“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
From 1971 – 1974 I was an undergraduate studying medical sciences at St John’s College, Cambridge. Last month, I visited some of my old haunts and (it goes without saying) I photographed some doors.
The college was founded by Lady Margaret Beaufort, the grandmother of King Henry VIII, in 1511. Above the gate, her coat of arms depicts heraldic yales, mythical beasts (a formidable combination of an ibex with revolving horns and a wild boar with tusks). This is not the only college with links to the yale, for example, across the Atlantic there is a university of the same name.
A statue of Lady Margaret stands between two leaded windows. She was a fascinating woman who was depicted in Phillipa Gregory’s book “The White Queen”. She had been married three times by the time she was 15 (the first marriage was when she was just 6) and lived through the 30 turbulent years of the Wars of the Roses. She was the matriarch who founded the Tudor Dynasty when, at the age of 13, she gave birth to a son who became Henry VII. It’s all a bit Game of Thrones.
Within the grounds of St John’s College there is a much older building known as the School of Pythagoras. It was built in 1200, before Cambridge University was founded. I recall attending a demonstration/lecture of hypnosis there in 1972. The building now houses the college archives.
The college chapel is on the north side of the court and the dining hall is on the west side. Queen Elizabeth the First rode into the dining hall on a horse during a state visit in 1564. As an undergrad, I had to wear a gown when taking meals in hall. Part of the D-Day Landings were planned in Second Court, and the treaty between England and France arranging the marriage of King Charles I to Queen Henrietta was signed here.
Famous alumni of St John’s include William Wordsworth (poet), William Wilberforce (abolitionist), John Dee (alchemist who first promoted the idea of the “British Empire” and the colonisation of North America), Thomas Fairfax (general of Parliamentary forces during the Civil War), Derek Jacobi (actor), Thomas Linacre (founder of the Royal College of Physicians), John Couch Adams (mathematician who predicted the existence of the planet Neptune from his calculations), Richard Penn (grandson of William Penn and lieutenant governor of Pennsylvania), John Herschel (astronomer who coined the word photography), Manmohan Singh (Head of State of India) and Cecil Beaton (celebrity photographer). One of my contemporaries was Douglas Adams, author of “A Hitchhiker’s Guide to the Galaxy”.
The police cruiser was nestled in foliage on the central reservation at the north end of Lake Shore Drive. It was 9am on Saturday morning and we had just driven through the slalom at the junction of Sheridan and Hollywood. All four of the south bound lanes were bathed in sunshine and almost devoid of traffic. The speed limit was 40 mph, but everyone seemed to be driving at 60 mph. “The cops only get excited when you exceed 60,” said J, the driver. I looked behind us and sure enough, the cruiser remained stationary. “Perhaps he’s eating breakfast,” I said.
We were headed for Costco, a subscription-only discount warehouse.
“It gets crowded on weekends, so we want to be there for opening at 9.30,
” said my card-carrying chauffeur. We turned west to pick up Ashland
“I need some coffee,” said J. He pulled over to
the right-side lane and cut into a vast supermarket car park. “Jewel Osco
has a Starbucks.” We stopped by the entrance and J entered Jewel. He came
out a minute later without a coffee. “The Starbucks concession is a block
away from the entrance, and there’s already eight people waiting in line.
Ten minutes later and lacking in caffeine, we parked in Costco’s massive lot. There was already a mob of people milling around outside the main door. We collected a huge supermarket trolley and lined up. Some customers had chosen a larger, flat-bed trolley for bulk purchases. For some reason, an elderly man in front of us had a carton of panty liners. With wings. J and I speculated on the circumstances of his purchase, which he was presumably returning for a refund.
A Vietnamese couple collected a loose unclaimed trolley, but
no sneaking into the queue was allowed. A man behind us growled, “Get in
line!” and they complied.
The entrance to Costco was a giant roller door, already half
open. At 9.29am the crowd was getting restive, people not in line were
jockeying for position. It reminded me of the start to a Formula One race.
The door rattled up and we were in. Ten metres from the
entrance there was a display of huge televisions, known as
“megatellys” by my children. I was distracted and stopped for a split
second to marvel at the crisp colours on a 75 inch screen. There was a howl of
disapproval from behind me. It was as though I had stopped a car in the middle
lane of the freeway. Shoppers flowed either side of me until I moved off.
The store was vast. It reminded me of the ground floor of an IKEA, with rows of tall shelving around the periphery. As I was a Costco virgin, I gawped at the array of products – food, clothing, electronics, Apple computers, pet food, sweets, toilet paper and fancy dress outfits.
