Poisoned

“Quick doctor, there’s an emergency. A girl has been poisoned,” shouted Andrew, one of the nurses at Kakumbi Rural Health Centre.

Heath care assistant Helen pushed past him, saying, “I will put up an intravenous line.”

“But we don’t have any intravenous fluids, Helen,” I said. “There’s no point. What has she been given?”

“Poison, doc.”

“Yes, but what kind of poison?” I asked.

“We don’t know. Probably it is some witchdoctor’s potion, some bad muti.”

“Great, so we haven’t a clue. Is she conscious?”

“Come and see her.”

She was about twenty years old, wearing tight jeans under a chitengi waist cloth and a tee-shirt. Half a dozen relatives, a few people from the waiting room and Daillies were crowded into the paediatric ward. “Can we clear the room, please?” I asked.

“Right, is she responsive?”

Helen lifted up the girl’s tee-shirt and bra, then gave her nipple a tweak. No response. Then she grabbed a handful of abdominal flesh and squeezed it. Again, no response. Not my normal way of assessing a patient, but maybe it is better than pinching an earlobe or rubbing a knuckle down the sternum. She was breathing calmly, her blood pressure, pulse and temperature were all normal.

“Has she said anything?” The nurse and health care assistants looked at each other and said, “No.”

“So how do we know that she has been poisoned, then?”

“That’s what the sister who brought her in from the village said.”

It transpired that the girl’s mother had accused her of stealing some money from the house, “because she is the oldest child”. There had been an argument and the girl stormed off to the local shop to buy some Indocid (indomethacin, a non-steroidal anti-inflammatory drug). The shop was out of drugs, so she went house to house, asking for medicine. She intended to take an overdose.

“Right, let’s get the sister to telephone the mother and find out more.”

Predictably, the sister was out of “talk time”, so I loaned her my phone to make the call.

“OK, what’s the story?” I asked.

“She has told the mother to come,” said Andrew.

“But we want information about what she has taken. Please get her to ring back and ask mum to find out who gave her the drug, what it was, how many tablets, when did she do it, etc.”

When the sister rang back, her mother told her that no one was admitting to giving her daughter drugs. But someone had seen her swallowing big blue pills. She had vomited some tablets which looked like white powder just before she collapsed at 8:30am.

Helen put on a pair of gloves, moved the girl to the edge of the bed and stuck a finger down her throat to make her vomit. An easy way to lose a finger, I thought. “Be careful, Helen,” I said. “Is there a vomit bowl on that side of the bed?” “No, we don’t have one,” said Helen. Great, fetch the mop.

I looked around the pharmacy, checking the drugs, looking for big blue tablets, but there were none, apart from my personal stash of Viagra.

Mother arrived and became agitated. She could not really add anything to the story but said that she wanted her daughter transferred to hospital. I agreed and asked Andrew to write out a referral. He said, “The hospital doctors will be angry with us because there is nothing they can do. The last time we referred someone like this, they told us to inject them with atropine.” I told him to make it very clear on the paper that we have no intravenous fluids and could not provide adequate supportive treatment should she become deeply unconscious.

After the girl was carried out to a taxi, Helen turned to me and said, “I could see her looking at us from the corner of her closed eyes. Her breathing is too calm. I don’t think she has taken poison.”

We agreed that there was a lot of psychological overlay. If we did have intravenous fluids, I might have tried a trick Dr R used to employ with hysterical patients in Nepal. He would put up an intravenous line, and run in two litres of fluids. This would fill up the patient’s bladder and rather than wet themselves, they would “wake up” and ask to use a bed pan or the toilet. Cruel, but effective.

Menstrual Hygiene Day

Being an old bloke, I don’t often think about periods. But I have to, and during the course of my work, I have seen some fairly unsavoury methods of dealing with menstruation. However, a local charitable, non-government organisation called Project Luangwa has tackled the problem of sanitary protection in this corner of Zambia and come up with an intriguing solution.

