Friday 28 March 2014

Endangered species - including homo sapiens


The South Luangwa national park is the most peaceful place one can imagine. It is 7am and a gentle sunshines on the river, and all is quiet apart from birdsong and the odd snorting hippo. Across the river there are lots of elephants and impala and giraffe - with improbably large birds in many of the trees. It is a delightful place to spend time and the sense of peace and relaxation is wonderful. For pics see http://www.robinpopesafaris.net/camps/nkwali.php

But in fact we are in a war zone. There are lots of people who have no job, no land, and need to eat, and there are also lots of people who are greedy. Elephant ivory and bush meat from the deer are tempting poachers in to the park with primitive rifles and modern AK 47’s. Rhinos have been wiped out in most of Africa.  Despite a lot of support from western donors the Zambian wildlife authority struggles to cope, and large areas of national parks - especially away from the main tourist spots- are heavily poached. There is  also a lot of illegal tree felling of what should be protected forests. 

The underlying pressure is population growth. For Africa in general this has been around 2.5 to 3 % per year for a long time. It doesn’t sound a lot - but half of all Zambians were under the voting age at the recent elections- and that even if fertility reduces to replacement level - 2 children per woman - there are so many young women that numbers will continue to rise rapidly for another generation. At present rates of growth Africas population, which is now just over 1 billion - similar to India and Europe - will reach over 3 billion (i.e. equivalent to half of the worlds present population) by 2050!

It is hard to see how large areas of land can remain untouched by these extra people - even if the pressure on resources does not lead to war between countries. So, if you are a pessimist - (someone who thinks we live in the best of all possible worlds) - don’t put off your african safari trip for too long. 



Sunday 23 March 2014

About food and health - and nothing to do with Zambia


And now for something completely different -as I am due to return to civilisation!?in 3 weeks, I have been looking at the medical press and there is some medical research you probably will not hear on the TV or read about in the press, but which is really good news for those of us who like good food. 
http://annals.org/article.aspx?articleid=1846638&resultClick=3  This is a review done by Cambridge University and funded by the British Heart Foundation which was published in the American College of Physicians Journal - the Annals of Internal Medicine. (i.e. This is solid science not far out crazy stuff)

They collected results from numerous research projects into dietary fat intake and coronary heart disease (heart attacks and angina) involving over 600,000 patients in all. High animal fat intake was NOT associated with an increased risk. A high intake of trans fats or hydrogenated fatty acids - (fats that are artificially solidified by injecting hydrogen) that are found in margarine, and fast foods, was associated with an increased risk. 

So dairy farmers, and lovers of butter, cheese, cakes and baking (who does that leave out?)  can celebrate with a good conscience and no adverse effect on their health. Food factories churning out rubbish however, better get ready - because transfats should probably be banned universally - as they have been in many parts of the world. 

So why did we (both doctors and the public) get conned into the whole animal fats cause high cholesterol causes heart disease? Good question, and I do not think there is a simple answer. In the 50’s when Heart Attacks became common it was observed that diseased arteries contained lumps of cholesterol, and foods with a lot of cholesterol also tend to have a lot of saturated fats (carbon hydrogen chains with all the hydrogen slots filled up). But fatty acids and cholesterol are chemically completely unrelated, almost all of our cholesterol is produced by the liver and not dietary. It is extremely hard to reduce cholesterol in the blood by altering the diet. Also rising animal fat intake in the developed world has accompanied a massive decline in heart disease over the last 30 years. 

However, a simple story can ignore inconvenient truths, most clearly when many cholesterol reducing drugs were found to have no benefit, and the bandwagon really got going when the pharmaceutical industry (firstly Merck, and then Pfizer and Astra) did find that statin drugs prevented deaths after heart attacks, and then various nutriceutical companies started making Flora and Olivio etc. The market for statins alone is over $20 billion, so the simple Myth that eating fats turns into cholesterol which then clogs up your arteries has had powerful support from advertising (both to the public and doctors) and has limped on despite being scientifically shot to pieces.

There is more on this at http://drmalcolmkendrick.org/ - but meanwhile - could you send some ice cream and brie?



Friday 21 March 2014

By the Grace of ...... (controversy rating - MAX)

I APOLOGIZE FOR ANY OFFENCE CAUSED BY THIS BLOG WHICH DEBATES RELIGIOUS BELIEF.  YOU MAY WISH TO STOP READING NOW. 

There is an issue which dramatically divides Zambians and many Europeans, and that is Christianity. It is a sensitive subject, because people here believe very strongly. There are a great variety of churches even in this small town, and they are mostly full on a Sunday. Many people spend several hours each week at services, and pay quite significant amounts to support their church. In fact church buildings and ministers of religion seem to be a success story here - both often bursting at their seams, and the only fat child I have seen in Mfuwe is the daughter of a pastor. 

