Underwear

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I have been regularly surprised by the nether garments of my patients at Kakumbi Rural Health Centre. Some people wear multiple layers, others nothing at all.

One lady who needed a gynaecological exam wore a chitenje (colourful wrap), over a skirt. Under the skirt she had on a pair of cut off jeans, black tights and finally a pair of panties. I asked my interpreter if this was normal and she said, “Of course, doctor. If she accidentally falls down in the village, she does not want to show off her private parts.” Not much chance of that, then.

The boys favour second hand underpants, with the waist band advertising their favourite football club, usually Chelsea. Stands to reason, really. Chelsea are pants. Sorry.

Other brands are obviously fake, such as “Kalvin Clines” or “G&D”.

A little girl, who always greets me with a wave from her compound when I am driving to the clinic, was caught short one afternoon on her haunches in mid pee. She stood up, panties round her knees, to wave and shout out, “Dok-Tah!” Unfortunately she kept on peeing.

Little boys just wear baggy shorts. Last week, I noticed a gang of four boys sitting on a bench outside the male ward at the health centre. I wondered why they were still there at knocking off time, when an old man told me that they had been waiting all afternoon to have their post circumcision checkups. I marched them into the nursing sister’s consulting room as she was packing up. “Let’s sort these boys out before we go home,” I said.

We lined them up and pulled down their shorts. The dressings on the first three boys had fallen off, so it was just a matter of having a look at the suture line and giving them advice about hygiene. The fourth lad at the end of the line was the smallest. Thanks to copious amounts of zinc oxide tape, his bandage was still attached. Rather than slowly peeling the tape off, the nurse decided to rip the dressing off quickly. The little lad gave a high pitched yelp and we looked down. Unfortunately, the “non-stick” petroleum gauze had been adherent to the head of his penis. His glans was red raw. The other boys hooted with laughter at his discomfort and tucked their tackle away. He fought back the tears, but couldn’t bear to put his penis inside his shorts. He left it hanging outside his pants, pulled down his tee shirt, and went outside to greet the world.

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The Human Immunodeficiency Virus

Before coming to Zambia in April, the last time I treated a patient who was suffering from pneumocystitis carini pneumonia (PCP) it was the early 1990s. He died from complications of HIV infection. Since the advent of combined, highly active anti-retroviral therapy in the latter half of that decade (coupled with the use of prophylactic antibiotics such as co-trimoxazole), PCP has all but vanished in UK.

Last week, I saw my first patient with PCP. She was very pretty, but emaciated. She said she was 21 but looked older. Her breathing was very rapid; she was gasping to get oxygen into her lungs and she had a low-grade fever. At first I thought she was too young to have PCP, as this affects people who have been living with HIV for several years, when their immune system has been progressively weakened. The locals refer to the gradual decline in health caused by HIV infection as a “slow puncture”. We would normally start PCP preventive treatment when tests indicate low immunity.

But girls can get married at 14 here in Zambia, although sexual intercourse is not legal until age 16. And beautiful young girls can be tempted by the attraction of wealth and status of predatory older men. Unfortunately, the erroneous belief that one can cure one’s own HIV infection by having sex with a virgin still persists. So this girl could easily have been infected five years ago.

I examined her completely and ordered the rapid HIV test. This came back reactive ten minutes later. A confirmatory test was also positive. How long had she been infected? In UK, we can assess the progress of HIV infection by checking the viral load and the number and proportion of special immune cells, CD4 lymphocytes. Amazingly, our health centre does have a CD4 testing machine, but it is reserved for pregnant mothers who are living with HIV. I couldn’t persuade the lab technician to break the rules and check my patient’s CD4 count. The result was probably not going to alter my management. My patient had advanced disease.

I turned to the senior nurse and asked, “What do you think?”

She said, “Pneumonia, she needs penicillin injections and gentamicin. It is what we give all people with pneumonia.”

“But it is highly likely that she has PCP. To have a bacterial pneumonia, you would be able to hear more signs in her chest,” I said. “Is there a protocol or guideline for treating PCP in Zambia?”

She was not familiar with any, but “it will be in THE BOOK.” We looked up PCP, but the book merely said it was an opportunistic disease associated with HIV infection. I try to work to the Zambian rules, but this was unhelpful. “She needs high dose co-trimoxazole. Do we have any injectable?” I asked.

“No, doctor, we don’t treat these people here. They need to go to Kamoto Hospital, where the district HIV/AIDS team is based. Or she can wait until next month when their mobile team visits the health centre and be assessed as a new patient with HIV,” replied the nurse.

“But she is almost in respiratory failure. She needs treatment now.”

“Eeeeh, doctor! Refer her, then.”

“She says she hasn’t got the 20 kwacha (£2) for the bus fare.”

“People are poor, doctor.”

She left the health centre with the help of relatives, clutching a referral form, trying not to vomit up the highest dose of co-trimoxazole I dared to give her. I have had no hospital feedback at the time of writing. Just another new case of HIV infection.

