Village People

Monday 17th January

My last of seemingly endless weekends spent working in St Francis over I am leaving Katete to sample life in a rural village and experience primary care in Zambia. I have spent a lot of the past few months comparing life and medicine here with what I knew at home. But having trained as a GP I want to see how primary care in Zambia compares to Ireland. Obligatory bureaucracy overcome including getting two drafts of a introductory letter for the district Medical officer and trying to liaise with Edward via phone trough crap reception I am on my way to spend a three nights and four days in Mpopo rural health centre.

Mpopo is a large village about 80km from Katete the last section off the tar. I am looking forward to having a relaxing stress free few days. I arrive at a leisurely nine thirty to find Edward who runs the centre has had to go to a training meeting and I am greeted by Roger instead. He explains that the health centre serves a catchment of over eight thousand people and provides acute care, chronic illness management, family planning, antenatal care, looks after about thirty on site deliveries per month and under five care (vaccinations, growth monitoring etc). HIV services are provided by an outreach team.

As well as the labour ward there is an on site ward with three beds where patients can lodge if they are very ill or whilst awaiting transport to hospital. There is a laboratory with a microscope, tests available are blood slide for malaria, haemoglobin (blood count), urine microscopy (to look for infection), RPR (syphilis test), sputum examination for TB and pregnancy test.

There are a load of patients waiting to be seen so we start. Now let me explain the staffing situation in Mpopo. Edward who manages the centre is a registered mid wife. Roger is a microscopist with two weeks training in laboratory techniques. His wife Telesa is a ‘certified daily employee’ whose role is supposedly to give admin support as well as clean and maintain the centre. Limbikani is the night watch man. Thomas is the data clerk, that’s it. When Edward the only trained staff member is away like today, at meetings or workshops, which seems to happen very frequently the others keep the show on the road.

I start seeing the patients with Roger helping to translate and outline how the centre works. We see malaria, pneumonia, chronic obstructive pulmonary disease, a woman with painful periods a child with tonsillitis among many others. About an hour in Roger tells me there is a child fitting on the ward. We go to find a seven year old boy who had been seen by Edward during the night. He is HIV positive but not yet on treatment, he came the previous night with seizures the family had no money for transport so an ‘ambulance’ has been called and is awaited. The child is still seizing he gets more Diazepam, he has had quinine to treat malaria, I suggest penicillin cause he may have meningitis, he needs to be in hospital. The ambulance eventually arrives but he dies later in St Francis.

We go back to seeing patients. I ask Roger how we are doing. His reply a ‘bit fine the way you work’. After thirty or so patients I suggest Roger see the patients and I can make suggestions, maybe things will move quicker and it doesn’t seem like Roger is too interested in learning anything from me. As a lab microscopist he has no clinical training but frequently sees patients. I quickly realise what he meant by ‘the way I work’ which involved getting something of a history and examining every patient if even just to check temperature, heart and breathing rate and check for pallor. Roger simply asks the presenting complaint be it headache, cough or fever. He almost never does any attempt at examining the patient, ‘consultations’ last less than two minutes. Based on the presenting complaint he prescribes some treatment, be it an antimalarial, an antibiotic or just paracetemol.

I would describe it as guess work, I can’t say how often he gets it right as I would need to assess the patients more. However he does frequently seem to make sensible decisions, having a low threshold for malaria treatment in the under fives, telling some patients to come for review if they don’t get better. He asks my opinion on some cases and I make some simple suggestions. Remember he has no training and no way to diagnose malaria (because he is seeing the patients therefore no lab). The last patient is seen just before six. Seventy five patients have been seen since I arrived.

While Roger has been seeing the patients, Telesa has been dispensing the drugs from a limited selection of antibiotics and painkillers and explaining to the patients how much to take and how often. As we are leaving the centre Telesa tells me there is a woman in the labour ward. She proceeds to examine the lady and deduce she is 4cm dilated, she doesn’t use a partogram to chart the labours progress but tells me Ronald does when he is here.

I am pretty disheartened after the day. I ponder that maybe the patients would be just as well off without any health care than what they have got today. I am shown to my accommodation. Like the health centre it has power but no running water. It’s a bare shell of a house with four rooms no furniture or appliances, thankfully I have brought a camping mattress and some bedding. There is a pit latrine round the back, I can’t see a bath room anywhere. Water is from a bore hole near by. I realise that I am hopelessly under prepared, what use is my laptop and mobile phone here. I have some bread, corn flakes and milk but nothing to eat them out of, how I am going to wash?

