Where there are no doctors

Weather - Maximum temperature 39 degrees Celsius

- Rainfall zero

Highlight of the week

Confidence is running high since HH was sworn in as the new president of Zambia 2 weeks ago. Could this be the beginning of the end of systemic corruption in Zambia?

Lowlight of the week

The Kwacha has rallied. Our pounds are worth 25% less than 2 weeks ago.

Update … our patient Andrew flew home last week. He spent 2.5 weeks in hospital in Lusaka and is now fully recovered. From what you may ask? Who knows! We have been told it was a combination of a tick bite illness and poor adherence to a coeliac diet. We are not convinced. As doctors, we always want answers. But in Zambia we are having to live without this luxury. We will never know what was truly wrong. But the most important thing is he is completely recovered.

Monday to Friday, we work at the Kakumbi Rural Health Clinic (RHC) from 0900 until 1300. It is the only primary care clinic for our population of about 35,000 souls. Kakumbi village is at the end of a 24km road between Mfuwe airport and the South Luangwa National Park.

At the risk sounding like an estate agent here is the low-down on the Kakumbi RHC facilities. The clinic has about 20 rooms. There are 2 main consulting rooms, a treatment room, a lab, two 3 bedded wards, a pharmacy, two small dark rooms for HIV tests and malaria tests. A maternal child health unit where pregnant ladies are assessed and babies are vaccinated and weighed. There is a light and bright modern office block in which HIV patients are supported and treated. Other clinical and managerial duties happen here too. A labour ward is in a separate building. And a further building is where the COVID vaccination program is housed. We often have electricity, but our bulbs are feeble energy savers, so even on the brightest day, the majority of the rooms in the clinic are gloomy. Our medical school mantra was that 90% of diagnosis is derived from patients’ stories. I challenge you to hear what our patients mumble through their poorly worn facemasks. Discerning visual information is even more uncertain. Visualise: dark skin in dark rooms. A dermatologist’s bad dream.

Am I selling this place to you yet? The Care Quality Commission (CQC) would have a field day here. Requires improvement? Inadequate? The CQC don’t really know the meaning of these words. The CQC might actually be vaguely impressed that some of the taps in Kakumbi RHC provide running water some of the time. All in all, the facilities and the resources available here are a quantum leap down from what we have in Britain. In Britain you might not be happy when you can’t see your doctor until tomorrow afternoon. How would you feel if there was no doctor whatsoever?

I’ll cut to the chase about why we are here in the South Luangwa valley. There are no salaried doctors at Kakumbi. In fact, there is only 1 doctor for every 12,000 people in the whole of Zambia. Seventy percent of our staff are employed by the government to work in the clinic. The remaining 30% are volunteers. Well-educated clinicians who are currently unable to find paid employment. I know how that feels. I worked myself as a volunteer in the year before I studied medicine. The work I did in a lab in Portsmouth improved my CV. But more importantly, the experience prepared me to make the transition from adolescence to card carrying member of society. The lack of wages was inconvenient, but I learnt to pay my way through a couple of part time jobs. In present day Zambia, these unemployed clinicians work, without wages, to get experience to make themselves more employable. Keith and I work alongside nurses, clinical officers, lab staff and admin staff. Seven days a week one clinician will run the pharmacy and two will assess and see patients. We support the clinicians. Rolling up our sleeves and getting stuck in really helps us to identify the issues. We work together to find pragmatic ways to cope with the gaps in what can be done. Mind the gap. Gaps in diagnostic resources and chasms in therapeutic options.

The clinic is open 24/7. There is one nurse on night shift to care for any patients on the wards and to see emergencies. Residents of Kakumbi seem better educated than the British populace. Emergency attendance is for emergencies. Very few patients attend out-of-hours. Those that do trouble the night shift are consistently poorly.

The routine day clinic starts at 0800. Patients start to appear. They wait patiently to be signed in. Basic information is recorded in their medical records. I’ve previously described the medical records system. After check in, patient record books are brought to the clinical staff in the consulting rooms. From the consulting room, the clinician usually stays seated and calls out the name of the next patient. Their voices have to travel some distance. The name might be called a number of times. Chinese whispers passed through the waiting crowd mean that the wrong patient often appears. Often the waiting masses will tut their disapproval when the right patient is eventually located. A quick stretch of our legs helps the Mzungu doctors to find the right patient straight away. The masses love us mispronouncing their unfamiliar names. Names often misspelled and illegible.

There are no formalities or long greetings. Merely a look up and the inevitable question: What’s up? Clinicians have their favourite things to say. Keith likes to ask what the patient would like to talk about today. Patients likewise seem to be working from a local script. Bodyache; fever; cough; headache; sneezing; flu; croup. One-word answers. You need to push to get detail. Since when? A day, or less. Flu means a runny nose we are told. Not a near death experience with the worst chills ever. Sneezing is interchangeable with flu. I have never seen anyone sneeze yet. Noses run and our translators tell us that our patients have flu, or sneezing. We blame the Chinese for whispering again. Croup also means a runny nose. You might see a pattern emerging here. Something is definitely lost in translation. Keith is determined to figure out what they are all trying to say. He reckons that he will be able to fathom their lingo eventually. I personally doubt it. If our colleagues, who have been speaking Nyanja and English for more than a decade, can’t decode the true meaning of common presentations, I reckon we are on a losing wicket, especially since the test match finishes in January. Either way, if they don’t have a raging chest infection, likely COVID, sepsis or malaria then the nuances are going to be academic anyway. Most of them have the valley cold.

