Sanctity of marriage

Yesterday I had the pleasure of delivering a healthy baby girl from a 14 year old mother. She looked completely bewildered as this child was handed to her, almost as if she hadn't realised what had been growing inside her these past 9 months. Teenage pregnancy is not an unusual occurance, in fact it might even be the norm in this area, and one of the reasons is illustrated by another patient of mine. She is a 26 year old who has been left infertile and childless following an ectopic pregnancy. She is absolutely distraught as you might expect any 26 year old to be. However, it is not just her yearning for a child that distresses her but also her yearning for a husband as in Xhosa culture she has little chance of finding a man without first proving her fertility. With such high unemployment her only realistic chances of an income are a husband working in the mines and child support grants which means her future is far from secure. The impact on the HIV epidemic of the need to prove fertility before marriage is plain to see. These young women are clearly having unprotected sex with casual partners with little thought for their own health.

If a woman manages to avoid HIV infection whilst proving her fertility the problem is not over. Choosing to marry brings many advantages but it also comes at a price as she will be entering into a very unequal partnership. Put simply, most Xhosa men are very reluctant to use condoms and women do not have enough bargaining power within their marriage either to insist on their use or to persuade the husband to have an HIV test in the first place. Add to that the very high prevalence of HIV in men who spend most of their time woring away at the mines and this puts married women in a very dangerous position.

If a woman passes the fertility test without being infected with HIV she is actually in a much safer position should she choose to remain unmarried. Not only has she proven her fertility but because she is unmarried she is in a much stronger bargaining position when it comes to condom use. She is much more likely to be able to refuse sex if the man will not use a condom and as such unmarried women are in a better position to protect themselves from HIV than married ones.

Whether many women think of this dilemma when considering marriage I'm not sure but I do see many unmarried women with children who seem to have put aside the idea of marriage as they have become a little older and wiser. For these women the chance to build a future through education and training seems to me to be of the upmost importance and is one of the reasons I'm so keen on the idea of microfinance in this area.

On a lighter note.....

Way back at the very beginning of my time in the Transkei I landed at the airport and was picked up by a driver from the hospital called Mabena. His English, while better than my Xhosa, was not great but we managed to pass the time during the journey with a conversation based largely on the words Liverpool, Steven Gerrard, FA cup and Premiership. I boasted of my time as a goalkeeper for my college while he told me that he was captain of his team and promised to give me a try out. Ever since then I have been known to Mabena as 'my goalkeeper' and he has been known to me a 'my captain' although despite my constant nagging the try out has yet to happen.

Luckily for me the hospital has recently formed a team and as the tallest guy around and quite frankly the only one who showed any interest I was a shoe-in for the number 1 shirt. Practices have largely consisted of 5-a-side games on a tennis court with no goalkeepers so I was a complete unknown when we had our first game recently.

The day of the game started with few surprises. Firstly, our captain had his first beer will before the scheduled meeting time of 10am. Secondly, the actual meeting time turned out to be about 12 o'clock and after driving half an hour to the pitch I was told that the opposition had not yet set off and were 2 hours away. So no great surprise then that the game kicked off about 4 hours late. What was more surprising was that each team had a full set of clean kit, the goals had nets, there was a ref with a whistle and two linesmen complete with football socks tied around stick for their flags.

The game itself was a scrappy affair on a dusty and uneven surface and as full-time approached with the score was locked at 2-2. The full-time whistle blew and no-one was satisfied so it was decided to play extra-time. By this stage the opposition were passing beer bottles between them as they played so I felt we had a chance. It was deep in the second period when a looping shot came in and with half an eye on bowling it out for one last counter-attack it slipped through my hands and trickled over the line. Gutted wasn't the word. I sheepishly returned the ball to the centre circle but the final whistle blew shortly after. I apologised to my team mates as we sauntered off but within five minutes it seemed to have all been forgotten. The focus turned almost immediately to the pub and how we were going to beat them in the pool competition later anyway. It's comforting to know that whether in Africa or Anfield some things never change.

The difference a decade makes

The 17th March 1995 was a Friday. In the UK it was ‘Red Nose Day’ and it was the day one of the Kray twins died. These facts are etched in my memory because it was the day I stuck an HIV contaminated needle into my finger. I remember almost everything about that day from the feeling of horror at the first sight of blood on my finger to the look on the face of my girlfriend when I told her later that evening. It was a Wednesday three months later when the consultant told me that the HIV test was negative. The details are a blur but I can still remember the sleepless night beforehand and the feeling of utter relief at the news.

