“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
Author:Dr Alfred Prunesquallor
Maverick doctor with 40 years experience, I reduced my NHS commitment in 2013. I am now enjoying being free lance, working where I am needed overseas. Now I am working in the UK helping with the current coronavirus pandemic.
We now have four clinical officers working at the clinic. There are just two consultation rooms, one with a couch, the other with a massive vaccine fridge instead. The treatment room does have a couch so if no one needs minor procedures, injections, dressings, etc., a clinical officer can work there, too. I had suggested that we might train up one clinical officer to become a de facto pharmacist, but our stock of drugs is so low that it is hardly worth the effort.
A new clinical officer started work this morning. She was very keen and wanted to sit with me as I was teaching another CO, trying to improve her consultation skills. In many cases, the history consists of a few lines – abdominal pain, headache, fever, cough – or something similar, occasionally with a duration. I suppose if your treatment options are extremely limited, why bother delving into the symptoms and signs if you don’t have the drugs to treat the illness you have diagnosed?
But with some effort, we can try some clinical diagnostic reasoning, come up with a plausible diagnosis and construct a management plan.
“OK, you have written abdo pain 2/7, can you tell me more about the pain?” I asked the CO. “The patient has belly ache,” she replied. “Anything else about the pain?” I inquired. “The patient also has headache,” she said. “Let’s stick with the pain. Have you heard of SOCRATES?” I asked. She said she hadn’t but when I wrote it vertically on the page of the patient’s exercise book and said “S stands for site, O stands for…” she said, “Onset.” Ah-ha, she remembered the mnemonic, but this refers to what was happening when the pain first occurred, not when it occurred.
Character of the pain is always difficult because of language, cultural and vocabulary issues. “What about radiation? Does the pain go anywhere?”
The CO wasn’t familiar with the concept of radiation. I gave her some common examples – kidney pain radiates? “To the other side?” “No, to the groin.” Gall bladder pain radiates? “To the groin?” No, to the shoulder tip. I explained about the mystery of dermatomes and their innervation.
A for associated symptoms was easy. Headache.
T for time or duration of the pain, constant or coming/going.
E for exacerbation. What makes it worse, what makes it better.
S for severity, but it is always severe.
The patient had attended a month ago with abdominal pain and headache. A urine test detected a tiny amount of blood and under the microscope, the spiny eggs of schistosoma haematobium. She took some pills for bilharzia, but perhaps this was an incidental finding, because she came back a fortnight later, with the same symptoms. She was treated for gastritis, but this didn’t work either. We needed a Plan C – how about physically examining the patient?
She had tenderness in the right lower quadrant of her abdomen, with a possible mass. We discussed the differential diagnoses and sent her off to the hospital for a sonogram. Hopefully this will give us a treatable cause for her discomfort.
I am trying to get the clinical officers more interested in their patients, to be more patient-centred as GPs are in the UK. Curiosity is a virtue.
One of my friends who lives on the eastern bank of the Luangwa River has a smartphone. The ring tone is the squawking call of a fish eagle. I still find myself looking up into the sky trying to spot an eagle when her phone rings.
Fish eagles are imperious birds. They like to perch high in dead trees, so they get a great view. This means that they are easy to spot and photograph. I took a dozen photographs of an immature fish eagle scanning a cabbage-covered lagoon in the park, trying to shoot every angle of his head. On returning home, I loaded up the images into my laptop, intending to delete most, keeping just one or two for posterity. But the eagle was so magnificent, that I found it impossible to cull most of the photographs. Here are a few for you to enjoy.
If they are not perched by the riverside, I sometimes see them on the ground, tearing at a lizard or a fish which they have captured in their talons. I have only ever photographed a fish eagle swooping down to pluck a fish from water once. And that was a cheat, when a guide took us out into Lake Naivasha in Kenya and threw a dead fish into the water. Our cameras sounded like the staccato of machine gun fire as the habituated eagle picked up the floating fish and flapped away.
In 2018, I bought a new Panasonic Lumix G9 camera, with a couple of Leica zoom lenses. They were on sale so I treated myself. There is a mode on the camera to record 60 pictures in a second. Even better, if you half press the shutter button, it will record the previous half second’s images. This makes up for my slow reaction time. So I pointed the camera at this majestic fish eagle, pressed the button as soon as I saw it take off and got sixty brilliant pictures as it left the branch. Job done, I thought.
Then I turned away from the viewfinder and watched the eagle swoop down onto the surface of the lagoon and catch a fish in its claws. It flew off into the distance to eat its fish supper in peace from intrusive paparazzi.
It was better watching the eagle in action with my naked eye than using my camera with its fancy electronic wizardry.
“The best laid schemes o’ mice an’ men / Gang aft a-gley.” – Robbie Burns
WARNING: This may be interesting for you if you enjoy observing the trials and tribulations of logistical planning, but otherwise, it might be rather boring. Even the accompanying photographs.
The Ministry of Health’s plan was simple: vaccinate all 14-year-old girls and give them a booster a year later to provide protection against cervical cancer. Repeat annually with each cohort of young girls.
Now, vaccinating infants is easy; their mothers bring them along to our community clinics to be immunised. But how do you access teenage girls? The obvious answer is to vaccinate them in school.
Not all girls go to school, however, especially in rural areas.
And students change schools, moving to different locations, for a better education, often at age 14.
Then Covid-19 arrives and schools close down, completely wrecking your strategy.
