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.

Categories
Medical Zambia

Sickle Cell Anaemia

I have seen more children with sickle cell disease during this stay in Zambia than my other two tours. It is a miserable, dreadful disease.

It is a genetic disorder of haemoglobin which alters the biconcave disc shape of red blood cells into a crescent or sickle. Being an autosomal recessive condition, a sufferer needs to inherit a sickle gene from both parents to be severely affected (HbSS). Only having one gene (sickle cell trait, or HbS) causes no problems (unless the oxygen level of the blood is reduced) and confers some protection against malaria. (This may be why evolutionary pressure has not eliminated the disease.) Paradoxically, patients with sickle cell disease (HbSS) are more susceptible to the dangerous form of falciparum malaria which can be fatal. 

Fetal haemoglobin (HbF) helps to protect babies for the first six months of life, but as HbF disappears, the affected child starts to become symptomatic. The abnormally-shaped red cells clog up the micro blood supply to bone marrow, causing acute and long-standing pain in the bones. The deformed red cells cannot revert to normal and they burst or haemolyse. The child becomes anaemic with less than 50% of the amount of haemoglobin as a child without sickle cell disease.

The sickling blood cells are filtered out by the spleen, which grows in size and then becomes destroyed as its capillaries clog up. The spleen is the location of immunological memory cells, which are lost when the spleen infarcts. This makes the child more susceptible to bacterial infections, especially streptococcal, meningococcal and salmonella (typhoid) infections.

Sickling cells also damage the lungs, causing chest pains and difficulty breathing. A stroke can result from sludging of red blood cells in the brain.

The child’s growth falters and the child is often stunted. Leg ulcers are a common complication which are very slow to heal.

Sickling crises can occur spontaneously but may be precipitated by lack of oxygen, dehydration or altered body temperature.

At the health centre, on Fridays, the laboratory runs a batch of tests for sickle cell disease. A drop of blood is mixed with a reducing agent to take away oxygen, which causes the cells to change into their classic sickle shape, seen under the microscope. Unfortunately, we have run out of reagent to do this test, so we have to send suspected children to the nearest district hospital, an hour away by bush taxi.

There is no cure for sickle cell disease apart from a stem cell transplant – but this is not an option in Zambia. We can correct the anaemia by blood transfusion, but this may only last a few weeks. We avoid giving iron tablets because of the risk of iron overload from frequent transfusions. Sadly we don’t have any stocks of folic acid, which helps red cell production. At the time of writing, we don’t even have paracetamol to treat painful crises. We do have polyvalent pneumococcal vaccine.

This is another condition where we can make the diagnosis but offer only limited symptomatic treatment with no hope of a cure. Most of our patients will not reach adulthood. It makes me feel depressed and impotent.

Categories
Medical Zambia

First day at the Clinic

Kakumbi Rural Health Centre

Baboons. Need I say more? At least a hundred of the little blighters, making mischief. But animals have priority on the roads, so I waited until they had crossed.

The road was badly cut up by trucks driving through the muddy sand. There were lots of pools on the track, but the deepest had been partially filled in with old bricks to provide a better grip for the tyres. The big dirt road had several streams running across it, creating gorges which needed careful negotiation. As I reached the tarmac road, a lorry came into view. The passengers in the back were waving frantically at me. I didn’t realise I was so popular, I thought, until I turned the corner and saw a large bull elephant ripping tasty branches from a roadside tree. So they were trying to warn me.

Good morning and welcome to South Luangwa!

Normally when you see one elephant, you can be sure that there are others nearby. But lone bulls do venture off on their own, so I wasn’t too alarmed. I drove slowly towards him but couldn’t resist a few photographs. Just to prove the veracity of the story, of course.

Further along the road, I saw bushbuck and puku antelopes, as well as another mob of baboons. The village hasn’t changed much. A few new shops here and there, more potholes in the road to the bridge and a new restaurant, which I will have to visit soon.

More churches have been built beside the back road to the clinic. The Obama Bar has closed during the day and its courtyard is a haven for grazing goats. But at night it remains highly active. The clinic road is worse and I passed the rear of a sign saying, “Road Closed Turn Right.” The clinic has a new HIV/AIDS block in shimmering white, built by US aid (PEPFAR). The clinic now deals with 875 patients living with HIV without the fortnightly visits from the district hospital.

New block built with US Aid money for HIV/AIDS support
Maternity Block, now usable as it has an electricity supply
First delivery of my tenure – I had nothing to do with this!
Incinerator and drug pit

The maternity block has finally got an electrical connection so it can function as intended. The consultation rooms look cleaner, water flows from the taps and there is soap. The only towel is the one I donated in 2014, which looked rather grubby. I wiped my hands on the seat of my trousers.

Erina starts the fire with plastic and wood to heat the steriliser

The staff who knew me were delighted to see me again. The new health workers welcomed me back and we chatted about the good old days. “But the drug situation is worse now. We have less medication now than we had when you were last here, doc.”

The clinic water supply tower
The patients’ toilets, with the incinerator in the background

People in the Ministry of Health must be worried about the increase in malaria cases in this district. We are adopting a proactive strategy of testing and treating anyone who lives near all new patients found to be suffering from malaria. Unfortunately, heavy rain has made it almost impossible to get to remote areas to carry this out. It will be an interesting experiment.

The clinic now runs two community clinics a week, in which I will participate, as well as a schools inspection and health education
programmes (sexual health is on the agenda again).

It feels great to be back.