Back in the UK

Time has a habit of doing funny things... No wonder physicists and theoretical mathematicians can hypothesise that time is not really linear but actually curved and even wobbles a bit! (I would not be surprised if it also gets tied up in knots as well.)

I have been recovering really well from what was confirmed as Dengue fever - in fact would think I was back to whatever passes as normal - and have been meaning to post something to tell anyone who might have been following these musings that I am safely home. When time, which was behaving itself quite nicely, suddenly does a jump and I realise that I have been home for 6 weeks, (and somewhere along the line gained a year in age).

The journey out of Haiti was accomplished using the luxury of a coach belonging to the Carib Line - a company based in the Dominican Republic and connecting many of the major towns and cities over the island. And when I remember the taxis and tap-taps and motor-bikes seen on the roads on and around Cap-Haitien this is really luxurious - with air-conditioning (so effective that blankets are provided) and a means of constantly adjusting the tyre pressures to maintain a balanced (and presumably safer) driving experience.

(Quite how the mechanics of the system work is beyond me but I have attached a picture to try and explain it.)

The coach line operates daily, with the incoming service arriving in Cap Haitien late in the afternoon. The coach is locked away in a compound over night, and departing passengers are invited to assemble at 8.00am. Tickets are checked, baggage is tagged and loaded, and we are invited to board. The coach is designed to hold over 50 passengers, but it seems like we are less than 20. All of us, if we want it, can get a window seat, and on some signal (which wasn't able to discern) the coach leaves, and so I begin my journey back to the UK.

The coach had comfortable seats, the potential for playing DVDs, an on-board toilet, and a hostess to help negotiate the border crossings.

We arrived at the border in good time - about an hour driving, and parked on a field

of mud (currently dry). We were immediately surrounded by hawkers and beggars offering us drinks, sweets or shoe-cleaning. After walking to the passport-control and having our documents scrutinised, copied, stamped and returned we walked back to the coach and waited for about 30 minutes.

The border crossing is a single track road-bridge crossing a fast flowing river. The river can be crossed directly by the more intrepid, and as no-one seems to notice or intervene, and that includes the border guards from both countries and the United Nations Observers, it is an option to consider for the traveller lacking travel papers. The river is also used for laundry and bathing, though given the colour of the water it is hard to imagine a whiter-than-white finish.

There seems to be no signal, but lorries are crossing either direction but with no clear pattern or priority. But obviously at our turn, the coach started and we crossed from Haiti to the Dominican Republic... only to drive into a yard and be "invited" into a customs shed - with all our luggage. As we parked we were surrounded by many, many children and young adults desperate to carry our luggage (clearly expecting a fee) and it took a fair bit of doing to insist on carrying our own.

(Though I was surprised how tired I still felt after the Dengue - on arriving at Robyn's just 6 weeks earlier I had carried my bag and another with a rucksack on my back up to the second story flat; on leaving it was all I could do to drag my own case down.)

We all had to take our luggage into a barn-like hall where the bags were opened and rummaged through. Quite what was being looked for was not apparent. There are times when wearing a clerical collar has advantages: as the man searching my cases looked at my collar and barely opened the bags, and muttered something like trusting the clergy! And also I found that my immigration forms had been filled in for me, and I was listed as "Religioso" on the occupation section.

On returning to the coach we were all given a big filled-roll and a soft drink and some water. As my appetite was yet to return, I followed the lead of some others and offered my roll to one of the children encircling the bus - it was quickly grabbed and taken away.

Again following some mysterious signal the coach left and we drove to Santiago.

The scenery remaining remarkably constant, while the condition of the housing and roads gradually improved as we came to the city.

The Spanish speaking Dominican Republic has a more "Latin" feel to it than its more French-feeling sister Haiti.

Most of the towns and villages we drove through had their own churches and police buildings; but also cock-fighting pits - though there did not seem to be any contests as we passed.

Having arrived in Santiago there was a few minutes delay before Ruben met us. (Ruben was our driver on arrival 6 weeks earlier, and was back in the Dom Rep to have his truck fixed.)

We were escorted to our hotel and it was a pleasure to enjoy a hot shower and an air-conditioned room.

The hotel staff were very good, and the facilities excellent.

After an early supper - and yes my appetite was returning - we turned in. Ross and Kim had an early start - their transport to the airport came at 5.00am and it was quite emotional to see them go.

I had a further 24 hours to wait, the time was taken waiting for Fiona to arrive, and then a brief sightseeing tour on foot before trying to sleep

After seeing Fiona and Ruben leave for the journey into Haiti, it was my turn to take the shuttle to the airport.

And after the formalities - again involving a rummage through the case, and then as I was one of the random stop and search candidates a more thorough searching of all my luggage it was time to go.

And after 4 hours on the plane, with a sleeping 2 year old and his mother as my row companions, it was really great to arrive in New York and meet Lorraine.

Further musings...

Dr Bell's clinical suspicions that I had contracted Dengue Fever were confirmed by the blood test result that had been sent to Port-au-Prince. Although Dengue is known to be in Haiti Dr Bell claims this was the first case he had seen here, as it appears most Haitians have some form of natural immunity. (Lucky them!) Although I felt as though I had lost quite a lot in the 2 weeks I was unwell, I am also aware of how much I gained as well.

I lost about 1 stone 4 lbs in weight (that's just over 8kg), but that will do me no harm at all!

I also seem to have lost some time - it's hard to explain but the memories I have of the time are very hazy.

What is harder to accept is that I seem to have lost a lot of energy: on several occasions I thought I was on the mend, and got up, washed and dressed, fully expecting to go the hospital to try and work, only to find I couldn't eat any breakfast, and then couldn't even stay upright and had to lie down.

But what I have gained is priceless, and probably beyond words: without meaning to I have obviously been a worry to those at home and those in Haiti - but Robyn had put herself way over the top in my care. The prayers of the Haitian church, as well as those from home, New Zealand and even further afield have been very humbling. The love and care of Cilotte - a Haitian nurse (whose injection technique I can recommend) and of Bernadette - Robyn's cook/housekeeper were so gentle. Bernadette arrived one day and just started praying - in Creole - and Robyn said that she simply felt that is what Jesus wanted her to do.

A good friend from England wrote to me, she said: "There are more ways than one to be a gift. Vulnerability allows others, usually labelled 'the needy', to serve you. Will pray that God uses this reversal for good." I join my prayers to that one.

And now for some more musings and observations - which may find their way onto this blog before it's wound up.

Shopping in Cap Haitian is an exciting adventure. Most of our food is bought by Bernadette from the market. And the market has everything. Chickens are bought live - from vendors who have them on poles - and it is common to see them being brought home on the motorcycles, on what is a one-way journey for them. At least we can know our meat is fresh.

Fruit and vegetables are in abundance, and the avocados and papaya (with lime juice) was a breakfast treat. A lot of eggs are eaten here (well I'll be bound) and they are sold hard-boiled along the streets.

