Monday Morning Meeting Revisited

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I arrived five minutes late for the 8am meeting today and missed prayers. Impressively, one nurse who had been on nights and another who had started her holiday both turned up for the meeting. One staff member came in 10 minutes after me, and then we had a full complement. I was sitting next to Nurse Zulu who was cold. She was wearing red woolly Christmas socks, with flip flops.

The first item on the agenda was community work. Mr Chulu, the public health inspector, encouraged staff to meet and engage with the community. Everyone thought this was a good idea, especially as community work attracts a financial bonus, but our clinics are extremely busy and no staff can be spared. We discussed how we might do this, but came to no decision.

After the meeting, I asked Mr Chulu to list the specific campaigns with which he needed support. The date for the mass dosing of people with DEC to counter filariasis has not been fixed. Neither has the date for the administration of vitamin A and de-worming tablets to children. He plans to visit the villages which have a greater incidence of malaria, to ask about the use of impregnated bed nets and to look for mosquito breeding sites. He wants to do some health education sessions in schools on HIV and sexually transmitted diseases. He said he would be grateful for my help.

The next item was the complaint about health workers “chit-chatting while the queue of sick patients grows longer on Monday mornings”. Everyone agreed that it was necessary to have a meeting on Monday as this was what all civil servants do. One health worker said, “If I go to the Ministry of Agriculture offices on Monday mornings, I have to wait.” Another countered this, saying, “But they don’t do any work. We have to see all these patients.”

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Helen, Health Care Assistant whose voice is so low she sings bass in the church choir

One nurse spoke about changing the day of the meeting, only to say it was not possible. Then something rather strange happened. “We could start work earlier, have the meeting from 7:15 till 8am, then begin seeing patients,” said a senior nurse. This would be a shorter meeting, so there should be a timed agenda, to avoid overrunning. “But what if staff come late? What do we do then?” “We send a volunteer to find out why that person is tardy.” Everyone agreed. I was shocked.

There were two official data collection meetings at Crystal Springs Hotel in Chipata, each lasting two days, with a generous per diem of $55. The letters specified who was to attend, so there was no discussion. We welcomed a new staff member who had been posted to Kakumbi as a punishment.

Finally, there was a disciplinary matter which took up 25 minutes. Someone was not doing their job and the new nurse in charge confronted the person at the meeting. This was not the first time the staff member had failed to do their duties. The “in charge” asked other people for their observations, and then asked the staff member to respond. Unfortunately, the response was in Nyanja so I didn’t understand it.

The nurse in charge replied by saying, “To deny is to disrespect your supervisors. Coming on pompous will make you lose out. Humble yourself and work.” The threat of disciplinary action was raised (a transfer to a less popular health post) if there was no improvement. It was rather intimidating, but someone spoke out in mitigation, “We are all human, we all make mistakes.” The written warning was entered into the minutes.

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This baby just made a “mistake”. Look at the puddle on the step. It won’t affect his weight measurement much.

At “any other business”, someone raised the issue of poor communication when patients with tuberculosis were transferred from Kamoto Hospital to the health centre. Apparently this is because the officer who used to do this job has left and not been replaced. Another problem was the lack of laboratory cover at the weekend, because the two workers had both been given leave at the same time. This was the busiest time of the year for the lab, with all the malaria tests being required. No one knew how this could have occurred.

There were no questions about the week’s rota (the main reason for having the meeting on Monday mornings). I asked about the public holiday, African Heroes Day, which falls on May 25th; we will just open for the morning on that day.

We kept to time and we made some decisions. All in all, more effective and efficient than many NHS meetings I have attended. I will have to get up earlier next Monday to see what happens.

 

Another Day, part 2

A woman was sitting on the steps of the clinic, gazing at the ground. I was told that she had mental health problems and wouldn’t speak. She was pregnant and had indicated that she had belly ache. A nurse had prescribed paracetamol and the woman had tried to take all the tablets. I sat down next to her. She stank to high heaven. Her clothes were filthy, she had no shoes and her hair was clogged with dirt. She wouldn’t speak to me so I asked Daillies for some background info.

No one knew her name, but she was from Malawi. And she was crazy. She never washed and she slept rough on the streets in Cropping. “Do we know her HIV status?” I asked. No one knew. “A man offered to give her n’shima (maize porridge, like polenta) if she would have sex with him. They went off into the bush and when they came back, he told her he had a wife and said goodbye,” said Chandra, the health centre volunteer. “Now she’s pregnant.” “You have to do something, doc,” said Daillies, “Or she will deliver at the side of the road.”

