Clinical Titbits Two

On my first day at the clinic we had a patient with a ripe abscess which needed incision and drainage. My colleague is a clinical officer, but she hasn’t had much practical experience at doing procedures. She previously worked in hospitals where a doctor would often take over if she felt unsure. I told her that I would tell her what to do, standing by to assist if something went wrong. Reluctantly, she agreed and went off to prepare a tray for the procedure. I realised that she was dragging her feet when she didn’t come back for 15 minutes.

Juvenile Puku looking cute with eyelash extensions

There was no local anaesthetic, but the abscess was about to burst so the skin was very thin, easy to cut without much pain. She cleaned the skin and started fiddling about with the single-use scalpel. This has a plastic cover over the blade which prevents the instrument from being used twice. She managed to trigger the mechanism before stabbing the patient, so I had to break the plastic to enable her to use it. She was very nervous and said she couldn’t do it. I offered to hold her hand and direct where to cut, but it was no use. Eventually, I agreed to do it and asked her to stand by with a kidney dish to collect the pus. She didn’t want to get too close. I plunged in the blade and a spurt of pus missed the dish, landing on her shoes. She wasn’t pleased with that result and resolved to be more resolute.

The next boil was on the scalp. Now scalps have tough skin and need a firmer approach. It was smaller and she had previously prescribed antibiotics, which hadn’t stopped the boil from forming. This time she was determined to do it herself. But she couldn’t bring herself to use the requisite amount of pressure. She kept stabbing repeatedly, causing the patient a lot of pain. “Be bold,” I said, “Just do it.” And to the relief of the patient, the next cut released the pus. (If any of you are cringing at this point, and wondering about local anaesthetic, we only have one bottle and that is reserved for obstetrics.)

Knob-billed duck splashing about in the lagoon

My colleague has taught me a new technique for removing foreign objects (beans, beads, stones) from nostrils. I would have formed a hook with a blunted needle and tried to claw back the object. Her solution was much more elegant. She removed the inside of a biro and put the external plastic tube inside the unblocked nostril. Then she told the child to close his mouth and she blew in the tube, causing a bean to shoot out. Excellent trick. I will certainly use this in future.

We have been working on consultation skills. She can be rather abrupt at times. “Are you a virgin?” she asked one teenage girl. When the girl said yes, she replied, “Are you sure?” I began to wonder how she might not be sure.

Mother teaching her baby survival skills

I prefer not to see patients by myself. My Cinyanja is extremely limited to 20 phrases and I don’t want to restrict myself to the privileged few who speak English. It is more educational if I see patients with the clinical officer. She consults and then I help her to sort out the problem in a logical way, translating for me at times. Sometimes, she hands the consultation completely over to me, for example, older men who complain about “lacking power”. With them I ask the usual questions, screen for heart disease and diabetes, then recommend that they try sildenafil, or Viagra. I have seen this at the local pharmacy as an orange-flavoured sachet. It’s a hot seller but it isn’t cheap.

The community health workers are very interested in my being a bachelor/widower. Some of them remember me from 2014 and don’t understand why I haven’t taken a wife. They offer to provide me with a Zambian wife, as “all men need a wife“. To satisfy their needs. I told them that I didn’t have any needs, I’d rather have a cup of tea. They burst into incredulous laughter at this and insisted that I did have needs which only a Zambian woman could awaken. I told them that my kit was “out of service” and had a “flat battery”. “Oh, don’t worry, doc, I know someone who has a beautiful battery charger!” As the investigative sleaze reporter in the now defunct News of the World used to write, “I made my excuses and left.”

Great white egrets having a punch up over a territorial dispute

One of the expats in the Valley was driving along the main road at about 11am and saw a schoolboy collapse. The nearest ambulance is an hour away, so she pulled over, lifted him into the passenger seat and drove him to the health centre. He did look rather poorly, but his rapid diagnostic test (fingerprick, takes 10 minutes) was negative for malaria. I don’t know whether it is a sixth sense or just experience of having seen thousands of cases of malaria, but the child LOOKED like he had malaria. Instead of just prescribing a few paracetamol, I insisted that the lab technicians examine a thick blood film. This is tedious and takes a lot longer, but it is more sensitive. They found the ring forms of falciparum malaria and he got the correct treatment. My colleagues don’t often deviate from “accepted practice”, perhaps because to do so would open them up to criticism. They lack confidence in their own judgement sometimes.

Having an epileptic seizure in later life is not good news. In the UK I would be thinking of a space-occupying lesion, but here in rural Zambia, my first thoughts were of infectious diseases. Could he have tuberculosis, a brain abscess, cerebral malaria or even cysticercosis? I asked the family a few more questions and it turned out that he really enjoyed eating pork. I am not certain, but I suspect this might be pork tapeworm cysts in the brain (cysticercosis). Without sophisticated investigations I cannot confirm this diagnosis, but if he has another seizure, I will offer him treatment with an anti-parasite medication, covered by a course of steroids (to avoid an inflammatory reaction in the brain to leakage of the cyst contents).

