Hospital Headaches

I wrote this during our first month in Mabaruma. It was a time of great frustration and little sleep. Many things changed for the better since I wrote it.

Last night was not an example of Mabaruma Hospital at its finest.

We had just got back from dinner at the house of a very kind family from Canada who have upped sticks to live in Mabaruma and run a little yellow Cessna plane for emergency ‘med-evac’. On the way home we had dropped in on the boys at the little bar next to our house, where every evening from 6 to 11 (the hours of electricity supply) they play deafeningly loud soca and drink ‘high wine’- 70% distilled rum. We paid for some sugar we had borrowed a few days earlier and had a chat to the owner, Sion, who was a bit plastered, as were the others. They seemed gentle and kind, and in a boozey way, were sorrowful for the loss of past American occupants of our house. One of them, Fred, kept wanting to shake our hand and mumble something drunken and friendly.

Later in bed we heard a little scuffle outside and a knock on our door followed soon after. It was Fred’s sister. Could the Doctor come please? Fred had been in a fight. My first reaction - perhaps to my discredit - was anger. It had been a long working day, and we were just drifting off to sleep through the Soca beats. Whereas with a ‘genuine’ emergency I feel a sense of duty toward a patient, when it is the result of a fight it seems so stupidly avoidable that resentment is difficult to resist. Perhaps I should have expected some form of disturbance, it being pay-day; the whole town was on the razzle, and just like any town in the UK on a Friday night, trouble was fairly predictable.

As I walked with Fred’s sister she told me what had happened: Fred had got really drunk, and had left his phone on a seat outside the tiny shack that Sion serves from. He’d popped over the road for something, then staggered back only to find the boys had hid it as a prank. A fight ensued, and Sion, perhaps still feeling emotional about his long lost friends, had taken to him with a long iron bar.

In the hospital I asked where the on-duty Medex was. There are two, one living 5 minutes from the hospital, the other much closer, just opposite me. It turned out the closer Medex was actually Fred’s uncle, and that in a moment of familial synchrony he was “so drunk he doesn’t know himself, Doctor”. That left me with the improbably named Nurse Herod to patch up Fred’s head.

Fred was in the treatment room. It looked like a scene from Sweeney Todd: the whole of his upper body was covered in drying dark blood, with quick little streams of brighter fresh red running on to the floor from a big bump on his head. He had lost the use of his left arm which had a small gash just above the elbow. He was writhing around on the bed splattering blood on the floor, walls and everyone near him. His family stood around looking worried and there was a big-bicepped policeman present who had attended to the scene with a rifle slung on his shoulder. Strangely given the circumstances it was the rifle that unsettled me the most.

My mild irritation at the start of the episode progressed to disbelief and anger over the next 20 minutes. I was here as an unpaid volunteer, not to replace anyone, but to add capacity. With Medex drunk, I was in effect covering for his alcohol problem – “how ‘charitable’ of me”, I thought. Nurse Herod showed off her credentials as the worst Nurse I have ever worked with by doing nothing but yap to her friends on her cellphone instead of helping as any sensible person would do- to find a suture set, or get some anaesthetic. With (blunt) suture finally finding its way into Fred’s scalp, she commanded me to stop - it was two minutes to eleven and the electricity was about to be turned off. I was half way through the first of what needed to be about 15 stitches and having disturbed the clot on Fred’s head, blood was starting to pour out again.

“What about the hospital generator?”

“Porter not here, me can’t turn it on without he”

Pay day: the Hospital Porter was legless at home, too.

In an unusual moment of inspiration Nurse Herod called the men at the generator plant to ask for an extension. I was leaning over the patient for 2 minutes in suspense before she looked glumly at me and said: “They never answer, generator too noisy.”

The lights went out. I was still attached to Fred via the black suture when a boy turned up with a battery-operated strip light. We decided to continue with that until, just as we got Fred to cooperate by turning his head the right way, the battery ran out. Next up was the oil lamp, and in its Dickensian glow we tried to fumble around with the stitch. The lamp started to sizzle whoever’s hands were holding it, and the heat it emanated was adding to my discomfort. Fred was wriggling again. It was a lost cause.

We downed tools and Nurse Herod cursed at Fred for cursing. He started flicking excess blood off his face onto the floor. Most of his family huddled in the doorway.

I asked Nurse Herod to do a pressure bandage on his head to stem the flow until it was daylight and he was sober. She left the room and made a call without doing the dressing. Fred continued to bleed.

I took a mental step back to summarise the situation: no Medex, no Porter, no Nurse, no light; blunt needles, drunk patient, blood everywhere.

The lovely, and very rotund Nurse Phillips arrived with bed hair. She smiled and squeezed my nose. Straight away she dressed the wound, winding the elastic bandage round and round Fred’s head and chin with like she was waving an imaginary wand, and as if by magic it was all over.

But it wasn’t, because the Policeman had been doing a bit of thinking too, and now he suddenly grabbed Fred’s arm where the gash was, where his humerus had probably been fractured. He demanded Fred keep still, which seemed strange because every time he squeezed Fred’s arm, he fell around the bed in even greater agony, as if electrocuted. It struck me as very sinister that the Policeman had noticed so keenly the extent of Fred’s apparently minor arm injury. Fred screamed out. The Policeman’s arm sleeves were rolled high up his arms. “I’ll show you pain, boy”, he said, and squeezed harder.

“Beddy-byes”, giggled Nurse Phillips. I felt bewildered about what I was seeing and unclear what it meant. Perhaps the policeman was helping the nursing staff to ensure Fred would stay in his bed for the night. In his drunken state he clearly wouldn’t though. Fred’s mother said “Tie he to the bed, make sure he no move”. In retrospect that would have been far less harmful than what was happening. Feeling tired, powerless and confused in a strange country, I obediently wandered into the star-speckled darkness hearing Fred’s screams and kicks getting quieter. I lay in bed for a good hour afterwards reflecting on an evening, which had begun with an act of humanity and ended in torture.

The funeral

Dorothy was 77 when she died. The first time I met her she was sitting in an armchair, the second time she was lying in bed, the third time she was unconscious. I loved visiting her and her family. She would sit virtually mute and motionless, her straight white hair pulled tight over her head watching as three generations of her offspring laughed, gyaffed, and ran around her. She and her husband now had 36 grandchildren and 12 great grand children. “I’m having trouble remembering all their names,” her husband Desmond told me. Mark the plumber was her son and lived downstairs.

Every time I visited I would be greeted by a chorus of stout-looking ladies breastfeeding in the little living space separated from the bedroom by some beautifully patterned dark bullet wood from the local forest. “Yes, Doctor”, “Good afternoon, Doc”, “Go right though”. When I came out their numbers would have swelled as other relatives and their children gathered to hear my verdict for that visit. Then, update over, I would be about to leave when one of them would pipe up with something like, “Doc, I’m troubled by pressure. Would you kindly take it for me?” It was always only one, it was like they had all silently agreed in my absence who was sick that day and that the focus should be on them. It didn’t seem to matter that the really sick patient – granny – was slowly dying next door.

Trying to get to grips with the Amerindian psyche has been a confusing and fascinating experience. They appear indifferent to almost everything around them, and the few emotional responses you do get seem somewhat muted by the absence of accompanying facial expression or physical movement. It’s like they’re speaking their lines, but not acting their part. “Mark got angry with Dick today” I once told Becky, recounting a major incident between the two people who make up the Mabaruma plumbing unit. “He didn’t scowl of frown but he just stared and said ‘I don’t know what they did to that boy when he was born, but his head is full of air’ Then he lapsed into silence again” In Amerindian culture this was noteworthy for its passion and verbosity. It was certainly the longest uninterrupted speech I had heard from Mark to date.

The rest of the family, generous and caring as they were, displayed the same baffling lack of emotional range. When I told Desmond that his wife was shortly to pass on and that we needed to think about stopping actively treating her with antibiotics and such, and start concentrating on things that would keep her comfortable in her last days, he just looked at me and said, matter-of-factly, “Well lets take down the drip, Doc”
“Well I would like you all to have the chance to think about this decision before rushing into it”
“OK. Take it down”
“You wouldn’t prefer to talk as a family first?”
One of the five plump middle aged daughters, each of identically short stature, interrupted from the head of granny’s bed.
“Daddy, what Doctor is saying is: we should make a decision tonight, then tell he tomorrow”
“Oh…” said Dad, looking sad and powerless. Tears had finally started to well up in his eyes.

Mark picked me up at 4pm the next day for what had become, in Dorothy’s final illness, a regular afternoon visit to their home in Thomas Hill. Several days back it had started to be less about Dorothy and more about a pastoral role for those around her. By being there and focusing on what was happening to her I felt that the family could focus too - despite their attempts to distract with their blood pressure ‘emergencies’. By talking about what seemed to be getting closer and closer they might all be better prepared for Dorothy’s passing.

Mark turned the car around. It was one of five private cars in Mabaruma, what would be called a ‘sedan’ in America, but that sounds far too flashy. It was a real banger, with bits hanging off by pieces of string. Sitting in the passenger seat I could feel clumps of grass brushing the underside of the vehicle and sometimes my legs would jolt upwards when a particularly large clump hit the loose floor. Today there were only eight people on the backseat, most under the age of seven. The record of eleven people set a month previously still stood. I offered one or two to come and share with me in the front but they refused.

“So how’s Dorothy today, Mark?”

Mark paused, looked at the steering wheel, and said “She dead” and threw the car into first, pulling off like he was furious. He wasn’t. “Yes, she died. I think it was the Diabetes tablets that did it”

Here we were again. Something or somebody had to be to blame. Despite my attempts to explain that Dorothy had been very old, that she had diabetes and had had a stroke a while back; despite telling them that during the 5 months I had known her she had slowly got weaker; despite all of this in Guyana there always has to be a single reason for the unwanted event. In some ways this has a lot in common with the scientific model: pathologically speaking she died of a single illness: bronchopneumonia. But the reality was that she had slipped away gradually over the previous few months. It’s an unfashionable way to put it, but she had died of old age.

