We chose Zambia as we wanted to go to an English-speaking, sub-Saharan African country, which was relatively stable and safe, which neither of us had been before; this only left Botswana, Namibia and Zambia! We felt that Zambia was right for us on reading a little more about the countries and so wrote to a couple of hospitals which were listed in "The Medic's Guide to Electives Around the World" and suggested by the "HealthServe" website and staff.

Surrounding Area and Climate

Chikankata is located at the end of a 31 kilometre unfinished road, which is a further ninety kilometres from the capital city, Lusaka. The majority of the hilly land surrounding the hospital is used as farmland for the many nearby villages. The landscape is very beautiful and ideal for walking in, with spectacular views spanning all the way to the Zambezi River.

The climate in Zambia is substantially different to our own. The period December to April (when we were there) is the rainy season, with spectacular thunderstorms causing river levels to rapidly rise and often flooding roads, making rural travel virtually impossible. May to September is the cooler dry period; while September to Early December is the hot season. During this time temperatures can soar rapidly and water shortage can be a problem for farmers' fields in the run up to the rainy season.

Accommodation, Food and Water

We were provided with accommodation at Chikankata, within the mission, which was basic but satisfactory. There are six rooms available for visiting students who come from all over the world to gain experience tropical medicine and nursing. Each room has an en-suite basin and shower, though some showers were more effective than others! The kitchen is well equipped but problems do arise due to the frequent power cuts, and infestation with vermin is a major problem.

There is a market and a few basic shops just outside the mission, which supply some tinned food, fresh eggs, vegetables, bread and various other bits and bobs. The nearest supermarket is in Mazabuka, approximately 75km away). A shopping trip by public transport (relatively regular minibuses from the market at Chikankata) takes an entire day, best kept for weekends!

The Zambian government has supplied a number of boreholes across the country, mostly operated by hand pumps. Chikankata recommends boiling boreholes water prior to drinking it, but this rarely seems to happen. The majority of people drink either un-boiled stream or borehole water. Education programmes in the communities are teaching villages the importance of purifying the water wither with chlorine or by boiling it before drinking, especially to children under five years. Tap water is not safe to drink, even when boiled and should only be used for washing in. Chikankata has fuel driven borehole next to the hospital for all on the mission to use.

The Hospital

Chikankata Hospital serves a catchment population of more than 70,000 people and also receives patients from all over Zambia. The 270 bed, single-story hospital is run by The Salvation Army on behalf of the Government of Zambia. While the government provide the majority of funding for the health and nursing services at Chikankata, The Salvation Army also significantly contribute financially. The hospital relies heavily on overseas sponsorship and donations for much of its care and its education programmes.

The hospital has 8 wards, male medical, male surgical, female, paediatric, ante-/post-natal and labour, "high-dependency", isolation and TB. There is one theatre, with a very basic anaesthetic machine and ventilator, so the majority of operations are done under spinal anaesthesia. It also has an out-patients department (OPD) which doubles as A&E and a new (Sept 2004) anti-retroviral (ARV) clinic called Muka Buumi is entirely donor funded, in this case by the Swedish International Development Agency (SIDA). At present there is only enough funding for 200 patients, although they are hoping to increase this to over 1000 imminently. Muka Buumi is the only ARV clinic in Zambia, which provides treatment free of charge, and so people often travel for days to be seen there.

At most there are 4 doctors to cover all 8 wards, however there were only 2 doctors for the duration of our stay, and for the last – 2 weeks there were no doctors at all – together, we had sole care of all the in-patients. Two of the doctors are surgeons, though neither has been formally trained – they learnt in refugee camps in the DR Congo and Zambia.

OPD is run by clinical officers – people who have had 3 years of training and can manage common conditions – quite similar to nurse practitioners. The clinical officers also have 'specialities', one runs the chest clinic for follow-up on TB patients, one specialises in ophthalmology and one in anaesthetics.

The ante-/post natal ward and labour ward are managed by midwives, except in complicated cases. There are nurses and student nurses on the wards – there is a nursing and midwifery training school on the mission – however the nurses are often absent from the wards and relatives are expected to 'bedside' and provide all care (washing, feeding, cleaning clothes) for the patients.

