Alcohol

I spent the whole of last weekend at a long and tiring pre-hospital trauma course. The medicine was relatively basic as we were mostly taught what simple life-saving procedures to do if we were to find an emergency as a passer-by, and there’s not much complicated stuff one can do without any medical kit. The main lesson for me was to avoid trauma in the first place, the presentations were crammed with excruciatingly graphic images and tragic stories. If victims of traumatic road accidents survive, and they often do with prompt emergency service attention and transfer to hospital, they are likely to be left with life-changing disability including brain injuries, paralysis, or amputations. Alcohol is commonly implicated in serious road accidents. It is a chemical close to my heart, so I decided to spend some time organising my thoughts on drinking and driving, and hypocritically lecture against alcohol use.

A tragic result from driving the morning after

In my experience, it seems that medical students as a group drink more alcohol than the average person. I briefly tried to find some data to back up or refute this stereotype but I didn’t find any numbers. Perhaps students are unlikely to admit actual alcohol consumption for articles or studies, or perhaps this information is not interesting enough to be gathered and published. This assumed culture of drinking at medical school might set the scene for unhealthy alcohol usage after qualifying; the old joke goes, the definition of an alcoholic is the patient who drinks more than his doctor. This is unfortunately seen in the levels of addiction and liver disease seen in doctors when compared with the general population. 

Now some fair disclosures before I begin preaching. I am a medical student and (therefore?) I enjoy a drink from time to time. I have drunk irresponsibly and excessively on occasions and have suffered some apocalyptic hangovers that are oddly still insufficient to condition me to stop drinking. Sometimes I drive after a pint, and worse, it seems likely that I have driven whilst over the limit in my youth – ignorantly having driven the morning after the night before. I should also make it clear that my fondness for alcohol is sometimes opposed by a personal dislike for road traffic accidents. It is a dilemma faced by all drinkers who also drive.

As of this morning (5th December 2014) the drink-drive limit in Scotland has become stricter, the maximum permissible alcohol level in the blood is now 50mg/100ml, down from 80, which remains the limit for the rest of the UK (the highest level in Europe, joint with Malta) . 50mg/100ml is a blood alcohol level of 0.05% and is the same as most European countries.  The intention is to reduce the number of drink-driving related deaths (over 200/year in the UK), not to mention the huge numbers of injured but surviving people, psychological harms and healthcare costs – particularly at this boozy festive time of year. A blood alcohol level between 0.05 and 0.08% is associated with a six-fold increase in the likelihood of dying in a car crash compared with 0.00% (and this doesn’t even take into account the harms to pedestrians unlucky enough to get struck by drink-drivers).

Graph from wikipedia

The blood alcohol numbers, while clearly stated and scientific-sounding, are nonetheless not very helpful in deciding how much one can drink before legally driving, which is what people actually care about.  Frustratingly, there are no clear guidelines on what is legal because individuals metabolise alcohol at varying rates, and the blood alcohol level will also depend on your: weight, age, build, gender, type of drink, time since drinking, amount drank, whether you’ve eaten recently and current stress levels.  Apparently, and according to popular belief, all of this taken together means that usually a man can legally drive after one pint of beer (2 units = 20ml or 16g pure alcohol) , and women can drink about half that. This should usually be ok under the stricter Scottish rules too.

Since the legal amount is so vague and variable in real terms (i.e. number of drinks) the advice is always the same:  avoid drinking if driving and avoid driving if drinking. It is too risky to guess what is legal and in any case it is safest to avoid alcohol completely. Which leads to an obvious and unpopular conclusion, why have a legal limit at all? Shouldn’t the law be consistent with the advice that no level of alcohol is acceptable? Driving with a blood alcohol between 0.02 and 0.05% is still associated with a 3x higher risk of dying.

Reaction speeds are undoubtedly slowed by alcohol consumption. It is sometimes argued that for some drivers the reduction in reaction speed from a pint, or two, will still result in “normal/legal” reaction speeds, i.e. possibly as fast or faster than distracted drivers, elderly drivers, over-tired drivers (junior doctor car insurance premiums are higher due to increased accidents following night shifts). This might well be true but misses the point that any impairment in driving ability is bad for all road users, especially avoidable impairment such as alcohol use.

The alcohol and pub lobby often claim that country pubs will suffer if people cannot drive to them or if people cannot have a drink with a meal. In my opinion if a pub is far enough away to warrant driving than it’s probably not worth making the effort to have one pint there anyway. Walking, taxis, and designated drivers seem like pretty reasonable solutions. It is also argued that lowering the legal limit criminalises the group of responsible people that drank alcohol the night before and have not completely cleared it by the time they drive. This situation is already the case, and I think its important that people are made to consider how long it takes alcohol to be metabolised (approximately one unit/hour). Further, the effect of alcohol on safe driving may be exacerbated by tiredness following a late night.

So I stand alongside nearly 80% of the Scottish population in supporting the reduction in the legal limit and would welcome the change being followed in England and Wales too. I haven’t done all of the research but at the moment I see some benefits of it being reduced further, say to 20mg/100ml.  As a medical student I am broadly opposed to unnecessary deaths, and there’s loads of evidence that control of alcohol use in drivers reduces death.

http://www.nice.org.uk/media/default/About/what-we-do/NICE-guidance/NICE-guidelines/Public-health-guidelines/Additional-publications/Blood-alcohol-content-effectiveness-review.pdf

Stoic Week

Today, Monday 24^th November 2014, is the first day of Stoic Week – an annual event started by the Stoicism Today team at the University of Exeter. The team at Exeter are some academics, philosophers and psychotherapists who run a blog that offers resources to explain Stoic philosophy and show how it can be useful in people’s lives.

I’ve taken a casual interest in philosophy since my school days, through until now this has been limited to a few popular philosophy books and internet comics, like this one. 

Superficially at least, I’ve always admired the Stoics, maybe because they feature early on in most popular histories of philosophy so I actually get to their chapter before giving up on the book. My understanding of stoicism is mostly limited to the word as it is commonly used; a stoic person is noble and uncomplaining, carrying themselves with a dignified and stereotypically British stiff-upper lip “mustn’t grumble” attitude. This ideal is basically the opposite of my usual snivelling, moaning personality and so I am quite keen to find out more about Stoicism and how it might improve my attitude to life.

To shoehorn some relevance to medicine in here, participants in last year’s stoic course reported a 14% increase in life satisfaction and a decrease in negative emotion. Like mindfulness and cognitive behavioural therapy (which are proven to be effective in treating depression), it seems likely that courses in Stoic resilience might have similar benefits in improving mental health.

Stoic Week is an event that invites people all over the world to spend a week thinking about the basic ideas of stoicism, on each day there is a different theme and some exercises to practise. The impact of stoic thinking on attitudes, behaviours and wellbeing is also assessed using online wellbeing surveys taken before and after the week. The website has loads of information about stoicism in general and includes a downloadable copy of the stoic week handbook and information on how to take part in the week.

