A Simple Request

Written by: Keith and Ginny Birrell

Highlight of the week: Finally a paediatric ward round at the district hospital. Challenging but worthwhile

Lowlight of the week: Super busy clinic side. Trying to manage sickle cell disease with no resources is not fun.

Maximum temperature: 34 degrees Celsius (lower than North Yorkshire)

Rainfall: A big fat zero

I blog to process. Process is my outcome. Time helps the process. Time can be short or long. When short, the process almost a reflex. When long, the emotions run deep. Please grab your tissues. This all happened a while ago.

Sundays are respected as a day of rest. Not a day for routine care. A day to take stock. We become tourists early doors. Then I play domestic Goddess. Make bread, yoghurt, chutney. But the Sabbath is less than sacred. Stuff still happens. On any day of the week. A threshold can be breeched. And our rest is converted to response.

It's Sunday afternoon. Our morning particularly fruitful. We escape the clutches of elephant trunks. Lions with full bellies choose not to chew our legs. We sit full of lunch at home. Satiated. With no thought of our next meal. We chillax. Calm before a storm? We watch the silent phone. Wary of its potential to change our day. The link to chaos forged over 20 years. The network of access, deep and wide. The ring tone changed annually to temper the triggering response to its call.

And so our watched kettle boils. The doc phone trills. A new tone. Insistent, despite its unfamiliar song. A summons. Selina from the clinic: Sorry to bother you. Do you have any yellow cannulas? I have a sick baby who needs one. A simple enough request. Cannulas are colour coded for their sizes. Grey and brown are stonking. For big people with large veins. Never in use in paediatrics. We prefer the gentler colours of pink, blue and yellow. The code not linked to gender. Solely according to decreasing size. Yellow are my personal favourite. The smallest gauge cannula that we can get here. Cannulation my superpower. I’m not dressed without a little yellow friend in my pocket. I pat my pocket and promise Selina an urgent delivery.

The drive to clinic is our ponder time. A septic baby needing IV antibiotics? Or perhaps severe malaria requiring Artesunate? Options are finite. Selina so self-sufficient. The request rare and significant. We arrive at clinic and head to the maternity wing.

Selina is at the reception desk in maternity. She looks relieved to see us. That precious yellow cannula not the sole agenda here. Selina shares her woes. In need of my superpower and perhaps a little more.

Selina’s voice a little unsure: Mum had been 34 weeks pregnant. The baby born 4 hours ago. Not doing well. She is in oxygen. She needs a cannula before I send her to the District Hospital.

Selina leads us into the labour ward. An oxygen saturation monitor bleeps ahead. Not a happy bleep. Low and slow.

A tiny baby girl lies wrapped up. A little dot. Weighing just 2.2kg. Pale. Blue. Sick. Her eyes closed. Her breathing slow and intermittent. At best she gasps 24 times in a minute. Nasal oxygen is running. An oxygen saturation in her boots explains the low pitched noise. 46%. Less than half the pass mark. Her heart is switching off. Just 60 beats each minute. A failing baby's rate. Bruises and petechiae cover her. Her belly is big and full of unhealthy organs. An oversized spleen and liver betray her deadly disease. Little dot won’t make the grade. 

At 4 hours of age the writing is on the wall for the little dot. Sharing that with Selina brings no real news to her. She is an old hand at this. An antenatal infection with rubella or cytomegalovirus most likely to blame. But we have no way of proving that. Nor of fixing her. Hypoxia. Hypothermia. Hypoglycaemia. Out of sorts. Not distressed. But out of time. Grand mum stands guard. Mum unable, or unwilling, to comprehend what is going on with her fading daughter. Dad nowhere to be seen. As per the cultural norm.

We weigh the options with Selina. Charting a path for baby, mother, family. Respectful of local customs and traditions. The yellow cannula has no role. Traumatic to site. Ineffectual and wasteful. Two ways are open. But both have dead endings. The first is to continue the oxygen, the monitors, the lip service. To stay amongst the other mums. Listening as the bleeps slow down until they stop.

The second is to take away the oxygen and the monitors. Leave equipment to one side. Support mum to hold her wee one. Even to take her home. In the knowledge that she can’t pull through. Selina’s words careful and caring. The family needs to be allowed to choose from 2 short straws.

We leave Selina and the family with Hobson’s choice. Our Sunday peace now broken. Broken spirits. The drive home silent. No words of solace. But the words come nonetheless. Well into the evening and the following day.

Our medical mentors don’t argue with our approach. Hippocrates pipes up first and likes our stance. First do no harm. He shouts. But we step gently and awkwardly. Our language skills poor. Our knowledge of local culture lacking. Delegating hard conversations to Selina feels limp. And yet we abdicate and defer to Selina’s instincts.

