The Behemoth

The Book of Job describes a monster, a behemoth, which is probably a hippopotamus. These beasts are huge, with adults weighing over 1.5 tonnes. The males don’t stop growing until they die, but the weights of females start levelling off at age 25 years. I was astonished when I looked down on a hippo from the Luangwa River Bridge and saw how broad in the beam it was. Hippos are barrel-shaped. Only elephants and rhinos are more massive land animals. 55 million years ago, they diverged from their nearest relatives, the whales.

On land, they can run fast for short periods, up to 20 mph. Normally, they trot briskly when getting away from a threat. When there is no danger, they walk slowly, often using the same route, leaving a set of parallel ruts, too narrow for a vehicle to use.

Male hippos joust and exert superiority. Their canines can be 50cm in length. They can open their mouths so the jaws are at 180 degrees.

They have thick skins (5 centimetres) but surprisingly not much subcutaneous fat. If they stay out of the water for too long during the day, their skin gets damaged and cracks. Hippos secrete a substance which turns pink in sunlight and protects them from UV radiation. It also has an antibiotic action.

They spend most of their time in pools or shallow rivers. They can’t float and cannot swim well, even though they have webbed toes. In deep water they move by bouncing off the riverbed. They avoid fast flowing rivers or keep to the edge where the current is less strong.

Oxpeckers remove parasites from the hippo skin, but they can irritate by keeping a wound open so they have access to nutritious blood.

All the important bits of a hippo are situated on the top of its head: eyes, ears and nostrils. It can shut its nostrils when it submerges, and can stay underwater for over five minutes before surfacing to breathe. Baby hippos are born underwater and have to learn to swim immediately.

Hippos usually live in large groups, called pods, with up to a hundred members. They are territorial, occupying 100-200 metres stretches of river. A big male tolerates younger males if they are submissive and stay away from the females. If they challenge and get defeated, they may be forced to leave the pod and become solitary.

Sex occurs in the water, with the female being submerged for most of the time while the male mounts her. Pregnancy lasts eight months and the young hippo suckles from its mother until it is weaned at about a year.

Hippos have a reputation for being aggressive if a boat transgresses on their territory or if they feel threatened on land (don’t get between them and the water or between a mother and her calf). They probably kill more people than crocodiles and elephants. They forage at night on land, eating mainly grass and vegetation.

People do like to eat hippo flesh, which apparently tastes like muddy, fishy pork. I have never knowingly eaten it.

Life Medical Zambia

The Good, the Bad and the Ugly

Il buono, il brutto, il cattivo – starring Clint Eastwood, Lee Van Cleef, and Eli Wallach

Working today at Kakumbi Rural Health Centre wasn’t really like being in a Spaghetti Western. The variety of clinical conditions cause me to feel joy, sadness, anger and despair, but this would not have been such a good title.

Not a pretty scar, but at least the ulcer has healed

The Good. I have written about this little girl with sickle cell disease in the past. She had a nasty ulcer on her thigh which stubbornly refused to heal until we started daily wound toilet and dressing. Slowly, it began to heal. She stopped screaming when she saw a nurse or doctor because she could see how the ulcer was responding and she became my friend. I hadn’t seen her for a month or so, but she turned up today to get her monthly supply of folic acid (to help produce replacement red blood cells), penicillin tablets (to stave off infection) and anti-malarial prophylaxis (patients with sickle cell disease are prone to more severe attacks of malaria). Sadly, we have run out of folic acid (even for the first trimester in pregnant women), stocks of penicillin have been exhausted and we have never stocked Maloprim. She ate her breakfast while waiting for the pharmacist to tell her we had no drugs to give her and smiled at the camera. Isn’t she beautiful?

Deep wound from hippopotamus bite, healing slowly but well.
Peek-a-boo behind the bushes, a hippo out of water.

The Bad. This man was bitten by a hippopotamus three weeks ago. Bad because he was acting badly when he was attacked by the hippo. He is a very lucky man; most hippo bites are fatal. The wound was debrided and allowed to heal from underneath (by “secondary intention”). This needs a bit more tidying up and he will have an impressive scar, but he has lived to tell the tale.

Crocodile bite. Shiny, tight skin. The calf is full of pus in the deep tissues.

The Ugly. Late yesterday afternoon, a man was fishing in Kapani Lagoon. He had probably bought “muti” from a sangoma – a magic potion which allegedly prevents crocodile attacks. It didn’t work in his case. He was bitten on the left leg and came to the health centre after normal working hours. Unfortunately, the nurse on duty sutured the main gashes and prescribed antibiotics which were not available.

Crocodile bite – thigh. Deep wounds, sutured in error, now with necrotic muscle visible in the base.