So I signed up to the course at www.modernstoicism.com. After completing 4 brief questionnaires designed to reveal my levels of contentment (or otherwise) I was given a quick summary of Stoicism from Epictetus’ handbook. I’ll try and summarise the summary as I understand it here:

Stoicism is an ancient school of philosophy founded in Athens about 301BC, by Zeno of Citium. Other important Stoics include Epictetus, Marcus Aurelius and Seneca. The core view of stoicism is that the highest authority is reason, and Nature, life and death exist as they appear to. Nature is governed by rational principles that we cannot change nor should desire to. In contrast, emotional responses are not subject to reason; they are falsehoods. So we can control our judgements through rational thought use this to inform our actions, and our voluntary actions are the only important thing; they are our true self.

Our body, health, possessions or status are often not due to our voluntary actions, we have no control and so it is not rational to be distressed with these things. By remembering this a person can meets hardship and even their own mortality with dignified acceptance; harm cannot reach one’s true self.

A much better summary can be found on the Exeter blog: http://blogs.exeter.ac.uk/stoicismtoday/what-is-stoicism/

The first day of the course suggests spending time thinking about the level of control a person has over there situation. Stoics think that confusion between what you can control (your thoughts and actions) with what you can’t (everything else) leads to unhappiness. Broadly speaking this is good advice; I try not to get annoyed when I get caught in traffic on the way to placement or when the teaching session I drove in for is inevitably cancelled. And the reverse is true too, it doesn’t make sense to feel too smug when things go well; the fact that I don’t have any real concerns regarding my shelter, health, safety, finances, education or future are not due to my thoughts or actions, they are lucky by-products of the accident of my birth.

But overall I’m not entirely sure I can get completely on board with the stoic thinking. There're far too many unwell, unhappy, or dying people in hospitals, and most of them do indeed meet their challenges with dignity and grace. I don’t see how a person with a terminal illness (and there are plenty of them) can choose to be not pissed off even if they have no control over their situation. I guess they are supposed to realign their thoughts with their reality, and accept their fate without emotion, but this seems to me a heartless and impossible expectation. Good stoics would argue that virtue is all that is needed for happiness but I think that an absence of terrible circumstance is important too. Maybe I've not fully understood the stoic attitude here, I suppose it is only day one.

Ebola and homeopathy

A few months ago I wrote a fairly patronising summary of the ebola situation as was, and optimistically opined that perhaps the problem had been exaggerated by the media. Annoyingly, the disease has yet to burn itself out and the most current data from the WHO reports that there have now been at least 13,700 cases and 4,900 deaths.

In the UK there has been only one, imported, case of ebola. This was William Pooley, who contracted the disease in Sierra Leone and was transferred to London in August. He was treated with the new drug ZMapp, made a full recovery and has returned to Sierra Leone to continue his help.

The vast majority of cases remain in the West African countries Guinea, Liberia and Sierra Leone, and so it remains quite unlikely that infected people from these areas will reach the UK and transmit the virus here. The risk is certainly not zero however, and so Britain is currently continuing with preparations for this possibility. Most trusts have published protocols and guidance for dealing with suspected ebola cases.

Spotted in a Birmingham Hospital's ITU

I attended a lecture at my hospital on the subject, and learnt about the procedures to reduce the risk of infection, such as extra PPE and keeping such patients isolated in negative pressure rooms. Importantly, the staff were warned not to transfer suspected blood samples to the lab via the pneumatic tube system we would usually use, in case the blood vials were to break and effectively aerosol the blood and virus all around the hospital.

Ebola not welcome: A sign on the entrance to an Edgbaston GP Practice

Perhaps the most important intervention will be the use of homeopathy to combat the epidemic. Resources should clearly be diverted to the development and distribution of a homeopathic cure, you can help by signing a petition to urge the WHO to do just this. Sign it HERE*.

The good news is that a team of homeopaths have been mobilised to frontline West Africa to begin this important work.

A cynical person might suggest that sending homeopaths to ebola zones is evidence of natural selection at work. This is a cruel joke, and meaningless too because evolution doesn't exist.

Some homeopathic pills to treat Malaria

Anyway, you can already easily buy homeopathic treatment for most diseases online, including pills for dengue, meningitis and tuberculosis.

And of course mercifully there are several homeopathic clinics in Africa many of which offer cures for HIV and AIDS. Not sure if I've mentioned on this blog but I went to Tanzania earlier this year. I’ve seen a little of how devastating HIV can be to communities and individuals, but luckily charities exist that aim to help reduce this suffering. This is one of them, http://www.homeopathyforhealthinafrica.org/ and it has characteristically virtuous aims:

- To relieve the suffering of HIV/AIDS patients using classical homoeopathy
- To identify the homoeopathic remedies most successful in treating HIV/AIDS
- To spread this knowledge throughout Tanzania and Africa
- To produce formal, ethical research
- To prove to the world what homoeopathy can do

For the unenlightened, homeopathy involves taking an ingredient that causes harm and diluting it significantly, thereby releasing its healing power. The standard dilution (such as for the linked cures for dengue and meningitis above) is “30C”, meaning the original drop has been diluted by 1 drop in 100, 30 times. So 30C means one part in 1060.
This level of dilution, such that there are zero molecules of ingredient left in the treatment, is vital for the homeopathy to work.

Regrettably however, the benefits of homeopathy are denied by some groups – for example educated people and "scientists". For example, some of these “scientists” published a paper in the Lancet that compared 110 studies of homeopathy with 110 conventional medicine studies and concluded that the effects of homeopathic interventions are merely placebo effects. (1)

The 2009 official WHO statement is similarly closed minded:

“There is no place for homeopathy in treating serious illness such as HIV, TB, malaria and infant diarrhoea in developing countries.”

Quite clearly a needlessly obstructive and unhelpfully negative attitude.

In all seriousness I wish the homeopathy team in Africa the very best and sincerely hope that they manage to avoid infection,  and especially so to prevent the spread of the disease further.



*Please do not sign this stupid petition


The reference for the paper I mentioned is:
1. Shang A, Huwiler-Müntener K, NarteyL, Jüni P, Dörig S, Sterne JA, et al. Are the clinical effects of homoeopathyplacebo effects? Comparative study of placebo-controlled trials of homoeopathyand allopathy. Lancet. 2005;366(9487):726-32.

How to Become an F1 Doctor - The Illusion of Choice

Some, including yours truly, may find it difficult to believe that in August 2015 I expect to begin life as a junior doctor. If everything goes to plan then I will nervously sweat and mumble and spread infection in a hospital – like what I currently do as a medical student, only more so (and with more direct consequences for the ill people I come into contact with).  

The most junior doctors in hospitals used to be called House officers, but since 2005 are now called FY1 doctors – because they are in the first of two years of the foundation programme. A complicated nationwide online system is used to match the 7000 or so applicants to their foundation programme jobs and hospitals. Put simply, each candidate ranks the available jobs in order of preference and is allocated one based on the number of points they can scramble together. Points mean prizes, and the prize here is precedence in allocation of your application choices.

I foolishly spend far more time complaining about the application process (see current whinging blog post) than actually thinking about my own application; the deadline is this week.  Now and then I become self-aware enough to feel a little ashamed of complaining and realise how good we have it as medical students; unlike almost every other degree programme in the UK nearly all of us that pass medical finals will get a job, somewhere. For the last four years there have been more applicants than jobs for them but for example last year in 2014 96% (7114)  where allocated jobs in the first round and places were eventually found for all 235 remaining on the reserve list.

