“The most we can do is to write — intelligently, creatively, critically, evocatively — about what it is like living in the world at this time.” Oliver Sacks. “To take a photograph is to align the head, the eye and the heart,” Henri Cartier-Bresson
My replacement arrived. We had the obligatory sundowners on Kapani Pan (where there had been lions just a few days before). I said my goodbyes to the expats and local staff at the health centre. No tears, just hugs. After my final early Monday morning meeting, I left behind some medical kit for the clinical staff, an electronic thermometer, a thousand candle power head torch to illuminate nooks and crannies, an otoscope which you can’t turn off without dissembling and a few tongue depressors.
It took about an hour to pack. One bag contained 540 origami cranes to be hung at my daughter’s wedding; it weighed less than 2kg. The other bag had my medical kit, some clothes which survived the “Boom” and handwashing of Theresa and a few presents. I travel light apart from technical stuff and electronics.
I had my laptop, mouse, two cameras, lenses, Kindle, music player, binoculars, battery chargers and iPad. This always causes problems at airports because I have to carry them as hand luggage to avoid theft from checked bags. At Nairobi Airport transit, my carry on bags looked so suspicious that I had to unpack completely. The security officer swabbed everything to detect any residue of explosives. I noticed that the screen of my laptop was dusty and asked the officer if he could clean it while he was checking. “Ah, sir, sorry. We don’t offer that service,” he apologised.
At Mfuwe International Airport, the checks were less stringent. I sat in the departure lounge after checking in, chatting to a Naturetrek birding tour party. An airport official interrupted me, “The District Commissioner wants to see you!”
For a brief moment, I thought I was going to be detained. Or perhaps they finally had my plastic Temporary Employment Permit card. But DC Caroline just wanted to bid me farewell and express her gratitude for my work in the Valley. I said goodbye to her and to F who had also come to see me off.
The my flight from Lusaka arrived so I went through security again, telling the staff the same joke about my trousers being about to fall down because I had had to remove my belt. “Those with boarding cards for the Proflight to Lusaka, please come to the gate.” Oops, while I was chatting outside with the DC, they had issued boarding cards and I didn’t have one. (Regular readers may recall that on the flight out to Mfuwe, the airline staff gave my boarding card to someone else.) No problem, they just printed off another card and I joined the queue of Chinese tourists taking selfies on the runway by the aircraft steps.
I feel sad at leaving. It is almost my second home now, my sixth visit to Zambia. But it is time to go, to move on. I have lots to look forward to in 2019. Including my appraisal and revalidation.
Well, only one wheel and it didn’t go bouncing down the road
in front of me; it just bent outwards.
I first noticed that the steering was sluggish in Chipata.
The car was not as lively when I accelerated. I thought that the power steering
had stopped working. Perhaps there was a hydraulic system which needed topping
up. However, being 150km from Mfuwe, I decided I should drive carefully home
rather than going to a garage in Chipata or calling for help from the lodge
which services the vehicle.
The journey back was enjoyable and I didn’t notice a problem
with the steering when manoeuvring the car over the high speed bumps on the
road. The rolling hills were verdant and fecund. I chased a thunderstorm as it
passed through, getting deluged with heavy rain and emerging into bright, clear
The following day, the fault seemed to have corrected
itself, but I made a mental note to contact the maintenance men to check it
over in the afternoon on my way to do a home visit. We did a community clinic
in the morning then after lunch I was driving on a bit of road that was part
tarmac, part dirt. Driving at no more than 30kph, I suddenly felt the front
passenger side of the car dip down and the vehicle pulled to the left. I braked
but was unable to control the car’s swerve to the verge of the road. The car
stopped before it careered down the embankment. I thanked my lucky stars and
got out of the vehicle.
The front passenger wheel was at an impossible angle and the
ball joints which attach it to the axle had failed. I am a complete novice when
it comes to making mechanical diagnoses, but the clue was the ball (from the
ball joint) sitting in the dirt. There was some liquid dripping from the axle.
I tried to call the maintenance men, but the mobile network was down. I decided
to use the car’s radio instead for the very first time and I was told help was
on the way.
