On international conferences, presentations and african dancing under the stars

hand washing at KCMC - just think about it next time you load your machine!

I am sorry it has taken so long to post again but the last 2 weeks have been extremely busy at work (yes I  have been working hard - the blog just seems to have been full of our amazing Christmas holiday exploits!)

I was back at work on Monday 9th January and preparations were well underway for the 17th International CME meeting at the RDTC on 11th-14th of January.  I was relieved to see that we finally had a programme which looked full and very interesting.  Michael, Vicky and I spent much of Monday and Tuesday going through the 3 ADDV students research presentations on the re-emergence of leprosy between 2005-2010 in a district of Uganda, the skin changes seen amongst Albino pupils at a primary school in Kenya and health care seeking behaviour among adult patients infected with tungiasis in the Mbulu district of Tanzania.  The students worked very hard and their presentations became much clearer.   I was pleased to see that the residents forum which we had suggested before Christmas was in the programme on Friday afternoon and  Alice, Julia, Esther and Emmanuel presented to us.  Unfortunately it was felt that Emmanuel's presentation did not have good histological back-up so this one was removed and in it's place Nohrasco was presenting a fascinating case of an apparently eradicated disease dracunculosis (guinea worm).  It was great for the residents and ADDV students as all the international experts began arriving on Monday and were very kind and gave intensive teaching sessions to all on the days prior to the meeting.  It was wonderful to see Claire Fuller, my previous colleague and now Medical Director of the International Foundation of Dermatology (IFD) who had travelled out with Professor Rod Hay Chairman of the IFD.  Claire kindly came bearing a large heavy bag packed by Stacey our wonderful nanny in England which had gourmet goodies including cheese - cheddar and red leicester, nutella, marmite and 2 large bars of dairy milk chocolate.  In case you are wondering how the cheese made it out here Claire, who is practised in the art of cheese transportation to Africa, told Stacey to freeze it first and then it is wrapped up in tin foil for the journey during which it gently defrosts.  Still I was glad to get it all into the fridge...

Claire also came bearing large volumes of specialist dressings for the baby with Epidermolyis bullosa and dermasilk suits.  I only hope we can contact the Mother and try to persuade her to bring her baby back to clinic where we can at least give Mum the dressings and suits even if she doesn't want to bring the baby back to the dermatology clinic again.  I find it heartbreaking how hard it is to help sometimes and I wish I spoke Swahili as being able to speak directly to Mum might make a difference.

Professor Masenga introducing the CME conference

The CME conference began in earnest on Wednesday morning in the main KCMC lecture theatre which became my second home for the next 7 days.  It was great to see old friends and to make new ones and I was so impressed at how much the international community embraces and supports the RDTC.   We were reminded at how much the International Dermatology community and the RDTC in Moshi had achieved since it was officially opened in 1992.  At that time there were fewer than 150 Dermatologists/ health care workers trained in Dermatology in SubSaharan Africa (excluding S Africa).  To date 217 medical officers from 16 African countries have graduated from the RDTC and many of them were there at the CME meeting.

The 500 club that helped to finance the RDTC

There was a truly African welcoming session with representatives from the KCMC and the Tanzanian representative from Stiefel spoke in front of a beautifully decorated blackboard with a fantastic picture of the RDTC drawn on it.  The next session was on leprosy during which I was proud to say that Kenneth our ADDV student gave an excellent presentation and handled the questions with applomb.  Leprosy is meant to be an eradicated disease in many areas but since being at the RDTC I have seen about 6 cases, some of whom are the infectious multi-bacillary sort.  It was very important to discuss the fact that leprosy is a re-emerging problem and a lively discussion was had by all on how to approach it.  Many health workers fail to recognise the disease and a school boy who we diagnosed had been seen for the year previously at another hospital.  This case raised many issues about the stigma of leprosy and also the ethical problem of contact tracing in a school in this situation.  The day progressed with talks on psoraisis, acne and our colleague Dr Vicky Yates gave an excellent presentation on Tuberculosis of the skin.

