“The most we can do is to write — intelligently, creatively, critically, evocatively — about what it is like living in the world at this time.” Oliver Sacks. “To take a photograph is to align the head, the eye and the heart,” Henri Cartier-Bresson
If you have been following my contributions to Thursday Doors over the years, you will know that I do voluntary work as a doctor overseas. Last year I was working at Kakumbi Rural Health Centre in Eastern Province, Zambia. It was distressing to see the lack of medical care for people with severe mental illness, schizophrenia and bipolar disorder. Their families would look after them as best they could; but if the patients became violent or started destroying property, this support could end. Patients would roam around the village, clearly very disturbed, behaving inappropriately (throwing stones at vehicles, wandering about naked).
Thursday’s door – torn off its hinges during a violent outburst by the man wearing white trousers. He has a long history of bipolar disorder. Neighbours managed to subdue him and chained him to the door to prevent him from doing more damage to people and property. They felt there was nothing else they could do. However, with mood stabilising medication, he is now able to lead a normal life.
Unfortunately, the Zambian Health Service has been unable to provide medication to treat this group of patients. I started treating them using very basic psychiatric medication which I bought from a local pharmacy (with some financial help). These patients need long term medication and if the supply were to stop, they are likely to relapse and become very unwell. So last year I asked my friends on Facebook if they would like to contribute and I raised over £1000. All this money has now been used up, purchasing medication locally for over 20 patients.
Drs Keith and Ginny Birrell (from North East England) are currently volunteering in Kakumbi. They have expanded the pool of patients to include people suffering from epilepsy and children with learning disabilities. Some of their anecdotes follow:
They have treated a 14 year old boy suffering from epilepsy which was so disabling that it prevented him from attending school. With medication, he is now almost seizure-free and is keen to start school (although he will be twice the age of his classmates in Year 1).
With anti-psychotic medication, a 49 year old woman, who suffers from chronic schizophrenia, is no longer having hallucinations or having violent outbursts.
Walking and bicycling are the main ways people get about in rural Zambia. Cycling can be very dangerous for people living with epilepsy, but with regular medication seizures can be well controlled (if the patient feels an epileptic attack coming on, they have been trained how to stop, dismount and lie in a safe place). Being able to ride a bike because their epilepsy is well controlled might seem trivial, but to this group of patients it is a major improvement in their quality of life.
When patients are stable, Dr Keith is trying to reduce the dose of anti-psychotic medication – to reduce side effects, not to save money!
I am hoping to raise £2,500 to buy medication for this group of vulnerable and disadvantaged patients. (I have donated £100 instead of sending Christmas cards this year.)
These are a half dozen of my favourite doors from 2020, the year of Covid: Zambia to Norfolk to Venice.
The door to our luxurious honeymoon room in South LuangwaThe door of the container which has been adapted to become a prison cell in MfuweBeach huts on the North Norfolk coast, pretty in pink and purpleJackdaw – Jackdoor in VeniceDoor in the backstreets of VeniceThe door of San Marco in Venice
Two years ago, I decided to buy a new camera. My trusty Canon 6D has served me well until I tripped over a tramline in Amsterdam. I had the camera around my neck and it got the ground, damaging a dial on the top.
I fixed it myself, but it fell off again, and I lost it. So I bought a replacement and fixed it on with Araldite glue. Unfortunately, this also fixed the dial in one position. I can use the camera, but I decided to buy another.
The Canon is full frame, and heavy, especially when lugging around lenses. So two years ago, on Black Friday I bought a micro 4/3 camera, a Panasonic Lumix G9. This has served me well in my travels (Myanmar, Thailand, Mallorca, Budapest, Venice).
It is supposed to be “tropicalised” to cope with dust, humidity, heat, snakes, etc. However, a few months ago, the blistering heat of Zambia melted the glue of the plastic grip covering the hatch where there SD cards are housed.
The grip has become unglued
I didn’t want to repeat my adhesive disaster, so I asked on line for advice. Panasonic were hunkered down behind Covid-19 proof firewalls, but I eventually got in touch with an authorized repair shop.
To glue the plastic skin back on was going to cost me over $100! I’m not going ahead with it. I can use it as it is, without risk of anything falling off or getting damaged. Grrr.
It was so hot that we opened both front windows for the car journey back to Kapani, regardless of the effect the wind would have on our hairdos. When we arrived, we looked at each other and smiled. At times we both thought that the wedding would never take place. But the marriage certificate was safe in a brown envelope on the back seat.