I understand that the nurses might seem blasé about tragic cases like this young girl. But you have to see this in context. In Zambia, the HIV epidemic killed hundreds of thousands of people between 1985-2000. A whole generation of young, educated professionals was decimated. Recently, the WHO Global Programme on HIV & AIDS has made anti-viral drugs easily accessible (thank you for promoting this, former US President George W Bush). The death rate has fallen, but we detect new infections every week.

People can attend the clinic to get tested for HIV. This is called VCT (voluntary counselling and testing). Last quarter, just over 11% of VCTs were positive in the 15-45 year age group.

Anyone who is admitted to the ward, attends the clinic with a sexually transmitted infection, or is persuaded to have a test by a health worker suspecting HIV infection, has a DCT (doctor counselling and testing). A greater percentage of these tests are positive.

Twice a month, the HIV/AIDS mobile team visits the health centre to monitor patients, give out their treatment and check for side effects. Our catchment population is 10,200 and about 900 patients are receiving anti-HIV medication. Fifteen years ago, these drugs would have been horrendously expensive, costing each patient thousands of pounds per year. Now they are free. For the moment, anyway.

The patients are grateful, but still do not volunteer that they are living with HIV when they attend the health centre for other problems. I have to keep HIV in the back of my mind with every patient I see. By and large, the patients are well. They have strange skin diseases which leave me perplexed. Probably fungal infections and weird presentations of “standard” skin problems, such as seborrhoeic dermatitis. Unfortunately, we don’t have the oral anti-fungal drugs, which are too expensive to be used for “cosmetic” problems.

Talking of cosmetic problems, I saw a patient who was taking anti-HIV medication, two months ago with a rare side effect. She had truly massive mammohypertrophy. Huge breasts. Football sized. The poor woman had been told this had been caused her anti-HIV medication, but changing this had not caused the breasts to return to their normal size. I suppose a mastectomy or breast reduction surgery would be the only option for her.

Everyone agrees that prevention is vitally important. But thirty years of health education, promoting safer sex, abstinence, sticking to one partner, etc has not done much to reduce transmission of HIV. The current reduction of incidence of new infections is probably related to anti-viral medication. This reduces the viral load and hence the infectivity of people living with HIV.

We have the capability to prevent vertical transmission, that is, pregnant mother infecting their babies. Over 90% of women attending our ante natal clinics have an HIV test on booking. The other 10% say that they have recently had a test, so don’t need another. If a woman’s test is reactive, they are counselled and offered anti-HIV drugs later in their pregnancy to reduce the risk of transmission. They are not offered a Caesarian section, but measures are taken to reduce infection in breast milk by treating the baby with anti-HIV drugs. A few women can afford to bottle feed their babies, but this option is not promoted because of the danger of gastroenteritis.

Zambia has highly sophisticated PCR (polymerase chain reaction) testing to look for the virus in infant blood. We take spots of blood from a heel prick, dab them onto a special absorbent card and send them off to the capital. Unfortunately, it currently takes three months to get the results, which is disappointing.

Children with HIV suffer more complications if they get malaria. I should have written WHEN they get malaria, as it is inevitable. I have seen two children develop severe malaria (it used to be called “cerebral malaria”), probably because their immune system was already compromised. They seemed to be getting better 24 hours after starting treatment, but then declined with convulsions and decerebrate posturing.

I have written before about the man who was almost scalped by someone running amok, wielding a grass cutting sword. Stopping the bleeding was difficult and suturing his wound seemed to provoke more bleeding. My consulting room was awash with blood. He must have lost a litre or more. He had to attend the local hospital for a police report, but he came back to me to have his sutures removed. He was wearing his best clothes and had his head shaved in a fashionable style, which gave me easier access.

“Oh, something I’ve got to tell you, Doc,” he said. “They did a test at the hospital and told me I am HIV positive.”

“I’m very sorry to hear that. Is there anything I can do to help?” I replied.

“No, Doc, I’m fine. It is just part of life. I will go on living. It will not stop me. Ow! That last stitch removal hurt.”

Caption Competition

Can you provide some suitable captions for the following photographs:

"You just stepped on my heel!"
“You just stepped on my heel!”
"Are you talkin' to me?"
“Are you talkin’ to me?”
Undercarriage deployed
Undercarriage deployed
Sweet head
Sweet head
"He swallowed your whistle, ref"
“He swallowed your whistle, ref”

Mumps

These children don't have mumps. They are just posing for the camera
These children don’t have mumps. They are just posing for the camera

One evening, over dinner, a Zambian guide at the lodge was talking about traditional treatments for illnesses. This was fascinating for me, and I filed away lots of interesting therapeutic techniques for future use.

When a patient with mumps came to the clinic last week, I examined the patient to confirm the diagnosis and said:

“You must find a small bundle of twigs, tie them with sisal and place them on your head. Walk to a pathway which forks into two and at the junction, you must dance until the twigs fall from your head. Then immediately walk home, without looking backwards. And in a few days you will be cured.”

