Categories
Medical Zambia

Foreign Body

This is the term health workers use for something which has entered a body cavity where it should not be. For example, a child might have pushed a plastic bead up its nose. But expanding this concept a bit, one could say that I was a foreign body working in Kakumbi Rural Health Centre.

On Friday last week, a mum told me that her child had something stuck in his ear. Looking inside with an otoscope I could see only dry, impacted wax. To make sure there wasn’t something deeply imbedded in the wax, I suggested that mother should put a few drops of oil into her son’s ears every night for a week and return for syringing. I confirmed with the clinical officer that we did have an ear syringe.

A week later the child returned. The wax looked soft and I thought it should easily flush out with gentle syringing. I found the large metal syringe but the plunger was lodged in the barrel of the syringe and I couldn’t budge it. I tried adding hot water to expand the metal, I used some detergent and finally employed brute force, but it was jammed solid.

The clinical officer said she would get a normal plastic syringe and flush out the wax while I attempted to fix the metal syringe.

Finally, I unscrewed everything I could and took it apart. The plunger was still immoveable, but there was an odd bit of rubbery material inside the barrel. At first I thought it was a sort of rubber diaphragm, but it wasn’t attached to anything. I fished it out and discovered it was a condom.

Having worked for over 20 years in a sexual health clinic in Leicester, my mind immediately plunged to the depths of depravity. “What kind of perversion is this? Having sex with an aural syringe, but maintaining the presence of mind to use a condom?” I thought, “That’s new one on me.”

I formed a mental image of what this might have involved, but after a few seconds I realised that someone had tried to use the lubricant on the condom to help the plunger to move. Unfortunately, it hadn’t worked but I take my hat off to whoever came up with that idea to solve the problem. Pure ingenuity.

Categories
Life Thursday Doors Zambia

Thursday Doors @ Kakumbi

This house has lost its roof, but not its door. Unsafe for nursing staff to live here.

Wherever you go, there are doors to pass through. Portes de passage. I arrived early one morning and went on walkabout to take some pictures of the doors near the clinic where I work.

I am not sure that I’d want to invest in PK if the state of the office is to go by

The local Roman Catholic church is made of brick with a portico and a sturdy door.

To call the faithful to prayer, there is no bell tower. Instead, the church official bashes on a wheel rim, hung from a tree, with a hammer.

Outside the police station there is an old container. It serves as a holding cell. It is said that when the door is closed, no prisoner is detained there. But it is like an oven in the heat, so the door has to be kept open so that any prisoner doesn’t cook. The container cell doesn’t have a toilet. I have heard it said that the prisoners all pass urine against one corner. The acid pee has rusted the metal allowing a prisoner to break out. But why would they do that when the door was open?

I am sure that there must be a joke here somewhere about cell blocks

And finally, it is washing day and the sheets are on the line in the sunshine. Just to the right, the lady of the house is entering nurses accommodation, through a secure door.

Categories
Zambia

The Behemoth

The Book of Job describes a monster, a behemoth, which is probably a hippopotamus. These beasts are huge, with adults weighing over 1.5 tonnes. The males don’t stop growing until they die, but the weights of females start levelling off at age 25 years. I was astonished when I looked down on a hippo from the Luangwa River Bridge and saw how broad in the beam it was. Hippos are barrel-shaped. Only elephants and rhinos are more massive land animals. 55 million years ago, they diverged from their nearest relatives, the whales.

On land, they can run fast for short periods, up to 20 mph. Normally, they trot briskly when getting away from a threat. When there is no danger, they walk slowly, often using the same route, leaving a set of parallel ruts, too narrow for a vehicle to use.

Male hippos joust and exert superiority. Their canines can be 50cm in length. They can open their mouths so the jaws are at 180 degrees.

They have thick skins (5 centimetres) but surprisingly not much subcutaneous fat. If they stay out of the water for too long during the day, their skin gets damaged and cracks. Hippos secrete a substance which turns pink in sunlight and protects them from UV radiation. It also has an antibiotic action.

They spend most of their time in pools or shallow rivers. They can’t float and cannot swim well, even though they have webbed toes. In deep water they move by bouncing off the riverbed. They avoid fast flowing rivers or keep to the edge where the current is less strong.

