ACROSS THE WIDE ZAMBEZI
A DOCTOR'S LIFE IN AFRICA
BY
WARREN DURRANT
Copyright @ Warren Durrant
Warren Durrant has asserted his right under the Copyright, Designs and Patents Act 1988 to be identified as the author of this work.
KINDLE edition
This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, hired out, or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent publisher.
First published in Great Britain in 2013.
PublishNation, London.
www.publishnation.co.uk
For my wife
PART ONE - WEST AFRICA
1 - Beginnings
The personnel manager swept his hand over the beetling crag of West Africa on the wall, where a green swath ran across the lower part of the map, and announced: 'This is the rain forest.' He pointed to a spot on the line of a river, a name, and added, 'And this is Samreboi.'
I was forty, unmarried, and, after ten years in general practice, was looking for a change. I had long had an interest in Africa, so when I saw the advertisement in the British Medical Journal for a medical officer for a timber company in Ghana, I applied. I later discovered that I was the only applicant. So much for the spirit of adventure in the old country The year was 1968. (This is unfair. I doubt I would have left the country while my parents were still alive (they died before I was forty); and certainly not if I were married with young children).
Here I was in the London office of the great United Africa Company, which many called the real government of West Africa.
Besides the personnel manager, the chief medical officer was present. He enlarged on the duties briefly indicated in the BMJ.
I would be sole medical officer to the company employees and families, and to the rest of the population of the town and a considerable area of the surrounding countryside. I would have a small hospital, where I would undertake some surgery: caesarean sections and hernias were mentioned.
My sole surgical experience then, consisted of the minor procedures of hospital casualty and general practice, and a handful of appendix operations, performed under supervision as a houseman. This experience, though limited, had given me that most important surgical initiation, the 'feel of the knife' - a breaking of the ice (to mix the metaphors), which confers that all-important first strengthening of the nerve.
Nevertheless I asked the doctor if I should try and get some more surgical ex-perience before I left. He said it would probably put me off. In fact, no training appropriate to African practice (embracing both surgery and obstetrics for a start) was available in England.
He explained that in my Herculean task I would have the help of medical assistants - a breed special to developing countries: half nurse and mini-doctor. These men and women receive two or three years' training in diagnosis and simple treatment. Some receive further training to take X-rays or give anaesthetics, work in laboratory or pharmacy, etc. Some girls train as maternity assistants, and not only manage normal deliveries, but twins and breeches also. All in all, they are the backbone of African medical practice, and without them, the task of the thinly spread doctors and even more thinly spread specialists would be impossible.
For I was also informed the nearest hospital with specialists was a day's journey away: too far for emergencies, and with too few specialists to deal with any but the most difficult cases.
I had a good idea of all this when I applied for the job. It was because I was looking forward to this kind of challenge that I applied in the first place.
In those days, one flew to West Africa by daylight, in a VC 10. By midday we were over the Mediterranean, and as the lunar mountains of the Atlas appeared, I knew I had left the bounds of Europe for the first time in my life - the bounds of law and safety, for the perilous world beyond - a romantic notion, both true and not so true. And then we were over the Sahara.
The plane seemed to be flying through a vast furnace, whose rising fires obscured the horizon and met in the smoking zenith. Clarity prevailed only far below on the desert floor, where from time to time mountain ridges appeared, which would have made delightful walks in the friendly Lake District, but here were lost in the appalling emptiness of a planet inimical to life. Dunes showed in tight ripples like the tide-ribbed beaches of home. Even lonely roads were seen, leading to the occasional ant-heap of an oasis, like a space station on the moon. Beyond all was the sea of sand. After some hours of this hellish progress, the sun wheeled for a few minutes in the starboard windows, before drowning in the brown shadow, rising from the earth. Lights came on in the cabin. The stewardesses served drinks. The kindly human world was restored.
Landing at Accra was like going back to the beginnings of the world (in Conradian phrase) - the moist and muddy world of the dinosaurs: one almost expected to see one lumbering out of the black African night, the blackest of all nights. The first thing I noticed on stepping out of the plane was the smell - no, not a bad smell: what I can only describe as a 'boiled' smell, the smell of a laundry, as if the whole country had been boiled and reboiled from the day of the Creation, which I suppose in a way was true. A sinister smell, with a certain burnt edge to it: a disgraceful smell, where morality was unheard of - abandoned on another planet. In the days that followed, this smell would come and go as I went in and out of air-conditioned buildings, themselves feeling as sinister as the cold of a morgue, until one got used to it and no longer noticed it, and it became lost even to memory, like the romance of first impressions.
The airport building was then little more than a large shed, awash with a sea of black faces, as if the night had invaded the building and threatened to overwhelm the feeble electric lights. At the barrier, one of the black faces lighted up for me: 'Dr Durrant?' This was Mr Aggrey, the company representative, who led me to a battered car. We both sat in the back, which was the proper place for 'masters' like us, and the chauffeur drove us to a large bleak hotel.