Last month, I saw a very elderly lady who is a regular attender at the health centre. She is very weak, anaemic and thin. Her muscles are wasted and her limbs are like sticks. The family keep bringing her for some medication to make her strong again. When I examined her, she had no teeth. She couldn’t chew food. All she could eat was maize porridge. The treatment was nutritious food cooked in a way that she could swallow it. No drugs, doctor? Well, I succumbed and prescribed a short course of multivitamins and iron tablets.

Another striking young lady

I was helping out at the family planning clinic recently when a striking young woman marched in. She was wearing tight, day-glo purple shorts and a figure-hugging pink fluorescent vest. This is certainly not the usual attire of women in rural Zambia. Virtually all of them wear a wrap-around skirt called a chitengi, which hides their legs and (sometimes) disguises their buttocks. Their tops are very functional, allowing a breast to be howked out to feed a hungry infant. At first all the other traditionally-dressed women in the queue were silent and in shock. Then they buzzed with indignation at this hussey who was flaunting her body at the clinic. The young lady received treatment and marched out, seemingly oblivious to the stir she had caused.

Thursday Doors – Wildlife Police Officer Medicals

Beautiful palm tree at the “golden hour”, lit by the setting sun

When I am performing occupational medical examinations, I have to use a spare room which has no door. This is why there is no door in this Thursday Doors post. Sorry.

About a fortnight ago, men in camouflage uniforms began turning up at the health centre insisting on having a medical check up. Most of these men were in prime condition and many of them had been working on anti-poaching duties for decades. “Why do you need a check up?” I asked them. A few just shrugged their shoulders and shook their heads. A few mentioned chaos in Human Resources or a reshuffle in the responsibilities of the departments of the Ministry of Tourism, National Parks and the Arts. Apparently, lots of paperwork had been misplaced or gone missing, so everyone had to photocopy their original documents for re-submission. This included a medical examination to be carried out by a doctor.

No one knows for certain how many wildlife police officers, storekeepers, plant operators, general office workers, supervisors, rangers, etc. there are in Mfuwe. Guesses ranged from 100 to 250. That is a helluva lot of medical examinations. Not only did these “big men” barge in on consultations with sick patients, they insisted on being seen as a priority. I talked to the nurse in charge, who agreed to take up the issue with his counterpart in the Wildlife Authority. “I will suggest that we should limit the number of examinations to five per day, first thing in the morning,” said Martin. I spoke to my boss, the District Health Officer, who said that any health worker could sign the forms. “But it specifies doctor,” I said. “Don’t worry about that,” he replied. In practice, the WPOs demand to see the doc.

An armed scout stands guard watchfully beside a baobab tree at a recent wedding in the Valley

Each day, about ten officers chance their luck, waiting for me just before 8am. If a senior officer comes along, he takes priority and jumps the queue. I try to get the triage health worker to record their height (we only have one measuring rod and it is in the mother and child health block), weight (the glass on the scales is so dirty and scuffed that I have to crouch down to make a reading), pulse and blood pressure (both our electronic sphygmomanometers died last week, so I do this by hand).

I can’t help myself from teasing the officers: “So, you are a Wildlife Police Officer? Have you arrested any lions for grievous bodily harm? Or have you booked any impala for exceeding the 40KPH speed limit?” Usually they don’t understand my warped sense of humour.

The forms look as though they have not been altered since Independence and ask me to assess their body type and their mental state. I ask them, “Are you strong?” and they all say yes. “Are you mentally stable?” and again, they all say yes. I asked one chap this morning if he was sure, and he said, “Decisively stable!” The door to the office doesn’t close properly (there is no handle on the inside), so the next officer in the queue watches what is going on. Sometimes I ask him if the person I am examining is mentally stable. This usually produces a guffaw of laughter. Especially if he is their boss.

Purples and pinks in the clouds at dusk

Some men are grossly overweight with pendulous abdomens. I have to measure their girth and their chest circumference, expanded and deflated. None of them understand my order to “Take in a big breath and hold it; now breathe out fully.” The official form suggests that all the officers must have a chest radiograph, but this is neither possible nor justified.

I ask all the officers about previous serious illnesses but not one has confessed to having hypertension or HIV. One man needed to be accompanied by his son and asked me if I could sign him back to work after he was hospitalised with cerebral malaria. Sometimes, they will even ask me to prescribe their blood pressure medication at the end of the examination. About 20% of the officers over 40 years of age have elevated blood pressure when I measure it. I give them the usual advice regarding lifestyle changes and ask them to return for further BP checks. I write about this in the comments section at the end of the report, but as hypertension is asymptomatic, the officers don’t regard a blood pressure of 200/120 as preventing them from working.

There are questions on varicose veins, hernias, the state of their teeth, hearing and speech, but nothing about their visual acuity, which I find strange when their job involves tracking poachers and looking for snares in the National Park.

