Dr Cillian Clancy writes about his experiences earlier this year while spending six months working in Zambia — which, despite the poverty of the patients and lack of facilities, was extremely rewarding
“Likely non-typhoidal salmonella septicaemia and possibly military tuberculosis. We can’t start ARVs until we address these. Now we need an LP.”
Four years after qualifying from UCD and having applied my degree in the wards and emergency departments of Dublin, Sydney Australia, Tullamore, Galway and Sligo, I chose to add a Zambian stamp to my list.
I want to be a GP. My friend and GP trainee, Dr Patrick McSharry, told me about Zambia and the clinic in which he and his two classmates, Dr Ronan Flynn and Dr Barry Kelly, had started earlier this year. I am doing a Diploma in Tropical Medicine this autumn and knew that Zambia would offer great learning opportunities. Other friends have been to Africa and other parts of the developing world, rarely returning with a bad word.
Zambia was first explored by the Portuguese in the 1790s. They followed landlocked routes beaten by Swahili-Arab slave traders from centuries before. The famous David Livingstone arrived in the 1850s to introduce Christianity and European values to combat the horrors of the slave trade.
In 1855, he discovered the awesome Victoria Falls, saying: “On sights as beautiful as this, angels in their flight must have gazed.” To the indigenous people, the Falls’ other name, Mosi-oa-Tunya (‘The Smoke That Thunders’), also speaks volumes.
Livingstone inspired missionaries in the following years and in the 1890s, the British South African Company laid claim to the country and began exploiting its vast copper resources in the northwest, known as the Copperbelt. The country became known as Northern Rhodesia (Southern Rhodesia is now modern Zimbabwe) with southerly Livingstone made capital in 1907.
‘Hut tax’ was imposed on the mainly African workforce and direct British rule imposed in 1924. The capital was moved to its current location, Lusaka, in 1935.
In the 1950s, amid pan-African nationalism, the UNIP (United National Independence Party), headed by Dr Kenneth Kaunda, arose in Zambia and agitated to bring about independence.
Following a short conflict known as the Chachacha Rebellion, the federation was dissolved and independence gained in 1963. Zambia was adopted as the country’s name at the same time.
Social philosophy
Kaunda became the first president and spent 27 years employing humanism as the country’s social philosophy. It led to nationalism of nearly all private businesses. By the 1970s, he disliked the opposition ANC (African National Congress) so much, he dissolved that party and made the UNIP the only legal party – and he, the only presidential candidate.
Corruption and mismanagement followed, in association with a huge fall in copper prices, making Zambia disastrously debt-ridden by the 1980s. Kaunda was ousted in 1990 by civil unrest sparked over food prices, hastening his political demise.
Much political shenanigans followed amid worsening corruption, leading to financial dire straits.
In 2005, Zambia was classed as a ‘heavily indebted poor country’ by the International Development Agengy and $7 billion of its debt was written off. Nonetheless, the country struggles under the weight of poverty, HIV and loss of its working generation to both. Unskilled labourers here earn ~$80 a month, forcing 60 per cent of people to live on $1.25 a day. There are 12.52 million Zambians and currency is the kwacha.
HIV is endemic in Zambia and affects perhaps 15 per cent of the adult population, sometimes higher in crowded suburban townships or ‘compounds’ like Linda, outside Lusaka, the one in which I worked. One in seven children are orphaned by the disease. On the back of HIV, tuberculosis (TB) has cut swathes through the malnourished and overcrowded populations. Malaria and cholera tend to be seasonal and were not very prevalent during my stay in the dry season.
Just prior to my visit, Zambian nurses and doctors had gone on strike for a month in protest at poor working conditions, not being paid and 26 billion kwacha going missing in the Ministry of Health. Twenty civil servants are now jailed after the public outcry led to their reluctant apprehension.
In spite of the Ministry’s poor record of meeting the country’s health needs, NGOs and foreign aid have bridged gaps. Most surprising for me was the little-publicised intervention by George W Bush in the fight against HIV/AIDS. He set in motion PEPFAR (US Presidents Emergency Project For AIDS Relief). This released funding of $15 billion between 2003 and 2008 for initiatives in 15 of the world’s countries worst-hit by HIV/AIDS. Its main aim was providing increased resources for multilateral efforts to fight HIV/AIDS.
This made ARVs (antiretroviral drugs) free for those on the programme. It gave the necessary power for countries to implement large-scale prevention and blood safety programmes. HIV testing, treatment and clinical follow-up became possible, of which I have firsthand experience. PEPFAR also has its sights trained on malaria and TB and integrated these into its action plans. Under the current US administration, a further $48 billion has been made available for the fight against these three scourges.
Largest health initiative
PEPFAR resulted in an increase of people on ARVs in Africa from 15,000 in 2004 to two million by the end of 2009. It is widely recognised as the largest health programme ever initiated by one country against a disease.
