HIV - the growing problem

An emaciated young man is carried into the clinic - barely able to talk - he is breathless and looks desperately ill. His pulse is fast and weak. The story is that he has had HIV for 4 years - and has been on the usual combination of drugs which he is reported to have been taking regularly. He attended a routine clinic only 4 weeks ago at which his CD4 count was measured and was found to be over 400 - not normal but not the sort of level where major trouble is expected, and he was told that he should be ok for another 3 months. Then he started to get headaches and a poor appetite, and by today his weight had gone down from 50kg to 45 i.e. approx 8 stone to 7. There are no breath sounds over the lower part of the left lung. His blood pressure is drastically low. He may have both meningitis and pneumonia. 

We arrange transport to the hospital an hour or so away and put up a drip and give him some antibiotics intravenously. I am afraid that i doubt he will survive. Why was he not brought in to us earlier? I have no idea.

This is the scenario that I had thought I would be seeing on a regular basis- but actually it is uncommon. What I am seeing often is patients who look well and come to see me about minor conditions who tell me (only on direct questioning at there is still stigma attached) that they have been on ARV’s (antiretrovirals), often for several years. I recently met a patient who told me that he had had HIV since 2000. 

So this is in a way a success. The problem that is obvious from the clinic is that we are diagnosing new patients most days. Today i saw an 18 year old girl - looking very healthy and smartly dressed - who came with the ‘usual’ complaint of headache. I had a feeling there was more to it and eventually the real problem emerged - genital warts. This is often a sign of HIV so we did the test and of course it was positive. 

Our medical education makes quite a big deal about how to go about breaking bad news - checking what people want to know etc. But with her basic English and my pathetic grasp of Njanja all i can do is hold her hand and sound sympathetic.  It sounds as if she has actually had very limited sexual experience and has been tragically unlucky. So we refer her to the ARV clinic.  If she attends it will be obvious to everyone what disease she suffers from. What will she say to her sister with whom she lives? and what to her parents? And we have no effective treatment to offer her for the warts! Poor kid. 

 So, unless there is change in the culture of promiscuity here the prevalence of HIV and hence the  burden of patients needing retroviral treatment is bound to rise. (That sounds as if we are not promiscuous in the developed world, which is of course nonsense.) How long will the drugs remain effective? How long will the donors generosity last? Is there any chance of a medical breakthrough in preventing infections?  I have asked around and it seems that noone is even asking these questions. 

We really don’t know how lucky we are do we?

To Give - or not to Give

What should be the response of the wealthy of the world to the suffering of people in Africa? We like to come and look at the animals and we are very keen to preserve the natural heritage that we Africa has in terms of wildlife. We also sympathize with people who find it difficult to feed their children properly, and cannot afford light to read after dark, and have no money for transport to get to hospital to give birth or to have broken limbs treated. 

We tend to gloss over the suffering and hardship the wild animals cause to the local people both in terms of risk to health ( there is usually a death or two a year here in Mfuwe from elephants and hippos and a similar toll from crocodiles), and damage to crops and property. Of course it is true that the camps provide employment - but the majority of people living in the area are not directly employed in the tourist industry. They are small scale farmers and fishermen and traders of various sorts. 

The various Safari Lodges, which are mostly but not all run by Europeans, try hard to help the local community in various ways. One way is to arrange for a Mzungu (i.e. white) doctor i.e. me to come from abroad to help at the rural clinic which would otherwise be run by nurses who have a pretty basic education. Another is to provide public health measures such as impregnated bed nets to prevent malaria. 

There are also Charity run feeding programmes for schoolkids and there are several organisations that sponsor schoolchildren by paying fees and providing textbooks and uniforms to children that otherwise could not afford to go. Furthermore the supply of drugs to Zambian hospitals and pharmacies especially for HIV and Malaria seems to be largely funded by overseas aid from the developed world. There are lots of churches in Mfuwe - but to my perhaps jaundiced eye - their well fed pastors do not seem to be a help to their poor parishioners - perhaps the opposite, at least in material terms. 

But are the donations wasted and does all this help lead to a culture of dependency? And might Zambia be better off without all this charity? 

