Medicine is like a box of chocolates

Shadreck is my next patient in OPD. He is a well dressed gentleman in khaki trousers and a white shirt accompanied by his wife. I recognise him and remember from the ward, he had been an inpatient a short time ago or so I thought. When I examine his green card however I am surprised to see that Shadreck’s admission had been way back in August. It’s a reminder to me of how quick time goes and that my time remaining here is short now. It also reminds me that even though it seems I am stuck in a time bubble here life is probably moving on at home.

Because I left at the start of the Irish ‘summer’ I sometimes think that it must still be summer at home. I have this idea when I arrive home it will be the start of autumn. Being away from home and experiencing life in a completely different country is great but sometimes you forget about the things you miss out at home especially your family and friends.

Shadreck had been treated for severe cardiac failure and required high doses of diuretics to remove excess fluid from his body. Unfortunately since his discharge he has been chronically under dosed with medications and now needs to be readmitted to get stabilised again. He is in good form nonetheless, we talk about ‘Chipata Motel’ the township where he lives in Chipata.

Despite having been here for some time being used to see patients severely ill, adults wasted away from AIDS, children with malnutrition, witnessing death on a near daily basis I am still often shocked at the dire circumstances a fellow human being can find themselves in. My next patient after Shadreck is Mary. She is 19 years old. The first thing I notice about Mary is the smell of urine. But that is not why she has come to the hospital today.

Mary weighs about 40kg, she looks horribly thin. She tells me her problem is cough shortness of breath and weight loss. Examining her there is almost no air entry in her left lung. Her chest X-ray shows a hydropneumothorax, the space where her lung should be is now filed with air and now some of this space is filled with fluid. She does not know her HIV status but is most likely positive. I admit her to the ward, later when someone tries to drain the fluid from her chest several hundred millilitres of frank pus is removed.

I try to ask Mary about her urinary incontinence. It is likely she has a vesico vaginal fistula following obstructed labour. Through an interpreter I try to delicately ask her about her pregnancies and deliveries, if she has noticed any problems, tell her there is a surgeon visiting in the next few weeks who may be able to help her. She denies any problems. She got married at fifteen and has two children but says the labours were fine and the children delivered at the local health centre. Maybe on the ward she will open up to someone about this. As part of my GP training we have to video some consultations we do with patients (with consent) so our communication skills and how we manage the consultation can be assessed. Here mostly working through an interpreter in a busy and hectic environment I fell most of my consultations would unfortunately fail.

Days and weeks pass by quickly, we have less doctors coming up to Christmas, there is more work to do. Sometimes I feel like I am enjoying it more, find the medicine more interesting, that I have an idea what I am doing now and can really make a difference. Other times I feel tired, start looking forward to finishing up in a few weeks, having a holiday, going home. One afternoon after a frustrating morning ward round Pearson walks into room 15 in OPD. I don’t recognise him at first and then think to myself it can’t be, but it is him.

Pearson had been on the ward three weeks ago with a three month history of a massive tumour on his left forehead, growing outwards, down covering his eye and deep, with an X-ray showing some destruction of his skull. He needed treatment quickly. He had some lymph node involvement in his neck one of which was biopsied and sent to the Netherlands for analysis. We gave him chemotherapy treatment for non Hodgkin’s lymphoma thinking that the most likely diagnosis in a HIV positive patient. We told him to come back in three weeks for his next cycle of chemo, the biopsy result may even be back via email then. We doubted that he would make it back.

Pearson is here now three weeks later, his tumour has shrunk dramatically, he feels well. While his left eye is still closed he can now lift the lid and the eye itself and his vision is fine. His results show he has a Burkitt’s lymphoma, a cancer common among African children and in HIV patients. This type of tumour can invade the central nervous system so this time as well as intravenous chemo I have to give him intrathecal methotrexate. This involves inserting a lumbar puncture needle through his back so it is in the cerebrospinal fluid then injecting the medication slowly through this needle. This way the chemo is in his CSF directly into his central nervous system and can reach the brain. It’s not exactly what I thought I would be doing when I decided to become a GP.

After admitting Pearson for his chemo I am seeing the next patient, a lady in for review of her blood pressure, more familiar territory for me. However in the middle of the consultation an emergency case is brought in. An eight month old child is placed on the examination couch, he is warm but not breathing and does not have a pulse.

As I commence CPR and my colleagues come to help me I learn from his father that he has had a fever since yesterday and had not been feeding well today. We continue CPR, can’t get an IV line so give adrenaline directly into the heart. After fifteen minutes his pupils are fixed and not responsive, he has no cardiac output, he is not breathing, he is dead. Probably one of the one million plus children who die from malaria every year in Africa. After barely a few minutes his father picks up his body and leaves for home. I return to my patient with high blood pressure and remind her of the importance of a low salt diet.

Happy Christmas!

Just to say (now that the internet is working again) I hope all those who read this blog had a happy Christmas and good luck for the new year. Thanks again to all those who have contributed to my fundraising efforts for St Francis.

What’s in a name?

Surnames are pretty boring here in Eastern Zambia. Much like most people on Achill Island having either Gallagher or Kilbane as their surname, here well over half of the patients have either Banda (which in English means plain) or Phiri (meaning hill or mountain) for their surname. The remainder comprise a scattering of Zulu’s, Tembo’s, Sakala’s or Mbewe’s. In fact when I see a patient with an unfamiliar surname I usually enquire and find that they are originally from a different part of the country.

Perhaps as a means of making it easier for people to identify themselves and keep numbers of John Banda’s or Mary Phiri’s Limited people here are extremely imaginative when it comes to forenames. Some of these names parents seem to pick in the hope that their children will grow up well, to be Good people, Innocent of any faults, live a Happy life, be Smart and do well in school, to be Humble and Decent.

Some I feel are pretty bad choices. I know being overweight here is a sign of affluence but I struggle to understand how anyone could call their daughter Fatness, or Vast for that matter. I think parents should love all their children just the Same no matter what Size they are. To many parents the arrival of a child is seen as a Gift, a Beauty something Precious. And while it’s good to spread the Love, Lovemore sounds like a chick from a James Bond movie.

Maybe parents pick names in the hope that they are Lucky. Calling your child Fertiliser may lead to a good harvest. Perhaps rather than a child they would have preferred the arrival of a new pair of Shoes or a Table. It’s difficult to put together the Chain of events that leads some choices though such as Tennis or Lightmaka or Butterfly or Dynamo to Note just some.

Sometimes the names bear Witness to the child’s arrival into this world. A boy delivered after a difficult labour is not let forget the fact for the rest of his life and often gets named Mabvuto (trouble). Some mothers are thankful for a Nice and Easy labour though. I hope it is Obvious to the reader that all words in italics are actual names of patients I have come across here working as a Doctor. Goodbye.

Katete Prison Blues

From time to time we have a prisoner from Katete state prison on the ward. They are easy to spot in their flimsy white uniforms of shorts and t-shirt usually with a prison guard by their bed. I have had a couple of issues with the prison staff regarding their care. At one point I discovered one of my patients who was confused handcuffed to the bed. The police officer said he was a suspect for cattle stealing and as they felt he was a flight risk and they were unable to provide a guard to watch him they decided to handcuff him. Understandably I was less than impressed that a patient already confused from sepsis was chained to the bed. This led to a heated dispute with the officer responsible until he rescinded.

Come to think of it my only real disputes since here have been regarding prisoners. Recently we had an inmate from the prison admitted quite unwell suffering from HIV and a TB pleural effusion whereby the space where one of his lungs should be was completely filled with serous fluid. After about a week’s treatment including draining the fluid and giving TB meds he was improving, was less short of breath and able to mobilise about the ward. I felt at this stage he was fit for discharge home.

However I didn’t feel prison was the appropriate place for him right now and it would be best for him to spend a few months recuperating at home with the care of his family before returning to serve the remainder of his sentence. Now bear in mind this man is a taxi driver imprisoned for eight months for non payment of motor related fines and has two months left to serve. Surely my suggestion that the remainder of his sentence be deferred sounds reasonable. I tell the prison guard I will be supplying a medical letter recommending this to the officer in charge and as soon as he Okays it I will discharge Misheck. I think this should be a straight forward procedure, but this is Zambia. Whilst not meaning to be over critical of this country which is populated by amazing friendly people with a vast depth of culture, the bureaucracy here can be infuriating.

The following day the officer in charge arrives saying it is not in his power to defer the sentence that the request must go through ‘channels’, that it would take many months, that only the President himself his excellency could grant such a request and so on. Cue another heated debate eventually leading me to desist from further conversation on the matter as it was futile. So my options now remain to leave the patient on the ward for a number of weeks with a guard 24 hours at the Zambian exchequers expense or discharge him to the prison.

What is a prison in Zambia like? The hospital is fairly basic compared to home so how will a prison compare? I don’t like the look of the food the patients get in hospital but Misheck tells me it’s far better than prison food. The guards inform me they have a sick bay for prisoners who are ill and that they bring patients regularly for review to the clinic or St Francis. I grant they do regularly bring inmates for medical attention but Misheck was really sick when admitted a couple of weeks ago.

I arrange a visit to the prison with Chisala one of the guards for Saturday morning. Some of the medical students come along for the trip. When we arrive I ring Chisala who tells me to knock and go ahead in. We are greeted by another guard Kelvin who recognises one of the students having been admitted to the surgical ward a few weeks back. Here at the outer gate one of the prisoners is working as a tailor mending uniforms. After a couple of minutes Chisala arrives in the gate with two cows trotters, which he proudly boosts will make a good meal. We have to leave our cameras and phones behind before proceeding through the inner gate.