The next two days were all strange old colonial buildings , the surf and golden sands at the beach club, a lush and varied landscape, glimpsed from the plane on the way to Takoradi down the coast. Then another chauffeur: Samson, to take me up country.
I sat in the front passenger seat, rather to Samson's surprise, the better to chat to him. The tarmac road was not very good, full of holes and puddles, through all of which Samson charged with ruthless speed, taking no care of whom he splashed with muddy water - and more surprisingly, they seemed not to resent it - nor of the agile children who dodged out of his way. For there were people everywhere, people who seemed to be made of rubber, so fluid were their movements, so utterly free of the tensions of the white man: the women in their long skirts, their elegant head-scarves, some carrying things on their heads, moving like water plants; the men in shorts and shirts, mostly ragged, prancing along; the darting children. A cloud of tobacco smoke actually preceded round a bend by half a minute an old woman with an enormous pipe. A social world full of greetings and talk and laughter, the talk delivered at the top of the voice, for in Africa, although I did not know it then, it is considered antisocial to talk quietly and therefore secretly.
We went through a mining town - Tarkwa - all hot tin roofs, ugly industrial workings and sheds, winding gear, shabby buildings of all colours, stores, awnings and colonnades, hoardings, a tranquil grove of palm trees: as seedy and lively and picturesque as only an African town can be. Then o
n to the open road again, which more and more gave way to earth - and the earth was the colour of gold. For this was the Guinea coast and the mine was a gold mine: the gold of the guinea pieces, the richest gold in the world.
Another mining town , Prestea, and then quite suddenly, the forest.
The rain forest was then in better condition than I fancy it is in now. Indeed, my son's school atlas seems to indicate that it has vanished from those parts altogether. Then it was still magnificent. The road turned to red laterite and became the aisle of a great cathedral. The forest giants stood two hundred feet high, with some, the emergents, towering even higher above the canopy: for the great trunks were naked until they met and joined together above like the surface of the ocean. The trunks were supported by buttress roots which rose about twenty feet and looked like the fins of a space rocket. Between, tangled the undergrowth, which it needed a panga (or cutlass as it was called in West Africa) to get through, except where well-worn paths had been made and kept open over the years by people travelling to the forest villages. To me it is the most beautiful forest in the world and still seduces my dreams.
Suddenly the road opened on a clearing. Industrial sheds, workers' houses, a few large houses set back in spacious gardens, where the managers lived. This was an outstation: there were two in operation at that time. Then the forest closed around us again for another ten miles.
And then we got there, the town of Samreboi. A long straggling street, barely tarmacked: a mile long, lined with the usual flimsy stores and full of people. Then larger buildings: the police station, churches, and, in a grove of trees, the hospital.
This was a single storey affair: the main wards and a number of other buildings all joined by concrete gangways, covered with roofing against the rain. I got out of the car. A tall handsome white man of about fifty emerged from an office and came towards me. This was Des Brennan, the locum. The previous incumbent had left some months before.
He shook hands with me and said: 'Dr Durrant, I presume.'
Well, there wasn't much else he could have said.
He took me into his office and gave me tea. Then he took me on a tour of the hospital.
There were a men's ward and a women's ward. There was a wide veranda, enclosed with mosquito mesh, where the children were put with their mothers. On the wards we met Miss Lemaire, a very pretty black girl, who was deputy matron. And in due course, we met Jenny, the matron herself, a redoubtable Scotswoman of middle age.
We met Mr Sackey, the chief medical assistant, a sort of regimental sergeant-major, with no nonsense about him. We moved on to the maternity unit, which contained a labour ward and two lying-in beds, where we met Emilia, the petite and dynamic midwife.
There were an operating theatre, a laboratory, pharmacy and X-ray department: all very rudimentary and staffed with cheerful, undaunted operatives. Lastly, there was a private ward for the managers. The hospital had about fifty beds in all, which is not many even for Africa. No food was provided. Patients were fed by relatives; and always at the front gate were women ('mammies', as they were called) selling food.
Des took me back to the office for a final briefing: he was due to leave next day. He waved his hand at an uncrowded bookshelf. 'There's some operating manuals there if you get stuck.' I may say he was a bluff Irishman.
He glanced at his watch. 'The bar'll be opening now. Come along. I'll introduce you to some of the boys.'
Des must have felt I needed the bar by then, and, by golly, he was right!
On our way to the club, we passed a group of black children with red curly hair. I had heard that the malnourishment disease, kwashiorkor, could produce this effect, but these youngsters were healthy and lively. I asked Des about them, and he said it must have been an Irish missionary or (with a glance at my dwindling locks and from my introductory remarks) 'a doctor from Liverpool'.
Next day, in an historic tableau, we shook hands before a large crowd of black faces, before his car disappeared in a cloud of dust and cheering small boys.