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This is not the patient referred to in the text. She just comes to recite biblical texts to the people in the waiting area in a very loud voice.

There is a social worker in the district, 70km away, but when I contacted her in the past about a psychotic patient with social problems, she was unable to offer much help other than to admit the patient to a hospital ward. I will have to discuss what possible courses of action there are with some more experienced people in the village, but it doesn’t look good at all.

Most of the staff had drifted off to lunch by 12.30pm but there was still someone in the waiting area. A mother sat quietly with her four year old daughter draped over her knees. I felt the child’s forehead and she was “burning up” as they would say in Leicester. An aural thermometer read 39.9C.¬† Mum couldn’t speak English, so I just went ahead and did a malaria rapid test myself. The line showing a positive test came up within 30 seconds, even before the control line.

I needed to calculate the dose of treatment according to the child’s weight. I led them to the weighing beam balance, but the child was too weak to stand. So I got mother to hold the child and get on the scale together (65.5kg). Then I asked mother to give the child to me. I cuddled the child while I fiddled with the balance (49kg), the difference being the weight of the child.

As I was doing the math, I became aware that the limp child felt really hot against my body. I thought to myself, the poor wee mite. Then I felt the heat spread down my trouser leg, and my shoe filling up with the child’s hot urine. She was so ill that she couldn’t control her bladder. Her mother was mortified and clutched her back from me. I told her not to be upset, it was only a bit of water. Unfortunately, my dreadful, mind-of-its-own Huawei “smart” phone survived the deluge.

I would have preferred to start an intravenous infusion to administer quinine and some glucose, but we don’t have any iv fluids in the clinic. I insisted that we keep her in the ward for a few hours until her temperature goes down and we are sure that she has ingested Coartem, and not vomited it. It is the children under five who bear the brunt of malaria. They have the least resistance. Once you have had malaria regularly for ten years, you will have built enough immunity to defeat the infection yourself (unless you also have HIV). Most of the fatalities are in young children. We haven’t lost one yet this season. This child was our 1,216th case of malaria in May. Last year in May, we had less than half this number. So the public health authorities didn’t spray the mosquito breeding areas this year.

As I drove home to change my clothes, I thought that I really didn’t mind being peed on; at least she hadn’t gone into renal failure.

Another day, another clinic

Friday is the second busiest day of the week at Kakumbi Rural Health Centre. I arrived early and got to work seeing those patients who spoke English. During May, about 60% of the people attending the clinic have malaria, so I have been trying to get the clerk who registers the patients to take their temperature and to refer those with a fever directly to the lab for a malaria test. But the protocol is that she is not allowed to do this, because she is not a doctor or a nurse.

I saw a well-dressed lady with her two children who both had colds. She told me that they had had a fever three days ago, when the coughing and sneezing started, but they looked fine now and a brief examination revealed nothing worrying. Paracetamol and fluids. Next patient.

“But doctor,” said their mother, “Aren’t you going to give them antibiotics?”

“No, they have a virus,” I replied.

“And what about malaria? Are you going to order a rapid diagnostic test?” she said.

“No, I don’t think they have malaria.”

“But are you sure, doctor?”

“OK, let’s do a deal. I will order the tests and if they are negative, you pay the cost of the tests. If they are positive, I pay you.”

“But doctor, I am a clinical officer at XXX and 90% of our clients have malaria.”

“Well, this isn’t XXX. We have plenty of malaria, but I don’t think your children have it at the moment. Do you want to take me up on the wager?”

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She agreed and took the children to be tested. As I opened the door, there was a posse of students carrying a patient like a roll of carpet. The patient was screaming and shouting incoherently. They barged into the room and laid her on the examination couch, where she rolled around spasmodically.

“What’s wrong?” I asked.

“She says she has got heart pain,” said the student leader of the group.

“When did she become ill?”

“An hour ago. She fell on the floor and can’t walk. We had to carry her here.”

“Is there any other history? Does she take any medication? Has she done this in the past? What is going on?” I asked.

“She’s got heart pain, doctor, that’s all we know.”

I ushered everybody out of the room except the patient. I quietly spoke to her, but she replied with groans and shrieks of pain. I noticed that as she rolled around the examination couch, she never came close to falling off. She turned onto her belly and lifted up her torso, as though she was doing push ups without using her arms. For a moment, I thought this was opisthotonos, possible tetanus or strychnine poisoning, but this behaviour was bizarre. I listened to her heart between spasms and checked her temperature, pulse and BP which were all normal. Clearly, I wasn’t getting anywhere. I suspected that this was hysteria so I called in the registration clerk, Daillies (Dilys).

