“The most we can do is to write — intelligently, creatively, critically, evocatively — about what it is like living in the world at this time.” Oliver Sacks. “To take a photograph is to align the head, the eye and the heart,” Henri Cartier-Bresson
The best way to approach this stately home is to cross the Carrick Roads (the River Fal) on the King Harry Ferry. It is a beautiful house, first built in 1824, with many later additions. The local village is called Feock and it is just a few miles outside of Truro, in Cornwall.
Ida Copeland, politician, activist, philanthropist and enthusiastic promoter of the Girl Guide movement, handed over the house to the National Trust on the death of her son. Externally, the house is splendid, with cream ionic columns and large windows looking south past Falmouth and St Mawes to the English Channel. Internally, it is more like a family home, albeit a rather posh one. There is a collection of typewriters, some Spode China and lots of basic family portraits.
One of the ancestors, Sir Humphrey Gilbert, “discovered” Newfoundland, but his ship, the Squirrel, was lost with all hands in 1583. The Gothic water tower has a golden squirrel as a weathervane.
The gardens are superb, with many hydrangeas in full bloom at this time of year. The rhododendrons are best seen in the spring when they are glorious. Look at my instagram feed to the right and see some of my flower photographs.
I must be lucky in love because I have neither skill nor good fortune when it comes to picking winners at the racecourse. The Kenyan St Leger took place on Sunday, June 24th at the Ngong Road Racetrack. We had nothing better to do, so we picked up the ingredients for a picnic at Junction Mall and called a cab.
In 1980 I was evacuated to Nairobi for root canal treatment from Southern Sudan. The local British community rallied round and tucked me under their wing until I could arrange my journey back to Sudan in a Landrover. My dentist drove me around Nairobi Game Park and a medical secretary I had met in Oxford took me to the races.
None of it looked familiar, although the grandstand was probably built before my first visit. There is now a nine-hole golf course inside the track. We paid the 200/- admission fee, bought a programme, bagged a seat on the bleachers with a good view and settled down to study the form. There were seven races, each with between 5-10 runners. Before long, I was completely bamboozled by all the names, jockeys, trainers, handicaps and past performances. The going was good, but I wasn’t.
The programme went into great detail about the different types of bet one could place. I knew about betting to win or for a place, but there were many others. You could place bets for two horses, both coming first or second in a race, intriguingly called a swinger. Plus a trifecta and a quartet, when you had to place all three or four horses past the post in order. Then there were accumulator bets, where the winnings (fat chance) from one race would be staked on the next race, and so on. The example clearly showed how 40/- could win hundreds of thousands of shillings if all the bets came good and you hit the jackpot.
I decided not to bet physically but placed imaginary bets on my chosen horses. Only one of my picks won, at 3 – 1, so I would have been out of pocket if I had staked real money. Selfie came in 4th, forget about Unforgettable which came in 3rd, and tough luck for Tough Cookie, which limped past the post in 4th place. Forewarned was what I should have been, as the Irish horse came in 4th.
My colleague is a more experienced gambler, but even he only bet the minimum amount (40/- which is equivalent to about 30 pence or 40 cents) on a few races.
In front of us, there was a hen party of white women, dressed in hats and finery, sipping something potent from a thermos flask. One lady wore a sash identifying her as a bride to be. To our right, there was a phalanx of teenagers wearing red tracksuits. At first, I thought it was the local Arsenal supporters group, but I think they were students on a school trip.
Four Kenyan singers kept us entertained with catchy tunes and slick dance moves, in between races. A disk jockey managed the backing music and sound system. As the alcohol in the thermos flask began to take effect, the bride-to-be joined the singers for some line dancing. Unfortunately, the booze had affected her co-ordination and she couldn’t match the moves of the other four singers. She got a hearty round of applause at the end of the song and tottered unsteadily on high heels back to her hen party.
We watched the horses being led around the ring, and how they reacted when the jockeys mounted. The races were all on the flat, varying from 1200m to 2600m. The starting gate was moved around the course. A team of lads helped to get the horses into the gate and after the start, the lads would pile into a van and come back to the grandstand. There must have been about 15 of them in the van, so when the door slid back and they dismounted it reminded my colleague of a clown car, where a never-ending line of passengers would exit. He even downloaded some appropriate circus music to play for their next exodus.
