospital chat, and see some awesome scenery. Highlights included:
- seeing three little kids, the oldest of which can't have been more than three years old, hanging out by the side of the road entirely unsupervised and going absolutely mental as I passed them on the bike - clapping, bobbing up and down, waving furiously. Ridiculously cute.
- coming into Port Alfred and seeing the bridge over the Kowie river at sunset after a long day on the bike, knowing that I'd made it just before dark.
- walking along the beach in PE in blazing sunshine and meeting up with Dr Smith, the anaesthetist I stayed with in November
- riding through the arid country near Grahamstown with cactus-like euphorbias making weird shapes and shadows all around
- having an open-air bath under the stars in the forest near Hogsback
- riding down the mountain in the early morning from Hogsback with the bike just ticking over in third, hearing the sounds and smelling the smells of the forest in the morning sunlight
- the thousands of yellow, green and white butterflies that scatter from every puddle as they hear my engine go past
- the sign as you cross the Kei bridge and enter the Transkei with a picture of a cow and warning of "Animals on Road - next 400km". No kidding.
Not really a highlight, but on the Sunday as I was heading back to Isilimela it was unbelievably hot - felt like I was riding into a hairdryer or one of those heaters they have above doors as you walk into department stores in winter. Unfortunately I ended up getting badly sunburnt on approximately 2 cm2 of my skin overlying each ulnar styloid - the only exposed part of skin between my jacket and my gloves... Makes for an interesting tan line!

Definitely feeling the Africa love - but the last few weeks have also been time for me to start thinking about going back to the UK as I have job interviews next week in Edinburgh and Dundee for further training. In some ways it's difficult to even imagine working back in the UK again as it's become so normal to deliver a baby by vacuum at 5am, then do a joint medical/surgical/gynaecological/
orthopaedic/psychiatric ward round, then mixed general practice and outpatients before being an anaesthetist in the afternoon. But while I'm learning a huge amount here, I think I owe it to my future patients to undergo a formal training programme. And of course there are other, perhaps even more compelling, reasons to move back to the UK... So I'll be heading back on Friday for a flying visit to Scotland and NI - would be great to see as many folks as possible but I'm only around for a week unfortunately before I have to get back to work here. I'll be the guy wandering around wearing about seven layers and a conspicuously new thermal jacket I felt the need to purchase on the internet when I saw the temperatures back home... Anyway looking forward to catching up with many of you next week! Over and out...

Merry Christmas one and all!

A busy few months in the Eastern Cape! Last time I blogged I was just about to pick Gemma up from Mthatha airport and have 10 days off together. We had an amazing time - we did a 5-day hiking trail in the Drakensberg mountains as well as a brief trip up to Lesotho. The wildlife was amazing - from little prairie dog-like ice rats in Lesotho to hundreds of baboons loping around the mountain sides in the 'berg, and stumbling across a group of eland only about 50m to seeing a lammergeier soaring overhead. And the mountains themselves are breathtaking.
We then spent a night at Oribi Gorge, a nature reserve on the Mzimkhulu river which sits perched on the lip of an enormous forested canyon. They offer several extreme sports including the world's highest (possibly only?) canyon jump - I couldn't just walk away from that. It was a bungee jump next to a waterfall - you jump from the lip of the gorge over the falls and plunge down towards the river before they winch you up through the falls. In short, it was terrifying. But there's something quite special about hanging next to a huge waterfall just above the forest canopy, hearing the sounds of the forest and feeling you're the only person there, suspended in midair. After that we had a fantastic 3 nights at the Umngazi River Bungalows and Spa - what a beautiful place. The thatched bungalows are on the river mouth, surrounded by fantastic gardens and looking out over a perfect golden beach. We had all-you-can-eat breakfasts, 3-course dinners and lunches every day, a sunset cruise on the river watching African fish eagles dive for their supper, a canoe trip through a Mangrove swamp, and a massage overlooking the ocean. It's hard to believe this luxury is just a few miles from Isilimela!

