Medical Thursday Doors Zambia

Thursday Doors – First Fatality

To qualify for the blog, I have to insert a door or two. This is the door (blocked with branches) of a local barbershop. The message on the tree reads “Welcome”, with a bench for people waiting to be clipped. Marky C, the owner of Get Smart Barbershop, appears to have disappeared. This is in Cropping Village, Mfuwe, Zambia.

It was on the cards, really. All the danger signs were there. The baby had failed to thrive and a few weeks before I started work at the clinic, she had been referred to the local hospital as an emergency. The hospital diagnosis was pneumonia, and the doctors had asked the mother to come to Kakumbi for follow up a week after she had been discharged.

Water Monitor Lizard, not connected with this post at all

The infant looked thin and gaunt. She was breathing quickly and using additional muscles of respiration to suck in as much oxygen as she could. Her mother was clearly very anxious and concerned. I asked her to remove her daughter’s outer clothes so I could examine her. The child’s chest looked deformed, as though there was a lump under the lower breastbone on the left. The spaces between her ribs were indrawn at each breath.

White-browed sparrow weaver
Mwanchilo – untidy nest in Nyanja

I laid my hand on her chest and counted the pulse – 200 beats per minute. The chest wall seemed to push up against my fingers and I could feel a thrill, a palpable murmur caused by turbulent blood flow within the heart. It was like a thrumming sensation moving from left to right. Listening with my stethoscope didn’t help me much because of the rapidity of the pulse and the noisy breathing. There were some crackling breath sounds at the base of the right lung but they didn’t sound like they were caused by infection. There were no peripheral signs of bacterial endocarditis.

Cordon Bleu, not connected with this post in any way

I hesitate to write “my heart sank” but that is what I felt. This child almost certainly had a ventricular septal defect – a hole in the heart between the left and right main pumping chambers. Part of the blood which was meant to be pumped into the aorta and around the body was being diverted into the right ventricle. This had become grossly enlarged and had deformed the chest wall. As the swollen right ventricle contracted, it “heaved” against the inside of the ribs. The abnormal flow of blood from left to right ventricle was causing the vibration I could feel with my hand.

Was I sure? I had no access to the hospital notes regarding the admission for pneumonia (if indeed, this is what it was). I could not see a chest radiograph or get the results of a cardiac ultrasound (ECHO). I was relying solely on my clinical examination.

White-fronted bee-eater
Mupepafodya – one who smokes cigarettes, given the habit of these birds to sit on thin twigs which resemble cigarettes

Sometimes, small holes create loud murmurs as there is a more distorted flow of blood, whereas bigger, more significant holes can cause less turbulence, resulting in a quieter murmur. This is known as “Maladie de Roger”. I hoped that the thrill I felt meant a smaller defect, as these can sometimes spontaneously close as the child grows. But the rapidity of the heartbeat was very worrying. The heart was working flat out.

Having made the diagnosis, what could I do about it? There is no access to surgery to repair complex congenital heart problems in Zambia. I told the mother that the baby was very ill with a heart problem, there was little we could do, but I would review her in the village at next month’s community clinic. I did not think that returning to hospital would help. I tried to convey the seriousness of the baby’s condition without pronouncing a death sentence.

African Open-billed Storks
Mtowa nkhono, one who likes breaking snails

Sadly, she returned that night to the clinic with the baby in extremis. An ambulance took the baby to hospital but she died on admission.

One might think that having a doctor working at the clinic must be beneficial. Doctors have more training, more skills and knowledge than the clinical officers and nurses. But just being able to diagnose the problem doesn’t mean you can solve it, especially when you have the meagre resources of a developing country.

“The good news is the doctor knows what’s wrong with you; the bad news is that the doctor can’t cure you.”

Bangladesh Thursday Doors

Opening doors to meet the locals

The local Bangladeshi community doesn’t see many white expatriates, in the flesh, out of doors, on the street. They see us flash past in minibuses and four-wheel drive SUVs, plastered with the logos of aid organisations, with little steel pennants on the front wing for a flag.

Occasionally they catch a glimpse of MSF expats walking from our team house to the office or buying ice cream from a local shop. Otherwise, they only see expats when they are ill and need to visit our clinics in the camp.

MSF has a strict security policy, restricting where and when we can roam. I often take a morning constitutional around the paddy fields and market area, as this has been designated a safe area.

