The Most Remote Hospital on Earth

It is a beautiful day with bright sun and blue sky – the first time the weather has been this nice since I came to Lubwe. The afternoon is slow; the male ward is almost empty. I head home early and decide to go for a run. It has been a long time since I last did any kind of running and I can already feel my legs atrophying.

I run out of the village, down the main road toward the next village, then turn back toward the market. Along the way, people stare at me as if asking why would anyone go running for no reason. Having gotten used to the staring by now, I give an occasional wave to them.

On my way back, I pass by the hospital again. People are loading packs of things onto a flatbed truck parked in front. Ms. K., the medical licentiate calls out to me. It turns out that there are two women who need emergency cesarean sections. Because the part that was needed to fix the autoclave has not arrived, there are no sterile instruments available here. The women will have to be transported to Kasaba Hospital forty-two kilometers away for the surgery. Ms. K. wants me to go along to assist.

I quickly change out of my sweaty T-shirt. The two women lay down on two thin foam mattresses on the back of the flatbed truck. Two nurses jump onto the truck, wedged against the two women in labor and bundles of surgical instruments that need sterilization. Ms. K. and I jump in to the front cabin and the driver guns the engine. We are off.

The sun is already setting when we head out of the village. We bump along the dirt road, swerving to avoid giant potholes that are now ponds, occasionally accelerating down flat stretches and often slowing to a crawl to go over rocky patches. The poor women, one is primipara and fully dilated, the other gravida 12 with twins, have to endure every bump on the road. Soon, the last ray of light evaporates; the headlights of the truck become the lone tumbling beacon hurtling into the black void. We pass villagers riding their heavy Chinese bicycles in the dark. In the distance, the horizon is illuminated by flashes of lightning. I look up into the starry night, hoping that rain would not visit, at least not until we get there.

Over an hour later, we arrive at Kasaba Hospital. As usual, there is no power. We fumble in the darkness down the hospital corridor to the operating theater, passing wards faintly lit by the ghostly light of single candles. The long journey, the darkness, and the lack of mobile phone reception (the village is too small for the mobile phone company to build a tower) combine to make it feel like I have arrived at the most remote hospital on earth.

Kasaba Hospital is connected to the outside world only by a perennially problematic landline phone. We had no way of informing them of our arrival beforehand. Caught unprepared, the nurses and other staff scramble to get things ready: bringing out instruments, getting fuel to run the generator, setting up the labor ward for delivery, etc. We sit in candlelight, waiting. After another hour, the lights come on – it’s power from the grid. Ms. K. starts to give the primipara patient another try with normal delivery. We set up the ventouse, and try to get the exhausted patient to push with her contractions. The lights flicker a few times; we are all hoping that power doesn’t go out at this time. With great effort, the baby is finally pulled out – it’s a boy, blue and not moving. Ms. K. cuts the umbilical cord and immediately takes the baby to the room next door for resuscitation. Exhausted, the patient slumps back.

I go to check out the resuscitation effort in the next room, where the other patient with twins is about to deliver. This patient actually does not need a cesarean section. She actually wants to have her tubes tied (after twelve pregnancies, I don’t blame her). But because of the rules set by the Catholic Church, a tubal ligation can be performed at the hospital (both Lubwe Hospital and Kasaba Hospital are affiliated with the Church) only as part of a cesarean section procedure. It is not allowed to be done as a procedure by itself, because that would be providing contraception. Even though the intention is the same either way, somehow one is okay but the other is not. Now it looks like it’s too late; she is not going to get her tubal ligation – the first of the twins is on its way out.

The team tries to resuscitate the blue baby with suction and the ventilator, both are barely working. The baby is clearly not going to be revived. As the resuscitation continues, the first of the twins is born – it’s a girl. As the baby starts to cry, my heart sinks. The first patient in the next room must think it’s her baby being successfully resuscitated! I look at Ms. K., who, with a dreaded look in her eyes, shakes her head. She will have to break the bad news to the first patient in the next room. “I hate doing this,” she mutters, standing at the door just out of view of the patient. As she mulls over how to break the news, the second of the twins is born. Both are very much alive and well. So with the babies’ cries filling one room and the mother of the twins smiling in joy, Ms. K. crosses the threshold to the other room to tell the first patient that her son has died from having been stuck in the birth canal for too long. “God did not give [the gift of life] this time. Maybe next time…” the first patient says resignedly upon receiving the news. There is no sign of any emotional reaction, just the same exhausted look on her face; all her emotions are tightly wrapped in her stoicism.