Life at the hospital has continued much as usual. It's been getting busier and busier in the run-up to Christmas as the Transkei diaspora return from their homes all over South Africa and further afield to spend the holidays with their families. It's noticeable that for most of my time here we've always had more female inpatients than male; however, now the reverse is true as all the men who work in the big cities return home for the festive season, bringing their TB, HIV and proclivity for stabbing each other to share with the already downtrodden inhabitants of our little corner of Pondoland.

My own medical learning curve has been as steep as ever! I've now performed three Caesarean sections, thankfully always with the support of one of my more experienced colleagues. The second one is particularly memorable for taking place in the evening during an especially violent thunderstorm. Our electricity supply is quite fragile and in electrical storms it often cuts our, which of course it did mid-operation. So for a few (mercifully brief) moments we were actually operating by the light of a mobile phone! I also was able to travel to Port Elizabeth for two weeks of Anaesthetic training where I stayed with a fantastic consultant anaesthetist and his wife who have been incredibly supportive to us out here at Isilimela. It was a real eye-opener to work in a tertiary referral hospital in South Africa with consultants and highly-trained nurses and intensive care facilities, etc etc. But depressing too in that they were also plagued with lack of supplies - they ran out of laryngeal masks and several inhaled anaesthetic agents while I was there - as well as victims of the mind-numbing bureaucracy and appalling management which seems to be the curse of the health service in South Africa. I'm much more comfortable with the basics of anaesthesia since returning from the course and have managed three general anaesthetics since coming back which have all gone very well.

It was also great to be in a proper city for a change. Mthatha, our nearest city, is only barely worth the designation. It's a horrible, sprawling, catastrophe of a city - if you have a mental image of ugly, decrepit, rubbish-strewn cities in the developing world, Mthatha is the archetype. There are no traffic rules other than might is right, there are no pavements, no entertainment facilities or restaurants worth mentioning, and its main purpose for us is that it houses the nearest bank capable of performing any useful services, if of course you have the requisite forms signed in triplicate and your passport, proof of residence and preferably a signed letter of authorisation from the president of the republic, although they are prepared to waive this requirement if you stand in line for most of a day and accept some minor scowling and exasperated sighing at your clearly unreasonable demand to have access to your money. However it is one of those eyesores which you can, in spite of yourself, grow to love. I particularly love the newspaper billboards with their ridiculous headlines. A selection: "THE MYSTERY OF THE GIRL - AND THE COW!!" or "MORE RAIN - BUT NOT HERE!", or my all time favourite, "NGO SAYS, SHOW US THE MONEY, BIKER BABE!". Unfortunately I've never actually come across the newspapers themselves but the billboards always crack me up.

Port Elizabeth, on the other hand, is a nice city with beautiful beaches right in the centre of town, theatres, museums, restaurants, coffee shops, and most interesting to me, an array of motorcycle dealerships. It's called the Friendly City, and is known for its low crime rate (in South African terms). Certainly I felt pretty safe nipping around in my rental car and took advantage of having access to civilisation, stocking up on books, camping gear, nice food, etc. At the weekend my host lent me a tent and I took off to Addo Elephant National Park which most certainly lives up to its name. I have never seen so many elephants - unbelievable. There were also wildebeest, lions, kudu, eland, haartebeest, jackals, ostriches, zebra and innumerable other animals and birds. From there I drove to Tsitsikamma National Park which is really the start of the Garden Route to Cape Town. It's a rugged coastline with steep mountains and deep, dark river canyons. Also very beautiful but unfortunately my experience was significantly hampered by severely bad weather on the second day there.

Also unfortunate was the lack of suitable motorbikes for purchase in PE, despite significant time and effort on my part spent searching. They were all too expensive, too old, or too unsuitable for the rigours of dirt roads in the Transkei. So, regretfully, I booked another bus, this time to Durban where I'd seen a bike on the Auto Trader. The bus was an experience in itself - they take economy class to another level. hbThere are five seats to a row instead of the usual four and I mostly had to sit in the foetal position to avoid either fracturing my kneecaps through repeated collision with the seat in front with every judder of the spluttering engine, or losing circulation to my legs from wedging them underneath the seat in front. Thirteen hours of this - complete with screaming toddlers, ladies of improbable girth in the adjacent seats, interesting aromas, and no on-board toilet (possibly, but not definitely, a causal factor in the disturbances in the olfactory landscape). This is Africa, baby. Anyway I got to Durban thanks to a little help from some friends, and purchased the aformentioned motorbike which now has pride of place in my living room. It's so nice to have some independence - not to have to rely on my colleagues (or much worse, the notoriously unreliable hospital transport) to get anywhere. Every time I take it out, I love it a little bit more. The locals also love it - if you want attention, drive a motorbike through an African village. There seems to be something innate to the African Y chromosome which makes you love bikes - the boys yell, run and caper wildly behind me, the young men make cool hand signals, the older men stare or try to flag me down for a lift. One girl even yelled at me to try and give me her phone number! Not sure if she wanted a date or just a taxi service.

