Monkey Business

Cotton-wool clouds, blue sky, muddy lagoon. Luangwa.

OK it was Sunday, not Thursday. They didn’t get in through the Door. But I am still submitting this via Norm’s blog.

Sunny Sunday morning, driving back home from a successful trip to the park (watched lions mating), it seemed as though all was well with the world. When I parked outside my house there was an explosion of activity. A small army of vervet monkeys were cackling on the verandah, scattering skins of fruit, bags of nuts and dried noodles. My fruit, my nuts, my noodles. How had they broken into my house?

I saw one small monkey hanging off the window frame beside the locked door. Inside it, the anti-mosquito screen had been clawed open. This was a similar MO to the baboon burglary which happened a few weeks before I arrived. (Someone had threaded a rubber toy snake through the window security bars to deter future attacks. When I first saw the snake, I got the shock of my life, but obviously familiarity breeds contempt.)

I shouted loudly and waved my arms. The monkeys scattered, some into the trees, some onto the roof and others went back into my house. I unlocked the door and screamed. Bad move. As I was standing in the doorway, the monkeys couldn’t escape that way, so they fled deeper into the house.

I left the door open and ran into the spare room, slipping on fruit skins, black papaya seeds and monkey shit. One monkey went into the bathroom, leapt onto the dividing wall between shower and toilet and had explosive diarrhoea. His aim was worse than the average bloke, missing the toilet bowl by a couple of feet (mine). The monkey jumped at the windows, but the mosquito mesh held and he bounced off, had another go, then scampered past me back to the kitchen.

Another monkey grabbed a packet of instant noodles and scarpered into the garden. Although they were dry and crunchy, he devoured them in a couple of seconds. He didn’t need Three Minutes, but he left behind the foil sachet of mystery-meat flavouring.

One monkey stole my precious packet of nuts coated with chilli crust and climbed a tree. I threw a rock at him, trying to get him to drop the packet, but it just convinced him of the value of his prize. The rock narrowly missed the car on the way down. I’ll never see those nuts again. Then he tried to piss on me from above, just to rub it in.

These are innocent! Baby baboons, not vervets

Back in the house, I realised that a monkey had gone into my bedroom. I screamed and shouted, causing him to attempt an escape via a closed glass window. He bounded up the wall and over the rafters, running across the top of my mosquito bed net. He went into the bathroom but I hesitated following him as he might become a vicious vervet when cornered. I looked for a weapon in the kitchen, grabbed a wooden spoon and ran back to the bathroom, only to see him flee over the wall to the bedroom and out the door.

I took a deep breath (bad move, considering the stench of monkey shit) and surveyed the damage. The kitchen was a wreck. The monkeys had tried to get into anything which might contain something edible. They had scattered tea bags over the counter, but luckily the Tupperware containers which F gave to me last week kept them out of the sugar and muesli.

I had bought lots of fruit from the Mission Market Garden which needed ripening outside the refrigerator. The papaya must have been the monkeys’ first target. All that remained were some black seeds from inside. The butternut squash had vanished, too. I have trouble peeling squash but the monkeys ate the lot. The guavas had all gone and the passion fruit with thinner skins had been ripped open. Inedible debris littered the floor. Surprisingly they couldn’t get into the thick, green-skinned oranges. The waste bin was on its side, contents raked through and scattered over the floor.

Everywhere I looked there was monkey shit. Some waste was formed and solid, but most was fruity and liquid. I had no idea that guavas went through monkey intestines so swiftly. Perhaps the liquid shit was the result of panic, as they had been caught in the act. It is not unusual for burglars to defaecate at the scene of the crime, scared shitless, adrena-diarrhoea.

Another innocent. An albino baboon baby in the Park

The vervets had shit on the fridge, on the wall, on the table, on the floor, in the bathroom and worst of all, on top of my mosquito net. There was a greeny-brown patch, surrounded by a damp stain of urine, right above where I sleep. It was beginning to ooze through the material.

I set to work cleaning and scouring. I used up a whole toilet roll (no kitchen paper available) and a litre of bleach. I mopped and swept out the kitchen, brushing the debris onto my sandy garden. To my surprise, an army of ants decided to bring small chunks of fruit BACK into the house for their tea. They even brought a small caterpillar with them (for the main course?).