Although they have some basic equipment and laboratory facilities, Chikankata is in constant need of drugs and other medical supplies, which are often donated by visitors. There was no equipment for measuring serum electrolytes, for analysing CSF or for culturing bacteria, among other things. Additionally whilst we were there, they ran out of swabs, urinalysis sticks and HIV testing kits. There was however a very sophisticated X-ray and ultrasound machine, which had again been donated by SIDA; this stood out in stark contrast to the other basic facilities.

Medications were very limited, such as analgesia, and many small operations were carried out 'under co-operation' to avoid using up precious supplies. It was also very frustrating to have such a small selection of antimicrobials when faced with so many infectious diseases. When we arrived the first-line treatment for an acute asthma attack was i.v. aminophylline, due to lack of working equipment, but before the end of our stay enough money had been raised to buy the hospital a nebuliser – this will have a huge impact on the treatment of many asthmatic patients.

We saw a fairly wide range of conditions, however the commonest by far were:

• Malaria (including cerebral malaria)
• HIV/AIDS in adults and children
• Massive weight loss/failure to thrive
• Kaposi's Sarcoma
• Probable PCP
• Multiple abscesses
• Chronic diarrhoea
• Many other presumed opportunistic infections we were unable to diagnose
• sexually transmitted infections
• TB
• Pneumonia
• Diarrhoea / gastroenteritis
• Malnutrition in children (including kwashiorkor)
• Fractures
• Burns

Work Undertaken at Chikankata

During our stay at Chikankata, we were actively involved in most areas of the hospital. Each day started at 0715 with morning prayers, following by morning handover at 0730 from the clinical officers or doctor on call. This was followed by ward rounds of the two hundred and seventy-bed hospital. The ward work is usually shared by between the four residents' doctors according to their particular area of interest. Unfortunately, during our elective only two of the four doctors were working, meaning the patient load increased for the two remaining doctors. As well as looking after the inpatients, the doctors' duties include the theatre, covering the 'out-patients' department and also running the HIV clinic twice a week.

Both of us have a special interest in paediatrics, obstetrics & gynaecology and infectious diseases. For the first part of our elective we spent the majority of our time working with the clinical officers in the outpatients department and also assisting with ward work on the paediatrics ward. We were given more and more responsibility as time went by and the number of clinical officers and doctors dwindled. Just over halfway through we were given responsibility of both the paediatrics and the intensive care wards. By the end of the second to last week at Chikankata, neither the two resident doctors was working for a number of reasons. This obviously meant that our own workload increased greatly as we were left with full responsibility of all the in-patients. Added to this we were required to cover the outpatients department should a problem arise that the clinical officers were unable to deal with. This situation, although exciting, was very difficult for us as in many cases we had never even been exposed to the conditions we were treating, let alone had sole care of the patients.

The main problems we encountered at Chinkakata were the lack of suitable drugs and the limit to diagnostic test available. This meant most of out diagnoses were made by clinical examination and history taking (often with a translator). Only patient care was limited greatly by what the hospital could provide weighed up against what the patients could afford. All healthcare is free for children under five, pregnant mothers and anyone over sixty-five. For everyone else, staff at Chikankata try to as compassionate and understanding as is possible when payments cannot be met. Another problem we ad to work round was the unreliability of power supply to Chikakarta, which was especially affected during the rainy season. The consequences of a power cut to the hospital were often catastrophic. The hospital had a very limited supply of oxygen, so had to rely on compressed room air supplied by compressors run on electricity. In the event of a power cut we were unable to use them. An emergency generator was in place, however this only supplied three of the eight wards and required diesel to fuel it – not always available.

Community Health Care

The work undertaken by Chikankata extends much beyond its inpatients and outpatients care. The hospital serves a catchment area of approximately 70,000 people although it also attracts many more from outside this area. Chikankata has set up a community outreach and education programme working through five rural health centres and a further eight out-postings from there. The work undertaken from these health centres involves antenatal checks, under fives clinic, immunisation and educational sessions, as well as a general 'primary care' service. A clinical officer, qualified nurse or volunteer community health worker staffs each of the five rural health centres. Each has a small supply of commonly needed antibiotics, some basic analgesia and anti-malarial treatment, all for empirical treatment, as there are no diagnostic tests available there. All health clinics are within radio contact of Chikankata hospital itself. Despite this, the feasibility of transferring an acutely ill patient or labouring mother from a rural community to hospital can be a very long and perilous journey, especially during rainy season when the roads are particularly dangerous. A team of health care workers from Chikankata visit these rural health centres monthly and also run 'mobile clinics' to the more distant communities, although this is not possible when the rains come in full.