My maiden voyage was getting the bike back from Durban which was a 7 hour trip. We broke it up by staying just outside Port Edward in a nature reserve on the Mtamvuna river. There are so many arrestingly beautiful corners to this country, often when you least expect them. The owners of the lodge where we stayed suggested we borrow their canoes and head down the river the next morning. If you've seen Blood Diamond - this is the river where they filmed it, I'm reliably informed. It's a swathe of green between sandstone cliffs with fish eagles in the trees and weaver birds in the reeds. There's also a lot of flying fish, who kept jumping out of the river when we paddled through - amusingly once just as I got a call on my cellphone from Gemma and a fish jumped right at me, only missing my face due to a fortuitously positioned canoe paddle!

Back at the hospital then life feels pretty settled. I suppose as you grow more used to something, certain things which were just different at the beginning, and therefore new and exciting, begin to bother you as you realise that they could and perhaps should be changed. A few of my efforts in this direction have borne some fruit - I wrote letters to the National Health Laboratory Service and to Department of Health bigwigs complaining about the poor service we were receiving and have since had a couple of meetings with them, resulting in the fact that we all (doctors) now have Blackberry mobile phones which link into the Lab's results software. Plus we've seen a real improvement in turn around times for essential tests. I've seen some
improvement as well from the nurses who've attended the training sessions I've organised for them, particularly in shock and fluid resuscitation - I get unaccountably gleeful every time a nurse tells me, 'we noticed this is shock, doctor, so we put up some fluids.' It just didn't happen a few months ago. However there are still a lot of frustrations about which I am powerless to do anything. For instance, last week a private GP transferred me a patient who was paralysed on one side of her body and had a coma score of nine (which is well on the way to being in a coma). He'd had her at his clinic for four days and now decided to transfer her to me, suggesting a diagnosis of Bell's palsy. For the non-medical, Bell's palsy is a short-term paralysis of one side of the face only which certainly doesn't cause you to lose consciousness; while any medical student could probably have identified this patient as a stroke. This is a routine occurrence from the private doctors in this area who seem to be entirely unregulated, and extract huge amounts of money from our impoverished population. Shameful. The ambulance service also seem to be operating in a different universe, refusing to transport patients who are at death's door but then bringing patients in the middle of the night who are suffering from 'painful neck veins'. It's infuriating, and there is no apparent recourse - no one to complain to, no superior to call. And the patients here are so unaware of their own abandonment by the bodies which should be providing essential services to them, or so apathetic in the face of it, that they are unable to complain themselves, as they should, and loudly. We are trying to pick our battles - and be encouraged by every small victory.

This brings me finally to Christmas. It's been strange celebrating in 30-degree heat when Europe seems to be in a deep freeze. It was especially jarring to see fake snow in shop windows in PE, with Christmas trees and Santa chortling, while people walk about in shorts and vests outside and the sun is splitting the heavens. Back at Isilimela we had a lovely day - I made a Christmas pudding and put it on to steam while we went to the beach and caught some waves - perfect temperature. On the way back, the dog was so tired (and probably dehydrated) he couldn't keep up with the bike so my colleague Bregje had to pick him up and wedge him between us on the motorbike, which caused much hilarity. Shame we didn't have a camera. The Christmas pudding was so good I almost wept. There's nothing like it. I was even quite glad that no-one else likes it that much - more for me. We also made a Pavlova as a Kiwi friend has come to spend Christmas with us and apparently it's traditional in NZ. So good times were had by all! My housemate and colleague Annelieke, had her parents coming to stay, who arrived yesterday so we saved Christmas dinner (roast beef with roasted sweet potato and butternut mash) for last night along with opening presents. Santa's elves in Mthatha seem to have a fairly limited repertoire so there was a strong personal hygiene theme in Santa's offerings this year!