My neighbour A helped me untie the net from the bamboo frame slung from the rafters, without slopping the faeces onto my sheets. Of course, there was also a month’s worth of gecko turds, dust and dead spiders on the top of the net. I took it over to his house where he hosed it down, before putting it in the washing machine. Despite a heavy duty wash, the net was still stained when it emerged. We arranged it on the washing line. The lady who comes in four mornings a week will hand wash it with “Boom” washing powder. (She did a great job and it now looks pristine.)

People who have been burgled often feel defiled, dirty and soiled by the intrusion into their private sanctum. I had similar feelings, but also in a physical sense. In a way, doing all the cleaning helped to relieve the disgust I felt. I wanted to shower, but the thought of standing where the monkey had crapped put me off, and I went to the lodge swimming pool for a chlorinated dip.

When we examined the portal of entry, it was clear that the wooden frame of the screening had warped in the humidity of the rainy season. The catch was flimsy and easily broken by the marauding monkeys. A brought his tool kit and screwed in the catches. I patched up a broken window with cardboard and locked a window where the screen had been shredded.

Crime Scene

A kindly gave me a plastic box with a hinged lid and snap catches to store food in the future. He called it an ammunition box. If only it had been filled with ammunition and I had had a gun, I mused. Monkey apocalypse!

PS Only later that evening, lying in bed did I look up and see a streak of diarrhoea on one of the rafters, directly above my head. Luckily I still had some toilet paper and bleach left.

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Close encounter of the tusk kind

I was invited out for a meal by my next door neighbours last night. 
I had a beer on the verandah to begin with, watching the sun set over the lagoon, now carpeted by a green algae bloom. V called us in for a starter of butternut squash soup with homemade bread. This was followed by chicken breast stuffed with Italian cheese and prosciutto, Hasselback potatoes with carrots and mushrooms. For dessert, there was a molten chocolate brownie with runny chocolate sauce inside and surrounded by raspberry coulis. I ws stuffed.

It’s not often that I have a banquet like this. We had some entertaining conversation and everyone began to feel tired (even though it was before 9pm). I accepted a gift of leftovers and picked up my super Lenser torch. Outside the front door, a security light came on and the coast looked clear.

Smaller elephants run away when startled by a safari vehicle

It is less than 40 metres to my home. I walked carefully, shining my torch to search for animal eyes in the dark. Just as I left the track, I came face to face with a bull elephant, about ten feet away. My torchlight may have blinded him or shocked him as he was chewing on a bush. I beat a hastier retreat than I should have (the correct procedure is to keep your eyes on the elephant and move backwards slowly). To my shame, I called out, “Alastair, there’s a f~@#ing elephant in my garden!” I need to be more “bush savvy.

We waited a few minutes, tracking his movements with our torches. He could be browsing on bushes for hours. Alastair was upbeat, “At least he’s keeping down the vegetation around the house.” I considered going back inside his house and having a cup of tea, but then we wouldn’t have a clue where he was when I tried to venture home again. Victoria offered to make up a spare bed.

Just then, the big bull moved across the track away from my bungalow. Alastair kept him in view with his torch while I nipped back home through the bushes, giving the elephant a clear berth. Phew.

Community Child Clinics

I help the health centre staff with two community clinics each week. These are extremely popular with the mothers who bring their children under the age of five years to be weighed and vaccinated. We are so busy that there is no time to deal with clinical problems, so we arrange for the children to attend the health centre where we can do a proper examination and perform tests.

This morning, we weighed 172 children. About 10% of the children were underweight, but 20% were already obese. The health educator gives advice to the mothers of both these groups, but I don’t think his heart was in it when talking to mums with fat babies as this is seen as an obvious sign of good health. We must have vaccinated over 50 children. Our data is very impressive, much better than children in the UK.

Being weighed
Fast asleep

Most children had “Road to Health” cards which set out their vaccination schedule, a graph of their weights, special blood tests, a record of de-worming and vitamin A supplementation, feeding method (99% breastfed only for the first six months) etc. Sadly, the clinic has run out of cards but an enterprising pharmacy has photocopied a blank card and sells the copies to the mothers for a small fee. Some older children have lost their cards, but if they bring a school exercise book, we can fill in the details from the clinic register. Today, I saw that one child’s exercise book/health record was looking a bit thin and asked what had happened. It transpired that his father often tore out a sheet when he wanted to make roll-up cigarettes.

