Vaccinating against Covid-19

This hasn’t been a smooth process. We knew the vaccine would be delivered to Primary Care Networks (co-operating groups of General Practices) in December 2020. I volunteered my services to the inner city practice where I work as a locum doctor and expected to start work as a vaccinator on 18th December. This was rearranged three times over the next four weeks before I jabbed my first patient with the vaccine.

Breaking the rules… again.

Organising a mass vaccination campaign is complicated:

Vaccine – you need sufficient supplies and cold storage facilities (especially for the Pfizer Biontech BNT162b2 vaccine).

Premises – you need a building big enough to cope with social distanced queuing, registering, vaccinating and post-vaccination observation for fifteen minutes (the guidance changed in December when two patients with serious allergies collapsed soon after being vaccinated). There should be plenty of car parking available. The Peepul Centre (@PeepulEnt) fit the bill.

Identification of the most vulnerable patients, contacting them by post/SMS/telephone/letter to explain the vaccination, check for allergies, get basic consent and give out appointments.

Staff – you need crowd controllers, volunteers to provide wheelchairs for disabled patients, multilingual clerks (many older patients in Leicester are not fluent in English and speak Gujarati, Hindi, Urdu or Punjabi) to fill in the vaccination forms, guides to take the patients to the vaccination hall, nurses and doctors to vaccinate, pharmacists to ensure the cold chain is intact and the vaccine is diluted properly and a receptionist to survey the patients waiting for fifteen minutes following their jabs.

Supplies – you need paper, computers, pens, masks, wipes, together with all the medical paraphernalia to give injections.

Training – the vaccinators need to be familiar with two new vaccines. Although each patient received a leaflet and several pages of detailed information about the vaccine, vaccinators needed to be able to answer their questions and give appropriate advice. As an active GP, I only had to complete three electronic learning elements; retired health workers had about twenty to complete before being eligible to give the vaccine.

I was disappointed, but not surprised, when the vaccination starting date was changed several times. This is a high profile operation and we had to make sure the mass campaign went smoothly.

Brief insert:

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I have been involved with mass vaccinations several times during my career overseas. In Burkina Faso (1979), we vaccinated thousands of children in villages across the Sahel against measles, tuberculosis, yellow fever, diphtheria, tetanus, pertussis and polio.

Mass vaccination in a village in the Sahel Region of Upper Volta (now Burkina Faso)

In The Gambia (1983), I was regional medical officer for the eastern part of the country when there was an outbreak of Group A meningococcal meningitis. After a thousand cases, with over a hundred deaths, the Ministry of Health organised a mass vaccination campaign. We vaccinated over 90% of the population in just five weeks. Imagine the logistics of the campaign: only one stretch of tarmac road, limited river crossings, no accurate maps or census data, refrigerators powered by kerosene to store vaccine, supplies of diesel fuel for the Land Cruisers and Rovers.

Using a dermal jet gun to vaccinate at a school in Eastern Region of The Gambia

The Rohingya refugee camp in Cox’s Bazar, Bangladesh was the largest in the world in late 2017. Medecins Sans Frontieres organised the vaccination of 170,000 children against measles in just ten days, stopping an epidemic in its tracks. We were lucky to have over 300 Rohingya health volunteers and the benefit of maps produced from drone flights, but this was a tremendous achievement. I left in November, just as a diphtheria epidemic was breaking out.

Child with severe measles in Kutupalong Health Facility, Cox’s Bazar, Bangladesh

More recently, while I was working in rural Zambia in 2019, I vaccinated 2,250 school children over a few weeks. Injecting vaccine into arms was the easy bit; I had a great team of helpers – teachers, crowd controllers, scribes to record the details of each patient in a ledger, to give each patient a vaccination card, someone to help me draw up the vaccine and a health educator. We had to work fast and cut corners in the process. This quick-and-dirty approach isn’t appropriate for modern Britain.

