Wildlife photographers tend not to pick typical holiday destinations for their work, as rare beasts don’t enjoy busy tourist hotspots. One of the things I love about these trips is that you get to see and do things that tourists wouldn’t necessarily be able to do, for example accompanying researchers or gaining access to restricted areas… Another great perk is that as wife of a wildlife photographer, you get some pretty cool shots of yourself in these places.

I was given a one-year sabbatical from my job in the UK, but only an 11-month contract at St Francis Hospital. It was time to join Will on his adventures.

The destination was Zimbabwe, one of Zambia’s neighbours. The task was to spend a few weeks with the Painted Dog Conservation (PDC) team and photograph the African painted dog pups at their den. African painted dogs are also known as African wild dogs. They are highly endangered, elusive animals, suffering greatly from loss of habitat as humans encroach on their territory, and falling victim to snaring or being killed on the roads by speeding vehicles. The dogs are famed for their hunting abilities, working together as a pack to bring down their prey (that is often much larger than themselves).

PDC are working tirelessly to conserve the dogs, with a large focus on educating the local community to reduce snaring, improve road safety, and treat/vaccinate domestic dogs against diseases that threaten the painted dogs.

The routine was wake up at 04:00, brave the chilly morning in a breezy Land Rover by driving to the den and following the adult dogs as they went out for their morning hunt. Wild dogs have stamina, and it was not unusual for them to do a 40km round trip (that’s almost a whole marathon) just to get breakfast each day. Jealous, the PDC tracker was incredibly skilled; he was able to track the dogs through thick undergrowth following their spoor (which I couldn’t even see half the time). We would return to the den with the adults, and watch them regurgitate chunks of impala for their pups and spend the rest of the morning watching the pups play with regurgitated impala ears or skin.

As my alarm went off each day, I would spend a split second wondering why I was waking up way before sunrise on my precious hard-earned holiday after an exhausting year at St Francis Hospital. Yet, as I watched the fluffy pups of one of the most endangered carnivores in Africa, I knew why I had joined Will, and I knew that I was very privileged.

When I accompany Will, not being a photographer myself, I often feel like I don’t contribute much to the process other than helping to lug some gear around. However, at PDC, I managed to make myself useful. Peter, the PDC managing director, is trained in darting animals to enable GPS collars to be put on the dogs, or to facilitate removing snares. As well as fitting a collar, when a dog is darted, he needs to collect blood and tissue samples to do DNA profiling. However, the dog may only be asleep for 40 minutes and there is a lot for one person to do in that time. He asked me if I would help out with the blood and tissue sampling, and that is how it came about that Dr. Nat’s final patient in Africa was a wild African painted dog!

I’ve taken a lot of blood samples in my life, from premature infants, hairy men and elderly ladies alike. However, my patients have always been human and are usually in a hospital bed or examination couch. So, it was somewhat surreal to be kneeling on the dirt in the bush with a sleeping painted dog in front of me, but even more alarming was what was behind me. In a hospital, I often ask relatives to wait outside while I do procedures, as it can be off-putting for the doctor to have onlookers, and distressing for the family to see the procedure. I don’t speak dog, so I couldn’t ask the pack to wait around the corner. After spending two weeks with the dogs, I learnt that they are very caring and attentive to their pack members, waiting if someone is left behind, constantly looking around to check on each other. Therefore, you can imagine that when one of their pack is unconscious on the floor, they all get a bit worried. I thought that I would be terrified having two painted dogs looking over my shoulder as I tried to take blood, especially as I had seen the same dogs ripping through an impala just a few days earlier. Yet, as I palpated for a vein on the skinny but hairy front leg of this incredibly beautiful creature, I was caught up in the moment and barely had time to notice his furry friends behind.

I managed to get plenty of blood and just finished obtaining the tissue sample when he woke up. Slightly dazed and confused he ran off and joined his pack. Later that day we saw him up and about sporting his new reflective GPS collar, which will help him to cross the road more safely at night.

I don’t know what the future has in store for Zimbabwe’s painted dogs, as they face so many challenges and threats, but I know that with people like Peter and Jealous in their corner their chances are that bit better.

But what a year it has been… and I decided it should go out with a bang.