I tried to re-iterate these ideas to Mark, especially as I knew his Dad was beating himself up for having given Diabetes tablets to his wife when she wasn’t eating. She had developed an unreadably low blood sugar in her last days of life, which he thought the tablets were responsible for. He may have been right, partially, but stopping the tablets hadn’t improved her sugar levels, and anyway she got sick before her sugars plummeted, not the other way round. Mark thought for a while. Or at least I think he was thinking. People who think usually move their eyes from side to side, external movement being an indication to what’s going on inside. Mark’s eyes weren’t moving, just staring straight over the steering wheel, his fleshy face completely still.

We passed somebody’s pet macaw sitting on a fence squawking.

“You see my birds, Doc?”, he said with a hint of animation.
“No, you keep birds?”
“Yes. I got some green lovebirds”
“Oh, really?”
“Yes”

We drove on in silence.

“So….how did you catch them?”
“In a trap”

The sun set over Chan-a-Sou’s marshy coconut palm field.

“Why do you keep them? Are they pets or do you sell them?”
“I sell them. You sell them in Georgetown you get 60, 70, 80 thousand dollars for a bird.”

He recited the figures rhythmically. He stared over the wheel again for a while.

“But you got to get a passion in them. You keep a black cloth over the cage. Then you leave it until the passion grows. The bird wants to see the other birds but you musn’t let it. When you take the cloth off the bird has plenty of passion, and starts to spread. This is something it does with its wings. Spreading. It spreads and makes a beautiful song. People will pay good money to buy a bird with a good song.”
“Who are these people?”
“Georgetown bird men. They’ll hear a good song and they’ll start what’s known as a bid. One will bid an amount of money then the next will make a higher bid and so. And sometimes there’ll be a competition. A singing competition. First bird to sing 25 times. Winner can take 30000 dollar.” Again his voice danced as he spoke of the sums, but his face was set.
“So when are you taking your birds to town?”
“Next time I get the opportunity. Not long now.”

We arrived. A carpenter was already engaged and had constructed the frame of the coffin in the middle of the yard. A few people had gathered and were sitting in chairs watching him work. A tarpaulin had been pulled over a wooden frame that I hadn’t noticed on previous visits. The whole yard had been turned into a big tent. Mark sat alone in the car while I went upstairs to express my condolences with Desmond.

The same five daughters were standing in the same place at the head of the bed. This time they were red eyed, and embracing each other. Granny had been moved to the living room. I sat with her husband on the bed she had died on.

“I want to thank you Doc from myself and on behalf of the whole family from the bottom of my heart for everything you’ve done for us. Our people don’t get time from our own”

I always feel a bit embarrassed when people are as profuse as this, especially people who are not profuse by nature.

“How are you doing?” I asked, “Are you coping OK?”

“Well I didn’t sleep at all last night, and I won’t sleep tonight”

This is traditional practice here. We lapsed into silence. I found myself thinking about Dorothy. I had spent hours with her family, but she and I had probably exchanged no more than four sentences the whole time. Sometimes in the UK people like to recall positive memories after a bereavement. So I asked:

“Do you think she enjoyed her life? You didn’t meet in your home village did you?

“Well, I came here from Maruca [a riverine area 60 miles south]. I was a drunkard, you know. But then I became a Christian. We met right here and got married. We had plenty of children, started young you know. Then she died. Yes. I suppose it was a good life.”

Later I returned on a borrowed bicycle to join the wake. I had been to one before. Our good friend David’s aunt had died in Georgetown and it was taking a long time to get the body flown back to be buried in Mabaruma. Every night for five days they had gathered at her immediate family’s house, just behind ours. Becs was away again so I went along alone, expecting a sober, sad occasion. Far from it: laughter guided me to the little house, and inside there were women cooking up some chicken and rice and children playing cards on the floor with an overweight, slightly dim young man with an oversized head and a big smile. I joined in cross-legged and he started to tease my poor playing skills. We were playing “War” (pronounced Waargh) and I was losing again.

“What’s your secret?” I asked. He took his shoes off and gestured to his feet.
“Six toes”, he said, “It lucky”

The children started laughing and pointing.
“Don’t trouble me, now. Trouble me six toes and you’ll grow more yourself! Even more!”
“More than 6?”
“Yes! 7 or 8 even!”
The children stopped laughing.

In Thomas Hill about seventy people were gathered. Just like at the six-toes party the deceased wasn’t mentioned. Small tables were occupied by groups of men playing cards and young children playing dominoes, while others looked on eating little plastic bowls of cook-up rice with sweet black tea. I joined one of the kids’ tables. Dominoes is the simplest game in the world, but somehow every time I play I get beaten. The loser leaves the table and is replaced after each game. I left after every single game I played with those 6 year olds and then had to beg to be allowed to join the table again. Eventually I gave up and started watching the carpenter who was now using a small power sander to smooth off the coffin right in the middle of the party. He was lit by a strip light hanging from a wooden beam. The coffin looked really good. Heavy, chunky looking, with nice routing, and a detachable ‘open casket’ head section.

The following day I made sure to get to the funeral. I had checked the hospital first and found a teenager lying on the observation bed, accompanied by her mother, both dressed in black. The patient was one of Dorothy’s granddaughters, who had been brought up by Dorothy, presumably because mum had her hands full already with the other kids. That afternoon, during the church service in Thomas Hill she had developed cramps in her arms. Experience told me that the cramps were caused by anxiety. Just as we in the UK get panic attacks with over breathing and hand tingling, over here they get cramps and body pains. We talked about how she was feeling. They agreed it would be best to go to the cemetery to say goodbye. We started to stroll.

At the cemetery twenty or so people had gathered and were waiting for the Thomas Hill group to arrive. Everybody wore something black, whether a top, a skirt or just dark glasses. I stood with Yvonne, a powerful matriarchal figure in her 70’s who used to be Regional Chairman and retained the authority of that role, but also had a wonderfully warm sense of humour. We watched as the clouds darkened and lightning started flashing.

“Did you know Dorothy well?” I ventured.

“Oh yes. Oh, look at those cows.” Some black cows were eating grass on the near edge of Chan-a-Sou’s orchard just opposite the cemetery. “It looks like they know something we don’t.”

Then we started talking about cows.

“I kept cows from 1972 all the way to 1998”

“Oh?” I said “Did you eat them?” They don’t milk cows here.

“Oh yes, but not straight away. I had to put the meat in the fridge for a few days before I could do that”

Another woman had appeared.

“I never eat” she said

“What, cow?” I said

She looked at me. “Beef. Its called beef after it dies”

“After you kill it!” chuckled Yvonne

“I never eat it. Get too attached. Aunty Denise’s daughter, she was the same. I would find her sobbing, weeping on the wall. ‘What’s wrong, dear?’ I would ask ‘Rosy the cow died’ she would cry and the tears streamed down her face”

“You can’t get too close to them,” advised Yvonne, “you can’t give them names.”

The funeral procession arrived. Three cars and two buses slowly squeaked to a halt. Throngs of people had arrived. Half the town must have been there: crazy Billie, Mrs Willis, Ron the Gil Scott-Heron doppelganger, the cleaners from the hospital, Dick the useless plumber, the Regional Chairman, the Chief of Police (in uniform) and Desmond and Dorothy’s 48 progeny.

Ken Door, the seven foot American New Testament Church Missionary, was their pastor. He usually looked like a kindly bear, but today he looked more specifically like a big panda; presumably he hadn’t slept either. His wife and daughter, dressed in black like Amish people followed him looking stern. They both had sharp looking noses and were extremely unattractive. Ken’s wife strapped on an accordion and they processed towards the grave through the baggy jeans, tight skirts and shades like a mediaeval circus act: a panda bear and his musical witches.

A hymn about meeting one’s comforter. I leaned over to Yvonne to tell her I may have to disappear quickly mid-service. It was because of a bad egg. I had run out of food that day and had tried to buy eggs for lunch. The little hut above where David lived had run out, as had everyone else as the fortnightly steamer was delayed. The fat woman who ran it asked me to wait while she plodded around her garden looking for eggs her ‘bush fowl’ had laid among the vegetables. Eventually she found just one, and gave it to me for free. It was small, and the dirty dark shell felt more delicate than usual, but I was starving. It was 2pm and I had missed breakfast. Back at the house I cooked up everything I could find: pasta, tuna, oil and then I cracked the egg in. It opened far too easily and before I could do anything its contents ran away into the pan. I think I may have smelt ammonia, but my stomach overruled my nose and after cooking it as well as I could I wolfed it down. That was four hours ago. Now I was getting churning feelings and cold sweats.

“You’re not going to….you know” Yvonne made as if to vomit “here are you?” and gave me a stern look.
“No, I’ll get well away before I need to do that. I just thought I should tell you in case I need to run away”
“Okay, dear” she smiled and turned back to the service.

Ken called for a few minutes silence to reflect on our love for Dorothy, during which several small groups of men started noisily chatting while the Regional Executive Officer’s secretary, a big boned lady with Dame Edna style glasses, started doing what looked like an impression of someone doing the twist after too much High Wine. This caused much hilarity among the women she was standing with. My phone rang. It didn’t matter in the slightest.

A group of three elderly ladies stood stooped over behind us. Perhaps it was my lunch, but they reminded me of sensa chickens like you find out in the river communities. Their hair was slightly ruffled, they all faced different directions and now and again one of them would stamp on the wet trodden grass and scrape a twig around with her foot. Occasionally one would suddenly turn her head sideways to squint inquisitively at the gathering storm clouds. They seemed oblivious to the proceedings.

