Mosi-oa-Tunya 'The Smoke that Thunders"
Sunday November 23rd 2008
Judy gazing into the crack in the earth into which the mighty Zambezi pours from the right side. It is the dry season with not much water at the Zambia end of the falls partly because some water is run off for hydroelectric generators. Less smoke and little thunder.
David Livingstone first viewed Falls from the up stream Zambian side on an island which now bears his name and to which you can be taken on a day’s trip. The most exciting trips are from the Zambian side but we are prejudiced. This can include a swim in Devil’s Pool, which extends right up to the edge of the Falls and from which you can look over their edge! We intend to do the trip in December/January before the Zambezi reaches its full spate when it is still possible to get to both the Island and Devils Pool. The island is right in the middle of the falls and the views from it are said to be spectacular. At this time of the year around the start of the rainy season the water levels are low enough to walk all the way to the island over large rocks
as the true culprit was a loosened wire, which took 2 minutes to repair!
This week they asked me to re-operate on an old man of 60+ who had a colostomy for bowel blockage from a large bowel cancer. I attempted this in the hope we would be able to close his colostomy. However the cancer was very fixed and after a trial dissection I decided we would do more harm than good from taking it out, particularly as blood for transfusion is in short supply. Two days later he was, somewhat remarkably back on his feet and is surprisingly cheerful. I met him on the corridor just after he had cleaned his colostomy site.
Tuesday 2/12/08
Six weeks into the struggle of learning how to cope with the HIV/AIDS clinic, just before lunch the counsellor acting as a translator asked Judy if she would see a lady who wanted advice about getting pregnant. Forty-five minutes later we were all a little wiser about the difficulties of these clinics even leaving aside the problem of language. The patient was a small bird like, pretty woman in her early 20s who initially was a little shy to discuss this, perhaps because of the male counsellor and myself. She placed on the desk one sheet of paper, which was the incomplete clinical record of a four year old child. As the child had her surname we wrongly assumed it was her child, not as it transpired, her dead sister’s. It was pointed out that we needed her own notes not the child’s. So after obtaining her number Judy retrieved a set of notes from the file store as the record clerk had gone to lunch. These appeared to be the correct number but were the rest of the wrong child’s notes. After obtaining the correct number Judy found the correct patients notes. Together with these and through the translator we established she had been on anti-retroviral treatment (ART) for 2 years, had two children aged 7 and 10 years and that in spite of having unprotected intercourse with her HIV positive husband for the last 2 months she hadn’t become pregnant.
The final plan therefore was to organize for both she and her husband to have their CD4 counts checked and if they were sufficiently high to have unprotected intercourse, she was also advised that it might take longer than 2 months to get pregnant. If after say 6 months they were still unsuccessful they would both have to be investigated for infertility. The need and pressure for an HIV positive mother of two to have more children may be mainly cultural as if she can't it might drive her husband to find another more fertile wife.
At the end of this long consultation the patient then asked for an ART prescription for the child whose notes she initially presented to us. We explained that it would be better for us to see the child particularly because the child hadn’t been brought to the last appointment. It was at this point that the patient revealed it wasn’t her child but her dead sister’s who presumably died from AIDS. Athough our patient is the guardian the child lives with the patient’s mother, the child’s grandmother, who lived one hour by bus from Monze. They found it difficult to bring the child who apparently is otherwise well on treatment. Judy agreed to prescribe another month of drugs but said the child should be brought to the clinic next time if at all possible.
This case demonstrate many of the frustrations of this clinic; the random way the patients enter the consultation room unannounced, sometimes two at a time, occasionally with the wrong or incomplete notes or without them at all, the lack of support staff to find the notes and the occasional problems of trying to understand the expectations of the patient with the almost insurmountable problems of language and culture. It is impossible to get annoyed with any of the staff as they are also struggling to cope with the large numbers of patients.
Sunday November 23rd 2008
Judy gazing into the crack in the earth into which the mighty Zambezi pours from the right side. It is the dry season with not much water at the Zambia end of the falls partly because some water is run off for hydroelectric generators. Less smoke and little thunder.We returned from Livingstone and one of the Seven Wonders of the World at 1730hrs, tired and a little bemused. The three hours in the Mosi-oa-Tunya National Park (the smoke that thunders; the traditional name for Victoria Falls) was great and we saw and learnt a lot about the animals but Mosi-o-Tunya (also the name of the Zambian beer) was not quite what we expected. The Falls are really just a huge crack in the earth about 1,700 metres wide and 100 metres deep, which the mighty Zambezi meanders up to and then plunges into.
