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Medical Thursday Doors Zambia

Thursday Doors at School

Zambia’s National Immunisation Schedule is very similar to that in the UK. After three injections in infancy against tetanus, there is a booster at school entry and another for school leavers. This isn’t so good for children who don’t go to school, but you have to cut corners sometimes. And children who have to repeat their first year may end up getting an additional jab.

We have been doing the fourth and fifth tetanus (with a small dose of diphtheria) in the local schools over the past few weeks. My job here is to help, support and assist, not to take over the programme. We sometimes end up running out of vaccine or syringes, bringing the wrong kind of syringes (BCG syringes are just 0.05ml, the other vaccines need 0.5ml syringes), forgetting to inform the school that we are coming or have had to alter the date. But we got the job done. I don’t know the precise figures, but we vaccinated about a thousand school children.

Door on its side

Here is a door in a classroom in Mfuwe. It may have been taken off its hinges, or it might have been pushed off by the scrum of schoolchildren crashing through the doorway. So this satisfies inclusion of this post in Thursday Doors.

The health inspector in charge of the programme has not been trained in vaccinations. I asked the nurse in charge of the clinic if it was ok for me to train the health inspector and he said he thought it was a good idea. Now in mass vaccination campaigns, speed is of the essence. You don’t take your time slowly inserting the needle, pulling back, injecting, then looking around for a cotton wool ball to place over the injection site.

It took some time for the health inspector to gain confidence, but after a couple of schools, he was able to inject at speed.

Drawing up the vaccine

Now some of you may have seen a clip on YouTube of a paediatrician playing with a baby before he vaccinates them. This looks marvellous and the doctor is to be congratulated. However, he isn’t trying to vaccinate 200 children in school without their parents being there to comfort and support them. This calls for military-like precision. You line ’em up and jab them.

We had a gang of young men and women who volunteered to help with the school campaign. They did some health education while I was injecting. They helped fill the syringes, recorded the children’s names and wrote out vaccination cards. One young lady’s help was invaluable when dealing with youngsters. They would fling their arms around her thighs, she would cover their eyes so they couldn’t see the needle, she would distract them by asking them questions and she made sure their left upper arm was immobilised.

Last week, there was a thunderstorm brewing and I started vaccinating as the rain started. Lightning flashes at the same time as injections was a double whammy for the children. My assistant was brilliant in this situation.

Ouch!

Sometimes the children would not feel the vaccination, other times they would jerk when the needle entered their skin. On a few occasions, this led to the needle going in deeper and hitting bone. Older girls could become hysterical and if we didn’t deal with this properly, it could become infectious, with all the students panicking.

Lining up for vaccination

We hadn’t reckoned on schools having a two shift system, with some pupils coming in the morning, and the remainder coming in the afternoon. I would return to the clinic, see patients about whom the nurse wanted my opinion, then return to the school.

Health education

We need to give the students a booster in a month’s time. The nurse in charge of the clinic felt that the students should come to us for their boosters, but this would overload the clinic with the risk of students being unwilling to wait and leaving before they had had their jabs. I suggested that we go back to the schools and do the vaccinating there instead. We all agreed that this was a great idea.

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Medical Zambia

Sickle Cell Anaemia

I have seen more children with sickle cell disease during this stay in Zambia than my other two tours. It is a miserable, dreadful disease.

It is a genetic disorder of haemoglobin which alters the biconcave disc shape of red blood cells into a crescent or sickle. Being an autosomal recessive condition, a sufferer needs to inherit a sickle gene from both parents to be severely affected (HbSS). Only having one gene (sickle cell trait, or HbS) causes no problems (unless the oxygen level of the blood is reduced) and confers some protection against malaria. (This may be why evolutionary pressure has not eliminated the disease.) Paradoxically, patients with sickle cell disease (HbSS) are more susceptible to the dangerous form of falciparum malaria which can be fatal. 

Fetal haemoglobin (HbF) helps to protect babies for the first six months of life, but as HbF disappears, the affected child starts to become symptomatic. The abnormally-shaped red cells clog up the micro blood supply to bone marrow, causing acute and long-standing pain in the bones. The deformed red cells cannot revert to normal and they burst or haemolyse. The child becomes anaemic with less than 50% of the amount of haemoglobin as a child without sickle cell disease.

The sickling blood cells are filtered out by the spleen, which grows in size and then becomes destroyed as its capillaries clog up. The spleen is the location of immunological memory cells, which are lost when the spleen infarcts. This makes the child more susceptible to bacterial infections, especially streptococcal, meningococcal and salmonella (typhoid) infections.

Sickling cells also damage the lungs, causing chest pains and difficulty breathing. A stroke can result from sludging of red blood cells in the brain.

The child’s growth falters and the child is often stunted. Leg ulcers are a common complication which are very slow to heal.

Sickling crises can occur spontaneously but may be precipitated by lack of oxygen, dehydration or altered body temperature.

At the health centre, on Fridays, the laboratory runs a batch of tests for sickle cell disease. A drop of blood is mixed with a reducing agent to take away oxygen, which causes the cells to change into their classic sickle shape, seen under the microscope. Unfortunately, we have run out of reagent to do this test, so we have to send suspected children to the nearest district hospital, an hour away by bush taxi.