We drank orange juice, scoffed our ham and chicken sandwiches, followed by a slice of gateau. My colleague managed to pick up a signal on his smartphone and kept me updated with the score in the England vs Panama football match. The score sounded like the odds of a poorly fancied horse, 6 to 1.
After a few virtual losses, my colleague started to get more confident in his ability to pick a winner. We both chose the same previously unraced horse, Fast Five, for the final event. He backed it to win a place. Unfortunately, another horse withdrew, so his bet was invalid. When the horse won, he waited patiently for his meagre winnings (actually, it was mainly to get his stake back), only to be told his bet was void because there weren’t enough runners to pay out on a place. Storm clouds were gathering to the south, but they didn’t look as angry as my colleague. So 80/- worse off (about 60 pence), we trudged away from the racecourse to our taxi pickup on Ngong Road.
A couple of months ago, I wrote a piece called Black Humour about how, in the event of my untimely death, I’d like my body to be transported to the graveyard on the back of a boda-boda.
Yesterday evening, I was walking home from work at dusk when I saw a boda-boda motorbike with a lurid black, red and white sofa lashed onto the pillion seat with rubber straps. I took a photograph, of course. I was shocked as the rider drove his bike into the courtyard of the hospital morgue.
I asked Maggie, who has moved her wreath-selling business to the mortuary gates, what was going on. She said that he was going to collect a corpse. “And fasten it onto the sofa?” I asked. “Surely he can’t do that?” “Who will stop him?” replied Maggie.
I waited a while, but no shroud-wrapped body was carried out of the mortuary. Maggie tried to sell me a pack of biscuits, but when I refused, she insisted that I say it in Kikuyu, “Ka!”
It gets dark swiftly in the tropics. Our security rules insist I can’t walk outdoors at night time, so I hurried home without seeing what happened at the mortuary. I’ll have to ask Maggie the next time I see her.
This National Trust property on the River Tamar in Cornwall has its origins in 1300. It is probably one of the most authentic Tudor houses in England. It is like a rabbit warren. The walls are covered in tapestries rather than wallpaper or painted plaster. There is still no electricity in the main body of the house. It is so dark that taking photographs inside was challenging. It was the first of many stately homes to be handed over to the National Trust in lieu of death duties.
The tapestries hide the doors.
This is the door into the bowels of the Cotehele Clock, at the end of the chapel. It still works and keeps good time.
I can’t resist showing you some of the other features of the house.
Sometimes there is no alternative; you just have to buy a pig in a poke. We had arrived in Nanyuki for the Memorial Day weekend and booked into the African-style Town and Country Hotel. I asked the receptionist if there was a reliable guide for the Conservancy. She gave me Mohamed’s card, so being a trusting chap, I telephoned him. We fixed a (pretty steep) price, for which he would guide us, using a 4 wheel drive vehicle, staying in the park all day starting at 6am.
At 6:15am the next day we were outside the hotel, freezing cold, stamping our feet to keep warm, waiting for Mohamed. A flash black SUV pulled up and Mohamed greeted us. I should have realised something was wrong when I saw an image of Muammar Gaddafi applied to the rear window. Sadly, he couldn’t guide us because he had been engaged to take an expedition up Mount Kenya. Then a rent-a-wreck maize burner stopped by the storm drain. This was to be our vehicle. Even in the dark early morning, we could see it was rubbish. I asked Mohamed about the driver. “He’s very experienced,” he said. “Yes, but can he guide us?” “He’s a trained guide,” he replied. “Does he even speak English?” I asked. “Of course!”
We piled into the car and I had grave misgivings. The springs in the seat were shot (as was the suspension) and having shut the door, I couldn’t get out. The side windows had been covered in black, plastic film, presumably to add an air of mystery or to keep out the heat during summer. The film was peeling away and strips would tear off as I wound the window up and down. If you are going to see wild animals, you don’t need dark windows.