Twelve hours later, he could not walk and had to be carried into the health centre. My colleague, the clinical officer who doesn’t like pus, asked me to sort him out. His leg was swollen and the skin was shiny and tight. The sutures needed to be removed. We have no scissors, so I had to do this with a pair of forceps and a scalpel blade. As soon as I snipped the first stitch, there was a mosi oa tunya (Victoria Falls) of putrid, orange-brown pus which burst from the wound. It stank so much I gagged. It reeked of rotting fish. Crocodile oral secretions are renowned for harbouring multiple pathogenic bacteria. I have never smelled a croc’s breath, but the pus probably smelled like crocodile halitosis.

The second wound I opened up had a different odour, sweet, sickly and fetid. The pus was watery and had bubbles in it. Looking deep into the wound, I could see the muscle had turned brown and black in parts. This is wet/gas gangrene, clostridial myonecrosis (dead muscle). This patient needed urgent surgical debridement, cutting away all the dead, infected tissue. Without a general anaesthetic, this is beyond my skill level. I knew that funds were really tight in the district and there was very little diesel left in store. We begged for an ambulance and were rewarded. I hope that I see him again before I leave and that his leg has been saved.

Because I am morbidly curious, I asked him how big the crocodile was. Like any fisherman, he extended his arms about a metre apart. “That small croc did a lot of damage,” I said. He replied, “No doc, that was the size of its head!”

Medical Thursday Doors Zambia

Thursday Doors – Wildlife Police Officer Medicals

Beautiful palm tree at the “golden hour”, lit by the setting sun

When I am performing occupational medical examinations, I have to use a spare room which has no door. This is why there is no door in this Thursday Doors post. Sorry.

About a fortnight ago, men in camouflage uniforms began turning up at the health centre insisting on having a medical check up. Most of these men were in prime condition and many of them had been working on anti-poaching duties for decades. “Why do you need a check up?” I asked them. A few just shrugged their shoulders and shook their heads. A few mentioned chaos in Human Resources or a reshuffle in the responsibilities of the departments of the Ministry of Tourism, National Parks and the Arts. Apparently, lots of paperwork had been misplaced or gone missing, so everyone had to photocopy their original documents for re-submission. This included a medical examination to be carried out by a doctor.

No one knows for certain how many wildlife police officers, storekeepers, plant operators, general office workers, supervisors, rangers, etc. there are in Mfuwe. Guesses ranged from 100 to 250. That is a helluva lot of medical examinations. Not only did these “big men” barge in on consultations with sick patients, they insisted on being seen as a priority. I talked to the nurse in charge, who agreed to take up the issue with his counterpart in the Wildlife Authority. “I will suggest that we should limit the number of examinations to five per day, first thing in the morning,” said Martin. I spoke to my boss, the District Health Officer, who said that any health worker could sign the forms. “But it specifies doctor,” I said. “Don’t worry about that,” he replied. In practice, the WPOs demand to see the doc.

An armed scout stands guard watchfully beside a baobab tree at a recent wedding in the Valley

Each day, about ten officers chance their luck, waiting for me just before 8am. If a senior officer comes along, he takes priority and jumps the queue. I try to get the triage health worker to record their height (we only have one measuring rod and it is in the mother and child health block), weight (the glass on the scales is so dirty and scuffed that I have to crouch down to make a reading), pulse and blood pressure (both our electronic sphygmomanometers died last week, so I do this by hand).

I can’t help myself from teasing the officers: “So, you are a Wildlife Police Officer? Have you arrested any lions for grievous bodily harm? Or have you booked any impala for exceeding the 40KPH speed limit?” Usually they don’t understand my warped sense of humour.

The forms look as though they have not been altered since Independence and ask me to assess their body type and their mental state. I ask them, “Are you strong?” and they all say yes. “Are you mentally stable?” and again, they all say yes. I asked one chap this morning if he was sure, and he said, “Decisively stable!” The door to the office doesn’t close properly (there is no handle on the inside), so the next officer in the queue watches what is going on. Sometimes I ask him if the person I am examining is mentally stable. This usually produces a guffaw of laughter. Especially if he is their boss.

Purples and pinks in the clouds at dusk

Some men are grossly overweight with pendulous abdomens. I have to measure their girth and their chest circumference, expanded and deflated. None of them understand my order to “Take in a big breath and hold it; now breathe out fully.” The official form suggests that all the officers must have a chest radiograph, but this is neither possible nor justified.

I ask all the officers about previous serious illnesses but not one has confessed to having hypertension or HIV. One man needed to be accompanied by his son and asked me if I could sign him back to work after he was hospitalised with cerebral malaria. Sometimes, they will even ask me to prescribe their blood pressure medication at the end of the examination. About 20% of the officers over 40 years of age have elevated blood pressure when I measure it. I give them the usual advice regarding lifestyle changes and ask them to return for further BP checks. I write about this in the comments section at the end of the report, but as hypertension is asymptomatic, the officers don’t regard a blood pressure of 200/120 as preventing them from working.

There are questions on varicose veins, hernias, the state of their teeth, hearing and speech, but nothing about their visual acuity, which I find strange when their job involves tracking poachers and looking for snares in the National Park.