Today is the only public holiday in the festive season here - the others fall on weekends and don't get rolled over to the weekdays; I feel slightly cheated. But I've had a great day - we walked to a local waterfall and went swimming in the plunge pool. Perfect. I'm on call over new year's weekend - a 72-hour on call when I expect to sleep very little. Port St Johns is one of the famous destinations in South Africa for new year's eve and there'll be a lot of drink and drug fuelled revelling, which in these parts translates into a lot of stabbings and haemopneumothoraces for me. So spare me a thought as you sing Auld Lang Syne this weekend, I'll probably be groggily hacking at someone's intercostal muscles trying to get a tube between their ribs at 2am local time. I'll be thinking of you all, friends and family in scattered arts and parts, and thankful for all you have contributed and continue to enrich my life with. Sorry it's taken so long for me to update this blog, reply to messages and emails, or respond to Skype requests - combination of increased workload and shocking internet connectivity for the last month or so. But here's to a better 2011 - grace and peace to you all for the coming year, and looking forward to seeing many of you when I come back in February or August.

Donkeys, monkeys, and whales' tails

Spring is definitely sprung in the Transkei, and everywhere little piglets, goatlets, cowlets and donkeylets (is there a real word for a baby donkey?) are scurrying around trying to fatten themselves up on the new grass pushing through the areas which were burned over the winter. Strangely, there's been a bit of a dearth in human births at the hospital (although we do have two kittens born to our resident cats in General ward) but I am far from complaining. My last weekend on call I only got woken up in the night 3 times in 3 nights which I think is some kind of record here. The garden is also starting to look good - we've been eating home-grown lettuce and rocket in salads for the last week or so, and the tomatoes and peppers are starting to flower.

We still have no access to a car but I have been making the most of my mountain bike. It's now three weeks since I cycled to Port St Johns for the weekend for the first time. It's only about 30 miles but the first half is on dirt road and mostly uphill. I'm no geologist but when the Transkei was formed it must have been squashed inwards from the coast - the land is in deep corrugated ripples. So on the bike you're caught in a never-ending cycle of punishing uphills followed by exhilarating downs - 5mph then 50. The downhill on the dirt road is really fun - especially because the taxis (almost the only other vehicles on the road) have to take it quite slow so you can zip right past them. There's nothing a taxi driver here likes less than being overtaken, especially by a cyclist!

The reason for going to Port St Johns was to go on a whale-watching boat trip. South Africa has (apparently) some of the best whale watching in the world and back when I arrived you could barely look at the ocean without seeing a few plumes of whale breath. But the season is drawing to a close now so I wasn't expecting all that much. However the boat trip itself would be worth the money (about £35 for 2 and a half hours) - the captain stopped to say a prayer before we headed out of the Mzimvubu river mouth into the open sea, and once we hit the waves, it's not hard to see why he does this every time! They get a 20 metre swell in these parts and we were in a tiny little boat - he also has to time it just right so that he goes on the crest of a wave over the sandbanks, as otherwise the boat would ground. The sandbanks are also constantly changing position from one day to the next so it's no joke. Pretty extreme.

Port St Johns itself has a stunning situation. The Mzimvubu (Xhosa for 'place of the hippos') river cuts between two hulks of stone, Mount Thesiger and Mount Sullivan, in a deep gully with native rainforest clinging to the sandstone cliffs. The day we went, there was a fine mizzly rain so the cliffs were draped in soft clouds - it made me think of photographs of China or Vietnam. When you get out to the open ocean, then the hills of the Wild Coast stretch for miles with golden beaches at the river mouths punctuating steep green hills covered in aloes and coastal strelitzia.

