We pull off the tarmac and drive for another four or five kilometres passing traditional villages before arriving at the home of ‘Dr Kamuchila’. After greeting us and sitting down outside Dr Kamuchila explains that he became a traditional healer following the death of eleven of his children in infancy. ‘a family member of the wife was witching the children and when they reached six months, they died’ While Dr Kamuchila received some training and guidance from elders including his parents most of his training and direction come from spirits who come to him in his sleep ‘so that even when a patient is coming tomorrow I can know that patient is coming, spirits talk to me in my sleep’
Indeed Dr Kamuchila later proudly shows us his qualification certificate, a hand written document from 2004 stamped – ‘Republic of Zambia, Chieftianess of Nyanje’. Dr Kamuchila claims to offer ‘treatment’ for a wide variety of ailments including headache, constipation, chest pain, abdominal pain, leg pain and cough. He does clarify that he can not treat TB and later informs us that he himself is attending the hospital for TB treatment. He believes that many of these ailments are cause by bewitching and that he can help his patients to discover who is bewitching them, even if that person has run away form the country.
I ask him about HIV and he explains that the problem is related to pregnant women passing on the infection to their children. He categorically states that this is a disease and has nothing to do with bewitching.
Intrigued to find out what the process involves I ask Dr Kamuchila to treat me as a patient. He leads us inside a small thatched building, we remove our shoes and the three of us sit on a grass mat. We are facing a wall a square of which has been painted black with charcoal. The procedure begins with Dr Kamuchila producing ‘medicine’ for us to take. Prior to offering it he checks that I have never had an operation or suffer from epilepsy. The medicine is a drink presented in a dirty cap, tastes foul and induces a fair degree of nausea. He explains that the drink is made from herbs which he has boiled and then fermented and that he and each of his patients must consume this at the beginning of the process.
Dodgy home made liquor on board Dr Kamuchila then passes around a bowl with water and twigs from which to wash our faces. He explains that after some thirty five minutes from consuming the medicine we will be able to see images on the black area of the wall which he describes like a television. He will direct the ‘grassie’ to find that person who is bewitching me so that I can see. Sometimes the process can take up to four hours. As part of the ritual he bizarrely produces a bible and asks me to open up a page and what is written there will direct us. Deliberately I open the book towards the back in an effort to avoid any vengeful Old Testament readings.
While we are waiting for the medicine to have its effects he sings some hymns including ‘John stayed in the house of the fish for three days’ and ‘Those who don’t believe in Jesus will be punished’ followed by a few Alleluias. After some time Dr Kamuchila begins to try to invoke the ‘grassie’ to show Cormac from Ireland who is now in St Francis what his problems are. Thirty five minutes of repeated invocations elapse and we sit looking at a black square on a wall. Thankfully the only adverse effect thus far from the medicine is nausea.
At this stage I find myself quite under whelmed by the process. Surely sitting looking at a crude painting of a TV on the wall isn’t what traditional medicine is about. I ask Dr Kamuchila does he not wear masks or do a dance. We have had enough and politely thank him for his time and explain I am relieved I have not seen anyone who is bewitching me. We ask what treatments would be offered if he had found a problem. He explains that he would make a razor incision over the part of the body where the problem is and the rub on herbs to affect a cure. We get to see some of the herbs he uses.
Throughout the time I can’t help thinking that we are not seeing the authentic deal, that he has altered the whole show because he has white people visiting from the hospital. He tells us he would just see five to six people a day and spend up to four hours with some of these. Doing the ward round in St Francis I see countless patients each day with razor mark tattoos from visits to traditional healers. I wonder did they actually believe that getting herbs rubbed into cuts in their skin would help them.
Such beliefs seem ridiculous until I remind myself that back home in Ireland many of my patients would also attend what we call complimentary health professionals with no evidence base such as homeopaths and osteopaths. Some even go to seventh sons of a seventh son in the hope of relief from ill health. Maybe deficiencies in mainstream health care are among the reasons why such enterprises exist both in Africa and Ireland.
