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Medical Zambia

Titbits

Some random thoughts, titbits, not enough for a blog by themselves.

The collective noun for elephants is a “memory”. For zebras, it’s a “dazzle”. But the what about the most numerous animals in the national park, impala? If you look carefully, you can see a black and white version of McDonald’s Golden Arches on their rumps. Indeed, for big cats, impala are the equivalent of fast food hamburgers. So I propose a new collective noun “a happy meal of impalas”. There was a herd of about fifty on either side of the track this morning. I slowed down, but they sometimes get spooked and run across to join the others, leaping really high over the roadside ditch, back legs kicking out behind them.

They are very beautiful, graceful animals
Not very convincing set of McDonald’s arches.
Photo taken during the dry season

As I drove back to my house after a home visit just after nightfall this evening, I rounded a corner and almost ran into a giraffe standing on the road. I expect to come across elephants and hippos, but four long, thin, camouflaged legs didn’t instantly capture my attention. I had to slam on the anchors and screeched to a halt in a cloud of dust. The giraffe just looked down at me and serenely wandered off.

Easy to see in the daytime, not so visible on a winding dirt road after dark

This morning I was driving through Cropping Village on my way to the clinic when a young girl did a series of cartwheels across the tarmac road. Out of sheer delight. This put a smile on my face for the rest of the day.

Our female nurses are very stylish and wear white individualised uniforms to show off their slim figures. One was late for the Monday morning meeting and I noticed that she was wearing a white tunic with a stand-up collar. Unfortunately this did not conceal a large irregular, purpuric, purple lesion over the lower right sternocleidomastoid muscle. She had a huge love bite. Of course, being a well-mannered doctor, I didn’t tease her about this, well, not much. Good for her, but the nursing officer in charge will be closely monitoring her attendance at early morning meetings in future.

She came with us to do community child care clinics in two villages today and felt so exhausted that she had to go and have a rest in the car. I didn’t blame her.

I showed the mothers and children the photographs which I had taken last month in their villages. They were all delighted. I offer a WhatsApp forwarding service of the photos if they give me their phone numbers, but few have smartphones. The children remembered how to play hopscotch, which I showed them last time I did the clinic there. They all wanted to have their pictures taken again. In the first photograph, they look serious and unsmiling. Then I make a joke or a funny face and they smile, allowing me to capture a happy expression.

I have seen a patient with hand, foot and mouth disease recently. This reminded me of when one of my daughters contracted this common viral infection when she was about five years old. I remember telling my wife about the signs while I was driving. I lifted one of my hands off the steering wheel to demonstrate where the inflamed papules and vesicles develop. When I looked down at my palm, I saw that I had caught the disease too!

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Medical Thursday Doors Zambia

Thursday Doors gone walkabout

Fancy bit of roadside carpentry to qualify this post for Thursday Doors!

The disheveled old man came into the consultation room and sat down on the chair. Two male family members had brought him to the clinic after he had gone missing from his home for more than a week.

“Uncle Buck just walked out the door,” they said.

The scouts of Conservation South Luangwa had found him on a routine patrol while searching for poachers and snares.

He avoided my gaze and didn’t answer my greeting. “He’s not right, doc,” said his relative. “He used to be a miner in the Copper Belt but ten years ago something happened to him, we don’t know what, and he stopped talking. He came home and hasn’t been the same since.”

This is not a rare event. Some Zambians feel that this withdrawal into silence and passivity is the result of witchcraft. Perhaps he felt alienated working underground in a harsh environment. I considered more medical causes, such as psychosis, dementia, encephalitis, cerebral tuberculosis, a stroke or post-traumatic stress disorder.

Uncle Buck gave us no clues. His rheumy eyes seemed to stare past me. I did a physical examination and reckoned that he was in good shape for someone who had been without food or water for nine days. “Do you think he used bushcraft to find food and safe water?” I asked. “No, he is not capable of doing that,” his relative replied.

Fish Eagle

He is lucky that he has a family who cares for him, gives him sustenance and shelter because there is no government social support.

Categories
Medical Zambia

Princess and the Frog

There was a terrific thunderstorm last night. To the west, I could hear lions growling and calling to each other, to the east I could hear thunder rolling my way. The lions stopped being grumpy when the wind started to blow. It was a cool, refreshing wind, giving relief from the humid, oppressive, stale air of the afternoon and evening.