The mothers queue up to have their babies weighed. One of the community volunteers hangs a basic scale from the lower branches of a shady tree. We use a bag with long handles to weigh the infants. Their legs fit through two holes in the bag and they are suspended from a hook on the scale. The volunteer records the weight and passes the child on to the public health officer for review of the weight and to see if any vaccines are due.

Suspicious

Many of the mothers are very competitive about their child’s health and weight. They are really keen to know the precise weight so they can boast to other mothers. It reflects well on them as excellent parents. When the child’s weight has stalled or failed to gain, they might ask for a second opinion about the value on the scale, especially when a short volunteer is looking up to read it (parallax).

Like mothers everywhere, they like to dress their children in their best clothes to see the health workers. The colours are gloriously outrageous, pink and orange being a favourite combination. Forget the colour wheel, these children are dressed to impress. I especially enjoyed a yellow knitted jump suit with matching cap.

Yellow knitted outfit

 The mothers and children sit in the shade on a mat while they wait their turn. I told the team about a video on the internet where a doctor plays with a baby, singing a song, touching them with the shielded needle until they are distracted and don’t notice the jab. Unfortunately, the children all know what is coming by the look on their faces. Of course, if the first child screams, all the others will too. Some mothers are genuinely concerned when their babies cry in pain, even though they know it is effective prevention against disease. Other mothers think it is funny and laugh. Perhaps that is their way of minimising it.

Fancy having to dress like your sister! Mum must have bought a job lot of material

The immunisation schedule is very similar to the UK, with pentavaccine, inactivated polio, pneumococcal and rotavirus vaccine, which comes in an oral form. Thankfully, it tastes sweet so it may lessen the pain of the jabs. Of course after getting needled in both thighs, most babies are crying so one has to be careful that they don’t choke on the rotavirus. Cunningly, we slip the liquid down the inside of the cheek, so it is easier to swallow between sobs.

And it wouldn’t work without help from our community volunteers

The babies often have biblical names, such as Enoch, Esau or Jehosaphat. Two names stood out for me – Wisdom and Miracle. When I asked Miracle’s mum why she had chosen that name, I was hoping that she would come up with a good story, but she said that she didn’t know what it meant. One of the local chemists is called Honest; his mother wanted to call him Earnest, but it was lost in translation when his birth was registered.

Domestic Matters

P1000997

My mattress is like blancmange. It rises up around me as though I am about to be swallowed up. The lighter parts of me seem to float on the surface, but my buttocks sink deep into the foam. I don’t think it is a “memory foam” mattress; it’s more Alzheimer’s really. I try to trick it by changing position and lying diagonally across the double bed, but it finds me out.

The bottom sheet is actually a duvet cover, complete with buttons. I think that there is another sheet for the other bed in the house, but it isn’t the same size. For the moment it doesn’t matter, because I sleep like a semi-enclosed log, but it shouldn’t be difficult to sort out. The top sheet is just a sheet, so it can take over as a bottom sheet and I’ll go topless. Needless to say, there is no need for a duvet in this weather.

I have four pillows, all of different consistencies, three of them have pillow protectors (how did they know that I drool?) and only one has a pillow slip. One pillow must be related to the mattress because when I lie my head back onto it, the sides pop up like blinkers on a horse. I eventually swap the pillows around until I find a comfortable position.

The bed is surrounded by a cage of fine mosquito netting attached to a wooden frame and suspended from the rafters. On one side, there is an overlapping layer which allows me to get into bed and keep a reasonable seal, akin to an airlock. On my first night, I sprayed the room with knock-down insecticide (“Doom”) before going to bed, but since then I haven’t bothered. I occasionally find crickets, ants, spiders, and mosquitoes have found their way in. No nkorokoro (a fat brown millipede) has joined me yet (read about the encounter in April 2014 when I first worked in the Valley).

I have an open wardrobe, like a bit of Ikea garage shelving, but as I don’t have many clothes, it doesn’t bother me. I have a pair of flip-flops, a pair of old sandals and a pair of boots which are not totally waterproof. The flip-flops have melted a bit after I sprayed my feet with insect repellent (DEET). F bought me a pair of soft wellington boots which are a godsend. I don’t like to keep my shoes outside the house because creatures might start using them as a home. I have already had to kill one black scorpion in the bathroom (“Oh, the black ones are not so bad. Just twenty minutes of agonising pain after being stung. Now the brown ones, their stings hurt like blazes for eight hours. And they like playing (sic) in those baskets where you keep your laundry.” Thank you, Victoria.)