It was only a week ago but already I’ve forgotten the date. Sixty patients had finished collecting a month’s supply of anti-retrovirals at the isolated rural clinic when a staff member saw her chance to grab a quiet word. She said she knew deep down that she had HIV and neither of us was surprised when the point of care test result was positive. It was at that moment that the needle slipped in my hand and stuck into my finger. As I had done more than a decade before I squeezed blood from my finger but my reaction couldn’t have been more different. With no occupational health service within 100 miles and a recent negative HIV test under my belt I simply put into action the plan I had rehearsed for this moment. I walked calmly to the pharmacy assistant and asked for a dose of anti-retrovirals. I then just returned to the newly diagnosed woman to offer her post-test counselling. I had no worries for the remainder of the day except the wave of medication-induced nausea that swept over me later that evening.

The important difference between the two events of course is the availability of anti-retrovirals. In 1995 I had yet to enter medical school and to many people, including myself, HIV infection meant an automatic death sentence. The knowledge that the chance of infection was only around 1 in 300 did nothing to alleviate the terror I felt. The image of Tom Hanks wasting away in the film Philadelphia was only too real to me as I was working as the phlebotomist on a ward where I regularly witnessed people in the last stages of AIDS. I had no idea, I’m not even sure if the experts new, what was on the horizon.

The figures are debatable but my chances of being infected this time are probably less than my yearly risk of dying in a car crash in South Africa. I also feel comfortable that should the worst happen I could still at least look forward to watching my own grandchildren grow up at the end of a productive life. With the rollout of anti-retrovirals gathering pace, at last many South Africans with HIV can expect the same. The hope is that should I be writing a similar post in a decade’s time the big news will be of the huge increase in the numbers accessing treatment rather than the fact that effective treatment exists at all.

Staffing issues

Before coming to Afica I was troubled by this point. If I was prepared to donate 6 months of my time to the cause then how should it best be spent when looked at from the point of view of the patients. In short, should I go to Africa and do the work there or alternatively should I stay in the UK, live in a tent in field whilst working extra hours in a UK hospital but sending all the money to someone I trusted in Africa. The thinking was that although the former would be something I would prefer to do for myself perhaps the potential receipients of my 6 months labour would prefer the latter and maybe that was what I should actually do.

While it hasn't taken me all year to work this out I now realise that without a shaddow of doubt the right thing to do is to come and do the work here. As I have eluded to before in these posts it is the shortage of human rather than financial resources that is the biggest problem most of the time.

I'm therefore left wondering if there shouldn't be a shift in thinking regarding the financial needs of hospitals like ours. I will stick to the doctor situation for now although the same could be applied to most other groups. There are 8 doctors working here of whom 5 are foreign, 1 is here as a part of compulsary service and only 2 are South Africans who are here by clear choice. There are 140,000 patients under our care and we are in the middle of an HIV/TB pandemic so the ratios are in no-ones favour. The bottom line is that rural African hospitals can't rely on do-gooder foreign doctors like me in the long-term . I'm personnally very happy with the terms and conditions here (except the lack of hot water!) but I'm not talking about me. For sure a limited amount could be done by tightening compulsary service rules for South African doctors but the reality is that large numbers of staff will only want to come here if the living conditions are excellent and to put it bluntly the salaries are very high.

Significant funds have indeed been chanelled towards improving staff living standards but I can imagine that it would be extremely controversial to direct extra resources towards higher salaries. What I would say is 'look at it from the patients' perpective'- would they rather have a bunch of extra doctors and nurses and rehab. staff etc. or more expensive pieces of equipment that no-one knows how to use or get fixed when they are broken? I think the answer is clear but I suspect the change is very unlikely to happen. Perhaps I should go back to the UK and live in my tent and use the money to fund extra salaries after all!

Cleaner hospitals

Before I left the UK I remember that 'Cleaner Hospitals' had become a new political catch phrase, along with 'tougher on crime' and 'small class sizes' etc. I also remember when the previous government privatised hospital cleaning in the UK. As I recall they basically sacked all the cleaners on Friday and by Monday same people were hired by the new cleaning companies but were paid less money, it was one of those great advertisements for the motivational attributes of the open market.