We showered and changed into comfortable clothing suitable for the bush. Andy at Mfuwe Lodge had very generously offered to let us stay there for the first night of our marriage. We had tea, then changed back into our wedding suits for a photoshoot. Ian S took the pictures, by the lagoon and around the lodge, when the light improved. We changed back into bush gear and drove down to the Luangwa River bank for “golden hour” photographs, followed by dinner at the lodge.
Carrying my wife over the threshold
The next morning, Anne went on an early morning safari drive, followed by breakfast in the bush. Afterwards, she had a relaxing massage and pedicure at the Bush Spa, overlooking the lagoon. Meanwhile, I went off to work at health centre and doing a community children’s clinic. I collected Anne in the early afternoon and we drove back to the doctor’s house. Later that afternoon, we held a reception in the bush, at Kalawani Salt Pan, for drinks at sundown, observing social distancing, of course.
Crowned eagle
The following morning, we met Fil at the Park gate at 6am and did some serious birding for three and a half hours in her open Land Rover. We were very lucky to see a pair of crowned eagles at Elephant Loop. We had Fil’s muffins for breakfast at Norman Carr’s memorial in the ebony grove by the river. He set up the first national parks in Zambia (Kafue and South Luangwa in 1960) and built a camp on the east bank of the Luangwa River for tourists at Kapani. This is where I have lived for the past three trips volunteering here. Glenn, the present manager of Time and Tide, offered us a night at Chinzombo, another luxury resort just a few kilometres down the river from Kapani.
Our bedroom at Chinzombo
Many thanks to Andy and Glenn for their generosity, we really appreciated it.
Thursday door – a gap in the canvas door to the bush lavatory, a flush toilet, not a thunderbox.
The term “glamping” – glamorous camping – is a perfect description of Chinzombo. There are just half a dozen chalets, each with their own swimming pool, overlooking the river. One massive tent contains a double bed, armchairs, writing desk and voluminous mosquito netting, the other contains a stand-alone bath, shower, toilet, handbasins and storage area for clothing, with leather straps and pouches in the style of a safari tent a century ago. The walls of the dining area and bar are decorated with fascinating photographs of Norman Carr’s life at Kapani.
The door to our luxury chalet at Chinzombo
After crossing the river in a boat, we had an evening game drive with Arron guiding. He showed us three leopards and a pride of lions. We could have followed the lions as they set off to hunt, but we felt it was better to leave them alone to kill their supper, as ours was waiting back at Chinzombo. We ate on our private deck, beside the pool, with hippos grunting and hyenas wailing in the bush around us. It was a magical, once-in-a-lifetime experience.
The following day, I took Anne to visit the Chipembele Wildlife Education Trust, half an hour’s drive away. En route, we stopped off to see a grey crowned crane colony surrounded by mopani forest. Anna and Steve welcomed us but we almost didn’t get to see the education centre as a herd of elephants were already visiting. We looked round the impressive centre when the elephants moved off before taking gin and tonics to the river bank for sundowners, accompanied by baby vervet monkey and two small baboons. Anna and Steve rescue animals and return them to the wild.
My replacement, Dr Zoe, arrived at the end of the week, ending our honeymoon. Four days later, we drove to Lusaka for the flight back to England (and fourteen days of quarantine).
Red barred doors at the Saloon. That’s not a pistol on the banner, but a hairdryer. Perhaps we should have dropped by here to get our hair done or have a stiff drink before the wedding ceremony.
Wedding celebrations are muted in the time of Covid-19, but if I could wave a magic wand and have a massive party in Mfuwe to celebrate our marriage, I know the perfect band to provide the music. They are called the Shambolics, from the Black Country of the West Midlands in UK, a Peaky Blindin’ Rock and Roll band. They play cover versions of classics such as Knocking on Heaven’s Door, Black Magic Woman, Long Tall Sally, Born to be Wild, Back in the USSR, Sweet Home Alabama, Bad Moon Rising, Johnny B Good, etc.
“Shambolic” accurately described both the preparations and the wedding.
Every week since submitting the required documentation and marriage application to Mambwe Civic Centre (the Boma), I have contacted Mr Douglas Banda, the Chief Accountant, to ensure the arrangements are in place. I paid the application fee and posted the banns at the Airport, the Fuel Station and Mayana Mini-Market (stapling a sheet of paper to the trunk of a nearby tree) on September 1st.
Three weeks later, Mr Banda told me that if anyone now objected to our marriage, I could sue them in a court of law for being malicious. Good to know, but when I next telephoned, Mr Banda’s assistant told me that he had misplaced my papers.
A few weeks before the ceremony, Mr Banda telephoned me to ask for the name and occupation of both our fathers. I explained that this information was in the application letter which I delivered by hand a month ago, which he had misplaced. He gave me an appointment for 2pm on a Friday afternoon, but surprisingly he was not in the office. I left the information he required with his assistant.