“Can you help us boost our coverage, Dr Ian?” asked D, who is in charge of immunisation campaigns at the health centre. I agreed and asked to see what had been accomplished so far.
D handed me six huge registers, in which the teams had recorded the vaccinations, given at six local schools.
“What does this mean?” I asked, pointing to rows of children’s names where the column indicating the date of HPV vaccination was blank.
“I am sure that they have had the vaccine, we just didn’t record it.”
That sounded very odd. If you bother to record the name and village, why wouldn’t you add the date of vaccination. Even if you just put ditto marks in the column.
We did some investigating. It turned out that the vaccinating teams were understaffed, so they asked the teachers to write down the names of all the girls in their classes who were 14. But not all of these girls were at school on the day the vaccination team arrived, or had refused to have the vaccine.
“Did you not know about this, D?” I asked him. “Ah, doc, I didn’t vaccinate at this school.”
“Right, how many 14-year-old girls did you vaccinate last June/July?” I enquired.
D didn’t know exactly, but the nurse in charge said that he had reported 269 to the Ministry.
OK, so how many girls are recorded in the registers as having been vaccinated? He didn’t know, so we copied the information from the registers into an Excel workbook and counted 311.
“Why do you think there is a discrepancy?” D didn’t know and neither did the nurse in charge. “Perhaps you vaccinated 269 schoolgirls and 42 girls who were not attending school?” I suggested.
“How about coming at this problem from a different angle. How many doses of vaccine did you use last year?” I asked. D said that the Ministry of Health had collected all the unused doses in August 2019 at the end of the campaign, so he couldn’t check.
“But that was last year, doc. I am worried about this year,” D said.
“So what is your target?” I asked.
“All the girls we vaccinated last year who are now 15, plus the girls who have turned 14,” he replied.
“What’s your estimate of the numbers?” I asked. D said that the Ministry of Health had worked out how many doses we should have based on some ten-year-old census data uprated by the estimated growth in population.
“So, how many do you think this year?” I asked. D wasn’t sure and wouldn’t hazard a guess.
“Okay, we don’t have precise figures, but is it logical to assume that at least the same number of girls are born each year? We vaccinated 269 or 311 girls who were 14 last year, so we should be aiming to vaccinate that number plus a similar number of girls who turned 14 this year.”
“If you say so, doc.”
“Let’s say about 600. How many doses of vaccine did the Ministry of Health deliver to us?”
“We got 550 this year,” he said after checking the records.
“And how many doses are left?”
“Good, so we are about half way there,” I offered. “How did you manage to vaccinate so many when the schools were closed?”
“The students who are in their examination years are still attending school.”
We looked at the Excel spreadsheet, where 145 15-year-old girls had received their second dose and 88 14-year-old girls had received their first dose, during the past two months.
“So, what can we do now? How do we get to the girls who are not at school?” I asked.
“We can use our community health volunteers to mobilise them,” he said. “Then we can vaccinate them all in one day going from village to village.”
“But students don’t always go to the school nearest to where they live. They try to get into the best schools or they get rejected from other schools. We are lucky to have their villages recorded in the register.”
The prospect of trawling through six registers was daunting until I discovered that D had a database of all the villages in the health centre’s catchment area. There are ten neighbourhood health committees, each with a volunteer health worker. A bit of magic with Excel and we were able to print out a list of all the 15-year-old girls who were eligible for their second dose in each location. We delivered the list to each volunteer health worker. They had 48 hours to locate the girls on their list, plus any 14-year-old girls, and we would be along to vaccinate at a particular time.
Unfortunately, some volunteers were unable to identify any of their target population. Others had tracked down every 15-year-old. They could tell us where the girls had relocated: back to Lusaka, to a good school out of our area, or who had become pregnant. We only managed to vaccinate another 20 girls.
In one village, D said he had a message to the girls who had come for their vaccinations. “During this time of Covid, when the schools are closed, keep yourselves busy. Don’t give in to temptation and go with boys because you don’t have anything better to do.” I looked at the group of girls on the mat and thought that they looked like mature, young women.
I foresee that there will be a big rise in teenage pregnancies in 2021.
We still had hundreds of girls to vaccinate. I asked A, the other health inspector, what we should do. She said, “We should contact the girls.” But how? “Some way.” Yes, but how exactly? It’s no good just saying what you want to happen without a plan to make it happen.
“Give me some time, I will think about it,” said A. But we don’t have time. The Ministry will be taking back the vaccines in August as it assumes we will have successfully completed the campaign by then, regardless of the disruption of covid. I had a plan to use the local radio station to spread the word, but I wanted A to come up with that suggestion, so I could make her take ownership of the problem. With some unsubtle prompting, she thought using the radio station would be a good plan.
“Okay, what would you say on the radio, A?” She wasn’t sure, so I drafted a short statement about preventing the number one cancer affecting women in Zambia, how safe the vaccine was, who should have it, and the dates and locations we would be offering the vaccine over the next few weeks.
D stumbled while reading the statement in English, never mind translating it into Kunda, the local language. I suggested a female voice would go down better for a health message directed at girls and young women. A translated the piece and gave a seamless performance. We drove down to Radio Mhkanya and I sold the story to the station manager. “It will make a great two-minute news article,” I said. He agreed and A went next door to do the interview.
I asked the station manager about the catchment area of the radio and he told me it was about 50km in all directions. I asked D to inform his colleagues in other neighbouring health centres so they could deal with any surge in demand for HPV vaccine in the coming weeks.
