Perspective

At Fimpulu Rural Health Center, there is a separate log book or register or tally sheet for pretty much everything. Visits to the outpatient department. Prenatal appointments. Family planning patients. Revisits or follow-ups of any and every kind. HIV drug dispension. TB patient visits. Kids identified as being nutritional deficient. Meds dispensed to the out-patient department, or maternity wing, or counseling/testing room. Malaria tests given.

Ya’ll. There’s probably 50+ registers. No joke. 

This week, a very official-looking woman came and basically audited our registers. After several hours of pouring over cramped and messy handwriting, she came into the screening room where I was working and, with a big smile on her face, proclaimed that “we are not doing well.” 

Turns out, there is yet another register (or three) that we should be keeping, and a line of protocol that goes along with it, that we’re lagging a bit behind in. Specifically, all children should be HIV tested after they are weened, and that test should be recorded in a register so that there is some record that it happened. Because the reality is that right now, it’s not actually happening. And that’s really not okay, in a place where the HIV rate is officially 13% but probably actually painfully higher.

Audit Lady was actually extremely kind and obviously cares about her job and the kids she hopes to help through it. We chatted for several minutes about ways to implement the proposed strategies and protocols. She took my phone number and gave me hers, saying that she had some written resources at her office that she thought would help me out and inviting me to stop by next time I’m in Mansa and pick them up. 

To speak my truth, I deeply passionately dislike the part of nursing that is charting. I don’t enjoy spending literally half of my time on the job just writing in books. I don’t know many nurses who do. It is the bane of nursing existence.

And 6 months ago, if you had told me that there are several dozen books that should be charted in on a daily basis at every rural health clinic in Zambia, I would have scoffed at the inefficient waste of time and the definite double-charting (writing the same information twice, or sometimes 3 or 4 times, in different books) that is surely taking place in such a system.

But then I jumped face first into hot water (that is to say, I started actually working at one such clinic), and my know-it-all-ness has toned down a squeak or two. There’s that old adage that you shouldn’t judge someone until you’ve walked a mile in their shoes. I think it is all too easy to walk a mile in similar shoes (i.e., a nurse who has relatively significant related experience but hasn’t actually worked as a nurse in this particular kind of clinic) and go ahead and cast judgment.

Because yesterday, an HIV+ mom came in to pick up ARV drugs for her HIV+ kids, and we didn’t know what meds to dispense, because their names weren’t on the register. She went home empty-handed with instructions to bring back their paperwork so we can try again.

At the end of every week, I pull about a dozen scraps of paper out of my nursing bag on which I have hastily scrawled the names and identifying information of every clearly malnourished child that I saw that week. I’ve been here long enough that I’m starting to get repeats, and that’s frustrating, because no follow-up is happening. I just keep writing down their names. Last week I found a register that is supposed to be used for that purpose, so that their names can’t be forgotten and dismissed as easily as little scraps of paper that end up left in my pocket and scrubbed to death in the laundry.

So that register of meds? That register is crucial. It means that we know exactly what medication a patient needs, and what medications they may have been on in the past, and what day they picked up their meds last time (and therefore whether they picked this batch up in time to keep from running out). It means that we can calculate how many of each kind of ARV in what doses we are going through in a month to avoid running out. 

And that register of under-5s malnutrition that I found forgotten in a stack of nonsense by the refrigerator? That means that when I encounter a malnourished kid, I can go back and see if they’ve been identified as such before. I can see if follow-up has happened with them. I can tell if they managed to slip under the radar somehow, or if they were fully on the radar and just not addressed.

And the birth register means that if a mom doesn’t show up with her newborn for postnatal within a week of going home, we know who and where and can try to figure out why. 

And when folks come through for the umpteenth time but we can’t find any history of them in any of our registers, it’s a sign to us that the flow of things is failing, and that we as practitioners are letting people slip through the cracks.

So it’s all in perspective. 

Of course, the system isn’t perfect. In the above examples, oftentimes the problem is actually caused by someone's failure to fully or appropriately utilize the registers. Writing it down doesn’t guarantee that anyone will do anything about it. With the frequency of staff turnover and building renovation that has reportedly happened in the last few years, some registers have been neglected or forgotten completely. There are stacks of old registers from years past that I honestly have no idea what to do with and have ceased to become very useful simply because of age and the sheer difficulty of locating anything within them. 

Nonetheless, all of these registers exist for a reason. Sometimes a functional reasoning, and sometimes merely a data-reporting reason, but a reason nonetheless. On more than one occasion, I have thought to myself that this and that procedure or log book or whatever could be consolidated to be more efficient, but the pattern so far has pretty consistently been that when I do some asking and digging, there’s a decent reason for why it is the way it is (even if that reason is just that the people who give the money… USAid, for example… require data to be recorded in a particular way).

For me, it poses an interesting challenge because of my unique position at the clinic. I am functioning pretty much like a full-time employee of the Ministry of Health in terms of my responsibilities, but of course, I am not that thing. We’re here through Choshen Farm, not the government. And there are a host of services and activities I would love to offer that are related but tangential to the services offered by the clinic. I both have a lot of freedom and take a lot of liberty in my position as it currently stands, but I am still functionally beholden to some of the daily doldrums. 

Like the registers.

