‘I’m suffering chifini,’ says my patient. Chifini? I’m stumped already. He’s my first patient at a small rural clinic in a remote region of Zambia and it’s the first day of a 4 month sabbatical away from my urban practice in Leicester. Is this the Nyanja word for worms? Or perhaps he’s referring to his HIV infection, or malaria, or TB. I’ve done my homework and my smartphone is loaded with apps on tropical medicine. I’m primed to administer exotic drugs like Coartem®, praziquantel, efavirenz.
I find a nurse and she kindly translates for me. Chifini, she says, means sneezing. He has a cold. Chifini. How beautifully onomatopoeic but also, how reassuring. Twenty-three years in UK general practice means I’ve had some experience in upper respiratory symptoms. I hadn’t expected to be on such familiar ground. But outside there’s a commotion. ‘Doctor, come quick.’ The nurse tells me that a young woman is struggling to breath.
I can hear her laboured respiration as I hurry to the three-bedded ward. ‘She’s a known severe asthmatic,’ says the nurse. Her relatives are around the bed, wailing. The patient looks at me imploringly. ‘Have we IV adrenaline? Aminophylline? Better draw it up,’ I say, as I plug my stethoscope into my ears. Her chest is noisy but it sounds upper airway and there is pretty good air entry. I slip her finger into my p02 monitor: 98% saturation. I sit down beside her, stroke her hand, and reassure her, coax her to relax. She calms and her laryngeal spasm abates. She breathes normally again. ‘We have family problems,’ says her husband, ‘and we are having difficulty conceiving.’ I’m on familiar ground again: she has somatisation of her anxiety.
So, I tell myself, the patients of remote tropical Africa have URTIs, they have asthma, they have anxiety, just like patients in Leicester. Perhaps experience of primary care in the UK is all that’s required for working in the tropics. I just have to learn a few words in Nyanja or at least Nyangish: ‘hotting’ for fever, ‘purging’ for diarrhoea, ‘it’s at rest’ for it’s got better, ‘at zero-nine-thirty hours’ for half past nine in the morning (they are always precise), and ‘disease of the moon’ for epilepsy.
But then come the crocodile and snake bites, the chancroid, and the tuberculous spines, the injuries from falling off a bicycle while being chased by an elephant (I expect there’s a Read Code for that, but here, thankfully, there are no computers to check). I then discover that there’s no water in the taps, the steriliser is out of action, there are no working scissors — just as well then that the bandages are so thin and flimsy that they may as well be toilet paper.
I soon find my reading and my smart phone apps invaluable. Purple skin lesions may be Kaposi’s sarcoma, haematuria is probably schistosomiasis, and it’s the mosquito-breeding season so ‘hotting’ is usually malaria. But there’s only so far that knowledge without experience can take me. This child strapped to her mother’s back is feverish, quiet, and has malaria — the Rapid Diagnostic Test has confirmed it — but exactly how ill is she? I’ve not yet got a feel for malaria’s form, its shape in time. How quickly may she deteriorate? Will oral medication be sufficient or does she need i.v. quinine? Should I keep her on our small ward overnight or will that be overcautious?
Fortunately, I’m not alone out here in the bush. I can ask our nurse. She’s seen as many hottings as I’ve seen chifini. Before long we find that our combined experience, along with a little improvisation on the equipment front, allows us to display a certain degree of capability for whoever walks, or is carried, in.
When I return to Leicester, one of my first patients is hotting, although they use the local term ‘burning up’. It’s some disappointment to me when I find out that they have not just flown in from somewhere near the equator because I now have a feel for tropical fevers.