The driver had difficulty getting the car into reverse, presumably because the synchromesh was knackered. We drove off down the main road in the wrong direction. When I pointed this out, the driver said we needed fuel. The fuel gauge wasn’t working so we had better fill up now.
We retraced our bald tyre tracks and turned off down a side road towards the Conservancy. Ol Pejeta is 90,000 acres of bush and savannah, sitting astride the equator between Mount Kenya to the east and the Aberdare Mountains to the west. It is a privately-owned, not for profit, wildlife conservation project. The sun was just rising behind Mount Kenya when we drove in through the main gate.
The guard at the entrance told us that we couldn’t pay using plastic. The machine wasn’t working. We needed to go online to book tickets. Yerrright. Suspecting a scam, we told him we’d pay on the way out when the machine was working. Our driver did a deal with the guards and he got regular updates on his phone about the locations of the best sightings.
Within a few kilometres, we realised that our driver was not a guide. Like John Snow, he knew nothing. Having worked for six months in South Luangwa Valley in Zambia, I could point out the animals and give a bit of a commentary. We had an enjoyable morning spotting black rhinoceros (120 in the park), elephants, zebra, giraffes and lots of different antelopes. We saw some birds, too. A kori bustard, ostriches, francolin, quail, various ducks and geese, grey crowned cranes, storks, ibis and spoonbills.
As the day warmed up, the driver took us to see the Chimpanzee Sanctuary at Sweetwaters. This seemed like a concentration camp with a viewing tower which looked like it could house a searchlight and machine guns. One sad chimp was eating leaves under a bush and another was close to the electrified fence. He looked miserable. Jane Goodall set this up in collaboration with the Kenya Wildlife Service in 1993 to house orphaned and illegally trafficked chimps. There are 39 chimps in two troops, on either side of the Ewaso Nyiro River. Before the torrential rains swept away some of the fencing keeping the hippos out, a ranger would take tourists on a bush walk through the forest. This wasn’t possible now, so we drove to Hippo Hide car park and walked along the river looking for hippopotami. After about half a kilometre, we met some tourists returning from the hide – no hippos.
The driver’s phone started ringing. Lions had been sighted. We joined the queue of vehicles jockeying for position to see a lioness who was crashed out in some long grass. She showed a spike of interest when a family of warthogs filtered through the trees in the distance, but then flopped down again as she didn’t rate the chances of pork on today’s menu.
The vehicle’s reverse gear was getting increasingly difficult to engage. The driver had to stop the engine, force the gear stick into reverse, depress the clutch and start the engine again. Manoeuvring in tight spots was extremely difficult.
We had lunch in the park – steak and chips, not impala or eland – and watched a storm approaching across the savannah. The driver was getting impatient, so we drove off to several dams (lakes, really) where there was a solitary hippo, that we could only see when it came up for air. It made a move to the lake shore, but was spooked by a family of waterbuck.
We drove past a farm within the conservancy which had long-horned Ugandan cattle. In the distance we spotted a group of rhino. The last male Northern White Rhino had died of old age and frailty less than three months ago. There are still two female NWRs, so a Southern White Rhino male was brought in to cross-breed, but no pregnancy resulted. Maybe some genetic engineering will help. They are asking for donors – for cash, not genetic material – to do a bit of Jurassic Park-style cloning.
The rhinoceri were a family group – mum, dad and baby. We stopped to watch on our own for fifteen minutes before the phone squawked again. More lions. We roared off, but missed them as they had wandered down to the main gate for closing time.
Finally we left the park before it began to rain. The credit card machine was still not working. We showed the senior guard our diplomatic cards proving we were residents and paid him the fee for the vehicle, driver and three tourists. It was not quite as much as I had paid Mohamed. We drove out of the gate and stopped. The driver went back to “explain to the guards that they had their pricing system wrong, because Friday counts as weekend rate if it is a national holiday.” Very suspicious. I thought he went back to get his cut of the cash. We didn’t get any receipt, of course.