We had a shopping list for a family barbecue, Ricky’s
Ribfest. First on the list was alcohol. Prominently displayed at the end of one
row there was a red wine on sale, “Portuguese blended red”. J said
that one of his family had recommended this and loaded three bottles into our
cart. A shopper behind us seemed impressed, too, adding a couple of the same
vintage to his cart.
Next stop was the food preparation area for turkey wraps.
Sadly, these were so popular that they had to be ordered 24 hours in advance. I
suggested a rotisserie chicken instead, but all twenty on the rack had been
purchased. It was just 9.35am but behind the counter I could see two ovens
packed with rotating chickens which looked perfectly roasted. Within five
minutes, they had been stacked on the rack and claimed by shoppers. But I
grabbed a beauty for $5.99.
The next item on the shopping list was cat litter. J asked a
shop assistant who pointed to shelving on the back wall of the warehouse. We
couldn’t find it. “He said it was over here,” I said to J. “No,
they wouldn’t put cat litter next to food items.” “Why not? The cat
hasn’t pooped in it yet.”
We bought a block of 500ml San Pellegrino carbonated water,
which was J’s guilty pleasure. I am not sure I could tell the difference in a
Potato chips – crisps, in English parlance – had a whole
aisle to themselves. There were no 25g packets, just large sacks. We grabbed
three different varieties. “What about other snack foods?” asked J.
The next aisle had pretzels covered with chocolate, filled with peanut butter,
sprinkled with rock salt – wrong on so many levels. No wonder there is a
serious obesity problem in the USA.
Having said this, dried mangoes dipped in chocolate were
delicious. I was sorely tempted. A 62 ounce pack of M&Ms caught my eye, but
it wouldn’t fit into my carry-on luggage to take back to the UK.
I steered the cart to the check out. J wasn’t familiar with self scanning machines, but the line here was shortest. After scanning each item, the machine told you what you had scanned and the price. When it came to wine, we needed assistance. I took off the wine and scanned our precious rotisserie chicken. A red light came on, but there were no spotlights or sirens. The shop assistant was puzzled. “Yes, J really does look under 25, doesn’t he?” I joked. She glanced at me and proceeded to override the computer system. She had to key in the date of birth of the purchaser, but gave up and keyed in her own date of birth. She got it wrong the first time, but eventually the wine went through. But there was still a problem – my scanning the rotisserie chicken. “My fault,” I said. She looked at me without understanding. After a week in the USA, I am learning a new language. “My bad,” I said in a thick midwest accent. I pointed out the chicken, but she still had to check through the entire list of shopping.
J started to move products prematurely from the weighing scale to our shopping trolley. This caused the computer more consternation, but we finally made it and paid.
“Wanna hot dog?” asked J. “The Vienna Sausage
factory is right next door so they just ship them over. They are famous. And
good.” Of course I said yes. The Costco hotdog is a loss-leader. The price
has not changed since 1985.
The spartan dining area after the checkouts had a limited
menu, limited to fast food. Beside the price of each item there was an estimate
of its calories. The quarter pounder hot dog sausage with bun and relish was
$1.50 and 552 calories with 46g of carbohydrate, 11g of sugar and 32g of fat.
If you added a free 20 fluid ounces of soda (Pepsi, Morning Dew, etc) this
would bump up the calories to 990. Costco displayed the recommended daily
calorie intake at 2,000 calories. So much for breakfast.
The hotdog came in a foil packet to keep it warm. The sausage poked out an inch either end of the bun. To add onion I had to turn a handle on a tin hopper to shred it over the bun. There was deli relish, two kinds of mustard (President Obama likes Dijon mustard on his) and ketchup.
It was absolutely delicious. While we ate the hotdog, we watched the
customers wheeling their purchases towards the exit. One man had a flat bed
trolley filled with small bottles of water (perhaps he was going to sell them
to tourists downtown for a dollar a bottle), another had a mountain of adult
nappies and toilet paper (best not to speculate).
We wiped our sticky fingers and pushed the trolley to the
exit. Barbara, the shop security officer, was checking all the till receipts. I
smiled at her and wished her good morning. “Never be nice to a checker,
because she will take it as a sign you are trying to steal something,”
said J. Barbara didn’t even blink. She poked through our plastic bags and
looked at the list of purchases, then waved us through. “Have a good day,
We loaded the car and drove north on Ashland Avenue, with Radio Rock FM playing blasts from the past. J guessed 1972, but he was a year out. 1973 classics don’t lose their appeal. A Bob Dylan number came on the radio and J cranked the volume to 11. What was the song? “Knockin’ on Heaven’s Door” of course, the inspiration for this post.