I of course believe in the enlightenment, Hume and Locke, and from there to Darwin and in modern times to AC Grayling and Richard Dawkins. I think that religion held back the development of science and freedom in Europe. So is Christianity helping or hindering Zambia and Zambians today?

Usually, I try to be diplomatic - when in Rome etc, but today the issues were impossible to ignore. A 30 year old woman with 3 children was brought into the clinic feeling weak and dizzy. She was extremely pale, and our lab measured her Haemoglobin as being 4.3. (normal is from 11 to 16). Haemoglobin is important stuff as it is the chemical that carries oxygen around the body. I have never previously seen anyone with a level under 6. She had been bleeding for a few weeks, and was dangerously ill. I explained that she needed to be sent to the hospital urgently to have the bleeding stopped, and for blood transfusion. Anaesthetics are very dangerous for patients with severe anaemia, so if she does not have a transfusion, her chances are poor. 

I was then told that she was a Jehovah’s Witness, and would not consent to a blood transfusion. I explained (nicely I hope) that this refusal would be likely to result in her children becoming orphans. The response was that they would trust in God, and that with God’s help she would survive. 

I did not say so, but this comment strikes me as crazy, given that everyone here must be only too well aware of many many Christians who have manifestly not been saved by the Almighty from the scourges of HIV, car crashes, crocodiles etc. When I ask the clinic staff how they square this fact with their beliefs they say that those people died because “their time had come”.

The overall philosophy seems to be that one has little direct control over one’s destiny, which is mostly a matter of fate. Maybe prayer helps, and maybe it helps people to accept what happens in life. To someone with my background, this is shockingly fatalistic, and I cannot help blaming the apathy I observe among the clinic staff on their religious faith. 

My interest in this issue gained me an invitation to the New Apostolic Church in Mfuwe last Sunday morning. About a hundred people crowded into a small hall, with about 40 more outside. The service was conducted by the elder along with several deacons, and an unaccompanied choir of about 15 with bass tenor alto and  soprano parts sang a whole succession of hymns beautifully - without the benefit of any sheet music. The service lasted a couple of hours and was in a mixture of Njanja and English. At the appropriate moment all newcomers including me had to stand up and announce themselves. At the end of the service the whole congregation formed a line in order to shake hands with everyone in turn. 

There seems no doubt that people find their religion a great support and a comfort. It is also true that there seems to be very little violence in society generally here, (wife beating excepted) and that people are polite and very friendly. Otherwise moral failings seem generally about as common in Zambia as elsewhere, although a sense of duty and responsibility among  those in authority, ie teachers, nurses etc. seems particularly lacking. The churches have clearly been an obstacle to progress over issues such as the use of condoms, HIV testing, and contraception. 

In the absence of a controlled experiment, we will never know whether Christianity does more good than bad. We may perhaps! see how the present situation pans out over the next 20 years or so. Meanwhile we can speculate and debate. 






Wednesday 19 March 2014

Volunteering - or Voluntouring?


Who I am doing this for? myself  - or the people of Zambia, and if it is the latter- exactly how much am i giving up in order to help them? 

Here in Mfuwe I am staying at a lovely budget lodge/backpackers called Marula Lodge - (marulalodgezambia.com). I am living out of a pretty small suitcase but I have a computer which plays DVD’s and I obviously have a intermittent internet connection. Electricity does disappear now and then, occasionally for a few hours, but the water runs reliably. There are a few things which i am looking forward to renewing an acquaintance with when i get back - such as chocolate, ice cream, non instant coffee, non white bread, a bath ….but the list is pretty short. 
This is of course a subject which is constantly discussed among volunteers, and Marula is visited by a constant stream of volunteers of all sorts. Some of them are doing mainly a tourist thing with a bit of work thrown in, often helping some sort of educational initiative. Some are working for big NGO’s and turn up in big 4X4s and seem to be living quite a ‘bwana’ (boss) lifestyle. However, many are coming here to the lodge for a break from a very tough existence living in primitive conditions for long periods of time. For example, I have just been chatting to a girl who is doing something I could not even cope with for a week. She is from California, and works for the US Peace Corps. She has been living in Zambia for the last year and a half without going home. She lives in a village which has neither electricity, nor running water, nor proper toilets (obviously). Even more impressively, she lives 12km from her nearest fellow volunteer, and there is only one man in her village who speaks English. She has a phone which she charges with a small solar panel. Her transport is by bike.  Once a month, she goes by bike 19km along dirt roads to the nearest town once, and then takes a bus to her HQ for a weekend, the journey taking most of the day. She is only here this weekend because her Mum is visiting. 