My suspicion so far (after just over 3 weeks) is that there is not a huge amount of waste at but that the dependency culture is a problem, and also the western derived culture that tells them that a government office job moving paper (or its modern equivalent ) about is the ultimate aim of all education. But it is also clear that in a society which is based on manual labour based agriculture - there is no way they can afford many of what we would regard as absolute necessities - and the conditions of life are still pretty brutal for most people despite the largesse of the west. Small contributions which would make no difference to our quality of life can really help here.  For  example charities such as Project Luangwa http://www.projectluangwa.org/ 

Health and Safety

This is a sad and shocking blog, which raises interesting comparisons between Africa and the UK and the way we deal with risk. 

Today I was having a short rest after lunch in my little semi detached one room bungalow at Marula Lodge, which is beside the Luangwa river and just outside the National Park, when I heard someone deliver a very large load of bricks from a huge dumper truck. Then the noise got louder and I realised that dumper trucks here just aren’t that big. I rushed outside and looked and saw that a large tree had just fallen and demolished the restaurant building. I guessed that there would be multiple casualties and I thought s..t - as this is possibly the worst place in the world outside antarctica to try and deal with such an event. The total sum of medical resources within 5 hours drive being me and a trauma bag with 2 litres of saline and a very small amount of morphine and an ambu bag and mask to help people who are not breathing.  If said casualties are trapped inside an unstable building with a very heavy tree  weighing it down it doesn’ t help. Then I thought maybe there was in fact noone in there - but a moment later it became clear from an impromptu roll call that one guy was missing- and a closer look revealed a still human form. After checking that that part of the building was stable i managed to get in to him. I could see one arm and the back of his chest. There was no breathing, and there was no pulse at the wrist. I had to tell everyone that he was dead and not to try to evacuate him, as it looked impossible and the attempt would be dangerous. It sounds terrible to say it but in a way I was relieved that I would not have to attempt the impossible, and that I had done  something that wasn’t hard but which I was probably the only person who could do with confidence and that was to confirm death. I was also relieved when I saw that he had had a massive blow to the head and chest that no one could have survived. 

The tree is a winter thorn - and after it fell it was clear that it was completely rotten with some sort of fungus at the base with most of it in fact hollow. It had also been dropping a few branches, but on the outside it otherwise looked healthy. People who have lived here for a long time said that they knew that they do sometimes fall over. However, there are lots of them dotted around various tourist lodges! 

The attitude here is that bad things will happen if they are fated to happen, not because we fail to prevent them. In the 3 weeks i have been here the local town (Popn 20,000 roughly) has experienced 1 drowning, 1 man killed by a hippo, 1 death from snake bite, 2 children brought into the clinic dead in the night from some sort of disease, and several aids related deaths. People expect to be killed by elephants, crocodiles, malaria, childbirth, road accidents etc. They do not seem to worry about risks, and do not bother taking precautions against any individual risk - perhaps because of fatalism, perhaps because trying to minimise so many different risks would be a 24 hour job.

 But in this case  I personally would have preferred it if a health and safety guy had visited and condemned the tree a while ago.

Kakumbi clinic - can I make a difference?

Every morning around 7 a mass of people make their way to a ramshackle rectangular single story building to wait in waiting areas in the open but under a roof. The clinic has 3 offices, a dispensary, 3 wards - one for children to be observed, one for women, (?where men go i havent worked out), and one for women in labour. There are 2 consulting rooms,  both of which are so small that the patient has to clamber around the doctor to reach the examination couch. UK infection control nurses would have a fit over both of these rooms. Then there is the pharmacy store- which is the only room to have air conditioning - so it is visited very frequently for consultation with the pharmacy technician, and a roomy and neat lab - ruled by a very neat and tidy lab technician who glories in the name of Troglet. 

This lab is an exception, as the other rooms are grotty, and not too clean, with paperwork, supplies of syringes, needles, malaria testing gear, instruments, iv fluids etc. all lying in a random mess. The walls go up to about 8 foot high but are mostly open at the top which doesnt do a lot to help confidentiality, and this is a Christian country in which we have to ask about sexually transmitted infections, and HIV in most consultations. Probably it doesnt matter as the doors tend to be left open anyway, and the next patient will tend to stand right by the doorway, so any attempt to preserve secrecy would be doomed to fail. 

