Back in Blighty

It is strange being cool again. What did I expect from an English summer? A heatwave was forecast to happen over the next six weeks, but the weather is changeable at present.  I love the bright greens of leaves and grass. The striking colours of flowers in front gardens are so bright that they seem artificial.

The city is still basking in the glow of the Premier League Championship. Banners showing LCFC soccer players flutter from the lamp posts. My friends took me to the New Walk Museum to see an exhibition celebrating not the Pre-Raphaelite Brotherhood (Christina Rossetti has some of her works stored away at the museum), nor German Expressionists, but a football team. The exhibition is called #Fearless, after the way the team played 18 months ago, when they were eight points adrift at the bottom of the league. No team had ever avoided relegation from this position.

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Fearless is the name given to centres dealing with sexual violence in India

Outside the tunnel leading the way to the main exhibition, there was a tabletop TV set up, showing how LCFC  gritted their teeth and won game after game through the winter. Not only did they avoid relegation, they rose to 14th by the end of the season. Their performance in the last few months of the season was stellar. The bookies foolishly ignored it and offered to pay out bets of 5,000 to 1 if City won the league in 2015/16. Some brave souls put down £50 and ended up winning £250,000.

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The exhibition was stunning. It was arranged around the walls of the hall, starting with the first day of the season. There was a great selection of photographs of the players and managers, hanging on banners from the ceiling. There were witty tweets and social media comments, discussing games. The underdogs became the top dogs.

I was overcome by emotion. My mouth was dry, my eyes were wet, there was a lump in my throat. I felt proud of the team of rejects and misfits who gelled into a team where the players really work hard for their colleagues. The entire team cost less than one Manchester City player.

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There were some dance steps painted on the wooden floor – how Mahrez skipped around defenders, how Ngolo Kante passed the ball backwards to his other foot before crashing it past the opposing goalkeeper. I tried to follow in his footsteps, but couldn’t do it, never mind keeping control of a ball at the same time.

A small boy sat in front of the successful team photograph so I had to take the shot. Then it was my turn. I paid homage to Ranieri.

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The exhibition was witty, too. A perspex cabinet contained a pack of Jamie Vardy crisps and a bottle of Wes Morgan spiced rum. There were tee shirts with funny slogans. Some of the tweets were hilarious. I was sad to leave, but I had to go to my annual appraisal.

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Time for a change

Early next month, I start work with Medecins Sans Frontieres (Doctors Without Borders) in Jahangir Puri, a slum area in North Delhi, at their new sexual and gender based violence clinic, Umeed Ki Kiran. The contract is for a minimum of 12 months.

From the clean air and pleasant climate of South Luangwa in July, I will be moving to a city with appalling air pollution in the middle of the humid rainy season in August. There are more people crammed into the Indian capital than there are in the whole of Zambia. I remember returning to London following my first visit to India in 1978. It was just before Christmas and the shoppers were out in force. But after struggling with the masses of humanity at Connaught Circus in Delhi, London seemed bizarrely  empty, even  with the crowds in Oxford Street.

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Instead of seeing leopards and lions in their natural habitat, the animals I am most likely to come across are rats and other vermin infesting the biggest fruit and vegetable market in Asia, which is close to the clinic. I admit that I would quite like to see some tigers, however.

So why am I doing it? This is a natural extension of my work in MSF Matsapha at the SGBV clinic but in a totally different context. Although I have all the clinical skills required, the new job will be mainly supporting, advising, training, teaching and coaching local health workers. MSF wants to demonstrate how to provide a world class service for survivors of sexual violence, raising awareness and acting as a catalyst for change. And I relish a challenge.

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This is NOT where I will be working in Delhi. “Consult for early discharge” sounds intriguing

I will miss the direct clinical interaction with patients (though I intend to apply for a medical licence in India). I could have volunteered to work as a doctor in Northern Myanmar with MSF, but at this time in my career, I feel  I need to pursue a slightly different path.

Because of the highly sensitive nature of the project, I do not intend to continue writing a blog about my work. But I may be tempted to write about everyday life in Delhi, with a few photographic illustrations. Watch this space.

I would like to take this opportunity to thank all my loyal readers. I think it is life affirming to write about the humour  which I see in my everyday experiences, regardless of the endless frustrations and inevitable cock ups of working in developing nations. I hope I have entertained you with my quirky view of life working as a doctor overseas.