We were fortunate enough to be involved with several aspects of the community-based work during our elective. We visited three rural health posts and helped to run antenatal clinics, under fives weighing and immunisations clinics, nutritional checks, and also basic medical care to the acutely ill in the community. Again, the lack of basic equipment was starkly obvious, as we had to perform antenatal checks without being able to measure the blood pressure. Every child under the age of five has their weight monitored regularly and receives Vermox (de-worming medication) and Vitamin A at least every six months as well as food supplements if necessary. The Zambian Government has instituted a vaccination programme which aims to provide essential vaccines to the under fives and pregnant women free of charge, as well as anti-malarials for all women who attend antenatal clinics.

Children's Christmas Parties

Chikankata is also heavily involved with working with the ever-increasing number of orphans and vulnerable children in the surrounding communities. Lack of knowledge and acceptability of contraception as well as the large proportion of people affected by HIV/AIDS has caused the number of children in this category to soar rapidly. In the run up to Christmas, Chikankata organised a number of children's Christmas parties originally intended for the vulnerable children and orphans. The generosity of many overseas donors made it possible for the invitation to be extended to every single child in each of the rural communities. Thirteen parties were organised, each attracting anything from three hundred to seven hundred children in total. Thanks to the kindness of friends and family we were able to assist financially as well as practically to the running of these parties. It was a truly incredible opportunity to witness the whole community coming together with a shared view of supporting the vulnerable children. For many growing up in such a resource-poor setting, this was the first time they had been given presents or food other than that which makes up their staple diet. Each child was given a party bag consisting of popcorn, sweets, crisps, a fruity drink and a balloon. The joy and excitement they expressed made the many laborious hours in preparation worthwhile.

Church

On planning our medical elective, we felt strongly that as committed Christians, we wanted to work in a mission-based hospital, where considering and catering for people's spiritual as well as physical and emotional needs is paramount. We were eager to gain some experience of working in this setting as we both are seriously considering undertaking overseas work in the future, in medical mission. This experience has heightened our awareness of the situations and needs we would face, should we return. The hospital is part of The Salvation Army Mission built there in 1946, which also includes a large high school, primary school, local radio station and church. The local Salvation Army's mission statement is, 'With heart to God and hand to man', a statement which they actively follow. It is a truly caring, outward focussed hospital that is actively seeking to care for and serve its surrounding communities. It was a privilege to be a part of it, even for the short time we were there.

We were both struck by the amazing sense of community in Chikankata. Amidst starvation, floods, poverty, orphaned children, malaria, and HIV, still the people of Chikankata are filled with hope and joy. Despite each day being filled with uncertainty beyond belief, we were so aware of their assurance that their lives are in God's hands. Each church service was filled with believers, longing to give thanks to God for his goodness and excited about sharing their testimonies about God's goodness and provision to them in their daily lives. The overwhelming sense that every single day is a blessing and an opportunity to serve God and His people is overwhelming present at Chikankata. They truly believe that life is not a right, it is a gift and there's nothing we can do to please God more than to offer it back to Him. We went to Chikankata with the somewhat naïve idea of helping the people, and in ways we did. We put a tremendous amount of time into caring for patients neglected by others. We prayed for out patients, hoping to see them miraculously healed and we were shaken when comfort, peace and strength helped us cope with the unbearably tragic situations we faced. We also felt encouraged and supported by the incredible community that holds all at Chikankata so strongly together. It was with amazing openness that we were welcomed in, encouraged and blessed during our time there.

Our elective was an important time for both of us in our own faith and relationship with God. Firstly we were reminded that our God is compassionate and He never leaves or abandons us. This became even more important for us as our length of time away from home increased. Secondly, each day is gift, a blessing and an opportunity. The best thing we can do with it is to offer it back to God, to ask each day how we can use it to best serve Him and others. Thirdly that people do die – children die, and it breaks God's heart so much more than it breaks our, to see people suffering. Through all this we were reassured by our belief that each child that died went straight to God, and we continue to have that assurance. Our prayers were, and continue to be, for the families left grieving, that they too would be comforted by that deepest of beliefs.

Finally we realised once again that the healing of souls is just as, if not more, important than the healing of the body. Our lives are so short and so uncertain. We won't know what will happen tomorrow until we get there, but at least we know it is all in His hands.