That evening we were all treated to a wonderful dinner under the stars in the truly magnificent garden of Professor John Masenga which when decorated looked like the set of a Bollywood movie.  The food, drink and company was fantastic but we were up bright and early the next morning.  The first session was introduced by Professor Ryan and was a insight into the subject of nutrition and the skin.  Mr Brad Snyder gave a passionate and fascinating insight into a project entitled Gardens for Health (www.gardensforhealth.org)  that they have set up in Rwanda.  In Rwanda there is much malnutrition so in conjunction with giving the food aid plumpinut, based on peanut and enriched with vitamins and minerals, parents and children are taught how to cultivate a garden at home.  There is a demonstration garden at the health centre where the families are taught and given the vegetables and foods that are needed for a balanced diet whilst their garden is growing.  They are given the seeds and the expertise (a home garden package) to make their own gardens so that at the end of the 3 month food supplementation period given to the malnourished child the gardens are ready for harvest.  Brilliant - Brad an enigmatic, slim, vivacious man also talked passionately about empowering women and children and also about the involvement of men into the project.  Following this talk Prof Ryan's sister talked about an equally brilliant garden project in India:  www.earthtrustnilgiris.org.

Brad's gardens for health talk

Other highlights of the day were our 2 other ADDV students presenting their research excellently making us very proud as some of the students find presenting in English an understandably daunting process.  The day ended with the now legendary RDTC quiz which I have to say was very difficult!!!  Then another dinner at El Rancho - famed for it's delicious Indian food ( I didn't think I would eat so much Indian food in Africa)

Friday's highlight has to be our 4 residents' polished presentations:  Dr Alice presented our case of junctional Epidermolysis bullosa, Dr Julia presented our case of Tuberous sclerosis, Dr Esther presented a very sad case of Proteus syndrome and Dr Nohrasco presented the case of dracunculosis complete with brilliant pictures of the 40cm worm being extracted from the patient's leg.

Nohrasco, Esther, Alice and Julia holding their prizes (left to right)

Everyone enjoyed the session and the residents all won prizes together with a previous resident, Dr S Kiprono's fascinating research presentation on the difference in skin flora found in the albino population.  Sebastian and I found this particularly interesting as the post-operative infection rate in albinos is 100% and is still 30-40% with prophylactic antibiotics.  Friday night was spent dancing at Mumbai Masala - yes you have guessed it another Indian restaurant.  It is always reassuring to see how much Dermatologists love dancing wherever they are in the world... . Brad was a brilliant dancer and impressed both us and the local African dancers!

I have to say that I was flagging by Saturday morning as the lecture theatre was very hot and did not even have a fan.  There was a reunion of previous ADDV students who presented many of their more difficult cases.  Later in the morning some of the IFD committee members visited Mafalda who was busy preparing the latest batch of suncream created from mostly locally sourced materials.  This Spanish project is brilliant - 2 suncreams are created locally in a small building with local materials.  The titanium dioxide and zinc oxide I think had to be brought into Tanzania and we were all worried about Mafalda being stopped at customs bearing large volumes of white powder.....  The first batch of suncream has been distributed to the Albino population who have then been asked about their experiences with the cream and a questionnaire completed.  Mafalda was about to distribute the second suncream so that the Albino population could trial this one to.  Then the suncream that was most favoured was going to be manufactured locally in large volumes providing employment for Albinos indoors away from the harmful sunshine as most work outside as subsitence farmers.  Mafalda was very pleased as she had recently returned from Spain where she had worked hard to raise more funds to build a larger building in the RDTC compound grounds to manufacture the suncream and also a workshop to sew protective clothes for the community.

Professor Rod Hay with Mafalda with suncream number 2

Just as good as Clinique!!

No rest for the wicked - whilst my family went to the hot springs and spent a happy Sunday afternoon jumping off a high tree branch into the water I went to the opening session of the 7th Georg Rajka international meeting on atopic dermatitis (AD).  As this meeting followed directly on from the CME it meant that many participants were able to attend both event.  I felt very fortunate as I am very interested in atopic dermatitis and it was great to hear fascinating talks on the prevalence of AD around the world.  Alan Irvine gave a brilliant lecture on fillagrin defects and Claire gave a very entertaining and informative talk on podoconiosis and coped admirably with a lack of electricity and hence slides for half of her talk!  The meeting was from 15-18th January and gathered together a field of international experts.  However sitting from 9am - 6.30pm in an increasingly stifling lecture theatre was problematic and I have to confess to dozing off in 2 particularly complex immunology lectures that seemed way over my head but did have very pretty green and purple pictures....