 

And POTUS begat PEPFAR

“And POTUS begat PEPFAR” sounds like a passage from the Old Testament. In 2003, George W Bush (POTUS) set up the President’s emergency plan for AIDS relief (PEPFAR) to combat HIV/AIDS. This initiative has saved millions of lives by providing medication, training, supporting labs and infrastructure. But there needs to be accountability, to find out what is being done with the money. So health centres throughout Africa come together regularly to review their data.

Last week, Eastern Province held a meeting of all the health centres to discuss their performance in Quarter 1 of 2016, as compared with the last three quarters of 2015. The afternoon before the meeting, our clinic staff were in a flap because they had not completed entering the data for Q1. They were concerned because other health workers could ask searching questions about the data, revealing possible poor performance. At their request, I joined the team, helping to calculate the figures and to prepare answers to potential questions in areas where it looked as though we were not up to scratch. We finished just before 17:00.

At 7:30 the next morning, I picked up the nurse in charge and the second in command (who had never attended a meeting like this before and was being “blooded”). We arrived on time at the venue at 8am to find the meeting room empty. A couple of male nurses were at the bar, watching edited highlights of the European Cup soccer on the big TV screen above the optics. Eventually proceedings got underway 40 minutes late. Unlike Swaziland, we did not sing a hymn at the start of the meeting; we just had a prayer asking for divine guidance. I think we needed it.

The first speaker from Headquarters gave an overview of the performance of the entire province, using amalgamated data. He showed over 40 “busy” PowerPoint slides packed with detail. Instead of facing the audience, he spoke to the screen, reading directly from the slide. From the expressions on people’s faces, I could see that the audience was reeling from data overload. What did it all mean?

“Any questions?” he asked. Silence. Not a dicky bird. So I thought I’d get the ball rolling. “Thank you for an excellent detailed overview of the results of Q1. Could you pick out one or two of the most interesting points which you want to highlight?” I said.

The poor man was completely flummoxed. It was his job to present the data, not to analyse it. He had no opinion on what was important and what wasn’t. I would have to ask individual presenters about this. Fudge. I don’t think he had really contemplated what he was saying. He just read out what was on the screen without any analysis or curiosity. We moved on, but not so swiftly.

The health centre scheduled to speak first was not ready to present, so Kakumbi got the call. Our nurse in charge did well, speaking quickly and clearly. Unfortunately many of our results were in the red, meaning suboptimal. The reasons for this are complex. You can skip the next paragraph if you get bored easily.

It is not enough to count the number of attendances, positive tests, deaths and so on. Using figures projected from the last census (five years ago), health centres have “targets” to meet. For example, taking into account the national birth rate, the CSO estimates how many pregnancies and deliveries ought to be taking place according to the catchment area of the facility. If the CSO data predicts 160 deliveries per year, then every quarter there should be 40 new babies. With population growth at 4% per annum, the population is automatically increased on January 1st in Quarter 1, so if you deliver 40 babies again, you will be underperforming because there should be 42 births. The actual performance of health centres is compared with the predicted performance. There is some leeway allowing health centres to do headcounts if they feel the CSO data is inaccurate, but this is very time consuming for centres with wide catchment areas.

The lady in charge of Mother & Child Health was critical of our apparently low number of deliveries. “Why are the women not coming to the centre to deliver?” The nurse in charge said that we practised in the Game Management Area, so pregnant women starting labour were unwilling to walk to the health centre at night through the bush. The solution to this was a shelter where mothers-to-be could stay, close to the health centre until they were in established labour. But our waiting area has been crammed with building materials for the shelter for months. No work has taken place. Unfortunately, this diversionary tactic did not work.

“Ah, but the number of women coming for their first postnatal visit is still less than it should be,” exclaimed Mrs MCH. “Women who have delivered could walk to the centre in daylight.”

Nurse in charge looked downcast. I spoke up, saying that our family planning clinics were so effective that we had fewer deliveries than the planners in the Ministry of Health in Lusaka predicted. Also, quite a few women would had been referred to the district hospital for operative deliveries, and they would still be inpatients there on day six.

