Surreal consults today.
Talking to unmasked patients about constant fatigue, constantly sickness with the ‘flu’ wanting blood tests to look for something ‘wrong’.
As there must be something wrong.
Right?
Oblivious. Absolute oblivious.
I wonder do they look at me and have
At a conference in Italy
Judges
Barristers
Dentists
Doctors
Coughing, Sneezing, someone was blowing their red nose today.
Not one single person has attempted to sit beside me or talk to me even when seat space was limited.
The 2 people that did sit beside me moved after 20
Here’s an interaction I had this week. The mask appears to trigger people, who ignorant I deal with immunosuppressed patients or just don’t care, well one of them (a patient) asked me why was I wearing a mask?
I thought they were concerned about themselves or me.
Before I could
“It’s ok I said. We’re done.”
She smiled and thanked me.
The oncologist wanted another round, another trial, another drug. Jaundiced with as much meat on her, as a KFC chicken wing sucked dry, she was done.
It was over.
That’s how we came to the decision about her metastatic
So yes as we said
Over and over
COVID a pansystemic, vasculitic, immune damaging, pro-inflammatory, neurologically punishing, cardiac injuring, pro-thrombotic, autoimmune driving virus.
If you are genetically predisposed to any disease, COVID is the rocket fuel that will
I shit ye not. Just happened.
Just been into ED to see some patients and Infection Control are visiting and checking the water supply as another location had listeria.
Anyway one of the infection control people then abruptly asks me about the 5 stages of hand washing.
1. We
Well well well
At work so many patients presenting with ‘flu’
“It’s the sickest I have ever been”
“I have no energy”
“I have been sick for 4 week and lost 12kg”
“I need antibiotics”
“I need steroids and antibiotics”
What links them
No flu 💉
I am so proud out her
As the year draws to an end she has been fastidious in her approach to Covid.
She has never had a day off school sick, ever.
Zero, zilch.
She actively chooses to wear her mask and carries her HEPA filter everywhere.
She puts it in faster than we do
Hahaha ahahahah what utter twaddle.
My daughter has worn a mask since the beginning of COVID, still does at school and everywhere we go and read this out loud.
ZERO respiratory infections.
ZERO, Nil, Nada. Sweet Eff A.
We wear them at work, all the staff and guess what no
I think masks give you short term protection. BUT they won’t likely stop most people getting an infection over a 3 month period. If you assume masks are 80% effective and you have one exposure per week to covid, with 100% transmission to the unmasked, then after 12 weeks then
At the
@monamuseum
and it begs the question.
When did decency die?
Forget your views on vaccination, mask wearing and the rest for a second.
The amount of coughing, sneezing and obviously sick people here are all 100% unmasked.
Wandering about so congested one guy said he
There you have it.
My daughters cross country.
She ran it 😷 in hand as she didn’t want it out of sight when not wearing it.
Meanwhile out of 200 students about 70 turned up.
Rest? sick with “Covid” was the answer.
Her teacher? Also off sick.
#CovidIsNotOver
Right…..so all the unmasked Covid positive patients I see daily, coughing, spluttering, long Covid, fatigue brain fog
Yet I don’t catch it from any of them
As,wait a minute, I wear a high quality N95, as does my wife who works in the same medical centre with exactly the same
And in shocking other news in the "I Told You So" section:
"No evidence face masks protected vulnerable from Covid, health officials admit"
"A rapid review report published by the UK Health Security Agency (UKHSA) investigated if high-quality masks, such as the N95, KN95 and FFP2
IgA nephropathy.
If you have never heard of it, keep your eyes and ears open.
I can’t recall Pre Covid a case of it.
Now thanks to COVID I have just come across my 4th case. Four, like wtf.
One of them needs a kidney transplant and asked the nephrologist why they had it?
Here’s another one
@hamishandandy
I had a 19 day old neonate brought into my GP practice which is 50km from the Emergency Department I also cover on my own.
The baby had a circumcision the previous few days and was not feeding.
It was grey, floppy, mottled, tachypnoeic,
This. This. This.
When HIV came along everyone were scared, no terrified! in the 80s. People sadly died alone, terrified and stigmatised.
The precursor to AIDS and one of its hallmarks features?
Pneumocystis jirovecii Pneumonia or PJP.
A fungal infection. Fungal!