The sound of rainfall is amplified by my corrugated iron roof . It became deafening as the storm grew nearer. I thought about rescuing my outdoor router from the deluge, but I didn’t want to meet some rather large cats sheltering on my verandah. They could sit on the wicker sofa if they wanted to, braving the scorpions.

I recorded the sound of the rain, then switched on the verandah light and recorded some video footage. Just watch the first ten seconds to get the drift. The sound of the rain drowned out the thunderclaps, but the lightning flashes were plain to see.

As I was doing this I noticed a small brigade (not enough for an army) of frogs hopping towards my front (and only) door. I retrieved the router and settled down in bed for a good read without any email or social media distractions.

In the morning, I saw a frog by the fridge. My new best friend. On previous stints as valley doctor, I have had frogs living in the doctor’s car, so this was not surprising. I took a photograph (regular readers will recognise this compulsion to document images) on my phone before I drove to work.

One of my first patients was a beautiful 11-year-old girl. I asked if I could take her photograph with my phone and she agreed. She wanted to look at the picture, so I switched from camera to photo gallery mode and turned the phone for her to see. The imageI had previously taken was the froggie intruder. When she saw this, her mouth dropped open in surprise.

Doctors are renowned for thinking on their feet, so as quick as a flash, I asked her if she knew any fairy stories. How about the princess and the frog? I glossed over the prince part, and said that sometimes if you kiss a frog, it turns into a princess. So I kissed the screen, pressed the “next” button and her photograph appeared. She was delighted.

Whilst I am not Patch Adams (RIP), I do enjoy making my patients smile or laugh.

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Medical Zambia

Counselling

“Are you any good at counselling, Doc?” asked the nurse at a community clinic.

“I’ve done a few courses in the past. I am not bad, but I can’t counsel in Nyanja,” I replied.

“That’s no problem, she can speak English.” Hmm, but well enough to understand the nuances of counselling? And I don’t have a deep familiarity with the local Kunda culture.

The nurse gave me no choice and beckoned a well-dressed young lady to approach me. “Counsel her. She’s HIV positive, refused Option B+ (being treated with anti-retroviral drugs in pregnancy and continuing after the birth), and would not let us treat or test her child.”

The clinic was at an end. She was one of the last mothers. We moved to a quiet place where we could not be overheard.

I began with “Hello, my name is Doctor Ian. How can I help you?”

“I don’t know if you can help me,” she replied. Touche.

“Do you know your HIV status?” I asked.

“They tested me at the antenatal clinic. They said I was positive.”

“Do you believe it?” I said.

 “No, I feel so well. I don’t think the test was correct,” she said.

“When someone tests positive, the lab always does a second test to confirm the result. We are very sure that you are living with HIV.”

This was too confrontational. She stopped talking and looked down.

“Has your husband had a test?” I asked.

“No, the clinic tried to get him to come for counselling and testing but he refused,” she replied.

“So he knows that your test was reactive?”

“We both don’t believe it,” she said.

The mother was in total denial. She felt that her child was growing normally and had been breast fed despite advice to the contrary by the nursing staff.

One of our fantastic volunteer community health workers

I have been involved with a similar situation in the UK when one of my patients who had been taking anti-retroviral drugs stopped and became pregnant. The dilemma was balancing the rights of the unborn child to have potentially life-saving treatment with the rights of the mother to refuse medication. Eventually, the mother relented and restarted treatment, or the child would have been removed from her care soon after birth by a court order. Things are different in Zambia.

“OK,” I said, “If you don’t believe it, that is up to you. We cannot force you to take medication. But I am worried about the child.” I decided to take a different tack, emphasising the good, rather than the bad.

“Before we had anti-HIV drugs, we discovered that about a quarter of babies born to HIV positive mothers became infected. Another quarter became infected after birth from breastfeeding. So the chances are 50:50 that your child is not HIV positive.”

“If the child’s test was non-reactive, we could all breathe a sigh of relief,” I said. “I am sure that you would be very happy with that result.”

“Yes I would, but I don’t need to have my child tested,” she replied.

