‘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.