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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 Zambia

Role Play

In these cold winter mornings, patients tend to arrive at the health centre after 9am. At 8.30am I was getting bored waiting for some action, so I pretended to be a patient. I walked into the waiting area, coughing and spluttering into my face mask, showing signs of being short of breath.

Nurse Kassy washing her hands in the Mother and Child Health clinic

The health worker at the registration-cum-triage desk stared at me for a moment, then burst out laughing, “Doc’s got covid, doc’s got covid!”

“What are you going to do with me, then?” I asked.

“We will do your vital signs and write them in your book,” said the health worker.

“Using the same thermometer as you use for everyone else, the same blood pressure cuff, examining me at the same table?”

“Ooohoooh,” (the timbre of this expression goes up in the middle, then down, signifying now I understand)

“We must isolate you from the other sick patients,” said one of the student counsellors who is working at the centre.

“Where?” I asked.

“You must go to the male ward. I’ll get the nurse to see you there,” she said.

“But are there any patients in the male ward already?” I enquired.

“Yes, there’s an old man with high BP being treated with bed rest,” she replied.

“Knowing what you know about covid-19, do you think that would be a good plan?” I asked.

“Why not?”

“Because covid-19 is more dangerous for older people, especially men and especially those with pre-existing conditions such as hypertension,” I said.

“Ooohoooh,” she replied. “I will ask my supervisor.”

The senior clinical officer appeared on the scene and said that I should be isolated in the new building behind the maternity block where pregnant women stay if they are due but not in labour.

The room reserved for pregnant women who are not in labour, and future covid patients.

“And how will you treat me?” I asked her.

“The treatment is to give oxygen,” she said.

“But we don’t have any,” I replied.

“Yes, that’s right. But the treatment is oxygen.”

I have come across this mismatch between theory and reality on several occasions. Health workers are able to manage the cognitive dissonance of the situation. We know what should be done, but we can’t do it, so there’s nothing we can do.

“So how do you know that I have covid-19?” I asked.

“You are in a high risk group as you have travelled from overseas.”

“But that was nearly a month ago. Surely I would have fallen ill before now if I had contracted the disease in the UK or on the flight out to Zambia,” I said. “How can you distinguish covid-19 from a chest infection, influenza or a common cold?”

“We do a test.”

“But there are no tests available in the health centre.”

Indeed, there is no easy way of diagnosing covid-19 without a specific test. But there are several indicators which might tilt the balance in favour of covid-19 rather than another respiratory infection. I explained about covid-infected patients in the UK who lost their sense of smell and taste. A dry cough, rather than a productive cough, points towards covid-19. We went through other suggestive symptoms, such as lack of appetite, fever, shortness of breath and fatigue. But chest pains, tummy upsets, and runny nose are less sensitive indicators.

At night, I can hear a strange cry coming from a spotted “laughing” hyena. It is more like a croak with a bit of wheeze. We joke that the hyena has covid-19.

Judging by the look on their faces, I could see that the difficulty of diagnosing covid-19 without a test was beginning to sink in.

“But every day we see lots of patients with upper respiratory tract infections. We are not isolating them,” said the student-on-placement.

“So what do you do with them?” I asked. “We have no broad-spectrum antibiotics and are running low on paracetamol. And even Piriton.” This was teasing them about the standard management of the common cold.

“If they are not very ill, they should go back to their home and self-isolate,” said the clinical officer.

Southern Ground Hornbill. He lives on lizards, snakes, fledglings, beetles. He walls up his mate-for-life in a hole in the trunk of a tree until their eggs are hatched.

“And what about the other people in their household? Should they also self-isolate? Or only if they have symptoms?”

“These people are often daily paid (they only get paid if they do a day’s work) or farmers who need to work outside the home. If they don’t work, they don’t eat. They don’t have savings to tide them over.”

“And what if they become more unwell? Will they return to the clinic for help?”

“They should not come back here if they are ill,” said the clinical officer. “We will send them away.”

“But they might not accept that. They could decide to get a taxi to go to the hospital, spreading the disease as they go.”

“We could keep them in the pregnant women’s quarters until the get better.”

“Who will look after them there? Do we have protective clothing?”

“Yes, we have about four disposable gowns, boots and visors,” said the clinical officer. “We had the training some months ago. We know how to put it on and take it off.”

“And you haven’t forgotten?”

“One nurse will stay with them all day, so she can keep the protective clothing on all the time.”

“In September and October, it gets extremely hot and humid before the rains come in November. How is she going to cope wrapped up in PPE?”

Hippos don’t practice social distancing.

“There is an isolation ward just outside Mambwe (less than an hour away by car) where we can send people who are unwell and we cannot manage them,” said the clinical officer.

This was news to me. “Is it equipped and ready to receive patients? Is oxygen available there?” I asked. No one knew.

I told them that the District Officer of Health informed me that any extremely unwell patient requiring oxygen and possible ventilation would be transported to the new hospital at Petauke. I had driven past this brand-spanking-new hospital the day after I arrived in Zambia. It was locked shut.

“How will we know if it has arrived in our locality?”

“We will probably see a cluster of cases, possibly unexplained deaths.” In the capital, Lusaka, people who have been very ill have avoided coming to the hospital for treatment. Perhaps they think that if they didn’t have covid-19 before, they would certainly get it when they were admitted to hospital. Their relatives would bring them to the hospital when they were moribund, and many of the first positive covid-19 tests were done posthumously – BID, brought in dead.

“So, what should we do?”

“Pray!” The nurse in charge of the heath centre is a pastor in the Bread of Life Church in Mfuwe.

And wash your hands, wear masks in enclosed spaces, keep socially distant from others, stay indoors if you have any symptoms, and, yes, pray.

Morning sun over an island in the Luangwa River.