Now we
@DrMLivingston
I think often about how a spate of rare pneumonia cases in otherwise young healthy adults are part of what finally raised the flag on AIDs becoming part of the public consciousness and how today those same headlines would be just another Tuesday
How can it keep getting worse?
FEVER is not a main symptom. WHAT!
Hello immune system, where are you???
Oh thats right your broken, from repeated infections.
So expect more fungal infection, more leprosy and god knows what else old worldy diseases to pop up and say hello as
"[The main symptoms of the new Omicron strain EG.5.1] are a sore throat, a runny nose, a blocked nose, sneezing, a cough without phlegm, a headache, a cough with phlegm, a hoarse voice, muscle aches and pains and an altered sense of smell..
However, shortness of breath, a loss
Here we go
Supposed to be going to swimming pool with the family it’s 38 degrees here at 5pm.
Instead I am in the ED repairing a saw wound to a patients finger who would otherwise require retrieval and transfer to plastics in Perth.
The flight alone would be $20-30k.
Yet
Dry tinder?
Wife is having her immunosuppressive medications at an infusion lounge in a WACHs hospital.
She is there with our 12 week old daughter. No staff wearing 😷.
Patient next to her being now being tested for
#COVID
Our most vulnerable exposed like cannon fodder
Well that was a hell of a 3rd week.
Every other patient with RSV moved to 5 patients back to back and 3 ED attendances with Bronchy kids in one afternoon.
Meanwhile I am asked why are they are sick ‘again’ when they only had the flu 4 weeks ago.
I tell them that was Influenza
Well what can I say we are living in odd times
Wife is doing Pilates on her own tomorrow, it will be very Covid safe as everyone else is ‘sick’ that’s all she has been told.
Meanwhile child in daughter’s class, parent has Covid.
They attended in a cloth mask yesterday which
The more we understand the role of viruses, including COVID the more we see a complex interplay from oncogenic (Human Papilloma Virus), Neurological (Epstein Barr Virus), Hemorrhagic (Ebola), immunodeficiency (HIV).
Yet COVID we are apparently ‘over reacting’ to as it’s just a
As you may have heard before,
"..more than three-quarters (nearly 80%) of people with long COVID we studied had POTS (Postural orthostatic tachycardia syndrome). Multiple studies, including our own, have shown viral infection is the most common trigger for POTS.
We suspect some
Well my daughter finally made the school newsletter!
This time science week, oh the irony! Or maybe that was the point.
Here she is in her usual N95 mask and mobile HEPA filter she carries everywhere so it is by her noggin.
Still at school, still not a sick day recorded.
Now I hear some (for now) delegates at the
#WONCA
conference have now tested POSITIVE FOR COVID
Great.
Just great.
This was entirely predictable.
Entirely.
Where was the mitigation attempt?
❌Location had no HEPA filtration
❌Masks were pretty much absent
Doctors from all
“Human metapneumovirus or hMPV, was detected in 1168 people last week. Influenza was detected by PCR in 1424 people, while respiratory syncytial virus, or RSV, registered 436 cases, according to NSW Health data.”
Right, right. So someone better not
Staying in Motel.
Having a wine with wife on our mini balcony which overlooks the motels restaurant.
A man, his wife and 2 kids walk out and then he says to her
“I don’t know what it is lately, but every time I have been out for dinner in the last month everything taste like
Well that rounds out another exciting week of 🦠 dodging.
Where are we up to now? RSV, HPIV-3, hMPV and what else to knock them out the park?
COVID is back.
Of course it is.
I know for shits and giggles it has to be BA.2.86 (Pirola) due to the way the patient contracted the
Is it just me that can’t spot the irony of 4000 unmasked doctors at a conference with doctors from all over the world amid surging COVID in every single state?
All learning to sign COVID-19 in Auslan
The visual ‘sign’ here isn’t very good for patients, our vulnerable population
Being a GP is cough/colds and referrals for obstructive sleep apnoea it seems
.
@hamishandandy
As a rural and remote ‘GP’
I do skin checks.
I also have a surgical list where I remove them. Every single week.
I do point of care ultrasound where I have picked up bowel cancer,
Good news everyone.
My daughter who I have been accused of suffocating with a mask, who takes her HEPA to school, who is fully vaccinated, who has never had a day off school sick.
This little tough nut.