The night is getting late. We leave the patients at Kasaba Hospital to recuperate and pack the sterilized instruments onto the back of the truck. It would be after midnight before we arrive back at Lubwe Hospital.

Reaching Out

I am going on a safari today. A 4WD is involved, but it has nothing to do with wild animals. I am following the health outreach team to a remote village to carry out the childhood immunization program and adult HIV education program.

Lubwe may be a rural village, but it feels like a metropolis compared to Chamalawa, the remote village we are heading to. After over an hour of bumping along a pothole-ridden dirt road and down an overgrown trail, we arrive at the village shaken, but not at all stirred. The day’s activities will be carried out under a tree and inside the “church” built of bricks with a grass roof. We drive to the village school so people know that we are here. They must not get too many foreigners coming through, because at the sight of my camera, the children instantly go wild. To avoid causing too much commotion, I start taking photos discreetly around the clinical officers who are weighing the children and giving them vaccines and vitamin supplements.

The Welcome Committee at Chamalawa Village

Babies are weighed on a scale hung from the tree

Women waiting in line with their babies

Clinical officers giving out vaccine shots and vitamin pills

At around noon, we start the HIV education program. A group of about twenty pregnant women gather in the rudimentary church. The two HIV educators from the hospital take turn explaining to the women what HIV is, how it is transmitted, how it can be prevented, and the importance of knowing one’s status, especially for pregnant women. At the end, the women are asked whether they would like to get tested and are given the option of refusing the test. Without much deliberation, they all agree.

So we start an assembly line: one nurse registers the women, I take their blood, and another nurse drops each woman’s blood onto the rapid test strip. Some clearly shows their anxiety, both at seeing the needle and at the thought of finding out soon whether they have been infected with the virus; others are very relaxed and barely show any concerns. While waiting for the results of the tests, we proceed to give the women tetanus shots and examine them. The examinations take place on a thin foam mattress placed on the ground behind the pulpit. Almost all of the women are clinically anemic. Afterwards, they receive iron supplement tablets, de-worming tablets, and malaria prophylaxis.

Soon, the HIV rapid test results are ready. I take a glance at the tray of test strips. Fortunately, none of the eighteen women tested today is positive. The women are asked to wait outside. The two nurses each takes a corner of the room, the women are called in one by one to have their results disclosed and discussed with them.

With that, the day’s session comes to an end. We eat a meal of nshima and beans prepared by the women in the village. And then we start the long and bumpy journey back to Lubwe.

The Keyword Is Improvisation

It is late in the afternoon and rain is coming down hard, I have just seen another patient with TB. After having the nurse escort him to the isolation unit, I go to look for Dr. P. to discuss the treatment plan for the patient.

I find him in the female ward, writing up a new admission. The patient is a woman with a ruptured ectopic pregnancy and needs emergency surgery. The TB patient will have to wait; I will be assisting the surgery. We get the theater staff ready and prepare for the surgery. First, we inform the staff to stand by and run the generator in case of an electricity outage. The theater nurse, who doubles as the anesthetist, informs us that, because the autoclave is not working, we will be using the last sterile tray of instruments. We push the patient down the outside rain-slick corridor to the operating theater. The nurses get the patient ready on the operating table while Dr. P. and I change into scrubs. There is no disposable theater caps, so shoe covers will be used as our caps. While we try to follow aseptic technique as much as possible, the theater set up sometimes makes it difficult. For example, the scrubbing area is INSIDE the theater. Because of the frequent power outage, the taps are dry today. We scrub, not with fancy chlorhexidine or iodine solution, but with plain old soap, and rinse with water that had been stored in a jug. The autoclave malfunction means there are no sterile cloth theater gowns, so we put on the last two backup disposable ones.

I prep the patient’s abdomen with sterile wash. The patient is lying on the very un-sterile canvas stretcher on which she was carried to the theater. The scrub nurse and I then drape her with a single layer of thin sterile drapes. The other nurse follows Dr. P.’s orders and injects ketamine and diazepam into the patient’s IV port. When the patient stops moving too much on pain test, Dr. P. makes the first incision. We are soon digging deep into the abdomen. Suction? Forget about a suction tip, it’s just the end of the suction tube. Overhead lighting? Only the one in the center is working; it might actually be better if someone stands there holding a flashlight. Electrocautery? Don’t even think about it; might as well wish for a theater with laminar flow ventilation. Dr. P. concentrates intensely on the surgery; the whole room is silent except for the clanging of the instruments and the whirring sound of the fan in the corner.