The not so mighty Zambezi showing its way out of the crack into Zimbabwe on its way to the Indian Ocean.
It flows out of one end of the crack or gorge. It is so large that even with little water at the end of the dry season it generates a lot of spray. The border between Zimbabwe and Zambia is arranged so that 66% of the Falls are up stream and 34% down stream in Zambia and the reverse in Zimbabwe. This means that it is difficult to appreciate its full size and structure without walking on the Zimbabwe side. However visas are required just to go the few hundred yards across a bridge, roughly the length and appearance of Bristol’s Clifton Gorge Suspension Bridge, to get into Zimbabwe and the visas are very expensive.
Mosi-oa-Tunya in the wet season showing the suspension bridge into Zimbabwe just right of centre at the bottom of the picture. Zambia has 66% of the upstream part of the falls on the right including Livingstone Island and Zimbabwe 66% of the downstream on the the left. The Zambezi flows out of the crack and under the bridge and runs between the two countries into the vast man made Kariba lake and eventually through the Kariba Damn and finally to the Indian ocean.
David Livingstone first viewed Falls from the up stream Zambian side on an island which now bears his name and to which you can be taken on a day’s trip. The most exciting trips are from the Zambian side but we are prejudiced. This can include a swim in Devil’s Pool, which extends right up to the edge of the Falls and from which you can look over their edge! We intend to do the trip in December/January before the Zambezi reaches its full spate when it is still possible to get to both the Island and Devils Pool. The island is right in the middle of the falls and the views from it are said to be spectacular. At this time of the year around the start of the rainy season the water levels are low enough to walk all the way to the island over large rocks
Tourists walking on the edge of the falls in the dry season.
whereas when the river is in full spate it is not even possible to get there by boat and it is impossible to swim in the pool. The waters are also lower on the Zambian side because a lot is diverted for hydro-electricity. However in spite of all these difficulties it is a lovely walk on the Zambian 34% down-stream side and we have taken some photos of people walking right up to the edge of the falls on the up-stream side (see above) and the bottom of the falls you can't see in the wet season. We had to negotiate a small suspension bridge and some aggressive baboons to get this picture.
It is impossible to go anywhere near the falls without getting saturated at the height of the rainy season. We should be able to get some very instructive ‘before and during the wet season’ photos although it is difficult to keep cameras dry even in plastic bags.
On the 3 hr trip around the Mosi-oa-Tunya safari park we saw elephants, rhino, hippos, crocodiles, giraffes, zebra, buffalo, impala, warthog, large monitor lizards (which eat crocodile eggs), wildebeest (type of deer) and lots of birds, all from an open land rover in large very
comfortable arm chairs.
There was a slightly threatening sky but it remained dry, very warm and mostly sunny. All the vegetation was fresh light green after all the rain we’ve had in the last few days. 
The ground was mostly sandy and is now starting to look like a newly sown lawn.
There was a slightly threatening sky but it remained dry, very warm and mostly sunny. All the vegetation was fresh light green after all the rain we’ve had in the last few days. 
The ground was mostly sandy and is now starting to look like a newly sown lawn.However the rest of the weekend was cooler (26-30 degrees Fahrenheit) with the odd shower and mostly cloudy.
Our hotel had rondavels with ensuite accommodation and was really very comfortable. A mixture of slightly plush and ethnic but a good bathroom and tea/coffee tray. Sadly it didn’t have a particularly good restaurant as was advertised.
The journey to Livingstone with about a hundred passengers packed into the 'luxury' blue 'Family Mazahendu' bus was a mostly comfortable experience taking over 4 hours to get there and a similar time back. There were 3 seats one side a very narrow central isle and two seats the other. The seats were less than one shoulder width in size so we had to sit slightly overlapping. The problem was one third of the journey was on unmade roads over which even I couldn’t sleep. There were great potholes full of rainwater. We caused cascades of yellow ochre coloured water as we went through, as the earth was no longer red. At one point in the middle of nowhere and still on the unmade road the bus came to a halt with the engine running.
Our hotel had rondavels with ensuite accommodation and was really very comfortable. A mixture of slightly plush and ethnic but a good bathroom and tea/coffee tray. Sadly it didn’t have a particularly good restaurant as was advertised.
The journey to Livingstone with about a hundred passengers packed into the 'luxury' blue 'Family Mazahendu' bus was a mostly comfortable experience taking over 4 hours to get there and a similar time back. There were 3 seats one side a very narrow central isle and two seats the other. The seats were less than one shoulder width in size so we had to sit slightly overlapping. The problem was one third of the journey was on unmade roads over which even I couldn’t sleep. There were great potholes full of rainwater. We caused cascades of yellow ochre coloured water as we went through, as the earth was no longer red. At one point in the middle of nowhere and still on the unmade road the bus came to a halt with the engine running.