Two other British doctors were leaving on the same day as me and we thought it would be fun to have a leaving party. We wanted to invite the hospital staff and anyone else who had left an impression on us during our time in Zambia (including the world’s happiest Chitenge seller, our favourite taxi drivers, and so on…)

There aren’t many options for venues in Katete. There is a bar called the Executive Bar (not so executive really), a place to buy beer that has a pool table and a slightly seedy undertone called Mr. Warden’s, and finally, a bar with a pleasant outdoor area (and a pond) called Malo Gardens. Despite some construction work going on in the grounds, Malo Gardens was the best choice and were very accommodating. Jaffet, the manager, said we could have a private area outside, we could choose how many crates of beer and soft drink that we wanted to buy, bring our own snacks, and have a braai where people could buy food (T-bone or Chicken). The private hire price was a steal at only 100 kwacha (about £12)… and with that our party was arranged.

We made invitations, and started handing them out at work. There was a buzz in the air at the hospital and everyone I passed would say “Dr. Natalie, you are having a leaving party, where’s my ticket?”… No matter how many times we explained that they weren’t tickets, just invitations, and that you didn’t need one to get in on the night, people kept saying “can I take a few tickets for my friends?”… There was no point fighting it, we just printed more ‘tickets’!

The party was due to start at 19:00, so we got there at 18:30 to set up (which involved putting crisps and roasted peanuts into chopped up water bottles – don’t forget the 3 R’s). We hadn’t hosted a Zambian party before, and weren’t too sure whether people would actually show up, or if it was just politeness when people said they would come… But at 18:59 the first guest arrived… I greeted him, took his drink request and opened his Mirinda Orange, and by the time I looked back up from the bar, the area was filled with smiling faces from St Francis Hospital – all clutching their ‘tickets’ of course. It seems that the ‘fashionably late’ concept hasn’t reached Zambia yet, and by 19:10 the party was in full swing and we didn’t have time to catch our breath from that point on!

I felt very touched that so many people came. We danced to Zambian tunes until late, and I wondered why we hadn’t done a party for the whole hospital sooner. It felt wonderful getting everyone together outside the hospital walls, and everyone was smiling and merry and wearing their finest. It gave me a chance to meet the partners, sons, daughters and friends of my colleagues, as well as giving me the opportunity to say proper farewells to all the people that I worked with over the past year.

I realized that although my time in Zambia was almost over, I was still learning a lot about the country. I observed that people fell into two classes: Mirinda Orange drinkers, or Mosi Beer drinkers… Coke, Sprite and Castle Beer were distant seconds in the drink choices. Secondly I observed that Zambians love to dance, with no age restrictions. Elderly nurses, young doctors and stern-faced office staff; everyone got involved in the Zambian beats filling the dancefloor… I smiled to myself when church songs (re-mixed as dance-floor fillers) would come on; we all had a good dance to the pumped-up version of “This little light of mine, I’m gonna let it shine”. I’ve become rather fond of Zambian dance music, but I have to accept that my rhythm and grooves pale in comparison to my Zambian friends and colleagues.

Although the night was filled with smiles and laughter, I kept remembering with a heavy  heart that the following morning I would be driving away from St Francis Hospital… but hopefully not forever.

The cultural anthropologist Margaret Mead said “Never doubt that a small group of thoughtful committed people can change the world. Indeed, it is the only thing that ever has.” Whilst the current bunch at St Francis Hospital may not have changed the world, her quote still resonates. Of late I have been stealing moments to look around me at work… and as we clear through a packed outpatient clinic or attend to a ward emergency with the smoothness of a well-oiled machine despite all the challenges of a rural African hospital, I wonder if there’s anything we couldn’t do as a team if we put our minds to it.

A few weekends ago, on my weekend off, my phone rang on a Sunday evening just before dinner. It was one of the other doctors informing me that a road traffic incident had occurred nearby, and multiple casualties would be arriving, and could I come in. I did a quick change of clothes, grabbed my safety glasses, and my bag, and made my way in. On the 3-minute walk to the hospital, I bumped into two other doctors who had also made the change from Sunday shorts and t-shirts to scrubs and splash goggles. The team had been mobilized!