Inside is a barren open space with five or six buildings and a toilet block scattered about. The prisoners are mostly sitting down on the ground, it’s hot this morning and there is little shade here. Kelvin explains that this is a medium security prison housing prisoners with sentence of five years or less. There are currently 152 convicts or people on remand (people awaiting trial) here. Some are currently in the prison farm in Msoro camping and sowing crops.

Our first stop on the tour is the ‘sick bay’. We are shown into a tiny room with no windows about 7*6 foot. There is a single mattress on the floor with a net above. Nobody is in sick bay right now but we are told sometimes there are three or four prisoners here. Must be fairly cramped. I enquire about medical care for people from sick bay and informed that someone form Katete urban health clinic attends weekly. In addition sick patients are allowed daily visitors.

Beside this there is a door behind which is the ‘women’s wing’. We are brought here next. It looks like a scene from a Dickens dramatisation, some kind of back alley that Oliver Twist might run down. There is a building facing the perimeter wall some six feet away. There are three wooden doors on the outside to three separate rooms. There are just three female prisoners right now sharing one of these rooms. I later learn the other rooms are used for solitary confinement.

One of the female prisoners is awaiting trial for murder. I briefly get to talk to her, she doesn’t enjoy the prison and tells me that the death of her friend was an accident. With her in prison is her 17 month old daughter Anna. If convicted Anna’s mother faces a sentence of up to 12 years. The death sentence still exists in Zambian law but for men only. The last execution was in 1997. When I ask what the method was I am told it’s a government secret.

We go back through the wooden door into the main compound, the men are sitting about mostly. One is listening to music on headphones, Chilasa informs me he is one of the captains appointed to oversee the other prisoners. We enter cell one, a building where we are told 25-30 prisoners sleep. However there is only cell one and two which would leave quite a shortfall out of the 127 men here. We are told each prisoner has a mattress. In the corner of the cell behind a screening wall is a single toilet. It’s a proper toilet and clean.

We go next to cell two the same size, except kitted out better. On one wall is a big blackboard being used as a sort of count down calendar. The days of December are being rubbed off as they pass, below this reads ‘coming soon: January’ and then ‘next attraction: February’. Elsewhere on the board is a list of activities including ‘Bible day’, ‘quizz day’, ‘complaint day’ and ‘yoyoyo day’ which I’m told means stories. Hen there is a bible quote from one of Peter’s letters ‘one day freedom’. I ask about the spiritual needs of the prisoners and am told that the various churches do come. ‘The churches they do assist us a lot, they provide soap and other commodities, they are helping a lot’ Kelvin explains.

In another corner of cell two is a small TV belonging to one of the prisoners. It along with the single light bulb in each cell are the only twentieth century items here otherwise the prison could be literally be from the eighteenth or nineteenth centuries.

The kitchen is in another building. There is no electricity, water is carried from a burr hole outside. Behind the building some prisoners are lighting fires under where the pots are inside. There is a bowl of Kapenta (small dried salted fish) outside as well as the trotters resting on a lump of wood, flies swarm all about. Chisala tells me there is just nshima and kapenta to eat right now. Normally there is beans and rice but these are currently out of stock, sounds like the pharmacy report in St Francis. The prison does have some ducks here and goats and these are occasionally on the menu.

At the end of our visit we sign the book back at the gate. I am surprised to see the name of one of the hospital staff in the book and am told he came to bring a few prisoners with a guard to do some work around his house. I am told I can do the same at any time if I wish, my own chain gang. The prison is basic but not as bad as I thought it would be. There is a laid back atmosphere no hint of violence, the prisoners even have their own football team. The accommodation is simple but probably not a whole lot worse than the hospital. How will they feed over 100 on two cows trotters? Am I comfortable to discharge Misheck there or not?

Katete Mosque

Some of the medical students had arranged a visit to Katete mosque with Yahyah a member of Katete stores Muslim community. I haven’t met Yahyah before but am told he has a shop at the stores which sells nice chitenges among other things. I have never been in a Mosque before and whilst rural Zambia may be a strange location for my first visit it ties in nicely with my previous visits to Christian services.

Yahyah doesn’t at all look like he belongs in Zambia. Whilst many of the Indian Muslim population to be seen in Katete or Chipata are dressed in traditional dress and have beards Yahyah is clean shaven and sports a Liverpool football shirt, slightly modified with the sponsors logo for Carlsberg lager concealed. When he speaks he betrays a slight hint of a scouse accent. But he does belong here. Brought up in Chipata 90km from here he is a second generation Zambian. After school he spent eight years in Liverpool where he still has family before returning to settle in Katete. As well as his shop he has interests in the transport industry and Liverpool football team having previously been a season ticket holder.

Its wet and soggy on the evening we visit the mosque, the electricity is out and the daylight is fading. The dusty ground has a new soggy feel underfoot thanks to heavy rain, the first real day of the rainy season. The Mosque is dark and quiet but Yahyah’s welcome is warm and enlightening about the importance of Islam to him and his fellow believers here in Katete. We take of our shoes at the entrance and the girls don improvised scarves to cover their heads.

Not having been in a Mosque before I have few reference points to compare Katete Mosque with. Its about the size of a small parish church at home, at the entrance there is a washing area, beyond that a small hallway before the main part of the building. To each side there are separate rooms one of which is for women to worship in. Time seems to be a big deal to the Muslims who practice here at least. At the head of the main chamber there is a big clock as well as a big digital time display.

There also seems to be some sort of digital count down clock next to that, I’m not sure as I don’t get a close look at it. Perhaps the poor light is playing tricks on me or my imagination or my prejudices. I forget to clarify this later with Yahyah. Towards the entrance there are various timetables for the times at which the five times daily prayers should be said varying with the sunrise and sunset for each day of the year. Strict adherence to timetables isn’t a major feature of African life and I wonder how well Zambians manage to keep to this.

Yahyah speaks proudly but not boastfully about his faith and the Mosque. The Mosque was originally built in the 1960’s, pointing North towards Mecca. There remains just eight Indian families in Katete but yet the Mosque is thriving with several smaller satellite Mosques in the surrounding areas. One of these is in a remote village where Yahyah explains many of the village have decided en masse to convert to Islam. People generally say their prayers at home but come to the Mosque on the Muslim holyday Friday (Juma).

On Friday’s they will pray together and the priest will give a sermon. Services are generally in the local language of Nyanja rather than Arabic or Urdu. Yahyah is quick to point out that sermons here are purely on religious issues and that members of the community here have no interest or tolerance in extremist beliefs which he feels are against the teachings of the Koran. I ask Yahyah about the role of Islam in the fight against HIV/AIDS, he acknowledges that infection rates are lower in predominantly Muslim communities largely relate to sexual abstinence before and fidelity in marriage.

Its time for evening prayers and the call to prayer rings out over the loudspeaker. As we walk towards the car Yahyah explains that many of those who call prayers have traditionally been Ethiopian emphasising the importance in Africa’s role in the spread of Islam. We meet some others coming for prayers, an Indian man in traditional dress pauses to greet Yahyah and then shakes hands with the men amongst us before proceeding inside.

The visit is eye-opening, the Mosque is so different but in many ways so similar to Christian places of worship here. I am impressed by Yahyah’s friendly welcoming nature and also the strong emphasis of community among the Muslim population here.

World AIDS Day

World AIDS day is held on the first of December each year and is marked by events around the world. I had never heard of World AIDS day before and didn’t really know what it meant. It seems to me working in St Francs every day is AIDS day as we deal with AIDS and all its related conditions and feebly sympathise with those who have lost loved ones to AIDS.

At the hospital the day is marked by drama, games and an educational briefing on HIV/AIDS at the football pitch. Staff members wear new World AIDS day 2010 t-shirts. To get some idea of what the day means I ask some colleagues and patients what world AIDS day means to them. Whilst most of the staff are enthusiastic about the concept many patients have never heard of World AIDS day.

‘It’s a day when you remember people who suffer from AIDS’
Mwambwa, patient

‘It centres on controlling the pandemic, we get to educate people and campaign for voluntary counselling and testing’
Harrison, student nurse

‘They do candle lighting ceremonies where we remember our friends and relatives who have died from HIV and AIDS’
John, nurse

‘Back home I didn’t know that world AIDS day was the 1st December, it should be a day for people from outside countries with high HIV levels to raise money and awareness’
Guru, medical student

‘I only know it is the day for people living with HIV. To me it is a very bad day because many people are dying’
Abraham, patient

‘It’s a commemoration day where we remember people with HIV and AIDS, not only those but everyone, those who have died, who are suffering and those who are preventing themselves’
Greyson, nurse

‘I hadn’t heard of it’
Postan, patient

‘It reminds us of the events and awareness of HIV, also the world as a whole it, reminds everyone of its dangers and existence’
Amitano, school headmaster

‘We must at least make more effort to find the cure, let those that fund help with more resources and share equally’
Charles, workshop

‘It’s the remembrance of people living with AIDS and those who have died’
Naomi, clinical assistant

‘I remember my relatives who have died of AIDS, if that time the ARVs were there maybe they would be alive now’
Catherine, clinical assistant

‘To me it reminds me of what I have done for our friends with HIV and what I think could be done for them’
Frank, lab technician

‘World AIDS day is a day to commemorate and trying to sensitise (people) to get to know about AIDS , to make everyone feel free and to encourage people to get tested’
Kapembwa, lab technician

‘I think of our staff who have died’
Dr Shelagh Parkinson, hospital director

‘It doesn’t really mean anything, I just observe it as a normal day’
Esnart, patient

‘It’s a day when we remember those people who have died from HIV and AIDS’
Charity, clinical assistant

‘For me concerning the day I can’t say much but since I am involved in the home care programme we meet clients with them their concerns and the problems they are meeting and then celebrate the day together’
Agrassia, nurse

‘The people who are positive and the people who have died, we remember them’
Miriam, clinical assistant

‘It’s a reminder that the problem is still there, to work harder to spread the word so that we can empower the community to encourage prevention’
Harrison, Clinical officer

‘It’s a day that people in the community celebrate the campaign against the illness’
Zingani, cotton plant manager

‘The day given to people to commemorate and remember those who died’
Ackless, patient

‘It’s a sign to say that the world has HIV’
Amed, daughter of patient

‘I know nothing, I am just surprised to see nurses wearing T shirts with World AIDS day’
Lebitina, patient

‘A day where we remember those who died and sensitise the others to say the world is full of HIV so we need to keep on spreading the message, it is not the end, HIV is still being spread we need also to prevent’
Limbikani, clinical assistant

‘Even to remember those who died a long time ago even before the virus was discovered’
Tembo, clinical assistant

‘Asking yourself do I know my status, it is important to know so you can take care of yourself’
Frida, ward attendant

‘Everyday should be world AIDS toady, world TB day, world malnutrition day, world measles day, they all get forgotten about’
Helen, Doctor

‘At least, better than tomorrow’

The intricacies of Chew or Nyanja or whatever it is they call the language here never ceases to both amuse and frustrate me. Rather than have one word for something there is often two or more. If asking a patient ‘mo sanza?’ and not getting a response it may be worth while trying to ask ‘mo luka?’ instead to enquire if they are vomiting. Similarly when enquiring about abdominal pain if ‘mimba uwawa’ doesn’t work try ‘mala uwawa’ instead.

