In private

I found all the technology hiding in the private practice world of Zimbabwean health care.

As in many other countries, there is 2-tier health care with (1) government, public sector that is sliding scale and (2) the private practice world with increased access, costs, efficiency, and quality of care. In both cases, it's pay-as-you-go or hope your Medical Aid (insurance) covers you. Medical Aid doesn't reimburse physicians very well, and not everybody takes it... hmmm, sounds familiar? If government doesn't have what you need, you can separately purchase it from "in private." Need lamotrigine? MRI spine? Myasthenia antibody tests? You guessed it, I'll write you a req to get it in private.

My mentee, Andrew, took me to the private Baines/MRI institute for a meeting with Dr. Nayak, the only neuroradiologist around (trained abroad, used to work as a professor in Canada). He is great and although private, has a semi-academic stance. He set up imaging for Parirenyatwa (the University hospital where I have been working). Currently, University CT scan needs repair of a part, and has been down for the better part of a year with no recovery date in sight. An MRI machine Dr. Nayak helped set up some years ago ran out of helium years ago during a helium shortage and was obsolete by the time everything was available. So, now, if you want imaging, you ask the patient to "organize funds" and obtain "in private." I have been referring all the patients to Dr. Nayak, since he can do the MRI cases I really need for $500. He is trying to compete with cheaper CT scans because he sees so many low-yield CTs done when an MRI would have given the answer. He is willing to do pro bono because he is so sincere about cases that need urgent imaging.

He also runs weekly neuroradiology conferences with invited neurosurgeons and interested residents, and this week -- a neurologist :) The neurosurgeon brought some spine cases of patients who he had done EMG. Unclear how he was trained. Dr. Nayak showed some cool cases from exotic to bread and butter. See if you can guess the diagnosis of this 23 year old female with first time seizure. Answer.

Great Zim III: safari

Wildlife adventure continues in the
nearby Lake Kyle national park. Despite being summer (the rainy season), the lakebed is visible and hard enough to drive on. The volume of water is low. This is a product of global warming, recognized from farmer to doctor to driver.

In this "bay" we find 6 adult and child hippos that intermittently rise up from the water to snort or get air. Do you see the top of their heads poking up from their submerged safety? An eagle flies towards them.


Warthogs abound, whether on the plains or in the nearby town. One local villager feeds the warthog sadza as they assist in cleaning off dinner plates. There are no dogs here.

Great Zim II: origins

The great kingdom of the early Shona people in the 12th - 16th century lay here at Great Zimbabwe. It is the second largest man-made stone structure in Africa following the pyramids. Archaeologists confirmed the complex was built by Africans, rather than other debated origins such as Phoenicians. It is no Macchu Picchu, but is impressive for it's solid stonework made WITHOUT any mortar and is largely still standing. 

Brief history lesson: British  Cecil Rhodes colonized this land in the late 1880s forming (Southern) Rhodesia, which combined with northern Rhodesia (Zambia) and Nyasaland (Malawi) to form a federation. By 1960s, Malawi split off. Ian Smith declared Rhodesia independent in essential rebellion from Britain, since they parents had a rule of no independence before minority rule and Rhodesia was entrenched in white majority government. This is when Mugabe and others led civil war to overthrow the white govt that only apartheid South Africa recognized anyways. In 1980, independence was granted and Mugabe elected president. Country renamed from Shona dzimba
(house) dza (of) mabwe (stone), referencing these Great Zimbabwe ruins. 

The ruins are a 3-part complex. The first is a hilltop residence of the King and his senior sister-wife. It's designed as a fortress and works in the natural boulders into the design, like this passage that forced visitors (or attackers) to go up single file.

The king's meetings were held in this courtyard, where he and his wife made decisions from the wing of the Eagle shaped edifice. The  bird motif is repeated in soapstone totems (now in a museum) with one to represent each king. 

The Great Enclosure is composed of an inner and outer wall that served to train the town's boys & girls in daily activities. The walls of the enclosure are 4 m wide at the base and 3 m wide at the top, with no mortar between the brick. A feat! The conical tower is an icon of Zimbabwe and was previously featured on the Zim dollar. Now they just use the US dollar, everywhere, in a cash market society. 

