Tryp... tryp... tryp. A pain in the bum

Photo of the week: We get held up on our way to work

Highlight of the week: We dance our way out of clinic. There is no cure for our strange gyrations. We are compelled to dance for our lunch. But at least it’s a free lunch for our staff.

Lowlight of the week: The party is over. This is our last full week as Valley docs.

Maximum temperature: 42 degrees Celsius

Rainfall: The forecast suggests that our seasonal rains will be lower than average. Average at best.

It’s 1905. South Luangwa is in splendid isolation. Dual forces are at play. Forces hell bent on depopulating our Valley. A deadly illness is affecting colonial settlers. Sleeping sickness. Colonial authorities declare South Luangwa a no-go area. Cattle and men go home. The wildlife go wild. This is the beginning of South Luangwa as a conservation hotspot.

It’s Sunday. One hundred and twenty years later. Our day of rest. We charge double rates on a Sunday. To deter the not-so-sick from calling us. We plan our day: a drive in the park; a bush breakfast and coffee; home for a late brunch; a relaxing afternoon; a dip in the pool to cool down; a comforting evening meal; early to bed.

But our Sundays rarely go to plan. It’s Zambia, don’t you know? We start with a kerfuffle. None of our guide friends are free. Their open game viewing vehicle is double-booked. Plan B is a self-drive. It’s Joel’s last day here. We can’t not go in the park today. Breakfast is made the night before. Bags readied. Kettle full. Coffee grounds await.

05:00. The dreaded alarm clock goes off. Still dark. Silent. The baboons are very sensibly still sleeping. We drag ourselves up. Shower. Dress. Boil the kettle and make coffee. Fill the cool bag with breakfast and cold water. In the car by 05:45. At the park gate by 06:00. We glean some info from a guide. There may still be a leopard up a tree. With a kill. On the way to Wafwa. I saw it last night. It’s 50:50 that the leopard is still there. 

The uncertain post prandial habits of a leopard determine the direction of our drive. We turn right down Mushroom loop. En route to Wafwa. The Dead Luangwa. A now dry oxbow lake. But our instructions are vague. The candidate trees numerous. I swear I look up all of them. No leopard to be seen. But that’s fine. The park is peaceful. We watch a herd of elephants lazily walk to the river’s edge. Drink. And turn around. Three giraffe go one step further. Into the water. They cross the river, right in front us. The water barely laps their ankles. Scarcely. Drought the word on our dry lips.

We continue to head north. Chipela Chandombo Lagoon our breakfast oasis. One of the few lagoons in the valley still holding water this year. Mzungu’s doors open cautiously. A lone hippo plays dead in the lagoon. No threat here. We alight and drink in the scenery. We drown our breakfast muesli with milk. Coffee also rehydrates us.

It’s 08:30. Breakfast is serene. Birds flying. Impala drinking. Peaceful. Quiet. We listen for alarm calls as ever. Expecting the bush telegraph to warn of danger. But there are none. Our breakfast time sacrosanct. We savour our breakfast. On cue the serenity is broken. By an unwelcome harbinger of doom. An annoying little ringtone. An insistent chirrup. An alarm call of sorts. The Doc phone. Hi guys. Sorry to bother you. My husband has a bite. I think it might be a spider bite. But I am worried it could be a tsetse bite gone bad. All this talk of sleeping sickness has us worried sick. Can you come and see him?

A picture arrives through the ether. A lesion of interest. A possible chancre. A purple ulcer surrounded by redness. All that is missing here is the story of a painful tsetse fly bite in the preceding days. Our interest is piqued. Mzungu becomes FAB1. I become Lady Penelope. Parker, my loyal chauffeur, engages the Rolls Royce thrusters. We head off to clinic. Thunderbirds are Go!

Let’s take a short intermission here to tell you a bit about Trypanosomiasis. Easy for you to say. Most medics here call it tryp. To avoid tripping over their tongues, most likely. Sleeping sickness is the lay spin on it. Tryp is a parasite spread by tsetse flies. Bastard flies sums it up. With chainsaw mouthparts. They bite through clothes. Boy flies and girl flies both bite. At least they aren’t sexist. Neither gender gives a figs arse about DEET. Not caring that they hurt when they bite. Oh and tsetses are almost immortal. Armour plated. A full Newton force is needed to crush their robust bodies. An apple dropping from a decent height onto hard ground might just do it.

There are 2 forms of tryp. In West Africa tryp causes a chronic, protracted illness. Trypanosomiasis Gambiense takes weeks to months to wear you down. Leading to a gradual decline in health. Your brain function muddies up. Altered sleeping patterns. Eventually it is fatal, if not diagnosed and treated. But Trypanosomiasis Rhodesiense is much more aggressive. Found in Eastern and Southern Africa. A fast burn. Symptoms appear 7 to 10 days after a painful bite. Then comes an ulcer surrounded by anger. The chancre is often not especially painful. But it usually looks angry. Fever. Headache. Muscle and joint pain follow in short order. The parasite makes a beeline for the brain. Wreaking havoc on brain functions. Confusion. Delirium. And death is inevitable without treatment. Within 4 weeks or so.

