Highway to……..

A final beer in Peponi yesterday evening

It was with a heavy heart that I climbed into my taxi this morning. In the breaking pre-dawn light and to the sounds of gentle waves lapping the beach, I walked from our banda (hut) in Peponi down the fine sandy paths to the car. Met by the warm greeting of our ‘taxi-driver’ friend, we loaded up my bags, and set off.

I left my sleeping children and sleepy wife to head back to the UK. They will be heading off to Australia in four days’ time (brought forward) for our original planned holiday ‘on the way back’ to the UK. Perhaps slightly inconveniently, I now have to ‘pop back’ to the UK first, to address my future career prospects. I will be flying out to re-join them in Australia in a week’s time. Life is never dull.

It is a long drive to the airport, the first hour of which was on dusty bumpy tracks, before joining the main tarmacked road from Tanga to Dar es Salaam. Half-way there (about 4 hours in), the unusually late  rainy season (by a good 3 weeks) finally declared its intention to begin. Nothing too exciting fortunately, but some heavy intermittent rain showers hammered upon the roof and windscreen. It was deafening and made driving all the more exciting – more ‘excitement’ is definitely not required. We passed several crashed vehicles (including a lorry that had gone off the side of the road), but fortunately, our driver is excellent and I felt very safe in his hands. Interestingly, the temperature on the car thermometer dropped from 35°C to a mere 24°C – and I certainly noticed that I was probably more comfortable than I had been for the vast majority of our time here. What a pleasure not to be hot and sticky!

We passed the time with a healthy conversation of mixed Swahili and English (his English being far better than my Swahili, but it is fun nevertheless). We were pulled over by the Police a few times (such things seem an almost compulsory part of any long journey) and documents and licences were dutifully checked. Apart from that, the journey was otherwise fairly uneventful until we were about 40min from the airport….

We encountered the most enormous traffic jam, joining the back of what would turn out to be a monster. The sort of which I just don’t think happens in Europe. With only a few of the most major routes across the country tarmacked, and then only as single carriageway, when disaster strikes, it is carnage. Later, we would learn that it was over 20km long. Odds on caused by some form of traffic accident exacerbated by the rains. Road etiquette is pretty crazy. Once the traffic had been stationary for a while, options started to emerge. Firstly, we followed a number of other cars driving down the opposite side of the road – whilst slow, this was still fairly exciting as it was often up blind summitted hills. Then when the occasional car came the other way, we would drive up the opposite hard shoulder. This worked well until we then encountered a major road improvement project (they are making part of this road into a dual carriageway) where the hard shoulder tapered out. This was about the same time that more frequent vehicles started coming in the opposite direction, including some massive lorries. I was bemused to see some of the ‘Bunge’ (covered three wheel motorbikes – ‘rickshaws’) as well as a few cars electing to use the ‘under construction’ portion of the road. Surprisingly, they did not just sink into the sand, but I was relieved that we did not follow. Something you just would never see in Europe.

We were in trouble though. Already 45min had passed and progress was minimal, a few kilometres at best. I had had plenty of time to get to the airport, but having felt completely laid back about things, was now starting to wonder if we would make it in time. Every hill we climbed revealed a huge line of stationary traffic snaking into the distance. As luck would have it, as we ground to a halt yet again, a local indicated an ‘off-piste’ alternative. This diversion was risky given the rains, but the car managed the muddy tracks well and we started to make significant progress towards our next goal – the split in the highway that turns off towards the airport.

We were within spitting distance of the split, less that 1km away, but unfortunately we had reached the end of this rat run. We had been deposited in a rather large lorry park. The back routes could take us no further and we sat waiting with the other ‘ratrunners’ to re-join the main road. The minutes ticked by and it was becoming painful. Time was getting tight. It was only 1km to the turnoff and the ‘word on the ground’ was that the route to the airport was clear, if only we could get there. But we were going nowhere. Eventually, my driver suggested that we hire a Bunge (rickshaw) as it could squeeze past the traffic – he could park up and we would go together. More waiting and just as we were about to change vehicles, things started to move. We re-joined the carriageway and could see the turning up ahead. There was hope! Some further creative driving got us to the junction, and we were free.