“But I think that it is your negative attitude towards the mothers which is causing the low attendance,” replied Mrs MCH, triumphantly. Nurse in charge agreed that midwives did criticise women who had delivered at home when they came for postnatal checks at the centre. “It is government policy for all women to deliver in a health facility and we were just pointing this out.”

Hmm. The previous day I had heard a complaint from a pregnant woman who said she was turned away from the health centre because she was barefoot. Nurse Zulu said that this was a misunderstanding. She had given a talk to antenatal women on appropriate footwear in pregnancy with the health message: “Do not wear high heeled shoes; you must wear flat ones.” So the woman thought she would be turned away if she wore no shoes. It is obvious that Nurse Zulu was from the paved streets of Lusaka. I have never, ever, seen a patient in Kakumbi wearing high heels. They wouldn’t last five minutes on the dusty, uneven, dirt roads. Surely she could have been discussing more important issues at the antenatal clinic?

I know that some nurses speak harshly to patients who are dirty and smelly, accusing them of being disrespectful of health workers. The atmosphere of the clinic is not as patient-centred as it is in the NHS. For example, at lunchtime, staff get very irritated if there are still patients waiting to be seen and I continue working. If I wasn’t there, I guess that the doors would close at 12:30 and the patients would have to wait until 14:00 to be seen. Maybe Mrs MCH had a valid point.

We fielded the next few questions, agreed to look into providing mobile antenatal care (a non-starter) and, with an audible sigh of relief, nurse in charge came back to her seat.

Now it was another health centre’s turn to run the gauntlet. Their data looked fantastic. Immunisation coverage 246%. How could this be? “Oh, we vaccinated a few villages outside our catchment area.” But 246%?” “Yes, it is very high so we did a head count. This showed we were just overperforming by 130%.” I tried to stifle a laugh, making it into a cough. No one asked any further questions about this, probably because no one knew the answers.

I felt sorry for the medical officer in charge of the district hospital as he was unwell and had to present his data sitting down. When he finished, he said, “Thank you for not asking any questions.” But we did. “At the beginning of the year there were 78 new HIV positive patients taking anti-retroviral drugs, but at the end of the year, there were just 70. What happened to the eight?”

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The medical officer in charge said he didn’t know. “Had they died?” “Did you transfer them to other units?” He could not offer an explanation, so the discussion ended. There was no suggestion that he should look into this, that it was a glaring omission. He had presented the data, that was his job. If it wasn’t recorded in the dataset, he knew nothing about it.

I don’t think that many health workers analyse their data critically and try to find out what happened. They see their job is to collect the data, without any detailed examination of the results. That is done by the people with desk jobs at headquarters.

The day wore on. More people presented excellent results, 100% for good indicators, 0% for bad indicators. Several people were happy to say that they had exceeded their targets, well over 100% in some cases. The number of people diagnosed with an STI equalled the exact number of contact tracing slips issued. It looked too good to be true. Doubts started to creep into my mind about the veracity of the data.

This reminded me of a similar situation of a few years ago in Swaziland. Every centre was reporting almost perfect results. This was not credible, so instead of allowing health centres to submit their data, the Ministry of Health Monitoring and Evaluation SWAT team would descend unannounced on health centres, scoop up their ledgers and prepare the data themselves. No more Mr 100%.

Lunch was also over 100%. There was no shortage of nshima (Zambian polenta). My meal was a whole fish which filled the plate. I ate the flesh and put down my knife and fork, to the astonishment of my fellow diners. “Eh, Dr Ian, you are not a Zambian,” said one. “I always start with the eyes. Then the head. It is the tastiest part.” I said he was welcome to pick the skeleton I had left on the plate, but he declined.

After lunch, the atmosphere in the meeting became torpid. One sleeping health worker was delegated to take the minutes, but he declined, saying that there was a secretary to do this. People were stifling yawns. Some people were fiddling with their smart phones beneath the table. I tried to keep awake by guiltily doing some work on my laptop.

At the end of the meeting, everyone felt exhausted. More than a few seemed demoralised. We must have heard a dozen virtually identical presentations. The questions had petered out. It was time to go home. Did anyone have anything else to say?