It is considered good manners to stop when you pass a vehicle
which has broken down to see if there is anything you can do to help. Half a
dozen vehicles stopped for me and one chap told me that he had a spare
whatchamacallit in his garage if I needed it. Another person offered the
opinion that the car had already done 240,000 km and with the state of the
roads it was driving on, she was surprised that the ball joints hadn’t gone
already. The same problem had occurred with a local chief, but his vehicle
careered off into the bush with him frantically turning the steering wheel to
I was rescued and taken home within the hour. If anyone
needed medical attention, they would have to send a car to pick me up until
another vehicle could be pressed into service. The next day I grabbed a lift to
the village and R took me to the scout training camp deep inside the national
park to do a first aid workshop. Gunshot wounds, fractured limbs, vehicle
accidents, animal attacks, snake bites? All of the above, but mainly basic
hygiene, using medication properly, keeping wounds clean and avoiding infection
On the day I left Mfuwe, the ball joints and other parts had
arrived from Lusaka, but the car had not been fixed. I hope I have not
developed a reputation as a car wrecker!
A week before my departure from Zambia I drove to the immigration office at Chipata. I responded to their rather threatening email by asking for the location of their office and whether I needed to bring any supporting papers, but i didn’t receive a reply. I used Google maps to get a general idea of the town layout but the red marker pin for the office seemed to be close to the downs, a shambolic local market. I decided to aim for the Boma or administration centre.
I reached Chipata Boma just before 10am and found the office in the next street. At the front door a guard from the private security firm Octopus asked me to fill in the visitors’ book. While I was completing the details (identity document number, car registration, address, etc) I asked the guard if he had eight arms so he could capture any wrong doers. He looked blank. “The Octopus has eight tentacles,” I explained. His facial expression didn’t change, “What, bwana? Testicley?”
I should have known by now that many Zambians don’t get my weak attempts at humour. The security guard was not familiar with octopus anatomy. He directed me down the corridor. Immigration Officer Priscilla was staring at a computer screen while finishing her breakfast at her desk.
“You should have come here immediately after we sent the email,” she chided me. “But I asked for my authorisation to be sent to Mfuwe Airport Immigration Office when I applied online,” I replied.
“The plastic cards are not yet in stock, so you have to come here, to the provincial centre,” she said. “What have you been doing in Mfuwe?”
“I’m a volunteer doctor at Kakumbi Rural Health Centre,” I replied.
“What kind of doctor? I am getting these headaches…”
I explained that I didn’t have my medical equipment bag with me and my practice was restricted to the Mfuwe area. She pressed me further, so I asked for more history concerning her mutu.
“Are you very stressed?” I asked. “That can cause mutu like you describe.”
She agreed and went back to picking at the keyboard, filling in data fields. There was a scuffle in the corridor and two officers entered the room with a man wearing handcuffs. He sat on the floor leaning against the wall and smiled at me.” Illegal immigrant. Second time he’s come here from Malawi,” explained one of the officers.
“Next time, turn right instead of left and go to Mozambique instead,” I told him. I will never learn; Malawians don’t get my facetious humour either.
Officer Priscilla left her ornate, highly-polished Chinese desk with my passport and papers. I chatted with the dusty Malawian until he was taken to be charged. Priscilla returned and made a great show of stamping a page in my passport. I am never sure if the violence used to do the stamping is to emboss the paper or if the ink pad is dried up and worn out.
“This will take you to 15th of May, then you return here and I will give you another three months and another. We want people like you here, doc.”
“Thank you so much, but I am leaving next week.”
“No, but when are you coming back from leave?”
“I’m not leaving to go on leave. I will be departing, going back to my family.”
She understood the importance of family ties and I told her about my daughter’s impending wedding.
“But you must come back. We need you here. There are no doctors in Mfuwe. You have been helping us. God bless you.”
I took my passport, signed the security guard’s ledger and left. Legal again. I took the opportunity to visit the town’s two supermarkets, Spar and Shoprite.
Whenever I have been working in rural Africa and I return to the UK I marvel at the variety and opulence of the food on display at supermarkets, even Aldi and Lidl. How can anyone need so many types of breakfast cereal? I used to buy coffee in bulk because of my subliminal thinking that “it might not be available next week”.
So visiting Spar, even with its depleted shelves, was part of the process of readjusting to life at home. There was even a small coffee shop to remind me of Waitrose. Only patrons could sit here and use the toilet facilities. On the wall above the key for the toilet was a sign “New. We now offer iced coffee!” It was hot and humid so I ordered an iced coffee and went to the toilet.
When I came back, there was a mug of lukewarm grey liquid on my table. “But I ordered iced coffee,” I protested. The people at the next table volunteered the information that they saw the waitress adding the ice to my (hot) coffee at the table. Coffee with ice, rather than iced coffee.