There was one supermarket which for convenience (not for price) we used to visit. It is called the Kokyage and visiting it was a mixed experience. There are not many supermarkets in the UK or NZ that have the benefit of an armed guard at the door. But this supermarket is not alone in this - all the banks, and many other businesses have it as well - guards toting what can only be described as pump-action shotguns but without the butt - more like enormous pistols.

And although I always spoke with the guard, and he became very friendly, it is sobering to imagine what might happen...

The Kokyage is well air-conditioned, which made it a welcome break on the walk from the hospital, but outside is surrounded by children begging. Some of whom are dressed and suited for the part - others look a little too well fed. Robyn says that Haitians are very good actors, and these kids certainly know how to turn on the pathos. "I'm hungry" "Give me a dollar" "Grand-gout" (which is Haitian for hungry). They have even followed us the half a mile or so home with hands outstretched. Robyn advised us not to give, and once we had this in mind, and it was recognised, we were left alone a little. I tried to turn the tables once - and said to them to give me a dollar - and they did give me a Haitian coin (quickly returned!)

Begging does seem to be a fact of life here. It was not uncommon - in fact usual - for people to approach us on the streets because we are white (blanc) and to ask for money. Sometimes it verged on the aggressive. And being rich, it doesn't come easy to be remined of it by people who really do have nothing. But at other times it is a feature of even those we are working with - asking if we can give them money for this project or that item of need. But if we start where do we end? And what is the right judgement - is a lamp-bulb for a projector more important than the work of a pastor? It was very tempting to remind the askers that we are only white, but we are not God. I havn't fully resolved that issue by any means.

Leaving the hospital was very moving.

I managed enough energy to go in for the last 2 days. On the last day I was helping the junior anaesthetist with some spinals, and the anaesthetic nurses had an exam. But they all came into the office having post-poned the exam for an hour and made some very generous gifts - for me and for Lorraine, and the request that I come back. So for someone who has felt so useless over the last 2 weeks it was an emotional moment.

I have various other musings and events, and more importantly people to describe - but that will be for later. I am writing this from the Dominican Republic - and have just bade farewell to Ross and Kim. Fiona arrives later today, and I fly to New York tomorrow.

Port-au-Prince

On January 12 at about 4.50 in the afternoon “the” earthquake hit Port-au-Prince in the south of Haiti.

Officialdom records over 300,000 people having been killed, and the figure is more likely to be in the region of 500,000. The majority being buried in mass graves just outside the city. As in any disaster there are the, perhaps, expected stories of heroism and humanity, but also the rather shabbier accounts of self-interest and human exploitation.

Jean-Claude, Robyn and I flew to Port-au-Prince on a Saturday morning, as ostensibly this was the reason for our being in Haiti in the first place. The domestic and international terminal at Cap Haitien Airport is about 30 minutes from the centre of the city, and to get there involves negotiating the usual traffic obstacles – potholes, other drivers, pedestrians, lorries, tap-taps and a mass of motorcycles. We cross over the river, and the bridge is slowly returning to being a major trading area, as the memory of the earthquake slowly fades and with it the fear of a local recurrence.

At the airport our hand-luggage is x-rayed in common with anywhere else in the world, but the loud “beep” generated as we walked through the scanner seemed to generate scant interest.

Waiting in the “departure” area were several nuns – although Roman their precise orders were not obvious; an Episcopal Bishop and assorted other travellers. Flights were going to Port-au-Prince, The Turks and Caicos, and the Dominican Republic. Our plane could seat about 25, and was piloted by 2 pilots from the Dominican Republic. The flight took about 30 minutes, and we had clear views over the Haitian country, and it appears very green, and largely unpopulated.

Port-au-Prince from the air is at once much bigger than Cap Haitien, and it takes a while for the evidence of the earthquake to become apparent.

We are met by Spentz, who with his family have lived in Port for the last 8 years. He is a business man, and is clearly doing very well. He drove us around the city, and included areas of all degrees of prosperity, as nowhere was exempted from the damage. As he drove it was the almost casual comments that were the most disturbing:

“this was a school – 1300 children were killed here”

“just here a girl was saved after having her legs amputated, but the remaining 12 members of the family all died.”

“this was a bank – all the employees got out of the earthquake, but were killed by a gas explosion”

“on the day after the earthquake you couldn’t walk or drive down this street because of the masses of bodies lying on the road.”

All over the city there are piles and piles of rubble, a very little bit of salvage is being attempted – in the whole of the city we saw only one bull-dozer. There are a lot of tents, and rows and rows of “porta-loos” many of which are just outside the presidential palace. In the more prosperous areas there are more concerted attempts at salvage, but still people are living in tents in the garden.

Spentz was in his car when the earthquake struck – and tried to get out of it, but was not able. His children were at home with his sister, and all of them were unharmed. During the first night there were stories of extreme courage and acts of selflessness – whole communities working together to get people out, and when it was too dark and too late, there breaking out spontaneous services of prayer and hymn singing. But there are darker aspects too – the daughter of one of Robyn’s friends was trapped with a friend. The friend was freed, but because there wasn’t enough money to pay the extracting team her friend was left. Thousands of Haitian dollars exchanged hands in the immediate aftermath of the event.

Spentz was able to voice some of his concerns – and although he is a long way from being a politician it is people like him who are needed for the country – people who can stand back, and look away from self-interest, people who can recognise the faults and lessons to be learned from other countries, and who have a passion for the nation. Interestingly he is increasingly convinced for the need for very firm government – even the possibility of a dictatorship – to start the country back onto the long road of economic and social reform.

If we looked beyond the obvious signs of building destruction, it was very odd to see signs of “normal” life going on as before. On every street there were markets and stalls, as people try to eke out a living. Stalls as varied as sweets, second hand clothes, new suits, and car parts literally in front of piles of rubble the height of a single story building.

It became mind-numbing after a couple of hours, and the return flight became increasingly attractive. I think visiting the area was very important, if somewhat unpleasant, and even verging on the voyeuristic. But perhaps the most disturbing aspect of the visit was watching the reaction of Haitians back in Cap Haitien as they looked at the photographs we had taken: despite having lived with the reality of the events for the last 6 months, seeing them in silent tears was just too much.

From giving to receiving...

When I had first begun to grasp the reality behind the vision/plan that Robyn had for this mission - to be a "Gift" from the church to the people of Cap Hatien, it really hit home, and made what we were doing - or for most of the time trying to do - make sense. So to find myself unable to be that "gift" for several days has been really hard, as well as the physically reality of being knocked right off my feet.

For the best of intentions this entry is an intensely personal one - as I haven't really been able to experience anyone else's world for the last few days.

With hindsight I think I had been feeling unwell for a couple of days - low grade headache, a bit dizzy, not much appetite. On the Wednesday it had been quiet in theatre, and so we had finished early, and we had arranged to go out for a meal with 8 of Robyn's Haitian friends to a local restaurant.

As we were walking to the place I remember thinking quite clearly how I must be adapting to the heat situation because I had stopped sweating, and in fact was feeling a little cold - I kept getting covered in goose-bumps.