An hour into the surgery, the whole place goes dark – power is out. Dr. P. stands there elbow deep in the patient’s abdomen, I am holding the now suctionless suction tube. We stand there, waiting for the generator to kick in. After what seems like an eternity, the lights finally come back on. Dr. P. continues the surgery like nothing has happened, but we are all hoping the generator doesn’t run out of fuel anytime soon. Eventually, the surgery comes to a successful end. I do my part and close the skin. The two nurses mop up the blood from the floor and pack up the instruments to send to another hospital sixty kilometers away for sterilization. We all breathe a collective sigh of relieve, thankful that things had gone relatively smoothly.

With all the breach of aseptic practice from the beginning to end, you’d think the patient has no chance of avoiding some serious post-operative infections. But Dr. P. tells me that post-op infections actually do not happen that often here, despite the suboptimal conditions. So, from the post-op infection rates we are seeing in the West, are we getting diminishing returns from all the strict operating theater rules we practice?

Containing the Fire

The hospital holds HIV clinics three times a week. This afternoon I sit in on one of them.

One of the patients came in through the hospital’s outreach program. The program goes to villages in outlying areas and brings high-risk patients back to the hospital for HIV testing and, if found positive, offer them free counseling and antiretroviral therapy (ART). This patient, a woman in her late twenties, is thirty-two weeks pregnant and has just been tested positive for HIV. Although looking quite well, she, with a CD4 count of only 22, is likely to have been HIV positive for many years (by definition, a person has AIDS when her CD4 count is below 200). Not understanding the gravity of the situation, regarding both herself and her unborn child, she just wants to go home. It takes much convincing for her to agree to stay in hospital for two weeks while getting started on ART. The next hurdle comes when she is asked about whether she plans to breastfeed her baby. Although breastfeeding increases the chance for her baby to be infected with HIV, she has no other choice. Buying baby formulas is out of the question; they are prohibitively expensive for the average Zambian. The doctor sighs resignedly and hands the woman the admissions form.

Venting her frustrations, the doctor conducting the clinic tells me that although designated as the district hospital, Lubwe Hospital is affiliated with the Catholic Church and contraceptives are not allowed to be distributed through programs run by it. They can only tell people about the use of contraceptives like condoms for the prevention of sexually transmitted diseases and the pill or depot injections for contraception; the people would have to go to government-run clinics to access them. As is the rule with people living in extreme poverty in rural areas, going to see a doctor or to the hospital is something they do only after a long period of illness that does not resolve; preventive health is negligibly low on their priority list. Hence HIV, among other sexually transmitted diseases, spreads like southern California wildfires fanned by the Santa Ana wind. The high rate of vertical transmission, from mother to child, ensures that the burden of disease weighs heavily on the family and, by extension, the nation, forever enslaving them to poverty and condemning them to the misery of a Hobbesian life – poor, brutish, and short.

But all hope is not lost. Despite the enormous stigma still attached to HIV/AIDS, campaigns run by the government have made some inroads in educating the people about the disease and getting people to get tested. Although most of the testing are still done at the urging of health care professionals, a few have already come in on their own to get tested. With the hospital’s efforts to ensure patients’ confidentiality and the government’s policy of providing free ART, as well as the education programs that help to allay the fears and misconceptions about the disease, there is a glimmer of hope for Zambians. Is this a light drizzle on the raging wildfire that will eventually become a downpour or is it merely a bucket of water thrown in the general direction of the conflagration? I hope it is the former.

Man About Town

It is impossible for me to walk around the village without attracting a lot of attention. Being the only foreign visitor at the moment, I always get curious stares from villagers. Today I made friends with Howard, the son of Alice, the cook at the guesthouse. In the afternoon, Howard shows me around the village. Soon, I have gathered an entourage of kids, who follow us around and ask me to take their pictures. So, this is the village of Lubwe:

Howard (L) and his friends

A villager in his dugout canoe

Alice cooks delicious meals

"Whacha lookin' at?"

Cool hairdo!