“No one is going to force you to do this,” I said. “But if it was my child, I would want to know if the child could benefit from life-saving treatment. You might think that it is best not to know, but how would you feel if the child gets sick and you could have prevented this?”

Again, this was too confrontational and heavy-handed. She dropped her gaze and disengaged. “I will bring the child to the health centre next week,” she said. We both knew that this would not happen.

“I can bring the test to the village at next month’s community clinic if you want,” I offered. She nodded and returned to her child. I looked at the child’s weight chart, which showed faltering growth. I noticed a strange rash on the child’s scalp. As I bade her goodbye, I thought that the odds were against the child.

Another one of our fantastic volunteer community health workers

Broadly speaking, infants infected at birth with HIV fall into three groups. One third succumb to opportunistic infections quickly, before the first birthday. Another third gradually become ill over several years, and the last third is incredibly resilient, remaining well for a decade or more.

The mother is in denial, but what could be in store for her if she faced the truth? Would her husband accuse her of infidelity, beat her up and then abandon her? Would her world fall apart?

This situation is not unique. A recent paper in the Journal of the International AIDS Society https://doi.org/10.1002/jia2.25220 analysed the experience of people in Swaziland who tested HIV positive and immediately started treatment in 2014, despite having no symptoms. Most patients accepted the diagnosis and treatment but “others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment‐taking as a means of seeking evidence of their need for treatment and its effect.”

UNAIDS reckons that we can control the global HIV epidemic in a few decades if we adopt their 90:90:90 strategy – 90% of people know their HIV status, 90% of those who are living with HIV are taking anti-retroviral drugs and 90% of those on treatment have no detectable virus in their blood. It all sounds so simple and logical. However, prior to late 2015 when “Treat All” was proposed, health workers would only treat the patient immediately if they were very unwell or their immune system was severely damaged. We would wait until their CD4 count dipped below 350, or even 500, before offering treatment. This approach allowed the patient time to come to terms with the diagnosis and see the need for treatment. “Treat All” and Option B+ approaches both offer treatment at the same time as the patient has been told the diagnosis – a double whammy.

Categories
Medical Zambia

Scorpions

I have a deep hatred of scorpions. They have no redeeming features.

They look evil.

Their wicked claws clamp onto their prey so their malicious tail can loop over their head to deliver a fatal sting.

I don’t care if their venom has been used to treat impotence, rheumatism and epilepsy for the past 500 years, or that modern researchers find the venom can kill neuroblastoma cells. I detest them.

Discovered on the sink in my bathroom. My trembling hands resulted in this blurred photo

Apart from finding two under the pillow of my camp bed on the Omo River in South West Ethiopia in 1980, I have not had the displeasure of living in close proximity to them. Until now. I have killed three scorpions in my house since I arrived in Zambia in January, the last one a few days ago. I asked the lady who cleans my house if she had seen any more scorpions about. When she said yes, I asked her why she hadn’t informed me. “It was outside, bwana,” she replied. I breathed a sigh of relief. “There is a nest of them in the chair on your verandah.” WHAT?

I hope this skink eats scorpions in the wicker chair

My reaction was mild in comparison with my next door neighbour’s. She comes and sits on my wicker chairs occasionally. She went apoplectic with the thought of her bum being stung as she sat. “Don’t worry, I can inject the sites with local anaesthetic,” I said. “No, you will not,” she replied, “I’ll suffer in silence.”

In layman’s terms, there are two types – black and yellow. The sting of the yellow scorpion is more intensely painful and lasts upto eighteen hours, whereas the black scorpion’s sting lasts just twenty minutes. Size doesn’t matter, apparently.

Zambians rely on traditional scorpion healers to deal with the sting. If, for example, someone has been stung on the finger, the traditional healer will massage the digit, charming away the poison in a rhythmical manner. One can even go to scorpion healer school to learn how to do this.

I met this scorpion under a stone in the Thorny Forest of southern Madagascar

Medics prefer to inject a longer-acting local anaesthetic, such as Marcaine, to numb the pain. I have done this several times, with good effect. Just this morning, we injected a man who had been stung on the wrist. Three ccs of ordinary lignocaine 1% relieved the pain and numbed his median nerve into the bargain.