Kens voice took on a climactic, spiritual cadence, rising and falling like he was intoning a spell to contact the afterworld, which I suppose he was in a way. Then he said to everyone that if we wanted to have a last look at Dorothy to come now. Everyone looked around. Most had had a good gawp at the dead body, even a few passers-by who clearly didn’t have anything to do with the funeral. It was just like the hospital, where people would drop in and stare at the sick person. “Are you family?” I would ask “Then go away!”

The three old ladies were still strutting and scraping. All three were bespectacled. Two looked up, hard of hearing. “Eh?” We gestured for them to come. They hobbled over. “What? What is it?” the first one asked, who was wearing a sort of black lace bandana.

Yvonne said: “Do you want to see Dorothy one last time?”

“No!” hollered Bandana Granny “No! I don’t want to do that!”

“Me neither!” said Grannies 2 and 3

“It’s my glasses!” she yelled and pulled them off to show Yvonne. Two hundred people looked on. She continued shouting “I can’t see more than 6 inches with them! I don’t want to go there – I can’t see a thing! No, I’m not going!”

“Yes, yes, terrible!” joined in the other two, who had their glasses off now and were raising them to the sky as if to demonstrate how cloudy the glasses were. “Terrible, can’t see a thing!” They started comparing notes. I leaned over to let them know we had some delivered to the hospital recently if they would like to come in…

“Oh, yes. Doc! I’ve been meaning to come and see you for a while, it’s my headache…” but the growing wailing sounds drowned her out as the first shovel of earth was piled in.

People started to drift away. I wasn’t sure if we’d finished or not, so I waited. Mark was sitting a small distance from the main gathering, his face expressionless, still staring in front of him, but red from weeping. Eventually I started to move. My stomach was a ball of muscle and it felt like the vomiting might start soon.

As I left I heard several children shout in unison “Dr Sam!” I turned around. It was the dominoes kings. Nine of them were filling the back seat of Mark’s car, climbing around having fun while their parents were away. I squatted to chat through the open passenger door.

“Hey! How are you doing?” I heard a bang and one of them started crying.

“Henry pong he head on de car!” a little boy shouted and the toddler’s howling got louder.

I was about to go when a little girl I didn’t recognize stood up behind the passenger seat and faced me boldly. I stayed put. “Hello.” She didn’t reply, but continued her gaze. She had been dressed up for the funeral in a simple brown dress but had dispensed with the shoes and socks. I started to move to go when she smiled. I stopped and smiled back. She smiled again more broadly. She had two neat rows of tiny teeth and her eyes looked gentle. Then she spoke:

“Why did granny die?”

“She died of old age”

“That’s how I want to die.”

“Me too”

Slideshow!

We have managed to upload a slideshow to Flickr - here is the link below, or you can click on the slideshow pic to the right.

http://www.flickr.com/photos/83855790@N00/sets/72157606387691305/

A bit frustratingly, the slideshow starts at a random point - if you're interested in reading it the way we intended, click through to the picture of the white health hut which is the start of the story. Also frustratingly, you can only see the captions we've written if you are viewing the pics in the "White Water Set" on their biggest setting - this link should take you there, but please have patience!

Tobago Take Two

In the High Cost of Giving, we wrote about the village of Tobago and what a tough time they are having there. Things are still hard there, and its going to take a while and a lot of political will to get those people what they need, but I thought I’d counterpoint the picture of gloom we painted with a description of a day we spent there recently.

Sam had done a couple of clinics in Tobago before I managed to get over there with him – transport was difficult and scarce, and so taking me along for the ride just didn’t seem appropriate. Then one Sunday, we hitch hiked over there together – Sam had woken in the night worried about a little girl’s lung infection and wanted to check her before we went away for a week to Georgetown (what a hero). So we had a rainy day out there giving out worms tablets. Moved by the clear need for more effective healthcare, for health education, for nutritional education – we promised we’d go back, this time to give some health talks as well as run a clinic.

Than, in the gentle way of things here, the friends around us steadily began to get interested in our next trip. Bernice, a local retired teacher who lives nearby – wanted to come and do a storytelling session with the children (who get no education at all there). Jud, the pilot of the yellow plane, was interested in coming to see the situation there. His wife Karen is a dental hygienist – she’d like to come and give out some toothbrushes to the kids along with a dental chat.

Next came Godfrey Chan-a-Sue – he’s the local shopkeeper whose task it is to attempt to administer the gifts of Food for the Poor. He had sacks of Soya protein and also of back beans he could give us. There were two problems with this – getting it there and also getting people to eat it. Getting it there was solved after I paid a friendly visit to the local Regional Chairman (I wore make up for the first time in months – my equivalent of power dressing?). He agreed to provide transportation on the Sunday that we wanted to go. Next we had to get thinking about the food itself. Protein is exactly what is needed – protein malnutrition underlies the majority of the severely sick children’s cases that get admitted hospital, as testified by the swollen bellies and skinny arms of many of the children Sam sees there. The problem is that the soya protein flakes were completely unknown to the Tobagans, and we heard that there was something of a taboo around black foods. So the gifts of Food for the Poor were looking like a hard sell.

At this point we had out flash of inspiration. Somehow this trip was bringing together all aspects of our lives – we should give a cookery demonstration – cooking being an ever-growing obsession with us… We decided that the best person in the Mabaruma to give the demonstration (and it would be much more likely to be successful if it was a local – thinking of language and cultural barriers) was our friend Shaira. Shaira is by far the best cook in Mabaruma. She originally taught us all the Guyanese basics – pepperpot, cook-up rice, and just last night, local crab curry with blue crabs – more on that later. Shaira readily agreed, if she could bring along her lovely daughter Nureifa and her husband, David. At this point we were thinking – hell, yeah, the more the merrier….

As we drove out of town towards the village, we made an interesting gang. We had Jud and his family, the 7th Day Adventists, we had Nureifa and Shaira, who are the only Muslims in the village, we had David, Shaira’s husband and a devoted member of the rastatfarian brotherhood. We had Bernice, a fairly straight down the line Christian. And Sam and I, Atheists with a capital A. (We’ve taken to declaring this quite aggressively here. Otherwise you get into long tiresome conversations with various church groups attempting to convert you.) Quite a bizarre multicultural band of brothers.

We had a pretty special day in Tobago. We got there just as they were gathering for church (which turned out to have a pretty low turn out). Bernice and I attended the service – she’s a Christian and I’m nosey – whilst everyone else got set up for the day’s activities.

After the service we gathered as many people into the church as we could. Sam kicked things off by opening up a discussion about nutrition and self-sufficiency. The villagers are all too aware that’s its their removal from the river and their source of crabs and fish that is the cause of lots of the health problems, and there is a sense of grievance that the government has not done more to address this. A community boat is seen as a solution. What about the agriculture side of things though, Sam asked – the move was actually instigated by World Harvest who had started an agriculture project with the people when they lived on Simoto creek (now defunct – World Harvest have no presence here), and had got frustrated that their project kept getting flooded. Oh, then move all the people, perfect solution. The villagers said they still don’t feel confident as agriculturists – they’ve been taught a few things, but then when things go wrong, there’s no help and they lack the knowledge or resources to fix things. For example – on the new land, their first crops were wiped out by Acoushi ant. Any local farmer would have told them this but World Harvest didn’t know or predict it – so they lost their first crop, and haven’t the heart to plant more until they can afford expensive insecticides to protect their crops.

It’s a tough situation and not one with a single, simple answer. An encouraging thing on the day was that David, a local subsistence farmer, offered to drop in and help when he could, and to loan them the use of his insecticide sprayer if they could get the spray.

Next, we moved on to health and nutrition – trying to encourage people to grow crops to better nourish their families – and talking about ways they can cheaply replace the lost crab and fish protein from their diet. This included introducing the idea of the beans and the soya flakes. I found myself chipping in here instinctively, as what had occurred in the room was a complete division of sexes, with Sam speaking to the men and being ignored by the women, and vice versa. As a final addendum, we talked a bit about family size, prosperity and nutrition, and got the women thinking about family planning – showing them a packet of pills and explaining that they can choose when to have their children without affecting their fertility. Maybe this helped them make sense of me – everywhere I go here, people think its strange that I don’t have children yet.

Karen did her thing next, getting out her plastercast flip top mouth and displaying how to brush your teeth properly. She had toothbrushes to hand out but also explained how you can make a brush from a twig by fraying the ends – useful to know for camping trips. Then we dished out toothbrushes, toothpaste and condoms – interesting selection – before separating for our various tasks.

For Sam this was running a clinic at the front of the church. People line up in the pews and come up one by one to see him, with no sense of patient confidentiality, but in a village that size, I suspect there are no secrets. At the back of the church, Bernice ran a storytelling group, theoretically for the children but in the end she had quite a few of the men there too, enjoying her stories.

At the same time, Karen and I headed over to the nearest communal kitchen (this is a feature of Tobago life, the kitchens are shared between five or so families – wooden covered platforms on stilts with a wood fire on a raised wooden platform – the smell of woodsmoke is everywhere), to join Shaira in her cookery demonstration for the women of the village. Our hope with getting Shaira to do this was that she is such a great cook, she would inspire them by making delicious and nutritious foods. And she didn’t fail. With not much more than a couple of coconuts, some onions and garlic, dried thyme (which grows like a weed here) and salt, she cooked a big bean cook-up with soya flakes in, and a stew of greens and beans and soya. She also had the ladies make up some cassava bread.