In any cases I believe most of these practices are at best harmless and at worst may cause serious illness. In St Francis we have seen patients present with acute renal failure secondary to traditional medicine and even women who have tried to get abortion induced by the traditional healer by means of a stick shoved up into their womb.
We cordially say our goodbyes to Dr Kamuchila more certain than ever that what he professes is all a pile of nonsense. Thing is he is probably thinking the same about us.
(With thanks to Kapil Sharma Final Med, NUI Galway for help with this piece)
Sunday, July 25, 2010
Sunday, July 18, 2010
From Rhodesia to Zambia
‘There is a vast difference between Zimbabwe and Zambia because in Zimbabwe there is no freedom of speech of movement or freedom of land or rights. It’s under dictatorship through the government of Mugabe so people are fleeing that country, running away from unemployment, hunger, suffering’ explains Dustin who can be considered to be a reliable source of information on life in Zimbabwe. He is a distinguished figure with grey hair, well dressed in comparison to the other patients on the ward. Dustin was Shabami in what was then Rhodesia in 1942 though his parents were from Zambia. After completing school Dustin gained employment in a hospital pharmacy in the Zimbabwean midlands near the town of Gweru. He retired in 1997.
Despite having lived all his life in Zimbabwe Dustin felt he had little option but to leave there and come to live in Zambia. ‘I left a very good house there, but I left it through a bad situation, life is bad through the government, but here I am free there is land to plough’ He explains that he made the decision to leave Zimbabwe in 2000, leaving behind his home, the life he and his wife had built and some of his then grown up children. ‘I spoke to a certain gentleman whose family were poor, just keep the house and send me a small amount’.
Dustin made the decision to move to Msoro in Zambia’s Eastern Province because that is where his parents are from. He is fortunate in that he can still draw his pension from his long years of service, indeed he uses the opportunity when mentioning same to press me to discharge him so he can go to Chipata and collect same the following day. He speaks fondly of Zambia and the freedom he perceives people to enjoy here ‘Zambia is a free and holy country, freedom of speech of movement so it is a god country’.
Notwithstanding this concerns are rising regarding corruption in the Zambian government and indeed in recent weeks $300 million of aid for health care has been pulled on the back of these concerns. He is circumspect when I mention this ‘you find corruption in political groups everywhere they get money from donors and use it for themselves, not give it to the poor.’ I decide not to argue this point reminding myself I am from Ireland.
He talks fondly of his life in Zimbabwe and mentions in particular an occasion when he had the opportunity to help a friend of his daughters complete her studies. ‘There was a girl in school with my daughter who came to my house crying and asked for money which I gave her to complete her nursing exams, later she qualified as a nurse and worked in England. Sometime later she sent a card form there with English money which I used to build things up for my children’
I ask Dustin to tell me about his own children. ‘I have children, one completed university six years ago, he I a bank manager in Johannesburg. One is married and he is there in Zimbabwe’ Dustin’s two other children have passed away one son who was a church pastor quite recently ‘he had a long illness’. His daughter who had lived in Malawi passed away aged 30 ‘she had BP and died from a stroke’. He tells me none of his children suffered form HIV.
Dustin speaks some more about life in Zimbabwe ‘If you are going there be sure whatever you speak does not blame hi (Mugabe’s) party or his government. Farming is poor because he has chased all the good farmers, the hospital has no medicines, otherwise it is a good country, but with poor management’.
Criticism of Mugabe continues and in particular his treatment of the farmers who had been so vital to Zimbabwe’s economy. ‘These people do you known what they were doing, they were shooting white people in farms. When us Africans we are killing on another, outside countries supported Tsvangirai because he didn’t want the white to be chased away’.
