Farewell, My Fair Lubwe

At 6:00 a.m., the alarm clock wakes me up. The sound of rain hitting the roof and the gray skies make me want to stay in bed longer. But I have to get up; I have a bus to catch. With my backpack in tow, I walk to the convent where the hospital vehicle waits. I will be taken to Musaila and wait for the Mansa-Lusaka bus.

And so my stay in Lubwe comes to an end. I have come to feel very much at home at the guesthouse, the hospital, and the village. It has been a great experience, both as part of my medical education and as personal adventure.

At the hospital, I got to see and do so much, I felt like I was very much part of the team. I had a real taste of what it is like to work as a doctor – I ran OPD clinics, ART clinics, and doctor’s clinics; I admitted and discharged patients and did ward rounds; I reduced fractures, debrided wounds, and assisted in surgery. I have seen first hand how much the doctors and nurses can do with so few resources. The nurses and other hospital staff called me “doctor” with so much sincerity and respect it almost made me blush. It is something I am still not used to; normally when nurses in Australian hospitals call me “doctor,” it is drenched in a heavy dose of sarcasm.

I have gotten used to the daily power cuts; candlelight dinner was a guarantee every evening. I have gotten used to taking cold showers in the morning when there was running water and scoop water from a tub to wash when the tap dried up. I have gotten used to the slow pace of life in the village. I spent many evenings hanging out with the nurses at the bar, sitting in the dark, chatting and sipping on a couple of Mosi or Castle. During quieter evenings, my laptop became my movie theater, my stereo, my library, and my entertainment system.

Having made friends with some of the hospital staff, I hardly ever got bored. If I was tired of reading or listening to music, I could just take a walk to the market. Children would always wave to me, yell hello to me, and follow me along. Whenever I went for a run, a group of them would always end up running next to me. “Musungu!” became the constant chorus the children sang as I walked past them.

I have been spoiled by Alice, the cook at the guesthouse. Three times a day, I would always walk into the dining room with my meals on the table waiting for me. She has given me a great introduction to the local cuisine – nshima made from maize meal and cassava meal, accompanied by cassava leaves, pumpkin leaves, sweet potato leaves, rape, impwa, cabbage, sausages, chicken, fish, and even caterpillars. While the cooking here lacks the sophistication of other world cuisines, it is “back to basics” in its purest sense. And Alice has made my stay that much more enjoyable.

These two months were a sink-or-swim experience. I had no idea what to expect when I stepped off the plane in Lusaka. I threw myself into the deep end head first and, not only did I manage to keep my head above water, I was able to swim to the other end without running too out of breath. I came to Zambia to experience the unknown and the unfamiliar; I looked for adventure and a life outside of my comfort zone – and I found that I was very comfortable in it.

One Last Time

Today I am doing everything for one last time: going to morning report, doing ward rounds, seeing new patients, going to ART clinic in the afternoon, all for the last time at Lubwe Mission Hospital. The day doesn’t feel different from any other day. I spend the morning going between the male, female, and pediatric wards with one of the medical officers and reviewing one patient after another.

Late in the afternoon, after ART clinic has finished, I learn that the hospital administrator has planned a send-off party for me, at my place at the guesthouse tonight. After a quick packing job back at the guesthouse, I go out with my running buddy Anton for one last run – on our familiar route from Lubwe to Mashitolo and back.

Dan and Andrew are both nurses and star players on the Lubwe Medics soccer team.

Sidney and Christian are the numbers guys at the hospital

Cholwe: scrub nurse, clinic assistant, first aid nurse, and a damn good soccer player

Zulu is one of the clinical officers, and he likes his drinks

Teddy: nurse and cradle robber

After a shower, I eat my candlelight dinner for the last time. By 8:30 p.m., power finally comes back on and some of the hospital staff start to show up. We chat, we look at my photos, we take photos of and with each other. We eat, we drink, we dance in the courtyard under the starry night. I pop the champagne, make a wish, and open the send-off presents. The music from the stereo thumps into the wee hours – actually around midnight, but that’s the wee hours around here.

I am holding Dan's 6-month-old baby, Andy, and he doesn't seem to mind

Susan, the pediatric ward nurse, looks ravishing in her black dress and her bling

Saying goodbye with Dan and George

One last shot with Mokuka and Bennett the pharmacists before the evening is over

It’s time to get a few hours of shut-eye; I tuck the mosquito net under the mattress for one last time. Tomorrow will be a long day of bus ride to Lusaka.

Shock and Awe

Warning: the photos in this post may not be suitable for viewing at dinner time.