We have had no urinalysis strips for two months. The nurse in charge insisted that we use scarce health centre funds to buy some strips. Part of the medical examination involves testing urine. I refuse to waste urinalysis strips on asymptomatic, fit officers, so I just write “not required as has no symptoms.”

Morning light over the Luangwa River, taken from the bridge at the entrance to the park.

Finally there are some questions about patellar reflexes and pupil reactions, before a section marked “Comments”. I normally write “Fit”, sign, date and state the name of the health centre. We have one official health centre stamp, which has a central date. The numbers of the days of the month have fallen off, so I have to write that by hand. The ink pad is so parched that even with brute force I can only print a faded, illegible blue image.

I was taken aback when a senior officer asked me to use a darker stamp so he could photocopy the forms. At first, I thought he was asking to get “pre-stamped” forms which could be completed by anyone. Actually, he just wanted me to re-stamp all the photocopies of forms which I had completed that morning as the officers had made duplicates.

If it were up to me, I would abandon all occupational medical examinations as they are useless. I would introduce a more practical test – How fast can you run after a poacher? Can you sprint 100 metres in less than 15 seconds wearing full kit?

While I am filling in the forms, I make polite conversation. “Did you shoot the crocodile which attacked the 13 year old boy who was fishing in the Lupande River? On the news, it said his leg was allegedly in pieces.” No, they hadn’t located the crocodile. But they had responded to a distressed hippo which had strayed away from water and was sick. “We told the villagers to leave it alone, but they did not understand us,” said one WPO. “After we left, they attacked the hippo with machetes to get the best meat before it died and the hippo became very angry. It killed one of them.”

This is a very healthy hippo, taking a morning constitutional walk in the National Park.

The atmosphere this morning was rather subdued. It transpired that, allegedly, a civilian (a teacher?) had visited a bushcamp, picked up a semi-automatic weapon and fired three shots into a wildlife police officer’s chest, killing him instantly. There was a large crowd of family members outside the police post at Kakumbi, waiting for the body to be recovered. I wonder if the shooter would have passed the medical examination, especially the mentally stable question?

Names

Spur-winged goose takes off, narrowly missing a young male impala

Jester – I am not sure if this is meant to be Chester, or Jester. Maybe the parents are fans of Top Gun.

Hunky – The baby was not particularly big, just over 3kg at birth. And is growing normally. I wonder if the parents are fans of Marvel Superheroes and the Incredible Hunk. Or perhaps they see him growing up to be a bodybuilder.

Donoraold – This is how it was spelled. But Zambians have trouble with “R” and “L” consonants, often mixing them up. It is clear that this is Donald, as in Trump.

Arthur Chizzy – Arthur is a fine name, but partnered with Chizzy makes it sound like a spiv.

Ebeneziah – I called out for the next patient, “Ebenezer Zulu?” and a young lady came forward. “No, I called for a man, Ebenezer,” I said. “This is my book,” she said, “My name is Ebeneziah.” Okay, I am all for inventing new names, updating the Biblical classics, such as Jehosophat and Isiaiah. But who wants to be called Ebeneziah?

Gudlak – At first it sounded Norwegian, but then it became obvious as I said it.

Honeycomb on a big baobab tree. The bees have abandoned it, and honey guides, one of the only two types of birds who can digest wax, are gradually nibbling it away.

Proud and Praise – Twins, P and P. Alliteration.

Prince and Princess – Twins, but premature and not doing very well at present.

Prince and Prosper – Twins, P and P again. I reckon that they have found inspiration from Jane Austen.

Destiny – Ambitious

Sagacious – and I have met a Wisdom, too.

Golden – I have heard of an American football player called Golden Tate

Marvellous – But of course.

Bottle – This man told me that his previous two siblings had died in infancy, so he was given the name Bottle as his life was going to be poured out soon. He was in his 40s now. I recall another lady from Swaziland who had a similar tragic family, with nine children not surviving to adolescence. She was called (in siSwati) “Sorry going to die soon”. She was over 50.

Fatness – Delicious, no issues of body image here in Zambia

Mobile shoe and pant shop. Crocs definitely live on in the Luangwa Valley

Loveness – I asked the health inspector what he would do if he had been called Loveness as a child. He said he would change his name to Derrick. Which is what it is now.

Shopping in Cropping*

Gotta Go Whole Heart is the slogan on the stallkeeper’s red singlet. Hmmm.

We’ve all been there. Gone out to buy one or two specific items and ended up purchasing stuff you didn’t need. Mission Creep. I was driving home from the clinic when I saw a flash of scarlet in the corner of my eye. I pulled over to examine the piles of tomatoes on sale. They looked superb, cleverly stacked in a pile of four (a triangle of three with a larger one on top) to make them seem a better bargain. The bruised or unripe bits had been cunningly concealed. Nevertheless, I had just run out of tomatoes and they taste much better than those on sale in UK supermarkets – covered in plastic, taste like plastic.