Well, the Eastern Cape government can now claim to be ahead of the UK government on both counts. Until recently the hospital was cleaned by a group of generally older women who mopped the floors with various degrees of enthusiasm and kept it reasonably clean. However, someone somewhere decided to contract out the hospital cleaning to a private firm. So one day a whole new army of cleaning staff clad in heavy grey uniforms weilding yellow signs with flashing lights on top started patrolling the corridors. There are so many of them that it can be an obstacle course getting from one ward to another but the place is looking pretty spick and span. I don't think people have to worry too much about hospital super-bugs around here anymore- so one up for the Eastern Cape.

The killer move however is that instead of sacking the old ladies or making them carry yellow signs with flashing lights they just continued to employ them. They have been farmed out to some of the peripheral wards in droves, they now seem to have even more time for gossip and seem to be loving it. This means that since privatisation we effectively now have two complete teams of hospital cleaners working on the same hospital at the same time and no-one has been sacked or had their pay cut. Now why didn't the UK government think of that?

Learned helplessness

If you seperate a predatory fish from some prey fish with some clear perspex the fish will initially keep knocking into the perspex to try to get to the food, after a while it will give up trying and just swim around and ignore them. The interesting part is that if you remove the perspex the predatory fish will continue to ignore the prey and will not make further attempts to catch them, this effect is so extreme that the predatory fish will actually die of starvation before it tries again to catch the prey again- hence the fish has learned helplessness.

Life in the Transkei can sometimes feel like the life of the predatory fish. For example I've developed learned helplessness towards accessing various tests for my patients. I have tried hard to access CT scans through the government hospital but have had virtually no success and had essentially given up.

What I've learned is that just as in the fish story it is a dangerous mindset to slip into because you just never know when the perspex has been lifted. It often takes the fresh approach of a new member of staff to spur you into action and in my experience you can get some great results when this happens. For example, I've recently learned by chance of a new approach to the CT scan problem that may well work and it has spurred me on to revisit some other obstacles that I had previously abandoned.

Bumblebees

I remember learning that while most animals behave to get as much done for a given amount of energy expenditure (maximise benefit/energy cost) this isn't true of bumblebees. They behave in such a way as to get the most done per unit time (maximise benefit/time cost). This is because after a determined length of time they essentially 'wear-out' and die. I've noticed something similar in human resource poor medicine which I wanted to share.

In high human resource settings doctors are generally encouraged to make decisions based on health cost vs benefits. Prescribe a certain drug to enough patients and the adverse side-effects will be out-weighed by the improved quality and quantity of life (health benefits > health costs). When human resources become limited the doctor is often faced with a different question. Is it worth me spending a certain amount of time on an intervention for a given benefit to the patients (maximise health benefit / unit of doctor time). There are a whole bunch of initiatives I would like to start including aspects of preventative medicine and intensive care of the critically ill. The question is not whether there is a cost vs benefit advantage to the patients but given that time is very limited, which of these interventions should I choose to do at the expense of the others. Basically you need to have a much greater understanding of how much something works and not just that it works at all. Financial resources must be considered in both settings but where I'm working financial cost comes into it less than you might think.

I have something else in common with the bumblebee because the only other thing I remember learning about bumblebees is that according to the laws of aerodynamics it is impossible for them to fly!

The similarities

It is easy to get caught up in all the differences and oddities you are likely to encounter when you move to a new culture. What I hadn't given a thought to were all the similarities that I would find. Steven Pinker talks about the fact that in all cultures people tell stories, recite peotry, sing, dance, decorate surfaces and perform rituals but isn't it the differences in the stories and the rituals that people generally find interesting in other cultures?

What I'm talking about are the things that appear to be all but identical. I'm not surprised that young men love football and drink as much beer as they can afford but it's easy to forget, when people appear engrossed in a daily struggle to survive and bring up children, that there is always time for gossip for example. The old women standing beside the road may have no shoes and smoke long wooden pipes but if you eavesdropped I'm absolutely sure you would hear the same conversation that could be heard the world over about who doesn't keep their house clean and who's husband has run off with a younger model.

The way women look after their children also seems so similar to me. The absolute amount of money floating around might be different but children still nag for a few cents for sweets and mothers still seem to resist for a while but eventually give way for 'a bit of peace and quiet'. Flirting is another thing. A bit of harmless flirting with slightly older nurses seems to get you just as far on the wards here as it does in the UK.