(The little girl pictured is Jamily - oldest daughter of JP and Pauline who came to eat with us that night.)

That night was a rather rough one - I shivered and shivered, don't think it was quite a rigor; was dry retching a few times, then slept for a couple of hours, waking up dripping with sweat, and feeling as weak as a kitten.

I cried off work, and eventually went for a blood test at one of the private laboratories that flourish in the town. Robyn suggested testing for malaria, typhoid and a full blood count. She found a thermometer and my temperature was 39.7c (103f). As I was feeling worse all the time she took me to her doctor - who very kindly interrupted the World Cup to see me (and believe me the World Cup is taken very seriously over here.)

Dr Yvan Bell is Haitian, and very gentle and caring. He fully examined me, ordered samples (you can guess) and some more blood tests.

He wondered about Dengue Fever - because I did have some odd little red spots that I thought were insect related.

The test results were inconclusive on every front:

• I had been assiduous in taking anti-malarials, so if it was malaria the parasite might not have shown up;
• there is no specific test for Dengue fever (so I understand)
• and the samples were negative for Shigella, Amoeba, Giardia or Salmonella.

However I was feeling even worse - dry retching every few minutes, having very weird dreams and thoughts - weirder than usual. And by the next day Robyn insisted on a home visit. IV fluids next.

The system here is different to the UK - in case anyone has other ideas. Your friends and family go and buy the equipment and it is set up by you. Robyn duly appeared with a black bag containing some litres of IV fluid, giving sets and a cannula.

Given that we were me, a surgeon, and an ex-nurse there had to be a decision as to who was going to site the needle - I won!

The fluids and anti-emetics (anti-sickness) drugs began to ease things, and after a few days I am starting to feel slightly more normal again. Though I am still completely off any thought of food - which as most of you know is totally unlike me.

What has been so very humbling has been both the care given to me, and the love shown. It's not easy for me to receive, but I just had no choice. Robyn spent a lot of time just sitting with me. On the Saturday when she and the others went to Port-au-Prince Cillotte spent the whole day with me, just sitting in my bedroom reading, and when I was retching and retching she would rub my back and stomach, and sponge me down. She and Bernadette even gave me a bed-bath (very professionally - all modesty preserved, though by then I was past caring).

She also gave me the anti-emetic injections as often as needed.

Bernadette has been very caring too - coming in on Sunday so that I would not be by myself for any time. Such a sense of love and care being given by a people who have so little materially, it has been quite emotional.

I also found myself getting irrationally annoyed (and even angry) about little things - as I have said the water pump is intermittent here. And so to have to have someone go down to the well for water for washing, and for the toilet etc made me so cross when all it would take is for someone to fix the pump. Then I had to think of the tent cities in Port, or the shacks all along the roads, in everyone of which there might be someone just like me - feeling really ill, and no hope of water. Forgive me my self-pity Lord.

Saw Dr Bell again today who agrees that I am on the mend - just got to try and find some more energy. Hopefully next blog will be far less self-centred.

fevers...

Regretfully the blog is temporarily suspended due to a attack of either malaria or dengue fever. (Wikipedia has excellent accounts of both).

More will follow later except to say now that it revealed itself as a fever hovering around 40c and the most draining feelings of nausea and vomiting.

I could not be better looked after - room mate is Ross, who as a colo-rectal surgeon (but more likely as a father of 6 and grandfather of 6) is totally un-phased by all things connected to bodily functions.

And Robyn - once a nurse, always a nurse - who has been wonderful.

Many thanks for those who are praying for me - it not surprisingly makes a difference.

A view from the roof top...

The house in which we are living is tall and narrow. Enoch rents the house, and for a few weeks lived there with a friend. The friend now lives elsewhere, but as the rent is paid in advance - I think on an annual basis - Enoch has the house all to himself.

The previous tenant was a missionary with Medical Ambassadors - and who had made a lot of contacts with the locals, many of whom live close to, or on the street. In making these friendships she paid a price in material matters as she "lost" computers, money, books and more.

Just the other day there was a local boy knocking on the gate - he looked well-fed and clothed - and he said that he used to get peanut butter sandwiches from a white person who used to live here.

There are big iron gates or doors opening onto the street, and space for a car - or "machine" in Creole.

On the ground floor are some small rooms which are usually uninhabited - one of them even had a piano in it, though it had totally lost its tune! But at the moment Enoch is living in one of them. He effectively has an en-suite - for when the water is running.

The main "living area" in on the first floor - a balcony, a sitting/dining room (where the TV is) a kitchen adjoining the toilet/shower, and a sort of hallway with stairs going up and down: down to Enoch's sleeping area, and up to where Ross and I pass the night.

The upstairs room is big and open - big enough for 2 double beds (and a single bed for later), a computer desk and an outside balcony which is pictured. I have tried to show how high the balcony is, and also to what is behind us - a fairly steep cliff with some scrubby trees, and very often a number of goats. During the night the goats can sometimes be heard scrabbling up the cliffs by both their bleating and by the mini-landslides causes.

I say "mini" because just 2 doors away - and again pictured was a small primary school. A few days after the earthquake in January there was an unrelated tragedy at the school: a rock broke away from the cliff and landed on the school killing four of the pupils. Just one more tragedy amongst so much. The school is still closed and the buildings un-occupied.

The upstairs balcony has on it, as you might be able to make out - two water tanks, which are filled by the menacing pump (when it is working) and there is also an impressive looking satellite aerial - except that is useless in terms of TV picture, and the internet (which also uses it) is highly dependent on the weather.

It gives a glimpse of the sea, and is great for seeing the sunrise.

You might also be able to see piles of washing all over the place. Bernadette does our washing, and that of Robyn, Dale and Kim. And it is all hand-washed, then ironed (until just recently all the ironing was done by a charcoal iron - now it's electric).

The process is laborious, but done well. The water is drawn from the well, the clothes are wetted, soaped, scrubbed and rubbed on the concrete floor, rinsed, and rinsed again, vigorously wrung out (there is no "delicates" option) and brought up to dry on the balcony. This is a process repeated all over Haiti - except that the drying is just as likely to be done on the roof of the house, or on a hedge of cactus plants.

Many of the Haitians take a real pride in their appearance, and to see the smart. crisp uniforms on the school children, and the extent to which they dress up for church, it is hard to guess the difficult living conditions so many have to live in.

Bernadette is very good at her job, and the clothes service is fantastic.

bits and pieces

A couple of photos to try and support my claim that I have been in theatre most days! And that the sun-tan has come from incidental exposure rather than anything planned. I am pictured with Drs Nadine Compet and Jo-Ann Jean-Louis. They are both residents - Nadine has 2 years experience and Jo-Ann 2 weeks! In the other picture is Dr Carmel Leconte - chief Anaesthetist, and only permanent member of the anaesthetic staff. She originally came from Port-au-Prince, but after her marriage she came to the north of the country. Her husband is the head of Obstetrics and Gynaecology at St Justinien.