I made it to the airport in ample time, checked in, sent my hold baggage now crammed with souvenirs up the belt (the surgical instruments had been replaced by African crafts) and headed to security.

I write this in the airport restaurant waiting to board my plane. This is it. I am done. I really am leaving Tanzania.

Unfinished business.

I woke up this morning with a strange feeling. It would be my last day in Muheza. A surreal realisation that this ‘adventure’ is coming to a close. 

My wife, chidlers and our visiting friends would be setting off midmorning for a final weekend in Peponi, a last dip into paradise. The plan was that I would join them later, but I had many a loose end to tie up first. I had a lot to do today!

The whole day would be a very bizarre experience for me as the realisation struck home that each activity of the day was to be my last here. Sitting through the morning meeting, I made a special point of breathing the whole experience in, trying to ensure I had some mental souvenirs to carry away with me. I was sitting amongst my colleagues, many of them now friends, an almost daily routine that was soon to end for me. The clinical officer report, the nursing report then the death report (four this morning). There were the usual discussions surrounding such things, notably for me was that the clinical officer got a hard time for prescribing steroids to a snake bite (a quick check of Dr Google confirmed that this is not ideal). Once again my educational hat was immediately wondering whether this important discussion would be disseminated. Would there be learning and change? Would my consistent contribution to encourage such things begin to reap rewards? This morning it felt unlikely for this particular case, but seeds have been sewn and perhaps they just need time to germinate. The meeting closed with a reminder by the hospital superintendent of my departure. The reaction was generous; nobody wanted me to go but of course everyone wished us well!

I had an agenda today and for once I was assertive in dictating it. I needed to be super-efficient with my time to get everything done and get away at a reasonable time. There was one final operation to do, I needed to pack, and I was desperate to finish my present for the team.

I explained my time pressure to the local surgeons and we agreed that they would call me when the patient was ready in theatre. It was then back to the house to get on with my other tasks.

Firstly, I gave my attention to the present I was making, a photo-board (mugshots of the team) for the department. A familiar site on most NHS walls, I felt it would be both nice and valuable here. It had taken a long time to get done and I had been working on it in one way or another since before Christmas. However, as often seems to happen when an absolute deadline looms, a flourish of activity can bring it all together. My friends had been amazing in printing out quality photographs for me in the UK (I had struggled to easily find anywhere to do this locally), and my wife had managed to find a good quality pin board in Tanga yesterday (blimey, I completely forgot to mention in yesterday’s post that she had to go for round three of our visa saga – success I am delighted to report). But I got it finished just as the team called me to theatres.

Whilst Fridays are usually reserved for emergencies, we had been given the go ahead to do one of the two skin grafts still outstanding. Hoping to get them both done this week, for various reasons we had managed neither. Although disappointing, it was great that we would at least get one done. 

There were three patients on the ward who had been admitted over a month ago with horrendous leg ulcers. All young men (one in his 20s, one 30s, one 40s), two had sustained traumatic injuries and in the other they had emerged spontaneously (some infective cause I suspect). All three were substantial, encompassing most of the gaiter area (calf / ankle). Presenting late, all the wounds were infected had required extensive debridement, surgical toilet and dressings to try and salvage the legs. With such nasty wounds and extensive skin loss, these three men were flirting with the need for lifechanging amputation. However, some excellent basic work in both theatres and on the wards had gone a long way to salvage the situation. Two were now suitable to attempt grafting.

I had been really keen to get this done before I left as I had brought out a very heavy but brilliant bit of kit with me. If I could get the local team trained up in its correct use, it could transform their ability to manage these wounds. To put it bluntly, it might make life changing amputations unnecessary.

