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Medical Zambia

ICAP

There are small groups of buffalo around Mfuwe at the moment. To protect themselves from attack by lions, they merge into huge herds.

ICAP (“International Center for AIDS Care and Treatment Programs”) is an American organisation (Columbia University) which supports health teams managing patients living with HIV. Four years ago, when I was working in Swaziland with Medecins Sans Frontieres, I attended a two day meeting at a hotel in in Pig’s Peak organised by ICAP, where representatives of all health centres in the country presented their data. I recall sneaking away from the prize giving ceremony to watch a soccer match on television (well, it was Manchester United playing my team, Leicester City, in our premiership-winning season). Such mass events are very expensive. The new modus operandi is to use Zoom meetings.

I am not exactly sure why, but the ICAP Eastern Province team descended on Kakumbi, bristling with laptops. In one small office, 3m x 3m, there were five, with two participants using their own smartphones. The leader of the team had two widescreen laptops. Technical assistants were on hand to overcome any challenges, such as a disruptive “reverb” on the leader’s microphone. The zoom meeting was to allow a dozen medical officers to present last week’s HIV/TB data. The meeting began at 8:30am, but it took another half hour for everyone to log in and get settled. Three doctors didn’t virtually show up at all.

After an introductory speech by the team leader, each district officer commented on their data, which was being streamed as a PowerPoint presentation. The first talk was interesting, but by the sixth (almost identical) talk, I was beginning to fade. Each presentation was in exactly the same format, with the narrator reading the numbers from the screen. Some slides showed no activity, but this didn’t deter the doctor from ploughing through the zeros, rather than skipping deftly to the next slide, “nothing to see here”.

Occasionally, a speaker would highlight certain difficulties, try to explain them, but often without offering a solution. Several districts had the same difficulties. Perhaps they had discussed these problems at previous meetings, but they didn’t now.

For the first time I saw some data relating to Covid-19, which had obviously been “bolted on” to the standard format. We are still waiting for the tsunami to engulf us.

Grey heron perching on the back of an irritated hippopotamus

I learned that there was a screening tool in use at clinics to pick up patients who should be offered  HIV testing. By screening out low risk patients, the positive test rate was about 10%. Our clinic had offered no screening tool data because we hadn’t collected it. I must admit I have not seen the health volunteers using the tool. It looked very cumbersome and complex.

Phew

Some clinics had run out of HIV test kits. It seemed that the 90:90:90 (90% of the population knows their HIV status by having had a test in the past year, 90% of those who tested positive were on treatment, and 90% of those on treatment had no detectable virus) mass testing approach to control HIV was proving too costly.

Once someone is HIV reactive, it is important to offer testing to sexual contacts. This may sound simple but it isn’t easy. Just imagine if the same day that you had been informed you were infected with HIV, you were being interrogated about your sex life, extramarital relationships, use of prostitutes, etc. Not everyone wants to spill the beans at that critical time. But our contact tracing needed to improve.

As a group, children who were living with HIV were most likely to have detectable virus. It seemed obvious to me that this was because of poor compliance – the medicine tastes awfully bitter – but the team leader suggested we needed to analyse this further.

Grey crowned crane colony – over fifty birds – on a patch of marshy ground near my home

About half the patients had switched from an efavirenz regime to one containing dolutegravir, a drug with a cleaner side effect profile. No districts reported a shortage of anti-retroviral drugs, but there did not appear to be enough surplus for stable patients to be issued six or even three months’ supply (to try to reduce travelling during the Covid pandemic). Just 1% of newly diagnosed patients were found to be also suffering from tuberculosis (it was much higher than this in Swaziland).

It is obviously important to make sure patients attend and are not lost to follow up. Treatment supporters managed to contact 90% of those few patients who missed their appointments and successfully got them to come to the clinic.

One district reported having screened almost 1,400 women for cervical cancer (visual inspection of the cervix). Of these, the screeners found 34 with suspected malignant changes, 22 of which were treated with cryotherapy and 4 needed cone biopsies. These results are very impressive for a country which has no cervical cytology programme.

Happy children at one of our community clinics – they weren’t being vaccinated

I was also impressed that not one of the 3,500 patients receiving anti-retroviral drugs in our district had died over the past week.

In an attempt to engage the audience, the team leader asked a colleague to summarise succinctly, telling him he had four minutes. He took ten. The meeting took four and a half hours. I wonder how many clinicians joined the meeting, said their piece and went off to treat patients, leaving their laptop glowing and jabbering away in their office.

One thing I have learned from working overseas is to wait until you have been doing the job for a month or so before being critical and recommending change. If it were me, I would have these meetings every month, or even every quarter. I would circulate a compilation of all the district reports, highlighting how a district deviates (good or bad) from the norm. The district would have to explain why it was an outlying and what it had or hadn’t done to achieve that. But it is a case of “he who pays the piper calls the tune”, and if the Center for Disease Control and ICAP provide the finance, they get to decide what gets done.

I could not believe that the most senior doctors in the province spent 10% of their working week attending a zoom meeting which dealt with a disease which was largely under control, while diabetes and heart disease were disregarded and created much more morbidity and mortality. I mentioned this to the team leader, who agreed with me, but said that HIV was where the money was.