The first wildlife we encountered was a school of dolphins who, in time-honoured fashion, came to frolic around the boat. They are incredibly beautiful creatures and I can't think of any other experience where wild animals come so close and seem to want to interact with humans so much. I saw one baby dolphin, probably about two feet long. But it was whales we had come to see and we were all scanning the horizon for twin plumes of vapour (the Southern Right Whale has paired blowholes so the spray comes out in a heart shape). In spite of my very low expectations, after about 20 minutes we did see the telltale spray and sped off in jet-propelled pursuit, following the "footprints" that the whales' bodies leave on the surface of the water after they surface. Incredibly, we must have seen over twenty whales that morning, some only about 10 metres from the boat. At one point, a pair of whales just next to our boat surfaced to exhale - we must have been only about 20m away - the boat captain and I both got a faceful of moist whalebreath. Unbelievable. We then set off towards an area where a large group of sea birds had collected as the captain said this suggested dolphin activity. The birds themselves, cape gannets, are quite beautiful white birds with a streak of bright yellow on their heads and black tips to their wings and tails. When we arrived it was a frenzy of activity with dolphins circling, birds diving and little streaks of silver mackerel darting all around the boat. The only thing I can compare it to is that BBC documentary series about the Sea - I've never seen anything like it. As we got to the centre we realised that about 7 sharks had joined the feeding frenzy - I can't deny there was a little frisson of fear as those dorsal fins circled our little boat.

Back in Port St Johns we were staying at Second Beach (there are three beaches with equally original names) in a beautiful lodge with samango monkeys scavenging in the trees outside the window. It's easy sometimes to forget that this is in fact still Africa. But little things, like monkeys outside the window, or no running water for two weeks, serve to remind me every so often when I'm in danger of forgetting.

The hospital too has its share of TIA moments. Not transient ischaemic attacks - I've yet to see one of those here - but the time-honoured foreigner's exclamation, uttered with varying degrees of exasperation, bewilderment, or empathy with another's confusion, "This is Africa." For example, I have an elderly patient who was stabbed in the chest and had a massive haemothorax (blood inside the chest where the lung ought to be) who did quite well after I drained the blood out but was still extremely short of breath. It turns out he had nowhere near enough blood (Hb of 6 for the medics) so I arranged a blood transfusion - of course that takes 4 days as the blood has to go to Mthatha for cross matching and then someone from the hospital has to go to Mthatha to pick it up. Unfortunately after all that, the driver who picked it up decided it was too much effort to actually deliver it to someone in the hospital and so deposited it outside the security lodge at the hospital gates without mentioning to anyone, where it remained throughout the sultry Transkei night until the ward sister found it in the morning. Dilemma - do we give this man the blood which has been outside of the fridge for an unknown length of time and at an unknown temperature with unknown pathogens potentially multiplying furiously? Or do we let him wait, gasping, for at least another week (now a weekend is involved) and get some more, knowing that other, equally improbable, misadventures may befall this second lot? Nothing in my medical training has prepared me for this scenario! Answers on a postcard please.

I read a verse in Proverbs a couple of weeks ago which has been inspiring me ever since as it seems sort of emblematic of what we're doing here. "Rescue those being led away to death; hold back those staggering towards slaughter. If you say, 'But we knew nothing about this,' does not he who weighs the heart perceive it?" (Proverbs 24:11-12) Every so often when I feel what I am doing is insignificant, a bit like Sisyphus pushing that mythical rock endlessly up his mountain, that verse comes back to me. When you see the people I am seeing in our antiretroviral unit in a weekly clinic when I start them on AIDS treatment I really do feel like these people are being carried away to their death - they seem so powerless, trapped in a downward spiral which they have never understood. The treatment we have is far from perfect there have been some truly miraculous recoveries.

My Xhosa is still very limited but beginning to improve. Every so often I understand a little of what the patients say - I can recognise quite a few key words like cough, vomit, night sweats, blood, sputum, painful etc. I can tell patients to sit, lie down, ask them if it hurts where I'm pressing and tell them to breathe in and out. Pretty much the basics I need if I am going to examine someone. The clicks are difficult but I think I'm starting to get the hang of them. It makes the whole ward, and all the nurses laugh every time I do it though! There are three main clicks - x is like the sound you make when you want to make a horse giddy up, at the back of one of your cheeks. Q is the sound you make with your tongue against the hard palate when you want to make the sound of water dropping, or the clip-clop of horses' hooves. C is a sucking noise with the tip of your tongue just behind your front teeth, a bit like a "ts" noise or when you tut at someone (which of course, we all do regularly). I can make all of them now but it's difficult to integrate them into words especially when there's more than one click in a single word. Or difficult consonants are juxtaposed with the clicks - like when c is preceded by g or even ng in words like Ngcobo.

