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.

Pediatric Maternity

After morning reports, I follow one of the doctors to do rounds in the female ward and maternity ward. As we step into maternity ward, it suddenly strikes me that the women are so young! If it weren’t for their bulging bellies heavy with near-term pregnancy, the room could pass for a pediatric ward. Many of them are still teenagers, but are already on their second, third, or higher pregnancies. Poverty breeds, oh how true that is. Just walk around the village; it is a rare sight to see a woman of childbearing age without a little baby on her back.

ART Clinic

I am running the ART clinic this week. No, I am not teaching remedial painting. ART stands for antiretroviral therapy. For three afternoons per week, patients with HIV come to the clinic for review and to get more medications or, for those who are newly diagnosed, to start ART. Being in a country with one of the highest HIV infection rates in the world, the clinic is always booked solid.

And so I sit behind the desk in the clinic with a nurse next to me to translate and to help me fill out the forms. One after another, the patients come in. I ask about their general health, check on their adherence on taking medication, any side effects experienced, check the last CD4 count, and examine any new complaints. The vast majority of them are in excellent health, with no signs of immunodeficiency or any opportunistic infections. It is heartening to see how well the drugs work at keeping their CD4 counts stable or preventing them from dropping further.

Unlike the rest of the world, HIV transmission in Africa is mainly through heterosexual sex and from mother to child. So the types of people who come to the clinic run the gamut: men, women, the young, the old, babies. One patient could be a school teacher, the next one could be a farmer from a far-away village, followed by a six-month-old baby whose mother was never tested but are now both in hospital for opportunistic infections. There are those who are open about their HIV status, while others have not completely accepted it and have not even told their spouses. The most frustrating ones are the women who are on ART, but their husbands flatly refuse to come in for testing or to use condoms. The power of denial, that most potent ingredient in the making of the next generation of multi-drug resistant strain of the virus, can never be underestimated.

The Zambian government has made a huge effort to rein in the spread of HIV. At the ART clinic, patients get their otherwise prohibitively expensive antiretroviral medications for free, which are from a combination of government funding, donations from NGOs and pharmaceutical companies. These medications, like almost every other drug used at the hospital, are manufactured in India. I remember hearing a couple of years back that NGOs like Doctors Without Borders were publicly calling pharmaceutical companies to make antiretroviral drugs available and affordable to sub-Saharan Africa. Maybe this is a result of that, or maybe India has always been the source of medication to third-world countries.

I have seen billboards that encourage people to go for HIV testing with the goal of having an “HIV-free generation” in Africa. The ART clinic gives me hope that, with the continuing sensible government health policy, availability of affordable medications, and campaigns to education people and dispel any myths related to HIV and AIDS, Zambia is taking small steps to reach that goal, which may be a lofty one, but not a pie in the sky.

Bouncer Job

At the hospital, the outpatient department (OPD) is the first place patients go when they get sick during working hours. It is run by clinical officers who see all the patients that come in, prescribe medications, order relevant tests, and admit the serious cases. So they are more or less the bouncers for the hospital.

Clinical officers (CO’s) are people who have had basic training which is equivalent to an undergraduate degree in health science. What they lack in formal training, they make up through experience: a lot of the things they know, they learn on the job. The CO’s at Lubwe Hospital are very good at efficiently screening a horde of patients, picking out the ones with serious problems, and admitting them to the ward.

Because both CO’s at the hospital are away to attend workshops, I have been playing the role of CO for the last three days. In the morning, I arrive at the OPD to the familiar sight of a courtyard packed with crying children carried on the backs of their mothers, with a few elderly people here and there in the crowd. It is a rare sight to see men with their sick babies in the hospital. This is, after all, an area still steeped in the traditions of a male-dominated society. Child-rearing still falls squarely on women’s shoulders.

OPD waiting area on a slow day

I take the stack of patients’ files from the patient registration window and head into one of the clinic rooms with a nurse. With the nurse interpreting, I take quick histories from each patient, do abbreviated examinations, and decide whether to send the patient to the lab for a couple of tests, or send them on their way with a few days’ worth of medication, or as a last resort, admit them. Most of them have nothing more than a little respiratory tract infection, many of them come in with a self-diagnosed case of malaria, and diarrhea among children is so common, their mothers don’t even remember to mention it unless questioned specifically about it. It is so easy to just get into autopilot and write everyone a script for either an antibiotic or antimalarial or both. After a dozen scripts of the same things, I eye the pile of files, in which I seem to have hardly made a dent. I am constantly being reminded of how many people are waiting outside by the sound of moaning and crying babies. I try to go as fast as I can, but talking through an interpreter can be frustrating. Quite often, I ask what I think is a straightforward question, only to see a five-minute discussion between the nurse and the patient, with a one-word answer coming back to me at the end. Thus, history-taking can be a trying experience.

By lunch time, my ears are ringing from having tried to listen to the chest of countless sick babies who scream at the top of their lungs at the sight of someone in a white coat approach them with a stethoscope. Pediatrics is now inching lower and lower on my list of potential careers; I find it hard to think when babies are screaming next to me. I know, I have not done my pediatrics rotation yet, but in these couple of days, I feel like I might as well be a vet – the one who is sick is not able to say what’s wrong, all histories are collateral at best.

By now, I really come to appreciate the hospital’s two-hour lunch break. It gives me time to vegetate after lunch and clear my head so I can face the onslaught of patients in the afternoon, when my own energy gets into a lull.