One pile of tomatoes, five kwacha. Is there a deal if I buy more than one pile? No, but I can pick the piles I want and if one tomato is soft or bruised, I am allowed to swap it for another. I pick three piles and decide to pay. Even the inflated muzungu price.

“What about these ground nuts?” said the traditionally-built stallkeeper.

“How much?”

“Two kwacha per tin,” she said, indicating a small measuring can, with groundnuts piled up into peaks.

Instead of being dried or shelled and roasted, these nuts had been boiled in their shells. I chose one, picked open the soft shell to reveal two white nuts, which were tasty. “I’ll have two tins, please.”

The stallkeeper made a grand show of piling as many groundnuts as she could into a tin and pouring them into a plastic bag. Then she conspicuously threw in another handful when she saw I was looking. Good for customer relations and not bad for 25 pence.

“What else you like?” she asked.

“That’s enough thanks,” I replied handing over a 50 kwacha note.

“No change,” she said. “How about some chips?”

I haven’t had chips for nearly two months, so I was tempted. She gestured towards a metal bench in which was set a deep dish, filled with bubbling oil and anaemic-looking chips (French-fried potatoes – for my American readers – is too generous a term). I said that I had to be going, I couldn’t wait for the chips to finish cooking.

Just like on the children’s TV show, Blue Peter, she showed me “some which she had made earlier” in an open plastic bucket.

Personally, I prefer triple cooked chips, crisp and crunchy on the outside, soft and fluffy on the inside. These looked like pale yellow slugs. But the lure of chips was too great. And they were only 30 pence for a portion.

“How much do you get in a portion?” I asked.

“Two handfuls,” she replied.

“Handfuls? Can’t you use an instrument, a slotted spoon or something?”

She tried, bless her heart, and the chips went everywhere but inside the plastic bag. She looked up at me, imploring me to change my mind. “Ok, just get them in,” I said.

This seemed to please her so much that she just filled up the plastic bag almost to the brim, packing them in with her greasy hands.

“You want salt?”

Before I could say, “Yes, just a pinch,” she dumped four fingertips and a thumb’s worth of salt into the bag. “It’s going to be thirsty work eating these chips,” I thought.

“You want sauce?”

My eyes lit up. Would it be brown HP or Heinz tomato ketchup? Neither. It was a two litre plastic bottle containing orange-pink fluorescent liquid called euphemistically “chilli sause” (sic).

No way was I going to let her add the sauce to my chips. I wanted to exert some control so I unscrewed the top, held onto the chip bag with one hand while I tipped in the big bottle of “sause” using the other hand. A large gobbet of thickened sauce had clotted in the neck of the bottle, so I gave it a slosh forward and behold – half my chips were slathered with gloop.

But buyer’s remorse had not yet set in.

I accepted my change, gave thanks and walked back to the car. I needed to tie the top of the plastic bag to stop the chips and slime from spilling out in the foot well. However, there was hardly any plastic above the chips to knot and my hands were so greasy that my fingers couldn’t get a grip. The chips were hot, too, making the task even more difficult.

I wedged them against the tomatoes and soggy groundnuts, hoping that I would be able to negotiate the potholes on the road home without needing to valet the car interior.

How does one eat an impulse buy of groundnuts and chips? Easy. I gave the groundnuts to my neighbour (as I am always eating her snacks when I go over to have a sundowner) and I piled the chips between two slices of Mother’s Pride. A huge chip butty, with a cup of tea to ease the salt-induced thirst. The sauce tasted of chemicals and chilli heat, mitigated by the spongy slices of bread. Wonderful.

That night, I had been in bed asleep for an hour or so when I was awakened by a telephone call, asking me to visit a patient. My stomach felt uncomfortably full and bloated. I had waves of colic and nausea. Within minutes I was on the toilet, purging from both ends. I literally didn’t know which way to turn to evacuate the contents of my intestines. I was sweating and felt faint. I diagnosed heat-stable staphylococcal enterotoxin food poisoning. In medical textbooks, the classic means of transmission is via a food-handler’s infected finger or whitlow. The chips? Surely the sauce would have neutralised the enterotoxin?

But the show must go on. When I was empty, I brushed my teeth, scrubbed my hands and within twenty minutes I was out of the house on a mission of mercy. En route I wondered who would turn out to be the most unwell, me or the patient?

*Cropping or Crapping?

Radio Gaga

It was A’s idea. “It sounds like you’ve been doing great work vaccinating in the schools. Why don’t you get the message out there, blow your own trumpet?” And what better way to do it than getting on local radio?

