Says Frederick from Kalabo, Western Zambia

November 1, 2009
Says Frederick from Kalabo, lower lip quivering, eyes moist, as he hugs the CNIS Instructors; "This is the best surgical course I've ever taken. Please come back again."
The rains have come early this year to Zambia's Western Province - in fact, they've come 4 weeks earlier than usual.
The Zambezi River immediately west of Mongu, now only 50 metres wide at the end of the dry season, will swell to a floodplain 50 kilometres in width in four months time when the up-country rains cause flooding.
The dry parched land springs to life with mangoes, rice crops and verdant greenery. With the return of the rain, however, so too does the malaria parasite-carrying mosquito return with its deadly vengeance.
For the Canadian Network for International Surgery (www.cnis.ca), this is their first foray into Zambia.
Sponsored by CIDA, this organization has for several years taught successful surgical skills courses in 7 other African countries. Instead of offering this first Zambian CNIS course in Lusaka the capital city, we choose to go to rural Mongu in oft-neglected Western Province.
A six member advance team hits the road, literally as you will soon learn, in a rented Toyota Condor.
In addition to the passengers, the vehicle is laden with 900 pounds of surgical teaching supplies, luggage, three quarters of a tank of petrol and an empty jerry can.
There is a petrol shortage in Zambia and not an additional drop is available in Lusaka.
“It's the South Africans” say some.
“No, it's Tanzania that holds up the supplies” say others.
“It's the economy and therefore it's political” seems to be the most commonly held perspective.
This is how life can be when living in a land-locked country.
We estimate that our petrol supply will get us to Kaoma, a village two thirds of the way to Mongu. Pathologically optimistic, we leave hoping for the best - there must be more fuel somewhere along the way.
We keep our speed at 80 kph to stretch our efficiency. We stop on the roadway for a picnic lunch, a tradition now with our many trips on this road. Neither the intense heat of the day, nor the buzzing of the flies can dampen our spirits.
Five kilometres from Kaoma, Jessica at the wheel, we hit a deep pothole with sharp edges. 'Boom-boom' - our right front and right rear tyres are destroyed beyond repair. We estimate that we have about an hour of daylight before we will be engulfed by darkness.
We change one flat tyre with the spare, while Lianne and Cameron J hitch a ride to Kaoma in the back of a passing truck; flat tyre and empty jerry can in tow. When they arrive, Kaoma is suffering from a power outage.
Joan, Jessica, Glynn and Bill enjoy the early night, entertained by the spontaneous arrival of several young boys. We see fires light up as evening meals are being prepared at a nearby village.
"Hello, how are you?" calls out the driver of a passing car, "can I help?"
Another man stops, "I live just 50 metres down the road. If you have any concerns, come and find me."
Then, at 10 pm, a truck approaches from Kaoma. Lianne and Cameron return with a brand new tyre and 10 litres of petrol. Imagine that. In the middle of the night, in a small African village suffering a power outage, they find what we need. For anyone who knows Africa, this is a miracle!
Fully re-packed, new tyre in place, our continued thrust to Mongu is delayed as we wait for Lianne to swap text message numbers with the mechanic from Kaoma. With the petrol gauge running below empty, we arrive in Mongu, drop off Joan Lianne and Jess with Sister Christina while the boys divert to the guest house run by Sister Kathy at Cheshire Home for physically challenged children, spaghetti dinner awaiting at 1am. Thank you Sister Kathy.
We do our important circuit meetings with Dr Sitali, the Chief Medical Officer for Western Province, with Dr Liywalii, the Medical Officer for Mongu District, and with Dr Silumesii, the CEO of the Lewanika General Hospital.
On short notice, Dr Sitali summons Dr Silumesii and I to meet with Mr. Noyoo, the Permanent Secretary for Western Province (think Provincial Premier).
"We're here with the Canadian Network for International Surgery to train local physicians and clinical officers sir."
"You know," offers the Permanent Secretary, "we had two young Canadian nurses teaching at the School of Nursing for 6 months last year. Do you know them?"
