Across the Wide Zambezi: A Doctor's Life in Africa

by Warren Durrant

  I went fishing by myself. There were some lovely dams around Gwelo and though I caught little, it was very pleasant to spend an afternoon among the sights and quiet sounds of the high open country. Sometimes little clouds sailed across the hot sky of summer, and I had recourse to an umbrella to save my skin. Other days were as grey and cold as Yorkshire (or seemed so), under the peculiar drizzle or Scotch mist of the country, called guti. But always lovely places alone with space and nature.

  Coming home from one dam along a dirt road I skidded (something one can do as easy as on a wet road, which I did not know), and after a few turns, ended up in the ditch. Typically, I had lost my bearings. It was night. I found the Southern Cross and quickly reorientated myself. The car was bent and undriveable. Some passing Africans told me I was fifteen miles from Gwelo, too far to walk, and directed me to the farmstead of Mr Pringle, whom I found watching his Sunday night telly. He kindly took me home, and we even got a garage man to rescue my car, which they assured me would otherwise be minus wheels by morning. They had to send to Italy for spares, and for five months I was 'without wheels' anyway.

  That year was a drought year, and one burning morning succeeded another as I showered and breakfasted and enjoyed the equally sensuous monotony of Delius's Cello Concerto on my record player. Very pleasant for me, but I little knew what a threat to life it was to the poor people in the tribal lands. The country was well-managed, and there was 'corn in Egypt' for the dry years, but even in Gwelo I saw the effects of malnutrition: a little boy on the verge of blindness from measles, whose sight I was able to save with a single dose of vitamin A.

  I noted, not for the first time, the originality of African parents in naming their children. In Zambia, one 'Disgusted, Bongo Bongo' had complained to the Times of Zambia about 'this practice of giving our children these ridiculous names derived from the culture of our colonial oppressors. How can anyone achieve dignity in life with a name like "Motorcar"?' Needless to add, 'Disgusted Bongo Bongo' was a name conferred on the writer by himself and not by his parents.

  These names would be plucked at random, it seemed, from the hedgerows of experience. A simple visit to the supermarket might result in such christenings as 'Weetabix' or 'Fairy Liquid' (the later a rather lovely name for a girl, though it was mostly the boys who were the subjects of such exotic experiments: the girls, as the carriers of tradition, I suppose, usually bearing such old favourites as 'Dorcas' and 'Rebecca'). A mechanic visited northern Zambia, left his handbook behind, and returned a year later to find a number of little 'Carburettors', 'Chokes' and 'Big Ends' - all boys, of course. In West Africa I met a 'Keyboard' Ankrah, and, in Zambia again, Andy Crookes collected a 'Durex' Musonda: acquired accidentally, perhaps!

  Popular names for boys were 'Hitler' and 'Stalin'. Knowing nothing of the details of those distant squabbles of the white men, African parents of the time yet recognised that these names represented powerful figures in their own circles, and the God of Africa is the God of Power. It amused me later, in Shabani, to greet my clerk each day with: 'Good morning, Stalin!'

  But top of my own collection were the three little boys I found before my desk one morning in Gwelo clinic, all in Balaclava helmets, for it was one of those cold days you can get even in summer on the Highveld: each one smaller than the last like Russian dolls. Their mother, who sat behind them, presented their cards. I could hardly believe my eyes. 'Are these their names?' 'Yes,' replied Mother, simply. They were: 'Anyway', 'God knows' and 'Breakfast'.

  3 – Marandellas

  One day, after six months at Gwelo, Mav told me I was wanted at Marandellas, as acting superintendent, no less, as the senior doctor there was on long term sick leave. Marandellas was a 'general hospital', a breed now extinct - really a glorified district hospital, augmented with an extra number of European beds, to be found in small towns with a larger than usual white population. These white beds were used by private GPs of whom there were a number in the town, apart from those occupied by the white government patients already mentioned. The hospital had an establishment of two government medical officers, including the superintendent. I made the journey with Anderson by train (my car being still in dock) - I first class, he fourth class: myself at government expense, Anderson at my expense. Not that I was too mean to buy Anderson a first class ticket, nor was the section banned to Africans. I knew where he would be most comfortable.

  When I arrived at Marandellas hospital, I stayed in the nurses' home for two weeks until I was able to find a cottage nearby to rent. There was no servant's accommodation, so Anderson found a bed in the township and came to my house on his bicycle. I was to stay at this hospital for twelve months, though when the super returned I reverted to number two. In the meantime, a succession of locums helped me.

  Three Scottish sisters arrived at the same time, but like the girl in The Nun's Story they were not happy to be assigned to the idle European hospital where they felt, quite rightly, they were under-used. They all moved later to Bulawayo where they more active and happy.

  Marandellas was always my favourite town in the country. At 5500 feet it was the highest, with the possible exception of Inyanga in the Eastern Highlands. It was on the crown of the Highveld, with vast sunlit views of fine grasslands and distant avenues of tall blue gums on the white farms. The landscape was broken by many stony kopjes, and winter and summer, the air was clear and bracing.