Then I had to fill in a form stating that there were no impediments to my getting married to my fiancée, that we were not under 21 years of age, did not need parental consent and were not related. I signed the affidavit but Anne would have to sign her affidavit before we could marry. The assistant financial officer told me that she could do it at the marriage ceremony, which seemed a bit last minute.
I contacted Dr George and Caroline, the District Commissioner, to confirm that they would be our witnesses. Caroline didn’t reply to my texts or WhatsApp messages, but she had previously assured me that she would be present, so I wasn’t that concerned. Dr George happily agreed.
Four days before the wedding, Anne arrived in Mfuwe at 11.30pm having been driven in a taxi from Lusaka Airport (just over 700km away). She recovered after a day’s rest and we spent the weekend visiting the National Park. On the morning of the wedding, I attended the early morning health centre weekly meeting, saw a few patients and then returned home. I combed my hair and got dressed in the off-white linen suit which Anne had brought from the UK. Of course, Anne looked radiant and beautiful (she always does) in her wedding outfit.
It was already 30 degrees C when we set off for the Boma. The air conditioning in the doctor’s vehicle is a bit ropey, so I wound down the driver’s side window and the wind ruffled my carefully-styled coiffure. Anne wisely kept her window only slightly open, so her hair remained perfect.
Forty three degrees Celsius showing on the car dashboard, driving to Mambwe
Right on time at 10:30am we arrived at the Boma and met Dr George on the steps outside. He is renowned for keeping “British” time (ie being punctual) as opposed to “African” time. He told me that the Clerk of the Council who would be conducting the ceremony was not around, so George went back to his office to work.
As required, we put on our face masks and washed our hands before entering the Civic Centre. The same maskless uniformed security guard asked us what was the purpose of our visit. When I reminded him that Anne and I were getting married, he immediately thrust out his hand to shake. I fist-bumped him instead. He escorted us to Mr Banda’s office. He left us there for 90 minutes, sweating in the heat, making small talk with a succession of ladies who came by to see the happy couple.
The Finance Office was about three metres square and contained three desks, one laptop computer (switched off) and lots of lever arch files arranged on shelving on the walls. Everyone was engrossed in their smart phones, Facebook and WhatsApp.
“What about your witnesses?” asked Mrs Phiri, assistant financial officer. I explained that Dr George was here, but I had not yet seen the DC. “You must telephone her immediately, then!” Caroline answered her phone but told me that she had been obliged to accompany a Minister to Chipata, the capital of Eastern Province, just over an hour away; she could not witness the ceremony. Mrs Phiri offered to be our witness, but deferred to Mr Banda, who said that he would step in to support Anne as her family were absent.
I asked another financial assistant if he could take some photographs using my camera. He agreed, so I gave him a quick lesson in how to use the camera on automatic mode. Other people offered to use Anne’s iPhone camera and her small Sony camera to record the ceremony.
At 11.47, the Clerk of the Council (CoC) arrived. “He is the one in the suit,” said the assistant finance officer. A large man wearing a sports jacket, shirt and tie got out of a car at the front of the building.
The assistant showed me a photocopied list of 20 items detailing the order of the ceremony. “We don’t do many weddings. The last time we had muzungus getting married here was in 2018. We had three that year.” The CoC obviously needed a crib sheet to remind him what came next.
At midday, the council chamber was ready for the ceremony. All the local government workers had left their offices and were now seated around the chamber. The CoC stood behind a desk, in front of a portrait of His Excellency, Edgar Lungu, the President of the Republic of Zambia. There was a colourful display of plastic flowers on the table and a miniature Zambian flag.
Anne and I removed our masks and walked up to the table. The CoC gave a speech about marriage. “In this Christian country of Zambia, it is right that a man should marry a woman. We don’t have men marrying men here, or women marrying women, you understand?” We nodded our heads, unsure of the relevance of this to our wedding.
He handed me a Bible and the affidavit which I had signed a few weeks ago. There were about eight paragraphs, but only three or so were relevant for me to read out, stating my name, the name of the person I was marrying and that there were no reasons why the marriage should not take place. I confused him by skipping the section where I had to declare that I had the permission of my family, or a magistrate, needed if I was under 21. I don’t think that the wording had been changed since Zambia gained independence in 1964.
Then it was Anne’s turn. The CoC tried to help her but showed her the wrong sections she had to read out. He then changed his mind and it became even more confusing. She hadn’t signed all the parts of the affidavit, but that didn’t matter as she had declared there were no impediments with her oral statement.