It was so lovely to meet more friends and the team from Nottingham's UK Dermatology Clinical Trials Network Jo Chalmers, Kim Thomas and Helen Nankervis gave excellent lectures and more importantly brought out more goodies for us.  Yes more chocolate and a very kind present of a kitchen scales so that we can bake our own bread, cakes and cookies...  Other highlights of the conference were a fascinating talk from Professor Grossman on AD and traditional healers - with so little dermatological expertise in Africa most people with skin disease go to a traditional healer (1 traditional healer per 100 of the population versus 1 dermatologist to 1 million of the population).  I also learnt about the brilliant psychoneuroimmunology work being doen by Prof Gieler in Germany and there was  a whole session on psychosomatic aspects and patient education.  I was pleased to see that I did much better in the RDTC quiz this time so I must be learning......

Carsten Flohr showing the African Dancers some moves!

On death, sorrow and being so far away from family

My Uncle Denis sadly died in his sleep on Sunday morning and today is his funeral.  Although he had been unwell for some time, as his heart function was poor due to previous heart attacks, it was still a shock and has caused great sadness amongst our family.  I am finding it particularly hard as I am so far away in Tanzania and unable to be with our family.  In Jewish tradition the burial is arranged quickly so it was not possible to even contemplate returning home.  Denis leaves his wonderful family; his wife Yvonne and their children Leo, Jessica, Olivia and Justin.

 

Passover 2009 - the Afikomen presents

On Sunday I sat with my boys Zac and Josh and we remembered Denis together.  We talked about how Denis gave Josh his flaming red hair.  We talked about all the Jewish festivals that we had spent together and we had such happy memories of being in the garden at Holne Chase on Rosh Hashana (the Jewish New Year).  Somehow regardless of the true date of Rosh Hashana (usually in September but the Jewish calendar is based on the lunar calendar so the dates of festivals change each year) God made sure that it was always sunny for the Rosh Hashana lunch festivities in Denis and Yvonne’s beautiful garden.  I remember standing in the garden every year talking to Denis about his beloved plants –  the delight he had when he told me about successfully growing passion flowers.  Zac and Josh talked about the happiness they had playing with Sybilla and Madeline for hours in the garden and climbing upstairs to play with the toys.  I in turn remember being Zac and Josh’s age and having the same happy Rosh Hashana times with Denis and Yvonne and the family: finding the Alladin’s cave of toys.  I remember all the seders (the Jewish festival Passover) we spent together with Denis as celebrant and him hiding the Afikomen and giving us clues as to where to find it.  I remember feeling very special when I was promoted from the childrens’ table to sit with my older cousins Leo, Jessica and Olivia who always looked so stylish and adult to me.  Then when I could keep up with the songs after the service had ended I thought ‘now I am an adult’.

Josh, Madeline and Zac at the Seder 2009: sorry only have laptop here so limited pictures!

The huge seder at Jessica and Keith's house - Denis is hidden under Madeline's arm! 

Denis was always so interested in my progress at school and later at Medical school.  He was made Professor of Chemical Pathology at the Royal Free Medical School and published an excellent student textbook.  Now as you might have guessed chemical pathology was and is not my strongest subject.  I remember spending an afternoon with Denis at Holne Chase before my final chemical pathology exam with him kindly and patiently explaining various concepts to me and helping me with my revision.

Although death is part of life it is so hard.  Denis was much loved and will be missed by all.  I am thankful that he died so peacefully in his sleep.  My thoughts and love are with his closest family Yvonne (his wife), Hugh and Raymond (his brothers), Leo, Jessica, Olivia and Justin (his children) and all his grand-children and great grand-children.

http://www.expertsearch.co.uk/cgi-bin/find_expert?4787

On the Spice Farm trip (1st January 2012) by Zac HT

Don't mess with us!

In the Spice Farm we saw and tasted many very peculiar spices and fruits.  In Africa there is this strange fruit called the Jack fruit which tastes sweet and slimey but I did not like it (but Mummy did or perhaps she was just very hungry).

