Categories
Medical Zambia

Radio Gaga

It was A’s idea. “It sounds like you’ve been doing great work vaccinating in the schools. Why don’t you get the message out there, blow your own trumpet?” And what better way to do it than getting on local radio?

Mnkanya Radio 88.3FM is our local Mfuwe station. It is situated half way between the national park gate and the airport. There is a cluster of modern huts on one side of the compound (the owner is trying to start up a lodge business as well), a reception and a recording studio. Towering above is a red and white radio mast. They mainly play music from Zambia, South Africa, Zimbabwe, Nigeria and the USA. Although they broadcast the news in English several times a day, the disk jockeys and station announcers speak in local dialects. Their Facebook page is a bit sparse but contains some news items such as


“police in kabwe has gun down two criminals de other one has died at de spot and de body dead has taken to de mochary in kabwe hospital while de other one z at kabwe central police wth severe injuries this has happend wen two criminals broke into acertain shop wen security officer phonnd de police without delayment and de police dd according to their works thus was around 24hrs on 20th january 2019”

At the clinic, I discussed the need to publicise our work in the community, to explain to parents exactly why we were vaccinating their children in schools. Mr C, the public health inspector in charge of community programmes, thought it was an excellent idea to use radio to do this. But he thought that the radio station would charge us as they charge advertisers. I insisted that this was a public service, the public had the right to know, and there was hardly any decent local news to broadcast. C wasn’t convinced.

He brought up the subject at the next clinic meeting. The nursing officer in charge agreed it was a good idea, but only if it didn’t cost anything, because the clinic could not afford to advertise. We agreed that once C had finished compiling the vaccination report, we would pay a visit to Mnkanya Radio in Mfuwe.

“Home of lxuary & confortable place”

Armed with the figures, we decided to drop in unannounced. If we had written a letter or email, it may have gone unanswered or we might even have been rebuffed. During the short drive to the station, I discussed strategy with the health inspector – key points, short sentences, snappy answers. I spoke about the ABC technique with tricky questions – Acknowledge the question (answer it if it is easy), Bridge to your safe ground, the area where you want to answer questions, and Communicate your key messages.

C wasn’t convinced. He was so worried that the radio station would want to charge us that he wasn’t listening to my advice. “You have done this before, doc,” he said, “You can represent the clinic.”

The recording studio

We drove into the compound and walked to reception. The small building was empty. A gardener noticed us and alerted one of the reporters. He took us over to the recording studio where they were broadcasting live.

“What do you want?” the reporter asked.

Mr C looked to me and I motioned for him to answer the question. He rambled on for a few minutes, using jargon (“TT” instead of vaccination against tetanus, a disease which can kill adults as well as young babies) and getting rather muddled. It is common for Zambians to pad out their English with bland phrases while they search for the right word.

I could see the reporter was looking less than impressed. Mr C turned to me and said, “Doc?” I emphasised that this was a good local news story; many families with school aged children would be interested; we had vaccinated 1,205 school children during February; the immunisation coverage rate was better than in the UK. The punch line was that we will be returning to the schools in March to give booster doses.

The reporter got out his iPhone ready to record an interview. I said, “It wouldn’t be right for a muzungu to talk in English to your listeners. The Zambian health workers and volunteers are responsible for this work and they should speak in Kunda or Cinyanja.” He agreed and pointed the iPhone microphone towards Mr C, who suddenly looked terrified.

“Can you give us a minute?” I asked. The reporter went inside, while I discussed interview technique with Mr C. “Martial your facts, speak in short sentences, don’t use jargon, tell them what a great job we have done,” I said. “You  can do it!”

The interview was very short, less than five minutes, but for Mr C it seemed like it was half an hour. The reporter blindsided him with a question about the vaccination schedule for schools in March. We didn’t have the vaccine in stock and there were some public holidays just to complicate matters. But Mr C went through his papers and eventually came up with a schedule for the listeners. “I will edit that last piece,” said the reporter, kindly.

Just before we left, I asked the reporter if he was interested in any local health stories. He told us that he was always on the lookout for anything that would get more listeners. On the way back to the clinic, Mr C was enthusiastic. “We could do plays with health messages… we could warn people about malaria… we might get a regular health spot,” he said.

“That will be a great deal of additional work, Mr C,” I told him.”You are already working flat out. And remember, actions speak louder than words. This is only newsworthy because it has been such a success.”

