Tropical medicine and hygiene

Highlight of the week: Four wild dogs trot right past our door as I’m logging on to take my exam.

Lowlight of the week: I’ve been confined to barracks. Last minute cramming. Keith sees 15 elephants at the local waterhole, but has nobody to share it with.

Maximum temperature: 33 degrees Celsius (almost as warm as the UK)

Rainfall: Less than a drop

Art for art’s sake. Gautier turns in his French grave as I play with the metaphor. My practice of medicine is a form of art. I’m still practising this art after 33 years. Three of those years have been in tropical countries. I more than just get by. I am one of the two best doctors in South Luangwa. I don’t need to study tropical medicine. My art is for art’s sake.

The idea of studying for the diploma in tropical medicine and hygiene was planted 7 years ago. We had been appointed as Valley doctor five years in advance of taking up the post. The idea failed to germinate. But the seed was hardy. The ground was fertile. But full of other crops. Retirement 2 years ago cleared the field of competition. And set the germination going.

Keith is already a diplomat. This is nothing to do with his calm demeanour and his ability to negotiate. Let’s go back to 1996. Keith oddly decides, after working in Zanzibar from 1994-1996, that he wants to know what he hadn’t known in the previous 2 years. He commits to going back to school for 3 months. His is a residential course at Liverpool University to gain the diploma of tropical medicine and hygiene. Meanwhile, I set to work. To pay for his course. I get myself on a paediatric training scheme. I am focused on becoming a consultant. I feel totally dissociated from tropical medicine. It holds no pull for me. I am not the slightest bit jealous of him. Learning long Latin names. Looking at poo and eggs down microscopes. Making sense of how parasites and bugs get into us and cause disease. I listen with disinterest as he waxes lyrical about it all. Nodding at the right times. Feigning interest. But I am totally underwhelmed.

The right-hand side of Keith’s name is weighed down with yet more letters. The DTM&H initials nicely summarise 3 months of concentrated lab and lecture-theatre graft. The complexities that make tropical medicine so fascinating. But without toilets and hygiene where would we be? Suffice it to say that breaking the lifecycles of our mini foes is either simple or obscure.

My 2022 brain feels less jammed-full of kiddie problems. Retirement feels good. There is more time on my hands. I start to explore options. A residential course? Or distant learning? Cost is certainly an issue. My pension will cover tuition fees. But I begrudge renting digs and paying more to be a resident. Keith nudges me to learn online. He likes the idea of a BOGOF deal. His knowledge is a little rusty. 25 years out of date. He wants to brush up and update our training manual. Diagnosis and Treatment. Glasgow University ticks our boxes. A 9-month course. Online. Lectures and tutorials. A 3 day stay in Glasgow is the icing on the cake. Allegedly something to do with microscopes and poo. But for me, Glasgow’s microscopy course is a thinly veiled excuse to hang out with the Rotchfords. Karen Rotchford is both an old school buddy of mine and an Alumni of the Liverpool School of Tropical Medicine and Hygiene. From the same intake as Keith. It’s no surprise that Karen will be the Valley doctor in April 2024.

Perhaps some of you can remember the tension that you felt when you applied for a place at university? It’s May 2022. I’m writing my personal statement. I feel embarrassed and nauseated to describe why I am the perfect would-be student at Glasgow. Nobody is going to beat me to my well-deserved place to study tropical medicine. There is only one place for each 3 course applicants. Had this been a dog-eat-dog situation I would have been a snarling determined wild dog.

As I write my personal statement I vex. What do they want to hear? Do they want a retired paediatrician who has hung up her NHS stethoscope? As a pensioner, I also have to persuade myself. Do I have the brain cells and the diligence to do this course? I have no doubt that my choice is true. Rejection would bring real distress. Not relief.

The application whooshes out of my outbox. I’m on tenterhooks as I wait to discover my fate. Three months of patient waiting leave me sapped. August comes and my success brings joy with fear. I pause momentarily, with my finger over return, as I send the course fees. There is no turning back now.

My learning begins in September 2022. The first task is to get up to speed IT-wise. All of my learning and assessment is to be online. I shudder at the thought of freshers’ week. But then I realise that I am a virtual student. Almost all of my social life, with fellow students, will be on WhatsApp and Zoom.

I apologise for this short digression. Please bear with me. It’s almost relevant. My mate Quentin has an expression borne from a former life. It’s somewhat unsavoury. But it often helps to sum things up. Quentin was a Major in the Royal Electrical and Mechanical Engineers. His men were perpetually at the ready. Waiting for her majesty, the Queen’s, whim. All their kit had to be ready in a trice. Quentin’s Sergeant Major was oft informal when chivvying the troops along. The expression mocked their battle preparations. Get your shit in a sock lads.

My course at Glasgow certainly has it’s shit in a sock. Immaculately organised. Online lectures. Loads of online books and image galleries. Live tutorials that are also recorded. Suggestions of podcasts for keen beans and eager beavers. Engrossing learning that is often rather gross. Maggots that grow in your skin. Worms that chew up your brain. I am hooked. And so is my virtual study buddy. Keith goes down a rabbit hole to explore the finer points of HIV medicine and how to conquer TB. We even journey with the TWIP team. This Week In Parasitism takes us on tropical medical tours of discovery, whilst we drive to Scotland and Portsmouth. My course organiser, Christina, part of the team. We follow her and her quartet. The piped pipers lead their acolytes.

