Visit to the Mission Hospital

I was surprised when the Bangladeshi police officer flagged down our car at the check point this morning. Normally the MSF logo on the vehicle allows us to pass without hindrance. We stopped and I rolled down the window, kept my hands visible and still on my lap, and looked straight ahead. This is standard operating procedure. No sudden movements, no sunglasses, no earphones or music playing. The senior person in the car is the spokesman.

“Where are you going?” asked the officer.

The medical team leader is an African lady, half my age. From the back seat, she replied, “We are visiting the Memorial Christian Hospital, just past Cox’s Bazar.”

The officer glared at me. “Is she your wife?”

“No, sir,” I replied. “I am old and she is young. I wouldn’t be able to cope.” I smiled to show I was joking in a self deprecating manner. The policeman snorted derisively and waved us on.

“I apologise for the bad joke,” I said as we drove away.

“Next time it would be better just to say we were married,” my boss replied.

Memorial Christian Hospital (MCH), in Malumghat, Chakaria Thana, is run under the auspices of the Association of Baptists NGO. The American and Canadian health workers who founded the original hospital in 1966 selected the location in southeastern East Pakistan due to its desperate healthcare needs and proximity to major transportation corridors.

In 1971, East Pakistan descended into war when it tried to secede from West Pakistan. Between 3 and 5 million people died in the war of independence. During the conflict, the American health workers attempted to leave the country, but the Pakistan Army advanced rapidly and cut off their northern escape.  Most of the team wasforced to cross the border into Burma, travelling to safety in Maungdaw in Rakhine State. Ironically, this is the reverse of the route that half a million Rohingya took over the past six weeks.  Two doctors stayed behind to keep the hospital functioning. Following independence, the site was often approached by the US government toassist in distributing aid. Since then, the hospital has outgrown the original buildings and a new four storey hospital is being built.

Two doctors stayed behind to keep the hospital functioning. Following independence, the site was used by the US government to distribute aid. Since then, the hospital has outgrown the original buildings and a new four storey hospital is being built.

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Surgeon Steve Kelley has worked here for 21 years. He is my main contact when I want to refer difficult surgical cases, especially war-wounded Rohingya and the victims of road accidents. Including elephant attacks.

In response to the massive influx of refugees, MCH built a temporary ward in just two weeks. It is a sophisticated structure of bamboo (painted black or white) and white plastic sheeting. There is a strip above the head of each bed with power outlet, oxygen and an alarm button. It is kept cool by ceiling fans.

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Some of the patients I had sent to MCH recognised me from their beds. Despite being in pain, all of them smiled when Steve came to their bedside. We moved on to the male and female surgical wards, then had a tour of the operating theatres and recovery area. Despite being fifty years old, the main hospital was incredibly clean. This, and scrupulous surgical technique, would account for the fact that not a single patient we have referred has developed a wound infection. If anything serious happens to me when I’m in Bangladesh, this is where I want to be treated.

The BBCChannel NewsAsia and CNN have all visited the hospital in recent weeks. One of the patients spotlighted was a five year old girl who had been shot through the forearm, destroying all the extensor tendons and shattering her radius. Her father had been carrying her when she was shot. After exiting her arm, the bullet hit her father’s head and killed him. Her bones are mended and she is going back for tendon reconstruction.

Neither her surgeon, Steve Kelley, nor Memorial Christian Hospital, featured strongly in the piece. But Steve, Brad and their colleagues perform life changing surgery every single day. The expat doctors and nurses here do this without getting paid. They have to raise money to fund their flights, their living expenses as well as running the hospital. No money comes from the US or Bangladeshi governments. They are all heroes, saints even. I was overcome with admiration for their selfless work.

Hospital Visiting Time

Government hospitals in Delhi are heaving with patients each morning. Doctors finish at 1pm to have lunch, so the pressure is on to get seen before then.  Visiting hospital is a family affair. The ratio of family supporters to a patient might be as high as five to one. This adds up to hordes of people.

The local hospital looked run down and in need of general refurbishment. It was very hot and there were not many overhead fans stirring the stifling air. Security staff corralled the patients into queues. If they had not been policing the lines, everyone would just crowd in, as they do in the Metro or at the supermarket checkout. Some people clutched scarves over their faces to keep out any airborne pathogens and noxious odours.

Away from the outpatients’ department, there were lots of corridors, linking hospital wards, departments and buildings which have been tacked onto the original design. The walls were splattered with red-brown stains. This wasn’t blood, but spittle from paan chewers. The dirt looked ingrained. I thought that even deep cleaning would never get the place pristine.

Family members provide a lot of the nursing care, but they are turfed out of the ward to allow the patients to get some rest or food. I saw small groups of people picnicking in the corridors. Meanwhile, orderlies wheeled large stainless steel food trolleys containing lunch to the wards, just like the NHS when I was a junior doctor, before the era of chilled snack foods.