It’s Monday morning. I seek Selina out. To support her and to catch up. The last chapter in our little dot’s life now written. The family finally decide to take the monitors and the oxygen off. They go home with the baby wrapped up in Mum’s arms. Five hours later our little dot comes to a full stop.

Stories often end with a full stop. But not this one. This tale has a nasty sting in it. A disturbing narrative soon develops. The plot mired in half-truths and misquotes. A healthy baby born early in clinic needed a little oxygen and was to go to hospital for more care. But the mzungu doctor took off the oxygen and stopped all of her treatment. She sent her home to die. Fake news. Written and hard to scotch. Selina does her best to set the record straight. My offer to see the family falls on stony ground.

My blog both process and outcome. My words chosen carefully. To heal and move on. A contrast to these careless rumours, scattered without insight. Words lashing my vulnerable underbelly. Scarring me, without prospect of repair. Selina salves my sores with kindness and her sanguine outlook.

Time has healed something now. There has been no community backlash. If anything we are held more tightly as part of this tangled settlement. I still don’t know how I could have helped little dot and her family more.

The hippos still call me at night. I strain to hear what they say. First Do No Harm. They grunt. The Hippocratic oath.

Seasonal Delights

Written by: Keith and Ginny Birrell

Highlight of the week: Keith teaches about sickle cell disease at both Kakumbi and the district hospital

Lowlight of the week: Ginny is laid flat for 3 days. Cause unknown but rallying now

Maximum temperature: 34 degrees Celsius

Rainfall: A light sprinkling

Mchere, Mchere, Mchere. The chant taunts Keith, as he opens his laptop in September 2024. Salt, salt, salt. The seasoning greeting. Keith is sharing a video with the waiting crowd. His hypertension clinic is centred around realistic lifestyle changes. Keith offers a riposte: Pepper, vinegar, lemon. His video gives hypertensives the healthy choices. Seasoning for hypertensives is not a seasonal issue.

It's 2026. Each year passes in a flash. Through a well-recognised pattern. A bit disjointed by global warming. But a pattern none-the-less. In the UK, we have a cold Winter; a wet Spring; a hot Summer; a windy Autumn. Zambia has her own seasons. Less variety. Perhaps more predictable. A wet warm season; a dry cooler season; a hot dry season. This year some divine force has brought a surfeit of rain. As the floods abate we await the seasonal consequences. Not the UK seasonal flow of hay fever and asthma, bronchiolitis and flu. Not just a sprinkling of some mild seasoning. We are about to be hit with a heavy-handed shake of malaria. Somehow the lid of the shaker has come loose. A glut of malaria will drop onto our population.

Malaria season comes when the rain stops. The smaller streams and rivers dry up. Leaving large still areas of water. Big puddles. The Anopheles mosquito loves big puddles. A great location to lay its eggs. Undisturbed by flowing current. Plenty of nearby vegetation. Our local population move into the fields. Farming season is upon us. The journey from farm to home too long for a daily commute. So sleeping under a cover in the fields is common. Mosquito nets do not travel well. The female anopheles spots her chance. Blood meals needed to nurture her young. She lays hundreds of eggs. Malaria unwittingly picked up and passed along. Propagated through family and friends. Via the bite of a hungry skitter. Our parasite foe needs 10 days in the mosquito. Before an Alien-style metamorphosis. The new deadly form ready to hop into our blood. In no time each female skitter is ready to spread the deadly seed. Unevenly, according to the shake of the shaker.

We have malaria year round in the valley. But it is spiking just now. Last week we had 80 confirmed cases in our clinic. By the start of June we expect to have over 200 cases per week. Much of the year we are looking for a needle in a haystack. A different fever needing a different approach. My viral URI mantra no help here. Deadly parasites need modern cures. Not masterly inactivity.

But now I am shooting fish in a barrel. Malaria symptoms often straight forward. Fever. Headache. Lethargy. Body pains. No appetite. Easy to describe. Easy to spot in a grown-up. But little people have no words. Their mums can guess: A headache? Body pains? More obvious with: The vomiting. The runs. More apparent, but not consistent. And yet: The coughs. The runny noses. Not entirely reassuring. To be sure I test.

The test of time less useful here. Plasmodium falciparum waits for no man. The brain its favourite lair. Cerebral malaria my fear. Fast and furious. Today I have RDTs. Rapid diagnostic tests. A lateral flow that rarely errs. A drop of blood well invested. A positive result no big deal. Six easy oral doses and our foe is flattened. No need to flap. I count and move on. The notification routine.

Under-fives always a worry. No history. No immunity. All their reserves pumped into growth. Wordless, they depend on all knowing mothers. And grandmothers. Advocates who need to press the right buttons. To say the right words. To the right people. The test crucial. Without testing: death all too common. Ninety per cent of malaria deaths hit under 5s.

But this year things are all change. We have a new weapon. Straight from an Oxford lab. The laboratory responsible for one of the COVID vaccines. We now have a malaria vaccine. Supplied to Zambia by GAVI and UNICEF. Free of charge. To work alongside mosquito nets and the spraying of houses and communities.