The Brennen Mesher

A Brennen Mesher took up a massive 6kg of our baggage allowance, but it is a beautifully machined tool that dramatically improves both the success of and scope of skin grafting. After taking a donor of skin (usually from the thigh with a special knife), you run it through the device and it creates fenestrations. This does two things, firstly it allows fluid out from underneath the graft when you lay it (blood, exudate, bugs) and fluid under the graft can prevent it from healing (it needs direct contact with tissue to get the nutrients it needs and to grow the tiny blood vessels that will allow it to live). Secondly these fenestrations allow it to cover a much wider area. The one I had brought out doubles the size of the graft.

With the patient on the table, I took down his dressings. The wounds were granulating well (this means trying to heal, creating a bed of tissue that the graft can sit on and grow onto). But there was a slight suggestion of low grade infection. This is not ideal as it reduces the chances of it healing, or ‘taking’ as we tend to say. Simply put, infection can kill the fragile graft. But it was now or not at all and I felt it was worth a try. This is not an easy decision as if the graft fails, you have created another ulcer on the thigh for no benefit. And these donor sites are not without potential complication, and they do scar. For a grafting of this size the donor site would be large.

I have done several skin grafts in my time, but on a smaller scale and I had not used the Brennen Mesher before (I had used other systems that require expensive disposables). However, the instructions that I had received before leaving the UK (and my experiments with paper) meant things went very well. My only quibble with myself was that the donor harvests with the Humby Knife were a bit ragged. You have to use this special guarded blade to regulate the thickness of the slices you take – too thin and the graft falls apart, too thick and the wound you create doesn’t heal - the donor site relies on the skin regenerating from the skin follicles that lie deeper than the slice taken.

My comment about this ‘unsightly’ work was met with a wry smile and utter bemusement. If not for my self-appraisal, neither the patients nor the staff would have even registered that there might be a cosmetic consideration. However, my professional pride was a little dissatisfied, which I think is important. I mention this because I believe it is the expectations that I have of myself that has driven me to strive for UK standards whilst working here. By doing this, remarkably perhaps, we have managed to achieve surprisingly good outcomes on the whole during my time here.

Nevertheless, the skin grafts were laid upon the gaiter wound, looked very satisfactory and were dressed. I can now only cross my fingers that they will take. They will remain untouched for 7 days before they are inspected. Too soon and you risk peeling the graft off with the dressing and ruining it. He will be on bed rest and antibiotics.

I will of course, be back in the UK for the moment of reckoning. Far from ideal but I have confidence in the team. There is also a distinct deja-vu about this situation. During my brief previous visit in July, we did a smaller skin grafting on a foot on my last day. That time the take was 90%. If we can get anything close to that it would be amazing and limb saving for this man.  

And that was it. My last operation in Muheza. I walked away from the operating room with a jovial exterior but a heavy heart. I was very sad to be leaving. All that was left to do was to present them with the gift I had made and say my final goodbyes. I don’t think my departure had really sunk in for any of us.

I left behind my scrubs, theatre shoes, headlight and a few other bits. But most of all, I hope I have left behind a legacy that will enable this surgical department to continue to grow. Turning away and walking out of the hospital gates was really hard. In my heart, I know that there is more unfinished business here than just the skin grafts and I hope that it will not be long before I can return, if even for just a short time.

I walked home and packed. At 3pm I climbed into the Hospital Car and drove down the dusty, bumpy road away from the hospital then out of town for the very last time. I had one last night in Peponi and would be leaving at the crack of dawn tomorrow to fly home.

A final photo, the two local surgeons and myself

Left holding the Baby for the 50th Mesh Hernia Repair

My first port of call this morning was to review the young lad with the abdominal pain. Expecting to have to persuade his mother to allow us to take him to theatre, I was surprised to find his bed empty. Just as I was fearing that he had been taken home, he walked through the other door to the ward. Coming in from outside, he spritely walked to his bed with a big, slightly coy, smile on his face. Even in the context of abdominal pain in childhood (it can be a tricky beast at times), this was all very bizarre. I examined his abdomen and it was blameless again. There was only one thing to do, I sent him home.

Today we would reach the landmark of fifty mesh hernia repairs. I am absolutely delighted, not least because the number has a significant feel about it. With the redecoration of the main theatre suite ongoing, we are still located over the way in the obstetric ward theatre. At one point, I found myself left ‘holding the baby’.

