I am sitting drinking a hot cup of tea, wrapped in a sheet with odd socks on under my skirt. Winter has come to Zambia and we are all unprepared. Having believed the childhood lady bird picture book that life in Africa would be continuous hours of sunshine and zebras we have all bought with us only summer clothes and now the nurses laugh at us when we emerge onto the wards cocooned in whatever various layers of scarfs, socks and leggings we can find. They also are taking winter dressing very seriously. Most of them are wearing whatever coat they found at the market which include full length fur jackets obscuring their white nurses’ uniforms or the more glamouous Paeds nurses who just bring the malnutrition room heater to the nurses’ station and sit cuddled around it. It had been sunny up until now but a few weeks ago the weather made a turn. This was inextricably linked in my mind to the day the EU referendum results came out and we were all awake from 3am with an increasing feeling of dread and cold worsened by looking bewildered out the windows at a grey and misty Zambian dawn, shivering in our sleeping bags.
Since I last wrote we have had a wonderful time on holiday in Malawi risking our lives on motorbikes over mountains as the sun was setting, wandering in green tea plantations under mountains and spending very precious time laughing and catching up with old friends. D has told you all about it in his writing last week, it was a lovely break from our little well-trodden routes around the hospital here and we arrived back full of energy for our last 6 weeks here.
The hospital has been a little quieter recently as it is cold and harvest time so people are staying at home. This has given us a lot more time on my wards to talk to patients and the nurses. The mothers on SCBU (our baby unit for babies who are very premature or who have infections or didn’t get enough oxygen at birth) especially the ones who have babies who are premature can end up staying with us for a very long time – the longest at the moment is a shy 17 year old mother whose little baby weighed 900grams at birth and is now on day 51. We get to know them quite well and whilst Dr Z (the Ukrainian doctor on our ward) likes to tease them by telling them they are going to stay up to Christmas (which backfired last week when one burst into tears in response) I prefer to try to persuade them to give their babies hilarious names fitting to their time in SCBU – Patience for the one who has been here 51 days, Rachel for one I resuscitated, Peace for one who cries a lot – you can see the hilarity. The mothers humour me but actually babies aren’t normally named here until they get home from SCBU and then the first child’s name is chosen by the grandparents who have to bring a gift for this privilege. The name has normally been chosen by the time they come back for review and I love finding out what they have decided on – the nurses tell me off because I get more excited about this than the actual weight of the baby which I am supposed to be checking. My favourite so far is twins called “Sarah” and “Same”.
Women have children very young. If they are in school when they get pregnant the father is meant to pay them “damages” for disrupting their education which is often calculated in number of cows. Money is also paid by a man to marry a woman – I discussed this during a break time conversation with three of the nurses which also included questions about the value of the pound, why refugees are leaving Syria and the social welfare system in the UK – all of which are quite tricky concepts to explain it turns out. The nurses were very excited to hear how much D. had paid for me and when I told them “nothing” they were horrified. Mrs P. one of the slightly older nurses who is especially motherly and kind exclaimed that she didn’t know how I could bear to live in a country “in which woman were treated as completely worthless like that”. I tried to protest that – no no – we actually quite liked it that we were not paid for like something to be sold – but this fell entirely on deaf ears and she just gazed sorrowfully at me as if I had been completely brainwashed by the “entitled men in my society”. D has gone down significantly in her estimation ever since.
A collection of my favourite moments:
- – I was called to see a newborn baby in SCBU, he had been placed wrapped in a green theatre cloth on the resuscitaire – pale, cold, not breathing. For once it was one of those babies who has read the Newborn Life Support protocol and started crying and wriggling after my first 5 rescue breaths. I popped out of the hot room to write something in the notes and when I returned a slightly older woman wearing the hospital red and blue gown was stroking the baby with tears running down her face saying to me “Doctor! A beautiful baby! Look he is a beautiful baby” repeatedly over again. It is rare to see mothers being that affectionate with the babies in SCBU and I was quite taken aback. It turned out this mother had 4 babies die previously and had seen this baby hadn’t cried when it was born and so had come to SCBU resolutely ready to collect the wrapped body of yet another dead child. Instead had found her baby – bright and eyes open.
- Babies over 3.5kg (about 7.5lb) are rare for us to see here. L and I came across one who looked monstrous in size – pink and chubby and screaming, wrapped in a giant flowery furry blanket – we had taken a full history from the mother about the possibility of diabetes, examined the baby in detail for any dysmorphic features – before we registered that this was just a normal sized baby. Babies in the UK will be a shock.
