In December I had an email exchange with Dr Ian Cross, one of our brilliant Virtual Doctors working to improve the standard of healthcare given in our clinics in Zambia and Malawi. Ian has a wealth of experience working in developing countries and it was fascinating to find out more about his motivations and thoughts on the charity, the coronavirus pandemic and medicine in Africa.

Edit: Whereas the pandemic has not affected Zambia and much of sub-Saharan Africa as it has in other regions of the world, since the beginning of 2021 Covid infections are now accelerating, particularly so with the presence of the so called South African strain, and our Covid Response is more important than ever.

Working overseas has always been part of Ian’s plan and his main motivation for training as a doctor. In the 1970s, doctors were in short supply in many developing countries and it was relatively easy to work in sub-Saharan Africa. When Ian first qualified, he worked for the Save the Children Fund in Burkina Faso, Sudan, Ethiopia and The Gambia between 1979 and 1984. He says, ‘back then my main motivation was philanthropy. I felt that my clinical skills would benefit many people where health services were basic.’ His motivation has steadily changed over the years and he now values working in Africa because it is so much more rewarding. The reason for this is that, ‘there are more challenges such as language, limited range and supply of drugs and lack of accessible special investigations. It means I have to rely on my eyes, ears, hands and experience more.’

It was in 2018 when Ian then found out about the Virtual Doctors. A GP colleague who was interested in working for the charity reached out to him, just to find out Ian’s opinion on the work they were doing and the service they provided. Ian tells us ‘I looked into it more and felt that I could provide good generalist advice because of my experience of having worked in low resource countries, especially Zambia.’ He has now been providing practical GP advice to Zambian health workers for two years using the Virtual Doctors app. Ian’s experience working in a Zambian rural health centre has proved very valuable in his role with the charity. He says ‘I understand the limitations of the local health service, the lack of medical supplies, laboratory tests and other investigations. Many people are too poor to buy the drugs they need or travel far from home to access specialised care.’ He can therefore offer the right support to clinical officers based on the resources available to them.

One of the difficulties Ian has found when working as a Virtual Doctor and answering questions on the app, is the lack of information given by the clinical officers about the patient and their medical history. In order to combat this, he thinks ‘there should definitely be some training for COs about how to take a history and examine a patient, plus how to distil this into a few sentences to be written in the app when asking for advice.’ This is something that the charity can aim to provide going forward. Ian spent time training clinical officers on his last placement in Zambia. He tells us ‘I tried to get them to summarise a patient, as if they were communicating over the phone with a doctor at their local hospital. Concise, relevant details are required.’ But training the clinical officers does not come without its challenges. Ian says ‘education in Zambia differs from that in the UK. In Zambia, the teacher doesn't ask the students for ideas or suggestions, students are simply told the information that they need to know or it is written on a board.’ With our ways of teaching, it is hard for people to overcome the fear of getting it wrong, and that is something Ian has found with both clinical officers and medical students alike.

The EU has classified Zambia as a low-risk country for Covid-19 and in three months Ian saw just two confirmed cases. I was therefore interested to find out Ian’s thoughts on the reason for this. He says firstly ‘there is certainly under-reporting. This is partly because of the lack of tests available, as well as the stigma attached to Covid-19, which discourages from getting tested.’ Then secondly ‘the climate allows people to live and work outdoors, not in confined, poorly ventilated rooms. In Zambia, the rates of infection are greater in towns, with high population density, and most Zambians live in rural areas.’ Zambia has therefore coped very well with the coronavirus pandemic, and Ian’s experience with Covid-19 in Africa is similar to what we heard from Martin Dedicoat in our previous blogs.

If Zambia were to be hit badly by the coronavirus pandemic, the shortage of necessary supplies would come as a huge problem in fighting the disease. The clinic at Kakumbi, where Ian volunteered most recently, The clinic sometimes has no running water. Carbolic soap is rationed, so a block gets cut into small chunks. Some goes into the nylon mesh bags for use outside the consultation rooms, next to the water container [WASH basin] donated by Virtual Doctors. The supply of gloves is limited, certainly not enough to change between every patient. Each member of the health centre staff is issued with a single surgical mask which has to last them a week. Given the limited resources available it is therefore somewhat of a relief that Zambia has not seen a significant number of coronavirus cases.

Covid-19 has instead had an impact on Zambian healthcare in other ways. Ian has observed deterioration in the amount of standard drugs and equipment available for other diseases. These are diseases that typically receive less coverage or attention and attract no additional external funding, such as diabetes, asthma, epilepsy, hypertension and mental illness. Ian tells us ‘It is really frustrating trying to manage chronic medical conditions like these when the drug supply dries up. Perhaps the national attention to Covid-19 has meant less attention and resources are directed to these diseases.

It is fascinating to hear about Ian’s experiences working with the Virtual Doctors both out in Zambia and at home using the app. I can certainly see why he was drawn to work overseas and just how rewarding the role must be. I was particularly interested in what he has seen of the Covid-19 pandemic in Africa and contrasting this with Martin’s experience in the UK, which was discussed in our last blog. Everyone at the charity is immensely grateful to Ian for the time he has dedicated to training clinical officers and working with the team out in Zambia, as well as his expert advice when answering cases at home.