I looked at my email. Priscilla had sent me a message – a notice to appear before an Immigration Officer (Section 14 of the Immigration and Deportation Act 2010). “To Ian Cross of Mfuwe Middlesbrough United Kingdom”. I was required to return to Chipata at 10am on May 8th to receive the temporary employment permit in plastic card format. “Failure to comply constitutes an offence punishable with a fine not exceeding 200,000 penalty units (?) or imprisonment for a period not exceeding two years, or both“. But I will be in Nepal then…
There’s a set of traffic lights in Chipata just outside Spar. They are so slow to change that impatient drivers cut through the fuel station and supermarket car park to avoid waiting. I noticed that the car’s steering felt stiff and sluggish as I pulled away from the lights. “Perhaps it’s because I’m driving on tarmac not dirt tracks,” I thought. Big mistake.
A month after my last visit to the Immigration Office, I returned. All three immigration officers were at their desks, dressed very informally. “Good morning,” I said, cheerily. “Am I at the correct office for immigration services?” They all laughed at me and said that they didn’t need to wear uniforms on “dress down Friday”.
I told the senior officer that we had finally managed to pay the extension fee on line and I showed him the receipt. The website said that when my permit was ready at Mfuwe, I would receive an email telling me to collect it, but there had been no email.
But the problem is that Zambia is introducing a new system of plastic cards to replace the green booklet with gold-embossed state seal. And the plastic cards are not ready yet. So I got another 30 day stamp in my passport, an updated letter and a stamp on the receipt.
“That will take me to 15th April,” I said. “I will be leaving Mfuwe on the 15th for KK International Airport in Lusaka, from which I will depart at 02:00 on 16th. Can you give me just one extra day so there are no problems when I leave the country?”
“No, that is not possible. Please come at least a day in advance of the expiry date to get another extension.”
“The 13/14th of April is a weekend. Do you open at weekends?”
“Only by appointment.”
“Can I make an appointment?”
But today I received an email from the Immigration Department: “Kindly come through to Chipata region immigration office to finalize your temporary employment permit application. Failure to which may result into prosecution.” That’s a two and a half hour drive away. I hope I can sort it out at Mfuwe Airport immigration office.
This is the concluding part of yesterday’s blog about my quest for a visa extension and work permit.
I drove back to the village where I had left the vaccination
team. They had given up waiting for me and had returned to the health centre
under their own steam. I had no time for lunch so I popped into a local NGO
office and asked to use their internet to do the online application.
Three hours and several handfuls of hair later, I gave up
typing in all my details for the tenth time only for the system to crash or
hang. “Come back in the morning at 8am and you can try again,” said
The following day, I woke up illegally in Zambia. Amazingly, the website accepted my application without a single blue screen of death. Instead of loading up several individual scans of supporting documents, K had merged them into a massive jpeg file which was still less than the maximum permitted upload size. This had been one of the major sticking points the previous afternoon.
But the next level of hell awaited me. Making payment. I
have no bank account in Zambia, so I had to ask D if he would pay for the
application using his local credit card. This failed authentication. Then he
tried his personal Zambian bank card, which also failed authentication.
Finally, I asked one the NGO administrators, and she gave her UK bank credit
card details, which also failed authentication.
I had to go to the local school to administer diphtheria and tetanus boosters to the students so I couldn’t sit sobbing in front of the computer for long. I contacted J who said, “I will sort it out, don’t worry, they won’t deport you as we’ve only just got you here.”
Halfway through vaccinating over 200 students, I received a text message saying that I should return to the immigration office at the airport and pick up a paper which would cover me for a month while they sorted out the problem of payment.
It was 2pm by the time we had finished vaccinating and I had
dropped off the team at the health centre. There was no time for lunch as I
needed to get my hands on the paper which would allow me to stay in Zambia
“You’re back again,” said the guard on the airport
perimeter. “Yes, but hopefully I will get my papers sorted out now,”
I replied. There was no guard in the sentry box so I walked through and knocked
on the door of the Immigration Office. The senior officer was there alone and I
explained that the application was successful but the payment had been
“What did you do wrong?” he asked.
“Nothing, but I think that it is because I don’t have a
bank account here and when other people use their banks or credit cards to pay
for my application, their bank security systems refuse to endorse the
transaction,” I said.
I explained that I had used an NGO credit card, an expat’s
Zambian bank card and another expat’s Barclaycard from the UK. Why would a bank
allow a transaction paying for a random person’s visa application and work
permit to a government agency?
“No, you are wrong. The system was set up to cater to people who had no bank account in Zambia. You could have used PayPal,” he said.
“Paypal wasn’t on the list of options,” I replied.
“Have you ever tried to use the system?”