“Ah, you are right, doc!” he replied.

When we got back to the clinic, Mr C made sure everyone knew that he would be on the midday news, and the afternoon news, and the evening news, and the late night news. Perhaps even tomorrow morning’s early news. He was a radio celebrity now.  

Categories
Medical Zambia

Pesky National Holidays

Wild dog or Painted Wolf, chewing a kudu (antelope) leg

Zambia is awash with National Public Holidays in early March. Friday 8th was International Women’s Day and Tuesday 12th was National Youth Day. This put a spanner into our well-oiled community health programme.

The Ministry of Health has prioritised data collection for the planned Human Papilloma Virus (HPV) vaccination campaign, which begins in June 2019. This is an expensive vaccine which will protect against cancer of the cervix (as well as other cancers and genital warts) only if it is administered before the girls are exposed to the HP virus. Cancer of the cervix is the most common cancer among women who are living with HIV in Africa. There is no national cervical screening programme, so introducing HPV vaccination is a no-brainer.

On Thursday 7th March, we received orders to collect the names of all girls who would be aged between 14 and 15 at the start of the campaign. We contacted all the schools in the area but, as many girls do not attend school, we had to ask our community health volunteers to go house-to-house to collect this data.

A male kudu – not the one eaten by the wild dogs

The following day was a public holiday, so nothing happened.

Then it was the weekend. Nothing happened.

Following the three day weekend, Monday 11th March was extremely busy in the clinic, but we managed to distribute the forms to list the girls eligible for HPV vaccine. The following day was another public holiday, so nothing was done. The forms should have been completed for Wednesday 13th March, but the teachers had not managed to fill in the information. Nevertheless, a team from headquarters arrived to collect the forms, only to find that, like us, none of the four centres in the district had successfully collated the data.

So they planned to return on 14th March at 10am insisting that the data should be ready. A health worker used his own money to put fuel into a motorbike to collect all the data from the schools in the early morning to meet this deadline. The biggest school still hadn’t finished the data collection, but we were assured it would be done by midday. When we picked up the forms, the teachers had clearly not understood the meaning of a column marked “Age 14 years” and another “Age 15 years”, because they included every girl, regardless of age.

Domestic disagreement between vultures

This whole process made me feel despondent. The campaign is not scheduled to start for two and a half months, but because of two public holidays, we only had two days to make arrangements. The quality of data suffered as a consequence of unrealistic, unnecessary deadlines. Even more sad is the fact that Zambia is planning to vaccinate the wrong group of girls. Instead of providing three vaccinations over two months, the Zambian programme will provide two vaccinations a year apart (the immunogenicity of the vaccine is excellent, so it may be that this will generate adequate immunity).

In the UK, we give the vaccine to 11 and 12 year olds in school. One of the head teachers told us that the majority of girls in her school were sexually active by age 15. They even have pregnancies at school in children as young as 12. Girls aged between 12-16 who do not attend school are more likely to be sexually active, married or pregnant.

I contacted the District Health Officer to express my concerns about this and he agreed with me completely. Policy is made at the highest level in the Ministry without consulting grass roots health workers. It is too late to change the strategy. The vaccine isn’t cheap, so the country is wasting millions of kwacha targeting girls who are already likely to be infected with HPV and so will not benefit from the programme.

Rant over.

Cute child at the community clinic

Normally, the second Tuesday of the month is Chikosi’s community clinic. Because this was a public holiday, we informed the mothers that we would be coming on Wednesday instead. But people forgot and turned up late. One of the community volunteers was absent, so we asked a health centre volunteer to help out with the weighing. He rigged up the scales, hanging from a tree branch and started weighing the children.

Within ten minutes, the mothers were up in arms. All their children had lost weight since last month and they were not standing for that! I checked the scales to find that they had not been zeroed. The children were weighed again and the mothers were happy with their infants’ progress.

During the minor riot, I saw an infant (strapped to his mother’s back) attempt to capitalise on the confusion and suckle on another mother’s breast, deftly pushing her baby’s head aside. It reminded me of the behaviour of cuckoos. Or perhaps he just wanted to find out if milk tasted differently from different breasts. Enterprising little chap.

