A phoenix from the ashes of COVID

Weather - Maximum temperature 44 degrees Celsius

- Rainfall zero

Highlight of the week

Our air-conditioning has been resuscitated

Lowlight of the week

3 days without air conditioning

Geoffrey’s story will pull on your heart strings. Heart strings already tense from a rollercoaster ride of emotions in the last two tumultuous years. COVID-19 has laid waste to so many lives and to so many ways of life. But Geoffrey’s story is one of hope, mediated partly by COVID-19. COVID-19 has given him a new lease of life!

A queue waited patiently. Not unusual. Some patients for Keith and some for me. It was 12:00 noon on a Wednesday. We had just returned from a community child health clinic in Nyamununga village. This queue of patients were the tricky ones. Complicated, or just outside the experience of the clinicians in Kakumbi Rural Health Centre. Geoffrey was one of the awkward squad, that our nurse John did not feel that he had the experience to manage appropriately. Geoffrey first met Keith 7 weeks ago. Geoffrey Banda looked on his last legs.

We encourage the staff to share their uncertainties with us. Even on outreach clinic days we do a quick ward round before, and after, our outreach clinics. This is how Keith came to first meet Geoffrey, a 62-year-old man with a history of obesity, hypertension and type 2 diabetes. This constellation of conditions all too commonly travel together. Common in Middlesbrough and Sunderland. Rare in Africa during our Tanzanian tour of duty in the 1990s. In 1994 malnutrition and tropical illnesses seemed to have the ascendancy in Zanzibar. But now both Zanzibar and Zambia in the twenty twenties have gained the dubious accolade of replacing one type of malnutrition with another. Non communicable diseases are not caught by traditional methods of contagion. Instead, the ill habits of Western lifestyle are trends that travel fast. Given oxygen and spread like wildfire by social media. Then sustained by businesses that rely on bad habits and addictions. In the medical community we fight a rear-guard action. Political and social will is needed to stop the rot. For now, Keith treats patients like Geoffrey when they are ready to reform.

Geoffrey contracted COVID at the start of July. He was fertile ground for the potential complications that have been reaping older and vulnerable people across the world of late. Afflicted by COVID pneumonitis, Geoffrey was soon referred to Kamoto hospital. Kamoto did not have any therapeutic options for Geoffrey, and he was quickly passed up the chain of command to Chipata Central Hospital. Four weeks passed. He received oxygen, steroids, antibiotics, insulin and anti-hypertensives. Geoffrey’s wife Martha stayed by his side throughout. They said their goodbyes. Geoffrey so breathless that Martha only saw him mouth her name. Although Geoffrey had a very definite COVID pneumonitis, his chest X-ray was suspicious for TB. He was started on TB drugs. TB drugs seemed to have been the key that unlocked the very start of Geoffrey’s recovery. Geoffrey was going to live – against all the odds. This close shave with death and rebirth all happened well before our tour of duty in Zambia started 10 weeks ago.

Geoffrey was discharged from hospital at the beginning of August. He came straight to our clinic in Kakumbi for follow up. His list of medication intimidated John. “Dr Keith will see you at 12:00. Would you mind waiting?” Geoffrey and Martha could not believe that there was a doctor in the village and vowed to wait. John breathed a sign of relief. He had not seen anyone look so poorly for weeks.

The initial greeting between Keith and Geoffrey was conventional enough. Keith introduced himself and greeted the duo. What would you like to talk about today? His old mantra. Geoffrey’s story unravelled. Often told by Geoffrey’s trusty sidekick Martha, who’s memory of events was crystal clear compared to Geoffrey’s hazy recollection. At least language did not add opacity to an already complex story. Geoffrey’s English is immaculate. Geoffrey quickly translated for Martha. Her English is about as good as our Nyanja.

It took Keith a while to figure out all the issues. Patients here are not used to telling their medical stories. They get no practice. Their clinicians mostly receive a brief pragmatic period of training. Six months for example. Keith has been training for 37 years now. Learning and teaching a craft that appears more complex with each passing year. Keith might ask the right questions. Or more commonly, skilfully leave space for the patient to share key facts. Keith probed to explore the parts of Geoffrey’s story that might point to a way forward.

When was your high blood pressure diagnosed? Geoffrey was not sure. A few years back maybe. What were your blood pressure numbers? He certainly did not know this. What have you tried in the past to improve your blood pressure? Lots of different medicines. It depends on what they have in the clinic. How did you feel on the medication? A bemused shrug. Keith’s communication skills would need honing here. He went back to basics. What are your symptoms Geoffrey? Let’s have a look together at your medications.