I stood up and said, “I appreciated being invited to attend. The meeting was very interesting and we ought not to lose sight of some important facts. No women had died in labour in the province in the last quarter. Immunisation rates were well ahead of those in UK. No drugs had been allowed to go out of date. The incidence of HIV appeared to be half of what it was two years ago. Only a handful of children had malnutrition. We ought to congratulate ourselves on the good work we are doing and look more closely at the indicators next quarter to see how we can improve further.” Cue dramatic applause and time for prayers. Phew. Clinical work had never seemed more enticing.

Kakumbi Clinic – my final days

Yesterday, as I drove to the clinic, I saw a man at the roadside, flagging me down. Normally, I wouldn’t stop (the medical association discourages picking up hitchhikers), but this man was in uniform. And he was carrying a very large rifle. I pulled over and he got into the cabin. We greeted each other and I told him I would drop him off at the village, which was fine with him. He told me he was a scout for ZAWA, Zambia Wildlife Authority. His uniform was jungle camouflage; policeman have green uniforms with a wavy red pinstripe, I should have known. I asked him if the gun was loaded and he shook his head. Nevertheless, I drove very carefully, gingerly picking my way between the potholes.

I picked up F from the craft shop by the fuel station and took her to the clinic. She was extremely helpful when we were doing health education sessions in schools, but had been ill recently. Her employers had asked me to offer her a consultation. F and I came to a shared understanding of the problem and how she might try to fix it. I brought her back to the craft shop and another lady working behind the counter asked me to see her. This time I did the consultation in the vehicle, with F translating for me. I worked out what was wrong and gave her some advice. Before I could leave, yet another lady collared me that she had “side pain”. I had been called to see someone staying in the Park, so I told her I would return to see her later in the day.

As I was driving back through the Park, a young man stepped out in front of the vehicle, waving his arms frantically. He looked rather strange, and not just because he was wearing a Manchester United football club shirt. When I stopped the car, another man hobbled over to me and asked for help. He recognised me as the Valley doctor because of the blue twin cab pickup I was driving. He showed me his swollen foot. There was a laceration right across the sole, caused by him stepping on a broken bottle. “I went to the clinic yesterday. No bandages, no dressings, no Panado,” he said. He had been given erythromycin and sent away. Despite the “no passengers” rule, I drove him back to the clinic and discovered his aunt worked there. She cleaned and dressed his wound, and I gave him some of the paracetamol which had been donated by kind ladies from the British National Police Aid Convoys. He needs to take a week off work to rest and elevate the foot. It was too late to attempt primary wound closure, it would have to heal by secondary intention.

As I was walking back to my car, I saw a gravely ill child, about 10 years old. “He’s got respiratory distress,” I said to the registration clerk. “No, it’s malaria, doc,” she replied. I dropped into the lab to check and see how many new cases of malaria we had diagnosed. The figures are still high, but are dropping gradually from their peak in May. As I left the clinic, I saw the mother struggling to carry the ill child on her back. It was really hot, so I stopped the car and asked where was their village. It was less than 5km away, but I felt I had to take them home. When we got there, I pulled over and examined the child. He had right lower lobe pneumonia and a fever of 39.8C, breathing rapidly, moaning softly and in obvious pain. I checked the medication he had been given and was relieved to find he had been prescribed anti-malarials, painkillers and antibiotics. As they got out of the car, I asked if anyone spoke English. A man came over and I explained that if the child was not better by tomorrow morning, they must return to the clinic. The man thanked me and picked up the child to take him home. I wondered if he would have received better care if I had referred him directly to hospital.

I drove back to the craft shop and took the lady with side pain into the store-room. I must admit, I suspected that this might be a fruitless consultation. Then I got the whole story. She told me that she had been unwell for months, with chest wall pain, night sweats and productive cough. She had been to the clinic and was prescribed antibiotics, but they hadn’t helped. I asked her if she had lost weight, but she had no access to scales. “Do your clothes feel loose?” She didn’t know because she used a chitengi, wrap around skirt. I examined her chest and there were reduced breath sounds in the lower left lung, where she was feeling pain. “I want to rule out tuberculosis,” I said. “Go to the clinic on Monday morning and produce some sputum for a TB slide. We may need to refer you to hospital for a chest Xray.”