One of my predecessors at Kakumbi Rural Health Centre treated a patient who had been stung by a yellow scorpion on the finger. She injected local anaesthetic around the base of the digit, a “ring block”. Meanwhile, the traditional scorpion healer appeared and massaged the finger. Within a few minutes the patient said the pain had been relieved. The following morning, the doctor reviewed the patient. “Do you feel any pain now?” she asked. “Only at the base of my finger where you injected me,” replied the patient.

You can’t win ’em all.

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Zambia

Mother and daughter

Mother is on the right, daughter on the left, facing each other

I was driving in South Luangwa National Park on the main Chichele Road, less than a kilometre from Mfuwe Lodge, when I saw Duncan, driving a safari vehicle slowly towards me. He pulled over on the left side of the road and I drew alongside. We greeted each other and I asked him if there had been any special sightings that morning. He said, “You are looking at two leopards.” “What? Where?” I responded. “In the sausage tree behind me.”

Sausage Tree fruit hanging down. Leopards are very surefooted in trees

He started his vehicle and drove onto the verge of the road so I could manoeuvre my vehicle to get a better sighting. It was enchanting. Two leopards, mother and daughter, were play fighting on a thick horizontal branch about halfway up a magnificent tree. The foliage prevented me from getting a perfect view, but it was clear that they were enjoying themselves. The daughter leapt above her mother onto another branch and out of sight.

She can see you, but she is very relaxed, not bothered at all by my presence.

It was after 10am and the morning safari vehicles were all leaving the park after four hours of driving. I was fresh and had no pressing engagements. I could sit in the shade, waiting for the cats to move into a more visible location in the tree. The other vehicles stopped for a few minutes, their occupants could chalk up another couple of leopard sightings, sadly not in plain sight, then moved on for breakfast back at their lodges.

Resting posture, back legs astride the bough

I did a three-point turn and parked in the optimum position to observe the leopards, all on my own. The daughter skipped through the tree and ventured out onto a branch in plain sight. She was playing with the sausage tree fruits, patting them with her paw like any domestic kitty. The fruits are shaped like a fat sausage, covered in velveteen fuzz, with a long stalk. They are firm and tough, weighing over two kilos. Mum decided to investigate and the bough sagged noticeably. The daughter managed to get a small sausage in her jaws and jumped over her mum and went back up into the tree. I managed to get this episode on videotape which I will try to embed in this blog after it has been uploaded to YouTube.

Still vigilant

I sat at the roadside for another 20 minutes until the leopards decided they were hungry and climbed gracefully down the main trunk into the long grass where they were invisible. It was a special experience.

South Luangwa is noted for its leopards. During my first visit as Valley Doctor in 2014, I lived in the territory of Alice, one of the most famous leopards in the park. I occasionally would see her in a tree when coming back to my lodgings. She was a prolific mother and gave her cubs the best start in life. She disappeared a few years ago at the ripe old age of about 15. Today’s mother was probably one of Alice’s progeny, whom I may have seen as a cub five years ago.

Female leopards stay in the area where they were born. Their mothers allocate a portion of their own territory to their daughters, but the sons have to leave and make their own way in the world. I know that the mother will be teaching the daughter to hunt in this location, between the Kakumbi Air Strip and the main Chichele Road.

Daughter on top, mother underneath

Alice’s mother was called Marmalade. She was so habituated to safari vehicles that she used them to sneak up on her prey, often crawling underneath so the tourists were treated to the sight of a leopard a few centimetres below their feet.

My present lodging is in the Game Management Zone, across the Luangwa River, outside the national park boundary. The theory is that people can live in harmony with wild animals. All very well in principle, but growing fruit and vegetables here attracts elephants, who can munch their way through your crop in a matter of hours.

My neighbour, V, reckons she doesn’t need to visit the park as she sees all the wildlife from her verandah. There have always been leopards in this area. I remember seeing a leopard cross the track when I was making a home visit to Kapani late at night back in 2014. When V moved into the area five months ago, she would hear a female leopard calling mournfully for her mate (who had unfortunately wandered into a hunting concession area and had been shot). The leopard would regularly pass by the bungalow, often leaving “presents” of killed baboons or small impala for V by her washing line.

The only gifts I get are turds from the evil vervet monkeys, one of whom knocked my WiFi router to the ground, pulling out the cable and crapping on it.