The driver’s head slowly descended to the very large steering wheel followed by the drivers mate’s head going through the same procedure. The driver and his mate rapidly regained their composure and reassured us the problem, something to do with the alternator, was solvable. Initially it was thought it might require repairing with some modified barbed wire found at the roadside although this was never used,
as the true culprit was a loosened wire, which took 2 minutes to repair! The bus is so shaken on the unmade roads it is amazing that it doesn’t just fall to bits as it rattles and rolls along occasionally at over 60mph, when allowed by other traffic. The road surface doesn’t seem to be a consideration in determining the speed of the bus!
The bus pulled into the Golden Pillow car park as it was getting dark and so ended another wonder filled weekend.
The bus pulled into the Golden Pillow car park as it was getting dark and so ended another wonder filled weekend.
Clinical Cases
And so back to the tales from work.
Man’s cruelty to man is understandable and even occasionally acceptable but man’s cruelty to children is difficult to understand in any culture. An 8-year-old girl has been on the ward for some days with abdominal pain for which no cause has been found. As she is not seriously ill we have suggested she goes home and be followed up in outpatients but she and her mother have been reluctant to accept this. On the ward round on Friday, before we went to Mosi-oa-Tunya it was revealed that she was HIV positive whereas her mother and a sibling were not, suggesting that the patient did not acquire HIV at birth. It was also revealed, and we confirmed, that she had extensive warts over her perineum, which is usually sexually acquired. Her father died 3 years ago and when we asked the child’s mother what he died of she just said he was sickly. There is a myth amongst some Africans that having sex with a virgin can cure HIV/AIDS and this may be one of the reasons that Zambia has a very active campaign against child abuse. Many kids in Zambia have such a tough time, even without any abuse it is a small wonder that many survive at all. The development of coping mechanisms must take a toll and abdominal pain may be one of the consequences.
The ward round also provided two more mango tree injuries, one an overlapping femoral fracture in a young girl and another severe posteriorally displaced supra-condylar break. There was also another snake bite and two more severe burns one in a small girl whose dress caught fire.
Man’s cruelty to man is understandable and even occasionally acceptable but man’s cruelty to children is difficult to understand in any culture. An 8-year-old girl has been on the ward for some days with abdominal pain for which no cause has been found. As she is not seriously ill we have suggested she goes home and be followed up in outpatients but she and her mother have been reluctant to accept this. On the ward round on Friday, before we went to Mosi-oa-Tunya it was revealed that she was HIV positive whereas her mother and a sibling were not, suggesting that the patient did not acquire HIV at birth. It was also revealed, and we confirmed, that she had extensive warts over her perineum, which is usually sexually acquired. Her father died 3 years ago and when we asked the child’s mother what he died of she just said he was sickly. There is a myth amongst some Africans that having sex with a virgin can cure HIV/AIDS and this may be one of the reasons that Zambia has a very active campaign against child abuse. Many kids in Zambia have such a tough time, even without any abuse it is a small wonder that many survive at all. The development of coping mechanisms must take a toll and abdominal pain may be one of the consequences.
The ward round also provided two more mango tree injuries, one an overlapping femoral fracture in a young girl and another severe posteriorally displaced supra-condylar break. There was also another snake bite and two more severe burns one in a small girl whose dress caught fire.
This little girl had extensive burns on her abdomen and legs here being debrided and after skin grafting with less than 50% take.
I also saw what I never thought I would see in Zambia, a glowing electric fire.
This was in ITU just for warmth in the cold time of year.
It is also used in the children's burns ward when children are nursed naked and who need the extra heat in the shade of the hospital even though the weather outside is really very hot.
This week they asked me to re-operate on an old man of 60+ who had a colostomy for bowel blockage from a large bowel cancer. I attempted this in the hope we would be able to close his colostomy. However the cancer was very fixed and after a trial dissection I decided we would do more harm than good from taking it out, particularly as blood for transfusion is in short supply. Two days later he was, somewhat remarkably back on his feet and is surprisingly cheerful. I met him on the corridor just after he had cleaned his colostomy site.
There are, of course very few colostomy bags, he just covers it with cotton wool, a sheet of material that women use for a wrap and then covers it with a plastic sheet, which keeps most of the flies off.
He was actually smiling when I met him after having a good wash.
This patient's kit (plastic container and bowel) for cleaning his colostomy and its cover for keeping clean.