There were very few wheelchairs, I noticed. Some patients had their own vintage three-wheelers, powered by hand cranking. There were no children’s buggies or pushchairs. Children walked or were carried. I saw hardly any porters. Family members helped patients to move around in the hospital.

I was visiting the obstetric department. As a male, I was not allowed to enter. I had to stand outside with the other expectant fathers-to-be. They all wanted to know about me. Who was my wife? Was she Indian or a foreigner?

The security guard on the door looked like a bouncer at a nightclub. He let me into the ante-room when I found out that I was a doctor. He apologised for keeping me waiting outside with the other men and we got chatting. He told me that not only was he a bouncer, but he trained people to be security guards. He didn’t have to do this job, he said.

I squatted down on a broken steel bench which tilted me forward over my knees. To my left was the labour ward, which was remarkably quiet. To my right, behind a screen, was the postnatal area. Female family members could attend their relatives who had just delivered. There was a pedal bin situated between the room I was in and the postnatal area. Some women were fascinated how this worked. They put their foot on the pedal and spat paan juice into the bin before the flip top lid closed. They also put blood-stained rags into the bin.

Two men tried to bluff their way past the security guard to see their new family member, but their bluster didn’t work. They tried begging and eventually, grannie came out with the newborn baby to the ante-room for the child’s first smartphone photographs.

Another delighted granny came out with a large box of Indian sweets which she offered to everyone, even me. Cynically, I thought her latest grandchild must be a boy.

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Outside in the hospital grounds, freshly laundered sheets were laid out on the ground to dry in the sunshine. I glanced to one side and saw a poster advertising free cardiac ultrasounds as a special offer, this week only. Priorities are different, here in Delhi.

In contrast, the private hospitals flourish. These can be small affairs, the size of a townhouse or huge state-of-the-art institutions, fully computerised, air-conditioned and spotlessly clean. 80% of all healthcare expenditure in India is private (The Indian Government spends just a paltry 1% of GDP on healthcare).P1290156P1290155

 

 

Light Greens

This is a not a self portrait. He looks green with envy. This is a mask from NE India, in the National Museum in Delhi. Taken with my Lumix LX100 shutter speed 1/10th second, f5.6, ISO 1600.

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On a more serious note, the clinic where I work in Jahangir Puri, North Delhi, for Medecins Sans Frontieres (Doctors Without Borders) is painted light green. The clinic deals with survivors of sexual and gender based violence and is called “Umeed Ki Kiran” (Ray of Hope).

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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.

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“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.

Can you hit my head some more?

“Can you hit my head some more, Dr Ian?”

Last month, I diagnosed a young lady with cervical cancer. Her symptoms of lower abdominal pain, vaginal bleeding and an offensive discharge had been repeatedly treated “syndromically” – in other words, treating the common diseases which would cause these problems without making a specific diagnosis. She had been given several courses of antibiotics which hadn’t helped. Her notes said “Chronic Pelvic Inflammatory Disease”, but no one had ever examined her. A quick look with a speculum and a vaginal exam revealed that she almost certainly had cancer.

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Nurse Zulu was impressed and asked me to give the staff a lecture on cervical cancer at the health centre. I agreed and we fixed a date on Friday afternoon at 1500. I put together a quick PowerPoint presentation on my laptop and arrived at the clinic at 1400 after lunch. The door to the staff room/office/antenatal/HIV department was locked. There was an unhealthy queue of patients waiting to be seen, and the nurses would have to work quickly to clear the decks before the lecture. Two nurses turned up at 1430 and opened up the staff room. Perhaps it was “Friday afternoon syndrome”, as they seemed reluctant to see the patients before the meeting. Nurse Zulu asked for some help with a sick lady who might have vomited blood. I asked if she had checked the vital signs, but she hadn’t, so I asked her to do this first.

I did a quick trawl of the patients, sending those who had fever to the lab to have a malaria test done before we saw them. Then I saw the patient with Nurse Zulu. The consulting room had the characteristic odour of malaena (internal bleeding which has been partly digested and comes out of the body as tarry, black motions). No one else recognised this. The patient had a low blood pressure and high pulse. She looked as though she had lost a lot of weight recently and her mucus membranes were pale.

I asked Nurse Zulu if she had examined her and she said no. I explained about malaena and asked the patient for permission to perform a digital rectal examination. I told Nurse Zulu that my gloved finger would be black with stool, and it was. I cleaned the patient and rolled her over onto her back. There was a hard, craggy mass in the epigastrium. I put together the salient points in her history and my examination to make a credible explanation as to what had happened. Nurse Zulu asked me, “How did you know her faeces would be  black? How do you know these things? I can understand what is happening now that you are teaching me.”