Dustin believes that if Morgan Tsvangirai takes over ‘it will be wonderful, he wants all the farmers who were chased to come back.’ I ask him is not concerned as a black Zimbabwean that the majority of arable land was in the hands of a small number of white hands. ‘These were the people who were working the property, they could build on the farm schools farmers, those are good people those British people’ When asked surely are they not Zimbabwean ‘they are not Zimbabwean, they are British’
He feels this is all the story he has to tell though I suspect there could be much more. ‘you said you don’t have a cough mixture for me’ I explain we may get some from the pharmacy the next day though his symptoms are related to cardiac failure rather than anything treatable with cough mixture. ‘I will sleep dreaming of that because tomorrow I will go to Chipata (to collect his pension) and then shoot to Msoro. What I have told you is the proper news, it is true’
Despite having lived all his life in Zimbabwe Dustin felt he had little option but to leave there and come to live in Zambia. ‘I left a very good house there, but I left it through a bad situation, life is bad through the government, but here I am free there is land to plough’ He explains that he made the decision to leave Zimbabwe in 2000, leaving behind his home, the life he and his wife had built and some of his then grown up children. ‘I spoke to a certain gentleman whose family were poor, just keep the house and send me a small amount’.
Dustin made the decision to move to Msoro in Zambia’s Eastern Province because that is where his parents are from. He is fortunate in that he can still draw his pension from his long years of service, indeed he uses the opportunity when mentioning same to press me to discharge him so he can go to Chipata and collect same the following day. He speaks fondly of Zambia and the freedom he perceives people to enjoy here ‘Zambia is a free and holy country, freedom of speech of movement so it is a god country’.
Notwithstanding this concerns are rising regarding corruption in the Zambian government and indeed in recent weeks $300 million of aid for health care has been pulled on the back of these concerns. He is circumspect when I mention this ‘you find corruption in political groups everywhere they get money from donors and use it for themselves, not give it to the poor.’ I decide not to argue this point reminding myself I am from Ireland.
He talks fondly of his life in Zimbabwe and mentions in particular an occasion when he had the opportunity to help a friend of his daughters complete her studies. ‘There was a girl in school with my daughter who came to my house crying and asked for money which I gave her to complete her nursing exams, later she qualified as a nurse and worked in England. Sometime later she sent a card form there with English money which I used to build things up for my children’
I ask Dustin to tell me about his own children. ‘I have children, one completed university six years ago, he I a bank manager in Johannesburg. One is married and he is there in Zimbabwe’ Dustin’s two other children have passed away one son who was a church pastor quite recently ‘he had a long illness’. His daughter who had lived in Malawi passed away aged 30 ‘she had BP and died from a stroke’. He tells me none of his children suffered form HIV.
Dustin speaks some more about life in Zimbabwe ‘If you are going there be sure whatever you speak does not blame hi (Mugabe’s) party or his government. Farming is poor because he has chased all the good farmers, the hospital has no medicines, otherwise it is a good country, but with poor management’.
Criticism of Mugabe continues and in particular his treatment of the farmers who had been so vital to Zimbabwe’s economy. ‘These people do you known what they were doing, they were shooting white people in farms. When us Africans we are killing on another, outside countries supported Tsvangirai because he didn’t want the white to be chased away’.
Dustin believes that if Morgan Tsvangirai takes over ‘it will be wonderful, he wants all the farmers who were chased to come back.’ I ask him is not concerned as a black Zimbabwean that the majority of arable land was in the hands of a small number of white hands. ‘These were the people who were working the property, they could build on the farm schools farmers, those are good people those British people’ When asked surely are they not Zimbabwean ‘they are not Zimbabwean, they are British’
He feels this is all the story he has to tell though I suspect there could be much more. ‘you said you don’t have a cough mixture for me’ I explain we may get some from the pharmacy the next day though his symptoms are related to cardiac failure rather than anything treatable with cough mixture. ‘I will sleep dreaming of that because tomorrow I will go to Chipata (to collect his pension) and then shoot to Msoro. What I have told you is the proper news, it is true’
Monday, July 12, 2010
On Call
I have always found the term ‘on call’ slightly misleading in medicine. In most jobs where I have worked the term rarely refers to sitting at home waiting for a call more often it has referred to 24 hours plus hard slog. In St Francis as in any hospital the doctors share out night and weekend on calls. There is no bleep or mobile phones – the security guard comes to find you – but otherwise things run pretty much the same.