Oxpeckers remove parasites from the hippo skin, but they can irritate by keeping a wound open so they have access to nutritious blood.

All the important bits of a hippo are situated on the top of its head: eyes, ears and nostrils. It can shut its nostrils when it submerges, and can stay underwater for over five minutes before surfacing to breathe. Baby hippos are born underwater and have to learn to swim immediately.

Hippos usually live in large groups, called pods, with up to a hundred members. They are territorial, occupying 100-200 metres stretches of river. A big male tolerates younger males if they are submissive and stay away from the females. If they challenge and get defeated, they may be forced to leave the pod and become solitary.

Sex occurs in the water, with the female being submerged for most of the time while the male mounts her. Pregnancy lasts eight months and the young hippo suckles from its mother until it is weaned at about a year.

Hippos have a reputation for being aggressive if a boat transgresses on their territory or if they feel threatened on land (don’t get between them and the water or between a mother and her calf). They probably kill more people than crocodiles and elephants. They forage at night on land, eating mainly grass and vegetation.

People do like to eat hippo flesh, which apparently tastes like muddy, fishy pork. I have never knowingly eaten it.

Categories
Life Medical Zambia

Two Seizures

Patients with seizures can be like buses; there are none for ages, then two appear within minutes of each other.

Two hippos, not buses, lying on mud beside Chipele Chondombo lagoon.

This morning, Loveness, a 10-year-old girl, limped into the clinic with her granny. I was surprised to see that Loveness had a left-sided hemiplegia. Her granny told us that she had had a stroke following a bout of severe (“cerebral”) malaria when she was two. She had recently moved with her mum to live at her granny’s house, which was in our catchment area.

It was difficult taking a history because of the stigma of seizures. Local people think that a seizure is a sign someone is bewitched and that the evil spirit inside the sufferer might escape and enter anyone who tries to help. Granny gave very guarded answers to our questions.

A detailed history is absolutely essential, with a reliable witness able to describe exactly what happens during a seizure. It is important not to ask leading questions, as patients often want to “please” the doctor by answering in the affirmative.

Loveness started having seizures spontaneously in January 2020. She had an aura, a sensation which precedes an attack; she felt someone was pushing her. She would fall down, unconscious and rigid, following which her whole body would shake for a few minutes. She had occasionally bitten her tongue and wet herself during a fit. She had been having about three convulsions per week since January, but recently she had experienced three in one day. The seizures were becoming more prolonged. Her granny sought help at the health centre because of this deterioration.

Little Bee-Eater taking off from a twig, wings backlit by the morning sun

Zambian children in the health centre are often very subdued. Some are frightened of a muzungu (white) doctor, but they usually refuse to answer questions, preferring their carer to give the history. I needed to examine Loveness’ central nervous system, and this gave me an opportunity to engage with her. I like to squat or kneel, so I am at eye level with the child. I even take my mask off so that they can see my facial expression. If I can make the child relax and smile while I am gathering information, that’s a bonus. We played games while testing her cranial nerves, screwing up her eyes, blowing out her cheeks, showing me her teeth, watching my finger moving in all sorts of weird directions. She had lost the use of her left arm and her left leg was stiff (hypertonic), with limited movement.

I came to the conclusion that the cause of her seizures was organic brain damage/scarring caused by cerebral malaria; she has epilepsy. In the UK, she would have seen a paediatric neurologist, had multiple scans and electroencephalograms, perhaps even being considered for brain surgery. Here in rural Zambia, we have two drugs to treat epilepsy – phenobarbitone and carbamazepine. The latter has fewer side effects but works best in temporal lobe epilepsy. We decided to try it and I will see her in the village next month during the community child health clinic.

I have some diazepam for rectal administration, to halt continuous epileptic convulsions, an emergency. (The drug is extremely effective but out of date and I can’t bring myself to throw it out because I cannot get any more.)

Just as we finished explaining the management plan to granny, the registrar told me that a baby was having convulsions now in the waiting room.

Agness was just four months old, but her disabled mother felt that breast milk was not providing her with enough nourishment, so today, for the first time, she fed her some pap – a thin, maize meal porridge, with cooking oil, sugar and salt. She didn’t use a spoon, but cupped the pap in her hand and poured it into Agness’ mouth. Health educators advise against this traditional feeding technique when giving educational talks in the villages. I don’t know why she didn’t use a spoon. Perhaps she was too poor to afford one.