Vaccinating in Mfuwe Day School, Eastern Province, Zambia

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I arrived at the Peepul Centre (Gautama Buddha gained enlightenment while meditating under a sacred Peepul (fig) Tree; Hindus and Jains also hold the tree to be holy) half an hour before the first patients arrived. This was fortunate, because I had parked in the wrong place and had to move my car to avoid a parking fine.

Two Primary Care Networks were using the auditorium at the same time. We had six vaccination stations, well-stocked with needles, syringes, plastic aprons, antiseptic wipes, cotton wool, masks, gloves and a laptop. The doctor in charge gave the vaccinators a pep talk and explained how to fill in the paperwork. Each vaccinator received a single vial of vaccine and we were locked and loaded, ready to get to work.

Almost all the patients were over 80 years old (one was 100), most of whom were of South Asian descent (this is typical of East Leicester). Most elderly patients were accompanied by a relative or carer who could help with clothing and communication. Few patients spoke English fluently, many of them were profoundly deaf and they were all wrapped up in multiple layers of clothing (it was bitterly cold outside). One lady was wearing six cardigans which I managed to peel away to reveal a patch of upper arm for the vaccination.

Some ladies were wearing short blouses, covered by a sari. The sleeves were so tight that I needed to undo the front buttons. Of course, I asked for permission to do this, so I could slip the blouse off their shoulder to access the deltoid muscle. One lady said, “You can touch me, you are my son!” which amused her daughter. It did require some tactical covering by her dupatta (scarf/shawl) to preserve their modesty.

I like a bit of banter with my patients, even when their English is as limited as my Gujarati. I find it is a perfect way to distract the patient from the injection. Intramuscular injections are less painful when the arm is hanging down and the muscles relaxed, so I learned the Gujarati term for “relax your arm”. This makes the patients think I know their language and they start a conversation.

Occasionally, I will detect a patient’s accent and share a little common history. “Where do you come from?” I ask as I roll up a sleeve. “Sunderland,” replied the patient. “My uncles took me to the Fulwell End at Roker Park to see Sunderland play when I was six. I still support them,” I said, after disposing of the needle and syringe. “It’s a cross we have to bear,” said the patient (Sunderland are languishing in the middle of the third tier of the football league).

One Indian lady invited me to have tea with her. Another gave me a non-socially-distanced hug (we were both masked and gloved). Several patients asked God to bless me and many others were very thankful. This was the first time that many of them had been outside their homes since March.

After half a dozen jabs, one gets the hang of things and the process becomes slick and efficient. The practice booked in patients every six minutes, but I could easily vaccinate two or three in that time, acquiring a reputation for being “quick on the draw”.

I usually flick the skin just before the injection, on the assumption that this non-painful stimulus shuts the nerve “gate” to subsequent painful stimulus, carried by slower c type nerve fibres. (Gate Theory of Pain, Melzak and Wall, 1965). One of the health workers I vaccinated said it was the best injection she had ever had, completely painless – cue “Yesss!” and fist pump from me.

Each constituted vial contains 2ml of fluid, which provides six doses of vaccine (6 x 0.3ml), with 0.2ml left over, which is discarded. I offered to use the remnants of each vial to make another dose, but this was rejected. “I don’t mind having the dregs for my dose of the vaccine,” I told the supervisor. “You can’t have the jab today in case you have side effects and are unable to vaccinate tomorrow,” he replied. I got my first dose at close of play the following day. I had absolutely no side effects.

I will be back in the Peepul Centre next week to do more vaccinating.

Thursday Doors – visit to the Boma

This piece was written in mid July 2020 arrived in just after I arrived in Zambia. I am posting it now that I have returned to the UK.

Main entrance at the clinic. An Arsenal Football Club shirt is never fashionable.

I was expecting to have to quarantine for a while, but  Dr George, the District Health Officer (who is my supervisor), told me over the phone that I was free to start work whenever I wanted, because my Covid-19 test had been negative a few days before I left the UK. Of course, if it turns out that my test at the airport was positive or I have been sitting in front of someone on the plane who has tested positive, then I will be informed and have to self-isolate. “Come and see me for a briefing,” said the DHO.