Then there are some words which have to share their meaning like ‘gona’ which can mean to lie, to sleep and also to sleep (in an intimate sense). Some words sound very similar and are easily confused. Whilst its perfectly rational to ask a mother if her sick child is breastfeeding ‘a yunka’ and also if he is having seizures ‘a kunyunka?’ one of my colleagues suffered some embarrassment when she asked a middle aged patient with epilepsy if he was breast feeding today.

Then there is the tonal aspect of the language. Sometimes I find myself asking some simple question to be met with a blank stare, followed by one of my Zambian colleagues repeating the same phrase minus the west of Ireland accent to get a full response. With all this difficulty I am usually delighted to come across the rare patient that speaks English. Whilst English is the only official language in Zambia most people speak little or none. Bewilderingly this includes most final year school students who actually sit their exams in English which doesn’t inspire much confidence in the education system.

Those that do speak English mostly comprise more well to do groups but I have come across many diverse others. Older people who completed education in the sixties and seventies seem to have good English. I have also come across many subsistence farmers with little or no education having much better English than the grade 12 kids.

Not surprisingly this English has its own not so subtle differences especially when Chewa is translated to English. On a ward round once I asked a patient who spoke English how he was feeling today. The response ‘at least, better than tomorrow’ initially caused me some alarm that he foresaw some medical catastrophe that was awaiting him the following day. That was until I remembered that in Chewa yesterday and tomorrow have to share the same word ‘melo’ and he meant he was feeling better than yesterday.

The term ‘at least’ is always an encouraging one to hear from patients. In the hierarchy of how one is feeling it easily trumps ‘a bit fine’ or ‘pangono’. On the issue of grading and assessing I recently volunteered myself to spend a day with a rural health centre inspection team. The government is assessing all the health centres in an effort to promote performance based funding. Regional hospitals like ours are charged with providing people to perform the random inspections with a representative from the department of health. This all sounds good in theory reward the health centres that are doing well, but hang on shouldn’t those that are not doing so well get extra funding to improve their standards?

Anyway the inspection process itself is fairly nonsensical. Instead of focusing on standards of care we start by inspecting many registers to see if they are up to date and tally with figures. We have to see if the outdoor latrines have doors that close from the inside and if the health centres have a separate pit to dispose of placentas. I do spend some time observing five consecutive consultations with children under five. In the first centre the clinical officer scores well because he follows the DOH guidelines correctly although all he actually does is get a blood slide for malaria on each child and review them later. In the next centre the nurse who is seeing the kids unfortunately doesn’t score so well because in the absence of any lab there she has to actually make decisions and treat the kids.

Perhaps the most bizarre is inspecting the minutes of the community health committee. Points were lost here for not recording the start time and end time of the meeting rather than what was discussed. One of the minutes from last year had mention of the swine flu ‘health education on fluenza (pig). The disease is in our country Zambia, town of Livingstone by the white tours. The disease is brought by pigs spreads by air causes the problem of coolness of the bodies. The facilitator Mr B gave the health education’. Health education indeed. Of note I have been recently offered the vaccine for swine flu which is just now available to health workers in Zambia.

It’s interesting to see some rural health centres and how they work. They are in effect the Zambian equivalent of General Practice with many differences. None have a doctor, some have a clinical officer (a prescriber with three to four years training), and most are run by nurses and may have only one nurse. When that nurse is not there the patients are often seen by clerical staff or the night watchman.

The standards of care vary greatly. There is little focus on chronic disease management. Many centres have a labour ward where women come to deliver. As part of the performance related funding the centre (and staff) are rewarded for seeing a labour through to delivery but not if the refer the woman to the hospital. As a result of this my Obs and Gynae colleagues have expressed concern that women with obstructed labour are not referred early enough as the health centre staff hope she will deliver. This has possibly led to some perinatal deaths among their children.

Hopefully before I leave I will get to spend some more time in a rural health centre or two, getting a better idea of what goes on rather than seeing if the management committee minutes have start and end times of the meeting recorded.

TB or not TB?

That is the question. Most days I find myself studying a chest X-ray asking myself this question. Holding the X-ray up to the sunlight I hope the longer I look that I will see some cavity, apical consolidation or anything that would make me more confident to say ‘yeah this patient has TB’. It isn’t an exact science and while I believe that every doctor should be able to interpret basic investigations likely a chest X-ray and an ECG I haven’t spent much of the past four years GP training studying X-rays.

It’s a difficult call as TB treatment takes 6 months. Starting treatment without good evidence can mean other diagnosis are missed and often undermines confidence amongst the population in the value of TB treatment. Not starting treatment can deny a patient a chance of effective cure. When I do see some ‘good evidence’ including when I see miliary TB (diffuse infection) I am relieved as I can confidently make the diagnosis even though this particular finding carries a poor prognosis for the patient.

Tuberculosis is often thought to be a disease of the past in Ireland, associated with a time when large numbers of people spent several months in TB hospitals receiving treatment and getting fresh air. Globally however the incidence of TB continues to rise. There are about 9 million new cases each year and 2 million deaths, most in sub-Saharan Africa despite effective treatment being available for over fifty years.

While many major infectious disease are easily diagnosed using blood, stool or urine tests the diagnosis of TB is very tricky. The bacteria that cause the disease grow very slowly requiring special laboratory equipment and time neither of which are readily available in Africa. Some patients with TB in their chest will be ‘sputum positive’ that is the bacteria can be seen in their sputum under a microscope. However many are not, especially those patients that are HIV positive and in these patients the chest X-ray can lack any ‘typical’ TB changes.

I often wonder what the patients think of this uncertainty regarding TB diagnosis. I ask Muwewe a lady on St Monica’s ward how she feels about her recent diagnosis of TB. She explains that she has been coughing since August and having left sided chest pain. She came to the hospital in August and was treated for a chest infection. Her sputum studies were negative for TB and she got a little better on treatment. However when she went home the symptoms soon returned. This is another difficult aspect of TB diagnosis with patients often getting temporary improvement on ‘regular’ antibiotics such as penicillin and chloramphenicol.

As we chat I note from her records that Muwewe is 38 years old and weighs just 37kg. I am interested to know why she remained unwell for a further three months, losing weight, getting weaker, before returning to hospital. She lives in a village about 30km away which is a long distance here. She explains the problem was the transport that she could not afford it. Eventually as she became more unwell her teenage daughter brought her to the hospital on a bicycle. Her village is not that far from the tar road that links Katete to Mozambique and I don’t quite buy her assertion about the transport. Often patients delay coming to hospital and try traditional medicine first or live in denial of the problem.

Muwewe understands that her TB has been diagnosed on X-ray changes alone but is happy to start treatment. ‘I feel very free, not uncomfortable as I am not alone suffering from TB’. She is also HIV positive. HIV and TB have a powerful relationship. Whilst many of the opportunistic infection we associate with HIV only develop in the later stages when there is severe suppression of the immune system TB infection is very likely to affect the HIV positive patient at any stage.

She speaks openly about her HIV status explaining ‘I can not hide even my husband is positive and is on treatment’. The family survive on income her husband makes from decorating shop fronts and signs. In recent months however because of her illness Muwewe has found it increasingly difficult to care for her five children ‘since I have been sick, at home the work has been done by my children and my mother’. Encouragingly for Muwewe if she has TB she is likely to get better in the coming months especially as her HIV infection is not yet very advanced.

I talk to Emmanuel Sikateyo one of the senior nurses here at St Francis and TB focal person. With others he is responsible for registering all new cases giving adherence counselling, arranging directly observed therapy and follow up. He feels among the challenges to diagnosis is stigma surrounding TB and its association with HIV. ‘There is a lot of stigma, patients deny they produce sputum because they think in the back of their mind that the moment I am diagnosed with TB I am HIV positive, which of course isn’t always true’.

Emmanuel also feels that we could have higher sputum positive rates if greater care was taken to get adequate samples. ‘Sometimes us the nurses and the doctors are not keen to instruct the patients on how to give sputum and getting three good samples’. Time is probably one major factor in this shortcoming. He also alludes to the absence of specialist help to aid diagnosis including physicians skilled in the use of bronchoscopy (passing a camera into the lungs) to get washings which are more likely to be smear positive.