Agness stopped breathing as she inhaled the pap into her lungs. She had a seizure, probably caused by lack of oxygen reaching the brain. The mother said that she had convulsed for an hour, but I didn’t consider that was reliable information, as she had no means of telling the time. The baby had regurgitated some of the pap.

The baby was extremely distressed, breathing rapidly at 76 breaths per minute, with inspiratory wheeze (stridor). I couldn’t hear any sign of any pap still in the lungs. She was not cyanosed. I don’t have a paediatric pulse oximeter to measure the saturation of oxygen in her blood. We calmed the mother and grandmother down, and Agness was able to breast feed intermittently. It seemed to give her some comfort.

Aspiration pneumonia is very tricky to treat. There had been some cooking oil in the pap, and this could cause lipoid pneumonia. Although initially, children may appear to be recovering, their condition can deteriorate a day or so later. We don’t have oxygen at the health centre. Intravenous antibiotics would normally be withheld for 24 hours to see if the baby is going to recover spontaneously.

The baby was now breathing at 60 breaths per minute and looked more comfortable. I thought we might be exiting the woods, but on reviewing the child after lunch, it was clear the child needed oxygen and more care than we could provide. I organised a transfer to the local hospital (I have since learned that the baby has made a full recovery after a week’s admission).

Black-headed heron landing on a hippo’s head in the lagoon.

In this blog, I write about and post photographs of the wonderful variety of animals and birds in South Luangwa. I don’t want to give the impression that I am just having a fabulous time on safari for three months so I include pieces about my work and clinical problems I am trying to manage. WordPress statistics tells me that clinical pieces are popular, too.

Getting vaccinated at a community child health clinic. Tough love, cruel to be kind.

But it’s probably obvious to some of my readers that my writing about these tragic cases helps me to cope with my own feelings and emotions. Extracting and transforming my sadness, frustration and helplessness into words on a laptop screen is cathartic. And in the words of the BT advert, it’s good to talk.

Categories
Zambia

Baboons

Baboons are like Marmite; you either love them or hate them. I hate them when they crash across the corrugated tin roof of my house at 6am, fighting and squabbling. But the rest of the time, I find them intriguing and (dare I say it?) cute.

Baboons trashed my veranda recently. Cushions scattered everywhere. Cotton throw thrown.
Baboons are very social creatures and spend a lot of their non-eating time grooming each other.
This is the bridge over the Luangwa River, the main entry portal to the National Park. On cool winter mornings, the troop are warming themselves in the sunshine.
Baby baboon suckling from his mother. I always wince when I see how they chew and pull her elongated nipples.
Bliss. Soaking up the sunshine
They have very expressive faces.
Cute baby baboon clinging to the side of an ancient tree
They are natural acrobats
Some advice. Instead of tearing around the park searching for big cats, sit back and watch the antics of a troop of baboons. Much more fun.
Categories
Life

Geckos

Not “Greed is Good” Gordon Gecko. This post is about the lizards. I share my house with at least a dozen. They are khaki in colour, and vary in size from 3 – 12 centimetres. They have suction pads on their toes so they can climb any wall and traverse any ceiling. They don’t bother me at all, because they do bother mosquitoes and other insects by eating them. Which is good news for me.

They tend to shun the limelight, preferring to hunt their prey behind the fridge or curtains. I don’t pay them much attention unless they catch my eye as they scurry from one location to another. Sometimes I see them chasing each other. Whether this is a territorial dispute or a mating ritual, I have no idea. Occasionally, I see one that has lost part of its tail. Geckos have the ability to shed their tail if it has been caught be a predator, to help them escape.

This isn’t a gecko. It is a water monitor lizard in the national park.

Recently I have noticed lots of gecko turds in my shower area. And by lots I mean 20-50 tiny dark shits, about the size of a matchstick head. The shower is separated by a partial wall from my toilet, but even if I leave the toilet lid open, they prefer to poop in the shower. I thought I’d give them something to aim at.

I don’t know why they prefer to use my shower as their toilet. But I have given it some serious thought.

I wondered if it was because of the increased humidity, from the wet floor of the shower. But my toilet leaks (clean water, not foul) and forms a puddle around my ankles, so I doubt that moisture is the answer.