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My interpreter looked at me in amazement. “How did you know this, doctor? Is this how you treat mumps in your country, too?”

To my shame, I couldn’t resist saying, “Yes.”

Today, the bird I have most enjoyed watching was the Lilac-Breasted Roller

Lilac-Breasted Rollers are ubiquitous in the National Park. These birds are easy to spot because of their gorgeous plumage and their habit of perching on dead trees where they have a panoramic view of their surroundings. From on high, they can spot lizards, scorpions, small snakes and insects on the ground. They swoop down on their prey and will often just hop about for a while on the ground after it has eaten.

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Rollers have excellent aerobatic skills. During the breeding season, males will fly high into the sky before zooming down like a Stuka, squawking loudly.

As its name suggests, the breast is lilac coloured, with an azure blue belly. The head has white whiskers and eyebrows, with a black bill and greenish crown. The back of the bird is cinnamon coloured. Adults have long twin tail feathers. Very exotic.

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You have to be quick on the shutter to photograph these birds. They are notorious for flying off when you reach for the camera.

Today, the animal I have most enjoyed seeing is the Waterbuck

Male Waterbuck
Male Waterbuck

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These antelopes graze in marshy areas and lagoons, but are not as “aquatic” as their name sounds compared with sitatunga in Uganda or lechwe in Botswana. I find them rather skittish and shy. As soon as I stop to take a photograph, they move on.

Female Waterbuck
Female Waterbuck

In Colombo Zoo, 30 years ago, I made the mistake of scratching a tame waterbuck on its muzzle as it poked its head through the bars. My fingers reeked of its rank scent for about a week, despite Lady Macbethean efforts to wash it off. Apparently other predators feel the same way, and will only attack a waterbuck if they are really hungry.

Family group
Family group

There are two types of waterbuck in Zambia. We have the standard type with a white ellipse around its hind quarters. The guides all tell the joke about how Noah was having some problems with basic hygiene on the ark. He had whitewashed the toilets, but the waterbuck was desperate to go and sat on the seat, acquiring a white ring. The other species is the Defassa, which is found in Kafue National Park. It backed into the urinals and has a white vertical stripe down the back of its hindquarters.

Today, the animal I have most enjoyed watching is the Hippopotamus

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Hippos are big in the park. There are lots of them. Even when an epidemic of anthrax culled scores of them five years ago, they bounced back. It only takes a few years for their numbers to return to previous levels. Of course, no one mentioned “anthrax” apart from as a whispered aside. We don’t want to scare away the tourists. Anthrax to most people in Britain conjures up memories of a remote Scottish island used as a testing ground for biological warfare in World War 2.

During the heat of the day, they flop down in the river or a muddy pool to cool off. They forage at night, eating huge amounts of vegetation. They like to sunbathe on sandbanks in the morning and evening, huddled in a pack. Their skin secretes a pinkish substance which one guide referred to as sunscreen. And although their skin is tough and leathery, it can burn. Under the skin is a thick layer of blubber, which assists with flotation and stores energy.

Basking in the last of the evening sun
Basking in the last of the evening sun

Each pod has a stretch of river or a part of a lagoon which they call home. They defend it aggressively against intruders. Steve Tolan from Chipembele did a long boat trip on the Luangwa River recently and recorded 300 serious hippo assaults on their metal craft. They were more dangerous than the huge crocodiles in the river.

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Anyone who has seen hippos in Africa will remember their deep grunting call. It really sounds impressive, basso molto profundo. I mistakenly thought that the low frequency noises passed better underwater, facilitating communication. Of course, they are grunting on TOP of the water. Perhaps it just lets the neighbouring pods know they are still around. It seems that they also employ clicks and more sophisticated noises underwater, much like dolphins.

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As the baby male hippos grow into adolescence they start play fighting. The jaws open over 90 degrees to display their massive teeth. These are hard, like ivory and slide against each other to slice up grass and veg. They can inflict serious wounds on people as well as other hippos. As they mature, the males are “encouraged” to leave the pod, to start a new life or to challenge an ageing bull hippo for his harem.

Hippos are huge. You can see how broad in the beam this female is in a view from Luangwa Bridge. There is a baby hippo in shot, too.
Hippos are huge. You can see how broad in the beam this female is in a view from Luangwa Bridge. There is a baby hippo in shot, too.

Hippos are not a usual target for poachers, but I am told that their meat is particularly tender. Their muscles may not be as toned as those of an impala, but they are very strong. Just getting out of the river to go and feed at night often involves climbing up a 45 degree muddy slope. And they can outrun a man on land, if only for short distances.

Last Sunday, on a game drive in the Nsefu Sector of the Park, we stopped by the river for a sundowner. One massive hippo on the bank started to defaecate. The hippo’s tail whirled around, splattering the green/brown slurry coming out of its anus over a wide area, marking its territory.

One of the guests in the safari vehicle, a loud American man with something to say about everything we saw, said, “That’s how I go to the bathroom!”

I replied, “What do you use to spread the shit around?”

His long-suffering wife said, “Touché.”

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