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Life Thursday Doors Zambia

Thursday Doors Wedding Planning

Simple doors next to Mfuwe Mini-Mart, Mayana

Our plans for a joyous celebration of matrimony on the 6th June in the Victoria Gallery at Leicester’s New Walk Museum were flushed down the toilet of covid-19. All weddings were cancelled by the city, by government diktat, from 20th March 2020.

My fiancée and I had agreed that I could volunteer at Kakumbi Rural Health Centre from July to October on the understanding that this would include a honeymoon on safari. Well, the only way we could have a honeymoon would be to have a wedding first. So, we set about doing this in Zambia.

In my previous three spells as Valley Doctor, I have attended two glorious weddings – Ed and Kirstie (2014) and Ken and Lauren (2019). Both took place in wooded areas outside the national park: the Ebony Grove and the Marula Forest. We decided that a simpler approach would be better, especially as we would not be inviting lots of friends and relatives. The obvious choice was to be married in a registry office at Mambwe Civic Centre, otherwise known as the “Boma”.

UK.gov website explained what was required: affidavits, notice of marriage forms, certificates of no impediment. I drove to the local government office building which is next to the District Health Office in Mambwe. The guard on duty asked my business and smirked as he led me into a courtyard, surrounded by offices. At the first office, the clerk assumed that I would be throwing a huge party and directed me to the Environmental Health Inspector to get approval for the venue. I told him that we only wanted a simple ceremony. He said that this was not the traditional Zambian approach to a wedding. I had to remind him that large gatherings were prohibited under the Covid-19 regulations. He suddenly realised that I was wearing a mask, and he wasn’t. He scrabbled around in the top drawer of his desk, searching for his own mask, before leading me to the chief accountant’s office.

The accountant pulled out several large lever arch files and showed me what I had to do. I needed to provide proof of identity, copies of passports, birth certificates, and, in my case, proof that my first wife died in 2012. These should be stapled to an official request to be married. He gave me examples of previous letters so I knew how to word the request. I needed to bring all this to him at the end of the week. In the meantime, I should meet the Clerk of the Council who will be officiating at the ceremony. We moved to another office, but the clerk was in a meeting. “He won’t be long, he is just finishing,” said his glamorous secretary. “Take a seat.” I sat down in a huge Dralon armchair. The stuffing was absent from part of the cushion, so I was tilted off to one side.

“Are you getting married? How exciting! To a nice Zambian girl?” the secretary asked.

“No, my fiancée is English,” I said. “You’ve missed your chance.” She hooted with laughter, but this didn’t bring the clerk of his meeting.

“Let’s go and finish up some form filling,” said the accountant. It was getting perilously close to lunchtime.

I filled out four copies of “Notice of Marriage” forms, otherwise known as the banns. I had no problem writing my details, but wondered how my fiancée should be described. Single was too broad a term, so after a short discussion, we settled on spinster. The accountant had no idea of what a web manager was, but when I told him that my fiancée worked in local government, he smiled and said, “She is one of us!”

He stamped and signed these forms, and instructed me where to post them. I have seen similar notices stapled to trees, outside the local mini-market, the filling station and the airport. He then told me that once he had received the application with evidence, he would arrange for an affidavit.

A lady in the corner of the office asked me if I was going to give her some shampay. It took me a while to realise that she was expecting to attend a champagne reception. I had to disappoint her. She told me that I needed two witnesses, one from my side, the other from my fiancée’s side. I was hoping that the District Commissioner and the District Officer of Health could provide this service. She told me that I would have to pay another fee to get the Registrar’s Certificate of Marriage.

Getting amorous? Two elephants disregarding social distancing

I went back to the District Health Offices to pick up vaccines and supplies for the clinic before their lunchtime shut down. While loading the vehicle, I met Reverend Ed, the clinical officer in charge of St Luke’s Rural Health Centre. He had been on a training course I ran last month and we were “best mates”. He asked me for a lift to Mfuwe (on church, not medical business) and I could hardly refuse.