So bearing that in mind, here is where I whinge at length about the system, conveniently grouping my complaints into two categories thus:

1) The points system is not perfect

Some jobs and some parts of the country are more desirable and therefore more competitive than others.  You can’t make every finalist happy (see current whinging blog post) and allocating randomly is clearly madness. So a system has been devised to rank students from best to worst such that the better get to go where they want and the worse have to go where they’re told. This is done by ascribing each student a score out of 100:

The educational performance measure (50 points max)

An applicant gets between 34-43 points for their decile in their medical school exams to date. I don’t think there’s a particularly strong correlation between exam score and competency as a doctor, common sense and teamwork and time management are more important than memorising textbooks (but maybe that’s me being defensive since I’m not top of the year by a considerable margin). Also some question whether the points awarded per deciles should be equivalent across all medical schools as is currently the case, despite different entry standards, different syllabuses, and different exams  (though this argument is usually made by those individuals with a snobbishly high regard for the calibre of their own institution.) Admittedly this system might change in years to come.

There are up to seven extra points given for other degrees, depending on how advanced the degree is (bachelors, masters, doctorate) and its classification. Again the number of points are standardised between degree subjects and institutions and includes intercalated degrees, all of which vary considerably. I spent three years getting a degree in biology. It was quite tough, sometimes it was fun and interesting, and I like to pretend it’s given me some life experience and a bit of a broader knowledge base, but I’m pretty sure that this doesn’t make me a better prospective doctor. Essentially I’m getting rewarded for being indecisive about my career.

Finally there are up to two points available for publications, the same number of points for having your name attached to any pubmed number regardless of its relevance, the quality of content or the journal it's published in. I think this leads to a pretty cynical approach where research is regarded primarily as a means to build and decorate CVs, and it is depressingly a feature of the entire medical career structure.

The situational judgement test (50 points)

The other 50 points come from the situational judgement test (SJT), a curious exam sat by every applicant. It uses 70 multiple choice or ranking-type questions to assess whether a candidate is able to make safe and sensible non-clinical professional decisions.

Here it is theoretically possible to score anywhere between zero and fifty– making this 2 hour 20min exam far more important for the job application process than the performance across an applicant’s entire medical degree (where the difference between top student and bottom student translates to only 10 points).

In reality the SJT isn’t quite so discriminatory; over 80% of applicants are within the 10 point band between 35 and 45, in a negatively skewed approximately bell shaped distribution. The average score in 2014 was 38.95 (SD 4.25). The SJT is perhaps more useful in its function as a safety net - candidates that score very poorly are flagged up to assess whether they are suitable to work as a junior doctor despite being able to complete medical school.

2013 SJT results distribution

Given that I have not taken the test yet (I’ll sit it in January) I can’t really comment on its particulars, but I suppose that I am relatively impartial because it hasn’t been used to assess me yet. The test has been used since 2013, an inauspicious inaugural year that was distressing for the applicants as after jobs had originally been declared the tests were remarked, many scores went up or down and so changed the outcome for many.

The SJT is still a relatively unknown quantity, and as such it is fairly odd that our futures are so dependent on it. The existence of the SJT seems to curiously disincentivise one from working to do well in medical school exams, and adds an almost completely random element to the application process. We are advised that it is a test that is impossible to revise for, but that hasn’t stopped entrepreneurial organisations from offering wide ranges of dubious and expensive preparation materials and training courses.

2) Choice is an illusion

I am chronically indecisive. I have no clear view of where I want to be in five years, or what sort of doctor I want to be (if any: plan A is still scratch card windfall). During my time at medical school I haven’t been able to exclude many specialties from my list of potential jobs or careers and I’m not drawn to any particular part of the country for any reason. Plus some people say I overthink sometimes (see current whinging blog post).  I therefore seem to find the applying for F1 less straightforward than many people I know.

The foundation programme is usually six different 4-month rotations, during each the junior acts as dogsbody to senior doctors in a specific area of medicine. There are several levels of apparent choice at work before a job is allocated, firstly the area of the UK (there are 21 “foundation schools”), the hospital, and the specific clutch of six rotations themselves.

Each coloured block here is a foundation school
The first decision is ranking these in order of preference

So with just these three factors there are many hundreds of possible combinations available to consider. Unfortunately, outside of the hospitals I’ve been placed at around Birmingham I have no knowledge of the relative merits of any other part of the UK, or any other hospitals. And I also have no real knowledge about what are the differences are between different F1 jobs. More uncertainty is introduced because all foundation jobs are “subject to change”; I know of people who ended up frustrated with three completely different FY1 rotations to the three they applied for (and were allocated to).

Further considerations that might affect how much you would want a job include the team you will be working with and the consultant you’d be serving under –unfortunately both of which are impossible to know until you start work. You might also attempt to guess where your friends might end up, which is at least as confusing as attempting to predict the future for yourself.

According to the Mental Capacity Act 2005 (completely unnecessary tenuous reference) a person’s choice is valid only if they fully understand the benefits, risks and alternatives of a decision. I don’t feel at all confident that I meet this charge. There is a huge amount of information online comparing different areas to work by every imaginable characteristic, so much information that it becomes impossible to digest it. Deciding what is important (City or Rural? North or south? Medicine or surgery? Is it too competitive? Known or unknown? Accommodation? Old friends or new people? Things to do outside of hospital? And so on?) is difficult and often arbitrary, and the decision is never completely informed due to the uncertainty that remains as to the true nature of the location, hospital and job you apply for.

Perhaps most confusing is that applicants rank all the deaneries before we know our scores – as mentioned above the SJT is shrouded in mystery and ensures that no one is at all sure how strong their application will be until after the results. Perhaps I’d apply to a competitive deanery if I was sure I had enough points to secure a decent hospital and job were I to get it. But regrettably I still don’t know what I want, and anyway it’s quite hard to even guess which deaneries and which jobs will be competitive since this seems to change a great deal from year to year.

So maybe I'm a little defeatist and pessimistic but I feel completely overwhelmed by the scope of possibility for next year, and I have gained almost no useful predictions as to where I will want to be, what I want to do or what level of control I have in effecting my choices. It’s not ideal that I take the same fence-sitting approach to clinical decisions too. One thing I am sure of is that after what will be seven consecutive years of being a student I’m really looking forward to getting a job. Any job.

Languages (and Lack Thereof)

One of the best things about the West Midlands is the diversity of people that can be found here; there are slightly more than one million people living in Birmingham and almost a quarter of these were born outside of the UK. I like to think that the small snapshot of Birmingham life I see in the hospitals represents a charming microcosm of the Midlands and, if you allow me a small extrapolation, is something of a model of our terrific multicultural and international planet.

Most recently I’ve been placed in West Birmingham, an area of high ethnic diversity even for the midlands – overall only 53% of Birmingham residents identify as “White British” compared with 92.4% of those from nearby Worcestershire. 

According to a Telegraph article from last year there are over a hundred languages spoken by school children in Birmingham. (As is always the case with internet articles, best to ignore the comments. Here they are even more reactionary, right wing and racist than you might expect given this newspaper.) This rich complex of languages spoken is fascinating,  but occasionally leads to some interesting communication problems.

