Not “Greed is Good” Gordon Gecko. This post is about the lizards. I share my house with at least a dozen. They are khaki in colour, and vary in size from 3 – 12 centimetres. They have suction pads on their toes so they can climb any wall and traverse any ceiling. They don’t bother me at all, because they do bother mosquitoes and other insects by eating them. Which is good news for me.
They tend to shun the limelight, preferring to hunt their prey behind the fridge or curtains. I don’t pay them much attention unless they catch my eye as they scurry from one location to another. Sometimes I see them chasing each other. Whether this is a territorial dispute or a mating ritual, I have no idea. Occasionally, I see one that has lost part of its tail. Geckos have the ability to shed their tail if it has been caught be a predator, to help them escape.
Recently I have noticed lots of gecko turds in my shower area. And by lots I mean 20-50 tiny dark shits, about the size of a matchstick head. The shower is separated by a partial wall from my toilet, but even if I leave the toilet lid open, they prefer to poop in the shower. I thought I’d give them something to aim at.
I don’t know why they prefer to use my shower as their toilet. But I have given it some serious thought.
I wondered if it was because of the increased humidity, from the wet floor of the shower. But my toilet leaks (clean water, not foul) and forms a puddle around my ankles, so I doubt that moisture is the answer.
Perhaps the act of defaecation is a social event in gecko culture. It may be that all the geckos in my house get together to crap ensemble. Many antelope in the park have a communal toilet called a “midden”. All the impala or puku prefer to poop in the same spot, so it looks like someone has spilled a bucket of black peas on the ground. Could it be that each gecko’s shit contains hormonal messages, showing a female lizard is “on heat” (does this expression even apply to cold-blooded creatures?) or a male is producing lots of male hormones? Perhaps my shower pan is the equivalent of gecko Facebook, where they communicate with each other chemically in their poo?
Interesting: on the left is the shit situation last night, on the right is the shit situation this morning. Not much difference. Perhaps they sleep at night and poo during the day?
Whatever the explanation is, I don’t really care. I just think of all the noxious insects they have eaten to produce this amount of crap. And I never look at the soles of my feet, anyway.
“The best laid schemes o’ mice an’ men / Gang aft a-gley.” – Robbie Burns
WARNING: This may be interesting for you if you enjoy observing the trials and tribulations of logistical planning, but otherwise, it might be rather boring. Even the accompanying photographs.
The Ministry of Health’s plan was simple: vaccinate all 14-year-old girls and give them a booster a year later to provide protection against cervical cancer. Repeat annually with each cohort of young girls.
Now, vaccinating infants is easy; their mothers bring them along to our community clinics to be immunised. But how do you access teenage girls? The obvious answer is to vaccinate them in school.
Not all girls go to school, however, especially in rural areas.
And students change schools, moving to different locations, for a better education, often at age 14.
Then Covid-19 arrives and schools close down, completely wrecking your strategy.
“Can you help us boost our coverage, Dr Ian?” asked D, who is in charge of immunisation campaigns at the health centre. I agreed and asked to see what had been accomplished so far.
D handed me six huge registers, in which the teams had recorded the vaccinations, given at six local schools.
“What does this mean?” I asked, pointing to rows of children’s names where the column indicating the date of HPV vaccination was blank.
“I am sure that they have had the vaccine, we just didn’t record it.”
That sounded very odd. If you bother to record the name and village, why wouldn’t you add the date of vaccination. Even if you just put ditto marks in the column.
We did some investigating. It turned out that the vaccinating teams were understaffed, so they asked the teachers to write down the names of all the girls in their classes who were 14. But not all of these girls were at school on the day the vaccination team arrived, or had refused to have the vaccine.
“Did you not know about this, D?” I asked him. “Ah, doc, I didn’t vaccinate at this school.”
“Right, how many 14-year-old girls did you vaccinate last June/July?” I enquired.
D didn’t know exactly, but the nurse in charge said that he had reported 269 to the Ministry.
OK, so how many girls are recorded in the registers as having been vaccinated? He didn’t know, so we copied the information from the registers into an Excel workbook and counted 311.
“Why do you think there is a discrepancy?” D didn’t know and neither did the nurse in charge. “Perhaps you vaccinated 269 schoolgirls and 42 girls who were not attending school?” I suggested.
“How about coming at this problem from a different angle. How many doses of vaccine did you use last year?” I asked. D said that the Ministry of Health had collected all the unused doses in August 2019 at the end of the campaign, so he couldn’t check.
“But that was last year, doc. I am worried about this year,” D said.
“So what is your target?” I asked.
“All the girls we vaccinated last year who are now 15, plus the girls who have turned 14,” he replied.
