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!