Our start to the day’s operating was far from smooth. There was quite a period of delay as the first patient to arrive was very hypertensive and had to be cancelled. He may have genuinely fallen foul of the phenomenon ‘white coat hypertension’ (this means that the blood pressure goes up disproportionately in the presence of medical stress and isn’t actually a problem), given that the previous three readings in clinic and on the ward had been normal. However, I have been very careful to support safe practice here, and was thus very happy to endorse the anaesthetic decision to postpone the surgery. The second patient required quite a lot of ‘pre-optimisation’ as well (an issue not dissimilar to the previous case, but not so severe) and, not unreasonably, the local surgeons had disappeared to use their time productively. However, after a short while I was summoned to the operating theatre from the coffee room. I walked in to be told that the spinal had been put in and the patient was ready on the table. I was the only surgeon present. Hmmm. No-one was answering their phones. Hmmm.

I had had no intention of performing this final mesh procedure myself (it would be the local teams final opportunity to perform this procedure with my supervision), but you really can’t leave a patient waiting on the operating table. I did not rush, but I dutifully scrubbed and prepared the operative field. The local surgeons were still yet to arrive despite my encouragement to locate them. Much to my dissatisfaction, I had to continue. I made the skin incision. However, with the knife barely leaving the patients skin, they bundled through the door much to my relief. They got scrubbed and I welcomed them warmly to the operating table. They took over the case at my request, I de-scrubbed and stepped back to watch them at work. It was a tricky case and would take them a long time (over two hours in the end). But the quality of the operating was very good and I know that speed will come with more experience. I sat in the corner pretending to get on with some admin, all the time slyly watching them work. It was a real delight for me to hear how they coached each other through the procedure, recounting the steps I had taught them. I knew it was going to be a challenge, and it was particularly pleasing to observe how carefully they operated. They recognised the difficulties, each time pausing and slowing until they had made sense of things and knew they could move forward again safely. 

I could not have been more proud. I sat there silently, soaking up those moments, savouring them. There I was, thousands of miles away from home, sitting in an operating theatre in the heart of rural Africa, witness to something very special for me. We really had done it.

In the face of so much challenge, in an environment so far removed from what I would take for granted in the NHS, we had never-the-less established a service that is remarkably close in quality to what you might expect to find in the UK. Whilst I would be leaving in just a few days’ time, I would be going content in the knowledge that the local team are safe, thorough and understand what they are trying to achieve. I felt genuinely confident leaving this new service in their hands. What a great result. What a fantastic step forward in the provision of healthcare for this population.

It also brought me much satisfaction and pleasure to have shared this moment with our visiting friends. Their complimentary comments and approval of the service we had developed was fantastic to hear. Perhaps it was more than that though. Their professional opinion was important to me. It was validation for what we had worked so hard to achieve, feeling almost like a stamp of approval. On what will become a very memorable moment in my time here I am sure, it felt a very fitting way to be ending this chapter of the project.  

Party!

My time here is rapidly ticking away. The morning started with a presentation at the hospital meeting. I had volunteered to share the experience of the Surgical Department activity during my time here. It was a really nice thing to do, summarising what we have achieved these last five months. Whilst I ensured that it was a balanced report ‘warts and all’, these were thankfully very few and it was certainly a report that I was proud to be sharing.

As I neared the end, I had a moment of hesitation. Caught completely of guard, my throat tightened as I praised the work of the local team and started to suggest some things to encourage a vision for the future. A slightly awkward period of silence ensued.  Evidently, I am very proud of what they have achieved. It will be hard to leave. It felt like an age to me (silently berating myself and imploring self-control and composure), but I managed to do so and finish strongly. I was rewarded with the most delightful applause – the hand rubbing, followed by some synchronised quick claps, building up to two large claps that they ‘throw’ at you. I smiled broadly.

After the meeting it was back to reality. The surgeon nun was visiting once again from Korogwe and we went to review the boy from yesterday. Disappointingly, he was more sore and we agreed to return later to decide if surgery was indeed required.

