My first tour of duty as a medical volunteer in rural Zambia was in 2014. The clinic hasn’t changed much over the past six years. All of the original staff have moved on, apart from a cleaner and some local volunteers. There have been some renovations – the ward ceiling which was collapsing from the weight of bat excrement has been partly replaced, the labour ward has relocated to a new block and USAID has built a six-room HIV/AIDS clinic. Some small rooms have been divided up into smaller rooms to provide dedicated space for counselling, family planning, HIV and malaria testing. It has had several additional coats of paint.
The clinic failed an inspection a few years ago. The list of improvements is still attached to the wall, and a few have been implemented. For example there is now a dangerous drugs cupboard. This has two lockable doors, but unfortunately someone lost the only key. The only “dangerous” drug supplied to the clinic is diazepam injection, which we use to halt epileptic seizures.
The covid-19 pandemic is just starting to take hold in Zambia. There are complicated posters on the clinic walls, in English, providing information about the disease. Around the clinic there are buckets of water, basins and bars of soap for people to wash their hands. We have tried to enforce a policy of mask wearing for all staff and patients, but it is difficult to refuse to attend to a sick patient whose mouth and nose are not covered. The main consulting room has three washbasins. I have no idea why, but only one basin has a tap. The tap usually has running water. I donated a towel to the clinic six years ago and remarkably, it is still here. Someone has used bleach to try and clean it, so it looks a bit piebald. I try to avoid using it and re-contaminating myself, but it isn’t easy pulling on latex gloves when your hands are wet.
Many of the doctors who have volunteered here over the past twenty years have done some teaching. It is better to train nurses how to diagnose and manage patients so they improve their skills, than just seeing patients on your own. I taught nurses how to examine ears, throats and eyes using a pocket diagnostic set which I left behind last year. Other doctors have left shiny auroscopes and ophthalmoscopes. Doctors feel “naked” without these basic tools. I found two sets on a shelf covered in dust in their cases. Once I had replaced the batteries, they were perfect. I suppose the clinic doesn’t have funding for such essentials.
The clinic has a graveyard of ear thermometers which have worn out or succumbed to the dust. They are very useful because they are quick. A more traditional thermometer tucked into an armpit takes a couple of minutes to cook – and then you find it has changed position and not recorded a true temperature.
There is an old mercury sphygmomanometer for measuring blood pressure, but I was told it was “not functional”. There were beads of mercury in the glass tube and I thought it should stay on the shelf because it was dangerous. The registration desk has an electronic sphygmomanometer, but the battery cover has gone missing and it has been replaced by sticky elastic strapping. The batteries were dead yesterday, so I brought some from my own torch at the house to help them out. Today I was surprised to find that someone had bought new batteries and we were in business again. But for the entire morning I was pestered by the staff for the replacement batteries I’d brought. They can wait until I have returned to UK!
Last year, the clinic ran out of bandages and gauze swabs, so this time, I brought a supply with me (thank you for the donation, Su). We needed to use some during the first week I was at work. Dressings do tend to disappear quickly so I asked the clinical officer to lock the supplies in the pharmacy store. I separated the kit into piles of dry dressings, non-adherent dressings, different sizes, bandages, tape, gloves and steristrips (thin bits of tape to get wound edges together when stitches or staples are not required). Today, I needed some steristrips to do a bit of first aid and was disappointed to see some of my supplies randomly stuffed into plastic baskets in the corner of the treatment room. I searched for five minutes before finding the strips, and sadly, that was the last packet.
Working in low resource settings isn’t easy. It is not for every doctor. The variety of drugs is limited and “stock outs” are frequent. The range of investigations is restricted, the nearest X-ray machine (when it and the radiographer are both working) is an hour away by car. Taking a history using an interpreter can be difficult, especially when patients don’t understand what you are trying to do – you’re a muzungu doctor, surely you know what’s the problem without asking all these questions? I rely on my physical examination skills and broad experience. This can be frustrating when communicating with specialists who rely more on the appearance of a CT or MRI scan, when I want to know what the chest sounded like to know if it has changed since they last saw the patient.
The nurses in the clinic use me as a consultant to help them with the most difficult clinical problems. This means that I often see patients with untreatable conditions. I can tell them the diagnosis but I cannot always offer treatment or cure. I am trying to improve palliative care here.
In contrast, when I am working in village clinics for children, I am most usefully employed in recording all the details of vaccinations on an incredibly detailed tally sheet. These sheets have been photocopied so many times, that the print is faded and the tiny font is difficult to read. The data we collect must be accurate as it will be scrutinised by headquarters. Injecting an infant with vaccine is easy by comparison.
It is important to keep calm, equanimity rules. Showing annoyance is considered very bad manners and even raising your voice can cause offence. Although the work can be frustrating, the patients really appreciate what is being done for them. Even if the “free drugs” are only free when they are in stock, else patients have to buy them at the local chemist.