I walk down to the village to try to find some food. It’s a big place several hundred people must live here. The village square is populated by grazing cattle and playing children. I bump into Thomas the data clerk from the centre. He hasn’t been working today but out in the fields planting. He never got to complete school and was a taxi driver in Lusaka, he got this job ahead of eleven others with more education. His role has been financed by the World Bank under the performance based funding for scheme which I did some inspections for a while back. Since he started working in the centre last March he hasn't been paid. Thomas shows me around the village, the two taverns, three or four shops selling basic clothes, soap and detergent but no food, the various different churches, the cattle shed in the square which he says belongs to a cooperative.

When I arrive back at the centre Edward has returned. We chat in the centre for a bit between seeing a few patients who have arrived to the centre. He tells me there had been four trained staff here but now he is the only one. He seems frustrated and disillusioned with the work, being on call every night. He plans to return to hospital midwifery. I tell him about my background and that yeah things are different in Ireland a centre like this would have probably three GPs a nurse or two as well as support staff. Edward tells me a new teacher for the school has just arrived and will be staying in the house with me. I greet Paul briefly and retire to sleep.

Tuesday 18th January

I wake at six from a dreadful nights sleep punctuated by heat and rolling of the camping mattress to hear Paul outside slashing branches, what is he doing? I go to the bore hole to wash my teeth get some water to drink. I have decided I can’t possibly stay here another night, I will go back to Katete this evening and commute out the other days.

The morning is just the same I sit with Roger seeing patients, there are less today but he still moves super quick. However he seems much more receptive to comments and suggestions I make and I realise that in Ireland it is unlikely anyone with so little training would do as good a job in such difficult circumstances. A lot of the patients like at home don’t have a whole lot wrong with them, like at home the mothers seem to bring all the children to be seen at once. I am starting to feel a little better about things and decide to be more stoic and not return sulking to Katete this evening. At midday I go to get some water and find that the pigs and chickens outside the house have been joined by a team of kids from the school clearing the ground.

Their new teacher Paul is from Katete and has been appointed deputy head master here. His wife and children will be staying in Katete where she also teaches and they have their home. He describes it as a promotion to isolation. He is prepared for life here has a little electric stove, meal to make nshima, tomatoes for relish and eggs along with his laptop and stereo. Earlier he had been cutting branches to repair the houses wash area, a grass fence enclosed square outside which I hadn’t noticed. I ask Paul if he wouldn’t mind sharing some food with me which he enthusiastically agrees to.

In the afternoon I go with Telesa on an outreach visit to another village. Telesa’s duties are listed on the notice board in the centre. Tuesday afternoon is polish the floors day, the floors don’t look like they have been polished in a long time. I drive us a few kilometers down the track to the next village where dozens of women have gathered under a tree with their children. Community health volunteers weigh the babies and organise child health records.

Over the next couple of hours under the tree we vaccinate countless children against measles, diphtheria, polio, haemophilus and tetanus. We give oral and depot contraception to women who understand the benefits of family planning and allowing some time between pregnancies, we give antenatal care to pregnant women including folic acid, iron and intermittent presumptive malaria treatment. One of the community health volunteers gives a talk on nutrition and different food groups. The women sing some songs to the first white visitor to their village in a long time (if ever), everyone is intrigued by my camera and looking at he photos I am taking. Because this is Zambia we don’t leave until after we have been fed with nshima, vegetables and something I think was chicken.

When we get back to Mpopo we see the last of the patients in the clinic. I have a wash (throw a bucket of cold water over myself) in the newly discovered ‘bathroom’, enjoy some more nshima with eggs prepared by Paul and retire much more content than twenty four hours before.

Wednesday 19th January

Still no sign of Edward today. Roger continues seeing the patients with me trying to give some hints and suggestions. A local councillor brings his son in his twenties. He has been coughing for some months has been loosing weight and has had a fever for the past few days. He previously had TB sputums checked a few months ago which were negative. He looks obviously ill, is breathing fast, very thin. Ernest ascertains only that he has a cough for some months. I ask him what he is going to do. ‘Check sputums for TB’. I try to say no as politely as possible. I explain this is a sick patient who needs treatment and investigations in hospital.