Making contact

On the journey home, I told him I was getting married and he offered to officiate at the Anglican Cathedral round the corner from his health centre. He could provide a marriage certificate for less than a pound, and thought that the local government charge of £50 was extortionate. “But they have to eat, I suppose,” he commented. And we need an official legal document which would be recognised in the UK. I was told that in some cases, the registrar had refused to conduct a marriage unless it had already been blessed in church. Well, thanks to Reverend Ed, we have a back up plan if that happens.

Holding trunks

I have also learned that registrars may offer unsolicited advice to newlyweds. One new wife was told that she must carry a mobile phone with her everywhere she went, “even to the market”, so her husband knew where she was and could contact her at any time. I wonder how much this represents the husband’s control over his wife and how much it relates to the importance of marital fidelity in a country which has been devastated by HIV/AIDS.

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Life Medical Thursday Doors Zambia

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.

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Life Medical Thursday Doors Zambia

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.

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Life Thursday Doors Zambia

Thursday Doors Shops on Airport Road, Mfuwe

Religion plays a big part in the lives of Zambians. After all, David Livingstone brought Christianity to the area (even if he didn’t convert more than a handful of locals). So it is not surprising to have shops with names referring to the Almighty.

At first, I thought it said, “God is cable phone accessories”. Eli D has some neat artwork advertising what he is selling, but perhaps the kerning could have been better.

There are other Biblical references, such as this Hair Salon (often spelt “Saloon”). I think the three Hebrews refers to Shadrach, Meshach and Abednego who were cast into the fiery furnace – a bit like sitting under the hair dryer as shown in the illustration on the wall.

And God First Shopping Centre provides worldly goods

I initially thought this was God’s Favourite Shop, complete with handwashing station and a red chhatri, a booth selling Airtel airtime.

But this is my favourite. The Mountain of Salvation Food Cafe.

Aunty Shane is keen on bright colours. She sells anything from television screens to plastic kitchen storage baskets. Ride on by.
Was this something to do with the Three Musketeers, All for One and One for All? Or does it mean they sell everything to everyone?
Soft loans, hard core seems to be issuing from the front door. GRZ=Government of the Republic of Zambia, of course.
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Life Thursday Doors Zambia

Thursday Doors @ the shops

More commercial doors in the village where I am living and working in Zambia. Sadly, my favourite shop has ceased trading. It was a bar called “Two Beers” which was the phonetic spelling of the owner’s name, Tobias. Say it out loud in a Zambian accent.

“God gives in different ways”, well when I last bought some fried potato chips here, I was given a nasty dose of food poisoning.
Naturally we should all follow Aunt Bwalya’s advice.
A pleasant greeting, but even though my hair is thinning on top, I am not in the market for a wig just yet. Nor cosmetics. It looks like a bus shelter more than a shop.
The B&B looks snazzy with the zebra skin motif inside the shop. Look how the illustrations have been painted on the inside of the doors, so they show what’s on offer when they are fixed wide open.
Jussie Dreadlocks Salon has security bar doors which allow free air circulation.
People could have a wide variety of choice of hardware on the left, but I like the subtitle of Tiza’s – pa-pa-pa-pa passelo. Very onomatopoeic.
Bit by bit? Surely, bite by bite would be more appropriate. Sausage is so good, they advertised it twice. Interesting that the illustration shows they keep the neck on the chicken when cooking it.
Bars have just been allowed to reopen on relaxation of Covid-19 restrictions. DXT – deep Xray therapy? The Raster Leggie bar is legendary.
Chichetekelo hardware has more variety than People’s Choice.
Rock City looks like a bar, but sells pink ice cream (allegedly)
K & Pear? CNK sounds like “Sink” Phones, not sure it is a winning name.
Let Love lead us where?
Uncle Petty has moved from the shop with a leaky roof across the road. Sadly, the black and white cat on the counter has died since I was last here in 2019.