"Yes sir, I do. Your angels have returned."
"They made a big difference here."
Everywhere we go we hear shouts, squeals of delight and we see hugs and kisses as Lianne and Jess meet one friend after another. It seems that they own the whole town of Mongu!
These two young women, in addition to having their own parents back in Canada, appear to have developed a network of surrogate parents who also care for them intensely - think Linda, Fay, Joan, Gary, Glynn and Bill.
We have formed a Lianne and Jessica vetting committee through which all potential suitors will have to apply!
The bar is high. Ne'er-do-wells and business executives wearing patent leather shoes need not apply. Humanitarians, Environmentalists and Ranchers with vast tracts of land in Africa suitable for co-operative living might get some consideration by the committee, if they’re lucky.
"Don't call us - we'll call you!"
Three days later, also running on empty, the heavyweights arrive, Bob and Gary. The final planning for the course is underway.
The team lays out the 40 teaching modules in the classrooms made available to us at the School of Nursing that sits a mere 40 metres away from the Lewanika General Hospital.
It was at this School of Nursing that Lianne and Jessica taught for 6 months last year.
It was at this School of Nursing that Cameron O'Connor, before leaving to study Medicine in Australia, made functional 12 old vintage computers, networking them into the student residences, fully loaded with nursing curricula and other educational files. They're still up and running Cameron O, and students use them every day.
It was at this School of Nursing that the "pass rate" rose from 33% to 70% following Jessica, Lianne and Cameron O's interventions.
Of concern here is that the pass rate fell the following year after they left. There's obviously much more work to do.
And so it is only fitting that Lianne and Jessica should return to participate in support of this CNIS programme.
They were charged with developing a Nursing Skills lab along the lines of the surgical lab. To our surprise, their preparations are already complete and they deliver their program to the nursing community each day. It proves to be a huge success.
Joan, having met with Dr Margaret Maimbolwa, Assistant Dean of Medicine in Lusaka, now meets with key nursing stakeholders in Mongu, paving the way for UBC-Okanagan nursing students to study here.
Cameron J, a third year student at Quest University in Squamish, is here to write a report on the effectiveness of this surgical skills teaching session. He will get University credits for his report.
The workshop participants are a mix of Physicians, Clinical Officers, Medical Licentiates and a Nurse Practitioner.
The learners come to Mongu from all districts within Western Province. Some come from Kalabo by pontoon crossing the river since they live west of the floodplain. Some have come from Sesheke, a village in the south that borders on Namibia. It took them many hours to get here by car, also using a pontoon to cross the river. Others have come from Lukulu in the north-west. Two have come from Kaoma to the east, the site of a UN refugee camp where Lianne and Jessica took their students to work, to learn and to ease some of the suffering they witnessed amongst the 10,000 people there.
That's right, it's the same Kaoma where Lianne and Cameron J performed the miracles of the new tyre and the petrol.
Lihana, an Afrikaner nurse practitioner with the Pentecostal Church and Sister Mabel, a Zambian nun come from villages that lie adjacent to the Angolan border. I am told that the people they care for are amongst the poorest in the world. Bless these women for what they do.
Glynn speaks to Lihana each day in Afrikaans. He teases; “Ons Boere moet saam staan!” (We Boers must stand together)
He also runs 10 kms each day. On one occasion a small boy emerges from a thicket. “Makuwa (white man), how are you?”
Dr Silumesii, visibly excited, opens the conference. “We welcome the Canadian Network for International Surgery to Mongu.”
That first evening the Zambian national television and radio services release a news piece about the course. Dr Silumesii smiles widely. He's a beautiful man.
No sooner had the course begun than Glynn and Bill are called to the casualty room at the hospital. A young man is brought in from Kalabo. A large 5 pronged fishing spear has been thrust into his right chest wall, deeply embedded in his lung. He is noticeably short of breath, he has a large pneumothorax and his mediastinum is deviated to the left. Fortunately, he has no haemothorax.