Mnkanya Radio 88.3FM is our local Mfuwe station. It is situated half way between the national park gate and the airport. There is a cluster of modern huts on one side of the compound (the owner is trying to start up a lodge business as well), a reception and a recording studio. Towering above is a red and white radio mast. They mainly play music from Zambia, South Africa, Zimbabwe, Nigeria and the USA. Although they broadcast the news in English several times a day, the disk jockeys and station announcers speak in local dialects. Their Facebook page is a bit sparse but contains some news items such as

“
“police in kabwe has gun down two criminals de other one has died at de spot and de body dead has taken to de mochary in kabwe hospital while de other one z at kabwe central police wth severe injuries this has happend wen two criminals broke into acertain shop wen security officer phonnd de police without delayment and de police dd according to their works thus was around 24hrs on 20th january 2019”

At the clinic, I discussed the need to publicise our work in the community, to explain to parents exactly why we were vaccinating their children in schools. Mr C, the public health inspector in charge of community programmes, thought it was an excellent idea to use radio to do this. But he thought that the radio station would charge us as they charge advertisers. I insisted that this was a public service, the public had the right to know, and there was hardly any decent local news to broadcast. C wasn’t convinced.

He brought up the subject at the next clinic meeting. The nursing officer in charge agreed it was a good idea, but only if it didn’t cost anything, because the clinic could not afford to advertise. We agreed that once C had finished compiling the vaccination report, we would pay a visit to Mnkanya Radio in Mfuwe.

“Home of lxuary & confortable place”

Armed with the figures, we decided to drop in unannounced. If we had written a letter or email, it may have gone unanswered or we might even have been rebuffed. During the short drive to the station, I discussed strategy with the health inspector – key points, short sentences, snappy answers. I spoke about the ABC technique with tricky questions – Acknowledge the question (answer it if it is easy), Bridge to your safe ground, the area where you want to answer questions, and Communicate your key messages.

C wasn’t convinced. He was so worried that the radio station would want to charge us that he wasn’t listening to my advice. “You have done this before, doc,” he said, “You can represent the clinic.”

The recording studio

We drove into the compound and walked to reception. The small building was empty. A gardener noticed us and alerted one of the reporters. He took us over to the recording studio where they were broadcasting live.

“What do you want?” the reporter asked.

Mr C looked to me and I motioned for him to answer the question. He rambled on for a few minutes, using jargon (“TT” instead of vaccination against tetanus, a disease which can kill adults as well as young babies) and getting rather muddled. It is common for Zambians to pad out their English with bland phrases while they search for the right word.

I could see the reporter was looking less than impressed. Mr C turned to me and said, “Doc?” I emphasised that this was a good local news story; many families with school aged children would be interested; we had vaccinated 1,205 school children during February; the immunisation coverage rate was better than in the UK. The punch line was that we will be returning to the schools in March to give booster doses.

The reporter got out his iPhone ready to record an interview. I said, “It wouldn’t be right for a muzungu to talk in English to your listeners. The Zambian health workers and volunteers are responsible for this work and they should speak in Kunda or Cinyanja.” He agreed and pointed the iPhone microphone towards Mr C, who suddenly looked terrified.

“Can you give us a minute?” I asked. The reporter went inside, while I discussed interview technique with Mr C. “Martial your facts, speak in short sentences, don’t use jargon, tell them what a great job we have done,” I said. “You  can do it!”

The interview was very short, less than five minutes, but for Mr C it seemed like it was half an hour. The reporter blindsided him with a question about the vaccination schedule for schools in March. We didn’t have the vaccine in stock and there were some public holidays just to complicate matters. But Mr C went through his papers and eventually came up with a schedule for the listeners. “I will edit that last piece,” said the reporter, kindly.

Just before we left, I asked the reporter if he was interested in any local health stories. He told us that he was always on the lookout for anything that would get more listeners. On the way back to the clinic, Mr C was enthusiastic. “We could do plays with health messages… we could warn people about malaria… we might get a regular health spot,” he said.

“That will be a great deal of additional work, Mr C,” I told him.”You are already working flat out. And remember, actions speak louder than words. This is only newsworthy because it has been such a success.”

“Ah, you are right, doc!” he replied.

When we got back to the clinic, Mr C made sure everyone knew that he would be on the midday news, and the afternoon news, and the evening news, and the late night news. Perhaps even tomorrow morning’s early news. He was a radio celebrity now.  

Mamba

Picture courtesy of Alastair Anton

Dr John Seaman, my boss when I worked for Save the Children Fund from 1979-1984), first introduced me to the term MAMBA – “Miles and miles of bloody Africa”. But this blog post is not about monotonous stretches of acacia scrubland in the Sahel. It is about the notorious snake.

My neighbour sent me this photograph of a snake coming down from a tree against which he had been leaning five minutes earlier. It is a black mamba, the most deadly snake in Africa. Contrary to its name, black mambas are usually grey or even brownish snakes, but their name comes from the black colour inside their mouths. This is not a view I want to witness.

These snakes can grow upto three metres long. They avoid contact with humans, only striking when they feel threatened or trapped. But they often strike repeatedly. A mature snake can inject 100mg of highly potent venom in each bite. This is double the amount needed to kill an adult human victim.