Fortunately the light in the daytime in Zambia is strong as very few lights in the building are working- strangely these seem to all be in the offices! Even the offices cannot be protected from the other main logistical problem which is that the water tank which is up on a platform above the clinic, is leaking badly, and the budget of the clinic is not sufficient to pay for a replacement. 

People have a card with a number on to identify them, and this number then allows the right medical file to be found on several rows of shelving. Often patients forget their number and lose the card, so they can end up with several different copies of medical records. The obvious alternative would be to file by name, but surnames are mostly Banda   or Phiri and with no records of date of birth - the confusion between different Thomas Banda would be a huge problem. Also patients like the ability to lose their records as it allows them to get a second opinion every 3 months when the new doctor arrives. 

As one might expect - every day brings a few patients who are much sicker than is common in the UK. Patients arrive looking very unwell with Malaria and are simply given a few tablets of Co-artem and are sent home. In my first couple of days work i have also seen a really nasty tonsillar abcess (it was really gratifying to see how much good a big dose of Penicillin in his bum did), a child who was generally looking ill with an infection on his scalp - but sadly whose HIV test was positive, an old lady with a stroke, a very old lady with acute heart failure and probably a cancer in her abdomen, and a man writhing in agony with kidney stones.

Which leads on to the next big problem with the clinic, which is lack of drugs and dressings. There are barely any of the latter, and in a country full of dirt and insects that is not great! As far as drugs are concerned, there are plenty of HIV drugs and we seem to be ok for Malaria, and we have Aspirin -(useful for the stroke), but otherwise very few, and nothing that could be expected to treat renal colic for example,or anything very helpful for palliative care. I suspect that there is a logic to the extremely limited drug supply, which is that the culture fully embraces polypharmacy  (just like the uk! ) and the general attitude is 1 drug good - 4 drugs better! so some nurses will prescribe for dizziness for example - panadol, an antihistamine, valium/diazepam, and multivitamins. So perhaps the idea is to restrict the supply, then we can restrict the harm! Perhaps we should adopt this principle in the UK?

So, should one try and do something about these issues, - or just put up with the deficiencies of the system, learn to accept them,  and do the best i can with the tools available,  and then go back to the UK having learned how to implement that passive strategy. We shall see how I manage. 

Bikes and phones- reasons to be cheerful

2 technologies are dominant in the streetscape in zambia, the mobile phone, and the bicycle. Mobiles are a must have and if possible people seem to spend even more time texting here than in the uk. There are a surprising amount of Blackberries here, sometimes owned by apparently quite poor people, and generally the phones seems quite neat and smart. There is a 3G network which has pretty good coverage and allows skype voice calls and mobile internet services. In only a decade or so they have caught up to a level of communication that took the developed world a century of hard work to achieve. 

Bikes are a big contrast - they look like the bikes from the 1950’s mainly, almost all black, with old fashioned handlebars that look like a bulls horns, only male type frames, a carrier on the back - often with a basket made of reeds, and a heavy looking stand, and no gears. They need to be strong, as most bikes have a rider/pedaller, and a passenger, either on the rack at the back, or riding ‘croggie’ sitting on the crossbar trying hard to keep both legs raised out of the way of the knees of the person who is pedalling. In the absence of a passenger, surprisingly  large amounts of firewood or fruit or veg can be transported on the back. If you are on a bike alone and you want to look like a bit of a dude, you sit on the rack behind the seat and pedal from there like Peter Fonda in Easy Rider on his customised Harley Davidson.  There are no lights, no bells, and i haven’t seen anyone use any brakes, either. Luckily this part of Zambia is so flat it makes Lincolnshire seem like the alps. The bikes are a brilliant solution to the problem of how to get around in a hot flat poor country. Unfortunately bikes have one huge disadvantage in this area, which is next door to South Luangwa National Park ….. They are not popular with Elephants. For reasons that are unclear, the sight of a bike induces a similar reaction to that observed in owners of Chelsea tractors in London. Both become enraged at the image of effortless progress and jealous of the low fuel consumption(I am guessing about the Ellies) and charge. Unfortunately, the result can be a pile of junked metal and at best, a badly injured cyclist, so sadly I have been advised not to try riding a bike in Mfuwe  (or London), especially as my possible sources of medical assistance are few to say the least. 