Over the last seven weeks, I have seen quite a few things at the hospital that I am sure I probably won’t see in Australia:

Malaria, while always on the back of a clinician’s mind in Zambia, is hardly ever one of the differential diagnoses in Australia unless the patient has traveled to endemic regions like Africa or Southeast Asia. In the last seven weeks, I probably have seen and treated more patients with malaria than I will for the rest of my career in Australia.

Malnutrition, with severe cases in the forms of kwashiorkor and marasmus and milder cases presenting as anemia, is so prevalent, the hospital has a special kitchen to cook food for feeding those admitted for it. Anemia is so common, the hospital guideline is to transfuse those whose hemoglobin has dropped to 5 g/dL or lower (that’s VERY anemic); otherwise the bloodbank would run out of blood in no time.

TB is also quite a common illness in this part of Zambia. The hospital has a special isolation ward for it. While the TB ward has only had a few patients in the last couple of months, many patients who come to the hospital with respiratory complaints are tested for it.

HIV is a big killer. We send patients, both inpatients and outpatients, for HIV testing as often as GPs in Australia send overweight patients to test for blood sugar level. Not only are pregnant women who come for antenatal check ups tested, the hospital sends outreach teams to test pregnant women in outlying villages. I have seen patients come in for the first time with full-blown AIDS barely clinging on to life; on the other hand, at the ART clinic, I have seen many asymptomatic patients come in to get their medication to keep their infection in check and their CD4 count up.

These two patients presented for the first time with fungal infection of their skin. Both were then diagnosed HIV positive while in hospital. Their fungal infections were successfully treated and they were started on ART.

But none of these is as dramatic as some of the wounds that come through the hospital. As usual, all of these patients presented only when their pain became excruciating or when parts of their limb fell off.

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This patient fell off a bicycle and got a puncture wound on his ankle. He thought nothing of it at the time. But three weeks later, as his leg got more and more swollen, became more and more painful, he finally decided to come in. When I examined him, his leg was swollen to twice the size of his other leg. Barely a slight touch would send him through the roof. The infection had spread to mid thigh but, lucky for him, spared the bones. We pumped him full of antibiotics for a couple of weeks, debrided the wound, and he eventually left the hospital smiling.

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These are two patients with very similar injuries. One said her finger just started to swell up on its own. The other patient suffered a snake bite to his finger. In both cases, the wound got infected and eventually the bones were exposed while the rest of the finger became swollen and painful. Both of them got their affected finger amputated all the way down to the metacarpophalangeal joint.

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This patient was bitten by a snake on his foot. Fortunately, the snakes around here are rarely poisonous. Unfortunately, he, like so many others in this area, has a very poor concept of hygiene. The bite became infected; the skin started to erode away. He just kept it wrapped in a dirty rag until the foot became too painful to walk on. When he came in to hospital, flies were circling around the wound. We debrided the wound, kept it in wet dressing, and gave him antibiotics. Eventually the infection settled, granulation tissues formed, and he went home happy. Too bad I didn’t get a picture of his foot the day he went home; it was healing beautifully.

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This farmer dropped a hoe on his foot and made a very small break in the skin. But similarly, he didn’t keep the wound clean. He hobbled in to hospital with the foot swollen with a huge blister. When the blister broke, the skin generally sloughed off, leaving the strip of necrotic skin in the middle. I ordered an x-ray and made sure the infection had not spread to the bones. I then debrided the wound, scrubbed it clean and washed it with copious amount of saline.

And this is what it looked like two days later. Isn’t it beautiful?

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This series of photos is the most impressive wound of them all. This patient’s wound started as a scratch from a tree branch at the front of his leg. Again, lack of hygiene = massively infected wound. Treatment was the same: wound debridement and wet dressing.

Despite the antibiotics we gave him, his infection started to advance up towards his knee and the back of his leg. A week later, the skin on the newly-infected part started to melt off. Notice the anterior and lower half of his leg was already starting to heal. The patient was again in agony; it took pethidine and diazepam to calm him down. We changed around his antibiotic regime a bit and went for a second debridement.

Two days after the second debridement and his leg was looking good! The infection has stopped advancing. The leg may look like raw hamburger, but it’s a good thing – it’s getting good blood supplies, which promotes healing. It may not look it, but the patient was now in minimal pain and only required Panadol (same as Tylenol).

Today, his leg is looking amazing. The granulation tissue at the anterior part of his leg is already epithelializing. The rest is on its way. The infection is gone; the patient is happy, He should be able to go home in a week.