We have had no urinalysis strips for two months. The nurse in charge insisted that we use scarce health centre funds to buy some strips. Part of the medical examination involves testing urine. I refuse to waste urinalysis strips on asymptomatic, fit officers, so I just write “not required as has no symptoms.”

Morning light over the Luangwa River, taken from the bridge at the entrance to the park.

Finally there are some questions about patellar reflexes and pupil reactions, before a section marked “Comments”. I normally write “Fit”, sign, date and state the name of the health centre. We have one official health centre stamp, which has a central date. The numbers of the days of the month have fallen off, so I have to write that by hand. The ink pad is so parched that even with brute force I can only print a faded, illegible blue image.

I was taken aback when a senior officer asked me to use a darker stamp so he could photocopy the forms. At first, I thought he was asking to get “pre-stamped” forms which could be completed by anyone. Actually, he just wanted me to re-stamp all the photocopies of forms which I had completed that morning as the officers had made duplicates.

If it were up to me, I would abandon all occupational medical examinations as they are useless. I would introduce a more practical test – How fast can you run after a poacher? Can you sprint 100 metres in less than 15 seconds wearing full kit?

While I am filling in the forms, I make polite conversation. “Did you shoot the crocodile which attacked the 13 year old boy who was fishing in the Lupande River? On the news, it said his leg was allegedly in pieces.” No, they hadn’t located the crocodile. But they had responded to a distressed hippo which had strayed away from water and was sick. “We told the villagers to leave it alone, but they did not understand us,” said one WPO. “After we left, they attacked the hippo with machetes to get the best meat before it died and the hippo became very angry. It killed one of them.”

This is a very healthy hippo, taking a morning constitutional walk in the National Park.

The atmosphere this morning was rather subdued. It transpired that, allegedly, a civilian (a teacher?) had visited a bushcamp, picked up a semi-automatic weapon and fired three shots into a wildlife police officer’s chest, killing him instantly. There was a large crowd of family members outside the police post at Kakumbi, waiting for the body to be recovered. I wonder if the shooter would have passed the medical examination, especially the mentally stable question?


The Road Branches

When I see a branch in the road I know I need to pay attention.

If a truck has broken down, the driver will place branches at the side of the road 100 metres behind and ahead of the vehicle. The driver might be trying to change a flat tyre or could be lying under the vehicle doing some repairs, so I slow down.

If there is a huge crater in the road, a large upright branch stuck in it will alert other road users. If there is a track in the bush with a large branch across it, it means that the track is impassable ahead.

I saw a series of branches laid in the road on my way home and assumed it meant that there had been a death in the locality. Etiquette states that you switch on the hazard warning lights and slow down, passing the home of the recently deceased person in first gear. This is what I did in this situation until I realised that there were no homes in the vicinity. The branches were actually marking potholes which had just been filled with a mixture of crushed bricks and cement. The road menders didn’t want people to drive over the wet cement mixture.

This is a deep pothole with a branch that’s lost its leaves

This set up a slalom where drivers were weaving around the branches while avoiding oncoming traffic. I am not sure how long the makeshift repairs to the tarmac will last.

This vegetation in the road is water hyacinth and “cabbage” which has been dragged across the road by a hippopotamus. Hippos move out of the lagoons and eat grass at night. They are such lumbering beasts that they drag water plants with them for part of the journey. You can see their pathways better in the dry season as two parallel tracks, a hippo belly width apart, worn into the dried vegetation.

There was a major road building project in 2016 when I was last in the Valley. A perfectly good tarmac road from colonial days was widened, which involved the destruction of many mature trees at the edges of the road. The money ran out before the road builders could tackle the most appalling part of the road in the villages of Cropping and Kakumbi. There is no tarmac on this stretch of dual carriageway (potholed, muddy road to hell) crossing the Matanje River. Both roads are bone-jarring, cratered tracks, but the road going west is worst. Ignoring the Highway Code, many drivers use the east bound carriageway to go west. Both tracks are wide enough for this (apart from on the bridges) but the situation is complicated by the tortuous route drivers take to avoid the suspension-crunching crevasses and deep puddles. One might swerve into the “outside lane” (there are no actual lanes) and find oneself heading directly towards an oncoming vehicle avoiding the same obstacle.

Matanje River
This is the road to the health centre after a dry spell

The side street which leads to the health centre is a succession of muddy pools, each with a resident family of ducks and ducklings. In an attempt to avoid vehicles getting stuck in the mud, people have laid down grass stalks and foliage on the road. This is now beginning to rot and gives off an awful stench as you drive over it. Coupled with the stink of burning plastic at the health centre, it reminds me of the scene in Apocalypse Now, where the US Airborne Cavalry commander proclaims how much he enjoys the stench of napalm, “It smells of … victory.”  My thoughts exactly when I reach the clinic without having been bogged down in the mire.