The scene of my and my geckos’ ablutions

Perhaps the act of defaecation is a social event in gecko culture. It may be that all the geckos in my house get together to crap ensemble. Many antelope in the park have a communal toilet called a “midden”. All the impala or puku prefer to poop in the same spot, so it looks like someone has spilled a bucket of black peas on the ground. Could it be that each gecko’s shit contains hormonal messages, showing a female lizard is “on heat” (does this expression even apply to cold-blooded creatures?) or a male is producing lots of male hormones? Perhaps my shower pan is the equivalent of gecko Facebook, where they communicate with each other chemically in their poo?

Interesting: on the left is the shit situation last night, on the right is the shit situation this morning. Not much difference. Perhaps they sleep at night and poo during the day?

Whatever the explanation is, I don’t really care. I just think of all the noxious insects they have eaten to produce this amount of crap. And I never look at the soles of my feet, anyway.

Categories
Zambia

Elephants

Local Zambians are scared of elephants. Quite rightly, too. They regularly kill people. Get between a calf and its mother and you are asking for trouble. The locals think that elephants hate bicycles and will attack cyclists. I know a local man who came across an elephant while riding his bike on a bush track. He threw down the bike and lay beside it, pretending to be dead. The elephant examined his motionless body with her trunk, sniffing and nudging him. As it moved off, the elephant kicked out at him with its back foot as if to say, “I don’t believe you’re dead.” This glancing blow fractured his pelvis.

I feel very safe in my car if I meet an elephant on a track, but my predecessor as Valley Doc was terrified when he came across a bull elephant blocking the road. He reclined the car seat to horizontal, lying out of sight and stayed as still as he could while dialling for someone to rescue him.

I was on foot in the dried-out lagoon when I took this picture. He was obviously interested in something else as he made his way to the forest.

I think I can read the signs when an elephant is irritated and wants me to get lost. If it is safe, I reverse and keep out of its way. If it is calm, I stop the vehicle and wait for it to move off the track. They can come very close, within a metre, and often look at me, sizing me up, not a threat, as they plod past.

Very rarely elephants will attack vehicles. I have heard of one young bull breaking off a tusk in the radiator as he tried to flip a game-viewing Land Cruiser. I reckon I can detect testosterone-fuelled bluster, when young bulls make a mock charge. You just have to read their body language and stay calm. And keep the engine running.

I enjoy just watching them quietly, learning more about their behaviour. I saw a female bring her calf to a water hole, but the edge was so steep and deep, the calf’s trunk couldn’t reach the water. The mother drank her fill then turned to her calf, manoeuvred its head under her trunk and regurgitated water into the calf’s mouth. She did this several times until the calf was sated.

A few weeks ago, as soon as it turned dark, I heard the sound of elephants wrecking the bushes and small trees beside my house. I had been invited to dinner and was hoping to walk over to my neighbour’s house, across 50 metres of rough ground. She telephoned me to say that a family group (about six) of elephants were grazing around our houses and not to come. I waited for half an hour, checked that the coast was clear and walked to her house, flashing my torch into the bushes to make sure the elephants had gone.

We were just sipping a pre-dinner drink on the verandah when my neighbour said, “They’re back. The elephants are round the front.” As no one had answered the front door, one bull elephant decided to come around the back, where the verandah overlooks the lagoon. We watched as he lumbered past the side of the house, pausing to pull off some weeds from the thatched roof for a quick snack. He then padded over to a dead tree and scratched an itch.

Rather recklessly, I was sending images of the elephant back to the UK using WhatsApp. The notification noise of a reply on my smartphone is particularly jarring. The bull stopped demolishing a tree branch, turned to the noise and walked over to the verandah. He peered under the thatch where we were externally motionless, but internally trembling. After a few seconds, he decided that leaves were more interesting and he moved off. Eventually all the elephants walked down to the lagoon and we breathed sighs of relief and excitement.

Sorry about the poor quality. It was night and this beast was very close

Sunday lunch, a barbecue by the river, what could be more pleasant? We drove an hour south on a well-graded road and pulled over under the shade of a huge tree and started a fire. As the mopani flies (tiny midge-like creatures that get in your eyes and up your nose) were troublesome, we lit some dry elephant dung to create smoke which repels the flies. We arranged out portable chairs around the fire, trying to be near the smoke but not choked by it. It worked very well.