Thursday Jaws, sorry about the pun. Actually, I don’t think the lion (Ginger) thought it was very funny.
This sounds like an examination question! Recently I have been working in the community as a general practitioner, a family doctor, here in the United Kingdom. I must do this for at least a month each year in order to retain my medical licence, without which I would be unable to work overseas. Also, I need to have an annual appraisal and every five years the UK’s General Medical Council considers whether to revalidate my licence.
Five similarities between working in primary care in the UK
1 Not all my patients speak English
I enjoy being able to consult in English, but having said that, about half of my patients here don’t speak it as a first language. This is because I work in an inner city, a very cosmopolitan area. 95% of the time, I manage to get by with a limited vocabulary and basic grammar, but I still need an interpreter for a few patients.
This can cause some administrative problems, because of the revalidation requirement to collect anonymised, written feedback from at least 35 consecutive patients. This isn’t easy if some of my patients (in the UK) can’t speak or read English well.
In contrast, only 10% of my Zambian patients speak English fluently enough for me to consult effectively. These are mostly the well-educated and well off. I don’t want to be restricted to caring for the most privileged, so I always try to work with a Zambian nurse or clinical officer. They take a history from the patient and we discuss their clinical management. It turns the consultation into a useful teaching exercise.
2 Lack of free medication
It was frustrating to be unable to prescribe common
medication in both countries, for cost reasons. In the UK, NHS prescribing for
about 75% of the population used to be free. However, many of the most
frequently prescribed medications, such as simple painkillers, antihistamines, antibiotic
eye ointment and certain skin creams are no longer free; patients have to buy
these products from a pharmacy or a supermarket.
In Zambia, medication prescribed at a health centre is free, but in such short supply that the range of drugs is very limited. Occasionally the health centre ran out of basic items like paracetamol and intravenous fluids. I would regularly write out a private prescription for the patient to take to a pharmacy in Mfuwe or Chipata.
3 Restricted prescribing
In UK primary care, all medical records are computerised. Sometimes,
when I decided a patient needed a certain drug, the computer would try to
change my mind. “Try this form (tablet, capsule, syrup) of the drug, it is
cheaper.” Or I would be urged to switch to a similar drug, which might have
fewer side effects or is less likely to interact with other drugs. The computer
might not think I was competent to prescribe a drug (even though I know that
this is what a specialist would prescribe if I were to refer the patient to
hospital). GPs and specialist pharmacists have produced treatment algorithms
and guidelines based on clinical evidence and if I don’t follow it religiously,
I will be asked to explain why. I may be censured if my explanations are not
considered good enough.
Sometimes the patient tells me that they have already tried the drug recommended by the computer and it hasn’t worked or they cannot tolerate it. Or it interacts with another drug they are taking which has been prescribed by a hospital specialist, unknown to the computer.
Occasionally I reject the guidelines because the patient doesn’t like a drug’s taste or doesn’t want to take it in a gelatine capsule as they are vegetarian or it is considered”haram” or forbidden. Artificial intelligence tends to assume all patients are similar; I treat them all as individuals, sometimes quirky, but with valid opinions about their medical care.
In Zambia, certain essential drugs may not be available, particularly for non-communicable diseases. I had to beg a local charity to provide three months’ supply of haloperidol to treat the dozen or so patients suffering from severe enduring mental illness in Mfuwe. We only had limited stocks of a tricyclic antidepressant with troublesome side effects (amitriptyline) even though fluoxetine (Prozac has been in common use in the UK for over 25 years) is cheap and well tolerated.
We had no insulin and oral medication for diabetes was often out of stock. We had no inhalers to treat asthma and had to use oral salbutamol tablets instead – an ineffective practice we stopped doing in the UK 50 years ago. The range of drugs to treat high blood pressure was very limited and stocks were often in short supply. We would occasionally run out of basic drugs to treat epilepsy.
4 Many patients consult with self-limiting illnesses
People in the UK and Zambia often seek medical advice
because they think that they are unwell and that the doctor or nurse will be
able to treat them. In both countries, care is free at the health centre or
In the UK, patients with a cold or viral upper respiratory tract infection will have often tried taking simple preparations, either traditional (tamarind, honey, chilli and lemon juice, any combination) remedies or cough syrups from the pharmacy for several days with no resolution to their symptoms. Some patients feel their symptoms are so severe that they need treatment with antibiotics. Others would prefer to avoid antibiotics but consult to see if the doctor thinks they need them.