Daillies bent down to the patient and spoke firmly into her ear for a minute or so. The patient stopped convulsing. I asked Daillies if we could move the girl to the ward, and to my surprise, the patient got off the couch and staggered out of the room with Daillies supporting her.

The girl’s father was waiting outside, but she disregarded him and lay on a bed in the female ward. I called to the father and he explained that she had suffered two previous episodes of heart pain. The nurses at a rural clinic had diagnosed hypertension. “Well, if they took her blood pressure when she was raving, of course it would be high,” I said. “I took her BP just now and it was fine. I am sure that this is not the problem. Has she been under any stress recently? Has anyone been bullying her at school? Does she have a boyfriend? I know that there are some exams coming up, has she told you that she is worried about them?”

Nothing, no clues. “Wait a bit, doc,” he said, “The last time this happened she had drunk a lot of sweet pop. Could this be the cause now?”

I was rather sceptical about this theory – a sugar rush causing hyperactivity? Nevertheless, I checked her blood sugar (4.7 normal) and did a rapid test for malaria (negative).

Daillies had continued to talk to the girl and she was now responding almost normally. She sat up on the bed and I sat next to her. “What happened?” I asked. She eventually told me that she had been physically punished twice by a teacher for something she hadn’t done. She could not stop thinking about the injustice and it turned into a frenzy. I explained that her behaviour was a strong reaction to stress, that her heart was normal, her blood pressure was fine and the tests I had done showed nothing abnormal.

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We spoke for ten minutes about how to handle stress, what to do when you feel cornered with no options, how to seek help from supportive fellow students or teachers. I invited her to return to the surgery and have a chat with me if she felt under pressure in the future, and she got up to leave. Her father gave me a strong handshake and warmly thanked me. I turned to go to the lab and looked at the results of the children of the clinical officer – both negative, but they had vanished. I wouldn’t have collected on the bet, of course.

Things that go bump in the night

It gets dark quickly in Africa. The sun sets about 5:40pm, the sky glows yellow, then orange and finally red, with smudges of smoky clouds over the horizon by 6pm. And by 6:10pm it is pitch black. I had been invited out to dinner, so at 7pm I locked my front door and started up the engine of my blue twin cabin pickup. I reversed out of the makeshift carport and felt the front driver’s side wheel bump twice. This was my second flat tyre in ten days. The first tyre had worn away the inside tread, making steering difficult over uneven gravel roads at 60kph. The puncture was in the wall of the tyre, however. I had replaced it with an equally dodgy spare tyre and this was as flat as a pancake.

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I live in an area adjacent to the National Park called the Game Management Zone, where wild animals co-exist with humans, but without strict protection. For the past three nights I have heard a lion roaring. This is not like the noise made by the lion which roars at the beginning of old films. It is more like a deep growling, almost like a comedy sound effect of water going down a drain. It is unmistakable once you have heard it.

Recently I have heard a strange screeching noise, followed by a fainter response. I don’t know what this is, perhaps an owl. Not the twit-twoo call, but more like a little owl’s screech.

I have also heard hyenas yelping close by. They make a high-pitched “yooo-up” cry, not like a laugh at all. Hippos make low pitched grunting noises, but elephants make the deepest sound, so low that you feel its vibration as well as hear it. Apparently they make this noise to communicate with other elephants over a kilometre away. When they are not communicating, they are tearing branches from trees, another distinctive sound. Two nights ago, I heard a furious, frantic yelping¬† from wild dogs in the dried out lagoon two hundred metres from my home. They make this sound when “psyching” themselves up to go on a hunt.

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Leopards make a coughing noise, but I haven’t heard this very often. At 8:30 this evening, coming home from visiting a sick tourist, the lights of my truck picked out a beautiful leopard as it slipped across the track. I cut the engine and turned off the headlights, opened the passenger window and shone my torch over the bush to see if I could catch its eyes. It was obviously moving away from me so there was no reflection from its choroid/retina. I have heard of big cats attacking passengers of motor cars through open windows, so I closed it promptly. I was only 100 metres from my home.