She is helping to train local volunteer health workers, mainly to do health education talks to the villagers.  HIV and Malaria prevention and encouraging Ante- natal care are among the most important issues. She says that Africans are generally happier than Americans, which is not intuitive, considering that they face major threats to their most basic needs, such as how to feed my family and keep them healthy.  She personally is ‘as happy as I have ever been’. The only way I can explain this is that she is feeling that her work is worthwhile and fulfilling, and that her relationships with local people are authentic and rewarding. In both cases - this is of course relative to the US. 

So my minor degree of deprivation of a few favourite luxuries pales into insignificance by comparison. But, I am outside my comfort zone quite frequently in my work in the government clinic, both in terms of my skills and ability, and in terms of the lack of drugs, equipment, and referral options. So, although I am having a hugely interesting human experience as part of my trip here, I think I can say that I am not just a voluntourist.




Saturday 15 March 2014

Bike blog - please excuse some technical language







It is 7am and rush hour in Mfuwe - there a few cars but hundreds of bikes, with an average number of passengers of around 2. The bikes look like a throwback to the 1950’s - in that they are generally black in colour, and have cows horn handlebars and old style brakes which use rods and levers instead of wire and cables. The marketing is all about reliability and strength, rather than style or speed. Typical brands are “Atlas Super Strong’ or ‘Buffalo’.  The bikes are made generally in China and come to Africa in a rather crude and unadjusted state. They retail here for around 60-70 pounds when new, and the quality is appropriate to the price. Nonetheless, the ownership of a bike shows that a family is pulling itself off the breadline and is a potent status symbol. The bike will then be used by the whole family, with the luggage rack at the back usually carrying a passenger (ladies decorously riding sidesaddle - like some Victorian film), or a woven basket up to 2m wide with vegetables, or a heavy load of firewood. Children often perch on the cross bar- sometimes even infants. Not surprisingly, this is well in excess of the design parameters and when you throw in the state of the roads, it all adds up to some sick bicycles. The common issues are - brakes - often non existent and usually not functional (luckily Mfuwe is very flat), and seats - often leaning sideways at a crazy angle or not existing at all, with the rider either just standing up, or sitting on the luggage rack leaning back as in an Easy Rider pose.  Pedals are a common problem with kids often riding in flipflops just on the pedal axle which looks painful. There are of course neither lights nor reflectors. 
So roadside bike repair workshops and bike spare suppliers do a roaring trade. They will respoke a wheel quite happily with no equipment to speak off just sitting on bare earth. They also specialise in a very african bike modification which seems to be aimed at reinforcing the front forks. Hammers seem to be used for bike repair surprisingly often, but they get results! 

So Kakumbi clinic has no patient car park, but lots of bikes outside, and when the mobile HIV clinic comes to town - it looks like Amsterdam railway station - well almost. (Why HIV patients are more likely to have bikes we will discuss another time). 

It is hard not to approve of this development. It would be nice if the bikes were made in Africa so that the money is not being sucked out of the economy, but who could compete at that price? The local people have an effective, non polluting means of transport, so they can get to school, healthcare, shops, work,etc. Loads including sick patients are transported by someone walking beside the bike while the wood or patient sits on the rear carrier. Obesity is rare. 

So what are the drawbacks? There are conflicts over bike ownership, - including at least one divorce recently! but the main problems are very similar to with cars - and obviously less severe. Cyclists seem to get hit by cars even more than pedestrians do, which is a tragedy that is mainly caused by the standard of Zambian driving. Men fall off their brakeless bikes when drunk and their bare feet suffer very nasty wounds, which we struggle to keep dressed and clean. But the main problem is when the kids get their feet in the wheel. The results can really make me wince. 

Joy


xxx rated xxx blog stop reading if the thought of blood etc. is upsetting.

During my spell here i have been taken under the wing of the clinic Midwife  - a larger than life character literally - called Grace. Perhaps unwisely, I told her that i was interested in brushing up my skills in the Obstetric department.  Since then, when opportunity arises, and the clinic is not too busy, she throws me in the deep end and sees how i cope. 

In medical education in the 1970’s, students had to spend many hours with women in labour and actually deliver babies. I found it fascinating and rewarding, being granted an intimate view (literally) of the emotional lives of patients at the most significant event in their lives. I still remember some of those women 30 years later. I then worked as a junior doctor in the UK and I was also in charge of the maternity ward during our spell in South Africa, and I am still proud of our results there, including a zero death rate for mothers. 