It's the little differences

When you move to a place like the Transkei it is pretty obvious that you are going to encounter areas where your own culture is at odds with the local culture. After all it’s one of the reasons for visiting a different culture in the first place. What is interesting then is not that you find differences at all but exactly which things are different and also which things are surprisingly similar.

The latest difference I have encountered is in the attitude to exercise. My naïve view of Africa, based on the seemingly endless supply of talented distance runners from East Africa, was of children running 10km to and from school every day and perhaps a few talented adults out on the roads training. I couldn’t have been more wrong.

I go running after work often wired up to an iPod and sometimes with a head torch, thankfully no-one can see that I also have a chest strap under my shirt measuring my heart rate. To begin with I quite enjoyed the small trail of children joining me on the roads. However, the only things I notice now are the old women who, when they spot me coming, start jogging in a caricature of accentuated strides, swinging arms and a mocking giggle. Worse are the groups of young women who simply burst into fits of laughter as I go by.

When you think about it for a minute of course it’s a completely crazy pastime. They all know that I have a car and a housekeeper and could quite easily sit on my veranda sipping cool beer after work. Instead I choose change my clothes and then to run off in a seemingly random direction only to turn around at an arbitrary point and run all the way back, sometimes I do all this in the rain and the pitch dark. I don’t actually go anywhere useful, meet anyone or collect anything. I just get tired, hot and sweaty for no obvious reason at all.

Worse than running is cycling, sometimes I take a bike to a peripheral clinic and rather than drive home in a nice comfortable 4x4 I put on a yellow helmet and some strange shoes and huff and puff my way home on a bicycle instead. To someone who would walk 10km because they don't have a few Rand for public transport this clearly seems like a crazy decision.

If they knew that one of the reasons I did all this was actually to lose weight it would be the last straw. In this area you can reliably predict the income of an individual by measuring around their waist and most people spend more than half or their income on food the idea of deliberately losing weight remains completely foreign. I can't wait to tell them about those crazy foreigners who eat as much as they can only to then pay a doctor to suck all the fat out of their belly so they can start eating again.

Frustrations

Up until now I've tried to resist writing anything too negative so I'll try to get it all out in one go. I think the worst frustration is that although there is often money available it often gets spent in ridiculous ways. There are so many expensive pieces of equipment lying around that either no-one knows how to use or are not working and no-one knows how to fix them but when you want something simple and cheap it is not available. For example, someone recently installed a very expensive state of the art piece of anaesthetic equipment in our operating theatre, it must have cost £10,000, yet we have no trained anaesthetist and no specialist surgeon with little hope of either arriving soon. Just recently the head of maternity services spent her budget on an enormous desk and comfy chair that are sitting in her office (I think the chair gets more use than the desk); this is in a department that often has inadequate resuscitation equipment for sick newborn babies. It feels like living in dictatorship when the despot spends the last of the foreign currency on fighter jets rather than grain.

I thought that because South Africa is a middle income country it might be spared some of the corruption found in other African states. However, even in the medical profession there are many stories of doctors who claim full salaries from the government but spend less than half of their time working in the public hosptials and the rest of it working in private practice.

I must balance these frustrations with some of the freedoms that working in this environment gives you compared to working in a First World setting. Paperwork for doctors is generally kept to the minimum required to deliver effective care rather than the excessive amounts required to stand up in court, and similarly it is not necessary to over investigate healthy people for reasons of avoiding litigation rather than because it is what they really need. The bottom line is that wherever you work there will be frustrations, when you move from the Developed to the Developing World you really just swap one set of frustrations for another.

About altruism

Some people have suggested to me that it is altruistic to leave the UK and come to work in a remote rural setting but in my view this could not be further from the truth. Altruism is when you behave towards someone in a way that is harmful to yourself while being beneficial to the other person. Being run over by a car in the act of saving a complete strangers life would be an extreme example. Such acts are pretty rare and when it comes to choosing a job or a way of life they are completely unsustainable. If the people who came to work here were true altrusits they wouldn't last more than a few months, the only way to stay for a long time is to enjoy it.

It has occured to me that if I wanted to be altrustic I would move back to the UK, live in a tent, work 120 hours a week probably in some private hospital somewhere and send all the money out her to be spent for the benefit of the community by someone I trust. Maybe I am overerestimating what that money could do or underestimating what I am actually doing here but it is possible that this choice would be of more benefit to the community.