Apart from the type of cases seen that is. Call on Saturday started in the paeds ward which is quite compared to busier times of the year. First up ITU only about six children here seriously ill from malaria or pneumonia, unfortunately one child dies during the round despite resuscitation attempts. Most of the others are doing ok, some need blood, transfusions are generally only given if Haemoglobin less than 5, a couple need NG tubes siting as there oral intake is not good and they will develop hypoglycaemia unless they get glucose water.
Next up is the acute malnutrition area. These are mostly children under two though there are some older. When many arrive they are acutely unwell, oedematous and septic. Most are on broad spectrum antibiotics. Feeding is commenced on F75 and then move on to plumpy nut (F100 is currently not available in the hospital). Some of these are very complex cases being HIV positive from maternal transmission or being on TB treatment.
After that the rest of the paeds ward seems like a breeze. Most of the children here are no more unwell than those on paeds wards at home, many are ready for discharge some need a day or two more, some that are not doing so well need changes in treatment or further investigations. From there it is onto the babies room for more of the same.
Paeds done we can move onto the adult wards taking one side each. In the male side St Augustine I start in the ‘ITU’ which isn’t exactly what we are used to at home, this is simply an area near the nurses station where the patients are under closer supervision and the wards two condensers for oxygen are located. Here there is a young man in an unconscious state following an alcohol binge a few days ago with aspiration pneumonia and possibly had a head injury. There is a man who is HIV positive and has a pneumonia occupying pretty much all his right lung, he gets to have one of the oxygen machines.
Next up is a man who has renal failure secondary to diabetes and complicated by pulmonary oedema. His creatinine is higher than what the lab can measure here but renal dialysis is only available in Lusaka. The next patient is extremely unwell. He has advanced HIV, TB and has now presented with abdominal pain and vomiting blood, he is in hypovolaemic shock needs fluids and blood, is to unwell for the surgeons to take to theatre and unfortunately has a very poor prognosis.
Beside him is a teenager who presented with new onset cardiac failure with cardiac failure and valve disease on echo. He is being treated for infective endocarditis. The man across form him is HIV positive and has presented with a 2 week history of severe headache and neck stiffness. He has no neurological signs but is confused and non compliant with attempts to perform a lumbar puncture. After some intravenous diazepam I manage to do the LP, his CSF is clear but comes spurting out under pressure (normally comes out like a tap dripping). Immediately after the LP he has had great relief from his headache, the analysis of the CSF will probably show cryptococcal meningitis an opportunistic fungal infection not uncommon in HIV patients.
From the ITU it is onto the rest of the ward all 30 patients don’t need seeing just the sick ones the new admissions and ones fit for discharge. When I am done there I head to special care baby unit where premature infants are cared for in cockroach infested incubators in an uncomfortably hot room off the maternity ward. A child born a few hours ago has just being brought in. The child has Gastroschisis where most of its intestines and stomach contents are outside its body. At home this would have been picked up on ante-natal ultrasound and the baby delivered in a specialist unit and presented to neonatal surgeons for corrective surgery. Here there is nothing we can really do.
After that a two day old premature baby is brought in. She has not fed, passed urine or opened her bowels since delivery. The family have given her some herbs to see if this will help. She is flat, cold and hypoglycaemic. Despite efforts at treatment she later dies.
I enjoy a short break before beginning the evening round back in paeds. First reviewing the ITU patients and then see the new admissions. Most of the eight new children who have arrived have fever, vomiting, diarrhoea, cough or a combination of these. In a normal GP on call at home I would see very similar children but I am definitely more nervous of a child with a fever here. After seeing these I head back to the adult wards to do the same review the ITU patients and see the new admissions. In St Monica’s I discover one of the patients in ITU has passed away. She again had HIV and had been extremely unwell.
After the evening round in St Augustine I am informed a new patient has arrived and is extremely unwell. He is 28 breathless, sweating, with a slow heart rate and extremely anxiety and restlessness. His brother informs me he has taken some cotton insecticide. A quick search through a useful St Francis hospital guideline booklet informs me he has organophosphatase poisoning and I need to treat him with repeated doses of intravenous atropine.