The case loads are very different from the UK - although there are General Surgery, Orthopaedics, Urology, Oral Surgery, Obstetrics and Gynaecology lists - the content of them is quite different, and the choice of surgery also very different.

There have been a lot of prostatectomies done here - but none have been done endoscopically, all open and (I think) transvesical in approach.

There have been a lot of fractured femurs - motor-bike, football, falling out of cars - but there is no X-ray facility in theatre, so they are all plated (rather than rodded) and I assume get a check x-ray some time later.

70% of the cases are done under spinal anaesthesia - including children as young as 12. The only failed spinal I have seen was one of mine - I did wonder why the anaesthetic nurse asked me to do the spinal as they are usually very keen on doing the job themselves. This patient was 17 years old, and coming for second skin graft to his foot - (he is epileptic and fell into a fire). All was going well as I sat him forward, cleaned his back, but as I started to feel for the space on his back to place the needle he virtually took off out of the table, and that was almost before I had got the needle out of the tray! Despite being almost too forcibly held, he was not going to sit still and I went quickly for a general anaesthetic.

Nadine is very keen to learn and one prostate list all the cases were done using epidural anaesthetic - as she was keen to learn that technique.

One thing I have discovered about teaching is that it has resurrected skills I may once have had but use rarely now. So keen was Nadine to do brachial plexus block, that she persuaded me to teach her site one for a prolonged tendon repair - and it was the only method of anaesthetic necessary, and it worked so well that then every possible time a nerve could be used the request has come to try it out. And so I have to quickly remember how to do (and then teach) femoral and sciatic nerve blocks. And I have been surprisingly impressed with how effective they can be.

Away from theatre, and back to home life. There had been a consistent run of power cuts from about 4.00am to 9.00am. This had been going on for about a week, and given that there had to be cuts, it wasn't a bad time to have them.

But then the pattern changed a little - and moved to midnight to 4.00 am and no power, which was rather more difficult chiefly because of no fans.

The reason we think is because of the World Cup. Haitians in general are passionate about football, and so the World Cup has been a big thing here. There are broadly speaking 2 big divisions: those who follow Brazil, and those who follow Argentina. And it is not uncommon to see the flags of the 2 countries on cars and motor-bikes, and also to see the team strip being worn. The change in power cuts we think is so that the morning matches can be seen.

When the matches are on - life is distinctly quieter. Today Brazil were playing Korea, and a number of the physio patients didn't turn up, and the theatre lists finished early!

But for us the match of the day was New Zealand's opening encounter with Slovakia. That was scheduled for 6.30am our time - which is fine as I generally get up at about 5.00am.

The television at Enoch's has seen better days. To turn it on or off requires a pen to be shoved into a hole (crude but effective), and the picture is pretty shaky and broken. It makes following the ball tricky, but possible - just. Ross improved the picture a little by using some surgical dressing plaster he had to secure the aerial slightly more firmly into its' socket.

We were eating our breakfast to the match commentary - given in Creole, and by 2 commentators who are also in Haiti, just watching the match as we are. Every now and then, the oral commentary is interrupted by a voice from the sponsors - Mattato Supermarket, urging us to shop there and nowhere else.

Just as it seemed Slovakia were to score - the power failed and we resorted to the internet, only to find that the ball was kept out by the NZ goalie.

Power was resumed after five minutes, and we had the misfortune to see NZ go a goal down, but then with seconds left - to equalise. Much shouting from the dining room in Enoch's house!

It seemed to make the day go quite well.

Two photos to finish with - the Episcopal church seen from the front;

and the interior of Robyn's church taken on a weekday. Most of the flowers have been removed for cleaning, but a few have been left out. This in no way gives a sense of the people who are there on a Sunday, nor either of the attendance during the week. I came in for a moments prayer, and all over the building there were individuals or couples either sitting quietly or reading the bible. Clearly in a country which has so very little in material and other resources there is a spiritual hunger that is being met.

Sundays and other thoughts...

Sundays are fast becoming my favourite day in Haiti. Which is a bit of a confession as on Sundays we generally don't go to the hospital, or look into theatre. The day starts early. Up before sunrise - at round about 4.30 am, shower or wash, depending on the water situation - further confessions: I usually pray for a shower! But without becoming too detailed it is amazing how little water it takes to wash body and hair. (And not wanting to waste the water - it goes into the toilet cistern.)

If I've remembered - and by now on Sunday three there should be no excuse - the coffee left in the fridge can be drunk iced, and we get dressed up for church. I stick to short-sleeved clerical shirt and long trousers with socks and shoes; though many Haitians will come with vest, shirt, tie, suit trousers and jacket, and highly polished black shoes. (How they keep them that way is beyond me - please note there is a lot of dust in Cap Haitien.)

We intend to get to church by 5.30 in order to get a seat in the main auditorium. The service is finished in just over 2 hours, and we tend to leave during the last hymn in order to get out before the major crush, and more importantly so that Robyn can get away without having to talk to nearly everyone! (It would be an exaggeration, but almost every step feels like it's accompanied by a shout of "Miss Ro, Miss Ro". Robyn is clearly much loved and her return has been noticed by many who have both missed her when she left last year, and those who want to know what she is going to do next... and not a few remind her that they said she would be back!!)

So it usually takes about 15 minutes to get back to the flat. And the final obstacle is the flight of stairs up: Sunday School is held on the floor below Robyn's flat, and climbing up is a feat of ingenuity as children and parents are both coming and going.

After a quick change we headed off to a local hotel for breakfast. The Roi Christoph - named after the infamous self proclaimed King who built the palace we visited yesterday, and who, we are told, also worked at a hotel on the same site before his emancipation and elevation to (or seizing of) the throne.

A great choice of eggs - soft boiled, scrambled, fried, sunnyside up, omelet, or poached; there is a selection of fruit - today was bananas ("fig" in Creole - not to be confused with "banana" which is the cooking banana - or plantain and tastes very like potato to me.) papaya, and mango with a lime juice topping; or there is spaghetti. Everything is accompanied by coffee and bread, and we ate well, in the warm, with breezes from the air and overhead fans, and the anticipation of a swim to follow. Ross and I swam, Dale read (or was it dozed) by the poolside, and it felt very relaxing.

A number of people - Haitians and foreigners - come just to swim, and make a family day of it. There were a few others in the pool, but it was hardly crowded. (Quite amusing when the enormous palm tree next to the pool decided to shed a branch which came down with a loud crashing sound and there was much scurrying away of the family playing around the trunk.)

Unlike the pool at the hotel last Sunday, this one, though older, has much clearer water, even if there is a liberal sprinkling of flowers and leaves on the surface - but they are all fresh and don't mar the enjoyment at all.

The hotel also has a wi-fi system, and a number of people have their laptops out and in use. But we have found the reception to be patchy, and this time didn't bring anything with us.

