New Rhodesians

We got back into town this morning in the mission vanette. It was possibly the most uncomfortable journey yet - I was sharing the passenger seat with Maggie, so I had to balance on my left buttock every time Mr Banda shifted the gearstick into second. Meanwhile, Chas was obliged to perch on top of a large pile of cassava on the back, wrapped in a government issue blanket. I think I got the best deal.

We spent the morning at the Kabulonga market - a monthly event where all the well-off residents of Lusaka assemble to eat cake and haggle over traditional African crafts. Nearly all of the people who go are Afrikaans or expats. It is nice, but slightly odd at the same time. It is by no means the worst excess of white Lusaka society - I have heard an eyewitness account of an impromptu Gilbert and Sullivan recital in one of the posher cafes - but at times you are left wondering if 1964 ever happened. However, despite vague worries about neo-colonialist behaviour, we went along, as there aren't many opportunities to purchase handmade farmhouse cheddar in this part of the world. Very good too.

Back to the diary:

17th May 2006

Violet is two years old and severely anaemic following a bout of malaria. She was transfused on admission, but the situation has not improved. We have been trying to get venous access to re-transfuse her, but we didn't manage yesterday. Today, to my irritation, her parents are agitating to take her home. Sister Valeria and I take them to the office for a chat.

I explain that if she gets another bout of malaria in the near future, it will probably kill her. The father tells me that they live in a village far from here (there are only two terms of geographical description in Mpanshya - a place is either "near" or "far"). During the week that they have been in hospital with Violet, they have missed the harvest and the monkeys have eaten all their maize. So, their choice is either to take their seriously ill child home and salvage what food they can, or to starve. I suddenly lose my appetite for strongarm tactics, and write a prescription for iron and vitamins.

24th May 2006

I am doing a round with Mrs Lipalile, one of the nurses, and she asks me to see some triplets who have been admitted to the nutrition centre. She tells me they are from a nearby village, Lukwipa, and their mother gave birth to them on her own at home. She didn't know it was a multiple pregnancy. They are now 17 months old, and are frequent attenders at the nutrition centre.

We arrive at the centre, and are greeted by the howls of three tiny toddlers. They are competing for a nipple. Taonga and Mary win the fight and snuggle into their mother contentedly; Natasha cries even more loudly. The older brother, who looks about five, picks her up and tries unsuccessfully to console her. I think I only spend 10 minutes examining this family but it seems like a long, long time.

As we leave, Mrs Lipalile asks me if I have children of my own. When I tell her no, she says "You must have one here! We will deliver you, we are very good midwives." I thank her for the kind offer, and tell her I will let her know. Hmm.

26th May 2006

Joost has been the first of us to get malaria. He was feeling ill earlier this week and went to the lab to get tested. He seems remarkably cheerful despite his affliction. I start to feel slightly dodgy a couple of days later. Nothing specific, just a woolly head and a short fuse. Arguably not a huge variation from my normal state. I put off going to the lab, hoping it might get better, but it doesn't. Eventually I go along to see Mrs Mwale, the technician, and sheepishly offer up my digit for a blood slide. I am passed the result a couple of hours later in a sealed envelope marked "Dr June". One trophozooite. It's malaria but only just. I nick the only remaining course of combination antimalarials in the hospital, and take the afternoon off.

Lessons in statistics

One in ten Zambian children die before reaching the age of five; the average life expectancy here is 33; the third most common cause of death in this country is road traffic accidents. You’ve probably heard these statistics, or something like them before. They are unpalatable enough from a distance, but being here in the middle of it all is an uncomfortable situation at times.

The diary extracts are a bit grim this week. But I figured you’ve stayed with us this long, and you can probably cope. Me, I’m trying to keep a sense of proportion about it all – most of these deaths are certainly preventable, but probably not through my efforts alone. They are less my personal failures than the product of systematic disadvantage, from the womb onwards. It doesn't always feel like that at the time though.

27th April 2006

An unbelievably awful day. I spent half my morning trying to get a line into an anaemic 10 month old baby. I finally succeeded after about 20 attempts, and we got blood for cross matching this afternoon. Unfortunately the cannula was blocked by the time the blood came. I spent another hour trying every place I could think of – scalp, groins, everywhere – and couldn’t do it. Being able to find a vein is sometimes the difference between life and death here. Today, it wasn’t possible.

Another little girl, one of my HIV patients, collapsed and died a few hours later. She had appeared to be getting better from a chest infection, but she was badly undernourished. She was severely anaemic too, but the only blood we had was cross matched for the other baby. I know that the lack of available blood probably didn’t make much difference to the outcome for this child. But I can’t help feeling angry and frustrated about having to watch her die.