Three bums

George cooked the pork chops and boerewors sausage to perfection. The chicken thighs in spicy sauce were delicious. The baboons are afraid of people in this remote area so they didn’t pester us trying to steal food. Elephants are vegetarians, they didn’t want our food, but we had to keep our eyes open in case they lumbered into our party area. The breeze shifted after lunch (and a couple of gin and tonics), so I moved my chair, paying attention to where the smoke was drifting.

Fresh elephant dung, left a few metres from my house in Kapani

No sooner than I’d sat down when I asked, “Folks, I can smell elephants, can anyone see them?” Elephants do have a distinct, strong odour. Everyone scanned the horizon until Vicki pointed out that I had moved my chair over a flattened mound of fresh elephant dung. Normally, it looks very distinctive, like bowling balls, but this had been picked over by baboons, looking for choice bits of undigested food, and they had scattered it about. So much for my bush craft!

Categories
Medical Zambia

A Surfeit of Clinical Officers & Urine Pots

We now have four clinical officers working at the clinic. There are just two consultation rooms, one with a couch, the other with a massive vaccine fridge instead. The treatment room does have a couch so if no one needs minor procedures, injections, dressings, etc., a clinical officer can work there, too. I had suggested that we might train up one clinical officer to become a de facto pharmacist, but our stock of drugs is so low that it is hardly worth the effort.

A sink in the clinic without a functioning tap or running water.

A new clinical officer started work this morning. She was very keen and wanted to sit with me as I was teaching another CO, trying to improve her consultation skills. In many cases, the history consists of a few lines – abdominal pain, headache, fever, cough – or something similar, occasionally with a duration. I suppose if your treatment options are extremely limited, why bother delving into the symptoms and signs if you don’t have the drugs to treat the illness you have diagnosed?

But with some effort, we can try some clinical diagnostic reasoning, come up with a plausible diagnosis and construct a management plan.

Bat faeces in the roof has damaged the ceiling in the male ward. Note the mosquito net slung from the energy-saving light bulb

“OK, you have written abdo pain 2/7, can you tell me more about the pain?” I asked the CO. “The patient has belly ache,” she replied. “Anything else about the pain?” I inquired. “The patient also has headache,” she said. “Let’s stick with the pain. Have you heard of SOCRATES?” I asked. She said she hadn’t but when I wrote it vertically on the page of the patient’s exercise book and said “S stands for site, O stands for…” she said, “Onset.” Ah-ha, she remembered the mnemonic, but this refers to what was happening when the pain first occurred, not when it occurred.

Character of the pain is always difficult because of language, cultural and vocabulary issues. “What about radiation? Does the pain go anywhere?”

The CO wasn’t familiar with the concept of radiation. I gave her some common examples – kidney pain radiates? “To the other side?” “No, to the groin.” Gall bladder pain radiates? “To the groin?” No, to the shoulder tip. I explained about the mystery of dermatomes and their innervation.

A for associated symptoms was easy. Headache.

T for time or duration of the pain, constant or coming/going.

E for exacerbation. What makes it worse, what makes it better.

S for severity, but it is always severe.

A surfeit of plastic urine bottles, all stored in the lab. Last year we were washing out and re-using them; this year, we are flush.

The patient had attended a month ago with abdominal pain and headache. A urine test detected a tiny amount of blood and under the microscope, the spiny eggs of schistosoma haematobium. She took some pills for bilharzia, but perhaps this was an incidental finding, because she came back a fortnight later, with the same symptoms. She was treated for gastritis, but this didn’t work either. We needed a Plan C – how about physically examining the patient?

She had tenderness in the right lower quadrant of her abdomen, with a possible mass. We discussed the differential diagnoses and sent her off to the hospital for a sonogram. Hopefully this will give us a treatable cause for her discomfort.

Carmine bee-eater, a bird on the wire.

I am trying to get the clinical officers more interested in their patients, to be more patient-centred as GPs are in the UK. Curiosity is a virtue.

Categories
Zambia

African Fish Eagle

One of my friends who lives on the eastern bank of the Luangwa River has a smartphone. The ring tone is the squawking call of a fish eagle. I still find myself looking up into the sky trying to spot an eagle when her phone rings.