We learn that following his injury, he has been transported 70 kilometres by dugout canoe down the Zambezi River to Kalabo, from whence he was trucked an additional 74 kilometres in the back of a Toyota truck to Mongu over one of Africa’s most challenging roads. Thirty two hours lapse from initial injury to assessment by us.
The only chest tube to be found anywhere in Western Province sits in the bottom of Bob's CNIS kitbag. Says Bob; “I’ve got two tubes, take what you need.”
We rig up a makeshift under-water system, and drain the pneumothorax. Safe now for a general anaesthetic, Glynn proceeds with endo-tracheal intubation. We prepare to perform a thoracotomy, if necessary, and lay out makeshift instruments. We remove the spear. This task proves to be easier said than done. The fish spear has large reverse tines designed to prevent it from being dislodged from its prey. In extracting this spear, these tines present a significant challenge. I make deep releasing incisions along each of the five barbs, but the patient's tissues still tear with the spears removal. However, no bleeding ensues from either the chest wall or the lung. The operation is over. Glynn is satisfied that the patient’s condition is stable. Lianne acts as my scrub nurse, while Jessica removes the chest tube 4 days later and he's ready for discharge. The police arrive to claim the weapon for forensic examination. On our last visit with the patient, he musters up the only two words that he knows in the English language, “Thank you.”
As the course progresses, the students become progressively more enthusiastic, animated and open. Some begin to tell their stories as they relax and settle in. Professional life is hard for them.
On a daily basis they encounter clinical challenges whose complexity is not infrequently beyond their ability to cope. They soak up the learning. The 'aha' moments are touching to watch as they recognize how they will apply their newly learned skills when they return to their communities.
Gary teaches spinal anaesthesia on a spine mannequin, opens and re-sutures abdomens on a simulation model, demonstrates complex urinary catheterization techniques, also performing a supra-pubic cystostomy.
Of course, he leads the Orthopaedic unit that sees the students wrap each other’s limbs in plaster of Paris simulating the fixation of broken bones, and the amputation of bamboo simulated legs.
Gary's clinical Orthopaedic skills are in high demand. He is asked to see 3 children with unusual presentations of osteomyelitis, infections of bone. He removes a lesion from a woman's foot and he consults a patient with a facial infection. There are abscesses to be drained, mal-united fractures to be corrected, skin ulcers from poorly applied casts; the list goes on…
Says Gary; “Just wait till our Anaesthetists back home know that I'm now doing spinal anaesthesia!”
“Yeah Gary, we now know who to call for our obstructed urinary bladders!”
Glynn teaches anaesthetic techniques, supervises endo-tracheal intubation on adult and child mannequins, demonstrates draping techniques, and the insertion of rectal tubes in the treatment of sigmoid volvulus. Students leaving his work station are overheard repeatedly muttering out loud to themselves; “Yes I can, yes I can. I can intubate that patient.” They may love Barack Obama in Africa, but they also love Glynn!
Says Glynn; “it's all good - I'm loving it! Every day it goes from good to better. You can quote me on that.”
He also teaches normal and abnormal Obstetrical deliveries on a pelvic mannequin. The students listen in rapt silence. Then, the students burst into raucous laughing and clapping, as Glynn delivers the mannequin baby. 'Look' he says, “It's a boy - a white boy!” Dr Silumesii grants Glynn privileges to treat a 23-year-old American woman, here to teach at a local school. She has vomited, she's listless and unrousable when she presents at the casualty room. After a few hours of treatment, Glynn discharges her.
Her Ambassador father calls from America.
“Your daughter is going to be fine sir”, says Glynn speaking into a cell phone. Thousands of kilometers away, on another continent, a relieved parent sighs, “Thank God.”
Bill demonstrates suturing techniques on pig skin, bowel anastomosis suturing on pig intestines and chest tube insertion on a freshly slaughtered pig torso. At the end of the day, the students braai the pig, returning the next morning well satiated. Let nothing be wasted.