There is a floor-standing fan which keeps me cool if it is exceptionally hot and humid. I haven’t used the air-conditioner yet. There are mosquito netting frames on those windows which open, but not those which don’t. One of the windows has been broken, but I keep the curtains closed in the bedroom so I don’t see it. The anti-mosquito mesh is torn in places. I think this may have occurred when the house was invaded by baboons which trashed the place a few weeks before I arrived. Someone left a window open and they forced their way in. Now there is a toy rubber snake coiled around the window bars to deter further forced entry.

P1360349I have two useful bedside tables, for a reading lamp and a place to leave my on-call phone charging. My bathroom is around the corner, with a shower, toilet and hand basin. There is a table to store toiletries, but no towel rail (it’s on order). It is difficult getting towels to dry in this humid weather at the best of times. They tend to smell after a few days of being hung from the rafters. My neighbour, Victoria, has very kindly offered to pop them in her tumble drier (luxury). This avoids my getting attacked by tumbu fly, a medical condition where Cordylobia anthropophaga botflies lay eggs on laundry drying in the open air. The eggs hatch and larvae burrow into your flesh if you wear non-ironed clothes or use a towel. This gives rise to a boil which contains a maggot. The treatment is to cover the air tube (spiracle) of the maggot with Vaseline, so it is forced to escape into the fresh air. Charming. This is not as uncommon as you might think. The previous doctor in 2016 was affected after she did some sunbathing on a towel by the pool of a lodge.

The kitchen/diner/living room is large and spacious, perhaps because there isn’t a dining table. I eat off a small table which doubles as a desk. The kitchen units are concrete, painted with enamel paint. Unfortunately, the surfaces are cracked, chipped and uneven so it always looks grubby, even when it has been scrubbed. Pots, pans, plates and glassware stand on wooden racks; the knives, forks and spoons are stored in tin cans which have been covered in brightly-coloured cloth. On the first day, I washed all the crockery and cutlery, because it felt gritty with dust and grease.

I have a propane gas oven with a hob and an electric fridge freezer. There is no washing machine, as Theresa, who comes in four mornings a week, hand washes for me. I have plans to get her to prepare n’shima maize porridge and bean sauce for me at least once a week. It’s easy, you just set it going on the stove and leave it for four hours.

Theresa has given me a list of essentials to buy from the village stores. I need “Harpic Cleaning” (I got Jif), “Tile and Floor” (there are no tiles and the floor is concrete), “Dettol Germs”, “Lifebuoy” soap, “Mr Muscle” and “Handy Andy” for window glass. A third of the dishwashing liquid has gone within three days so I may be looking to buy industrial quantities.

I have a lockable store cupboard, but it is possible to enter it by climbing over the wall, as there is no ceiling enclosing it. There is another smaller bedroom with ensuite on the other side of the bungalow. Outside, I have a verandah, covered in corrugated iron sheeting and built around an existing tree. I have three Lloyd Loom wicker chairs and a coffee table outside. Unfortunately, the atmosphere is so dark and humid that it is perfect for mosquitoes, so I rarely sit on the verandah unless it is hot and dry.

The roof is corrugated iron, with an interesting dormer window feature, just for show (and a possible bat entry point). Baboons scamper over the roof as soon as it gets light, squabbling and playing, making a hell of a racket. At night, it is usually quiet and tranquil. But something falls onto the roof from the overhanging tree in the middle of the night (Could this be baboon poo? Rotten branches? Small creatures that have fallen asleep and lost their hold? Heaven knows.) Rain, however, sounds much heavier than it is and can be deafening.

P1360414I have a Huawei wireless cube internet gateway strung from the roof (the mosquito netting forms an insulating Faraday Cage inside the house). I buy 12GB of data for about £13 per month. I hope this should last me. I can access WiFi from inside the house. The service is rather poor, especially when everyone gets home after work, so I fire it up at 6am when it seems more lively. Perhaps that’s when the Chinese Intelligence Service is listening.

I have a garden, but it is just grit, gravel and sand at the moment. There is a new grass fence giving me some privacy but I am a bit concerned about the resultant heap of rotting grass stalks from the old fence which I have to walk past to get to my car parking stand. It is the perfect home for snakes; I have already seen a junior black-necked spitting cobra nearby.