By now it was dark. The lights on the vehicle were not good, but this didn’t stop the driver from putting his foot down and racing along the rutted dirt road, back to town. Despite the clapped-out vehicle and the lack of expert guidance, we had really enjoyed ourselves. It was time for a pseudo-French meal at Le Rustique, much better fare than the beans, rice, cabbage and chapatis we eat at Embu.
At weekends, when the weather is changeable, I wander around the back lanes of Embu, observing life and photographing doors, sad person that I am. Here is an interesting set of photographs of D.E.B. Kamui School (“Motto: Effort is Success”).
The school authorities are very clear about their educational strategy. They can teach these skills working in rather decrepit classrooms. I like the image of the cooking pot held above the fire by teacher stones and the “digital” school painting with five digits.
Further on down the road, there was a shop with a black plastic awning over the barred and caged window. The shop is called “A Shade of Hope”. It reminds me of a radical bookshop run by Alan Milburn (who later became Health Secretary in the New Labour Government) in Newcastle called “Days of Hope”, which was so alternative that wags called it “Haze of Dope”. Nothing like that here in this shop. There is a door in the dark grey metal gate. The kiosk to the left looks like it has seen better days, but it is still in use at peak hours.
There are lots of car wash sites in Embu, which is understandable given that most of the back lanes and roads are not sealed. Boda-boda motorcycles get splattered with mud during their rides in the bush. This salubrious establishment offers to clean your carpets, as well as your cars. There is another advertising hoarding at the back of the yard offering “full pressure body wash”, featuring a scantily clad lady suggestively wielding a power hose. Not for a family blog post.
Out of town, I saw these handsome doors (gates) on sale at the side of the road. Contrast this with the rusty corrugated iron doors behind these boys whom I photographed in the county on a rainy Sunday afternoon.
Good restaurants are thin on the ground in rural Kenya. The two doctors who were here in Embu before me would drive two hours to a restaurant outside Nanyuki called the “Trout Tree”, just for Sunday lunch. Well, anything is better than rice, beans, cabbage and chapattis after a while. We had already planned to stop here for lunch on our way back from our safari at Ol Pejeta.
We got there quicker than we had anticipated at 11.30am, too early for lunch. A large group of safari tourists were already moving down to the restaurant. “Why don’t we go for a walk until 1pm and reserve a table once this group has moved on?” I suggested.
The restaurant is built into a massive tree. It overlooks the trout farm. In the forest surrounding the farm, there were troops of colobus monkeys. The staff of the restaurant fed the monkeys at midday so they would come for lunch at the same time as the customers. They were a good tourist attraction. A few tree hyraxes (about the same size as a large rat) visited the diners on the top floor of the restaurant.
The maitre d’ was rather flummoxed by our request to be shown some walking trails. “There are none here. This land is all owned by farmers. Why do you want to go walking anyway? Why not sit in the bar and wait for your table?” We didn’t believe him and walked up the steep drive to the main highway. Across the road, we could see a rough track.
We followed the track up to a radio tower on the hillside, enjoying the clean air and sunshine. We could hear voices in the woods but no one came to chastise us for trespassing. By the time we got back to the treetop restaurant, it was 1pm. The big group of Safari tourists were just leaving. I quizzed them about the food and they recommended the trout. Well, they would, wouldn’t they?
We settled into a prime location and waited for the waitress. Service was extremely slow. It started off badly when my Danish colleague saw Carlsberg beer on the menu and ordered an ice cold bottle. It was not available, so he had Guinness, but was concerned about its provenance as the label had come adrift in the ice chest where drinks were kept. He wasn’t impressed by the smoked trout pizza, either. He kept us amused by reading out bad reviews from TripAdvisor as we waited for our food.
I asked for plain tap water and the waitress refused to give it to me. She said, “If tourists drink our water and get sick they will blame the food at the restaurant.” I told her that I live in Embu and drink the water from the tap, but she still refused to serve me. However, I had some wholesome vegetable soup, followed by the grilled whole trout with garlic butter and chips, which was very tasty.
We ordered tea and coffee with home-made biscuits but were given fresh fruit salad instead. After pointing out the mistake, the waitress said we could have it on the house, free of charge. But what about our tea and biscuits? It took a long while to get lukewarm water and tea bags. By this time it was almost 4pm, time to get back to Embu before darkness fell.