Forget rags and bits of cloth. The absorbing power of material made from bamboo fibre is much better than cotton. Local women make the pads with three layers of bamboo and cover them in brightly patterned fabric. They have “wings” which fasten around the panty gusset and keep the pad secure. They are low profile and are virtually invisible under clothing.

They are designed to be washed and re-used. But no girl wants to advertise to the neighbourhood that she is having her period by pegging out pads on the washing line.

Instead, Project Luangwa has designed an inconspicuous cloth bag which has pockets inside to house the pads which have been washed. This can hang on the line without attracting attention. You can use the pads for two years or more, so despite the initial outlay, they end up being much cheaper than buying disposable protection every month.

How do you disseminate this brilliant idea? Project Luangwa sponsors Girls’ Clubs in the local schools, so girls who attend can hear about the pads and hear about their friends’ experience of using them. But many girls don’t go to school and their mothers haven’t heard of the new style re-usable pads. So Project Luangwa held an awareness raising session on Saturday afternoon, under a massive tree in Fwalu.

Members of SEKA, a local theatre group, dressed up in cast-off Somerset NHS Paramedic uniforms and piled into the back of a pickup truck. They drove down the main street beating drums, attracting lots of interest from the population. One man was wearing a scary mask and he terrified the local children when he jumped down from the vehicle.

The insistent drumming made me want to get up and dance, but I left this to the experts (since he passed on, I have stopped doing my Prince impression, much to the relief of casual spectators). I sat on a comfortable seat with a good view of events and took photographs instead. Between dances, there were bits of drama to illustrate how having a period need not prevent you from living a normal life. Interestingly, several male actors had female roles and hammed them up to the delight of the audience.

The Girls’ Clubs each did a dance. Four small girls lined up opposite four larger girls (who were adopting the male role). In turn, each pair danced towards each other, twitching their buttocks in time with the drums and thrusting their pelvises in a very provocative manner. “In the village, this often leads to sex,” said someone sitting next to me. Well, that might reduce the need for sanitary protection for nine months, I thought.

The best dancers were rewarded by spectators stuffing money into the performers’ chitengis. These are brightly coloured pieces of cloth wrapped around the dancers’ waists, designed to draw particular attention to jiving buttocks.

After an hour, there must have been a crowd of 250 people of all ages watching the show. Now was the time to hit them with the educational message. Ladies showed the audience the pads, demonstrating how they fitted onto panties and how they could be dried inconspicuously. Then Karen came out and did some mathematics to show that re-using these pads saves money in the long run. She wrote out the figures on sheets of white paper and placed these on the ground. “How much will you save after two years use of the pads?” she asked the masses. Although a few women hazarded guesses, it was a man who got the answer correct and won a sanitary protection pack.

When money is tight, people are more concerned about the present, rather than planning ahead to make savings in the future. The girls seemed to get the message, but I suppose the proof of the pudding is in the eating. If the pads are culturally acceptable and the girls can see their value, the initiative will succeed.

All the girls who participated in the dancing and singing received a free sanitary protection pack. Already they are planning how to celebrate Menstrual Hygiene Day next year. No jokes about this being a red-letter day, please.

Top and Tail

Headgear for children is very important in Zambia. It makes a statement. But I wonder what their mothers were trying to say?

But don’t forget footwear.

But for the full effect, check out this fashion victim who features in both sets of photographs above

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Mass Deworming

There’s an old joke about a woman who painted her doorstep pink. When asked why she did it, she said that it kept the elephants out of the house. “Elephants? That’s just ridiculous!” replied the questioner and the woman said, “Ah, but you have never seen any elephants in my house, have you?”

I have never seen any children in Zambia with intestinal worms. Plenty of mothers think that their children have worms because their children have bellyache or bloating. And plenty of nurses are happy to go along with the mothers’ requests to prescribe medication to “deworm” their children. So when I questioned the nurses about the wisdom of mass deworming during National Child Health Week, I received the obvious answer. “You don’t see any worms because our six monthly deworming campaign is so successful.” We shall probably never know.