A further challenge facing Emmanuel and those involved in TB monitoring here is the number of patients from outside our immediate catchment area. ‘As a second level hospital we have an influx of patients because of seemingly better service than the government hospitals. We see these patients initially when they are ill, they come for review but as they get better they say ‘why should I come to St Francis to get my sputum examined as transport is expensive’. In this way patients get lost to follow and may not complete treatment with risk of severe illness or drug resistant TB. In recent years more people have a mobile phone (or at least a SIM card and occasionally access to a phone, or a family member or neighbour with a phone) and patients can be contacted this way if they default from follow up.

One of the encouraging facts Emmanuel tells me is that in recent quarters we have had a 90% cure rate for smear positive cases. Still there are many challenges including increasing numbers of cases since the start of the HIV epidemic. Emmanuel sees HIV and poverty as the main factors that contribute to TB in Zambia ‘if you look at our patients their social status is poor, usually crowded tiny houses where it is easy for TB to transmit, if they are lucky access to two meals in a day.’ Until these issues are addressed the question of ‘TB or not TB’ will continue to occupy the minds of health care workers in this part of Africa.

On the road again

Knowing that my mother and sister were coming to visit in October gave me something to look forward to, a break in the middle of my stint here. I wasn’t quite sure what they would make of it or how they would entertain themselves in a hospital for the first week before I brought them to see some of Zambia’s tourist sites in the second week. Their first introduction was Lusaka international airport which kind of makes Knock airport look like a major international hub. I decided to take them into town for some breakfast before making the five hour journey back to Katete.

Unfortunately there had been an accident on the road and we had to divert through some of Lusaka’ side roads giving them an earlier than anticipated experience of Zambia’s untarred road system and poverty as we crawled along for an hour in the dust and heat. At least getting them to Manda Hills shopping centre was back to civilisation they were used to. The two main malls in Lusaka’s outskirts are a surreal experience in Zambia, a white dominated environment with African staff in the shops and restaurants serving them. However, it does give us a chance to get some good food, and for me to stock up on supplies from a proper supermarket (without having to pay also which was nice).

We made it back to Katete after a pretty uncomfortable drive in the presence of severe heat and the absence of air con. My guests made do the first week relaxing, reading and checking out some of the local sites and attractions such as cosmopolitan Katete stores, the road to Mozambique and the experience of getting a bike taxi. I got the hint that whilst this was relaxing they were pretty bored come the Saturday.

On the Saturday night we went on Katete’s main tourist attraction, a cultural visit to a local village from Tikondane community centre near the hospital. There we got to see traditional dancing including Nyao under the moonlight and enjoy some really tasty Zambian food in Benson’s house all prepared without electricity. Somewhat bizarrely this experience of traditional African culture takes place in the same village where I attended the Jehovah’s Witness convention a few months back.

After mass on Sunday we head to South Lunagwa national park one of Africa’s greatest national parks. Using the direct route the park is a mere 125km form St Francis. I have a 4*4 and it’s the dry season so it should be easy, right. The first 25km are fine along a good quality gravel road but then it gradually descends into a bumpy track. Halfway, at Msoro we cross a not quite dry river bed. Feeling pretty chuffed with myself for navigating across I get out to take a snap only very oddly to find a local on site with his camera and a name tag around his neck signifying his status as a professional photographer. Msoro is home to an Anglican mission with a Cathedral (in the middle of nowhere) and a school. There we inquire the route to Mfuwe (the town at South Luangwa’s gate).

We are directed through what looks like someone’s back yard. From here the ‘road’ gets worse and is really only a narrow dirt track through the bush. We pass through beautiful villages, over some more dry rivers and up rocky hills. We pick up occasional passengers, giving them lifts from one village to the next, some of these are so unfamiliar with a vehicle that they can’t figure out how to open the door, forget about seat belts.
During the whole five hour journey (yes five hours for 125km) we meet three other vehicles. My passengers start to become increasingly frustrated at the length and bumpiness of the journey. When I think we are nearly there we come to a place where the track diverges in two. A young boy directs us one way but doesn’t sound too confident, I decide to trust him. A shockingly rough 5km and half an hour later I am starting to utter profanities under my breath cursing him and about to join my passengers in frustration. I stop and ask a young woman carrying a child ‘Mfuwe?’ I say pointing straight ahead ‘ah waii’ she responds. I am here more than long enough to know such a response from a patient is a definite no. I ignore her and much to our relief within 2km we find ourselves on the short stretch of tar that links Mfuwe airport to the park.

We are staying in Flatdogs camp right by the park gate. We are greeted by Adrian one of the owners and asked about the journey. In seven years he has never been that way and says ‘that’s more of a bike track isn’t it’. Yes. The few days in South Luangwa are fantastic. We get to see countless animals on the game drives through magnificent landscape, elephants, hippos, buffalo, lions and even a leopard. We go on a walking safari enjoy really good food and luxury accommodation at Flatdogs. Visiting a National Park is expensive but Flatdogs do offer a discount for hospital staff. Having been to a few different parks in Africa to anyone thinking of going on a safari trip to I couldn’t recommend South Luangwa enough.

We return to Katete on the ‘main road’ through Chipata. It’s not tarred either but is actually a road as such, the distance is longer its less interesting but takes only three and a half hours. After South Luangwa I take my guests to see Zambia’s most famous tourist attraction Mosi oi Tunya better know as Victoria Falls. We pass a great couple of days seeing the falls from the ground and a helicopter ride, taking a sunset cruise on the Zambezi (at $50 its pricey but is a free bar and I make sure to get my moneys worth) and generally relaxing. After that it’s back on the road to Lusaka where we spend a night and after dropping my family at the airport for their morning flight I head back to Katete and back to work.

Magazi

The most useful treatments in medicine are not the high tech patented medications that pharmaceutical reps constantly push on GPs and other doctors at home. In fact the most useful treatments are not even medicines per say. Oxygen, fluids and blood are usually the first priorities and the most effective interventions for seriously ill patients few other treatments are as beneficial and work so quickly. One might think then that these simple low tech treatments would be easily available here in St Francis, unfortunately not so.

We do have some supplemental oxygen. This does not however come from ports in the wall connected to a mains supply like in a hospital at home. Nor does it even come in refillable and mobile cylinders like a GP would have at home. Oxygen is delivered through a few oxygen concentrators. These are helpful but can only deliver low flows of oxygen up to four litres per minute (giving maybe 28% oxygen, hypoxic patients at home would receive up to 100%). For paeds and neonates one concentrator can serve a few patients but for the adults its just one machine per person. With two to three available on each of the male and female medical wards this can often lead to difficult decisions as to who it is gets the supplemental oxygen.

But fluids should be in good supply, and they are in fairness, just not consistently the same fluids. A bag of fluids costs the hospital about $5 so we are encouraged to be judicious in the use of fluids, ‘if the gut works use it’. Through some complex ordering and procurement process the hospital gets essentials like fluids from medical stores in Lusaka. Problem is medical stores don’t always issue what is ordered. With fluids one month we may have ample supplies of normal saline and little dextrose, the next month the reverse. Then the next month again we may have little but ringers lactate.

At the Tuesday morning clinical meeting we get a list from pharmacy what is out of stock. Items currently out include oral cloxacillin (in the absence of flucloxacillin an essential drug for us to treat staphylococcal infections), spironolactone (a very useful potassium sparing diuretic, used in cardiac and hepatic failure to help the body clear excess fluid) and even cotton wool.

Oh and blood, though we have just got some in last evening. Being short of meds and fluids is an inconvenience and we have to search for alternatives. However when a patient needs blood there is no alternative treatment. When I cam here as a medical student in 2003 the hospital sourced its own blood supply. The staff would go out a couple of times per week usually going to schools and encouraging teenagers to donate (this group less being likely to be HIV positive if not yet sexually active and beyond the age for asymptomatic maternal transmission). The blood was then screened in house. When I went to donate then it was just a matter of going to the lab having a needle put in and letting the blood out into a giving set. There was rarely a shortage of blood.

Since that time the blood bank has been centralised. Blood supplies are managed nationally, screened centrally. The hospital now has to order blood from the nearest blood bank in Chipata. The blood comes pre typed with A+ or O- or whatever on the label but there is little trust in the system and all the blood is retyped here. There are frequently shortages of particular blood types and from time to time we go a few days with no blood what so ever. Patients die because there is no blood. This is progress, Zambia style.

So what can you do in the absence of blood? Use you own, your colleagues, the medical students. This should be easy but as part of the centralisation process the hospital no longer has access to sterile blood giving sets. That leaves us literally putting an IV line into the donor withdrawing 20mls, giving it to the recipient, getting a new sterile syringe repeat the process etc (over twenty times for one unit of blood).

This is a tedious process and can be messy, its hard not to spill a small amount of blood when swapping for a new syringe. The patient or parent needs to give informed consent, the donor needs to be screened for HIV and Hepatitis B. Fortunately one of my colleagues has taken on the mantle of managing this process when it needs to happen. She has a clear knowledge of what donors are available, their blood types and who needs blood the most, particularly amongst the children. The other evening I helped her take 400mls from one of the medical students with the desirable O negative blood group and split it between three sick children who are all doing well since.

I am a little envious as my previous donation went to a middle aged woman with anaemia secondary to her HIV medication AZT. I was fairly pleased that her haemoglobin went from 1.9 to 8 after 400mls of my blood (the margin of error in the lab is plus or minus 2) but unfortunately I learned she died a few weeks later, but at least not from anaemia.

A centralised blood transfusion service makes sense in a country like Ireland with first class infrastructure. Zambia covers a huge area with sparse population centres and disastrous infrastructure and really it would make more sense if certain hospitals could be licensed to manage their own blood supplies. There could be regular inspections to ensure proper screening and quality control is available. In theory there are more risks to transfusions this way but every transfusion carries a risk and the biggest risk to a patient with critical anaemia is not getting blood.