“I am not allowed to,” he said. “But I don’t
understand why a local bank, Zanaco, declined the payment. Let us go and ask
the bank manager of the branch at the Airport.” He picked up his officer’s
cap, its peak decorated with gold piping, and we marched to the 100 metres to
The bank manager listened to our story and suggested that we
should try to access the eservices.zambiaimmigration.gov.zm website. I used my
local phone, which has a small amount of data available. It refused to allow me
to log in. We tried the bank manager’s computer, with the same result. Then the
immigration officer asked me for my username and password so he could inform
the IT officer who would try to track down the fault.
He noted that the bank manager’s computer had limited
internet connectivity, which may have prevented access to the site. The manager
showed that his computer could access other sites without any issues.
“What happened when you tried to pay?” he asked
“I was informed that I would be leaving the Immigration
website and joining Barclays payment website. In order to make the payment, I
had to write the name, address, email address, etc of the person making the
payment for me, along with their card type, number, expiry date and code.”
“That’s where you went wrong. You should have entered
YOUR details, not the owner of the credit card’s details,” he said.
“I disagree,” said the bank manager. “You
know in Zambia, it takes time for new systems to bed in.”
“Well, what can we do now?” I asked. “Is it
impossible to make the application using paper and paying in cash?”
“Yes, that should be an option with a new system which
has not been fully tried and tested,” said the bank manager.
“No,” the immigration officer replied, “I will have to give you a piece of paper allowing you to remain in the country for 30 more days until we sort this out.”
Before walking back to his office, I stopped by at the Airport Post Office as I had been told that there was a letter waiting for me to collect. The lady sitting behind the counter had her head slumped forward and I thought she was either dead or asleep. In fact, she was fiddling with her smartphone, hidden out of sight, under the counter. I told her I had been informed that a letter was waiting for me to collect at the airport. She flatly denied any knowledge of a letter. “What is it? Who is it from?” she asked. I said I didn’t have a clue. But my mother had sent me a birthday card to Mfuwe in May 2014 which was not delivered. “Five years ago? We only keep undelivered mail for six months,” she said while hunting through a large cardboard box containing dozens of packets and letters. She found nothing addressed to me and went back to her social media.
The immigration officer was waiting for my passport. He connected the printer to his computer and printed off two forms, which he clipped together and added a sheet of carbon paper. He instructed me to complete and sign the bottom section of the form and handed me my right to stay here for another month. Now was not the time for light-hearted comments about whether the online system would ever allow me to pay for the visa/temporary work permit. I smiled, shook his hand and said goodbye.
On entry to Zambia, I was granted a 30-day business visa. This was about to expire so I needed to visit the Immigration Office at Mfuwe International Airport. I had all the paperwork I needed to extend my stay: a photocopy of my passport, medical license, medical registration, letter of appointment by the non-government organisation who brought me here, two passport photographs (which make me look like a Mafia henchman), my passport and 2,250 Zambian Kwacha. I telephoned the Immigration Officer to see if he was in the office. He told me he wasn’t, but his colleagues would deal with me.
The guard at the entrance to the airport recognised me and waved me through without inspecting the underside of my car with a mirror on a stick. I left my vehicle in the Airport Car Park, illegally occupying Kapani Safaris’ slot, and walked to the checkpoint. Another guard asked me not to sign the admittance register under the last entry, but to give my details after the previous day’s list. Apparently, he should not have started a new page for a new day, and he was trying to fill the gap.
The immigration office is beside the Airport Control Tower.
It is a small room, made even smaller by the stacked cardboard boxes against
one wall. There are two desks and a table for the printer (you have to connect
the printer cable to each computer manually, it isn’t networked). There are
some plastic and metal seats for visitors. The walls are decked with torn and
drooping posters warning of the dangers of illegal immigration and the benefits
of foreign investment. I remember it well. On my first visit here, I urged the
outgoing senior immigration officer to apply for Sir Alex Ferguson’s job at
Manchester United (the Premier League is a very safe topic of conversation in
Zambia) and got my visa extension and work permit on the spot.
There were two new immigration officers, one with two gold
stripes on his epaulettes and one with just one stripe. I made my first mistake
by handing my paperwork to the more junior officer. He shuffled the papers and
passed them to his senior.
“Where is your supervisory letter from the District
Health Officer?” he asked.
“Last time I applied, Dr Mashanga telephoned your boss
and complained that he had more important things to do than to write letters
for a doctor who was helping the country for free,” I said.
“But he still had to provide the letter requesting your
services, didn’t he?” replied the officer. “You will have to get his
letter before we can process your application.”
“And all applications now have to be made online on the Immigration government website,” he added.
“But I have brought all the paperwork, the cash,
everything, so you can process it here today? It is the last day of my
“We do not have a scanner and we cannot access the
internet,” he replied.