Well
She sat the PEAC (Primary Extension and Challenge) for the Gifted
Another week filled with more than usual patients sick every other appointment and in ED.
Its not COVID (Thankfully for now) but it probably is RSV - Respiratory Syncytial Virus. Something I have only ever witnessed causing respiratory problems in kids/babies.
Until now
Adults
Argh. Meant to post the photo.
Daughter gets an award wearing 😷 since the beginning.
200 kids at her school.
Maybe 1/3 missing from assembly?
Teacher now wearing a 😷 as half the teachers are getting sick with COVID
#CovidIsNotOver
Started our latest practice in Kojonup today
Every single clinical room has a HEPA ✅
All corridors have wall mounted HEPA ✅
Waiting room has wall remounted HEPA and huge
@ionmax
HEPA ✅
It’s not hard to have clean air throughout the building.
#COVIDSafe
There must be a tipping point like the person behind me at Chemist Warehouse everyone has one.
Standing in the queue and the only person masked.
His child (intermittent bronchospasm) asks what what they are buying.
Its durotuss.
They want it to break up whatever is ‘trapped’
Nothing like reading X to see lay people speaking with assumed authority.
Meanwhile, we have Covid circulating and I am trying to make sense of the sheer number of patients with iron deficiency I am seeing.
Thus far over 80 patients and counting from a population of just 400
Well what else to expect?
Immunocompromised wife turns up for infusion.
No mask wearing by any clinical staff.
Goes for a coffee prior and spots no less than 13 clinical staff, all unmasked, some coughing and then a patient with a very mucus sounding cough, barking away of
Merry COVIDmas
Been in a new clinic for 2 days
Every other patient COVID symptoms/URTI
On and on.
It’s rife. We have masks available. Not a single person wore one.
Glasses, N95, HEPA, Glen 20
Can’t keep going at this rate of infection.
#COVIDisAirborne
#CovidIsNotOver
NSW Health predict a new wave of COVID will peak in December.
🔹E.5 variant currently accounts for about 50% of cases in NSW.
🔹GPs have seen positive patients incorrectly assume they have a cold.
@RyanPark_Keira
@NSWCHO
@NSWHealth
Good morning denial!
Sweet sweet denial. Happy Friday.
Spoke to our software vendor this morning as our assigned relationship manager has been absent still since
#WONCA
from work.
No returned emails or phone calls.
Only to be told today have a really bad “flu” by their
@BrianAlex665
@hamishandandy
Got a cannula in its vein
Gave a fluid bolus
Gave early IV antibiotics
Called neonatal evacuation team (NETs) for retrieval
When it got to the tertiary they were unable to place another cannula, decided against an Interosseous and told mum that cannula saved the baby’s life.
Welcome back to
#Australia
!
HEPA Filters, N95s, Enovid
Never caught a thing
#Italy
immigration pop your mask down to see your face
#Doha
immigration poo your mask down to see you face
#Perth
the
@AusBorderForce
officer asked us to do the same as Italy/Doha
Until a supervisor in
We were able to show that they (masks) were able to BLOCK particles the same size as the virus (Covid)
So yes’s again. Masks work. Work work work work work work work!
#COVIDisAirborne
#CovidIsNotOver
Does wearing a face mask help to prevent Covid? Linsey Marr, a Virginia Tech University professor specializing in aerosol science, explains what scientists have learned since the pandemic began.
Violet Affleck. What an example.
Showed this to my daughter who still masks at school and still without a single day off sick. She is not alone in this.
#COVIDisAirborne
#CovidIsntOver
Wtf
Be kind?
Kind! to the smartest people in the room choosing not to inhale a potential death sentence?
As though, we are the ones who are in the wrong and deserve sympathy for our actions. Meek individuals who deserve our sympathy. How degrading.
Wearing a mask is not an
With COVID-19 cases increasing in the community, some people, including people at higher risk of severe illness, may choose to wear a mask to protect themselves, such as when in indoor settings or on public transport. Be kind and considerate of someone’s choice to wear a mask.
Well it appears it’s not all RSV
Jeepers.
It was RSV 2 weeks ago!
Just seen a swab - Human Parainfluenza 3 (HPIV).
So not only has my 😷 and HEPA saved me and my family form RSV that was/is going around.
It’s also doing a tidy job of keeping me from getting sick from
You do you! Right?
