Progress

Photo of the week: Stumpy's new tongue twister

Highlight of the week: A gorgeous stay at KuKaya resets us.

Lowlight of the week: We have gone off the Kapani leopard big time. We lose a close canine friend.

Maximum temperature: 41 Celsius

Rainfall: Only sweat, blood and tears.

One step forward. Two steps to the side. A knight’s move. There may be a plan. But that plan is not obvious to the casual observer. This week I’m musing about big data. Big data in Little Luangwa.

It’s 2015. Middlesbrough, England. We have been talking about going paper-free for years. Our trust is way behind the times. And yet, we don’t seem to be able to get our act together. Could it be a money thing? Do we lack computer know-how? Is the Boss not wearing the right trousers? Keith’s practice went paper free in the 1990s. I remember his angst at losing his little Lloyd George notes. He grumbled that his consultations would slow. But Lloyd George was cancelled overnight. Herrington Medical Centre progressed. The hand-written word died quietly. Fifteen years later, we are cajoled by the Trust to be the first department to bite the bullet at James Cook. Young and dynamic. Ready to evolve. Evolve is our new system. Naïvely we agree.

The bullet is bitter and takes some digestion. It takes about a year for Evolve to become fully embedded. Plenty of ward rounds crash and reboot. We falter as the computer says No! The tightrope seems impossible to tread. Paper in one hand. A computer in the other. Carrying both is perilous. Continuity ever important. Effective medical records the key to effective care. For 6 months we use both. Painstakingly we tolerate the duplication. Inching along to an elusive and ever distant goal. But we get there.

It’s 2020. The pandemic hits. We feel smart and smug. We are still the only paper free department at James Cook. We can work from home. Do clinics from home. Check on patients from home. Because all of our records are electronic. Paediatrics has evolved to like Evolve.

Fast forward to 2025. The rest of James Cook hospital is still dithering over its IT options. Our young and dynamic department can crow. Rest on our laurels. Mr Darwin could have written about this many years ago. Only the fittest will survive. Evolve and progress. Change and time marches on. Make the wrong choices and regress. The wrong beak on the wrong finch. Betamax videos. The Sinclair C5. The past is littered with also-rans. Likewise, the writing seems to be on the wall for paper. But what is good for Peter is not always good for Paul. Can Zambia embrace computerised medical records?

The sky is blue in South Luangwa 180 days per year. So a bit of blue sky thinking here would not be out of place. Our blue sky future in Kakumbi might include a virtual clinic network, permitting constant access to online records. Furthermore, the consistent coding of diagnoses and medications could permit Mambwe district to send us all the stock that we need, when we need it. For those of you who are currently indulging in blue sky thinking don’t let this particular Debbie downer burst your bubble for now…….

Even blue skies can turn cloudy - and so, we take the rough with the smooth. We are married to this Valley. In 2021, we made a vow: to return as Valley doctors for ten years, one annual stint at a time. Like any marriage, this commitment calls us to face sickness with health, year after year. For a decade, we stand by that promise.

There is massive contrast here between richer and poorer. We are funded to be here by the rich. Allowing us to champion the poor. Our ebony groves and mopane woodlands are not the same refuge as Sherwood forest though. There is no robbing, nor Robin here. But our time and expertise is gifted to the poor nonetheless. The rich give to the poor.

For better, for worse. While we’d like to believe that 'better' is always within reach, our experience as old African hands has taught us to expect the 'worse' too. The recurring frustration of empty drug shelves has nudged us to think differently - and so, we’ve leaned heavily into lifestyle medicine. Gently, we’ve placed many of our eggs in the fitness basket. Traditionally, Zambian culture has celebrated the status symbol of large bellies and buttocks. Yet, here in the Valley, we’ve made real progress in promoting the value of slimmer waistlines. Our converts have shaped their bums and tums - without skinny jabs. Even when the shelves are full: lifestyle is better, not worse, than medicine.

In 2025, the enduring vow takes on renewed importance: forsaking all others. In an age of overindulgent choice and instant access, that promise can seem outdated - almost trite. But in a ‘Trumpian’ Africa, where USAID support teeters on the edge, every tool to prevent Kachilombo cha AIDS must be embraced. We understand that men here will be men, and women will be women - so we offer some choice: Condoms. Circumcision. Or monogamy. But the greatest of these is love. Or... should that be faith?

Forgive me the digression - I do want to talk about big data and progress. But progress means little without first understanding the direction of travel. For now, I’m still making knight’s moves, opening the game with a few cautious gambits. Our VSO training in 1994 taught us patience: wait, watch, learn. After four tours of duty we now match the record here, totalling 15 months of round-the-clock service. That time has earned us the right to speak about how things really are - in our clinic, and in our community.

Over our four tours of duty, we’ve witnessed many changes here in Zambia. Some have undoubtedly been for the better - but others, not so much. Drug supplies remain inconsistent: occasional feasts, but more often, famine. The clinic has been especially quiet these past two weeks, likely due to a current drug shortages. We are, once again, in the midst of a famine. It’s fascinating to observe how health-seeking behaviour shifts in response. Patients know we have few medicines to offer, so many bypass us entirely and head straight to the pharmacy - where a cornucopia of pills awaits. There, with just a hint of their symptoms, patients and pharmacists collaborate to pull a mix of brightly coloured packets off the shelves. But medicines cost money, so they often leave with just two or three of everything: a couple of antibiotic tablets, some painkillers, a few vitamins. When they start to feel better - usually because their self-limiting illness has run its course - they stop taking the medication altogether. Not because the tablets worked, but in spite of them. And so, the cycle continues: antibiotic misuse rises, and antibiotic resistance grows, false health beliefs are reinforced. The pharmacists prosper - and so does Big Pharma.