For example, I have a few Asian friends (see I can’t be x-ist some of my best friends are x), and I’m often jealous when they’re able to whip out some language skills and converse with some of the patients better than I can. However I especially enjoy when patients and staff assume language based upon someone’s appearance or skin tone, so there are a few medical students getting frustrated by their daily apologies and explanations that no, sorry, I only speak English. Now and then I fake offense when patients assume that I won’t be able to speak Urdu just because I’m white(ish), though it would be more convincing if I learnt some phrases to justify this.

Almost always patients will speak very good English even if it is their second language, though occasionally they will require some clarification through a linguistically talented staff member or understanding relative. Sometimes translators are booked too, especially for outpatient’s appointments, though sometimes this seems unnecessary. I remember a series of appointments during my psychiatry placement where a translator was duly booked every week for a completely mute schizoprenic patient, whose partner could speak perfect english anyway.

Occasionally all of these solutions are absent; this week I met a young man who was both completely deaf and completely Polish. Further, he had fallen off a motorbike in Greece and provided his (Greek) medical reports. His mother knew Polish sign language and spoke no English so an additional Polish to English translation step was required. This made for slow progress. Luckily, he was able to read some written English so when I had to take some blood I prepared a few notes to pass him. The notes seemed to be understood and when I waved my sharps bin at him he gave me the thumbs up.  I still gave a pointless running commentary of the whole process though.

I recently was talking to another excellent Polish gentleman with a fairly nasty looking deep leg injury. He couldn't speak perfect English but made sure that his slight lack of comprehension was more than made up for with his compliance and positive attitude. Are you feeling better today? Yes! Is your dressing comfortable? Yes thank you! Yes! Are you in any pain today? Yes! Where is the pain? Yes! No problem!
I am a big fan of this attitude.

ITU

This post is a slight departure in tone from what I’ve written before; I feel the urge to write about some quite affecting and upsetting events from recent weeks, to make an attempt to record their significance and impact before I become hardened to the harsh realities of modern medicine. For confidentiality and out of respect for the privacy of those involved I’ve changed most of the details about what follows but remain honest in my attempt to convey how I felt. It’s difficult to communicate what I mean: writing it down helps a little, but I don’t expect what follows to be of much interest to anyone else.

Hospitals are an altogether unpleasant place to be. Unless a person is paid to be there (or , like me, is learning how to eventually be paid to be there), that person’s  visit to hospital is inevitably associated with an adverse event, it is either a trip necessitated by their own sub-optimum health, or a visit to someone close who is unwell. During my most recent attachment I spent some time on the hospital’s intensive care unit (ICU, confusingly aka ITU or CCU), that quiet part of the hospital reserved for the care of the hospital’s most unwell patients,  the patients who require close monitoring and often multiple organ support.  The patients are often sedated and ventilated, supported by a network of drains and lines connecting to various machines. Their existence is simplified to some matrix of data regularly reporting their oxygen levels and blood chemistry and other important values. A patient must be really quite unwell for admission to ICU, and so unfortunately many of them do not recover – about a third will die on the unit. There were ten patients on the unit at the beginning of my week’s attachment, of which a good outcome (eventual discharge home without serious disability) was only a realistic possibility for one or two. Patients with hypoxic brain injury and no chance of regaining meaningful function are depressingly common.

The consultant explained that the job is like spinning plates, supporting several patients at once by bolstering their failing organs until they either make some recovery of function, or they don’t. The doctor must also communicate with anxious relatives often, calmly and kindly explaining the situation and inevitably breaking bad news several times a day.

I found it odd then, how a doctor could be so professional, understanding and compassionate with the relatives but seemingly so ruthlessly frank, flippant, and perhaps even brutal when discussing the patient in private, within seconds the patient becomes anonymous and insignificant. Given the type of patient on the unit, and their bleak average outcome, it is understandable that the staff may become desensitised to the individual tragedy of every case and the devastation that such conditions wreak on patients’ families. Patients on ICU can become dehumanised. They can quickly come to be regarded as non-responsive fleshy masses in union with tubes and wires and bleeping machines, large and awkward Tamagotchis that inconveniently occupy hospital beds (an expensive hotel at around £2000 per night).

This is probably not at all as I’ve described it; I don’t doubt the competence, concern or sense of responsibility of the medical staff. They work tirelessly and do an excellent job. It would be impossible to become deeply emotionally involved with every patient and perhaps if one were to this may impair the ability to function as a good doctor. But I can’t help but be disappointed in the apparent absence of compassion; I don’t ever want to reach the stage where I regard a dying patient as just another occupied bedspace on the ward.

I verified my first death on ICU, with one of the junior doctors. A woman in her 50s had had a completely unexpected and catastrophic bleed in her brain and only survived for a few hours on the unit. The verification of death is a mundane responsibility for doctors in hospital, it is supremely common and necessary but I found it surreal and was a little shaken in taking part. There is no formal legal definition of death in the UK and so verification simply requires clear documentation that several normal signs of life are absent. This lady was completely and indefinably different in death compared to the appearance of living patients but paradoxically one could still regard her as simply sleeping comfortably. She was still warm when I checked her pupils, felt for her pulse and listened for heart and breath sounds. I tried to illicit a response to pain by pressing firmly on the bone between her eyes, and then mechanically and self-consciously uttered “time of death 09.25”, as if I were transported to a medical TV drama.

A short while later I accompanied the ITU registrar to an emergency call in A+E. As we hurried to the resuscitation room he explained that usually these alerts turn out not to be too serious, but since he’d had a long run of simple cases recently he thought this one might turn out to be significant, and his premonition sadly rang true. We arrived moments after the ambulance to a manic scene. A tiny toddler lay on a startlingly over-sized bed in the bay dwarfed by medical staff in a flurry of activity around him. He had no heartbeat and one of the junior doctors was performing chest compressions. 

Almost immediately the registrar took over the ventilation of the child with a bag and mask and I was ordered to ring for the ITU consultant. After what seemed like ages I got through to him and I quickly mumbled my panicky message: paediatric cardiac arrest in resuscitation, please come ASAP.  Soon there were 12 people around the bedspace, taking turns to perform chest compressions on his miniature torso. A nurse barked timings over the ordered chaos, cues to administer adrenaline and assess whether any signal could be picked up by the heart tracing. At one point the A+E consultant optimistically shouted “stop CPR! There’s activity on the monitor!” only to immediately concede “no activity, resume CPR.”  

By this point a small audience of medical students had gathered, awkward morbid voyeurs feeling helpless and hopeless and in the way but a grim curiosity rendered us mostly unable to tear our eyes from the terrible scene unfolding. I will remember the next 15 or so minutes as some of the worst of my life.  The boy’s inconsolable mother watched impotently as the boys whole body was jerked up and down by the compressions. The simultaneous assertive voices of the team strained to compete with the suffocating sound of drilling intraosseus access points into his tiny shin bones, because it was impossible to get access to his veins to administer fluids. Eventually there was a slow realisation of the inevitable which surpassed the atmosphere of panic. I couldn’t stay in the room.

After 40minutes without a heartbeat the team closed the curtains. Alfie was two years old when he died, from a cardiac arrest following a seemingly standard tonsillitis. He had been seen by his GP and prescribed the correct antibiotics, but tragically he had become septic, his heart starved of oxygen stopped, and he died. His father arrived at hospital moments later.