Along with the deworming, we give vitamin A supplements to children aged from one to five years. Vitamin A prevents keratomalacia (softening of the cornea resulting in blindness after an attack of measles or any other severe disease/infection). But the diet of children here is quite high in vitamin A as green leafy vegetables (called rape or spinach) form the basis of the “relish”, a sauce which adds flavour to the staple carbohydrate, the stodgy, maize-meal porridge, nshima. “Ours not to reason why, ours but to do and die.”

National Child Health Week involves half the clinic staff going out to villages (“outreach”) to weigh and treat children with albendazole and vitamin A. I stirred the pot again by asking why we didn’t just add this activity to the regular vaccination outreach clinics we did each month.

“Because it is NCH week, that’s why,” said Nurse In Charge.

“But wouldn’t it be more sensible and save resources?” I objected.

“No, it is National Policy so that is what we will do,” said NIC.

“I think Doc Ian is right about it saving resources. We have no money for fuel for the motorbikes and we are relying on him to transport us around in his vehicle.”

See what happens? My questioning of authority seems to stir up trouble in a country where civil servants generally do what they are told, however daft it might be. I was banking on the Provincial Mother & Child Health Department being unable to provide us with the vitamin A and deworming drug, but the medication was delivered at the last minute.

It seems to me that the two main benefits of visiting the villages during NCH week are that we see all the disabled children who don’t attend clinic, and that we can perform an accurate headcount of all the children in the locality, recording core data such as name, age, mother, vaccination status, etc. We might not be able to do much for the children with Down’s Syndrome, Cerebral Palsy, Microcephaly, developmental delay and other conditions, but it is important to remember that they exist and their families need support. With a headcount, we can also challenge the Central Statistics Office projections of how many children there ought to be, based on last decade’s census.

Here is a child with Down’s Syndrome, two years ago, whom I saw again, showing some improvement. And other child with serious malnutrition wearing a huge pair of trousers, sitting on nurse John’s knee.

Mothers in the more remote villages take their time getting to the appointed area, usually in the shade of a huge mango tree. The shade is welcome, but a deluge of insects, bird poo, leaves and twigs rains down on our heads and onto the medication. Mfuwe is more urbanised, so when the mothers see my vehicle arriving, they flock en masse to the weighing area with all their preschool children in tow. Yesterday, we weighed, dewormed and vitamin A supplemented 370 children. Today, in Fwalu (a suburb of Mfuwe), we probably saw 500. We also vaccinated children if they were due to have or had missed any immunisations. And we offered voluntary HIV testing for the mothers.

It was chaotic today. Mothers wanted their children sorted out early in the day, so they could get on with their lives. They crowded round the volunteers at the weighing tree. All our attempts to make them form an orderly queue failed miserably. I even played the “mad muzungu” to force them back, but all I succeeded in doing was to terrify the infants.

The pinch point in the process is Mr Chulu, Health Promotion Officer, who was writing down all the details of the patients in a register which he can compare with the official register. He decides which child needs vaccinating and writes on their records that they have been supplemented and dewormed. The cards move on to the next stage, where I normally work: the medication table. Children from 6-12 months get a blue vitamin A capsule (100,000 units) squirted into their mouth. From 13 – 24 months they get a red vitamin A capsule (200,000) and half an albendazole, crushed and made into a slurry in a small plastic medication cup. Children over 24 months get a tablet of albendazole and a red vitamin A capsule. Some two year olds can crunch up a tablet, but others need to have it crushed and suspended in water.

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The mothers wanted to have a “sweetie” too, so I offered them the last of my strong mints.

The next station is for vaccination and finally the mothers go on to a more private area to have their HIV status checked if they wish.