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Oral candidiasis

I only worked at the clinic on Wednesday and Friday this week. I assisted with the under 5s outreach on Thursday, when we did our first ever mobile antenatal clinic. No pregnant women came. We obviously need to improve our publicity. On Friday, the nurse in charge wanted me to review the HIV patients. I saw a young woman with full blown AIDS; a new patient with a pleural effusion, which was very likely to have been caused by TB; someone with possible Pneumocystis pneumonia; a man with a swollen testicle and epididymis, again probably caused by TB; two people with declining CD4 counts (immunological failure, possible resistance) who swore that they never missed a dose of medication – they need viral load estimation; a man with a submandibular salivary gland abscess, which Nurse Zulu lanced with gusto and delight as it produced lots of pus.

Apart from the people living with HIV, I saw several other patients who had been referred to me. One young lady had a necrotic abscess caused by a spider bite – it resembled a mini Vesuvius. A middle aged man who, despite completing six months treatment for tuberculosis, had deteriorated. His voice was hoarse, the left lung was collapsed and he had an enlarged liver. I told him that he probably had lung cancer, not TB, and he said that this was what the doctors at St Francis Hospital Katete had said, too. Another man had a septic arthritis. I diagnosed a retropharyngeal abscess in another patient. A 40 year old woman came with her mother, both of whom had dense cataracts in their left eyes, they matched. They suspected sorcery; I suspected untreated glaucoma in one and corneal scarring in the other. But I was happy to find that my hypomanic patient, whose family had chained him to a door, was doing well once he had started taking anti-psychotic medication.

There’s never a dull moment in Kakumbi Rural Health Centre. At times, I felt I was flying by the seat of my pants over the past three months, but I thought I coped quite well. I am going to really miss it.

Marketina

“There is a belief in Zambia that if you are HIV positive and you sleep with a mad person, you will be cleansed of the infection, ” said Nurse Zulu. “That is why three quarters of the mad people are HIV positive.”

Living with severe enduring mental illness in developing countries is bad enough even without HIV infection. But suffering from both is a toxic mixture. You need to be fairly stable in order to comply with anti-HIV drug treatment and to attend clinic appointments at the correct time. Unfortunately, we have no anti-psychotic medication at the clinic. The patients who need it don’t have the means to travel two hours by bus to get drugs from Chipata Hospital. There is a national psychiatric hospital in Lusaka called Chainama, where hundreds of in-patients live inside a wire fence. According to Nurse Zulu, some live inside a cage. The patients are segregated according to how violent they are.

People with severe mental illness exist on scraps and leftovers, sleeping in doorways or wherever they can find shelter. Villagers provide community care when they can, tolerating bizarre, disruptive behaviour until a line is crossed and the police intervene. The police treat all lawbreakers equally and make no allowance for mitigating circumstances unless there is an official certificate from Chainama stating that the person is mentally ill and not responsible for their behaviour.

When I arrived at the clinic, our reception clerk informed me that a mentally ill pregnant patient had delivered a baby in among the empty market stalls overnight. “You should have sent her to Chipata, doctor,” said Daillies. “Everyone was watching the baby come out, even small children.” Perhaps I should have tried, but I have no legal powers to force her to go to hospital. The baby girl was tiny, just 1.8kg, born at least six weeks prematurely. Her mother did not seem interested at all, and paid the baby no attention.

Some local women rallied around and were offering to provide foster care, as clearly, the mother was in no fit state to look after the child. They were discussing how to feed the child. I asked about any woman whose baby might have recently died, a wet nurse, but there were none. Two of the women who were willing to help both flopped a breast out but could not express any milk. Daillies grabbed hold of the mother’s breasts and squeezed but unsurprisingly, there was no milk, just colostrum. “Baby will need formula milk,” she said.

I contacted a doctor at Kamoto about a referral to social services and he told me that both mother and baby should pass on to Chipata Hospital. I wrote out the referral, but another visiting doctor took a more practical approach, saying that it would take weeks for social services to respond. He suggested we make local arrangements to care for the baby here in Kakumbi. One of the women said that there was no baby milk formula in Chipata Hospital and the baby could starve. We did manage to obtain some prophylactic treatment against HIV for the baby. One matronly woman agreed to take on the role of foster mother to look after the child.

Two compassionate expatriate ladies offered to help with all the accoutrements needed for a new baby, feeding bottles, baby grows, nappies, blankets, formula, bucket for bathing, etc. One even provided some food for the mother, who has no visible means of support. We will wait until we are contacted by social services to decide what further action is needed.