I spent the rest of the day thinking about this event. Whilst the parents howled and embraced each other I watched the medical team slowly file out of the room, each to return to their jobs, and their lives. Alfie was two years old. No amount of thinking makes the outcome okay, nothing about this story is fair. 

Swapping Cells for Self Satisfaction

About two and a half years ago I went to London to jettison a few of my extra stem cells, I gave them to a stranger who needed them more than I did. Whilst this was of course exceptionally heroic, selfless and fantastic of me, it was also extremely easy: I had to endure the hardship of a couple of days off uni, free transport to and accommodation in London, spending a couple of comfortable hours attached to a machine that selectively extracted (apheresis) my extra blood cells (which I’d made with the help of a few G-CSF injections previously). I then had some time to leisurely amble around London and see a few friends before travelling back home feeling smug.

I was probably insufferably sanctimonious for a good while after this, I’d proudly wear my Anthony Nolan T-shirt confident in the knowledge that I’d be eventually starting my medical career with a plus-one advantage on lives saved and so I’d casually drop my admirable sacrifices into Facebook statuses and conversations wherever they could be shoehorned in. My delusional sense of self-importance slowly began to wane as I began to realise that what was easy for me would be hugely significant for a patient somewhere whose treatment cells carried no guarantee of success. There was a very real chance that for someone in the world suffering a long and unpleasant encounter with blood cancer my donation of stem cells represented only an unfulfilled promise of cure, a missed chance, a dire conclusion. Suddenly I didn’t feel quite so cheerfully heroic anymore.

Yesterday my mood on the subject changed somewhat: I received a short thank you letter from the lady who received my cells, and truly it made my week. I’m grateful for the letter and its consequence and I will keep it always. The Anthony Nolan Charity takes steps to prevent premature contact between donor and recipient to minimise any potential for emotional harm or coercion, and to protect anonymity and patient confidentiality. For these reasons I’ve been asked not to share the contents of the letter but I think I can share my inference that the writer is a European lady who, to my delight, is both alive and well. (In addition she has my DNA kicking about in her veins which is pretty cool; I hope she doesn’t bleed at any crime scenes.)

So it’s super easy to give someone a chance at life, and, reverting to smug mode, it feels really great. I’ve also come to appreciate that not all of these chances end as well as it did for my recipient and so I have two conclusions:

One, self-congratulatory fist pumping is not always immediately appropriate, better to be humble and to try and first consider the impact and risks for the patient (let the patient be your first concern etc.).

Two, for these patients to even have a chance requires as many people as possible to register to give up some blood if they are a match. I cannot overstate how easy it is to join the register, and the donation process is itself ludicrously easy (and painless), and also a fun and exciting day out. I can’t see a reason not to sign up.

(You get to feel a bit pleased with yourself by getting involved too, but see above for some obvious caveats. Basically, be classier than me.)

“DEPARTMENT OF HEALTH HATES WOMEN”

I recently came across the following news article, from the excellent and reputable Daily Mirror
NICE condemn breast cancer women to death while fatties jump the queue for gastric bands

This is columnist Carole Malone’s response to the news that the NHS will not fund the new anti-cancer drug Kadycla due to its cost. She attacks the organisation responsible for recommending treatments for NHS funding (NICE), who cleverly hide their misogynistic evil behind a seemingly friendly but inaccurate acronym – the letters actually stand for “National Institute for Health and Care Excellence”, so NIfHaCE, the liars.

Since the UK has infinite resources the NHS is never ever strained, and so any and all treatments can easily be purchased and provided to patients. It is therefore clear that NICE exists only to arbitrarily deny access to treatments and thereby condemn certain groups of patients to death – chiefly women.

To be clear, I don’t actually think any of this. My thoughts are, as they always are, complicated and confused and difficult to summarise but I will at least commit to disclosing that I think Carole Malone is a moron.  Cancer, and the commonest is breast cancer, is clearly an extremely an important and emotive topic and so newspapers should especially careful to avoid publishing such irresponsible and misleading columns.

NICE is actually a pretty good idea. Clearly any decision, and particularly those involving healthcare, should first consider the balance of costs and benefits before the best option is chosen. NICE is organisation that exists to do just that: they review all the available data before publishing guidance on the best practice on managing specific conditions, and the cost-effectiveness of various new or existing medicines and treatments.

Kadcyla (or trastuzumab emtansine) is a clever new drug that targets HER2 positive breast cancer cells, using the existing drug herceptin to deliver emtansine a (cytotoxic chemotherapy) directly to diseased cells. It’s used for aggressive, metastatic HER2+ve disease and can extend a patient’s survival for a few months, in some cases. A few months may not be much but of course it’s literally a world of difference when compared with the alternative.

Unfortunately drug development is extremely expensive. Companies must recoup their costs and make some profit before the patent protection expires – usually 20yrs in the UK. This must of course be collected (usually indirectly) from those patients who would qualify for treatment and use the drug – so rarer diseases are more expensive per patient. The Swiss manufacturer, Roche, has set the price at £6,000 per month and so £90,000 for 15 months treatment. This corresponds to approximately £165,000 per year of life obtained, and far in excess of NICE limitations, where the normal cut off is £20,000-30,000 per year, but sometimes up to £50,000 for exceptional cases and end-of-life treatments. In addition, it is hard to assess the quality of the life that is extended but blighted with the effects of the disease and the side effects of the treatment.

Crucially, the money that is not spent on kadcyla is spent on treatments that meets NICE requirements and will have a (much) larger benefit to other patients elsewhere. This is obviously pretty bleak for the patients with horrendous, rare, difficult to treat, end stage disease, and it’s absolutely not my intention to belittle or diminish their situation, but surely there’s no sense in diverting funding from areas where more can be done?

Or maybe, like NICE, I just really, really, hate women with cancer.

Ebola for Dummies

I don't want to brag, but I have access to the internet pretty much 100% of the time nowadays, and so very occasionally I glance at some of the news websites. There seems to be quite a lot of column inches dedicated to the ongoing West African Ebola Epidemic, and perhaps rightly so since if the news articles are to be believed this virus is proving to be a fairly destructive problem. Fear-mongers hypothesise that this is the beginning of the apocalypse. I’ve seen Outbreak and Contagion, so maybe they’ve got a point? Embarrassingly for a so-called medical student I knew almost nothing about this important disease, so I’ve now spent a few hours reading about it using my aforementioned internet access. And because I haven’t written anything on this blog since my elective I’ll write down what I found out here.

Ebola haemorrhagic fever is caused by the Ebola virus (EBOV) first isolated in 1976: usually an 800nm tubular protein mesh covered in a lipid bilayer and containing a single strand of RNA which codes for 288 amino acids as eight proteins. It is impressive that such a tiny and relatively simple bag of molecules is responsible for the miserable disease – as of the beginning of august over 1600 cases and 887 deaths have been reported to the WHO.

Electron micrograph of an ebola virion

Ebola haemorrhagic fever is also known as Ebola Virus Disease (EVD) and is one of the most virulent viral diseases in the world. It is named for the Ebola river in the Democratic republic of Congo (then Zaire), where the first cases were recorded. The virus is first acquired upon contact with bodily fluids from an infected animal, usually from handling infected wild animal carcasses – including primates hunted for bushmeat. Bats are thought to be the reservoir species for the ebola virus, from which apes and other wild and domestic animals can become infected – the virus is a zoonosis.