Just because I'm not an altruists doesn't mean that I think this is any old job. Nobody's perfect and I don't mind admitting that I can feel a little pleased with myself when people ask me what I'm up to. I wish it wasn't so but I can't help it. Nor does it mean that I haven't made sacrifices, a clean hot shower would be real luxury at the moment for example, but hasn't everyone had to make sacrifices along the way.

It also doesn't mean that I think this is the most important thing in the world either. I honestly beleive that a group of motivated teachers, businessmen or water engineers could have a huge impact on this community that would probably far outstrip the benefits that can be acheived by improving healthcare. All I'm saying is that when it comes to leaving the world in a better place than you found it it certainly beats marketing cigarettes to children or writing computer viruses for a living.

The meme pool

Something that has struck me about the HIV/AIDS epidemic in the Transkei is the effect it must be having on the meme pool. A meme is a unit of cultural information such as an idea of practice that is transmitted from one generation to the next either verbally of by repeated action. An example might be a child noticing that her father always unplugs the television before he goes to bed, she copies this behaviour when she gets older, not because her father's genes have influenced her or because she has learnt that unplugging the television is important but because she is copying her father. This is a form of non-genetic inheritance which has some important differences to genetic inheritance. Firstly memes can be passed between individuals or group that are not genetically related such as between groups of friends and unlike genes, memes do not necessarily have to be beneficially to the individual to be propagated, like computer viruses they just need to be good at replicating.

In the Transkei approximately 20% of adults are infected with HIV and without treatment the majority will have died in 10 years. Assuming they are infected around age 20 and become sick some time before they die that means that many of the years that they could potentially spend propagating their memes will be lost. Remember that you don't have to be in your reproductive years to propagate a meme, you just have to be someone that people copy.

With our current level of knowledge about HIV there is only one way to avoid this once you are infected. You must possess the memes 'willing to accept HIV status', 'willing to join an HIV support group' and 'diligent pill taker for the rest of my life'. Although I wouldn't exclude genetic influences on these behaviours they might well be described as memes.

At the moment it seems clear that these memes are more likely to be present in the female popultion who often thrive on the support group environment and seem much more organised about taking medicines than men. Although this is of course a generlisation it seems likely to me that unless there are radical changes to the way we treat and prevent HIV, the popultion meme pool will shift towards acceptance of HIV status and disciplined pill taking as anyone not possessing these meme will die and have less opportunity to pass on their own memes to people around them.

Similar arguements could be made about the way people are infected with HIV in the first place. The meme 'only have unprotected sex with someone who you know (or are very confident) is HIV negative' would spread very successfully if it was readily copied by the group. The meme 'always use condoms when having sex' would also pass to the next generation, interestingly this would be at the expense of the genes as anyone who always used a condom would not be passing their own genes to the next generation.

There are of course many generalisations and simplifications to my arguement, including the interaction of memes with genes, although I would expect the gene pool to be altered in a similar way to the meme pool. Also as I said earlier these memes won't propagate simply because they are beneficial to the individual but given that not possessing them results in your early, death deleterious memes would have little time to propagate. Presumably there are experts in memetics out there studying these effects but if not I think it would make a fascinating study of non-genetic natural selection at work.

NGO's

I am sorry to post what amounts to a 'rant' but it's been that kind of week. NGO's (Non Governmental Organisations) often get a bad press for reasons ranging from disorganisation to culturally inappropriate interventions that have little long-term impact. However, as a rule I would be quick to congratulate most NGO's for the undoubted good work that they do, in fact I am currently employed by an NGO although I work in a public sector role.

This weeks however I have seen first hand the negative impact that well meaning interventions can have. An NGO has moved into our area in an attempt to improve one of the patient services (I would rather not identify them on the internet so have omitted the exact details). That is a great idea and we are keen to form a partnership with them to improve these vital services. We even presented their job opportunities to our own staff and encouraged them to interview. The NGO is paying triple the wages that we can pay and are working in the same field so there should be no problem. However, the NGO has not been organised enough to actually find any work for the new staff to do. The result is that they are sitting around being bored while earning triple their old salary. Of course they are still friends with our current staff who, not surpisingly, now all want to go and work for an NGO. So at a stroke they have spent a great deal of money, they have reduced the quality of care for the patients by recruiting our staff who now do no work and they have managed to demotivate all of our remaining staff- thanks alot. Even worse if they don't get their act together and produce results soon their own funding will be withdrawn and all their staff will be out of work- great.