The Village complex is the home to the junior wives (apparently polygamy was practiced).  Traditional dance and dress with animal skins. Anklets were tied to the calves with shakers made from dried gourd.

Last time I traveled to South America and Ladakh, India, I was impressed with the similarities in dress, practices like women carrying tying children to their backs and loads on their heads, and various styles of anklets or music dance amplification.

The archaeologist in me wondered about the story of Great Zimbabwe, and what evidence supported many of the claims. While the majority of the story is from the oral tradition, there is evidence of diet/kitchen from animal bones, beads, pottery in varying levels that have been carbon dated showing the different timing of occupation, and trade items from China or the Middle East supporting Great Zimbabwe as a town of trade. Although this area is land-locked, it was full of gold and attracted visitors from far away. Even today!

 

Great Zim I: on the road

Weekend trip to Great Zimbabwe, an archaeology and UNESCO World Heritage site, south of Harare. Remember, the one that connects to the caves to the north? But to get there is an adventure in and of itself.

When in doubt, SIPHON!

At 9am, I was picked up by our driver as planned with the rented (=paying a friend) car. Were we actually leaving on time? No. The radiator is acting up. After an hour of cooling the engine, pouring in water and coolant, it was clear this car was not the safe choice. We downsize from a petrol-guzzling land rover to a Toyota. It has a donut spare on the back tire; another hour goes in finding a new one. And of course, the issue of fuel -- we had already paid to fill up the guzzler. Solution depicted.

PS: There is no "customer service," "discounting" or validating that incredulous feeling of why the driver did not check the car the night before upon receipt. I probably could have worked my usual magic, but this transport was organized by a Colorado professor who was far too polite to haggle. His solution... "low expectations."
At 12:30pm, we depart, passing through the flat, grass-tipped savannah peppered with wind-swept trees and sun-baked corn husks to which I have grown accustomed. 4 hours, 2 $1 tolls, and 1 police checkpoint later, we arrive to Masvingo - the closest main town before the ruins.

The trusty guidebook leads us to St. Francis of Assisi church, honoring Italian prisoners of war who were brought to Rhodesia (Zimbabwe) from Ethiopia during WWII in 1940s.


Some are interred here, and their ashes are stored behind their memorial plaques.





The ceiling inside is covered in mosaic-style paintings. The outside has an Italian villa feel. Contrast this with the outdoor churches of the Apostles seen frequently in any potential corner of field, full of worshipping Africans dressed in white.

We reach the hotel, and while the others decompress, I grab Jackson to drive out to the lake. We run into young boys not tending to their herds well (hiding in the bushes instead of keeping their goat / cows / buffalo off the road). But, we eventually catch the picture-perfect sunset. Breathtaking.

Puncture

There are spinal taps galore for every patient with a stiff neck, r/o meningitis. For neuro, we are seeing a lot of CN palsies, especially in HIV patients. It often represents seroconversion, opportunistic infection or TB, or lymphoma.


Have you ever used an 18 Gauge IV cannula for an LP? I can now say yes. See the green tip object in the upper left on the tray? That's it. It's actually recommended in the essential drug list of Zimbabwe if no spinal needles are available - and routinely done throughout subsaharan Africa.

I actually failed the tap with the cannula, but I think it was because the patient was very dry and cachetic since I know I was in the right space. There is something about being volume down leading to unsuccessful taps short of crypto and having very high ICPs. Next time, a resident helped me sweet talk the nurses from the theatre (OR) to share their 19G spinal needles. She had to ring this old school bell to call them.

Despite getting a spinal needle, I have yet to see a manometer. Instead of giving up, we got creative and used IV tubing to literally measure the opening pressure.

Cavewoman

Made it north ~150 km to Chinhoyi caves.
Rangers attempt to charge us triple "foreign" rate. As everything is a negotiation, our colleagues explain that we are physicians working at Pari. This is highly respected, and we get in for the locals' price. Being a doctor matters!

Upon entry, I spot bright blue beyond a tree and am unsure if that is sky, water, or some reflection. The "sleeping pool" reveals herself as I approach. Perfect quiet, circles radiate outward on the surface with each calcium drip from the stalactites hanging above.

Friday night

...and the lights are low.

Looking out for a place to go...

@ Mekka the hip, Mayan-themed nightclub in ritzy Borrowdale. 