A flatbed truck carrying around 60 people along the Great East Road had swerved to avoid a bicycle, and had lost control, sending all the passengers hurtling out onto the tarmac. We reached the receiving area outside OPD, to find the large flatbed truck stacked with casualties (yes, after being flung out onto the road, they were then re-loaded onto it to be driven to the hospital). It was dark, and people were using mobile phones to provide a bit of light for offloading the patients. Despite the darkness, I was already able to deduce that there were a lot of casualties and some pretty serious injuries.

The floor of OPD was used as the triage area, with multiple casualties squeezing onto the handful of mattresses strewn around on the floor. We got to work triaging. The word triage comes from the French work ‘trier’ [to sort] and was first put to use to deal with multiple casualties on the battlefield in Napoleonic times. In its most basic form, casualties are divided into three groups: those who will likely live whatever care they receive, those who will likely die whatever care they receive, and those for whom immediate care might make a positive difference in outcome.

Our first aim was to get people off the floor in outpatients. We used stickers on foreheads to categorise people. Anyone who needed urgent attention was sent to the operating theatre or ward. The walking wounded that needed treatment that night were sent to a holding room to be reassessed later. If required, cannulas were put in, intravenous fluids put up, and pressure bandages applied before sending them on the journey from outpatients to the ward. There are only a handful of stretchers at St Francis, so the mass exodus of patients from the floor of outpatients involved piggybacks, precarious wheelchair rides and other forms of ingenuity.

Inwardly, I think most of us felt fairly out of our depth at various times throughout the evening, and yet outwardly, as a team I think we looked pretty calm and collected. There were understandably moments of panic, such as when a severed hand was found in the truck. I just heard a nurse going around saying “has anyone seen someone without a hand? I have a hand here…”

Everyone mucked in and did whatever jobs were needed. The doctors were busiest early on in the incident, when triage and decision making was needed. However, later on once all our management plans needed carrying out, the nurses were suddenly the busy ones. So at midnight, myself and another doctor from the medical team did the intravenous antibiotic drug rounds on the male and female surgical wards to help out the nurses.

When I left the hospital that night, there were six little toddlers with deep scalp lacerations and head injuries side by side in a bed. We didn’t know their names, or who their Mum’s were (as their Mum’s were probably in theatre or too injured to go around locating their babies), so the children had temporary names like “blue trousers, floral t-shirt” to identify them. But, don’t worry, I can happily say that all of these toddlers made good recoveries, and they were all reunited with their families over the course of the next few days.

As with any major incident, the evening helped to revealed some of our weaknesses and learning needs to us – not least the fact that we didn’t have a major incident plan for the hospital, nor did we have a designated receiving area for triage. However, it also showed us some of our strengths. The events that evening made me realize that there might not be many of us, and we might not be the most skilled or experienced clinicians around, but we are a team… and a pretty good one at that.

However, moving to Zambia was different. There was an added pressure that I would be doing a lot more than bartering for trinkets in a marketplace, or trying to find a bathroom in a restaurant, I was going to be working as a doctor.

It was quite daunting knowing that I was going to be providing healthcare to sick patients in a country where I didn’t speak the same language as the majority of people. Back home, overseas doctors are required to pass a PLAB (Professional and Linguistic Assessments Board) exam before they can practice medicine in the UK. Yet, I started working here in Zamia with only a few Chichewa words at my disposal. My Chichewa vocabulary has definitely improved during my time here, and my ‘lost in translation’ problems have reduced. I can get by on ward rounds and in simple consultations without the need for a translator, but I don’t think I would do very well if I were required to sit an exam.

I know that I use phrases that are grammatically incorrect, I ask single word questions, and frequently have to say ‘pepani, sindikumvetsa’ [sorry, I don’t understand you] while I look around for someone to translate for me. Yet, my good-natured patients smile and laugh at me, and patiently listen to my awkward questions ‘chimbuzi kangati lelo?’ [bowels open, how many today?].

However, more interesting is the impact that Zambia has had on my English! My Zambian colleagues all speak excellent English, but with a Zambian flair. As time goes on, I seem to be picking up some quirky expressions and noises.