Structure comes after the woolly fringes of retirement. Wake. Breakfast. Study. Exercise. A couple of hours a day feels right. Ten hours a week. My brain saturated with more. But bored with less. My fellow students must envy me. They work to pay their bills and fees. And study instead of live. But I now live and study. And living includes enjoying Yorkshire’s countryside. I fight with Keith to lead our mini-peloton. Our biking just as important as study.

But I eschew frippery. I decline to organise holidays. Weekends away are fine. A snow-shoeing trip in France with Sue and Andy declined. A trip to Costa Rica to stay with Robin and Heather shelved. I keep to schedule. Gradually, I force my brain to accept new facts.

Time is warped. The subject matter is all consuming. But there is always more to know. It’s April 2023. Our arrival in Mfuwe suspends my learning. Only briefly. I have short dalliances with wild dogs and leopards. But our time in the park is rationed. Keith has to resist the urge to book up lodge stays. The perks of our job will have to wait. My course material is now all at hand. But the focus shifts. Understanding is side-lined. Retention my new goal. Christine still conducts the orchestra. But we beat to the new rhythm. An R word. Revision. Abhorred by students. It describes graft. Not excitement. Not exploration. Graft and drudgery.

Learning is all well and good. The good is self-evident. My patients get cures and safer care. But a diploma in tropical health is a different kettle of fish. The certificate is evidence that these particular fish are well steamed. Ironic when uncooked fish harbour so many unsavoury parasites. But the certificate is only given to those who make the grade. Dare I mention the E word? I have to take an exam.

I am not a fan of sitting exams. They scare me senseless. Twenty-nine years have elapsed since I last succumbed and permitted others to check out my worth. Expectations have always been lowered in advance of my exams. To such an extent that I started to believe the prophesies. Although I have a good exam record, that record doesn’t come easily. I work methodically. Read. Understand. Repeat. A steady Eddie. Never a crammer.

My brain must be a bit addled by now. By the ravages of time. Not as crisp as in days of yore. All told, I am rather intimidated by new obscure diseases; drugs with far-fetched spellings; insects with habits that need toothcomb study; and Latin names that the exam board insist are de rigueur.

Back I come to graft. The prize seems so distant. A diploma that seems beyond reach. How do I keep to task? How can my interest in details stay fresh? I start with good, old-fashioned, flashcards. I drive to clinic and Keith coaches. Ruts and potholes. Dust and blinding orange morning light. Little Ellie tolerant on the back seat. Her battle fatigue following finals not evident. Ellie brings me sharply into modern times. I get with the program. Viral flashcards, created by other students take over my life. The Anki app is my saviour. Thanks to Ellie and my fellow pupils.

There is only one Valley doctor this week. Exam week. Keith toils in clinic. Ward rounds. Requests for Haloperidol and Artane. Crashing computers. Buzzing tree clinics. A suspected heart attack. Meetings. Shopping. Meanwhile back at the ranch: I party with Anki.

I toy with fear and surprise. I aim to control the controllable in the run up to E Day. Baboons on the roof might set off the online invigilator’s alerts. Disqualification a real possibility. Uncontrollable, I figure. Move on. My main fear is the internet. My online exam needs 3 megabits per second. We pay for 5. But my speed test says 1. Gid and Adrian come to the rescue. Gid’s speed test scores 17. Gid surrenders her study for the day and posts a do not disturb sign on the door – which Herbert, the cat, ignores. Their inverter guarantees power.

Only Gid’s creatures remain an uncontrollable. Cats inside. Baboons and elephants outside.

Today is Thursday. E Day. Preceded by a fitful night’s sleep. I rehearse parasite life-cycles, and WHO priorities, in my head. Gid and Adrian welcome us at 0800. I line my kit up in the study. Computer. Pen and paper. Coffee. Sandwiches. All my shit in a sock. With dread, I enter the boarding room before my ordeal starts. Suddenly, Esnart, Gid and Adrian’s housekeeper, breaks the spell of dread. Wild dogs. She shouts. Come quick. Keith and I rashly dash outside to get a better view. Four wild dogs trot across Gid and Adrians’ track. Heading off to hunt. Perhaps an omen? Hopefully not a portent. Keith quickly kisses me goodbye and wishes me good luck. He is off to track the dogs. Or off to clinic to see his first appointment. I’m not sure which.

The exam is tough. Four papers. Five and a half hours all told. Brief comfort breaks in between. I remember the challenging questions. Two of the papers hold no concern. I should make their grade. But the other two papers could go either way. A huge male elephant visited Gid’s house mid-way. So, whether I pass, or not, it is a good day by our definition. And of course, any day that contains wild dogs is outstanding. But I won’t know the final day’s grade until August. For now though, thanks to Adrian and Gid. Thanks to a stable internet and power supply. I’m still in the game.

Nine months down the line. My gestation is complete. My course is finished. I may, or may not, be a diplomat. The letters after my name remain unetched. Four extra initials wait patiently. Failure will hurt. But the course has stretched me. My competence has flourished. Keith has gained from yet another unmissable deal. The cobwebs removed from his grey cells. The new online edition of Diagnosis and Treatment is propagating in Zambian primary care. So even a failure is a resounding success. For now, I can relax a little and enjoy the rest of our time in the Valley. My only outstanding question to Keith – when can we book our next camp stay?

Photo of the week

Keith has a good day.

A nasty snake bite together with pneumonia

Show and tell. Our prevent stroke programme

4 wild dogs in our garden

An elephant comes calling during my exam