In Zambia, patients with minor self-limiting illness expect to be given medication, and often resent being given a scientific explanation why antibiotics won’t work. Traditional healers (sangomas) understand the value of placebos and encourage the patient to return, as this is how they make money.
In both countries, with easy, free access to healthcare, patients often have a low threshold for seeking advice. One of my patients in the UK brought in her infant son because he had been awake from 2am to 4am that morning. A patient in Zambia brought in her daughter because she had vomited once just an hour previously.
5 Obstacles to referring patients to specialists
In the health centre in UK where I have been working, it is
reassuring to have hordes of specialists in our three city hospitals available
to see patients who require further investigations or surgical procedures.
Twenty years ago, I knew most of the hospital specialists
and could write a personal referral letter. I knew that Ms A was the best
orthopaedic surgeon for shoulder problems, Mr S was the best gynaecologist for
patients whom I thought did NOT require a hysterectomy, for example. The
consultant would read the letter and decide on how quickly they should see the
patient based on the quality of information in the letter. Those days are long
gone in the NHS.
Now I have to use a complicated referral system called PRISM which leads me through a box-ticking pathway of algorithms to ensure that my patients meet strict referral criteria. For example, if the patient is 64, not 65 years old, or if I haven’t prescribed drug X, my referral could be rejected.
This approach stops whimsical referrals from GPs (in the past, some might just write, “Dear Dr, please see and do the needful.”) but it erects barriers for patients to access specialist care. I think that limiting access in this way amounts to rationing care.
There is an express “Two-Week Wait” referral for patients who might have cancer but they must meet even stricter referral criteria. Not all patients meeting the criteria are found to be suffering from cancer (about 15-20% are) but conversely, some patients who don’t meet the criteria are found to be suffering from cancer when they eventually see a specialist several months after the GP referred them. Perhaps this is why Cancer Research UK recently revealed that cancers are diagnosed later in the UK than other comparable European countries.
In rural Zambia, if we don’t have the resources or expertise to treat a patient, we can refer that patient to hospital. This may not be as simple as it sounds. The nearest district hospital was 50 kilometres away, manned by a single junior doctor assisted by a modest number of nurses and midwives. The provincial hospital had more staff but was 150 kilometres away. There was a very limited supply of fuel for ambulance transport in emergencies, so most patients (or their families) had to pay for private vehicles to take them to hospital.
There is a strict referral pathway, clinic to health centre
to district hospital to provincial hospital to University Teaching Hospital in the
capital, Lusaka. If I wanted to refer directly, I could telephone the District
Health Officer or a specialist at UTH in exceptional circumstances, such as
childhood cancer or leukaemia.
And one difference, consulting children
I enjoy interacting with patients wherever I am. I am touched by the Zambian children who wear their best clothes to come to the community clinic or health centre. They are much quieter and more reserved than children who see me in the UK. They are usually mute and refuse to describe their symptoms in their local language. They stare fearfully at the strange muzungu doctor, like rabbits at night caught in the headlights. Their parents tell their stories for them, not always reliably. “My son has a headache,” they might say because the child has a fever and has been crying. They don’t understand the need to answer detailed questions because they view the doctor as omniscient, like any traditional healer or sangoma.
Children at the health centre in the UK tend to be more communicative and occasionally rather naughty. A mother brought her infant and two older children to the health centre, and while I was examining the infant, the other children started jumping up and down on my examination couch.
Their mother said, “I’m sorry doctor, but they were behaving so badly outside, I told them that the closed-circuit TV camera would have recorded it all and they would be punished by being forced to spend the night in the health centre.”
I replied, “So that’s why they are trying out the bed, is it?”
Overlooking the beautiful bay of Himare, there is a lonely, overpriced restaurant. A canvas poster proclaims that it has the best view in Albania.
Behind the Trammonto Bar-Ristorante there was a ruined farmhouse. It had been connected to the electricity supply at one point, so its dilapidation cannot have been more than a decade ago.
Higher on the promontory, there was a modern house which did not look as interesting. As it had been built on a slope, there was a door in the roof, reached by a staircase.
But there is an older Himare (Himare Fshat), built on a steep, rocky hill above the beach. Old churches, some ruined, some ruined but still being actively used for worship, huddle within the ancient walls of a castle. Houses built into the castle walls are still lived in.
Back in the tourist town of Himare, there are some other doors of interest.