Bill also demonstrates the closure of the post Caesarian section uterus using beef hearts as the simulation model.
Braam, you will be pleased to know that I taught them the Stellenbosch stitch just as you taught me in Inuvik. The hearts provide supper for the kitchen staff.
Says Bill to the students; "Think micro-circulation. Handle tissues gently. You're an artist - the good outcome of your patients is your art-piece. Make haste - slowly. Your index finger is the most valuable surgical instrument ever invented – it’s soft, it’s connected to your brain, and it’s free – use it. Remember, it's never about you - it's always about the patient."
Bob, our leader, is remarkable. He is so very experienced in all matters African, surgical and educational. His real forte, however, is in humanitarianism and compassion. He lives what he believes.
He is detail driven, yet broadly comprehensive when it comes to the preparation of the workstations each day, in his coaching of Glynn Gary and Bill, and in his communications with the students. He is infinitely patient. It's a pleasure to work with him.
In the world of helpful people there are all the others, and then there is Mrs. Kababa, the Librarian at the School of Nursing.
"Mrs. Kababa, we need animal body parts for teaching."
"Yes, I can do that." And the parts arrive.
"Mrs. Kababa, we need drinks for the students, morning and afternoon." Done.
"Mrs. Kababa, we need lunch each day." Done.
"Mrs. Kababa, Gary and Bob need some bamboo to simulate a long bone with a hollow cavity. They want to demonstrate how to amputate a leg. Dr Silumesii says that there is no bamboo in Western Province."
"I can get some," says Mrs. Kababa, "there is some in the village by the church next to the orphanage."
"When do we get it Mrs. Kababa?"
"Now."
She leads Bob and Gary, on foot, deep into a village where her in-law auntie lives. A dozen children follow. “Can you see it?” asks Mrs. Kababa.
Bob and Gary look about and all they see is an ever increasing throng of villagers.
“It's here”, she says.
Right before them stand the only 4 stems of bamboo in all of Western Province. With auntie's approval and with a sledge blade produced by an eager young man, Bob fells one stalk, Gary clinging to its top to stabilize it!
Bamboo in hand, Bob Gary and Mrs. Kababa leave the village like pied pipers; a hundred entertained and delighted villagers in tow.
“Hey Mrs. Kababa, we thank you.”
Cameron and Bill perfect the ‘Mosi high five’ hand wave, Mosi being the name of the local beer.
The wave assumes that one can have 5 Mosis. When you have had one beer, you are allowed 4 more. You flash one finger and you follow with a 4 finger wave. When you've had two, you flash two fingers and follow with a 3 finger wave. And so on it goes with the Mosi high five wave!
Glynn, learning about this new hand waving system, and looking at the rack of empty beer bottles we leave behind, decides that in life there really is a ranking system.
In the front row sit the Sisters, Lianne, Jessica, Bob, Dr Silumesii and Mrs. Kababa. Several rows back, Mosis in hand, sit the rest of us flashing various combinations of the Mosi high five wave.
We pay our respects to Sister Kathy when we leave.
'Gentlemen', she says, 'sit down; have a beer and a snack.'
Perplexed, Sister looks quizzically at Cameron as he flashes one finger at me and then follows with a four finger wave! The first Mosi of the day tastes good.
At the completion of the course, Lihana, the Pentecostal Nurse Practitioner and Sister Mabel, the Zambian nun approach the podium, as do all the others in turn, to receive their CNIS certificates signed by both Bob and by Dr Sitali, the Chief Medical Officer for Western Province.
"Veels geluk, Lihana."
"Baie dankie."
"Congratulations Sister, you've done well."
"Thank you very very much. I've learned a lot."
Says Frederick from Kalabo, lower lip quivering, eyes moist, as he hugs the CNIS Instructors, "This is the best surgical course I've ever taken. Thank you for bringing it to Mongu."
"What part of it did you find most helpful, Frederick?"
"All of it. All of it. Please come back again."
