Letter from Zambia 'Naught for your comfort'.

From the privileged position of the academic, removed from the harsher realities of clinical medicine, it is difficult fully to appreciate the health problems of Zambia. The elderly white person, like me-for life expectancy for men is under 50-can still 'enjoy' a somewhat colonial lifestyle with servants, clubs and High Commission. The poor of Lusaka are kept at bay by barbed wire, 24 hour security guards and the apparent invincibility of the expensive motor car over the pedestrian. The statistics of health and disease-so alarming, so inaccurate-do not impinge. The camel has always found the eye of the needle a problem. My change in social status and possession of wealth as a white man in this part of Africa is a sore embarrassment after a life in public health medicine in England, where one neither belonged to the rich elite nor wanted so to do. Yet life in Zambia in 1997 must be like living in Victorian England, where death was all around and accepted as part of the way of life. Indeed, the culture is imbued with the funeral and attendance at the funeral. Staff are always excused for a funeral and anything is cancelled for a funeral. The funeral is at short notice, and is expensive in time, travelling and in the hospitality extended to very many guests. The frequent funerals can be extremely disruptive in a hospital or business, and cause much unplanned and sporadic absenteeism. Grief is expressed openly and noisily; the coffin-makers ply their trade with profit (the cost of a simple coffin equates to the monthly average wage). There is a major problem in finding burial grounds reasonably near the city of Lusaka-cremation is unacceptable. The University Teaching Hospital alone with some 1800 beds provides 30—40 funerals a day. The death rate in the children's wards can reach 30 per cent in the wet season, and 70-80 per cent of patients on the adult wards are suffering from terminal AIDS. The statistics are incomplete and of poor quality. The 1993 data suggest 40000-50000 deaths per year from AIDS in a population of 9.5 million, with 1:3 of these deaths in children: the predicted figures for 1997 are 80000-100000 deaths. In 1993 there were 70 000 AIDS orphans and by 2000 there will be between 200000 and 500000. The population growth rate in Zambia is 3.6 per cent, i.e. the population doubles in number every …