A came out beaming. She wanted to hear her voice on the radio, so the interviewer put headphones over her ears and played the clip back to her over the computer. She was delighted. Even D wanted to hear.
There was a spring in her step as she walked back to the car. She was a radio star; everyone would hear her voice on the news over the next 24 hours. Perhaps this will boost her performance at work, too.
Footnote: Unfortunately, the radio broadcast has so far resulted in no eligible girls coming forward for vaccination.
Now I have seen some high blood pressures in my time, but this old lady’s 285 systolic was one of the highest I have seen here in Zambia. She had been taking two tablets, a calcium channel blocker and a combination diuretic. She claimed that she never missed a dose. When I took her pulse, it was galloping along at over 120 beats per minute. I tried checking with my pulse oximeter, which clips gently onto a fingertip and displays the oxygen saturation of blood, along with the pulse rate. It showed 116.
There are not many options available in rural Africa to treat blood pressure. I have become less keen on using beta blockers after my experience in Kenya that they did very little good. They may reduce the pressure, but there is little evidence that this results in reduced mortality. But they do reduce the heart rate, and this lady’s heart was going like the clappers. I asked her son to go to the pharmacy and buy some atenolol to see if it would help.
When morning clinic was over, I stopped by the ward to review her. I took her pressure myself and it had fallen to 170/95 with a pulse rate of 76/minute. This is still higher than normal, but I was delighted. I asked the son to make sure that she took the atenolol together with her normal tablets for blood pressure, for the foreseeable future. I said that she could go home and have some decent n’shima (stiff maize porridge) for lunch, but go easy on the salt.
She sat up and swung her legs over the edge of the bed. She started swaying and needed some support from her son as she walked out of the ward into the sunshine. I wondered whether her carotid arteries were so stiff and calcified from decades of atherosclerosis that she needed a high blood pressure to get the blood and oxygen to her brain. I made a note not to treat her hypertension so aggressively in future. I didn’t want her falling over from postural hypotension and breaking her hip. It is important not to follow guidelines slavishly, without taking into account the patient as an individual.
Almost every morning when I do a ward round, there is an elderly person lying on a bed resting to reduce their blood pressure. If the blood pressure is extremely high (250 systolic), the nurses might have panicked and given furosemide (a diuretic), a practice I have advised against. But, if there isn’t anything else in the drug cupboard, what can you do? A group of fussing relatives surrounded a little old lady on the bed. I asked what was wrong. “BP,” came back the answer. I could have guessed.
One daughter could speak reasonable English so I asked her to tell me the history. Her mother had had hypertension for years but had given up taking pills. Perhaps she was being treated by the sangoma (witch doctor) or drinking herb tea (made with aubergine leaves). I have even seen people collecting elephant dung to make antihypertensive tea. Perhaps the elephant had been eating aubergines.
“And why did you come to clinic?” I asked. Her mother’s hand had become paralysed. Sometimes the local language doesn’t have the vocabulary to express subtle changes, so paralysed might mean not moving because it hurts or no feeling, numbness. “She is moving her hand now,” I said. “Yes, and she has started speaking again.” I looked at her school exercise book but the notes were very brief and didn’t mention a stroke or transient ischaemic attack.
The old lady looked miserable. Via her daughter, I asked her to squeeze my index fingers with each hand to assess the strength of her grip. “You can do better than that! Go on, try to hurt me!” I urged playfully. Her grip improved as she really put some effort in. The right hand was slightly weaker. I wanted to check her facial movements, so I pretended that she really was hurting me. I made an exaggerated show of trying to pull away from her. Eventually she let go and I waved my index fingers in the air, pretending to get some feeling back. This made her laugh, and I could see both sides of her face moving equally. It looked as though there was no residual neurological deficit. Disregarding social distancing, I put my arm around her shoulders and told her I was impressed with her recovery.
I told the family that I was going to add a small daily dose of aspirin to try to reduce the risk of another “mini stroke”. I discovered the pharmacy didn’t have any in stock, so I checked in my stash of drugs in the car and discovered a strip of aspirin tablets about to go out of date next month. As I handed it over, the family started chanting: “May Almighty God bless you and keep you safe,” “We will pray for you and your good works,” “Thank the Good Lord who has sent you to help us.” All for 14 aspirin.
In these cold winter mornings, patients tend to arrive at the health centre after 9am. At 8.30am I was getting bored waiting for some action, so I pretended to be a patient. I walked into the waiting area, coughing and spluttering into my face mask, showing signs of being short of breath.
The health worker at the registration-cum-triage desk stared at me for a moment, then burst out laughing, “Doc’s got covid, doc’s got covid!”
“What are you going to do with me, then?” I asked.
“We will do your vital signs and write them in your book,” said the health worker.
“Using the same thermometer as you use for everyone else, the same blood pressure cuff, examining me at the same table?”
“Ooohoooh,” (the timbre of this expression goes up in the middle, then down, signifying now I understand)
“We must isolate you from the other sick patients,” said one of the student counsellors who is working at the centre.
“Where?” I asked.
“You must go to the male ward. I’ll get the nurse to see you there,” she said.
“But are there any patients in the male ward already?” I enquired.
“Yes, there’s an old man with high BP being treated with bed rest,” she replied.
“Knowing what you know about covid-19, do you think that would be a good plan?” I asked.
“Because covid-19 is more dangerous for older people, especially men and especially those with pre-existing conditions such as hypertension,” I said.