I looked downhearted and asked if he could make an exception if I managed to get Dr Mashanga’s letter to the office by this afternoon. Perhaps it was a moment of weakness, or I may even have treated one of his relatives, but he called his boss who gave his approval. He even told me to leave the documents and the money with him so he could process my application as I drove to and from Mambwe.
I telephoned Dr Mashanga and asked him if he could write a
supporting letter for the Immigration Department and he agreed. I drove to the
District Health Offices in Mambwe and asked a colleague if he could photocopy
my Zambian medical license and registration while I saw the boss.
Dr Mashanga was very relaxed and asked me how I was getting
on. I had seen him just a few weeks ago but I gave him an update. “We have
no paracetamol, no small catheters for giving intravenous fluids to children,
no sterile gloves, no non-sterile gloves, no antibiotic eye ointment…”
“But thank you for the medication to manage diabetes
and hypertension. I would like to make a register of patients suffering from
these conditions so you can make an estimate of what medication we need to
manage the patients. Unfortunately, we have no antidepressants or
“That’s an excellent idea. Please go ahead,” he
We chatted for a few more minutes about my concern about the
magnitude of the impending malaria season. I had imagined that Dr Mashanga’s
secretary would be typing my letter as we spoke, but he suddenly said,
“What dates should I put on your letter? When will you be leaving
us?” Clearly, he hadn’t started the letter.
He took a pad of lined paper and wrote out in block capitals
(probably necessary given the reputation doctors have for appalling
handwriting) a draft for my approval. I scanned it and agreed. He asked me to
look again, as there must be no errors when dealing with Immigration.
He took the letter to be typed and a Home Economics teacher
from the town entered the room to discuss donations for National Women’s Day on
the 8th March. “How will you be celebrating the day?” I asked her.
She replied that it was National Women’s Day as if that answered my question.
On being pressed, she said that they would be highlighting local women
entrepreneurs. “In class, the girls learn domestic tasks which can earn
them money when they leave, such as handicrafts.”
Dr Mashanga returned to the room and explained that the
Department had no funds at present, but the event was several weeks away.
Intriguingly, he added, “We want to avoid the situation which occurred
last year.” I didn’t dare ask. I wanted my letter for my application which
needed to be filed today.
The letter arrived in quadruplicate. He signed two copies, gave me one and I thanked him as I left the room in haste. My colleague handed me back the originals of my registration and medical license, saying, “Sorry. No toner.”
I drove back to the airport but this time I had to explain to the guard why I had returned. He nodded and waved me through. I photocopied the two documents at the Airport Gift Shop. There was no need to sign the attendance book again at the sentry box. Perhaps the space below yesterday’s visitors was now full. The senior immigration officer (three gold stripes on his epaulettes) shook my hand and told me that his boss had overturned his decision to process my application in person, not online. “Unfortunately, the website is not accessible in this office,” he said. I said I would try to complete the online application today, but what if I didn’t? What if some officials came to the health centre and demanded to see my visa and work permit?
“But that would be us, and we know that you have all
the paperwork prepared,” he said.
“When I have completed the application online, when
should I come to pick up my work permit?” I asked.
“When will you be leaving the country?” he asked, depressingly. “We no longer use the embossed green booklets, we have introduced plastic cards now. However, we don’t have any cards at present so we will give you a paper.”
Warning this post contains graphic sexual material which may be offensive to some
When I am consulting in the health centre, I normally work with a female clinical officer. We see the patients together. She takes the history in Cinyanja and summarises the problem; I ask further questions for clarification. She doesn’t normally examine patients, so I do that and point out any physical signs. We usually see one or two ladies with gynaecological problems in each session. They could be suffering from a variety of disorders – anything from dysfunctional uterine bleeding to carcinoma of the cervix; genital herpes to secondary syphilis. The clinical officer regards me as an expert, so my examination of the patient becomes a teaching session (with the patient’s consent, of course).
We had just seen one lady with post-menopausal discomfort, dryness and pain on intercourse. I made a diagnosis of oestrogen-deficiency resulting in atrophic vaginitis but the clinical officer asked if this could have been caused by Nsunko. I had never heard of Nsunko. She told me that it was a herb which was used in various forms to improve sexual pleasure by tightening the vagina. “For the man, right?” I asked her. She laughed and said, “For both. But it is mainly to make the vagina warm for the man.”
I was aware of certain astringent herbs which some women put inside their vagina, but these act by shrinking the vagina and can cause painful scarring. The clinical officer said that Nsunko could be used like this, but it can also be inserted into the anus for several hours at the same time as the woman has vaginal sex. It seemed farfetched, but she insisted that the chemical could diffuse from the anal canal to exert an effect on the vagina. This technique was commonly used by female sex workers.