They can move quickly, 10 mph for short distances. It can rear up 40% of its length, allowing it to inflict bites on the upper body. When fully grown, they have no natural enemies in the wild. They eat rodents, birds, bats and even other snakes.

Juvenile mambas are lighter in colour

The venom acts swiftly and many people who are bitten do not survive long enough to get medical attention. The supply of anti-venin is parlous, with manufacturers stopping production on commercial grounds. It can take 10 ampoules of anti-venin to treat envenomation.

Zambians might seek help from a traditional healer before going to a clinic. I was fascinated to learn how a sangoma (witch doctor, medicine man) would treat mamba bites. First, one must carve a basin-like depression in a large termite mound*. The victim has to pass urine into the depression and make a thin paste with the powdered earth, and this is then drunk.

My colleague, an old Africa hand, asked, “But this poison gets into the blood, into the central nervous system. How can drinking his muddy urine counteract this?”  

“No, you misunderstand,” said the sangoma. “The family of the victim has to drink the paste, not the victim.” As if this made the treatment more rational.

*Interestingly, mambas often live in holes in termite mounds.

Pesky National Holidays

Wild dog or Painted Wolf, chewing a kudu (antelope) leg

Zambia is awash with National Public Holidays in early March. Friday 8th was International Women’s Day and Tuesday 12th was National Youth Day. This put a spanner into our well-oiled community health programme.

The Ministry of Health has prioritised data collection for the planned Human Papilloma Virus (HPV) vaccination campaign, which begins in June 2019. This is an expensive vaccine which will protect against cancer of the cervix (as well as other cancers and genital warts) only if it is administered before the girls are exposed to the HP virus. Cancer of the cervix is the most common cancer among women who are living with HIV in Africa. There is no national cervical screening programme, so introducing HPV vaccination is a no-brainer.

On Thursday 7th March, we received orders to collect the names of all girls who would be aged between 14 and 15 at the start of the campaign. We contacted all the schools in the area but, as many girls do not attend school, we had to ask our community health volunteers to go house-to-house to collect this data.

A male kudu – not the one eaten by the wild dogs

The following day was a public holiday, so nothing happened.

Then it was the weekend. Nothing happened.

Following the three day weekend, Monday 11th March was extremely busy in the clinic, but we managed to distribute the forms to list the girls eligible for HPV vaccine. The following day was another public holiday, so nothing was done. The forms should have been completed for Wednesday 13th March, but the teachers had not managed to fill in the information. Nevertheless, a team from headquarters arrived to collect the forms, only to find that, like us, none of the four centres in the district had successfully collated the data.

So they planned to return on 14th March at 10am insisting that the data should be ready. A health worker used his own money to put fuel into a motorbike to collect all the data from the schools in the early morning to meet this deadline. The biggest school still hadn’t finished the data collection, but we were assured it would be done by midday. When we picked up the forms, the teachers had clearly not understood the meaning of a column marked “Age 14 years” and another “Age 15 years”, because they included every girl, regardless of age.

Domestic disagreement between vultures

This whole process made me feel despondent. The campaign is not scheduled to start for two and a half months, but because of two public holidays, we only had two days to make arrangements. The quality of data suffered as a consequence of unrealistic, unnecessary deadlines. Even more sad is the fact that Zambia is planning to vaccinate the wrong group of girls. Instead of providing three vaccinations over two months, the Zambian programme will provide two vaccinations a year apart (the immunogenicity of the vaccine is excellent, so it may be that this will generate adequate immunity).

In the UK, we give the vaccine to 11 and 12 year olds in school. One of the head teachers told us that the majority of girls in her school were sexually active by age 15. They even have pregnancies at school in children as young as 12. Girls aged between 12-16 who do not attend school are more likely to be sexually active, married or pregnant.

I contacted the District Health Officer to express my concerns about this and he agreed with me completely. Policy is made at the highest level in the Ministry without consulting grass roots health workers. It is too late to change the strategy. The vaccine isn’t cheap, so the country is wasting millions of kwacha targeting girls who are already likely to be infected with HPV and so will not benefit from the programme.

Rant over.

Cute child at the community clinic

Normally, the second Tuesday of the month is Chikosi’s community clinic. Because this was a public holiday, we informed the mothers that we would be coming on Wednesday instead. But people forgot and turned up late. One of the community volunteers was absent, so we asked a health centre volunteer to help out with the weighing. He rigged up the scales, hanging from a tree branch and started weighing the children.

Within ten minutes, the mothers were up in arms. All their children had lost weight since last month and they were not standing for that! I checked the scales to find that they had not been zeroed. The children were weighed again and the mothers were happy with their infants’ progress.

During the minor riot, I saw an infant (strapped to his mother’s back) attempt to capitalise on the confusion and suckle on another mother’s breast, deftly pushing her baby’s head aside. It reminded me of the behaviour of cuckoos. Or perhaps he just wanted to find out if milk tasted differently from different breasts. Enterprising little chap.