Our under 5 clinics are as busy as ever. Already providing vaccines at 2, 3, 4, 9 and 18 months. For all children. The new malaria vaccine is given at 6, 7, 8 and 18 months. Sadly, it does not tie in with the other childhood vaccines. So each child gets a jab most months.

The staff numbers are the same. But the clinics take longer. More paperwork to record in log books. More dates on under 5 cards. And more jabs jabbed.

The malaria vaccination programme started just as we left the valley in October last year. Predicted to prevent 70% of childhood malaria the jabs offer the possibility of wiping out severe malaria and death in under 5s. Our toddlers are the first to be fully protected with 3 vaccines. The booster vaccine starts in October 2026. Malaria won’t go way just yet. But at least our little dots will have defence.

Over-seasoning of childhood with malaria might become history. Meanwhile, we continue to immunise our community against the over-seasoning of their food with salt. Low sodium salt is not yet a reality in this recess of Zambia. But at least the new knowledge of the harms of table salt can be peppered onto peoples’ plates to move them from season to season.

Donating to “Reduce Stroke” - the clinic is now locally known as "Mcheri" meaning "Salt"

Dear supporter,

Thank you very much for considering donating to reducing the chance of heart attacks and strokes in South Luangwa. Project Luangwa has agreed to receive donations for this program and this can be done by bank transfer to UK bank (details below). If you are making a donation to this project, please add the notation Reduce Stroke to the payment, in order to help us track it. If you would also like to send an email to ian.macallan@projectluangwa.org then this will also be very helpful. If you are from outside the UK, please contact us directly and we will advise how best to send your donation. 

Thanks again for your kind support.

Metro UK Bank Account Details

Metro Bank PLC

Account number: 21201928

Account Name: Project Luangwa

Sort code:  23-05-80

Swift code:  MYMBGB2L

IBAN: GB88MYMB23058021201928

Bank Address:

Metro Bank Plc,

One Southampton Row,

London

WC1B 5HA

Recipient Address in UK:

Project Luangwa

 George Fentham Meeting Room

 Marsh Lane

 Solihull

 United Kingdom

 B92 0AH

Low Hanging Fruit

Written by: Keith and Ginny Birrell

Highlight of the week: Our paper "Can a lifestyle-centred, low-dose model improve hypertension and diabetes care in low and middle-income countries?" is accepted for publication

Lowlight of the week: A loose screw in Mzungu's tyre deflates us

Maximum temperature: 34 degrees Celsius

Rainfall: Not on your Nelly

The awakening is in no way rude. A soft knock on the door, brings us both back into consciousness. Keith’s personal phone is softly purring. The screen facing down brings no insult to our eyes. Doctor Keith we need your help urgently. I’m just outside your door. Keith’s naked body only visible to mosquitoes. Modesty quickly achieved. Our uninvited guest vague with the nature of our emergency. She is bleeding badly. We can’t stop the bleeding.

I begin this story in the middle of the night. But the beginning of the story precedes this polite awakening. Let’s rewind the clock a little: It’s Monday night. 20:30. Late for us. Our first night call this year. A reluctant patient. But reasonably straightforward. Probable heat-stroke. Reassurance. Explanation. A safety net and guidance on sucking eggs.

A tasty slice of key-lime pie kicks our blood glucose levels into the air. Our drive home offers 4 more sweet treats. Four bushy-tailed mongoose cross our path. We smile, enjoying the feast. This drive home always offers something. It’s been pretty quiet. I reflect. No real emergencies yet. The Q word has been uttered. In code. Research about how saying the word quiet can bring on medical misery, painstakingly undertaken.  It’s a silly medical superstition, the papers conclusion Broadcast in a learned scientific journal. The Christmas BMJ. 2019. 

Welcome back to the middle of our quiet night. It’s 22:40. A noise outside. A voice. A gentle, but persistent, knocking at the door stirs us both from our reverie. At the same time Keith’s personal phone hums. The doc phone most definitely quiet. Keith’s phone invites regular traffic. A hot line with boundaries. 20:00 the Rubicon.

Andrew calm and polite waits for us to rouse. We couldn’t reach you by phone. I’ve come to find you. We have a client who seems to be bleeding from the vagina.

Within 5 minutes we are fully dressed and on the road. Mouths doubtless offensive. No time to freshen up. Blasphemy also possible. I don’t wake up full of cheer. Keith negotiates the familiar bumpy dusty tracks. We leave Andrew to eat our dust. A dip. A jink. An elephant! A huge grumpy bull elephant shakes his ears. Threatens to charge. But sees the steely determination in Keith’s eyes and backs off. Keith swerves past him and floors the accelerator. Keith silent. I process our limited triage information. Out loud. Andrew, not medically trained, has left us in the dark. Bleeding crivens. I swear. Vaginal bleeding is not our core area. Pregnancy always possible. Vaginal injury normally comes with a lot of drama. We stay in the dark, but rehearse our options. Gloves. IV lines. Tranexamic acid. Resuscitation.