“Ooohoooh,” she replied. “I will ask my supervisor.”
The senior clinical officer appeared on the scene and said that I should be isolated in the new building behind the maternity block where pregnant women stay if they are due but not in labour.
“And how will you treat me?” I asked her.
“The treatment is to give oxygen,” she said.
“But we don’t have any,” I replied.
“Yes, that’s right. But the treatment is oxygen.”
I have come across this mismatch between theory and reality on several occasions. Health workers are able to manage the cognitive dissonance of the situation. We know what should be done, but we can’t do it, so there’s nothing we can do.
“So how do you know that I have covid-19?” I asked.
“You are in a high risk group as you have travelled from overseas.”
“But that was nearly a month ago. Surely I would have fallen ill before now if I had contracted the disease in the UK or on the flight out to Zambia,” I said. “How can you distinguish covid-19 from a chest infection, influenza or a common cold?”
“We do a test.”
“But there are no tests available in the health centre.”
Indeed, there is no easy way of diagnosing covid-19 without a specific test. But there are several indicators which might tilt the balance in favour of covid-19 rather than another respiratory infection. I explained about covid-infected patients in the UK who lost their sense of smell and taste. A dry cough, rather than a productive cough, points towards covid-19. We went through other suggestive symptoms, such as lack of appetite, fever, shortness of breath and fatigue. But chest pains, tummy upsets, and runny nose are less sensitive indicators.
Judging by the look on their faces, I could see that the difficulty of diagnosing covid-19 without a test was beginning to sink in.
“But every day we see lots of patients with upper respiratory tract infections. We are not isolating them,” said the student-on-placement.
“So what do you do with them?” I asked. “We have no broad-spectrum antibiotics and are running low on paracetamol. And even Piriton.” This was teasing them about the standard management of the common cold.
“If they are not very ill, they should go back to their home and self-isolate,” said the clinical officer.
“And what about the other people in their household? Should they also self-isolate? Or only if they have symptoms?”
“These people are often daily paid (they only get paid if they do a day’s work) or farmers who need to work outside the home. If they don’t work, they don’t eat. They don’t have savings to tide them over.”
“And what if they become more unwell? Will they return to the clinic for help?”
“They should not come back here if they are ill,” said the clinical officer. “We will send them away.”
“But they might not accept that. They could decide to get a taxi to go to the hospital, spreading the disease as they go.”
“We could keep them in the pregnant women’s quarters until the get better.”
“Who will look after them there? Do we have protective clothing?”
“Yes, we have about four disposable gowns, boots and visors,” said the clinical officer. “We had the training some months ago. We know how to put it on and take it off.”
“And you haven’t forgotten?”
“One nurse will stay with them all day, so she can keep the protective clothing on all the time.”
“In September and October, it gets extremely hot and humid before the rains come in November. How is she going to cope wrapped up in PPE?”
“There is an isolation ward just outside Mambwe (less than an hour away by car) where we can send people who are unwell and we cannot manage them,” said the clinical officer.
This was news to me. “Is it equipped and ready to receive patients? Is oxygen available there?” I asked. No one knew.
I told them that the District Officer of Health informed me that any extremely unwell patient requiring oxygen and possible ventilation would be transported to the new hospital at Petauke. I had driven past this brand-spanking-new hospital the day after I arrived in Zambia. It was locked shut.
“How will we know if it has arrived in our locality?”
“We will probably see a cluster of cases, possibly unexplained deaths.” In the capital, Lusaka, people who have been very ill have avoided coming to the hospital for treatment. Perhaps they think that if they didn’t have covid-19 before, they would certainly get it when they were admitted to hospital. Their relatives would bring them to the hospital when they were moribund, and many of the first positive covid-19 tests were done posthumously – BID, brought in dead.
“So, what should we do?”
“Pray!” The nurse in charge of the heath centre is a pastor in the Bread of Life Church in Mfuwe.
And wash your hands, wear masks in enclosed spaces, keep socially distant from others, stay indoors if you have any symptoms, and, yes, pray.
“I’ve got BP, doc,” said the elderly man lying in the ward. “So why have you admitted this patient?” I asked the nurse. “He has BP, doc,” she said. “We all have BP, otherwise we would be dead,” I answered. “Having blood pressure means that blood and oxygen can get to our vital organs. Why did he come to the clinic? Usually hypertension doesn’t cause any symptoms unless it’s very high.” The patient intervened, “I’ve got problems passing urine, doc. It doesn’t come out as quickly as it used to, it stings and I needed to get up to wee four times last night.”
“So let me guess, when they did your vital signs at the registration desk, they noticed your blood pressure was elevated, so they sent you to the ward to rest, in the hope it would come down?”
“Exactly,” said the nurse. “Well, lying down and resting will reduce blood pressure, but it isn’t a useful treatment for everyday living.” The nurse agreed, but said that she couldn’t send him home if his BP remained high. “But what about the reason he came to clinic?” I asked. The nurse said that she reckoned this was “prostate”. I agreed that this was a likely diagnosis in a man of his age, but was there any way we could find out more? I had in mind the International Prostate Symptom Score, a screening tool checking different aspects of prostatism. “Yes,” said the nurse, “I did a digital rectal examination. It felt big, but I don’t know what a big prostate feels like, really. Can we do the rectal examination again together, so you can teach me?”