The public health inspector gave a long talk on interpretation of the weight chart (“Road to Health”) which documents average weight over the first five years of life. Unfortunately, the official charts have not been available since August 2018 when they went out of print. An enterprising local pharmacist photocopied the charts on blue and pink card, but charged the mothers 10 kwacha (=US $1). Most of the babies under six months of age have school exercise books with the vaccination schedule, de-worming, vitamin A supplementation, HIV checks, etc., all written by hand. But there is obviously no graphic representation, which made the talk on growth rates, centiles and danger zones rather academic.

Kojak – bald, lollipop-sucking detective. Selinge = syringe spelt phonetically by Zambians.

We had some more great names. It is common to combine two names into one – Izaister is Isaiah combined with Esther. Rolister is Rosa combined with Alister. I believe that “truncated concatenation” is the correct term. The public health inspector comes from northern province and is unfamiliar with the local names. He also finds it difficult to read the names written in English. When he struggles, I take over and spout “Mwukambwiko” fluently, much to the amusement of the mothers, who hoot with delight at the muzungu who knows more Kunda than the Zambian health worker.

Some children had missed out on their vitamin A booster a few months ago. The vitamin is an oily liquid in a soft capsule with a teat. I bite off the teat and squirt the oil into the child’s mouth at an opportune moment. It doesn’t taste of anything, but it has a greasy sensation in the mouth. I devised a cunning plan to have the child breast feeding, the mum takes the nipple out of the child’s mouth, I squirt in the vitamin and the child latches on again within a second. Seemless. I am still trying to get the oil stains out of my trousers, however.

Children are eligible for measles vaccine at nine months. Health workers use a crude month reckoner, but one mother pulled out her smart phone and did the precise calculation, demonstrating that her child just met the criterion to have the vaccine. We didn’t argue with her.

A little girl attending the clinic in her party dress, with socks and sandals, eating a fritter.

The date of the next clinic is not quite four weeks away, which is the interval between the first three vaccinations. Health workers like to stick to the official guidance for vaccination, because they will be criticised by supervisors if they don’t. But this was a tricky one. Do we vaccinate slightly early, do we defer the vaccination to the following month or ask the mothers to come to a different clinic location? Life is too short to worry about this, so I made an executive decision to ignore the slightly shorter interval. If their supervisor detects this deviation, they can always blame the muzungu doctor, who has by then left the Valley.

Categories
Bangladesh Medical

Diseases which should never happen

Before today, 11th November 2017, the only person I knew who had diphtheria was my Aunty June, who had contracted the disease in 1935.¹

“Have you seen the woman with the white throat?” Dr Nadim asked me.

P1320703At first, I didn’t click. What did he mean by a white throat? Was he describing vitiligo on the front of her neck? It was a shock when I saw the patient. There was a thick, greyish membrane on the right side of the back of her pharynx, inside the mouth. Her neck was diffusely swollen, known in the trade as a “bull neck”. She looked uncomfortable and couldn’t swallow without pain. It was just like it is described in textbooks – but diphtheria is so rare nowadays that it only merits a brief entry in the Oxford Handbook of Clinical Medicine. There is nothing else which causes this appearance. (See my previous blog post about diphtheria for more information)


In our other isolation room, we have three children with tetanus. Two have neonatal tetanus, a disease which has been virtually eliminated from the world by vaccinating women in the antenatal period. I have seen seven Rohingya patients suffering from tetanus in the two months I have been working here in Kutupalong.


Some diseases are so feared that we may not speak their name. Cholera has become “severe acute watery diarrhoea”. Poliomyelitis is “acute flaccid paralysis”. The Bangladesh Health Ministry has organised vaccination campaigns in the refugee camp to prevent both these diseases, but not before one boy contracted “acute flaccid paralysis” which could have been wild-type polio. We admitted him to the ward for observation, but his symptoms did not progress, and we discharged him after a week.


The only letter I have ever written to The Times newspaper was to criticise Nigella Lawson’s view on measles vaccination, which she felt was too risky given that measles was not “a serious disease”. I wrote that measles could be lethal. I recall admitting twenty children suffering from measles to a hospital ward on a single day in 1980 in Southern Sudan; by the next morning, only twelve were still alive. Nigella didn’t reply.

Here we have a measles isolation tent. Six months ago, Cyclone Mora blew the tent onto the roof of the hospital laboratory. It was retrieved and fixed more securely to the ground. When I visited the tent last month, it was hotter than Hades.

The mothers were complaining that there were no fans in this furnace of a ward. The children looked irritable and ill, lying on mats on the floor. I checked them for dangerous complications of measles and we said we would get one of the logisticians to bring a power cable into the tent to run a standing fan.