Meanwhile, I gathered some ladies round me and started asking them to help me to learn their language. I am writing a play about Tobago, which examines the events that brought the people here, asking questions about what does it mean to try and develop a place? How do you effect the people and culture you are in contact with? In the play, there are characters speaking Warau, so I asked the women to translate my dialogue into their language, making recordings and writing out phonetically what I heard. They were initially surprised by my request, but soon we were happily beavering away, with different people debating hotly amongst themselves how best to translate “have you got ice” “he’s your sweet man” etc. Then one of the women, Victoria Hosea, began to sing to me. Her voice was rough and strong, and very beautiful as she sang versions of English hymns, first in Warau then in English. Then one of those magical rare moments of synchronicity occurred. The play begins with a true event – one which happened to these people. In 2005, floodwaters threatened their lives in their old homes, and the radical (and controversial) solution to this came in the form of the religious NGO, World Harvest – who uprooted them all from their homes of many generations. The song Victoria chose to sing me next was called “Brother Noah where are you?” And so I found myself sitting in a kitchen in Tobago, being sung this haunting, prophetic song by this wonderfully wise woman, being handed the perfect gift to complete my play:
“Brother Noah, where are you? Where are you? Where are you?
Brother Noah where are you? The rains are falling down”.

By the time we had finished, Shaira had cooked her stew to perfection. There was happily enough for everyone to try the nutritious cook-up and stew, and the improvised meal back in the church had a celebratory feel. There was something good about sharing a meal with the people we had come to help. After that, the rest of the beans and the soya were shared out to each family, everyone excited about cooking with the new food.

By mid-afternoon, it was time for us to get our lift home. We said our farewells – I will be going back to the village next month with my theatre group, and I have a feeling everyone else will be going back for one reason or another. We drove home through Hosororo, a leafy village nearby, where Shaira’s friend, brother Louis, gave us each a freshly picked young coconut. We drank the water from inside and then split them open to eat the nutty white jelly from the middle. Then we all headed down to Hosororo falls – a local set of rapids with (unusually for Guyana – most water here is brown) clear water to swim in. We all cooled off with a swim – even Shaira and Nureifa came in – before all nine of us piled on to Jud’s small 4X4 vehicle – which is about the size of a golf buggy – for our drive home.

I can’t remember a better day I’ve had recently, and its one that really brings into focus a truism about volunteering. Sam recently asked a project manager, Tim, at VSO – who do you think gets most out of volunteering – the governments you work for, or the people you help? Tim shrugged and smiled – it’s the volunteers who get the most, of course.

Its Opening Night….

“Well – maybe its time you put them in front of an audience” Sam suggested. This was his solution to my bemoaning my group’s mid-project doldrums – attendance rates were right down, we had generated lots of material but not yet polished it to a performable state, and the idea of ever performing to anyone seemed very remote.

The group are a team of local teachers who (alongside apparently endless extracurricular training to bring up their professional standards) had been giving up their precious evenings to become Mabaruma’s first and only Community Theatre Group. Our remit was public health education, and alongside training them as performers, I was also training them as drama workshop leaders in their own right. At some point in August, this should blossom into spin-off summer schools at Nursery, Primary and Secondary level. On top of that will come my own cherished outreach trips – taking shows to remote Amerindian villages around the region – the first time this has ever been done here.

But half way through the project, this end seemed impossibly out of reach, so I took Sam’s advice and scheduled a preview performance – there’s nothing like the prospect of an imminent audience to energise an acting company and focus everyone’s minds.

Last night was the preview performance of our first (yet to be named) show. We played to an audience of friends and family, plus some local relevant experts – the Regional Health Officer came along to give her input, as did the local director of Red Cross. It was hardly a West End opening – no champagne and nibbles, darling – and until 10 minutes before we started it looked as though we would have to cancel, as the power was down (a transformer in the town generator had burst into flames the night before). But at ten to seven, just as we were deciding whether we had to pull up our stumps or else perform in the dark (far more forgiving) the fluorescent striplight flickered into life.

The performance was rough and ready – some of the material had only been rehearsed once – but the evening was incredibly helpful, both for shaping the health message and getting extra feedback. Here’s a rundown of the content, so you can get a sense of what we are up to. We tried to work with a broad selection of material and forms, local and international, and also aimed at as wide an age range as we could.

‘Little Jonny and Victor Vomit’ – a street theatre piece for children, where Victor the Vomit Bug lurks around Little Jonny as he plays cricket, plays with his dog, visits the latrine, eats his cookies. The kids have to shout out what Jonny is doing wrong as he fails to wash his hands, drinks untreated water etc. Then Victor turns on the audience, looking for children who haven’t washed their hands and scaring them (which they love). Finally, the children are invited on stage to whack Victor to death with enormous bars of soap and bottles of bleach, to much vocal approval from the audience.

‘How to Stay Healthy’ – a glove puppet piece about three kittens – Pinkie, Fluffy and Blackie - who decide to eat mangoes straight from the floor without washing them. The kittens get sick, and learn their lesson – always wash your fruit before you eat it.

‘Family Planning Skit’ – skits are the main form of theatre here. In this one, our two performers Seetama and Anthony, have a ball sending themselves up as a mother and son who are both as confused as each other about safe sex. Anthony is accused of impregnating a girl called Samantha – but its impossible, he claims, as they practiced safe sex. This involved Samantha drinking cold water, jumping up and down and putting her head between her knees after sex. Eventually, a local health practitioner offers some advice – these are family planning myths which won’t protect you from pregnancy or from STI’s like HIV either. The best thing is for Anthony to use latex condoms which he can get from the hospital. At this Seetama joyfully runs off to fetch him some – and returns with an enormous box of condoms which will last him a lifetime and more.

‘Nutrition Playlet’ – this short drama tackled some more emotionally difficult subjects, and raised some laughs where we really weren’t expecting them. We’ll be looking at this and seeing if there’s a way we can adapt to this. The play involves a young mother bringing her very sick baby to hospital – the baby is malnourished and has fallen sick, on top of which the mother has given it local constipating medicine as treatment. The nurse tries to educate her about caring for her baby, but it is too late and the baby dies while they are trying to treat it. Next we see the mother ten years later – again with a young child. She speaks about how she has learned all about how to care for her child through nutrition, and that she never wants what happened to her first child to happen again.

‘Chronic Illness Skit’ – another skit – here, two friends meet on the street, Betty and Sati. Betty has been diagnosed with Hypertension, and is trying to think of ways that she can remember to take her tablet every day, even when she feels OK. This is a big health issue here, where people with chronic illnesses don’t keep taking their medicine once they feel well, and so get into cycles of illness. Together they go through some options – what about with my alarm clock? Says Betty – but you switch it off and go back to sleep, says Sati. OK – what about with the chicken feed? Says Betty – but what if you feed the tablets to the chickens, says Sati. Eventually, they find the solution – in Betty’s pants drawer (or panty bag as its called here…) – she never leaves home without her knickers on….

‘Tiffany’s Story’ – Forum theatre piece. This was the biggest experiment of the night – staging our first forum theatre piece – in which the audience are actively encouraged to get up on stage and change the course of events. We had no real idea how the Guyanese audience would respond to this. Tiffany’s story also has challenging content. When selecting our theme, I asked the teachers to identify a group they believed was oppressed locally. This might seem like a strange request, but the central idea of Forum theatre is to identify with social groups who are in oppressed situations socially, to put them on stage, to try to activate positive change for those groups and to raise awareness of their plight – most importantly through awakening their own sense of empowerment and dissent.

Somewhat to my surprise (perhaps I had over-romanticised the appearance of happy families here in Mabaruma), almost all of the teachers wanted to treat the subject of child sexual abuse. They told me that it is very common in this community – one welfare survey came up with a truly staggering 79% of children suffering some form of sexual abuse in the home. Depressingly, the official response to this statistic was a bit of a shrug – well what can be done if its so prevalent? In a way they have a point – resources here are extremely scarce – there is not a single social worker in the region, let alone women and children’s refuges or counselling. Perhaps most depressing of all, most teachers knew of at least one case where a family had tried to act and a father or a step father had been reported to the police, only to have the police bought off and the charges dropped. For teachers who had acted on a child’s behalf, this also raises frightening prospects of reprisals. Their view though, was that the vast majority of cases go completely unchallenged, with poverty playing a major role. For too many of the women here, the economic consequences of challenging a partner’s abuses - possible abandonment and destitution - are just too harsh, and so they too end up complicit in their children’s situation.

So – into this quite complicated picture we have waded, with Forum theatre as our tool. In Forum theatre, you develop a scripted core, in which a central protagonist is depicted in the situations which oppress them. The emphasis is very much on the oppression side of things, with the aim being to provoke the audience into challenging the protagonist’s passivity and offering alternative strategies. And then acting them out themselves.

Our scripted core was in the end a bit long (this is previews remember, so we’ll be cutting). We had a scene over breakfast (Breakfast at Tiffanys, get it?) where Tiffany’s father bullies the mother into leaving for market, before abusing Tiffany. Next we see Tiffany at school, rejecting her friends’ attempts to talk to her. Then we see her in class – a teacher has noticed her strange behaviour and wants to know what’s wrong. The piece continues with a scene with her headmistress and eventually with a highly apathetic Welfare Officer.

When we replayed each scene, we encouraged the audience to stop the action when they wanted Tiffany to behave in a different way. They would then explain what they wanted, and then come on stage and enact it. The actors on stage would stay in their characters and improvise to try to keep the action going the way their character wanted it to. We had some excellent interventions – with various Tiffanies managing to stand up to the Father, call for help from neighbours, talk to their friends or their teachers about what is happening. And eventually, in a brilliant adaptation of the form, we had audience members replacing other characters. The Red Cross director was so disgusted at the apathetic welfare officer, she got up and replaced her, making her a sympathetic and caring figure.