I was immediately taken back to my days as a very junior hospital doctor. “If you don’t put your finger in, you’ll put your foot in it,” an aphorism that is burned into my cerebral cortex. If I had not done a digital rectal exam on a patient, I would surely be asked about my findings by the consultant leading the team. But here was a nurse volunteering that she had been proactive. I was very impressed. Then I thought, did she do the rectal exam before or after she had checked his blood pressure?
I glanced down at the patient who was looking alarmed. I thought for a moment and decided we could postpone the digital instruction for a week. Three rectal exams in one day would send anyone’s blood pressure through the roof. I told the nurse I would get hold of some guavas of different sizes and practice. I suggested we check a urine sample, which showed signs of an infection, so we treated him with antibiotics.
“But what about the hypertension?” I asked. “He is already taking a calcium channel blocker, but it isn’t controlling his pressure,” she replied. “What other drugs could we use, perhaps one which would help him pass urine more easily?” “A diuretic?” she answered. “Yes, that would make him produce a lot of urine, but his problem is getting it out. Any other drugs?” “Beta blockers?” she ventured. “I was thinking of trying an alpha blocker, which might improve the flow of urine and his blood pressure.” “Never heard of it,” she replied.
We made a plan: treat the infection, continue his normal blood pressure treatment, see on Friday next week when we are both in the clinic, recheck his blood pressure, urine and prostate, in that order. He didn’t show up.
Dorcas was 84 years old and had suffered from “BP” for the past 15 years. Muzungu doctors had wrestled with her hypertension without managing ever to get it under control. I read through two tattered school exercise books which serve as patient-held medical records. I suspected that the reason for poor control was the lack of consistent supply of antihypertensive drugs at the clinic. Indeed she admitted that she had run out of medication (so had the clinic) and couldn’t afford to buy more. She was lying in the female ward, resting.
Ward rounds are good teaching opportunities. I asked the nurse what she might expect to find when examining someone with long term uncontrolled hypertension. “High BP,” she said. “But what might be the effects of high BP?” She didn’t want to guess, so I prompted her. “Why do we try to control blood pressure?” “To stop heart attacks,” she said. “Great, so what might you find when examining her heart?” “High BP.”
I realised I was going to have to go back to first principles. “The heart is a muscle. It pumps blood. The stronger it pumps, the higher the pressure. So do you think her heart muscle will have been affected by chronic hypertension?” “Yes,” she said. OK, how could we detect this? She didn’t know, so I asked her to look at Dorcas’ chest. I could see the apex beat, bouncing away almost in her axilla. Then I asked her to feel for the heartbeat. She correctly located it and described it as “forceful”. “What you can feel is the bottom of the heart tapping on the ribcage. It is typical of left ventricular hypertrophy. Try listening to the heartbeat.” She told me she didn’t have a stethoscope. I offered her mine, “Share my earwax, if you dare.”
We discussed the two heart sounds, and how much louder the second sound was: lub-DUB. As I explained where to place the stethoscope on the chest to hear blood flowing through the heart valves, I noticed a pulsatile swelling just to the right of her upper breastbone. Her swollen ascending aorta had distorted the chest wall. The most likely cause of this would be an aneurysm, following decades of untreated syphilis.
I am not sure that it would do any good at this stage, but we treated her with penicillin injections. No heart surgeon would want to operate. Although her aorta was swollen, the wall would be thinner than normal and could burst at any time with catastrophic results.
ICAP (“International Center for AIDS Care and Treatment Programs”) is an American organisation (Columbia University) which supports health teams managing patients living with HIV. Four years ago, when I was working in Swaziland with Medecins Sans Frontieres, I attended a two day meeting at a hotel in in Pig’s Peak organised by ICAP, where representatives of all health centres in the country presented their data. I recall sneaking away from the prize giving ceremony to watch a soccer match on television (well, it was Manchester United playing my team, Leicester City, in our premiership-winning season). Such mass events are very expensive. The new modus operandi is to use Zoom meetings.
I am not exactly sure why, but the ICAP Eastern Province team descended on Kakumbi, bristling with laptops. In one small office, 3m x 3m, there were five, with two participants using their own smartphones. The leader of the team had two widescreen laptops. Technical assistants were on hand to overcome any challenges, such as a disruptive “reverb” on the leader’s microphone. The zoom meeting was to allow a dozen medical officers to present last week’s HIV/TB data. The meeting began at 8:30am, but it took another half hour for everyone to log in and get settled. Three doctors didn’t virtually show up at all.
After an introductory speech by the team leader, each district officer commented on their data, which was being streamed as a PowerPoint presentation. The first talk was interesting, but by the sixth (almost identical) talk, I was beginning to fade. Each presentation was in exactly the same format, with the narrator reading the numbers from the screen. Some slides showed no activity, but this didn’t deter the doctor from ploughing through the zeros, rather than skipping deftly to the next slide, “nothing to see here”.
Occasionally, a speaker would highlight certain difficulties, try to explain them, but often without offering a solution. Several districts had the same difficulties. Perhaps they had discussed these problems at previous meetings, but they didn’t now.
For the first time I saw some data relating to Covid-19, which had obviously been “bolted on” to the standard format. We are still waiting for the tsunami to engulf us.
I learned that there was a screening tool in use at clinics to pick up patients who should be offered HIV testing. By screening out low risk patients, the positive test rate was about 10%. Our clinic had offered no screening tool data because we hadn’t collected it. I must admit I have not seen the health volunteers using the tool. It looked very cumbersome and complex.