Always being curious, I asked, “How do they do that?” She told me that women boiled herbs in water and soaked strips of cloth in the resulting liquid. They would then push the cloth into their anal canal.
In parts of Africa, men prefer “dry sex” for increased friction and pleasure. However, traumatic intercourse is associated with increased transmission of sexual infections, including HIV, because of abrasions on the sexual organs.
In Zambia if a wife has sex with another man, the husband is entitled to an immediate divorce. However when a husband is unfaithful, it does not mean that the marriage is over – “ubuchende bwamwaume tabutoba inganda”.
She told me that she had worked in other regions of Zambia where there had been a sexual health outreach programme targeting sex workers. “We could go to the Obama Bar at midnight and offer sexual health screenings,” she said. I wasn’t sure about extending my working day that long. And I had been warned about the perfidious practices of “harlots” in the village bars by Mrs Mwanza, one of the nurses with whom I worked in 2014. You can read about this here.
I told her that if she brought it up at the next health centre staff meeting, I would support her, but she backed down. She didn’t want to be associated with such a sensitive initiative.
PS I was saddened to hear that the infamous “Penis Inn”, a hotel-cum-brothel where the local Rotary Club used to meet, has now closed down. The Rotary Club now meets at the new Tinta’s Restaurant. Chicken and chips, US $4 with complimentary popcorn.
She looked me straight in the eye and said, “I’m itchy in front and I’ve got warts.” Zambian teenagers are not renowned for such direct talk. I asked her if she was sexually active, “Kuchin dahna*?” It is a phrase I use so often in the Kunda dialect, it slips off the tongue. She shook her head and vehemently denied it. “So how did you get genital warts, then?” She averted her gaze and I realisedI had been rather too aggressive in my approach.
The nurse came to my rescue with some softly-spoken words in local language. “She has agreed for you to examine her, doc,” she said. I pulled the dirty curtain down over the barred windows and adjusted my hundred-candle-power head-torch while she got up onto the couch. She had genital warts with an inoffensive, white vaginal discharge, but there were no other signs of a yeast infection.
Zambian health centres follow the WHO guidance using syndromic management of suspected sexually transmitted diseases without needing to do laboratory tests. This is directed at the lowest skilled health workers.
Vaginal discharge? Blanket treatment for all STIs which cause this, using a sawn-off shotgun approach. Last of all, consider bacterial vaginosis and yeast infections, strangely enough, which are the most common causes. Multiple antibiotics will make candidiasis worse, of course.
Genital ulceration? Blanket antibiotic treatment for syphilis, lymphogranuloma venereum, granuloma inguinale, chancroid – but we don’t have drugs to counter genital herpes, which is the most common cause.
I detest these syndromic guidelines with a vengeance as I feel they will cause massive problems with antibiotic resistance, something which is being recognised with dismay in Thailand. It is sloppy medicine. But it makes the patient and health worker feel that something has been done. They have ticked the box, even if the treatment is ineffective, no one can criticise them (apart from me).
Already gonorrhoea has developed resistance to the
recommended drugs. With the approval of the District Health Officer, I had
produced an alternative regime utilising gentamicin, an injectable drug which
used to be supplied to the health centre. Supplies of this drug dried up, so
the nurses reverted to a failing regime, much to the annoyance of their
patients. Eventually, their gonorrhoea will burn itself out, leaving a legacy
of urethral strictures, epididymo-orchitis, salpingitis and infertility.
The latest Zambian treatment guidelines recommend giving
long-acting penicillin injections for genital warts, even when secondary
syphilis has been ruled out by a blood test. Penicillin doesn’t cure genital
I ordered rapid tests for syphilis and HIV, and went on to
see more patients. Half an hour later, my patient returned with the test
results – syphilis negative, HIV reactive. Whilst we diagnose up to five people
a day with HIV in the clinic, I was not expecting this result. We took some
more history from the stunned teenager. She now revealed that she had attended
in January and had been given some injections. This would fit with the Zambian
(in my view, flawed) treatment guidelines. She then said that she had been told
a blood test was positive. So why wasn’t she offered immediate treatment with
anti-HIV drugs? Something wasn’t right.
I left her with the nurse and went to the lab. I looked
through the register of all the serological tests done since the start of 2019
but couldn’t find her name. I showed the book to one of the three lab workers,
one of whom said, “Oh, I must have got the results muddled up.” She
crossed out the word “reactive” in red pen next to the HIV test
request and altered the syphilis result to reactive.