That’s what they say. Who cares no ones bothered.
Until
Just been shopping with the family in our masks. Some bloke takes it upon himself to make the L sign above his forehead at my wife and kids, others precede to fake cough at them.
A family, a mother and
Thanks all for your support, it’s important to me to know that sometimes when your masked up, you really do feel on your own.
X for all its criticism has shown that it’s one place where you can feel contact with others like you, who think the way you do.
Of all the Influenza
Monday morning
Now getting ready to drive 250km from a regional location to a remote location, to provide a medical service to a town and shire that has none, zilch, nada.
Being away from my family again for another week, no FIFO roster, just week after week, after week.
This
Out with the old, in with the new
Moved the other filter to nurses room (didn’t have one)
1000CADR
Already done scripts for Paxlovid this morning.
Here. We. go
Got another 2 to unbox.
#COVIDisAirborne
#CovidIsNotOver
Thanks for the kind messages I showed my daughter this morning and she was giving them all 2 thumbs up.
Especially meaningful as on the 🚗 ride home she mentioned she was not invited to another classmates birthday party.
Her classmate told her no invite as she was an ‘outcast’
@Ac06854005
@JasonM98282978
True but then I didn’t cough sneeze or sound congested.
At one point there would not have been 30 secs without someone coughing and others trying to suppress theirs with water
Australia
Why would you go there? everything is going to kill you.
Tonight was cold but that meant cold = clear skies.
Clear skies = Milky Way.
I said to my wife point to the heavens and show people why we moved from the UK to Australia.
And there, we, go.
iPhone 14. No
People thought we were mad for sending our kids to school in a mask
“It’s unfair”
“She will be made fun of”
Today is cross country.
My daughter is at school. Many are not.
COVID it seems is very and entirely predictable
#CovidIsNotOver
Well that’s it.
Till Monday ha ha.
Last sleep, one more clinical day and I have done this stint.
6 weeks in a empty accomodation.
30 clinic days, 60 clinical sessions.
3200km driven. Over 1100 GP consults and multiple ED consults done.
From road traumas, fractured limbs,
Holy moley.
Common sense advice from the VIC CHO.
💉 Stay up to date with vaccination
😷 Wear a properly fitted N95
🏠 Stay at Home if unwell for at least 5 days
💊 Have a plan with your GP for antivirals
No feel sorry for people in masks or wash your hand advice
Hooray.
Have you noticed more of your friends or colleagues seem to have COVID at the moment? Victoria is currently seeing increased COVID transmission. Here is a quick reminder of some simple steps to help to protect you and your loved ones.
Animals getting COVID
China/Netherlands/Ireland/India and potentially the UK some sort of odd pneumonia which may even be Avian Flu.
Then I am doing a procedure in the hospital wondering why there are no HEPA filters
No one knows where they are except I found one hidden away in
But wait, there’s more!
@hamishandandy
Only fair right?
21 day old.
Another neonate.
I was consulting a patient just across the road in GP land, probably doing something silly like referring a patient to a specialist as I am clueless, you know how it is.
There was a
Well there we go.
After 6 weeks elsewhere I am back for 2 weeks to my usual stomping ground.
Patient with baggy blue, “I am sick, again” swabs awaited, what now?
I am left to ponder 🤔 and that sums up the last 2 days, adults sick kids sick sick sick
One parent summed it up
Went to the AC Milan vs Roma game
@OptusStadium
and were amongst the very, very, very few masked
Wife, my daughter and I
Plenty of coughing, sneezing and obvious ‘spicy’ cough in some
The looks
Passive comment
Pointing
Given all the chatter on social media not a single
@hasselljpb
Not with COVID John.
There is no retained innate immune memory long term and look at the USA and UK were cases are rising to more pandemic levels. There are two more strains coming. If we had herd immunity this wouldn’t be a problem. We don’t and never will.
Plus in my entire
Monday tomorrow.
More bloody Covid I suspect or indeed expect.
Hopefully new HEPA filters arrive
I am swapping out the trusty Smarthome 5S for 3 x Ionmax Aire X 6-Stage UV
1000 CADR so they tell me.
Was speaking to ABC journalist who was surprised my daughter has still, to
Wakey wakey eggs and
Pertussis.
Get those surfboards out we are due to ride the next wave of Pertussis and all the sickness and sadness that brings.