I got my shoes cleaned. Having asked what the usual rate was from some Haitian's who had just had their's cleaned, and seen that is what they paid, I approached the man. In my best Creole i asked the price, agreed on it and left my shoes. When they were returned - beautifully polished, amazingly the price had doubled! Again in my best Creole I declined to pay, reminded him of the quoted price and he backed down. Off course feeling very small by now I did then give a tip, as the service was cheap by any standard, and we in the developed world have such a higher standard of living.

After a leisurely time of it we had an appointment to keep: we had been invited to the home of Ruben and Jacqueline for a meal.

Ruben was our driver from Santiago to Hiati, and Jacqueline (known by many as "big momma" or "Jaa") his wife live about 30 minutes from the centre of Cap Haitien.

Ruben is a Baptist Pastor - looking after a country church with a number of satellite fellowships. The church is not big enough to support him financially, and so he works as an English and Spanish teacher to supplement things. Jaa is a registered nurse and works in the OMS Mission compound near to where they live.

Jaa, and later Ruben, have been some of Robyn's longest friends. Robyn and Jaa worked together at Vaudreill in Haiti, soon after Robyn got here, setting up a Nurse Training Scheme run by a Mission Society. Ruben was on the scene then - with tailor training and a call to the ministry, he and Jaa were engaged. For their wedding Robyn was their "marenne" - which sounds a bit like a mixture of chief-bridesmaid, god-mother, mentor, supporter, and general all-round supporter to the couple. (Most marriages in Haiti have one, but it is both a role and term that is new to me.)

When Ruben and Jaa had their only son - Rudolph, but known as Babe - from the age of 5 he lived with Robyn in Cap Haitien in order to go to school. Jaa says that Robyn is a second mother to him. (This something Robyn has done for many, many children, and even now we are still being introduced to one of her "boys" - I can remember Babe, Dodley, Pousch - or her "girls" - Santia, Sandra, Kethia, Ruth-Marnie... to name but a few.)

Babe now lives in the USA and is a nurse himself.

Ruben and Jaa have been building their house for the last 17 years - and have lived in it for about 15 of those. It is off the main road, up a hill, and from nearby there are spectacular views of the surrounding plain, with the Citadel (above Sans Souci near Millot) in the distant background.

In the photo the Citadel can just be seen on the ridge just left of centre on a peak.

The house is habitable, but still needs to be finished. It is big, airy and cool - helped by fans. It is surrounded by a big wall with iron gates. There is a fantastic covered patio area where I was able to doze for a few minutes.

There is a charcoal kitchen, and a great meal had been prepared. We were offered salad (washed in treated water!), chicken, pasta, potatoes, deep-fried savoury rice balls, beans and rice, washed down with home-made Lemon and Grenadine juice.

Only three of us from the "team" were able to go out to their house, and the table had been set for three.

It took great persuasion to get Jaa to eat with us. (Ruben was still out working in the churches - this is Sunday!) And although Jaa and Ruben have a couple of church girls living with them now, they wouldn't eat with us either.

We saw the puppies at the back - off-spring from "Wolf" the dog Robyn gave to Ruben and Jaa a few years ago. Wolf's brother "Doggie" now lives with Cilotte - another great friend of Robyn.

(There are a lot of dogs on the streets of Cap Hatien - and they are clearly all related! If you ask a child to draw a generic picture of a dog it would probably look like a Haiten one! The dog in the Simpsons cartoon series

is also clearly a close relative!)

Robyn has kept cats - the last one was a good ratter, so Robyn kept him, until the neighbours killed it, and (I kid you not) ate it.

We drove home dodging the usual frenetic driving of the motorcycles and tap-taps. On the front of just a few were emblazoned - "Psaume 136", "Cadeau Dieu", "Magnificat", and "Jezu Merci", and that combined with "Jehovah Raphe Construction Materiaux" and "Shekinah automobile parts" we needed little reminding of the presence of religion here!

Excursions to the country

(Have not been able to sort out the photos properly - hope they make some sense...)

Haitians, it would seem, have a special liking for Psalm 91. A few days after our arrival in Cap Haitien we had cause to pray (as a group) for a little girl and her family. When I say” we”, at that time it was Robyn, Dale and me, along with Ma Theo (elderly widow who shares a house with Robyn – and who is a Roman Catholic) and Bernadette (house-keeper and cook, and member of the Baptist Church), along with the family involved. Robyn started her prayer by reading Psalm 91 in a standard French version, and to my surprise, Ma Theo sank to her knees and joined in, and so did Bernadette, and they said it from memory.

Psalm 91 with its’ promises of safety and protection in the presence of God; a God who will cover us with his feathers, and under whose wings we will find refuge...

Tap-taps are seen all over Haiti – they are a vehicle which has a close resemblance to an estate car and a minibus and yet it is actually neither and still seems capable of carrying up to 20 people (or more if the cab roof is used). They are frequently emblazoned with religious sentiment and words of hope – or are they simply prayers for safety?

Psalm 91 was the emblem emblazoned on the one in front of us as we weaved and ducked our way out of Cap Haitien en route to Millot and the ruined palace of Sans Souci – meaning “Without Worry”, or perhaps even “No Worries”...

We had a day off – though not so lucky for the two physios who had to work in the morning for the benefit of three visiting American Rehabilitation Physicians. But at about 2.00pm we all (Robyn in the driving seat, Ross, Dale, Kim and me) set off in a borrowed car for this town which lies about an hour from Cap Haitien.

The roads are terrible, and although the tarmac ones are full of enormous potholes, much of the way is not tarmac at all. We were forced to stop by a very energetic man waving a red flag with an intensity or enthusiasm rarely seen in the UK, as there was some road works going on. A very pleasant French man told us that his firm had been contracted to level and repair the road in three places along the route – but it didn’t seem that these three places were connected in any place.

Anyway after about a 10 minute wait we were off again, except that we weren’t... As we drove off, admittedly over a lot of cut up tarmac and other rubble, there was a lot of unpleasant

grinding noises, and the car lost all power. So now we were stuck in the middle of some roadworks – with half the road only in use, cars coming towards us, and cars stuck behind us. We got out, and pushed the car forward for a few yards out of the immediate bottleneck and it quickly became apparent what was wrong – the drive shaft had disconnected at the universal joint. (I’m sure those mechanically minded will excuse me if I use the wrong term, and those not mechanically minded will recognise that the car would not go, and that something was hanging down from under it!)

I have been stranded in foreign countries before because of vehicles failing, and yet still I am not used to it. And being a natural pessimist wondered how we could deal with this problem. Did pray – but only half-heartedly – and at that point received a text from Lorraine hoping that I was enjoying my day off! It didn’t help matters to know that England were failing to beat the Americans at football at that very moment. But Robyn rang the owner of the car, who arranged to come out with some of his friends to fix it for us. A passing lorry driver had stopped and seen what was the matter, and could tell James exactly what he needed to fix the problem – I think it may have been little more than 4 nuts and bolts and some spanners, certainly no jack was involved.