I never felt more alone.
2 - My First Caesar
I will never forget my first caesarean section. I was wakened by the telephone at three in the morning of my fortieth birthday. Emilia the midwife spoke.
'We've got a breech, and it's stuck, and we can't get it out, and there's another one inside.'
When I got to the labour ward, it was as she said. An African woman was lying on her back on the delivery couch, her long legs up in the stirrups. She stared fixedly at the ceiling, in all the fathomless impassivity of her race. Two other nurses stood beside her, one on each side. They and Emilia stared expectantly at me out of their black eyes, over their masks.
Hanging from the woman's loins was a small body, feet first, limp and grey, quite obviously dead.
When I applied the foetal stethoscope to the woman's belly, I could hear the faint heart-beat of a second twin.
My first thought was that picture which all medical students remember and never see in real life of locked twins, where the head of the first twin is trapped by the head of the second. If the reader lays his two fists together, opposite ways, he will get the picture.
I did not know how to deal with locked twins, so told Emilia frankly: 'I'm going to get the book out.’
In the office, I took down an old copy of Eden and Holland from the scantily stocked shelf, Des Brennan had indicated.
As far as I remember, Eden and Holland informed me (rather unnecessarily) that the first twin is usually dead. The head should be severed from the body (or vice versa presumably, depending how you look at it), and pushed back into the pelvis, to allow the passage of the second twin.
Armed with this knowledge, I returned to the labour ward, and, using some instrument I dare not try to remember, severed the neck. The body fell into a bucket, with a dull clunk.
Now I tried to push back the head. It would not budge. The initiated will guess what I discovered next. The first twin was a hydrocephalic - a big-headed monster. Moreover, my examination revealed that the woman had a contracted pelvis, a common disability among the undernourished women of the Third World. She would have difficulty delivering any kind of baby, and this was her first pregnancy.
I decided to 'cut my way out of trouble', by which we in the trade mean a caesarean section. I asked Emilia to prepare for operation, while I repaired once more to the office and Eden and Holland.
The chief medical officer in London had told me that the classical operation is the easiest. This means a vertical incision through the uterus. It is true it is the easiest, but the lower segment (cross cut) operation is far superior, and any doctor worth his salt will learn it as soon as possible.
As it turned out, the classical operation was going to be more appropriate to this particular case.
I read up the details of the operation, and made my way to the theatre, feeling hollow and afraid in the sweltering African night. There was no time to send this woman anywhere else with any hope of saving the baby, or even, perhaps, herself. Besides, country doctors in Africa are not expected to transfer cases for caesarean section.
At the theatre, I found Mr Sackey had arrived. He was to help me. There remained the question of the anaesthetic. I had discussed this with Des Brennan, during our brief handover.
'What do you do about anaesthetics?'
'We do spoinals.'
'How do you do a spinal?'
'You do a lumbar puncture, and bung the stuff in.'
Which, I might say, is not the last word on spinal anaesthesia. I expect Des thought, if you've got to shove a fellow in the deep end, the less said about it the better.
Mr Sackey, who seemed to know more about spinals than me, had got a drip going, laid out the tray, and sat the woman up across the operating table. He looked expectantly at me.
I did the lumbar puncture, and ' bunged the stuff in'. Mr Sackey laid the lady flat, and wound the table head down for a few minutes. Presently, he levelled it again, and set up a scree
n over the patient's chest. During a spinal anaesthetic, of course, the subject remains fully conscious, but is numb from the waist down.
Then we scrubbed up, gowned, and gloved. I remember seeing Mr Sackey's packet of Tusker cigarettes lying somewhere, and mentally catching at this homely object, like a psychological straw.
The operation went easier than I expected. I removed the second twin from the open womb. It was small and inert and covered with meconium, which is the baby's faeces, passed in distress, and a sign that it had had little time to live, if it was not dead already.
I cut the cord, and handed the object to Emilia, like a muddy little frog. She took it into the next room, and went to work on it. Presently, I heard the cry of a baby.
'Is that our baby?' I asked.
'Yes,' replied Mr Sackey, impassively.
To confirm his statement, Emilia bounced back into the theatre, bearing aloft the blindly staring little creature, wrapped in a towel.
'Jesus Christ be praised!' I shouted. Obstetrics can be an emotional business in Africa.
I removed the two afterbirths. Now remained the problem of the severed head, still stuck rock-like in the depths of the womb.
I tried to remove it with my hands. No movement. I applied forceps. No go. Finally, I stabbed the head several times with a pair of scissors, and it came away.
At this point, the patient woke up (sic).
What was more surprising was that she had been asleep so far. I have already explained that a spinal anaesthetic leaves the patient awake. But with the screen before her eyes and finding nothing further expected of her, she decided to improve the occasion with a useful nap.
Across the Wide Zambezi: A Doctor's Life in Africa Page 1