Boats drying by Lake Chifunabuli

A bird resting on what used to be a canoe

Girl with bright smile

Corral by the lake

Village market

Villagers selling vegetables and dried fish

One of the shops at the market

These guys are just waiting for your bike to break down

Got enough firewood for tonight

Tough kids at the Boys School

Don't be deceived by her looks, this one is quite a tom boy

Howard pretends to be driving a tractor

Local Foods

I have been eating local food since I arrived in Lubwe. The local staple is called nshima. It is made from ground maize boiled into a porridge, which then sets into the consistency of cake. This bland staple is normally eaten with side dishes the locals call “relish,” which can be vegetables and meat or fish. Locally, vegetable side dishes are normally made from cassava leaves, pumpkin leaves, sweet potato leaves, or a leafy vegetable related to canola called rape. Because Lubwe is next to a large lake, fish is a major part of the local diet.

Today, my lunch features nshima, bream from the lake, and cassava leaves. Yummy!

Tied Up in Red Tape

Today I am tagging along with Sister Rose on a trip to Mansa, the capital of Luapula province, one hundred kilometers or two hours away from Lubwe.

Inside the convent

Sister Rose, the hospital administrator

Kalumba the driver detailing the Landcruiser

These guys love 50 Cent

When I came into the country at Lusaka Airport, I had to fork over US$100 for a visa, the most expensive visa I have ever gotten. To add insult to injury, they only gave me thirty days and told me that I would have to apply for a temporary permit during that time so I can stay the full two months. So Mansa is the closest place for me to take care of that. I go into the immigration service office in the middle of town and explain to them my situation. After a while, I am called into an office. The official tells me to write an application, attach a couple of passport photos, and pay one million kwachas. “One million kwachas?!” I exclaim, “That’s almost three hundred US dollars!” Together with the visa at the airport, I will have paid almost four hundred dollars to stay in the country for two months. Facing the prospect of having to bleed for that privilege, I calmly explain to him that I am a medical student working at a hospital for two months; I will only need one month of extension on the visa. “Can I apply for a study permit instead?” I ask hopefully. “That one is cheap; it’s only 250,000 kwachas (US$65),” says the officer. Seeing a potential drop in price, I ask, “Can I apply for that one then?” “You’ll have to go to Lusaka for that; we don’t do it here.” My heart sinks. It means extra expenses and at least two weekdays to travel to and from Lusaka. I consider bribing the officer, but decide against it when he gives no hint of being open to such backroom deals; plus the poster on the wall sternly warning against corrupting officials means I may get in more trouble than I bargain for. I again explain to him my situation, emphasizing the part that I am a student and that I only need a month of extension in my passport. After a pause, the other official in the room takes my passport and says he will be back. I sit down in the couch and make awkward small talk with the officer in the room. After five minutes, the official comes back and tells me, “I understand your situation. You can come back the day before the visa expires and we’ll give you another thirty days. You won’t have to pay anything.” Pleasantly surprised and almost not believing what I have heard, I thank him profusely. Wow, from having to pay almost $300 to getting a visa extension for free, all without a cent of bribery – that is the most flexible rules I have seen and the most clean officials I have met.

Christian is one of the accountants at the hospital

The hospital on the left, the guesthouse on the right

With that taken care of, the next order of business is to change money. In the past, I had always traveled with cash in US dollars and my ATM card. For some reason, I decided to take traveler’s checks to Zambia. I dart in and out among the three banks in town to check on their exchange rates. The Zambian kwacha has appreciated against the US dollar quite a bit in the last few years (that shows how weak the US dollar has become – it’s falling against even the currency of one of the poorest countries in the world). I am then reminded that dealing with banks in third-world countries is only slightly less frustrating than trying to cut through the red tape of government agencies. After two hours of running in and out of the banks, I find out that, in this town, my traveler’s checks are worth about as much as the paper they were printed on. Defeated, I scrape together US$200 cash to change at the Zambian National Commercial Bank. After disappearing for a half hour, the teller comes back with forms in quadruplicate with a half dozen rubber stamps. After paying a hefty commission, I finally get my small stack of kwachas. Note to self, never ever take traveler’s checks to travel, ever again!