“What’s your estimate of the numbers?” I asked. D said that the Ministry of Health had worked out how many doses we should have based on some ten-year-old census data uprated by the estimated growth in population.
“So, how many do you think this year?” I asked. D wasn’t sure and wouldn’t hazard a guess.
“Okay, we don’t have precise figures, but is it logical to assume that at least the same number of girls are born each year? We vaccinated 269 or 311 girls who were 14 last year, so we should be aiming to vaccinate that number plus a similar number of girls who turned 14 this year.”
“If you say so, doc.”
“Let’s say about 600. How many doses of vaccine did the Ministry of Health deliver to us?”
“We got 550 this year,” he said after checking the records.
“And how many doses are left?”
“Good, so we are about half way there,” I offered. “How did you manage to vaccinate so many when the schools were closed?”
“The students who are in their examination years are still attending school.”
We looked at the Excel spreadsheet, where 145 15-year-old girls had received their second dose and 88 14-year-old girls had received their first dose, during the past two months.
“So, what can we do now? How do we get to the girls who are not at school?” I asked.
“We can use our community health volunteers to mobilise them,” he said. “Then we can vaccinate them all in one day going from village to village.”
“But students don’t always go to the school nearest to where they live. They try to get into the best schools or they get rejected from other schools. We are lucky to have their villages recorded in the register.”
The prospect of trawling through six registers was daunting until I discovered that D had a database of all the villages in the health centre’s catchment area. There are ten neighbourhood health committees, each with a volunteer health worker. A bit of magic with Excel and we were able to print out a list of all the 15-year-old girls who were eligible for their second dose in each location. We delivered the list to each volunteer health worker. They had 48 hours to locate the girls on their list, plus any 14-year-old girls, and we would be along to vaccinate at a particular time.
Unfortunately, some volunteers were unable to identify any of their target population. Others had tracked down every 15-year-old. They could tell us where the girls had relocated: back to Lusaka, to a good school out of our area, or who had become pregnant. We only managed to vaccinate another 20 girls.
In one village, D said he had a message to the girls who had come for their vaccinations. “During this time of Covid, when the schools are closed, keep yourselves busy. Don’t give in to temptation and go with boys because you don’t have anything better to do.” I looked at the group of girls on the mat and thought that they looked like mature, young women.
I foresee that there will be a big rise in teenage pregnancies in 2021.
We still had hundreds of girls to vaccinate. I asked A, the other health inspector, what we should do. She said, “We should contact the girls.” But how? “Some way.” Yes, but how exactly? It’s no good just saying what you want to happen without a plan to make it happen.
“Give me some time, I will think about it,” said A. But we don’t have time. The Ministry will be taking back the vaccines in August as it assumes we will have successfully completed the campaign by then, regardless of the disruption of covid. I had a plan to use the local radio station to spread the word, but I wanted A to come up with that suggestion, so I could make her take ownership of the problem. With some unsubtle prompting, she thought using the radio station would be a good plan.
“Okay, what would you say on the radio, A?” She wasn’t sure, so I drafted a short statement about preventing the number one cancer affecting women in Zambia, how safe the vaccine was, who should have it, and the dates and locations we would be offering the vaccine over the next few weeks.
D stumbled while reading the statement in English, never mind translating it into Kunda, the local language. I suggested a female voice would go down better for a health message directed at girls and young women. A translated the piece and gave a seamless performance. We drove down to Radio Mhkanya and I sold the story to the station manager. “It will make a great two-minute news article,” I said. He agreed and A went next door to do the interview.
I asked the station manager about the catchment area of the radio and he told me it was about 50km in all directions. I asked D to inform his colleagues in other neighbouring health centres so they could deal with any surge in demand for HPV vaccine in the coming weeks.
A came out beaming. She wanted to hear her voice on the radio, so the interviewer put headphones over her ears and played the clip back to her over the computer. She was delighted. Even D wanted to hear.
There was a spring in her step as she walked back to the car. She was a radio star; everyone would hear her voice on the news over the next 24 hours. Perhaps this will boost her performance at work, too.
Footnote: Unfortunately, the radio broadcast has so far resulted in no eligible girls coming forward for vaccination.
In these cold winter mornings, patients tend to arrive at the health centre after 9am. At 8.30am I was getting bored waiting for some action, so I pretended to be a patient. I walked into the waiting area, coughing and spluttering into my face mask, showing signs of being short of breath.
The health worker at the registration-cum-triage desk stared at me for a moment, then burst out laughing, “Doc’s got covid, doc’s got covid!”
“What are you going to do with me, then?” I asked.
“We will do your vital signs and write them in your book,” said the health worker.