Fish eagles are imperious birds. They like to perch high in dead trees, so they get a great view. This means that they are easy to spot and photograph. I took a dozen photographs of an immature fish eagle scanning a cabbage-covered lagoon in the park, trying to shoot every angle of his head. On returning home, I loaded up the images into my laptop, intending to delete most, keeping just one or two for posterity. But the eagle was so magnificent, that I found it impossible to cull most of the photographs. Here are a few for you to enjoy.

If they are not perched by the riverside, I sometimes see them on the ground, tearing at a lizard or a fish which they have captured in their talons. I have only ever photographed a fish eagle swooping down to pluck a fish from water once. And that was a cheat, when a guide took us out into Lake Naivasha in Kenya and threw a dead fish into the water. Our cameras sounded like the staccato of machine gun fire as the habituated eagle picked up the floating fish and flapped away.

In 2018, I bought a new Panasonic Lumix G9 camera, with a couple of Leica zoom lenses. They were on sale so I treated myself. There is a mode on the camera to record 60 pictures in a second. Even better, if you half press the shutter button, it will record the previous half second’s images. This makes up for my slow reaction time. So I pointed the camera at this majestic fish eagle, pressed the button as soon as I saw it take off and got sixty brilliant pictures as it left the branch. Job done, I thought.

Then I turned away from the viewfinder and watched the eagle swoop down onto the surface of the lagoon and catch a fish in its claws. It flew off into the distance to eat its fish supper in peace from intrusive paparazzi.

It was better watching the eagle in action with my naked eye than using my camera with its fancy electronic wizardry.

Categories
Life Medical Zambia

Human Papilloma Virus Vaccination

The best laid schemes o’ mice an’ men / Gang aft a-gley.”  – Robbie Burns

WARNING: This may be interesting for you if you enjoy observing the trials and tribulations of logistical planning, but otherwise, it might be rather boring. Even the accompanying photographs.

The Ministry of Health’s plan was simple: vaccinate all 14-year-old girls and give them a booster a year later to provide protection against cervical cancer. Repeat annually with each cohort of young girls.

Now, vaccinating infants is easy; their mothers bring them along to our community clinics to be immunised. But how do you access teenage girls? The obvious answer is to vaccinate them in school.

Not all girls go to school, however, especially in rural areas.

And students change schools, moving to different locations, for a better education, often at age 14.

Then Covid-19 arrives and schools close down, completely wrecking your strategy.

“Can you help us boost our coverage, Dr Ian?” asked D, who is in charge of immunisation campaigns at the health centre. I agreed and asked to see what had been accomplished so far.

D handed me six huge registers, in which the teams had recorded the vaccinations, given at six local schools.

“What does this mean?” I asked, pointing to rows of children’s names where the column indicating the date of HPV vaccination was blank.

“I am sure that they have had the vaccine, we just didn’t record it.”

That sounded very odd. If you bother to record the name and village, why wouldn’t you add the date of vaccination. Even if you just put ditto marks in the column.

D with three girls waiting for their HPV vaccination

We did some investigating. It turned out that the vaccinating teams were understaffed, so they asked the teachers to write down the names of all the girls in their classes who were 14. But not all of these girls were at school on the day the vaccination team arrived, or had refused to have the vaccine.

“Did you not know about this, D?” I asked him. “Ah, doc, I didn’t vaccinate at this school.”

“Right, how many 14-year-old girls did you vaccinate last June/July?” I enquired.

D didn’t know exactly, but the nurse in charge said that he had reported 269 to the Ministry.

OK, so how many girls are recorded in the registers as having been vaccinated? He didn’t know, so we copied the information from the registers into an Excel workbook and counted 311.

“Why do you think there is a discrepancy?” D didn’t know and neither did the nurse in charge. “Perhaps you vaccinated 269 schoolgirls and 42 girls who were not attending school?” I suggested.

“How about coming at this problem from a different angle. How many doses of vaccine did you use last year?” I asked. D said that the Ministry of Health had collected all the unused doses in August 2019 at the end of the campaign, so he couldn’t check.

“But that was last year, doc. I am worried about this year,” D said.

“So what is your target?” I asked.

“All the girls we vaccinated last year who are now 15, plus the girls who have turned 14,” he replied.