P1360422Since I wrote this, I now have lovely new (I don’t care if they are mismatching) sheets for my bed, the pile of grass stalks has been shifted (at first I thought a group of marauding hippos had devoured it), and my bathroom has been painted with bright yellow gloss paint. I feel quite at home, even though we have killed another intruding scorpion.

Thursday Doors

I can’t resist contributing to this addictive blog. The doors in rural Zambia are not as fascinating as Italy or Montreal, but they are doors just the same.

These are the school toilets at Rumase School in Kakumbi

Note the yellow plastic barrel with a tap to allow students to wash their hands after using the toilet. There’s no soap, but what the dickens, you can’t have everything. I went to the school to vaccinate students against diphtheria and tetanus. This is a booster dose. The head teacher had informed the parents and no one declined to have their child vaccinated. We had 100% uptake (though some children may have been off school for some reason).

I explained to the class why we were vaccinating them. I told them that it might hurt a bit, but it would be better if they relaxed and were not tense. Not one child squirmed or wriggled. No one cried. Such a brave bunch of children.

This is the door of one of our volunteer community health workers

I don’t just vaccinate children in schools. I accompany the team for community under 5’s clinics twice a week. You can read more about this in my blog next Thursday (but not in Thursday Doors). We weigh children and identify those who are failing to thrive. Our vaccination coverage is almost 100%. The mothers are convinced that the vaccines keep their children healthy. We also de-worm the children and give vitamin A supplements (to avoid blindness) every six months. Adults get mass treatment with diethylcarbamazine to prevent elephantiasis (from filariasis).

The doors might look neglected and in need of some tender loving care, but the children are certainly looked after well, by both the health workers and the parents.

The Road Branches

When I see a branch in the road I know I need to pay attention.

If a truck has broken down, the driver will place branches at the side of the road 100 metres behind and ahead of the vehicle. The driver might be trying to change a flat tyre or could be lying under the vehicle doing some repairs, so I slow down.

If there is a huge crater in the road, a large upright branch stuck in it will alert other road users. If there is a track in the bush with a large branch across it, it means that the track is impassable ahead.

I saw a series of branches laid in the road on my way home and assumed it meant that there had been a death in the locality. Etiquette states that you switch on the hazard warning lights and slow down, passing the home of the recently deceased person in first gear. This is what I did in this situation until I realised that there were no homes in the vicinity. The branches were actually marking potholes which had just been filled with a mixture of crushed bricks and cement. The road menders didn’t want people to drive over the wet cement mixture.

This is a deep pothole with a branch that’s lost its leaves

This set up a slalom where drivers were weaving around the branches while avoiding oncoming traffic. I am not sure how long the makeshift repairs to the tarmac will last.

This vegetation in the road is water hyacinth and “cabbage” which has been dragged across the road by a hippopotamus. Hippos move out of the lagoons and eat grass at night. They are such lumbering beasts that they drag water plants with them for part of the journey. You can see their pathways better in the dry season as two parallel tracks, a hippo belly width apart, worn into the dried vegetation.

There was a major road building project in 2016 when I was last in the Valley. A perfectly good tarmac road from colonial days was widened, which involved the destruction of many mature trees at the edges of the road. The money ran out before the road builders could tackle the most appalling part of the road in the villages of Cropping and Kakumbi. There is no tarmac on this stretch of dual carriageway (potholed, muddy road to hell) crossing the Matanje River. Both roads are bone-jarring, cratered tracks, but the road going west is worst. Ignoring the Highway Code, many drivers use the east bound carriageway to go west. Both tracks are wide enough for this (apart from on the bridges) but the situation is complicated by the tortuous route drivers take to avoid the suspension-crunching crevasses and deep puddles. One might swerve into the “outside lane” (there are no actual lanes) and find oneself heading directly towards an oncoming vehicle avoiding the same obstacle.

Matanje River
This is the road to the health centre after a dry spell

The side street which leads to the health centre is a succession of muddy pools, each with a resident family of ducks and ducklings. In an attempt to avoid vehicles getting stuck in the mud, people have laid down grass stalks and foliage on the road. This is now beginning to rot and gives off an awful stench as you drive over it. Coupled with the stink of burning plastic at the health centre, it reminds me of the scene in Apocalypse Now, where the US Airborne Cavalry commander proclaims how much he enjoys the stench of napalm, “It smells of … victory.”  My thoughts exactly when I reach the clinic without having been bogged down in the mire.