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This woman in her sixties came in like this. Upon getting her history, I learned that her problem started as a cut on her toe. It quickly became gangrenous and fell off. She didn’t want to go to the hospital at that point. The gangrene spread to the other toes and they fell off too. Still, no hospital. After the entire foot dropped off, that was when she decided to take a trip to the hospital – carried by a relative on the back of a bike! The nitrogenous smell emitted from the leg was unmistakably that of gas gangrene – it definitely made a permanent imprint on my olfactory memory. Treatment was amputation of that leg before the gangrene spread up. Unfortunately, she also had heart failure, which meant she wouldn’t be able to tolerate general anesthesia. To stabilize her heart failure would take time – time she could ill afford. As we lack the expertise in handling this type of situation, we referred her to the provincial hospital.

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Doesn’t this picture just make you go “Awwwww”? This girl fell from a tree and broke one of her legs. Standard treatment here is not to refer her to an orthopedic surgeon, because they don’t exist in this part of the country. The old-school method is traction – long abandoned by hospitals in developed countries. Here, it’s still the standard treatment. So she was strung up to a pair of railings over the bed for three weeks. The other leg was on traction simply for balance. She didn’t mind at all; when I saw her, she was just happily playing in that position. This picture was taken just before the strings were cut and she was sent home.

Now, that’s something you don’t see everyday!

Instant Diabetes

I can’t believe how much sugar the people here eat!

I remember during my first week here, I made someone a cup of tea. Having seen that people like their tea sweet, I put in two teaspoonful of sugar. He took a sip, looked at me, and said, “Oh, there’s no sugar in it.” And he proceeded to add another three spoons of sugar. At the time, I thought maybe it was just him that preferred his tea sickly sweet. But as time went on, I realized that everyone wanted to get that sugar high. A few weeks back, there was a multi-day workshop at the hospital with people from other clinics attending. Some of them stayed at the guesthouse. At breakfast, each table had a heaping bowl of sugar and it was always empty when everyone finished.

Now when I make someone a cup of tea, I serve it with a bowl of sugar on the side and just watch as they put spoonful after spoonful of sugar into it, until it goes well past the saturation point. There is always a sludge of semi-dissolved sugar at the bottom of the cup, which is slurped up at the end. And that’s how they enjoy their tea-flavored sugar water; it’s instant diabetes – just add water.

Ironically, poverty is probably the reason that people here haven’t all developed type II diabetes despite the incredible intake of refined sugar. Obesity is virtually unknown here. Almost everyone engages in physical activities on a daily basis, from tending the fields to fishing to walking or cycling long distances to go places. If Zambia ever reaches the level of affluence of the West, this collective sweet tooth would surely send the whole country into a sustained hyperglycemic state.

Big-Bellied Baby

One of the most confronting things to see at the hospital is children with malnutrition. There are always small babies and young children at the PCM (protein and caloric malnutrition) ward; some are too weak even to cry.

Just the other day, a mother brought in her one-year-old baby with paraphimosis, a minor condition that is easily treated. Upon undressing the baby, it was apparent the baby was severely malnourished. With wispy hair, swollen arms and legs, and a huge abdomen, the baby had all the classic signs of kwashiorkor. Upon further questioning, the heavily pregnant mother revealed that there are two other children at home. When asked if they are okay, the mother said, “Yes, they are healthy.” But to her, healthy probably just meant not acutely ill. If her one-year-old baby didn’t develop paraphimosis, she wouldn’t think to bring the child in to hospital. A brief examination of the mother revealed a picture of clinical anemia. So, after treating the paraphimosis, we admitted the baby to the PCM ward, where he was put on a feeding program to nurse him back to health. The pregnant mother was given iron, folate, and multivitamin supplements.

It is often frustrating to see how the combination of cultural, geographical, and economic factors conspire together to keep the cycle of poverty and malnutrition going. There is no real economy to speak of in this area besides fishing; villagers otherwise occupy themselves with subsistence farming. Education is often not placed high on a family’s priorities. Children are raised, and sometimes educated, until they reach puberty, then they are considered of marrying age. Many people become parents in their teens. The low social status of women means that decisions of reproduction are often made by men, who sometimes would compete with other men to see who can have the most number of children as a way to prove their virility. So the usage of contraception is out of the question. Even if a couple wants to use contraception, the remoteness of this area makes it difficult for family planning clinics to reach. The high number of children in each family and the perceived low value of an education often mean children don’t go to school, even when primary education is free. The number of mouths to feed, the lack of income, and the monotony of a subsistence diet directly contribute to the malnutrition of both babies and adults. The lack of an education confines the people to doing unskilled work, keeping them in the lowest rung of the socioeconomic ladder. Each factor is both a cause for and a result of the other factors; all of them are tightly intertwined to form a straightjacket that binds the people in dire poverty.