Keeping the Faith

Mshanga calls me at half six in the morning saying I can meet ‘the Father’ this afternoon at four this afternoon. This presents two difficulties, first unlike most Zambians I don’t wake up until seven and secondly I will still be working at four. After some conferring we arrange to meet at six instead. Arranging a meeting with the local Catholic priest seems more complex than it should, with Mshanga who I have seen as a patient acting as go between.

Down at Katete Boma St John the Evangelists is a quaint church the outside painted in bright colours. The priests have a comfortable home behind. I greet Fr Lawrence and Fr Lazarus, they are both much younger than most priests at home, well spoken and intelligent. I firstly learn that in addition to St John’s the parish includes no fewer than 13 outstations some up to 80km away on rough roads. This might explain their elusiveness and why there is rarely actually a mass at St Martin’s at Katete Stores.

I ask the priests how they spend their time apart from Sundays when they are travelling around try to get a mass in in a few of the outstations. Fr Lazarus talks about some office work they have to attend to as well as visitations to schools and the hospital. He explains their role when called to see a sick person ‘at least we are able to talk, just like that, give a bit of hope to them, we don’t give the sacrament (to those that are not Catholic) but we will visit and pray for anybody’.

I am interested in the role the Catholic Church plays in life here. They explain that the parish is now fifty years old and Fr Lawrence adds ‘the Catholic church is one of those Churches with a lot of numbers. Everyone is expecting us to lead by example in a number of issues. We have a branch of home based care, an orphan’s programme that cares for everybody regardless of denomination’. They go on to outline the Church’s role in helping newly married couples as well as civic duties including helping people understand legislation, helping in community development and involvement in elections monitoring.

Having seen and experienced some of the vast number of new age Christian and Evangelical Churches around Katete ask the two fathers of their views on these ‘new’ churches. ‘We try to develop relationships and instil the spirit of ecumenism like during world AIDS day, even allowing those churches to use our premises, the choirs arranging choral festivals together’ says Fr Lawrence before he outlines challenges that arise for instance when a person passes away and there is confusion within that family as to which Church the deceased belongs.

This seems a little like a rehearsed Fr Jack ‘that would be an ecumenical matter’ type of response but it does seem that different Churches cooperate much more here than at home like recently when there was hospital Sunday and a number of Churches held a joint service at the hospital.

Maybe I can angle a better response by addressing the issue of funding. The priests explain the various ways the Church is funded here (entirely from parishioner donations with no outside funding). Firstly there is the Masika where each household gives some of the harvest to the Church. Then there is the Zambala (basket collection) people are expected to give 2,000kwacha (35cent) for this. There is the Yachitukuku a further collection for premises collection. Finally and most astonishingly to me there is the Mtulo which Fr Lazarus explains is a type of Church tax. Public employees and business people are expected to give 10% of their income and those not working 15,000 kwacha (€2.50) per year.

The only bit of criticism I get about the Pentecostal Churches, which I believe are heavily funded from outside is from Fr Lazarus ‘we are told they get money from America and Saudi Arabia’. He further tries to explain their increasing popularity ‘they have some leaders who are charismatic those sects, that people just get inspired by’. This point help emphasise some of the challenges these priests face covering a vast area and huge numbers of people ‘to have a greater impact where the place is today is difficult, some of the people they don’t know us, that physical contact is not there’ he adds. Indeed Zambia has over four million Catholics and just 382 diocesan priests.

Four million is a lot of people and religion is a big deal here so what role can the Church play in health promotion? ‘It has been very supportive we have three Catholic mission hospitals in the Eastern Province’ Fr Lawrence explains. Fr Lazarus talks about the role of the missionaries in health, education and agriculture. So what about HIV? ‘We have to accept this is a disease in our midst that needs full time support for those suffering, those that are not infected are affected through brothers, sisters or other relatives’ says Fr Lawrence. He outline the role of the Church in home based care, helping people get access to medications, some parishes have even set up their own VCT (voluntary counselling and testing) centres.

‘There shouldn’t be stigma because that kills fist he adds’ before explaining the Churches preaching on abstinence. This leads nicely on to my number one question that is the Churches attitude towards the use of condoms and other contraceptive methods. As a doctor I offer patients advice on contraception, prescribe contraceptives and encourage condom usage. As a Catholic I think the Church gets unfair criticism on the whole condom/HIV issue. Yes condom use needs to be encouraged and will help in the fight against HIV, but the church suddenly turning around and telling everyone to use condoms is unlikely to have a dramatic impact. Indeed people abstaining from sex out of wedlock would in theory have a dramatic impact.

I still try to develop the point and explain abstinence is an unrealistic expectation for most people ‘you are blocking out procreation, which is good in marriage, the Church doesn’t allow contraceptives’ Fr Lazarus intercedes. I further outline my view of the benefits of the option of contraception to a woman who has children and wishes to keep her family to a manageable number. ‘In that case now we say natural family planning’ he continues. I try to gently explain the massive unreliability of this especially in resource poor setting like Zambia (most households don’t have a thermometer) but he cleverly replies condoms don’t work if not used correctly either.

We talk a little about traditional beliefs in Zambia which the fathers feel is declining over time, though not judging by the vast majority of patients I see with traditional healer tattoos. They feel on of the biggest challenges facing the Church here is from poor relations with the government ‘the political powers are not pro-poor and the Church is pro-poor. The Church speaks out and the government says you should preach and not talk about life issues’ Fr Lazarus explains before Fr Lawrence recalls a recent event of a Bishop being threatened by members of the ruling party for speaking out. ‘Another challenge, there are Catholics in the government, we still have problems with corruption leave their Catholicism?’ he adds.

On other challenges facing the Church Fr Lazarus again speaks of HIV/AIDS ‘that is a big test on one’s faith, people ask how is God there’ they also talk about challenges from Satanism, those who covet money and material goods. They also speak of difficulties facing young people and feel there should be some spiritual counselling in schools.

They ask me is there anything that has surprised me in Zambia. I speak of things like the positivity of people in the face of adversity, how people go to Church and celebrate service even though there is no priest and the strength of faith in people here. I explain that poverty may partially explain this, Fr Lawrence agrees explaining a Marxist thought ‘religion is an opium of the poor’.

The conversation tails away, they want to know where in Ireland I am from, what I think of the Zambian work ethic. Unsurprisingly despite living all their lives in Zambia they have met several Irish priests and religious including an Irish priest 40km from here. They even bring up some mention of the Irish enjoying a drink or two. I am tempted to respond to this by asking if they have ever met a Fr Jack Hackett but I hold my tongue.

Life in Slow Motion

‘I feel like its two years when its only six weeks, the time passes very slowly’ says Newton as we chat in Kizito. Newton is lying on his bed, there is a Denham pen inserted just below his knee, at the end of his bed hangs a 5kg weight and a 2kg bag of sand. The weight is applying traction to his leg through the pin allowing his shattered thigh bone to unite and maintain its original length.

I don’t spend much time in the surgical wards. The hospital’s surgeon Mike Currie spent over twenty years working as a GP in Somerset so there is little flow in medical consults compared to the stream from the other direction requesting lymph node biopsies, formal chest drains, reviews of abdominal pains. Like medicine though surgery is different here. Back home Newton’s comminuted fracture of his femoral shaft would have been treated with open surgery and internal fixation without the need for lying in bed for six weeks. Either way though the fracture should heal well.

Newton explains that he was working cutting down a tree with a chainsaw when the accident happened. ‘It fell and one of the branches got stuck in the neighbouring tree, then wind came and without knowing it feel on my leg crushing it’. Thankfully he was not alone and there were people there to free his leg. However he was in an isolated area of the bush about 50km from his town. He recalls how his colleagues brought him to a nearby village where they were able to splint the leg with some sticks. There they were also able to call his uncle who came and picked him up.

He went to a town’s hospital but as there were no doctors there his uncle decided to drive him a further 80km to St Francis. ‘The following morning I went to X-ray and then to theatre for the pin.’ I glance at the X-ray showing fragments of bone where once a smooth femur existed. While the time passes slowly Newton can feel that his fracture is healing ‘my leg is getting better, at least, it is not as painful as it was and I can lift it a bit’. Newton passes the time listening to gospel music on a small radio his friend has brought him, reading any magazines he can lay his hands on and talking to fellow patients.

Newton describes the downsides of lying in traction as including have to wee into a jug, open his bowels onto the bed pan and pain from the pin site ‘right now the fracture part is not paining, but what is paining is here in the knee and and it doesn’t allow you to move, you have to be here, I have just been lying here on the bed, I have not stepped onto the floor.’

He is not a big fan of the hospital food either, and particularly the quality of the nshima ‘its not an easy thing but I just have to eat. You know the food prepared for many people is not as good as food prepared for individual persons.’ I assure him that in most hospitals I have worked the patients tend not to like the food.

I ask Newton about the effects of his confinement on family life and business. He is 32 married with three young children. Newton has a small business cutting timber. He cuts this under license in government owned forests ‘we pay loyalties to the local chiefs then you get a letter to recommend to the government’s forestry department. I sell the timber in Petauke and Lusaka. They use it for making furniture. It’s a fair living.’

The likes of health insurance, income protection even social welfare certs wouldn’t be common in Zambia and Newton explains he will loose a lot of money due to the fracture. Again as I have seen here time and again it is the family structure who will some to his aid. ‘Relatives will help me out and help out with my wife and children’. Newton’s aunt will spend the entire six weeks staying by the hospital, coming in with food and doing his washing. His wife needs to stay at home and care for the children but they do manage to visit once a week or so getting bus transport.

The knock on effect is that Newton’s two employees are also now out of work. He optimistically hopes to be back working within a month of going home.