I was dumbstruck. I had been relying on the fact that all positive HIV test results are double checked with another test (“Determine“). “I have just been talking to this young girl about how her whole life is going to change with a positive diagnosis for HIV, and now you tell me that it was an error? If I hadn’t come to investigate her previous results, would you have informed me?” I asked angrily.
Now, displaying anger is considered ill-mannered and uncouth in Zambia. Perhaps the embarrassment I had caused by getting visibly annoyed (I wasn’t shouting, just being calmly furious) made the lab technician laugh. “There’s no problem, doc, she isn’t HIV positive,” she said in an off handed way. Dismissing the issue in this manner didn’t improve my mood. The lab tech didn’t apologise or show any degree of remorse. I didn’t know whether to believe her, so I walked out of the lab and took ten minutes trying to re-establish a degree of equanimity.
Where was her previous treatment record? Filed away in the labyrinthine medical records room, inaccessible without her registration number (she had lost her ticket). So I checked through the attendance register for January and found no record of her having attended. And the Sexually Transmitted Infection register, again no record.
The lab technician came to me and asked what she should do with the patient’s medical record. “It’s her fault for losing the ticket which would have allowed us to retrieve her old notes,” she said. I told her to repeat both tests and bring me the actual test strips. These confirmed that she had had syphilis. She recalled that her initial tests had been done in November, not January, so I had been looking in the wrong year.
The syphilis test we do is actually an antibody test which is positive for life. We don’t have quantitative tests (such as Rapid Plasma Reagent or Venereal Disease Research Lab tests) which would let us know if she had been effectively treated for syphilis after she had had three doses of benzathine penicillin in November. I considered whether these warts could be condyloma lata (secondary syphilis), rather than condyloma accuminata (common or garden genital warts). She could even have been re-infected with syphilis from an untreated boyfriend. Time to re-treat; better not to compound an error. If only we had access to the old fashioned quantitative tests.
The patient was mightily relieved that she was not HIV positive and expressed no anger at the lab technician’s error. Phew, that was a close shave.
Footnote: I am writing this as a physician who worked in a hospital genito-urinary medicine (STI clinic) once a week for 25 years in Leicester.
* I was informed by the nurse that the phrase “Kuchin dahna?” can also be translated as “Do you want to have sex?” Context is all!
I arrived first to the meeting room at 6:59am for the 7am
weekly Monday meeting. I would have been earlier but the police had barricaded
off the muddy track to the clinic and I had to make a detour. Three male health
workers turned up in the next few minutes and we began with a prayer at 7:10
when no one else had joined us. At least this time, we did not pray for God to
speed the missing nurses to the meeting.
The nurse in charge of outpatients said that he had been
seeing many babies with pneumonia. The National Immunisation Programme includes
polyvalent pneumococcal vaccine which is given at 2, 3 and 4 months, but babies
were getting sick before they had completed the course. The only intravenous
antibiotic we have is benzyl penicillin. In other settings, intravenous
gentamicin and ampicillin would have provided better treatment.
He also complained that we had no asthma drugs at all, not
even salbutamol tablets. He asked if I could help out with salbutamol nebuliser
solution. I have some in stock, but it is out of date and waiting to be
disposed of. If the situation arises where I judge it to be life threatening, I
will use the out of date medication and face any consequences. But we must not
have any out of date stock on the shelves at the health centre.
No one turned up to clear the weeds and rubbish from around
the health centre last weekend. Not even the health inspector who suggested
that we should do it. One volunteer buttonholed me saying that he had done my
share of the work and wanted reimbursement. I told him that I was a volunteer,
Another volunteer managed to persuade a health worker to
lend him the Health Centre motorbike over the weekend for a “family
emergency”. He was caught at a police road block and the bike keys were
confiscated. The District Health Officer will decide on his punishment.
On the subject of police road blocks (revenue raising
activity), I was stopped today because my vehicle was muddy. The policeman
asked me why I didn’t clean it. I told him that the road to my house was
atrocious and the car would be splattered with mud again as soon as I drove to
work. He grunted and accepted this.
The nurse in charge told us to be on the lookout for unhealthy activity around the health centre. Last week he had come across a young mother who was bathing her newborn baby in brown water which looked like it had been collected from a nearby pond. The water was cold and the newborn was shivering. Most young mothers are accompanied by their own mothers or an auntie, who teach them how to look after their new baby. This new mother had no support, unfortunately.