When speaking to my Mum recently, she told me she had a mouth ulcer, and I said ‘Oh no, is it paining?’ which I immediately realized made no sense to her, and I quickly said ‘I mean, does it hurt?’ I also listen to the conversations taking place between myself and the other British doctors at the hospital, and smile as I hear spatterings of Chichewa and Zambianisms sneaking in. The multi-toned ‘ooo-uuu-ooh’ noise made by Zambians in exclamation has been adopted by all of us, and we now use it without thinking about it. So, at dinner, you might hear ‘There is cake for dessert tonight!’ followed by a chorus of appreciative ‘ooo-uuu-oohs’.

One of my other favourites in Zambian English is the added sound at the end of words. Every syllable in Chichewa ends with a vowel. This means that if an English word has consonants clumped together, an ‘a’ sound is often inserted to link up them up, e.g. ‘hookworm’ becomes ‘hook-a-worm. Similarly, if a word ends in a consonant, an ‘ee’ sound gets placed at the end of word, e.g. then-ee.

To add extra complexity, the letters ‘R’ and ‘L’ are interchangeable. From what I can gather, more often than not ‘R’ seems to be pronounced as ‘L’ and ‘L’ as ‘R’.  There is British doctor called Rebecca here, who is now known as ‘Dr Labecca’, and a Charlotte known as ‘Dr Sharrot’. When I asked a patient what her baby was called, she replied ‘Bracings’, but I found out later he was called ‘Blessings’. I asked someone at work to recommend a bar in Chipata, and he told me to go to Bruggums. I spent the evening telling people I was going to Bruggums, but when the taxi pulled up to the bar, through a grove of blue gum trees, I saw the sign for ‘Blue Gums’.

I am not fluent in Chichewa, but I’m trying… and I’m becoming increasingly proficient at (and rather fond of) Zambian English…

Here in Katete, with so few doctors, there is really no option other than getting involved in hospital management… and when I say involved, I don’t just mean showing up for a meeting or two…

Currently at St Francis Hospital covering medicine and paediatrics, there are five doctors (myself included). We are all about the same age and have all been doctors for roughly the same amount of time.

On a pretty regular basis, we find ourselves frantically trying to devise contingency plans because the pharmacy has run out of insulin, or the full blood count machine has broken, or the blood transfusion stocks have been used up. As crazy situations unfold all around us, I often take a moment to marvel at the problem solving and innovating that we’re doing despite our inexperience.

It isn’t all excitement though, and there is no way to avoid paperwork when getting involved in management roles. The administrative task of notifying the ministry of health of all cancer diagnoses at the hospital has fallen upon me.

There is also no avoiding leadership. The matron for the medical wards cornered me a few weeks ago, and asked me to chair the medical department budgeting and directorate meeting. She handed me a stack of papers with spreadsheets about equipment ordering and estimated spending for the next three years. She asked me to propose an agenda and schedule a meeting. Although I was somewhat daunted by the endless tables of numbers, the issues that arose about our limited resources and ever increasing patient numbers made for an interesting meeting. It felt nice to be discussing changes and improvements that will last beyond my time here.

Although I will always be first and foremost a doctor, this year at St Francis Hospital is equipping me with skills beyond the clinical that are bound to come in handy wherever I may find myself in the future.

When I arrived, the land was parched and the dust muted everything to a shade of brown. Now, the world looks so vibrant. The sky is a deep blue, the trees and vegetation vivid green, and there are colourful flowers blooming everywhere. It feels dreamlike…

The rains really have brought life to the land. Anything planted will grow; you actually have to try pretty hard to prevent plants from growing! Back in London, I used to battle against the elements to try and grow herbs in sad little planter boxes. Here, I have a mint plant that is threatening to take over the entire garden and possibly most of Katete, and a basil plant that is following closely behind. My vegetable patch has also been coming along well, and I am particularly proud to have grown my first aubergine! To add to my list of fruit trees, I have now discovered bananas growing in abundance at the back of the garden, which bodes well for smoothie making!