We reach camp. Staff relief is palpable. Tense shoulders drop. Thank goodness you are here. We walk towards the client’s  room, gathering information. Not vaginal bleeding, it transpires. Rectal bleeding. With massive haemorrhoids. Hanging out. We are warned: There is blood everywhere!

Inside the dimly lit room. White floors and walls smeared with red. Sheets and blankets covering the worst of it. On the bed, lying face down, is our patient. *Pereina. 57 years old. A towel preserves Pereina’s dignity. Her backside under wraps. Pereina tells us that she has been struggling with grapes issuing from her backside. Piles have been troublesome for years. Thank God you are here.

Pereina lies prone. The towel drawn back reveals the low hanging fruit. But the expected grapes are replaced with a large fleshy grapefruit. The whole of Pereina’s rectum lies ripe for inspection. No proctoscope required here. A healthy rectum, bright and beautiful. But totally inside out. Prolapsed and sitting neatly between Pereina’s buttocks.

Fortunately, Pereina is no longer bleeding. The red paint, so liberally anointed over bathroom and bedroom is a mere cupful. Not enough to threaten life. Her pulse, a jaunty 125, betrays her emotion, rather than a perilous blood loss. Our focus is drawn away from her veins back to a huge grapefruit in the room. Keith is going to need those gloves after all.

Now, imagine that you are about to pass a large grapefruit. Per rectum. I imagine that you are all now averting your eyes, or leaving the room. Imagining that you can decline what needs to now happen! The camel needs to pass through the eye of a needle. Pereina’s tears soak my hands. I take the head end. Keith takes the tail end.

Let’s slow your breathing down Pereina. Keith has done this plenty of times before. The kind lie. Jelly covers the grapefruit, and Keith’s hands envelope the fruit. Gentle pressure persuades the fruit to change. A metamorphosis. Fruit becomes: fruit of the sea. An octopus in Keith’s hands invaginates. An amoeboid arm enters the anus and reaches the pelvis. Body follows arm. Arm follows body. The octopus gains entry leg by leg. Fifteen slow minutes test Pereina’s belief in God and in Keith. You can do it. Can’t you Doctor Keith? Keith cautiously plays with the conditional tense. Yes, I can. But the future is less certain. For a full, slow, 15 minutes. Until the last octopus leg chooses to enter the dark recess.

As a UK primary care doc Keith has comfort zones. Those zones, when crossed in England, have predictable outcomes. He can spin the ball gently out to the scrum half. A whole team of skilled professionals wait for his delivery. The paramedic deftly passes the ball onto the surgical team. Keith’s role as a gatekeeper has well defined edges.

In Zambia we are not only the scrum, but also the whole first 15. There is no one else on the pitch. Pereina’s phantom pregnancy, and imagined vaginal bleed, fails to give birth to a tiny individual, needing my normal services. But I know what I don’t know. And I make an executive decision to involve the off pitch substitutes.

Fida is on-call. In a paid capacity. His colorectal skills in great demand. He is barely home after a super busy day at Darlington Memorial Hospital. He picks up my WhatsApp video call immediately and smiles. Genuinely happy to see my smiling face. Knowing instantly that this is not a social call. I pass the phone to Keith, who now has clean hands.

Fida and Keith begin to hatch a plan. With all of the options that we have in the bush considered. 24 hours of bed rest with the bed-foot raised. Laxatives to avoid straining. A reasonable chance of a game drive on Wednesday. A protective hand to keep the octopus holed up during defecation.

It's 01:30. We head home. Weary. Memories of the key-lime pie sugar spike distant. Instead healthy fruit occupy our thoughts. Our grapefruit appropriately squared away. Our mission, accepted but unexpected, to keep the octopus at bay. We chew over the flesh of our next day’s play. Hoping that Pereina can keep her buttocks clenched for a while. At home our alarm clock gets a nudge. Sleep takes us and keeps us. Early exercise not an option for Tuesday.

Tuesday. 12:30. We are at our most distal tree clinic. Mothers, babies and staff on a go slow. No rush. They don’t know that we need to review Pereina this lunchtime. Clinic one in the bag. Clinic two is done at snail’s pace. The doc phone trills. A summons. Urgent and insistent. The grapefruit is back. Thankfully, there is no blood this time, but our instructions for rectal first aid are not received with confidence.

Our tree clinic staff have a stark choice. Pack up within 2 minutes, or take a long walk back to clinic. Instantly, a means to an end is discovered. Photos of cards. Registers shelved for later. Jabs and polio drops in double quick time. Mzungu fills as part of an emergency drill. In town we off load our staff with their heavy boxes and kit. Their walk back to clinic short now, at least.