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This photograph bears no relation to the baby in this blog

“But the baby doesn’t have a name,” said one woman.

“What about calling her Marketina, because she was born in the market?” suggested another. This reminded me of a newspaper report in Swaziland of a baby born while the mother was in a supermarket.  That baby was named “ShopRite”.

“And what about her second name? Doc Ian, what is your second name?”

I politely declined, saying that it should be an African name. There is already a woman, now aged 32, with the unfortunate name “Docta Cross”, who was born in the Gambian village of Galleh Manda when I was Regional Medical Officer. But that’s another story.

I think it would be better to give the child a traditional name meaning “Blessings” or “gift from God”.

Excrement

Several months ago, I mentioned in a blog that an infusion of elephant dung is a traditional remedy to treat hypertension. About half of what elephants consume passes through its intestines without the nutrients being digested or absorbed, so it is just possible that vegetation could contain chemicals with an anti-hypertensive action. But I would rather take tablets.

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Even this elephant is spreading his ears in surprise at the use of his dung

A well-respected guide told me about the traditional treatment for crocodile bites. As soon as possible, smear the wound with human faeces. The (twisted) rationale for this is that the bite introduces pathogenic bacteria from the crocodile’s mouth, so by providing an alternative substrate (faeces), the bugs won’t attack human flesh. “Of course, the doctors wash it out when the patient gets to hospital, but it is the best initial treatment before antibiotics are given,” he said. “That is total crap,” I told him.

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This photograph of a boy wearing a baby’s woolly hat, covering the strap of a handbag has nothing whatsoever to do with this blog

He went on to tell me about the use of male hippopotamus dung for treating babies with colic and constipation. The dung should be mixed with water and left overnight. Then it is strained and the supernatant is given to the baby orally. I am not surprised that it treats constipation; the baby is likely to get diarrhoea from this potion.

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Hippo spraying its dung around using the propellor action of its tail

My next door neighbour burns dried elephant dung in an attempt to keep mosquitoes away. I am not sure it works very well, as I still get bitten when I visit the house. My other neighbours swear that the smoke from burning elephant dung deters mopani flies and wasps in remote rural areas.

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Luxury in the Bush

If Bilbo Baggins had $5,000 to spend on a day’s vacation on safari, Luangwa House is where he would choose to go. It looks like a palace for hobbits. The thatched roof undulates over the crazy-paving walls. The dried grass porch outside the main entrance is held up by four tree trunks. The front door is massive, made from thick planks of wood and broad, horizontal strips of metal. It is hinged on top, just off centre, so when it opens, people can pass either side of it. The upstairs bedrooms have balconies which look like drawbridges.

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You may think that $5,000 a night is exorbitantly expensive, but it can accommodate four couples, each with a bedroom  and themed en suite bathroom. The house has its own chef and servants. There is an infinity pool and a decked pier which leads to a sunken observation room, from which one can photograph the animals at extremely close range.

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The decor of the interior is simple but beautiful. The dining table is polished marble. A sculpture of a leopard (by my neighbour, Pam Carr) made from the thin limbs of a strangler fig tree covers one wall. The back wall is completely open, giving a panoramic view of the lagoon and bush. The comfortable settee has cushions covered by Tribal Textile designs.

Su, Tabitha and I went for a viewing when the house was vacant. Lovemore (“His name is appropriate,” said Tab), the butler, showed us around. The main room is one huge space up to the thatched ceiling. The living area has no air conditioning because it is so open, but there are several ceiling fans hanging from the rafters to waft the air around in the hot season. The floor is cool, polished stone.

The bedrooms are spacious and tastefully furnished, with hardwood planks built into the walls for shelving. The bathrooms are unique. One has a large semi-circular window between his’n’hers showers. Tree trunk emerge from the walls and the floor (to provide separate places for toiletries). The other bathroom has a copper theme. The bowls, taps, bath and shower fittings are all copper.

As we sat outside, elephants trundled up to the lagoon to drink and cool themselves down. Across the plain there were impala, bushbuck and puku. We gazed out, hoping to see a dramatic chase and kill, but it all looked tensely tranquil. Forget early morning game drives; I could spend the day watching the action from a comfortable chair on the veranda and by the pool.