Despite the income loss, pain, bad food and boredom of lying in bed for six weeks Newton has nothing but high praise for the hospital ‘out of all the hospitals I have seen I count this one the best, all the doctors and staff are so committed.’ So how long more has he left in traction ‘Four weeks and three days down, I have got countdown time in my head’.

On your bike

The only downside of having free weekends is finding something to do with them. Katete is a fairly isolated spot, the hospital is situated of the ‘great’ east road about 4km from the town of Katete stores. There isn’t much going on around here. I pass my free weekends sleeping, reading, going to the nearest supermarket (in Chipata 90km away) to stock up on food every few weeks and continuing my ‘Christian churches of Zambia’ tour.

This tour has been stuttering along a little unfortunately. Services starting much later than advertised, lasting several hours, being in Chewa (my understanding of which looks like it will never extend beyond about 10 cardinal medical symptoms) and often being frankly bonkers dampen my enthusiasm. I did manage last week to head along to the ‘Bread of Life’ service after a kind invitation from a staff member in the hospital. This service took place in a partially completed church literally in the middle of a row of other born again Christian or Pentecostal churches.

When we arrive the first thing I notice is there are no poor people here. The congregation consist mainly of well dressed young women with children plus or minus accompanying husband. One of the elders is talking about a forthcoming conference and is asking each member to cough up 100,000 kwacha towards hosting it (about €16, a lot of money here).

After that there is singing not form a choir, but from ‘the praise team’. Naff music is blasted through loudspeakers from a keyboard and the team sing uplifting Christian songs. It’s all very unZambian but at least a lot livelier than the JW service. There are much less people here though and all are well to do, this church doesn’t have the mass appeal brought by distributing free bibles but it seems to have targeted a niche in the market.

The pastor gets up to do his thing, first off all blessing all the children and casting the evil spirits out of them. He then begins his sermon which lasts well over an hour. He dressed in smart suit and speaks in English. I guess the reasons for this may include the targeting of more well to do Zambians who tend to be educated and have English and also the fact the pastor is from another part of the country and doesn’t speak the local language. He speaks through the loud speaker often with great gusto and pleads with the crowd ‘can I get an Amen?’ after the important points. A male member of the praise team stands beside and impressively translates everything into Chewa at great speed.

The first theme is to ‘think big’ which sounds reasonable until the pastor starts using the analogy of a ‘mad person’ who can not think big ‘their minds are finished’. Zambia is not the place to have a psychiatric illness. He talks about having the right attitude and mentions how a plane he saw once brining the bishop from America to visit had to have the right attitude towards the wind in order to fly. He talks about discipline and how George Washington with a small army defeated a larger one because of discipline. The next point is integrity and here he focuses on the evils of being or having a ‘sugar’ daddy or mammy. The entire congregation is asked to declare ‘I will never be a sugar daddy/mammy’.

Church visits and shopping aside I try out some of my pastimes from home. There is a golf club in Chipata, the 4th oldest in Africa and 36th oldest in the world. I’m rubbish at golf but find it an enjoyable way to pass time and relax. Chipata Golf Club is more a brown patch of land through which many roads and paths cross and with 9 holes in the ground with flags located in fairly random locations. Anyway it’s cheap (the ‘brown fees’ are just 5000 Kwacha, less than €1) and a bit of fun for a gang of us to play one Saturday. It’s a pretty strange experience, teeing off there is no golf course to be discerned just brown landscape and people walking through it into town. On one hole we literally have to play out over a busy road, thankfully nobody manages to hit a car but we do witness a crash.

When you make it to the brown the caddy scrapes a smooth path on the ground to the hole for to put along. The browns are hard to judge, there are no breaks but you have to be careful not to hit the ball down into the dirt. At one point a guy just cycles over the brown on his way somewhere, elsewhere there is a homeless man living under a tree on the course.

On another Saturday I go for a cycle. I don’t own a bike, having a car here was my priority. Some of the other volunteer Doctors have bikes and I borrow one for an afternoon. The bike is a Chinese import costs about 500,000 (a little over €80) at Katete stores. They think this is great value, I think they have been had. It’s rickety, squeaky, the gears are stubbornly resistant to change and the back brakes don’t work.

I cycle across the road and down some tracks. For the first few kilometres I see nobody just beautiful peaceful African countryside. Cattle are grazing here and there but there are no fences, just open countryside. After a bit I arrive in a traditional African village, kids run out from everywhere to gawk at me (I’m not far from the hospital they probably see a muzungo every couple of weeks but I’m still a novelty). The village s fairly big and I am almost hoarse at shouting ‘Muli bwanji?’ (How are you) by the end.

Continuing on a few kilometres I come to a kind of gravel road with lots of people walking. I deduce that if I take a left on this road I will end up back at Katete stores and can make my way home from there. There are more people now, its 5 pm, making there way home from the stores or work or wherever they have been for the day. People enter and exit the road from various paths and tracks out of the bush. I feel vindicated when after a bit the road leads onto the tar but then discover I am not at the stores but quite a bit down the Mozambique road.

The tar is easier to cycle on, the bike creaks less. It’s a little uphill to the stores then downhill back to the hospital. On the way I overtake many people walking and am overtaken by a lot of people cycling. Walking and bicycle are far more popular modes of transport than vehicles. People here tend to cycle on single gear standard issue black bicycles (in fairness they look much sturdier than the one I am on). Young girls overtake me, old men overtake me cycling almost effortlessly, lots of bicycle taxis overtake me, some even carrying two passengers.




Back on the ‘great’ east road at the stores there is more vehicles. The road is narrow and vehicles approaching to overtake a cyclist usually emit a shrill blow of the horn so as to say to the cyclist ‘get the hell of the road’. I have done this to cyclists myself many time and now I see things from their perspective. It’s pretty frightening hearing the sound and suddenly there is a massive truck a few meters behind you travelling at over 100km per hour. You swerve off the road onto the dirt that runs alongside the tar, there is often a treacherous drop between the tar and the dirt and then it’s hard to get back onto the tar.

Everywhere along the road the kids are again shouting ‘How are you?’ I reply ‘I am fine and how are you?’ to which he same child responds ‘fine and how are you?’ I turn off the road safely back at the hospital. There is a beautiful sunset over the African countryside, its good to be here.

Mwai

Sometimes the hospital seems an uncomfortable place to be in. A five hour and a half ward round seeing all the patients in a packed medical ward can be pretty uncomfortable as can arriving in OPD to see a queue out the door. SCBU is always uncomfortable when you have to go there on call. First of all it is full of tiny babies who I have little experience in looking after. Then it is hot, very hot and getting worse as the temperature outside rises and then there is the omnipresent smell of milk which I find somewhat nauseating.

Mwai is 3 days old and weighs just 1800g. He lies in his incubator in the Special Care Baby Unit in St Francis. Incubators here are not like what we know at home. Mwai’s incubator is basically a box with glass panels. There is a light bulb in the box under which there is a tray of water to disperse heat and moisture through the incubator. Mwai shares the incubator with a few cockroaches. Mwai’s mother Clemintina kindly agrees to talk to me so I can get an insight into the life of one of the mothers here in SCBU. Exildah a qualified nurse who is now training to be a midwife helps me translate, we move from the incessant heat to a cool office.

Clemintina explains that Mwai was born in the hospital as she had a twin pregnancy. She delivered at 36 weeks but unfortunately Mwai’s twin was still born. Tragically for Clemintina her two previous pregnancies did not carry to term and she lost both in the second trimester. ‘Despite all the other losses I am happy to have Mwai’ she explains before going on to say that so far things are going well, Mwai is bright and alert and feeding ok. However she finds it difficult hat her baby is here in SCBU. ‘It is difficult for me having been here for some few days, but my mother has come to be here to support me.’

The mothers of the SCBU babies stay in a room nearby and come regularly for feeding. Many of the babies are too premature to suck effectively so are fed with expressed breast milk via a tube. Clemintina finds that the environment makes it hard for her to bond with Mwai ‘I am not feeling ok because I would like to be with my baby, but here I can only spend some hours so there is distance between me and my baby. I didn’t really expect to have to stay here, but for the sake of the baby I know I must stay wherever there are good things.’

Clemintina does though understand why her baby needs to be in the incubator ‘I was told that my baby wasn’t strong enough so it had to be kept warm’. Even Clemintina finds the heat difficult to cope with and she has noted the cockroaches attracted here by that same heat ‘If there would be any poison for them, that would be good.’

Clemintina is 23, married, Catholic and has a lot of aspirations for the future. Exilidah translates that she wishes for the baby to grow up well, go to school and lend a helping hand in the future. ‘This is our African way of life’ Exildah explains, ‘people who have gone to school and been educated will plough back, if one is to be educated it benefits all members of the family, (that person) becomes a source of income, a bread winner.’


Currently Clemintina and her husband survive as subsistence farmers, they grow maze and ground nuts which they then sell at the market. Clemintina says she would like just four children. I ask will she consider using birth control to limit her family size to four. I am surprised by her response that she wishes use the ‘Jadel’. Exildah explains that this is a subdermal progesterone implant. Implanon a similar product is available in Ireland and I have previously had some patients opt for it as a contraceptive method but until now wasn’t aware of its availability here. Exildah explains that it can be got for free from the Ministry of Health but unfortunately not enough staff are trained in its insertion.

I tell Clemintina that I feel that is wise and responsible plan to have and ask her what she thinks of the Catholic Church’s view on birth control. ‘I understand the Catholic Church and family planning issue, but looking at my history it is difficult for me to say I am not going to use family planning because at the end of the day I might be the one who to die.’

I also want to ask Clemintina does she know why her three other babies did not survive. ‘I have been told it is about hard work (on the farm), that is the reason the babies die, there can be other reasons such as witchcraft.’ The topic of witchcraft presents itself to me almost everyday but I am surprised to hear it from Clemintina who comes across as a well informed and independent thinking young woman. I ask who may be responsible for the witchcraft ‘it could be from my own family’ but do not challenge what seems to be a deep seated belief in much of the population here.