“Using the same thermometer as you use for everyone else, the same blood pressure cuff, examining me at the same table?”
“Ooohoooh,” (the timbre of this expression goes up in the middle, then down, signifying now I understand)
“We must isolate you from the other sick patients,” said one of the student counsellors who is working at the centre.
“Where?” I asked.
“You must go to the male ward. I’ll get the nurse to see you there,” she said.
“But are there any patients in the male ward already?” I enquired.
“Yes, there’s an old man with high BP being treated with bed rest,” she replied.
“Knowing what you know about covid-19, do you think that would be a good plan?” I asked.
“Because covid-19 is more dangerous for older people, especially men and especially those with pre-existing conditions such as hypertension,” I said.
“Ooohoooh,” she replied. “I will ask my supervisor.”
The senior clinical officer appeared on the scene and said that I should be isolated in the new building behind the maternity block where pregnant women stay if they are due but not in labour.
“And how will you treat me?” I asked her.
“The treatment is to give oxygen,” she said.
“But we don’t have any,” I replied.
“Yes, that’s right. But the treatment is oxygen.”
I have come across this mismatch between theory and reality on several occasions. Health workers are able to manage the cognitive dissonance of the situation. We know what should be done, but we can’t do it, so there’s nothing we can do.
“So how do you know that I have covid-19?” I asked.
“You are in a high risk group as you have travelled from overseas.”
“But that was nearly a month ago. Surely I would have fallen ill before now if I had contracted the disease in the UK or on the flight out to Zambia,” I said. “How can you distinguish covid-19 from a chest infection, influenza or a common cold?”
“We do a test.”
“But there are no tests available in the health centre.”
Indeed, there is no easy way of diagnosing covid-19 without a specific test. But there are several indicators which might tilt the balance in favour of covid-19 rather than another respiratory infection. I explained about covid-infected patients in the UK who lost their sense of smell and taste. A dry cough, rather than a productive cough, points towards covid-19. We went through other suggestive symptoms, such as lack of appetite, fever, shortness of breath and fatigue. But chest pains, tummy upsets, and runny nose are less sensitive indicators.
Judging by the look on their faces, I could see that the difficulty of diagnosing covid-19 without a test was beginning to sink in.
“But every day we see lots of patients with upper respiratory tract infections. We are not isolating them,” said the student-on-placement.
“So what do you do with them?” I asked. “We have no broad-spectrum antibiotics and are running low on paracetamol. And even Piriton.” This was teasing them about the standard management of the common cold.
“If they are not very ill, they should go back to their home and self-isolate,” said the clinical officer.
“And what about the other people in their household? Should they also self-isolate? Or only if they have symptoms?”
“These people are often daily paid (they only get paid if they do a day’s work) or farmers who need to work outside the home. If they don’t work, they don’t eat. They don’t have savings to tide them over.”
“And what if they become more unwell? Will they return to the clinic for help?”
“They should not come back here if they are ill,” said the clinical officer. “We will send them away.”
“But they might not accept that. They could decide to get a taxi to go to the hospital, spreading the disease as they go.”
“We could keep them in the pregnant women’s quarters until the get better.”
“Who will look after them there? Do we have protective clothing?”
“Yes, we have about four disposable gowns, boots and visors,” said the clinical officer. “We had the training some months ago. We know how to put it on and take it off.”
“And you haven’t forgotten?”
“One nurse will stay with them all day, so she can keep the protective clothing on all the time.”
“In September and October, it gets extremely hot and humid before the rains come in November. How is she going to cope wrapped up in PPE?”
“There is an isolation ward just outside Mambwe (less than an hour away by car) where we can send people who are unwell and we cannot manage them,” said the clinical officer.
This was news to me. “Is it equipped and ready to receive patients? Is oxygen available there?” I asked. No one knew.
I told them that the District Officer of Health informed me that any extremely unwell patient requiring oxygen and possible ventilation would be transported to the new hospital at Petauke. I had driven past this brand-spanking-new hospital the day after I arrived in Zambia. It was locked shut.
“How will we know if it has arrived in our locality?”
“We will probably see a cluster of cases, possibly unexplained deaths.” In the capital, Lusaka, people who have been very ill have avoided coming to the hospital for treatment. Perhaps they think that if they didn’t have covid-19 before, they would certainly get it when they were admitted to hospital. Their relatives would bring them to the hospital when they were moribund, and many of the first positive covid-19 tests were done posthumously – BID, brought in dead.
“So, what should we do?”
“Pray!” The nurse in charge of the heath centre is a pastor in the Bread of Life Church in Mfuwe.
