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Life Medical Zambia

Role Play

In these cold winter mornings, patients tend to arrive at the health centre after 9am. At 8.30am I was getting bored waiting for some action, so I pretended to be a patient. I walked into the waiting area, coughing and spluttering into my face mask, showing signs of being short of breath.

Nurse Kassy washing her hands in the Mother and Child Health clinic

The health worker at the registration-cum-triage desk stared at me for a moment, then burst out laughing, “Doc’s got covid, doc’s got covid!”

“What are you going to do with me, then?” I asked.

“We will do your vital signs and write them in your book,” said the health worker.

“Using the same thermometer as you use for everyone else, the same blood pressure cuff, examining me at the same table?”

“Ooohoooh,” (the timbre of this expression goes up in the middle, then down, signifying now I understand)

“We must isolate you from the other sick patients,” said one of the student counsellors who is working at the centre.

“Where?” I asked.

“You must go to the male ward. I’ll get the nurse to see you there,” she said.

“But are there any patients in the male ward already?” I enquired.

“Yes, there’s an old man with high BP being treated with bed rest,” she replied.

“Knowing what you know about covid-19, do you think that would be a good plan?” I asked.

“Why not?”

“Because covid-19 is more dangerous for older people, especially men and especially those with pre-existing conditions such as hypertension,” I said.

“Ooohoooh,” she replied. “I will ask my supervisor.”

The senior clinical officer appeared on the scene and said that I should be isolated in the new building behind the maternity block where pregnant women stay if they are due but not in labour.

The room reserved for pregnant women who are not in labour, and future covid patients.

“And how will you treat me?” I asked her.

“The treatment is to give oxygen,” she said.

“But we don’t have any,” I replied.

“Yes, that’s right. But the treatment is oxygen.”

I have come across this mismatch between theory and reality on several occasions. Health workers are able to manage the cognitive dissonance of the situation. We know what should be done, but we can’t do it, so there’s nothing we can do.

“So how do you know that I have covid-19?” I asked.

“You are in a high risk group as you have travelled from overseas.”

“But that was nearly a month ago. Surely I would have fallen ill before now if I had contracted the disease in the UK or on the flight out to Zambia,” I said. “How can you distinguish covid-19 from a chest infection, influenza or a common cold?”

“We do a test.”

“But there are no tests available in the health centre.”

Indeed, there is no easy way of diagnosing covid-19 without a specific test. But there are several indicators which might tilt the balance in favour of covid-19 rather than another respiratory infection. I explained about covid-infected patients in the UK who lost their sense of smell and taste. A dry cough, rather than a productive cough, points towards covid-19. We went through other suggestive symptoms, such as lack of appetite, fever, shortness of breath and fatigue. But chest pains, tummy upsets, and runny nose are less sensitive indicators.

At night, I can hear a strange cry coming from a spotted “laughing” hyena. It is more like a croak with a bit of wheeze. We joke that the hyena has covid-19.

Judging by the look on their faces, I could see that the difficulty of diagnosing covid-19 without a test was beginning to sink in.

“But every day we see lots of patients with upper respiratory tract infections. We are not isolating them,” said the student-on-placement.

“So what do you do with them?” I asked. “We have no broad-spectrum antibiotics and are running low on paracetamol. And even Piriton.” This was teasing them about the standard management of the common cold.

“If they are not very ill, they should go back to their home and self-isolate,” said the clinical officer.

Southern Ground Hornbill. He lives on lizards, snakes, fledglings, beetles. He walls up his mate-for-life in a hole in the trunk of a tree until their eggs are hatched.

“And what about the other people in their household? Should they also self-isolate? Or only if they have symptoms?”

“These people are often daily paid (they only get paid if they do a day’s work) or farmers who need to work outside the home. If they don’t work, they don’t eat. They don’t have savings to tide them over.”

“And what if they become more unwell? Will they return to the clinic for help?”

“They should not come back here if they are ill,” said the clinical officer. “We will send them away.”

“But they might not accept that. They could decide to get a taxi to go to the hospital, spreading the disease as they go.”

“We could keep them in the pregnant women’s quarters until the get better.”

“Who will look after them there? Do we have protective clothing?”

“Yes, we have about four disposable gowns, boots and visors,” said the clinical officer. “We had the training some months ago. We know how to put it on and take it off.”

“And you haven’t forgotten?”

“One nurse will stay with them all day, so she can keep the protective clothing on all the time.”

“In September and October, it gets extremely hot and humid before the rains come in November. How is she going to cope wrapped up in PPE?”

Hippos don’t practice social distancing.

“There is an isolation ward just outside Mambwe (less than an hour away by car) where we can send people who are unwell and we cannot manage them,” said the clinical officer.

This was news to me. “Is it equipped and ready to receive patients? Is oxygen available there?” I asked. No one knew.

I told them that the District Officer of Health informed me that any extremely unwell patient requiring oxygen and possible ventilation would be transported to the new hospital at Petauke. I had driven past this brand-spanking-new hospital the day after I arrived in Zambia. It was locked shut.

“How will we know if it has arrived in our locality?”

“We will probably see a cluster of cases, possibly unexplained deaths.” In the capital, Lusaka, people who have been very ill have avoided coming to the hospital for treatment. Perhaps they think that if they didn’t have covid-19 before, they would certainly get it when they were admitted to hospital. Their relatives would bring them to the hospital when they were moribund, and many of the first positive covid-19 tests were done posthumously – BID, brought in dead.

“So, what should we do?”

“Pray!” The nurse in charge of the heath centre is a pastor in the Bread of Life Church in Mfuwe.

And wash your hands, wear masks in enclosed spaces, keep socially distant from others, stay indoors if you have any symptoms, and, yes, pray.

Morning sun over an island in the Luangwa River.