And how about your diabetes? Geoffrey told Keith that the clinic rarely had medicines for diabetes, but whilst in Chipata he had been started on insulin. He had bought a glucose meter and miraculously he had a way of sourcing insulin and refrigerating it in Kakumbi. Our clinic and pharmacy do not have insulin and there is one glucose meter shared by 35,000 patients in the Mfuwe area. Diabetes care is an orphan in the South Luangwa Valley.

Geoffrey was still unwell. He was unable to walk unaided. Each sentence was punctuated by a breath or two. His heart rate and pulse rate were both a bit on the high side. His blood pressure was 135/80. His blood sugar was 6.4 mmol/l. Keith’s finger probe displayed his oxygen saturation: 95%. Three key normal readings. Not bad for a man said to have diabetes, high blood pressure and COVID-19 pneumonitis. Not to mention obesity and TB. Oh, and did I fail to mention something else? His weight was now 68 kg. Geoffrey’s brush with death had mediated a drastic weight loss. He had lost 30 kg.

Geoffrey’s lungs sounded shocking. The noises in his lungs would have kept medical students queuing up for hours to listen. Is that a rub or a crackle they might muse? A musical cacophony fit to confuse the keenest ear. The combination of COVID pneumonitis and TB had left its inflammatory footprint, not only on the x-ray machine but also transmitted via Keith’s stethoscope.

Neither Keith, nor I, expected to have fruitful shared decision-making conversations in the South Luangwa valley when we started work here 10 weeks ago. Geoffrey and Martha now appeared ripe for Keith to test out the possibility of really involving a patient and his family in weighing up what mattered to them and what they were capable of doing to address their health concerns.

Keith had a conversation with Geoffrey and Martha. They decided, with Keith’s support, to stop one of his blood pressure medicines and also to skip the insulin for a couple of days or so. He would use metformin instead of insulin for the time being. An unusual journey was just beginning. A patient with chronic ill health was starting to stop medication.

A consultation is jam packed with energy. Over-dense for mere mortals to assimilate and digest. Rome wasn’t built in a day. Keith could not even give Geoffrey a day. Keith fished for a way to empower Geoffrey and Martha to improve their diet and activity levels. It’s a challenge even in the UK to supplement patients with enough materials to permit them to become experts by experience. (Experts by experience is a buzz phrase that aims to put patients at the centre of making their own decisions.) In Kakumbi, it’s rare for us to be able to offer patients an information leaflet. Could Geoffrey access some materials online? The internet has become a favoured way to share materials with patients in the UK and elsewhere. Sorry, we don’t have a computer. What about a smart phone? Do you have WhatsApp? Yes, to both!

Keith had worked with our boss, the district medical officer. They agreed to translate a leaflet that Keith had written in English to help people manage type 2 diabetes in developing countries. In the absence of other viable options of care the leaflet focuses on helping people to understand how their diet can affect the spikes and troughs in their blood sugar, linked with how quickly the carbohydrate in their food enters their blood stream. These are the principles of the low GI diet, AKA the low Glycaemic Index diet. Keith offered to send this leaflet in Nyanja to Geoffrey’s WhatsApp account. Geoffrey loved the idea. He had always wanted to improve his diet.

And so: Geoffrey had access to the bat-phone number. Not a planned move on Keith’s part. But on reflection: all of the subscribers to the medical fund in South Luangwa have access too. Geoffrey does not abuse his ready access to Keith. When Geoffrey left the clinic after that first meeting he knew to watch out for thirst or passing lots of urine. He knew that we wanted to know if his blood glucose went above 16 mmol/l. He agreed to meet Keith again after a week.

Over the next 6 weeks Keith and Geoffrey met regularly. Geoffrey’s blood pressure and blood sugars stayed low and cautiously almost all of his medications where stopped. Last week Keith told Geoffrey that his diabetes and his high blood pressure were in remission. Since metformin is hard to come by in Kakumbi, Geoffrey had previously elected to stop it. Even though he knows it can give him preventative benefits. But the main thing that has changed about Geoffrey is his lifestyle and his fitness. Geoffrey now goes for a regular walk and grows his own vegetables. Martha and he cook together and have made some amazing changes to their diet. The low GI diet means that Martha and Geoffrey stay full for longer and keep their risk of future diabetes to a minimum.

Thanks to COVID-19 (and a dash of TB) Geoffrey now has a spring back in his step. His brush with death has given him a new lease of life. Three chronic diseases have been kicked into the long grass. The doctors amongst you will be excited by this. A quick search on your disease database at work will remind you of what a rarity this is. A phoenix.

Winter is coming

They were telling us they were twins (we think)

We like the off the shoulder look

Photo of the week: Caption competition.