A CDC graphic from http://www.cdc.gov/vhf/ebola/resources/virus-ecology.html

Like seemingly every other disease in the world, the disease first presents as a “flu-like” stage due to the inflammatory reaction to viral particles and cell debris . These general symptoms appear about a week after contraction of the virus, and the early fever mimics other more common tropical fevers such as malaria or dengue. However, EVD becomes more severe as the virus produces a glycoprotein that binds to the interior surface of blood vessels and significant bleeding – seen as haematemesis (vomiting blood), petechiae and purpura (bleeding into the skin), as well as bleeding from elsewhere such as the eyes, nose, gums, GI tract etc.

The mortality rate can be as high as 90% as organs fail, though I imagine this number is highly variable depending on the strain of the pathogen, accuracy of diagnosis and promptness and effectiveness of (supportive) treatment. There is no specific treatment and no available vaccine but survival is increased with early interventions such as balancing fluids, electrolytes and coagulation and treating secondary infections.

Now

Since March 2014 in Guinea, West Africa, there has been an ongoing epidemic of this disease – and the most severe outbreak ever recorded, caused by the most dangerous strain, Zaire ebolavirus. The strain has since spread to neighbouring Sierra Leone and Liberia. As of today, August 4th, here have been no cases outside of Africa, though (worryingly?) two infected Americans have been flown to the states for treatment.

WHO epidemic figures up to August 1st

So far, the total number of deaths from the disease is still low, and whilst each case is individually horrific the overall disease burden is insignificant when compared with influenza or TB or HIV or malaria or any one of hundreds of others. Further, compared to other pandemic scares like SARS or bird flu, after five months the virus is fortunately yet to deliver the global chaos that some have predicted.

Home again

After Peponi I began the very long and tiring journey back to England. Getting back to Dar es Salaam involved a broken down daladala and an eleven hour bus journey. My flight had a stop-over in Doha, a glitzy and tacky shrine to extravagance and materialism; amongst dozens of exclusive luxury boutiques there were four supercars that were being raffled in the departure lounge, a vulgar contrast to humble Tanzania. In my sleep-deprived state I first got on the wrong train from Heathrow, and when I found the right one I had to buy a new ticket since my railcard was amongst my stolen possessions, but eventually I made it back home.

Here are a few of the great number of things I will miss about Africa:

1. I love it when young black men call me "brother". It makes me feel cool and accepted even though they are almost always trying to sell me something.

2. I love the culture of politeness. It is customary to say pole, roughly "my sympathies", in greeting a person who is ill or doing any kind of work, and to greet elders with shikamoo, roughly "I show my respect". I'm always startled when kids say it to me.

3. I love the optimism of Tanzanian people. It's considered bad manners to be negative, such that when asking how someone is (Habari...) you are basically expecting to be answered with "good" (mzuri) or similar. Even when a patient is terribly ill or dying they are unlikely to admit it and will usually report that they are "not too bad" when asked.

4. To an extent, I like the pace of life in Tanzania. There is literally never ever a hurry, and I am very surprised when things occur even vaguely on time. Even in truly horrendous traffic there is no stress or time-pressure, every driver seems in good spirits and reassuringly utters polepole (slowly slowly) to excuse any tardiness.

5. Whilst I'm not a huge fan of Tanzanian food I do like the drink. Stoney Tangawizi (unfortunately coca cola company) is a delicious ginger beer, kilimanjaro coffee is awesome and Zanzibar spiced tea is fantastically exotic. I've also developed a taste/dependency on some of the beers especially Serengeti and Tusker lagers, and I'm a fan of a generous glass of konyagi with ice and lemon, a fragrant mystery spirit.

6. I like the genuine enthusiasm some of the children show when meeting a mzungu (white person), some of the more outgoing younger children in more rural areas are likely to frantically wave, shout, sing and dance when we are spotted and it makes me feel extremely important.

7. I really like the friendliness of Tanzanians including the absurdly long greeting rallies undertaken when greeting even complete strangers, the openers and corresponding responses confusingly change depending on who is talking. It's a challenging but warm ritual.

It's nice to be home but I'll be back to Africa soon, I hope.

The North Coast

Tanga, Peponi, Pangani

I decided to take another bus to spend my last few days in Africa with Laura and Rhi at the coast. The bus took me from morogoro to Tanga where I hailed a Bajaj to take me the 30km down the coast to where the girls were staying. The road was like driving on cobblestones and the drive was impossibly slow and uncomfortable, after an hour we had managed to get just halfway. I was a little surprised when my driver abruptly stopped the vehicle and arranged for me to balance with my two rucksacks on the back of an adolescent’s motorbike to complete the journey. Whilst much quicker and more comfortable I spent the entire ride grimacing as I clung onto my bag and my driver, but managed to avoid falling off long enough to get to peponi (paradise) beach resort.

It certainly was a paradise, especially relative to some of the previous places I’d stayed. I’d become a little weary of staying in the worst hotels I could find and so was happy to pay a little more to share Laura and Rhi’s beach hut. It had a hammock looking out onto the Indian ocean and there was even reliable hot running water.

The following day we rented bikes, all rusting clunking single-speed machines and, initially at least, a joy to ride. We applied a generous layer of suncream and began to slowly make our way towards Pangani, 18km to the South along the coastal road. Amazingly I managed to transform both my T shirt and hat into a darker colour over the course of the trip using my powers of perspiration. Eventually the potholes took their toll on our comfort, my saddle broke as we reached our destination. We stopped for lunch at a deserted hotel where I sampled the mysterious “spaghetti with egg”, literally a spaghetti omelette about 2 inches thick, excellent carb-loading for the trip back.

We cycled around the town and visited some of the grisly decaying buildings used when Pangani was a slaving port. There are numerous horrific stories form this period, for example it is said that slaves were buried alive in order to strengthen the foundations of some of the buildings. Other buildings where slaves were imprisoned or executed have deliberately been left to ruin and are overgrown with trees whose majestic roots are hastening their downfall. I suppose that rather than preserve these buildings or commemorate the events with plaques the local people would prefer to let these memory be erased – stories from the slave era are still common as they have been passed down the generations.

The customs house, a site of previous slave imprisonment.
 It's now used to store coconuts and other products.

I tried to spend my last night at Peponi in the gently rocking hammock but even though I had carefully covered as much exposed skin as possible I was savaged by mosquitoes on my face, hands and the small area of briefly exposed skin on my lower back. I took refuge for a few hours in the hut but returned to the hammock early in the morning to watch the sunrise.

Witchcraft

The hike I did on Wednesday was as difficult as expected, but mercifully there were some clouds so it wasn’t as hot as the previous few days. I started from Morogoro at 7am with an enthusiastic trainee guide, Grayson, and his qualified supervisor, Evans (who inaccurately and pleasantly referred to me as Dr Jon, especially after I “cured” his aching feet with some ibuprofen), and we gradually ascended up uluguru mountain towards the rainforest. The higher we got the cooler it was and by the time we had reached the highest point at 1pm, Bondwe peak (2008m), my guides had got out their fleeces. It was especially steep in parts where landslides had obliterated the path and we were forced to take shortcuts directly upwards through the forest. The lower slopes of the mountains are densely populated with villages and farms of the Luguru tribe but there is an abrupt change at the treeline where pristine rainforest begins; I was lucky enough to spot an enchanting troop of black and white colobus monkeys, which I’m told are usually very shy and rarely seen. I ran out of water fairly early on but followed my guides in refilling my bottle from a beautiful but perhaps less than sterile stream, an infection risk that seemed necessary to combat dehydration as the afternoon sun came out fighting.