The public health inspector gave a long talk on interpretation of the weight chart (“Road to Health”) which documents average weight over the first five years of life. Unfortunately, the official charts have not been available since August 2018 when they went out of print. An enterprising local pharmacist photocopied the charts on blue and pink card, but charged the mothers 10 kwacha (=US $1). Most of the babies under six months of age have school exercise books with the vaccination schedule, de-worming, vitamin A supplementation, HIV checks, etc., all written by hand. But there is obviously no graphic representation, which made the talk on growth rates, centiles and danger zones rather academic.

Kojak – bald, lollipop-sucking detective. Selinge = syringe spelt phonetically by Zambians.

We had some more great names. It is common to combine two names into one – Izaister is Isaiah combined with Esther. Rolister is Rosa combined with Alister. I believe that “truncated concatenation” is the correct term. The public health inspector comes from northern province and is unfamiliar with the local names. He also finds it difficult to read the names written in English. When he struggles, I take over and spout “Mwukambwiko” fluently, much to the amusement of the mothers, who hoot with delight at the muzungu who knows more Kunda than the Zambian health worker.

Some children had missed out on their vitamin A booster a few months ago. The vitamin is an oily liquid in a soft capsule with a teat. I bite off the teat and squirt the oil into the child’s mouth at an opportune moment. It doesn’t taste of anything, but it has a greasy sensation in the mouth. I devised a cunning plan to have the child breast feeding, the mum takes the nipple out of the child’s mouth, I squirt in the vitamin and the child latches on again within a second. Seemless. I am still trying to get the oil stains out of my trousers, however.

Children are eligible for measles vaccine at nine months. Health workers use a crude month reckoner, but one mother pulled out her smart phone and did the precise calculation, demonstrating that her child just met the criterion to have the vaccine. We didn’t argue with her.

A little girl attending the clinic in her party dress, with socks and sandals, eating a fritter.

The date of the next clinic is not quite four weeks away, which is the interval between the first three vaccinations. Health workers like to stick to the official guidance for vaccination, because they will be criticised by supervisors if they don’t. But this was a tricky one. Do we vaccinate slightly early, do we defer the vaccination to the following month or ask the mothers to come to a different clinic location? Life is too short to worry about this, so I made an executive decision to ignore the slightly shorter interval. If their supervisor detects this deviation, they can always blame the muzungu doctor, who has by then left the Valley.

Spotted Eagle Owl

Dusk in South Luangwa National Park. It had just started to rain and visibility from the safari vehicle was limited. The spotter’s searchlight picked up something in the middle of the laterite road. We had been flushing nightjars along the road, but this was different. At first, I couldn’t see it because it was facing away from us. It turned and gazed at the intruders who had interrupted its hunt.

Spotted eagle owls are infrequent visitors to the park, but are widespread over southern Africa. It is easily recognised by its small size (for an eagle owl) and the horns on each side of its head (which are composed of feathers).

Spotted Eagle Owl

This bird is a night owl, hunting by sight for rodents, lizards, insects, small snakes and birds. Usually, they perch on a favourite bough above a popular thoroughfare, but this one was in the middle of the road, searching for prey at ground level. Once they pounce, they devour their food quickly, gulping it down in one, rather than tearing it apart.

When you see one, there is often a mate close by. Like many birds, they mate for life. They nest on the ground, under cover of a bush, rather than in a tree.

The bird flew off and we moved forward slowly. It then landed closer to the vehicle but the spotter’s light startled it and it took off again, hiding in a leafy tree.

Compare this bird with the Verreaux’s Giant Eagle Owl, that I photographed in the car park of the lodge at the end of the game drive. The pink “eye shadow” on the upper eyelid makes me smile every time I see it, as if this bird is not glamorous enough without “makeup”.

Verreaux’s Giant Eagle Owl

In Zambia, eagle owls are regarded with suspicion. They are widely believed to be involved with witchcraft and black magic. Harry Potter understands this very well, of course.

Thursday Doors – First Fatality

To qualify for the blog, I have to insert a door or two. This is the door (blocked with branches) of a local barbershop. The message on the tree reads “Welcome”, with a bench for people waiting to be clipped. Marky C, the owner of Get Smart Barbershop, appears to have disappeared. This is in Cropping Village, Mfuwe, Zambia.

It was on the cards, really. All the danger signs were there. The baby had failed to thrive and a few weeks before I started work at the clinic, she had been referred to the local hospital as an emergency. The hospital diagnosis was pneumonia, and the doctors had asked the mother to come to Kakumbi for follow up a week after she had been discharged.

Water Monitor Lizard, not connected with this post at all

The infant looked thin and gaunt. She was breathing quickly and using additional muscles of respiration to suck in as much oxygen as she could. Her mother was clearly very anxious and concerned. I asked her to remove her daughter’s outer clothes so I could examine her. The child’s chest looked deformed, as though there was a lump under the lower breastbone on the left. The spaces between her ribs were indrawn at each breath.