So we had about an hour in the warmth – there was a breeze and so not too hot, watching and being watched by a selection of villagers, passers-by on foot, bike, motorcycle and Tap-tap, by

horses, mules, donkeys and chickens. There was even one enthusiastic jogger. Someone even volunteered the final result of the England match. We watched the road being graded and cleared and then sprayed with water to keep the dust down – very obligingly he turned off the hose as he past us, but it was fun to see the children running to keep up with the truck and its’ refreshing fountains.

And then Francois, Peter and James all arrived in an open top truck – along with the necessary equipment and an obligatory hammer. Their sentiments were “Your problem is our problem Miss Ro”. Francois and Peter got on with repairing the car, while James took us the remaining 15 minutes to complete our journey – this time on the back of a truck, dusty but fantastically refreshing.

Millot contains a hospital which has a better name than the one at St Justinien, and from all accounts is better equipped and set up to perform more complex surgery. It is a Roman Catholic hospital, and since the earthquake has been set up with a number of tents, or marquees, to act as wards and to provide accommodation for families. But we weren’t stopping there – our destination was Sans Souci - the palace (one of the 8 palaces) built by Henri-Christoph – the first “King” of independent Haiti. The Palace is next to a big domed church, and is near to a citadel – which was also built at the time in fear that the French would return to reclaim Haiti. More can be read about Henri-Christoph on Wikipedia, save to say he was born in Grenada, was a slave, and rose to serve in the French Army and proclaimed himself King. He tragically took his own life in 1820 at the age of 53 – fearing a coup. But the palace he built was at the time very spectacular – covered in mirrors and with a cannon at every window. The building was largely destroyed in the earthquake of 1843, but significant portions remain. Our guide was Charlo – and he spoke understandable, if quaint English: “this is the kitchen guard for if someone want to poison the feed”...

Our journey back was fantastic, as Kim and I opted for the open-top truck all the way home, which included the briefest wetting of sea-spray as we passed the coast – wind and waves stirring up the water. The journey finished with us teaching Peter to count in English – we had reached 35 when Enoch’s house was reached.

Bernadette had made some fantastic soup, and for the first time for a few day I was actually hungry. Church tomorrow – Enoch’s choir is leading some of the worship for one of the Harvest Festivals, and we have been warned that it will be very crowded... Pretty sure I will sleep tonight whatever the weather or power situation.

Churches...

We have come to Haiti as the guests of the Evangelical Church of Haiti. It was Robyn's dream, vision or inspiration (call it what you like) for the church to provide a gift of physiotherapists, surgeons and anaesthetists to the people of Cap Haitien in general, and the hospital of St Justinien in particular. And as such the group is necessarily Christian.

Personally I had come with the intention of being entirely "medical" - in that I did not choose to preach or be involved in church work here other than as a member. In fact before coming I had briefly tried to contact the Anglican (or Episcopalian) Bishop to tell him I was coming, but could only receive an "out of office" reply to my e-mail.

However on my first day working in the hospital I was contacted by Pere Noe - Father Noah - of the Episcopal Church who was looking forward to meeting me, and so at 8.00am the next day Robyn and I went to his church.

He is a youngish man (I find in many cases I cannot accurately guess the Haitian's ages - usually putting them several years below their actual years: is this because they are naturally young looking? Or is it to do with a lack of smoking?) But my guess is that Noe must be in his 40s. He is married with three daughters and speaks very good English. Following the earthquake, and largely because of fear of further ones affecting Cap Haitien, his wife and daughters moved to the United States and he sees them only occasionally - but he assures me he speaks with them most days. The Episcopal church is very near to where Robyn lives, and the cross on the top can be seen from the balcony. The church is next to a secondary school which Pere Noe has built up in his time here.

I was impressed that we were stopped as we tried go in by a security guard - it is not just the foreigners who are targets for kidnappers - and we were escorted to Pere Noe's office.

Pere Noe is also responsible for a Technical College offering courses in mechanics, electronics and other fields.

As well as being the Parish Priest in Cap Haitien, Noe is also the Archdeacon for the area and looks after a number of churches up to three hours drive away. The Episcopal church is not big in Haiti and so there are not enough priests to cover the whole area.

I was invited to come to church, and accepted, being able to come on the second Sunday - there being two morning services at 6.30 and 8.30am, I would be able to go the Robyn's church at 6.00, and then make an early exit and go to the Anglicans afterwards.

That second Sunday dawned early - and by 5.15 am we were being driven to Robyn's in time for the 6.00 start.

If anything it seemed more crowded than the previous week - but we were able to be seated near enough to the front for Ross to be welcomed this time.

Two different worship groups led the singing - one of them being an all male choir with some

very striking melodies and harmonies. Again the bible was honoured as we all stood to hear the readings, and as before the second one from the New Testament was read by the reader and

congregation by alternate verses.

Pastor Megy chose to preach from Numbers 5. 11-31; which is a passage I have never heard preached from before! Please read it for yourself to see what I mean.

The service was to be followed by communion - which is taken very seriously amongst the church, and follows a Presbyterian tradition of completing communion cards, and being made

ready to come. And as we arrived there was a long queue of people wanting to return their cards before the service began.

As I had a further church to go to, I chose to leave just before the communion part of the service. And was later very touched to hear that Pastor Megy had told the congregation where I was going and that he also prayed for me going there.

And as I made my way out it struck me just how well attended the church was. It took me 10 minutes or more to leave, just because of the numbers of the people. They were sitting and standing on the stairs, and some were going and some were coming, and although eventually the door came into view, it took a long time to reach it. And for me who is not good in confined places, it took a bit of self-control not to feel some panic at not being able to get out! Sadly I found myself starting to ruminate on what might happen if someone fell over on the stairs, or even if an

earthquake was felt.....

Outside the church the crowds dispersed, and dodging the roadworks I made the short distance

to The Episcopal Church.

I am slightly ashamed to admit a certain sense of relief on entering the building: partly because it was familiar - with a central altar, a smell of incense and a choir/music group practising. But also was it because, like quite a few Anglican churches, there were not many of the congregation there!

Certainly in my own church in York, with 5 minutes to go before the service starts the building can feel half empty, and suddenly everyone arrives... To a similar degree the same happened here, and by the time came for the start about 180 people were there. But initially not to feel so

pressed in was a relief.

Pere Noe invited me to robe with him, and to con-celebrate the Mass. I was slightly anxious about the heat, and wearing my clothes and wearing a cassock alb and stole - but was happy to accept the invitation.

The Mass was in Creole - but I was assigned a service order and a hymn book. Pere Noe preached - following the Revised Common Lectionary, but I fear most of his points were above

my grasp of the language.

We then moved to the peace - and it was very emotional for me to move through the congregation sharing peace, and to meet up with colleagues from the hospital too.

The con-celebration went well, my knowledge of the liturgy combining with a basic understanding of French/Creole made me feel I could say the words with integrity.

Administration was unexpected - I held the chalice, walked next to Noe who had the bread, and as we came to people he gave me a wafer to intinct and then to give to the communicants. It seems like anyone who could walk received the elements.