When we first came to the valley in 2021, tryps seemed to be asleep. Our predecessors knew nothing about its latent ways. The received wisdom being that sleeping sickness has been properly put to bed. I won’t be needing to know about that. I delude myself. The tryp parasite disorganising my thoughts already.

Two years tick by. It’s 2023. I am doing my DTM&H course. Tropical medicine. And let’s not forget that critical hygiene part. Diseases around the world are now my daily diet. I want to cope with the bugs and nasties found in South Luangwa. But I’m forced to take in the also rans. Fascinating and alien-like parasites, but surely they’re all irrelevant to me? My remote course in Glasgow goes big on Tryp. A whole week of my timetable seems focussed on this niche ailment. I plan to doze through the lectures on tryp. This could be a big turn off.

The timetabled tryp week kicks off. I have a pillow at the ready. Next to my computer. But as I practice closing my eyes, Professor Lucille Blumberg appears on my screen. From Johannesburg. South Africa. Lucille opens my eyes. Wide. She presents a series of cases. Tourists on holiday. Many from South Luangwa. At this point I cancel the day dreaming plan. I’m in the room. Well, the virtual room, at least. Six cases since 2011. Not common. But ever present. After the lecture, I stay online. For a private word. I explain that we have been told there is no tryp in our Valley. This seems to be a mistake. Closing our eyes to the sleeping beast. Potentially this approach is responsible for late presentations and avoidable deaths. I now have a hot line to the Human African Trypanosomiasis expert.

This year the sleeping beast has awoken in our valley. The first confirmed case of tryp in 6 years was in April. Three months before we arrived. The diagnosis was delayed. The incumbent doctors were late to the party. Confounding factors confounded them. A plan is made, to play things better next time. Experts in South Africa arrange meetings. Zoom clicks into action.

It’s June. We are at Manchester airport. Being Trumped by the Qatar air traffic control shutdown. Fireworks cross the Gulf skies and we are stranded. I stand in a queue for 2 hours at the Qatar desk. Keith is on a conference call with Lucille and Evan Shoul amongst others. About Tryp. They discuss education campaigns. Raising awareness. How do we ‘fess up that there is still tryp in the valley after all? Might the tourists stop coming? A plan is made. Tourists and locals should watch out for painful bites going bad. Increased surveillance. Information sharing. And a plan of action for suspected cases. Photos of lesions of interest. Communication.

There is a new kid on the block. The tropical health block that harbours our specialist colleagues Lucille Blumberg and Evan Shoul. A wonderkid. A new, safe, drug that kills tryp, dead. Treatment these days for tryp should be straightforward. But there is a but. Delay in diagnosis, or delay in starting treatment, and our noxious, antisocial, parasite has a field day. Munching up brain tissue. Irreversibly scrambling neurones and their vital connections. The wonderkid is taken as a course of tablets. A little monitoring is needed. But otherwise the little Pac-Man style brain munchers are sent packing in short order.

But until this week the wonderkid drug is a little hard to come by. Fexinidazole. Held centrally by WHO. Apparently there is no Fexinidazole held in Zambia. That’s all well and good if you have medical insurance and can get to Jo’burg. Where Lucille and Evan will guard your back. And most importantly they will guard your brain. But it’s not so good for lowly Zambian farmers and safari staff. Who might just languish on understaffed wards, waiting for an elusive test. Dying in want of a diagnosis. Invisible to WHO surveillance. No disease. No drugs. Chicken. Egg.

Testing is also an issue. There are no quick and easy tests for tryp. Skilled laboratory technicians are required. Most lab staff have been taught from the same faulty song sheet. With the wrong music. They tell us that blood needs to be taken between 01:00 and 04:00. Plain wrong. Any time of day will do. No one wants to be up during the witching hour. So many don’t test. And that usual test is pretty tricky to do well. The sleeping tryps stay cloaked, masquerading as common or garden malaria or meningitis. No known sleeping sickness. No notification to WHO. No need for drugs to cure it. Get the supply chain wrong. And no supply. Unknown unknowns our problem here.

Let’s return to Sunday morning. We beat a hasty retreat from the park. Our patient, Bruce,  meets us at clinic at 09:30. He looks chipper enough. Walking wounded. A pain in his bum. At the site of the bite. No fever. A mild headache. General aches and pains. We examine the bite in more detail. And share the uncertainty. WhatsApp style. Our WhatsApp group is super high powered. Lucille, Evan, ourselves and Franklin. Franklin the top tryp doc in Zambia. And then we place our bets. Each of us ventures our opinion.