It was quite a hit as a piece, with most people very engaged, and a few people coming up time and again with different possible strategies. Happily there was a lot of fun and laughter, despite the tough subject matter. In the improvisations, the performers really shone, as they hung on to their characters, or adapted them at instructions from the audience, with great sponteneity and playfulness. In terms of hosting the piece, the role of the Joker (who kind of conducts the audience, mediating their desires) was a real learning curve for myself and Candaisy, who were both chipping in. In particular, we should have enlivened the younger audience members early on (it tended to be confident older women who intervened), and also to try to find ways to get male members of the audience feeling able to identify with and play Tiffany. I’m not sure if this will be possible – gender roles are very defined here – but I will try. I still can’t help feeling it was a real success though, with a sense of thrill as each new intervention began, and with the older women getting to model positive behaviour for the younger ones, also putting over the message that there are people in the community who will listen and help you if you need them.

Its going to be interesting putting this piece in front of a more mixed audience. I hope and pray it will have a positive reception, and if it raises a hornets nest (its pretty critical of the current welfare system in place) I hope it will be with a positive outcome. I suspect I can’t really mediate for that, but in the immediate term, I think the piece should at least raise awareness and model more assertive behaviour for young people. And it’s a joy to be making theatre which the audience can change, adapt and get real pleasure out of moulding.

The Grand Finale!
Anyone who knows me will recognize the irony of this one. I was really keen to use song in the show. One of the exercises we did was to take popular songs which everyone knows, and to subvert the lyrics to deliver a health message. The most successful of these was based on “Rum Until I Die” a massive Soca hit around the Caribbean in the past couple of years. My group adapted the lyrics into “Rum will make you die, Rum will make you die, so you’d better stop now, and live a better life!” Going on to describe in 4 verses the tragic consequences of alcoholism and the positive outcome of choosing to abstain. “Pass out this message to all your buddies – give up the rum and save your monies”. Oh yeah. Just now.

The High Cost of Giving

We’ve found NGO presence high here in Guyana. Favoured by international organizations as a more direct route to people in need than sometimes corrupt or cumbersome governments, they tend to wield considerable power in terms of resources, manpower and skills. Unfortunately, the work done is not always unquestionably good, as we’ve discovered. Sometimes the results are tragic, as Tobago’s story shows.

Tobago is a local village that we kept hearing about when we got here. A child with pneumonia from there had died just before we got here, and that wasn’t the first case. We’d been asked by Annette Arjoon, who is the dynamic character involved in regenerating the Amerindian communities in the Northwest, to look in on the village if we got the chance. She told us they were a struggling community, but it took several months to piece together the full story, which goes something like this.

Back in 2005, Guyana was victim to high levels of flooding, which are attributed locally by many people to global warming. Whether or not this it true, what is certain is that the worst hit were the river dwelling Amerindians – known here as Riverain communities. These people mainly belong to the Warau tribe. There are nine Amerindian tribes in Guyana (as distinct from the African Guyanese and East Indian Guyanese who are the majority of the population): the Warau have been characterized as choosing remote lands to settle on, often swampy lands unlikely to cause conflicts over ownership as no-one else would think to live there. Historically, the Warau adapted to this environment, becoming skilled boatmakers and fisherman, cultivating cassava on land behind the river and building simple homes on stilts with palm roofs and often without external walls.

Many rainy seasons bring floods, but 2005 was worse than usual, the water level reaching into houses filling them with mud and crabs. Bouts of sickness followed as a result of the water, mud and poor sanitation.

The plight of the people living around Simoto creek in particular came to the attention of an American Christian NGO. Shocked by the conditions the people were living in, they funded a plan supported by the local government to re-house the whole village. (Apparently it was election time and seen as a vote winner). Land was identified for the new village about five miles from Mabaruma, between Hosororo and Wauna. 40 houses were built on the steep hill that was chosen, along with a community centre and a church. Water was pumped to standpipes in the village, and latrines were built well away from the dwellings.

It seemed like a great act of philanthropy – entire community rescued – yet just three years down the line it’s a very different story, and its sad to say that the NGO is nowhere to be seen.

On the surface, Tobago looks like a successful Amerindian village – the houses, 40 mint-green clap-board huts which stack prettily up the hillside look new and clean. The latrines line up next to (but not too close to) the narrow creek that runs below the hill and the villagers congregate there to wash clothes and socialize. The community centre is beautifully crafted from local wood. But the appearance of the people gives away the real issue. Adults have sores at the corners of their mouths. Children suffer from ‘white mouth’ (oral thrush) and have oversized bellies suggestive of protein malnutrition.

The sorry truth is that these people are poorer and sicker than they were before. Removed from their river environment, they have to make long journeys to catch crabs and fish, meaning less to go around for everyone – hence the protein malnutrition. It also means fewer surplus crabs to sell, so they are economically worse off, and less able to buy extras. So the previous diet, based on cassava and fish, which worked, is now largely a diet of cassava – which is not working. They don’t understand the connection between poor diet, malnutrition and sickness. The result is malnourished children, hospitalizations from simple illnesses such as diarrheoa and vomiting, coughs and colds as well as widespread TB, and several unnecessary deaths.

The atmosphere of the village is quite strange – just five miles from Mabaruma and down the hill from the leafy village Hososroro, it feels extremely isolated, with few visitors, and none of the basic amenities you’d see in a naturally evolved settlement – no-one is running a shop, for example, no-one has the money to buy a generator, so come nightfall there is no light, no noise. The NGO, having built the houses, latrines and a church, didn’t provide anything else – like improved roads, communication, or a shop or supply line – the villagers have to bring all supplies in themselves, and have no means of transportation to do so.

Most surprising is the lack of a school. In a village with 95 children, at a distance from other villages, it seems a pretty appalling oversight on the part of the planners to leave this out. Currently perhaps 10 of the children (the strongest ones) head up the gruelling hill to Hosororo each morning – where they get a lunchtime meal from the nuns there – but everyone else stays in the village.

Being geographically closer to Mabaruma, where the hospital is, hasn’t solved any access problems either. Before, the river trip was long but cheap and not too exhausting – now, for most people, the cost of the bus ride into Mabaruma is far too much except in emergencies. So no mothers attend the ante-natal clinics at Mabaruma - hence poor education about nutrition for small children. It also means that local women are denied their only opportunity to have an HIV test, which is offered as part of routine antenatal care.

Local people are getting involved piecemeal to try to sort things out, but here resources are scarce, and the difficulties in transport and communication mean even the simplest act, like running a clinic there – take on the proportions of an heroic act. What seems saddest of all is that these people’s lives have been uprooted, turned around, dropped again at a whim by an NGO whose aims are unquestionably positive (and certainly whose US funders wouldn’t condone this behaviour). The traditional skills of the Warau culture – boatbuilding, fishing – are in danger of being wiped out in a single generation. The Warau language itself, already in danger through exposure to mainstream Guyanese creole and standard English - still the primary language in the schools - could slip away with the culture, in their new and alien lives. Not to mention the immediate, unnecessary tragedy of malnourished babies dying of treatable sicknesses in hospital, through lack of education and resources. It’s a mess which could really have done without western intervention at all.

We’ve seen a few other strange examples of NGO “do-gooding” gone wrong out here. Another US organization which ships foodstuffs from the US at great cost and effort frequently delivers pointless items – an electronic scrubbing brush in an unpowered village, anyone? In need of an emergency M&M? Its often like those harvest festival collections of oddments, when parents take advantage of donating food to clear out some of those peculiar purchases from the cupboard.

NGO’s aren’t always too well behaved towards their volunteers either. A British NGO, Project Trust recently responded to an 18 year old gap year student teacher’s plight with amazing indifference. Our friend Tom had been robbed at knifepoint by 2 of his students in his own home. He was distressed and a bit traumatized by the robbery. The culprits were arrested, and Guyanese justice being what it is, it was looking unlikely that the case would go to court or his belongings be returned to him, as he was due to leave the country this month (July). We got a barrister we’d met in Georgetown to intervene and give the police here a bit of a shakedown, and things looked more positive. Until Tom appealed to his NGO for direct support, in funding him to stay out here and fight his case. Without even consulting the barrister, they advised him against the case – it wasn’t worth the trouble. Not worth it to whom, we had to ask. It turns out, this had happened to the student placed at Wauna the previous year, when the NGO had also done nothing, and not felt honour-bound to tell Tom (or his parents) of the situation he was walking into. The lack of responsibility towards their young volunteers is pretty appalling, not to mention the lack of foresight. What will it take for this NGO to act?

As we are finding, being an NGO is very far from guaranteeing effective administration, ethical behaviour or even competence. In Georgetown we heard a number of stories, about NGO’s being set up explicitly to meet the funding criteria, then the funds disappearing along with the NGO. Many international bodies prefer funding NGO’s, as Governments in developing countries can be vulnerable to embezzlement, or even just deadly slow bureaucracy. But who are the NGO’s answerable to? Who regulates them? And in the case of Tobago – how can they be held responsible for the consequences of their interventions?

There’s clearly no simple answer. Some of the most fantastic work out here goes on through NGOs. At the same time, the crusading approach, storming in, making judgments based on your own cultural expectations, has to be discouraged, and genuine grass roots collaboration strived for. Respect for local culture, nurturing of local skills, encouraging independence and enterprise, has to be valued. And its very heartening to see that one of the most outstanding groups here is the UK’s own VSO. Collaborating with local and national government, appointing excellent practitioners, developing specific job specs the fulfillment of which will have led to greater national expertise – its an organisation worth working for and supporting.

