“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
Kakumbi Rural Health Centre has been going through some lean times recently. The lack of medical supplies is very frustrating for a doctor. I feel like a soldier going into battle without armaments. Even simple pain killers, such as paracetamol (what is called “Tylenol” in the USA) have been in short supply. I guessed as much before I came, so I loaded up with medication to distribute when necessary.
I was just coming to the last of the paracetamol which had been donated by the lovely Neeta in Leicester, when the health centre received a shipment of medication. Apart from a huge carton of male condoms, I could see a few thousand tablets of paracetamol. Wonderful, I thought.
At this Monday’s team meeting I learned that Zambian Government inspectors had examined some drugs. Two of the batches of paracetamol from one generic manufacturer were found to be below their quality standards.
“So were the paracetamol tablets we received from the defective batches?” I asked.
“No,” replied the nurse in charge. “But the government decided to withdraw all the paracetamol just in case.”
On the road to the airport, there are lots of interesting shops.
There is a wedding planner in the village. The service is a one stop shop, all you have to do is to step through that door. Metal security outer doors are needed to protect the variety of goods and services on sale.
I asked who the director of ceremony was and found it was this lady having her hair braided. She said she was a pastor in the Bible Baptist Church. Somehow, I don’t fully believe her.
Of course, all over Africa, the British Premier League is well known. Most people support the big sides, such as Manchester United, Chelsea, Liverpool or Arsenal. Occasionally, there will be someone sporting a Leicester City Football Club bobble hat.
But I have never met a Spurs supporter here. Well, I think he is a Spurs supporter by the name of his shop.
This is the term health workers use for something which has entered a body cavity where it should not be. For example, a child might have pushed a plastic bead up its nose. But expanding this concept a bit, one could say that I was a foreign body working in Kakumbi Rural Health Centre.
On Friday last week, a mum told me that her child had something stuck in his ear. Looking inside with an otoscope I could see only dry, impacted wax. To make sure there wasn’t something deeply imbedded in the wax, I suggested that mother should put a few drops of oil into her son’s ears every night for a week and return for syringing. I confirmed with the clinical officer that we did have an ear syringe.
A week later the child returned. The wax looked soft and I thought it should easily flush out with gentle syringing. I found the large metal syringe but the plunger was lodged in the barrel of the syringe and I couldn’t budge it. I tried adding hot water to expand the metal, I used some detergent and finally employed brute force, but it was jammed solid.
The clinical officer said she would get a normal plastic syringe and flush out the wax while I attempted to fix the metal syringe.
Finally, I unscrewed everything I could and took it apart. The plunger was still immoveable, but there was an odd bit of rubbery material inside the barrel. At first I thought it was a sort of rubber diaphragm, but it wasn’t attached to anything. I fished it out and discovered it was a condom.
Having worked for over 20 years in a sexual health clinic in Leicester, my mind immediately plunged to the depths of depravity. “What kind of perversion is this? Having sex with an aural syringe, but maintaining the presence of mind to use a condom?” I thought, “That’s new one on me.”
I formed a mental image of what this might have involved, but after a few seconds I realised that someone had tried to use the lubricant on the condom to help the plunger to move. Unfortunately, it hadn’t worked but I take my hat off to whoever came up with that idea to solve the problem. Pure ingenuity.
Wherever you go, there are doors to pass through. Portes de passage. I arrived early one morning and went on walkabout to take some pictures of the doors near the clinic where I work.
The local Roman Catholic church is made of brick with a portico and a sturdy door.
To call the faithful to prayer, there is no bell tower. Instead, the church official bashes on a wheel rim, hung from a tree, with a hammer.
Outside the police station there is an old container. It serves as a holding cell. It is said that when the door is closed, no prisoner is detained there. But it is like an oven in the heat, so the door has to be kept open so that any prisoner doesn’t cook. The container cell doesn’t have a toilet. I have heard it said that the prisoners all pass urine against one corner. The acid pee has rusted the metal allowing a prisoner to break out. But why would they do that when the door was open?
And finally, it is washing day and the sheets are on the line in the sunshine. Just to the right, the lady of the house is entering nurses accommodation, through a secure door.
The Book of Job describes a monster, a behemoth, which is probably a hippopotamus. These beasts are huge, with adults weighing over 1.5 tonnes. The males don’t stop growing until they die, but the weights of females start levelling off at age 25 years. I was astonished when I looked down on a hippo from the Luangwa River Bridge and saw how broad in the beam it was. Hippos are barrel-shaped. Only elephants and rhinos are more massive land animals. 55 million years ago, they diverged from their nearest relatives, the whales.