Certainly it’s not typical of a tsetse bite gone bad. Still a tryp chancre is at the top of our list. It needs to be ruled out. The story, and the lesion of interest, both point to a spider bite, or a tick eschar. Spider toxin leaves doctors all at sea. We have no tools in our kit for that. But at least tick bite fever is easy to treat. We’ve talked a lot about our favourite test before. Time. But tryp steals time. We can’t wait for time to make our diagnosis. We can’t wait for the deadly Pac-Men to munch on Bruce’s brain to give the game away. Time waits for no man. Our problem is time critical.

It's Sunday. There is a skeleton staff in the clinic. No duty lab technician. Lucille’s words echo in my head: Get a drop of blood. There’s no need to stain it. Look down a microscope at a low magnification. Fresh tryps will dance. But my enthusiasm is instantly dashed. The first hurdle too high. The lab is locked and the key is out of town. Drat. And double drat.

But Keith holds the ace card. He plays it with a flourish. Gloria promised me that she can test for tryp should the need arise. He announces with a smile. He barely supresses a smirk. I’ll message her to see if she is available. I stay quiet. Not wanting to dash Bruce’s hopes. Sunday remains the Sabbath in Zambia. The best we can realistically hope for, is a test on Monday.

I close my eyes to let the sleeping sickness take me for a moment. But when I open them Gloria fills my view. In her Sunday best. Straight from church. Lady Penelope stands down. Gloria who works for the fisheries and wildlife department, has access to the holy grail. A laboratory with microscopes and a PCR kit. To cut a long story short: she even has the ability to detect the minutest particles of tryp DNA in blood. It will take a few hours. It needs laboratory graft. But if we provide the blood, Gloria can do the tests. Our patient rolls up his sleeve. Blood is drained from a vein. And off Gloria goes. Promising to contact us in 4 hours. With the result.

Nobody has placed a bet on Tryp. Yet it’s still on the table. Our WhatsApp group plans for contingencies. We chase the elusive Fexinidazole. The word on the street is that, despite assurances that it can be made available within 24 hours, it would take 5 days to arrive in Lusaka. Five days that Bruce does not have. We treat Bruce for the treatable. That includes doxycycline, a simple antibiotic that does for tick bite fever. Best taken on a full stomach and not just before you sleep. We warn Bruce not to sleep after taking his antibiotics. And we say a silent prayer, on the Sabbath, to ward away sleeping sickness.

Its 17:00. We are driving to the airport. Joel is off on his adventures. After a month cooped up in Kapani and Kakumbi. Joel leaves our nest a little empty. He fledges and aims to flit around. Two months of fluttering around Botswana. Namibia. Possibly South Africa. The phone starts to warble again. It’s Gloria. The PCR is positive. Bruce has tryp.

Organising Bruce’s ongoing care involves a familiar and frustrating battle. Another insurance company trying to save dollars. I can’t bear to describe the convoluted dance that Bruce’s wife, myself and the monkeys representing Bruce’s insurance company have over the next few hours. We have grumbled about this process before. A battle I always seem to win. But the protracted campaign tests my grit and Bruce’s wife’s resolve. Bruce’s unscheduled trip with tryp to Jo’burg is magicked as a consequence of my 13 years training to be a doctor and my 18 years in practice. This Valley has invested in Valley docs for one main reason. We can do magic. And that magic is ensuring people fly out of the Valley when they need to. In extremis.

But this isn't the only magic worth reflecting on today. This Sunday, an extraordinary team of professionals come together - both virtually and in person. With One shared mission: to save Bruce's life. A true display of the One health system in harmony. Vets, human doctors, and public health experts, all working in sync.

Here we are, in the heart of rural Africa. United through accessible technology. WhatsApp keeps us singing from the same One song sheet. Together, we work toward a definitive diagnosis. On standby, Africa’s leading expert and her team prepare to tackle this strange and fascinating parasite. Meanwhile, Gloria spends her entire Sunday in the lab. Dedicated, focused, relentless. NHS - read this and weep.

Tryp … tryp…tryp. This won’t be the last we will be hearing about this parasite. We have had 3 confirmed cases this year. The wildlife and fisheries department are setting up tsetse traps all around our Kapani home camp tomorrow. To catch tsetse flies. To explore their guts and glands, looking for human tryps. They will look for any hot spots. Tourists are almost never affected. But they need still need to know to look out for painful bites going bad.

The writing is on the wall for tryp. We now have a safe effective treatment in our hands to treat patients in all stages of sleeping sickness. But the key to us winning this war is to share uncertainty. Tourists, guides and docs must all play their part. Bad bites are shared with us on WhatsApp. Even if it is a pain in the bum.

P.S. WHO has woken up to our plight. Fexinidazole is now in Zambia. No big trip is now needed to treat tryp.

Remote cam picture of the week: Get a room.

Setting tsetse traps in Kapani. 

A rare siting of wild dogs. All a bit camera shy

Another uninvited visitor glows in the UV light