Some clinics had run out of HIV test kits. It seemed that the 90:90:90 (90% of the population knows their HIV status by having had a test in the past year, 90% of those who tested positive were on treatment, and 90% of those on treatment had no detectable virus) mass testing approach to control HIV was proving too costly.
Once someone is HIV reactive, it is important to offer testing to sexual contacts. This may sound simple but it isn’t easy. Just imagine if the same day that you had been informed you were infected with HIV, you were being interrogated about your sex life, extramarital relationships, use of prostitutes, etc. Not everyone wants to spill the beans at that critical time. But our contact tracing needed to improve.
As a group, children who were living with HIV were most likely to have detectable virus. It seemed obvious to me that this was because of poor compliance – the medicine tastes awfully bitter – but the team leader suggested we needed to analyse this further.
About half the patients had switched from an efavirenz regime to one containing dolutegravir, a drug with a cleaner side effect profile. No districts reported a shortage of anti-retroviral drugs, but there did not appear to be enough surplus for stable patients to be issued six or even three months’ supply (to try to reduce travelling during the Covid pandemic). Just 1% of newly diagnosed patients were found to be also suffering from tuberculosis (it was much higher than this in Swaziland).
It is obviously important to make sure patients attend and are not lost to follow up. Treatment supporters managed to contact 90% of those few patients who missed their appointments and successfully got them to come to the clinic.
One district reported having screened almost 1,400 women for cervical cancer (visual inspection of the cervix). Of these, the screeners found 34 with suspected malignant changes, 22 of which were treated with cryotherapy and 4 needed cone biopsies. These results are very impressive for a country which has no cervical cytology programme.
I was also impressed that not one of the 3,500 patients receiving anti-retroviral drugs in our district had died over the past week.
In an attempt to engage the audience, the team leader asked a colleague to summarise succinctly, telling him he had four minutes. He took ten. The meeting took four and a half hours. I wonder how many clinicians joined the meeting, said their piece and went off to treat patients, leaving their laptop glowing and jabbering away in their office.
One thing I have learned from working overseas is to wait until you have been doing the job for a month or so before being critical and recommending change. If it were me, I would have these meetings every month, or even every quarter. I would circulate a compilation of all the district reports, highlighting how a district deviates (good or bad) from the norm. The district would have to explain why it was an outlying and what it had or hadn’t done to achieve that. But it is a case of “he who pays the piper calls the tune”, and if the Center for Disease Control and ICAP provide the finance, they get to decide what gets done.
I could not believe that the most senior doctors in the province spent 10% of their working week attending a zoom meeting which dealt with a disease which was largely under control, while diabetes and heart disease were disregarded and created much more morbidity and mortality. I mentioned this to the team leader, who agreed with me, but said that HIV was where the money was.
My first tour of duty as a medical volunteer in rural Zambia was in 2014. The clinic hasn’t changed much over the past six years. All of the original staff have moved on, apart from a cleaner and some local volunteers. There have been some renovations – the ward ceiling which was collapsing from the weight of bat excrement has been partly replaced, the labour ward has relocated to a new block and USAID has built a six-room HIV/AIDS clinic. Some small rooms have been divided up into smaller rooms to provide dedicated space for counselling, family planning, HIV and malaria testing. It has had several additional coats of paint.
The clinic failed an inspection a few years ago. The list of improvements is still attached to the wall, and a few have been implemented. For example there is now a dangerous drugs cupboard. This has two lockable doors, but unfortunately someone lost the only key. The only “dangerous” drug supplied to the clinic is diazepam injection, which we use to halt epileptic seizures.
The covid-19 pandemic is just starting to take hold in Zambia. There are complicated posters on the clinic walls, in English, providing information about the disease. Around the clinic there are buckets of water, basins and bars of soap for people to wash their hands. We have tried to enforce a policy of mask wearing for all staff and patients, but it is difficult to refuse to attend to a sick patient whose mouth and nose are not covered. The main consulting room has three washbasins. I have no idea why, but only one basin has a tap. The tap usually has running water. I donated a towel to the clinic six years ago and remarkably, it is still here. Someone has used bleach to try and clean it, so it looks a bit piebald. I try to avoid using it and re-contaminating myself, but it isn’t easy pulling on latex gloves when your hands are wet.
Many of the doctors who have volunteered here over the past twenty years have done some teaching. It is better to train nurses how to diagnose and manage patients so they improve their skills, than just seeing patients on your own. I taught nurses how to examine ears, throats and eyes using a pocket diagnostic set which I left behind last year. Other doctors have left shiny auroscopes and ophthalmoscopes. Doctors feel “naked” without these basic tools. I found two sets on a shelf covered in dust in their cases. Once I had replaced the batteries, they were perfect. I suppose the clinic doesn’t have funding for such essentials.
The clinic has a graveyard of ear thermometers which have worn out or succumbed to the dust. They are very useful because they are quick. A more traditional thermometer tucked into an armpit takes a couple of minutes to cook – and then you find it has changed position and not recorded a true temperature.
There is an old mercury sphygmomanometer for measuring blood pressure, but I was told it was “not functional”. There were beads of mercury in the glass tube and I thought it should stay on the shelf because it was dangerous. The registration desk has an electronic sphygmomanometer, but the battery cover has gone missing and it has been replaced by sticky elastic strapping. The batteries were dead yesterday, so I brought some from my own torch at the house to help them out. Today I was surprised to find that someone had bought new batteries and we were in business again. But for the entire morning I was pestered by the staff for the replacement batteries I’d brought. They can wait until I have returned to UK!