Inspection

I was concerned to see an undated notice pinned to the wall in my consultation room relating to a visit by Dr Aaron Mujajati the Chief Executive Officer and Registrar of the Health Professions Council of Zambia. I suppose this is akin to being inspected by the Care Quality Commission in the UK.

It summarised six areas in which our clinic was failing. First of all, it appears that the government health facility didn’t have an operational license (contrary to Section 36(1) of the Health Professions Act No 24 of 2009). This resulted in the clinic being charged under Section 36(2) of the same Act.

Then there was no evidence that the facility had a Dangerous Drugs Cupboard (presumably under lock and key with a register of drugs). I wasn’t surprised at this, as we don’t have any dangerous drugs. Indeed, the strongest painkiller we have is paracetamol, and we ran out of that earlier this month. But the fact remains, a health centre must have a secure box to store dangerous drugs should we be issued them.

There was criticism that most wards did not have emergency trays and most emergency drugs were out of stock. Well, we only have two wards with neither having a secure storage cupboard in which to keep an emergency tray. Even though we don’t have any emergency drugs. I thought it was a tad unfair to lay the blame at the pharmacist for not ensuring there are emergency drugs when the orders he had submitted were not filled.

Some standard operating procedure (SOPs) manuals were not available at the facility. The problem is that there are so many SOPs with nowhere to store them. The consultation room desk has a pile of SOPs a foot high. Together with the British and Zambian National Formularies, the registers for Sexually Transmitted Diseases, the inpatient record files, the referral ledger, the TB register and several others I have forgotten about, there is hardly space to leave a stethoscope.

Seriously, there was no evidence of safe drinking water at the facility. We have a borehole which pumps clean water into a water tower which supplies the neighbourhood, including the local police station. But we couldn’t produce evidence of its sterility.

Finally, we were not insisting that all patients living with HIV (and others) should take isoniazid prophylaxis (IP) to reduce the risk of tuberculosis. All staff need to be trained how to do this and we should have a committee to ensure adherence to standards. Although this is standard WHO and Zambian Ministry of Health policy, it is very unpopular among patients. Even when an excellent, non-government organisation, such as Medecins Sans Frontieres, is running a health centre in Africa, adherence to IP is problematic.

The report ended by stating that Kakumbi Rural Health Centre posed a moderate risk to patients and visitors, with a risk grading of 66.8%. Because of the clinic’s major violations of the HP Act No 24 of 2009 of the Laws of Zambia, the Registrar ordered immediate closure, pursuant to Section 50(1) of the same Act.

Two different “memories” (or herds) of elephants crossed my path on the way to the clinic this morning.

I’m glad I wasn’t working at Kakumbi when the Registrar did this inspection. The local populace would have been up in arms about the closure. Although we could have acquired a lockable box in which to store carbamazepine (which is classified as a dangerous drug in Zambia), sent a sample of tap water for bacteriological testing, hunted out the SOPs which were missing and labelled a tray as “emergency drugs” in each ward, that all might not be enough. I presume that getting the Ministry of Health to grant a license (sic) should be easy enough, but perhaps not when the clinic had been officially closed.

I have since heard that the official has moved to another position, in one of the hospitals which he ordered closed.

My love affair with rubber

“It’s only flat at the bottom part”

This began in July 2014, when I had three flat tyres in a week, just before I was due to leave after my first tour in Kakumbi Rural Health Centre. There was speculation that a sangoma, or witch doctor, had cursed my vehicle in an attempt to stop me from leaving.

This morning, I drove to the clinic for our 7am meeting and when this concluded, I returned to my vehicle to collect my medical kit. My front driver’s side tyre was flat. As one joker said, “It is only flat on the bottom side, not the top.”

I unloaded my emergency medical gear from the rear of the Toyota Prado and liberated the tyre wrench and jack. The first problem was that the tyre wrench was a very snug fit onto the wheel nuts, which made it difficult to get a good grip. When I managed to get a good fit, I couldn’t shift the nuts, partly because they had been tightened by Superman and partly because of the friction between the tyre wrench and the metal surrounding the nuts.