Exildah outlines her thoughts on the reasons for Zambia’s high peri-natal and maternal mortality rates. ‘We are a developing country, most of our women come from far areas as to where they can find a clinic. The other thing is our literacy levels, most of the women in rural areas are uneducated, they get married at an early age.’

I thank Clemintina for her time and openness in talking about her and Mwai. ‘I called the baby Mwai because of my history, it means Lucky.’

Africa Time

I may have mentioned before that things move fairly slowly here. When I first travelled from Lusaka up to Katete I had bought myself a ticket for the ‘7 o’clock’ bus. Arriving at half six I loaded my bags, the engine was running already, bus two thirds full, happy days I thought the seven hour journey will begin on time. Of course not. Over the next few hours I sat impatiently, the engine kept running, various people got on and off the bus, hawkers selling air time, biscuits, torches even wigs. From time to time the driver would rev up as if to move, but no. Workers from the bus company hassled any intending traveller trying to get their custom and not loose out passenger to rival bus companies.

At about half ten the bus was full and it left. For the three and a half hours waiting in the hell that is Lusaka inter-city bus terminal I fidgeted, looked at my watch frequently, got up several times to look around for signs of movement. I was the only white person on the bus and also the only one impatient for its departure. The Zambian people sat patiently just letting the time pass.

It is a Sunday afternoon working in the hospital and I stop for a moment to look around the ward. Yeah there were thirty sick patients there but the place is a sea of tranquillity. Most of the patients are lying on their beds. Each bed had a bedsider, a relative staying with the patient to provide care including changing, washing and giving oral medications. Looking through the ward all of the bedsiders and the patients are just sitting there waiting patiently, just like the people on the bus.

Trying to compare to similar experience at home I couldn’t see any relatives just sitting by the bedside waiting and waiting. Remembering Sunday’s in Castlebar hospital the relatives might by watching the TV seeing Mayo loose in Croke Park again, or reading a newspaper or magazine. There is no TV on the ward here and nobody is reading. I can’t help wondering what are they thinking about, what is going through their minds. I try to find out from some of the patients and bedsiders that speak English. There isn’t anyone about to translate and my Chewa doesn’t extend beyond medical terms.

Kenny has been in hospital for about a week. He has renal failure either due to sepsis from his pneumonia, his HIV meds or recent treatment with gentamicin from a rural health centre. Unfortunately I can’t offer him dialysis so all I can do is stop his HIV meds and hope his renal function improves. He says he passes the time talking to his wife who is by his bedside, usually about their children who are at home. ‘I am always encouraging them to be strong and to be realistic in everything that, one must be convinced in mind to say I am sick’ Kenny says. His wife explains that she just spends the time nursing her husband, she needs nothing else to occupy her mind. Kenny adds that when he is awake they chat and crack some jokes.

Meck has very little English but explains his main thoughts is fear of relapse of nose bleeds which have been cauterised a few days ago (medically it is the least of his worries). He inquires what my name is, in the hecticness of the past few days I obliviously haven’t formally introduces myself to him. He then adds that he wants to go home and see his children.

Further up the ward Edison’s dad sits by his bedside. Edison is 19, has just been diagnosed HIV positive, has a pathetically low CD4 count of 3 and is also in renal failure. His dad has really good English. He says he feels sick himself at present and spends some time thinking about that ‘otherwise I think about the young boy, most of the time when I am here I consult the bible and read and get courage out of the readings’. He stays each night in a boarding house next to the hospital while his sister sleeps on the floor beside Edison.

He likes the boarding house, fifteen to twenty people are staying there ‘the place is good, we always take prayers there’. He swaps shifts with his sister at visiting times, that is six in the morning and half past four in the afternoon. What does his sister do during the day time? ‘She goes back to prepare some breakfast, she remains there washing clothes for Edison, doing other things’. He explains that his wife is at home with their six other children and he thinks also of them. He thinks especially of Edison’s twin brother who is well ‘but right now he can’t go to school as I am here and need some money so I can’t afford the fees’.

I commend him on his English and enquire did he acquire this through his work. I expect him to say he has some government job or has worked in the mines or Lusaka. ‘I am just a peasant farmer, I got my education before this modern education’. I ask him how he feels about Edison’ illness ‘I don’t feel right, I can accept it because he is a human being and my son, I can not decide how he might have got that illness’.

Some of the patients and bedsiders are outside sunning themselves. I find Frank stretched out on the ground. He was just admitted today, diagnosed with HIV yesterday. The lumbar puncture I have done today has found Cryptococcal meningitis a serious opportunistic infection found in advanced HIV. ‘I feel better’ he says looking relaxed and at ease.

Samuel’s mother is outside also. He has been admitted quite sick with diarrhoea and vomiting. He was in hospital in January, was diagnosed with HIV then but didn’t attend for follow up and has not been taking treatment. Samuel is among those men that present here like images from a live aid video, gaunt with sunken cheeks, wasting away. His mother is an upbeat and resourceful woman. She doesn’t leave the hospital instead she gets food here and does the washing in the bathroom. She says the bedsiders pass their time discussing patient’s conditions. ‘We encourage each other, encourage them (other relatives) not to feel lonely in the hospital’

Perhaps it is this positive attitude and outlook to life that allows people here to remain so patient, knowing things will happen when they will and that not everything is under their control be it what time the bus will depart or when or if their loved ones will get better.

The Big Smoke

Having been working hard for the last couple of months and given some new Doctors have arrived from the UK I decided to take a few days off. First thing to do was go down to Lusaka to pick up my work permit. Like everything else here the process of getting this has moved slowly. Many months ago a whole multitude of forms were sent to the Zambian Medical Council (including a translation of my degree from Latin to English). Only once registered with them could a work permit be applied for.

The head office of the department of immigration is in a leafy relatively affluent area of Lusaka. Inside it looks like any public service building at home, various desks computers and large numbers off staff who appear to be doing very little. Despite all the computers I have to check myself through various hand written books to see if the permit is ready. On seeing that it is I am passed through various desks until I find the one from which to pick it up, most of the staff are sitting down looking around or taking calls on their mobiles. Anyways I get the permit go to a further desk to get my passport stamp and get out of there.

I have travelled the five hours to Lusaka with some others from St Francis. Sabina a Swedish nurse who has been here for a few months and is going to spend some time in an orphanage in the Copper belt and a Canadian couple Steph who is a nurse here in St Francis and Ben who is on a placement in Katete from Engineers without borders. We decide to go to a movie that evening.

While lots of people in Lusaka live in poverty there is wealth here, a couple of shopping centres similar to what we have at home and a cinema. The entry fee of K14,000 (about €2.40) is cheap compared to home but beyond the reach of the vast majority of Zambians. It is nice to see a movie and relax but several times the surreal-ness of the previous day being working in an isolated hospital and now being in a fancy modern cinema hits me.

There isn’t a lot to do in Lusaka so having completed our business we leave the next day. I have a couple of more days off and hit to Malawi. Whilst most people might go to Malawi to relax by the lake, swim or dive, my interest is in seeing Lilongwe’s famous tobacco auction floors. Malawi’s capital is considerably smaller than Lusaka but is a much shorter distance from Katete even allowing crossing the border and temporarily importing the car (I discover on the way back I should have temporarily exported it from Zambia, but this offence is overlooked on showing my newly acquired work permit and mentioning I work in St Francis).

The public are allowed to come see the tobacco auctions by appointment. I have arranged to get a tour at 9 am and after much getting lost in Lilongwe’s industrial area arrive about ten past and subsequently have to wait around, African style, for an hour and a half. Ronald from the communications department is going to show me around. He a short man, very neatly dressed friendly and cordial. He explains we have little time as he is busy preparing for a launch the following day of a company wide HIV/AIDS policy. There is a certain irony in a company involved in the business of selling carcinogenic tobacco taking an interest in their employee’s health but it is encouraging in many ways.

Ronald leads me onto the floors. We walk past a sign stating ‘To all our Customers, Please do not bribe our members of staff: It is unnecessary, It is Costly, It is evil’. We enter a massive shed the size of several playing pitches, there are bales of tobacco over the entire area and the whole place is a frantic hive of activity, people are hurrying here and there, buyers inspecting bags of tobacco, workers literally running with barrows bring new 200kg bales onto the floor. It is an impressive sight all the more so because all the people here are African, this is not some white dominated industry or a remnant of colonial times, it is indigenous commerce.

Ronald explains that in all ‘Auction Holdings Limited’ the company which runs the floors employs 4,000 people. The company is 42% government owned with the remainder in private ownership. The government he explains are keen to protect and promote the industry which accounts for 70% of Malawi’s foreign exports and 15% of its GDP.

The auctioneer proceeds along the rows of tobacco at an alarming pace selling each bale. He chants out words and prices at an incomprehensible speed, someone behind him takes note of the ticket on the bale and the buyer. About 10,000 bales are sold each day

I am interested to know who is buying and selling the tobacco. ‘80% comes from small farmers who produce 5-10 bales per year and can expect to get about $200 per bale’ outlines Ronald. The small farmers don’t come to Lilongwe to sell the tobacco themselves but instead sell to agents who then bring the tobacco to the auction. There are only five buyers, representatives from tobacco companies here in Malawi. These buy the dried leaf from the floors, process it and then export it to tobacco companies in China, the US and Europe where it is made into Cigarettes and other tobacco products. A few more steps along the chain someone in Ireland is forking out whatever it is, over eight euro for a pack of fags.