“What’s your estimate of the numbers?” I asked. D said that the Ministry of Health had worked out how many doses we should have based on some ten-year-old census data uprated by the estimated growth in population.

“So, how many do you think this year?” I asked. D wasn’t sure and wouldn’t hazard a guess.

“Okay, we don’t have precise figures, but is it logical to assume that at least the same number of girls are born each year? We vaccinated 269 or 311 girls who were 14 last year, so we should be aiming to vaccinate that number plus a similar number of girls who turned 14 this year.”

“If you say so, doc.”

“Let’s say about 600. How many doses of vaccine did the Ministry of Health deliver to us?”

“We got 550 this year,” he said after checking the records.

“And how many doses are left?”

“About 300.”

 “Good, so we are about half way there,” I offered. “How did you manage to vaccinate so many when the schools were closed?”

“The students who are in their examination years are still attending school.”

We looked at the Excel spreadsheet, where 145 15-year-old girls had received their second dose and 88 14-year-old girls had received their first dose, during the past two months.

“So, what can we do now? How do we get to the girls who are not at school?” I asked.

“We can use our community health volunteers to mobilise them,” he said. “Then we can vaccinate them all in one day going from village to village.”

“But students don’t always go to the school nearest to where they live. They try to get into the best schools or they get rejected from other schools. We are lucky to have their villages recorded in the register.”

The prospect of trawling through six registers was daunting until I discovered that D had a database of all the villages in the health centre’s catchment area. There are ten neighbourhood health committees, each with a volunteer health worker. A bit of magic with Excel and we were able to print out a list of all the 15-year-old girls who were eligible for their second dose in each location. We delivered the list to each volunteer health worker. They had 48 hours to locate the girls on their list, plus any 14-year-old girls, and we would be along to vaccinate at a particular time.

He is not going to be vaccinated

Unfortunately, some volunteers were unable to identify any of their target population. Others had tracked down every 15-year-old. They could tell us where the girls had relocated: back to Lusaka, to a good school out of our area, or who had become pregnant. We only managed to vaccinate another 20 girls.

In one village, D said he had a message to the girls who had come for their vaccinations. “During this time of Covid, when the schools are closed, keep yourselves busy. Don’t give in to temptation and go with boys because you don’t have anything better to do.” I looked at the group of girls on the mat and thought that they looked like mature, young women.

I foresee that there will be a big rise in teenage pregnancies in 2021.

We still had hundreds of girls to vaccinate. I asked A, the other health inspector, what we should do. She said, “We should contact the girls.” But how? “Some way.” Yes, but how exactly? It’s no good just saying what you want to happen without a plan to make it happen.

“Give me some time, I will think about it,” said A. But we don’t have time. The Ministry will be taking back the vaccines in August as it assumes we will have successfully completed the campaign by then, regardless of the disruption of covid. I had a plan to use the local radio station to spread the word, but I wanted A to come up with that suggestion, so I could make her take ownership of the problem. With some unsubtle prompting, she thought using the radio station would be a good plan.

“Okay, what would you say on the radio, A?” She wasn’t sure, so I drafted a short statement about preventing the number one cancer affecting women in Zambia, how safe the vaccine was, who should have it, and the dates and locations we would be offering the vaccine over the next few weeks.

D stumbled while reading the statement in English, never mind translating it into Kunda, the local language. I suggested a female voice would go down better for a health message directed at girls and young women. A translated the piece and gave a seamless performance. We drove down to Radio Mhkanya and I sold the story to the station manager. “It will make a great two-minute news article,” I said. He agreed and A went next door to do the interview.

I asked the station manager about the catchment area of the radio and he told me it was about 50km in all directions. I asked D to inform his colleagues in other neighbouring health centres so they could deal with any surge in demand for HPV vaccine in the coming weeks.

A wearing her Manchester City shirt. She claims not to know a thing about soccer.

A came out beaming. She wanted to hear her voice on the radio, so the interviewer put headphones over her ears and played the clip back to her over the computer. She was delighted. Even D wanted to hear.

There was a spring in her step as she walked back to the car. She was a radio star; everyone would hear her voice on the news over the next 24 hours. Perhaps this will boost her performance at work, too.   

Footnote: Unfortunately, the radio broadcast has so far resulted in no eligible girls coming forward for vaccination.