“Give me a long enough lever & a place to stand and I will move the earth,” said Archimedes. So Aaron, the clinic volunteer, went off to find a length of steel tubing which would fit over the end of the tyre wrench. This did the trick, but we couldn’t fit the jack under the designated points on the chassis without digging a small hole in the ground.

I removed the spare from the back door of the Toyota while Aaron removed the front wheel. After attaching the spare, I noticed it was a bit soft but thought that it was normal for long-term spares to lose a bit of pressure. I went back to my patients, but after an hour, Aaron came in to tell me that the spare we had fitted was getting softer. I didn’t want to be stuck at the clinic, so I decided to drive to the filling station in the village where there was a compressed air hose. Unfortunately, it was not functioning, so I telephoned Greg at Kapani and asked him if I could get the tyres sorted at his workshop.

I drove gingerly to the workshop and dropped off the flat tyre. I could see there was a plug on the shoulder of the tubeless tyre which looked dodgy. The lads soaped the tyre, filled it with air and diagnosed two leaks. But they had no repair kit for tubeless tyres, so I had to source one from Flat Dogs. In the meantime, the pressure in the spare tyre on the front driver’s side had fallen to less than 10 whatsits per thingumy, when it should have been 30. I pointed out that the rear passenger side tyre looked soft, too. The mechanic pumped both tyres up and I said a little prayer, before setting off for Flat Dogs Workshop. I went on to the clinic and finished seeing patients just after 1:30pm and drove back to Kapani with the puncture repair kit.

The mechanics were putting a tractor engine back together again. This involved a JCB, thick nylon rope, a heavy duty car jack, and several wooden blocks. They manoeuvred the two parts of the engine casing into alignment, then pushed them together with manpower and bolted it into position. I was exhausted just watching them do it.

Dodgy tread

I drove the vehicle around to the workshop to pick up the mended tyre and I felt the rear driver’s side tyre was deflating. The lads had trouble getting the nuts off that wheel also. They used a different tyre wrench and ground down a bit of my tyre wrench so it would fit in future. Strangely enough, they could not find a puncture in this tyre. “We will keep it under observation,” said the chief mechanic, “as it is a spare.” I was not impressed by this logic. However, when they tried to fit this wheel onto the back door mounting of the Toyota, the washers on the wheel nuts would not fit into the holes in the wheel. By now it was knocking off time, so they asked me to return tomorrow when they would switch the original spare tyre onto the back door and the “under observation” tyre onto the front driver’s side.

After thanking the mechanics for their help, I mentioned that I thought it could be the work of a sangoma again. They considered this but were not sure. Then I told them that I had seen a new oil patch at the front of my carport…

Dead Drunk

Half a dozen men carried the unconscious man into the health centre and laid him on a bed in the male ward. The clinical officer felt she needed a bit of support, so she asked me to see him with her. I asked if anyone knew what had happened.

“He was drinking cane spirit last night and passed out. We couldn’t wake him up this morning to go to work.”

No one knew if he had any significant past history. He was a regular drinker but had never been like this before. He was well before he got drunk and he didn’t appear to have hit his head.

My initial assessment began with calculating his Glasgow Coma Scale (GCS). I asked the clinical officer to speak to him in Nyanja but he was oblivious. He wasn’t even moaning. Score one. I tried to get some response to painful stimuli, pinching his earlobe or rubbing my knuckle up and down his breast bone. There was no reaction so he scored one. His eyes were closed but when I opened pulled his eyelids apart, his pupils were small and sluggishly responsive to light. Again, he scored one. His GCS score was 3/15 which is pretty dire.

While I examined him further, I asked the clinical officer to get some 10% dextrose for intravenous infusion. Alcohol can cause hypoglycaemia, and although we don’t have any blood glucose testing strips, it seemed a reasonable course of action. I have a pulse oximeter which showed his blood was 93% saturated with oxygen. His blood pressure was 108/76 and pulse 96/minute, thready with low volume. His temperature was 35.8C, slightly low but not enough to be hypothermic. He was breathing shallowly and rapidly at 22 breaths per minute, but his lungs sounded clear. There were no heart murmurs. His abdomen was soft with no masses, enlarged organs or fluid. His arms were floppy but his legs were stiff. His breath gave no clues (kidney or hepatic failure, diabetes); it did not even smell of alcohol. I tried to check his fundi but the batteries in my fancy ophthalmoscope were flat.