The prolific garden produce does mean that I have to be creative in the kitchen to find ways to use it all. Mint has been working its way into salads, risottos, and was quite useful when it turned Pimms o’clock at our last braai. The basil, tomatoes and aubergines have brought an Italian flair to Katete (and given me an arm work-out in the process) with homemade basil focaccia, homemade margherita pizza and aubergine parmigiana.

It has been over a week now since the last proper rainfall, and with each day that passes, a bit more moisture leaves the ground, bringing us ever closer to dry season… I want the rains to stay, not just for the awesome purple and orange skies, and the fields of dancing sunflowers and the lovely vegetables in my garden… but mostly because the farewell to the rain brings me ever closer to my own farewell to Zambia, and I’m just not ready for that yet.

I live in the Eastern province of Zambia, which means that Malawi and Mozambique are the most easily accessible. The Malawian border is only an hour from Katete. Having been in Katete for over 6 months now, we decided it was time to visit our closest neighbour.

So, a few weeks ago, we took our Land Cruiser onto Malawian soil to do a road trip as a farewell to two friends from St Francis Hospital, Geoff and Charlotte, who were returning to the UK from Lilongwe.

As with most land borders, as we crossed over the imaginary line into Malawi, although the terrain, temperature and vegetation were very similar on either side of the border, there were enough differences that made it obvious straightaway that we were in a new country.

The first noticeable difference is in the population density. Malawi is a small country with a lot of people. Malawi has a population density of 128 per sq km, to Zambia’s 17 per sq km. Malawi is smaller in area than some of Zambia’s provinces. When driving through the Eastern province in Zambia, it is easy to go for very long distances without seeing anything or anyone. In Malawi, there are people lining the roadsides and emerging from maize fields, and with so many mouths to feed, every patch of suitable land has been farmed.

The other difference is that as you drive further into Malawi the fields and hills seen at the Zambian/Malawi border make way for mountains. JRR Tolkein is said to have visited Malawi in the 1930s just before he wrote Lord of the Rings. As I saw rolling hills, misty mountains and jagged peaks, I could see what his inspiration was. When we reached the Shire highlands (pronounced Shirry), it was confirmed, I was in Tolkein’s Middle Earth.

Malawi also seems to have more remnants of the colonial era than Zambia does, as evidenced by our visit to the beautiful Satemwa Tea Estate in the Shire highlands, with the original plantation house still open to guests for afternoon tea and as a beautiful place to stay.

I found Malawi to be beautiful and full of variety. Within a week, we had climbed a mountain, relaxed while sipping tea and overlooking plantations, and snorkelled with the colourful freshwater fish of Lake Malawi. At the end of our trip, refreshed and invigorated (although sad to be saying farewell to our friends), we drove back over the border away from Middle Earth and back to work.

Now, half way through my year in Katete, it is easy for me to look back and divide my packing into two groups: things I should have left behind, and things I can’t imagine being without.

Here are some examples of items in the ‘why did I bring that’ group:

Leather shoes – they may seem like a good idea, something to smarten up an outfit. However, they get dusty and muddy within seconds of being outside the house, and are highly impractical in the rain. They’ve been left untouched in my wardrobe since I arrived.

Skirts/Dresses that end above the knee – in Katete, women cover their legs. This isn’t true of women in Lusaka, who will happily bare their knees. However, here in the Eastern Province, showing your knees is like wearing a very low cut top back home… You get a lot less attention if you just keep them covered.

Here are some examples of items that I can’t imagine being without, and that should be in the suitcase of anyone leaving for a stint in rural Africa:

Crocs flats – a plastic shoe may seem silly. However, when there are no pavements or tarmac, and the conditions are either incredibly dusty or incredibly muddy, it is beneficial to have a washable shoe that is waterproof and comfy!

LED Lenser Torch – In central London streetlights, shop signs and car headlights mean that you are never in the dark. In rural Zambia, there are no streetlights, and half the time there is no electricity, so when it goes dark, it goes really dark. Do not move to rural Africa without a good torch. In the UK, before Will left the house, I would hear him mutter a checklist ‘phone, keys, wallet’. Here in Zambia, it goes ‘phone, keys, wallet, torch’. The LED Lenser is so bright it feels like daylight, and it is rechargeable. It makes walking into the hospital at night when I am on-call much less scary – good for spotting snakes on the path, dogs in the distance and other such hazards! LED Lenser have a range of different torches, including a pocket sized torch (for me), and a superbright, find-the-animals-in-the-trees torch (for Will).