80% of adults have not had a pertussis booster vaccine in 10 years.
But don’t worry only newborn babies and young kinds will
Well this is genuinely terrifying for us but also the kids
What are we doing to them?
LoL jUsT a CoLd….
Cardiometabolic pathways
Neuronal damage
1 in 10 infections = Long Covid
Premature cardiovascular death and aging
We have literally cut the umbilical cord from our own
Every parent should watch this interview with Consultant Cardiologist Dr Rae Duncan summarising the latest research on
#LongCOVID
and potential long-term impacts on kids from repeat COVID infections.
@Sunny_Rae1
@BBCOne
@mmgeissler
The chicken has come home to roost
This week URTIs in full swing in WA
“It’s not Covid, I’ve tested” comes every single reply.
“I need some antibiotics”
I remind them they don’t
“Why don’t you get sick” 🤢?
I point to my mask and
@ionmax
HEPA
Meanwhile daughter is doing
Wife went to see an eyebrow tattoo company in Perth.
10 tattooists
They each do 5 sets of eyebrow tattoos a day at $690 each
All fully booked
$3450 per tattooist, per day.
Yet 2 years of pre med, 5 years of med school, 2 years of post doc training and 5 years of specialist
People of Perth
I am in a vehicle driven by someone who is happy to wear a mask
Even cleaned the vehicle prior for us
Happy to take you here and yonder in masked bliss and safety (pre arranged due to wife’s immunosuppression)
Windows open ✅
Masks on ✅
Very respectful to
Nope
Not a single child we have vaccinated including my own have had a single problem
I have never seen a single ED presentation or GP presentation which reflects this one bit.
Yet kids born in the past 2 years and adults who either never got a vaccine or completed the primary
We are going back in time
A time of pre vaccination
Where words like intubation and ventilation or ECMO are making a Christmas comeback.
All borne from platforms of misinformation and nonsense sending us back to an amnesic time of Covid that has been forgotten.
The horror of
Germany’s largest university hospital, Berlin’s Charité, warns:
The number of Covid infections that require intensive care is increasing.
10% of the cases treated in intensive care in the clinic are artificially ventilated with so-called ECMO therapy.
@cptnjamescook
@hamishandandy
Very difficult when General Practice has billions of underfunding
Expected to do more for less
Perception of us being basic referral machines, this just adds fuel to the fire
Off to bed
The URTI/Flu-like/Gastro patients are on the up.
“It’s not Covid” they tell me
Then other patients ring saying they are cancelling as they have Covid.
🤷♂️
1 in 19 is the current infection rate, so I asked ChatGPT what it would forecast given current rates and it
I worked in Leighton in the UK it was 2011.
I was on nights. It was 0400.
We had a standby call, male with chest pain ETA 5 mins. 10 mins later no sign?
Next minute ambulance arrives.
Turns out the chap had arrested x 2 (VF) en route.
He was being lowered on the ambulance
Really putting my faith in this VBreathe, Enovid, N95 and glasses and air ducts pointing air behind me
Several people in this cabin
Snorting
Sneezing
Coughing (mucus sounding)
Congested conversation
The beginning of their Influenza/COVID or other induced Rhinitis
Plane travel
That’s all I hear in Tasmania
“Post pandemic”
“Post COVID”
We are post nothing, absolutely nothing.
The amount of moist coughing here in Tasmania, the flight, just the background of society.
Pretending this does not exist and has ended, which is clearly has not, will be
Silicosis
2021
73 claims, 5 deaths
230 a YEAR Australians develop lung cancer due to past exposure.
COVID
22885 Deaths
194 weeks since first death recorded
117 a week or 16 a day.
Silicosis = 0.013 deaths/day
COVID = 16 deaths/day
COVID = 1230 x more deadly than Silicosis.
#QandA
: A damning report into silicosis, an irreversible lung disease that has been linked to working with engineered stone, calls for a world-first ban on the stone benchtops.
What will you ask?
Meanwhile in the land of Covid minimalism and denial.
My daughter masks, zero sick days, zero covid, neither do we or the in-laws.
However here I am seeing kids who don’t as per Kate’s ‘advice’
Conjunctivitis, URTIs, diarrhoea
Parents sick, grandparents phoning begging for
This is our 6th power outage since last week
Our power went out yesterday afternoon
Our food is ruined, totally.