I like interacting with the locals. Despite speaking only a handful of Bangladeshi (or “Chittagongi” in this area) words, I can get by with pidgin English and lots of sign language. I hadn’t had a proper haircut since July (done by a Pakistani barber in Green Lane Road, Leicester), so when I finished clinic early last week, I went into Ukhiya to look for a barbershop. Unlike Delhi, there aren’t any barbers plying their trade on the pavement. Well, Ukhiya doesn’t actually have any roadside pavement yet. I was given some general directions by a friend so I managed to find the shop easily.

I am quite used to being the object of people’s curiosity. They don’t glance surreptitiously at me; it is a full-on, open-mouthed stare. I engage with the starers, greeting them and they are obliged to interact: “Salaam Alaykum.” “Alaykum Salaam.”

When I walked into the hairdressers, all the clipping stopped for a moment as the barbers noticed a foreigner in their midst. Even the customers were eyeing up my reflection in the mirrors. But the boss ushered me into a seat and within a few seconds, everything went on as before.

There was an old television fixed up high in the corner of the room showing a Banglawood movie. After some sharp words from the boss, a minion came over, picked up the remote and started stabbing at it. He had been told to look for a foreign station. The only one was a sports channel, showing grainy video of a football match. How about that for hospitality?

One of the barbers came over and established I wanted a haircut. He tied a tissue around my neck and draped me with a plastic cape. Now the difficult bit. What kind of cut do I want? Most Bangladeshis have a short back and sides, some with quite elaborate styling on top. My barber, Mr Sharma, had a good style. I pointed at his hair, then at my hair and smiled. No joy.

How much did I want off? I said, “Chota,” which means “a little bit”. “Speak Hindi?” he asked and rattled off a few phrases which I didn’t understand. Then I played my trump card. I knew the Chittagongi/Rohingya word “alpo”, which also means small. “Trim, small, alpo, understand?”

He nodded and set to work with comb and scissors on one side of my head. After five minutes, I came to the conclusion that alpo meant leave a little, rather than cut off a little. We had crossed the Rubicon now, so I let him continue.

Every now and then, the television commentator got excited and instinctively I turned my head towards the TV screen to see who had scored. The barber grabbed my head and repositioned it as he wanted. I suppose the TV is for the benefit of those waiting, rather than those being scalped.

Mr Sharma kept clipping. I now knew his first name, Liton (or maybe Lytton). He could see I was sweating in the sultry heat, so he turned a fan onto me. This made my hair fly up so he sprayed it with water to keep it in place.P1320674

I was reassured when he used a new razor blade to shave the edges and clean up my neck down to the shoulder blades. He soothed the razor burn on my neck using a machine like a large shaving brush, which vibrated and showered me with talcum powder.

My rampant eyebrows were trimmed and he dealt with my nostrils and ears. I probably paid extra for the obligatory head, neck and shoulder massage – the full Monty. There was some discussion over the price. Locals pay about 50 taka, 75 if the salon is air-conditioned, and 100 -150 taka in the big city, Cox’s Bazar. I gave Liton 100 and he was happy (about 90p).

Liton Sharma, hair stylist, wearing a Ma Durga teeshirt


The haircut took about 45 minutes, and it was getting dark as I left the shop. Outside, a group of children sitting on a handcart started giggling as I walked past. They had been watching the performance. I didn’t have time to chat, so I walked briskly back to the house, wondering how hilarious my new haircut was. It looked fine in the salon…P1320954

Yesterday, I was waiting at the roadside for an ambulance coming from the clinic with a seriously ill patient. It was 7:30am and I attracted a crowd before a man shoo-ed people away. We chatted. He understood why I was there and was able to explain to all the curious bystanders. They were satisfied. He had 100kg of green chillies in four burlap sacks. In the mouth of each sack was stuffed some fresh grass. A goat joined us and kept nibbling on the grass. I wanted to see what would happen if it ate a chilli, but the man waved it away. A little boy dressed in his Friday-best white outfit came over to practise his English. A grizzled old rickshaw driver was also curious. He cycled past a few times, then came over to make my acquaintance. I tried asking him how old he was. He understood my age but didn’t know his own. The frame of his cycle rickshaw said “A Long Life”.P1320951

A succession of barrel wallahs passed me. The low sunlight made photography difficult and I should have used video to capture their bouncing gait, in synch with the oscillations of the bamboo pole across their shoulders. The trick is for them to keep moving.P1320946

The ambulance arrived and I accompanied the patient to Cox’s Bazar.

PS This piece was written a month ago when I was still working in Bangladesh.