I knew when I came here that stuff like this would happen. I suspected that I would gain an unsettling familiarity with the sound of the paediatric death rattle. I suppose I had hoped that I might rise to meet these challenges when I was here; that I would somehow acquire an air of calm authority in the face of such crises. However, my diffidence and indecisiveness are proving to be portable qualities. And in retrospect, the notion that international relocation might induce a sudden professional metamorphosis was perhaps based in something other than reality.

People who do this kind of work often talk in vague terms about “doing your best”, but everyone neatly avoids discussing the possibility that one’s best might not be terribly good at all. These children deserve better than me. Unfortunately, in the absence of a paediatric intensive care specialist, they will have to endure the improvisations of a bewildered GP. I did choose to do this, I opted to place myself at the sharp end, and I am not sure if my decision is currently serving anyone’s interests.

2nd May 2006

The first day of the course for antiretroviral treatment supporters. This is the next stage of the ARV rollout programme; improving support for people on treatment for HIV in the community. This group consists mainly of local teachers, and I am training with three colleagues.

I arrive for my slot, clutching my pieces of flip chart with my wobbly marker pen diagrams. I stand up and introduce myself. My colleague, Hateyo, leaps to his feet and translates my introduction into Chinyanja. I am a bit taken aback – I was told that this group would all be fluent in English – but I let him carry on.

I proceed to explaining the cellular biology of HIV in as close to layman’s terms as I can manage. Hateyo enthusiastically translates for me, and his explanation goes on for some time. I don’t understand what he is saying, but I can hear the words “reverse transcriptase”, “CD4 lymphocyte” and “messenger RNA”. Evidently he has decided to correct the deficiencies in my presentation with a bit of added scientific jargon. In the absence of any idea of how to bring things under control again, I opt for a fixed grin and I plough on through my material. Hateyo continues in much the same vein, like a Springer spaniel who has just been allowed off the leash. I finish exactly on time, feeling completely demoralised, and head back to ART clinic.

Later, I discover that the slot immediately before mine was delivered by a Zambian colleague in English with no translation. I don’t generally have much of a problem making myself understood amongst English speakers here. I think the problem is that being able to talk before an audience is seen as something of an honour here, and any potential opportunity for public speaking has to be seized. I am training again tomorrow. Time to be assertive, I think, even at the expense of cultural sensitivities.

3rd May 2006

Back to the training centre. I am introduced by Hateyo, and I stand and say good morning. Hateyo does not sit down. I gesture towards an empty seat nearby. He walks over and picks up some notes that are lying on the chair and offers them to me. I catch his eye, he finally realises what I mean, and sits. I get through the next 90 minutes with only two or three spontaneous contributions from him, which I consider to be a small triumph. Hopefully this marks the end of my training career.

4th May 2006

Today, five people are coming from the orphanage in Nyampande for medicals. I begin seeing them one by one, hopeful that a cursory examination will suffice. But predictably, they all have some ailment or other that needs attention, and the process takes forever. I have to run off to attend a death in the hospice midway though the morning. I am feeling a bit harassed.

Paperwork finally completed, I bump into Sister Valeria who apologetically tells me that eight Catholic Brothers have arrived from Lusaka in anticipation of a full medical examination as well. I make no attempt to veil my displeasure at this news. If I was interested in this type of work, I’d be on BUPA’s payroll rather than here.

In the afternoon, I am trying to locate a translator so I can see some outpatients when I see a commotion at the emergency admission door. Some people are unloading a man from a minibus. He is groaning. I try to obtain a story about what has happened, but everyone is talking at once. Having dumped the casualty on the bed, the minibus occupants disappear.

I take stock of the situation. Obvious right femoral fracture, blood pressure unrecordable. Not good. Even if through some miracle, I managed to open up his leg and tie off the bleeding artery, we do not have enough blood in the hospital to replace what he has already lost. And we are three hours from Lusaka. The implications are obvious. He is twenty-four years old.

Despite this, Sister Valeria and I get to work, putting in lines, cross matching blood, debating whether he needs a chest drain or not. He is begging me to give him some water. I refuse, because somewhere in my head I have convinced myself that it will be okay, that we will get him to an operating theatre somehow, and we must keep his stomach empty in preparation. We continue: antibiotics, tetanus prophylaxis, chest X-ray. He tells me he is going to die and I emphatically contradict him.

Two hours after he arrives, we are forced to acknowledge the futility of all this activity. We stand by the bed as he dies. I am a mess of blood (his) and snot (mine) but I am past caring. I am wishing I had just given him some water.

There is still a queue of patients waiting to be seen. I examine a baby who pees on my foot, and throw antibiotics at the others. Then the Brothers arrive for their medicals. I do it on autopilot. On another day, the idea of asking a series of trainee priests to drop their trousers might have made me smile a little. Not today.