Operating on a little person

The operating list was in the obstetric ward theatre, which despite my initial reservations was a perfectly acceptable venue and actually worked out very well. We had an unexpectedly challenging paediatric hernia, which turned out to be a combination of hernia, maldescended testis and hydrocele (this means that the testicle had not migrated correctly into the scrotum on that side and was surrounded by a balloon of fluid). Far from the slick masterclass I had hoped, it was however perhaps excellent learning for all of us and went very well (herniotomy plus orchidopexy [fixation of testis in the scrotum]).

Further progress to our planned schedule was trumped by a C-section. My visiting friend was keen to get involved and I found myself happy to add to my experience of two.  We cracked on. It was a difficult procedure with the baby’s head wedged deep in the pelvis. It was also a hot and sweaty affair; the older air-conditioning was significantly less effective and we were both cursing the mandatory plastic aprons (without them we would have been soaked through with almost every body fluid though). One thing I won’t miss leaving Africa is the sweat pouring down my back and dripping off my forehead in such cases.  However, for all such things I am pleased to report that the baby came out safely and crying albeit with a funny shaped head (this is normal and resolves) – I am not sure if I will ever get used to obstetrics.

With that interlude completed, we were once again able to continue with our list. It was an exploratory laparotomy in a middle-aged man with chronic right lower tummy pain and an USS that suggested appendicitis! I was extremely sceptical, but like the handful of other such cases I have faced, the only option left available is to have a look inside the abdomen. Whilst certainly an invasive procedure, there is the potential to miss important mischief and no-one is yet to decline despite my cautionary counselling. Interestingly, all the previous cases (normal findings with routine appendicectomy) have remarkably reported full resolution of their symptoms.

Having successfully embraced the local teams request in the past, and despite my ongoing reservations, we conducted the procedure under spinal anaesthesia alone. In the UK this would be unheard of as we normally insist on general anaesthetic with full muscle relaxation to improve our access. Once again, embracing their practice was successful and it is certainly something that I might consider for very selected cases back in the UK in the future. After a brief flirtation with the ascending colon (initially we thought that there was a stricturing tumour – I initially got excited, but it turned out to be unusually pronounced muscle spasm of the colonic wall) it was indeed normal and we performed a routine appendicectomy before closing. Once again I smiled at the enthusiastic comments about the length of this worm like structure, but when you have seen over 500 of these things, I could confidently say it was within the normal spectrum.

On completion of that case, we had run out of time and concluded our operating for the day. We returned to see the young boy and all of us agreed that he needed surgery which we would schedule for the following morning. However, his mother was very reluctant to let us proceed despite gentle encouragement by the visiting surgeon nun. I cursed my decision to cancel him on the table yesterday. A most unsatisfactory situation, I hoped that things would be easier in the morning.

The evening was a fine affair. We had arranged and financed a party for 60 of the hospital staff that had worked most closely with us. Every single one came. Free drinks and a free meal were evidently ample encouragement. It was truly delightful and towards the end there were a few speeches followed by some gifts for us. They had had a dress made for my wife and a shirt for me. So lovely. And to compliment those, we were also given a few reams of beautiful African material which they paraded to us under the accompaniment of music and dancing and then wrapped these around our whole family. Twice – they are huge! There was a requirement for a vast number of photos and it felt like our wedding day, standing on show with various different combinations of the staff. The children were fantastic about it all, despite being tired and I am so glad because it clearly meant a lot to the staff.

It was then a very late night for a very tired Family Shim.

This picture is with the entre theatre department staff 22 in total

Ha! No water….Let them eat cake.

With all the terrible flooding wreaking havoc and causing death and destruction just a little south of us, it seems slightly bizarre to be commenting on our lack of water. The rainy season is still yet to start here, and it is now very notably late I am told. Apparently, we are having an unprecedented period of drought and the piped water supply to the whole of Muheza has been dry for the last three weeks. Unfortunately, that means that our water tanks are now almost empty again and we are back to rationing. I am hoping that I will be able to squeeze out another couple of quick showers in the mornings after my runs. But I won’t hold out too much hope.