The other impressive team here is, once again, the yellow plane run by the 7th Day Adventists – Wings for Humanity. The group has committed to a long-term presence here working alongside the government to provide a service that just couldn’t be provided by the government alone, but which saves ordinary people’s lives on a regular basis. Their commitment is humanitarian – there are no religious strings attached to the work that they do, and they are in it for the long haul, committing to the region for the next 10 years, so it’s a service policy makers and local people can rely on for a time to come.

And in case anyone’s wondering where the name “Tobago” came from – the administrator who named the place chose it, as he had fond memories of the idyllic Caribbean island of the same name. The gap between the original and its namesake couldn’t really be any wider.

Wings for Humanity

One of the most enduring themes working as a doctor in Mabaruma has been: access. This place is 24 hours by 'steamer' from Georgetown, 8 hours by speedboat + bus, or for the lucky few, an hour by plane. The steamer is an experience I will never forget, more about that on another blog, but not for the faint of heart (or any other illness for that matter). The speedboat has, we are told, been troubled by overinterested pirates, and the plane only goes on alternate days, and is quite expensive - definitely beyond the reach of most Region 1 residents.

So with Georgetown Public Hospital being the only referral centre in the country, Mabaruma Hospital needs to be equipped and manned to cope with sick patients who need stabilising before being transferred. But it isn't, and the transfer facility creates a great big hole in the Regional Health budget, so it is avoided where possible. There is also a cultural factor that anyone who has worked in A+E will recognise. I saw it first when the RHO (Regional Health Officer), who takes ultimate responsibility for all transfers, puffed out her chest and said 'We can manage this ectopic pregnancy - they deal with much worse stuff in Port Kaituma'. She wants us to be seen as the ballsiest and most capable region.

This makes for some very hairy situations. For anyone who doesn't know about ectopics, they are pregnancies that implant where they shouldn't, and as they fix into their tissue of choice, usually a fallopian tube, they try to develop a blood supply to the foetus. At about 8 weeks into the pregnancy the blood vessels rupture and the mother can end up with a devastating internal bleed, requiring blood transfusion and an operation. These are two things we are without in Mabaruma (no blood, no surgeons). The careful clinician will pick up early signs of an ectopic and urgently refer to a gynaecology ward, and breathe a sigh of relief as he does so. I saw my first ectopic a couple of weeks into my work here, and I was not granted that relief: 'Let's observe and see what happens' the RHO stoutly advised and my hair thinned a little further.

Sometimes it isn't quite that urgent, but patients still need the expert care they can only get in Georgetown. For example we get a lot of snake bites here, especially just after its rained. The important species is called labaria. It's a small snake with a helical stripe running down it's brown/ green body. The venom can cause bleeding - from the puncture site, but also elsewhere, particularly the gums, which are inspected daily. Any sign of bleeding warrants a tranfer in the next 24 hours as it usually escalates and requires a transfusion.

More trivially, broken bones need the Xray facilities not available here, and eye injuries need examining properly using kit we just don't have. These all have to go to the capital eventually.

One taactic I have developed is to 'collect' patients to please the RHO's purse strings. Here's how it goes: in addition to the commercial flight there is a charitable aeroplane, a rather cute Cessna 4 seater in yellow, run by two families, one pilot from each family. Their purpose is to help with medical evacuations and they have undoubtedly saved many lives in so doing. However, fuel is a big cost - about 100 quid per trip - so the Ministry of Health pay for that. This means the RHO still has budgetary issues to consider with this service. How to make her use it? Get as many patients as possible into the plane: 3 in the seats and one in the baggage area at the back (it needs to be a small child that doesn't weigh too much) and sell the idea to RHO. It tends to go something like this: 'I've got a snake bite, a broken arm, a high risk pregnancy and a girl whose eye was hit by a green mango - can we use the yellow plane?'

Without the yellow plane the budgetary pressures would be such that many serious cases would not get the care they need. Either that, or the poor patients would be put through 24 hours of vomiting hell on the steamer. It is a fine enterprise, and everybody who reads this should help them! Here is the link for their website: US:: http://www.wfhguyana.org/, or Canada: http://www.flywfh.org/ all donations go directly to the costs of upkeep of the plane.

Chupucabra in Georgetown

“You know, I think this shows that God is answering my prayers” – Headmaster Mr Marcus fixed me with a stern look, which seemed out of keeping with the outsize badge he sported in the middle of his tie – Teachers Make a Difference, in jolly typeface and bright colours. “I didn’t know how I was going to make this happen, I prayed to God, and now, you’re here.” And his stern face cracked into his characteristic expansive grin.

I was in Mabaruma Secondary School’s head’s office, having offered my services during our stay here. He whipped out a piece of paper showing a school calendar year with the 3 months to July sketched out with a rehearsal schedule for the National Schools Drama Festival. How fortuitous, I thought – 3 months is long enough to do some good work here.

Next morning, having spoken to the Education Ministry, I had discovered that we had 3 weeks, not 3 months. Blimey, I thought – but still – why not – its an opportunity to motivate the kids to take part with the possibility of a Georgetown trip ahead of them.

In the next 3 weeks, with a crazed look in my eye, I rehearsed 3 groups of children in 3 plays (one for each house in the school) at the end of which they were judged by the local great and the good at a “school drama festival”. And to realise that there hasn’t been drama here for 18 years made it feel like quite a meaningful event. The winning show was Chupucabra, by Guyanese writer Paloma Mohamed, an HIV awareness play which features a crisis meeting amongst all the vampires of the world (you’d be surprised how many there are) because the blood is going bad.

When they first read the play, most of the group hadn’t seen a script before. In the process of rehearsal we had been through various dramas – Abigail, a pretty 14 year old, in tears because she didn’t want to play Ol Higue, the Guyanese bloodsucker; Lennard threatening departure over creative differences, and our star, Denicia, playing the African vampire, Obayifo, unable to come to Georgetown as her family are 7th Day Adventists and so travel on a Saturday is forbidden. We got thru’ though, and on Weds 14th May, the group arrived in Georgetown, having travelled since the day before, overnighted in Moruca, used 5 different forms of transport, lashed by the wind and rain and all a bit sunburnt. And still smiling.

We rocked up to the National Culture Centre – a modernist theatre complex the equivalent of our National Theatre – and sat in the auditorium waiting for our rehearsal to begin. And we waited. And we waited.... After 4 patient hours we were told we could use the stage space for an hour. Travelling so far we had been unable to bring our set with us, so were cobbling it together from scraps backstage – at this point it was looking pretty sorry for itself.

We then had the worst rehearsal I can remember them ever doing. Its an ensemble piece, which had meant copious amounts of energy trying to get all the group focused and supporting one another onstage instead of drifting off, eating food, texting their friends or giggling. For my first rehearsal on the stage at the National Culture Centre, I came close to tears as my (admittedly sleep deprived) group proceeded to mumble, forget lines, yawn, upstage themselves and in the end (the point at which I had to stop them) hide behind a bench and giggle. Its was pretty mortifying. It was also the first time they had been into (let alone onto) the stage of a theatre, full stop, let alone a theatre of this size.

We trailed back to the YMCA despondent, and then began the strange procession of kids' relatives who wanted to take them off to visit other relatives, cousins, deliver crabs brought from Mabaruma, and various other important duties. I became increasingly frustrated, feeling that the children were more interested in running errands than in the piece they had come here to do, and also a bit perplexed. Why were there so many older male relatives wanting to take the teenage girls away? Where were the women in this, who usually carry the far heavier load of family commitment? Adolescent sex begins young here in Guyana, and its not at all clear to an outsider just what is going on, but I made myself pretty unpopular by insisting on HM’s ban on any children spending the night out.

Next day I went on a mission to borrow a steel drum for our show – I had managed to beg, borrow and steal all the other parts we needed (including a beautifully painted Silk Cotton Tree painted onto a flat). The steel drum was the last thing I needed.

I had tracked one down to the prison service –apparently they have a good band there. I am guessing they have time to rehearse. So next morning I went to the prison director’s Mr Erskine’s office to ask to borrow one. He was fine with me borrowing it and sent me with an escort round to Georgetown prison.

The prison is a grim, steel and barbed wire fenced compound in the middle of town. Tired and quite scary looking prisoners were lining up in handcuffs ready to go to court when I arrived, looking, I suspect, ridiculously out of place in my summer dress. There were a few proposals from prisoners (not all of marriage) which I studiously ignored, but couldn’t help being fascinated by the figures I saw running round the compound in the stifling heat, each with another prisoner riding their shoulders. What were they doing? Training as boxers, of course.

Heading with my drum back to the cultural centre, I met the kids, and we watched some of the others entries – they were good. I pointed out to the kids strong points in other performances – voice projection, characterisation. They nodded. Yes Miss.

It was coming up to our slot, and I gave them their pep talk. They were buzzy and excited, and so was I. In four weeks, we’d come a long way together. Behind the closed curtains we set up – our tree, the drum, benches taken from backstage, a huge bin borrowed from another show, a load of grass strewn about from the play before, and brilliantly, at the last minute, a stage hand turned to me: “you want a shallow grave?” I was hearing things. “Huh?” “You want a shallow grave? We got one”. Was this a Guyanese technical term? What did he mean? He led me to the back of the stage where, leaning against a load of flats was a foam gravestone headed with RIP. A shallow grave. Fantastic.

The curtain went up, I cued the music and over the system blasted “you wanna be starting something” by Michael Jackson. “Stop” I hissed over the cans. “Thats the wrong song, the wrong song – its Thriller – the bit with the scary man’s voice” “Sorry, sorry” the sound guy mumbled.