And wash your hands, wear masks in enclosed spaces, keep socially distant from others, stay indoors if you have any symptoms, and, yes, pray.
In autumn 1978, before my first medical job overseas, Dr John Seaman, chief medical officer of Save the Children Fund UK, advised me to invest in a proper, sturdy suitcase, a Globe-Trotter. “Go to Harrods and ask the assistant to jump onto the case from a chair to demonstrate how tough it is,” he said. I went to Harrods but the eye-watering price of the Globe-Trotter deterred me from asking for a demonstration. As a result, I have bought a succession of cheap pieces of luggage ever since; false economy. The zip holders on my grey Samsonite case have been replaced twice, and one of its wheels is wonky, but it is fairly secure. The soft-walled Delsey Sidewalk can carry more supplies, but both its wheels have fragmented; I will leave it behind in Zambia.
Even with a generous luggage allowance of two suitcases each weighing 23kg, I couldn’t pack all the medical equipment and supplies I had collected. I packed the cases equally, the more valuable items in the more secure case. I guessed that each weighed about 20kg, but I needed to check. The cases were too big to fit onto a set of bathroom scales, so I stepped onto the scales carrying a case, noted the weight, then put the case down and subtracted my weight from the total. 25kg and 23kg. Perhaps Ethiopian Airlines will allow some leeway for a medical volunteer, I thought.
I packed my iPad, Kindle e-reader, laptop, binoculars, camera and long lens into my secure backpack. It weighed almost 10kg against the allowance of 7kg, but I could justify needing to keep expensive stuff with me on board. Thank goodness this airline allows carry on luggage, unlike some others who fear it will increase the risk of Coronavirus infection.
The only way I could carry both cases was by dragging them behind me. They were so wide that it was an effective way of keeping a social distance from others. Heaving them up and off the train to London St Pancras was trickier. The underground was quiet, even at “rush hour”, though I did struggle to get the cases down a few short flights of stairs, huffing and puffing behind a mask.
I found the check-in desk at Heathrow Terminal 2 and had more difficulty manoeuvring the cases around the maze of narrow, roped-off paths. The first attendant scrutinised my passport and documents before telling me that I had to see her supervisor at the end of the row. I dragged my cases past other check-in desks and smiled sweetly at the supervisor. She told me that she would have to call the station manager for the flight, could I wait a few minutes.
She took photographs of all my supporting documents, visa and passport to email to the manager. Five minutes later, she called the manager again and I was granted permission to fly. I heaved my cases onto the weighing scales while she was tapping on her computer keyboard, hoping she wouldn’t notice the excess. She tagged the cases and attached “heavy” labels to them before asking me where I wanted to sit. I said, “Away from everyone else, please.” She assigned me three seats in a middle row at the back of the plane.
The inflight entertainment system was not working, but I didn’t mind. I was able to scrunch down into three seats, wrapped myself in a blanket, extended the middle seatbelt as much as possible so I could lie on my side and fasten myself in. I pulled up my mask so it covered my eyes as well as my nose and mouth and managed four hours of fitful sleep.
Being seated at the back of the plane meant there were fewer passengers around me, but I didn’t get a choice of meal and there was no coffee left. We landed in Addis during a thunderstorm and had to stay on board for 20 minutes until the tropical rain eased off. After waiting for a couple of hours in Bole International Airport, I boarded the flight to Lusaka. I had three seats to myself at the front of the plane, perfect for a quick disembarkation. I had heard that it could take three hours to get through immigration and health checks, so I was perfectly positioned.
At Kenneth Kaunda International Airport, all passengers fill out three similar forms, declaring their lack of covid-19 symptoms and how they can be contacted if their test, or the test of a nearby passenger, turns out to be positive. One health worker noted my temperature and collected one of my health declarations. An immigration officer asked for my papers. Her raised eyebrows indicated that she was impressed I had managed to obtain a visa. “Go to the diplomatic channel,” she ordered. The next immigration officer in the kiosk was confused by my supporting documents. He saw that I had been in Zambia last year and asked his boss what to do. The boss nodded his head and the officer started typing my details into the computer using two forefingers. On the narrow desk there was not enough room for the keyboard, so half of it was unsupported. Each prodded keystroke risked it falling off the table.
I was disappointed not to get a pretty page stuck in my passport. The immigration officer just stamped my entry onto a cluttered page and waved me through to the health desk. The health clerk misspelled my name on the request form and swab container and handed it back to me. I said, “I have proof of a negative test from four days ago, done by the NHS.” She wasn’t interested and waved me over to the swabbing team.