On the first day, we were woefully unprepared. We needed to buy plastic cups, bowls, spoons and jugs. We didn’t have a pair of scissors, so the health care assistants were cutting through slippery gel capsules with a scalpel blade. I just nipped the teat off the capsule with my teeth. (Don’t worry, I had a clean bill of health before I left UK.) To crush the tablets we were using two spoons. I even had trouble cutting the tablets in half. My hands got really oily from vitamin A (it is fat soluble). It was difficult washing out used plastic medicine cups in cold water with a greasy emulsion on my fingers. Those cups which had fallen in the dirt were revolting as it was impossible to decontaminate them. I had nothing to clean my hands apart from alcohol gel. This was soon used up so I had to wipe my hands on the seat of my pants. My trousers will need a good dose of Toss and a rub with a Boom bar to be wearable again.

By day four (today), we were more prepared. We had several pairs of scissors, an empty lignocaine glass bottle to crush the tablets in a metal bowl and I had a towel suspended from my belt to wipe my hands clean after handling oily capsules.

I realised that I was the only health professional who was working standing up. Everyone else was in home-made wooden chairs with string seating. The tables were very low, just 50cm from the ground, so my back was aching from bending down.

My job was to give the children their medication. I have spent the last four days blatantly lying to the infants, calling the albendazole tablets “sweeties”. The innocent souls open their mouths and take the tablet from my finger and thumb. No one has bitten me yet, but they do suck the tablets out of my grip. Then I give the vitamin A. It is best to do this without warning. No patient centred explanations of how this medication is going to protect them, just squeeze their cheeks and when their mouth opens, squirt it in. The mothers are my accomplices in deceit.

Sometimes, the children have been eating a dayglo coloured ice block in a plastic sheath and their lips feel cold. The children finish sucking out the ice and e-numbers, then chew on the plastic and call it “bubble gum”. I try to get them to spit it out before I give them any medication. I am bound to get some viral illness from having my fingers in the mouths of a thousand children. (I know one former Professor of Paediatrics who never touches children in the street when he is overseas to avoid contracting germs.)

Of course, some of the children are terrified of the white man giving them foul-tasting orange medicine and squirting oil into their mouths. They scream blue murder and cling to their mother, little knowing that actually, she is on my side. Occasionally a volunteer is called on to help pin the child down for dosing. One effective, but highly dangerous, approach is to tilt the child backwards, head down, and apply the plastic medicine cup to their lips, while their nostrils are closed. Sometimes the children struggle to the end, spewing forth an eruption of oily, orange froth which goes into their eyes or trickles down their necks. Other times, children give up half way through, knowing that they are beaten, and take their medicine reluctantly and passively.

The other mothers enjoy the spectacle while they are waiting for their children’s turn. They hoot with laughter when a child swallows the entire vitamin A capsule from my fingers and chews it, or if a child tries to make a break for freedom, gets captured and then returned. Two years ago, the carnage was worse. We had to give five tablets of mebendazole, not just a half or one tablet of albendazole. Here are some photographs for comparison. First 2014:

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Then 2016:

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All very tiring work. Mr Chulu was exhausted. Never fear, next week is Voluntary HIV Testing Week, and we have been asked to target secondary schools.

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Twitching

The best ornithologists identify birds by their call. In the Game Park yesterday morning, D correctly identified that the hissing sound was coming from her rear tyre. We pulled off the main track and D chose a level piece of ground to change the wheel.

My birthday present had come early. Two of the most knowledgeable birders in the Valley were treating me to a guided safari. Although I can claim to be able to recognise about 60 species of birds in South Luangwa, this is just a sixth of the total. And I am pretty rubbish at spotting them, too.

I see a flash of wings in front of the vehicle and D tells me what it is.

“How did you know that?” I ask.

“I could see a hint of red under the wing, it is the right size, it is behaving the way I’d expect it to behave. I would have missed that colour if I had been wearing sunglasses.”
We spent the first twenty minutes of the safari parked on the bridge over the Luangwa River. We spotted wire tailed swallows, a gymnogene (African Harrier Hawk), lesser striped swallows, sparrows with glorious chestnut-coloured plumage, Egyptian geese flying over in formation, and a dozen other species while safari vehicles drove past, on their relentless quest to show tourists some big game.