My own view is that the world has enough NGO's now. I think that anyone wishing to found a new NGO should think very carefully about their own motives as I'm convinced that a talented motivated individual could have a much bigger impact on the world by re-organising an existing organisations than going to the trouble of setting up a brand new one.

Milestone

At the risk of patting ourselves on the back we are pleased to announce that we put our 1000th patient on ARV's last month. There was some debate, or perhaps arguement, about which exact patient was the thousandth, at least three people were told that it was them. Perhaps it is like being the one billionth person in India or China, it's best just to pick someone at about the right time and go with it. As my personal contribution was small compared to the collective effort I think I can say that it was pretty fantastic to get there. There has never been a waiting list to start so it represents everyone in the area who is tested for HIV, who needs the drugs and most importantly has committed to take them lifelong.

One thing that struck me the other day was the strengh of the link you have with the patient. If as a doctor you spend your life handing out pills for high blood pressure you have to treat quite a few people for quite a long time to prevent one of them having a heart attack. That means that you never actually know which of the patients is still alive as a result. With HIV medication it is different, when I talk to a guy who had 'full blown AIDS' 2 years ago but now leads a normal life I can be as certain as a doctor ever can be that he is alive because of the drugs. Many branches of medicine can say the same of course, any surgeon who removes a malignant cancer at an early stage for example, but it is not something I have experienced that often and it's a good feeling.

About being rich...

Since I started earning a doctor's salary I've never been short of money, but neither have I ever felt truely rich. By that I mean that I have always found it hard to undestand how someone could spent £1,000 on a pair of sunglasses or £2,000 for a night in a hotel. It just seemed like a waste of money; could the expensive sunglasses really be that much better than a pair for £20 from the chemist for example?

South Africa has one of the largest income inequalities in the world. The average income of the richest 20% of South African households is 45 times more than the average income of the poorest 20% of households for example. Thus I find myself being in the former group while living in an area made up mostly of the later group. So while I earn something like 8 times the minimum wage, with the employment rate being under 10% in this area most families survive on far less than that.

I bought 12 bottles of wine today and it cost more than the monthly income for many families and I drove home in a car which for many is as far out of reach as a helicopter is to most people in the UK. I don't see why I should feel more guilty about that than if I had done the same thing in the UK but I do. And it has definatley opened my eyes to why people pay so much for their sunglasses.

Microfinance in the Transkei

The HIV unit could not run without it's 20 or so counsellors. They are all volunteers who do a great job supporting the programme. Their primary role is in educating patients about HIV/AIDS and about the drugs that can be used to tackle the infection.They run support groups and do individual counselling to prepare patients to start their lifelong therapy. They do many other vital things from translating for the doctors to filing and even cleaning the buildings. Although technically volunteers they should not be confused with people who have perhaps retired and have some free time on their hands. As there are very few employment opportunities around here most see it as a full-time job; it is skilled work and they work very hard. The problem is that the government does not recognise their vital role and therefore won't fund their positions, they are therefore paid a stipend through the charitable funding of the programme. It amounts to around 800-1000 Rand per month. To put it in context a loaf of bread costs 5 Rand and a hospital cleaner takes home around 3500 Rand per month. Quite understandably, when a cleaning position becomes available many of the counsellors apply for the post. I think I would consider becoming a hospital cleaning for a 4-fold pay increase!

This is where microfinance comes in. Most of the counsellors want to carry on with their job but really need to supplement their income and they often have an idea for a small business venture. My only knowledge of business it to try to make more money than you spend but I'm trying to help with simple advice and a little start-up capital in the form of an interest free unsecured loan. So far we have six ideas that are at various stages of development. Christina has a camera which she uses to take photos of local people, she makes a 4 hours round trip to Mthatha to print the pictures and then sells them on at a profit. Another idea is to use a sewing machine that was donated to the hospital to make linen and other items, a third is to simply buy basic items like paraffin and sell them on in a small shop in a village. It is early days but so far all the loan repayments have been made on time and although I am expecting to lose some of the money the hope is that as loans are repaid more loans can be given. I'm grateful to members of my family and some friends who have kindly offered to take on the financing of some of the projects.