Interestingly, primary black Africans (and a few Indians) party here. Whites down the block. 

You're in the mood for a dance.  And $3 virgin pina colada.

And when you get the chance... 

Dancing occurs around your table, rather than the dance floor. The music played here is primarily  top 40 US (Kanye, Niki Manaj), South African, and Nigerian. 

Night is young and the music's high. We went to dinner a prior night and found these  musicians in the restaurant.

Apparently, Adele is universal with no color, gender, or limits. Isn't it amazing the way the way the accent vanishes?
It must be due to the wiring differences between singing and speaking, and why aphasics may benefit from Music Intonation Therapy. 


With a bit of rock music, everything's fine.

A sense of urgency - or not

Zimbabweans are "chill," "relaxed," often without a set schedule. It's nice. Until it's your patient.

There is an emergency system. That you pay for. These are private ambulances that may be covered by your employer or self-purchased insurance plan. 

Nonetheless, I have been struck by the general lack of urgency when it comes to very ill patients. Maybe it's because there are limited resources, it's easy to move slowly since it probably won't affect outcome. But, that's quite a pessimistic view. 

I have watched 2 patients die, and wondered if urgent care would have changed the outcome. One was in the casualty ward (ED) in the trauma bay (right). I happened to be eyeing a TBI patient next door, when I noted a 3rd year resident quietly asking the nurse for a functional Ambu bag. I meandered over and saw a patient with very shallow breaths. Unclear if there was a pulse. There was no crash cart. When I asked if he wanted to intubate, he responded, "it's too late" and there was apnea on the monitor. He asked the nurse to confirm absent breath sounds and covered the patient with the sterile, tan blanket. I inquired as to the history, and I got "obstructive uropathy;" the urologists placed a suprapubic cath and asked "physicians to see" = admit to medicine. No help there. He was moved back to the trauma bay with the nurses noted shallow breathing, and the admitting medicine physician was eventually called. Unclear what the delay was to arrival-at least 20 min. There is no loudspeaker, pager, or code team. The casualty officer (nurse) then informed the wife and son, and they cried out loud. I watched, and cried inside.

Challenges

Practicing neurology in Zim has been one of the hardest things I have ever done.

With no confirmatory diagnostics, limited therapeutics, and rare oversight, cases have been extremely challenging. Not to mention +HIV in >13% of the adult population. So if you see a CN 7 palsy in HIV+ patient, can you claim a self-limiting Bell's palsy and leave it at that? Actually, Yes.

My handwritten "plan"

How about acute onset myelopathy in a 75 year old female, hx of treated pulm TB, with no history of trauma. No, you can't have an MRI.
She is empirically on TB meds, prednisone, and B12.  Too bad there are no IV steroids in stock at the moment.

Empiric therapy is the rule. Every HIV+ patient with neck stiffness is on CTX -- then it's stuck for 7 d. TB meds for questionable CXR is understandable.

Most common challenge is acute strokes with no imaging and high BP (we're talking 250s/120)? ASA? I have been going with Yes.
Unless there are some major clinical signs that indicate hemorrhage

Occasionally, you can convince a family to spend $200 on a noncontrast head CT at a neighboring private hospital to please help you rule out a hemorrhage and manage appropriately. We even got one on this TBI case, a young 21 year old male hit by a vehicle in a presumed RTA (road traffic accident).











As Zim was previously colonized by UK, most of the Shona-speaking patients thankfully also speak English.

The medical training system also mirrors the UK.
Undergrad=med student: 5 yrs
JRMO=intern: 1 yr
Govt experience/house officer: 1-2 yr
MMED/registrar=resident (e.g. IM): 5 yrs 

Chitungwiza

The Zimbabwean people are so open, welcoming, accommodating and treat me like family. Literally, I spent the afternoon in Chitungwiza - the next town over - with Baba & Mai Mametsuwa (Caroline's family).

Mai (Mother) made an all vegan meal from their garden sugar peas served over sadza, of course!

They took me around town, and I saw people in their daily routine selling, buying, being.

There is a mix of both "high density" (no garden) areas and rural space (thatched huts etc).






No matter where you are, communal farming on government land is respected. It is a beautiful place.










Balancing rocks (below) are a big thing. They naturally fall this way.