Another food shop has ceased trading. It was called “God Gives” and attached to the side was their fast food outlet, “God Takeaways”.

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Life Thursday Doors Zambia

Thursday Doors @ Mfuwe

On the road to the airport, there are lots of interesting shops.

This furniture shop is open plan, without doors, unfortunately. Laz-e-Boyze

There is a wedding planner in the village. The service is a one stop shop, all you have to do is to step through that door. Metal security outer doors are needed to protect the variety of goods and services on sale.

I asked who the director of ceremony was and found it was this lady having her hair braided. She said she was a pastor in the Bible Baptist Church. Somehow, I don’t fully believe her.

Director of Ceremony. Note the doorless grass-walled toilet in the background

Of course, all over Africa, the British Premier League is well known. Most people support the big sides, such as Manchester United, Chelsea, Liverpool or Arsenal. Occasionally, there will be someone sporting a Leicester City Football Club bobble hat.

But I have never met a Spurs supporter here. Well, I think he is a Spurs supporter by the name of his shop.

Tottengram Hotspur Football Club – spelling mistake?

More shop doors coming next week.

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Life Thursday Doors Zambia

Thursday Doors @ Kakumbi

This house has lost its roof, but not its door. Unsafe for nursing staff to live here.

Wherever you go, there are doors to pass through. Portes de passage. I arrived early one morning and went on walkabout to take some pictures of the doors near the clinic where I work.

I am not sure that I’d want to invest in PK if the state of the office is to go by

The local Roman Catholic church is made of brick with a portico and a sturdy door.

To call the faithful to prayer, there is no bell tower. Instead, the church official bashes on a wheel rim, hung from a tree, with a hammer.

Outside the police station there is an old container. It serves as a holding cell. It is said that when the door is closed, no prisoner is detained there. But it is like an oven in the heat, so the door has to be kept open so that any prisoner doesn’t cook. The container cell doesn’t have a toilet. I have heard it said that the prisoners all pass urine against one corner. The acid pee has rusted the metal allowing a prisoner to break out. But why would they do that when the door was open?

I am sure that there must be a joke here somewhere about cell blocks

And finally, it is washing day and the sheets are on the line in the sunshine. Just to the right, the lady of the house is entering nurses accommodation, through a secure door.

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Medical Thursday Doors Zambia

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.

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Medical Thursday Doors Zambia

Hypertension 1

Pulpation Room sounds like where wood chips are crushed to manufacture paper. It is actually a private area where midwives can examine pregnant ladies’ bellies. As well as being my door of the week, for Thursday Doors.

“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.”

A Hadeda Ibis having a bath in Mbomboza Lagoon

“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?”

Pied Kingfisher, an all year round resident in the South Luangwa National Park.

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.

Dawn over the Kapani Lagoon, 100m from my house

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.

I never tire of watching baboons. But I get fed up with them fighting on my tin roof at 6am each morning.

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.

The more you look, the more you find.

Categories
Medical Thursday Doors Zambia

Working in the Clinic

I interrupted two antelopes, Puku, that were grazing near the lagoon, close to my house

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.

These are your Thursday Doors for this week. The Dangerous Drugs Cabinet.
Avoiding unprotected contact with wild animals is difficult where I live. The baboons clatter across the tin roof at 6am each morning, squabbling, screeching, mating and defaecating.

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.

The curtain arrangement provides basic confidentiality. My old green towel is by the middle sink.
Handwashing station. We have several of these around the clinic.

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.

Medical equipment which is no longer being used, gathering dust on a shelf

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!

Improvised cover for the electrical BP measuring machine, elastic sticky strapping tape.

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.

Being cruel to be kind; vaccinating an infant in the open air, by a baobab tree in the village. 130 infants attended this clinic. Immunisation coverage is much better than UK, no anti-vaxxers here. The mothers know the vaccines protect their children.

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.