At the end of the administration Noe handed me an oil stock and said that some of the congregation might come forward for anointing: and they all did. I resorted to the English language this time, having at the administration of communion tried to mumble what I thought the French/Creole for the "body and blood of Christ" was, grateful for a God who is above every race, nation and tongue, and all were anointed in the name of the Father, Son and Holy Spirit, with the prayer that Jesus Christ might be real to them and to fill them with his Holy Spirit. When this was finished - and it took some time - I asked Noe to anoint me, and I anointed him.

(I need not have worried about the heat - and on this score the Episcopal Church wins hands

down - the fans were blowing a near gale, and with no power cut, it was almost balmy!)

After worship, and by now ready for breakfast, it was a joy to come to the Robyn's home and

partake of a brunch made up of pumpkin soup (more of a stew really) and coffee.

On both Sundays in the afternoon we have adjourned to a hotel for rest and a swim. And even though I am not much of a swimmer there is something wonderful about immersing ourselves in the cool water - even if there is a degree of soupiness to the water quality.

This Sunday we went to Mont Joli hotel - which is expensive and relatively luxurious, but was also the host to a local Christian Missionary Radio Station which was holding it's 60th Year anniversary of existence. The Christian world being as small as it is meant that Robyn knew a lot of those attending - including a number who had flown back from the USA and Canada just for the event, and so she was in the position of having to speak to many people all dressed in their Sunday best, while she (and the other three of us) were all in our swimming gear! Photos best not wanted here!

Torches and other things

This is going to sound like a piece of unmitigated advertising, but one of the best purchases I made for coming to Haiti was a Maglight pen torch!

We had been warned about the inevitability of power-cuts, but I wasn’t really sure what that would mean in practice. Robyn and some of the Haitians spoke darkly about periods of power-cuts lasting 4 weeks, but for my first 3 or 4 days there were none...

Then one morning I woke at 4.00am and realised that it was because of someone moving about outside and talking. And it took a moment to realise that I could hear them talking because the fan wasn’t working. The fan noise had become for me a bit like the background drone of a engine, or a “white-noise” masker that you can get to detract from the irritation of tinnitus. And so consequently I was spared from a lot of the normal noise that accompanies a house and street life. But with a power cut that distraction had gone, and I was aware of a lot more going on around me, and also a lot more aware of the heat! That time the power cut was for about an hour, and the relief was great when the motor re-started. But until the sun rises at about 5.05am – (yes, I have seen it rise) unless you are well aware of the surroundings a torch is a very handy device.

One evening I was using the torch to project patterns onto the wall – as the focus changes so do the patterns - and I was subjected to some good-natured teasing. I think the phrase “boys and their toys” was mentioned. The next day and the torch started to come into it’s own – in theatre one of the power-cuts happened while a patient in the lithotomy position, (the operation was for haemorrhoids) and the surgeon was literally working in the dark... Until that is the Maglight pen torch came into its own. (Not sure if it the sort of use likely to find its way into an advertising schedule) – but one added factor was that this patient was HIV positive, and it does not take much imagination to see how working in the dark with needles and scalpels puts the surgeon at significantly increased risk...

Also that night we were eating at a friend’s house – on the lower floor, and there was a power-cut – and the only torch was the same one (it had been at a long way away from the operation site) and verily it was a lamp unto our spoons, and a light upon our food....

And please try to remember the state of the streets, and the size of the manholes, and then you too can give thanks for a Maglight pen torch!

(The teasing about men and their toys was more than mitigated by the gift of some batteries for when the current ones expire.)

The Power cuts have got worse the longer we have been here: there seems to be a pattern developing: occasional loss during the day, but a fairly consistent stopping (all over Cap Haitien) at about 4.00am, for about 5 hours. This is the coolest part of the day, and so missing the fan is not such a problem. Many of the hotels – there are a few – have their own generators, and listening to them start up is sickening as we move as slowly and gently as we can to avoid over-heating.

The hospital clearly also has a generator – but it is not as reliable as it might be. Frequently during cases the lights are flickering on and off with the intensity of a fair-ground, and would be a risk factor for anyone with stroboscopic induced epilepsy. But it’s not only the lights: I am sure that the constant power surges are what damages the air-conditioning, and so after the first two or three cuts of the day the air-con functions only as a fan, circulating increasingly hot air. Ross was operating during one particularly florid bout of cuts and discovered that the diathermy machine had to be re-configured after every power drop – time consuming and irritating to say the least.

I am surprised how good-natured most people remain despite the conditions and equipment. There are very few raised voices in temper, and generally everything gets done.

As a post-script to previous postings: I was surprised to be told how few people drink the tap water when they have, and made a few more detailed enquiries, and in fact many Haitians do drink the tap water... Is there a surprise that during my first week here I was involved in the staged closure of an abdomen in a 10 year old boy: his original diagnosis was peritonitis secondary to typhoid causing a perforation of the large bowel?

Also on the Consent Form front: some patients, (so far only urology patients) do have a consent form in their notes, where the patient has consented to “Le procedure”....

Finally a couple of pictures to lighten the literary load: Ross involved in closing the originally typhoid-induced perforation (It was the first case of typhoid-induced perforation he had seen as well).

And the second – taken from a distance at the back of the surgical ward: a cleaner is filling her bucket from a well, and the container that she threw down into the well to collect the water is tied to pieces of suction tubing and IV giving sets!

PS As I am waiting for the pictures to upload the water in the tank has run out, and the electric pump has finally failed. It makes the Old Testament account of Abraham's servant being given water by Rebeccah (Genesis 24) and Moses giving water to Zipporah (Exodus 2) and Jesus by Jacob's Well (John 4) all the more credible...

More Hospital Musings

Being based in the Operating Theatres has meant I have less to do with the Hospital Wards than Dale or Ross. But having been to the surgical ward early in my time here it made a big impression on me. And obviously a deep one because Dale confided she was not looking forward to her first visit... Then having been on, she thought it was even worse than she had been expecting. But how much is bad – in any situation or circumstance? And how much is simply relatively bad? What is always unacceptable? And what is acceptable because of culture or condition?

Many, many of the Haitians are very moral, and hold high standards. For example at many of the churches it is not acceptable for women to wear short skirts or tight trousers, and Pastor Megy – from pulpit or more directly – has been known to ask people to sit “decently” to retain modesty. But in the theatre I was immediately struck by how patients arriving in theatre would often lie naked on the operating table, before anything was done to them, and on occasions for quite some time. But there was little sense of embarrassment or humiliation. And it is not limited to the theatre – I have heard about private out-patient clinics where patients are told to take off all their clothes and lie down until the doctor comes in – again with no sheet to cover them while waiting. But in theatre this is something I find uncomfortable – and whether interfering, or imposing my standards, I generally try to ensure patients are covered as much as possible...

The word that, for me, best describes the wards is “crowded”. Crowded with patients, beds, relatives and doctors. There are no screens, and on the surgical wards both men and women occupy adjacent beds. Relatives are essential because they provide the food, help with patient washing and dressing – both clothes and wounds, and in certain cases they buy the medicines.