Says Mwewa from a mission hospital near Kaoma, "I will teach my staff the whole curriculum. It's been very helpful."
The tall Dr Mwaba, leaning forward, whispers successively into each of our ears, "You have no idea what it means to us that you have come here to teach this course."
Maliseco, a physician from Sesheke, can't go home directly because rains have washed out the road south of Senanga. He takes the bus to Lusaka, connects with the bus from Lusaka to Livingston before taking his third bus ride to his home on the Namibian border, a journey of more than 24 hours. We imagine that on his way home he might be quietly reciting his lines, "Yes I can, yes I can, I can intubate that patient. I can amputate that leg if I have to. I'm thinking micro-circulation. Make haste - slowly. I didn’t realize it before - but I am an artist - my patient will do well."
Before he leaves he does express one problem with the course, "The course was fantastic, but it should have been two weeks long, not one. I didn't want it to end."
On the successful intubation of the airway mannequin he says, "I just saved a life, there will be many more lives to save."
Says one of the ward nursing sisters to Jessica and Lianne, "I want you guys to come back to complete those nursing in-services."
Says Sam, "You can't eat an elephant in a day; it takes time to do that. Thanks for coming for the whole week and spending the time with us.
I hope I never have to amputate a leg, but if I have to, I know now that I can."
Says Bob, "A colostomy is a life-saving procedure."
Says Mwewa, "I won't have to refer patients out for colostomy now."
Says one of Gary's students, "We need to change what we do so that we do it correctly."
Asks Dr Silumesii, hands gently clapping in cultural context, "When will you be back?"
Pleads Mrs. Kababa, "Come back soon."
As we leave for Lusaka, a tanker truck with fuel is seen arriving in Mongu. Lianne spends four hours in line. They offer petrol in aliquots of only 10 litres at a time, but through force of personality, she secures enough petrol for our return.
On our last night, a party for 150 School of Nursing students and all of the CNIS participants is held. That's right, the arrangements courtesy of Lianne, Jess and, of course, Mrs. Kababa.
It's a barn burner - traditional dancing, with music, singing and food.
To the startled amazement of all present, the attendees learn that the event is a gift from the UBC Okanagan School of Nursing students, the Global Nursing Citizens. Jessica reads a moving letter from the Canadian nursing students to their Zambian counter-parts.
We pay a parting visit to the Bishop of Mongu. En route home, we all pose for photos standing inside Jessica's now famous pothole, with our familiar clusters of young boys there to cheer us on.
The sighting of five elephants, a dozen zebras, two sable antelope, warthogs, Impala, monkeys and Marabou storks completes our trip's enjoyment.
And so this journey to Zambia's most neglected province comes to an end - new friends made - many challenges still lie ahead. We'll be back.
Says Joan, who has had more than a decade of experience teaching nursing students rotating to Ghana, "This place is perfect for our UBC Okanagan students. The ground work is in place."
Says Jessica, "I never fully realized the impact we had with people when we lived here. My big lesson that continues to be reinforced is the importance of relationship building."
Says Lianne, "We did some amazing things this week. The changes that occurred during the week were outstanding."
Says Cameron, "For any humanitarian project to be sustainable, it must augment local capacity. In order to learn from a new experience, one must first rid oneself of any expectations and assumptions."
Says Bob, "The enthusiasm of the Kelowna group is akin to a cork popping off a vintage wine bottle! I've enjoyed this course more than any I've ever taught."
Says Glynn, "I came along to Western Zambia wanting to help. The CNIS course transferred skills, and relationships were built with our colleagues in this part of the world. Their patients will benefit. I am grateful to have a small part in the process."
Says Gary, "Teaching this CNIS course in Mongu taught me about teaching in this context, and taught participants about hands on learning. That combination has created a sense of trust and confidence between us and the medical community in Western Province. This opens the door for future teaching and learning opportunities. We will be back.”