Both bikes and phones have spawned an array of supporting businesses. About a quarter of street stalls sell top up vouchers for the phones, and many of the rest sell bicycle parts - tyres, tubes, seats, puncture repair. There is quite a bit of broken glass on the roads and i have a sneaking suspicion about who puts it there! 

It is extremely easy to be very pessimistic because of the huge problems that Africa is facing- AIDS, corruption,  and  population growth being the most obvious. But seeing bikes and phones, 2 things that have clearly made life better for most people, and have not depended on charity, does allow one to have a little hope that progress can be made.

Africa - tragedy or farce?

Is africa a comedy or a tragedy? The answer of course is that it is both at the same time. Today I have been helping at an outreach clinic (as i am not really supposed to be doing a doctors work because the lady doing my authorisation in lusaka has for some reason not been into work the last few days!)
At both village locations I caused great delight. My attempts at saying' very well thankyou' to their zambian 'how are you' - were met with uproarious laughter - followed by a song of welcome. The children all wanted to touch my skin to see if the colour would come off. Smiles all round. The ability of people to take pleasure in small things here is humbling.
But then we came to weigh and record the children's weights, and a worrying pattern emerges. The babies are all breast fed and put on weight very well for the first year or so. After that typically, weight gain is very slow indeed or non existent so that a child who has been of average weight aged 1 is down around the bottom 3% by age 4.  Very often one can see why - as  beside the 2 or 3 yr old child is a mum with a new baby on her back.
So - what is happening with contraception - and what do people want? - i don't really know except that the morning after pill is not available at the clinic - nothing official it is just O/S out of stock.
What is clear is that the rapidly growing population puts huge strains on the demand for everything - but jobs in particular. I am sure that i will be seeing the consequences for peoples everyday lives in stark reality in the clinic in the next few days.

Arrival in Zambia

A rainy morning in Lusaka.

Outside my hotel window there is traffic noise, a cloudy sky, steady rain, wet pavements, a few piles of earth beside a hole someone has been digging. Not much different from Scunthorpe or Hull.
Then you see that someone is walking down the dual carriageway in between the two lines of traffic - selling papers, and that the trees are acacias and other exotic plants, and that none of the pedestrians is fat, and then you see that there are babies being carried on women's backs - and of course that all the people are africans- and you realise that you really have, after 1 short days travel, arrived in Southern Africa.

I know that i am now in a world where life is cheap, where a third of the patients that i will see in Kakumbi health clinic have HIV, where children will be dying regularly from easily curable diseases such as malaria and pneumonia, where the clinic will regularly run out of crucial drugs for epilepsy and diabetes, and where the ability to pay for transport to a hospital 4 hours away will make the difference between life and death. But, on the surface, the first impression is that everything is the same as England. The wifi works well, the card key in the hotel seems easier to use than in the UK, the immigration desk took electronic fingerprints for the paltry sum of $50, and the taxi drivers electronic passcard at the airport worked with no problem. Everyone is on their mobile as in the UK. And I have so far witnessed neither begging nor crime.

My hopes are that i will have an interesting and worthwhile stay during the next 3months. I will be on call 24/7 for the tourists and staff of  the safari camps in the South Luangwa national park in South Eastern Zambia, not far from the border with Malawi. I expect that to be fairly routine, with the biggest issue being in cases which  may need urgent specialist attention and where i will have make a decision and then  do the admin for getting medevac done by air - mainly to Jo'burg. The tricky part of the job looks like being my role in helping out at the Kakumbi clinic where i will be trying to fit in with and help the local staff who are basically nurses who have done only a couple of years of training. Dealing with pretty sick people in a poorly resourced and probably dysfunctional setting with a group of African staff will be challenging and frustrating no doubt, but I hope it will also be worthwhile. Fingers crossed that I will be up to the challenge.