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.
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:
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.