I had an appointment to see a patient at 8am, so I arrived 10 minutes early to be properly prepared. The health centre was very quiet, with no out patients in the waiting area, and just a few mothers with their babies outside the Mother & Child Health Clinic (MCH). With the temperature at 15C, it was pleasantly cool for me, but for the Zambians it felt like winter. It is winter for them.
Gradually the health centre staff arrived, first the cleaners to sweep away the dust of the previous day and night. The nurse on night duty came to hand over to the day staff but there had been no events which needed following up.
Because of the nationwide shortage of BCG vaccine, we wait until there are at least 12 neonates present before opening the 20 dose ampoule. It is a tricky vaccine to give, just into the top layer of the skin, 0.05ml. Most of the women were waiting for this for their babes.
I saw a mother with her seven-day-old baby sitting outside the MCH clinic. The baby was wrapped up in a blanket, with just the face visible. Mother was obviously very proud of her baby and wanted to show it off to me. I asked if I could take her photo and she willingly agreed. (I offer to send photos which I have taken via WhatsApp to people who have smart phones, and she was delighted with the picture.)
I asked her for the name of her baby and she said what I thought was “Premi”. I immediately jumped to the conclusion that the baby had been born prematurely. I agreed it was a catchy name and asked her how early the baby had been born. She looked puzzled and said that the baby had been born on time. “So why did you call her Premi?” I asked. “It isn’t Premi doc, it’s Promise,” said one of our volunteer health workers.
We have two counselling students on placement at the centre. I teased this young man about his Adidas knees – perhaps he was speed praying.
In the meantime, the patient who was supposed to be at the health centre at 8am had turned up at 8:25am. After the consultation, I looked around for the rest of the team accompanying me to the community clinic at K.
We had a discussion about the lack of childhood vaccines. The District HQ allows us a limited number of vials of vaccine each month. This strict control avoids excess vaccine being left at the back of the refrigerator and going out of date. But this “just in time” supply system can cause problems if we mistakenly order less vaccine than we need. There is no back up.
“We will need more vaccine for Thursday,” said D. “Can you drive to HQ and pick it up for us?”
I said that this wasn’t allowed according to my terms of service. The health centre was supposed to be able to arrange monthly deliveries of supplies. There were vehicles coming to Kakumbi from HQ and these could replenish our stocks. Then D asked me if I could supply fuel for the health centre motorbike to make the trip. This was just $5 but I decided to wait and see if they came up with another solution before I dipped into my pocket.
“We didn’t get enough needles and syringes, either,” said R, the senior MCH nurse. Last week, we had been forced to use 5ml syringes and separate needles instead of the prepacked 2ml syringes with needles.
“And I found vials of vaccine which had been partly used, returned to stock. These should be used up within a few days. There should be a date on the bottle,” complained R. She made sure that these vials were the first to be used at the community clinic.
Last week, one of our volunteers in the furthest village we serve asked to consult me about a personal medical problem. I agreed to do so the following day, but ended up having to cancel at the last minute. I felt guilty about this, so I after I had dropped off D at the scheduled clinic with the vaccine and paperwork, I took R with me to interpret during the consultation with the volunteer.
We met the volunteer at the roadside and she got into the vehicle to direct me to her house in the village. I parked in the shade of a tree and we went inside her small mud-brick home. It was very simple and plain, with a table, three chairs and some bedrooms leading off the main room. There were drapes over the doorways, but no doors. The corrugated iron roof was gaping at the apex, allowing a ray of bright sunshine to penetrate the dim interior.
I took her history and examined her. I thought her symptoms could be caused by muscle spasm in her shoulders and upper back, so I palpated this area and felt knots of muscle. When I massaged the tender parts of her trapezius muscle, she became uneasy. I asked if I was hurting her, but she said no. I wondered if it was because doctors and nurses do not often touch their patients when examining them. I moved on to take her vital signs and used an ophthalmoscope to look into her eyes. I could not find anything seriously wrong, so I asked her if there was anything troubling her, and stress or worries.
Immediately she began talking about a family dispute which had upset her greatly. I said that sometimes when doctors cannot account for a physical pain, it might be caused by mental upset and distress. As R explained this to her, I saw her head nodding. She seemed happy to wait and see if her symptoms got better.
As we got into the car, R told me I had made a social faux pas. “Doc, she was uncomfortable when you were examining her shoulder muscles. This is what men do when they want to get their wives ready for sexual relations,” she said.
We drove back to the community clinic. It was busy with mothers and children, with part of the location having been commandeered by brick makers. Two men were digging clay in a deep pit, filling a wooden mould and turning out blocks. There must have been a kiln in operation as some of these bricks had been fired. I took some photographs, joking with the workmen that they must be building a swimming pool. They didn’t understand this, so I changed the joke from a swimming pool to a fish pond.
This clinic is the busiest in the region. Last month, we reviewed 198 children, checking their weight, monitoring them if they had been exposed to HIV prior to delivery and with breast feeding. We monitor the children’s weight and development, primarily to detect those who are sick or malnourished. In fact, more children are overweight than underweight. About 10-20% of the children are due for immunisations.
Many of the mothers use the occasion to show off their clothes and their children’s fashionable outfits. There is competition between the mums as to whose baby has put on the most weight. I can’t speak Kunda, apart from a few words for diseases and parts of the body, but I could overhear enough English words in their conversation to understand what they were chatting about as they compared their children’s growth charts. “My baby has gained more weight than yours!”
194 children later, just after midday, we finished. One mother brought her baby right at the end. I didn’t like the tone of the voices admonishing her for coming so late, so I went over to her and found out that it was her first baby, born less than a month ago. Her baby would have to wait for BCG until next month, when she could also get the first vaccines. She didn’t have an under 5s card, but had brought a school exercise book, so I entered her child’s demographics and weight and the vaccine schedule on the first page. “So the father is Rabson Zulu, and the baby is also called Rabson Zulu?” I asked. The volunteers behind me shouted out, “Call him Junior!” OK, Rabson Zulu jnr it is.
D is posing with our trusty village volunteers who help to run the clinic.