Because we are still seeing occasional patients with malaria, it is hard to ignore a fever without a definite cause. Likewise, we are heavily promoting the early detection of HIV. So, a test is often suggested. A queue quickly forms outside the lab. We exaggerate in calling it a lab. It’s a lovely clean, freshly decorated room with plenty of windows. But for some unfathomable reason, all the action is outside the lab. HIV tests and Malaria rapid antigen tests are done in separate dark rooms. The lab should have a microscope and blood count analyser. But both are languishing in dire need of repair. The lab does check blood sugar levels and do pregnancy tests. And they have a fancy test for picking up pulmonary TB. Otherwise, the next port of call for investigations is Kamoto hospital. An hour down the road if you can find a truck to take you there. We’ve talked about the lateral flow tests that we have at Kakumbi for COVID before. Executive summary: By the time that we know that a patient has COVID for sure, that horse has usually bolted.

Once a test has been processed, the patient is sent back to us. Then things get tricky. Patients generally want to go away with a medicine. They have been conditioned to expect a little something. Something to reward the time they have invested in the whole clinic ritual. In Britain, doctors have long since banned issuing medications for self-limiting problems. It’s important to avoid clogging up the system with patients wanting freebies. But Zambians are excited to have free consultations and some free medicines. And most people seem to want their share of the booty. So, in Kakumbi, if a patient has a fever, or pain, they will end up with a token amount of paracetamol.

The pharmacy at Kakumbi clinic can’t cope with generous handouts. And we don’t want to reinforce the habit of giving medicines out for self-limiting symptoms. Two days’ worth of paracetamol might seem miserly, but it is something of a compromise. Patient education is a nicety that lacks any depth from many of our colleagues. We are focussing on patient safety for now. Safety netting patients for when they should be coming back is more important than telling patients what the problem is. Sophisticated shared decision making in Kakumbi might take some time to catch on. Keith has been doing it when time and language permits. Our colleagues watch and listen in wonder. The journey of a thousand miles starts with a single step…..

Martha is told to go to the pharmacy to get her medication. Before she has even left the room, the next patient is called in. One out, one in. The beat goes on.

Vaccinations are a relatively new kid on the block in Africa. In the 1990s we saw plenty of pneumonia, gastroenteritis, meningitis and measles in Zanzibar. In our small hospital, in Kivunge village, on average five children died in any week from these preventable and treatable infections. No-one would appear to bat an eye. Of course, the parents would wail for hours. Parental grief was more audible than palpable. But many Kivunge staff seemed to have become battle hardened. Externally the staff showed little emotion, or surprise, at the loss of a wee tot. Zanzibari society in the 1990s seemed to accept this natural wastage and compensated by eschewing family planning. In modern day Zambia the vaccination programme is robust and it has expanded hugely compared to 25 years ago. We vaccinate against streptococcus now. Streptococcus causes the majority of bacterial pneumonia and some meningitis infections. We also vaccinate against rotavirus, a common cause of gastroenteritis. I have not yet seen a dehydrated child with diarrhoea and vomiting in South Luangwa. A distressingly common occurrence in 1990s Zanzibar.

Our vaccination clinics have a near 100% uptake. There is no place here for anti-vaxers. Even if people did read Facebook and Twitter in the South Luangwa Valley, the memory of child deaths and real vulnerability to preventable disease would ensure that good sense will prevail. It is not just the local elephants that benefit from memories to guide them in making sensible decisions. Memories of childhood fever have programmed parents and grandparents to seek care early. The expectation that modern medicine will protect their children is quite fair. But it does mean that many want medicine whenever they have a fever, even if that fever is transitory and self-limiting. Zambians are yet to understand the potential harms caused by medicines, both traditional and modern. So, we do our best to explain the nature of these viral illnesses to staff and patients alike. What happens in the pharmacies and shops around the corner is a different matter. Septrin and Flagyl are available over the counter to those who can afford them. No prescription needed, no questions asked.

Our day in the clinic finishes at about 1300. On average we see 50-60 patients between us in a morning. Patients with severe breathlessness, severe malaria or children with a very high temperature are treated in one of our 6 inpatient beds. Those who need an operation, or an essential test outside of our repertoire, have to go to the hospital at Kamoto.

Our work in the clinic is busy but rewarding. Our job is often to find the needle in a haystack. This is what I used to teach junior doctors in the UK. Where the pattern of illness is not quite right, the examination reveals something unexpected, or things just don’t add up. Share your uncertainty with your colleagues and your patient. Keith and I end up scratching our heads, asking our local staff for their input and involving the patient. Jointly we come up with a way forward. The time to think, using our in-patient beds, is more useful than any of the investigations that we have in either Kakumbi or in Middlesbrough. My favourite investigation of all is time. Patience is key. Don’t just do something, stand there for a while first. You will rarely regret it. The problem, or more likely the solution, will declare itself.

After a 2-month honeymoon, the Kakumbi team are beginning to work out how we fit in and vice versa. Usually, they get a new doctor every 3 months. New doctor, new foibles. Handovers can be cursory and knowledge of local guidelines are patchy in the first month or so. But we feel that having two of us here for 6 months might steady the ship a little. Our skill sets across general practice, paediatrics, tropical and development medicine give us a fair shot at doing no harm at least. Who knows, If everything works out: perhaps you will still be reading this blog in 4 years’ time, when we return for our 4th tour of duty.

The lab

Kakumbi Rural Health Centre

The records room and dispensing room

Our ward - all cleaned up ready for the CQC

Photo of the week.