On land, they can run fast for short periods, up to 20 mph. Normally, they trot briskly when getting away from a threat. When there is no danger, they walk slowly, often using the same route, leaving a set of parallel ruts, too narrow for a vehicle to use.
They have thick skins (5 centimetres) but surprisingly not much subcutaneous fat. If they stay out of the water for too long during the day, their skin gets damaged and cracks. Hippos secrete a substance which turns pink in sunlight and protects them from UV radiation. It also has an antibiotic action.
They spend most of their time in pools or shallow rivers. They can’t float and cannot swim well, even though they have webbed toes. In deep water they move by bouncing off the riverbed. They avoid fast flowing rivers or keep to the edge where the current is less strong.
Oxpeckers remove parasites from the hippo skin, but they can irritate by keeping a wound open so they have access to nutritious blood.
All the important bits of a hippo are situated on the top of its head: eyes, ears and nostrils. It can shut its nostrils when it submerges, and can stay underwater for over five minutes before surfacing to breathe. Baby hippos are born underwater and have to learn to swim immediately.
Hippos usually live in large groups, called pods, with up to a hundred members. They are territorial, occupying 100-200 metres stretches of river. A big male tolerates younger males if they are submissive and stay away from the females. If they challenge and get defeated, they may be forced to leave the pod and become solitary.
Sex occurs in the water, with the female being submerged for most of the time while the male mounts her. Pregnancy lasts eight months and the young hippo suckles from its mother until it is weaned at about a year.
Hippos have a reputation for being aggressive if a boat transgresses on their territory or if they feel threatened on land (don’t get between them and the water or between a mother and her calf). They probably kill more people than crocodiles and elephants. They forage at night on land, eating mainly grass and vegetation.
People do like to eat hippo flesh, which apparently tastes like muddy, fishy pork. I have never knowingly eaten it.
Patients with seizures can be like buses; there are none for ages, then two appear within minutes of each other.
This morning, Loveness, a 10-year-old girl, limped into the clinic with her granny. I was surprised to see that Loveness had a left-sided hemiplegia. Her granny told us that she had had a stroke following a bout of severe (“cerebral”) malaria when she was two. She had recently moved with her mum to live at her granny’s house, which was in our catchment area.
It was difficult taking a history because of the stigma of seizures. Local people think that a seizure is a sign someone is bewitched and that the evil spirit inside the sufferer might escape and enter anyone who tries to help. Granny gave very guarded answers to our questions.
A detailed history is absolutely essential, with a reliable witness able to describe exactly what happens during a seizure. It is important not to ask leading questions, as patients often want to “please” the doctor by answering in the affirmative.
Loveness started having seizures spontaneously in January 2020. She had an aura, a sensation which precedes an attack; she felt someone was pushing her. She would fall down, unconscious and rigid, following which her whole body would shake for a few minutes. She had occasionally bitten her tongue and wet herself during a fit. She had been having about three convulsions per week since January, but recently she had experienced three in one day. The seizures were becoming more prolonged. Her granny sought help at the health centre because of this deterioration.
Zambian children in the health centre are often very subdued. Some are frightened of a muzungu (white) doctor, but they usually refuse to answer questions, preferring their carer to give the history. I needed to examine Loveness’ central nervous system, and this gave me an opportunity to engage with her. I like to squat or kneel, so I am at eye level with the child. I even take my mask off so that they can see my facial expression. If I can make the child relax and smile while I am gathering information, that’s a bonus. We played games while testing her cranial nerves, screwing up her eyes, blowing out her cheeks, showing me her teeth, watching my finger moving in all sorts of weird directions. She had lost the use of her left arm and her left leg was stiff (hypertonic), with limited movement.
I came to the conclusion that the cause of her seizures was organic brain damage/scarring caused by cerebral malaria; she has epilepsy. In the UK, she would have seen a paediatric neurologist, had multiple scans and electroencephalograms, perhaps even being considered for brain surgery. Here in rural Zambia, we have two drugs to treat epilepsy – phenobarbitone and carbamazepine. The latter has fewer side effects but works best in temporal lobe epilepsy. We decided to try it and I will see her in the village next month during the community child health clinic.
I have some diazepam for rectal administration, to halt continuous epileptic convulsions, an emergency. (The drug is extremely effective but out of date and I can’t bring myself to throw it out because I cannot get any more.)
Just as we finished explaining the management plan to granny, the registrar told me that a baby was having convulsions now in the waiting room.