Our drive to camp is rapid and elephant free. Somehow rectal first aid training has resulted in a tameable octopus. Pereina is smiling with relief and her freshly trained and accomplished zookeeper hugs Keith. Keith admires her work. A fruitless bottom.

Keith and Fida’s first plan has unravelled. No game drive tomorrow then. A different game plan will be needed. Pereina is going on a rather longer journey. Her operation has just been brought forward. A stitch in time and all that….

Pereina despite her confinement to bed jumps into action. Her insurance company is given a nasty bite in the backside. And within a couple of hours we have permission to evacuate. Meanwhile the camp team also step up to the plate and book her onto the next commercial flight to Lusaka. A plan is taking shape. All we need now is some nappies or panty liners and some Bridget Jones knickers.

Now being camp doctors has some fringe benefits. And when the sh*t is hitting the fan, or even the pan, we usually have access to 5 star food. Not exactly a free lunch. But gratefully received nonetheless. We peel off to a tasty plate of food. 

The spell is broken by a WhatsApp call from Pereina. Could you come now Doctor Keith? Thankfully there is no video. Our lunch at least is neither grapefruit nor octopus. Keith hot foots back to Pereina’s chalet and asks her to adopt the position. The octopus goes quietly back into its lair.

Evacuating Pereina is not what you think. Yes, of course we are giving her Movicol to keep her poo soft. Not in bowel prep doses. But she also needs a hop, a skip and a jump to get her back to a land where laparoscopic witchcraft can be performed. To hold her rectum permanently inside her bottom.

The hop is a quick flight to Lusaka. Pereina checks into Lusaka’s finest hospital. Under the care of a fine surgeon. She will not need to go under the knife just yet. We need the skills of the wider medical team. Pereina needs upskilling. She receives a rapid course in octopus entrapment. Keith’s hands operating remotely. Through clinicians somewhat familiar with this uncommon procedure.

The power of positive thought is key. Fida tells Keith that no medical escort is needed for her long double flight home. Keith tells Pereina that she is up to the job. That whilst on the job: she must guard her octopus lair. Not let grapes become a grapefruit. And so it comes to pass. Pereina becomes the guardian of the octopus lair. Ready for a skip and a jump.

*Names have been changed to protect identity. "Pereina" has read the full blog and given us permission to publish it

Snap. Crackle. Pop

Written by: Keith and Ginny Birrell

Highlight of the week: Ginny's sourdough pizza from Ian' starter.

Lowlight of the week: Sleep is stolen from us. Business is booming.

Maximum temperature: 34 degrees Celsius

Rainfall: Not a drop

Snap, crackle, pop. Wholesome noises. Evocative. Summoning up my childhood. But a subtle change to snap, crack, pop and my stomach wrenches. But more of this later….

It’s April 2021. We retire. Sage advice from a dear friend directs our thoughts. Bruce, a step ahead of us, opines that we might seek balance in retirement. Our jam packed diaries need filleting. One entry per day the way forward. Be it a plumber or cutting the lawn. Overachievement the enemy. A foe worth fighting. An overzealous Yang. Surrender to the Yin. Passivity in life, suggests Bruce. Let balance into your lives.

Time marches on. Five years pass. Our diaries are either empty, or full. Yin and Yang compete. It’s April 2026. Somehow Bruce’s maxim is put to one side for the day. We have two diary entries today. Dropping staff off at the peripheral clinic and meeting with our bosses. One more than two. The light dominating the dark. The balance is threatened.

Kakumbi clinic our first stop. Staff and kit fill Mzungu. Doors ajar to avoid greenhouse heating. Kennan, a clinical officer, seizes his chance. He is going off shift, after a steady night on-call. Doctor Keith. I have a patient for you. From last night. Please would you take a look at him? The baton is passed. A promise from Keith to cast an eye. In ten minutes, after community clinic drop off.

Five members of staff. A wooden frame for height measurement – an instrument of torture. Vaccines and scales. Nyamununga tree clinic is set up. Diary entry number one is scored through. It’s 08:15.

Back at Kakumbi, Keith talks to *Arthur about his semi-conscious friend *Sidney. Arthur is a bit vague about the nitty gritty. Sidney has been like this before. Confused and responding to an overactive imagination. Kennan gave him a jab of diazepam last night and now Sidney is away with the fairies. There is no smell of booze, but Sidney loves kachasu. Intoxication his default state. Sidney reeks of urine and his self-care leaves a lot to be desired. Kachasu supplies ran out 3 days ago and Sidney has been on edge ever since. Last night he seemed mad. Arthur chooses the clinic over the witch doctor. Knowing that they fixed him a year ago. Light wins over dark.