Foraging for Jack fruit

 There is a type of spice that is used for lipstick and war paint and the plant looks like red balls with green little spikes and blue dots on the top of them.  When you break them open there are little seeds that are red that you crush and can then use for lipstick and warpaint.  

I don't know why Mummy has to buy lipstick!

There is this other weird seed that is brown and has little red lines all over it and this is a nutmeg seed. 

so this is where bananas come from

A man called Ali Baba (not sure this is his real name) made us amazing things made out of coconut leaves.   First he made us a tie, then he made us a ring and then a watch and sunglasses and a basket that we could put all of our spices in and one more thing that was a cool frog.  Last of all a lovely weird hat which we have worn all the way back to Kilimanjaro.  

I know you wish you could have some of these....

There was a man that climbed to the top of the top of a very high coconut tree with rope around his legs.  His name was James Bond (we think!) and we drank the coconut drink from the coconuts which was yummy.

James Bond is very good at climbing trees

I know we look really cool....

On Stone Town, Antiquity, Bondage, Charity & Decline

We said that Stone Town deserved its own entry into the blog, in part because of its amazing history, but also because it somehow challenges you to think about what you have experienced in a way other places we have visited don’t.

In effect Stone Town is like marmite, you either love it or hate it!

It has such a rich history, exemplified by its architecture, visitors and politics. We can’t hope to do it justice on our blog but if you have time I would like to share with you some of its jewels...both shining and tarnished.

Post its separation from the mainland a few million years ago, the racial makeup of Zanzibari’s has been blurred by the inter-racial mixing of Arab and mainland African immigrants. The Portuguese became the dominant power across East Africa c16 usurping the Arabs who controlled much of the slave trade during this time. Two centuries later the Arabs returned and it was not long before the Busaidi dynasty transferred its capital from Muscat to Zanzibar. By 1832 Zanzibar had become one of the most important trading centres of the Western Indian Ocean, again chief amongst its commodities were slaves. The trade was controlled on the island by the enigmatic Tippu Tip, a king-maker and in essence the chief of slave trade across Africa. It was not unheard of for some of his slave caravans to number over 4,000!

You see what you can see from the sea?

The large Omani coralline fortress and palaces dominated the shoreline of Stone Town by the time many of the western explorers started to adopt Zanzibar as their starting point for exploration in Africa. For example seeking to identify geographic entities such as the source of the Nile. Sir Richard Burton (not the Welsh actor bloke) upon seeing Stone Town from the sea described it thus...‘Earth, sea and sky, all seemed wrapped in a soft repose...under a blaze of sunshine which touched every object with a dull burnish of gold’. Eloquent and poetic, ironically he later wrote how much he detested the placed! (Ah marmite)

David Livingstone, who was in Zanzibar in 1866 preparing for his final exploration was somewhat more honest in a way Scots and Yorkshire men are when he stated...‘The stench arising from a mile and a half...of two square miles of exposed sea beach, which is a general depository of the filth of the town is quite horrible...[I]t might be called Stinkabar rather than Zanzibar’. In fairness to the Livingstone, little has changed along the sea front and although some will describe the smell of Stone Town in terms of the aromatic spices they do little to mask the stench of the fish or meat in the market.

At the time of the great explorers visits Britain had started to carry out anti slavery patrols and by 1873 the exports emanating from Zanzibar ceased. This effectively led to a large reduction of squalor as the slaves, who could be found in many cases roaming the myriad of side streets in search of food, slowly dispersed to find work out on the land.

Around this time Zanzibar became a British Protectorate and, what can only be described as a puppet regime led by the Sultans, maintained power. Britain effectively swapped Helgoland for Zanzibar in a deal conjured up by PM Lord Salisbury and the German Kiaser, as Britain also took control of Kenya and Uganda, Germany maintained dominance over Tanganyika (now mainland Tanzania). The British imported their colonial architecture but, under the influence of the architect John Sinclair, introduced a number of features derived from the Islamic architecture of Istanbul and Morocco.

The House of Wonders...wonder whats in it?