Advice for Medical Students

Before you formally accept your elective place in a developing country such as Zambia, make sure you definitely want a developing medicine experience. We had an amazing time that has made a deep impression on us and our future plans, but the appalling amount of disease, death, poverty and injustice you will see is hard to deal with, and if you aren't committed to that sort of work you will find it very hard.

Getting ready to go to Zambia can't be done in a rush; we needed multiple extra vaccinations (despite both having travelled quite widely already!). It is also important to take an HIV post exposure prophylaxis (PEP) kit, as the availability of anti-retrovirals (ARVs) in Zambia is very limited! Do go early to occupational health and a specialised travel clinic. It is also important to get a good "kit" – a mosquito net and repellent is essential, as is your own personnel mini-pharmacy. A don't forget sun cream.

In terms of clothing, urban and rural Zambia are very different, as were being off and on the 'mission' (the area around the hospital). In rural Zambia a woman should always wear a chitenge (basically a sarong/wrap skirt) over her bottom half (with another skirt or trousers underneath), this has many good points, including keeping your normal clothes a bit cleaner! On the top half T-shirts are fine, local women have their breasts out all the time (usually with a child attached), but for a white woman to do the same would probably raise a few eyebrows! Even in developed and touristy areas short skirts are best avoided (a woman's thigh and bottom are the main sexual areas in Zambia) and very skimpy tops could get some stares.

Zambia is a Christian country, and Chikankata is a Salvation Army hospital, so it is easier to fit in and get to know people if you are a practising Christian. However the hospital does accept students who are not Christian and you would not encounter any hassle or prejudice regarding your own religious beliefs.

Holidays

Zambia is a fantastic country to holiday in, and we were very surprised to find the vast majority of people in tourist areas were already working or living in Zambia or the surrounding countries – it is decidedly not over-developed! Whenever you're travelling in Zambia, don't be afraid to haggle or ask for a volunteers/NGO discount… you usually get some money off! Lusaka, the capital, is nice city and pretty safe, but definitely not worth visiting purely for sightseeing! Though if you're in need of some Western style pampering the out-of-town mall at Arcades has a fantastic restaurant, "Rhapsody", and a top-notch cinema!!

Without a doubt no one should go to Zambia without visiting Victoria Falls, at Livingstone, SW Zambia. Here the mighty Zambezi plummets down and divides Zambia and Zimbabwe. For adrenaline highs, natural beauty and even small safaris you simply can't beat it. Recommended accommodation: budget "Fawlty Towers", mid-range "The Waterfront", top-range (i.e. if your parents come to visit!) "The Royal Livingstone" but check out "The Lowdown", the local, monthly, ex-pat newsletter, for great locals deals. Recommended activities: see the Falls, go rafting, do a bungee jump/gorge swing, see the Falls again, visit Livingstone Island (and if the water's right, swim on top of the Falls!), go on a sunset booze cruise, and the crème de la crème: microlight/helicopter over the Falls.

The other wonderful thing to do in Zambia is to go on Safari – there are three main game parks, South Luwanga, Lower Zambezi and Kafue. Kafue is the most untouched, natural, largest, but hardest to get to park – only for the dedicated! Lower Zambezi primarily involves canoe safaris on the Zambezi – watch out for the crocodiles, seriously! South Luwanga has some of the best game viewing in all of Africa and some fantastic lodges – we got a locals deal and stayed at Mfuwe Lodge...paradise!!

At the end of our elective we headed up to Tanzania to get some quality relaxation and beach time in Zanzibar. By far the cheapest and most fun way to get there is by train. The Tazara train goes from Kapiri Mposhi (200km north f Lusaka – jump on one of the many coaches every day) all the way to Dar Es Salaam. It takes 2 whole days (including 2 nights) but if you travel first class – half price with a student card!! – you get a cabin with four beds, plus use of a lounge car with videos, plus dining car, plus toilets and basic showers. The views of both Zambia and Tanzania are fantastic, you go right through a game park in Tanzania – we saw giraffes, impala, warthogs and more from our carriage!

It's easy then to get to either Dar harbour or airport and hop over to Zanzibar; we headed up to Nungwi for white sand, blue seas, great diving and amazing food. A day or two in Stone Town is also a good plan, if only for the night market – if you love seafood, you'll be in heaven! Plus you can visit a spice farm and get on with some hard core souvenir shopping.