Two nurses in full “Ebola-style” personal protection suits, hoods, visors, masks, wellington boots and double gloves took nasal swabs from all the passengers. I asked if I needed to quarantine, and she said, “No, but we will contact you if we need to in the next 14 days.” I thanked her and collected my luggage from the conveyor belt. A customs officer inspected the baggage tags and waved me through. My taxi driver, Friday, was waiting for me outside. He said that he remembered me from my first visit, six years ago. He had parked his taxi 400 metres away, across the official car park, in the apron of a petrol station, probably to avoid exorbitant airport parking fees.
During the journey to the hotel, I looked out for familiar landmarks, but could not see anything I recognised. There were lots of new buildings and shopping malls, but the streets were eerily quiet. There was a statue of a giant chicken commanding a roundabout near the city centre. It is probably called ZamChick. I would have remembered that, I’m sure.
If you are inspired by my photographs of beach hut doors in Norfolk, I would recommend that you pay a visit to two other places. Go to the Sandringham Estate, to walk in the wonderful woods, and have a meal in the visitor centre (roast dinners on Sundays). Then call in at Snettisham on the coast, where the Royal Society for the Protection of Birds has some hides on brackish lagoons and overlooking the Wash. Check the tide tables so you can time your visit to see the waders being pushed into the muddy shoreline by the incoming tide.
The beach hut tradition is not dying. There are new huts being built and old huts being repaired.
I like watching police dramas on TV, so I was interested in this pistol found at the base of the stairs, obviously a “throw down” – an untraceable gun, dropped at the crime scene by an officer who needs to justify a “bad squirting”.
The Hotel de Paris is the best restaurant in town. It was constructed in 1820 for Lord Suffield, as his coastal retreat. Ten years later, Pierre le Francois converted it into a hotel. Hence the name.
Stephen Fry worked as a waiter there in his youth.
Does anyone recall a similar notice about noticing that you noticed, from Embu in Kenya? I can’t find my post, but it was in 2018.
Across the Gangway from this row, the Rocket House Cafe does great lunches (try the Ploughman’s with local Norfolk Dapple and Binham Blue cheese, bread and a pickled onion) and even better views. When a ship was in difficulties, a rocket would be fired from this spot to alert all the volunteer lifeboatmen. Nowadays, they just send out an SMS text message.
Under the cafe is the Royal National Lifeboat Institute Museum, dedicated (very appropriately) to Henry Blogg. He served the RNLI for 53 years and is credited with saving 873 lives from drowning in the North Sea. The lifeboat covers a huge area of coast, 40 miles either side of Cromer.
Set in stone on the promenade above the pier, there are some quotations about Cromer. My favourite was from a young Winston Churchill, “I am not enjoying it much.” That was in 1888.
“Whenever I’m on the Norfolk coast and it’s a bit grim, I console myself with remembering that at least I’m not in Yarmouth.”
Cromer is a pretty town on the north-east coast of Norfolk, famous for its dressed crab, its pier and its glorious beach. There has been a jetty, poking out into the North Sea, for centuries but the present pier was constructed in 1902. It houses the pavilion theatre and a lifeboat station. But I came to walk on the sand at low tide. At the foot of the low cliffs there are dozens of bathing huts, providing me with an opportunity to record their colourful doors.
People “go to Venice to expire”. Especially famous people. Wagner died in a building which is now the casino. Diaghilev, Ezra Pound, Albinoni, Titian and Dante all died in Venice.
It is also a wonderful location for films. Indiana Jones & the Last Crusade, Casanova, Casino Royale, The Tourist, and many others.
Luchino Visconte’s film Death in Venice (1971) opens with a long shot of a ferryboat steaming across the lagoon, accompanied the sad adagietto from Mahler’s 5th symphony. Aschenbach (played by Dirk Bogarde) dies from cholera, seated in a deckchair on the lido in the final scene.
I kept an eye out for a small child wearing a blood-red raincoat, scurrying across a bridge, but I didn’t even see a funeral barge on the Grand Canal unlike Donald Sutherland in Nicolas Roeg’s film, “Don’t Look Now“.
There are ten churches facing the Grand Canal. Here are a few:
Not everyone is as fond of Venetian churches as I am. The Victorian art critic, Ruskin, described one famous church, San Giorgio Maggiore, thus: “it was impossible to conceive a design more gross, more barbarous, more childish in conception, more servile in plagiarism, more inspid in result, more contemptible under every point of rational regard”. He didn’t like it much, did he?
Some of the churches were open, but none that I entered permitted photography. I would have liked to photograph the message in one church which said that the celebration of mass could be joined online, for a contribution of 1.50 Euros. I wonder how many people would log on, and drop off during the sermon?
I think that churches in Italy will open this weekend, subject to social distancing measures.