Every breath you take

Photo of the week. My birthday present from Keith

Highlight of the week: Turning 60 was quite good fun

Lowlight of the week: Our hearts were almost broken. For 24 hours we believed that Lucy the leopard had been killed by a crocodile. But a reprieve today as she was seen alive strutting her stuff. In our eyes she has been resurrected.

Maximum temperature: A cool 33 degrees Celsius

Rainfall: None at all but we did see a cloud

I am breathing through a straw. It’s 1991. Somehow all the air that I breathe needs to come through a narrow tube. I’m 10 metres under the waves. Immersed in the Mediterranean sea. I’m not a fish, but I’m in water. My breathing is steady. My tube may appear narrow, but it is just the right size. But squeeze that tube and I am in trouble. Inspiration still OK. Expiration a problem. I have  simulated an asthma attack. 

Dr Ginny. Please see this one next. She is sick. Little Joyce and I meet eyes. We know each other. A quick assessment: Wheezy. Oxygen sats 90%. A fast pulse. Breathing fast. Unable to complete a sentence. Her asthma out of whack. Joyce is 6 years old. This is our third meeting. In 2 months. She’s officially a frequent flier. Somehow her lungs are failing her. Somehow we are failing her. Why can’t we fix her dodgy tubes? Why can’t her scuba pipes let her breathe?

Some malicious trigger trips a switch. Tightens her tubes and steals her voice. Each time she coughs a bit then gasps for air. Her mum carries her to clinic. On a good day mum borrows a bike. Our traffic light system at Kakumbi allows her to jump the queue. She has never waited to see me yet. Her care too urgent. Our care too rudimentary. Reactive not proactive.

Joyce gets the best reactive care to be had. I fish out a bag of tricks. A blue inhaler. A spacer with a mask. Five puffs of blue magic given through a simple plastic bubble. Low tech but still state of the art. Mum is sent to collect 6 magic beans from the pharmacy. Prednisolone. Her scuba pipes are being rebored.

Ten minutes pass and a smile appears. Joyce’s face a picture of relief. My smile reflects hers. She will now wait on the ward to let time and steroids quell the wheeze. Blue puffers at the ready to damp down any flaming embers. I ponder the options and hold my chagrin. Joyce can’t get state of the art asthma care here. Asthma care here sucks. We are stuck in the Dark Ages. Using make do medicines.

Let’s go back to the Dark Ages for a quick refresher. I remember prescribing salbutamol suspension in the hope that patients could tolerate the shakes and the racing heart. And hoping that eventually some of the beta excitation would land in the lungs. In the 90s progress binned the oral medicine and people moved on to gas cannisters. But of course those gas cannisters of salbutamol have their own problems. Let’s leave the ozone layer to one side for a moment. The metered dose inhalers come without a regulator. No way to stop you from spraying your throat. No way to get the gas into your lungs rather than your stomach. Repurposed Styrofoam cups served as make-shift spacers for the docs in the know. Heath Robinson eat your heart out.

The late 90s heralds a new kid on the block. A regulator of sorts. The drug companies realise that money could be made by creating purpose-built spacers. My scuba analogy finds another parallel. Salbutamol finds its mark. And my sub aqua lungs don’t explode.

Most days in Zambia we’re back here in the Dark Ages. Making do. I have a precious blue inhaler. Rationed and always attached to a spacer. The inequity of access to effective healthcare grates. The clinic pharmacy never houses even a single inhaler. For half of your daily income those with an income can buy an inhaler around the corner. Feed or breathe.

Gladly, we don’t mess about with nebulisers here at least. Our oxygen concentrator is coveted by the labour ward. And spacers are safer and more effective than a nebuliser anyway. Never mind that nebules don’t exist. Home nebulisers made a guest appearance in the UK in the Dark Ages. Mostly because a dependence on a home nebuliser allowed you to claim Disability Living Allowance, rather than because of clinical necessity.

But I digress. Joyce’s smile is waning. I relent and give her 5 more precious puffs. I bow to clinical imperative and visit the boot of our car Mzungu. I give Joyce a blue inhaler and a brown inhaler. Hardly the safest approach. Hardly the British Thoracic Society party line. And I give the family a quick tutorial on how to make a new style Heath Robinson spacer. Made out of a plastic drinks bottle. John Noakes and Peter Purvis smile down on me. Even without double-sided sticky back plastic my efforts pass muster. The base of the bottle, best cut through with a hot knife is tailor made for the inhalers. A slit near the mouth of the bottle creates a valve for little tots. 5 normal breaths the norm for little people. Big people take one deep breath and hold for 10 seconds when able.

Ostrich-style I provide unsustainable inhalers. Kicking the tin can down the road.

We major in lifestyle measures here. Often tinkering with the way that people live is all we have. Joyce’s family are banned from cooking inside. Smoke the prime trigger. All the other offenders are outside our control. Dust, pollen, mould, colds, pollution. We pay them lip service, but we know that we are fighting a rear-guard action.

We have a plan. Mum gets with the programme. A daily preventer. Rescue prednisolone at home. A wish and a prayer that mum can buy another inhaler when this one runs out.

Time is usually my favourite test. But in Joyce’s case time is not on my side. I am tested by the prevailing inequities of healthcare in Zambia. I leave in a week’s time. My attempts to train Joyce’s mum and the healthcare team will be tested by time. Let’s hope that time brings light into the Dark Ages. Zambia’s aspires to provide modern asthma care. Let’s hope that Joyce doesn’t expire before that happens.

Baboons and vervets share the spoils. 

Nothing beats a male lion in the early morning light

The dogs having chased their breakfast into the river 

Keith treats me to some bespoke jewellery from Mwezi Blu