I talked to the lady and her relatives about what was happening, then shipped her off to Kamoto with a referral letter for a blood transfusion and an upper abdominal ultrasound scan. The next patient was a 50 year old man who looked very ill. He was perspiring profusely, with beads of sweat standing out on his forehead. His temperature was 39.8C, but a malaria test was negative. Without examining him, Nurse Zulu asked her senior colleague what was wrong. “It’s malaria season, repeat the test and even if it is negative, we still need to treat him for malaria.” Not altogether logical.

Before I could act, the patient was ushered out the door and sent to the pharmacy for malaria treatment. I caught up with him in the queue and asked if he minded my examining him there and then. He wasn’t shifting much air into his lower right lung and I diagnosed early pneumonia. Nurse Zulu appeared and I demonstrated the signs:

“While he breathes in deeply, just look at how his chest moves. Tell me what you can see,” I said.

“Nothing,” she said.

“Look more closely.”

“I am looking closely, but I still cannot see anything.”

“Put your hands around his chest and see which moves the most.”

“My left hand,” she said.

“What does that mean?”

“I don’t know.”

I explained that the chest was moving unequally because less air was entering the lower right lung.

“Now listen to the chest.”

“There are no crackles or wheeze, it is normal.”

“But which side is loudest?”

“The left side.”

“And what does this mean?”

“I don’t know.”

I explained about how all his signs were explained by pneumonia. I altered the patient’s medical records, gave him the correct treatment and asked to see him on Monday at the clinic.

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Nurse Zulu said, “Can you hit my head some more, Dr Ian? I want you to bang in some knowledge.”

She turned to her senior colleague and said, “John, you must come and consult with Dr Ian. He knows what is wrong with all the patients. He explains it to me and it makes perfect sense. It is wonderful.”

Of course, I haven’t a clue what is really wrong with half the patients attending the clinic. I recognise patterns of symptoms, using 40 years of experience of the natural history of diseases, and hopefully I don’t make many unsafe clinical decisions.

Nurse Zulu said, “You have done it again, worked out what is wrong with the patient. How do you do it?” I explained that I work like a detective, putting clues together to find out who did the crime, making hypotheses and shooting them down when the evidence doesn’t fit. It is no use just writing down what the patient says and giving medication to counter their symptoms. Headache = paracetamol; chest problem = antibiotics; difficulty breathing = salbutamol tablets for asthma; runny nose and sneezing = antihistamines; feeling generally unwell = multivitamins.

History taking is abrupt and I am never quite sure that my words are translated properly into Kunda (the local dialect) or Nyanja, with their limited vocabulary. I can’t request a wide array of investigations. I just have to use my common sense and my five senses to examine the patients thoroughly. If I manage to persuade nurses to do this more often, then I think that my time here will have been successful.

 

PS The people illustrated above are not those mentioned in the text.

Where there is no psychiatrist

Mental illness happens everywhere in the world. I have seen Zambian patients with depression, anxiety, obsessive compulsive disorder, psychosomatic conditions and hysteria. Being aware of the cultural context is important, and good communication is essential. To get a history from patients, you need a good translator who can help you interpret patients’ symptoms. It may be a false impression, but I think that neurosis occurs more frequently in people who are middle class, have had some education and can speak English. When I don’t have a translator, these are the patients who consult me.

Psychosis is less common. Over the past two months I have seen half a dozen people suffering from severe mental illness. One teenager may have had a brief psychotic episode, which made her dreams seem like reality. She had dreamed someone was cutting her legs with a knife, which caused her to experience leg pains for several weeks. She also suffered visual and auditory hallucinations, seeing things which no one else could see and hearing voices threatening to cut her legs. This have been the first presentation of psychosis, but her symptoms improved when she changed schools. We will just have to watch and wait.

Other patients with psychosis manage their symptoms differently. An older lady who hears voices deals with them as though they were tinnitus. A younger man just smokes more cannabis in an attempt to mask his symptoms.

I have tried to requisition some basic drugs for mental health problems. Ironically, diazepam (which is despised by most GPs in UK) is the only medication I have available. Perhaps this will change if my attempt to have Kakumbi recognised as a higher level health centre.

M is a 22 year old man with a three year history of severe mental illness. His hypomania can be a bit wearing if he insists on making his presence felt. Perhaps he is just asking for attention in a dramatic way. But last week, when he started assaulting people, wrecking his home and destroying his family’s goods, his mother took drastic action. She chained him to the door he had pulled off its hinges. I did a home visit, examined him and tried to arrange for an ambulance to take him into hospital. The ambulance driver was sympathetic but my request was denied because it was not an emergency. No mental health problems are seen as emergencies. M was certainly not well enough to travel by public transport. I sedated him with diazepam while we considered our options.

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As luck would have it, the following day we needed to transport a newborn baby urgently to Kamoto Hospital so we persuaded the driver to take M and his mother as well. The District Commissioner agreed to help out with a vehicle if M needed to see a psychiatrist in Chipata. I hope he will make a swift recovery and be discharged to my care with a guaranteed supply of medication.