  The town itself was small - I called it 'Stow-on-the-Veld', for a number of reasons, not least because it had the largest percentage of Britons in the country: around the bar in the club they outnumbered the Rhodesians. They were mostly old, and I used to say it was a sort of elephants' graveyard where all the old 'Poms' went to die. It even had something in the town centre called the 'Green', which was usually brown, and most of the shops were built around it, apart from those on the main Salisbury road. But it was the usual spread-out African town, far more spacious than anything tucked up in the Cotswolds. There was a number of leafy avenues in the town itself, but houses spread out to a distance of seven miles - each fifty or a hundred yards apart, in up to ten acres of land. Even the township, Dombotombo, looked cleaner and more picturesque than most.

  Marandellas was famous for its schools, both government and private, all of which were modelled on the English prep and public school system, and mostly European. There were good African schools in the country, but not one tenth as many as were needed. Beyond all spread the European ranches for about thirty miles, and beyond them, the African tribal lands.

  In those lands the hospital covered two 'rural hospitals' - another Rhodesian peculiarity: more than a clinic, as it had beds, as many as fifty; but was run by medical assistants. The doctor visited weekly, and saw cases. Emergencies were sent to the main hospital, after calling the ambulance from that place.

  And scattered throughout the district were small clinics run by the local authority, which were supervised by the provincial medical staff. These could refer patients to the main hospital with free bus vouchers. Emergencies at night had to find their own way usually in the car of the local headmaster, unless the clinic had a telephone and could summon an ambulance from the main hospital.There was a clinic also in Marandellas township, run by the local authority.

  At Marandellas I did my first brain operation, having assisted Mav at them before: a man with a head injury with signs of internal bleeding. These cases can last a day, and they can succumb in an hour. Potter of Oxford had written: 'Some emergencies are relative: this one is absolute.' And as to the surgeon to do the operation - 'the first one competent to do so' - a principle long abandoned in specialised Britain, with some notorious disasters as a consequence.

  I could have sent this case to Salisbury, an hour away by ambulance, except that I had found you must add two hours to the time of the journey to include the preparations at either end. And the man could well have died in that time. Fortified by Potter's philosophy, I ordered the patient to theatre.

  This did not please Sis
ter Fleet. Sister Fleet was a highly competent nurse, and a very pretty girl besides (though no doubt that has nothing to do with the matter), but she was the type who would argue with the doctor. No African nurse would do anything so unwomanly (with one or two exceptions I have met, and pretty unsavoury specimens they were). Now I was never too proud to take advice from any quarter, high or low, (or in between), but I simply did not agree with Sister Fleet, quite apart from her manner of delivery, which was sharp.

  I drilled the necessary hole, evacuated the blood and sutured the bleeding vessel, and had the feeling I was winning, when Sister Fleet poked her head round the theatre door.

  'He could have been in Salisbury by now.'

  To this nobody replied. Besides myself they were all Africans in the theatre, and Africans are not in the habit of making unnecessary remarks.

  'Besides, you're using the wrong instrument.'

  She was wrong. I was using a burr. Perhaps she was thinking of a trephine, an instrument I saw even specialist surgeons use later. I tried it myself, but found it a clumsy tool. At the time, I was not sure, so said nothing. Besides, it was not the time for a debate on the subject.

  Sister Fleet and I got over our tiff and became good friends - especially after I left the hospital. And most important, the patient made a good recovery.

  Then disaster. I was doing a caesarean section, when the nurse anaesthetist put the breathing tube down the wrong way. I got a live baby, but the mother died two days later from brain damage. In cases like this, the senior carries the main responsibility. Unless one knows one's staff very well, one should always check their work - a principle I was to learn here the hard way.

  There was an inquest before the district magistrate, when I and the nurse appeared, and I, of course, had most of the explaining to do. The courts were always very understanding towards medical people, and the matter was not further referred. Patients and relatives would show equal indulgence.

  This is not to say that the guilt/blame nexus is absent from African culture. As I have said, nothing is supposed to happen by accident, and some source of spiritual interference is sought for, either a witch or an offended ancestor. But the doctor is rarely blamed or suspected - an attitude, I suppose, we owe to its careful cultivation by the witch doctors themselves over the centuries; whose business, of course, is to impute (or deflect) the blame. Witchcraft was never a crime under colonial law (which did not recognise its objective existence): to acc-

  use anyone of witchcraft was - a position all African countries, to my knowledge, retain to this day. So a discreet witch doctor would stick to ancestors.

  Where a wife was lost, a husband would quickly find another; African reasons for marriage being more practical and less romantic than ours. (The man who danced round the theatre in Ghana found a new wife within months; nor was this a reflection on the sincerity of his grief. Among the poor, love - and hate - comes through propinquity rather than inspiration.) When a woman is widowed, it is not so simple.

  Sometimes her brother-in-law is obliged to marry her and take over her children. In other customs (conspicuous in Rhodesia/Zimbabwe, where there are pressures to change them), the widow is stripped of everything by the dead husband's family - house, property, children - and sent back to her own people.

  A woman was run over by a bus at the terminus. Her leg was crushed below the knee. I thought it impossible to save and said I would have to amputate. She cried and refused. The nurses worked on her and she dried her tears and bravely accepted.