I guess this is living the reality of climate change. Genuinely quite scary. Perhaps it is time for such things to register as a wakeup call on a global level and that we can start to try and make amends before it is too late.

So that, together with the recent nightly power cuts, certainly seem to be gentle reminders to appreciate reliable utilities when we return to the UK.

Today has been a funny day. Major theatres are still out of action with the refurbishment in full swing. Despite many assurances to the contrary, I just can’t see it being ready to use again this week. Whilst frustrating in many ways (being both predictable and avoidable perhaps), they are doing an excellent job and I am keen that they are allowed time to finish it properly. The theatre team have settled very well into our alternative venue in the obstetric ward and I think we will manage some elective work there after all.

There was a first for me today; I cancelled a patient on the table. I had been asked to see an 11 year old boy at the end of morning rounds. Although the history was a little confused and the findings far from classical, at that stage he seemed to have a peritonitic abdomen. A decision to operate was made and arrangements began. However, a little while later I watched him walk very happily towards the obstetric theatre. Alarm bells ringing, I re-examined him ‘on the table’ before he was put to sleep. The clinical picture was now completely different. His abdomen almost blameless. Never one to allow pride to overcome making the right decision, I sent him back to the ward for further observation. I suspect that he will go home tomorrow. I felt slightly bad for our visiting friends as their first few days have been a little bizarre I expect. Things have been far from the normal for here, and this normal being very far removed from the UK anyway. However, they seemed to take it all happily in their stride and we had an early finish to the day.

This was excellent news as it is our littlest daughter’s 6^th birthday today. We returned for birthday lunch and of course birthday cake and tea a little later. A huge effort had been made by my wife and other daughters to give her the best possible day. They had created a wonderful chameleon cake and she had plenty of presents with those sent out or bought here. She had an excellent day, with lots of whatsapp video chats and things to do and enjoy. She did say at bedtime though that she missed seeing her friends and the rest of our families in person – it was one of those incredibly sincere and mature moments that children sometimes throw at you. It made me both smile and feel a little sad for her. She is a very happy and content little lady though and I’m sure stories of her African Birthday will be told for years to come.

Cake and presents!

A final flourish

Today is my last Monday in Tanzania and it has been pretty full on. The hospital is a hive of activity and it has been an eventful and pleasing day.

Yesterday we were delighted to welcome some friends from the UK; a Surgeon / Anaesthetist couple who brought their 15month old daughter with them. Having been involved with lots of work in Africa in the past, they are both midway through training in their chosen specialties and were keen to try out the reality of Africa with a child! They had somehow managed to co-ordinate their on-call rotas and leave requests, managing to make it out here. It’s a big thumbs up so far. Their daughter seems to love it. And she certainly likes the new big friends she has found in our chidlers. For us it has been really nice to share some of our time here with such people.

Somehow, a few weeks ago I had agreed to pay for the redecoration of theatres. Expecting it to require just a modest amount of funding, the quote turned into something more substantial. £1,500 might not sound a lot, but here that’s a massive amount of money. Hesitation to commit to such expense personally (given that we are scraping the bottom of our barrel currently) was soon to be overcome by the generous offer from family to make contributions as a birthday gift. Before I knew it, the whole thing was financed, and the work was commissioned. I was genuinely delighted. One of the best birthday presents I think I have ever received.

I had hoped the work might have been completed during our stay in Zanzibar. Unfortunately, whilst it was started at the weekend it is now midway through and walking into the theatre complex today made me rethink the reality of the weeks operating schedule. Dust, plaster and paint everywhere. Operating this week might be a little lighter than I had anticipated! But I am absolutely delighted that this work is underway. It will make a massive difference to the department. Not only will it make it easier to keep clean (improving sterility), it should reduce the likelihood of flies in theatre and will certainly have a nicer feel for the staff who work there. Another small but significant step to raising the bar of surgical care here. A herculean effort is underway to get things finished….I am being open minded…. (rest assured, we have moved emergency work into the previously dormant theatre in the obstetric ward, but we really do need to reserve that for unplanned work only).