I asked the clinical officer to do a rapid diagnostic test for malaria, an HIV test and a test for syphilis. Our laboratory has a limited number of tests on offer. All investigations were negative.

“Are we missing anything?” I asked myself. “Could it be methanol poisoning?” The men who brought him to the clinic said that they had drunk the same spirit as our patient, albeit not as much, with no ill effects.

“Or sleeping sickness?” I wondered. Zambia has only 50 cases per year, so that would be very rare.

“Maybe he has had a stroke or a cerebral event?” If this was the case, there would be little we could offer.

The clinic doesn’t have an ambulance, so we have to telephone the district hospital to send their vehicle. But we know that they don’t have any fuel. And it takes an hour for the vehicle to get to the clinic.

I decided on a course of masterly inactivity while the 10% dextrose corrected any alcoholic hypoglycaemia. Well, that isn’t exactly true. I went back to the consulting room and continued to see patients.

After half an hour, one of the drunk’s pals told us that he had woken up and wanted to go home. I was happily surprised; I have never seen anyone with a GCS of 3 who recovered so quickly.

This is not a rare event. On Monday afternoon at 1pm we had another unresponsive drunk in the clinic who had finished three small bottles of 47% cane spirit during the morning. Perhaps he was a Boomtown Rats fan (“I don’t like Mondays), but that’s a hellish way to start the week.

Egyptian goslings on a pond near Mbomboza

Post Script: Last Christmas, someone was brought to the clinic dead from alcohol poisoning. There were also cases of children aged 10 and 12 who were brought to the clinic the worse for wear. Each small bottle of spirit costs just 40 pence.

First day at the Clinic

Kakumbi Rural Health Centre

Baboons. Need I say more? At least a hundred of the little blighters, making mischief. But animals have priority on the roads, so I waited until they had crossed.

The road was badly cut up by trucks driving through the muddy sand. There were lots of pools on the track, but the deepest had been partially filled in with old bricks to provide a better grip for the tyres. The big dirt road had several streams running across it, creating gorges which needed careful negotiation. As I reached the tarmac road, a lorry came into view. The passengers in the back were waving frantically at me. I didn’t realise I was so popular, I thought, until I turned the corner and saw a large bull elephant ripping tasty branches from a roadside tree. So they were trying to warn me.

Good morning and welcome to South Luangwa!

Normally when you see one elephant, you can be sure that there are others nearby. But lone bulls do venture off on their own, so I wasn’t too alarmed. I drove slowly towards him but couldn’t resist a few photographs. Just to prove the veracity of the story, of course.

Further along the road, I saw bushbuck and puku antelopes, as well as another mob of baboons. The village hasn’t changed much. A few new shops here and there, more potholes in the road to the bridge and a new restaurant, which I will have to visit soon.

More churches have been built beside the back road to the clinic. The Obama Bar has closed during the day and its courtyard is a haven for grazing goats. But at night it remains highly active. The clinic road is worse and I passed the rear of a sign saying, “Road Closed Turn Right.” The clinic has a new HIV/AIDS block in shimmering white, built by US aid (PEPFAR). The clinic now deals with 875 patients living with HIV without the fortnightly visits from the district hospital.

New block built with US Aid money for HIV/AIDS support
Maternity Block, now usable as it has an electricity supply
First delivery of my tenure – I had nothing to do with this!
Incinerator and drug pit

The maternity block has finally got an electrical connection so it can function as intended. The consultation rooms look cleaner, water flows from the taps and there is soap. The only towel is the one I donated in 2014, which looked rather grubby. I wiped my hands on the seat of my trousers.

Erina starts the fire with plastic and wood to heat the steriliser

The staff who knew me were delighted to see me again. The new health workers welcomed me back and we chatted about the good old days. “But the drug situation is worse now. We have less medication now than we had when you were last here, doc.”

The clinic water supply tower
The patients’ toilets, with the incinerator in the background

People in the Ministry of Health must be worried about the increase in malaria cases in this district. We are adopting a proactive strategy of testing and treating anyone who lives near all new patients found to be suffering from malaria. Unfortunately, heavy rain has made it almost impossible to get to remote areas to carry this out. It will be an interesting experiment.

The clinic now runs two community clinics a week, in which I will participate, as well as a schools inspection and health education
programmes (sexual health is on the agenda again).

It feels great to be back.