Anyway I'm pretty excited as both my medicine and my Xhosa can take a short rest for a while. I have annual leave for the next 12 days as Gemma's coming from Scotland - we're going to be hiking in the Drakensberg then relaxing at the coast for a few days. It's the first time off I've had since our last expedition, to the Western Isles back at the beginning of June. I've rented a car (a Kia Picanto - we shall see how it handles the road back to Isilimela tomorrow) and am currently relaxing with two of my colleagues in the Maloti mountains, just south of Lesotho. We're staying in a backpackers lodge next to a beautiful waterfall run by two kayakers who have renovated an old farmhouse. No electricity and all the water is collected rainwater! Really nice. As I type I'm on the verandah looking out over the river gorge with huge black clouds drifting off into the distance after they have deposited their cargo of rain. It was totally dark about 20 minutes ago due to the clouds and the heavy rain, and now, as it's brightening up, the cockerel is crowing - must think it's dawn again. Driving here last night was the worst visibility I've ever seen - about two metres at times. We were driving in second gear, navigating using the lines on the road which I could just about make out at the tip of my bonnet (although the line on the nearside of the road was usually obscured by the beam from my headlight in the fog so I mostly had to use the line in the centre of the road). Crazy. The sun's coming out now so perhaps it's time for another foray into the outdoors. I'll leave it here but thanks once again to all for writing, texting, phoning, praying. Whale watching season runs April to October so now's the time to start booking for next year...

An eventful few weeks since my last installment - life is settling back into a more usual routine in the hospital after the disruption of the strike, but life is anything but normal here.

The conference I attended in Durban 2 weeks ago was really excellent. The speaker was a very passionate South African specialist in infectious diseases whose enthusiasm was definitely infectious. Unfortunately, that's not the only thing I'd picked up. I started feeling a bit ill even before I left Isilimela and by the middle of the conference was feeling pretty rubbish. We went out for a curry on the night of Eid al Fitr - Durban has a large population from the Indian subcontinent and is famous for its "bunny chow" which is a curry served in half a loaf of bread. I started to feel really nauseated not long after starting mine, and couldn't actually finish it which is almost unheard of for me. Then all that night I was up with a roaring fever and diarrhoea, but still didn't figure out what was going on until Sunday morning by which time I hadn't really eaten in 24 hours due to the nausea. I had a huge (about 5cm) swollen lymph node in my right groin which was really painful every time I moved my leg, and then noticed a swollen welt with a necrotic core just to the side of my right knee. Pathognomonic for tick-bite fever. I should have realised ages earlier but hadn't ever noticed being bitten etc etc. Anyway the upshot was I had to have a week of Doxycycline, couldn't eat a thing for 4 days, and missed a day's work. Back to normal now, thankfully. Apparently it's a bit of a rite of passage for foreigners coming to work in these parts, especially if you're foolish enough to take your dog for a run to the beach through the long grass and the marijuana plantations...