There is no cure for sickle cell disease apart from a stem cell transplant – but this is not an option in Zambia. We can correct the anaemia by blood transfusion, but this may only last a few weeks. We avoid giving iron tablets because of the risk of iron overload from frequent transfusions. Sadly we don’t have any stocks of folic acid, which helps red cell production. At the time of writing, we don’t even have paracetamol to treat painful crises. We do have polyvalent pneumococcal vaccine.

This is another condition where we can make the diagnosis but offer only limited symptomatic treatment with no hope of a cure. Most of our patients will not reach adulthood. It makes me feel depressed and impotent.

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Medical Zambia

Cobra

Male Kudu

Just before dawn at 5:30am, he was emptying the ashes from last night’s campfire into the pit latrine when he felt a sharp pain in his foot. He looked down to see a small snake rearing up ready to strike a second time. When he saw the hooded neck, he knew it was a cobra. He retreated quickly and the snake slithered off into the bush. There was no thought of revenge, no need to kill the snake for identification purposes. There were two small puncture wounds on the outer border of his little toe.

I didn’t get word of this until 7:30am when I was en route to Mambwe to see the District Medical Officer. My appointment was for 8am and it had already been cancelled once so I opted not to turn around. The nurse in charge at Kakumbi is very senior and no doubt had managed many snake bites in the past. I alerted him by SMS that the patient would be arriving by boat from a bushcamp at about 8:45am.

I instructed the camp manager to get some polyvalent (it counteracts envenomation from the most common snakes in the region) antivenin from the medical refrigerator in my house and bring it to the clinic in a cold bag.

The important thing to do in these situations is for both the patient and health care worker not to panic. Gone are the days of slicing into the fang marks and sucking out the poison; the patient is likely to get a nasty infection and it has no effect of the outcome. Tourniquets are only useful if you know that the venom is neurotoxic, to stop the spread of the poison around the body before the doctor can administer antivenin. Wash the wound to remove any venom on the surface, then keep calm and rest is the official advice.

At Mambwe District Health Office I met our former pharmacist from Kakumbi. “Does Kamoto Hospital have any antivenin?” I asked him. He said no, while remarking that they had had more snake bites than usual this rainy season.

I received a text that the patient had arrived and discussed the management plan with the nurse in charge. He set up an intravenous infusion which we would need if we were to give antivenin, gave the patient some diclofenac anti-inflammatory pain killer, a tetanus toxoid booster and insisted on complete bed rest. The initial observations were encouraging and I felt I didn’t need to rush back to the clinic.

About half of snake bites are “dry” and don’t contain significant amounts of venom. The snake is just protecting itself; it is not planning to eat the person it has bitten. In my patient’s favour were the following factors – he was a 70kg man and the snake was small, less than a metre in length; the bite was on the foot, rather than the head or neck; he received prompt first aid.

I have written about snakebites in Swaziland in my blog in the past if you want to learn more, click here. In simple terms, venom from vipers causes local pain, swelling and necrosis around the bite and venom from cobras is a nerve toxin which causes paralysis. We were closely observing the patient on the lookout for signs of paralysis which can begin upto five hours after the bite.

The decision to start antivenin is tricky. Ideally, the best results are when antivenin is administered soon after the bite, but it may not be needed and there is a high likelihood of the patient developing anaphylactic shock and dying. Some experts give adrenaline before the antivenin. We didn’t have any adrenaline at the clinic. The antivenin that the camp boss brought to the clinic was past its expiry date, so I told the nurse in charge that it would be my decision whether we used it or not, not his. He gave some hydrocortisone instead.

“Are you looking at me?”

As an aside, what would you rather have if your life was at risk from envenomation – antivenin which was out of date (and possibly less potent as a result) or no antivenin at all? I’d go for the expired stuff, personally, evn though my safari supply of adrenaline was also out of date.

When I got back to the clinic, I reviewed him. His blood pressure and pulse were stable, his pain was controlled and the bite site was not swollen. He was hungry and had eaten a late breakfast (patients with significant neurological damage cannot swallow or open their mouths). His breathing was relaxed and not laboured. An early sign is drooping eyelids, but his eyes were normal. This leads on to respiratory arrest and I would have had to intubate and hand ventilate the patient until we could get him to an intensive care unit, probably at Chipata Hospital a few hours away.

Ground Hornbill – in a tree. He kills cobras.

When I left the clinic at 1pm, there was no change in his condition and he had passed the critical five hour period where “cobra syndrome” can occur. I felt he should remain on the ward for at least 12 hours, possibly staying overnight, just to be on the safe side.

I was surprised when I opened the cold box containing the antivenin when I returned home. The camp boss had just brought one vial. Sometimes it can take ten vials to control mamba or cobra envenomation. I discovered that the fridge sorely needed defrosting and now I know exactly where to find adrenaline for injection. Even if it is expired.

Lady Luck smiled on us today.

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Thursday Doors Zambia

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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Zambia

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.

Categories
Medical Zambia

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.

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Zambia

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.

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Thursday Doors Zambia

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.

Categories
Zambia

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.

Categories
Medical Zambia

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.