And so began our first and I suspect only performance on the national stage of Guyana. It was shambolic, it was halting, it was a bit giggly. It was also brilliant – it was the first time I’d seen this group of 15 kids from the remotest region in the country perform with costume, set, lights, sound. They looked pretty scared, but they carried on. They were nervous, but they got through it and started to have fun. They began to get a few laughs for their lines. They got off on the wrong line and managed to correct themselves. They were an acting company. They did really really well.

The show came to an end and they were called to the front of the stage. Up came one of the judges – he is a Guyanese comedian, I think, and had given feedback after each piece. He’d already had complaints from other teachers, but what he did to my lot was infuriating.

He gave a critique as if they had just appeared on Pop Idol and he was Simon Cowell. He flounced around the stage telling them off for not projecting enough, he made jokes at their expense, at one point he began mimicking one of the kids. Their body language went from glowing excitement and growing self esteem, to beaten looking and angry, regretting they had even come here. I was furious and complained to the organisers, as it seemed to me he completely undermined the purpose of the entire endeavour.

Anyway – my lot weren’t downhearted for long. I think there is a bit of a tough-love culture here, which the kids resist passively by secretly realising that these so-called authority figures haven’t necessarily earned that authority, and not really respecting what they say. What saddened me was that it might have undone all the work I had done in getting the kids interested in theatre, and so halted the rewards that were beginning to show through increased self-confidence.

We spent the rest of the trip enjoying the city – the National Museum, where an eclectic collection places a Rolls Royce beside a giant anaconda, and later to the zoo, where we were all transfixed by the real life anacondas, not to mention the mating tortoises and the spider monkey that had escaped and was running around on the roof. And when we get back to Mabaruma, I hope the group will form the core of a community theatre group in the coming months, or even, fingers crossed, years ahead.

Animals Which Live in Our House or Sam’s Ark

Some people have expressed an interest in the fauna that coexists in our immediate vicinity, so here is the current lowdown. I suspect this may change a bit as the rainy season progresses....

Gheckos: Instead of TV, when we’re fed up with the interminable Proust of an evening, we’ll lie back in our hammocks and watch the gheckos hunting on the ceiling. Its pretty exciting stuff. Watch as they chase flies! Gasp as they capture moths twice their size! Turn a blind eye as they momentarily mate in a slightly bored fashion! Leap out of your skin when the suction pads on their feet don’t do the job and they land on the floor looking dazed after a 20ft drop!

Bats: We never see these, but have the early morning squeaks and rustles plus the ample droppings to prove they are there.

Really big flying Cockroaches: Less scary now than when we first got here, they seem to keep a low profile, so we only see them now by accident. Like opening a drawer that hadn’t been used in a month, to find 3 frantically scurrying away from the light.

Mosquitoes: I (Becs) am the unfortunate foil here. If I am in the room, Sam is never bitten. Its so unfair. They love me. Some days I get so fed up with the constant biting I just get back under the net for some peace.
A recent gift has been an electrified tennis racquet which works brilliantly at killing them. Mosquito tennis – they light up like tiny indoor fireworks.

Ants: These come in waves. When we first got here it was tiny ones – small enough to get into all our food including jars of peanut butter. Now some really big ones have arrived.

Cats: We have adopted/been adopted by (not sure which) a couple of skinny, manky but very sweet cats. They seem to have seen off the rats.

Chickens: More a garden thing – livestock of all kinds wanders around the village all the time, and some afternoons they come and hang out in our yard. No eggs yet unfortunately.

Hummingbirds: These don’t come in but seem to find a great supply of ants (see above) climbing up the stilts to our house. Occasionally one will come and feed for a few minutes up and down the concrete columns. Like a cross between a bird and an insect, we haven’t been quick enough to photograph one yet.

Songbirds: The Guyanese capture these as pets and have competitions with them – betting on whose bird will sing first. We don’t have a captive one but, as our house is of the traditional design, on stilts with slatted windows, occasionally of a morning, one will pop in, hop around, and pop out again. Beautiful.

Cows: They come to eat the grass now and then. They’re ok but they leave a lot of flies behind. We sometimes confuse them by mooing at them from inside the house.

Lizards: Outside we have a couple of big one which chase each other round the yard. Inside I found a very small one hiding behind a broom today, about 3cm long.

Giant moths and butterflies: These blunder into the house now and then, and seem to go into shock quite quickly unless they happen to find a way out again.

First time in the Amerindian village

Within days of arriving in Mabaruma, we were excited to hear that an outreach trip was going out the following day to one of the villages in the region; Sam would get his first genuinely remote medicine experience, and I could tag along for the ride. It seemed like a great chance to get a feel for Amerindian culture, and to see how it could be running workshop sessions with them.

To elaborate – when we met Minister Ramsammy, confusingly, his vision of what I could do in the villages seemed clearer than Sam’s role. The Department of Health had had a breakthrough in some of its education work, through the use of drama games. They’d realised what its sometimes easy to forget in the cut & thrust of theatre in London – that the shared experience of making and watching drama creates powerful and memorable and sometimes life changing experiences, and is almost definitely more effective than lecturing a group of secondary school students about safe sex. Therefore, the focus was on how to roll out edutainment to the regions. The problem here is that essentially very few (read zero) Georgetown professionals will dream of heading to the regions for more than a day at a time. Sam and I had agreed to be there for 4 months. Thats why the Minister had a glint in his eye.

His confidence in my ability to create blossoming drama in the villages was not shared by any people I discussed it with. Amerindian culture is not known for its exuberance or expressivity; they themselves tend to be quiet, unassuming people (which possibly accounts for their historical lack of representation politically, socially or otherwise). Though actually, more than anything, they generally live so remotely, their exposure to the rest of Guyanese culture – or any element of global culture – is frequently negligible.

Mabaruma, Region 1, is seen as almost the remotest of the remote in Guyana. You can’t get here by road – you can go taxi-boat-taxi-boat-taxi, as you weave your way through the profusion of rivers and tracks that wend their way through dense jungle. Or you can fly. When you get to Mabaruma, you find a single road, lined with rubber trees, so pleasantly shady, and at each side, the municipal buildings of the region. Its a tiny, sleepy town. Yet Mabaruma begins to look positively urban once you head out into the villages.

On our first outreach, we were bound for White Creek, a village maybe ten miles away, but a good hour and a half’s driving over the most terrible roads you can imagine. We passed through villages on the way – Hosororo, Wauna, finally getting to White Creek just before lunch. We arrived at the village centre – scattered buildings along the way get a little denser until you reach the Health hut, next to the cricket pitch and the local schools. The health team swung into action – Monica the local Community health officer showing Nurse Johns (the vaccinations specialist) and Sam to the spaces they could practice in, and Dentex (the equivalent of the Medex in the dental world – trained somewhere between a dentist and a dental nurse) set up his portable chair – it was his first visit to the village, as became apparent by the procession of terrible teeth that greeted us in gappy grins.

I went off in search of the captain. The Amerindian villages elect a captain for three year terms, and visitors to the village should seek him out and get permission for their activities. Norman, White Creek’s captain, was almost regal – gentle, quiet, with the most perfect posture I think I have seen, and thirteen children. The families here are very big.

I explained that I would like to run a theatre games session with some of the children – I thought this was the best plan, to get my first sense of how I could work with groups here. He suggested I use the local school hall as it was Easter holidays and sent me off in search of the Headmaster Lloyd, while Norman spread the word that there would be games for children from 10 years up the next day at the school.

That night we slung our hammocks in the Health hut – the opposite of taking our work home with you I suppose – and the next morning Lloyd let me into the school. Like a latter day Julie Andrews, I was all smiles as the kids drifted in – 50 of them in the end, and ranging in ages from 2 (Rocky a very smiley toddler) to 25. I guess it was something to do that day.

The session that followed was invaluable to me, though not the easiest or most obviously successful I have ever done. We played a wide range of games – from the very simple stop, freeze – when I found myself being followed round the room like a mother duck with fifty slightly confused ducklings behind me, to name games which were painfully slow (the children, and particularly some of the girls, were incredibly shy about using their voices in public) but great fun in the group parts when, en masse we would shout everyone’s name and action at full voice.

A big part of the shyness is to do with the educational culture, I think. Most lessons are “chalk and board” – teacher dictating, children copying – in the worst cases without really understanding. There isn’t a widespread participatory approach in any discipline as yet. So the blank, rabbit in headlights look when asked to invent an action for your name in front of a big group is quite understandable, and we got there with everyone in the end.

Also, as we’ve learned since being here, there is a language barrier. With most Guyanese in Georgetown and Mabaruma, the language is Creole, the common Guyanese language which has evolved through all the many groups here – African, East Indian, Portugese, English and Chinese. Its a vibrant, colourful and very expressive language. Most people, once they realise we are English, will slow down and speak more clearly (and sometimes more loudly). But in the villages, Creole is spoken with the local accent, and possibly the second language to the Amerindian local one (though more and more rarely, the original languages seem to be dying out). So the looks of incomprehension I found myself faced with were often due to my English accent.

Most successful were the group games – singing, chanting, and an adaptation of Whats the Time Mr Wolf (Whats the time Mr Jaguar) which was a big hit. Less successful were games which involved physical contact (People to People) or a vocabulary which included any sense of theatre (a sculpting game where you made your partner into any character or emotion you liked met with a nonplussed silence).

Still, what seemed clear to me was that the lack of expressivity I’d been warned about was, of course, just skin deep. Once they understood the games, and begun to know and trust me, the group were by turns highly focused, wildly exuberant and very characterful. Of course, this is just the first step, but it gives me hope that the edutainment project, when I get it started, will find a fruitful home here.

Cooking Guyanese style....