I guess the average smoker at home is spending about €3000 per year if smoking twenty per day. The tobacco farmer in Malawi has to survive on $1000-$2000 per year to support him and his family. I am unsure on the maths as to how many smokers’ habits his 1000-2000kg of tobacco feeds. It’s hard to know what view to take on this industry. On the one hand it provides valuable employment and capital into the country from export revenue. On the other hand tobacco is a harmful product the health effects of which I see everyday when working in General Practice at home. In addition there are reports of child labour in Malawi’s tobacco industry.

Perhaps the mission statement in Auction Holdings Limited reception sums up my confused thoughts on it ‘To play a leading role in improving and managing the best systems for handling and marketing tobacco and other products and services which are user friendly, fair and provide value to shareholders and other stakeholders.’

Kulamba

While working in Geriatrics at home I once commented to a colleague how our image of elderly people was quite skewed. From experience there I sometimes thought all elderly people were ill, suffering from various degrees of poor mobility and dementia and needed high levels of care. Only when working in General Practice did I get to see that the majority of elderly people lived quite healthy and independent lives and continued to make a valuable contribution to society.

Occasionally here in Zambia after long hours and days on end working I get a similar view of the people. It comes to seem to me that all Zambian children are malnourished or currently seriously ill with malaria and that all Zambian adults are suffering from TB or some HIV related illness and that most will die before forty. In reality thankfully most Zambian children whilst underprivileged by our standards are well nourished and many have the opportunity to go to school. Most Zambian adults are not HIV positive, have jobs, families, relationships and interests.

Time spent away from the hospital on weekends off helps give me a fresh perspective of life in Zambia, gives me an opportunity to see the beautiful countryside and to experience local culture. The people of this part of Eastern Zambia mainly belong to the Chewa tribe. National borders in Africa were mainly decided by European colonists so the Chewa people occupy much of Malawi, the Eastern part of Zambia and northern Mozambique. Every year in August they hold a thanksgiving ceremony called Kulamba (worship) close to Katete.

One of the nurses from St Augustine, John Banda (the quintessential Chewa name) takes a group of us along to the last day of the four day festival. The overall set up reminds me most of the ploughing championship at home. It’s down a dusty (rather than muddy road) there is lots of traffic, throngs of people are coming and going and there are all manner of stalls and hawkers pedaling their wares. The centre-point of the festivities is however quite a bit more entertaining than comparing one furrow to another.

In the middle of the area there is a raised circular platform for dancing and entertainment to take place. Overlooking and right beside this is a thatched shelter housing the Undi Paramount Chief of the Chewa people on his throne. Next prime viewing position goes to a viewing stand containing dignitaries including the president of Zambia. The general public are formed in a circle around, those at the front sitting, more standing towards the back other further back perched on trees to get a good vantage point of proceedings.

When we arrive the colour of our skin pretty much guarantees us front row seat and our cameras get us into the press area right beside the chief’s throne. Various people are introduced from each of the three countries of Malawi, Mozambique and Zambia. These then proceed to the chief with all manners of gifts in thanksgiving to him including several mattresses, a chest freezer and a washer dryer interspersed among many wrapped unidentifiable objects. The gifts are given as a form of worship to the chief

The chief is sitting on his throne (an armchair like one from your grandmother’s living room) receiving these items. He is surrounded by ivory and a leopard and lion skin, though I am unsure these are real. Several men in brightly coloured dress carrying bows and arrows surround him, John explains these are the subordinate chiefs.

After each presentation of gifts, there is dancing. Many of the dancers are people (or two together) dressed in the form of an animal and believed to be transformed into such for the festival. John explains this is called the Nyao and that nobody is to know who these people really are or to disclose their identity. People who perform the Nyao are taken out into the bush for two months initiation and training by elders. John tells me later that previously almost every male Chewa had to undergo that initiation before they got married. Others dance with fire or are dancing up along tall poles, it is an amazing spectacle.

The whole experience is a fascinating mix of traditional culture and the modern commerce required to support such festivals. Despite the fact the signal is fairly rubbish here both the major mobile phone operators are out in force as are the banks. Outside that there is of course the mass commerce of food stalls, clothes sellers and just like festivals back home alcohol. Indeed the main sponsor of the event is Chibuku. This is a cloudy beer (called shake-shake) sold in milk carton type containers that is extremely popular. Whilst it’s advertising slogan promotes ‘taste the goodness’ my main encounter with it is in frequent alcohol related medical problems such as liver disease (again much like home).

Front row seats guarantee photoparama for us. In typical Zambian fashion at one point we are told not to be taking photos unless we fork out for an official press pass and then a couple of seconds later one of our groups request to meet the president is enthusiastically granted. We file up to meet ‘His Excellency’ Rupiah Banda (himself a Chewa, from this area and extremely popular here).

We get a brief handshake the chance to say where we are from, I utter something ridiculous like ‘I am from Ireland our countries are great friends’. Sadly we don’t get a photo op nor do I get the opportunity to ask him what kind of a country is he running that we often have no blood supply for several days or that the country ‘ran out’ of Insulin a few weeks back or why aid agencies withdrew hundreds of millions in assistance due to fears of irregularities in the department of health or for that matter why is it taking so long to process my work permit. Nonetheless it is of course a great honour to meet him before he leaves in his motor cavalcade.

It was strange to see the president being subordinate to the chief at the event and while he was being whisked away back to Lusaka I was comforted to think that the Undi Paramount chief would be staying locally providing community leadership. Not so unfortunately. John explains that the chief lives in Lusaka and because of this ‘is not nicely connected with the people, I think it would be better if he stayed in the area’. Whilst political leadership in Zambia often serves self interest it is truly heartening to see and experience the richness of the local culture and the pride the people have in that culture.

Death

Dealing with death and breaking bad news are among the more difficult aspects of work as a Doctor. Unfortunately here in St Francis it is something you have to do a lot. Death seems to come in waves after a couple of weeks of few deaths suddenly a glut of patients are dying. It seems every few minutes you are taking a relative aside saying ‘I am sorry your father/sister/husband has just passed away’ or ‘I am sorry your mother/brother/wife is very sick they have pneumonia/meningitis/renal failure (generally secondary to HIV) we are going to give them the best medicine and care we can but I think they are going to pass away unfortunately’.

Then there is breaking bad news to the patient themselves. Recently I had a man present with massive right leg swelling and what he claims was a short history of poor urinary flow. A rectal examination reveals a rock hard prostate, blood tests show his kidneys are impaired and an ultrasound reveals in addition to his prostate mass he also has a mass in his bladder. The right leg swelling is secondary to obstruction of lymph drainage by these cancerous masses.

He is a happy cherry man in his 60’s, that is until I try to break as gently as possible (how can such news be termed gentle) that he has advanced prostate cancer and unfortunately there is no treatment we can offer save from pain relief (even that we don’t have a lot of) and a suprapubic catheter if he goes into urinary retention. At that point he breaks into tears. I feel utterly helpless to offer him any comfort, at least if I was his GP at home I could ask him to come back in a couple of days to talk some more, to come if there is any problems, get the hospice involved if appropriate, could communicate more effectively with him without the language barrier. Instead a couple of hours later he is packing his bags to go and I probably won’t see him again. The tragedy of this mans case is that he had previously presented to another hospital and was not diagnosed.

The same day I have to tell a young man in his 30’s some bad news. He is a father of young children, a farmer by profession, HIV negative. He has just presented with abdominal pain and swelling. His liver feels like a massive irregular shaped rock has been transplanted into his abdomen. His abdominal swelling is caused by haemorrhagic ascites (bloody fluid). His diagnosis is Hepatocellular carcinoma. This is a common cancer is this part of Africa particularly in men aged 20-40. The prognosis is bleak. Again I have to explain the same spiel, I am very sorry etc, etc.

Sometimes such conversations seem to pass by in your head without thinking too much, become the same as doing a procedure or writing a prescription. It’s easy to forget that these people are somebody’s husband, father, brother or son. It is also easy to forget that their death particularly if in hospital will put huge financial strain on the family, an income earner may be lost and it is much more expensive to transport a dead body back to the village than a live one.

Death is commonplace here and as such is dealt with differently in the hospital. Staff members often seem unperturbed by the occurrence, resuscitation attempts are rarely commenced (if they are appropriate) and there are no single rooms for dying patients so the family can have peace. Screens are pulled around the bed after the incident but there are no candles or no Chaplin. One of the more humbling aspects of the death is that as the body is being moved to the mortuary all of the bed-siders for the other patients accompany the family there. The women cry and wail as the body passes.

As a doctor there are selfish aspects to death also. Recently whilst compiling mortality statistics for the past two months as I was terrified it would look awful but allowed myself be a little pleased when the ‘mortality rate’ was in fact similar to previous months. Some deaths seem to affect us more than others. Two types of patient tend to die here. The first presents extremely ill and passes away in the first 48 hours, these deaths tend not to affect us much. We didn’t get to know the patient ‘they presented too late there was nothing we could do’

The second presents with complex medical problems is in the hospital for a few days, we get to know them and their story recognise their relatives on the ward round. What limited investigations there are available are done in an effort to find out exactly what is wrong, various treatments are tried, books are consulted at night and thoughts turned over in your head. When they die there is more a sense of personal loss as well as failure. Then there is the frustration ‘if only I could have done this test, consulted that specialist, had the other medication’.

Overall the sad fact is that life expectancy at birth in this country is under 40 years. Several things will need to happen for this to change. Antenatal and perinatal care in the community will have to improve to decrease perinatal mortality. Immunisation programmes will have to be expanded to cover disease such as pneumococcus. There will have to be greater awareness of malaria prevention, safe drinking water and the dangers posed by diarrhoeal disease. The HIV infection rate will have to be decreased through mass testing and education. Health care staff numbers will have to be increased and levels of training vastly improved.

All of this will take money and political leadership, neither of which are in abundance in Zambia at the present.