Inspection by the Eastern Province Chief Medical Officer
I didn’t notice anything amiss when I drove up to the clinic at 8:15am this morning. I had been desperately seeking internet access using my neighbour’s router at the MTN shop, so I was a bit late. I parked under the tree, next to the lab, where my vehicle would benefit from shade until late afternoon. I greeted Trognes, the lab technician, who was wearing her new Beyoncé-style wig and walked towards my consulting room. I saw some colourful new blankets on the beds in the female ward and thought to myself, “That’s good, someone is making an effort to make the health centre look beautiful.”
Nurse midwife Regina showed me my room. The table had been cleared of clutter and it was covered by a new piece of linoleum. I was pleasantly surprised, but an unkind thought crossed my mind.
“What’s going on, Reg?” I asked. “Why have you tidied my room and put new blankets on the inpatient beds?”
She said, “They are not new blankets.”
“So why are we using them now? Is it because it has turned cold at night? And why are there no new blankets on the beds in the male ward?”
“Ah, doctor, we have to be careful. Some of our clients are teefs. But we have some visitors.”
Dr Daniel, the Chief Medical Officer of Eastern Province, was here with a team to inspect the health centre. I greeted him warmly and offered to show him around the clinic. We started with the lab and I introduced him to Trognes. He asked how we were managing and Trognes said we were doing okay. Apparently, it is bad form to complain to your bosses when they visit as they want to believe everything is going swimmingly.
I wasn’t having any of this. “How about the lack of HIV and hepatitis B tests? We have no cuvettes for the Hemacue machine, so we can’t estimate haemoglobin. Our haematocrit machine no longer works. Our PIMA CD4 machine is on the blink and needs constantly resetting. We don’t have enough sample bottles. We have not had a viral load result back from Chipata in over six months. We have a brand new fluorescent microscope but no auramine stain to make slides of sputum to improve our pickup of tuberculosis.” I don’t think I took a breath. I get excited sometimes.
Dr Daniel looked taken aback. “What’s this?” he asked Trognes. “I can explain the auramine,” she said. “I haven’t had the training yet, so it hasn’t been supplied.” We went through the list of problems, with the Province’s Laboratory Chief on hand to call up people who might be able to provide us with what we needed.
Nurse Zulu came to the lab and tried to charm Dr Daniel with her beaming smile. Seeing how impertinent I had been, she piped up with, “What about our lack of intravenous fluids?”
“Oh, there is a national shortage of normal saline,” he replied. “But you should have some Ringer’s Lactate, surely?”
When I said that we have no iv fluids at all, he looked rather shocked.
“It is the height of the malaria season and we ran out of Coartem (the first line drug to combat resistant malaria here) earlier this week. We went to district HQ but they had none to give us, so we were forced to borrow some from the clinic at the airport. But this will only last two days.”
“Ah,” said Dr Daniel, subtly changing the subject, “What are you doing about this increase in malaria?” We discussed the inappropriate but innovative ways the villagers were misusing their impregnated mosquito nets (as fishing nets, for example). Then we talked about insecticide spraying. I asked about using primaquine to reduce the infectivity of newly diagnosed patients (by killing gametocytes), but it was too expensive and not government policy yet (though it was WHO policy almost ten years ago).
Then we talked about the lack of drugs for basic conditions such as diabetes, hypertension and mental illness. We have no creams for skin conditions, and neither drops nor ointment for eye infections. Dr Daniel talked about the logistical problems of getting supplies to the periphery. But I think we all knew that the drugs just weren’t there.
“I am worried about the shortage of HIV drugs,” I said. Dr Daniel said that this was not a true shortage, but it was manufactured by central medical stores where there was a load of Atripla which had an expiry date of end June 2016. The reasoning was that by restricting supply of Atripla to health centres, all the about-to-expire drug would be dispensed. After June, we would receive masses of Atripla with an expiry date of end 2017, so we could issue three, or even six, months’ supply to stable patients. Perhaps I will still be here when this happens, but somehow I doubt it.
Dr Daniel said that there were patients to be seen. He wanted to see patients himself so he could see what problems we were facing for himself. He could ask the patients what they thought of the clinic and he could have a look at the quality of the note keeping. He took the right hand consulting room, I took the left and we set to work.
After a couple of hours, we were still at it. I popped my head around the door to his room and asked him if he needed anything. He didn’t have a stethoscope, so I loaned him mine. Then I couldn’t find my spare, so I had to use a Pinard (the trumpet which midwives use to check the fetal heart).
“Doctor Ian, there is a lot of malaria in this place. I have seen fifteen patients already,” Dr Daniel said. “And I’ve seen about the same,” I replied. “I think we are on track to see 800 cases this month.” He looked genuinely surprised, almost as though he was used to health workers exaggerating their workload. I said, “It might make the clinic work more efficiently if the health care assistant registering the patients and doing their vital signs, immediately sends all those patients with a fever to the laboratory for a rapid diagnostic test for malaria before they see the nurse or doctor.” Dr Daniel replied, “That’s a great idea. Maybe she could even do the test at registration?” “At this rate, we should move the registration desk to the lab,” I said. We went back to seeing patients.
There were no more patients who could speak English for me to see, so the volunteer brought in twenty sets of notes of patients living with HIV. I worked my way through these patients, with the volunteer acting as interpreter when I got stuck. I have a crib sheet of consisting of twenty or so common questions written phonetically in the local dialect. “Mukosola magazi?” – have you coughed up blood; “Kuturula?” – do you have diarrhoea; “Befu?” – any difficulty in breathing; “Kunjonga?” – abdominal pain and so on. As long as the patients answer “No” I can cope. As soon as they start telling me in their language that the pain started last Tuesday when they ate okra and beans at Kefu village, I am completely lost.
I finished at 12:45 and started seeing regular (non-HIV) patients again. There was an influx of students from the local secondary school, most of whom had malaria. Normally, the clinic would shut for lunch from 12:30 – 2pm, but because the doctors were still working, the pharmacy assistant, lab technician and registration clerk had to keep working, too. “Aren’t you going to stop for lunch?” they asked me. “Well, if Dr Daniel is still working, it would look bad if we packed up and left him on his own,” I replied. The staff grumbled but kept on working.
Just when it looked as though the new patients had slowed to a trickle, a four year old child was brought in with a temperature of 39.7C having a seizure, caused by malaria. The child was unconscious and incontinent. Sadly, the mother had been to the clinic earlier in the morning, but took one look at the huge queue and decided to go home. We had no parenteral quinine and no intravenous fluids. The child was unresponsive with a frightening Glasgow Coma Scale score. Time to get an ambulance to take the child to hospital.
We stopped seeing the “morning” patients just after 2pm. But by this time, there were a dozen patients who had turned up for the afternoon session. I tidied my desk and left to see a tourist at a lodge who was unwell. I look forward to seeing Dr Daniel’s report on his visit to the clinic, it should make interesting reading.
PS Dr Daniel contacted the District HQ and we got a fresh supply of Coartem over the weekend, thank goodness. We had 41 cases of malaria before lunch today.