Hand-held blender – My hand-held blender takes up barely any luggage space, and has opened up the world of soups and smoothies. Nobody should ever move to a country that has an abundance of tropical fruit trees without being able to blend. Having mango trees but no mango smoothies would be a crime. Mango season is over, but recently I discovered two guava trees in my garden, which are now fruiting, and guava smoothies are pretty yummy too. Nat’s seven ways with Guava? I’m working on it…

In malaria endemic areas such as Zambia, most people who reach adulthood have developed a partial immunity to malaria; reducing the risk that malaria infection will cause severe disease. Children on the other hand are still developing this partial immunity, leaving them vulnerable to malaria.

Over the past few weeks, the Paediatric ward has gone from its baseline of ‘fairly busy’ to ‘totally crazy’. There are often two or three children to each bed (infection control has to take second place when there are more sick children than there are beds), and malaria is demonstrating daily that it is a killer.

The WHO estimates that a child dies every minute from malaria in Africa and of all people who die from malaria in Zambia, 50 percent or more are children under 5 years of age. These statistics are easy for me to believe after seeing three children die from malaria during a night shift last weekend. I have seen more seizures since moving to Zambia than I have seen in my entire career to date, with malaria responsible for a large number of these fits.

Doctors tend to memorise the doses of drugs that they prescribe regularly. A previous job in geriatrics led to various laxative concoctions becoming deeply engrained in my brain. My time in psychiatry left anti-psychotic and anti-depressant doses imprinted. Now, malaria season in Zambia means I will never forget the dose of Quinine, Artemether and Phenobarbitone.

One other thing is certain, the seizures, the severe anaemia and the rainy season mortality figures all serve as an effective reminder to ensure that I diligently take my Lariam tablet every Thursday.

After I finished picking his brain about some of the things I might encounter in Zambia, his exact words were “you do know what the biggest threat to you is out there?” to which I quietly mumbled the correct answer: “TB…”

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. It is an ancient disease, with evidence found as far back as 3000 BC in the spines of Egyptian mummies. However, it was in the 19th and 20th centuries that TB first became a major public health issue (known then as the consumption) causing widespread illness and death. Transmission was helped along significantly by poverty, overcrowding and lack of sanitation, problems still faced in many parts of the world today. Roughly one-third of the world’s population has been infected with M. tuberculosis, and new infections occur at a rate of one per second on a global scale.

Once a person has been infected, TB can sit latent inside the body without causing active disease. Many people clear the bacteria and never develop symptoms of TB, but this requires an intact immune system. When you throw HIV into the picture, TB has a new aggression, and my time here in Zambia has proven to me that I should believe the WHO statistic that TB is responsible for one quarter of all deaths in HIV.

TB most commonly affects the lungs, but can affect almost anywhere in the body. Since moving to Zambia, I have seen abdominal TB, TB adenitis (TB of the lymph nodes), TB spine, TB meningitis, TB of the spleen, and TB of the adrenal glands. I have seen a teenager crippled so badly by TB that he is permanently bent double and can barely walk. His X-ray (below) shows how much destruction TB can cause to a spinal column that should be as straight as an arrow. I see patients coughing up blood and struggling to breathe, and neck lymph nodes so big and matted that the patient could barely turn their head. I have also seen far too much death at the hands of TB, and I know it is a disease to take very seriously.

TB is spread from one person to another when a person with active TB of the lungs coughs, sneezes or talks sending infected droplets out into the environment. The people at risk are those who are in enclosed spaces with someone who has active lung TB and is coming into frequent contact with these infected droplets… therefore, family members, household contacts… and healthcare workers.

I have a small wing off the side of my main ward called the Khonde [verandah] for people who have confirmed or suspected open TB. Back home, entering such an area would involve protective gear including a special facemask, apron and gloves. Here, given that we lack alcohol hand gel, it goes without saying that personal protective equipment is lacking. I just have to hope that despite coming into contact with copious amounts of TB that my immune system does its job…