Instrument of Torture

Photo of the week: An elephant emerges into the early morning sunshine

Highlight of the week: Ellie and Crispin are back in the valley - with our new electric toothbrushes - skanky teeth be gone

Lowlight of the week: A frustrating week with lots of taxi services to fit around our work

Maximum temperature: 34 degrees Celsius

Rainfall: None here in the valley

I blame the French. They are usually to blame. Responsible, in our eyes, for syphilis. The English externalise. Finding it hard to take personal responsibility when things go awry. Our nearest neighbours, and longest sparing partners, stand accused. Now responsible for our modern system of measurement. The metre. A way and a means of comparing. Ours is bigger than yours they chant.

Take an imaginary line from the equator, pass through Paris, and keep going. Until you get to the North Pole. Then, divide that distance by ten million. And there you have it. Voilà. A metre. Cast it as a metal bar. And the metric system is born. The new normal. A means of setting people apart. Heightism is born. Sod Politically correctness.

As a junior doctor in 1993 I looked after little tots in Tyneside. Care in the community of a sort. Checking school starters for deviations from the norm. Looking for late developers that might need extra help. And for short kids who might have a problem with their genes. Truth be told: if you measure 100 kids, you will always find some short ones. I blame their parents. If only kids would wear their genes, visibly, to school we could short circuit the whole façade. But of course, you find a short kid and their short parents want to swap the stunting effect of their genes with growth hormone. For now I’m going to leave Turner’s syndrome and genuine hormone deficiencies out of my commentary. They are too niche to worry your pretty little heads about.

Prepare yourself for a rant. A rant about a new health priority, chosen by the powers that be in Zambia. Nutrition is a valid concern in Southern Africa. Getting a decent meal is a challenge for people who live below a fairly low bread line. We have been measuring children’s arms for many a year. Tagging them for extra support, and extra nutrition. The evidence supports this worthy crusade. Mid-Upper Arm Circumference. MUAC. It is our key, simple, weapon. A way to find little mites in need. Low tech. Quick. Cheap. Easy.

But now in South Luangwa we have the son of MUAC. We hope for an evolution, but sadly we are presented with a mutant. Unfit for purpose.  A wooden frame designed to measure height and growth. Brace yourselves. My rant is in its infancy. Our infants now  have more measurements taken as they opt into the vaccination programme. Their weights already point the finger at smaller than usual tots. Now we have an extra layer of complexity threatening to overwhelm our already busy community health workers. Let me leave you guessing for a few minutes as to why I think measuring height is a bad idea in South Luangwa.

As a paediatric endocrinologist I was in charge of weights and measures in Middlesbrough. So I know a thing or two about heights and growth. I totally get that short people don’t like to be short. And that short parents don’t want to have short kids. Let me remind you that Zambia is classed as a Low or Middle Income country. An LMIC. With a strong emphasis on the letter L. I live for a third of each year in a country that needs to pick and choose how it spends its health Kwacha frugally.

At any one time I would have 30 little people with aspirations of grandeur receiving injections of growth hormone in Middlesbrough, England. My hospital served 1 million people. So let me guess that in my current Zambian Valley population of 20,000 souls that there may be one child at any time that might benefit from growth hormone injections. The manpower of our community clinic is wielding a new instrument of torture in the hope of finding a single short child. And on finding that one child we will look in our pharmacy for the absent growth hormone that could make everything right. In truth I am using artistic licence here. The new growth contraption is meant to find stunted children. Every school child already knows how to do that. Whilst picking teammates the titches are left behind. Our tots hanging from trees to check their weights somehow finds us littler ones than usual. VAR is provided by our multicoloured MUAC tape. The MUAC rarely lies. But now we have a random number generator running interference with our efforts to spot malnutrition in the community. Please hold your horses. I will show you my working as I lay into the new wooden instrument of torture.

As a growth guru in Northern England I had 3 main weapons: skilled staff; calibrated height measures; attention to detail.

Let’s fast forward to 2026. Our under 5 clinics are busy noisy places. Perhaps one hundred children swing from a tree. In well-seasoned and often stained hot pants. Two hundred might grace one particularly manic village canopy. Keith bought them some decent scales to make the numbers mean something. The pink and blue cards record their weight plots.

In principle growth is easy to monitor. Weigh a child each month. If the line goes up, the child smiles and everybody is happy.

On a bad month the growth line might be flat. The smile can also flatten and it’s that that makes us shift uneasily in our camping chairs.

And if bad goes to worse the growth line looks upside down. This negativity is usually matched with a grimace. MUACs are drawn swiftly from the holsters. Our Spidey senses  on edge.

Enter stage left the new wooden instrument of torture. Used to measure a version of the truth. A fraction of the distance from the Equator to a Pole. Judged by line of sight without the benefit of any real sense of calibration. But we now have heights recorded on growth cards and in registers. Never to be acted upon. Never to influence management. Statistic collected. No cause. No effect.

Our instrument of torture is a wooden structure. It has markings on it indicating height or length. It can either be stood up for a vertical child. Or laid on the ground if a baby is only capable of being horizontal. The feet should touch the bottom part. A sliding wooden slat should be lined up against the top of the head. Children are rarely straight and need to be squeezed gently into the reverse rack. This takes two people with inclination and training. And a number is created. Rarely indicative of height and almost never plotted against the age of the child. But job done. Rubbish in.

We pluck out cerebral palsy and early malnutrition using the well-oiled, proven tools of tree clinic surveillance. And our staff are now putting new time and new energy into a worthy malaria vaccination programme. They adapt and react. Happy to mobilise for a worthy cause. But let’s not send them off on goose chases in villages where we have no geese.

Let’s put the rubbish out. Monsieur Guillotine knew how to draw the line.

Remote cam photo of the week. Night time visits from elephants have begun

Sundowners at Wildlife

A banded mongoose family check us out

A beautifully plotted growth chart showing a flat line after 5 months. Plotted and then ignored until my spidey eyes spotted it last month. Further enquiries revealed Mum was a school girl who returned to school when the baby was 6 months old. This was when the breast feeding stopped. The baby is  just about surviving on watery porridge. She  is now in the nutrition programme getting extra food and support

A more typical weather beaten taped chart for a 4 year old

A MUAC tape - cheap, reliable, portable. Green is good. Red is bad.