They very often sleep under or beside the bed the patient occupies, but on the floor. The wards are roofed and walled with window spaces, but they have no glass – as it is not necessary because of the heat.

The surgical ward has a central courtyard which is used for treatment and washing – clothes and patients, and is usually buzzing with activity.

Patients are brought to theatre either by wheelchair or trolley – depending on the case, and the (by now expected) rules of driving apply with an interplay of artistry, ingenuity, goodwill and good luck ensuring not too many toes are run over or fractures bumped! Most patients arrive in theatre with an IV cannula in place, which is good as the heat is good at dehydrating. However consent forms are not used – just being on the trolley and in theatre is presumed as having given consent; and neither are any of the patients fixed with a name band, which is a big departure from the normal and expected practice in both the UK and New Zealand. (And for those who know what I mean – there is no pre-list “huddle”, and neither has the WHO check list made an appearance!)

On Sunday night (I was not involved in attack or treatment!) a local doctor was shot – either as part of an attempted kidnapping or as part of a robbery. He was in theatre for about three hours, and although he survived, he is currently paralysed from the waist down. He was going to be sent to the neighbouring Dominican Republic for further assessment and treatment. He still has the bullet in him. When I went to see him there were members of the UN sponsored Police Force – a Frenchman and an Egyptian, both in their local uniform, joining the general melee around his bed. They were wanting the bullet for forensic analysis, but realistically the assailants are unlikely to be found.

Dr Carmel Leconte had come in to anaesthetise the case, and was telling me today how she, who lives a few miles outside the city, feels unsafe if she is not home by 6.00pm, and when being driven to the hospital to attend to the case at 9.00pm and back at past midnight (by ambulance) she felt very nervous.

We were given strict instructions by Robyn not to venture out alone today– as she had to go to the Dominican Republic to collect the next member of the party – Kim (Physiotherapist) who is due in tomorrow.

On Mondays the theatre is given over to cleaning and emergencies only. While a minor emergency did materialise it was not possible to do anything because (again) the hospital had run out of oxygen. As it happened there was some teaching planned for the new interns and Anaesthetic nurses – and I joined in listening to a well prepared talk on Anaesthesia and Hypertension – delivered in French.

I quite enjoy regional anaesthetic techniques, and am waiting for the opportunity to teach interscalene nerve blocks, and if Dr Nadine is as competent and adept with them as she was with the epidural it will not be long before she is doing them unassisted. One big advantage with patients here is that generally they are not overweight – which makes every anaesthetic technique easier, and secondly (and to me I find this quite surprising) smoking is quite unusual.

Whereas tobacco use seems to be quite high in parts of Africa and Asia, it has a low prevalence here.

I am in two minds about photos to illustrate the wards: in general most Haitians love having their photo taken, but I wonder if it might be infringing privacy a bit too much to take some from the hospital wards. I will just try and add one from theatre – of Nadine after a successful epidural (taken with the patient’s consent!)

Water, water everywhere, yet not a drop to drink...

Having been out of the UK for 15 days now - not that I'm counting you know - one of the things I have very clearly been taking for granted in England, and very much miss over here, is the water system. Water is piped to many houses in Haiti, (though not all by any means) and it is pumped from wells. There are no de-salination plants, and none are needed, as despite the heat, there is sufficient rainfall to keep the wells supplied. But the water that comes from the wells and is plumbed to the houses is not

safe to drink. When I asked why, the matter of fact answer is that there is "far too much faecal contamination". And I don't think this view is held only by the whites - or "blancs" as we are known in Creole. I have yet to see a Haitian drink from the taps, and many use water sterilising tablets to treat the water for washing dishes. (I wish I knew this before deciding to brush my teeth using tap water.... but to date no bouts of vomiting... yet!)

Drinking water is bought in plastic bottles, larger 10 litre containers, and some rather strange sachets. (Which I've photo'd, and placed my phone alongside for a size reference.) These sachets contain about a mug of water and can be bought in supermarkets, from the side of the street, or from any number of the traders who walk the city with a bucket or similar (often on their head) which contains any number to buy. I have seen them on the side at church, and the streets are littered with empty sachets. Having been bought, a corner is bitten off (perhaps another version of gastro-intestinal Russian Roulette?) and the water is there. Robyn keeps a number in her freezer, and it is quite pleasant to get one completely frozen and spend a 15 minute (or longer) spell consuming it. The fun we can have here!!

But water is also more than just for drinking. Every day for me starts with a wash down - shower is perhaps too grand a word for it. But the water for most houses has to be pumped up to the tanks, and for many (and that includes both the houses I have stayed in here) it is not done automatically. It is such a disappointing feeling to be standing in the shower area - on a couple of occasions having managed to soap myself, only then to find the water has run out...

There is often a large bucket in the bathroom, and I managed to find enough water to wash the soap off.

I'm amazed how little water I can use when necessary. And off course the water also flushes the toilet - usually... Again it's a good idea to keep

the water tank topped up!

The plumbing is very often tortuous in design, and precarious in practice. White plastic pipes at strange angles and connected (more or less) to bits of hosing. At Enoch's house there is the added

excitement of the water pump - pictured.

The pump itself is on the ground, and is electrically run. The operating switch looks more like something that should be attached to the Electric Chair, and is connected to the pump by the white wire - hanging loose of course. When the switch is thrown there is a significant shower of sparks,a groaning and whirring, and hopefully water is pumped into the tank. However it is clearly a big drain on power, as the fuse-box on another wall gets incredibly hot very quickly... So to try and keep the water levels satisfactory I try and use the pump for a series of short bursts.

Our laundry is done by hand by Bernadette, who has been a cook and cleaner for Robyn for many years. Bernadette has 7 children: her first husband died after the first 2 were born, and her second husband is often away leaving her with the children.

(Ruth, her youngest, now 12, is delightful, and always presents her face for a kiss whenever she meets us.) Bernadette comes to either Robyn's or now Enoch's house - which we are using for a base - on a daily basis, and cooks breakfast and very often an evening meal. She is a good cook, and more about the food later. But she also does the washing, and ironing - everything wonderfully cleaned, ironed and folded by the end of the day. And no washing machine or ironing board in either house.

But we have a luxurious standard of living compared to most.

On Saturday we walked about half a mile along a dirt track near the coast. We past fortifications from the time of the French in the 18th Century, including walls 2 metres thick and cannons lying on the ground. And then surprisingly at the end of the road was a (comparatively) luxurious hotel. Modern with en-suite bathrooms (probably no hot tap). We stayed for drink and gazed out to sea watching the fishing boats tacking out from the shoreline. Under the canopy, and with view, drink and surroundings it was very pleasant. But we had walked past shacks made of wood, with corrugated iron roofs, no windows and no plumbing at all. Washing hanging out to dry on the cactus plants, makeshift wires and roof edges. On our return one of the locals was having his daily wash: out on the roadside, using a bucket dropped down into a well, pulled up and poured over himself. It made using the electric switch at Enoch's seem like a privilege after all.