It is less than an hour’s drive from my home to the district headquarters, the Boma. Dr George was waiting for me in his office. “The situation regarding medical supplies is worse than last year,” he said. I suppose this was to pre-empt any request I might have for extra drugs. “We are even running short of paracetamol.”

Reluctantly, I shelved my nascent plans for improving the management of chronic diseases such as hypertension, diabetes, asthma, and epilepsy.

I have plenty of experience of working in “low resource environments”. For example, 40 years ago, on the day I started work at a hospital in Southern Sudan, the hospital pharmacist was arrested for stealing the facility’s entire drug supply for the next six months. Allegedly.

Mambwe Civic Centre, know popularly as “The Boma”

 “And I hear that you are hoping to get married here?” said the DHO. “I think that nurse L might be available!” This was a cheeky reference to a former nurse in charge of the health centre who had a romantic liaison with a previous volunteer doctor.

I explained that I had planned to get married in June at the New Walk Museum Victorian Room in Leicester, but Covid-19 restrictions had put paid to that. We hoped that my fiancée could get a flight and a visa to Zambia during the next three months and we could have a civil marriage ceremony at the Boma. Dr George offered to be one of my witnesses.

We swiftly moved on to the Covid situation. There had been a three-month period of “phoney war” during which the country braced itself for the worst but there were less than a thousand cases and just a handful of deaths. Now the rate of infection was accelerating. Sick people were avoiding hospitals until they were moribund and “BID” – brought in dead, testing positive post mortem. The nidus of infection was the capital city, Lusaka, and the Copper Belt towns. Testing at the borders had picked up a handful of cases (truck drivers). Few of the tests carried out in Eastern Province were positive.

The population had been warned repeatedly, but the great plague had not arrived. Some people were saying it was a hoax, “fake news”, or more bizarrely, “it only infects white people”. Very few people were wearing masks at large gatherings (attendance at ceremonies was supposed to be limited to 60 but the previous week, an estimated thousand people attended the funeral for a “big man”).

“What do I do if I suspect someone is suffering from Covid?” I asked.

“Contact me and I will tell you what to do,” he replied.

“Does the local hospital have oxygen and a ventilator?”

“There are a few cylinders of oxygen, but no ventilator. The provincial hospital has a ventilator, but all suspected Covid patients will be managed in the new hospital at Petauke.”

I had passed this brand-spanking-new Chinese-built hospital on the drive from Lusaka. It looked forlorn and empty, with just one car in the car park. Before I had chance to ask, “How are we going to transport sick patients to this hospital, over four hours away by car? Who is going to look after the patients?” the DHO told me that arrangements would be made. Plans were afoot. In the meantime, at the clinic we were to encourage social distancing, hand washing and wearing masks.

“We Zambians are movious, we like moving about, we visit family, we like to travel, so it is only a matter of time before Covid spreads from the capital,” he said.

I thought of the Jonda bus, packed with passengers for 12 hours, ferrying people between Lusaka and Mfuwe. I asked about the availability of testing. “You cannot test at the moment,” he replied. “But managers of safari lodges in Mfuwe should verbally screen their employees every day, check their temperatures and send home those with symptoms to self-isolate.”

“If we discover any tourists whose tests at the airport turn out to be positive, they will have to remain in isolation at the lodges,” he said. “That could be an expensive undertaking,” I thought. “Will I be able to organise a medical evacuation by air? Would this be restricted to within Zambia?”

“I am sure we will cope,” he said. “I’m late for a meeting. Don’t hesitate to call me. Welcome back.”

Caroline, the District Commissioner (DC), was in her office was a hundred metres away, so I walked across to pay her a courtesy call. I entered the secretary’s office and could hear a heated discussion in the DC’s office next door. “Do you have an appointment with the DC?” the secretary asked me. “No, but I know her very well,” I replied. “How long have you known her?” “Since 2014,” I said. “Are you sure?” he asked me. “We are friends,” I said.