Despite the diazepam Sidney is stiff. Things aren’t completely clear. We arrange to test the testables. To treat the treatables. His blood glucose is fine. The lab team is enlisted for malaria, syphilis, sleeping sickness and HIV tests. A plan for thiamine and baclofen is hatched and we peel off to address diary entry number two. Mzungu heads off to collect boss number one and boss number two. Priya and Choti our Luangwa Safari Association Medfund masters.

Our diaries nudge us gently to meet with our District Medical Officer and the doctor in charge of the district general hospital, Velos. Boss number 3 and boss number 4 if you like. Our agenda not solid, and open to sway one way or another. But balance the only essential element. Our meeting venue is the District Hospital. Far in the bush. Near the airport.

We reach the hospital 30 minutes later. Smiles and welcomes. On time. Less traditional African and more clinical and practical. Our minds meet. A little pull. A little give. Ideas blend in a productive meeting. We agree to share skills in a realistic fashion. Two large group meetings in each month, unless the course of unpredicted events intervene. Priorities are discussed and we exit sharply. Ticking off our second diary entry efficiently as we go.

Meanwhile, back at Kakumbi: we have tests brewing. All the lab tests say No. But time is our key test. Sidney is up and about. Wandering around picking up imagined items on the concrete floor. His limbs are all fully functional. His brain however, is still well below par. We seek input from Arthur and scratch our heads. DTs seem the best fit and Keith offers something to keep the possibility of fits at bay. He fishes out some drugs from the back of Mzungu and we explain a dosing regimen to Arthur. Sidney will have some hard choices to make when he sees Keith again on Monday.

Arthur by now has been in clinic for 16 solid hours. Caring. Forgetting to care for himself. The room is hot. An unforgiving concrete environment. Thirst and hunger have been deferred. We forget the health of carers at our peril. Peril waits patiently.

We turn our backs briefly and step outside. Away from the heat and stuffiness of the ward.

A whoosh of air, as a rigid body swings through 90 degrees. Snap, crack, pop. Immovable concrete stops a human form from further descent. An equal and opposite force. Sudden and unforgiving. Jaw hits concrete. Concrete wins. A sickening snap. The crack offends our ear drums. A pop as blood spurts forth from mouth, chin and ear. In an instant, carer becomes patient 

Arthur is fitting. Tonic as he fell like a log. Then clonic. Several beats. Blood is gushing from a badly cut lip and a chin wound. Grabbing gloves from pockets, we support his airway. Talk to him in calm voices, to tell him that he will be fine. A pool of blood on concrete provides a sample to check his glucose level. He comes around quickly, but his first urge is to head to the bathroom. Keith man-handles him as he heads to a room full of unforgiving bathroom fittings and another concrete floor. Saulos, really our number 1 boss, the clinic in charge, magically appears in an immaculate white uniform. He too guards Arthur’s body from further insult. Whilst calmly cleaning blood from Arthur and the clinic whilst remaining unmarked himself. We shepherd Arthur back to a bed and start to survey the damage. Arthur takes a litre of oral rehydration solution. In a scene reminiscent of Ice Cold in Alex. Opening his mouth to permit access for fluid and light. The inside of his lip is badly cut, but stitches are unlikely to help here. Keith rashly takes comfort that the mandible might be OK. Despite the loud crack that insulted his ear drums earlier.

The cut under the chin draws Keith’s focus. If nothing else this can be fixed. Within 5 minutes four sutures patch up at least one part of our wounded Samaritan. Blood seeping from his right ear gives cause for concern and we decide that X-ray vision might be needed. On the plus side there is no spinal fluid coming from the ear. Arthur’s brain seems to have been protected. His jaw taking the brunt of the impact. The lack of both nausea and headache reassuring. Expecting pain we give paracetamol and ibuprofen.

Meanwhile, the carers of the carer are wilting too. Thirsty. Hungry. Hangry. The ability to make rational decisions is dwindling. The only viable decision is to eat and drink. Care for the carers. We head off to lunch, with a promise of immediate return. Resuscitation in mind.

Saulos, being the boss, thinks of the bigger picture. Without carers our small inpatient bays are nothing. Food and drink vital fuel for rehab. Carers the catalysts, providing impetus for patients to rally. Family and friends our salvation. Saulos calls the cavalry. And Arthur’s Dad appears out of thin air. A second call discovers that the ambulance is heading the wrong way and won’t be available for 6 hours. Meanwhile, Saulos is also busy in his hypertension clinic. His 2 year old baby. Keith the surrogate father.

Within 30 minutes Keith is back. A quick word in Arthur’s good ear establishes that Arthur’s brain is just fine. Keith’s brain is now also back on form. Rebooted with food and fluid. His request for Arthur to open his mouth seems to fall on deaf ears. But despite the clot in his right ear, Arthur is neither deaf nor dumb. Sixty minutes after that sickening crack a fractured mandible declares itself. The hinges of Arthur’s jaw horribly swollen and seized up.