Says Bill:
Lianne and Jessica, without your leadership and logistical skills, we would have crashed and burned. Your concurrent work with the nursing modules to match the daily courses is a 'first' for the CNIS. Very well done. No, very very well done! We call this the Mongu modification of the CNIS course
You are absolutely invaluable members of our team - always there for everyone and in all circumstances. So much joy, so much fun, so humanitarian, you're both very precious. Thanks to both of you, Losi girls.
By the way, your suitors vetting committee is hard at work looking after your best interests. Literally dozens upon dozens of applications have been received. The committee regrets to inform you that not one of your potential suitors has been invited back for second interviews.
Cameron, your Quest University assignment to evaluate the effectiveness of surgical skills training in Zambian context is eagerly anticipated. Having sent this blog to your Professor, Cameron, I have leaked your complicit role in the creation of the Mosi high five hand wave to high level sources. Sorry about that! You are fun to be with and you're an invaluable member of this team. We all love having you with us. See you in Medical School, hopefully in the Okanagan.
Joan, thank you for making this trip with us. Your love for Africa is palpable. To have someone with your experience and seniority to advise and to encourage, is a real gift to all of us.
Gary, what can I say? It's not often that I'm lost for words. Your commitment, your passion, your joy of life, your friendship - they are all over the top. Thank you my friend.
Glynn, Makuwa, how are you? You are both the high octane fuel and the spark plug - what a combination! You engage fully in all life has to give. Your ethical purity and your openness set you in front row along with the Sisters, Lianne, Jessica, Bob, Dr. Silumesii and Mrs. Kababa, in spite of the occasional Mosi that you quaff from time to time. You have a unique personality, and I love it. Agh man, It's all good. You go from good to best. You can quote me on that! Alles van die beste.
Bob, I've known you through UBC connections for more than two decades. Working with you this week has been one of my career highlights. You are a very special person and I'm honoured to be your friend.
Mrs. Kababa: You are an inspiration to all of us. Your work at the church, with the orphanage, with your School of Nursing and the way in which you support us when we are in Mongu - it's remarkable. We thank you and we love you Mrs. Kababa.
Dr. Silumesii: Andrew, thank you for the leadership and support that you provide. We would be lost without you. We are so pleased that the CNIS course was so well received by your colleagues. We look forward to further collaboration with you in Western Province.
Dr. Maimbolwa: Margaret, I've left my last comments for you. As a national leader, you are a beacon to all Zambians and to all of us who want to work in your country. Thank you for your constancy and thank you for directing us to Western Province.
This CNIS course far exceeds my expectations. Judging from the enthusiastic response from the students, it has been very well designed for deployment in the African context.
On returning to Canada, the following e-mail is received from Dr Andrew Silumesii in Mongu:
We will forever be grateful for the opportunity we have to collaborate with such wonderful people as you. The CNIS course was simply a masterpiece and our memories of it remain engraved on our minds. We are so thankful for your bringing the course to Mongu. Everyone really appreciated the course.
Your patient with the spear in the chest is doing great. He visited my office yesterday in great spirits to claim his spear. Of course I wouldn't let him have it because it has to go to the forensic experts, but it was such a joyful moment for me to see him alive and well. Dr O'Connor's patients are fine too.
We look forward to more collaboration. We will soon send our ideas regarding the non-infectious diseases component to Dr. Hawker and Dr. Murphy.
Kind regards, Andrew.
p.s. Jess and Lianne were simply amazing. Everyone keeps talking about the 'makuwa' ladies.
Next year, as a fundraiser for a fledgling NGO that we're founding, The Okanagan Zambia Health Initiative Society, I will ride my bicycle 4500 kilometres from Lilongwe, Malawi, through Zambia, Botswana, and Namibia ending in Cape Town.
I'll be riding with Tour d'Afrique. If you want to join me, log onto www.tourdafrique.com and book any one of three legs I'll be riding, or book all three.
We're leaving Lilongwe April 7, 2010, arriving Cape Town May 15, 2010.
It's best that you start training now!!