Agness was just four months old, but her disabled mother felt that breast milk was not providing her with enough nourishment, so today, for the first time, she fed her some pap – a thin, maize meal porridge, with cooking oil, sugar and salt. She didn’t use a spoon, but cupped the pap in her hand and poured it into Agness’ mouth. Health educators advise against this traditional feeding technique when giving educational talks in the villages. I don’t know why she didn’t use a spoon. Perhaps she was too poor to afford one.
Agness stopped breathing as she inhaled the pap into her lungs. She had a seizure, probably caused by lack of oxygen reaching the brain. The mother said that she had convulsed for an hour, but I didn’t consider that was reliable information, as she had no means of telling the time. The baby had regurgitated some of the pap.
The baby was extremely distressed, breathing rapidly at 76 breaths per minute, with inspiratory wheeze (stridor). I couldn’t hear any sign of any pap still in the lungs. She was not cyanosed. I don’t have a paediatric pulse oximeter to measure the saturation of oxygen in her blood. We calmed the mother and grandmother down, and Agness was able to breast feed intermittently. It seemed to give her some comfort.
Aspiration pneumonia is very tricky to treat. There had been some cooking oil in the pap, and this could cause lipoid pneumonia. Although initially, children may appear to be recovering, their condition can deteriorate a day or so later. We don’t have oxygen at the health centre. Intravenous antibiotics would normally be withheld for 24 hours to see if the baby is going to recover spontaneously.
The baby was now breathing at 60 breaths per minute and looked more comfortable. I thought we might be exiting the woods, but on reviewing the child after lunch, it was clear the child needed oxygen and more care than we could provide. I organised a transfer to the local hospital (I have since learned that the baby has made a full recovery after a week’s admission).
In this blog, I write about and post photographs of the wonderful variety of animals and birds in South Luangwa. I don’t want to give the impression that I am just having a fabulous time on safari for three months so I include pieces about my work and clinical problems I am trying to manage. WordPress statistics tells me that clinical pieces are popular, too.
But it’s probably obvious to some of my readers that my writing about these tragic cases helps me to cope with my own feelings and emotions. Extracting and transforming my sadness, frustration and helplessness into words on a laptop screen is cathartic. And in the words of the BT advert, it’s good to talk.
Baboons are like Marmite; you either love them or hate them. I hate them when they crash across the corrugated tin roof of my house at 6am, fighting and squabbling. But the rest of the time, I find them intriguing and (dare I say it?) cute.
Not “Greed is Good” Gordon Gecko. This post is about the lizards. I share my house with at least a dozen. They are khaki in colour, and vary in size from 3 – 12 centimetres. They have suction pads on their toes so they can climb any wall and traverse any ceiling. They don’t bother me at all, because they do bother mosquitoes and other insects by eating them. Which is good news for me.
They tend to shun the limelight, preferring to hunt their prey behind the fridge or curtains. I don’t pay them much attention unless they catch my eye as they scurry from one location to another. Sometimes I see them chasing each other. Whether this is a territorial dispute or a mating ritual, I have no idea. Occasionally, I see one that has lost part of its tail. Geckos have the ability to shed their tail if it has been caught be a predator, to help them escape.
Recently I have noticed lots of gecko turds in my shower area. And by lots I mean 20-50 tiny dark shits, about the size of a matchstick head. The shower is separated by a partial wall from my toilet, but even if I leave the toilet lid open, they prefer to poop in the shower. I thought I’d give them something to aim at.
I don’t know why they prefer to use my shower as their toilet. But I have given it some serious thought.
I wondered if it was because of the increased humidity, from the wet floor of the shower. But my toilet leaks (clean water, not foul) and forms a puddle around my ankles, so I doubt that moisture is the answer.
Perhaps the act of defaecation is a social event in gecko culture. It may be that all the geckos in my house get together to crap ensemble. Many antelope in the park have a communal toilet called a “midden”. All the impala or puku prefer to poop in the same spot, so it looks like someone has spilled a bucket of black peas on the ground. Could it be that each gecko’s shit contains hormonal messages, showing a female lizard is “on heat” (does this expression even apply to cold-blooded creatures?) or a male is producing lots of male hormones? Perhaps my shower pan is the equivalent of gecko Facebook, where they communicate with each other chemically in their poo?
Interesting: on the left is the shit situation last night, on the right is the shit situation this morning. Not much difference. Perhaps they sleep at night and poo during the day?
Whatever the explanation is, I don’t really care. I just think of all the noxious insects they have eaten to produce this amount of crap. And I never look at the soles of my feet, anyway.