The process of Arthur’s transfer to Velos hospital is shrouded in a haze. Our District Hospital - built to serve an international airport that will hopefully never need its services - is in a far flung field. This distant location, without a transportation system to speak of controls the flow of accidents and emergencies to Velos. And yet Arthur arrives. His dodgy X-rays arrive on the Doc phone this evening. Blurred images bounce to Germany. Blurred facial bones that blend into facial bones, needing intercontinental expert input. Ralph, bless him, is always on-call! His reply super-quick. The jaw is broken. A condyle needing an expert fix.

Keith has a mere 3 months of ear, nose and throat training under his belt. That means that he got a full month, back in 1991, to learn how to fix each ailing part. Ralph suggests an expert, so Keith hands on the baton. At first a proper expert seems to be on hand. Satiel, a highly skilled ENT surgeon, based at Velos, answers Keith’s WhatsApp instantly. Agreeing on surgical intervention.

But Satiel is actually out of the loop. On distant and extended leave and unable to offer personal help. But at least he knows a friend. A chap in Chipata with the skill to pin Arthur back together. Arthur is sent even further down the road.

We take the blow on the chin. Arthur should get the care he needs, but much further down the road. Meanwhile, Arthur can’t eat, since his mouth won’t allow him to separate his clenched teeth. A prolonged pre-surgical fast is forced upon him, not by anaesthetic guidance, but by physical obstruction. The burden on his family is massive. Long journeys make the carers role a huge headache.

What’s the craic? Ask Phil and Christina at sundowners. Crack a word too triggering for us both. We flash back and relive the trauma of the day. At least we are not nil by mouth this evening. We sit by the Luangwa opening our jaws freely. Able to eat tasty treats and wash them down with a passionfruit G&T and above all able to jaw-jaw. We debrief at the end of an overfilled day. We regret not providing some sort of safety net for our kind Samaritan carer. Could we have recognised the physical stresses imposed on a single carer and have prevented Arthur’s full face dive onto unyielding concrete? We had no way of knowing that poor Arthur was prone to seizures.

Our guilt will at least ensure that Arthur’s aftercare is second to none. Keeping his fits at bay part of the plan.

*Names have been changed to protect anonymity. Permission has been granted to publish this story.

Polio

Written by: Keith and Ginny Birrell

Highlight of the week: We get our remote camera set up outside the house

Lowlight of the week: Our kitchen air conditioning unit gives up the ghost

Maximum temperature: A cool 32 degrees Celsius. Winter is coming

Rainfall: Zero. We are reliably informed it will not now rain until November

Edward Jenner is turning in his grave. EJ gives the world a juicy panacea. Yet, Truth Social thinks that the Orange man knows best. The new Pope taketh away.

Vaccines. Most people love them. A few are not so sure. Some definitely hate them. Information is either too readily available. Or there is not enough. Social media. Full of truths. Mistruths. White lies. And huge whopping fabrications. So, what should you believe?  This conundrum runs deep.

Measles having been cancelled in our heyday starts to run riot again, thanks to Chicken-Licken running around in the limelight. A fine mess. Thanks to a researcher wanting more funding. Or notoriety?

Now meningitis B also grabs the headlines. Should we jab, or shouldn’t we? The Daily Mail campaigns both ways. On alternate days. It was ever thus.

We live in a valley of cause and effect. Too recent measles and polio has carved painful voids in Zambian families. Edward Jenner once showed us how to plug those gaps. There is now universal vaccine coverage thanks to him and to Zambian belief in science. Our tree clinics full. It’s a pity that science and history have been cancelled elsewhere. This week we wrestle with an old foe. Polio. Our District is mobilising forces. We march at dawn. But more on this later.

In 1988, the World Health Organisation set an aim to eradicate polio worldwide. To date, cases have decreased by 99%. Wild polio is now only present in 2 countries. There are challenges to complete Polio eradication. But it is feasible. And that is thanks to Mr Salk and Mr Sabin. Mr Salk killed his vaccine. And delivered it with a jab. Mr Sabin made children happy with an excuse to eat sugar at school. His attenuated vaccine goes straight to the gut. Alive. Where polio loves to live.

But Darwin will tell you, if you stop to listen, that wild things are wild. Give them enough time, and a soupy broth to support the possibilities…. And so we have live vaccine virus happy in muck. In the sewerage system in Lusaka.

But the story does not end there. This attenuated live virus can mutate - becoming something of a ninja. In its altered form, it might regain the ability to cause polio. When vaccination rates are high, this risk is contained. But if coverage drops, the door opens for this ninja to spread and a new spark looks for tinder.

Earlier this year, Zambia reported vaccine-derived mutant polio virus to be circulating in the Lusaka sewage system. Without apparent illness so far. But we hear the ticking. The familiar ticking of a timebomb. Public health Zambia seeks to defuse this bomb. With a mass polio campaign. Under-fives hold the key. They are the dry tinder.