Let me tell you about my run to the beach, in fact. It's just so beautiful that I think I ought to describe it. I have to run down a steep hill from the hospital to join the main (dirt) road that leads to the beach. It goes past the 'spaza' shop which is the only commercial outlet in these parts for miles around, apart from the shebeen (an African tavern, for those of you not familiar with SA slang; and the locale for many of our weekend stabbings). I run along the road until it meets the Siningwana river which I follow as it wends its way through subtropical rainforest - the rains are just getting going properly here so everything is starting to get lush and green again. At the minute the deep greens of the trees are setting the dun hues of the dry grassland off just perfectly in the evening sunshine (or the pale dawn half-light, depending on when I get to go). I have to turn off the road to cut through a little patch of forest where you run through the aforementioned marijuana and long grass. Apparently the British banned the people of Port St John's from growing tobacco as they wanted a monopoly on the trade some time in the 19th century, so they turned to marijuana instead and it's always been a part of local culture since. There's usually a fair number of blokes in rasta hats trying to sell me dagga, the local weed. All the while there are a few groups of local mamas walking home, or kids, or men coming back from fishing, who greet me with, "Molo, doc" or, "Ewe, igqira!" ('Greetings, doc' or 'Hey, doctor!') Then you rejoin another road and start to climb up the hills above the Siningwana valley and that's when you first glimpse the ocean - the beach at Siningwana mouth with its huge cliffs and breaking waves. There's a lagoon, as there seems to be at the mouth of all the rivers here, between the beach and the forest just beneath the road at this point. Not infrequently, you'll see someone out fishing in a canoe. I carry on a bit further over the hills, pass a small village of rondavels painted in the ubiquitous but not unattractive mint green, terracotta and salmon pink that the Xhosa seem to love to paint their dwellings, and start descending through thick forest to Mpande beach. The trees get bigger, there are giant palms and trees with huge gnarled roots which extend right down to the beach. And then suddenly the ocean is in front of you, invariably as wild as this coast's name claims it to be; roaring and making the air thick with its spray. There's rarely ever anyone else there - occasionally a few boys going across to the football field or a solitary figure heading from one coastal village to another. I can head in for a quick swim, then turn around and do the whole thing again in reverse. It's about 5 miles round trip and takes about 45 minutes. Stunning.

Unfortunately I haven't managed it as much as I'd have liked, just a couple of times a week lately. Either I finish work too late and it's dark, or I'm on call and can't leave the house, or I'm knackered after being on call the day before, or it's my turn to cook dinner etc. The on call shifts have been ok although I feel like they're taking their toll a bit as well. I never thought I'd appreciate the European Working Time Directive given how much crap it felt like we had to deal with from it, but there is something really psychologically draining about knowing you are solely in charge of a hospital and all that its catchment area can throw at you for 72 hours straight. In reality, though, last weekend was not as bad as it might have been. I probably averaged 5 or 6 hours sleep a night. I had three stabbings - thankfully people are usually too poor to have guns here so they stab each other when they get drunk rather than shooting which is what they prefer elsewhere in South Africa. Usually they're not very good at it either, and the really bizarre thing is that usually the stabber accompanies the stabbee to the hospital in an apparent act of remorse. So thankfully no major organs were damaged and it just meant I had some creative suturing to do. I also had two ladies with imminent eclampsia and one who had already fitted - but I just had to transfer them all to Mthatha. The really scary point was on Sunday evening just before my colleagues were due to get back I was called to a primigravida in labour who was fully dilated but just not pushing the baby out. Having never before attempted either, and with my instruction from the South African Family Practice Manual, I had to perform an episiotomy and a vacuum extraction for a baby which just didn't want to come out. For the non-medical out there, that's exactly what it sounds like - you basically attach a glorified hoover to a plastic cup roughly the size of a baby's head, attach that to the baby's head, and pull hard. I'm not going to say it went swimmingly well - most of us in the room ended up covered in blood (HIV negative, fortunately) when the cup came unstuck but suffice it to say that both mother and baby did very well in the end, thankfully.

It's been a bit of a week of firsts for me. I also did my first general anaesthetic - entirely unplanned and learning how to work the anaesthetic machine as I went. It was a lady who, for a series of complicated reasons, we discovered had an ectopic pregnancy and was bleeding into her abdomen while she was on the operating table. Unfortunately the spinal anaesthesia had failed (the first time it's happened to me since I got here - not a great moment for that to happen) so we were doing it with Ketamine anaesthesia, but she was getting too much pain and it was impossible to proceed. So we had to convert to a general - but after several attempts couldn't get her teeth open enough to pass a laryngeal mask. So I had to bag and mask her with Halothane for the whole procedure (over an hour.) She did vomit once, so I had to suction a few times, and I was sure I could hear crackles in her right lung at the end of the operation so started her on antibiotics for aspiration pneumonia anyway. Thankfully she was alright afterwards and went home 2 days later looking a picture of health. It was all a bit scary but I think it's encouraging for this general anaesthesia course I'm doing in November - at least I have a better idea of what I need to learn/practice. And I'm probably not quite so terrified as I might otherwise have been, although I'm assured I kept a pretty calm facade throughout the whole fiasco. I also passed my first intercostal drain yesterday - for a 70 year old man with a massive haemothorax (he'd been stabbed on Saturday, attended a neighbouring hospital who sutured his thoracic wound without examining his chest and then attended his clinic on Monday feeling very short of breath - no wonder, his Haemoglobin was 6g/dL). I also had to put in an intraosseous line for a dehydrated 1 year old last week - it's like an ATLS masterclass out here.