It was during this period of British ‘rule’ that Zanzibar found itself in bother with their ‘protectors’ following a change of Sultan who was not the flavour of the month back in the UK. Hence, August 27^th 1896 saw the shortest recorded war in history. Lasting a mere 38mins (approx) the British Navy bombarded Stone Town almost totally destroying Sultan Braghash’s recently built architectural masterpiece, Beit al-Ajaib (House of Wonders) 1883. It’s colonnaded façade, fretwork and imposing clock tower stood four floors high, and was the first to have running water, electric lights and a lift. Suffice to say the dispute was short lived and England soon had ‘its man’ in place to continue an orderly rule over the locals and maintain Britain’s strategic position. Some 500 men died and the whole of the Omani Navy was sunk during this not so epic battle. This navy domination would have been Trafalgar like had the Omani had more than the one ship!  

Puppet rule continued until WW II, following which it was clear Britain had to reduce the commonwealth (no money in the bank...Coalition followed by Labour mmmm!). Although the Arab Omanis maintained power the majority of Zanzibari’s were Shirazi’s, decedents of freed slaves and mainlanders. They despised the rule of the Omanis and the Indian traders who become prominent landowners. By the 1960’s there was a farcical handover of power by the British via a contrived election leading to the majority of the voters not been heard as the constituencies were carved up to suit the Omanis (Zanzibar, England...we know how to do elections!). 

Forodhani Gardens...Eden with overtures of Stinkabar!

Revolt was quick to come; January 11^th 1964 heralded the beginning of a bloody and murderous revolution. Led by the self proclaimed Field Marshal Okello, a Ugandan (think precursor to Ide Amin) there was a genocidel stench to how the revolution was handled.   For those of you who have come this far I can highly recommend Don Petterson’s book Revolution in Zanzibar, an Americans cold war tale, West View Press (2002). It is believed many thousands perished at the hands of Okello’s henchmen, I was only too happy to read that the incoming Zanzibari government got rid of him and he eventually found his way to Uganda. It was here, it is said, that he came to a sticky end at the hands of Amin!

Revolution led to independence of an African kind and there was a huge strategic battle fought over little Zanzibar by East and West. Eventually Tanganyika took the view that there should be a merger. A Union was formed and following a ‘competition’ the new country was named Tanzania.

Today Stone Town still exhibits many of the buildings created by the rich Omani Sultans and Sinclair, but they are in decay. The Aga Khan Trust for Culture has invested millions into the restoration of buildings such as the Old Dispensary and had plans for much more. However, I fear corruption and the clear mismanagement of such charity will mean little money will actually flow into real development.

The Old Customs House...just needs a wash gov!

The buildings described in the ‘guide books’ are little more than ill kept relics of a recent past. Although these texts lavish adjectival embellishment there is a lot to be said for simply being honest about the state of Stone Town. The labyrinth of back streets plays host to the real sights and sounds of Stone Town and is reminiscent of the bazaar towns of North Africa. It's here you will see the real Zanzibari’s simply going about their business rather than the Rastas' who pedal ethnic tat along the main thoroughfare Kenyatta Road.

Wanna buy a door?

Many of the buildings that were the hub of administration, the Old Customs building, Sultans Fortress, Tippo Tip’s house are pretty run down affairs. Although you can peak inside Tippo Tip’s house it is simply a squat for numerous families and bares no resemblance to the structure it once was. However, the door is a typically ornate Zanzibari door. These beautifully put together structures are a mix of many cultures with each element having relevance to spirits and gods. In the 1990’s a survey was carried out by UNESCO, during which they found of the 1500 Stone Town doors in existence from previous records there were now only 300 left; many being dismantled and sold or stolen.

So in essence, it’s a wonderful place to explore, there is much to see for those willing to dig around, but as I said its marmite. Love it or hate it, it will leave you sticky and smelly but if you like that kind of thing you will want to go again I know I do; (Although I hate Marmite!)