I sat quietly until the hubbub subsided and the secretary ushered me into the DC’s office.  The DC must have had a change of heart about an email message she had ordered to be sent. “Recall the message,” she told the secretary. “I don’t know how,” he replied. I said that I would try to help, and went out to wrestle with Gmail. Unfortunately, there is only a 30 second grace period during which messages could be recalled. “Why don’t we just delete it?” said the secretary. “That will delete it for you, but not for the recipient,” I said. I returned to the DC’s office and admitted defeat.

 Although the day was pleasantly warm, she was wearing a thick overcoat. “Dr Ian, welcome back,” she said. “Why did you neglect me? You said you would keep in touch when you left last year, and I didn’t hear a word.” I remember last year being in the airport departure lounge when I was paged over the Tannoy to return through security to say goodbye to her. As a result, I missed getting my boarding card, but they let me on the plane anyway.

With the District Commissioner at Mfuwe Airport in April 2019

“I thought you would be too busy to hear from me,” I replied.

“Busy?” she asked.

“Yes, I have heard about all the hard work you have been doing.”

“What work? Who has been talking about me?”

I was hoist by my own petard. “Ehrrr, your work preparing for the epidemic of coronavirus,” I said. “Everyone is saying you are doing a good job…”

She paused for five long seconds and looked me in the eye. I felt she could see right through my weak attempt at flattery. She told me how she had been touring the district, giving out masks and informing the people of the epidemic. “Are you protecting yourself, Dr Ian?” I told her I had a visor, masks, gloves and aprons. “What about hand sanitiser?” I didn’t have any so she clapped her hands and an aide entered and brought me a large dispenser of alcohol-based sanitiser.

The conversation moved on to other matters, her hardware business, transporting cement in the family truck from Lusaka to the district, her farmland (“the workers phoned me to say that there were lions in the field”) which she intended to develop after she had retired, and her plans to build a tourist lodge on the airport road. She had been very busy since I left in April 2019.

We talked about my cancelled wedding and I told her of my plans to marry at the district HQ if my fiancée could get a flight and a visa. I said that I hoped no one would object to the marriage. She laughed and promised she wouldn’t, as she, too, had plans to marry. I congratulated her, but it turned out that she was teasing me. She said that she had a soulmate, but no plans to marry. The temperature in the office had risen, so she called an aide to operate the air conditioner.

As we chatted, she fielded several phone calls. She told one caller not to be so disrespectful as to have a conversation with someone else while he was on the phone to her. After she put down the phone, he rang back and she told him to call her later in the morning.

I received a call about a patient and politely told the DC I would have to get back to the clinic. She told me that we must meet again soon and I left the office.

The nurse in charge of the health centre had been busy requisitioning supplies. We loaded my car with needles, syringes, intravenous fluids, precious little medication and a huge box of condoms. When I said that I didn’t think condoms were very popular in Mfuwe, I learned that this had changed since the Coronavirus lockdown. With less employment, it seemed that people were enjoying their extra leisure time responsibly.

Thursday Doors – A Great Start to the Morning

I had an appointment to see a patient at 8am, so I arrived 10 minutes early to be properly prepared. The health centre was very quiet, with no out patients in the waiting area, and just a few mothers with their babies outside the Mother & Child Health Clinic (MCH). With the temperature at 15C, it was pleasantly cool for me, but for the Zambians it felt like winter. It is winter for them.

Gradually the health centre staff arrived, first the cleaners to sweep away the dust of the previous day and night. The nurse on night duty came to hand over to the day staff but there had been no events which needed following up.

Because of the nationwide shortage of BCG vaccine, we wait until there are at least 12 neonates present before opening the 20 dose ampoule. It is a tricky vaccine to give, just into the top layer of the skin, 0.05ml. Most of the women were waiting for this for their babes.

