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Life Medical

Vaccinating against Covid-19

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

Breaking the rules… again.

Organising a mass vaccination campaign is complicated:

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

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

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

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

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

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

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

Brief insert:

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

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

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

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

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

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

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

Vaccinating in Mfuwe Day School, Eastern Province, Zambia

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

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

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

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

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

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

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

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

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

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

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

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Life Zambia

Thursday Doors The Wedding

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.

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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.