But that was a long time ago, and I am very rusty indeed. So when I was asked today to assess a patient I was a bit nervous. A 25 year old  who was in her 4th pregancy had been in labour for the last hour or so. She was accompanied by her Mother (the thought that husbands should attend births is bizarre to Zambians). She was having quite frequent contractions but not making a sound, despite no painkillers at all (as is the norm here). I checked her tummy. The babies heart rate was fine, and I could only feel less than half of the babies head, which meant that the head was likely to be well down into the pelvic canal. Internally the waters were bulging and the head low down, and neck of the womb fully open. 

Shortly afterwards, with no further sound from her, a nice big baby boy was born. He did make a noise! We got the cord cut, did the injection of oxytocin to help the uterus contract, and gently delivered the placenta, while Mum lay exhausted. 

It is obviously a primitive rather than a rational response, but I found the experience deeply joyful and uplifting. I am grateful to those involved for letting me share it. 

Monday 10 March 2014

Job satisfaction - or not?


Fulfillment, self - actualisation, feeling worthwhile. Are these things more important for doctors than for other people? Probably not - but certainly during our long medical training we long to stop being spectators, and to do something useful. We want to help - and if that help is appreciated that is also nice. 
But then we can often find that many aspects of our work fail to live up to our expectations. There are many patients whose degenerative disease we can do very little for. There are probably even more patients who come to see us with symptoms that have more to do with their psyche and their place in society than with classical diseases, and whom we are also poorly placed to help. We also become painfully aware of all the patients whose problems are actually caused by medical treatment in the form of harmful drugs, harmful medical tests and failed operations. We know that our efforts in preventative care with respect to diabetes, blood pressure, cholesterol, cervical smears etc. only help a small minority of patients. Even when we do the right and helpful thing for example stitching up the head wound of a drunk - he expresses no gratitude, and we can get a bit fed up with the likelihood that he will be back soon with the same problem. 

So perhaps the answer is to go and work somewhere like Africa where one can prevent needless deaths and suffering by diagnosing and correctly treating curable diseases such as infections which might otherwise have gone untreated. The patient says thankyou and comes back and is better - and a warm glow spreads around. 
That scenario does actually occur - sort of. It is common for patients to come into the clinic complaining of ‘malungu’ (malaria) which consists of ‘mbepo’ chills, ‘kupyay’ fever, and ‘muto’ headache. I do the rapid test for malaria and sometimes it is positive. The patient gets better quite quickly on co-artem treatment (based on artemisia a chinese herb!) What is not to like? Well, just that there is not a lot of skill or training or experience involved so one does not feel particularly useful. The clinic receptionist could maybe do it as well. 

More serious harm to the self image of the hero helping his poor african brothers comes from some basically fit and well africans who have a bit of a cough and a cold. They come to the clinic for some strong Mzungu (i.e. white) drugs,  and possibly a sick note, and perhaps understandably, do not sympathise with my wish to mainly see patients whose life i am going to save! Explaining to them that they will recover with no treatment does not go down that well and scores zero on the fulfillometer. 

Then there is the not so rare occasion in which my skills and training and experience are simply not up to it in this environment. I am pretty baffled several times a week. Partly there are things i just am not experienced in, like HIV treatments or Sexually transmitted diseases, and partly it is things like skin rashes on black skin. 

Last in the frustration game is when i know the right treatment - but we do not have it in stock at the time, or we never have it - i.e. Asthma inhalers, or decent wound dressings. Or when the patient needs to go to hospital an hour away and they have no money for the journey. A woman aged 40 or so came in today, known HIV, on ARV drugs but looking unwell, feeling weak, but with no obvious specific diagnosis. I did a referral letter and drove her back to her home about 2 miles away as she was too weak to walk back. I am hoping that she manages to borrow the money to get a lift to the hospital but I have no idea if she will be able to do that. Even if she does get to hospital it is likely I will never know what happened to her, as this usually relies on someone physically delivering a discharge letter back to the clinic - which is rare. 

But there are some patients that i can help, who probably would not get that help if i was not around. A tonsillar abcess, pneumonias, ear infections, wounds that need stitching, probable stomach ulcers.  And every now and then a life is saved! Yesterday a young girl of 21 came in. ‘Pregnant and dizzy‘- were the symptoms. Not obviously exciting. But then I felt her hand, which was very cold, and it became clear that she was seriously ill. She had had low abdominal pain, and was very pale with a weak pulse and a very low blood pressure.  A ruptured pregnancy in the fallopian tube with internal bleeding was the obvious diagnosis. Luckily I managed to get an IV line in and gave some saline, and the relatives understood the need to get her to hospital quickly. She had a successful op at the local hospital and she is doing well. 

Without my presence in Mfuwe  she would certainly have died. Which I cannot often say in England!