She handed back the Bible and the CoC asked about the rings. I had Anne’s ring in my pocket in a box. She was on my left, so when I reached for her hand to put on the ring, her right hand was nearest to me. Anne deftly put her left hand out and I took the hint, squeezing the ring onto the correct finger.
I caused more confusion because I said that I didn’t want a ring. As a doctor I am always washing my hands and I don’t like soap getting under the ring irritating the skin. The CoC then checked our names; I genuinely think he had forgotten them. He mispronounced our names (Zambians often add an “y” to English words, so Anne became “Annie”) and then pronounced us man and wife. The council chamber erupted in applause and ululation as we kissed.
I had been warned to check the spelling of our names on the wedding licence as it was not unusual for these to be wrong. These were correct, but there were four minor spelling mistakes on the certificate. The CoC didn’t know who had to sign and where on the licence; Dr George helped him out. George gave a speech saying that the easy part was over and the difficult part of the marriage was to come, which was worrying, if realistic. He told me that the secret to a good marriage was admitting you were wrong when you knew you were right.
My witness, Dr George, offers us advice on how to have a happy marriage
Mr Banda signed as our other witness. He said that now Anne was my wife, no one could touch her apart from her husband…and her adopted father (him) who was giving her away. Creepy. He spoke for a few minutes, echoing the good wishes of Dr George.
The CoC decided to talk about marriage as a journey. “You are here in Mambwe, and soon you will be on the road to Chipata, but it will be a long time before you get to Lusaka,” he said. He had forgotten the “in sickness and in health… till death do us part” bit, and said, “You are now married until ehr, death, ehr … until you die!” There was nothing in his homily about a wife obeying her husband because this is taken for granted in Zambia.
The marriage certificate
Finally, the CoC said that it was traditional for there to be dancing at Zambian weddings and did we want this? We agreed and several members of the audience hit the central area of the chamber doing impromptu dance moves. I was impressed by the amount of movement people could get from shaking their hips and buttocks. “That will be another 300 kwacha,” he said. I paid 1000 kwacha for the licence I told the assistant financial officer that the additional 300 was for “refreshments” for the audience and dancers.
Some of the dancers were more enthusiastic than others
Masks were discarded. Hands were shaken. Everyone was smiling. People took more photographs, inside and outside the chamber. Even the security guard wanted to be included in the photographs.
Dr George is on the far right wearing blue, but his mask has slipped. The security guard wanted a place in the limelight.
We walked to the doctor’s car with Mr Banda in our wake. He was insisting that as Anne’s surrogate father, he was entitled to a dowry payment. I dismissed this claim with a smile and genuine thanks. Nice try, but no cigar.
The ceremony was so shambolic and random that we dissolved into laughter at times. We should have arranged for it to be videotaped. But after all the chaos, we were now legally man and wife. We drove off to start our honeymoon.
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.
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.
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.
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.
Lions are lazy. They spend much of their time during the day sprawled out like shaggy rugs, only moving to keep in the shade. Dusk to dawn is their most active time, when they hunt.
They get tormented by flies, especially when their muzzles are stained with blood from a recent kill. When the lion can’t stand it any longer, it will raise its head and snap its jaws together in an attempt to trap the fly.
Lions are social creatures, living together in a pride – a dominant male (or more, if they are brothers) with a harem of females and their offspring. As soon as young males become mature, they leave the pride and look for another to challenge the dominant male. Once defeated, the old male will be driven off to lead a solitary existence, eventually dying of starvation as his hunting skills diminish.
Lions are apex predators. Their favourite food is buffalo and an adult is big enough to provide a good meal for the entire pride. Most of the hunting is done by the females acting together to ambush an animal, bring it down by leaping onto its back, then grabbing it around the neck to suffocate it.
They will eat carrion. When hippos were dying from anthrax 14 years ago in the Park, lions would take over a corpse and eat their fill.
Safari guides give names to the prides in South Luangwa National Park – the Mfuwe Pride, the Chipembele Pride, the Hollywood Pride (whose lions seem to know that they look photogenic, and pose like film stars for the cameras).
On Sunday, we saw a pride of seven lions with a buffalo kill at the Luangwa Wafwa – an oxbow lake still containing water five months after the last rains.
When I came to South Luangwa this year in July, there was talk of a man-eating lion in the Nsefu sector of the Park. The wildlife authorities asked an ex-big game hunter if he could find and kill the lion. Once lions discover they can kill people, they may realise how easy it is to grab a child as quick meal. The hunter managed to shoot the man-eater with his camera but couldn’t get a clear shot with his rifle. No further deaths have occurred.
Have Stethoscope, Will Travel 