Our vaccines are ruined again, including all our private thousands of $$$ down the drain? Who pays for that?
No hot water
No aircon it’s 34 degrees today.
We still
01/11/2023 my wife and I took over a failed MM6 General Practice that was open 3 half days a week.
We increased this to 5 full days
Fast forward 222 days till now
We have ticked off all chronic care ✅
We have seen all backdated patients, completed all reviews and recalls ✅
What happened to hybrid immunity and the pandemic has ended?
Look what happens when vaccination rates drop due to people entrusting their health to unqualified nobodies on social media.
KP.3 is not the end, there will be another wave and another and another.
The more
New Covid FLiRT variant KP. 3 is “increasing in abundance” in Victoria, as the government orders an escalation to Stage Two hospital and health service measures. It comes amid monkeypox and measles outbreaks >
Why this doesn’t surprise me
I went to visit the aged care residents in WA I look after.
We are having a COVID Surge in this state.
I was the only health professional around them wearing a mask.
There is no circuit breaker to protect them.
None.
#COVIDisAirborne
I was doing my oldies review.
As well as managing their goals of care, multiple medications, diabetes control, asthma control, blood pressure control and reducing delirium.
I was asked to review a ‘skin tag’
It wasn’t a skin tag but an bleeding ulcerated amelanocytic
Not me
Not at work
Not out shopping
Not getting a haircut
No RSV, No COVID, No Pertussis, No HMPV, No Influenza
Also applies to my wife, my daughters
Just call it ‘luck’ I guess
😷 + Enovid + CPC mouthwash
#CovidIsAirborne
#CovidIsNotOver
Queensland: "Doctors are acquiring RSV, COVID and influenza in the state’s hospitals in rising numbers, sparking the state’s peak medical body to call for urgent action to better protect medics in an already struggling healthcare workforce."
@qldhealth
JN.1 raging through the states
Seeing loads of it locally
Loads of people trying to get Telehealth appts (when my day is already full) due to testing positive.
Yet there I am still working. N95, glasses, HEPA.
Still no JN.1 or EG.5 for me, or my family.
Sensible advice from
Data released today confirms that Victoria is seeing increasing levels of COVID-19 in the state, driven by the dominance of a new Omicron subvariant JN.1.
Don’t let COVID spoil your Christmas.
Remember the key actions that we know help to protect you and your loved ones.
1/3 🧵
A reply got me thinking about our outfit and rural health.
From this medium it would appear that this graft is all at my expense.
Yes I travel and do the doctoring but
There is so much more to it.
None of this would be possible without my wonderful wife Rachel.
None of it.
I am seeing lots more COVID than RSV/Influenza but yet not a single mention by the
@theprojecttv
Experts are warning of a long, sick winter, with cases of COVID, RSV, Pertussis, Influenza, Mycoplasma Pneumonia, Rhinovirus, Adenovirus, Atypical Pneumonia, Sepsis and
Experts are warning of a long, sick winter, with cases of RSV reaching 100,000 and whooping cough cases crossing 10,000.
Dr Max Mollenkopf tells us why this cold and flu season is so bad this year.
Just seen this article
@smh
Is this comment a joke?
“Michelle Leech, the Medical Deans Australia and New Zealand president, suggested student and junior doctors could help staff the new clinics, helping fill potential shortages and gain vital experience along the way”
I have
Don’t worry peeps
It not just NSW health
@Qantas
also treating mask wearing people like idiots as we are finding out during our flight today from Perth to Sydney
“For those wearing masks, in the event oxygen masks drop, facemasks must be removed to apply”
Because obviously
Australia: After weeks of posting numbers of Covid deaths at 30-50 a week, 685 deaths are suddenly added on the 10th September 2023.
WHO Data download:
Australia 🇦🇺
We in the midst of a huge outbreak with KP.2
Now look at this
KP.3
KP.2 and KP.3 can evade XBB.1.5
KP.2 can offer some immunity against KP.3 but i suspect when it gets here we will do this all against
And we’re not even at the peak of KP.2
This is exhausting
Well WTAF
Just been told that electric may be out for 1 WEEK and we just have to suck it up.
I am furious.
1 week of no income
1 week of PAYING for alternate accomodation
1 week of rotten food
1 week of a remote town have NO doctor as there is now no infrastructure for them