White-browed sparrow weaver
Mwanchilo – untidy nest in Nyanja

I laid my hand on her chest and counted the pulse – 200 beats per minute. The chest wall seemed to push up against my fingers and I could feel a thrill, a palpable murmur caused by turbulent blood flow within the heart. It was like a thrumming sensation moving from left to right. Listening with my stethoscope didn’t help me much because of the rapidity of the pulse and the noisy breathing. There were some crackling breath sounds at the base of the right lung but they didn’t sound like they were caused by infection. There were no peripheral signs of bacterial endocarditis.

Cordon Bleu, not connected with this post in any way

I hesitate to write “my heart sank” but that is what I felt. This child almost certainly had a ventricular septal defect – a hole in the heart between the left and right main pumping chambers. Part of the blood which was meant to be pumped into the aorta and around the body was being diverted into the right ventricle. This had become grossly enlarged and had deformed the chest wall. As the swollen right ventricle contracted, it “heaved” against the inside of the ribs. The abnormal flow of blood from left to right ventricle was causing the vibration I could feel with my hand.

Was I sure? I had no access to the hospital notes regarding the admission for pneumonia (if indeed, this is what it was). I could not see a chest radiograph or get the results of a cardiac ultrasound (ECHO). I was relying solely on my clinical examination.

White-fronted bee-eater
Mupepafodya – one who smokes cigarettes, given the habit of these birds to sit on thin twigs which resemble cigarettes

Sometimes, small holes create loud murmurs as there is a more distorted flow of blood, whereas bigger, more significant holes can cause less turbulence, resulting in a quieter murmur. This is known as “Maladie de Roger”. I hoped that the thrill I felt meant a smaller defect, as these can sometimes spontaneously close as the child grows. But the rapidity of the heartbeat was very worrying. The heart was working flat out.

Having made the diagnosis, what could I do about it? There is no access to surgery to repair complex congenital heart problems in Zambia. I told the mother that the baby was very ill with a heart problem, there was little we could do, but I would review her in the village at next month’s community clinic. I did not think that returning to hospital would help. I tried to convey the seriousness of the baby’s condition without pronouncing a death sentence.

African Open-billed Storks
Mtowa nkhono, one who likes breaking snails

Sadly, she returned that night to the clinic with the baby in extremis. An ambulance took the baby to hospital but she died on admission.

One might think that having a doctor working at the clinic must be beneficial. Doctors have more training, more skills and knowledge than the clinical officers and nurses. But just being able to diagnose the problem doesn’t mean you can solve it, especially when you have the meagre resources of a developing country.

“The good news is the doctor knows what’s wrong with you; the bad news is that the doctor can’t cure you.”

Renewing Old Friendships

Last week, young Desmond (see a previous blog Desmond Doktah), saw me in the doctor’s vehicle negotiating the muddy potholes of the street outside the police station which leads to the clinic. He hauled himself up onto the running board and grinned at me. I grinned back. I had heard that he had been unwell, but he looked fit and healthy. He said that he would come for a consultation with me at the health centre during the school holidays.

I enjoy re-establishing links with people whom I have met or treated in my two previous missions here in Kakumbi. Of course, the doctor has a high profile, and everyone recognises the doctor’s car, even if they confuse me with another male muzungu doctor.

Occasionally, I will see my writing in someone’s health records, a cheap school exercise book and it strikes a chord. Or at least, I can see how I was thinking about the clinical problem at the time.

Most of the health centre staff are new to me apart from six: Jesse, the cleaner and register keeper, Erina and Margaret, who help in the mother and child health block, Celestino and Mike who are community HIV support workers, and John Mbewe who is the enrolled nurse in charge of HIV care.

John Mbewe vaccinating while wearing his waistcoat “Champion Against Open Defaecation”

Daillies, my former translator, and Helen, who was so skilled at handling hysterical patients using the power of Jesus, both work at the Airport Clinic now. Chanda, who volunteered at Kakumbi for ten years without pay, now has a post at the district HQ in Mambwe. Mr Chulu has taken over as environmental health officer at Kamoto District Hospital. I have met them all again (apart from Helen).

Maurice, another one of our volunteer community health workers, weighing babies

Dr Mashanga, my supervisor at Mambwe District, warmly welcomed me back to the Valley and promised to get me the additional drug supplies to enable me to treat patients with mental illness, asthma, hypertension and diabetes. We now have atenolol, nifedipine, metformin and glibenclamide in stock at Kakumbi.

I also visited Caroline Mwanza, the District Commissioner. I could see her outside her office, under the shade of a magnificent tree. I waved at her and she cocked her head onto one side, wondering who on earth this old muzungu could be, coming to greet her. Then her face beamed into a smile as she recognised me. We hugged and embraced each other before she marched me off to her air-conditioned office for a long chat.

It’s great to be appreciated and greeted so warmly by everyone. Zambians are so friendly (and so are the expatriates living here).