Apart from medicine, the garden is coming on nicely. We now have tomatoes, chillies, lettuces, and a few herbs growing pretty convincingly. Unfortunately I suddenly lost a whole load of butternut squash, pepper, courgette and aubergine seedlings at the end of last week and I still have no idea why. One of the many things I have to puzzle over out here.

This weekend I spent in the Drakensberg with my three Dutch colleagues (we have now been joined by a third doctor from Holland). The mountains are just immensely beautiful there. It's such a contrast to the outdoors back in the UK where on any given day in good weather you are just one of a multitude of eager hikers taking over the mountains. I think in three days hiking we saw two other people. So we had these beautiful trails, with huge caves, waterfalls and clear pools for swimming all to ourselves. Unbelievable. Unfortunately my camera battery gave out on day 2 and I'd forgotten to bring my UK adaptor to recharge it so I have little evidence of this beauty but you know, sometimes that's maybe for the best. The plants there are also incredibly beautiful - lots of varieties I recognise from gardens back in the UK where I guess they must've been exported for decorative purposes. But also loads of indescribably pretty little alpine flowers just growing everywhere - especially one called Berkheya which looks so perfect it's hard to believe it's not artificial. The petals are small and papery, in a very architecturally pleasing arrangement (I half-remember something from a poster in a Maths classroom at school about Fibonacci numbers?) Anyway my inner botanist was happy as a clam.

Unfortunately on the way back, the 10-year old Jeep Cherokee which we share here decided once again to throw in the towel. This time it's either the automatic clutch or the transmission fluid - but it refuses point blank to go into any gear. Apparently it's done roughly the same thing 3 times in the last year although with a slightly different flavour, and ultimately a different cause, each time. And in between there's been lots of other problems. The real issue is that we live 17km down a dirt road and the nearest Jeep garage (the only place where they can fix all the electronics in that car) is a 5 hour drive away in East London. It's quite frustrating for all of us, as we're stranded here yet again, but pretty heartbreaking for Annelieke who actually owns it. I think we're going to have to sell it and buy a car we can service/repair in Mthatha, which is a bit of a hassle. I'm definitely thinking about the bike again too. On the subject of bikes, I'm now the proud owner of a beautiful Specialized Hardrock mountain bike which has been great for nipping about the local roads when I haven't quite enough time for running. And it should be good for exploring the Transkei on the weekends as well - there's a few nice backpackers' lodges within a day's cycle.

So all in all, things are going well. South Africa is living up to my expectations - it's beautiful, challenging, fertile ground for learning new skills and remembering old ones. I am really blessed to be here and to have such an amazing opportunity, and doubly blessed to be able sometimes to see that I am also able to be a blessing to others. I should really talk about some of my patients, too, but there's so much to say and this blog is already, typically, wordy. But I love seeing people coming in with their minor traumas and going out with big smiles on their faces. I stitched a man's lip a couple of weeks ago - the plastic surgeons would've gone mental - but he was so grateful afterwards that he no longer had a big gaping hole in his face. And the children who come in malnourished due to TB and leave looking healthier, happier, playing again and gaining weight. Or the lady who was on the ward the whole way through the strike because of Pneumocystis pneumonia who none of us thought would make it, who is now started on ARVs, gaining weight and has gone home looking like a new woman, smiling and laughing. The flip side is there are a lot of people who are just sick for a long time, and don't recover. And often we are not sure what is wrong or whether our treatment is likely to make any difference. But every so often, you have a fantastic surprise. And I guess that's one of the many things that makes life here worthwhile.

Thanks again for reading, and keeping in touch, and praying.