Many believe that data holds the key to solving this riddle. Data is power. Data is knowledge. Data is money. We need to understand what illnesses people are experiencing, what medications they require, and how many patients the clinic actually serves. When you control the data, you can control the drugs. Monitor usage. Improve supply chains. Deliver the right medicines. In the right amounts. At the right time.

It's 2021, the clinic runs entirely on paper records. Each patient has a book, stored on-site. Retrieved and used at every visit. A diagnosis is required and recorded in a large ledger.  Along with any prescribed medication - a system that creates a basic record, of sorts. But accuracy is inconsistent. Diagnoses are often imprecise, and prescribing can feel arbitrary. Books go missing. Previous visits are rarely reviewed. Continuity of care is the exception, not the norm. A significant challenge for managing long-term conditions.

Fast forward two years - it’s 2023. To our astonishment, a computer system has been installed. Laptops now sit in every room. The paper is gone. A nationwide government IT health programme has arrived. Zambia, it seems, is ahead of the curve.

Meanwhile, in the UK, the government has spent millions attempting to create a similar nationwide health IT system - one that allows records to be accessed seamlessly across GP practices, community centres, and hospitals. So far, it remains little more than a pipe dream, failing spectacularly despite continued investment. Instead, most UK hospitals have rolled out their own electronic health record systems, with mixed results. Many are clunky. Unpopular with clinicians. Riddled with glitches. Time-consuming to use. Worse still, they don’t interface with primary care - so the whole idea of a connected system remains elusive. With that in mind, we didn’t hold high hopes for Zambia’s new system.

And rightly so. The Zambian system faces immediate challenges: unreliable networks, slow internet, and limited computer skills among staff - most typing with a single finger. It doesn’t seem to enhance consultations in any meaningful way. We are issued logins and, somewhat reluctantly, try to engage with the system. While plenty of data fields exist, most go unused. A few words might be entered under 'presenting complaint', but there is rarely any documentation of history or examination. A basic diagnosis is recorded, followed - when the system allows - by a prescription. When the system goes down, as it often does, we simply revert to books and paper.

Zambia, 2024. And nothing has changed. Poor data in, poor data out. It’s painfully slow, waiting for the system to load - when it works at all. Keith and I inevitably fall back on pen and paper. This is the year of load shedding - or power cuts, as you and I would call them. The clinic’s solar panels rarely work, and no power means no internet, no computers, and no data collection. No big data.

We return in 2025, hopeful for progress. And sadly 😉 the computers are still sitting on the desks. But this time, the staff seem a little more optimistic. The IT system has undergone a major upgrade, funded by the US (though for how long, we wonder) and South Africa. The clinic’s Wi-Fi network has noticeably improved, and the in-charge is now firm: we must use the system.

It’s Monday morning. As usual, the staff are deep into their weekly meeting. By the time they emerge, a crowd of 30 patients is already waiting to be seen. The team filters into the consultation rooms. Keith and I agree to divide and conquer - one room each, paired with a member of staff. The computers are switched on. But all we see is the familiar spinning wheel of doom. The network is down. Again. At that morning’s meeting, staff are told they’re no longer allowed to use books. Or scraps of paper. The IT system must be used - no exceptions. So we sit. Unable to see a single patient.

An hour passes. The waiting crowd swells from 30 to 40… then to 50. They sit patiently. As do we. Waiting for something - some invisible force in the ether - to change. Eventually, the in-charge relents. Scraps of paper are torn from old ledgers. Patients are registered manually. Piles of paper are handed into each room, with just a name, age, and village scrawled at the top. That scrap becomes the record of the day. It’s binned when the patient goes home. No continuity. No data.

Hoping for progress, we’ve actually taken a major step back over these four years. Exercise books once kept a basic record, and while the computer system is surprisingly user-friendly, using it properly means each patient’s visit takes 10 to 15 minutes - everything documented, a thorough record kept. The system requires a diagnosis before you can send a patient to the lab, pharmacy, or home. It doesn’t just expect it - it demands it. Yet, what gets recorded can be comically on occasions. Histories are shallow, examinations cursory and the plan usually includes whatever is available in the dispensary. These knight’s moves lead to ill-fitting prescriptions. Online prescriptions allow the pharmacy to track medications - and our drug cupboards remain bare.

There is no central record or regulation for our local private pharmacies. They can buy and sell whatever they like. Profit is their bottom line. Better sales drive higher salaries. Bonus style. Their stocks eclipse our clinic pharmacy. No prescription needed. Many cut out the middle man and a potentially long wait in clinic. The pharmacy, eager to please, sell whatever the customer wants. No queue. Corners cut.

I would have made a terrible data analyst - especially here in Zambia - knowing that so much of the data being entered is unreliable, even meaningless. Our own staff benefit from close supervision, so we assume their diagnoses and prescriptions are more accurate than most. But across the country, the majority of clinics are run by clinical officers and nurses who receive little to no support after qualification. It’s the classic problem: rubbish in, rubbish out.

IT is here to stay. A necessary evil. It’s not my first love though. I prefer to doctor. To teach. My patience with revolving wheels is poor. Revolutions that precede evolution undoubtedly. But for now: I can’t wait.

Our knight is moving in a manner that would be certifiable anywhere else. But that doesn’t mean that our knight should stall. Our Zambian clinical notes are currently stranded. Occasionally fluent and online. But usually elusive, papery and thin. But chess-style gambits are often seen from way off. Part of a master plan. Our Grandmaster out of view. We should trust that progress is not stale-mate.

Web cam photo of the week: Cross species cooperation. Getting groomed at the water hole.

A post coital roll in the grass

The crocodiles make fast work of a dead hippo