I saw a mother with her seven-day-old baby sitting outside the MCH clinic. The baby was wrapped up in a blanket, with just the face visible. Mother was obviously very proud of her baby and wanted to show it off to me. I asked if I could take her photo and she willingly agreed. (I offer to send photos which I have taken via WhatsApp to people who have smart phones, and she was delighted with the picture.)

Promise

I asked her for the name of her baby and she said what I thought was “Premi”. I immediately jumped to the conclusion that the baby had been born prematurely. I agreed it was a catchy name and asked her how early the baby had been born. She looked puzzled and said that the baby had been born on time. “So why did you call her Premi?” I asked. “It isn’t Premi doc, it’s Promise,” said one of our volunteer health workers.

We have two counselling students on placement at the centre. I teased this young man about his Adidas knees – perhaps he was speed praying.

In the meantime, the patient who was supposed to be at the health centre at 8am had turned up at 8:25am. After the consultation, I looked around for the rest of the team accompanying me to the community clinic at K.

We had a discussion about the lack of childhood vaccines. The District HQ allows us a limited number of vials of vaccine each month. This strict control avoids excess vaccine being left at the back of the refrigerator and going out of date. But this “just in time” supply system can cause problems if we mistakenly order less vaccine than we need. There is no back up.

“We will need more vaccine for Thursday,” said D. “Can you drive to HQ and pick it up for us?”

I said that this wasn’t allowed according to my terms of service. The health centre was supposed to be able to arrange monthly deliveries of supplies. There were vehicles coming to Kakumbi from HQ and these could replenish our stocks. Then D asked me if I could supply fuel for the health centre motorbike to make the trip. This was just $5 but I decided to wait and see if they came up with another solution before I dipped into my pocket.

“We didn’t get enough needles and syringes, either,” said R, the senior MCH nurse. Last week, we had been forced to use 5ml syringes and separate needles instead of the prepacked 2ml syringes with needles.

“And I found vials of vaccine which had been partly used, returned to stock. These should be used up within a few days. There should be a date on the bottle,” complained R. She made sure that these vials were the first to be used at the community clinic.

Last week, one of our volunteers in the furthest village we serve asked to consult me about a personal medical problem. I agreed to do so the following day, but ended up having to cancel at the last minute. I felt guilty about this, so I after I had dropped off D at the scheduled clinic with the vaccine and paperwork, I took R with me to interpret during the consultation with the volunteer.

We met the volunteer at the roadside and she got into the vehicle to direct me to her house in the village. I parked in the shade of a tree and we went inside her small mud-brick home. It was very simple and plain, with a table, three chairs and some bedrooms leading off the main room. There were drapes over the doorways, but no doors. The corrugated iron roof was gaping at the apex, allowing a ray of bright sunshine to penetrate the dim interior.

I took her history and examined her. I thought her symptoms could be caused by muscle spasm in her shoulders and upper back, so I palpated this area and felt knots of muscle. When I massaged the tender parts of her trapezius muscle, she became uneasy. I asked if I was hurting her, but she said no. I wondered if it was because doctors and nurses do not often touch their patients when examining them. I moved on to take her vital signs and used an ophthalmoscope to look into her eyes. I could not find anything seriously wrong, so I asked her if there was anything troubling her, and stress or worries.

Immediately she began talking about a family dispute which had upset her greatly. I said that sometimes when doctors cannot account for a physical pain, it might be caused by mental upset and distress. As R explained this to her, I saw her head nodding. She seemed happy to wait and see if her symptoms got better.

As we got into the car, R told me I had made a social faux pas. “Doc, she was uncomfortable when you were examining her shoulder muscles. This is what men do when they want to get their wives ready for sexual relations,” she said.

We drove back to the community clinic. It was busy with mothers and children, with part of the location having been commandeered by brick makers. Two men were digging clay in a deep pit, filling a wooden mould and turning out blocks. There must have been a kiln in operation as some of these bricks had been fired. I took some photographs, joking with the workmen that they must be building a swimming pool. They didn’t understand this, so I changed the joke from a swimming pool to a fish pond.

