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.
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.
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.
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.
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.
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.