So I was not about to grovel about under the vehicle, trying to place a concrete block below the chassis jack point (because my bottle jack is too short) at 7:15pm with all my noisy neighbours making me fully aware of their presence. The host of the barbecue dinner telephoned me and offered to come out and pick me up, then to drop me back at home after I had eaten, but I felt it was too much trouble. I was supposed to be joining a photoshoot in the Park the following day, starting at 6am, so I needed to rest if I was going to change the tyre at dawn. Fortunately, I found that a colleague in the next camp was going to the same event. He offered me a lift if I could get there by 5:45am, so I walked warily along the track to Kapani workshop, flashing my torch from side to side, but I saw no gleaming eyes in the gloaming.

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PS Four punctures in ten days, in two tyres = new tyres needed. I am driving my old car, Phyllis, until they are available. The steering is slack, the suspension is shot, but it feels like putting on a comfortable, old shoe again.

The Internet

 

My house is in an internet black hole. To make things worse, all the windows are covered with fine metal mesh to keep out insects. Apparently, this makes my house a “Faraday Cage”, impervious to radio waves. It’s a double whammy.

The doctor has access to a dongle which fits into a USB port and contains a SIM card. It works when I am at the clinic, so I can look up clinical information on the internet. I have burned through 2GB in two weeks, so I was trying to curb my internet habit when my next door neighbour offered to let me use his new Huawei router for WiFi. He buys 10GB each month and he let me use it, as he was going to South Africa for a few weeks. I burned through that in a week, too, so I had to buy another bundle.

I went to the phone network MTN shop in town to get Christine’s help. I should mention that when she set up my dongle last month, she left her SIM inside, and put my SIM into her phone. And she blamed me for this. But everyone deserves a second chance, especially when there is no one else who could show me how to set up the system on the router.

I gave her 250 kwacha and she added it to the SIM. She then used this to buy a 10GB bundle. Simple enough, I thought. But when I got home, it didn’t work. I could connect to the secure network but there was no internet. I changed some settings, I changed my computer to a previous restore point when I knew the internet had been working, I tried to access a helpline, but I was offline. I almost ruined my Adobe Lightroom photographic editing programme doing this, and that would have been a disaster.

I went back to Christine the next day and she contacted MTN’s customer helpline on my behalf. Our call was in a queue for two hours so I gave up. The next day, I asked an IT expert expat who said that the bundle had not been purchased and applied to the account. Christine managed to get hold of the MTN customer helpline and this was corrected. For a brief instant, I had access, but Gmail home page was plastered with warnings about insecure access and people trying to attack my computer. It then shut down and would not let me connect at all.

“What’s going on, Christine?” I asked. “I think it is because you bought the bundle before the old bundle expired.” “But you told me I had no more data left on that SIM,” I said. “That’s why I bought the new bundle.” I asked her to try again to contact the MTN customer helpline and went to work.

This afternoon, Christine said she had some news for me, “Two other expats with this router have been having problems with their network, exactly like you.” Now she tells me.

I had a brainwave. “What about putting the router SIM into my dongle?” I asked. Christine said that she would try. In order to keep the dongle safe while she interrogated its SIM using her phone, she stuffed the dongle down her cleavage. There wasn’t much room for it, but I suppose it was as safe a place as any. Needless to say, it didn’t work either. It looks as though I am stuffed, too, when it comes to accessing the web.

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Christine put my dongle down her cleavage

But after a week of internet deprivation, I have now managed to get the receptionist at Croc Valley to get on the phone to Customer Services at MTN and my connection is restored. Thank you, H.

Monday Morning Meeting

“We always have a meeting on Monday morning. It informs the staff what their duties will be during the coming week. All government officers have a Monday morning meeting. It is how we do things here in Zambia.”

There have been some complaints to the District Commissioner about the health centre staff “sitting about talking when there are lots of sick patients queuing up to be seen”. She had received several SMS messages early on Monday morning. So the following day, she had visited the clinic and berated the health workers.

At a dinner party earlier this week, she asked me what was going on. I told her that the staff have a meeting every Monday from 8 – 9am. They normally speak in Nyanja, which excludes me, so I often miss the meeting and arrive for work at 9am. When I attend the meeting, they do switch to speaking English, but that makes the meeting drag on for longer.

But Monday is the busiest day of the week. We only provide emergency cover from noon on Saturday, so there are lots of clinic outpatients. Nurse midwife Regina runs a very popular Family Planning Clinic on Monday mornings. The clinic is heaving with patients, clogging up the waiting area, pushing into the ante-room outside the consulting rooms, lying down on the edge of the veranda.