- We have a Paediatric clinic once a week where we bring complicated children back for review and counsel parents about children with chronic disease such as Downs Syndrome, Cerebral Palsy and Epilepsy. Last week I saw a 3 and a half year old little girl with beautiful braided beaded hair and a puffer jacket coat who had a huge mass in her abdomen – I was able to make a likely diagnosis of a particular type of cancer, explain this to the family and then arrange for her to be transferred to a Lusaka for treatment. The father had a lot of questions and it was lucky that our one other child who has the same cancer but who now comes back weekly for chemotherapy was on the ward at the same time and I was able to put them in beds next to each other to make friends and share experiences. It’s rare for us in the UK as junior members of the team to be able to manage the whole story of a patient from presentation to treatment plan and it was very rewarding. The clinic is one of my favourite parts of the week because we also get to see some children coming back who we have spent hours with, sick and unconscious, not walking again after severe malaria, quiet and apathetic with severe malnutrition who are now cheerful, smiling, playing. Particularly recently has been an extremely cheeky little boy called ‘Happy’ who perpetually wears a pink velour tracksuit who came in a wheelchair puffy and swollen up with Nephrotic syndrome (a condition where your kidneys leak out all your protein) and spent a week in our ICU. He came back skinny last week with his devoted parents who faithfully record all his treatment in a dog-eared exercise book, high-fiving the nurses and telling me “hello Dr Laychel – we should cut off some of your hair and stick it to my head”,.
We were doing the ITU ward round last week when we turned around to see 5 police men and about half a village crowded into our little treatment area around a small bundle which contained a little baby covered in mud who had been found abandoned in a ditch lying there for what we were eventually worked out was about 24 hours. We gave the baby a hot bath still scrutinised intently by the village who seemed to have set up camp in the ward – this clearly being equivalent of reading the Daily Mail for them – before they were ushered away by one of our stern kitchen staff. The family of the baby were identified and managed to bring in the mother, a school girl who had reportedly panicked as she didn’t want to tell her father she was pregnant, and had thrown the baby away. This presented the social work team with a dilemma. Put the woman in prison as the police were suggesting and the baby would likely starve. Formula milk here is very expensive. You also need clean water to make it which means more money for firewood. Families will often over dilute it to make it go further. We see babies in malnutrition whose mothers have died and have been fed nothing but milkshake and yoghurt because the one tin of formula milk they can afford has run out. In the end the baby was sent home with the mother after counselling from the police and social work team who told me “we decided forgiveness is the most important”. Families here make huge sacrifices for their children but amongst them are a few who are neglectful or abusive. This is something I have found difficult to deal with – repetitively trained as we are in the UK to “safeguard children” “information share” and pick up on any possible signs that a child is at risk. I see these signs all around me but there is very little to do about them. L and I are looking at our management of malnutrition for all children admitted in the year 2016. We particularly remember being asked by our nurse in charge “Do the children with malnutrition in your country often die?” He was disbelieving when we tried to explain that we don’t see cases of severe malnutrition often, if ever. One child who has stood out to us is a little girl with HIV, TB, the child of a young single mother who was charming and spoke good English and who was admitted twice and then died on the third admission. Retrospectively we can recognise signs this mother was not feeding or looking after the medical problems of this child. The unanswered questions of how we could have better protected this child do weigh heavily.
This is our last week in Zambia! Coming back to the UK seems a little daunting although top on my list of things I am looking forward to is eating strawberries. Our life here is in many ways very simple and well defined. People right in front of you need help, you can help them in a small way. For a short time you can pretend there are no more layers of complication than that. Going home means we need to face normal life and challenges which seem much more blurred and harder to fix. A lot of my friends at home are disillusioned with our systems and decisions by our leaders. It is easy to feel downhearted but I hope that we can be determined as a generation to not run away from things because we are disillusioned about them but to have courage to make kind, wise and thoughtful decisions as we try to navigate the way forward. One thing I want to be better at when I get home is holding things lightly. Knowing that I am happy to be able to experience what for so many is an inconceivable privilege – a peaceful walk, a hot shower, eggs and coffee on a Sunday morning, a warm scarf on a cold slanting day, the opportunity to study in a library full of books or walk between the multiple rooms in my house – to enjoy these things – not to feel guilty about them – but to recognise that if in the blink of an eye they were all removed from me I would still be luckier than an immeasurable number of the world to have experienced them in the first place.
Thank you so much for keeping up with our time here and all your kind words and support. We are so excited to see friends and family at home again. I will write to let you know when we are back home – we have a few more weeks before the interlude is over and the next scene begins*
*D dared me to use that line. Analogy at it’s best.