A villager riding one of the ubiquitous Chinese bikes

After jumping through the two bureaucratic hoops, it is now time to do some grocery shopping. We go to ShopRite, a South African grocery chain, in front of which some beggars and street hawkers hang out. This is the closest place to Lubwe with a supermarket where meat is available. It is a smaller version of a standard supermarket with a much smaller selection. Who needs a hundred different teas, fifty varieties of yoghurt, and a dozen cuts of the same meat anyway? I pile the grocery cart high with staples like rice, potatoes, and maize meal, and enough meat for a couple of weeks. After this, it may be a while before I have a chance to go grocery shopping. My meals will be supplemented with vegetables grown around in the guesthouse and what I can buy at the Lubwe village market.

Sister Rose in the rear view mirror

On the way back to Lubwe, I continue my shopping by picking up tomatoes and sweet potatoes sold by farmers on the side of the road. By the time we roll into Lubwe, the sun has set and the whole village is enveloped in darkness – yes, power is out again.

Eating Native

I went to the village market to buy some vegetables today. One of the things I bought was a bag of, I was told, mushrooms. In the dim light of the market, I thought what was in the bag looked too small and not at all like mushrooms, but I bought it anyway. They must have played a joke on me, because later I found out it was actually a bag of caterpillars, which is a common source of protein for the locals. So for tonight’s dinner, I am eating caterpillars as the “meat” dish. They are kind of crunchy, and not at all squishy as I expected. And they actually don’t taste half bad, although I am constantly reminded that I am eating caterpillars as the little spikes on them keep tickling my mouth as I chew.

What's the vegetable doing next to my caterpillars?

Start of Elective

After ten hours of good sleep under an insecticide-treated mosquito net, I wake up in the morning feeling refreshed. At eight o’clock, I meet Sister Rose for a detailed orientation of the hospital. Lubwe Mission Hospital, in the village of Lubwe (pronounced “LOO-way”) at the shores of Lake Chifunabuli, is the primary referral hospital for the Samfya health district. The top illnesses being treated at the hospital reflect the poverty of sub-Saharan Africa: malaria, anemia, protein and caloric malnutrition, TB, and HIV/AIDS. The Zambian government, in an effort to raise the general health of its population and to combat the widespread problem of HIV/AIDS, is providing free health care to its citizens. So someone newly diagnosed with HIV can get prompt and free counseling and anti-retroviral treatment. This is sorely needed in a country where the life expectancy at birth is a mere 32 years (yes, that’s thirty-two).

The hospital is home to a large collection of the most basic equipment like the antiquated x-ray machine with a dark-room for developing films manually, an ultrasound machine from the 80s donated by some hospital in Japan, and a first aid room that looks more like a torture chamber than a place of healing. Among this medical equipment graveyard, there is an occasional brand-new machine like the newly arrived automated film development machine and the CD4 counter in the lab. I soon realize the limiting factor to the functioning of the hospital is electricity: when power is cut, which is very often, the x-ray machine doesn’t run and the lab cannot analyze bloods. There is a generator, but it is expensive to run and is only used during emergencies like when someone needs an emergency cesarean section.

Main gate of Lubwe Mission Hospital

You can always pray to Mary on your way to the ward

View of the courtyard from outside the male ward

The scary-looking first aid room

After orientation, I meet up with Dr. P., who only recently arrived at the hospital from the Democratic Republic of Congo. He takes me to the male ward and starts rounds. With twenty beds set two feet apart from one another, the ward does not offer any privacy for consultation. Every question we ask the patient is heard by everyone else. During examination, the patient is partially shielded from the other patients by a movable screen pushed around by the nurse. In the first two hours, I am already seeing my first cases of malaria, TB, and HIV. All the patients are from rural areas, most are uneducated and don’t speak any English, and by the looks of it, possess little more than the shirts on their backs. As the belief in witchcraft is still deeply held among the people, most patients have already seen witch doctors over the years before coming to hospital, as evidenced by the healed scars from cutting on various parts of the body that ailed them.

The nurse's station in male ward

Male ward

Treatment cupboard

George is one of the nurses

Signs in the hallway

A simply but ingenious design for a trolley: 1 piece of canvas, 2 poles, and 2 metal bars on top of a cart

Patients waiting to be seen at the doctor's clinic

The HIV counseling center and clinic

Blood bank

The lab

Signs for outpatient clinic and to encourage people to get tested for HIV

Entrance to outpatient clinic

After work, I decide to take advantage of the remaining daylight and walk to the lake. The guesthouse is next to a primary school. Soon I am surrounded by a group of kids wanting me to take their pictures. Smile!

Kids playing on the swings at the guesthouse

Kids outside the Catholic church