Dr Engulula, the Congolese surgeon, after seeing the video on my computer of James Robertson Justice in the Carry on Doctor film doing an old style surgical ward round and teaching medical students by humiliation, thought that we should copy this and proceeded to do so on a case of appendicitis demonstrating some now little used physical signs. The VSO idea of disseminating skills sometimes runs a tortuous course!
Tuesday 2/12/08
Six weeks into the struggle of learning how to cope with the HIV/AIDS clinic, just before lunch the counsellor acting as a translator asked Judy if she would see a lady who wanted advice about getting pregnant. Forty-five minutes later we were all a little wiser about the difficulties of these clinics even leaving aside the problem of language. The patient was a small bird like, pretty woman in her early 20s who initially was a little shy to discuss this, perhaps because of the male counsellor and myself. She placed on the desk one sheet of paper, which was the incomplete clinical record of a four year old child. As the child had her surname we wrongly assumed it was her child, not as it transpired, her dead sister’s. It was pointed out that we needed her own notes not the child’s. So after obtaining her number Judy retrieved a set of notes from the file store as the record clerk had gone to lunch. These appeared to be the correct number but were the rest of the wrong child’s notes. After obtaining the correct number Judy found the correct patients notes. Together with these and through the translator we established she had been on anti-retroviral treatment (ART) for 2 years, had two children aged 7 and 10 years and that in spite of having unprotected intercourse with her HIV positive husband for the last 2 months she hadn’t become pregnant.
The advice to HIV couples even when they are both “reactive” (HIV positive) is that they should continue to use condoms until they want to have a child and that they should only try to have a child when their CD4 counts (a measure of special white cells in the blood) are high indicating a low viral load. This means the risk to themselves from each other and to the planned child will be lower and is acceptable. We were surprised that the treatment with ART has become so well established and successful that the ethical dilemmas of taking the risk of bringing an HIV positive child into the world is now sufficiently small for this to be the standard advice. This is because the life expectancy of parents on ART is greatly extended and that Prevention Mother To Child Transmission (PMTCT) can be effective. This is why it so important for all pregnant woman to be tested for HIV and if positive to be treated with specific therapy. All their babies are then given a short course of ART and are then tested at six weeks which is the earliest it is possible to establish their viral load.
The patient then asked about whether she should breastfeed and we had to make sure, through the interpreter that she realized breastfeeding wasn’t the only way she could give her baby HIV. The other two ways of mothers giving their babies HIV is during pregnancy and at the delivery. However once in this situation it is safer to breast feed than not as they can better avoid gastrointestinal and other infections caused by giving formula milk, and not getting the mothers anti-bodies through the breast milk.
The final plan therefore was to organize for both she and her husband to have their CD4 counts checked and if they were sufficiently high to have unprotected intercourse, she was also advised that it might take longer than 2 months to get pregnant. If after say 6 months they were still unsuccessful they would both have to be investigated for infertility. The need and pressure for an HIV positive mother of two to have more children may be mainly cultural as if she can't it might drive her husband to find another more fertile wife.
At the end of this long consultation the patient then asked for an ART prescription for the child whose notes she initially presented to us. We explained that it would be better for us to see the child particularly because the child hadn’t been brought to the last appointment. It was at this point that the patient revealed it wasn’t her child but her dead sister’s who presumably died from AIDS. Athough our patient is the guardian the child lives with the patient’s mother, the child’s grandmother, who lived one hour by bus from Monze. They found it difficult to bring the child who apparently is otherwise well on treatment. Judy agreed to prescribe another month of drugs but said the child should be brought to the clinic next time if at all possible.
This case demonstrate many of the frustrations of this clinic; the random way the patients enter the consultation room unannounced, sometimes two at a time, occasionally with the wrong or incomplete notes or without them at all, the lack of support staff to find the notes and the occasional problems of trying to understand the expectations of the patient with the almost insurmountable problems of language and culture. It is impossible to get annoyed with any of the staff as they are also struggling to cope with the large numbers of patients.
HIV Reception desk in Monze Mission Hospital who do their best to find the right record for the right patient; not always easy or possible to find what the clinician needs when surrounded by lots of anxious patients and badly filed medical records.
The most numerous of the workers are the counsellors, who are all HIV positive and are my translators. The whole clinic is under resourced and undervalued by the hospital, which is very shortsighted as these resources will be needed more and more in the future. I can’t help wondering how much this is due to the fact that the hospital is underfunded or because it is now run ultimately by an elderly Italian Bishop who seems remote from the problems of the hospital, and passes many of them on to his PA who seems equally out of touch with the hospital's problems.