Fan repaired, hole persists!

And so on to the main event for the day – outpatients. I knew it was going to be a huge clinic as I had integrated a special mesh follow-up clinic for the majority of those in our series. I felt it was important to encourage a robust system of feedback for the local surgeons, as well as capturing important data to validate what we have done here. As I walked through the door, I immediately noticed the now working ceiling fan – what a great omen for the day – it would be a comfortable marathon at least. Whilst a mammoth 44 patients were seen, the majority were follow-ups and doing brilliantly.

If ever I needed a final reminder that what I have undertaken here has been worthwhile, this was it. It felt a little like an indulgent success parade, with patients modelling beautiful scars and a significant number regaling delight in the outcome of their surgery. Whilst all the mesh patients were fantastic to see, the highlight for me was a couple of the children who I had brought back to review before I left. To see them thriving was such a pleasure. The little boy who had had a big recurrent hernia was particularly special for me. Motherless, his grandmother smiled broadly as she showed me his now near normal inguinal region (groin). Whilst the original broad scar was a clear indictor that he had had surgery, our little fading pencil line was only a hint that we had ventured back in. All the inevitable post-operative swelling had disappeared and I felt an enormous wave of satisfaction that my work here has been done well. Such things will probably make a real difference to this child. I feel he could certainly do with a few better deals of the cards.

Zanzibar – A sobering exit.

We have had a lovely final 24hrs on Zanzibar. The beach we look out over is quite remarkable. The gradient is extremely gentle and the reef encircling this part of the island is about 1500m off shore. This creates the most incredible tidal variations. At high tide, it laps the ramp up to ‘our’ garden. At low tide there is a 750m walk out to the remaining lagoon beyond which lies the reef. The water is the most stunning blue and has a swift current as the vast volume of water tries to exit through a gap in the reef somewhere distant.

The beach and lagoon are places of much activity at low tide. There are numerous seaweed farms tended by local women. Our understanding is that these are a recent initiative to create an industry for the ladies here, with the plants being sold as a food item or as an ingredient in beauty products. 
There are also numerous local fishing activities as you might expect and for us the lagoon current was to be an excellent playground. We walked upstream then waded in and allowed ourselves to be swept back downstream in the warm water. It was excellent family fun – we are all water babies at heart.

We also went out on a boat trip with our host to visit a snorkelling spot. Wanting to offer our younger two children the opportunity to see coral and reef fish we were not to be disappointed. Predictably, close to land the coral was very limited, but the fish were plentiful and our littlest even spotted a most beautiful moray eel. The local crew also took full advantage of the paid trip, and found an octopus that they deposited in the bottom of the boat – interesting for us, sad for the octopus as it was heading for the cooking pot!

Octopus in the boat and Moray Eel in the lagoon

Sailing back

Our departure from Zanzibar later that day though offered a more sobering perspective. Amongst all the thriving tourist business, local life still remains challenging. Our taxi driver stopped to speak to a lady sitting by two children. They must have been about 8 and 12. It transpired that they had just lost their mother. Their father had already died 3 years ago. Our driver had stopped to offer his condolences as is the custom here. My conversations with him suggest that these deaths are probably HIV related. Regardless, for us all sitting in the car it was a fairly stark reminder of the challenges faced here. The children we saw sitting outside, stoical but clearly grieving their loss, were essentially the same age as our older two sitting next to us. An extremely sobering thought. The extended family network here is incredibly strong, so they will have somewhere to live and will be cared for. But what an extremely difficult way to start out in the world. My wife and I exchanged a look that clearly said we were feeling the same thing – heartbroken.

We left Zanzibar on another delightful flight, this time with an all-female (and equally glamourous) flight crew, arriving safely home in Muheza late in the evening. I must say walking through the door was a real pleasure for me. It was that very pleasant feeling of returning home.

And so we enter my final week here. Slightly earlier than originally planned, I have got to fly back to the UK next weekend before then heading back out to re-join my family in Australia for our planned holiday on our ‘return’ leg. I think it likely to be an eventful final few days.