Guyana always seemed like a good bet for interesting food – masses of tropical fruit and veg as the raw materials, plus the cultural influences of generations of East Indians, Africans, Caribbeans, Chinese and Portugese, not to mention the native Amerindian food.
It hasn’t disappointed us – here are a few of our favourites:

Pepperpot: One night, Shaira, our Islamic friend and Guyanese cuisine guru, said: “a friend of mine is killing a cow tomorrow – you want some?”. And so our first opportunity to cook the most famous Amerindian dish came about.
Early the next morning we collected the still warm meat from Ray’s place. Ray is the dominos champion at the local bar. Grinning from ear to ear with a well-earned shot in his hand, he had butchered every bit of the animal, from head to hoof. And for evidence, there on the table, side by side, was the head and tail. Our bag was the last one hanging under the house.
That evening, Shaira arrived to teach us to make Pepperpot. As it wasn’t Halal, she didn’t have any, but seemed happy to see us tuck in to the thick, delicious dark brown spicy stew.

This is how you make it:
Chop the beef into 1 or 2 inch chunks and dry fry it – we had about 2 kilos of beef bits – so heat the pan and chuck the meat in with no additional oil, it will brown in about ten mins with the steam and oil it creates. Next add your seasoning – 2 onions, 6 cloves garlic, all chopped, a chopped hot sweet pepper, 4 or 5 cloves, a small cinnamon stick, a teaspoon sugar (demerera of course), eight or ten leaves of married man’s poke (local variant of basil), a generous teaspoon of thyme, 2 stock cubes and a pinch of salt. Fry off the liquid and add about 50 mls of casareep.

Ah – casareep. This looks and smells and tastes like thick salty treacle, and is one of the many products of cassava. Its had a very significant role historically in Amerindian culture. Made by grating cassava, squeezing out the liquid and then reducing it for hours until its black and tarry. Adding a rich flavour to stews, it also works as a preservative. So, living without power as the Amerindians did for millennia and largely still do, its a fantastic way to preserve meats – just boil it up once a day, you can keep adding to it as you catch more meat and game. In Georgetown there is an historic pepperpot, more than 40 years old!

As we too have no fridge, it was great for us too. It fed us for a week.

Metthem: Another Amerindian classic. On first hearing the term “ground provision” we suspected Methem might be a bowl of dust. Its actually the local term for root vegetables, which are dear to the heart of all Amerindians. This dish showcases them all in their carb-heavy splendour and may go some way to explain the chunky stature of those who enjoy it.

Its a coconut milk stew containing the big 3 from the world of ground provision – sweet cassava, sweet potatoes and eddo (a potato-like root veg which turns an alarming bluish purple when you cook it). It also contains a generous portion of dough (rhymes with snuff), which tops up the carb count. Delicious – and time for a nap.

Cook-up rice: Unusually for Guyana, everyone has their own way of cooking this – but it will always taste of scotch bonnet peppers.
Its rice and peas cooked with coconut and chilli, often with some chicken or fish, and will be familiar to anyone who has been to south London. It was really nice to get here and order something so familiar – it felt like home away from home. Ah, Peckham.

Eddo Leaf curry with Roti: There’s an initially incomprehensible love of eddo leaf here. Possibly because it grows in such profusion, people seem willing to put in the man hours to make it edible. Unprepared, it will sting your mouth like a jellyfish. Its the above-ground leaf of the underground eddo.

To prepare, you need to strip out the veiny stems, and boil it twice, changing the water. Then use it like spinach to make a curry.

Roti: Dom – if you’re reading this, we have learned to make roti. Oh yes.

Make a dough from self raising flour, water and a little oil. Knead for 10 mins intil firm and springy, then roll out to a flat disc. Roll your disc into a sausage (a bit like making a swiss roll). Cut into 4 or 5 sections. Then take each one, unroll it in your palm, lightly oil it, and reroll it tightly, tucking the end tightly into the centre. Cover and leave for 15 mins – its the oil soaking in which leads to the flakiness of the cooked roti later on.

Heat your roti pan (a large flat aluminium pan which works well for making toast too). Roll out your roti to approx 7” and bake it on the dish unoiled, for about 1 min each side. Then turn and lightly oil one side, bake for 30 secs, turn oil and repeat on the other side, so each side has taken a light golden brown.

Clapping the roti – the most important part – do this as quickly and as hot as you can bear. If you need to put it in a towel. Clap the roti vertically between your hands, straight across the disc so your are (apparently) rupturing it, not flattening it. It will tear a little but basically stay in one piece – resulting in a flaky Indian pancake good for picking up curry.

Roti variant – Puri: We were much mocked in one Georgetwon restaurant for mistaking puri for roti. Puri is roti stuffed with split peas, as any fool know.

Farine and Tasso – a Rupununi special: Farine is yet another product of cassava, much loved in the south of the country. Ground up & dried, it looks a bit like couscous. Evelyn Waugh hated it as dry and tasteless, he may have been eating it uncooked. Sandy, our hostess on Dadanawa ranch made a version similar to a couscous type salad, with oil, garlic and veg, which was great with the tasso (dried preserved beef). The beef here is strangely tough but very tasty – the same goes for the chicken – could it be because they are not mass produced?

Chow Mein: the Chinese influence and emergency supper. If you have noodles and a can of mixed veg in the cupboard, you’ve got dinner.

All Fruits Great and Small

There’s fruit and veg here that you will never see in any supermarket or even on a South London market stall. Here are some examples of some wonderful and strange things we have have eaten:

Soursap: Twice the size of your head, green and scaly like a lizard and shaped like a bull’s heart, the fruit inside is white and milky with lots of black seeds inside. Chewing on the fruit leaves you with a mouthful of fibre. Best strained and made into a drink.

Plumroses: Pale yellow and round, the size of a shallot, with a green “navel”on the top. Eaten whole, they have crisp firm flesh. They smell like roses and taste of Turkish delight.

Whitey’s: Green/yellow pods – like a hard shiny broad bean. Inside: white fluffy seed pods a bit like fruit pastilles. The fluffy stuff tastes like sherbert and there is a black seed inside.

Cashews: They grow on trees! The bright red fruit is the size of a very small pear. Hanging of f the bottom is one cashew nut. The fruit bites a bit like an apple but the flesh inside is pale white and sharp flavoured.

Bananas: Of course. There are many variants of the small, very tasty Caribbean variety. Occasionally you can get “bush bananas” which progress from pinky brown to a very pretty rosy pink when ripe, and are slightly firmer than their yellow cousins.

Avocado Pear: or “pears” as they are called here. We have a big tree in our yard. The season is just starting and they say you can find them the size of a football.

Bora Beans: String beans gone mad. Up to 2 foot long, you can buy a bunch that looks like a handful of green snakes for 25p.

Passion Fruit: Here they are bright yellow and as big as your fist, but too sour to eat. Mix the flesh with water and the ubiquitous Demerara sugar (this is where it comes from) for a delicious fruit juice.

Bread Fruit or “Pap fruit”: A big green knobbly globe containing a nut and a sort of artichoke-like surround. Makes a great curry and the nut is good too – but it makes you “pap” (Guyanese for fart).

Doctor's Stuff

Here's a little insight for all the doctors who might read this, in particular, the Amersham Vale gang.

Well, its a bit like putting into practice everything I've ever learnt from medical school through to general practice training. I am the sole doctor for the 12 bed hospital - but it usually keeps in only 5 or so patients at a time. In addition, there is a daily outpatients clinic, first come, first served. So its primary and secondary care all by the same doctor.

The hospital tends to get alot of children with D&V and pneumonia, plus the occasional septic arthritis. There's A&E type work too, especially on payday when everyone gets drunk on high wine (a poisonous blend of distilled rice and sugar which seems to have a similar mood altering effect as say crack cocaine) and beats each other up. There is an unexpectedly high number of abscesses - face, shin, finger - so lots of I&D, which I hadn't done for quite a while.

Not much tropical medicine though. I haven't seen a single case of Malaria, perhaps due to the strength of the bed net programme. Lots of TB - and there's a well organised team of DOTS workers who manage that.

Primary Care: there's a lot of hypertension and diabetes, and a lot of headache and "weak weak doctor" which may sound familiar to South London GP's. Depression is not a recognised diagnosis, which is reflected in the drug cupboard: just an unopened old pack of Amitriptytlline.

In fact, the drugs supply is very good for such a remote hospital in a relatively impoverished area. The only glaring absences are statins (only available in the capital Georgetown), Mefenamic Acid and ear drops for otitis externa.

The personnel problems are dire. No Guyanese doctor will work here. About 50% of the Guyanese population live in Georgetown, and it appears that very few ever go to the regions. This government has initiated a big training scheme, with over 60 medical students from the regions - meaning largely Amerindians - currently training in Cuba, and it is hoped that some of these will want to return to the regions. But until that results in more doctors on the ground, the government have gone for a dual solution: import Doctors from Cuba and train up "Medex's". These are like super-nurses, with similar prescribing rights to doctors and plenty of experience, but less formal training. They are the backbone of the country's health system.

Unfortunately, the Cubans don't tend to last long. In Mabaruma they seem to get sick, go to Georgetown and never appear again. Having seen the conditions in which they work, I don't blame them. Its hard enough working in a new culture, not to mention a new language (their English is invariably abysmal, and Creole takes some getting used to even as a native English speaker) but on top of that they are on call 24/7. Not to mention the distress of the frequent deaths of young children, which is unfortunately not a rare occurrence, often due to the long distances they travel to hospital whilst seriously sick.

In addition to Medex's and Cuban doctors, each village has a local Community Health worker. Highly knowledgable about their communities, these workers have quite limited prescription powers, and work directly in the villages, referring people to hospital when necessary - though unfortunately not always in time to help.

So its the Medex's and the CHO's that I will be working with for the rest of my stay - some of this has begun already, and I hope will be a means by which my presence here achieves more than just patching up drunk boys on payday.... Fingers crossed!