My visit began with the dazzling contrast of Heathrow and Lusaka. My first foot set on African soil was not a progressive one. The queue for visas for ‘non-VIPs’ moves at a leisurely pace so for a change, my rucksack was circling the baggage belt when I got there for the first time ever!
Two very kind Irish missionary nuns, Sr Regina and Sr Mary Teresa, had given us their sturdy Toyota Hilux for the duration of the trip.
Lusaka greeted us as a dusty, littered and concreted cityscape with Soviet-style architecture against the clear sky. Any phone/camera charger imaginable is available at every traffic light. Not to mention fruit, phone credit and puppies of varying breeds! We stayed in a Franciscan college compound, enclosed by high electric fences.
All roads were potholed and dusty red. You knew a wealthy person’s home if there was someone outside, paid to water the road to prevent dust crossing over their barbed, high wall.
Linda Compound holds about 25,000 people. Before the intervention of Neri Clinics — at the suggestion of Srs Claudia, Regina and Mary Teresa — residents had to walk at least four miles to get medical attention. Not the worst if you are well, but very hard if you are sick. Neri Clinics is a group of Irish men and women, drawing inspiration from Irish missionaries past, who wish to deliver excellent healthcare to people in most need.
Staffed on the ground by Zambians, the clinic in Linda was opened by Dr Kenneth Kaunda; the Irish Ambassador to Zambia, his Excellency Bill Nolan; and other dignitaries in March 2009. Before it, no clinic existed in Linda but the generosity of ex-minister Simon Zukas helped in taking the idea to a fully functioning primary healthcare clinic in six months. Since opening, almost 2,000 patients have registered. On average, 30 patients are seen per day.
The practice doctor aligned his holidays with my arrival, allowing me take on the daily clinics. Patrick had taken the brunt before my arrival. Armed with lecture notes in tropical medicine and the ever-trusty Oxford Handbook of Tropical Medicine, I navigated through presentations from the mundane to the floridly tropical.
Poverty and disease
Never a dull moment, as the signs and pathology that offered themselves on examination were fascinating. Having to broaden and reprioritise differentials was altogether refreshing. I encountered the many social impacts of poverty, disease and cultural traits played out in the words of the patients. None more so than the 23-year-old HIV positive lady who was experiencing a threatened miscarriage, having lost her first pregnancy at 12 weeks the year before.
She was upset because her husband would leave her if she did not have a baby soon, yet his beating her left me in no doubt as to the cause of her condition. On top of this, she reluctantly accepted the equivalent of $6 from me so she could afford a scan to check the baby.
However, overwhelming warmth was extended to me by the people of the area. They never jeered at my sometimes comical charades and were ever patient with my recurrent page-flicking.
I had the pleasure of seeing three other medical areas in Lusaka at very different places on the care spectrum. Patrick and I made regular visits to the Mother Teresa Orphanage and Hospice for the Sick and Dying in Mutendere. The place is spotless, lined by trimmed hedges, tidy flower beds, symmetrical vegetable patches and brightly painted single-storey buildings.
Unmistakable was the garb of the sisters, blue and white, among the many happy children playing in the yard. Our first port of call was the infant orphans, mostly parentless due to AIDS or poverty. For the most part, children were healthy but one had a congenital cataract and another hydrocephalus.
On arrival, arms would go out, delighted to be held and tickled. Not so happy to be laid down again, though! The older toddlers were a boisterous lot too and one in particular was utterly fixated by my stethoscope.
Mattresses under beds
After play, we would meet with Sr Rebecca for a round. She interned in Poland after her degree, followed immediately by the move to Lusaka where she was doctor to the male ward for the almost four years. Easily 15 beds deep and five across, the room/ward was dim but well ventilated. Separated by a long screen, the far third of the room was for the very sick. In some cases, people took up mattresses under the beds when space was tight.
My first visit there was on my own. Nothing could have prepared me for it. So sick and desperate were the men, but heartbreakingly eager to smile when smiled at and asked how they were.
Indescribable air of calm
Sr Rebecca brought an indescribable air of calm and caring to the room, passing between the patients, recollecting histories and managements with the finest detail, displaying the most impressive chest x-rays, then asking for and appreciating any further help we could offer. To say I was in awe would put it mildly. One patient passed away shortly after we saw him. Sister said a discreet prayer and passed on to the next case.
Limited by resources and means to investigate thoroughly, as is all too often the case in the developing world, clinical acumen is sharpened and trust is built in one’s eyes, ears and hands. All those Talley and O’Connor examination skills come into their own. In a few cases, patients were palliatively transfused based on their conjunctival pallor.
Language and culture
Another great difference I encountered in the patient-doctor relationship was the care of inpatients. Relatives were in attendance at the bedside throughout to wash, feed and assist the ill. They were often better than documentation for history of the admission, also. Outside of this, language and culture proved not to be the barriers I had expected.
My second encounter with the Lusakan health service was a week in Our Lady’s Hospice in Kalingalinga, Lusaka headed up by Cork-born Sr Catherine ‘Kay’ O’Neill.
