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.
Friday, November 26, 2010
Monday, November 22, 2010
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.
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.
Sunday, November 7, 2010
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.
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.
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