  When she was resuscitated and under the anaesthetic, I felt a pulse in her foot. That and a nerve are usually all that is necessary to save the limb. I went to work with a medical student on attachment to the hospital (David Hurrell). We cleaned up the wound and even managed to close the skin without tension. We set the leg in plaster. (Later, I would learn how to apply traction through a pin in the heel.) Imagine the woman's joy when she came round! It was cases like that which made me glad I had come to Africa.

  One night an old man was brought in with a distended abdomen, vomiting and absolute constipation - nor gas nor faeces. I knew what this was before the X-ray confirmed it. Not only the intestinal obstruction, which any British surgeon would have recognised by this point, but the special African kind - primary volvulus, either single or double. The first type is rarely seen in Western Europe: the second never.

  A volvulus is a twist in the large or small bowel: a double, or compound, volvulus is both together, in one enormous knot. Why the latter is so common in Africa (the district doctor sees two or three a year) nobody knows.

  I could, of course, have sent this man to Salisbury, where there were specialist surgeons; but I knew I was going to be in remote places, where it would behove me to be confident. I decided to do the operation myself, with David assisting.

  When I opened the abdomen, I could see nothing but a pool of black gangrenous bowel, and felt like closing it again there and then in despair. I explored and found healthy bowel. Then I went ahead.

  First one excises the affected section of large bowel, then the same for the small bowel. All this I did, and the nurses measured twenty feet of black small intestine, leaving about six feet behind. People can live after such a loss, though they never again have a weight problem! I joined the healthy small bowel to the large bowel, and then I turned my attention to the gap in the large bowel.

  The proper thing to do next is to bring it out to the surface in a double-barrelled colostomy, and come back in six weeks when all is clean and healthy, and close it. In my ignorance, I closed it there and then.

  Next day, the old man was leaking faeces from his wound. Something had obviously broken down inside. I sent him to Salisbury, where the surgeon saved him with the colostomy I should have done in the first place.

  I went up to Salisbury to see my patient, and met the surgeon, who gave me a friendly and instructive talk on the subject. This surgeon was a brilliant if fiery young fellow from South Africa. I later learnt that he fell out with the anaesthetist during an operation. In true colonial spirit, they doffed gowns, etc, and settled it with a punch-up in the corridor outside, before returning to finish the operation. Of course, they were carpeted by the 'headmaster', but kept their jobs, which I doubt they would in England - or even Ireland nowadays!

  And once a week, as I said, I visited the rural hospitals, a hundred-mile morning run in a van, and in my car, when I got it back: the dirt roads in that district being in good condition.

  First stop, Chiota, with a great crowd of patients standing outside, or packed on the veranda if it was raining. I would see only selected cases, then do a ward round. So on to Wedza. The little town of Wedza looked like a Mexican village in a spaghetti Western, complete with the Happy Hotel, a two-storey shack. The hospital lay outside the town, and in the distance, Wedza mountain, a large kopje, glowed like an amethyst in the fresh morning air. Wedza provided no food, so the grounds were always full of relatives at their cooking fires.

  And as in Ghana, I considered the first purpose of my visits was educational. This principle ran through the service from top to bottom, and from bottom to top, as the doctors could learn from the nurses about local customs, etc.

  So the doctors attended annual refresher courses at Salisbury or Bulawayo, staying two or three nights at good hotels at government expense, and getting pumped full of information every day: and given protocols. There were protocols for everything from obstructed labour to meningitis. And the district doctors made up their own protocols for the simpler activities of the rural hospitals (not forgetting the splendid auxiliaries' handbook produced by David Taylor): though those 'simpler activities' included the management of typhoid and malaria. And all maternity units, rural and urban, used that wonderful invention, the Rhodesian partogram.

  Many practical contributions to modern medicine have been first developed in Africa: such as the rehydration salts, now familiar to every British mother; and the under fives' road to health chart (less fam
iliar because its main use in Britain must be keeping children's weights down). But the partogram is the most ingenious.

  It consists of a large chart which records the progress of labour, and is crossed by a warning line which prompts the midwife to seek medical aid if the graph line reaches it. It contains much more information, such as the foetal heart gradings, which were all explored for the first time in Rhodesia, sometimes in tragic circumstances, when the mother refused caesarean section, and the doctors sadly discovered every milestone on the baby's road to death. This chart is now used throughout the world.

  When a mother, transferred in prolonged labour from one of the clinics, arrived at the hospital at night, the sister on duty had only to read out the chart to me over the telephone and I could order a caesar if necessary and snatch an extra hour's sleep while they got ready.

  Only by such rules of thumb could the system be run so efficiently with non-specialist staff. And by broad standards, efficient it was.

  One morning I arrived at Chiota to find a lad of sixteen on a stretcher, rocking himself up and down, moaning and holding his head. Before I did the lumbar puncture which proved it, I guessed he had meningitis. I filled in a head-sheet and told them to call the ambulance from Marandellas. When I got back from my rounds in the afternoon, the lad was on treatment, and in a few days made a full recovery.