Last year, the clinic ran out of bandages and gauze swabs, so this time, I brought a supply with me (thank you for the donation, Su). We needed to use some during the first week I was at work. Dressings do tend to disappear quickly so I asked the clinical officer to lock the supplies in the pharmacy store. I separated the kit into piles of dry dressings, non-adherent dressings, different sizes, bandages, tape, gloves and steristrips (thin bits of tape to get wound edges together when stitches or staples are not required). Today, I needed some steristrips to do a bit of first aid and was disappointed to see some of my supplies randomly stuffed into plastic baskets in the corner of the treatment room. I searched for five minutes before finding the strips, and sadly, that was the last packet.
Working in low resource settings isn’t easy. It is not for every doctor. The variety of drugs is limited and “stock outs” are frequent. The range of investigations is restricted, the nearest X-ray machine (when it and the radiographer are both working) is an hour away by car. Taking a history using an interpreter can be difficult, especially when patients don’t understand what you are trying to do – you’re a muzungu doctor, surely you know what’s the problem without asking all these questions? I rely on my physical examination skills and broad experience. This can be frustrating when communicating with specialists who rely more on the appearance of a CT or MRI scan, when I want to know what the chest sounded like to know if it has changed since they last saw the patient.
The nurses in the clinic use me as a consultant to help them with the most difficult clinical problems. This means that I often see patients with untreatable conditions. I can tell them the diagnosis but I cannot always offer treatment or cure. I am trying to improve palliative care here.
In contrast, when I am working in village clinics for children, I am most usefully employed in recording all the details of vaccinations on an incredibly detailed tally sheet. These sheets have been photocopied so many times, that the print is faded and the tiny font is difficult to read. The data we collect must be accurate as it will be scrutinised by headquarters. Injecting an infant with vaccine is easy by comparison.
It is important to keep calm, equanimity rules. Showing annoyance is considered very bad manners and even raising your voice can cause offence. Although the work can be frustrating, the patients really appreciate what is being done for them. Even if the “free drugs” are only free when they are in stock, else patients have to buy them at the local chemist.
7:30 am start, prompt. Most of the health centre staff who should be here are wearing masks and waiting for the opening prayer. The nurse in charge asks the most timid, quiet staff member to lead the prayers. We all bow our heads while she mumbles into her mask. I can’t understand a word of what she is saying, but I “amen” along with the rest of the team when she stops.
Her next task is to take the minutes book and read out what we decided last Monday. Again, her voice is very quiet but her English is halting as she tries to read the handwriting of the previous scribe. We get the drift.
What is on the agenda? The malaria sensitisation campaign is underway. I find this rather strange as the peak months for malaria are April – June. Perhaps now we are less busy treating malaria we can find the time to educate the population about how to prevent it. We are recruiting insecticide sprayers for next month. Unfortunately, we don’t have the capacity to spray all the surrounding villages, but some are complaining that they missed out last year on both spraying and free mosquito nets. I must admit to having seen mosquito nets being used in the gardens to protect crops against birds. And some say they have also been used as fishing nets.
One good idea is for the health inspector to alert community health volunteers when someone tests positive for malaria from their village. They have rapid diagnostic kits and will test people living near the “index case” to snuff out an outbreak. Test, treat and track. Where have I heard that before?
The nurse in charge is a very experienced midwife, but he made a plea for other midwives (and any assisting nurses) to remain calm when there is an emergency. “Don’t panic,” he said. “Don’t run around looking for things to do. Just calmly assess the situation. The women are not going to expire immediately. You have got time to make an assessment.” I find this is usually true, but when obstetric calamities occur, things can go bad very quickly. However, I agree with his sentiment and nod sagely. I wonder what catastrophe happened last week that I was not aware of?
The lab technician seems to be working much better now she is alone in the laboratory. Last year, there were three technicians. Too many cooks spoiling the agar broth, I suppose. She informs us about all the tests which are available, but some we can’t use, because they are reserved for certain patients, people living with HIV or pregnant women. It’s a shame I can’t order a haemoglobin estimation for “ordinary patients”, especially as the local hospital won’t transfuse blood unless I know the patient is very anaemic (5g/dl or less than half the normal amount).
Later this week, we will be visited by the Regional ICAP (“International Center for AIDS Care and Treatment Programs”) Team to support our work with patients living with HIV. Perhaps this is a reward for the excellent care provided here, which has improved drastically over the past five years (since my first tour of duty here). The clinic provides anti-retroviral drugs for over a thousand patients in Mfuwe. The vast majority are compliant, their disease is suppressed. The last baby to have been infected by their mother during pregnancy was in October 2019. I find it rather odd that they are paying attention to such a small centre, even if we are doing such great work.
What makes me uneasy is the contrast between excellent HIV care and the poor care for diabetes, hypertension, asthma, epilepsy and other chronic diseases. The difference is, of course, that HIV care gets massive funding from the Global Programme for HIV AIDS.
The nurse in charge issues every staff member with a paper mask which must last them for a week. In the UK, these masks are discarded after four hours as they become damp and less protective after being in contact with moisture in our breath. I am pleased to see everyone keeps their nose covered. In a comment aimed at me, the nurse says, “We are forced to make compromises.” Indeed.
