Local brew

Weather - Maximum temperature – 41 degrees Celsius

- Rainfall 2mm

Highlight of the week

It’s been raining cats and dogs. Nothing to do with the weather mind. 20 lions, 30 wild dogs. Cubs and pups galore.

Lowlight of the week

Our getaway weekend in the bush is disturbed for 2 emergencies.

In 2008 a family, who had cooked up some wild mushrooms in Scotland, fell ill. They had foraged for mushrooms regularly, and usually knew what to eat, and what not to eat. They all needed dialysis, and one of them: Nicholas Evans, author of The Horse Whisperer, ended up having a renal transplant. All from eating humble mushrooms. So what? I hear you ask. What is the relevance of this to our weekly blog? This episode is not about personal misadventure. Breathe easy Mum and Peter. My kidneys are fine. This is a tale of patient misadventure.

Our daily routine at Kakumbi Rural Health Clinic starts with a peek at the inpatient beds. The beds are rarely occupied. We work at a clinic, rather than a hospital. Six beds offer us the chance to watch patients over a few hours, or a day or two. Patients can receive basic emergency treatment. They can also have key investigations and some of them need the most powerful investigation of all: the passage of time. These patients aren’t usually fit to walk home and aren’t sick enough for us to use the precious ambulance that is only for dire emergencies.

So why six beds? The number seems arbitrary. Two major factors are at play here. Our nearest referral hospital is about an hour away by car and most of our patients do not have transport or money. Even if a patient can get to Kamoto hospital, there is a very limited range of things that they can do to test, or treat, our patients. So, we only send them if we know that Kamoto hospital can help them. Six beds that often all lie empty. Imagine our surprise to find the wards almost full, with five occupied beds, this Monday.

All five patients were adults. Keith rubbed his hands together and got stuck in. Adults aren’t really my cup of tea. But a lack of outpatients who could speak English, and a scarcity of translators, meant that I had to roll my sleeves up and help out with the inpatients too.

Patient number one was a pregnant 19 years old. She had presented overnight with profuse vomiting, diarrhoea, abdominal cramps and a fever. The staff had already started her on intravenous fluids. Food poisoning was their working diagnosis. Keith reviewed her in a bit more detail. The onset of her illness had been very sudden the previous evening. She had a fever and a fast heart rate. She was not dehydrated. She was alert and able to talk normally but looked and felt dreadful. We checked her malaria screen and urine sample. The urine dip test was positive for white blood cells but not for nitrites. Perhaps she had a urine infection. We had no other way to check this and recommended antibiotics for her.

The pieces of a jigsaw started to come together. We found out that four of our patients were from one household and the fifth was a neighbour. All our inpatients had a similar story, pregnancy excepted. Five adults. Two men aged 20 and 45. Two more women aged 23 and 43. Their symptoms varied only in severity. All had vomited profusely and had a little diarrhoea. At some stage they had all been febrile. We gave all five patients oral rehydration salts to sip. Paracetamol to bring down their temperatures. Two patients were given an injection for nausea and vomiting.

There is a statute in England that obliges us to call the Health Protection Agency (HPA) in situations like this. They would have been coordinating sample collection, taking detailed histories, and searching for the possible source of this outbreak. In fictional America, House would send his interns out to the community to break into dwellings looking for weird and wonderful nasty bugs or toxins. But these are not English patients. This is not fiction. The equivalent of the HPA in Zambia are our environmental health officers. They are members of our clinic staff who usually make sure that we are collecting data about childhood vaccinations. We sit with one each Tuesday and Thursday, under a tree, as we jab the under-fives. Environmental health officers hand out impregnated mosquito nets to parents. They hand out rapid diagnostic malaria test kits to village headmen and undertake school visits. In schools they make sure that toilets are clean and food is properly cooked. Of late they also tell teachers off for not wearing face masks or insisting on social distancing. Classrooms hold 70 children or more. Square that one Dr Whitty.

The story evolved. You might say it brewed a little. Fermented perhaps. All of our patients had drunk African juice the previous evening. A non-alcoholic preparation known locally as Tobwa. This is a fermented drink made from sorghum, maize, or millet. It seemed the likely culprit.

Clinically our patients showed evidence of a toxin-mediated illness. Toxins are produced by bacteria, but they act too fast to be a normal infection. The toxins produce immediate and often drastic chemical reactions. This toxin we believe was produced by Staphylococcal bacteria. Antibiotics are usually futile. Supportive care and symptom relief are the order of the day.

A family member was sent home and returned bearing the offending liquid. House and the Health protection agency would know exactly what to do with this offensive brew. With that in mind I went to find our environmental health officer. Amina decided it should go to Kamoto Hospital. When could we take it? Amina wanted help from International rescue.

Now, Kamoto hospital has no microbiology lab. We are the only people at our clinic with a car. But we were not about to drive off on a wild goose chase. A two hour round trip without hope of paydirt. Let’s find a willing volunteer to test the Tobwa in vivo, Keith suggested tongue-in-cheek. We took the idea to the ethics committee. The committee said no. International rescue stood down. We were told to put the offending liquid into a fridge. Someone would take it to Kamoto hospital as soon as possible. It’s probably still there now.

Toxins act out of the blue. Fast. But toxins also hold onto their prey, the lining of our patients’ guts in this case, for a predictable length of time. And then, hey presto, in the case of Staphylococcal toxins, in less than a day you are fine again. All our patients started to improve after about 12 hours. One by one, they were fit for discharge and were sent on their way home. Fortunately, this toxin does not cause renal failure. So, no dialysis or transplantation needed here. Who would have guessed that Scotland was more dangerous than Africa?