On a brighter note, a mother gave birth to twin boys last
week, Melvin and Elvis. They are doing very well. However, another set of twins
(boy and girl) have not gained any weight since being born six weeks ago. They
have both been admitted with pneumonia. The girl was just 1.4kg but instead of
making sure she got the first feed, her mother was favouring the boy who was
1.8kg. I told her that girls were just as valuable as boys, that I had three
girls myself and she agreed to pay more attention to her daughter.
Zambian health workers are able to deal with cognitive dissonance remarkably well. There is a course to train nurses how to perform medical terminations, when abortion is still illegal under the constitution. Every patient is encouraged to have an HIV test to know their status, but because this approach has a low pickup rate and is expensive, we are being castigated. Instead, we have been told to target those people who are most at risk, even if this is against national policy. We heavily promote condoms to the young while at the same time preach abstinence before marriage. Perhaps if you don’t think about it too hard, you can cope with conflicting policy and advice.
I had been hoping to provide antipsychotic drugs for the dozen or so people with severe enduring mental illness in the area. Unfortunately, the District Medical Officer told me that the psychiatric ward at the provincial hospital were so short of medication that they could not spare any. I was told that there are (at the time of writing) no antipsychotics in the public health system in Zambia. Basic drugs like haloperidol cost just 10 cents a tablet. I have been out with my begging bowl and thanks to an NGO (you know who you are, Karen) we now have enough drugs to treat the most disturbed patients for the next three months. It is not helpful to say that such a situation is intolerable without doing something about it. Seriously unwell patients are forced to tolerate the toxic effects of continued psychosis which will have a permanent, detrimental effect on their future lives. If they have a future.
In a small pond by Mopani Spur, in South Luangwa National
Park, there are some lesser moorhens. They are reclusive and very difficult to
spot, never mind to photograph. Just as I picked up my camera, my phone rang. I
am on call 24/7 and have to be available, within an hour of the National Park
gate at any time. I answered the call and made an emergency visit to a lodge
within the Park.
It took a while to sort out the problem, so it was after
10am when I left. Instead of driving out of the park, directly to the village,
where I had other patients to review, I decided to take a short detour around
Mbomboza lagoon and onto River Side Drive. It had been raining when I drove
into the park at 7am, but the roads were passable.
The reason for the detour was that I knew the approximate
location of a special bird’s nest. Pel’s Fishing Owl is very rare and I wanted
to see it on its nest with fledglings. River Side Drive has deteriorated since
we had floods last month. Parts of the road are compacted grit and laterite,
easy to drive on even when they are underwater. Other stretches are muddy and
potholed, and these require more attention and driving skill.
Up ahead I could see two huge potholes across the road. I
thought I could put my passenger side wheels between the potholes, and my
driver side wheels on the edge of the road. Bad move. My vehicle skidded off
the road into thick, sticky mud. The
black cotton soil is notorious for trapping cars.
I engaged four wheel drive, low range and tried to drive
forward, but this just pushed a heap of mud ahead of my front wheel. I tried
reversing and the back wheel dug down deeper into the mud. I was well and truly
stuck. I looked around carefully for wild animals. There are often elephants
and hippos in this area, and occasionally lions and leopards. I tried to open
the driver’s side door, but I was in too deep. I got out the passenger side and
assessed the situation.
I thought that if I drove back and forward repeatedly with
the wheels straight, I could make a firmer base for the tyres. I dug out lots
of thick sludge behind both wheels with my hands and got back into the vehicle.
The passenger side wheels were not getting much traction. Eventually I managed
to get enough momentum to reverse out of the ditch I had created, back onto the
road. I was really lucky. It would have been very embarrassing to have to call
for help from other lodges.
I was rather rattled when I got to the corner where the nest
of Pel’s Fishing Owl was located. The road was flooded. I stayed for a few
minutes waiting for the classic call, but heard nothing. I drove out of the
park and went to an NGO office to wash off some of the mud.
After doing some shopping for medication, sorting out a
clinical problem and buying a data bundle for internet access, I drove home. I
spotted a new red warning light on the dashboard. What have I done now? The
handbrake was not jammed on, but I could see some brake fluid leaking from the
rear driver’s side wheel.
I parked up and a mechanic removed the wheel. The problem was a worn out brake pad and something wrong with the piston which applies the brake. “Did I do this?” I asked him. “No, doc, this wasn’t your fault,” the mechanic replied. I sighed with relief. The wheel had been squeaking for the past six weeks and it had been dismissed as unimportant. It turns out that the safari vehicles get so much mud and crud in the brakes that they need new brake pads every few months.
So I was off the road for a day and a half until they fitted “modified” brake pads. If there had been an emergency, the lodges would have provided transport for me to get to the patients. And I spent most of that time in bed ill with man flu.