A black and white colobus (Colobus guereza)

Nearer the bottom of the mountain we were alerted to a woman’s blood curdling screams. My mind raced as I tried to think what could be the cause (in order: childbirth, trauma, grief, assault, epileptic seizure, psychiatric illness) and the guides quickly brought me to the source of the commotion. I had a very basic first aid kit with me and very basic medical student knowledge in my head but I concluded that if there was a medical problem there was a slim chance I could help. It turned out that I could not. We rushed to the scene, where a violently writhing woman was held down by four others, screaming a mix of incomprehensible gibberish, Kiswahili and her local language. There was no obvious physical injury and it didn’t look much like a typical seizure to me so I asked my guide to translate what was happening, I was surprised when he replied “evil spirits”.

The woman and her sister had been communicating with their ancestors and had inadvertently become possessed by malicious spirits (this is apparently very common and such communication with the ancestors is therefore discouraged). The priest had been called and he began to exorcise this woman’s sister who was being similarly restrained in a nearby house. The exorcism involved two men, at least one of which was a priest, shouting (I picked up some of the words from the daily church services at Machame e.g. “mungu” = God, “yesu” = Jesus) and frantically gesticulating over the distressed woman. This went on for some time and was watched by quite an audience of other villagers alongside me and the guides. Eventually the woman abruptly came round (no post-ictal state; further evidence against epilepsy) with apparently no memory of the previous commotion. The situation was completely new for me but I was just glad that I hadn’t had to do anything.

My guides explained that belief in witchcraft, evil spirits, warlocks and witch-doctors is very common here, alongside simultaneous belief in Christianity or, more commonly around Morogoro, Islam. Further, local people are much more likely to first attempt traditional medicine for most problems than consulting modern, western, medical help. I learnt that the beliefs permeate all aspects of life; a person is as likely to visit a witch doctor to bring them good fortune in work or love as they are for medical problems. I was surprised that my university-educated guide explained to me, in perfect English, how we keeps his money in a bible to prevent it being taken by evil spells, as that had happened to his less-cautious friend. He also warned me not to give money to warlocks lest they use my gift to magically extract the rest of my money from me.

There are many many traditional beliefs and superstitions that persist in Tanzania. People here are quick to confirm the existence of some of these practices – for example in parts of Tanzania and elsewhere in Africa twins are considered unlucky and are killed on birth, and albino people have been killed to create good luck spells and remedies – but quickly deny that they believe in these extreme examples themselves. As might be expected with the existence beliefs like this to continue, health awareness in the general population is mostly quite poor. For example my guide was amazed at my ability to remove pain with ibuprofen, he’d never heard of simple painkillers before. The dangers of smoking, alcohol or diet don’t seem to be widely known. “Blood pressure” is an extremely vague concept for most Tanzanians and many have bizarre ideas as to what causes and prevents it. Alarmingly given the prevalence of HIV, knowledge of condom use (still a taboo topic in Tanzania) is poor too; Laura and Rhi recounted how 20-40yr old taxi drivers in Moshi watched intently as a condom was demonstrated and explained to them using a coke bottle. Tanzania has a reasonable education and literacy rate for Africa (69%, ranked 19/52 countries, and improving), I suggest that increasing basic health education in parallel would be beneficial.

Mary leaves

Post Mary/ Weird things Mary does

Over the past six weeks I have had the privilege of getting to know my co-traveller, Mary. We are both from the same University and took the risky decision to go to Tanzania together despite not knowing each other at all previously. It has been a fantastic shared experience but nonetheless Mary has taken the decision to return home one week before schedule, allegedly to have more time with her family before the next academic year begins. It’s okay though because I am very familiar with women leaving me. 

Mary mentioned a while back that, shockingly, she had never read my blog. I expect that she never will – so it’s a safe place to record some of my observations of the nuances of her behaviour without fear of her finding out: 

- Mary is rightly very cautious about the dangers of unsafe drinking water – she has avoided tap water religiously for the entire trip. She instead has been drinking exclusively Serengeti brand lager, 8 bottles a day, plus extra for washing fruits and vegetables with. She’s a mean drunk.

- In addition she been vigilant in preventing disease from insect bites, having fashioned a burqa-esque garment out of mosquito netting that she insists on  wearing at all times.

- She has attempted to kidnap several African children from the hospital and orphanage, but thankfully gave up interest when she couldn’t fit them in her suitcase.

- Admirably Mary quickly became very proficient at Kiswahili, but communication is not completely problem-free as she refuses to pronounce any consonants.

Some of the above facts might not be completely true. However, what is definitely true is that I enjoyed our evolution from strangers to friends and will miss my companion as I continue alone, not least because I have eaten her leftover food at every meal for the past 42 days (yes, I am a glutton.) Further, for 42 days Mary has reminded me to take my anti-malarials, and also saved me by lending me money when I lost my debit card. 

I’ll quickly jot down my few days without my sidekick so far. I left from Zanzibar early on Sunday morning as Mary was preparing to spend her last African day dolphin watching. I took a comfortable ferry, a couple of taxis and a long uncomfortable bus to get to Morogoro by the evening time. I’m reassuringly quite sure that I am indeed staying at the cheapest hotel in town; the surly owner speaks no English and there is only very infrequently running water. On a few occasions I have been locked out of the place as the owner insists on taking my key if I go out, and then disappearing for long periods. 

I got chatting to an excellent local guy, Joseph, who has been invaluable showing me around. He fills his time working as an unofficial (uncertificated) tour guide and I opted to follow him up the mountain on Monday. Joseph, casually wearing jeans, genuinely couldn’t understand why I was so slow and sweaty on the way up, he often runs up the mountain to buy cheaper vegetables. The path was dubious in places but the views where spectacular. Joseph is unbelievably chatty and enthusiastic and talked pretty much non-stop. When we got back he introduced me to his family at his house and we had an truly excellent ginger-tea/coffee brew, (one could call it toffee. Or key). I joined him to watch Spain-Portugal in a local bar later.

Today I explored more of the town and I spent some of the afternoon reading in the poshest hotel in town. This has to be the main thing I’ve learnt from Tanzania – I’ve often spent the night in a terrible hotel for no money and then used all of the facilities at expensive hotels for free. I also made two trips daladala to the central bus station outside of town. The first attempt was unsuccessful, I was hassled by hustlers and I eventually found that the bus company  I was looking for no longer exists (I have annotated my guidebook for future reference), but Joseph came on the second and easily found me an alternative ticket, hopefully I’ll eventually get to Tanga and meet up with Laura and Rhi.

Tomorrow I’m doing more hiking in the Uluguru mountains, a different route further and higher than yesterday. I eventually decided not to continue with my planned overnight stay in the mountains as to my great surprise camping in the village worked out five times more expensive than my current crummy hotel. Elsewhere in Tanzania staying with villagers is a good way to save money, but there is quite an established programme here whereby extra funds go towards conservation and local development – worthy causes I would like to support more. Unfortunately since losing my wallet I’m wary about spending in case the money (Mary’s) hidden in my shoe runs out before I can get to the airport next week, so I’m doing the slightly cheaper option with the same programme but have to walk faster to get the hike done in one day instead.