Between the doses I take out my palm pilot and read about this in the Oxford handbook of A&E medicine. It details a multitude of investigations which I should carry out, none of which are available to me. Thankfully the treatment is the same and it advises me on signs to watch out for when the patient is appropriately atropinised. After he is settled I found out that this young man is single, suffers from epilepsy and has poisoned himself on a previous occasion. After this I retire for some sleep.
Apart from the type of cases seen that is. Call on Saturday started in the paeds ward which is quite compared to busier times of the year. First up ITU only about six children here seriously ill from malaria or pneumonia, unfortunately one child dies during the round despite resuscitation attempts. Most of the others are doing ok, some need blood, transfusions are generally only given if Haemoglobin less than 5, a couple need NG tubes siting as there oral intake is not good and they will develop hypoglycaemia unless they get glucose water.
Next up is the acute malnutrition area. These are mostly children under two though there are some older. When many arrive they are acutely unwell, oedematous and septic. Most are on broad spectrum antibiotics. Feeding is commenced on F75 and then move on to plumpy nut (F100 is currently not available in the hospital). Some of these are very complex cases being HIV positive from maternal transmission or being on TB treatment.
After that the rest of the paeds ward seems like a breeze. Most of the children here are no more unwell than those on paeds wards at home, many are ready for discharge some need a day or two more, some that are not doing so well need changes in treatment or further investigations. From there it is onto the babies room for more of the same.
Paeds done we can move onto the adult wards taking one side each. In the male side St Augustine I start in the ‘ITU’ which isn’t exactly what we are used to at home, this is simply an area near the nurses station where the patients are under closer supervision and the wards two condensers for oxygen are located. Here there is a young man in an unconscious state following an alcohol binge a few days ago with aspiration pneumonia and possibly had a head injury. There is a man who is HIV positive and has a pneumonia occupying pretty much all his right lung, he gets to have one of the oxygen machines.
Next up is a man who has renal failure secondary to diabetes and complicated by pulmonary oedema. His creatinine is higher than what the lab can measure here but renal dialysis is only available in Lusaka. The next patient is extremely unwell. He has advanced HIV, TB and has now presented with abdominal pain and vomiting blood, he is in hypovolaemic shock needs fluids and blood, is to unwell for the surgeons to take to theatre and unfortunately has a very poor prognosis.
Beside him is a teenager who presented with new onset cardiac failure with cardiac failure and valve disease on echo. He is being treated for infective endocarditis. The man across form him is HIV positive and has presented with a 2 week history of severe headache and neck stiffness. He has no neurological signs but is confused and non compliant with attempts to perform a lumbar puncture. After some intravenous diazepam I manage to do the LP, his CSF is clear but comes spurting out under pressure (normally comes out like a tap dripping). Immediately after the LP he has had great relief from his headache, the analysis of the CSF will probably show cryptococcal meningitis an opportunistic fungal infection not uncommon in HIV patients.
From the ITU it is onto the rest of the ward all 30 patients don’t need seeing just the sick ones the new admissions and ones fit for discharge. When I am done there I head to special care baby unit where premature infants are cared for in cockroach infested incubators in an uncomfortably hot room off the maternity ward. A child born a few hours ago has just being brought in. The child has Gastroschisis where most of its intestines and stomach contents are outside its body. At home this would have been picked up on ante-natal ultrasound and the baby delivered in a specialist unit and presented to neonatal surgeons for corrective surgery. Here there is nothing we can really do.
After that a two day old premature baby is brought in. She has not fed, passed urine or opened her bowels since delivery. The family have given her some herbs to see if this will help. She is flat, cold and hypoglycaemic. Despite efforts at treatment she later dies.
I enjoy a short break before beginning the evening round back in paeds. First reviewing the ITU patients and then see the new admissions. Most of the eight new children who have arrived have fever, vomiting, diarrhoea, cough or a combination of these. In a normal GP on call at home I would see very similar children but I am definitely more nervous of a child with a fever here. After seeing these I head back to the adult wards to do the same review the ITU patients and see the new admissions. In St Monica’s I discover one of the patients in ITU has passed away. She again had HIV and had been extremely unwell.