This clinic is the busiest in the region. Last month, we reviewed 198 children, checking their weight, monitoring them if they had been exposed to HIV prior to delivery and with breast feeding. We monitor the children’s weight and development, primarily to detect those who are sick or malnourished. In fact, more children are overweight than underweight. About 10-20% of the children are due for immunisations.

Many of the mothers use the occasion to show off their clothes and their children’s fashionable outfits. There is competition between the mums as to whose baby has put on the most weight. I can’t speak Kunda, apart from a few words for diseases and parts of the body, but I could overhear enough English words in their conversation to understand what they were chatting about as they compared their children’s growth charts. “My baby has gained more weight than yours!”

194 children later, just after midday, we finished. One mother brought her baby right at the end. I didn’t like the tone of the voices admonishing her for coming so late, so I went over to her and found out that it was her first baby, born less than a month ago. Her baby would have to wait for BCG until next month, when she could also get the first vaccines. She didn’t have an under 5s card, but had brought a school exercise book, so I entered her child’s demographics and weight and the vaccine schedule on the first page. “So the father is Rabson Zulu, and the baby is also called Rabson Zulu?” I asked. The volunteers behind me shouted out, “Call him Junior!” OK, Rabson Zulu jnr it is.

D is posing with our trusty village volunteers who help to run the clinic.

Malaria Eradication Campaign

In May 2016, Kakumbi Rural Health Centre recorded 1,385 cases of confirmed malaria. This year, the figure for May was less than 800. What had made the difference? 2020 was a much wetter year, with more standing water enabling mosquitoes to breed for longer, so it is unlikely that the reduction in cases was caused by different climatic conditions. But what we did have in 2020 was a cadre of volunteers in the outlying villages who were trained to test and treat anyone with symptoms of malaria. Not only that, but the volunteers tested people who lived close by the “index cases” of malaria, even if they had no symptoms.

Training as part of the malaria eradication campaign

The Malaria Eradication Campaign is generously sponsored by USAID. It aims to end the scourge of malaria in Zambia using a multifaceted approach. For heavily affected areas, the emphasis is on vector control and spraying insecticide onto surfaces inside huts. (“Emphasize that this is not gassing!”)

For areas such as Kakumbi, with less than 150 cases per thousand population, the approach is more subtle, relying on testing asymptomatic contacts of proven cases of malaria (index cases) to snuff out transmission. The next stage would be mass anti-malaria treatment throughout the district over a three day period.

Volunteer training at Kakumbi, attempting social distancing.

The volunteers had some basic training in how to test and treat for malaria. Some volunteers have been very successful, with 70% of people whom they tested with symptoms having a positive test. Others have not yet had a positive test, leading us to believe that they weren’t doing the test properly. They will come to the health centre for further training.

Morris might by past retirement age, but he is one of our most diligent, effective volunteers. I am not sure I will be going to his optician, however.

Another aspect which needs further training is how they record testing for malaria, how many tests were positive, how many drugs and tests were left at the end of the month, etc. The figures are not yet reliable – garbage in, garbage out – but USAID demands hard evidence, so we will just have to improve. To make things more complicated, the scheme demands that volunteers report their data weekly to their nearest health centre and use a mobile phone app to do so. This is ambitious, to say the least.

Mikey is always smiling. He is one of our HIV support workers as well as a malaria volunteer. I like his funky, asymmetrical mask style chic.

Along with testing kits and antimalarial drugs, the volunteers were expecting to get supplies, such as gloves, a bicycle, a rucksack, torch, gloves, soap/hand sanitiser, raincoat, galoshes, etc. Most have not yet received these items. I was intrigued by one necessary item spelled as “Ambullela”. Saying it out loud, the meaning is clear – umbrella. We have been giving out chunks of soap and a handful of gloves to our volunteers who attended the training. The cheap blue chunks of soap are incredibly caustic.