We had only moved a couple of hundred metres (black headed heron, great egret, pied kingfisher, etc) when the hissing of the back tyre brought us back to earth. Or nearer to the earth on that side of the vehicle. We efficiently jacked up the LandCruiser and took off the wheel, but there was a problem with the spare. And the second spare, too. A knight in shining pickup arrived and took D away to mend the tyre, borrow a spare and bring her foot pump. F and I stayed with the vehicle, desperately trying to improve our bird count.


It is good sense not to wander away from the vehicle. D had pointed out fresh lion tracks, made that very morning, in the dust of the trail, but she said that they were long gone. We trusted her, but she is as fearless as Leicester City FC. We spotted some vultures, but they didn’t stop to circle above us. D was back within the hour, we replaced the mended tyre and resumed the drive.
Sitting on the raised back seat behind the two birders gave me the theoretical advantage of a higher viewpoint. But they seemed to spot things together, their binoculars moving synchronously in the direction of a bird. I had to look where they were looking and hope that I was seeing the same bird. It is a bit like finding big cats by looking at where antelopes are staring.

“Did you see the juvenile Martial Eagle, Ian?” they asked me.

No, I was looking at a babblers in the undergrowth below the raptor.

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We stopped for breakfast at the side of a lagoon and I looked intently around to see what birds were around. “Do you want to see the pair of Giant Eagle Owls over there, Ian?” asked D. I had completely missed them. And the puffbacks. And that tiny bird perched on a reed, which must have been a malachite kingfisher because they are the only birds that do that. Above our heads, D spotted a bee hive, with open honeycombs. I did spot a fish eagle, and D told me where its nest was, that it was a female being allowed off the eggs for a few minutes. D had already noticed that a nearby turtle dove’s call had altered subtly, indicating distress or danger – the fish eagle is an enemy. It’s the way what you see is put into context by an expert guide which makes it so fascinating. True bushcraft.

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The shortbread biscuits were very tasty, but the vacuum flask containing my herbal tea was more suitable as a handwarmer. We had driven less than 5 kilometres in 5 hours. The most impressive sighting was a young bataleur eagle locking talons with a big African fish eagle in flight. “You’ll never see that again,” said D.

We were stumped by a nest in a palm tree with a fledgling in situ. We will have to wait to see the parents for the identification.

We spotted 67 different species during the course of the morning. Some were identified audibly, “I heard it, I don’t need to see it, I know it is there.”

I offered to buy lunch at a local lodge. While we were waiting for food, I thought about the similarities between being a superb guide and an excellent diagnostic clinician. Experience, encyclopaedic knowledge, being able to piece together a few bits of evidence to formulate an answer. Oh, good hearing and eyesight are important, too.

Unfortunately for me, my girls say I am going deaf and I have been known as “blindy batty” in the past.

Magic Light

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This is a photograph of a man with a goat strapped to the parcel rack of his bicycle. It has absolutely nothing to do with the blog.

“I want your expert advice, doc,” said Nurse Zulu. “Can you see this patient with me? I don’t know what is going on.”

The patient was a 15 year old girl who had been complaining of bellyache for the past two weeks. She had been seen last week and given some antacid tablets for indigestion, but this medication had not helped.

She said that the pain was in her lower abdomen, but she didn’t volunteer any further information. It was not related to her periods, eating, passing urine or moving her bowels. It was constant, nothing made it worse or relieved it. She was not taking any traditional medicine, she had no past history of note and there was no family history of abdominal pain.  “Kunyanga, ” she kept repeating, bellyache.

“Have you ever had sex?” I asked. “Is there any discharge?”

No, she said she was a virgin.

She laid on the examination couch and I felt her tummy. She winced as I pressed on her lower abdomen. I said that it would be helpful to do a gentle internal examination and she agreed. I put on my super bright headlamp and Nurse Zulu said, “That’s doctor’s magic light. It can tell if you are a virgin.”

The girl’s eyes widened and she whispered, “OK, I lied. I had sex last month!”

She had pelvic inflammatory disease.

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A dust devil whirlwind just across the way from the clinic. Again, it has nothing to do with this blog, but I think it is an interesting photograph