The following day, the mothers were delighted at the cooling breeze from the fan. I was less than delighted with the increase in numbers of ill children.

P1320829
The waiting area where we assess children with measles to determine whether they are so unwell that they need admission to the tent. Note the logo on the tee shirt of the man wearing a blue checked lunghi.

 

A week later, the mothers were angry again. The fan had stopped running. I saw that the plug had come out of the socket, perhaps when moving the fan to make room for another mattress. I moved the fan closer and replaced the plug. The fan remained dead. The mothers looked downhearted.

I couldn’t give up and lose face, so I tried twiddling the switch governing the speed of the fan. Still no good. Then I tried a bit of “percussive therapy” – I bashed it and the fan spun into life. A cheer went up (mainly from me). Everyone was happy. The spotty children were all doing extremely well and would soon be discharged.

The logistics team have now fixed up a massive awning over the top of the tent to provide some insulation from the hot sun. The patients find it much more bearable now.

P1320769
Measles tent with protective bamboo roof/shade 

 

The misery caused by all these diseases could have been prevented by routine immunisation. This has been so successful that many parents (like Nigella) in developed countries have become rather blasé about having their children protected. Sadly, many Rohingya in Myanmar have not had the luxury of that choice; they had no access to vaccination. The consequences of this are plain to see in the hospital.

 

 

¹ My father and his siblings were quarantined at home, issued with a bottle of “Thymo-Cresol” disinfectant and not allowed to go to school. Crucially, this impacted on his performance in the grammar school entry examination, the Eleven Plus. He said,” With this period of isolation, all my dreams of becoming Prime Minister came to an end.”

Categories
Bangladesh Medical

Diphtheria

On 11th November 2017, in Kutupalong hospital, I diagnosed the first case of diphtheria in the refugee camp. Although I had never seen this illness during my professional career, it was instantly recognisable. Three weeks later, the hospital was seeing a hundred Rohingya patients a day suffering from diphtheria, with a mortality rate of 10%.

In 19th Century Britain, diphtheria was known as “Boulogne Sore Throat” as there was an outbreak across the Channel in France. Queen Victoria’s second daughter and her grandchild died from diphtheria within a week of each other.

The French physician Bretonneau first used the Greek word diphthera meaning “prepared hide or leather” to describe the disease in 1826. It refers to the thick, grey membrane of dead skin which covers the back of the throat in patients suffering from diphtheria. This “pseudomembrane” can obstruct the airway, suffocating the patient. No wonder the disease was known as the “strangler”. An epidemic struck Spain in 1613, “el ano de los garrotillos” (the year of strangulations).

P1320697

People can be asymptomatic carriers of non-invasive diphtheria which do no harm. But when a bacteriophage (virus) infects the corynebacterium it stimulates the production of the dangerous toxin. This poison kills cells in the throat but has a more serious, delayed action which damages the heart, kidneys, liver and nervous system.

A Prussian military doctor, Emil von Behring, won the first Nobel Prize for Medicine in 1901 after developing diphtheria anti-toxin in 1890. He repeatedly injected sublethal doses of toxin into a horse. The horse’s immune system neutralised the toxin. Horse serum anti-toxin is still used today to treat diphtheria. However, it is in short supply as there are so few cases of the disease in developed countries. Since mass immunisation against diphtheria was introduced in the UK in 1940, the disease has become extremely rare. The last British fatality was in 1994 when an unimmunised child picked up the infection on a trip to Pakistan.

Diphtheria is part of the WHO childhood immunisation schedule. Unfortunately, many of the Rohingya children who fled from Myanmar last year had never been vaccinated. In the overcrowded conditions in the refugee camp, diphtheria can spread rapidly by droplet (aerosol) transmission. Over 300,000 young people needed immunising – three doses, a month apart – to halt the epidemic.

The outbreak in Kutupalong refugee camp in Bangladesh was not an isolated event. Last year there were serious epidemics in Indonesia and war-torn Yemen, with many fatalities.

I have always been a fervent believer in immunisation because I am convinced it prevents mortality and morbidity. Perhaps because it has been so successful at eliminating diseases such as tetanus, measles, rubella, polio and diphtheria, many parents are unaware how deadly these diseases can be and they are frightened about the infinitesimal risk of vaccine side effects. But I have seen what happens when the system for vaccinating children breaks down, resulting in death and misery.