Categories
Medical Thursday Doors Zambia

Monday Morning Meeting

The only door in this post, sadly. It is the door to the admin section of the health centre. Note the height chart written on the wall to the left.

7:30 am start, prompt. Most of the health centre staff who should be here are wearing masks and waiting for the opening prayer. The nurse in charge asks the most timid, quiet staff member to lead the prayers. We all bow our heads while she mumbles into her mask. I can’t understand a word of what she is saying, but I “amen” along with the rest of the team when she stops.

Her next task is to take the minutes book and read out what we decided last Monday. Again, her voice is very quiet but her English is halting as she tries to read the handwriting of the previous scribe. We get the drift.

It is important to adjust your ears so you can detect sounds of danger from all angles

What is on the agenda? The malaria sensitisation campaign is underway. I find this rather strange as the peak months for malaria are April – June. Perhaps now we are less busy treating malaria we can find the time to educate the population about how to prevent it. We are recruiting insecticide sprayers for next month. Unfortunately, we don’t have the capacity to spray all the surrounding villages, but some are complaining that they missed out last year on both spraying and free mosquito nets. I must admit to having seen mosquito nets being used in the gardens to protect crops against birds. And some say they have also been used as fishing nets.

One good idea is for the health inspector to alert community health volunteers when someone tests positive for malaria from their village. They have rapid diagnostic kits and will test people living near the “index case” to snuff out an outbreak. Test, treat and track. Where have I heard that before?

The nurse in charge is a very experienced midwife, but he made a plea for other midwives (and any assisting nurses) to remain calm when there is an emergency. “Don’t panic,” he said. “Don’t run around looking for things to do. Just calmly assess the situation. The women are not going to expire immediately. You have got time to make an assessment.” I find this is usually true, but when obstetric calamities occur, things can go bad very quickly. However, I agree with his sentiment and nod sagely. I wonder what catastrophe happened last week that I was not aware of?

This male kudu has the curly-wurly horns of a mature bull. 360 degrees of antler twist per year

The lab technician seems to be working much better now she is alone in the laboratory. Last year, there were three technicians. Too many cooks spoiling the agar broth, I suppose. She informs us about all the tests which are available, but some we can’t use, because they are reserved for certain patients, people living with HIV or pregnant women. It’s a shame I can’t order a haemoglobin estimation for “ordinary patients”, especially as the local hospital won’t transfuse blood unless I know the patient is very anaemic (5g/dl or less than half the normal amount).

Later this week, we will be visited by the Regional ICAP (“International Center for AIDS Care and Treatment Programs”) Team to support our work with patients living with HIV. Perhaps this is a reward for the excellent care provided here, which has improved drastically over the past five years (since my first tour of duty here). The clinic provides anti-retroviral drugs for over a thousand patients in Mfuwe. The vast majority are compliant, their disease is suppressed. The last baby to have been infected by their mother during pregnancy was in October 2019. I find it rather odd that they are paying attention to such a small centre, even if we are doing such great work.

Lion cub hanging out with the pride.

What makes me uneasy is the contrast between excellent HIV care and the poor care for diabetes, hypertension, asthma, epilepsy and other chronic diseases. The difference is, of course, that HIV care gets massive funding from the Global Programme for HIV AIDS.

The nurse in charge issues every staff member with a paper mask which must last them for a week. In the UK, these masks are discarded after four hours as they become damp and less protective after being in contact with moisture in our breath. I am pleased to see everyone keeps their nose covered. In a comment aimed at me, the nurse says, “We are forced to make compromises.” Indeed.

The Human Papilloma Virus (HPV) vaccination programme is stalled. Girls who are 14 – 15 years of age are eligible for two jabs, a year apart, to protect them from cervical cancer. It began nationwide last year and Kakumbi Rural Health Centre staff gave 269 girls their first HPV shot. We don’t know for sure, but we estimate that 90% of this cohort of girls go to school. Schools are the obvious location to round up and vaccinate the girls. But with the Covid-19 situation, all schools are closed apart from “examination year classes”. Unlike last year, we cannot just tell the teachers to line up eligible students for vaccination. Our problem is not just the girls waiting for their second shot, but another 270 girls now aged 14 who need their first shot.

Little bee-eaters sharing a perch. I particularly like the blue eye-shadow

Regular readers will have read my previous blog article about my misgivings with a vaccination programme which should have been given to 10 – 11 year olds, before they have become infected with the oncogenic strains of HPV. Once a girl starts having periods, boys consider her ready to have sex. A significant percentage of 14 year olds are not only sexually active, but are already young mothers.

I must have been daydreaming/brainstorming how to solve this problem when the quiet nurse in the corner started talking softly into her mask. “She’s leading the prayers,” I thought, dropping my chin onto my chest and clasping my hands. A few seconds later, I squint up at everyone else; no one is praying. She is actually reading out her minutes for us to approve. Nonchalantly, I try to adjust my posture to disguise the fact that I wasn’t really praying. I couldn’t tell if the other health workers had noticed and were smirking behind their masks. But I am used to making mistakes and they are used to my strange ways.

We finish at 8:15 am, ready to start the busiest day of the week at the health centre.