But until digitalization (and reliable electricity, and computer literacy) sweep the sub-Saharan, I pray that God will keep me humble (and knock me down when I need it) in regards to the way it is and what I might initially perceive to be a “better” or “right” way.  There’s probably a list of ways that I personally could improve in this area. Feel free to send me your suggestions.

Maybe I could write them all down in a register.

Hope Rises

I heard the footsteps coming up the lane to our house, racing the rain, and I hoped futilely that they were making for the bush path that leads to our neighbor’s house (where sleep is not actually a thing). The knock and “odi!” pull me from bed and draw me to the door. One of David’s teacher colleagues is there. She lives by the clinic. She tells me that someone has collapsed. A few minutes later my own footsteps are racing the rain. I think on my way that I am so thankful for the series of events that landed us in our dear house with the purple walls right across from the clinic instead of a decent walk down the road. I also murmur a prayer of thanks for the slight rain, that cools the air and dissuades the mosquitos.

 It takes a good amount of Q&A to figure out what exactly happened and who exactly all the people present are as I try to rouse the unconscious woman. The most easily identifiable culprit, cerebral malaria, falls flat with a negative Rapid Diagnostic Test. I start an IV and run dextrose, trying to balance the possibility of hypoglycemia with the probability of exacerbating a hypertension problem with IV fluids. A car pulls up and the driver informs me that he has brought me a maternity case. I let them into the maternity ward then return to greet the ambulance, who came to pick up the unconscious lady, just as a second maternity case arrives.

Nine females in a room together: Two in labor— a young scared witless first time mom, and a veteran of five previous births. One a toddler and therefore wholly uninterested. One toddler’s mother whose relation to the aforementioned laboring women I’m still not entirely clear on. One wise old grandmother who kept putting gloves on (please don’t put your fingers inside of anyone, Bambuya…). One auntie. Two mothers holding and caressing their exhausted daughters, who appear strangely small and young and in need of their mommies in this moment for two girls about to become mothers, whether for the first or sixth time. And me.

The room smells of that curious mixture between bleach and blood. Both mommas progress slowly through labor at an almost identical pace, and I go through an entire box of gloves flitting back and forth between them. The younger of the two is in utter despair at the task before her but still feisty enough to cop a swing at the auntie who throws a tease her way. The other is taking far longer to progress than I expected, and my gut tells me something is wrong (but you can’t write “gut instinct” as reason for referral, so we press on). They labor through the night. I wonder at what point it is appropriate to begin using the greeting for “good morning”— 3am? dawn? Both of them vomit. Veteran Momma eats and drinks to keep her strength up, but Newbie Momma is scared and tired and won’t even take water. Between sips and checks and reassurances I slip into the back room and try to sleep for little spurts. When sleep won’t come, I pull out my yarn and crochet bunny slippers for the babies that are on their way to meet us, and in every stitch goes a prayer and a song. 

When dawn pushes its way through the dusty curtains that I haven’t gotten around to straightening yet (the string that holds them up is crooked and ohhhh the insult to my OCD), I give up on sleep altogether. My saint-of-a-husband drops by and deposits two pieces of french toast for breakfast on the table in the entryway, where they will remain for several hours until everyone gets done being born and stuff. Newbie momma delivers first, and between her relief and her extended family’s clamor I can feel the frustration and exhaustion of Veteran Momma, who has been laboring longer and surely has paid her dues for long deliveries with the first five births. Blessedly, she follows soon after. The cause of her complication and delay becomes glaringly evident, and I handle it to the best of my ability. The immediate danger is passed, but high risk of infection and Veteran Momma's general poor state after delivery prompt me to send my second patient in 12 hours to Mansa General Hospital. I pray an OB is on duty somewhere and will give her the attention she needs. As the car pulls away, I look down at my clothes and realize that I am wearing the body fluids of no less than 4 people (though 2 of them were less than an hour old, so somehow that doesn’t bother me as much. But still. Meconium everywhere). 

Prego moms and newborn babies are, in my experience, easily the most vulnerable people I encounter here. I’m not exactly sure how many neonatal sepsis cases I’ve dealt with in the last few weeks. Somewhere between 6 and 12. Umbilical cord infection was the obvious culprit in probably 90% of them. A couple weeks ago I carefully wrapped a 2-week-old boy and tearfully handed him to his devastated 18-year-old mother, who alternated between screaming the name of the child she had just lost and crying for her own mother. Not even an hour later, I welcomed a precious 3kg little boy into the world. That same little boy would be back in my arms 6 days later, fighting infection, spending the night with his momma in the same bed in the same ward that he stayed in the day he was born.

There is a deep and terrible beauty to existence here. It is raw. It is communal, and it is fragile. It is the jokes and jests of the half a dozen women who coached Newbie Momma through a slow and painful right-of-passage into adulthood. It is the surprising efficiency with which those same women sprang into action the second the baby was born, cleaning up momma and bed and wrapping up baby and disposing of the placenta. It is the deep searing tragedy of children lost before they ever really even had a chance to be, infants who slip away before they can even be named, as if somehow that namelessness gives them the peace to go, because they aren’t anchored here. 

It is all of those thing. 

And today, blessedly, it is life. It is a dainty precious baby girl and a hearty cone-headed baby boy. It is complications that didn’t complicate as much as they should have. It is improvisation that actually worked and laughter and joy to be shared. Today, it is hope, and it rises both defiant of and oblivious to the statistics or the hard of days past, because that’s just what hope does.