We are supporting the Kenyan Ministry of Health’s policy to improve the management of chronic non-communicable diseases (NCDs – hypertension, diabetes, asthma and epilepsy in the first instance) in rural clinics and health centres. Before we started work in Embu in August last year, most people with NCDs went to the local district hospital for treatment or attended a private clinic. We think that highly trained doctors working in hospitals should be treating more complicated conditions, and leave the simpler stuff to primary care. If this scheme is implemented throughout Kenya, it will save the Ministry of Health billions of shillings.
Eleven months later, almost 2,000 patients with NCDs receive their treatment at their local health facility, where local health workers have not just been trained, they have been mentored to improve their knowledge, skills and attitudes.
The usual approach to training rural health workers is to get funding from an aid agency to run a course in a hotel conference room. After eight hours of death by PowerPoint, the health workers get a certificate and are considered trained. We are using a different approach, mentoring.
Our 12-strong team of highly trained clinical officers, nurses and health promoters have been trained to mentor health workers in five rural health centres and two dispensaries. The cycle lasts for six months, with weekly visits, a structured learning programme, one-to-one teaching, observation of clinical practice, etc. The mentoring team uses a set of disease-management guidelines which have been specifically designed for rural Kenya. These can deal with over 90% of the patients we see, but when the guidelines don’t seem to fit, the mentors ask for advice from the expatriate doctor.
All that wheezes isn’t necessarily asthma.
The mentor asked me about a 65-year-old lady with rheumatoid arthritis who had a year-long history of expiratory wheeze, nocturnal dry cough and chest tightness. She said she had cooked for years using dried cow dung in a restricted kitchen area. She didn’t smoke, but her husband had done in the house for years. A few months ago, she had started taking 10mg prednisolone (steroid tablets) for arthritis, which had helped to improve her wheeze. The steroids were stopped and her wheeze came back.
Examining her she had widespread expiratory wheeze. Her peak expiratory flow doubled after salbutamol inhalation. I concurred with the mentor that the diagnosis was adult-onset asthma, which is pretty rare.
Contrast this with a 45-year-old man who had attended the health centre with shortness of breath and a cough a week previously. The nurse (not on our programme) had treated him with two different intravenous antibiotics, oral antibiotics, salbutamol tablets and antihistamines. The nurse had diagnosed asthma and asked him to come for review when the team attended.
On closer questioning, the patient said he was feeling much better. He had similar episodes once every two or three years. Clearly, this was a chest infection, not asthma, as the unmentored nurse had thought.
Another lady with a 20-year history of asthma treated with salbutamol tablets (we stopped using these in UK general practice when I was in medical school) had enrolled in our NCD programme a month ago. She had been prescribed a reliever (salbutamol) and a preventer (steroid) inhalers instead of tablets. She told us that she had only had one attack during the past month when she had been caught in the open by a cold rainstorm while she was farming. It became apparent that she had been using the steroid for relief and the salbutamol for prevention (the wrong way round). Still, even so, she felt better. She will improve even more when she uses the inhalers properly.
It is really important to spend time with patients to understand how to use their inhalers. We don’t have any placebo inhalers to demonstrate technique (I am working on this). When observing our mentor in the consulting room, I saw one lady who managed to use her salbutamol inhaler upside down. When she eventually managed to fire off a dose, the gas was unable to get out of the closed mouthpiece and came up alongside the aerosol canister for her to inhale.
While visiting the Ngong Road Racecourse watching the Kenya St Leger, I messaged my father in England (who has an uncanny knack of picking winners). He replied, warning me of a storm forecast for 5pm. We called a taxi and left the track at 4.30pm. There was a traffic jam on Ngong Road. There is always a traffic jam on Ngong Road. The first juicy raindrops fell just as the taxi arrived at 5.20pm.
On the way home, we passed the birthplace of doors. Still being held up in the jam, I was able to take some photographs from the taxi.
These are for the rich folks. The poor people get by with doors like this.