Instinctively when we come across an adult vomiting we assume intoxication. As medics we can’t help but use our intuition, based on experience, to make best guesses. Making a diagnosis is a key to being able to come up with a provisional management plan. We have a steady trade in dealing with alcohol intoxication in our clinic. There is good reason to use the word intoxication to describe the effect that alcohol has on us. We imbibe it at our peril. Especially when the dose is uncertain. Do you remember the heady days of adolescence? We all lacked judgement and many drank too much too fast. Many in Kakumbi have no idea how much they are drinking since local brews like Kachasu can contain anything between 20 and 70 per cent alcohol by volume.

Daniel came in unconscious this Tuesday at 1 am. He never woke up. His friends had found him in the toilets of a local bar, surrounded by his own vomit. Despite best efforts at resuscitation, he was pronounced dead at 05:00. When we arrived at clinic, just before 09:00, it was hard to find a place to park. There was a lorry, a make-shift hearse, in front of the clinic and a throng of people, mostly young men, milling around ready to act as a cortège. Another group, mostly young women, sat wailing and sobbing. Grief is expressed visibly and audibly. Death is accepted and people move on. There are no post-mortems. There is no obvious learning from bitter experience.

Substance abuse is relatively rare here in South Luangwa. Smoking tobacco is niche. Cannabis is frowned upon across the board, but Western marketing of CBD as a panacea is making waves. By the way CBD is not a panacea. The evidence base that is medicinal for any ailment is extremely poor. It is produced commercially. I will say no more. Alcohol however is accepted as part of the tapestry of life. Rich life or poor life. Often rich life causing poor life.

Zambians have ready access to cheap alcohol. Whilst a bottle of Gordon’s gin retails at 200 Kwacha (about £9). Gordon’s is well out of reach of the locals. Local gin is half that price. Still too expensive for the common man. But the locally brewed and distilled moonshine, Kachasu, is cheaper than chips. Technically illegal, highly alcoholic and readily accessible. Since the manufacture of Kachasu is not regulated, its contents are not benchmarked. It may contain as little as 20% ethanol by volume or as much as 70% or more. Reports of people becoming blind after drinking Kachasu make us suspicious that it can contain methanol. Kachasu is usually produced from fermented maize. Some accidental contaminating microbes: yeasts; fungi; and bacteria, produce methanol rather than ethanol. Both types of alcohol are concentrated by distillation. Hey presto. Blindness and death in a bottle.

We see a variety of symptoms of intoxication. Staggering. Confusion. Vomiting. Convulsions. Unconsciousness. Daniel’s presentation included the whole spectrum. His is the first alcohol related death that we have witnessed first-hand. Daniel’s death provides postmortem evidence of what our culture can do to people. Society’s ills expressed.

A startling number of patients admit to consuming a bottle of spirits per day. Alcoholism is the thin end of the wedge. Harmful drinking is one of a raft of so-called non-communicable diseases that have probably been imported from so-called developed countries. I just have a couple of beers at the end of my day to unwind. Justin shares his story. Justin is one of those in the wedge. His hypertension and type 2 diabetes tick inside of him. Will he be lucky and live? Or will his heart stop sooner rather than later? Alcohol is nudging things in the wrong direction.

Divining for alcohol related harm is tricky. Who does it affect? The disaffected unemployed? The well to do, with cash to splash. Suspect everyone. Smell everyone. Of course, face masks and social distancing make this even more tricky. Ask sensitively. As a paediatrician, I am having to learn even more adult history taking skills. I previously mentioned that my history taking repertoire now includes questions about sexually transmissible infections and HIV status. I’m also trying out new questions to tease out details about alcohol intake. My poker face hides my surprise as a well-spoken, smart looking young man tells me he drinks until he passes out. By day he serves tourists G and T with ice and a slice. His exclusive remote camp might attract the likes of Tom Cruise.

Both in the UK, and here in Zambia, drinking problems commonly masquerade as epilepsy. Epileptic seizures are by definition: unprovoked seizures. Both alcohol intoxication and alcohol withdrawal are two of the commonest things that provoke seizures. So not technically epilepsy. Emmanuel, a 32-year-old farmer, one of Keith’s patients, had been taking carbamazepine for 4 years. He had a bad patch after splitting with his wife and drank like a fish. His seizures may have been triggered by intoxication or withdrawal, or both. Somehow, he put his life back together and decided to abstain from alcohol. Emmanuel has been seizure free for 3 years now. Keith has seen him on 4 occasions. They decided together to cautiously withdraw and stop his carbamazepine. Emmanuel is enjoying sobriety and his epilepsy has been cured. It’s not all doom and gloom in the Valley.

We have seen the effects of this hooch on both locals and ex-pats. It is not pretty. There is no Alcoholics Anonymous here. Stopping drinking abruptly may bring its own worries. So, Keith negotiates. How about not having a drink until sundown? How about only drinking beer? Or half a bottle of spirits? He has to be realistic. Most patients know they are harming their bodies and minds. It’s the same in the UK.

So, no local hooch for us. Or Tobwa for that matter. Luckily, we can afford Gordon’s Gin. Which we do not touch on school days. A bottle lasts us a whole month. You can guess who gets the lion’s share.

Tobwa - it smells as unappetising as it looks

Distilling Kachasu

Changing a tyre in the bush. Look closely and you will see some lions watching us under a tree less than 60m away. Luckily for us they were full of buffalo!

Photo of the week