BTL Not Offered Here

I just finished seeing the last patient on the male ward. Just when I am getting ready to go home, the midwife comes up and asks me to check on a new admission on the labor ward.

The heavily pregnant woman was at the market earlier in the day when her water broke. She felt the baby’s arm coming out, and was brought in to the hospital. The nurse pulls back the sheets and reveals the baby’s forearm reaching out from the birth canal, an occasional twitch of the hand signals that the baby is still alive but may be in distress. The fetal heart sound is barely audible through the fetoscope. Fortunately the Doppler ultrasound picks up a definite fetal heart beat. By now, the medical officer is called in and everyone prepares the theater for an emergency Cesarean section.

It is the woman’s eleventh pregnancy but her first Cesarean. Upon learning that she is about to undergo a Cesarean, the woman asks if she can have a bilateral tubal ligation (BTL); in other words, she wants her tubes tied. One constraint of working at a Catholic mission hospital is that, contraception of any form is not allowed, even if it means a future pregnancy may jeopardize the woman’s health or may even cost her life. So, sticking to the rules, the medical officer denies the request. The surgery goes without a hitch and a healthy baby boy is born. The mother, who is only forty-two, will go home in a few days and will probably come back pregnant a twelfth time in a few months.

And so the life of this couple is greatly affected by a policy made by men in funny dresses ten thousand miles and a universe away, men who never had to raise a child. While mission hospitals like this one have save countless lives, the Church’s idiosyncratic rules have also helped to keep those lives impoverished. Hospitals should operate based on the rational and reality on the ground and not be bound by rigid rules that ignore the suffering of the people they serve. I have heard about previous doctors who would do BTLs “off the books” or as part of a Cesarean section, while leaving out that little detail off the op notes. If that was true, it was probably because the rational side of them as doctors had led them to break the rules. And, as they say, rules are made to be broken. The Catholic Church, of all people, should be familiar with that one, I would tend to think.

Beach Tar on My Feet

Today is a day for some fun under the sun – I am going to the Samfya Beach with James and Dan, two nurses at the hospital.

After the rain stops in the morning, we get into the cab we booked last night and head for Samfya. The town is only thirty-five kilometers away, but it takes the cab more than an hour to get there, thanks to the torn-up dirt road. Samfya, situated at the shores of the immense Lake Bangweulu, is the nearest town to Lubwe. The town itself does not have much to offer, but it boasts a small beach by the lake at the edge of town. Being in a landlocked country, this is as close to going to the beach as people get.

We get dropped off at the beach. I stand under the shade of a tree and whip out the tube of sunscreen and start applying. James and Dan look at me and ask, “What’s that?” “Sunscreen, so I don’t get sunburned.” “You need that?” they are puzzled. Of course, with skin black to a sheen, they don’t really get the concept of sunburn. Having worked indoors almost everyday for the last six weeks, I have already lost my tan. Now standing next to these two guys, I really am a blinding sight.

James rubs sand on his body so he can look like "the white fathers" while I look downright pasty next to these guys

We jump into the warm water for a swim, but not farther out than going waist-deep. The lake is crocodile-infested, but one hasn’t been sighted at the beach for a while now. Some beach goers just sit under the trees while braves souls, including us, venture out for a quick dip in the shallow parts. In the distance, rain clouds are dumping rain at the far end of the lake but appear to stay put, leaving us warm and dry under the sun. Fishermen in their canoes and boats row by. A group of people in a speed boat skim across the open water. A few groups, families, start to come and claim their patch of sand for a few hours. The atmosphere is relaxed; no one is in a hurry. We splash around a little more and decide to walk into town for lunch.

The rain in the distance decides to stay put and let us have the sunshine

Fishermen in their dugout canoes

James and Dan flirt with the waitress at the restaurant by borrowing her powder

Just enjoying a drink after lunch

Second-hand shoes on sale

The tailor waits for business

Barber shop, closed for Sunday

Get your 25-kg bag of mealie meal here

After an afternoon of swimming, sitting at the beach, and horsing around, we pack it in and catch the same cab back to Lubwe. Upon reaching the meeting place, we learn that, while the cab is there, the driver is away and cannot be reached on his phone. It is now dark and too late to get another cab to Lubwe; no one is willing to go to Lubwe knowing that he will not be able to get another fare back to Samfya. We have no choice but to sit in the cab and wait, and wait, and wait…

About three hours later, the cab driver finally appears. Hungry and tired, we start to shake our way back to the village.