Then there is mission creep, the temptation to expand (and dilute) the aims of the programme. For example,  “If we have a cadre of volunteers in villages expert in testing for and treating malaria, why can’t they treat malnutrition and diarrhoea in children with oral rehydration solution, or pneumonia and diarrhoea with antibiotics? This is called integrated community case management, for the management of childhood illnesses. It would reduce the numbers of patients attending health centres, so theoretically, there would be more time for government health workers to care for the sickest patients.”

There are problems with this approach. Firstly, health centres don’t have enough medication to treat the patients they are seeing with pneumonia and diarrhoea. Volunteers may be keen, but they are not as well trained as nurses and clinical officers. No one in the health centre has been identified to train and supervise the volunteers, they are left to fend for themselves. There are concerns over antibiotic stewardship, increasing bacterial resistance and overtreatment.

How did the personal trainer get in on the act?

During the height of the malaria season in May, health centres actually asked volunteers to bring in their stocks of tests and drugs because of shortages.

I have worked with many of these volunteers in community child health clinics over the past six years. Some of them are excellent. Others cannot manage to plot a child’s weight on a growth chart properly. I have doubts about their basic numeracy. They are not being paid a penny and their communities do not always recognise their efforts. Perhaps they want to get an umbrella, a bicycle and a rucksack from the project, or even see this work as the first step to getting a government job. I don’t know how long their enthusiasm will last, especially among the younger volunteers who need to earn money to support their families.

Since the end of World War Two, there have been attempts to eradicate malaria, some successful and others ending in failure. In Sri Lanka, the milder form of malaria, Plasmodium Vivax was replaced by the more dangerous form, Plasmodium Falciparum, following an antimalarial campaign which very nearly succeeded.

But I am more concerned that the programme will be very successful, malaria will be almost completely eradicated for several years. Indigenous people will lose their immunity to malaria which is not longer being “topped up” by mild infections. And when malaria returns, which it almost certainly will, it will be even more deadly than before, to adults as well as children.

Murphy’s Law

“If something can go wrong, it will go wrong”

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.

Cinderella never lost one of these

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.

The mannequins have curves in all the right places for local ladies

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.”

“But that means we won’t have any again!”

You couldn’t make it up, could you?

Warthogs are great. They can erect their hairy mane to a Mohican style. Their trotters are so dainty that they seem to be too small to carry their weight. And I love the wing of white hair sprouting from the cheeks – looks like a florid Edwardian moustache.

Foreign Body

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.

Two Seizures

Patients with seizures can be like buses; there are none for ages, then two appear within minutes of each other.

Two hippos, not buses, lying on mud beside Chipele Chondombo lagoon.

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.

Little Bee-Eater taking off from a twig, wings backlit by the morning sun

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).

Black-headed heron landing on a hippo’s head in the lagoon.

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.

Getting vaccinated at a community child health clinic. Tough love, cruel to be kind.

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.

A Surfeit of Clinical Officers & Urine Pots

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 sink in the clinic without a functioning tap or running water.

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.

Bat faeces in the roof has damaged the ceiling in the male ward. Note the mosquito net slung from the energy-saving light bulb

“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.

A surfeit of plastic urine bottles, all stored in the lab. Last year we were washing out and re-using them; this year, we are flush.

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.

Carmine bee-eater, a bird on the wire.

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.

Human Papilloma Virus Vaccination

“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.

D with three girls waiting for their HPV vaccination

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?”

“About 300.”

 “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.

He is not going to be vaccinated

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 wearing her Manchester City shirt. She claims not to know a thing about soccer.

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.

Hypertension 2

Art in Nature. Wonderful bark.

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.

Elephants in the dusty evening light, wandering over the salt pan to plunder village gardens

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.

Well-camouflaged ground squirrel

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.

Saddle-billed stork

“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.

Marabou Stork. How ugly can you get? I am sure that his mother loves him.

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.