After the evening round in St Augustine I am informed a new patient has arrived and is extremely unwell. He is 28 breathless, sweating, with a slow heart rate and extremely anxiety and restlessness. His brother informs me he has taken some cotton insecticide. A quick search through a useful St Francis hospital guideline booklet informs me he has organophosphatase poisoning and I need to treat him with repeated doses of intravenous atropine.
Between the doses I take out my palm pilot and read about this in the Oxford handbook of A&E medicine. It details a multitude of investigations which I should carry out, none of which are available to me. Thankfully the treatment is the same and it advises me on signs to watch out for when the patient is appropriately atropinised. After he is settled I found out that this young man is single, suffers from epilepsy and has poisoned himself on a previous occasion. After this I retire for some sleep.
Tuesday, July 6, 2010
Mbusa Wabwino
The name of the paediatric ward in St Francis translates to ‘Good Sheppard’ in English. During the busy malaria season, from January to April after the rains, 90 or more sick children are there receiving treatment. Today it is relatively calm just two children are receiving blood transfusions for anaemia secondary to malaria another, two year old Edwin is awaiting blood.
Whilst the blood is being cross-matched staff nurse Shalom is inserting a nasogastric tube and instructing Edwin’s mother Margaret on giving glucose water through this tube regularly to help prevent hypoglycaemia another complication of malaria.
Margaret tells me Edwin first became unwell two days ago when he had a fever appeared to have abdominal pain and started fitting. She did not know what was wrong. She explains she wanted to come to go to the health centre earlier but that ‘the bicycle was not ok, their was a problem with the chain’. When she did set out with Edwin it took over seven hours to reach the rural health clinic from where she was told Edwin needed to go to hospital which took a further two hours. ’It doesn’t feel nice that my child is in hospital but I am happy we have got here and can get treatment’
Margaret her husband and their four children live in a small two roomed thatched home in the village of Mbangombe. Her husband has a garden where he grows vegetables to sell by the roadside. She explains ‘he will make 140,000 kwacha per week if at all.’ This works out at about €24 and the family have no other income. They are lucky in that water is available from a dam nearby and they can afford the 5,000 kwacha per month to send their oldest child to primary school.
Margaret tells me that she does not know anything about malaria but she has knows that a lot of children have died from the disease. When I ask if her children sleep under mosquito nets she says ‘yes, we were given the nets in the clinic because they want to prevent mosquito bite’ but she had not been aware that malaria is spread by mosquito bites.
In the future she hopes Edwin will be able to go to school and that ‘when he grows up he will be able to chose what he wants to do’
Whilst the blood is being cross-matched staff nurse Shalom is inserting a nasogastric tube and instructing Edwin’s mother Margaret on giving glucose water through this tube regularly to help prevent hypoglycaemia another complication of malaria.
Margaret tells me Edwin first became unwell two days ago when he had a fever appeared to have abdominal pain and started fitting. She did not know what was wrong. She explains she wanted to come to go to the health centre earlier but that ‘the bicycle was not ok, their was a problem with the chain’. When she did set out with Edwin it took over seven hours to reach the rural health clinic from where she was told Edwin needed to go to hospital which took a further two hours. ’It doesn’t feel nice that my child is in hospital but I am happy we have got here and can get treatment’
Margaret her husband and their four children live in a small two roomed thatched home in the village of Mbangombe. Her husband has a garden where he grows vegetables to sell by the roadside. She explains ‘he will make 140,000 kwacha per week if at all.’ This works out at about €24 and the family have no other income. They are lucky in that water is available from a dam nearby and they can afford the 5,000 kwacha per month to send their oldest child to primary school.
Margaret tells me that she does not know anything about malaria but she has knows that a lot of children have died from the disease. When I ask if her children sleep under mosquito nets she says ‘yes, we were given the nets in the clinic because they want to prevent mosquito bite’ but she had not been aware that malaria is spread by mosquito bites.
In the future she hopes Edwin will be able to go to school and that ‘when he grows up he will be able to chose what he wants to do’
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