Let’s set the clocks back: Its 2021. We are preparing for our first trip to Zambia. We speak to a previous Valley Doc. Light is shone on the unknown. But the doc is essentially disparaging about his role in the peripheral clinics: Twice a week you have to leave the busy clinic where you do worthwhile work. And drive the staff in the doctors car to the under 5 outreach clinics. It’s a really ridiculous clinic. There is nothing for you to do there. You are basically acting like a glorified taxi service. 

It's dawn. Monday morning. Our baboons have lost their role. We beat them with a 5am call to prayer. Yet we pray to the yoga gods. We HIIT the prayer mats to finish the job. Exercised, we move on. And collect the amassed troops at Kakumbi clinic at 08:00.

Where have you been? You should have been here at 07:30!

News to us. We have 4 teams of staff to distribute to the villages in our area. They eagerly approach the car. And squeeze in. Amoeboid. An extra one in the front with me. 5 squashed on the back row. 5 in the boot. This is no time to tell my mini joke. The nuance is lost on the Nyanja/ Kunda audience. Our white Hilux Mzungu is purpose built for this role.

Fully-laden, Mzungu, with a slow puncture hissing from the left rear tyre, rises and falls through the ridges and gouges of the ungraded roads. We dodge the larger pot-holes of the main, tarmac road. But the dusty morning light, random bicycles and competing road users make the preferred line tricky. Inevitably our three and a half wheels jar into craters. Somehow, we rise from the sink-holes to regain flat asphalt. Staff sway and blend together like tetras. Apologies punctuate the chatter.

A shout, too late, advises of a missed stop. An extra body impossibly squeezes in. Turn offs. Drop offs. We reach the last village. Agreements are made for the later pick-up. The first run is complete. Then repeat.

The polio taxi service. Not resented. Unlike some docs before us. Part of the process. Vital cogs that drive the chain that prevents polio.

Rising early, missing lunch, finishing late. Our team tread the trail. Moving house to house. Finding small mouths. Dropping in Sabin’s elixir to ward off future palsies.

So what are the teams doing in the bush? They have a target. To vaccinate every child under the age of 5. Having previously sent out word to the village elders. Informing them of the campaign. The staff traipse door to door. Village to village. By foot. A motorbike improves access to far flung pockets. To squeeze a drop of polio vaccine into every child’s mouth. They mark the child’s pinkie finger nail with indelible ink once vaccinated. No double doses allowed. Chalk marks on houses. A code. Parents saying yes. Children unable to say no. The campaign kicks off.

Eventually we return to clinic. Via the garage. A flaccid rear tyre is our first resuscitation of the day. A puff of air or two. Our mechanic reports the prognosis: It’s respiring Doc. We agree it has a chronic respiratory issue. We add it to the non-communicable disease hit list. We agree to use puffs as required. And schedule a tyre transplant further down the road.

We find a skeleton staff at Kakumbi. And flesh out the numbers. Adding four hands to Kennan’s capable two. Our six hands risk infestation, as we inspect Lilian’s little mitts. Scabies is the consensus. But mum is not happy. Her agenda is to secure the polio vaccine for her little mite. She’s six, but small enough to pass as five she claims. Ageism isn’t fair. Our hands are tied unfortunately. Under-fives are the chosen ones. Age just a number. But the number 6 is unlucky today.

The campaign trail marches on. Numbers populate audit sheets. Describing doors entered. Chalk marks. Sour baby faces. Smiling mothers. Collection at 15:30. The team receive a pat on the back. Day one is on target. Our boss deserves plaudits. Saulos gets a pat on the back.

Day two sees District oversight. The boss’ boss wants more. 15:30 becomes 17:30. Food an afterthought. Keith collects exhausted staff from the dregs of the day. No perks. Save for pride. He takes spent staff home. Rashly offering emergency food and taking a short-cut to village homes. Double whammies land in Keith’s solar plexus. The empty stash of emergency food in Mzungu insults empty bellies. The muddy village trails clutch Mzungu’s wheels. A diff lock and 4 wheel drive save the day, but paint the village reddy-brown. As well as Mzungu’s whiteness.

The long days sap. Day 3 brings resignation. Day 4 steely determination. Heavy legs trudge through day 5. Shoulders sag as Day 6 dawns. Those chattering positive voices from Day 1 converted to proud weary reflections. Polio put to bed for another year. Our small army of volunteers and under-paid staff hungry and thirsty. Allowed to rest on Sunday.

We pay homage to our idols. Those figures from history who left an indelible mark on our planet. For good. Jenner amongst them. 2,236 under-fives now bear the stigmata of polio vaccination. A blackened little pinkie nail. 94% of our under five population now wear a shield against a paralysing unseen virus. South Luangwa protected by a virtuous belief system and a week’s hard graft. We turn our backs on false idols.