The real Stone Town can be found down here...Classic Indian Vespa :)

On a very African Snorkelling Trip and Magic Hands: Zanzibar 22 December - 1st January

So there we all were trying to have breakfast at 7 30am to be ready prompt for the boat which was leaving at 8am.  However the kitchen could not cope with the rush of preparing fruit and panacakes for all of us all at once and poor Ibwana became very stressed!  We managed to rush our breakfast only to find that Bob Marley appeared about 8 15am to say that the captain of the boat’s relative had unexpectedly died and so he had to attend a funeral.  Bob was making more and more frantic loud phonecalls on his mobile, his stutter getting worse with each call.  At about 9am we walked down the beach to another boat and stood there whilst the boatmen kept hopefully pulling the starter motor – it would splutter to life for a few short seconds and then die out.  After about 20 mins of this Bob said “ boat no good” !!  By this time it was 10 am so we went and sat in Nyota, the guest house Bob was attached to where the boys annoyed everyone by swinging wildly on the hanging chairs.    Apparently we were now waiting for some cars to take us across the island to a different boat.  So we sat and sat and sat and I dreamed of being asleep still… Then at about 10.30am a 7 seater taxi and a car arrived so we all piled in and began a most uncomfortable bouncing journey over dirt roads and winding tracks across the island.  We arrived at a beautiful bay overlooking Mnemba Atol and this time the 4 seater car with the girls was not there and surprise surprise there was no boat either!  About 20 mins later the others arrived having taken a completely different route and we kept looking out to sea more and more hopefully.  Bob kept saying “the boat is coming” and waving vaguely out to sea.

Where is the boat????

Zac found a friend on the beach

At 11.30am Hannah said very quietly to Bob “ If the boat does not come soon I think some of us might want to go home” at which point Bob waved even more vaguely but vigourously out to sea saying “boat coming very soon” and at 11.45 am a boat did arrive.  Bearing in mind we had been trying to go snorkelling now for almost 4 hours.  So we climbed into the boat and looked around but there didn’t seem to be any snorkelling equipment at all and more worryingly no life jackets for the boys.  I asked poor Bob who kept up his frantic phone calls and said “equipment is coming” and waved out to sea again.  Next came a hilarious boat ride zipping across the sea to any boats that we could see to ask them for their spare snorkelling gear which was then thrown into the boat whilst we were still moving.  We must have gone round about 4 boats in this fashion and finally some life-jackets were thrown in too for the boys.  We ended up with a motley collection of snorkelling gear which made a bit of a mockery of us all carefully writing down our shoe sizes the night before!  Between us we all had part of the snorkelling equipment – Aaron and Josh had no flippers and Hannah had no snorkel  but by this time we were all just desperate to jump in the water.  We were pretty hot and pretty disgruntled by this stage but as soon as we jumped into the sea and opened our eyes it was absolutely AMAZING!!!  Right under our noses was a huge coral reef with multi-coloured fish zipping their way around – we saw little zebra fish swimming round tiny coral columns, angel fish which were blue and yellow, harelquin fish, a whole shoal of long nosed spear fish, groups of grouper and so many more.  Zac was zipping about really well and Josh was brilliant and could snorkel although he hadn’t worked out that if he jumped off the boat then his snorkel would fill with water so he wouldn’t be able to breathe!

Do I look good in my snorkelling gear?

Captain Josh driving the boat

Josh with Talia

Josh with Olivier the 6 foot 8 French gentle giant working for MSF in Kenya

The next site was even more incredible as we moored off Mnemba Atoll.  This is probably the best snorkelling site in Zanzibar and has a single private lodge on the island that you can stay in if you are very rich and want to be very remote. As soon as we jumped into the water and looked down there was a coral spiral directly below swarming with technicolour fish that looked straight out of ‘Finding Nemo’.  I saw one of those little fish cleaning a bigger fish’s gills and we were surrounded by huge zebra fish who swam all around this strange multi-coloured collection of clumsy mazungus.  I think it was the best snorkelling I have done in many years and Josh loved it even if he would jump in doggy paddle around for a few minutes, get out and then want to start the whole process again.

Mnemba Attol - a peaceful retreat for a few very rich people

We had a fantastic couple of hours snorkelling and even the nausea making road trip back couldn’t dampen the greatness of the trip.  It seemed to reflect so much about Africa – you wait and wait and wonder what if anything will actually happen and then when it does it surpasses all expectations….

The boys playing on our beach on our return

Back on the beach we discovered Sabrina, a graceful woman who wants to be a lawyer and if her results are good hopefully she will get a place to study law.  She has truly magic strong hands and gives the best massages I have ever had.  Imagine lying on a sunbed next to the Indian ocean having a massage listening to the waves crashing on the shore and every time you open your eyes  the view is waving palm fronds against a background of azure blue skies…………..