If we have a full complement of staff, we can get to work quickly and clear the queues. But our senior nurse is away on long leave (three months) and another has to go to Lusaka to take an examination. One nurse has been on night duty and another is on “days off” following night duty. And recently we have had to send a nurse to the District HQ or Kamoto Hospital, to beg for supplies.

A health care assistant had to go to Mambwe to get a cheque for the clinic running costs. The cheque is then given to someone reliable who can deposit it in the nearest bank, at Chipata (two hours away). Four days later, the cheque will have cleared and someone will need to go to Chipata again to withdraw the funds and buy mops, cleaning materials, paint, soap, toilet rolls, paper, carbon copy sheets, batteries, pens, etc.

The DC told me that I need to show the health centre staff how to be more patient-centred. “You treat the patients with respect, you show that you care for them, you do not dismiss them. I think that the way you deal with them is almost as important as the drugs you prescribe,” she said. She’s correct.

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This won’t be an easy task. I am only here for another two months. In other situations, I have tried to improve standards by “leading from the front”, offering a personal example of how to work more diligently and respectfully. However, here in Kakumbi, it has been known for the nursing staff to knock off and allow the expatriate doctor to finish the clinic by themselves, so I am not sure that this approach will work.

Regina approached me and asked me if I had been able to explain to the DC about the increased workload of the malaria season. I told her that the DC was well aware of the additional patients we were seeing and the pressure the clinic was under from drug shortages.

“But why do we hold a meeting on Monday morning, the busiest time of the whole week?” I asked her.

“Because all civil servants in Zambia have a meeting every Monday morning. It is what we do,” she replied.

“Well, why can’t we hold the meeting on a Tuesday, when it is quieter, and there is no huge Family Planning Clinic?” I said.

“Because we have to have the meeting on Mondays. To know what duties we have in the coming week,” Regina replied.

“But let’s assume the staff know what their duties are on Monday, let them start work on Monday morning at 8am and deal with the massive queues. Then on Monday afternoon, or Tuesday morning, we can hold the weekly meeting. Would that work?” I said.

“No, Ian, you don’t understand how we do things in Zambia. This is our way.”

“OK, perhaps you can make the patients aware that the clinic starts late on a Monday because of the important meeting. Tell them to come after 9am on Mondays, explaining the reason,” I said.

“But if they are sick they will come at any time. Sometimes we are called out of the meetings to see emergencies. They will not understand.”

“Regina, what is more important – the needs of the patients or the staff rota?”

“If the clinic is not running properly and efficiently, with everyone knowing their jobs, the patients will not get a good service,” she replied.

I’m not in charge here. I am a volunteer. I help where I can. It is not my job to impose change. But I wonder what would happen if the DC, the DMO or Dr Daniel suggested changing the time of the meeting. How would the staff respond?

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Leopard

Su spotted it first as it crossed the track about a hundred metres in front of us, heading for the river. I was too busy steering the vehicle to avoid potholes and missed it completely. Once the leopard reached the river bank, it could turn right (downstream) or left (towards us). We gambled that it would come our way, so I manoeuvred the pickup to a place where we had a good view of the river between the bushes.

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Sure enough, within five minutes, we saw the leopard languidly moving past us on the riverbank. Its belly was so low it would be wet from the dewy grass. As it walked, its shoulders seemed to rise up higher than its back, in an attempt to reduce its visibility. I was fascinated by its paws, which were not fixed and rigid, but which flipped forward before touching the ground. It reminded me of a human walking with foot drop (take note of how John Thaw used to walk as Inspector Morse, flicking his foot forward to avoid scuffing the point of his shoe).

Su grabbed a few photographs and I reversed back along the track to the next viewpoint. The leopard was obscured by long grass, making photography difficult (cameras tend to focus on grass in the foreground, rather than the leopard in the background). I turned the pickup around and drove back to find a place where safari guides take their guests for morning tea, right on the river bank. I positioned the vehicle so we were facing downstream. We only had to wait a few minutes before the leopard appeared at the edge of the bushes.

After Su had taken more photographs, the leopard padded between us and the riverbank, totally unconcerned about our presence. We lost sight of the leopard as it moved down to the edge of the river. I re-positioned the pickup and took this series of photographs as the leopard re-appeared on the bank. She looked beautiful.

There wasn’t a track to follow the leopard and the main route swung away from the river, so we had a decision to make. Do we double back to the road causeway and look down into thick bush to get another glimpse of the leopard or do we call it a day and go looking for other animals? Su said, “Let’s go and find some wild dogs.” Easy choice. It wasn’t even 7:30am.