The Human Papilloma Virus (HPV) vaccination programme is stalled. Girls who are 14 – 15 years of age are eligible for two jabs, a year apart, to protect them from cervical cancer. It began nationwide last year and Kakumbi Rural Health Centre staff gave 269 girls their first HPV shot. We don’t know for sure, but we estimate that 90% of this cohort of girls go to school. Schools are the obvious location to round up and vaccinate the girls. But with the Covid-19 situation, all schools are closed apart from “examination year classes”. Unlike last year, we cannot just tell the teachers to line up eligible students for vaccination. Our problem is not just the girls waiting for their second shot, but another 270 girls now aged 14 who need their first shot.
Regular readers will have read my previous blog article about my misgivings with a vaccination programme which should have been given to 10 – 11 year olds, before they have become infected with the oncogenic strains of HPV. Once a girl starts having periods, boys consider her ready to have sex. A significant percentage of 14 year olds are not only sexually active, but are already young mothers.
I must have been daydreaming/brainstorming how to solve this problem when the quiet nurse in the corner started talking softly into her mask. “She’s leading the prayers,” I thought, dropping my chin onto my chest and clasping my hands. A few seconds later, I squint up at everyone else; no one is praying. She is actually reading out her minutes for us to approve. Nonchalantly, I try to adjust my posture to disguise the fact that I wasn’t really praying. I couldn’t tell if the other health workers had noticed and were smirking behind their masks. But I am used to making mistakes and they are used to my strange ways.
We finish at 8:15 am, ready to start the busiest day of the week at the health centre.
The general manager of one of the nearby safari lodges decided to have a team-building, morale-boosting trip to the National Park for sundowners on Sunday. (It is traditional to find a pleasant spot to watch the sunset while enjoying a drink, hence the term sundowners.) Seven of us drove into the park at 4.30pm, planning to meet up with friends at 5pm on the open plain of WaMilombe.
I really enjoy being driven in an open, high vehicle. The view is so much better than the view from the driver’s seat in the doctor’s car and I can concentrate of seeing animals, instead of trying to avoid potholes. The Luangwa River spills over into WaMilombe during the rainy season, creating a vast, shallow lake. Mud from the river fertilises the soil, creating rich grassland, perfect for herbivores. The floods recede, draining away into streams which carve deeply into the muddy soil, creating excellent cover for carnivores hunting the herbivores. This makes WaMilombe popular with leopards, and people who want to view leopards in action.
The plain is bordered by ridges on two sides, the Luangwa River and its dried-up tributary, the Mushilashi River. Leopards like to rest in trees on the ridges, while they look out for their next meal. Normally, the plain is dotted with antelope, puku and impala, but this evening it was empty. A solitary game drive vehicle was stationary under a tree close to the Luangwa. Game vehicles only stop for refreshments, toilet breaks and when there is something interesting to see. We decided to take a look.
Stretched out in the shade was a beautiful young leopard. We stopped ten metres away and took photographs. The leopard wasn’t interested in our interest. Its belly looked full. The driver of the other game vehicle said that there were two other leopards over by the ridge. As we crossed a deep dried out stream bed, we disturbed another leopard, who trotted away from us, towards the trees. Our driver could see another leopard hiding below the ridge, so we went to get a closer look. As soon as we began to observe leopard 3, leopard 2 sauntered over to leopard 1. As it approached the shady tree, the leopard speeded up, and ran up the tree trunk.
We realised that there was something attracting leopard 2 to the tree, so we returned and parked under the branches. We could seen the fresh corpse of an impala, draped over a thick branch. Leopard 2 was partially hidden by leaves, but we could see and hear it eating. I wasn’t expecting a sac of antelope intestines to plummet from the tree, just missing by inches the only vegetarian in our vehicle. Partially digested grass and manure splattered against the side of the truck. Leopard 1 decided to capitalise on this good fortune by picking up the guts and returning to its favoured position by the trunk of the tree.
Both leopards gorged on the remains of the impala while we watched. The sun began to set so we left the feast and drove to the bank of the Luangwa River, where we could safely get out and have a drink. The sunset was magnificent, but not as impressive as the afterglow which lingered in the sky for twenty minutes, getting deeper and deeper red. I took a selection of photographs of the sky reflected in the river as the light faded. Hippos started leaving the river to eat grass during the night. We could hear baboons giving alarm calls on the other side of the river, but we couldn’t spot another leopard in the gloaming.
When it was pitch black, we drove back to the leopard tree. A hyena was lolloping about, hoping for some titbits to fall from above. I got a poor photograph using the headlights to illuminate the scene. We were a mile from the park gate when a large grey shape appeared in front of us. I could pick out four elephants, munching away on trees. We drove carefully past and joined the main dirt road leading to the gate. The driver slammed on his brakes, creating a cloud of dust. “There was a puff adder in the middle of the road back there. I’m going to reverse, let me know I am not going to run it over.”
The lighting conditions were very poor, but the puff adder was clearly recognisable, as a short, fat snake, with a triangular head and typical diamond markings on its back. It might look fat and sleepy, but that’s its modus operandi. It stays still, waiting to attack with one of the most rapid strikes of any snake. Its venom causes massive tissue damage. Not the sort of snake you want to step on during a walking safari in the bush.
About a kilometre from my house, we stopped again to allow a lion to cross the road. Bush highway code: animals have priority on these tracks. As we waited for a second lion to emerge from the bush to join its sister, I reflected on how fortunate it was to be able to see these savage beasts in their natural environment. And we had just popped out for a couple of hours on a Sunday evening for a social drink with friends.