Later in the morning a man comes actually referred here form another rural health centre to have his urine checked under the microscope for schistosomiasis as he has been passing blood in his urine recently. I let Roger go and prepare the slide and use a local school teacher who is here with his daughter to translate for a while. When Roger tells me the slide is negative I ask him does that mean the patient doesn’t have Schisto. Yes, he replies because if it was there I would see it. I point out that the microscopy is positive in only about half of cases. I try to explain my rationale (be it right r wrong) for treating schisto – I treat anyone with blood on urine dip with no obvious explanation such as menses or infection. It’s a single dose of safe medication and such a policy would have saved this man coming 20km for a time consuming and ultimately not useful test.

The remainder of the day continues much like this. I know if I was Roger I would having me sitting in asking him questions pointing things out. A lady presents following a bite from a spitting cobra on her foot out in the fields this morning, her whole leg is swollen. Roger is content just to give her some antibiotics and send her home. I have seen enough patients need amputations following local tissue infection after snake bites to persuade him to refer her for IV antibiotics and so the leg can be observed in hospital for a few days.

Often people in secondary care complain about too many referrals from primary care. I feel patients should be referred when a hospital investigation is needed to reach a diagnosis, treatment only available in hospital is needed or where managing the patient s beyond the skills available in primary care. There are a lot of mitigating factors in Mpopo such as distance to hospital, transport costs and patient reluctance but it seems many patients who should be referred are not.

Thursday 20th January

My last day in Mpopo. There is another village clinic today which I am looking forward to. In the morning I spend some time with Roger seeing patients. A mother brings in her 5 year old daughter, she has come frequently with abdominal pain. She is pale I show Roger the importance of checking for pallor. He asks should we check a blood count. No, there is little to be gained in him spending time looking down a microscope estimating this. I explain we should just give her iron, treat hookworm which may well be causing her anaemia and stomach pains and follow her up. Surely this is a more sensible approach in a resource poor setting.

Later I head out with Telesa to another village. Among the community health volunteers here is Davison the head man. After the vaccines we do the family planning. Telesa tells the women who have got depot contraception to come again on 20th April. I politely point out that the depot is effective for twelve weeks not three months (almost thirteen weeks). How was she supposed to know that after all this afternoon her duties should be scrubbing the walls. After the health promotion talk one of the volunteers promotes his little business selling bottles of chlorine for 800 kwacha (15cent) which would make about 100 litres of this village’s filthy well water a little less unsafe to drink. He is also selling condoms, 500 kwacha for three.

We eat our meal (though I don’t chance the water the chicken here is really good) head back to Mpopo and I pack my things. Where was Edward? Perhaps he was uneasy about me observing him work, perhaps he genuinely had something to do, perhaps he thought he would just bugger off because I was here. I don’t know if things would have been any better with him here. With al due respects to the profession of midwifery it is not a qualification to deal with acute childhood illnesses such as malaria or chronic diseases such as asthma or hypertension. Looking at some of the records it seems he just does the same as Roger does in the consultation, after all it is from him Roger learned to work this way.

I take some photos and say goodbye to Roger and Telesa. They are really nice people who are trying their best in difficult circumstances. They have been welcoming and open to suggestions but I don’t known if their practice will change much from my visit. For me it has been an eye opening experience living in the village completely isolated from he outside world, this is Africa.

So what would I do with this model of primary care? There is a good argument for just closing the centre (and others like it) as the standard of care is so unsafe, but that wouldn’t achieve anything. In fact the government are opening more of these centres thanks to donor money and proudly boasting about the ‘improvements’ in primary care. I think the Zambian authorities should forget about this façade of having trained nurses in the centres because in practice they are not there.

People like Roger and Telesa should be upskilled on how to identify acutely sick patients and have clearer protocols on how to manage them. Chronic care could be provided by a mobile team with a clinician who could visit once a week, this would also help staff training. The community health volunteers could take over the admin side of the centre. I think any pregnant woman with a hint of means would be crazy not to take herself to St Francis for delivery. Centralising maternity services would be difficult and costly. More staff would be needed in the hospital (maybe Edward among them). To entice patients I think you would need to supply a one of payment to each mother who has delivered in the hospital scaled on the distance to her home. While costly this would probably dramatically reduce perinatal mortality.

Whilst the above is an actual account of my experience of primary care in a village in Eastern Zambia the name of the village and the health centre staff have been altered. I would like to thank ‘Roger’, ‘Telesa’, ‘Paul’ and the people of ‘Mpopo’ and its surrounding villages for their kindness and hospitality.