An interesting change has come about for this 26-inpatient bed facility with the advent of ARVs. Reversing the fortunes of countless HIV victims, the hospice still takes in patients very ill with AIDS complications but more so, its mission is in the ARV clinics.
Clients are screened for HIV and referred here for CD4 counts (viral loads in many cases are too expensive) and clinical staging according to WHO protocols. Decisions are made to start and alter ARVs, prophylaxis is initiated against opportunistic infections and health education dispensed – all free of charge under the funding of PEPFAR.
The service is manned by clinical officers. Having studied medicine for three years, their grounding is heavily based around local diagnoses. They find it almost impossible to leave Zambia and practice medicine elsewhere, thus solving the ever-present brain drain of fully qualified doctors to better-paid pastures. The three doctors, Lubasi, Willie and Kelvin (in final year), were more than competent, practically well trained and hungry for knowledge as their library is poorly stocked and books are too expensive on their salaries. My books got so much attention, even over nshima, a local maize dish, at lunch.
ARV clinics
Our ARV clinics were held every day, morning and evening, with paediatrics on a Wednesday afternoon. We did a patient ward round every morning and afternoon before the start of clinic. Dr Mutemba, a thoroughly impressive nephrologist from University Teaching Hospital (UTH), led rounds four days a week also, allowing the clinical officers to field queries and learn in a teaching-based round.
Morphine was a huge issue. It is so strictly regulated that only patients transferred from UTH to the hospice had any meaningful supply for their pain needs. 200mg between three patients for a week was the case. This did not include palliative patients admitted directly. The situation is changing, but slowly.
My third experience of local health infrastructure came thanks to Dr Mutemba, who invited me to work in his medical emergency department in UTH. He heads up the ‘filter’ area of the hospital, which acts as an urgent medical outpatient clinic for problem cases referred by local clinics. It was divided into areas of those who could walk and those who could not. Those mobile patients would be seen, in turn, by doctors in several rooms next to an observation ward.
The often-obtunded patients who arrived in the curtained area at the end of the observation ward were seen by me or the other doctor present. Five nurses were also present and it was seriously busy.
In an eight-hour shift, we saw more than 40 patients. History, examination and the seemingly inevitable lumbar puncture, ascitic or pleural tap would have to take about 15 minutes.
Dr Mutemba informed me that a provisional diagnosis and initial therapy was required, as further evaluation occurred with the admitting team once the patient was wheeled to the ward.
I quickly learned that so many Zambians present to hospital late in their disease. My worst morning there left me with two patients deceased before assessment and one died on his way to the ward, having had initial treatment for likely pyogenic meningitis. All were under 33 years.
Non-medical projects
I saw some of the other non-medical projects in the Lusaka area. The Irish missionary priests of the Society of African Missions (SMA) do so much more than attending the spiritual needs of their parishioners, but also improve their communities. In Chainda, east of Lusaka, Fr Jim O’Kane from Tyrone has built an impressive community centre in a particularly deprived area. There are classrooms for educating children by day and adults by night, as well as the vast hall as a centrepiece.
Successive teams of volunteers from Ireland have made it possible and I was happy to see it all but finished, with classes of adults working through the evening.
A passion for football
I met Vincent, a Spanish national there for over a year. Driven by a passion for football and backed by an NGO with a similar sentiment, he has set in motion a school/workshop/sports facility for orphan teens.
With his contacts among the local teams, a soccer tournament was organised on the pitch in the Linda. Patrick had the idea that all teams could have their blood pressure checked and heart valves auscultated between matches. The result was free membership for one year at Neri Clinics in Linda.
Needless to say, the novelty of a bunch of muzungo doctors pitch-side was enough to form a queue a mile long. Spectators joined in too and because women do not care for soccer all that much, we captured the ideal cohort of primary-care evaders – young males.
Mantra on the day
The outcome was three young men turning up at the clinic in the two days following the tournament, but who knows how many over the next few weeks and months? Hopefully our mantra on the day of ‘know your status’ (HIV) may help those at risk or in the early stages to take control of their health for a better future.
Zambia held so many new experiences for me when out of my white coat, too. These included an unforgettable microlite flight at dawn over Victoria Falls, the finest steak in the period Lusaka Club restaurant and GAA matches on Setanta. Balancing this was our run in with O’Brien, a local traffic cop. Convinced we were doing 91kph (where 61kph was closer to the truth) in an 80kph zone, he demanded the equivalent of $40 as a fine but settled quite uneasily for a $10 ‘no receipt’ standard charge for the privilege. We are by no means the exception here.
Africa is full of contrasts – happiness despite grinding poverty, corruption stacked against dire need and poor health alongside strong spirit. I strengthened my appreciation and respect for those less fortunate and those striving for better.
Neri Clinics is a registered non-profit charity that prides itself on having no administrative costs allowing 100 per cent of donations to go directly to those in need. For further information or to donate, please visit www.nericlinics.com.
About Greg Baxter