The uluguru mountains from
http://www.panoramio.com/photo/18162682

A brief diversion

The blog has become stylistically stale. 

So here are some rubbish haiku about places in Tanzania.

Suffocating hill

women work the hot wild slopes

near Morogoro

- - -

Lost in stone alleys

grilled octopus at sunset

ships go sailing by

- - -

Tall ugly buildings

where busy rich people hide

dirt and crime are here

- - -

Doctors work nearby

clouds cover your snowy peak

and mosquitoes too

- - -

Quiet fishing village

the sea nuzzles close

and contentedly

- - -

Centre of nowhere

proud capital half-finished
many ways to leave

Uluguru Mountains, Stone town, Dar es Salaam, Machame, Gezaulole, Dodoma

To Zanzibar By Marine Craft

I spent 5 nights in Zanzibar. This became quite an overwhelming lot of blog so I’ve arbitrarily divided it into two more manageable chapters:

Chapter 1

(Temporal Zygomatic Buccal Mandibular Cervicalà branches of the facial nerve)

“Motorised craft” doesn’t have quite the same ring as “motor car” in the traditional mnemonic, but it is more accurate – we took a ferry from Dar to Zanzibar. Farcically, upon arrival we had to go through customs and immigration despite arriving from the same country. Another tense moment occurred when I was questioned about my (non-existent) yellow fever vaccination certificate– apparently a requirement for entrance to Zanzibar. I had opted not to get vaccinated for some good reasons I think: 1) Tanzania no longer requires vaccination for travellers from Britain, 2) Tanzania is low risk for yellow fever, but most persuasively, 3) The vaccine would have cost me about £60 and I’m cheap enough to really dislike having to pay to not get diseases I wasn’t planning on getting anyway (but I am aware that I may come to regret such hubris.) So overall I thought I should be allowed into Zanzibar without a vaccination, but instead I lied to the officer and mumbled that I’d lost my certificate, he frowned and let me through.

The ferry lands at Stone town or “Mji Mkongwe”, on the larger of Zanzibar’s two main islands, Unguja. 50km to the North lies Zanzibar’s forgotten other half, the more religious, conservative and less developed Pemba – where there is scarcely running water or electricity. Zanzibar was unified with mainland Tanzania in 1963, a few months after both parts gained independence from British rule.

It’s quite hot in Zanzibar and I think am at a risk of sunburn - particularly as one of the many common side effects of my anti-malarial tablets (cheap and cheerful doxycycline, £15) is increased sensitivity to the sun. So far I'm a bit burnt – I am an embarrassing and stereotypical Brit abroad, but I've no malaria or yellow fever yet. Doxy is also used to treat chlamydia, so there’s that. Most other travellers opt for the alternative tablet, Malarone, which is usually much better tolerated and gives the secondary benefit of recreational vivid dreams – but at over 10x the price.

Stone town itself is a labyrinthine mess of narrow twisting alleys linking grand Indian mansions and mosques, a cross between Disney’s Aladdin and Venice minus the canals. It’s impossible to not get lost to the point where to reach a destination it’s quicker and more enjoyable to turn corners at random until you chance upon where you want to be. From what I’ve seen, stone town appears significantly wealthier and more developed than most of mainland Tanzania and, given the stunning beaches, clear waters and lively reefs, is an extremely popular tourist destination – it has been strange to come across luxurious hotels and sea-view restaurants, most cafes even have wi-fi internet.

Consequently, for the first time so far this trip we have felt like proper tourists, holidaymakers rather than travellers, and have enjoyed the novelty of comfort. We have taken some dhow trips to nearby islands and snorkelled amongst menageries of colourful creatures. We’ve seen islands amok with crustaceans, including terrifying coconut crabs (tree climbing monsters as big as a cat) and gruesome public toilets home to several layers of pulsating hermit crabs. We’ve also clambered around a 1500yr old Baobab tree and done a fair bit of lazing on the beaches; I’m beginning to think the tourist hat really quite suits me.

I have also eaten more seafood than ever before in my life. I don’t even especially like seafood but it seems a shame not to sample Zanzibar’s famous octopus soup or barbecued lobster, all significantly tastier, fresher and cheaper than anything I could obtain in Birmingham. Today (Thursday 13th June) we visited Prison Island – once used to quarantine those with yellow fever.  The island is home to a managed colony of 200 giant tortoises, which were once common all over the islands. We made acquaintances with several of these beautiful and peaceful dinosaurs, including a devastatingly charming 189yr-old fellow.

Forodhani gardens evening seafood market is exellent

Chapter 2

I got tattooed yesterday. My first ink looks totally 100% badass: An awesome snake wrapped around a sword on my right deltoid. And it barely even hurt. It’s a shame that Zanzibar is such a Muslim country – I can’t sufficiently display my tattooed guns without being disrespectful. I hope the henna doesn’t fade by the time I get back to the UK.

Today (Friday 14 June) I took a trip 25km north of stone town to the fishing town of Mangapwani. Mary didn’t fancy another daladala trip so she stayed back to lounge by the sea. The daladalas in Zanzibar have open sides so they’re slightly cooler – but just as cramped; there was no room for me inside so I made to hang off the back with some of the other men. To my disappointment my comrades quickly concluded that I didn’t have the mettle to enjoy the breeze and so rearranged the passengers so there was room for me in the front passenger seat. This sort of special treatment is so common that I’m starting to believe that maybe I am VIP, it just hasn’t been recognised in Britain yet.

It was good to get away from the commotion and papasis of stone town, but doing so meant that I was kicked off the daladala in the middle of nowhere. I started walking down the road in an attempt to find the coast and the caves I’d been looking for only to later learn that I was headed in the completely wrong direction. After a fairly long and indirect walk I eventually made it to the coral cavern and was eager to go inside to take refuge from sun. The cavern contains about 200m of tunnels under the village and contains some mineral water pools, from which some of the locals collect water for drinking - in the company of lots of bats. A local boy with a flashlight became my guide and I duly followed as he scrambled and clambered deep inside, quickly regretting my flimsy sandals and cumbersome rucksack. It wasn’t nearly as cool as I’d hoped inside and, worryingly, the boy, Abdhul, would occasionally switch off the light to prove that it was indeed pitch black, before explaining that some of the tunnels had become impassable due to some cave-ins - 127 hours came to mind. Some time later, when my claustrophobia subsided, we managed to squeeze up a narrow chimney to the surface and I then made my way down a dirt track to a small quiet beach where I spent a few hours sitting pensively – and reading Stephen Kings Pet Semetary on my brother’s kindle (verdict so far: okay). When it started to rain I decided to keep exploring and came across the historical slave chambers, another dreadful pit used to hide slaves whilst smuggling after the slave trade was made illegal in 1873.

Attractive feet on my private bit of beach at Mangapwani (Arab's coast)

Now I am back at the hostel where I’m excitedly preparing for my last night in Zanzibar to be disrupted by the England – Italy match at 1am, I have begun to develop my 4-yearly interest in the sport and I really hope England footballs lots of goal-scores. Edit - It wasn’t worth it.